The pitchforks are changing hands. In 2009, it was Democratic members of Congress supporting health-care reform who were set upon by outraged constituents. When they passed the Affordable Care Act anyway, it cost their party control of Congress in the 2010 midterm elections. House Republicans subsequently voted more than fifty times to repeal or cripple the A.C.A. Nineteen Republican-led states spurned the offer of federal funds to expand Medicaid coverage. In January, Donald Trump’s first act as President was to order government agencies to avoid implementing, as much as is legally possible, what has become known as Obamacare.
But Obamacare, it turns out, has done a lot of good. It guarantees that people with preëxisting health conditions cannot be rejected by insurers or charged more than others. It has reduced the number of uninsured people by twenty million. It has increased access to primary care, specialty care, surgery, medicines, and treatment for chronic conditions. Patients are less likely to skip needed care because of the cost. As a result, according to studies conducted at Harvard, the A.C.A. is saving tens of thousands of lives each year.
Now Republicans in Congress are facing the wrath of constituents who don’t want to lose those gains. Conservatives have had to back off from their plan to repeal Obamacare now and worry about replacement later. Instead, they must grapple with what they have tried to ignore: the complexities of our health-care system, especially in the four vital areas of employer-sponsored coverage, Medicaid, the individual insurance market, and taxes.
Half of Americans get their health coverage through their employer. For them, the A.C.A. brought such popular changes as uncapped coverage, inclusion of children up to the age of twenty-six, and requirements that insurers cover not only primary care but also pediatric dental and vision care, mental-health care, and, with no co-payments, preventive care. The Republicans probably won’t risk eliminating these provisions—except for contraceptive coverage—but they dislike the measures that have kept employers providing health benefits: tax penalties for big companies that don’t; tax credits for small businesses that do.
It was Obamacare’s dramatic expansion of Medicaid, in participating states, to all Americans living near the official poverty line that produced the largest reductions in the uninsured. Many Republicans have vowed to cut back the program’s funding, and to send the money to states as a lump sum, or “block grant.” This approach, however, is apt to throw millions out of coverage and many states into fiscal crisis, and key Republican governors and senators are opposing it.
Republicans are also divided on what to do about the roughly ten per cent of Americans—freelancers, independent contractors, and the like—who aren’t covered by an employer, don’t qualify for Medicare or Medicaid, and must rely on the individual health-insurance market. Before the A.C.A., these people were the most vulnerable in the system; twenty-seven per cent of non-elderly adults have a preëxisting condition that makes them effectively uninsurable without the law’s protections. Now they can sign up through online exchanges for plans that are priced without regard to health history and are subsidized based on income.
Republicans claim that the program is in a death spiral. It isn’t; enrollment has held constant. But there is a need to draw in younger, healthier people to offset the costs of older, sicker people and keep the premiums steady. Doing so depends on promoting HealthCare.gov widely and enforcing the tax penalty for people who don’t sign up. The President, however, has issued a raft of contradictory directives that ultimately instruct the government to do neither. As a result, more and more insurers are saying that they will pull out of the exchanges, risking the collapse of the individual market.
Having promised to get rid of the insurance mandate, Republicans are considering alternatives, but so far they are all inadequate. A requirement for people to maintain “continuous coverage”—to take an example supported by the new Secretary of Health and Human Services, Tom Price, and Speaker of the House Paul Ryan—would mean that people who lose their insurance temporarily, because they, say, change jobs or suffer a financial setback, would also lose their preëxisting-condition protections. For these people and for others left behind, Price and Ryan advocate state-run “high-risk pools.” But, in the thirty-five states that offered high-risk pools to the uninsurable before the A.C.A., inadequate funding delivered terrible coverage, with extremely high premiums and deductibles, and annual limits as low as seventy-five thousand dollars. Hardly anyone signed up.
For orthodox Republicans, the central issue is, of course, taxes. Obamacare increased them, particularly for high-income individuals and for industries that profit from the expansion of coverage, to pay for the costs of reform. (The A.C.A. actually reduces the deficit.) Many Republicans have made cutting those taxes their top priority; others see preserving coverage as the imperative. Each side thinks the other is committing political suicide. But, with so many Americans beginning to recognize how much they stand to lose, the political equations are shifting.
Governance is forcing Republicans to confront the reality that repeal without replacement is untenable. In a stalemate, Congress would likely need to delay repeal and, to reassure skittish insurers, focus on small-scale repairs, such as affirming that subsidies will continue to be funded, and either enforcing the existing mandate or revising it so that more young and healthy people sign on. (For instance, healthy people could be charged an extra ten per cent on premiums if they forgo insurance for a year, the same as the penalty for elderly people who refuse Medicare Part B.) In addition, the states that sat out the Medicaid expansion in order to thwart President Obama would be free to join in under a Republican Administration, as many would like to. “Insurance for everybody,” Trump has vowed. A Trumpcare compromise could yet bring us a step closer to it.
But legislators have no time to waste. Insurers must decide by April whether to offer a plan for the exchanges in 2018, and at what price. That requires certainty about the future. Pitchforks have their uses, but crafting health-care policy calls for more delicate instruments. The basic functioning of the health-care system is at stake. So are American lives. ♦
The Affordable Care Act
The Affordable Care Act (ACA), also known as Obamacare, was signed into law in 2010. The act aimed to provide affordable health insurance coverage for all Americans. The ACA was also designed to protect consumers from insurance company tactics that might drive up patient costs or restrict care.
Millions of Americans have benefitted by receiving insurance coverage through the ACA. Many of these people were unemployed or had low-paying jobs. Some couldn’t work because of a disability or family obligations. Others couldn’t get decent health insurance because of a pre-existing medical condition, such as a chronic disease.
The ACA has been highly controversial, despite the positive outcomes. Conservatives objected to the tax increases and higher insurance premiums needed to pay for Obamacare. Some people in the healthcare industry are critical of the additional workload and costs placed on medical providers. They also think it may have negative effects on the quality of care. There are frequent calls for the ACA to be repealed or overhauled.
Here’s a look at some of the pros and cons of Obamacare.
More Americans Have Health Insurance
More than 16 million Americans obtained health insurance coverage within the first five years of the ACA. Young adults make up a large percentage of these newly insured people.
Health Insurance Is More Affordable for Many People
Insurance companies must now spend at least 80 percent of insurance premiums on medical care and improvements. The ACA also aims to prevent insurers from making unreasonable rate increases. Insurance coverage isn’t free by any means, but people now have a wider range of coverage options.
People with Pre-Existing Health Conditions Can No Longer Be Denied Coverage
A pre-existing condition, such as cancer, made it difficult for many people to get health insurance before the ACA. Most insurance companies wouldn’t cover treatment for these conditions. They said this was because the illness or injury occurred before you were covered by their plans. Under the ACA, you cannot be denied coverage because of a pre-existing health problem.
No Time Limits on Care
Before the ACA, some people with chronic health problems ran out of insurance coverage. Insurance companies set limits on the amount of money they would spend on an individual consumer. Insurance companies can no longer maintain a pre-set dollar limit on the coverage they provide their customers.
More Screenings Are Covered
The ACA covers many screenings and preventive services. These usually have low co-pays or deductibles. The hope is that if you’re proactive in your healthcare, you can avoid or delay major health problems later. Healthier consumers will lead to lower costs over time. For example, a diabetes screening and early treatment may help prevent costly and debilitating treatment later.
“The ACA is going to help all Americans have higher quality and less costly healthcare in the decades to come,” says Dr. Christopher Lillis, an internist in Virginia and a member of Doctors for America.
Lower Prescription Drug Costs
The ACA promised to make prescription drugs more affordable. Many people, particularly senior citizens, are unable to afford all their medications. The number of prescription and generic drugs covered by the ACA is growing every year. Savings on prescription drugs exceeded $15 billion within the first five years of Obamacare.
Many People Have to Pay Higher Premiums
Insurance companies now provide a wider range of benefits and cover people with pre-existing conditions. This has caused premiums to rise for a lot of people who already had health insurance.
You Can Be Fined if You Don’t Have Insurance
The goal of Obamacare is for people to be insured year round. If you’re uninsured and don’t obtain an exemption, you must pay a modest fine. The fine is expected to increase over time. Some people think it’s intrusive for the government to require health insurance. ACA supporters argue that not having insurance passes your healthcare costs on to everyone else.
Taxes Are Going up as a Result of the ACA
Several new taxes were created to help pay for the ACA, including taxes on medical device and pharmaceutical sales. Additional taxes were also created for people with high incomes. Funding also comes from savings in Medicare payments.
The wealthy are helping to subsidize insurance for the poor. Some economists, however, predict that in the long term, the ACA will help reduce the deficit and may eventually have a positive impact on the budget.
Enrolling Can Be Complicated
The ACA website had a lot of technical problems when it was first launched. This made it difficult for people to enroll and led to delays and lower-than-expected signups. The website problems were eventually fixed, but many consumers have complained that signing up for the right family and business coverage can be tricky.
Many hospitals and public health agencies have set up programs to help guide consumers and business owners through the setup process. The ACA website also has sections devoted to explaining the procedures and available options.
Businesses Are Cutting Employee Hours to Avoid Covering Employees
Opponents of Obamacare claimed the legislation would destroy jobs. The number of full-time jobs has gone up in recent years, but there are still reports of businesses cutting hours from employee schedules. Business with 50 or more full-time employees must offer insurance or make payments to cover healthcare expenses for employees. By reducing hours, businesses are able to get by the 30-hour-per-week definition of a full-time employee.
The ACA is subject to changes every year. The legislation can be amended, and budget decisions can affect how it is implemented. Changes in the healthcare field, along with changes to the political makeup of future presidential administrations and Congress make it likely that the ACA will be tinkered with for years to come.