 David Hess (www.bestconsultingspecialistsinc.com) In the final question of the 2017 Miss U.S.A Pageant (fox, n.d.) , Miss D.C. Kara McCullough was asked if affordable healthcare for all U.S. citizens is a right or a privilege. She responded that it was a privilege but she later clarified on Fox and Friends “ It’s definitely a good aspect to have affordable health care for people but I definitely am not taking my health care for granted. And that’s why I said it’s a privilege.” Social media (@MissUSA) has been quick to praise and harsh to criticize her response. Whether you agree or disagree with her response, the question itself serves to highlight three aspects underlying the health care debate currently underway within the U.S.A. The first aspect is whether having healthcare is a right or privilege. The second aspect is should health care be affordable. The third, but hidden, aspect is what should the role of government be in supporting the first two aspects. It is this third aspects that ignites the controversy, not only in the Kara McCullough’s response but, in the health care debate in general. Since we have more than the 45 seconds to respond than did she, let’s exam each aspect of this question separately. Is healthcare a right or a privilege? The preamble of the Constitution defines itsreason for creation and contains the wording, “…promote the general Welfare”. Article 1, Section 8 reads, "The Congress shall have Power to lay and collect Taxes, Duties, Imposts andExcises, to pay the Debts and provide for the common Defence and general Welfare of the United States." The first 10 amendments to the Constitution make up the Bill of Rights and were designed to set limits on governmental power. Amendment IX states, “The enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the people.” This ammendment was added to ensure that any right not speccifically stated within the Constitution does not negate it from existing. The Courts and Congress have interpreted and used these three sections to support programs such as infrastructure improvements, grants, minimum wage, and even the social security system. According to Cornell University Law School, the court interpretation has been that the Federal Government does not have the power to legislate the general welfare of the country. The Federal government merely has the power to spend revenue on a matter of general welfare. (Cornell University Law School) It is, then, up to the courts to decided if healthcare is a right as as contained under the definition of “general welfare”. The Supreme court has not decisively weighed in on this and given that neither the 321 million people living in the United States, nor our 100 Senators, nor the 435 Representatives have been able to agree on this topic, it seems unfair to ask a Miss U.S.A. contestant to answer the question; even one as educated as Kara McCullough. Should health care be affordable? Regardless of whether healthcare is a right, how can society deny that obtaining it should be affordable? There is, however, a debate centered around the definition of affordability, and in defining what happens when it is not affordable. Standard dictionary definitions don't provide any help because they use other nebulous, debatable terms such as “inexpensive” or “reasonably priced”. Therefore, I looked for an economic definition. Uwe E. Reinhardt, Economics Professor at Princeton, reported in an article written for a blog of the New York Times in 2010 that M. Kate Bunford and Mark V. Pauly defined affordable healthcare to the representatives on Capitol Hill as, “What a family could spend with its disposable income for health insurance premiums plus out-of-pocket costs on a minimally adequate package of healthcare benefits, and still have enough money left over for a minimally adequate package of all other basic necessities of modern living (food, housing, schooling, clothing etc).” With this kind of definition being proposed to Capitol Hill, its clear why members of government can’t reach an agreement. They get stuck in a quagmire debating the term “minimally adequate”. Is the economic bar of minimally adequate set at the countries median household income, or at a State’s median income, or at the poverty level, or…? Some advocate that the economic forces of supply and demand, if left alone, will solve the affordability question. Let’s turn to the data to see if it supports this position. Data published by the Kaiser Foundation and reported by Time (Tuttle, 2016) , as well as another 2016 Kaiser Foundation report (Cynthia Cox, 2016) was reviewed. The first report indicates that while the premium price of healthcare for the average household has continued to increase since 2001, the rate of rise has steadily decreased.  However, the rate of increase between 2016 and 2017 does not show a continuance of this trend. For a 40 year, old non-smoker making $30,000 per year, the 2016 Kaiser report shows the national average monthly Silver Premiums increased by 24%, but at least 18 States had premium increases exceeding that, five of which were greater than 50% with Arizona reporting a whopping 145% increase. In 2016, the Department of Health & Human Services stated that 20 million people in the U.S.A gained health insurance since the Affordable Care Act was passed in 2010 so demand increased yet Kaiser reported the number of healthcare providers is decreasing leaving 21% of ACA enrollees with only one provider.  None of this should not come as a surprise if we understand the forces of supply and demand. In creating the ACA, government directly intervened in the demand for healthcare by adding those 20 million new households. The ACA requires that all persons must obtain health insurance. It guarantees coverage even for those with pre-existing conditions. It provides premium subsidies for lower income households to help them meet that requirement. It is supposed to offset these subsidies by requiring younger and assumed heathier households to obtain healthcare and pay premiums if they do not get healthcare via another method such as an employer. Come tax filing, the ACA penalizes those who have not obtained healthcare. These provisions created an increase in the demand by moving the demand line to the right. Initially, providers, seeing what they thought was an opportunity, jumped into the market. Price stickiness and more providers getting into the market created more competition and maintained downward pressure on prices. However, the new demand was composed of people from an aging population and people with preexisting conditions. Theoretically, their extra “costs” should have been offset by the younger age population, with less healthcare needs and expenses, joining the demand population. I have been unable to locate data to validate this offset has worked but suppliers dropping out of the healthcare market indicates their costs are too high and implies that the offset has not occurred. A reduction in providers, combined with increasing provider costs, is once again increasing the rate of increase in the healthcare premiums. What would have happened to healthcare premiums if the ACA had not been implemented is speculation. The ACA went into effect in 2010 and proponents claim victory for the reduction in the rate of premium increase between 2011-2016. (See Chart 1). However, the rate was already on a path towards that in the preceding 5 years. Regardless, what is occurring in healthcare premiums is a prime example of the forces of supply and demand. (Click on this link if you need more understanding about economics.)
This brings us to the question of the role of government. Government can be defined as how a society or community is, or chooses to be, controlled or regulated. In the U.S.A., government works for the people. If society believes health is a right as defined within the constitution wording “…promote the general welfare” , then government’s role is to protect that right. How they protect that right is another area heatedly debated. Advocates of Universal healthcare as the way to protect the right point out the United States as the only developed country not using such a system. However, opponents of Universal healthcare are quick to point our deficiencies in these Universal Healthcare systems such as waiting times, and to South Africa whose system was grossly inefficient and failed. Others advocate for a more privatized system but with government regulation and subsidies to control or offset costs. A third camp weighs in a more libertarian approach of absolutely no government interference. To all of these I ask if the unregulated forces of supply and demand would result in true reduction in premiums, or if it would result in collusion between providers, or create monopolies that would serve to drive costs up. Such was the case in the early 20th century with the railroad monopoly and government’s intervention led by Teddy Roosevelt through the Sherman Antitrust Act. The point of this whole discussion is, was it fair to ask such a controversial and complex question, with so many aspects of discussion, to a Miss U.S.A contestant given only 45 seconds to answer, and no time to prepare a response? i advocate the answer is NO and as such, the criticisms of social media are ill placed, and show a lack of compassion and understanding of the complexity of the issue. We all need to answer for ourselves if “affordable” healthcare for all U.S. citizens is “a right or a privilege” and then get down to the work at hand of solving the related issues. Society can ill afford to have a large percentage of its population without affordable healthcare.
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