ACA Repeal: the idea of responsibility

The legacy of healthcare muddies any discussion about what to do next.

  • What responsibility do individuals have to care for themselves and avoid burdening others?
  • Since Congress has created rules on exclusivity that have massively inflated pharmaceutical prices in the US, what responsibility does the government bear for making healthcare affordable?
  • What is the proper balance between public good and greed for health practitioners and insurers?
  • Since government regulation has created the malpractice mess and allowed the AMA to protect the small minority of physicians who are incompetent and careless, what obligations does the government have to consumers?

Neither the ACA nor the current repeal effort addresses the root causes of the current mess.  The House bill is unsatisfying because it’s a band-aid, not a cure.

Susan Combs, CEO of an insurance brokerage, offers an interesting perspective on ACA repeal.

“I know many people tout that requiring health insurance is ‘unconstitutional,’ yet you don’t hear people saying that in regards to auto insurance,” Combs says.

“It’s all about mitigating your personal risk and you have a duty to do so. The mandates help to balance out the risk pool. It is very important to have the high utilizers in with the young and healthy, this in turn helps to manage and control the costs.”(1)

The duty to minimize risk is recognized by the courts, but the US doesn’t do consistency well. On the one hand, we want people to live as they wish. On the other, we want to hold them responsible when their behavior affects others.  With healthcare, these desires clash. There are so many examples.

  • In general, when an uninsured individual needs healthcare, the cost falls on taxpayers. Is that fair?
  • The motorcycle rider who opts not to wear a helmet raises both motorcycle and health insurance rates for others.
  • The parent who chooses not to have a child vaccinated raises the risk of serious illness for others, and that impacts their health insurance rates.
  • People who are obese are at greater risk of a variety of illnesses, and are prone to later detection of disease, than those of standard weight.  Both the illnesses and delayed detection drive up the cost of care. That cost hits all insurance policy holders in a state.

What is the individual’s responsibility to mitigate risk? To oneself? To the group?

And yes, the government has aggravated the mess and has an obligation to undo the damage.  The current bill doesn’t address that at all.

A note on cost increases for insurance:

“I’m concerned about the age rating ratio changing from 1:3 to 1:5,” Combs says. “Many consumers don’t get that this means that if a 20-year-old was paying $200 per month for insurance, that a 64-year-old, on the same plan, is currently capped at paying $600 per month. With the new proposed bands, that would go up to $1,000 per month. The increased tax credits won’t scratch that surface.”(1)

Costs will go up and the tax credits will be insufficient to offset the increase.  They may be insufficient to motivate healthy individuals to buy insurance.



  1. Claire McInerny, Erin Moriarty-Siler, “Benefits experts weigh in on ACA replacement,” Benefits Pro, 8 March 2017.

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