The road to the passage of the PPACA was long, which initially included negotiations with Republicans, who apparently never had any intention of voting for anything that President Obama supported, even though they had a lot of input, including well over 100 amendments. Their obstructionism while feigning cooperation caused some aspects of the bill to be watered down, namely the absence of a public option, i.e. a "Medicare for everyone" option.
Part of the strategy of obstruction included egregious public lying about the details of the plan. The most memorable was the non-existent "death panels", which although thoroughly debunked, was believed and internalized by many people. Republican lawmakers and right-wing talk-show hosts and bloggers worked overtime to portray the details of the plan as inaccurately as possible.
Most of the opposition to the bill was ideological or political rather than practical. The bill, later the law, addressed many of the problems with our healthcare system: eliminating exclusions for pre-existing conditions, eliminating lifetime maximums, eliminating the option of insurers to drop you when you most need it, requiring that all insurance plans have minimal essential coverage, the setting up of health care insurance marketplaces where consumers could compare the different plans to make intelligent choices, offering subsidies for low- and middle-income people in order to make insurance more affordable.
It's difficult to be seriously against any of these provisions.
To be sure, there were problems. One of President Obama's promises was that you would get to keep your current insurance if you liked it. This turned out not to be true. Not because the government was overtly forcing you to change insurance, but because many policies did not meet the PPACA's requirements and, rather than fixing the plans, the insurance companies eliminated them. This is one of the clubs that today's Republicans are using to bludgeon the PPACA and kill it.
A second problem was that a central part of the law required states to expand Medicaid. The Supreme Court ruled that this was not constitutional and 19 states decided to not expand Medicaid, leaving many people out in the cold. (The plan was that anyone who was earning less than 139% of the poverty level would be eligible for the expanded Medicaid coverage, anyone with 140-400% of the federal poverty level income would be eligible for subsidies). Since the law assumed that anyone whose income was less than the poverty level would be able to get Medicaid, there was now no provision for people who needed it most to be able to get coverage, or even qualify for subsidies. By the time this Supreme Court ruling came down, the Democrats had lost control of Congress and a change in the law to fix this problem was impossible.
Another problem, one that I also view as more ideological than pragmatical, was the requirement that everyone have insurance or pay a penalty. This, surprisingly to many, was ruled constitutional by the same Supreme Court, however, it angered a lot of people who felt that they shouldn't have to buy insurance if they didn't want to, especially those who were already penalized by the Medicaid non-expansion. The people who are against this requirement fall into two categories. The first, is as I opened this paragraph with, ideological. People who have insurance, or are wealthy enough not to have to worry about medical expenses, but believe that requiring people to have insurance is an infringement on freedom. The other category consists of people who, cannot afford insurance, even with subsidies, or have decided that their money is better spent elsewhere. But insurance is all about shared risk. When you're young and healthy, you don't need, or don't think that you need insurance, but when you're older, or when calamity strikes, then you need it. This whole concept seems to elude many people.
Finally, in 2016, premiums and deductibles started to increase greatly, insurers also started leaving the marketplace leaving some areas without a plan eligible for subsidies.There were several reasons for this. One was that many people chose to pay the penalties, which were still fairly low, rather than buy insurance. Another was that the initial premiums were based on estimates of participation that turned out to be overly optimistic. Insurers started dropping out due to lower than acceptable profits and the uncertainty engendered by the Republicans insistence on repealing PPACA and finally Trump's election.
President Trump's and the Republicans' opposition to the PPACA, when not purely political, focuses mainly on the rising premiums and deductibles. Despite being cast as failing, imploding, exploding, a disaster and any other negative description that you can think of, the PPACA is for the most part, doing what it was designed to do: bringing affordable, comprehensive health care to millions of Americans who previously couldn't afford it. Republican opposition to the PPACA has always been based on the fact that it was Obama's baby, and they were hell-bent on obstructing everything that he did. In my opinion the focus in the last year on premium and deductible increases is merely an excuse.
The Republicans have talked about repealing the PPACA for the last seven years; during the 2016 presidential campaign they started talking about, not only repealing, but replacing, since they realized that many of their constituents were benefiting for the PPACA. But when the opportunity presented itself, it became apparent that they had squandered those years and had quickly cobbled together a bill that did a lot of harm and did good only for the wealthy.
Okay, premiums are going up; but the questions that no one is asking are "What would the premiums be if the PPACA had never been enacted?" Since those who are below 400% of the federal poverty line qualify for subsidies, the rate increases pertain to those who are above that amount. Of those who are earn more than that, what percentage are buying individual, and not group, insurance? It's that small percentage who are bearing the brunt of the increases.
So what needs to be fixed?
- Costs: One of the reasons premiums go up is that the ratio of older/sicker people to younger/healthier people is too high. The individual mandate was supposed to fix that, but the penalty isn't high enough to persuade someone to buy insurance if they don't want it and there are way too many exemptions. There is no mechanism for people to have to prove that they have insurance. Getting everyone in the risk pool will allow insurance companies to remain profitable and keep costs down. Increase the penalties, eliminate exceptions, tighten monitoring.
- Costs again: Trump says that he has a brilliant plan to reduce premium costs by increasing competition. I don't think there is any such plan, but if there is, go for it. Part of this alleged plan is to allow insurance to be sold across state lines, which is already legal and encouraged under PPACA. The House bill that was passed and now the Senate bill that is being considered do not address this at all.
- People just on the other side of the subsidy cut-off? Increase subsidies
- Find a way to cover the people who cannot get affordable coverage because their state did not approve Medicaid expansion. Put pressure on Republican governors or find a way to expand coverage federally.
- Insurers leaving the marketplace: Require all plans to be offered on the Healthcare exchanges, possibly loosen the requirements of what has to be offered in each plan. This would allow for a wider range of options, but would give consumers a better tool for comparing all policies and give eligibility for subsidies for any and all policies.
Understand that the American Healthcare system is very complex with many moving parts. There is no simple fix, despite political posturing to the contrary.
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