Article   |   Volume 159, Issue 6

Health Insurance Reform And Intimations Of Citizenship

Nan D. Hunter

June 2011

Sometimes what is implied and inferred can be as important as what is stated. In this Article, I argue that the political debate that preceded the enactment of the Patient Protection and Affordable Care Act (PPACA), as well as the legal debate that now swirls around the question of its constitutionality, mask a foundational question about national identity. PPACA, of course, does not literally constitute or reconstitute citizenship (although it does require legal residence as the price of admission). But it creates the potential for broad public conversation—as has never before occurred in the United States—regarding the question of what the relationship should be between membership in the American community and meaningful access to health care.

At face value, PPACA primarily seeks to make the individual and small-group health insurance markets rational and workable, to fill the enormous gap that has existed in coverage, and to create insurance exchanges to regulate quality and police access. Upon full implementation, it will achieve nearly universal, but also probably quite uneven, coverage and will perpetuate a deeply fragmented model of social insurance. If one imagines the health care system as a political domain, with the various institutions and subsystems as components, PPACA is less like our Constitution and more like a reinvention of the Articles of Confederation. Under PPACA, health insurance in the United States will remain a federated collection of risk pools, located in workplaces, public systems, and the new exchanges.

Nonetheless, the debate that has accompanied PPACA’s adoption is about something bigger than spending curves, comparative effectiveness, or even medical-loss ratios (not that any of those should be considered trivial). The deep structure of this hyper-technical statute gestures to the existence of a health care universe that, in Habermasian terms, could be its own lifeworld. For persons with chronic diseases, the health care system truly becomes a world unto itself. For others, it may be more like a foreign country visited for an intense but brief period of time, or perhaps one to which we pay little attention. Although the internal operations of the health care universe are seldom thought of as political, its power is such that, upon entry, it may bring us life or death, profit or poverty, autonomy or dependency. Health Insurance Reform And Intimations Of Citizenship -