Nobody Should Be Celebrating the Affordable Care Act
By David Sirota and Andrew Perez, Jacobin
13 June 21
Presidents Obama and Biden yukked it up this weekend in a video celebrating
the Affordable Care Act. But the real thrust of Obamacare was always finding
ways to pretend to address the health care crisis while protecting the
health insurers fueling it.
In fortifying for-profit health care companies, the Affordable Care Act
became a cautionary tale about the political supremacy of an insurance
industry that many Americans hate. But it has now become something even more
profound: the ACA's modest popularity, forged in desperation, proves that an
initiative can now be considered a political "win" even as it preserves a
problem, steamrolls alternatives, and makes a crisis more difficult to fix.
In essence, a policy sold on the "audacity of hope" has helped deflate hope
for anything better.
This past weekend, winning and hope were the big messages from the White
House, where President Joe Biden and former president Barack Obama released
a video celebrating the news that a record thirty-one million Americans are
now getting their health insurance coverage through Affordable Care Act
exchanges and an expanded Medicaid.
There's a lot of laughing and yukking it up in the video - it has the corny
vibe of a nineties buddy-reunion comedy flick, and in this case, the intent
is to gaslight. You're supposed to walk away from the Instagram-optimized
clip feeling like everything is going in the right direction - and most
importantly, feeling like "the ACA works," as Sen. Chris Murphy (D-CT)
triumphantly declared.
Now sure, the ACA has been working to boost insurance industry profits and
executive pay - indeed, as millions of Americans lost their health insurance
last year, six health insurance CEOs were paid a combined $120 million.
Those winnings are also working for politicians - some of those riches have
been recycled into more than $150 million of insurance industry campaign
donations funneled to Democrats since Obamacare was first enacted.
But the Democrats' signature health care law is not working nearly as well
to address the health care crisis that is quietly exploding across the
country.
The ACA "Works" Best for Insurance Companies
Amid all the triumphalist rhetoric about the ACA, consider a few data
points:
The uninsured rate in America has steadily increased over the last several
years. Nearly thirty million Americans were uninsured in 2019, according to
Census data.
Eighty percent of Americans told Gallup that they have not seen their health
insurance premiums decline since the passage of the ACA - and 50 percent say
they fear being medically bankrupted.
Medical claim denial rates have been skyrocketing. Insurers reject more than
one out of every six health insurance claims made by patients on ACA
exchange plans.
Reuters recently reported that while the uninsured rate is lower than it was
two decades ago, "the proportion of adults unable to afford doctor visits
climbed from 11.4 percent to 15.7 percent."
"Annual family premiums for employer-sponsored health insurance rose 4
percent to average $21,342" in 2020, according to data from the Kaiser
Family Foundation.
Among those with employer-based health care coverage, "About one in five say
that someone in their household has been contacted by a collection agency in
the past 12 months because of medical bills, and 9 percent say they have at
some point declared personal bankruptcy because of medical bills," according
to a 2019 Los Angeles Times/KFF study.
To be sure, the simple, straightforward expansion of Medicaid was the best
part of the original law. But by its own authors' admission, Obamacare went
out of its way to try to halt the larger push for a single-payer system,
because in the words of Obama Health and Human Services secretary Kathleen
Sebelius, they believed "dismantling private health coverage for the 180
million Americans that have it, discouraging more employers from coming into
the marketplace, is a bad direction to go."
The real thrust of the ACA has always been to find ways to pretend to
address the health care crisis while enriching the health insurers that are
fueling it.
The law spends hundreds of billions of dollars on such subsidies, and the
American Rescue Plan expanded who's eligible for subsidies. Those
expenditures are touted for somewhat decreasing people's premium costs - and
indeed, more than one million Americans recently signed up for ACA exchange
policies. But subsidizing coverage only limits the premium costs people pay
themselves, with the government picking up the rest, on what are expensive
plans. Overall health care costs remain sky-high.
While the new ACA sign-ups were celebrated as an enormous victory, many more
Americans lost their employer health insurance coverage during the COVID-19
pandemic. And left unsaid by all the fist-pumping, high-fiving,
self-congratulation from pro-ACA politicians is the fact that the ACA
exchange plans that more and more Americans are being forced into also tend
to feature excessive out-of-pocket costs - meaning many people are being
shuffled onto plans they can't actually afford to use.
Health insurers saw their profits boom during the pandemic last year, too,
while millions lost their job-based health insurance coverage and people
avoided going to doctors and put off elective procedures.
Overall, a decade into the ACA's attempt to prop up and promote corporate
health insurers, "individuals with private insurance were more likely to
report poor access to care, higher costs of care, and less satisfaction with
care compared with individuals covered by publicly sponsored insurance
programs," according to a study by California researchers just published in
the Journal of the American Medical Association.
Put it all together, this data shows the ACA works in the same way a train
robbery works - it works really well for the thieves but not so well for the
passengers.
Demoralization, Tribalization, and Health Care Surrender
People generally understand their insurance company is out to screw them.
About a third of unvaccinated Americans believe they "might have to pay an
out-of-pocket cost to get the COVID-19 vaccine," even though it's free,
according to recent survey data from the Kaiser Family Foundation.
And yet here's the thing: many of the passengers seem fairly content with
the heist - or at minimum, grateful that it's just larceny and not an
execution.
Gallup recently found that even as health care costs continue to increase,
more Americans are now saying they are satisfied with what they're paying.
When it comes to the ACA in specific, KFF's most recent polling found 53
percent of Americans view the program favorably.
Some of that can be attributed to the varied and nebulous understanding of
what the ACA hodgepodge actually is. Some understand it primarily to be just
a long-overdue prohibition on denying coverage to people with preexisting
conditions. Some view it as just subsidies for slightly lower premiums. Some
perceive it as the devil they know that's safer than the devil they don't.
And some see it as at least modestly better than the Republican agenda of
just sending people to the glue factory when they get sick.
Fair or unfair, justified or unjustified, the bottom line is this: after a
decade of Democratic Party propagandizing and GOP offering no alternative at
all, the ACA remains somewhat popular. The support is thin - lots of polls
show Americans want to see the program improved - but there's no denying
that it has support, even as it has politically fortified an abusive,
for-profit insurance industry.
Of course, the ACA has helped make sure more people are able to get ripped
off on medical care rather than get completely cut off from the entire
medical system. In that sense, the ACA is better than nothing at all, just
like a train robbery is better than being thrown off the back of the
caboose.
But the ACA's modest popularity reflects demoralization and tribalization at
least as much if not more than it reflects genuine satisfaction with the
existing system.
After decades of watching other industrialized countries establish
functioning universal health care systems and our government continue to
prop up a system based around corporate health insurance, many Americans
have concluded that nothing will change, that even tiny improvements are a
huge win - and that policies like the ACA that are billed as
transformational don't transform much at all. Meanwhile, in a nation where
public policy is now just fodder for the red-versus-blue bloodsport, any
mention of ACA shortcomings is often seen first and foremost as betraying
the blue team, so the program's popularity is further bolstered by home-team
spirit.
The popularity that has accrued to the ACA doesn't exist in a vacuum. As the
law itself enriches insurance companies and thereby strengthens their
political power to block structural reform, Obamacare's modest popularity
further bolsters insurers by reducing the public demand for change.
For example, Americans' contentment with the crumbs offered by the ACA goes
a long way in explaining why even something as minimal as a public health
insurance option has become a political laughingstock akin to the football
in the famous Charlie Brown-Lucy scene.
For a decade, the Democratic Party and its allied liberal groups in
Washington have been able to beat back discussion of universal health care
by pretending they support a public option to compete with private insurers
- and then they have inevitably cast aside the proposal when they regain
power. This is what happened in 2010, and what is now happening again after
Biden abandoned his public option promise in favor of a health care policy
quite literally written by insurance industry lobbyists.
"The health insurance public option might be fizzling. The left is OK with
that," NBC News reported over the weekend. "Joe Biden campaigned on making
the public option a reality, but so far, he's done little to get Congress to
enact one. Instead of outrage, influential progressives seem to be OK
watching the promise go unfilled, preferring to pursue universal health care
through other means, like expanding Medicare eligibility."
The public option betrayal is indirectly linked to ACA popularity: sure,
public option promises helped Democrats win elections, but they pay no price
for abandoning those promises because hey, everything's totally fine and
here's a tweetable Biden-Obama ACA commercial to prove it.
The same dynamic is at play with proposed Medicare expansion and
full-fledged Medicare for All. Like a public option, those policies may be
conceptually supported by a majority of Americans, but it's been a
half-century since the creation of Medicare.
That's a half-century of insurance industry hegemony in American politics -
a half-century of the country being conditioned to expect that when it comes
to health care, nothing can fundamentally change. All those years have
taught successive generations that even if we may like the idea of big
changes, we should just be content that the ACA protects people with
preexisting conditions, lets more people buy bad insurance, and preserves a
predatory health care system that "only" bankrupts half of all cancer
patients.
Perhaps that perception is correct. Perhaps America's government is so
uniquely corrupt and singularly captured by the health care industry that
our most enduring form of exceptionalism will be permanently remaining the
only industrialized country to not guarantee medical care to all people.
But as resigned as many may be to an eternity of ever-increasing medical
bills, that doesn't have to be our destiny.
We don't have to reward inadequate policies with favorable opinion polls.
Regardless of slick White House videos or football-spiking tweets from
senators, we don't have to believe it is some enormous victory that millions
of people were thrown off their employer-based health care but at least some
of them were able to get crappy coverage on for-profit insurance exchanges
that involve high out-of-pocket costs and high claim denial rates.
In short, we don't have to just accept that the best we can hope for is a
policy that funnels more cash to private insurance companies in exchange for
smaller and smaller discount coupons for more and more expensive medical
care.
Perceiving that downward spiral as normal and laudable is a choice by
elected officials, by party powerbrokers, and by voters - and it is a choice
we can reject.