The Patient Protection and Affordable Care Act, also known as Obamacare, is the most controversial piece of legislation right now in the United States. It marked the key line of battle in last year’s presidential election, it is a galvanising force for the Tea party, and it was the primary cause of last month’s federal government shutdown. Earlier this week, while driving through Georgia, I tuned into a talk radio station in which a preacher was claiming that God demanded all pastors to vigorously oppose the ACA as it represented all that had gone wrong with the US. But what is the ACA? And why has it inspired such strong opposition?
The primary purpose of the ACA is to provide universal healthcare. In the UK most healthcare is provided by the state through the NHS and paid for by taxation and national insurance contribution, but in the US healthcare is mainly provided by the private sector and paid for through private insurance. Over 50 per cent of Americans have employer-provided health insurance. The very poor are covered through Medicaid, and the elderly are covered through Medicare. But prior to the introduction of the ACA there were still almost 50 million people who had no coverage, and many of those who did had coverage that was inadequate for their medical needs.
The ACA created a patients’ bill of rights to protect consumers from the worst excesses of the insurance industry – it ended pre-existing conditions exclusion for children and arbitrary withdrawals of coverage, and enforced mandatory reviews of premium increases. The ACA also provides free access to preventative services like flu shots, childbirth counselling, and tests for blood pressure, diabetes, and cancer. From 2014, all Americans will have access to affordable healthcare; middle- and low-income families will get tax credits that cover a significant portion of the cost, and Medicaid will be expanded to cover a lot more people.
The benefits to society of universal healthcare may be clear to progressives, and in much of Europe they are clear to supporters of most political parties, but in the US polling over the past year has consistently shown that a majority are opposed to it. There are a number of reasons for this: for many Americans government is inherently ‘bad’ and should do the bare minimum; the ACA is an encroachment too far into their privacy and freedom. For a not-insignificant minority, the problem is with Obama himself, either because he is black, or because they believe he is a Muslim, or a communist, or that he should not legally have been allowed to run for the presidency. Some are concerned at the economic cost of the ACA, though most experts agree it will have an overall positive impact on the economy. And others believe that the ACA was forced through Congress without lawmakers being given the necessary time to work through the detail. It is certainly true that the ACA is long and complex; however, it is comparable with many other pieces of US legislation.
There have been two major setbacks for the launch of the ACA. First, the online exchange – healthcare.gov – has suffered major problems from the outset. The hope had been that states would run their own marketplaces, but in fact most have relied instead on healthcare.gov; this exacerbated the problems for a website that was not well designed in the first place. The site is easy on the eye but is not as simple as it needs to be to navigate and has some surprising ‘features’, and in addition the back end has simply been unable to cope with the demand. At the time of writing 80,000 people have signed up for health insurance online; this is believed to be a much smaller figure than the administration had anticipated. Second, in 2012 Obama promised that those who already had insurance would not be affected, but in the past few weeks many people have had their policies foreclosed by their insurance companies and have had to seek new insurance. There were certainly early stumbles when Medicare and Medicare were introduced almost 50 years ago, but these setbacks have come at a time when Republicans, and much of the media, are looking to make any hits they can. Obama has apologised for both the performance of the exchange and for his broken promise, but he has nevertheless taken a substantial political hit.
There have also been difficulties in getting the ACA functioning as intended across all the states, though this is the responsibility of Republicans rather than the Democrat administration. Medicaid is paid for jointly by the federal government and by individual states, and under the ACA states are allowed to opt out of the expansion. Despite the fact that the federal government is paying the bulk of the expansion costs, only 25 states plus DC have opted in so far, with 25 states opting out. In other words, the majority of Republican governors nationwide have taken the decision to leave large numbers of people in their state without health insurance in order to make a political point.
However, in the long term the introduction of the ACA has been, and will be seen as, a major success for Obama and the Democrats. The debate on healthcare in the US has shifted considerably, even in recent weeks and despite the mistakes that have been made. At the beginning of the recent shutdown the Republicans were seeking to overturn it, then they sought to delay it, and now they are seeking to improve it. Numerous Republicans have stated that they too want to extend healthcare to everyone, though insist that they would pass more efficient legislation. The ACA has a Republican origin: it is very similar to the Massachusetts healthcare reform law, passed in 2006 by then-governor Mitt Romney. The ACA is certainly not a perfect law, and its implementation has been far from perfect, but its aim – the provision of affordable universal healthcare – is fundamental to the proper functioning of a modern civilised society, and moderate Republicans, who, since the recent federal shutdown have found a new strength at the cost of the Tea party wing, recognise this. Obama’s goal was shared by John F Kennedy and Bill Clinton among many others, but they were unable to match his achievement. Whether it will have been seen to be successful enough by next November’s elections remains to be seen, but it will be sufficiently embedded by January 2017 for the Republicans to be unable to roll back the clock. Universal healthcare in America is here to stay.
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