I was in Key West, Florida on a family vacation when the Supreme Court decision came down. To be honest, between snorkeling, walking Duval Street, and seeing all the places where Hemingway wrote “Farewell to Arms” (he must have traveled the city with his pad and pen, writing a few words here and there, in anticipation of future entrepreneurs) I didn’t pay it much mind on Thursday. I did catch a glimpse of Fox News on Friday in the airport (The Last Call Lounge, the only airport bar with a beach) and boy were they ticked off. No sound but the closed captions bristled with exclamation points and the faces were very red.

On the airplane ride back I read most of Inside National Health Reform by J E McDonough. I must admit that, though I consider myself well informed on the law, I learned a lot. The first part is about the policy creation process and is fascinating. I was unaware of how much the law is consciously modeled after the Massachusetts model (which was informed in large part by the Heritage Foundation, a conservative think tank). The second part includes the details of the different sections. I had not read a lot about the mandate and so was surprised when I found that the guiding principles for Title I (the mandate section) are sound (need for insurance market reform, need for individual responsibility, and need to subsidize the costs for those who wish to take responsibility but are unable due to circumstances) and reflect conservative values. The law requires market participation and offers extensive choice. The increased support for care of the poor through Medicaid (Title II) would take a significant burden off the states and local governments. So why the fuss?

In “The Struggle for the Soul of Health Insurance” Deborah Stone identifies the values we as a country are struggling to reconcile. As discussed in the book, she describes the conflict. One arm of this conflict is the principle of solidarity – the view that health insurance exists to protect us from high medical expenses, allows us to look out for one another, and is there for us when we encounter unexpected but predicable expense, a pay it forward thing. The other arm is the principle of actuarial fairness – the notion that we can select out a group or groups of people that we wish to share risks with. Though not mutually exclusive, the talking heads on television have staked out a position and vociferously encourage you to do the same. The law tends to appeal to those of us who favor solidarity, particularly as a consequence of the Medicaid expansion. We tend to call it the Affordable Care Act. Those who do not want to cast their lot with the poor and sick tend to use the term Obamacare.

The law anticipated that poor sick people typically are not an actuarial asset and provided coverage under the principle of solidarity through Medicaid.  To accomplish this, it took a hodgepodge of state eligibilities and created a single criteria (income below about 133% of poverty) and offers a lot of money for states to join-up. The curve-ball is that Thursday’s Supreme Court ruling reaffirmed that Medicaid is voluntary and should states not choose to offer enhanced care as outlined in PPACA to their citizens, they are not compelled to do so. Our legislature and fellow Alabamians, clearly falling in the ObamaCare camp, may elect to eliminate this program entirely. In searching for understanding, I found this quote from a libertarian blogger:

Trying to equalize health care consumption hurts the poor, since most feasible policies to do this take away cash from the poor, either directly or through the operation of tax incidence.  We need to accept the principle that sometimes poor people will die just because they are poor.  Some of you don’t like the sound of that, but we already let the wealthy enjoy all sorts of other goods — most importantly status — which lengthen their lives and which the poor enjoy to a much lesser degree.

Apparently, in states that opt out very poor folks will now be mandated to purchase coverage they cannot afford, I guess teaching President Obama a lesson.

The Medicaid “problem” in Alabama could be solved with a $1.00 tax on cigarettes, should the legislature elect to do so. To quote the House Speaker (who calls the law ObamaCare and whose wife, Dr. Susan Hubbard, is a Professor and Associate Dean in Auburn University’s College of Human Sciences so he is probably in my health insurance actuarial group)

“With our budgets already strapped for funds, the last thing we need is a mass increase in Medicaid healthcare costs,” said House Speaker Mike Hubbard, R-Auburn.

Perhaps this is why I am unwilling to declare victory at this time.