This image is a work of an employee of the Executive Office of the President of the United States, taken or made as part of that person's official duties. As a work of the U.S. federal government, the image is in the public domain.

Official White House Photo by Chuck Kennedy of President Obama’s signature on the Affordable Care Act.

As the landmark Affordable Care Act prepares to begin enrolling Americans in health insurance on Oct 1, news accounts are focusing either on the confusion and glitches that inevitably accompany rollout of a program of this scale and complexity, or the way that “Obamacare” has become the focal point in the latest round of brinksmanship over the federal budget.  But against news of uncertainty about and political conflict over the Act, I want to assert that there is an underlying ethical clarity to this issue: providing access to affordable health care is a moral obligation.

This claim rests on the broadly supported idea that in a fair society all members must have sufficient if not equal opportunity to pursue whatever life goals they wish. As philosopher Norman Daniels has persuasively argued, providing health care plays an important role in ensuring that people have sufficient opportunity by protecting their health and providing financial security. Without such protection, people are vulnerable to losses of health and wealth that severely impede their ability to live a good life. In the widely quoted words of Martin Luther King, Jr., “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

Daniels’ philosophical argument is reinforced by strong evidence that lack of health insurance results in suffering and early death for tens of thousands of Americans ever year. Though the precise numbers are contested, credible estimates in the peer-reviewed public health literature range between 22,000 and 45,000 early deaths that can be attributed to lack of health insurance. In 2009 testimony before Congress, Dr. John Z. Ayanian of the National Academies’ Institute of Medicine summed up his analysis of more than 100 such studies published since 2002:

Uninsured Americans frequently delay or forgo doctors’ visits, prescription medications, and other effective treatments, even when they have serious disease or life-threatening conditions. Uninsured children are 20 to 30 percent more likely to lack immunizations, prescription medications, asthma care, and basic dental care…. Among working-age uninsured adults, 40 percent have one or more chronic health conditions such as asthma, hypertension, depression, diabetes, chronic lung disease, cancer, or heart disease. Uninsured adults with such chronic conditions are two to four times more likely than their insured counterparts to have received no medical attention in the prior year. Because uninsured adults seek health care less often than insured adults, they are often unaware of health problems such as high blood pressure, high cholesterol, or early-stage cancer… Uninsured adults are also more likely to be diagnosed with later-stage cancers compared to their insured peers. If hospitalized for a serious acute condition, such as a heart attack, stroke, or major trauma, uninsured adults are more likely to die after admission to a hospital. Uninsured adults are 25 percent more likely to die prematurely than insured adults overall, and with serious conditions such as heart disease, diabetes or cancer, their risk of premature death can be 40 to 50 percent higher.”

It is, of course, possible to disagree about the best way to provide affordable health care. And the Affordable Care Act is, of course, far from perfect. But the Act represents a hard-won political compromise between different approaches to the problem, and will make affordable, quality health insurance available to most of the estimated 44 million Americans who are currently uninsured. As the political circus over Obamacare plays out, we should keep the underlying ethical imperative in mind. To be morally credible, any call to reverse or delay the Affordable Care Act care must include an alternative means of providing health care to the tens of thousands of Americans who will suffer and die without it.

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