Writing about the political dance in Washington, DC is not a pleasant task. I intend to skirt around the edges of it. It is marginally about health care and largely about the relative power of the two major US political parties.

Nonetheless, since it has brought the Obama health care plan back to the top of the national political agenda, it is worth recalling some basics.

First, the principle of insurance is that a catastrophic risk is spread across as many people as possible making advanced contributions so that funds are pooled and available to any individual suffering that risk. For example, individuals buying life insurance at a young age receive a favorable premium rate and are likely to contribute for a long time, much longer than the time it would take to accumulate the death benefit, but for those individuals not so fortunate, the monies are there in a pooled risk fund to be distributed to the family of someone who dies prematurely. The risk of an expensive illness with accompanying medical costs is similar.

Second, millions of Americans have not had health insurance. Some of those are young, feel invulnerable and do not want health insurance. Others have pre-existing health impairments and have been refused health insurance. Still others do not receive insurance through their employers and cannot afford it on their own.

Third, there are negative consequences to our society for these uninsured:

1. Those without insurance still must be treated when they get ill or have a motor vehicle accident.
2. The young, less likely to be net expenses to a pooled risk fund, need to be part of the contributors under the principle of insurance
3. Those denied insurance because of pre-existing conditions need to be saved from bankruptcy, and the hospitals need to be protected from having to serve them at no cost.
4. Those who do not have insurance through their employers, who could not afford individual insurance policies, require a means to participate.

Fourth, the Patient Protection and Affordable Care Act (PPACA), commonly known as “Obamacare,” is an honest attempt to address those concerns, as well as reining in the ever-rising costs of medical care.

Fifth, the term “socialized medicine” is easily bandied by politicians, but there are two distinct areas of government involvement in health delivery that can more accurately be called “socialized medicine,” and “socialized insurance.” The US has both. Socialized medicine occurs when the government provides access to healthcare either directly through government clinics or through social insurance used in government health facilities. In that case, the health care providers are government employees. Foreign examples are the National Health Service of the United Kingdom. In the US the system of hospitals under the Department of Veterans Affairs (VA). Socialized insurance is when the government supplies health insurance but the healthcare practitioners are not government employees. Medicare is socialized insurance, as are the national health systems of Canada, France, Italy, and Germany. There are advocates for socialized insurance in the United States, under the banners “Medicare for All” and “Single-Payer.” There is no recognizable group that favors socialized medicine in the US–NONE.

Sixth, Obamacare is neither socialized medicine nor socialized insurance, because all of the providers are private, and all of the insurers are private. An early proposal to include a “public option” form of insurance was dropped. It is not surprising that Obamacare is completely privatized–it is a proposal in concept by that most conservative think tank, the Heritage Foundation. (More recently, it has taken a further turn to the Right by engaging former SC Senator Jim DeMint as President; however, it has always been quite conservative.) Its proposal was adopted, supported, and implemented by the Republican governor of Massachusetts Mitt Romney. The theory was that the accelerating costs of healthcare could be addressed by a market system, and the government assumed the role of creating the market or even playing field for the insurance companies to compete for business.

Seventh, the individual mandate, which draws a lot of the political fire, was part of the original Heritage plan by Stuart Butler in a 1989 paper, and of the Romney plan. It is essential to the effectiveness of the system in two major ways:

1. It makes the younger, healthier citizens participants, with the benefit of their consuming less than they contribute but not being a burden when struck by accidents or rare illness.
2. More importantly, it makes possible the elimination of pre-existing conditions. If pre-existing conditions could not prevent obtaining insurance, no one would buy insurance until contracting an illness, and would then be assured of acceptance. Because the insurance would have to cover the illness, with no reserve built up, with no spreading of risk across the entire population per the insurance principle, the insurance would be nearly unaffordable with the premiums set at the level of the average illness since it would have to cover the risk. Pregnancy benefits are often rated that way in insurance policies since the benefits being paid are nearly assured.

Eighth, there is the issue of affordability. Enterprises with over 50 employees are required to provide insurance. Most already do, but these employers are a very small segment of the workforce, perhaps 10 percent. The rest of us are self-employed or employed by smaller enterprises. If they already provide health insurance that is fine, but under the individual mandate, if they do not, then anyone working there including the executives will have to fulfill the mandate by finding insurance on the exchanges, and by shopping for the level of coverage at a premium they can afford. Both affordability and insuring the young are addressed in part by requiring adults to be eligible until age 26 for insurance under their parents’ plan.

For those at the bottom of the pay scale, those who do not qualify for Medicaid, which can have very stringent asset limitations (in California, for example, having funds over $2,000 disqualifies one from Medi-Cal), those often called “the working poor” may be eligible for government subsidies. In addition, the federal government is offering states financial incentives to expand the Medicaid program to cover more of the working poor.

Finally, there is the issue of what is health insurance coverage? If we want to require people to buy it, we need to be able to say what is and what is not acceptable coverage, to avoid individuals and businesses buying something so minimal that it complies with the law but does not address the problem of access to health care. An individual buying a policy hat pays $100 daily for hospital care has not really bought insurance. So, the government through implementing regulations has stipulated what a minimum policy contains. This has raised issues of conscience for those who do not believe in one or more aspects of medical science as applied to health care.

The religious reservations are well-known in the United States. Among them are a preference for Christian Science practitioners among Christian Scientists, an avoidance of blood transfusions among Jehovah’s Witnesses, rejection of birth control measures among Catholics, as well as rejection of pharmaceutical and surgical interventions to prevent or abort a pregnancy among numerous denominations. The law has allowed a religious exemption for churches. The point of contention has been for practitioners who participate in commerce and do not wish to compromise their religious beliefs by providing the means for something they consider murder. From a public policy view, the problem is multiple:

1. Recognizing that right by owners of businesses and organizations may deny access to some of their employees who feel equally strongly that obtaining those treatments is their right.
2. Recognizing those rights by one group implies, under equal protection, recognizing such objections by all groups and individuals. That places the government in the powerful and unwelcome position of determining which religious beliefs are legitimate and entitled to protection, an intrusion into religion that most Americans would find offensive.
3. Recognizing that right with respect to abortion, would open the possibility of recognizing objections to all forms of insurance. A business owner might claim religious exemption to providing any insurance, undermining the public purpose of the law.

In order to address these concerns, the law limits religious exemptions to religious institutions, such as places of worship. There are pending court cases that may change the way this challenge is addressed in order to comply with First Amendment considerations.

One theory of American government is that the states act as laboratories for the society and the nation, trying approaches, which, if successful, can be generalized. That has occurred here, with Massachusetts providing the laboratory. As the national experiment is just beginning, it is too early to tell whether the proponents or opponents of Obamacare have correctly analyzed its impact and future. Five years from now, it will be much clearer. I look forward to seeing that day and looking around to see what worked and what did not, what needs changing, what has been correctly changed, and what has not. I have often thought that politics is America’s most engaging indoor sport, and, at this moment, Obamacare is at center court.