Why Obamacare’s promise of an affordable health system is dead

Amid all the handwringing over Donald Trump’s election and despair over the future of the Affordable Care Act, one question has been lost — do all Americans, rich or poor, young or old, sick or well, have a fundamental right to health care? Despite the rhetoric of “affordable quality health care for all” and the false promise of a $2,000 savings on the family health insurance premium, both of which helped propel Obamacare along its tortuous path to victory in the spring of 2010, Americans still have not embraced health care as a basic right for everyone. Although the law brought health care to some 20 million people who finally got insurance to pay for it, the ACA did not resolve that fundamental question which has dogged American health care debates for decades.

Ex-Washington Post reporter T.R. Reid, who spearheaded the failed ballot initiative that would have brought truly universal health coverage to Colorado financed through taxes, told me, “Half (of the people) don’t want to pay for other people’s health care.” For them it is not a basic right. Yet, he said, he often explained to audiences that they pay for it anyway through Medicare, Medicaid, and the private insurance system — a tough point to get across.   

Our collective inability to come to grips with that proposition has made the Affordable Care Act — concocted as a wobbly, layered wedding cake — vulnerable to electoral backlash. It was only a matter of time before it happened. As The New York Times reported in its post-mortem on the vote in Wisconsin, voters in the state “had grown discontented with Mr. Obama’s policies, particularly the Affordable Care Act.” 

Most Americans did not have a dog in the fight over the ACA. That wasn’t the case when Congress passed Medicare and Social Security — social insurance programs that provided the right to benefits at age 65 for everyone who had paid into the system during their working years. They had a vested interest in the success of those programs. By contrast the vast majority of Americans have had no such stake in the ACA, and instead are detached from its provisions, many of which don’t affect them.

Republicans, with their relentless insistence on repealing and replacing the Affordable Care Act, have reframed the discussion of what’s politically possible to achieve in America at the moment, and what is possible is not a truly universal system with everyone covered at a reasonable cost.

Some 156 million Americans under age 65 already had insurance through their employers at the time of the law’s passage. Keeping young adults on the family policy until age 26 was useful for some families, but many employers already allowed that, and the provision affected only about seven million people. Removing annual and lifetime caps on benefits has been a boon to the relatively few families with catastrophic illnesses and catastrophic expenses. The ability to buy health insurance regardless of your health status was super important but only to those in the relatively small “individual” insurance market. It was irrelevant to those with employer coverage or insurance from government programs. Medicaid expansion, arguably the most important feature of the law, affected only the poor who are out of sight and out of mind for most Americans. Many came to see the Affordable Care Act not as something to help those left out of the insurance tent but as something that was pinching their own pocketbooks. And when insurers began abandoning the Obamacare markets this fall — leaving more than 40 percent of all HealthCare.gov counties with just one insurer, few options, and high premiums especially in rural areas — voters registered their discontent at the polls. Contrary to the spin from the government and the press accounts based on it, half the people buying policies in the individual market were not eligible for subsidies to help them out, a fact continually overlooked by the media.

Almost weekly I receive an email from someone, often living in a small town or rural area, telling me what they will have to pay next year. From Indiana came a note from a self-employed man who said Anthem had increased his $836 monthly gold plan premium for him and his wife to $1,336, an amount he considered unaffordable even with a subsidy. What’s worse, the rate hike came with increased coinsurance costs for hospital stays he had to pay until he reached his out of pocket maximum of $14,300 for next year. He would now have to pay 50 percent of the bill if he or his wife needed hospitalization instead of the 20 percent required by his current policy. That 150 percent increase in the coinsurance sent him scrambling for new coverage. He found a new policy with a premium of only $700 with his subsidy.

It’s not just people in rural areas who’ve become disenchanted. Just ask New Yorkers who were enticed to sign up for one of the insurance co-ops that promised cheap insurance but later found cheap coverage was not a sustainable business model and closed their doors. Many of its customers later flocked to Oscar, a tech-savvy Google-backed start-up carrier that was also supposed to deliver cheaper insurance. Bloomberg News just reported the company has suffered serious losses and is looking to diversify.

Republicans, with their relentless insistence on repealing and replacing the Affordable Care Act, have reframed the discussion of what’s politically possible to achieve in America at the moment, and what is possible is not a truly universal system with everyone covered at a reasonable cost. If the mandate disappears and insurance companies must still cover the very ill, premiums will rise and may become more unaffordable than they are now. Insurers may not even insure them. Insurers may not even insure them. As one insurance official told me long ago, "We don't wan't to insure the burning house." Nor do I expect the next phase of the continuing Obamacare debate to focus on health care as a basic right. There will, though, be a lot of wonky talk about preexisting conditions, whether the private insurance carriers are in fact able to provide coverage to very sick people and still make money, whether to keep the mandate that most all Americans must buy coverage, and ultimately, whether it’s possible to require insurance for sick people if the mandate is repealed.

All this is heavy-duty policy wonk stuff and hard for the public to grasp. There’s a danger the discussion will be limited to policy wonks and their friends in the media, talking in the kind of jargon and spin that leaves out the public once again.

Shortly before the election MIT professor Jonathan Gruber who was instrumental in designing the Affordable Care Act appeared on CNN to discuss the health law’s future. Recall that a couple of years ago, a clip was unearthed that revealed some remarks Gruber had made about the law’s passage. “Lack of transparency,” he said, was a “huge political advantage” because lawmakers didn’t know what the bill did, adding that “the stupidity of the American voter … was really, really critical for the thing to pass.”

At the end of October, Gruber told CNN, “the law is working as designed,” and he downplayed its emerging shortcomings. There was just one problem with Gruber’s assessment. The “stupid” public thought otherwise.

Veteran health care journalist Trudy Lieberman is contributing editor of the Center for Health Journalism Digital and a regular contributor to the Remaking Health Care blog.