Obamacare and Business Values

Yesterday, the US Supreme court mostly upheld Obamacare, also known as the Patient Protection and Affordable Care Act. (See the full decision here [PDF].)

The Big Decision may have been made, but clearly lots remains to be sorted out. One of the questions that arises, from an ethical point of view, is the way that businesses, including especially insurance companies, should conduct themselves under the new plan.

Under Obamacare, Americans will be required to carry health insurance (or face a penalty) and, importantly, insurance companies will be required to sell policies to all comers, regardless of pre-existing health conditions. While the debate has focused primarily on the proper role of government, the Patient Protection and Affordable Care Act clearly has significant implications for private companies.

Note how different this is from, for example, Canada’s system. In Canada, insurance is provided by provincial health plans, and care is provided by physicians (as private contractors) and private, not-for-profit hospitals. Private insurers still play a role in pharmaceutical coverage, but almost no role at all in basic healthcare. Under Obamacare, in comparison, insurance companies effectively become an instrument of public policy: important elements of the way they conduct their business (and in particular the actuarial rules they apply) will no longer be up to them. This is far from the only example of private companies playing a role in public insurance: in the UK, private companies play a significant role in administering employment insurance services, and in some Canadian provinces private insurance brokers sell auto insurance plans underwritten by a public insurer. With regard to insurance, the distinction between private and public is far from water-tight.

How should companies conduct themselves when they play a role in delivering publicly-mandated insurance? Should they continue to think of themselves entirely as private, profit-seeking entities? Or should they — like industrial firms during times of war — take up public values?

Just what values are instantiated in a public insurance scheme is a matter of some debate. Public insurance schemes are often seen as promoting egalitarian values — ‘we’re all equal and hence all deserve equal access to basic healthcare.’ Others argue that what’s really at stake in such schemes is not equality, but efficiency (and argue that the current patchwork American system, for example, is quite inefficient in a number of ways). Others argue that, for insurance quite generally, solidarity is the key value — and one with obvious salience when insurance is part of the welfare state. Of course, to the extent that insurance companies are “merely” private corporations, they are guided by basic norms related to loyally seeking profits for shareholders. But even private insurance companies are subject to special limits on their profit-seeking. From a legal point of view, it is recognized that insurance companies are morally special: the legal principle of uberrima fides implies that the level of trust required between insurer and insured makes the relationship special, from an ethical point of view. And then, with regard to mutuals and not-for-profit insurers, stewardship of a shared resource (i.e., the insurance fund upon which members rely) is a key value. It seems right that private and public insurers would be guided by different mixes of these values.

So the question American health insurance companies face, at least in principle, is whether they should conduct themselves like private or public entities. And the question Americans face is which standard to hold them to. The answer, I think, is not clear. But it’s worth pointing out that the goals of an institution — public or private — don’t automatically have to be the goals of the larger system of which it is part. As I’ve pointed out elsewhere, the individual parts of a system don’t need to act according to the values of that system — sometimes they contribute by playing a more narrow role.

The coming years are sure to see significant changes in the US insurance industry. Whether the US government can succeed in getting private insurers to play a public-policy role remains to be seen, and depends in part on the willingness of those insurers to take up a public mission. But it depends just as much on whether the system Obama has designed is capable of harnessing the profit motive of insurance companies using it to get them to perform an important social function.

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