The District of Columbia’s Obamacare czars — the board that sets rules for the phony insurance marketplace, or “exchange,” that the law creates — have decided that henceforth insurers shall be forbidden by law to charge smokers higher rates than non-smokers. Smoking, as it turns out, “is a preexisting medical condition,” according to Dr. Mohammad Akhter, the chairman of the D.C. Health Exchange Board. Two liberal states, California and Connecticut, have decided likewise, while Colorado and Alaska have rejected the idea.
As expected, the definition of “preexisting condition” is proving infinitely malleable, with behaviors born again as conditions. If smoking is a condition, then drug addiction is a condition, self-mutilation is a condition, a penchant for BASE jumping is a condition, juggling ampules of penicillin-resistant syphilis — practically anything qualifies as a condition under such a plastic understanding.
There are many ways to implement a bad idea. For instance, Congress might have passed a law requiring that all U.S. insurance companies no longer charge smokers more for their coverage. The state of Connecticut might have passed a similar law. New York City might have passed that law. But in each case, voters who saw that stupidity for what it is would have somebody to vote against. Obamacare eliminates the option for democratic response. Instead, it creates a body of political appointees immune from being held accountable at the ballot box. And who are those appointees? In the case of D.C., you will find few surprises: The SEIU has a man on the board, along with a lot of time-serving political types, a fellow from the Brookings Institution, a lobbyist, etc. Don’t like their boneheaded decisions? Too bad.
There will be thousands and thousands of decisions like this in the coming years, and voters will have very little recourse against them. That is part of the genius of bundling the welfare state with the regulatory state: Whether you are a Democrat who basically likes Obamacare and wants to revisit a few of its flaws or a Republican committed to tearing it up root and branch, you have basically the same hurdle to clear. It might be easier to sell the idea of revision to the general public, but the structural legislative barrier is the same as if you were repealing the law wholesale. The question of ending “discrimination” against smokers is so many levels removed from democratic accountability that even those who are strongly opposed to the idea will probably have no effect. To get to the board, you basically have to fire the mayor, which is no small thing in a corrupt and backward place like our nation’s capital.
Obamacare was sold as a way to help poor people and sick people get health insurance, but, as the D.C. decision shows, the actual intent of the law is the abolition of health insurance. The notion of insuring a preexisting condition is an oxymoron; insurance is by nature concerned with that which may happen in the future rather than with that which already has happened. In very large groups, human health outcomes are predictable with a fair degree of precision: Given 10 million people, actuaries can make pretty accurate predictions about how many people are going to get lung cancer and how many are going to be in car accidents. Some factors are relevant to some conditions: Being 17 years old and getting in a car accident, for example, or smoking and heart disease, emphysema, cancer, etc. Insurance, which places a price on calculated risks, will take some of those factors into account. But you cannot in any meaningful sense insure somebody against cancer when they already have cancer.
Obamacare is designed to destroy the insurance market. Markets do not function without prices, and Obamacare ensures that prices will not be allowed to emerge. There is a medical price associated with smoking, but the District of Columbia has decided to suppress that price by law. Pretending that smoking has no relationship with health-care costs does not make it so — it is only a way to push costs around in a way that is agreeable to the likes of Barack Obama, converting a system that prices risk into a system of entitlements.
That leaves us with a system that is private in name only — which is the point. It is meaningless to say that we have a private system in which private consumers buy insurance from private insurers when the insurers have been forbidden to price their products, and have instead been converted into something somewhere between a public utility company and a government contractor. Sure, you are free to buy any insurance you want — but if what you want is a lower rate for being a non-smoker, the point is moot, because it would be a crime for anybody to sell it to you.
This will get much more complicated in the very near future. Our knowledge of the relationship between genetic factors and serious disease is growing very quickly. One hopes that one of the benefits of that growing knowledge will be better treatments. But what will almost certainly precede those treatments is the knowledge of the brute facts themselves, data about which genetic markers are correlated to what extent with which diseases. If smoking is a preexisting condition, then surely your genome will be a preexisting condition, too. And with the federal government holding a whip hand over medical-research dollars, do you think that it will be eager to fund cutting-edge genetics research, the results of which will most assuredly complicate the politics of health care? Do you think that it will be eager to approve clinical trials that will make political life more complicated? Certainly not. And if you think that these boards will be operated independent of politics, ask yourself why the treasurer of the D.C. board is an SEIU operative “responsible for coordinating SEIU’s national-issue campaign efforts” — not a doctor, not a scientist, but an old-fashioned political hack, one Khalid Pitts of USAction and the Gephardt campaign.
Inhibiting prices is not an unintended consequence of Obamacare: It is the main thing the law is intended to do. A market without prices is by definition a market that will not function. What comes after that is obvious. The argument for Obamacare was “Everybody gets insurance,” but the final product will be something between “Everybody is on Medicaid” and “Everybody has access to the fine health care on offer at the infirmary in the county jail.” And that is happening, one unaccountable decision at a time.
— Kevin D. Williamson is a roving correspondent for National Review. His newest book, The End Is Near and It’s Going to Be Awesome, will be published in May.