Health Insurance and the Affordable Care Act ("Obamacare").
Issue:
Healthcare insurance in the United States is a national disgrace. It was tragically deficient prior to the enactment of the Affordable Care Act, or "Obamacare" ("ACA") and it remains to be seen whether the ACA will suffice as reform. The ACA is both hailed as our salvation and derided as a confusing mess that - at best - takes wildly insufficient or inappropriate steps toward true reform, harms businesses and workers and imposes an unconstitutional obligation upon citizens.
What has not changed with the ACA's passage is this: the cost of healthcare insurance is a financial burden for millions of people and puts truly sufficient health care out of reach for millions more - and ensures that even the insured often lack adequate coverage.
Deception:
Ironically, the now legendary problems during the launch of the ACA website amply illustrate the two most egregious deceptions surrounding healthcare insurance:
• the claim that the private sector should have a role in healthcare insurance, and
• the claim that the ACA is preferable to a universal, public healthcare insurance system operated by the U.S. government, referred to here as "single-payer" (meaning that the single payer of any person's healthcare expenses would be the U.S. government).
Though the functionality of the website has improved, its failures illustrate the fundamental deficiencies of both the former and current healthcare insurance systems in the United States.
Reality:
Healthcare for all is essential to a prosperous and just society to the same degree as public safety, mobility, education, assured retirement funding and access to justice. The safety, complexity, necessity and cost of healthcare dictate that its quality and cost be regulated so as to ensure that all citizens have affordable access to effective treatment. The question is this: how can the financial costs of healthcare be regulated and covered so that its availability is sufficient and fair for all?
While the nation wastes its time debating the deeply flawed ACA, the true solution to our healthcare insurance crises has been lost in the noise of the squabble between a Congress bought off by the healthcare insurance industry, a President weakly committed to reform, a press more interested in the politics than the issue, and a deeply mis-led public.
Our pre-ACA healthcare insurance system was a tragic burden foisted upon the United States population by Congress and business and negatively affected all patients and their families with its various limitations on healthcare availability and its often outrageous and unaffordable costs. At the same time, it benefited business by funneling vast amounts of wealth into the pockets of those who provide no direct healthcare benefit or who provide healthcare of inferior quality - and those pockets are worn by everyone from insurance companies to drug companies, public relations firms, advertisers, equipment manufacturers, lobbyists and large hospital corporations.
Though the ACA does make some improvements to the accessibility of healthcare insurance the improvements are not nearly enough - and the extent to which it may make healthcare insurance more affordable is heavily dependent on an individual's circumstances. The ACA policies are proving in many instances to be more expensive than insurance under the previous options and at least as complex. The ACA does nothing to remove the cost added to policies to cover insurers' profits, nor does it remove the bureaucracy of the claims process.
Largely in place as of January 1, 2014, the ACA is apparently the best effort of a Congress and Administration for whom healthcare insurance was a political, not personal concern, as Congress and their staffs enjoyed the benefits of a healthcare insurance plan for federal employees subsidized by tax-payers. In response to subsequent political pressure the ACA was amended to force Congress members into the same insurance exchanges as the rest of us, but their salaries of $174,000 per year mean that they, unlike the average citizen, are not financially burdened by the high costs of health insurance. In their wonderworld of isolation from the financial realities of the average person, Congress created a monstrous healthcare insurance bureaucracy designed to appease the population shy of the point of alienating their big-money campaign contributors in the heathcare insurance industry and those voters still hostile to, and ignorant of, the benefits of government-provided single-payer healthcare insurance for its citizens.
There are numerous problems with the ACA legislation, the first of which is its genesis as the offspring of a shotgun wedding. Neither house of Congress put any passion into finding a truly effective solution to the national disgrace of our pre-ACA healthcare insurance system - and the Obama Administration was dragged to the altar, first as begrudging matchmaker between the feuding parties and second as duty-bound officient. While the credit for goading the Obama Administration and Congress into passing healthcare insurance legislation may be assigned first to Representative Nancy Pelosi of California, at the time the Speaker of the House, the credit for fashioning a truly effective and affordable healthcare insurance system for all citizens goes to no one - because the ACA falls far short of this goal.
Regardless of its beginnings or the intentions of its crafters, this act does not make the dramatic changes necessary to bring affordable healthcare and healthcare insurance to everyone. Comparing the ACA to the failings of the previous system we find that overall improvement is dubious, woefully inadequate and varies wildly by individual (see the second part of this essay below, "Deception Explained"). To this sad state of affairs we add a profoundly disturbing feature: the ACA forces citizens - for the first time in U.S. history - to purchase a product (healthcare insurance) from private industry regardless of one's situation, assets or station in life (see "Deceptions Explained" in the second part of this essay below for the case against the mandate).
The Case Against ACA and For Single-Payer:
We can argue all we want regarding the problems, shortcoming and promise of the ACA but this is barking up the wrong tree. The ACA's first and foremost failure is that it fails to remove the cost of insurance industry profit from our healthcare system.
Certain essential commodities and services are affordable and readily obtained when left to market forces - such as groceries, clothing, automobiles and information - but even these are often subsidized by the government, indirectly for all (through government subsidies to businesses and through tax deductions to both businesses and individuals) or directly for those with low or no income. Other essential commodities are either provided to all through government non-profit operations or by a market highly regulated to ensure maximum availability and affordable cost - such as water, police protection, mass transit (including airlines), farming, sanitation and oil.
It goes without saying that a healthy population, like a safe population, is a worthy and critical investment in civil society - for a healthy population is essential to the productivity and security of our community. Healthcare is an essential service that should be available to everyone through non-profit insurance that supports both non-profit and for-profit health care providers (doctors, nurses, community hospitals, pharmaceutical houses, equipment manufacturers etc.).
The current mix of for-profit and government insurance, privately- and publicly-run healthcare facilities and a pharmaceutical industry held virtually unaccountable for its costs is, by contrast, simply unsustainable - which is why millions of citizens continue to go without essential healthcare or are suffering the harm of insufficient healthcare. The ACA does little to move us away from this model toward an efficient, streamlined and affordable system. As well, the ACA fails to eliminate the use of employer-sponsored healthcare insurance plans for employees. These plans constitute the single-largest tax-deduction expense to the U.S. Treasury, an inequitable wealth transfer that exceeds the cost to taxpayers of even the home mortgage deduction. In so doing constitutes a tremendous expense to business, employees and taxpayers.
The ACA is a bad solution to a worse problem. It does little more than codify the previous market for healthcare insurance, aside from adding a few additional critical regulations on the for-profit healthcare insurance business. It has gained approval from many citizens and Congress members due to its appearance as a reform of the private insurance market, but it is not what it may seem. It is nothing but a legal requirement that citizens patronize the private for-profit insurance business while imposing a few new obligations on those businesses in return for the increased profits they realize from a substantial increase in customers.
Resolution:
Healthcare insurance should be provided by one entity - the federal government - that would tax all citizens to provide insurance to everyone regardless of age, race, sex, income, place of residence or health history; make fair payment to healthcare providers for consistent care and costs; eliminate the costly insurance, claims and payment bureaucracy, and fashion a national program of cost containment that ensures all healthcare providers are compensated fairly for their contribution to our health - whether they be for-profit companies or non-profit entities.
Think this sounds fantastical? Such models are successful in many countries and are available for us to customize for our society. Healthcare coverage could be structured similarly to Social Security, a highly successful program despite the many claims to the contrary. Like retirement, public safety and public services, basic healthcare can be best provided to all citizens under a single-payer system free of the middleman curses of profit and red tape. It would bring all citizens into one program, ensuring the inclusion of the healthy as well as the ill - which is necessary for the system's solvency.
Related Essay: Social Security
People and institutions who provide actual healthcare deserve to make a living but insurers do not deserve to profit off healthcare except perhaps where individuals choose non-essential elective care. Like Social Security, which ensures all citizens a decent retirement income without profit to investment brokers but which allows the brokerage business to flourish by serving those who elect to invest beyond their Social Security contributions, a single-payer healthcare insurance system would provide a lower-cost, profit-free standard of care while allowing citizens the choice to supplement their insurance through private, for-profit insurance brokers.
Single-payer is not a pipe dream. Though it is repeatedly dismissed by politicians, pundits, pollsters and profit-makers as unrealistic - and the public largely accepts their deception - it can be accomplished with enough political will. Creating a single-payer system will require that Congress look to the needs of people rather than the profits of business. The "public option" should be the "Public Health Trust", a single-payer system that ensures each and every one of us affordable, quality health care throughout our lives.
Healthcare insurance in the United States is a national disgrace. It was tragically deficient prior to the enactment of the Affordable Care Act, or "Obamacare" ("ACA") and it remains to be seen whether the ACA will suffice as reform. The ACA is both hailed as our salvation and derided as a confusing mess that - at best - takes wildly insufficient or inappropriate steps toward true reform, harms businesses and workers and imposes an unconstitutional obligation upon citizens.
What has not changed with the ACA's passage is this: the cost of healthcare insurance is a financial burden for millions of people and puts truly sufficient health care out of reach for millions more - and ensures that even the insured often lack adequate coverage.
Deception:
Ironically, the now legendary problems during the launch of the ACA website amply illustrate the two most egregious deceptions surrounding healthcare insurance:
• the claim that the private sector should have a role in healthcare insurance, and
• the claim that the ACA is preferable to a universal, public healthcare insurance system operated by the U.S. government, referred to here as "single-payer" (meaning that the single payer of any person's healthcare expenses would be the U.S. government).
Though the functionality of the website has improved, its failures illustrate the fundamental deficiencies of both the former and current healthcare insurance systems in the United States.
Reality:
Healthcare for all is essential to a prosperous and just society to the same degree as public safety, mobility, education, assured retirement funding and access to justice. The safety, complexity, necessity and cost of healthcare dictate that its quality and cost be regulated so as to ensure that all citizens have affordable access to effective treatment. The question is this: how can the financial costs of healthcare be regulated and covered so that its availability is sufficient and fair for all?
While the nation wastes its time debating the deeply flawed ACA, the true solution to our healthcare insurance crises has been lost in the noise of the squabble between a Congress bought off by the healthcare insurance industry, a President weakly committed to reform, a press more interested in the politics than the issue, and a deeply mis-led public.
Our pre-ACA healthcare insurance system was a tragic burden foisted upon the United States population by Congress and business and negatively affected all patients and their families with its various limitations on healthcare availability and its often outrageous and unaffordable costs. At the same time, it benefited business by funneling vast amounts of wealth into the pockets of those who provide no direct healthcare benefit or who provide healthcare of inferior quality - and those pockets are worn by everyone from insurance companies to drug companies, public relations firms, advertisers, equipment manufacturers, lobbyists and large hospital corporations.
Though the ACA does make some improvements to the accessibility of healthcare insurance the improvements are not nearly enough - and the extent to which it may make healthcare insurance more affordable is heavily dependent on an individual's circumstances. The ACA policies are proving in many instances to be more expensive than insurance under the previous options and at least as complex. The ACA does nothing to remove the cost added to policies to cover insurers' profits, nor does it remove the bureaucracy of the claims process.
Largely in place as of January 1, 2014, the ACA is apparently the best effort of a Congress and Administration for whom healthcare insurance was a political, not personal concern, as Congress and their staffs enjoyed the benefits of a healthcare insurance plan for federal employees subsidized by tax-payers. In response to subsequent political pressure the ACA was amended to force Congress members into the same insurance exchanges as the rest of us, but their salaries of $174,000 per year mean that they, unlike the average citizen, are not financially burdened by the high costs of health insurance. In their wonderworld of isolation from the financial realities of the average person, Congress created a monstrous healthcare insurance bureaucracy designed to appease the population shy of the point of alienating their big-money campaign contributors in the heathcare insurance industry and those voters still hostile to, and ignorant of, the benefits of government-provided single-payer healthcare insurance for its citizens.
There are numerous problems with the ACA legislation, the first of which is its genesis as the offspring of a shotgun wedding. Neither house of Congress put any passion into finding a truly effective solution to the national disgrace of our pre-ACA healthcare insurance system - and the Obama Administration was dragged to the altar, first as begrudging matchmaker between the feuding parties and second as duty-bound officient. While the credit for goading the Obama Administration and Congress into passing healthcare insurance legislation may be assigned first to Representative Nancy Pelosi of California, at the time the Speaker of the House, the credit for fashioning a truly effective and affordable healthcare insurance system for all citizens goes to no one - because the ACA falls far short of this goal.
Regardless of its beginnings or the intentions of its crafters, this act does not make the dramatic changes necessary to bring affordable healthcare and healthcare insurance to everyone. Comparing the ACA to the failings of the previous system we find that overall improvement is dubious, woefully inadequate and varies wildly by individual (see the second part of this essay below, "Deception Explained"). To this sad state of affairs we add a profoundly disturbing feature: the ACA forces citizens - for the first time in U.S. history - to purchase a product (healthcare insurance) from private industry regardless of one's situation, assets or station in life (see "Deceptions Explained" in the second part of this essay below for the case against the mandate).
The Case Against ACA and For Single-Payer:
We can argue all we want regarding the problems, shortcoming and promise of the ACA but this is barking up the wrong tree. The ACA's first and foremost failure is that it fails to remove the cost of insurance industry profit from our healthcare system.
Certain essential commodities and services are affordable and readily obtained when left to market forces - such as groceries, clothing, automobiles and information - but even these are often subsidized by the government, indirectly for all (through government subsidies to businesses and through tax deductions to both businesses and individuals) or directly for those with low or no income. Other essential commodities are either provided to all through government non-profit operations or by a market highly regulated to ensure maximum availability and affordable cost - such as water, police protection, mass transit (including airlines), farming, sanitation and oil.
It goes without saying that a healthy population, like a safe population, is a worthy and critical investment in civil society - for a healthy population is essential to the productivity and security of our community. Healthcare is an essential service that should be available to everyone through non-profit insurance that supports both non-profit and for-profit health care providers (doctors, nurses, community hospitals, pharmaceutical houses, equipment manufacturers etc.).
The current mix of for-profit and government insurance, privately- and publicly-run healthcare facilities and a pharmaceutical industry held virtually unaccountable for its costs is, by contrast, simply unsustainable - which is why millions of citizens continue to go without essential healthcare or are suffering the harm of insufficient healthcare. The ACA does little to move us away from this model toward an efficient, streamlined and affordable system. As well, the ACA fails to eliminate the use of employer-sponsored healthcare insurance plans for employees. These plans constitute the single-largest tax-deduction expense to the U.S. Treasury, an inequitable wealth transfer that exceeds the cost to taxpayers of even the home mortgage deduction. In so doing constitutes a tremendous expense to business, employees and taxpayers.
The ACA is a bad solution to a worse problem. It does little more than codify the previous market for healthcare insurance, aside from adding a few additional critical regulations on the for-profit healthcare insurance business. It has gained approval from many citizens and Congress members due to its appearance as a reform of the private insurance market, but it is not what it may seem. It is nothing but a legal requirement that citizens patronize the private for-profit insurance business while imposing a few new obligations on those businesses in return for the increased profits they realize from a substantial increase in customers.
Resolution:
Healthcare insurance should be provided by one entity - the federal government - that would tax all citizens to provide insurance to everyone regardless of age, race, sex, income, place of residence or health history; make fair payment to healthcare providers for consistent care and costs; eliminate the costly insurance, claims and payment bureaucracy, and fashion a national program of cost containment that ensures all healthcare providers are compensated fairly for their contribution to our health - whether they be for-profit companies or non-profit entities.
Think this sounds fantastical? Such models are successful in many countries and are available for us to customize for our society. Healthcare coverage could be structured similarly to Social Security, a highly successful program despite the many claims to the contrary. Like retirement, public safety and public services, basic healthcare can be best provided to all citizens under a single-payer system free of the middleman curses of profit and red tape. It would bring all citizens into one program, ensuring the inclusion of the healthy as well as the ill - which is necessary for the system's solvency.
Related Essay: Social Security
People and institutions who provide actual healthcare deserve to make a living but insurers do not deserve to profit off healthcare except perhaps where individuals choose non-essential elective care. Like Social Security, which ensures all citizens a decent retirement income without profit to investment brokers but which allows the brokerage business to flourish by serving those who elect to invest beyond their Social Security contributions, a single-payer healthcare insurance system would provide a lower-cost, profit-free standard of care while allowing citizens the choice to supplement their insurance through private, for-profit insurance brokers.
Single-payer is not a pipe dream. Though it is repeatedly dismissed by politicians, pundits, pollsters and profit-makers as unrealistic - and the public largely accepts their deception - it can be accomplished with enough political will. Creating a single-payer system will require that Congress look to the needs of people rather than the profits of business. The "public option" should be the "Public Health Trust", a single-payer system that ensures each and every one of us affordable, quality health care throughout our lives.
Deceptions Explained.
First, what about that website, healthcare.gov?
The problems with the ACA website that plagued its launch on October 1, 2013 highlight two of the greatest deceptions regarding the ACA:
FIrst, the claim that the private sector should play any role in healthcare insurance because it is claimed to be more capable that the U.S. government is ludicrous, given that problems with healthcare.gov can be attributed directly to dozens of private contractors who built and operate the site, including some of the nation's largest corporations, in addition to a flawed government bidding process. The U.S. government has a clear record of competence operating any number of organizations and systems throughout its history, systems larger than the ACA - as do many private companies. The flaw is not in "the government" any more than it is in the private contractors. The problem is in the obscene complexity of the ACA and in a government contracting system that is stacked against smaller, newer or more competent firms that are often better equipped for the task than the entrenched contractors well accustomed to bidding for government work - though evidently not as accustomed to working well with multiple partners.
Second, the claim that the ACA (or the pre-ACA system) is preferable to a universal, public healthcare insurance system operated by the U.S. government is readily challenged by the complexity of the ACA, wherein multiple insurers attempt to present multiple plan options to multiple demographics in multiple locations under multiple policy configurations. The extent of bureaucracy necessary to administer the ACA is another primary reason for the difficulties presented in building and operating the website. Some of the state sites are faring considerably better, notably Kentucky's, as these are servicing far fewer people and providing far fewer plan configurations for their users. Still, the difficulty the U.S. government experiences with healthcare.gov would be virtually eliminated by a single-payer plan. Why? It would eliminate the key complexities in the ACA: insurance companies, tiered plans, subsidies, the Medicare/Medicaid interface, the Internal Revenue Service ("IRS") and demographic considerations etc. The ACA requires individual plan and payment arrangements customized for each and every person in the United States and ties healthcare into the IRS. A single-payer system would eliminate these complex and needless variables.
Deception: the ACA is inferior to pre-ACA healthcare insurance options.
The ACA does indeed offer some gains over the previous system for those who can afford the premiums, although these do not ensure affordability of either care or medication:
• insurers must cover all applicants within new minimum standards and at the same community-based rates irrespective of pre-existing conditions or gender;
• insurers can no longer turn down applicants based on prior medical history;
• insurers can no longer place a lifetime limit on benefits;
• some subsidies will be available to help some low-income people obtain some insurance;
• some states will offer an expansion of Medicare/Medicaid coverage, to varying degrees;
• some co-payments, co-insurance and deductibles will be eliminated for some "essential" services.
Sound good? Some of it is, and for these reasons the ACA is an improvement over pre-ACA options, but much of it is not an improvement because the ACA is not an overhaul of the extremely dysfunctional pre-ACA system. Rather, it is a modification of a deeply flawed approach to ensuring healthcare for citizens. To wit, note all the qualifying "somes" in the points above. These may seem negligible now but are proving to cause major hardship for many. Furthermore, coverage and costs under the ACA vary wildly by state and costs are still unaffordable for many. The current media coverage that praises the new premium offerings as affordable in states with competitive insurance marketplaces (such as California and New York) seem to be written by people with above-average incomes, as even the lowest planned monthly premiums are too high for millions of workers - even with subsidies - and offer a bare minimum of coverage with very high deductibles and co-pays that render any savings in premiums moot.
Deception: the ACA is preferable to a universal, single-payer, public healthcare insurance system operated by the U.S. government ("single-payer").
Despite the advantages of the ACA over the pre-ACA options as noted above, most of these are realized only by forcing insurers to provide additional coverage (such as unlimited coverage of lifetime expenses) in exchange for the increased business they will realize by a vastly increased customer base of citizens now forced to purchase insurance. The core problems of the pre-ACA system are not addressed by the ACA; these problems would be resolved a a single-payer system.
Under the ACA:
• Patients will still find themselves struggling with bureaucratic nightmares of paperwork and payments inherent in a system that relies on claims to, and payments from, for-profit insurers;
• The profit element in insurance policies is still present, unnecessarily raising costs for everyone without access to a consumer-run, co-operative non-profit insurance plan;
• The price advantage of the lower-cost plans is too often negated by higher deductibles and co-pays;
• Employer-sponsored plans will still impose a drain on the public treasury and U.S. businesses;
• Plan choice is heavily restricted;
• Meaningful regulation of the healthcare and pharmaceutical industries remains absent;
• The much vaunted promise that people can keep their old plans is proving to be a joke, as insurers are canceling these plans in unprecedented numbers to comply with, or profit from, the ACA;
• Some businesses have cut employee hours to less than 30 per week, the threshold at which they must offer an employee-sponsored plan, or are reducing plan quality, and this movement continues to gain momentum as the full measure of the ACA becomes reality; and
• Everyone will still be at the mercy of the marketplace - rather, everyone will be forced into being at the mercy of the marketplace due to the mandate that all citizens purchase insurance.
Deception: the ACA mandate to purchase healthcare insurance is constitutional.
The mandate, which is the requirement that all citizens purchase healthcare insurance under the threat of a substantial fine, is a dangerous precedent and serves only to allow Congress, the President and the Supreme Court to abdicate on their responsibility to fashion a truly fair and public single-payer plan free of the cost and bureaucracy of for-profit insurers. It is designed specifically to force those with little or no need for healthcare insurance to participate so as to increase the revenue flowing to for-profit insurance companies. Why? Without participation by all people, the revenue to insurance companies would not be enough to offset their increased expenses under the new ACA-imposed regulations noted above. This was the tradeoff Congress and the President made to negate opposition by for-profit insurers - a fool's errand from the start.
Those that defend the mandate make comparisons to other "forced" purchases, such as automobile insurance or house insurance - yet the difference is profound. Purchasing a car or house is optional in our society and in this way, so is the purchase of car or house insurance; and even where one's choices in life result in ownership of a car or other property the options for insurance are usually many and competitively priced. Being alive is not a choice, however, unless you choose to commit the crime of suicide. There exist no other laws that compel all individuals to make purchases from private business simply by virtue of being alive.
Yet what about the need the most people have for healthcare at some point in their lives, emergency or otherwise? Do we all not need to be covered for this eventuality? Usually so, but if it is in the nation's interest to ensure that everyone has coverage so that nobody freeloads on the healthcare industry and taxpayers, and the country determines that everyone must therefore participate through contributions to the cause, this can only be done in a just and constitutional manner if the insurance program is a publicly run program such as Social Security or Medicaid/Medicare. Requiring all citizens to patronize private industry is both wrong and unconstitutional.
The danger of the "individual mandate" regarding the purchase of healthcare insurance lies in the precedent it sets. It opens the door to future spending requirements for citizens based on government edict regardless of the choices each of us make in life. The U.S. Supreme Court, in upholding the individual mandate, dismissed its unconstitutionality under the Commerce Clause of the U.S. Constitution on the grounds that it is not a "purchase" but a tax. Never mind that a forced purchase from a private, for-profit insurer is nothing but extortion, or that the penalty for not purchasing insurance is nothing but a fine. What would qualify the mandate as a "tax"?
Social Security, a highly successful program (see Social Security Solvency) passed constitutional muster precisely because it is a tax on citizens which in turn provides real, unconditional benefit in the form of retirement and disability payments from the taxing authority that controls the Social Security Trust Fund, the federal government. The money paid in by citizens is paid back out to us by the fund. The bureaucracy involved is minimal. No profit lines private pockets. In this same way, a government-sponsored healthcare insurance system, or "single-payer" system, would constitute a tax on citizens that would be returned to us in the form of healthcare coverage. Forcing us to purchase policies from private, for-profit insurers is not a tax but forced patronage of private business.
The Supreme Court unwisely relied on precedent established by two previous cases that were not only inapplicable to healthcare insurance but were bad decisions in their own right:
From these two unfortunate decisions sprang the Supreme Court's decision that the imposition of the ACA's individual mandate on citizens was within the constitutional rights of the federal government. In the wisdom of the court, citizens can be forbidden from growing wheat or cannabis for the benefit of personal consumption yet can be required to buy insurance for the benefit of private business - regardless of its affordability or adequacy of coverage.
This deceptions in the healthcare insurance debate are many and profound. Until we expose and understand these deceptions we will continue to suffer the tragedy of woefully insufficient and overly costly healthcare.
The problems with the ACA website that plagued its launch on October 1, 2013 highlight two of the greatest deceptions regarding the ACA:
FIrst, the claim that the private sector should play any role in healthcare insurance because it is claimed to be more capable that the U.S. government is ludicrous, given that problems with healthcare.gov can be attributed directly to dozens of private contractors who built and operate the site, including some of the nation's largest corporations, in addition to a flawed government bidding process. The U.S. government has a clear record of competence operating any number of organizations and systems throughout its history, systems larger than the ACA - as do many private companies. The flaw is not in "the government" any more than it is in the private contractors. The problem is in the obscene complexity of the ACA and in a government contracting system that is stacked against smaller, newer or more competent firms that are often better equipped for the task than the entrenched contractors well accustomed to bidding for government work - though evidently not as accustomed to working well with multiple partners.
Second, the claim that the ACA (or the pre-ACA system) is preferable to a universal, public healthcare insurance system operated by the U.S. government is readily challenged by the complexity of the ACA, wherein multiple insurers attempt to present multiple plan options to multiple demographics in multiple locations under multiple policy configurations. The extent of bureaucracy necessary to administer the ACA is another primary reason for the difficulties presented in building and operating the website. Some of the state sites are faring considerably better, notably Kentucky's, as these are servicing far fewer people and providing far fewer plan configurations for their users. Still, the difficulty the U.S. government experiences with healthcare.gov would be virtually eliminated by a single-payer plan. Why? It would eliminate the key complexities in the ACA: insurance companies, tiered plans, subsidies, the Medicare/Medicaid interface, the Internal Revenue Service ("IRS") and demographic considerations etc. The ACA requires individual plan and payment arrangements customized for each and every person in the United States and ties healthcare into the IRS. A single-payer system would eliminate these complex and needless variables.
Deception: the ACA is inferior to pre-ACA healthcare insurance options.
The ACA does indeed offer some gains over the previous system for those who can afford the premiums, although these do not ensure affordability of either care or medication:
• insurers must cover all applicants within new minimum standards and at the same community-based rates irrespective of pre-existing conditions or gender;
• insurers can no longer turn down applicants based on prior medical history;
• insurers can no longer place a lifetime limit on benefits;
• some subsidies will be available to help some low-income people obtain some insurance;
• some states will offer an expansion of Medicare/Medicaid coverage, to varying degrees;
• some co-payments, co-insurance and deductibles will be eliminated for some "essential" services.
Sound good? Some of it is, and for these reasons the ACA is an improvement over pre-ACA options, but much of it is not an improvement because the ACA is not an overhaul of the extremely dysfunctional pre-ACA system. Rather, it is a modification of a deeply flawed approach to ensuring healthcare for citizens. To wit, note all the qualifying "somes" in the points above. These may seem negligible now but are proving to cause major hardship for many. Furthermore, coverage and costs under the ACA vary wildly by state and costs are still unaffordable for many. The current media coverage that praises the new premium offerings as affordable in states with competitive insurance marketplaces (such as California and New York) seem to be written by people with above-average incomes, as even the lowest planned monthly premiums are too high for millions of workers - even with subsidies - and offer a bare minimum of coverage with very high deductibles and co-pays that render any savings in premiums moot.
Deception: the ACA is preferable to a universal, single-payer, public healthcare insurance system operated by the U.S. government ("single-payer").
Despite the advantages of the ACA over the pre-ACA options as noted above, most of these are realized only by forcing insurers to provide additional coverage (such as unlimited coverage of lifetime expenses) in exchange for the increased business they will realize by a vastly increased customer base of citizens now forced to purchase insurance. The core problems of the pre-ACA system are not addressed by the ACA; these problems would be resolved a a single-payer system.
Under the ACA:
• Patients will still find themselves struggling with bureaucratic nightmares of paperwork and payments inherent in a system that relies on claims to, and payments from, for-profit insurers;
• The profit element in insurance policies is still present, unnecessarily raising costs for everyone without access to a consumer-run, co-operative non-profit insurance plan;
• The price advantage of the lower-cost plans is too often negated by higher deductibles and co-pays;
• Employer-sponsored plans will still impose a drain on the public treasury and U.S. businesses;
• Plan choice is heavily restricted;
• Meaningful regulation of the healthcare and pharmaceutical industries remains absent;
• The much vaunted promise that people can keep their old plans is proving to be a joke, as insurers are canceling these plans in unprecedented numbers to comply with, or profit from, the ACA;
• Some businesses have cut employee hours to less than 30 per week, the threshold at which they must offer an employee-sponsored plan, or are reducing plan quality, and this movement continues to gain momentum as the full measure of the ACA becomes reality; and
• Everyone will still be at the mercy of the marketplace - rather, everyone will be forced into being at the mercy of the marketplace due to the mandate that all citizens purchase insurance.
Deception: the ACA mandate to purchase healthcare insurance is constitutional.
The mandate, which is the requirement that all citizens purchase healthcare insurance under the threat of a substantial fine, is a dangerous precedent and serves only to allow Congress, the President and the Supreme Court to abdicate on their responsibility to fashion a truly fair and public single-payer plan free of the cost and bureaucracy of for-profit insurers. It is designed specifically to force those with little or no need for healthcare insurance to participate so as to increase the revenue flowing to for-profit insurance companies. Why? Without participation by all people, the revenue to insurance companies would not be enough to offset their increased expenses under the new ACA-imposed regulations noted above. This was the tradeoff Congress and the President made to negate opposition by for-profit insurers - a fool's errand from the start.
Those that defend the mandate make comparisons to other "forced" purchases, such as automobile insurance or house insurance - yet the difference is profound. Purchasing a car or house is optional in our society and in this way, so is the purchase of car or house insurance; and even where one's choices in life result in ownership of a car or other property the options for insurance are usually many and competitively priced. Being alive is not a choice, however, unless you choose to commit the crime of suicide. There exist no other laws that compel all individuals to make purchases from private business simply by virtue of being alive.
Yet what about the need the most people have for healthcare at some point in their lives, emergency or otherwise? Do we all not need to be covered for this eventuality? Usually so, but if it is in the nation's interest to ensure that everyone has coverage so that nobody freeloads on the healthcare industry and taxpayers, and the country determines that everyone must therefore participate through contributions to the cause, this can only be done in a just and constitutional manner if the insurance program is a publicly run program such as Social Security or Medicaid/Medicare. Requiring all citizens to patronize private industry is both wrong and unconstitutional.
The danger of the "individual mandate" regarding the purchase of healthcare insurance lies in the precedent it sets. It opens the door to future spending requirements for citizens based on government edict regardless of the choices each of us make in life. The U.S. Supreme Court, in upholding the individual mandate, dismissed its unconstitutionality under the Commerce Clause of the U.S. Constitution on the grounds that it is not a "purchase" but a tax. Never mind that a forced purchase from a private, for-profit insurer is nothing but extortion, or that the penalty for not purchasing insurance is nothing but a fine. What would qualify the mandate as a "tax"?
Social Security, a highly successful program (see Social Security Solvency) passed constitutional muster precisely because it is a tax on citizens which in turn provides real, unconditional benefit in the form of retirement and disability payments from the taxing authority that controls the Social Security Trust Fund, the federal government. The money paid in by citizens is paid back out to us by the fund. The bureaucracy involved is minimal. No profit lines private pockets. In this same way, a government-sponsored healthcare insurance system, or "single-payer" system, would constitute a tax on citizens that would be returned to us in the form of healthcare coverage. Forcing us to purchase policies from private, for-profit insurers is not a tax but forced patronage of private business.
The Supreme Court unwisely relied on precedent established by two previous cases that were not only inapplicable to healthcare insurance but were bad decisions in their own right:
- Wickard v. Filburn (1942): this decision forbade farmers from growing wheat as feed for their own livestock on the grounds that this would affect the market price of wheat, which is comparable to prohibiting you from growing your own garden on the grounds that it would affect the market price of produce. It was a bad decision that has served as precedence in the ensuing decades for government over-reach in controlling the activities of its citizens to the economic benefit of business.
- Gonzales (previously Ashcroft) v. Raich (2005): relying upon Wickard v. Filburn as precedent, the court prohibited citizens from growing their own medicinal marijuana ("Cannabis") on the grounds that it would affect the market price of cannabis, a contraband substance not eligible for public sale in the first place. Again, this was a bad decision aimed at cementing government control over the activity of individuals in a matter that should be of no interest to the federal government. It has since been pre-empted in several states through the passage of laws allowing for medical and recreational access to cannabis.
From these two unfortunate decisions sprang the Supreme Court's decision that the imposition of the ACA's individual mandate on citizens was within the constitutional rights of the federal government. In the wisdom of the court, citizens can be forbidden from growing wheat or cannabis for the benefit of personal consumption yet can be required to buy insurance for the benefit of private business - regardless of its affordability or adequacy of coverage.
This deceptions in the healthcare insurance debate are many and profound. Until we expose and understand these deceptions we will continue to suffer the tragedy of woefully insufficient and overly costly healthcare.