HEALTH CARE/Joan Retsinas

When Facts Meet Rhetoric: The Success of Obamacare

Lay off the Affordable Care Act! Stop the bashing — especially from well-insured, healthy voters, who so loathe this President that they lambast a major improvement in the lives of “ordinary” Americans – the ones the bashers claim to speak for.

The law is not Utopian. Utopia exists only in fiction. But the law has accomplished some major feats. In this season of rhetorical outrage, it is time to broadcast those statistical successes.

The Act sought primarily to expand outreach. Before passage, roughly 44 million Americans were uninsured, with at least as many “underinsured,” paying for policies that covered little care, at exorbitant costs. The linkage between employment and health insurance was never robust: many employers didn’t, or couldn’t, pay for health insurance. Many employees couldn’t pay the cost-sharing premiums. And part-time, temporary, “contract,” and self-employed workers were akimbo in the employer-based system.

Today, the number of uninsured has shrunk to roughly 33 million. From 2013 to 2014, the percentage of uninsured dropped from 13.4 to 10%..

Before Obamacare, high school and college graduates found themselves with diplomas, yet without coverage. Their parents’ policies did not routinely cover them after age 19 unless they were full-time students. Their health care costs tend to be minor: those new graduates have yet to encounter the expensive diseases of their parents. Diabetes, heart disease, cancer, multiple sclerosis, arthritis – all may lie in their future, but not in the immediate present. Yet insurers said “no.” Today’s policies let people (whether dependent or not) stay on their parents’ policies until age 26. In 2009 30% of this age-cohort had no insurance; in 2014, 14%.

Since 1965, poor Americans with children relied on Medicaid, the joint federal-state insurance program; but poor people without children generally did not qualify. Furthermore, states could set low eligibility limits. The Act opened the doors of Medicaid, allowing states to expand coverage, raise income eligibility. (Initially, the law demanded that states open their Medicaid doors; the Supreme Court ruled that states had the choice). To date, 31 states have expanded Medicaid: in these states, the number of uninsured has, predictably, shrunk. In the states that refused, bowing to ideology over compassion (or even common sense, since the federal government included generous subsidies to states for expansion), the number of uninsured has not shrunk dramatically. (Income-eligibility in those states is $8,870 for a family of three).

The Act let people enroll, with subsidies dependent on income, in a private-sector plan via a “health exchange.” The media detailed the messy roll-out of the plans, the high costs even with subsidies, the eagerness of some large insurers to drop unprofitable “lines.” All true – and all potentially addressed by a “public plan” option. Nevertheless, the exchanges bolstered coverage.

Furthermore, the law took aim at the trifecta of horror: “pre-existing condition” exemptions, low caps on services, fine-print exclusions for basic services.

The Affordable Care Act is not perfect: we still have too many Americans without coverage, too many people paying too much, too high costs overall, especially for super drugs. Regional disparities persist: in Massachusetts, 3.3% of residents have no insurance; in Texas, 19.1% (partly reflecting the numbers of undocumented immigrants). We need to reform this law.

Sadly, though, this election promises no reforms. Donald Trump wants only to win, not to govern. He has issued no meaningful proposals vis a vis Obamacare, other than “repeal.” And his followers don’t care. (If they did, they would have picked a pragmatic Governor, like Kasich or Bush.)

Hillary Clinton has wooed Bernie Sanders’ “progressives”. While she won’t press for universal health insurance, she has promised to push for reforms; specifically, to add a public option to the Act, to let people younger than age 65 buy into Medicare, and to spend more on community health clinics. Yet she is tethered to Wall Street – hardly the stance of a reformer. Besides, Congress must enact any changes, for better or worse; and neither candidate exudes the collegiality necessary to work with Congress. In retrospect, passage of the Affordable Care Act emerges as a wondrous political feat.

Indeed, today the passage of any meaningful legislation would be a miracle.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email

From The Progressive Populist, September 1, 2016

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