The Affordable Care Act (ACA) has been under attack from its conception, and the issues that surfaced during its initial rollout have only fanned the flames around President Obama’s signature legislation. The GOP-controlled House voted 46 times to repeal the law. Then they shut down the government. Now opponents are lighting their torches with schemes to delay and defund. They point to a glitchy website, dropped “insurance plans,” and higher premiums as evidence of the legislation’s systematic failure. Nothing could be farther from the truth, and the ACA remains an important ethical and philosophical first step in improving healthcare in this country.
The failures of the current U.S. healthcare system accentuate the ACA’s significance. The ever-increasing costs and expenditures – coupled with the lack of viable coverage – span social and economic boundaries. Almost a third (30 percent) of adults ages 19-64 lacked health insurance in 2012, and an additional 30 million were underinsured and unprotected from high out-of-pocket costs. At over 2 trillion dollars a year, our nation’s healthcare expenditures constitute 17.6 percent of GDP (for public expenditures), or $8,233 per person per year.
No matter how you measure it, America pays enormous sums for what amounts to average care relative to other developed nations in the Organization for Economic Cooperation and Development (OECD). And much of that damaging cost is borne by citizens least able to afford it.
Ideally, a good healthcare system allows all citizens to obtain basic, essential care without fear of financial ruin. It is for this reason that all of the OECD’s developed countries have implemented universal healthcare; the sole exception to this rule is, of course, the United States. With a fragmented system that hides costs and neglects patient outcomes, it shouldn’t come as a surprise that the number one cause of bankruptcy in this country is healthcare expenses.
If America’s healthcare system is so broken, then why has it been so difficult to enact reform? Opponents criticize it as “socialized medicine.” But the ACA neither provisions a single-payer nor offers a public option. The plan itself is largely modeled off of Mitt Romney’s plan in Massachusetts. Even the idea of an individual mandate was originally proposed by The Heritage Foundation, a conservative think-tank, and swathed in the conservative hallmark of personal responsibility.
The reason for our failure to reform is twofold: the political influence of powerful interests and the underlying philosophies that we have historically applied to the idea of healthcare.
In an interview with The Politic, Dr. Howard Forman, a practicing radiologist and professor at the Yale School of Public Health, School of Management, and Department of Economics argued that “the main opposition to this bill is political not policy.” Dr. Forman, who has worked in the Senate as a health policy fellow on Medicare legislation, believes that the “fundamentals behind the bill are good fundamentals,” and that the ACA has come under fire due in part to “very deep-pocketed stakeholders.” The interest groups of medical device manufacturers, physicians, and hospitals have established “an enormous amount of inertia in keeping things the way they are.”
When asked about the effective health care reforms of other countries, including those undertaken by Mexico in the past few years, Dr. Forman pointed out the enormous portion of our GDP that is devoted to healthcare, and that change becomes more difficult with every passing year due to the power we invest in interest groups. “Everybody has a lobbyist,” he says, “And they all want to make sure that they come out ahead.”
Dr. Forman explains the higher premiums and dropped insurance plans that opponents frequently cite as the product of properly defining a minimum amount of coverage, and remarked that “a lot of these policies that are being cancelled by all rights shouldn’t have even been called health insurance.” In addition, the act creates “a marketplace that’s much more transparent” and “substantial enough subsidies for the poor and near poor” to offset costs for those in need, so that “almost everybody that participates in this is getting some net benefit.”
In addition to party politics and interest groups, American philosophies toward health care have shaped our current system. Other developed countries have established universal health care on the premise that health is a human right. Dr. Forman observes, “In most other countries the feeling is that healthcare is a necessity good, and in our country it is felt mostly as a luxury good.”
This lack of a “health care right” derives from a disconnect between equity – the idea of what is fair – and equality not present in other countries. David de Ferranti is the president of the Results for Development Institute, a Washington D.C.-based organization that focuses on issues such as global health in lower and middle income countries. In a lecture at Yale, de Ferranti compared the progress of other developed nations in healthcare to our own. When asked to explain the lack of universal coverage in the U.S., he remarked, “There is a huge tolerance for inequality in this country.”
This tolerance stems from the double-edged sword of individualism. An ideal of American culture, the concept of bootstrapping carries with it a unique sense of personal responsibility and control. This may explain why only 45 percent of Americans believe that poverty is a matter of circumstances out of one’s control, whereas 72 percent of Britons blame bad luck, social injustice, or the inevitability of modern life. The individualistic outlook neglects residents who cannot afford healthcare on their own. In this country, equity and equality of health have existed as profoundly distinct concepts. The ACA begins to challenge this separation, with the idea that even the poor should be able to afford at least a basic package of essential health services.
This widespread aversion to health reform in the United States is a 20th century development. Naomi Rogers, Associate Professor of History of Medicine at Yale, commented on the historical progression of health reform attitudes in an interview with The Politic. Before the nation developed the image of healthcare as a employer-delivered, monetized good, “the ideas around health insurance often were phrased as a kind of health right. Just as somebody had a right to unemployment insurance […] a person had a right to health care.” This was before World War II, when there were still efforts to add healthcare to social security
Then attitudes began to shift. “It’s really from after WWII that many people began to think of health benefits as something you get from your job,” explains Rogers, “Increasingly, people began to see health care less as a health right, and more as a question of money.” The wage freeze at the time prompted workers to ask for increases in health benefits rather than salary. In a 1960’s political campaign, American Medical Association physicians warned of “socialist healthcare” and stonewalled further government intervention. Rogers explains that since then, those who could not receive health insurance from their jobs were left out. “People who were unemployed, domestic workers, housewives: all these people were sort of forgotten.”
The ACA still operates under this employer-centric structure, which explains why liberal opponents attack Obamacare for not doing enough. According to Rogers, it doesn’t offer a complete fix and “simply does not cover everybody.” It also serves to illustrate the “interesting concept of health insurance rather than health right.” The ACA, passed under the scrutiny of stakeholders, is limited. At a certain point, Rogers asserts, “you really have to say: what about these people who are not covered?”
Ethically and philosophically, the ACA is an essential first step for America. Medicaid, expanded to include a federal entitlement based solely on poverty, could become a powerful new statement in health equity. The idea that adult non-parents living in poverty now have a federal right to Medicaid, explains Dr. Forman, is “a big change […] a philosophically important change to say that we believe poor people are entitled to some basic health care.” It’s imperative to note that, at its core, the ACA is profoundly American. “It’s not one size fits all. Poor people are still going to have poorer health insurance policies than rich people, which is part and parcel what the nation wants,” observes Forman.
Despite our progress, a host of challenges lie ahead. The ACA does not insure everyone. It remains to be seen how effective preventive medicine can replace emergency room visits. Our cost problems, though mitigated, still loom ahead. “If [the ACA] works, it buys us 30-40 more years of a functioning system,” Dr. Forman notes. Then again, “it remains to be seen how it all plays out. It doesn’t fix everything.”
The challenges of national health reform explain why these movements have generally taken a long time. de Ferranti argues that “the prime lesson from other countries, such as middle income countries and those in Europe, is that it takes at least ten years to get it right. [This] means getting started right away, because you’re going to have to go back and fix things.” Professor Rogers notes that Medicare and Medicaid had glitches and required amendments: “Why do we assume legislation is perfect?”
The path forward will not be an easy one. Machiavelli was correct in saying that “There is nothing more difficult to carry out, nor more dangerous to conduct, nor more doubtful in its success, than an attempt to introduce innovations.” But we must press onward. The Affordable Care Act will not cure all of our health care ills; it still leaves people uninsured, only temporarily curbs our costs, and it contains real problems that must be addressed. But its passage demonstrates that we as a nation have begun to move past historical precedent, to declare that nobody should go bankrupt from getting sick, and to reclaim health as a human right.