Ezekiel J. Emanuel, Opinion contributor Published 2:58 p.m. ET July 24, 2017 | Updated 7:26 a.m. ET July 25, 2017<\/p>\n
Protest in Chicago in June 2017.(Photo: Scott Olson, Getty Images) <\/p>\n
What is the health care debate all about? Freedom. Specifically two different conceptions of freedom. <\/p>\n
One is freedom to buy what you want. In this view, the country is a collection of 325 million individuals, and freedom is everyone pursuing their lives without interference. The other is freedom from worry. It views America as a community, and freedom is knowing you can get help when you are sick and in need. <\/p>\n
The difference is illustrated by one of my late patients, DotAhern, whohad chronic myelogenous leukemia. She was kept alive and continued to actively work as a substitute teacher in the public schools ofWorcester, Mass., by a medicine that cost tens of thousands of dollars every year. While comfortably middle class with a suburban house, she could not afford to pay for that medication out of her own salary. <\/p>\n
Fortunately, her insurance paid. And her insurance premium was affordable. Why? Because other people were also buying health insurance, but they did not need tens of thousands of dollars in drugs or medical services. <\/p>\n
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There is no way of sugarcoating it: The other people buying insurance were subsidizing Ms. Aherns care. Eventually, when they had an illness or accident requiring expensive medical care, thatin turn would be subsidized by still others. Ms. Aherns freedom to have health insurance at an affordable premium required other people to buy health insurance. <\/p>\n
That is how all insurance works. Lots of people buy car, homeownersor flood insurance paying premiums but only a few people use the insurance in any given year. Those who dont file claims are subsidizing those who do. <\/p>\n
But what if these other people said they wanted the freedom to buy health insurance that covered fewer services, and therefore had a lower premium? <\/p>\n
House SpeakerPaul Ryan says the Republican approach is better forthese people: Freedom is the ability to buy what you want to fit what you need. Or as House Majority Leader Kevin McCarthyput it: Were taking steps toward a free and open marketplace where families can buy health insurance that works for them. <\/p>\n
But if many people decide to buy insurance that covers less, then Ms. Ahern will have to pay more lots more for her insurance. And if this process continues, her premiums will eventually be unaffordable or, more precisely, there will be no insurance. She alone will be responsible for paying tens of thousands of dollars for the drugs thatkeep her alive and working. <\/p>\n
The freedom Ryan and McCarthy laud isthe freedom of individuals to buy only what they want at that very moment, and not have to pay for rehabilitative services or maternity care or mental health care or dental care for children or Ms. Aherns expensive cancer drugs. Itmeans that older individuals and people who have cancer, Parkinsons diseaseor diabetes will be priced out and lose the freedom from fear that accompanies having health insurance. <\/p>\n
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The fundamental and inviolate law of health insurance is that the only way to ensure that a person with cancer or an older person who is at high risk of having heart disease or diabetes can have the freedom that comes with affordable health insurance is to require other Americans who are unlikely to use much health care to buy health insurance, too and not just insurance that covers the few services they will use. Freedom not to have health insurance for some necessarily, inescapably means the loss of freedom to have health insurance for others. <\/p>\n
This requirement can be accomplished in two ways:We cankeepthe Obamacare approach ofrequiringeveryoneto buy health insurance and subsidizingthose with lower incomes so that they canafford the premiums. Or we can adopt the Medicare approach thegovernment providesall Americans with a minimum health insurance package and they canbuy coverage for additional services,such as drug coverage,at subsidized rates. <\/p>\n
There are no other options that really work. Approaches that charge much more a penalty payment to people who dont buy insurance immediately are not sufficiently effective. Besides, paying a penalty for not buying insurance looks a lot like the Obamacare mandate Republicans deride. <\/p>\n
The basic choice on health care reform is this: We can givefreedom to young healthy people to buy what they want and deny the Ms. Aherns of this country freedom from worry about whether theycan afford health insurance and get theirlifesaving drugs. Or, we can recognize that at some point in our lives, most of uswill be like Ms. Ahern we will contract an expensive illness and need other people to help us by keeping health insurance affordable. <\/p>\n
Unless you are invincible, and will never get sick or in an accident and needa doctor or hospital, you too will need the help of others, and the freedom that comes with knowing you will be able to count on them and get the care you need. <\/p>\n
Ezekiel J. Emanuel, an oncologist, a venture partner at Oak HC\/FT and chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania, advised the Obama administration on the Affordable Care Act. His new book, Prescription for the Future: The Twelve Transformational Practices of Highly Effective Medical Organizations, was published last month. <\/p>\n
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