Defending the Patient Protection and Affordable Care Act

My op-ed in the Kansas City Star was on Medicaid specifically. That governors and legislators can make a conscious decision to keep hundreds of thousands of their own citizens uninsured rather than expand Medicaid says a great deal to me about their values. I have different values than they do. To put it briefly, I would say I see a choice between an ethic that says, “We’re all in this together” and another ethic that says, “I’ve got mine and you’re on your own.”

Regarding the insurance exchanges, a few thoughts. First, there have been concerted and unstinting efforts by Republicans to sabotage health reform by refusing to cooperate in any way and doing everything in their power to stop others from doing so. Some states have even prohibited state employees from helping citizens to navigate the new system. Many Republican legislators have taken the highly unusual step of refusing to provide constituent services to people in their own districts, if it means helping them understand the new system.

The states that set up their own insurance exchanges (Kentucky is one example) are doing reasonably well. Those that didn’t, aren’t. For now. Forcing the federal government to construct a single exchange for 30+ states has clearly had the desired effect of throwing a wrench into the gears. The way I see it, those who made sure that their states would refuse to cooperate on creating an exchange and/or expanding Medicaid have caused large numbers of their own citizens grievous harm. I was in touch with Dr. Larry Dossey recently, and the way he put it was, “I cannot get my mind around the refusal to aid sick people who cannot afford medical care.” Efforts to sabotage PPACA have precisely that effect. There is no practical proposal from Republicans as to how to deal with the problem of the uninsured, other than more of the same. Or worse.

With any major social insurance program (this was true of Social Security and all those that came after, which I consider to be among our nation’s greatest accomplishments), there have always been problems with the initial rollout that need to be fixed. There is no example I’m aware of where that was not the case, including the Medicare drug benefit rollout under the President George W. Bush’s administration, which (because it occurred in the computer age) is probably the best comparison to look at. Basically, for all their weak points, these programs have resulted in MAJOR reductions in poverty and the suffering that comes with it. People who get old and don’t have that much money are not faced with anything approaching the level of exposure that would be the case without the protections these social programs afford. I fully expect this to happen over time with the health reform law, as well.

Which is not to say that it is an ideal law. It’s not. I do believe, though, that it was the best law that could be passed given the power of the drug companies and insurance industry. The choice between the imperfections of PPACA and the pre-PPACA status quo is, to me, day versus night. I don’t want to go back to midnight in America.

Regarding some of the young and healthy paying somewhat more for insurance policies that meet PPACA’s requirements … a few points. PPACA makes it illegal for the first time to deny or rescind policies based on past or present sickness; it requires for the first time that insurance companies spend 80-85% of premiums on actual health care services; and for the first time eliminates lifetime limits and the kind of out-of pocket expenses that can lead to bankruptcy.

I’m not going to go through the entire list of its other protections and policy changes here, but the pre-existing condition exclusion change alone should make it clear that something will have changed in a major way starting in January 2014. It should be added that banning discrimination based on pre-existing conditions is only economically feasible if combined with an individual mandate to purchase insurance. Any claims to the contrary are either uninformed or intentionally misleading. It’s legitimate (though I disagree) to say you think insurance companies should be allowed to exclude people based on pre-existing conditions. It’s not legitimate to say you want to ban pre-existing condition exclusions but also eliminate the individual mandate. Those in Congress (the entire House Republican caucus) and elsewhere who propose that are banking on people’s ignorance, pure and simple.

For any people being charged higher premiums (and it’s a very small percentage of the population, somewhere in single digits, perhaps low single digits), yes, I agree that this is a concern. But they are not getting premium increases for the same policy they had before. There are many more protections against catastrophe. If you’re fortunate enough to avoid catastrophe, you may never notice these protections and it may seem that you’re getting the short end of the stick right now. (The sliding scale of subsidies for those under 400% of the poverty level will cushion the effect for many.) The numbers are going to be different in each state, and different among the various policies available on the exchanges in each of the states. So generalizing on a nationwide basis is not really possible.

Final page after the jump.