Atul Gawande does some old-fashioned shoe-leather reporting for the New Yorker in his hometown of Athens, Ohio, and unearths some valuable insights:
A right makes no distinction between the deserving and the undeserving, and that felt perverse to Maria and Joe. They both told me about people they know who don't work and yet get Medicaid coverage with no premiums, no deductibles, no co-pays, no costs at all—coverage that the Duttons couldn't dream of.
"I see people on the same road I live on who have never worked a lick in their life," Joe said, his voice rising. "They're living on disability incomes, and they're healthier than I am." Maria described a relative who got disability payments and a Medicaid card for a supposedly bad back, while taking off-the-books roofing jobs....
"My personal opinion is that anytime the government steps in and says, 'You must do this,' it's overstepping its boundaries," Joe said. "A father, mother, two kids working their asses off—they're making minimum wage and are barely getting by—I have no problem helping them. If I have someone who's spent his whole life a drunk and a wastrel, no, I have no desire to help. That's just the basics."
Such feelings are widely shared...
Before I entered the field of public health, where it's a given that health care is a right and not a privilege, I had grown up steeped in a set of core Midwestern beliefs: that you can't get something for nothing, and that you should be reluctant to impose on others and, likewise, to be imposed upon.
Health care reform, in other words, shares some similar characteristics to what in the 1990s we used to call "welfare reform."
Gawande goes slightly off course in my view toward the end of the article when he writes about a guy who had a heart attack:
It was only after this experience that Mark realized what the A.C.A. had given him. Like twenty-seven per cent of adults under sixty-five, he now had a preëxisting condition that would have made him uninsurable on the individual market before health-care reform went into effect. But the A.C.A. requires insurers to accept everyone, regardless of health history, and to charge the healthy and the less healthy the same community rate.
Actually, at least 18 states — including Ohio, where Mark lived — had some version of a "guaranteed issue" law before ObamaCare. And the Health Insurance Portability and Accountability Act of 1996 (also known as Kennedy-Kassebaum) included additional guaranteed issue provisions at the federal level. That's not to say there was no pre-existing condition problem before ObamaCare. Without "community rating," or prices set without considering the pre-existing condition, "guaranteed issue" doesn't mean much, because they can offer you insurance with premiums you can't afford. Some states had both guaranteed issue and community rating but their premiums were also pretty expensive. And if you lived in a state without a state guaranteed issue law, you might have been out of luck. You could move to another state with more favorable rules, or wait for political pressure in your state to change the laws. (This short paper from the Kaiser Family Foundation has some maps showing the rules on a state-by-state basis.) But it's not really accurate, in my view, to say that Mark would have been "uninsurable" before ObamaCare.