The Irony and Limits of the Affordable Care Act

from Dissent magazine:


The Irony and Limits of the Affordable Care Act
By Colin Gordon - October 15, 2013


The federal government shutdown that started on October 1 resulted in a telling virtual irony. Thanks to the standoff in Congress, the government’s web presence—from the Census Bureau data portal to the National Zoo’s “pandacam”—was replaced by “Sorry, back soon” screenshots. Meanwhile, the website associated with the Affordable Care Act (the original object of the standoff) ran out of bandwidth due to overwhelming interest in the new health insurance exchanges. It was as if Congress closed the pool because they thought they saw a turd floating in the shallow end, and everyone jumped in anyway because they knew it was really a chocolate bar.

A larger irony is that the ACA is about as far from a government takeover of health care or the “final leap to socialism” (as Michele Bachmann sees it) as one can imagine. Such hyperbole is now about a century old. In 1917 insurance executives raised the fear of “Prussian” or “Bolshevik” medicine. In the 1940s the American Medical Association fabricated a quote from Lenin—“socialized medicine is the keystone in the arch of the socialist state”—to punctuate its Cold War campaign against public health insurance. During the early debate over Medicare in 1961, Ronald Reagan warned that “you and I may well spend our sunset years telling our children and our children’s children what it once was like in America when men were free.” These scare tactics usually worked. The power of southern segregationists in Congress doomed much of the New Deal’s timid universalism. Deference to the AMA virtually immobilized health reform in the 1940s and 1950s. Job-based coverage emerged as the next-best bet, while public policy retreated to occasional efforts to mitigate its failures—most notably with the passage of Medicare and Medicaid in 1965. Since then efforts to appease health care industry interests and avoid the “socialized medicine” label have routinely turned good intentions into bad policy or legislative shipwrecks. Republican pollster Frank Luntz’s now-infamous 2009 memo “The Language of Healthcare” set out the basic talking points that would later pepper Ted Cruz’s filibuster: any public program or option is a slippery slope to “government takeover” and national health systems (insert Canadian or British horror story here) that stifle innovation, encourage malingering, and ration care—either by forcing patients to wait or by pulling the plug.

This political history dramatically lowered the sights of policymakers. Since the 1970s, the notion of universalizing job-based coverage or displacing private insurers has been slowly replaced by a mantra of competition—marked by the rise of the HMO in the 1980s and the reign of “managed care” ever since. Recasting health care as a marketplace of individual coverage was the pet project of the right in the years before and after the Clinton health care debacle. The Heritage Foundation’s 2006 publication, “The Rationale for a Statewide Health Insurance Exchange,” enthusiastically compared state insurance exchanges to farmers’ markets or the used car clearinghouse CarMax. This was essentially the blueprint for Obamacare. The irony runs in the other direction as well. As Republicans insist on tarring an idea they came up with as the resurrection of Lenin, Democrats find themselves defending a policy they would have scoffed at a decade ago. Their defense depends on two, somewhat contradictory, strategies. One is to celebrate the transformation in health care by reminding Americans (especially the uninsured) that the ACA has made coverage easier to get and harder to lose. The other is to downplay that transformation by reassuring Americans (especially employers and the securely-insured) that the ACA will not affect them or their coverage. The truth lies somewhere in the middle.

The Promise of the Affordable Care Act

In terms of coverage, efficiency, and equity, the ACA is a far cry from a single-payer system. Some hope that it might push us along that path (either through its sheer failure or by incremental tinkering with its provisions), and some fear that it might block the way (by marginalizing the remaining uninsured or simply poisoning the well for future reformers). In either case, the ACA is better than nothing and it has already had a real impact. Health care costs are falling. While slower spending is largely attributable to a slow recovery from a long recession, it also reflects the rollout of some of the ACA’s cost-containment provisions and the response of private insurers to the threat (and now the reality) of modest health reform. And the uninsured are finding coverage. Thanks to the ACA’s requirement that insurers allow children to stay on their parents’ plan until they are twenty-six, the uninsured rate among young adults has fallen for two consecutive years. None of the economic calamity predicted (or pined for) by congressional Republicans has come to pass. The law actually imposes little obligation, cost, or uncertainty on employers. Ninety four percent of firms affected by the ACA’s employer mandate already provide coverage voluntarily. There is no empirical evidence that the ACA is a “job killer” or that employers are gaming the mandate (now pushed off to 2014 anyway) by ducking under the fifty-worker threshold or cutting workers back to part-time status. The promise for the future is substantial. The combination of insurance regulations and state exchanges provides coverage options for millions of uninsured Americans. Most of those finding insurance via the ACA will qualify for subsidies that reduce the costs of that coverage. And the ACA will enhance the health security of those who are already covered by checking the capriciousness of private insurers and providing a softer landing for those who lose a job or job-based coverage. .......................(more)

The complete piece is at: http://www.dissentmagazine.org/online_articles/the-irony-and-limits-of-the-affordable-care-act