JONATHAN COHN MARCH 23, 2011
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A year ago this week, Capitol Hill was full of noise as the House of Representatives debated, and then voted, on the Affordable Care Act. But one of the most vivid memories of that experience for me was an extended moment of silence.
It came very late on Sunday evening--after the floor speeches, the votes, and the press conferences had ended. The galleries had long since emptied and the Capitol building itself was virtually unoccupied, so that it was possible to walk the entire length of the building, on the ground floor hallway that stretches from the House all the way to the Senate, without hearing so much as a single conversation.
It felt more than silent. It felt peaceful and, yes, satisfying. A prolonged, difficult debate had finally ended. It was time to move on.
Except that we haven’t moved on. We are still having arguments about health care reform. In fact, we are still having the same arguments about health care reform. The Affordable Care Act is law of the land now, yes, but its critics are determined to change that. And while the prospects of repealing it legislatively remain relatively slim, the prospects of repealing at least part of it judicially seem far more realistic than they did in the spring of 2010.
So perhaps it is worth taking a step back, just for a moment, and remembering how we got to this point--why this debate started in the first place and why it led to the enactment of this law.
It’s really not that complicated. Around one-fifth of the non-elderly population, or somewhere in the neighborhood of 50 million people, have no health insurance. Many millions more have insurance with major gaps or limitations, leaving them at risk of financial or medical catastrophe. Notwithstanding legitimate debates over exactly how many people go bankrupt or suffer physical hardship because they can’t pay their medical bills, virtually nobody denies that the human toll is real and significant.
These problems are the product, in part, a dysfunctional health insurance system that evolved haphazardly during the 20th Century. They also the product of a medical system as inefficient as it is costly. The United States pays more--far, far more--for health care than any other developed nation. But the care does not seem to be better overall, to say nothing of the fact that it is patently less available.
The goal of reform was really two-fold: In the short term, to make sure everybody can afford to pay for medical bills without financial distress; it the long term, to make the health care system as a whole more efficient, so that it no longer applied such a crushing financial burden on society. A single-payer system, like the ones in France or Taiwan, would have accomplished this. So would a scheme that turned health insurance into a regulated utility, as the Dutch and Swiss governments have done.
Political compromises, dating back to the earliest days of the 2008 presidential campaign, left the U.S. with a second-best--or, more accurately, a third- or fourth-best solution. It bolsters two existing insurance arrangements: Employer-sponsored coverage for workers in most companies, Medicaid for the very poor. It creates a new, regulated marketplace--insurance “exchanges”--for everybody else. Then, through a combination of tax changes and alterations to Medicare, it tries to reengineer medical care itself, wringing out administrative waste and focusing resources on the treatments, and care styles, that provide the most bang for the buck.
It’s easy to find the flaws--and to figure out who’s responsible for them. Doctors, hospitals, drug manufacturers, and device makers fought changes in the delivery of medical care that might affect their incomes; unions lobbied against tax reforms designed to discourage overly generous insurance; everyday Americans resisted changes to plans they already had. All of this blunted the Affordable Care Act’s efforts at cost control, which explains why, ten years from now, the best projections suggest we’ll have spent roughly as much on health care--as a government and as a country--as we would have if the law never passed.
At the same time, political conservatives fought to limit the bill’s expanse, demanding that the new outlays not exceed a $1 trillion, give or take. They had extra power, thanks to the filibuster, and were able to make the demand stick. As a result, the expansion of insurance coverage--via Medicaid and subsidies for private insurance--will not begin until 2014. Even then, somewhere around 20 million people, or 8 percent of the total population, will remain uninsured. And for some of the insured, the coverage will remain meager.
But the law’s shortcomings should not tarnish its many virtues. Eight percent uninsured means 92 percent insured, or around 95 of residents here legally. Or, to put it another way, more than 30 million additional people will have health insurance because of this law. The coverage, if not always as generous as it should be, will be enough to keep many if not most of the newly insured out of bankruptcy--and it will be available to almost everybody, regardless of pre-existing condition or insurance status.
The cost picture is also encouraging. The official projections suggest that, as of 2021, government spending (and, apparently, the country’s total spending) on health care will not be rising as fast as it is now. This is the critical distinction, because it’s the long-term burden of health care that threatens to bankrupt us. Critics doubt that officials will enforce planned changes to health care financing, but today’s lawmakers have no way to force action by their counterparts in the future. All they can do is put laws on the books--and that’s what they have done.
Are there better alternatives? Of course. But the loudest critics of the law, from the right, don’t have them. For all of their screaming, they have yet to put forward a credible plan that can do as much, let alone more, for less money. Their plans, stripped of misleading rhetoric, generally involve covering far fewer people, dramatically reducing the coverage that people have, or some combination of the two. Their dispute is not with the means Democrats have used to make health care affordable to all. It’s with the goal itself.
No, the way to improve the law is to build upon it--to bolster the insurance coverage, reach those Americans the law as written will not reach, and to strengthen the experiments in cost control that work. The best analysis of the law remains the one Senator Tom Harkin gave: The Affordable Care Act is not a mansion. It’s a starter home. But it’s got a solid foundation, a sturdy roof, and room for expansion.
A year from now, the presidential campaign will be well underway and the debate about the Affordable Care Act will likely be, if anything, more acrimonious than it is now. But perhaps after the election and, hopefully, after 2014, the country really will move on.
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9 comments
The PPACA has made some aspects of health care more accessible. But a solid foundation it is not. The experience in Massachusetts is showing that medically driven bankruptcies have not decreased. This is a scourge that other industrialized countries just do not face. The PPACA continues to attempt to rely on multiple for profit insurers vying to compete to best collect premiums and not pay for health care. We're getting underinsurance with higher and higher deductibles and copays. We patch some gaps with Medicaid, Medicare, SCHIP, the VA, Federally Qualified Health Care Centers, tax breaks, and soon to come subsidies, mandates, and Exchanges. The strong foundation, that's both fiscally conservative and morally sound, is a single, publicly accountable system to pay for our health care for us all.
- bsemple
March 23, 2011 at 1:44am
As I see it, this has never been a fight about medical care, otherwise we could solve it. It's a fight over ideology that will never end. We're still fighting over social security, but less. To me the fight makes as much sense as arguing over whether our laws should be governed by Sharia law which descends from the Koran or a system which descends from Roman principles. If you are in favor of the former, you are less interested in results than the satisfaction of knowing your side is in control.
- Nusholtz
March 23, 2011 at 8:02am
I agree, in part with Senator Harkin's "starter home" metaphor. Unfortunately, ACA is built on a shifting, high cost foundation--the private insurance system. As Dr. Ollie Fein, past president of Physicians for a National Health Program (PNHP.org) remarked recently: Congress should have built on our proven Medicare model--accessible, evenly distributed, cost effective, and constitutionally sound. Thankfully, HR 676, "The Expanded and Improved Medicare for All Act," has been reintroduced in Congress. With a single payer health care system, we could replace health insurance companies with a single streamlined public agency that will pay all medical claims (much as Medicare works for our seniors today). Monies now going to corporate profits will go for needed care. I'm happy to note that my progressive Congressman, John Yarmuth (Ky-3rd) has signed on as a co-sponsor. As I write this, Secretary Sebelius is on the Diane Rehm show, trying to explain both the benefits and the shortcomings of ACA. Listeners have been pointing out the flaws in the legislation. Now the Secretay is trying to explain HHS' intent to increase oversight of insurers and curb premium costs. To that, I say, "Lottsa luck!" TNR readers may go to healthcare-NOW.org to find a single payer group in their region.
- hmseil01
March 23, 2011 at 10:49am
Very good. A couple of things you left out that help explain why we're not further along than we are. The MAJOR thing is the Republican/Tea-Party propaganda machine that characterizes the ACA as "Socialized Medicine", "A Fiscal Disaster", "Death Panels", "A Government Takeover", "Obamacare". Which has the paradoxical result that 55% of America is against "Obamacare", while 80% are for every policy in the actual bill. If you leave that out, you might think 55% of America is actually against the ACA -- but they're not. Instead they're against the distorted image the Republicans/Tea-Party keep putting out ABOUT the ACA. So, this is not a problem with the ACA that can be 'fixed' by changing the legislation. Obama, the Democrats, and America should all be made aware of that, if they're not already.
- AllanL5
March 23, 2011 at 12:40pm
Does anybody have confidence that Obama and his staff can craft a simple message, repeated over and over, that convinces middle America that HCR (ACA) is for them, that without it, even they are but one illness away from financial ruin? I didn't think so. Most middle Americans believe HCR benefits somebody else, but paid for by those same middle Americans. That's understandable, given the lousy job by the Democrats in selling HCR in 2009 and the violation of the Reagan Rule (front load the benefits, backload the costs). But if Reagan can convince middle Americans that lowering income tax rates will benefit them, it should be easy to convince middle Americans that HCR is for them. Unfortunately, Obama is no Reagan. For one thing, I don't believe Obama has his heart in it. Sure, he can give a fine lecture about the details of HCR, but not the simple message, repeated again and again, that convinces middle America that they need HCR, that they want HCR, that HCR benefits them. That's not Obama. And for another, I don't believe he will stake his re-election on HCR. What we need is a W.J.B., an F.D.R., or even a Ted Kennedy, somebody both impassioned about the cause and able to convey that passion to middle Americans. Call me negative, but I don't see a President who sends troops to battle while visiting Brazil as someone up to the challenge of selling HCR to middle Americans.
- rayward
March 23, 2011 at 12:43pm
What does going to Brazil have to do with selling HCR? I agree with Ray's broader point that Dems, including the president have done a really, really bad job of selling what should have been the shining accomplishment of this administration, but don't get the connection. Ray, are you trying to say that in general, this administration sucks at understanding the messages their actions send?
- NR409654
March 23, 2011 at 1:46pm
If the economy and job growth were roughly speaking at the same levels they were in 2007, the ACA would be resolutely popular. As it is, economically anxious Americans are going to be down on the law until their general economic anxiety has been relieved.
- wildboy
March 23, 2011 at 2:23pm
Nutz writes: "As I see it, this has never been a fight about medical care, otherwise we could solve it. It's a fight over ideology that will never end." Indeed you are correct. And thus it was more important than ever that both sides come together, identify the core principles that would drive insurance that both sides could agree upon: 1) Nobody should lose their home or go bankrupt due to health issues 2) Nobody should be denied insurance due to pre-existing conditions 3) Those that plan will receive better care 4) Health care will cost, but shouldn't cost anyone more than 8% or so of their earnings (in an exceptional year) or 2% or so in a recurring year. In other words, if you earn $50K per year, then delivering a baby (an exceptional event) should cost no more than $4500. If it's more than that, then gov covers it. If you require insulin (an unexceptional event for a diabetic), then anything over $1000 per year is covered by the government. This plan could have been very cheaply provided to everyone, and would have broad support from the population. The costs would have been very low. And then we can decide how we want to change the 8% and 2% figures. That is where the arguing would start. Lefties would want both figures to be 0%, and righties would want both figures to be much higher.
- seattleeng
March 23, 2011 at 5:31pm
"3) Those that plan will receive better care" Say what? So, people who are too disorganized, too poorly educated, or basically too normal to adequately anticipate future illness and plan for it financially should be punished by receiving inferior medical care? As a medical professional--that is as a person who considers it his duty to provide the best medical care possible regardless of his patients' financial condition, ignorance, self-destructiveness or general unpleasantness--I can't get on board with item 3.
- AaronW
March 24, 2011 at 11:49pm