Bronze-level articleAffordable Care Act

From RationalWiki
Jump to: navigation, search
Guide to:

U.S. Politics

Icon politics USA.svg
Hail to the Chief?
Persons of interest
Dems should agree to scrap Obamacare, replace it with a Romney-style system modeled on what works in Massachusetts.
—Matt Yglesias[1]
If it works, will it still be called Obamacare? Success has many fathers.
Leonard Nimoy[2]
Mitt Romney Admits Obamacare Was Based on Romneycare—and That It Worked[3]

The Patient Protection and Affordable Care Act (PPACA or just ACA) is a law signed by President Barack Obama in March 2010 that reformed the extortion racket health care system in the United States. The act cut our rate of uninsured nearly in half while adding vital consumer protections to safeguard against predatory insurers. It was the biggest overhaul US health care had seen in quite a long time. In fact, the Affordable Care Act is the biggest anything to pass (that wasn't motivated by a major incident) in a long time, which is sad. Despite having the aim of ensuring that every American has health insurance, it is nowhere near a universal health care system; consequently, the wide majority in countries with universal health care (i.e. almost the entirety of the Western world) were laughing at it.[4] It's chief legislative architect quit the White House in 2012 to head up Big Pharma.[5]

Dems had a near super-majority during the Obamacare push and still almost derailed the ACA with infighting. They watered it down and begged blue state RINOs to cross the aisle, to no avail. Finally they had to ram it thru via reconciliation. It galvanized the opposition, spawned the Tea Party (the town hall meetings over "death panels"), and resulted in the epic GOP midterm sweep of 2010. When Obama took on the task of fixing healthcare, he took ownership of its problems: Democrats were not aided by passing it, and Republicans were rewarded for pushing for its repeal. 30 million Americans have health coverage thanks to the ACA, and many in that 30 million voted for Trump. And many of those voters are in states that used to vote blue regularly. 45% of voters thought the law went too far.[6]

Repealing Obamacare isn't something President Trump can do with an executive order, but with his support for it and the GOP controlling congress, it would be very surprising if Obamacare isn't over in 2017. Ironically, MassHealth, Romney's state-wide health insurance program, predates Obamacare and can't be repealed by Trump.


[edit] History

He has demonstrated, when he stepped into government in a very difficult state, that he could work in a difficult partisan environment, take some good conservative ideas, like private health insurance, and apply them to the need to have everyone insured.
—Jim DeMint, this quote will live with you forever.[7]

Unsurprisingly, the GOP hasn't had an new opinion on the subject in 40 years; the arguments presented against "Obamacare" are virtually identical to those presented by Ronald Reagan in a 1961 speech. In that speech, Reagan warned that if the U.S. were to adopt Medicare, the country would be on the slippery slope to err... socialism.Do You Believe That? The idea of mandating people to buy health insurance was long supported by conservative think tanks and Republican mullahs, until it became the staple of Obama's health reform.[8] For instance, Newt Gingrich was a longtime supporter of individual mandates, speaking in favor of it even as late as 2011.[9] Another example is the Heritage Foundation, who already in the late 80's came out in support of individual mandates.[10] It is literally a Heritage plan which Bob Dole put forward in opposition to Hillarycare in the 90s.[11][12] Makes you wonder what changed their mind.

Health care reform was one of Obama's goals when he took office in 2009. The goal of the act was to provide a new competitive insurance marketplace.[13] Once debate over health care reform began, it quickly became an albatross and received much attention in the media. The Affordable Care Act passed 219-212 in the House and 60-39 in the Senate, a process which took around six months.[14] (If you want a comparison, ARRA passed in three weeks. The PATRIOT Act, 72 hours.) The ACA was often referred to by the neologism "Obamacare" by its detractors. One of the biggest failings in the healthcare law was letting Republicans rename it. (President Obama has said as much, although he actually very much likes the name now.)[15]

People already forget the legislative history here, but Obamacare was incubated in the "Gang of Six", a committee of 3 Republicans and 3 Democrats. So, what happened? Basically, Mitch McConnell happened. He argued - brilliantly - that if he managed to deny Obama votes for something, it would be seen, by definition, as a partisan bill. It would not be seen as a compromise, despite any substantive compromises in the bill. By the time the Democrats realized this was what was happening, and that they'd never get a single GOP vote for this bill, it was too far down along the path to be re-written as a purely liberal bill. The GOP beat the Democrats at their own game; they got the Democrats to pass a shitty bill while at the same time they get to campaign against it as a partisan bill shoved down all our throats.[16]

[edit] Sticker shock

If you like your health care plan, you can keep your health care plan.
— website (now redacted)
A whole series of presidents developed credibility gaps, because people didn’t trust what they were saying anymore. And that’s Obama’s real problem: Once you lose the trust of a substantial part of the American public, how do you get it back?
—Larry Sabato, UVA Center for Politics[17]

Leading up to the ACA roll-out, plenty of people were telling Obama and his administration there was no plausible way most consumers would be able to keep their plans. He knew they were right but doubled down in '12 because it was an election year. He later apologized for it, but his approval rating plummeted.[18] Fact is, many wanted to keep their old shitty plans where they would have been paying for ambulance services, miscategorized out-of-network services and preventative care on their own dime or else on high coinsurance, all while paying impossibly high deductibles to boot. (But low premiums we guess!!)

The biggest problem surrounding the ACA is that it does not address the main problem with health care: cost.[19][20] The government could simplify the clusterfuck by just paying for medical insurance through taxes and not having to worry about high co-pays, or rising monthly prices with lowered benefits, or dealing with overworked/understaffed bureaucracies. But our "representatives" were using it as part of a larger partisan war; they don't really give a toss about "repeal" or "replace," they just needed to retain their seats in Congress. So they kicked the football around for a while.[21]

If it seemed like parts of the ACA are being chipped off on a monthly basis, Obamacare was purposely written to front load the benefits and back-load the costs, conveniently around 2017 when Obama would be sipping daiquiri in Hawaii.[22] He probably thought he was getting another Democrat in behind him who would implement the plan he actually wanted.

[edit] Provisions

Some of the provisions the ACA implements include:[13]

  • Probably the most notable aspect of the law is the expansion of coverage to 32 million more Americans
  • A Patient's Bill of Rights to protect consumers from some of the worst insurance company abuses
  • Resources that assist states in keeping health premiums down, protect consumers, and expand consumers' health choices
  • Creating a Pre-Existing Condition Insurance Plan that allows people who have an excuse for insurance companies to deny them the basic right to survive a pre-existing condition to receive coverage
  • Creating the Early Retiree Reinsurance Program so businesses can better provide coverage to retirees who aren't yet eligible for Medicare
  • Measures that will help small businesses claim their tax credit and allow the country's health care system to save costs while being more efficient
  • Allowing younger people to remain on their parents' health care plan until age 26
  • An individual mandate, Everybody who can afford health insurance is now required to buy health insurance. This helps support the insurance companies so that they can help the sick people and stops the idiots who think they are invulnerable and immortal from complaining about costs when they actually get hurt (and/or from making the rest of the state pay for them)

Not all of the act was implemented when it was passed. Starting September 23, 2010 services such as mammograms, immunizations, and colonoscopies (aka preventive services) will be covered by insurance and insurance companies will be banned from charging co-payments, co-insurance or deductibles for these. Consumers will also have the right to appeal a decision by an insurance company to a third party and choose which provider within their plan's network of doctors they want. Other provisions are gradually instated between 2010 and 2014.

[edit] Why we can't have nice things

[edit] Left-wing criticism

Some from the more liberal side of the spectrum claim that the law doesn't go far enough and that it should bring the US's health care system nearer to a universal health care system; specifically, they point to Obama's campaign support of a public health insurance option, which was included in the House version of the bill.[23] The law's current requirement for insurers to dedicate 80% of their premiums to health care, however, has been seen by some as paving the way for a possible single-payer or public option in the future.[24] The Economist is of the opinion that Obama shouldn't have made compromises from the start, pointing to the public option as more beneficial to business.[25]

Much has been said of the crappy rollout of, which was originally contracted out to a developer in Montreal.[26] It is unknown if this will have any long-term effects. Coverage has also focused on the continued extensions of the act's first enrollment period; by the end of March 2014, nonetheless, it seems the administration came close to the intended target (7 million sign-ups in six months) after all the brouhaha.[27][28]

[edit] Right-wing criticism

"Washington Takeover” beats “Washington Control." Takeovers are like coups – they both lead to dictators and a loss of freedom.
Frank Luntz[29]

To a conservative, the status quo always gets a point in its favor. The status quo was that no one was going to "keep their plan". Insurance companies are waging an administrative arms race with health care providers, constantly changing policies, plans, and coverage to find new ways to deny claims. Healthcare providers respond to this by hiring more staff to negotiate the maze of red tape. The ACA largely put an end to that by standardizing many areas of coverage that were already changing or lost. So, OK, while Obama technically lied,[17] the ACA does a ton of work to stabilize plans once the coverage-but-not-really plans were flushed out. Not getting to keep your current plan is a feature of the ACA, not a bug. ACA or no, your current plan was constantly changing in ways not beneficial to you. But good luck explaining that to the general public skittish about "socialized medicine". Even a public option was a bridge too far.

Mike Huckabee put out a well-known commercial asking people to support the act's repeal. Strangely enough, many health insurance companies are also opposed to the act, presumably because the federal government is curbing their ability to abuse their power. In particular, the GOP has an unreserved and unconditional loathing for this bill — as of 2014, they have tried to repeal it 54 times[30] — having used any excuse to try to get it repealed under the guise that it is "job killing." As it happens, the bill was run by the Congressional Budget Office, who don't take sides, and they said the effect on jobs would "probably be minimal," and then only because people get healthcare outside their jobs, while repealing the bill would lead to a deficit increase of about $210 billion. The Republican response was something like this:

This is a job-killing law, period. Anyone who argues otherwise is ignoring the construct of the health care law and the widely accepted facts.

They also cited a figure of 650,000 jobs, which they claimed was in the CBO report; it was not, and the Republican statement was rated as "false" by PolitiFact's Truth-O-Meter.[31]

Some "moderate" (in comparison to the rest of the GOP) conservatives have criticized the law for allowing employers to delay the mandate by a year but not allow individuals to do the same. The problem is that the employer mandate is relatively trivial, whereas the individual mandate is central to the law. (Some left-wingers, such as Jon Stewart, have been critical of this regardless.[32])

The one unambiguously valid criticism which consistently comes from conservatives is the bill's utter failure to deal with overlitigation in healthcare. Although "tort reform" is usually a code word for something, in the field of healthcare it is a genuine issue and the Democrats (who the trial lawyers just happen to own) belligerently refused to consider the basic changes that would have eliminated this problem. On even this issue, though, Republicans frequently overplay their hand to the point where they end up sounding just as ridiculous, sometimes even more so, than the situation to which they take exception.[33]

[edit] Constitutionality

"CNN [and Fox] just pulled the Dewey Defeats Truman of this generation."[34]

The most controversial part of "Obamacare" is the "individual mandate," requiring that every American either purchase health insurance or pay an annual fine.[35] At least five major court rulings were made concerning the mandate: four of them declared it to be constitutional and therefore removed the grounds for repeal. One, though — which was also the one involving 26 separate states, led by Florida — said the bill was not constitutional, and referred it up.

On June 28, 2012, The Supreme Court upheld this part in National Federation of Independent Business v. Sebelius, 567 U.S. ___ (2012) which is no surprise as a similar individual mandate was applied to sailors in the early 1790s by the 1st Congress, which had a fairly large number of members who were framers of the Constitution.[36] This owes not to the government's power to regulate interstate commerce, but to the government's powers of taxation, since the only penalty for not purchasing health insurance is that one has to pay more tax. This appears to have been a last-second decision, as the popular speculation in the weeks preceding the decision was that the individual mandate, if not the whole bill, was almost certain to be struck down.[37]

An additional argument not yet ruled on by any court is that the act is unconstitutional, tax power notwithstanding, as its introduction in the Senate violates the Origination Clause, which necessitates all bills providing for revenue to originate in the House. Historically, all court challenges to federal statutes based on this clause have failed,[38] since the courts' consistent interpretation is that revenue bills are only "those that levy taxes in the strict sense of the word, and are not bills for other purposes which may incidentally create revenue."[39]

Leaders of the Religious Right have also challenged the constitutionality of the law due to it enforcing employers to provide insurance for women that will help them obtain birth control. In Burwell v. Hobby Lobby, 573 U.S. ___ (2014) the SCOTUS this time allowed Hobby Lobby, a Christian-owned chain of hobby shops, to bypass this provision (effectively depriving its workers from contraceptive access), which could have unknown legal consequences in the future.[40]

[edit] More hysterical reaction

Imagine writing a health care policy agenda that appeals to the sort of people who think Twitchy is clever, and today's GOP will make sense.
—Josh Barro

Despite the fact that Obama's original health care plan did not include any nationalizations, instead focusing on regulatory measures such as outlawing the denial of coverage based on "pre-existing conditions," the plan's detractors have been squawking that it is a secret communist plot and will lead to the creation of "death panels" that decide whether your grandmother lives or dies (the insurance companies themselves are doing just fine rationing health care, thank you very much). This batshittery extended to the belief that it would create a secret army at Obama's disposal.[41]

On October 1, 2013, the law went into effect and began signing people up for health insurance. At the same time, however, the federal government experienced its first shutdown in 20 years due to the Tea Party, this time led by Ted Cruz, refusing to pass a budget or continuing resolution unless the ACA is repealed, delayed, defunded, or otherwise crippled, setting in motion the countdown to a particularly scary fiscal cliff scenario.

[edit] Trumpcare

No one who has coverage because of Obamacare today will lose that coverage.
—Rep. Cathy McMorris Rodgers (WA), who “didn’t deliver her remarks exactly as prepared"[42]

Health reform is a fool's errand because it runs into general political irrationalities. There are lots of people who finally got health insurance under the ACA who don't even know it was the ACA, because their state officials pretended that it was a state plan. Then there were the Trump voters who didn't think that the GOP will repeal Obamacare, or phase out Medicare, or try to privatize Social Security yet again, even as Republican officials were telling voters that is exactly what they planned to do.[43] Very few blue collar folks are eligible for Medicaid; this was a design flaw that overlooked human nature. People who have to pay for their healthcare, even a reduced amount, resent the freeloaders who don't work at all and get it for free.

The GOP was united in repeal, but no replacement has come anywhere close to coalescing. Many of them are free market fundamentalists who want the ACA destroyed, even if it means a devastating shock to the US economy. They must believe this is too politically toxic a position to take, so they talk about a replacement but can't name specifics simply because they don't believe in reform.

According to latest estimates, repealing the ACA in its entirety would cost roughly $150 billion through 2027 using Republican math, or $350 billion using conventional scoring.[44] Those costs will be shifted back onto Medicare and Medicaid, with less preventative care for Americans during their middle years. (Sure, cut Medicaid and Medicare completely, and there will be a huge surplus!)[45] Trump campaigned on repealing the "state boundaries". Here's a dirty secret: insurance companies already operate across state lines. The only thing state lines do right now is to allow each state to set their own regulations. The GOP plan is to eliminate state's rights by allowing insurance companies to be "based" out of whatever shithole will be best for business i.e. has the least regulation and consumer protection.[46]

Full repeal polls at about 18%.[47] Right now it seems most likely that they will repeal it in stages, and parts of it will remain:

  • Put their own brand on it ("TrumpCare"). Good portions of the ACA were picked up from conservatives anyways, and they've never had a credible alternative to the plan for the past 7 years. Insurance lobbyists will push for limited reforms rather than outright repeal. They've already poured who knows how much time and effort into the current situation.[48][49]
  • The Paul Ryan/Tom Price combo plan would repeal the taxes (which funds the subsidies) and removes Medicaid expansion, contraceptive and mental health coverage. It also destroys funding for state exchanges (the administrative part, not the actual plans).[50][51] The fiscal hawks in the Congress will not be very excited about this. Also, Medicaid would most likely be similar to the Indiana model.[52]
  • Arguably the most important and well-liked parts of the ACA cover pre-existing conditions and prevent insurers from dropping you when you got sick. Both will be impossible to keep without requiring a mandate (paying fines for not having coverage), which is probably the least liked part of the ACA. Just repeal the parts that help black people mandate—the "personal responsibility" part—and the rubes will love it. As prices skyrocket—because young, healthy people aren't doing their job and contributing to the risk pool—the rubes will demand full repeal and we'll be back to insurance companies killing people en masse as a business model.

Trump tried to repeal Obamacare but got too little support in Congress.

Had Republicans passed their own healthcare act, many of those who voted for Trump would lose their healthcare, and might be less inclined to vote for him in 2020. But I’d rather have Americans stay alive than have Trump look bad. As it is, he still looks bad, unable to deliver yet another campaign promise. Republicans are reprehensible, and this is what they get for vowing to sink ObamaCare without thinking through how they’d do it.
Jerry Coyne

[edit] External links

[edit] References

  1. Matt Yglesias on Twitter
  2. Or JabberwockDownTheHole's take: '"Keep calling it that. That way, when everyone loves it, they'll know who to thank!"
  3. Pema Levy Oct. 23, 2015 Mother Jones
  4. Americans, yes, you're still stupid.
  5. Obamacare architect leaves White House for pharmaceutical industry job, Glenn Greenwald, Guardian, 5 December 2012.
  6. NBC News Exit Poll Results: Large Share of Voters Feel Obamacare Went Too Far
  7. Mitt Romney's Health-Care Reform, The New Yorker
  8. People Who Wanted Market-Driven Health Care Now Have it in the Affordable Care Act, Brookings Institution
  9. Santorum calls Newt Gingrich a longtime supporter of insurance mandate, PolitiFact
  10. Why Republicans Oppose the Individual Health-Care Mandate, The New Yorker
  11. Stuart M., "Assuring Affordable Health Care for All Americans", Heritage Foundation.
  12. Klein, Ezra, "Unpopular Mandate", NYT 6.25.15.
  13. 13.0 13.1 The Affordable Care Act
  14. Not exactly "ramming in" a bill.
  15. Prokop, Andrew, "President Obama says he'd be happy to repeal Obamacare if Republicans have a better idea - But he’s deeply skeptical that they actually do have better ideas.", Vox (1/6/17 at 12:17pm EST).
  16. Ornstein, Norm, "The Real Story of Obamacare's Birth", The Atlantic 7.6.15.
  17. 17.0 17.1 (Angie Drobnic Holan, "Lie of the Year: 'If you like your health care plan, you can keep it'", Politifact (12/12/13 at 4:44 p.m.).
  18. Eilperin, Juliet, "President Obama apologizes to Americans who are losing their health insurance", WaPo 11.7.13.
  19. Demko, Paul, "Insurer’s Obamacare exit raises new concerns over law", Politico (04/19/16 09:35 AM EDT, Updated 04/19/16 06:19 PM EDT).
  20. Demko, Paul, "Experts see big price hikes for Obamacare", Politico (05/30/15 07:04 AM EDT).
  21. Kirsch, Richard, "Why the GOP Won't Touch Obamacare", Politico 11.3.15.
  22. Demko, Paul, "Obamacare's November surprise", Politico (05/02/16 05:22 AM EDT).
  23. Health-care reform: How the bills stack up, Washington Post
  24. How are you gentlemen!!
  25. Obamacare: Will the haters ever stop hating?, The Economist
  26. Obama promises to fix flawed health insurance website, CMAJ
  27. More than 7 million have enrolled under Affordable Care Act, White House says​, The Washington Post
  28. Zero for Six, The New York Times
  29. Luntz, "The Language of Healthcare 2009 - The 10 Rules For Stopping the 'Government 'Takeover' of Healthcare".
  30. The House has voted 54 times in four years on Obamcare: Here's the full list, Washintgton Post
  31. The health care law a "job killer"? The evidence falls short, PolitiFact
  32. Jon Stewart roasts Kathleen Sebelius, calls her a 'liar', Mother Jones
  34. Let the Memes Begin..., The New York Times
  35. What is the Individual Mandate?, Vox
  36. Don't complain, originalists.
  37. Did John Roberts switch his vote?, Salon
  38. Per WikipediaWikipedia's W.svg
  39. Based on the predecence set by Twin City Bank vs Nebeker, 1897
  40. The Hobby Lobby impact: A Q&A, Pew Research
  41. Hat tip to Louie Gohmert for this one.
  42. Robert Pear and Roger Kaplan, "In Private, Republican Lawmakers Agonize Over Health Law Repeal", NYT 1.27.17.
  43. Sargent, Greg, "These coal country voters backed Trump. Now they’re worried about losing Obamacare.", WaPo 12.27.16. We really have to figure out how to tie their ACA repeal with a Medicare shrink.
  44. "The Cost of Full Repeal of the Affordable Care Act", Committee for a Responsible Budget 1.4.07.
  45. "Accounting for Ryan's surplus", WaPo.
  46. Stephanie Armour and Anna Wilde Matthews, "Crossing State Lines Is No Easy Jaunt for Insurers and Local Regulators", WSJ (Updated 12/3/16 at 6:29 p.m. ET).
  47. Hellmann, Jesse, "Poll: 18 percent want full ObamaCare repeal", The Hill (01/13/17 at 10:22 AM EST).
  48. Abelson, Reed, "Health Insurers List Demands if Affordable Care Act Is Killed", NYT 12.6.16.
  49. Japsen, Bruce, "Insurers Want Obamacare Risk Adjusted, Not Repealed", Forbes (11/6/16 at 9:19 AM).
  50. Vinik, Danny, "6 big areas where Tom Price can change policy at HHS", Politico (11/30/16 at 8:44 AM EST).
  51. Sneed, Tierney, "5 Points On Paul Ryan’s So-Called Obamacare Alternative", TPM (6/22/16 at 12:47 PM EDT). One man's healthcare crisis is another man's libertarian utopia!
  52. Maureen Groppe, and Tony Cook, "Indiana Medicaid program could be blueprint for Trump", IndyStar (11/30/16 at 9:37 a.m. EST).
  53. “Obamacare is the law of the land”
  54. [1]

Personal tools