Health Care and the Myth of Self-Reliance

61 Pages Posted: 22 Aug 2015 Last revised: 2 Feb 2016

See all articles by Nicole Huberfeld

Nicole Huberfeld

Boston University - School of Public Health; Boston University School of Law

Jessica L. Roberts

University of Houston Law Center

Date Written: January 28, 2016


Both pillars of the Affordable Care Act that are designed to facilitate universal coverage — the low-income tax subsidy and Medicaid expansion — have been subject to high-profile Supreme Court cases. While in King v. Burwell the Court saved the ACA’s low-income subsidy, in NFIB v. Sebelius the Court frustrated Medicaid expansion, at least temporarily. We argue that there is a deeper story about health care access for the poor. Drawing from the history of the American health care system, vulnerability theory, and demographic data, we demonstrate that all Americans lead subsidized lives and could find themselves quickly moving from the private to the public system. We contend that the apparent political preference for private, or “hidden,” government assistance over public, or “visible,” government assistance has its roots in the American myth of self-reliance. Our analysis debunks this myth and reveals that the line between hidden and visible government assistance fails both theoretically and empirically. We conclude that a single government program for the poor would be more economically and administratively efficient.

Keywords: Affordable Care Act, ACA, King v. Burwell, Medicaid, health care reform, subsidies, health insurance, public health

Suggested Citation

Huberfeld, Nicole and Roberts, Jessica L., Health Care and the Myth of Self-Reliance (January 28, 2016). Boston College Law Review, Vol. 57, No. 1, 2016, Available at SSRN: or

Nicole Huberfeld (Contact Author)

Boston University - School of Public Health ( email )

715 Albany Street
Boston, MA 02118
United States

Boston University School of Law ( email )

765 Commonwealth Avenue
Boston, MA 02215
United States

Jessica L. Roberts

University of Houston Law Center ( email )

4800 Calhoun Road
Houston, TX 77204
United States

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