By Sheeva Azma
Health care reform can’t happen without buy-in from the actual health care industry (how would that happen)?
I’m one of the 6.8% of people in the United States that have Affordable Care Act insurance. That number used to be higher — 9% of people enrolled in the ACA last year dropped their coverage because it became too expensive due to Congress ending the COVID-era subsidy. At this point, it feels like politicians are waiting for the ACA to die so that they can say they killed it. It’s heartless and the statements politicians make about the ACA get repeated by their constituents.
I was shocked, as someone who has worked in the health care reform space, to see actual violence occur as a result of dissatisfaction with health care and the popularization of Luigi Mangione, the guy who fatally shot the UnitedHealth CEO and just pled guilty to that in trial.
Surely literally killing someone wouldn’t bring about health care reform, right?
It did not.
Health care reform happens through civil discussions and discourse. It happens in conversations with lawmakers and patients. It also can’t happen without buy-in from the actual health care industry (how would that happen)?
Unfortunately, the health care system is large and complex and people demand things from it without actually knowing if such things could be logistically possible (at least at this point in time). I would love to see more health care reform to bring down prices and align incentives in the health care system, but given that Congress just defunded health care for millions of people, I’m not holding my breath.
In all the dissatisfaction about the health care system, people like to bully the ACA. I have done several Instagram reels about that. Here’s parts 1, 2, 3, and 4.
My greatest pet peeve in our current era is that people complain about the ACA without knowing what it does…probably because they are not the minority of people who benefit from ACA health insurance (like me) and have not studied health care policy (like me) or stepped on Capitol Hill to speak to their lawmakers about their health care woes (also like me).
Here are some things the ACA actually did
One big reform in the ACA was that it made health care accessible by creating health care exchanges where people could buy their own healthcare directly from private insurers with federal subsidies. It also expanded Medicaid eligibility so that more people could have health insurance.
Regulatory reforms of the ACA included prohibiting insurers from charging more from or even barring people with pre-existing conditions and allowing young people to stay on their parents’ insurance until age 26. Another reform brought about by the ACA was the mandate that individual and small-group markets cover 10 core categories, including mental health, maternity care, and prescription drugs.
“If you like your health care, you can keep it,” was the ACA mantra in the Obama days. The bill also created several other reforms you can read about here.
The Center for Medicare and Medicaid Services (abbreviated CMS) oversees the federal health insurance exchange at healthcare.gov and sets participation rules. It also enforces consumer protections such as ensuring fair coverage for people ensured on ACA via monitoring insurance market rules; making sure insurers spend most of their consumer-paid dollars on medical care and quality improvements rather than on overhead; and rate review transparency, to make sure that insurers justify any significant rate hikes before price increases are implemented.
There’s more, but it’s way easier to insult something than bring about meaningful change.
Some people even happily declare they do not want to pay for other people’s health care, as happened to me when my local newspaper, the Oklahoman, interviewed me about my rising health care costs (see all the heartless Facebook comments I took the time to reply back to with snarky comments on this post).
Many demand Medicare-for-all, and a single-payer health care system administered through the government, which, ironically, the ACA makes possible. Dismantling the ACA would break down people’s access to the national health care exchanges. Theoretically, the exchanges could be used to administer any type of health care, whether nationalized or private.
The point is that it’s not a good idea to dismantle something that provides health care coverage for millions of Americans. The ACA just made health care access more possible within this same system. When people say they are frustrated with the health care system, they point to the ACA, but the truth is that the ACA is just another way to access the health care system.
The ACA is a legislative accomplishment in itself, even though, honestly, it did not do much except help more people be insured. Where previous administrations failed on health care reform, the ACA delivered on increasing health care access.
Now, that it’s been law for almost 20 years, it doesn’t make sense to dismantle it in hopes of something better. That would entail taking health care away from millions of Americans (though that number is currently dwindling due to the rising costs of ACA health insurance).
The rising costs of health care are a big problem, especially now, for ACA health care holders.
Beyond people’s opinions, our lawmakers also say they want to take away the ACA, which is ridiculous, since they also buy their health insurance on the exchanges, but with a “generous employer contribution shielding them from the premium cliff” that happened when they ended the COVID-era subsidies, per No Labels.
The experiences of people in Congress don’t match up with that of everyday Americans when it comes to health care, which is why they feel comfortable publicly stating that they will dismantle the ACA and eliminate health care access for (even still, after defunding the COVID-era subsidies) millions of Americans.
Before the ACA ever existed, there was Romneycare, which did the same thing as the ACA, just in Massachusetts — and that was created by a Republican governor. I’m sure that, had Mitt Romney been governor of Masschusetts today, Romneycare would have been criticized just as much as the ACA has, but surprisingly, in the run-up to the passage of the ACA, I never heard too much about the downsides of Romneycare. In fact, I was one of the early adopters — and I was grateful for the health care access, since I had been paying out-of-pocket for COBRA right before that (which was expensive, in case you didn’t know).
Let’s talk about how the ACA came to be, and challenges to it.
Passing the ACA took only 427 days
The big accomplishment of the Affordable Care Act, which took President Obama only 427 days from he day he took office, is that it didn’t try to reinvent the wheel. It simply worked with existing stakeholders in the health care industry, to expand health care access. This was also what set apart Obama’s successful health care reform efforts from that of both the Clinton and George W. Bush administrations (though the younger Bush also established Medicare Part D, which provided outpatient drug coverage for seniors).
The quest to create a national health care framework started on Inauguration Day. “Our health care is too costly,” Obama said at his inauguration, per the AMark Foundation. “We will restore science to its rightful place and wield technology’s wonders to raise health care’s quality.”
At least 60 bipartisan discussions later, the Patient Protection and Affordable Care Act (H.R. 3590), known commonly as the ACA, went up for a Senate vote on December 24, 2009, and passed by a vote of 60 to 39 along partisan lines. The “yes” votes came from 59 Democrats and 1 Independent (Bernie Sanders); 39 Republicans voted against, and 1 did not vote.
The House of Representatives voted on H.R. 3590 on March 21, 2010. Although only Democrats (219 of them) voted “yes,” 34 Democrats voted all House Republicans in voting “no.” The final vote was 219-212.
President Obama signed the 906-page bill into law two days later, on March 23, 2010.
If you’re interested in reading more about the journey to the passage of the ACA, I recommend this article from the AMark Foundation.
Republicans gained seats in the House and Senate in Obama’s second term and decided to shut down the government from October 1 to October 17, 2013, unless the ACA was delayed or defunded.
“They’ve shut down the government over an ideological crusade to deny affordable health insurance to millions of Americans. In other words, they demanded ransom just for doing their job,” wrote Obama in a statement on October 1, 2013.
This was the first government shutdown in 17 years. It didn’t work. The government reopened without action on the ACA.
Supreme Court cases have left the ACA largely intact
Various Supreme Court cases have also challenged aspects of the ACA, leaving it largely intact.
In 2012, the Supreme Court decided on National Federation of Independent Business v. Sibelius. This case had three main parts relating to 1) the employer mandate, 2) the individual mandate, 3) Medicaid expansion.
NFIB argued that the employer mandate, which mandated that larger companies had to provide health insurance for their employees or pay a tax penalty, interfered with state sovereignty. This was dismissed at the district court level, and so it was never ruled upon by the Supreme Court.
NFIB also argued that the individual mandate, which meant you had to have health insurance under the ACA or pay a fee, was a violation of the commerce clause. The Supreme Court ruled that no, the individual mandate was not unconstitutional — it’s not unconstitutional to regulate commerce, though it would be unconstitutional to get everyone to buy something.
Notably, the individual mandate was eliminated later on, thanks to legislation. President Trump and Congress worked together to pass the Tax Cuts and Jobs Act of 2017, lowering the individual mandate to $0, which took effect on January 1, 2019. In the Supreme Court case California v. Texas, Texas and other similarly-aligned states with governments oppositional to the ACA argued that since the individual mandate was now $0, the whole ACA was unconstitutional. The Supreme Court sided with states including California, who defended the ACA.
Lastly, in NFIB v. Sibelius, NFIB argued that Medicaid expansions were constitutionally coercive. The ACA originally required all 50 states to expand Medicaid under the ACA, which the Supreme Court ruled was unconstitutional. Therefore, Medicaid expansion under the ACA became optional, and 41 states opted in.
In 2014, the Supreme Court’s decision on Burwell v. Hobby Lobby gave religious organizations and certain for-profit companies exempt from the ACA’s contraception mandate. The court ruled that ompanies can get a religious exemption from the ACA mandate requiring them to provide health insurance coverage for specific types of contraception.
This related back to the ACA’s definition of preventative services. Previously, the ACA had required employers to provide health insurance plans that covered preventative services for women, which the US Department of Health and Human Services defined to include all FDA-approved contraceptive methods. Burwell v. Hobby Lobby clarified this in the context of religious organizations, who became able to exempt themselves.
Lastly, King v. Burwell, decided in 2015, set up ACA tax credits (subsidies) for health insurance coverage that expanded to all 50 states, regardless of whether a state set up its own insurance exchange or used a federal platform.
Fancy Comma, LLC 