Healthcare Reform after the Affordable Care Act

By Gerald Friedman

Can we finally move past the bizarre fight over the Patient Protection and Affordable Care Act (a.k.a.  the ACA or Obamacare) of 2010? When congressional Democrats and the Obama Administration adopted a program originally proposed by the right-wing Heritage Foundation that had been enacted into law in Massachusetts under Republican governor Mitt Romney, they anticipated building a national consensus behind a program that would bring health coverage to millions of Americans largely within the established private health insurance system. One would have expected opposition from the Left by proponents of a government-funded universal program; but nearly 70 years after President Harry Truman first pushed for a universal health insurance system, pragmatic progressives anticipated that by accepting a conservative program built on individual responsibility and private health insurance they would attract enough bipartisan support to enact the ACA easily and to enact it smoothly.

One may wonder if the pragmatists got this one wrong. When endorsed by Democrats, this Republican program attracted as much hysteria and as many lies as would a single payer proposal (or even a proposal for a National Health Service as in the United Kingdom). We have a political compromise where one side accepted less and the other gave nothing. We have the first major progressive social program since the Earned Income Tax Credit was enacted in 1975. With hundreds of billions of dollars in subsidies for working people, the ACA brings health insurance (through Medicaid and private health insurance) to millions of Americans, dramatically lowering the share without health insurance while improving coverage for millions who previously had inadequate plans. While regularly blamed for everything that is still wrong with American health care, the ACA makes things better by restricting the worst practices of the health insurance system, extending insurance coverage, and subsidizing coverage for millions of working Americans. With all of its limits and a troubled roll-out, the ACA is showing how government can make life better.

After all the exhaustion, fighting, filibusters, government shutdowns, computer glitches, and narrow Supreme Court decisions, it is easy to forget how little the ACA does and how many of the problems in American health care remain. Even with 33 million people gaining coverage through the ACA, most through an exchange plan or Medicaid, there will still be an equal number without health insurance. And while the ACA improves the overall quality of health insurance, it does nothing to reverse the growing cost-shift from employers to workers with rising copayments, deductibles, and premiums. Finally, despite a few tentative measures, such as restrictions on insurers’ Medical Loss Ratios and penalties for hospital readmissions, the ACA  effectively does nothing to slow the growth in health care inflation. As in Massachusetts, the pragmatic politicians behind the ACA enacted a program with the pleasures of extended coverage; they left the pain of cost containment for later.

Later is now. As much as its successes show that government can be an effective agent for social reform, the failures of the ACA show that the pragmatic politics of appeasing the Right lead to a dead end, where the cost of healthcare will continue to rise, undermining every gain achieved. Only a national single payer system, Improved Medicare for All, can control health care inflation and bring coverage to everyone. The ACA’s successes give us a taste of what we can do when we regulate healthcare finance to benefit people rather than to produce profit for insurers and drug companies. Its limits show us why we need a national single payer healthcare system.