Still Unfair to the Working Class: Health Care under the Affordable Care Act

Clark C. Havighurst, Duke Law School

Document Type Working Paper


The Affordable Care Act appears likely to worsen rather than cure the significant (but generally unrecognized) unfairnesses to middle- and lower-income working people that have long characterized private health care financing in the U.S. For example, the law’s mandate that individuals purchase “essential health benefits” requires them to pay for marginal benefits that many consumers with other needs might rationally reject. Also, the new law’s various elements of social insurance are to be financed, not from public funds, but by higher premiums paid by all insureds, like a regressive “head tax.” Lower-income insureds may also be shortchanged on the receiving end, getting less out of their insurance plans than better-off insureds while bearing the same premium cost. Finally, health insurance will still enable the many health care providers with monopoly power in specific submarkets to earn far more than just ordinary monopoly profits, all at the expense of insured consumers, whose exploitable number the new legislation will substantially increase. Nothing in the Affordable Care Act seems capable of offsetting not only the major unfairnesses and regressive redistributions of wealth already inherent in U.S. health care but also the new burdens the Act will impose on the working class.