In 2010, the Affordable Care Act was passed by the Congress and was signed into law by President Obama. The House, Senate and President were all Democrats.[i] Since then, a significant portion of the United State population has voiced disapproval of the act. Some of the opposition has been simply a partisan political party disagreement in basic approaches to government. The underlying premises of the law, improving the delivery of healthcare and making it available to the whole country are hard to argue against. Much of this bill had origins in the Republican law in Massachusetts, known as RomneyCare after the Republican Governor who proposed and shepherded health care reform[ii]. The passage of PL111-148 involved what was perceived as stampeding the bill through congress. With Senators Daschle and Kennedy no longer in the senate, the Democrats bypassed the possibility of a Republican filibuster, by using a maneuver called reconciliation or by changing the Senate Rules[iii]. One highly visible portion of the bill mandated that everyone have some form of insurance or pay a penalty[iv]. This was intended to ensure that insurance did, in fact, spread health care cost risks over the whole country. To allow people to have a marketplace for buying insurance, the bill encouraged states to establish purchasing cooperatives for individual insurance. This was to be accomplished through the establishment of government run “exchanges”. There were also many other aspects of the provision of healthcare that involved federal and state governments supervising or mandating (hopefully improving) various components of care.
Administrative problems surfaced as the roll out of the insurance exchanges began in 2013. Many of the buyers participating in the exchanges were those who did not have employer based or government sponsored insurance[v]. Despite a section[vi] of the bill that was supposed to simplify the language of insurance[vii], many of the various insurance options were difficult to read and understand. People didn’t appreciate the differences in coverage provided by the various levels of plans[viii]. Insurers were hesitant to support the exchanges, and often did not offer products on many of the state based exchanges. Many of those that did offered policies that covered care only through what are called “narrow networks” of physicians. This meant that at least a significant number of people who liked their doctors were not able to keep them[ix]. In 2016 it appeared that some of the problems associated with the functioning of the exchanges and insurance company participation were on their way towards resolution. A second major complaint against the bill was that it seemed to impose a number of governmental regulations/restrictions on some providers, especially health insurance companies. These entities had done some “bad things” in the past, in the name of business practices (maximization of profits). These included charging premiums for “pre-existing conditions” and putting arbitrary limits on how long the insurer was liable to provide payment for a patient condition. In addition, the practice of rescission was rampant, causing people who thought they were insured to be responsible for medical bills that they had believed were covered. In order to ensure that insurance would cover certain basic services, the Bill proposed a series of “Essential Health Benefits”. These included:
Essential Health Benefits in PL 111-1148
|1. Ambulatory Services
|6. Prescription Drugs
|2. Emergency Services
|7. Rehabilitative Services
|8. Laboratory Services
|4. Care for Pregnancy, Maternity and NewBorn
|9. Preventive and Wellness Care
|5. Mental Health Care including Substance
|10. Pediatric Care
There were things that were NOT included in the initial bill. Abortion was not included, nor was birth control specifically covered[x].
In addition, the bill limited the profits that insurers could realize. This was in the form of what was called a “Medical Loss Ratio”. For most insurers the MLR was pegged at 85%[xi].
The concept of spreading risk amongst the whole population by mandating that everyone in the country buy insurance (Individual Mandate) was immediately attacked as Congressional overreach. The Supreme Court got involved and eventually ruled that a special tax could be imposed by Congress, on those who elected/chose not to “play” in the health care insurance concept.
As the bill was being crafted, there was a significant amount of disinformation being promulgated. One of the worst pieces of misinformation that sought to discredit the bill was the concept of “Death Panels”. This term was used as a descriptor of the concept that insurers pay doctors or other health care professionals a fee for discussing with a patient what his/her wishes for end of life care. This would allow the discussion to be had while the person was in full command of his or her senses. Two women, Betsy McCaughey and Sarah Palin, fueled this misrepresentation of the spirit of the mandate to allow physicians to discuss end of life care, as “the government” supporting euthanasia. There was nothing in the bill to support that contention. In 1993 similar mischaracterizations of the Clinton “Health Security Act of 1993” was being proposed. The “Harry and Louise” advertisements misrepresented the tenor of the proposed health care plan and helped solidify opposition to the legislation[xii].
People also objected to allowing the Centers for Medicare and Medicaid Services to study ways of paying for and delivering care, which was proposed by the formation of the Centers for Medicare and Medicaid Innovation.
Almost all of the objections to the bill might be characterized as objections to government participation in the delivery of healthcare (payment, business practices, and provision of care). This was branded by many as “Socialism” and political posturing. It is even possible that some objected to Mr. Obama himself and did not want to support anything that he proposed[xiii]. Some objections were simply mischaracterization or misunderstanding of parts of the law.
[i] Most of the major bills relating to social welfare, including healthcare have been sponsored by the Democratic Party (Social Security in 1935, Titles XVIII & XIX (Medicare and Medicaid in 1965; The Affordable Care Act 2010). Republican congresses and Presidents made many meaningful revisions to these laws.
0[ii] https://www.mass.gov/info-details/health-care-reform-for-individuals accessed 7/11/2109
[iii] Changing the rules was called “the Nuclear option”
[iv] This provision is directly from Republican Massachusetts program. In fact, two of the Republican “Repeal and Replace” bills of 2018 had a similar provision, where if someone didn’t have continuous coverage (with a few caveats), insurers could charge a surcharge, for at least a year, on any policy that someone wanted to buy
[v] Government based insurance included the armed services and dependents, Veterans covered under the Veterans’ Health Administration and Medcare (Title XVIII of the Social Security Law) and Medicaid (Title XIX), Children’s Health Insurance Program and the Indian Health Service. These programs actually insure somewhere between 33-45% of all Americans. https://www.center-forward.org/wp-content/uploads/2012/04/Medicare-Medicaid-and-the-Military-04-12-update-2.pdf accessed 7/9/2019 https://www.crfb.org/papers/american-health-care-health-spending-and-federal-budget accessed 7/9/20190
[vi] Section 2715: “Development and Utilization of Uniform Explanation of Coverage Documents and Standardized Definitions”:
[vii] The simplification of language was not meant to take effect until late 2017, at least three years after the implementation of the exchanges. It is not clear that the readable Summary of Benefits and Coverage (SBC) provisions of the act have ever been fully implemented.
[viii] The basic plans were “Bronze, Silver, and Gold”. Each was more expensive than the next. Each had different deductibles and co-pays. In addition, each more expensive, program had fewer restrictions on what was “covered”.
[ix] This made President Obama appear to be going back on his promise of, “If you like your Doctor you can keep your Doctor”. (It might behoove politicians to remember that definitive statements like this and “Read my lips. No new taxes” often come back to bite the speaker).
[x] The “Birth Control Mandate” was added by a rule promulgated in 2013 related to “Women’s preventive health services” as put forth in guidelines supported by the Health Resources and Services Administration (HRSA). https://www.govinfo.gov/content/pkg/FR-2013-07-02/pdf/2013-15866.pdf accessed 7/8/2019
[xi] That meant that insurers had to pay out 85% of premium income for medical expenses. Fifteen percent was left for S, G, & A expenses and “profit”. This effectively would have limited the salaries paid to various executives.
[xii] The “Harry and Louise” ads were supported by the Health Insurance Association of America and are said to have torpedoed the HSA of 1993. https://adage.com/article/rance-crain/clinton-era-ads-harbinger-today-s-health-care-mess/245312#author_bio_box accessed 7/8/2019
[xiii] Many of the Republican postures relating to Mr. Obama including the birtherism controversy, and the Senate’s refusal to even consider Merrick Garland’s nomination to the supreme court are two blatant examples of this.