With the release of CAP’s Medicare Extra proposal, the debate about cost-sharing (i.e. how much patients should pay out of pocket) has kicked off again. Broadly speaking, the left thinks there should not be cost-sharing while the center thinks that there should. Here I provide the case against cost-sharing, one that centrists actually agree with in certain contexts.

The Egalitarian Case Against Cost-Sharing
The egalitarian case against cost-sharing is similar to the egalitarian case for all universal benefits, which is that egalitarians think people should not lead materially worse lives just because they are sick or have more health care needs. Under this principle, a diabetic person and a nondiabetic person who are otherwise identical should have materially equivalent lives. The diabetic person should be able to live in similar housing, wear similar clothes, and go on similar vacations. If you require the diabetic person to drain their personal disposable income on diabetes-related treatment, this will not be possible.

Of course, cost-sharing does not just require people with health needs to drain their income on medical treatment. It also causes them to forego medical treatment. Indeed, that is the whole point of it. But it doesn’t cause them to forego unnecessary treatment or needlessly expensive treatment. It causes them to forego all kinds of treatment as normal people cannot diagnose the severity of their own problems or properly judge the necessity of medical procedures.

The Case of Birth Control
Centrists basically agree with these arguments, but only in certain narrow cases that affect groups with a lot of institutional strength within the centrist tent. The best example of this is birth control. Obamacare required birth control to be completely free for insured people. Republican lawsuits and executive orders have since made it possible for employers to opt out of that requirement. The net result of this is that certain insured people will have to pay around $20 to $50 a month out of pocket for birth control.

Despite the fact that this amount is below what most cost-sharing advocates think the general out-of-pocket maximum should be, the reaction to this development has been very negative.

Tracy Wilkinson at Vox:

This new rule reflects a disturbing trend in both the Trump administration and the current Congress to dismantle women’s rights. The contraception coverage rollback does nothing to advance health, and the claims put forward to defend it are not supported by evidence. It’s a cruel, purely ideological gesture that will hurt real women — and the men and children in their lives.

Shilpa Phadke, Jamila Taylor, and Nikita Mhatre at CAP:

One in three women ages 18 to 44 say that they could not pay more than $10 per month for birth control if they had to buy it today. … As a result, contraceptives made up an estimated 30 percent to 44 percent of all out-of-pocket health care spending for women. … The new regulations rolling back contraceptive coverage take effect immediately and threaten access to contraception for millions of American women. … Furthermore, women experiencing economic hardship are less likely to take contraception or continue usage due to out-of-pocket costs.

Another CAP publication with no author:

Many people seem to think birth control is affordable, but high costs are one of the primary barriers to contraceptive access. It is for this reason that the Obama administration recently followed the recommendation of the Institute of Medicine to ensure that birth control will be covered as a preventive service with no cost-sharing beginning August 1, 2012.

New York Times editorial board:

The mandate, established under the Affordable Care Act, has helped millions of women avoid unwanted pregnancy by eliminating out-of-pockets costs for contraception. … The percentage of reproductive-age women who faced out-of-pocket costs for oral contraceptives, for example, fell to less than 4 percent by 2014 from more than 20 percent just two years earlier, according to the Kaiser Family Foundation. One study estimates that women are saving about $1.4 billion on the pill.

One point people writing in this genre especially like making is that, under the current regime, erectile dysfunction medication is covered but birth control medication is not. This is a direct gesture to the egalitarian case against cost-sharing, i.e. that it requires otherwise identical people to lead materially different lives because of their different health care needs.

Why Just Birth Control?
It is hard to understand how you can believe that requiring cost-sharing for birth control is unfair, dangerous to health, and financially ruinous while also believing that requiring cost-sharing for insulin or dialysis is fine. Yet that is basically where the centrist discourse is at this moment.

If I had to guess as to the source of this tension, it would be that centrists see gender discrimination when they ponder birth control cost-sharing, but do not see (or care about) diabetes discrimination or kidney failure discrimination in the other cost-sharing cases. Put differently, health care cost-sharing generally discriminates against the sick, but the sick are not an active identity group in the Democratic coalition.

Nonetheless, the case for free birth control is the case for free health care generally.