The number of uninsured and underinsured individuals prior to the Affordable Care Act (ACA) is striking, to say the least. 47 million non-elderly Americans were uninsured in 2012. Nearly all of the elderly (over 65) population are covered through Medicare but still, almost 640,000 elderly individuals remained uninsured in 2012. These statistics depict inherent problems in the health care system and a need to change the status quo. Before the ACA, those who were insured generally received coverage through job benefits, but unfortunately not every American has this luxury, which is why government programs like Medicaid and Children’s Health Insure Program (CHIP) exist.

Even still, these programs are not enough and display the need for an expansion of health care. Low-income, working individuals – particularly ethnic and racial minorities – can’t afford premiums and are frankly disincentivized to engage the individual market because there is a high chance they will get denied. Additionally, due to the Great Recession and the state it left the United States economy in, there has been heavy job loss as well as a lower likelihood of employers offering insurance.

To many, the ACA couldn’t have come at a better time, but even with its implementation there will continue to be many poor uninsured adults left without any coverage due to an individual state’s refusal to expand Medicaid. I truly believe that access to health care is an inherent human right and there is no question that the ACA will provide many the opportunity to gain access to insurance. However, how do we solve the root-cause of bad health? Like many health economics scholars, I will argue that education and self-care is a pre-requisite to better health and even with an imperfect health care system, the expansion of health insurance is substantial.

The goals of the ACA are to improve coverage for those with health insurance and improve access to and quality of care by controlling costs. The reforms took effect on January 1, 2014 and opened up insurance exchanges where individuals and small employers can now purchase coverage. Insurance companies can continue to sell health insurance outside of this exchange but there are rules they must abide by. Regardless, the benefit of selling outside of the exchanges is that plans may be cheaper; however, this advantage is directed towards higher income persons who can afford to “shop” around. So the question remains: Will the ACA truly succeed in meeting these goals?

The ACA has multiple provisions that will increase access to coverage for many uninsured Americans. The individual mandate requires U.S. citizens and legal residents to have some kind of health insurance, otherwise they must pay a penalty.

However, this mandate has the potential to increase health insurance costs as well as “disrupt coverage for individuals, families, employers, and Medicare and Medicaid beneficiaries” because of these penalties. These penalties are instituted in order to incentivize people to buy insurance, and these people must engage in cost-benefit analysis to see whether the benefits of obtaining health insurance outweigh the literal costs of health insurance. Those that purchase insurance in the individual market are guaranteed coverage for pre-existing conditions while government subsidies are implemented to help individuals pay for the cost of health insurance and find plans that fit their lifestyle.

The ACA attempts to guard against adverse selection, the idea that individuals who engage in risky behavior obtain health insurance and therefore will continue to engage in this kind of behavior.

Universal coverage, limited enrollment periods and risk adjustment among plans in individual and small group markets, on and off the exchange, are all solid attempts to prevent adverse selection.

However, individuals that choose to remain uninsured, secondary markets and the dumping of uninsured people into the new exchanges promote adverse selection. Since not all plans have to sell on the exchanges, where sicker people are, healthier people can still obtain private insurance in these secondary markets, raising premiums, as mentioned previously. Furthermore, there’s a high chance that employers dump all high-risk people into the exchange and small employers could leave the market and self-insure. Overall, adverse selection can go either way with the ACA, depending on the choices of individuals.

It’s more likely that the ACA will increase moral hazard, the idea that riskier individuals have no incentive to stop engaging in risky behavior because they have insurance that others (and the government) pay for. Universal coverage has the potential to actually increase unhealthy behavior because individuals are now protected.

Take Medicare for example. Economists Dhaval Dave and Robert Kaestner found in a 2006 study that men who recently received coverage through Medicare actually took worse care of themselves by exercising less and were more likely to smoke cigarettes and drink alcohol.

This may be an extreme example, but it does reveal problems inherent in expanding health insurance and how insurance does not facilitate good health practices.

So are Americans better off in lieu of the implementation of the ACA? Perhaps. However, moral hazard and the potential for adverse selection provide some legitimate criticisms of the ACA portraying a need for greater education. Education is the best way to be healthy – this is the most causal relationship and shows that those who are educated about risky behaviors are less likely to engage in them. Schooling causes, at least the most causal relationship studies have found, better health because of information gained about the ramifications of bad behavior, mandatory vaccines prior to attending school and a change in values.

Furthermore, healthy people can go to school while unhealthy people may not have the ability  to attend academic institutions. Healthier students are more efficient at adding to their stock of knowledge and this can lead to a feedback loop where schooling can have long lasting effects.

I absolutely agree with neurosurgeon and Assistant Professor of Neurosurgery at Emory Sanjay Gupta’s analysis in an op-ed he wrote for CNN, that, “if we are serious about a more healthy America, the real change starts in each and every one of us, and it’s not that hard to do.”

Health insurance helps insofar as it can save people once they have had a catastrophic health hazard impact them.

It can’t, however, preventatively solve health issues. Obviously, preventative check-ups are helpful and give people a sense of what they are doing right and wrong in their lives, but the real change must come from within.

A healthier America starts with Americans themselves.

It takes education and awareness. It takes healthy lifestyles and understanding. The insurance is just a nice touch.

Editorials Editor Priyanka Krishnamurthy is a College junior from Coppell, Texas.

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