Every family has its holiday traditions, and every year members of my family decide who will play Santa and hand out gifts on Christmas.  Meanwhile, everyone else assumes the role of pundit, starting conversations that make me wonder how we're all related.  Not surprisingly, this year seemed to focus on critiques of the health care law, and I bit my tongue as the retelling of elaborate personal experiences contradicted logic and facts.

I don't mean to be rude.  My family members have real concerns about a complicated law that I don't claim to fully understand myself.  But call me the bitter ghost of Christmas Past because here's the speech I developed in my head as the evening progressed:

Let's start with the concept of health insurance.  Much like other forms of insurance, it operates by pooling risk so that individual claims are paid out from premiums accumulated over time.  Except unlike the renters or car insurance you love to cite, everyone will make use of their health insurance at some point.  Problems develop when the sick max out their coverage, are dropped for being too sick, or are denied coverage altogether.  This is an area where governmental regulation has long attempted to intervene.

And despite your beliefs, the federal government has been actively involved in your health care for decades, most notably by administering Medicare and Medicaid.  Add to that the requirement that emergency rooms must treat all patients, regardless of ability to pay, the tax exempt status of most medical centers, and the national health system for our veterans and their families, and you'll find pervasive government involvement in the organization and administration of your care.

So dearest family, the unacceptable, unprecedented government intrusion into the private market you're ranting against has long been a reality.  But no one is attempting to turn the invisible hand into the iron first, so even with Obamacare, health care delivery remains in the private market.

That includes the plans "on that website," also known as healthcare.gov.  Those options are all from private insurance companies, and not the federal or state government.  What the feds provide are subsidies to reduce premiums for about forty percent of uninsured consumers, while the states that opt to expand Medicaid may cover benefits for the rest.  And for the first three years, the federal government is picking up the state tab for newly qualified Medicaid enrollees--enrollees who are just as deserving of health care as you are.

Now brace yourselves for a real blow: you all get government handouts, most of you because you're employed.  A huge federal subsidy, currently totaling close to $250 billion a year, has been around for decades and makes employer-provided health care costs a tax deductible expense.  If the value of your health plans were provided to you as part of your salaries, you would pay income tax on that amount.  Add to that the tax breaks on your mortgages and tuition costs, and then tell me with a straight face that the hardworking don't get help from the government.  Even Obamacare's most vocal opponents aren't trying to rock this boat.

This subsidy is just part of the calculation your employer makes when deciding whether to provide health insurance.  The quality of that coverage is also based on a calculation, and not a legal duty employers have to employees.  What Obamacare has done is to require plans to provide minimum essential benefits, so if your employer-provided coverage is changing, it's because your plan's coverage fell short in some way.

I realize that these are genuine concerns about Obamacare, concerns that highlight the importance of health and health insurance.  But now that the presents are unwrapped and my family has gone home, I also realize my anger is misdirected.  I've chosen to devote my professional life to health law and policy, but stewed silently when the topic came up around the dinner table.  The holidays are a time to learn from each other, so while I may have missed my chance this year, at least I can add a link to this blog on next year's Christmas card.

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