Trying To Sort Through The ObamaCare Jungle


Leonard Zwelling

I have written a fair amount about ObamaCare aka the Patient Protection and Affordable Care Act of 2010 aka the ACA. In fact, I wrote a whole book about it called Red Kool-Aid Blue Kool-Aid that is available on for about seven bucks. (Updated edition is in the works).

Let’s start with the big lie that led to this mess. “If you like what you have, you can keep it.” This was said by Mr. Obama as a presidential candidate and was never true. The ACA allowed all kinds of changes to occur that could cost some people their health insurance coverage.

For example, a small business of under 50 employees that had been providing coverage could decide to stop doing so and ask their employees to use the insurance exchanges.

Or a big business could decide to pay the penalty for not providing insurance and send their employees to the exchanges for private coverage.

And, as we have seen in the various raucous town halls around the country, it’s very hard to take away a benefit once you mete it out. America is not quite ready to have ObamaCare repealed without a viable replacement. And RyanCare isn’t it for a host of reasons not the least of which is that it lowers spending (that was needed to get it through the Senate with only 51 votes) by lowering the number of insured. In other words, it is indeed ObamaCare lite—very light.

The most frequent question I get about the ACA is: are you for it, sometimes phrased as if you were there in 2010 would you have voted for it? The answer is yes, but reluctantly. It was better than nothing, but only by a hair.

That “by a hair” is what all the fighting is about. For the 10 to 20 million with new health insurance (less than 6% of Americans) who did not have it before ObamaCare because they had pre-existing conditions, weren’t covered by their parents’ policies, or were not eligible for Medicaid and now are, the loss of ObamaCare might be catastrophic.

For those whose premiums have risen or who have had to forego raises at work to cover health insurance from employers or who have actually lost insurance completely, or lost insurance they liked or lost access to a doctor they liked, or own a small business having to cover employees that previously were not mandated to be covered, ObamaCare’s death would be just fine IF, we could get back to what we had before 2010 of which there is no guarantee. In fact, there is no chance we are going back to 2010, so give that up.

Both sides are misleading the American public.

So, how about a simple primer on what this all means?

First, the major problem with ObamaCare is that its purpose was murky. If its purpose was to cover all of the 50 million or so Americans (only about 16% of the population) without health insurance in 2010, it failed–partially, but not completely. It got less than halfway there mostly because the Supreme Court rendered the mandatory expansion of Medicaid to cover poor people by the states optional and many states elected not to expand it (like Texas). But some states did expand Medicaid and the senators from those states like the money that came from the federal government to expand Medicaid and are not fond of giving it up.

If the goal was to get everyone covered, we know how to do that and that’s not ObamaCare. We do it for those over 65. It’s called Medicare. Everyone pays in when they are working and everyone is covered when they get older. All you need to do is figure out how much you need to cover everyone (it’s got to be less than the $3 trillion we spend now!) and tax accordingly. If we need to means test single payer insurance, then we should. If we need to allow a private insurance market to continue for those who wish to have platinum coverage that they pay for, we should allow that, too. But I have not met the person over 65 who has declined Medicare yet.

The problem with this Medicare-for-all system that I describe is:

1. It is a single payer system and those are dirty words in American politics.
2. It would eliminate the insurance industry and about 1 million people might be looking for work.
3. It is still prone to corruption and that would need to be monitored, prevented and/or prosecuted as a federal offense.
4. Everyone would not get everything in the way of medical care that he or she would want from a provider in the form of expensive meds when generics exist, unnecessary MRIs, and elective plastic surgery and psychoanalysis would still be cash businesses.
5. Both patients and doctors would have to learn a new word—NO! For example, you may not get third line chemotherapy for lung cancer outside the context of a clinical trial unless you pay for it and, by the way, you may not qualify for the trial if you have coronary artery disease and diabetes.

So what’s wrong with all that?

See the real problem is still what Norm Ornstein said in 2008. “Everyone’s idea of health care reform is the same—I pay less.”

It’s still about the money in the health care-industrial complex of providers, insurers, big pharma, and big hospitals.

So let’s decide.

Is health care like Gucci loafers and something that only the rich can have, or is it like the police and access to affordable, quality health care is part of being a citizen? Privilege or right? Decide and act accordingly.

In 2010 no one decided, so we got this mess. My guess is that after the GOP is done in 2017, we will just have a new mess. The only difference will be that while Obama owned the old mess, Trump will own TrumpCare, i.e., the new mess. Good luck with that!

Finally, allow me to try to simplify another piece of the puzzle that has been made complex.

It is true that any Senate bill can be filibustered and voting on it blocked by a single senator. That filibuster can be overridden with 60 votes. That’s called cloture. BUT—using a process called reconciliation that is limited to use in matters of the budget, 51 votes, limited amendments, and limited debate is possible for passage of some bills in the Senate. This might allow the GOP to pick apart the ACA with RyanCare by focusing on fiscal matters as I noted above. This is why I believe the GOP will do just that and yet keep ObamaCare in place until they can conjure up a replacement—which they will never be able to do, in my estimation. Given that ObamaCare is a 1989 Republican idea from the Heritage Foundation, first implemented by a Republican governor (Mitt Romney), it is going to be hard to find a GOP alternative to a GOP plan.

Nonetheless, this will take until 2018 at which point there will be a new election and we shall see who wins, that is if we aren’t at war in the Middle East or on the Korean Peninsula.

Hey! You want me to be upbeat? Give me one good reason when the country has clearly gone mad and elected a tweeter-in-chief to occupy the Oval Office. The only good news is the entertainment value. Should be at an all-time high!

Here’s a useful summary from the NY Times:

Leonard Zwelling