Affordable Care Act

President Barack Obama

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“”Dems should agree to scrap ObamaCare, replace it with a Romney-style system modeled on what works in Massachusetts.

—Matt Yglesias

“”If it works, will it still be called ObamaCare? Success has many fathers.

—Leonard Nimoy

RomneyCare The Patient Protection and Affordable Care Act (PPACA or just ACA) was a law signed by President Barack Obama in March 2010 that reformed the health care system in the United States. The act cut the 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. The ACA was often referred to by the neologism "ObamaCare" by its detractors, but grew to be called that by both support and opposition. One of the biggest failings in the healthcare law was letting Republicans rename it.

The law currently requires insurers to dedicate 80% of their premiums to health care. This was seen by some as paving the way for a possible single-payer or public option in the future. 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 2016 voters thought the law went too far.

Ironically, MassHealth, Romney's state-wide health insurance program, predated Obamacare and could not have been repealed by Trump.

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.

If recent history is any guideline, it's political suicide for the Democrats to wade into the minefield of healthcare reform. Both attempts resulted in plummeting presidential support and nearly unprecedented midterm sweeps by Republicans the following year. The backlash sent waves of angry conservatives into power at Capitol Hill, saddling Clinton and Obama with obstructionist Congresses who forced them to abandon much of their platforms.

Individual mandates (forcing people to buy health insurance) were a pet project of conservative think tanks, until it became the staple of Obama's candidacy. Heritage Foundation was pushing the concept back in the Bush I years, (it is literally a Heritage plan which Bob Dole put forward in opposition to Hillarycare in the 90s) and Newt Gingrich was in favor of it as late as 2011. The Economist is of the opinion that Obama shouldn't have made compromises from the start, and instead showed people that a public option is more beneficial to business.

The biggest problem surrounding the ACA is that it does not address the main problem with health care: cost. 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. Its chief legislative architect quit the White House in 2012 to head up Big Pharma.

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 (despite many 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, it was too far down along the path to be re-written as a purely liberal bill. McConnell tricked the Democrats into passing a bad bill while at the same time campaigning against it as a partisan bill. The ACA passed 219-212 in the House and 60-39 in the Senate, a process which took around six months. (If you want a comparison, ARRA passed in three weeks. The PATRIOT Act, 72 hours.)

Obamacare is Romneycare. They got what they want. The rest is just posturing.

Sticker shock

“”If you like your health care plan, you can keep your health care plan.

—Heathcare.gov 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

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, 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.

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. 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!!)

Also, very few blue collar voters 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.

Much has been said of the crappy rollout of Heathcare.gov, which was originally contracted out to a developer in Montreal. Nevertheless, by the end of March, the administration came close to its intended target (7 million sign-ups in six months).

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. He thought he was getting another Democrat in behind him who would implement the plan he wanted.

Provisions

Some of the provisions the ACA implements include:

• 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.

Left-wing criticism

Progressives rightly claimed that the law doesn't go far enough; specifically, they point to Obama's campaign support of a public health insurance option, which was included in the House version of the bill. Democrats 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 through via reconciliation.

Right-wing criticism

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

—Frank Luntz

The GOP hasn't had a new thought on this issue in forty years. Their arguments are identical to those presented by Ronald Reagan in a 1961 speech.

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 a strong dislike for this bill — as of 2014, they have tried to repeal it 54 times — 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.

Opponents 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.

Some moderate 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 liberals, such as Jon Stewart, have been critical of this regardless.)

The one unambiguously valid criticism which consistently comes from conservatives is the bill's utter failure to deal with litigation-rich environment 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 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.

Constitutionality

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

The most controversial part of "Obamacare" is the "individual mandate," requiring that every American either purchase health insurance or pay an annual fine. 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. This owes not to the government's power to regulate interstate commerce under the Commerce Clause, 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.

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, 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."

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.

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 GOP kept squawking about how it would 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). Louis Gohmert even shared his belief that it would create a secret army at Obama's disposal.

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.

AHCA

“”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"

“”Congress should just tell Medicare to stop covering preexisting conditions, declare old age a preexisting condition, and Medicare is gone.

—Bruce Bartlett

The AHCA (American Health Care Act) is a bill that intends to take away healthcare from millions. Because every single healthcare bill now has to be named after the person who proposed it (or just happened to be there when it was proposed), the bill is colloquially known as "TrumpCare." 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. There were also Trump voters who didn't think the GOP would 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 plan to do.

Full repeal polls at about 18%. It seems most likely that they will repeal it in stages, and parts of it will remain. 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.

• Go back to pre-Obamacare. Using Republican math, repealing the ACA in its entirety would cost roughly $150 billion through 2027, or $350 billion using conventional scoring. Those costs will be shifted back onto Medicare and Medicaid, with less preventative care for Americans during their middle years.
• Agent Orange campaigned on repealing state boundaries. Here's a secret: insurance companies already operate across state lines. All they do is allow each state to set their own regulations. Trump's plan was to eliminate state's rights by allowing insurance companies to be "based" out of wherever is best for business.
• 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). As for Medicaid, it would likely follow the Indiana model.
• Remove the mandate. Arguably the most well-liked part of the ACA covers pre-existing conditions, to prevent insurers from dropping you when you get sick. Both will be impossible to keep without requiring a mandate, which is the least-liked part of the ACA. Just get rid of the parts that help black people "personal responsibility" part, and when prices skyrocket—because young, healthy people aren't doing their job and contributing to the pool—the rubes will demand full repeal.
• Or...the government could do what every other sane country does by paying for it through taxes, and not having to worry about high co-pays, or rising monthly prices with lowered benefits, or overworked/understaffed bureaucracies. But most of them are Libertarians who want the ACA dismantled, so they talk about a replacement but can't name specifics simply because they don't believe in reform.

On May 4, Congress stunned everybody by passing the World's Greatest American Health Care Act of 2017, which is specifically designed to spite anyone who even barely-benefited from the ACA. Nobody thought the GOP was dumb enough to gut pre-existing conditions to appease the Freedom Caucus. It's hard to convey the mendacity of this vote. This is a bill which passed without Congress reading the bill, while purposely avoiding a CBO score. There were 0 hearings. Trucks of beer were brought into the Rose Garden and Reps were drinking from kegs to celebrate passing this.

In keeping with tradition, AHCA isn't a healthcare bill as its core, it's a tax cut with Randian Eugenics built in. The GOP legislated a death spiral into the bill: The perverse incentive system of the AHCA stops healthy, young people from getting insurance until they need it, meaning that the insurance market will fail and fail quickly. Next come the asinine risk pools. Trump won over the "moderates" by adding $8bn over 5 years to the high-risk pools, which by some estimates need $30bn/year to be effective. And that $8bn isn't going to cover the 2.5 million people they need to insure. Anyway, these things don't work without socializing them to the tune of billions. The GOP likes to point out how Michigan has a successful program, yet ignore how their relatively-small, high-risk population needed $18bn from Medicare alone. The extra $8bn in Trump's amendment won't even cover Texas. But then, math is not Ryan's strongest suit: Ryan has been touting the $340bn in savings after the enactment of the AHCA. This is done by kicking 20% of the costlier patients (i.e. seniors, people with pre-existing conditions, poor people who rely on Medicaid) off the rolls. Then, as those Americans die, their costs drop and insurance premiums decline.

Among the other notable things in the bill: insurers will be allowed to charge rape survivors more for their premiums. ^{It's almost as if they're encouraging people not to report rape...}

Fortunately, repealing Obamacare wasn't something Trump could do with Executive Orders, so it failed to pass the Senate. But if you're Speaker Ryan and you now know you can just whip the moderates, why bother giving them concessions? He now owns the US healthcare system. Though four GOP senators have said they wouldn't vote in favor of the AHCA, so it failed! Then, the "skinny repeal" (the slightly better option of just repealing ObamaCare) was struck down when three GOP senators voted against it, causing it to fail by one vote. Good news, 22 million Americans get to keep their healthcare. Bad news, Trump is moving to bigoted concepts that actually have a shot.

Beyond Obamacare

Different groups and individuals have come up with various ways of extending coverage.

Public option

In mid-2016, President Barack Obama wrote an article for the Journal of the American Medical Association (JAMA) urging Congress to do more to curb the rising costs of healthcare. He noted that the lack of competition among regional health insurance plans warrants the "public option," or a government-run insurance policy that competes with existing private insurance. He pointed out that the number of uninsured Americans has dropped from 49 million in 2010 to 29 million in 2015 and that the rate of growth in healthcare spending has slowed thanks to the ACA. This article draws from a comprehensive review of Obamacare the President requested from his staff in 2015. A random survey conducted in 2009 by the Mount Sinai School of Medicine in New York found that 63% of doctors support giving patients a choice between public and private insurance, 10% favor the public option only, and 27% private insurance only. Therefore, almost three quarters of medical practitioners support the public option. Given that American public support for it ranges from 50% to 70%, medical professionals are even more supportive of government-run insurance than the laymen. American doctors already have experience with government-run healthcare, that is, Medicare, and they generally like it.

Medicare Extra for All

In addition to the "public option" suggested by President Obama, another way of going beyond Obamacare was proposed by the Center for American Progress known as Medicare Extra for All. It is the midway between Obamacare and the much more ambitious Medicare-for-All proposal, which would implement a single-payer system. (More below.) Under Medicare Extra for All, all U.S. citizens and legal residents would be eligible for coverage, which includes preventive care, vision care, dental care, hearing care, long-term care, and generic prescription drugs. Low-income individuals would be exempt from co-pays and deductibles. Employers may maintain their own insurance plans and employees may choose between government insurance or what their employers provide. Employer-provided health insurance would largely be tax-free. The government would have the power to negotiate the prices of prescription drugs, and medical equipment. However, how much this plan will cost is not known, though proponents admit that substantial tax increases will be necessary.

Medicare for All

Senator Bernie Sanders

Senator Bernie Sanders considers the lack of affordable healthcare in the United States a moral issue and proposed "Medicare for All" to address it. As its name suggests, this legislation seeks to expand Medicare to cover what it currently does not (completely) cover, including vision and dental care. It even goes above and beyond what some private insurance plans currently cover. While private insurance is presently part of Medicare, that would no longer the case under Medicare for All; nor would there be co-pays and deductibles. Medicare for All is a single-payer universal healthcare system. In order to fund his generous welfare program, Sanders proposed a payroll tax on employers and various new taxes on wealthy Americans and corporations.

Support for Medicare for All appears to be growing. A poll conducted by the Kaiser Family Foundation, a nonpartisan think tank, in March 2018 reveals that a majority of Americans support major reforms to the American healthcare system. Specifically, 59% support Sanders' Medicare-for-all proposal and 75% favor a public option or expansion of Medicare. Another conducted by Reuters in June and July 2018 shows that a vast majority of Americans, 70%, now support single-payer healthcare. Medical service providers are also warming to the idea. Even though their payments may fall in the long-run, administrative costs and the amounts of paperwork will also decrease. What really matters to them is not reimbursement rates but net income. Healthcare spending could drop to Canadian levels. Sanders wants to phase Medicare for All in over a period of four years.

See also

• Nancy Pelosi, who said, “We have to pass the bill so that you can find out what is in it, away from the fog of the controversy.”
• Commerce Clause

External links

• Read the Damn Thing!
• Seven Falsehoods about Health Care, A Final Weekend of Whoppers and Obama's Private Army, FactCheck
• Republican Talking Points on Obamacare — The agitprop straight from Congressman Eric Cantor's office.
• Three Days of Argument: Obamacare On Trial — Complete coverage of the arguments to the Supreme Court regarding Obamacare
• Health Care Reform Thought Bubble — A summary of the US debate so far.
• You will once again be fighting for our freedom. We're fighting for our right to live, to exist without health insurance!
• Jeez, Obama, can you just stack the Department of Health and Human Services with Canadian expats?
• Obamacare Enrollees Vote for Trump — Don't blame me, I didn't vote Republican. I voted for the GOP!
  • That dense motherfucker. - Shades of the farmer who voted Leave and was shocked to learn he won't receive any more EU subsidies.
• Paul Ryan, 2009: "I don't think we should pass bills that we haven't read, that we don't know what they cost" — "...unless we are the majority."
• On my way to steal yo' healthcare

Videos

• Affordable Care Act or Obamacare? You decide!

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