Some Thoughts About the Affordable Care Act

I was for the Affordable Care Act. I still am.

I felt, and still feel, that it's insane--freaking insane--that every American citizen does not have access to basic healthcare. It's unconscionable. It's a moral failure.

There is a huge--HUGE--gap in our safety net because health insurance is tied to full-time employment. Too many employers can game the system by hiring people just under full-time, making American workers work two jobs without getting insurance (or related benefits) from either employer. To say nothing of those who aren't employed or who would like to get private insurance but have preexisting conditions. The fact that you have to go through insurance companies to get healthcare in America is hugely problematic. Too many people are left out of the system. It needs to get fixed.

So some thoughts about the rollout of the ACA given how bad it has been.

Liberals didn't want the ACA. We didn't want insurance reform. We wanted healthcare reform. But since healthcare reform wasn't in the offing, we were stuck with the plan that originated from Republican think-tanks (I'm looking at you Heritage Foundation): The Affordable Care Act. That is, insurance reform.

At the very least, if we had to stick to the funding side, we wanted a single payer system. We didn't even get that. A single-payer system would have been so much easier than trying to corral all the private insurance companies as we are trying to do now.

Still, the ACA got more people insurance and enrolled more poor people in Medicaid. That was an improvement. So many of us voted for it. Even though it wasn't what we really wanted.

Enrolling through is still a mess. Hopefully they'll get it fixed. Soon. But the happy news is that since the ACA became law the highest enrollments have been from those joining Medicaid. Because of the ACA more poor people are getting access to healthcare. That's good news.

I believe in perfecting our Union. Well, I believe in reforming our Union. I'd like to believe that both Republicans and Democrats can work together to get every American citizen access to quality healthcare. And if that means reforming the ACA by all means let us do that. I don't care about the political winners and losers. I care about the outcomes.

I could care less about repealing Obamacare. But I care great deal about if you can improve it.

The wars in Afghanistan and Iraq cost the American taxpayers 4-6 trillion dollars. Along with the lives of over 4,400 US troops. Civilian casualty estimates are 100,000+. Those are innocent men, women and children. Finally, the Iraq war lasted eight years.

The ACA is pretty small potatoes by comparison. I'm willing to play the long game with this.

If you were patient with that war--given its cost in lives and treasure--I think you can spare some patience getting people some healthcare.

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44 thoughts on “Some Thoughts About the Affordable Care Act”

  1. Oh, yes. The politics have colored and distorted what the real discussion should be..

  2. I've struggled as a conservative with the idea that my tax money has fed more kids than my tithes. I also struggle with the fact that my coverage has changed and it now costs me more to make sure my family has the same health care that has been provided for them. I am a walking contradiction.

  3. Thanks so much for this Jennifer.

    As you your conclusion, I agree. I truly believe that if good-hearted Republicans and Democrats in the Congress were able to sit down and work the problem--work the problem and not the politics--without all the political talk and posturing and election challenges that we'd have, in hand, something pretty decent. And that's the great tragedy of America today. Compromise and working the problem isn't what Washington does anymore. And we all suffer.

  4. I'm a walking contradiction myself. I think conservatives and liberals who ache about all this and are willing to admit their views are a mess have a lot in common. I appreciate your spirit.

  5. Jennifer, my older daughter and her husband are both family practice M.D.s still paying (barely) off their med. school loans. They would concur with your thoughts and pain.

  6. A truly cogent post Richard!

    To add to the context of all this I'll point out that when the subject of accessible health care was discussed in the late 30's early 40's, the question of how to scale that up- should we do it through our public sector means, or through our private sector means was discussed. Those in charge of the private sector lobbied for it to be handled through businesses.

    Why? When a business pays out W2 income, it's on the hook for 7 1/2% percent of that on top of that wage. Therefor, when that business can pay part of that wage in the form of health insurance, it saves on wage expenses.

    The problem now however, is that due to W2 income remaining relatively flat for the last three decades, it's become cheaper to pay that 7 1/2% than it is to pay the insurance premiums.

    Where I have added frustration to those expressed so well by Jennifer as well as Richard, is that the Lobby which clamored for the business distribution of health care access to the American citizenry, is through its descendants, finding ways to jettison its "pledge"; on top of that, this lobby and its supporting culture is at the same time clamoring against any citizen action to organize health care access through our public means i.e., "no public option".

    I feel the frustration of a double bind on top of a lack of health care justice.

  7. It's hard to believe that President Nixon offered us pretty much the same plan almost 40 years ago before the advent of desktop computers.

  8. The entire post imputes bad motives to those who disagree that federal government is the best or only way to do these things. I can agree with the motives, and think you are marching 180 degrees in the wrong direction. People are signing up for medicaid, good. But did you know two other things. The majority of those are in states that didn't expand medicaid, so they were already eligible. They could have done this without the ACA which is cancelling more people's chosen policies than it is issuing. The second part of that is the number of doctors who accept medicaid has been falling for years. Having coverage and being able to use it are different things.

    And that gets to the heart of the debate. Liberal solutions all assume that original sin doesn't exist or is overcome/progressed beyond by good intentions by the "good people" and the law for the "bad people". And then they exempt "known good people" which just happen to look like rich people and friends of democrats from the effects of the law. A subsidiary of rejecting basic human anthropology (i.e. original sin), they then reject supply and demand. (Social Security is just on a longer term blow-up because it took a generation and a half to respond in birth rates and abortion.)

    If you wanted to get actual care to actual people. Take the ACA approach (mandates, no-pre-existing conditions, etc.) for a minimalist policy (i.e. what Obama called house insurance) and not the sex-change-for-everyone-policies mandated. A catastrophic plan is made available for everyone in the country. An HSA is set-up for everyone in the country. And put the subsidies and medicaid money into the HSAs for poor people. They can then pay the primary doc with real cash. But none of that would create democratic patronage jobs or give the power to mandate my medical morality on everyone else. Which make me wonder what the real intention was: power or getting people care. I can break the 8th commandment just as easily.

  9. "I could care less about repealing Obamacare. But I care a great deal about if you can improve it."

    I read the parts of the ACA having to do with cost containment through disease prevention a couple of years ago. I was taken back by the extent to which the ACA is not a set of measures to be carried out to reign in costs while maintaining care, but is--rather--a plan to make a plan: It funds studies and pilot projects to suggest and try new and better ways to accomplish its goals (patient protection, affordable care, expanded coverage). At first my reaction was that the emperor has no clothes. On further reflection I wonder whether the only hope of actually implementing a plan to improve health care depends on that plan not originating in (explicitly) political circles--in which case a plan to get experts to make the plan is brilliant.

    I don't know what a reasonable timetable is for reaping the benefits of thousands of studies. I would like to see some reporting on whether initial results suggest that with smarter approaches we can expand and improve care while reducing costs.

    But I fear the groups of medical experts convened to review the studies and suggest new ways forward. How will they avoid becoming mouthpieces for the vested interests that they are aligned with, of necessity, as industry insiders? Best guess? The experts will also avoid the tough political choices by doing what made them experts--calling for even more studies.

    What I'd like to see is a panel of respected business executives from outside of the medical industry review the results.

    But yes, we need to give this some time.

  10. Why is it so hard to draw, and respect, the vast distinction between (a) desired ends and (b) means? Virtually every person in the United States wants every other person to have access to decent health care. The quarrel surrounding the ACA - and it is, as it should be, a political bloodbath - is about MEANS. The alternatives to the ACA are about MEANS. The criticism of the ACA is about MEANS...and empirical effects, which can be clearly seen as we "learn what's in it." Does it not boggle any of your minds that our representatives would shove such a massive thing through WITHOUT HAVING READ IT THOROUGHLY? The problems with it are endless, but they were predicted by those who took the time to analyze what was actually in the bill. And now those who voted like lemmings to enact it are shocked - SHOCKED? - that the easily foreseen problems are as bad as they are.

    Computer programs can be fixed. Fundamentally incoherent policy can't, and when that policy is federal, its perverse effects are amplified. Is that so hard to understand?

  11. Except, of course, that unless we're able to get the ACA repealed or gutted, we're stuck with it in perpetuity, meaning that the "long game" price tag - as long as you're looking at the accounting ledger - is infinite.

  12. "And now those who voted like lemmings to enact it are shocked...that easily foreseen problems are as bad as they are." Except that existing problems are shocking too, and conservatives are not forthcoming with legislation that is better than both the shocking status quo and the naive assumptions of the ACA.

    As I noted earlier, the ACA is largely a plan to make a plan. Thousands of studies and pilot programs have been funded to look into better ways to do health care.

    Presumably a few good ideas may have come in. (Or is that possibility too politically charged to admit?) Where are the conservative leaders lining up to glean the results? Where are the bold conservative alternatives to the ruinous status quo? (The CBO report for June and August, 2011, on the long term fiscal outlook for the USA, projects healthcare costs will engulf us like a tsunami within 20 years.) At least someone had the guts to propose something.

  13. QB,

    I disagree with your staring premise that access to decent healthcare for all is a common goal. The position of the republican party has been and continues to be that the best way to provide healthcare is through a market driven mechanism. Markets exist to allocate scarce resources. If your perspective on healthcare is that it is, by definition, scarce then you can't believe it is possible for every person to have access.

    As for the question of reading bills. No. The US constitution is badly in need of an overhaul because it is not physically possible for 500 lawmakers to actually understand and have informed opinions on all of the complex issues needed to govern a country of 300+ million. That is the purpose of political parties and their leadership, to act as load sharing systems and allow certain lawmakers to focus on their areas of expertise while providing the others confidence that key principles are being reflected in the bills created

  14. Amen, Richard. The ACA provides further evidence that, In addition to a broken healthcare system, we have a broken political system. As has been pointed out the ACA is far from perfect...but as Richard pointed out its basic health insurance framework is a "conservative" proposal. Instead of viewing the ACA as a compromise approach and trying to make it better Republicans have done nothing but obstruct and try to kill the ACA.

    On the other hand, it is baffling to me how the administration has botched the role-out and done such a poor job communicating, specifically the now infamous mantra "If you like your plan you can keep it, period."...clearly this is not the case.

    The lack of access to even basic healthcare is this country is a political and moral failure, but if some need further motivation to take this problem seriously and do something about it, then realize that our broken, expensive and inequitable system doesn't just negatively impact the health and well-being of those without access and insurance. All of us, even the fully-insured and "healthy" are negatively impacted.

  15. Gabe, slight distinction. You can believe that "decent healthcare for all" is a common goal without pretending it is possible. As a society, we could choose to take whatever actions move us TOWARD the shared goal, rather than indicting those who notice that it is not possible (as though they, themselves, were choosing to withhold it).

    One of the things Republicans are so angry about is that Democrats recently made the promise that the goal will be met, as a moral substitute for asking whether it is possible for the goal to be met. Whether or not you blame the Heritage Foundation (and I think it is a red herring to blame a Democrat bill on a conservative thinktank--the Democrats passed the bill they chose to pass), the current bill does FAR less to increase "decent healthcare" than it does to increase something called "coverage." But "coverage" never made anybody healthier--it is the healthcare itself, not the "coverage," that makes sick people better.

    I am hopeful that there is some way (repeal, or change) to make the ACA something that actually increases healthcare itself. So far, the main result of ACA--as Richard notes--is a significant upsurge in Medicaid enrollment. What Richard does not mention is that this is accompanied by a significant decrease in actual Medicaid allotment per enrollee--and this in a time when growing numbers of doctors, nurses, and hospitals have decided they cannot afford to accept Medicaid patients. You do not have to be an Adam Smith capitalist to wonder whether the enrollees will actually receive care. I hope they do.

  16. Could I make a request? Next time you imply that conservatives are not suggesting ways to improve our healthcare situation, would you spend at least 30 minutes reading any outlet that actually publishes articles by conservatives? Or looking at some of the legislation that has been introduced by Republicans? Or using google to look at conservative proposals? Of course, you may not like the proposals--but most people who rhetorically ask why conservatives aren't making proposals have not even checked.

    I'm not saying the conservative ideas would work. But, in general, the complaint I have heard is not that they are impractical, but that they are modest--that they improve the status quo, let us say, by 5%--where the ACA has chosen an intentionally immodest goal. Those who believe the immodest goal will work, can rightly scoff at the proposal of modest improvements. But many of us do not think the world works that way--that compassionate people should reject modest improvements in order to "solve" such persistent issues as crime, poverty, and poor healthcare.

  17. It's funny, but Romney said something similar when he was contrasting what he did in Massachusetts from what Obama did. When people tried to pin him on what his policy would be, he kept saying, "I would sit down with people from both parties and try to find something that worked." It's a matter of debate whether this is what Obama tried to do--or whether the ACA may still become this--or whether it is all the fault of Republicans that the ACA was as partisan as it was.

  18. Richard, I love your site, and most everything you write is A+.

    But (You knew a "but" was coming.), I think you fell into a mimetic crisis this time. On the one hand you're asking for both sides to get together, but then you played your true hand by scapegoating the Republicans and the heritage foundation. Had this succeeded it would have been Obama's great achievement. When it fails, it's really the GOP's fault. I think you can do better than that. :)


  19. That would be true if I pointed that out just now. But from the very beginning I've made that observation, back when the legislation was being debated. I noted then that this isn't the plan liberals wanted.

  20. Sorry, but the facts won't you off the hook there. It was the Dems who freakin' voted for the thing. No GOP person voted for it. Zero. Nada. You can claim that certain Dems like Manchin held up a truly liberal plan, but it's just insane to scapegoat the Republicans and the Heritage Foundation for a bill that none of them voted for. It just don't fly, my friend.

  21. No I get that. But I'm not scapegoating them for the ACA. As I said in the post, I'm still for the plan. So I don't see how I can be scapegoating someone for something I agree with.

  22. We must remember that the ACA also benefits EVERYONE with health insurance in the sense that the companies can't set lifetime caps, use pre-existing conditions against you, improves senior's Medicare benefits including drug benefits, and allows young people to stay on parents' plan till age 26. Those benefits alone are a dramatic change for the better.

  23. To be fair, the insurance companies cannot deny you for coverage based on pre-existing conditions, but the plans are extremely unaffordable. They are very expensive.

  24. Yes. You're agreeing with this thing that you didn't really want in the first place. Something that as it flounders we can conveniently point out was all the GOP's idea. It was all their idea, even though none of them voted for it and was so much less than what the controlling majority of the legislature wanted.

    I don't know if you're pounding your head on your desk like I'm pounding mine, but can you at least see where I'm concluding that all this sounds suspiciously like scapegoating and that you're trying to have it both ways?

    (Insert a big toothy smile here. I'm really not trying to antagonize on this.)

  25. I just love how this discussion and especially on this blog draws the smug idiots out of the woodwork. In the immortal words of Han Solo, "Bring 'em on - I prefer a straight fight..."

  26. It appears this post is about an empire misusing its resources. I would guess that god cares more about helping just a few people by any means necessary rather than people becoming collateral damage as an empire struggles to keep its power.

  27. The state run marketplaces, such as the one in Minnesota, are doing much better than the federal one. I think that is because of two things. First, people trust their states and their own ability to manage state government than the federal government. Second, they very intentionally kept Obamacare out of the advertising. Obama has become a divisive figure. Anything with his name on it is up for controversy. The states who set up their own programs are the ones who will look wise in he end. The best repair, get it out of the federal hands and put it in the hands of the states. After all, the states know better what their citizens need than Washington, D.C.

  28. I really can't get into all the messy little details. What I can do is tell you what the ACA has already done for me and my husband. Cliff is a bilateral lung transplant recipient, one of the longest living recipients of lungs in the history of that particular surgery in this country. 20 years in January. Thank God for a doctor who steered us to an HMO at the beginning of this journey; thank God for the City of Chicago and the 10 plans we had to choose from in 1994. Ah, but then retirement. Dumped into a BC/BS PPO. Now spend half my life fighting with provider charges and errors and the insurance company and its nasty little screening company. Thank God I've got "my guy at the City."

    Okay. Here's what I want to say. Both Cliff and I are extremely grateful - for his donor's husband's decision, for the awesome transplant doctor who still follows his progress, for the innumerable angels who have helped and stood by us and cared for us for all these years. And we're grateful for just two little pieces of the ACA (an attitude which I express frequently down here in SW FL). We are grateful that the $1.5 million lifetime cap on his insurance policy is gone. A lot of people don't understand that their policies had "caps;" once Blue Cross paid $1.5 million over Cliff's lifetime, it was gone, baby, gone. Had he gotten sick, that $1.5 would have been gone in two weeks and we'd have been thrown into the "pre-existing condition" hell hole. That little coverage avoider will be gone as of 1/1/14. So, for us, two little items that most people don't even know about, two items that could have meant the difference between life and death for Cliff, two little items that caused me some sleepless nights are gone. Two little things. Gone for good. Good for Obama!

  29. You're right. Modest proposals don't count in my view.

    The reality is that by the time the Baby Boomers retire the ranks of Medicare will have doubled. If you look at CBO projections, you'll see that resulting entitlement spending will force the federal government into deficit spending that will bankrupt the nation, unless:

    (1) Payments to providers are cut, dramatically. But the first major medical provider (that I know of) just decided to drop Medicare (United Health). If we are already at the breaking point with respect to that option, it's of no further use.
    (2) We raise taxes, dramatically. No one thinks that would be productive--literally or figuratively.
    (3) We cut benefits, dramatically. But the fear inspired by that prospect makes it impossible to even have a discussion about the challenge (it was not by accident that the full title of "Obamacare" is "The Patient Protection and ACA.") Or...
    4. Dramatic savings are found through creating efficiencies in healthcare delivery and prevention of disease, including and especially the role of lifestyle factors in 75% of medical expenditures.

    We had better hope that the fourth works, because the first three will cause much harm and pain, whereas the fourth would make things better. The ACA is at least making an effort to move on the only sane option that's available.

    Do I reject "modest improvements"? Of course not. But a bold, systematic approach to making every possible modest improvement that we can find is needed.

  30. So much criminalizing political parties. I appreciate your point number 1, Richard, about wanting insurance reform. They are the bad guys driving up prices. I hope the party bashing gets old soon so everyone can look up and see who the real culprits are. gb

  31. I'm almost inclined to agree with you...but in Canada, our health care system is run provincially. I won't pretend to know all the ins and outs--there may well be federal oversight--but whenever I want to look at the US and shake my head at all the trouble decentralization is causing (and I'm pretty in favour of local decision-making, so I don't want to shake my head over decentralization), I have to remind myself that decentralized politics is how Canada handles a lot of things, too. And it seems to work here, or, anyway, it works better than it does in the United States. I don't know why. (I'm inclined to say it's because we're more liberal/socialist than the US, so our local decisions are just better, but that might not be it.)

  32. Where is God in this whole mess? Is there anyone left that believes that He is in charge?

  33. The goals you mention for healthcare reform are noble, but the ACA was never going to achieve those goals. It exacerbated the problem of employers cutting hours from workers by requiring them to give full time employees insurance. Now the lowest paid employees not only lack health insurance, they make less money to buy it on their own. The ever rising cost of healthcare is the real problem and this law does nothing to correct it.

    1) It is not fair to put the ACA on the heritage foundation. The only part of this bill that can be attributed to them is the individual mandate and they rescinded that idea numerous times since its original proposal in the early nineties. I hope this was just an honest mistake on your part.

    2) The federal website is not the problem. The prices on the exchange are outrageous. Furthermore, adding 4 times as many people to medicaid than individual buyers is not happy news. This will further drive up costs and not benefit them in the long run. Charity hospitals and clinics can still be a good alternative to medicaid.

  34. That was the intended design with a Federal exchange as the back up. In Michigan the Governor (a Republican wanted it), but couldn't get a GOP legislature to go along. Why? Because they didn't want to aid implementation of the ACA. They wanted it to fail.

  35. What is freaking insane Richard is that we think having insurance is a). Affordablr and b). Healthcare. I am all for universal healthcare. We should call this universal insurance coverage. Too I fail to see how this will help the poor. Subsidies not withstanding, some people can not afford anything extra. Ever notice how the only silent voice in all of this is that of the insurance companies?

  36. "You can believe that 'decent healthcare for all' is a common goal without pretending it is possible."

    But it has been possible, for decades, for most developed countries (including my own, Canada), around the world. It is difficult for anyone supporting socialized health care (or, I assume, the ACA) to believe those against socialized health care (or the ACA) really in good faith think it's impossible. It will obviously be difficult and complex, but that's a far cry from impossible, when it's been done already. To whit: it seems as though anyone who genuinely believes it would be impossible must also be unaware of the fact that it works acceptably elsewhere in the world. Of course they might be unaware, but I'm wondering if that starts to stray into the territory of willful ignorance.

    The "it's impossible" argument also seems terribly strange to me as a Canadian; one of our major problems in keeping socialized health care going is that a lot of our doctors are moving to the United States to practice there, where they get paid more. So Canada's major problem--loss of practitioners to the US--cannot possibly be the United States' problem. Certainly the US will have its own problems, like the bizarre and exorbitant cost of medication in the States, but those problems 1) can surely be fixed and 2) need to be fixed anyway.

  37. In order for me to accept your evidence that it is possible, you must first convince me that
    1) Countries that choose socialism really have, reliably, "decent healthcare for all" rather than their own healthcare problems--that I am being misled about the stories of people who (from Canada) choose to cross the border to get healthcare, or (in Europe) simply suffer without it, because it is not always available despite the promise of "universal availability."
    2) The U.S. does not have unique challenges based on its population and demographics that cannot be fairly compared to much smaller, much different nations.
    3) "Bizarre" is the right word for a system that pays doctors enough to draw more doctors, and pays pharmacists enough money to develop new drugs, rather than being the right word for a system that pays doctors little enough that they want to move away, and pays pharmacies little enough that they do not want to develop new drugs.

    I don't know that you are wrong. But you seem to ignore the very issues that those who wonder whether it is possible, are interested in.

  38. Thanks for this answer. It's a fair one. But it doesn't address my basic question--is it advantageous to have only one line, for everyone? Certainly it sounds fairer, and for that reason, if I were completely ignorant of economics, I would want one line in which everyone waited equally, regardless of income. But if I were not ignorant of economics, I might want a system in which the rich people could pay a new doctor to start a new "favoritist" line, because a) that would thin out the first line for the people who stayed in it, and therefore b) despite the inequality, everybody would get their care sooner. (I'm more sympathetic than you are toward the suffering of people who have to wait months or years for care--I think that is one way that 'decent healthcare for all' is not being provided.)

    It's part of my larger question about liberal-versus-conservative rhetoric in America, a question which so far I haven't seen addressed in a way that I understand: does the search for "fairness" merely make sure that the system is worse for everyone, including those at the bottom of the scale?

    Answering this question by comparing us to another (much smaller, population-wise) country is illuminating, but still leaves questions--would we, if we became more socialist, look more like the socialist countries where everyone's care is better, or more like the socialist countries where everyone's care is worse? Here's where the demographics come in--because I don't think the data show that all socialist systems result in a closer approximation of 'decent healthcare for all.

    Also, I should mention that I live in the US and have benefited from medical care that I couldn't afford, provided by the pre-ACA safety net, which I consider "socialist" in nature and which worked pretty well for me. So I'm not knocking government health care--I'm asking whether it makes sense to limit government involvement in healthcare to the poorest segment of society, who have already had government-funded healthcare for decades.

  39. Well, for what it's worth I also think that the ACA was maybe a bad idea...but also think that claim that it's impossible is usually a disingenuous one, because I don't think the evidence is sufficient to support that it's impossible for the US (I'll grant that the evidence suggests it might be extremely difficult and costly, but it only might be that).

    This may interest you: there was a conversation about a decade ago here about a two-tier health care system. One tier would be public and one tier would be private; doctors practicing in Canada would be required to spend a certain amount of time in the public tier, but the rest of their time they could spend in either, as they prefer. If you could afford to you could enter the private tier for a fee, but everyone was guaranteed health care eventually. It was eventually not passed, in part because people suspected (rightly, I think) that this wouldn't really improve waiting times on average, but simply improve the wait times for rich people at the (perhaps fatal) expense of poorer people.

  40. I am so sorry for you all. This issue is a blight on the whole of America. By the grace of God I was born in the UK. Bevan saved us from all the pain us citizens have to endure. I love the NHS and wish it was available to all of you. Pax

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