Though economics has always been a concern, there has also been an interest by many leaders over the years to provide health care to all U.S. inhabitants for humanitarian reasons. Franklin D. Roosevelt attempted to achieve it when he pushed through Social Security, but the insurance plank was defeated as it was “socialist”. His successor Harry Truman included the idea of universal health care in his Fair Deal, but that piece was eventually voted down because it was “socialist”. The idea gained new life with the election of Bill Clinton who submitted a comprehensive proposal developed by First Lady Hillary Clinton. It, too, failed to become law not just because it was “socialist”, but because it was associated with “her”.
Progressives never stopped pressing, however, and the issue was front and center again in the 2008 presidential campaigns. Candidates from both parties appeared poised to address health care reform, but Barack Obama was early in offering specifics. Essentially he wanted every American insured so that everyone could be healthy while at the same time address the ever rising costs of care. It was a plan based in large part on the Health Care Reform that Massachusetts had just implemented in 2006, under the leadership of then governor and Republican darling, Mitt Romney.
After the 2008 election, followed by two years of meetings with insurance representatives and medical professionals, considerable arm-twisting, many concessions and lots of presidential selling, the Patient Protection and Affordable Care Act (Affordable Care Act) became law in March 2010, though most elements would not take effect until 2014. The link above points to an in-depth summary of the act while the Kaiser Family Foundation ACA Summary is more succinct, but below is my attempt to summarize the high points:
- Provide all citizens and legal residents with health insurance through Medicaid or through private policies (provided either by employers or purchased by individuals), that have minimum “essential” benefits, no penalty or denial for pre-existing conditions and allow children to remain on their parents’ policy until they turn 26.
- Reduce national health care costs.
- Offer states a Medicaid Expansion plan that would raise the income limit for eligibility and provide 100% Federal reimbursement of the increased costs at the beginning, which would taper to 90% by 2020.
- Mandate (and incentivize with income-based subsidies), that all citizens and legal residents obtain health care coverage or incur a tax penalty.
- Mandate (and incentivize with tax credits and/or subsidies), that all companies provide employee coverage and penalized those who fail to do so, exempting companies with fewer than 50 full-time employees.
- Create a national exchange and encourage states to create their own exchanges where individuals and small businesses can shop for coverage.
- Contain or reduce health care-related costs by simplifying insurance administration, tweaking payment systems for both Medicare and Medicaid, enhancing efforts to eliminate waste and fraud, and shorten the approval time for generic drug availability.
Paid For by:
- An increased payroll tax on individuals earning more than $200,000.00 a year or couples earning more than $250,000.00 along with an increased tax on their unearned income.
- New fees from the pharmaceutical and insurance industries.
- A special tax on medical devices.
- Reduction of costs (see Implementation #5 above).
Republicans despised the law and vigorously fought its approval, but in March of 2010 they were the minority and Democrats believed that passing health care reform was worth risking losses in the 2010 mid-term elections. The casualties were realized that fall when Republicans took back control of the House of Representatives, nearly got the Senate and also won many state house and governors races. There were other factors in that poll, of course, like the perpetually low mid-year election turn-out for Democrats as well as it being the first opportunity some voters had to (re)act since a black man had been elected president.
Conservative lawmakers were incensed from the start. Few invoked “socialism”, however, as the final product was based on Romney-care, after all, and wasn’t a single-payer program. Instead, the most vocalized complaints were the mandates and the tax increases. There was also Sarah Palin’s declaration that the act would produce “death panels”; bureaucratic committees who would decide who would get care and who wouldn’t. So Republicans immediately launched a campaign to “Repeal and Replace” the ACA and for the next seven years repeatedly called for votes to either kill it, defund it or delay implementation, most of which failed.
The ACA was admittedly an imperfect plan. The major flaw, in this writer’s opinion, is that it did not result is a single-payer system, but it was at least movement. Many claim that there were major misrepresentations (“lies”, they call them), including “you can keep your current plan and your doctor” and that “premiums would stabilize before eventually going down”. While these may have been misrepresentations, it is possible that folk just failed to understand all of the implications of the voluminous act and had a limited ability to read tarot cards. The facts are, though, that 20 million more folk have health insurance today than did before the ACA and it has cost the federal government less than was predicted (New York Times – ACA Successes, Failures and Incompletes).
It has not, however, necessarily made health care more accessible. While insurance certainly protects against complete financial ruin due to catastrophic health issues, it does not guarantee easy or affordable access to a doctor or other basic care. While many employers were moving to High Deductible Health Plans (HDHP) even before the ACA, it has only gained popularity since the passage. One of the stated benefits associated with those plans is that it helps people understand the true costs of care and so they might slow their “over-use” of the medical system. That may be true, but for many gainfully employed individuals, coming up with $5,000 a year for non-preventative but very necessary doctor visits, testing and drugs is simply not an option.
Also, many insurers underestimated their profit margins or overestimated the number of young, healthy clients who would buy their policies, so in 2016 begin either implementing double-digit premium increases or completely canceling their offerings in some regions. Additionally, many of the 20-plus million people who gained insurance did so via Medicaid, which limits their access to a smaller number of providers and services, often resulting in the same “emergency room care” scenario as before.
So take some highly publicized weaknesses of the Affordable Care Act (all of which have undeniable personal consequences), cement conservative control of government by electing as President a non-ideological carnival barker who just wants to hear the crowds cheer and the stage appears to be properly set for HR 1628 (American Health Care Act).