November 25, 2013 | Posted By Wayne Shelton, PhD

The political right in the U.S. has mounted a formidable effort from the outset to mischaracterize the aims of the Affordable Care Act (ACA) and to mislead voters about the need for fundamental reform in healthcare. I take it as a given that the opposition to the ACA has never been about its efficacy to promote certain goals to expand coverage for more Americans; even if the ACA accomplished its goals perfectly, those on the extreme political right would still oppose it. That is, the opposition from the political right is not about whether or not the ACA will work effectively but about ideology—they oppose the ACA as a matter of principle. They are committed to the view that government should not be involved in healthcare and fear, perhaps rightly, that if the ACA proves workable it would lead to a single payer system of universal coverage for all citizens. They apparently see healthcare services being like any other market service provided in a capitalistic society. But upon even a superficial analysis, this position is flawed.

It is basic to free markets that the ability of an individual to use a certain service or product is a function his or her ability to purchase it. One of the few services that is an exception in our current capitalistic society is healthcare, albeit only at the level of requiring services at an acute level. For example no matter how desperately I need transportation to go back and forth to work, I will not get a free car as a function of someone else’s obligation to provide it. This is not true of healthcare: even if I cannot pay for healthcare or I lack healthcare insurance, if I get sick enough and show up at an Emergency Room, I’ll not only be stabilized, I’ll be hospitalized and be given all I need to improve, or more fittingly, to be rescued from dying. From a purely market point of view it seems pretty obvious if we wanted only efficiency, we would just let acutely sick patients die and not rescue them. This would be the logical conclusion of a purely market approach. But it would also be morally bankrupt and no one on the political right will say it explicitly, even if they believed it to be true. But by simply recognizing this ingrained de facto moral obligation to rescue acutely sick patients from death is significant in terms of how we view the nature of healthcare services. For it means that healthcare is not a normal market service, but a special service that people get, albeit only at the acute, rescue level of need. That being the case, it would seem our greatest public policy challenge today is designing a system that accommodates our moral aspirations and values to not let people die in the streets or at home with no care. Indeed it would also follow that it would make more practical sense to provide all people with access to primary care so as to decrease the need for less effective more costly acute care. It is in light of the progressive struggle to respond to these basic challenges that the recent developments around the ACA have been so disappointing and disconcerting.

Given the well-known, longstanding, entrenched opposition to healthcare reform in the U.S. and the failure of every effort to expand healthcare since WWII except for Medicare and Medicaid, how could the Obama administration be so unprepared to rollout the ACA? It is legitimate to ask: after all the planning for the past three years to roll out the ACA how could the website be so dysfunctional? There is simply no excuse for such incompetence. But as if the technical glitches didn’t cause enough negative press, the recent revelations of 5 million or so Americans who received cancellation notices from their insurance companies contradicted President Obama’s often stated vow that anyone who liked his or her insurance coverage could keep it. These are people who mostly have substandard policies but they are also at the mercy of insurance markets that are in continual flux, particularly with the introduction of new federal guidelines. It was highly predictable, with or without the ACA, that some people would loose their policies that they would have preferred to keep. So why did President Obama and many others in the democratic party over-promise and set themselves up for so much controversy?  Given the incendiary context of contemporary politics, the strategy was highly unfortunate and most unwise.

However, these unfortunate logistical shortcomings cannot distract everyone from the alarming facts about the current state of healthcare in America and the need for change. A recent report from the Commonwealth Fund brings to light some of the reasons why the ACA must move forward: U.S. adults are significantly more likely than their counterparts from 11 other industrialized countries to 1) forgo healthcare because of cost 2) have difficulty paying for healthcare even when they have insurance and 3) deal with time-consuming insurance issues. In addition to these obstacles the U.S. spends over $8,500 per person on healthcare, $3,000 more than Norway, the second highest spender.  And even though 75% of those surveyed said that U.S. healthcare should be fundamentally changed or rebuilt completely, we continue to be in a political quagmire regarding the ACA.  Even before President Obama was forced to retract his claims about no one losing his or her healthcare insurance, less than half of the American public supported the ACA. In spite of the fact that most Americans seem to like the provisions of the ACA such as not denying insurance to those with preexisting conditions there still seems to an ingrained bias against government and in favor of private insurance.

The ACA was intended to address some of the most egregious challenges in our system, primarily to expand coverage and to provide subsidies to those who need help, all while avoiding a single payer system and using the private insurance market.  There are no easy solutions or pain free ways to making this or any new system work. Some people may fare less well in the short run, but as a nation we will be better off if we find a way to make the ACA work effectively. Those states with governors who embrace the ACA and have expanded the Medicaid program are shining models of how to make the ACA work effectively. In Connecticut, Kentucky and Washington the legislatures expanded Medicaid and with enlightened leadership from governors the people are enrolling in respectable numbers, money is being saved and jobs are being created, and the majority of citizens are satisfied with what is happening. This shows what can be done when politicians work in a bipartisan effort for the public good.

The bottom line is that the political right has no viable alternative to the ACA so we must find a way to make it work. Those of us who support effective change in healthcare must stand firm, not become disillusioned and do what we can to make sure we do not loose this historical opportunity.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

3 comments | Topics: Affordable Care , Cost , Health Insurance , Politics


Dave Hoffman

Dave Hoffman wrote on 11/25/13 7:57 PM

Excellent commentary Wayne. one important question you pose is "Why wasn't the administration more prepared?". To answer that we need look no further than Congress - where for all of recent history they have been unable to agree on top line budget numbers for the twelve appropriations bills. This has resulted in a series of "continuing resolutions" based not on current and future needs but on the previous year appropriations. This Congressional gridlock has allowed opponents of ACA to freeze out any additional needed spending to implement the bill. It isn't a coincidence that in states where they choose to implement a state based exchange - and funded those efforts - problems have been minimal and sign ups have been as expected.
James Finnerty, M.D, M.A

James Finnerty, M.D, M.A wrote on 11/25/13 8:49 PM

Hi Wayne,
You are right on the "button" but, short of having a dictator take over, I think it will be awful difficult to achieve the goals you are professing.
Jim Finnerty
Heddy-Dale Matthias, MD

Heddy-Dale Matthias, MD wrote on 12/04/13 11:53 AM

I believe the proponents of this law have lied to the public since the ACA's initiation. They knew from the beginning that the ACA would be a huge tax on those paying taxes, but refused to tell US citizens. At the time of its passage the administration had NO idea how much this program would cost, but knew that taxpayers would foot the bill. I asked last year how the government would know its cost when physicians had no idea (we still don't to this day) how much we would be paid, insurance companies had no idea what their costs would be, etc. Yesterday, we heard that the insurance companies will be "reimbursed" whatever, it seems, they wish to charge. This is INSANE. This administration knew it would cost billions of dollars, and spent all their time obfuscating these facts. And most policies for less well off folks are a joke--who can afford a $8000 deductible? I have a $1000 deductible on a single private policy of $830/month. Who is better off with the ACA? The answer is insurance companies and the few folks with preexisting disease who can now get insurance. It would have been a much better idea to "give" direct subsidies to those needing them and letting them buy policies that were offered NATIONALLY in a competitive market. The ACA is a catastrophe for all involved.

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