What is right about the ACA, and how to address what is not

There has been much criticism of the Affordable Care Act (ACA, Obamacare) both from the Right, which is apparently horrified that public funds are actually being used to help needy people rather than bail out banks, and from the Left, which thinks it hasn’t gone far enough to help meet people’s healthcare needs. Count me in the latter camp, for reasons I will address soon.

However, first to address the criticisms from the Right.  On the whole they are wrong (no pun intended). The fact is that the ACA has done good. About 10,000,000 people who were previously uninsured have now gained health insurance coverage, both from the health insurance exchanges (that include subsidies for the low income) and through expansion of Medicaid, in those states that have opted to do so. This is a GOOD THING. One of the major reasons that the ACA has not done more good is a result of the specific actions that the Right has taken. The most obvious is the failure to expand Medicaid in states that they control, a fiscally unwise decision that is based entirely on a combination of ideology (Malthus as seen through the fantasy novels of Ayn Rand) that is about helping the wealthiest become even wealthier, and the politics of meanness (we will get votes by appealing to folks who don’t want to help them, usually code for racial and ethnic minorities). It is fiscally unwise because, in contrast to traditional Medicaid in which the federal government pays 60-80% of the cost (based upon the income levels of the state), under expansion it pays 100% of the cost for 4 years and then 90%. Medicaid expansion covers everyone under 137% of the poverty line. In contrast, in Kansas, for example, it only covers people who are BOTH very poor (under 30% of poverty) AND have another “qualifying” condition – most commonly mothers of young children and those children, and the disabled. Obviously, this excludes many people in Kansas, and millions across all of the states that have not expanded Medicaid.

There have been many other efforts to limit people benefiting from ACA. Many states (like Kansas) refused to open state-sponsored exchanges, and have tried to obstruct the federal exchanges, even trying to intimidate those working to sign people up. It tried to block passage of the ACA in Congress, and when it gained majorities has blocked every effort to expand funding, and blocked the creation of a “public option” to compete with private insurance companies. The entire series of efforts on the Right to block, limit, and try to kill ACA make its criticisms reminiscent of the person who killed his parents and asks for mercy from the court on the grounds that he is an orphan!

And yet, although it is largely their fault, some of the criticisms of ACA are spot on. Premiums have continued to go up in many places, making the policies available on the exchanges unaffordable to many. Combined with the fact that, despite the “individual mandate”, the penalties for not participating are far less than the cost of insurance, people are not buying it. Or they are buying terrible policies, also permitted by the ACA, that turn out to be worth very little when their purchasers actually get sick. In some places, major insurance companies (like Aetna and Humana) are pulling out of the exchange marketplaces altogether because, even with such high premiums, they are losing money.

The reason for this phenomenon is well-described in Health Care Law’s Beneficiaries Reflect Its Strengths, and Its Faults by Abby Goodnough and Reed Abelson in the New York Times of October 14, 2016. People with chronic diseases, many of whom had been previously uninsurable because of these pre-existing conditions, have flocked to buy insurance on the exchanges. They now have coverage, and are using it; they are among the 5% of people who cost 50% of health dollars (described by me in Red, Blue, and Purple: The Math of Health Care Spending, October 20, 2009), or 75% under the exchanges (per an official of Blue Cross/Blue Shield of Tennessee cited in the article). The difference is because the first estimate is based on all people in the country, and the BC/BS experience in Tennessee and elsewhere is based upon people who have actually signed up for coverage in the exchanges. In a vicious circle, low-income but (currently) healthy people, especially the young, have chosen to not sign up; this leaves the pool of those covered disproportionately ill and thus costly. Without premiums coming in from the people who would cost little or nothing, insurance companies’ outlay for care (the “medical loss ratio”) is too high for them to make a profit (or, at least, as much profit as they want to), and so premiums continue to rise, driving more people (and insurers) out of the marketplace. In addition, the competing demands of survival among low-income people are tremendous, as documented in the October 31, 2016 issue of The Nation, by Monica Potts in “The American social safety net does not exist”. (H/t Bob Bowman, on the Medicine and Social Justice Facebook page.)

This is the basis of the criticism from the Left – that the private insurance-based model of the ACA was designed to benefit the insurance companies (which is now sometimes failing). This was the purpose of the individual mandate, to get everyone, healthy or not, to buy in. But the solution is not to raise the penalty for not signing up, which is obviously counterproductive, but to automatically put everyone in the same pool, regardless of income, pre-existing conditions, age, or the state that they live in. This is what would happen in a national health insurance program, as advocated by Senator Bernie Sanders. Conceptually, it can be seen as putting everyone in the federally-run Medicare program (which already has, by virtue of insuring the old and disabled, the highest risk people). All of us are in, whether we need medical care or not. It is “insurance” only in the broadest sense, because everyone is in the pool, and the public sector – all of us, from our taxes and income-based premiums, pays for it.

Some people know that they are sick. They have one, or often more, chronic diseases. They may have cancer. They may have had trauma requiring multiple surgeries. These are the people who cost the most today. But all of us are at risk for joining that group, when we find out tomorrow that we have cancer, or are in an accident, or have a premature baby, or just gradually gather more chronic conditions as we age. These are those of us who find ourselves without coverage because, when we were healthy, it was too expensive. But it doesn’t have to be that way; a single-payer national health program covers all of us all the time.

The core concept of most insurance is that you only “win” by losing; you collect when your house burns down, or you are in a car accident, or you die. Health care should not be that way. We all should get preventive care, acute care, and care for our chronic conditions, physical and mental.

We can do this. We should. Now is the time. Now is way past time.