Understanding "Obamacare"

A number of talk show hosts, most notably Jimmy Kimmel, have had fun lately asking folks on the street what they think of "Obamacare." Revealingly people know very little about it:

Polls and surveys find the same widespread lack of knowledge about what the Affordable Care act (to give the law it's proper name) actually is, and what change to our health care system the reforms actually make. 

This confusion is, I think, largely the result of the fact that The Affordable Care Act is politically very divisive. Rhetoric from multiple sides of the political spectrum has greatly obscured how the law actually works. We must get past the rhetoric and actually take a careful look at the key elements of the new health care law.

I have taught Health Care Ethics at Marquette University and Harper Community College. A key aspect of this course is a careful consideration of how health care systems and health insurance works in the United States and abroad. Because of this I've been given ample opportunity to study the details of the new health care law (The Most reliable information on what is the law can be found at: Kaiser and the AARP) 

Here in short are the key elements of the law.

First, two important pieces of information.

1. It is important to note that "Obamacare" is not "socialized medicine." In countries like Canada and England there are no health insurance companies. The government pays the bill. But here in post health reform America, the for-profit private insurance companies that we have all used for decades remain the providers of health insurance for the majority of Americans too young for Medicare, too high income for medicaid, and not receiving Veterans care. 

2. For those Americans who receive health care from their employer the law changes virtually nothing. You will still have the same relationship to your health insurance company that you had before. One important change here, however, is that young people can now stay on their parents plans until they are 26.

Where things have changed is the individual private market. The reasons for the big changes here come from the following provisions of the ACA:

1. Guaranteed issue - insurance companies can no longer deny coverage to anyone who applies. For decades insurance companies have denied people coverage due to pre-existing conditions, Beginning January 1, 2014 they will be legally precluded from doing so any longer.

2. The Individual Mandate - with the exception of those whose incomes are too low, everyone must get insurance or pay a tax penalty (if your income is too low and your State accepts the expansion of medicaid that the ACA offers, then you will qualify for medicaid).  If you receive medicare, medicaid, veterans care or get insurance through your employer you already comply with this requirement. This is, perhaps, the most controversial aspect of the law. Many people seem to feel that legally requiring us to have insurance violates our personal liberty. It is worth noting, however, that the supreme court upheld the mandate as constitutional in 2012. It is also worth noting that the individual mandate was first thought of by the conservative Heritage foundation, embraced by Republican Presidential candidate Bob Dole, and first enacted by by Republican Governor and most recent Republican Presidential candidate Mitt Romney.

3. The Employer Mandate - with some exemptions, all employers with 50 or more employers must either provide an insurance plan to their employees or pay a tax penalty for each employee. Business with fewer than 50 employees are not subject to this requirement. 

Other changes that apply to the private insurance market are that annual and lifetime limits on what insurance companies would pay have been abolished. Women can no longer be charged more than men, and individuals who already suffer from an illness cannot be charged more on that account. 

Those who buy private insurance on the individual market will do so through either federal or state exchanges which must operate according to strict federal regulations. These Federal guidelines require that all insurance plans cover ten essential benefits (ambulatory patient services; emergency services, hospitalization; maternity and newborn care; mental health and substance use; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care).

There are, in addition, 4 types of plans, platinum, gold, silver, and bronze. These plans cover 90, 80, 70, 60 percent of costs respectively. The more costs the plan covers, the higher the premium is. Most Americans qualify for a subsidy which will pay for part of their premiums, thus lowering what they will pay.

Unfortunately the launch of the federal insurance exchange (States who have set up their own exchanges - not all States have - have been more fortunate) has been something of a problem. The web sight is not working properly and most consumers cannot access it. It remains to be seen if this technical problem will result in delaying certain aspects of the law, such as the individual mandate. 

The Benefits of the Affordable Health Care law are clear. For many years millions of Americans were denied access to health care because of pre-existing conditions or high costs. Many of these people will finally be able to buy health care that they can afford.

But there are disadvantages as well. Some Americans will see their premiums and/or deductibles rise. Furthermore, because the new law requires all health insurance plans to cover the ten essential benefits mentioned above, some current plans will be eliminated starting next year. These plans will be replaced by plans that cover more, and for most consumers cost less (thanks to subsidies) but to some 3-5% of Americans costs will rise up. There are those who believe that they should be allowed to pay less for their current plans which cover far less. They are not pleased with this situation. For more on this particular controversy see the very helpful piece in the New Yorker.

Most importantly the Affordable Health care Act has, hanging over it, one big question mark. The United States has by far and away the most expensive health care system in the world. It is debatable that the ACA does nearly enough to reduce these huge costs. If we really want to reduce our expensive system, further changes may very well be needed in the future. 

For a further quick, comprehensible  and comprehensive overview of the Affordable Health Care act in all it's particulars I recommend the following, rather humorous, 9 minute video from Kaiser:

A Plea to My Leftist Friends: Obama is not Romney - The Vote Matters

There are some on the left of the political spectrum (the real left, not what our media and pundits call the "left") who see no important and meaningful difference betweeen Romney and Obama. Both, they argue, are corporate puppets who don't really represent the needs of poor, working, or even middle class voters. Both are stooges of the Military Industiral Complex that murders civilians abroad and imposes American Imperial Policy on nations all over the globe.

My Friends on the left are surely right to see Romney and Obama as tools of the the American Military Empire, the Corporate robber barrons, and the absurdly rich plutocrats. Neither man's campaign or debate performances mention the extreme income inequality, growing poverty, and diminshing resources of our nation's poor. Neither questions American expceptionalism and imperialism at home or abrod. Even worse, neither man seriously addresses the erosion and whole-sale decimation of the American Middle Class. With these points I agree completely.

Why, then, do I claim that Obama is not the same as Romney and that this election actually does matter?

Here's why: Obama will preserve social security and traditional medicare. Romney, on the other hand, will do away with both, turning them - slowly and carefully no doubt - into privatized and ineffective shadows of their former selves. Romney will slash taxes even more than Bush already has, diminsihing public funds, and resulting in drastic cuts to the social safety net. Far fewer food stamps, less unemployment, even more drastically underfunded schools, an infrastructure that crumbles and erodes even more so than it already has.

Romney will repeal Obamacare and pass the Ryan Budget into law. Of course, many on the left are unhappy with Obamacare, seeing it as a sell-out to the Health Insurance Industry. There is merit in that criticism. I share in that dissappointment. Despite my reserveations about Obamacare, however, I prefer a system that eliminates pre-existing conditions, expands medicaid to cover more of the working poor, allows young adults to stay on their parents insurance until they are 26, and provides free vaccines, screenings, and birth control to many who desperately need these services. Whatever Romney would put in place of Obamacare, would include none of this. It is likely in fact, that he will reinstitute the worse of the practices of the private insurance market, and perhaps even make matters worse than they were before.

I know that, for us on the left, Obama is not "our man." I know that his foreign policy has been a human rights travesty. Drones, kill lists, suspension of due process, the arrest of Bradley Manning. Yes, these are deplorable. The United States and its leadership ought to be held accountable for all of this; Obama included.

But what is to be gained by letting Mr. Romney win? Will he and his party release Bradley Manning? Stop the drones? Be rid of the kill lists? Be serious. If anything they will expand and amplify this and possibly bring back water boarding and other tortures just for good measure.

Finally, don't foget that Romney will get to appoint as many as 3 Supreme Court Justices during his Presidency if he wins this thing. If you care about a court that is set to consider same-sex marriage, if you are concerned that Roe V. Wade not be overturned, this is very far from a trivial matter.

To vote for Obama is not to support his dreadful - and all too American - imperial foreign policy. Nor is to vote for the clear corporate power structure that he represents.

We must vote for Obama to keep what is left of our social safety nets -  food stamps, head start programs, unemployment insurance, social security, medicare, etc - out of the hands of Mitt Romney and the right-wing party that comes with him.

We must vote for Obama in order to build on that which is good in Obamacare. We cannot return to what existed before it pasts.

We must vote for Obama to protect women's reproductive rights and the hope same-sex couples to have their love recognized with legal marriage.

Obama may not be the "change we can believe in," he is surely not the progressive champion some took him to be. Despite this, however, we know that his opponents are radical regressives who will undo what is left of the New Deal and the Great Society. On social views that will turn back the gay rights and womens movements, and plunge us backward. If we re-elect Obama we can push his party to the left, we can build up genuine progressive movements locally from the ground up and change the political climate of our nation for the better.We can do this not because Obama is wonderful, or even willing to join us, but because with Obama we can retain enough of the old liberal ideas and institutions to move forward and build.

But if we don't defeat Mitt Romney, if we don't win President Obama a second term, it may take us a generation, or even several generations, to undo the damages of the radical, right wing, regressive, and destructive social and economic agenda of Mr. Romney, Mr. Ryan, and a Republican Party now run by openly extremist regressives.