The most incisive guide to issues facing the American family today . . . An invaluable resource for anyone wishing to stay on the cutting edge of research on family trends.
-W. Bradford Wilcox
Associate Professor of Sociology, University of Virginia
The Patient Protection and Affordable Care Act no doubt has lowered out-of-pocket financial costs for some Americans, but at the moral cost of requiring many Americans to participate in the funding of contraception against the dictates of their conscience and at the social cost of diluting the consequences of individual irresponsibility across an unfathomably wide risk pool maintained by a cumbersome bureaucracy. The resulting system mistakenly regards health insurance as a prerequisite for health care, as if mandating the former somehow guarantees the latter; deceptively equates “reproductive health care” with procedures and prescriptions that are counter-reproductive and dubiously caring; and undermines the natural family through mandates and incentives that run contrary to marital fidelity and personal responsibility.
With problems so challenging, no easy correction to the ACA regime can be found. However, two alternatives to the health insurance framework of the ACA correct at least some of the deficiencies: “health care sharing ministries” fund health-care costs even for the less affluent, without requiring the violation of pro-life consciences; and direct primary care arrangements reward individuals who assume personal responsibility for routine care while saving the catastrophic and unpredictable for either insurance or a cost-sharing ministry. While neither of these approaches comes without challenges, each deserves careful contemplation by health-care consumers. In fact, some families may find it prudent to pursue both avenues simultaneously.
Does the ACA Make Health Care Unfriendly to the Family?
As the statute’s name implies, the Patient Protection and Affordable Care Act of 2010 was intended to protect patients and to make health care affordable. Although some of the provisions in the labyrinthine regulations established by the act may accomplish one or the other goal, other provisions in fact endanger patients and make health care less affordable. These downsides to the ACA can be most readily observed by viewing the law through the lens of the natural family. The ACA discourages marriages, subsidizes birth control, and makes only modest improvements in the coverage of pregnancies for newly insured mothers, all the while underwriting imprudent behaviors—such as extramarital intercourse and substance abuse.
The message of the ACA to couples is simple: better not to marry. For a cohabiting couple, each adult may qualify individually under the ACA for a premium subsidy, which phases out for each person as his or her income approaches 400% of the federal poverty threshold (FPT)—roughly $47,000 per person, or $94,000 for their joint household if each cohabiting adult brings home half the bacon. For a married couple, by contrast, 400% FPT comes to about $63,000, since the FPT for a household of two adults is far less than twice the FPT for one adult. Because of additional quirks in the subsidy formula, the differential hits hardest in the center of the qualifying range, where a household earning $40,000 per year suffers a $1,400 marriage penalty. Can families in the lower middle class really afford a penalty that effectively constitutes 3.5% of their household income just because they are married?
A policy designed to help single moms—the most uninsured segment of the population—now incentivizes both moms and dads to remain or become single. The ACA subsidies do not so much benefit middle-class families as they do middle-class households—collections of unmarried adults, possibly with children, who live under one roof but each collect state benefits separately while not formally promising each other to remain together for life. Ironically, couples who married before the ACA was enacted in order to secure the benefit of a spousal health insurance plan now realize that they no longer can afford the higher, less subsidized premiums. “I guarantee you,” confessed one millennial bride pinched in the ACA’s marriage-penalty vise, “in six months I will either be divorced or I will have a [second] full-time job.” Oddly, the ACA does not require insurers to cover spouses (and in fact some employers dropped spousal coverage to trim costs), but the law’s “individual mandate” does require each spouse to obtain insurance somehow, whether this makes marriage cost-prohibitive or not.
The ACA includes puzzling provisions for young adults, too. For example, the legislation requires employer group plans to extend coverage to employees’ children under 26 years of age, but it does so regardless of whether these adult “children” are financially independent, living in their own households, or married. “This is known as the ‘adult-dependent mandate,’” or ADM, “although dependency is not a condition for coverage.” In fact, the misnamed ADM even requires that employer health plans extend coverage to adult children who are gainfully employed and have the option to receive insurance from their own employer rather than from a parent’s employer. Nevertheless, spouses and children of the young adults are excluded from this mandate, but still subject to the individual mandate. In other words, Dad, age 25, might be insured on Grandpa’s policy, while Mom and Junior have to seek coverage elsewhere. A more family-friendly regulation would instead foster cost-effective health-care plans for young adults who are holding down jobs and forming families—precisely the course charted by health-care sharing ministries (discussed below).
Meanwhile, the ACA’s phase-in provisions for plan years prior to 2014 fell short of guaranteeing maternity benefits, whether to principal policy holders or to their children of reproductive age. Although maternity and newborn care ostensibly were included among the ten “essential health benefits” of the ACA, and insurance providers were prohibited from excluding maternity coverage to the newly insured (being prohibited from excluding pregnancy as a pre-existing condition), large group policies initially were grandfathered into an exclusion of these new provisions. As of 2012, “roughly 70 percent of companies that pay their employees’ health-care claims directly ch[o]se not to provide dependent maternity benefits,” a ratio that some analysts projected to increase as the age of “dependent” rose to “children under 26.”
Insurance companies had a financial incentive to limit the inclusion of young adult dependents when possible. During the early years of implementation for the ACA, the ADM cohort of newly insured incurred a disproportionate level of health-care expenses, especially in the categories of mental health, substance abuse, and pregnancy. The ADM cohort spent 27% more overall on medical services than a pre-ADM cohort of dependents aged 19 to 25 who were insured prior to 2011. Mental health and substance abuse treatments accounted for 42% of hospital in-patient claims for the ADM cohort, compared to only 28% for the comparison group; pregnancy rates (primarily non-marital) also were significantly higher: 19% versus 5% of hospital in-patient claims for each group.In other words, the addition of new dependents to the insurance pool under the ADM has increased risk and, hence, cost. Compassionately, the government extended insurance to cover those with greater needs, but through a compulsive regulatory instrument that offered nothing to fix the root cause and, worse, incentivized the imprudent behaviors of some by requiring that others bear the consequences.
Most infamously, the ACA requires that employers provide insurance that covers the purchase of birth control, including abortifacients. Church-affiliated nonprofits as well as Christian-owned businesses have challenged this provision on the basis of a First Amendment conscientious objection to subsidizing behaviors classified as immoral by their religious beliefs. The problem, however, runs deeper than the surface issue of church versus state, as significant as that controversy may be. In a broader sense, the hallmark case, Burwell v. Hobby Lobby (2014), represents the regression of American political culture from freedom of contract back to the more primitive condition of competition for status. The deeper question at stake was not, as it may have seemed, whether Hobby Lobby would be free to choose for itself whether to fund contraception for its employees, but rather whether the federal government would grant a privileged status to a class of certain women (and pharmaceutical companies) who desire that government-mandated insurance policies fund contraception or grant a privileged status to a class of other women (and men) who, for religious reasons, object to funding abortifacient contraception. “A free society,” explains Cato Institute research fellow Trevor Burrus, “is like an operating system that helps diverse, civilized people live together cooperatively rather than combatively. Politics and overpoliticization, on the other hand, inevitably push us to live combatively rather than cooperatively, especially when it comes to issues like healthcare.”