Rarely do conservative opponents of the Affordable Care Act acknowledge the real human consequences of their campaign to overturn the healthcare reform law. But an astonishing op-ed published Friday by the Washington Post does just that.
Its author, Michael R. Strain of the American Enterprise Institute, argues that even though the result of repeal is that some Obamacare beneficiaries may die from losing their insurance, that outcome is moral. As the Post's editors succinctly and accurately headlined the piece: "End Obamacare, and people could die. That's okay."
In Strain's own words: "Repealing Obamacare could — although wouldn’t necessarily — result in more people dying. But it clearly would not be immoral."
Strain bases his argument on the fact that society applies cost-benefit analyses to policy choices all the time. Some of these balancings result in raising the mortality risk for some people in return for achieving broader benefits for the larger community. Repealing Obamacare involves just another one of these trade-offs, he argues, so what's the big deal?
But there are numerous problems with Strain's analysis, starting with his treatment of cost-benefit balancing using the "value of a statistical life," of VSL. He misapplies the principle to the Affordable Care Act, in the name of showing that repeal of the ACA would merely return market economics to their rightful place in our healthcare system.
It's regrettable that some people might face higher mortality rates as a result, he implies. But them's the breaks. "In a world of finite resources," he writes, "some people are going to die of potentially treatable illness and injury."
You can see Strain placing his thumb on the scale here. The U.S. may be a land of "finite resources," but there's no indication that the ACA breaches the resource ceiling. On the contrary, the signs are that the ACA is lowering healthcare's demand on resources by reducing the federal deficit and moderating the healthcare inflation rate. Why would even a "slightly higher mortality rate" be an acceptable trade-off for raising the cost of healthcare?
The one nugget of truth in Strain's presentation is that society often does make trade-offs between the cost of a policy choice and the prospect it may lead to higher mortality in a discrete population. This is not a new discovery. We may believe in the abstract that every human life is a pearl of limitless price, but we don't act that way. If we wanted to reduce traffic deaths to zero, we'd all drive around in Sherman tanks at 10 miles an hour. But we can't or won't bear that cost, so we drive flimsier cars at higher speed limits in the interest of maintaining a functional and cost-effective transportation system.
Strain observes that government analyses of policy options such as improving labeling on asthma devices and imposing stricter rest standards on airline pilots value the "statistical life" saved by these options at somewhere between $6 million and $10 million.
But the giant oak he attempts to raise from this acorn falls over from its own weight.
In the first place, Strain's illustrations typically involve discrete policy options with measurable effects. That's true too of the most wide-ranging application of VSL in healthcare, by the British government's National Institute for Health and Care Excellence (NICE).
As we reported in 2009, NICE decides whether the British health system should pay for drugs or treatments based on a metric known as the quality adjusted life-year, or QALY--it judges not only whether a new technology will extend a patient's life, but the quality of life of any additional years. If the cost of a QALY falls below a certain threshold, the technology may be disapproved.
Economists and government officials know that these balancing acts can be uncertain (here's how the Department of Transportation deals with VSL calculations). It's hard to judge the trade-offs even for a very specific policy decision. NICE typically uses its measures to compare one treatment with another, and its raw findings are subjected to other factors, including broad social effects and political pressure.
The more complicated the policy, the harder to judge the trade-offs. The ACA is very complicated, with scores of moving parts interacting with each other. Some may have less of an impact on raw mortality than on other conditions.
By uncoupling health insurance from employment, for instance, the ACA can allow a family member to quit his or her job and spend more time caring for children or elders--or starting a new entrepreneurial business. Insured workers with better access to preventive care will have lower absentee rates, be more productive because they're less worried over children's health. ACA subsidies will put more money in the pockets of working class families. The ACA changes how doctors get paid, to encourage them to keep their patients healthy rather than rack up reimbursable procedures, regardless of their efficacy. (HHS announced a new initiative in this respect today.) How do you calculate mortality rates or VSLs from all that?
The most important factor Strain ignores is that a key role of government is to moderate the impact of pure market economics. It's a right-wing shibboleth that the market consists entirely of individuals making free choices about their welfare. That's bunk. Individuals don't enter the market as equals, and often the only equalizing force is government oversight or regulation. The value of an extra year of life may be very different for some than others, and the amount they're willing or able to pay to lower their mortality risk will vary, depending on whether they're millionaires or cab drivers, healthy or suffering an agonizing disease, the head of a family or living a solitary, unhappy life.
Strain asserts that he's merely calling for a "nuanced" assessment of the ACA's costs and benefits, but his explicit goal is to justify the "benefits" of lower healthcare subsidies, less insurance regulation, smaller government by saying that these weigh more on the plus side than higher mortality does on the minus side. He's trying to evade the real consequences for some of the country's sickest and neediest residents of repealing the ACA by painting it as a morally neutral decision.
He proves just the opposite: Trying to dress up the argument for repeal as a cost-benefit balancing in which the cost can be counted in lost lives--"the fate that ultimately awaits us all," he writes glibly--is crass, crude and spectacularly immoral.