Health Care and the Myth of Self-Reliance

King v. Burwell asked the Supreme Court to decide if, in providing assistance to purchase insurance “through an Exchange established by the State,” Congress meant to subsidize policies bought on the federally run exchange. With its ruling, the Court saved the Patient Protection and Affordable Care Act’s (“ACA”) low-income subsidy. But King is only part of a longer, more complex story about health care access for the poor. In a move toward universal coverage, two pillars of the ACA facilitate health insurance coverage for low-income Americans, one private and one public: (1) the subsidy and (2) Medicaid expansion. Although both have been subject to high-profile Supreme Court cases, the Court upheld one but gutted the other. This Article hypothesizes that the preference for private “hidden” government assistance over public “visible” government assistance stems from the American myth of selfreliance. Yet this analysis reveals that the line between hidden and visible benefits breaks down on both theoretical and empirical levels. Drawing from vulnerability theory and demographic data, this Article demonstrates that all Americans lead subsidized lives and could move from the private to the public system. It concludes that a single government program for the poor would be more economically and administratively efficient.