The Wreck of Private Insurance

Having failed to defeat the Affordable Care Act in Congress, to beat it back in the last election, to repeal it despite more than eighty votes in the House, to stop it in the federal courts, to get enough votes in the Supreme Court to overrule it, and to gut it with outright extortion (closing the government and threatening to default on the nation’s debts unless it was repealed), Republicans are now down to their last ploy.

They are hell-bent on destroying the Affordable Care Act in Americans’ minds.

A document circulating among House Republicans (reported by the New York Times) instructs them to repeat the following themes and stories continuously: “Because of Obamacare, I Lost My Insurance.” “Obamacare Increases Health Care Costs.” “The Exchanges May Not Be Secure, Putting Personal Information at Risk.”

Every Republican in Washington has been programmed to use the word “disaster” whenever mentioning the Act, always refer to it as Obamacare, and demand its repeal.

Republican wordsmiths know they can count on Fox News and right-wing yell radio to amplify and intensify all of this in continuous loops of elaboration and outrage, repeated so often as to infect peoples’ minds like purulent pustules.

The idea is to make the Act so detestable it becomes the fearsome centerpiece of the midterm elections of 2014 — putting enough Democrats on the defensive they join in seeking its repeal or at least in amending it in ways that gut it (such as allowing insurers to sell whatever policies they want as long as they want, or delaying it further).

Admittedly, the President provided Republicans ammunition by botching the Act’s roll-out. Why wasn’t HealthCare.gov up and running smoothly October 1? Partly because the Administration didn’t anticipate that almost every Republican governor would refuse to set up a state exchange, thereby loading even more responsibility on an already over-worked and underfunded Department of Health and Human Services.

Why didn’t Obama’s advisors anticipate that some policies would be cancelled (after all, the Act sets higher standards than many policies offered) and therefore his “you can keep their old insurance” promise would become a target? Likely because they knew all policies were “grandfathered” for a year, didn’t anticipate how many insurers would cancel right away, and understood that only 5 percent of policyholders received insurance independent of an employer anyway.

But there’s really no good excuse. The White House should have anticipated the Republican attack machine.

The real problem is now. The President and other Democrats aren’t meeting the Republican barrage with three larger truths that show the pettiness of the attack:

The wreck of private insurance. Ours has been the only healthcare system in the world designed to avoid sick people. For-profit insurers have spent billions finding and marketing their policies to healthy people – young adults, people at low risk of expensive diseases, groups of professionals – while rejecting people with preexisting conditions, otherwise debilitated, or at high risk of heart disease, diabetes, and cancer. And have routinely dropped coverage of policy holders who become seriously sick or disabled. What else would you expect from corporations seeking to maximize profits?

But the social consequences have been devastating. We have ended up with the most expensive healthcare system in the world (finding and marketing to healthy people is expensive, corporate executives are expensive, profits adequate to satisfy shareholders are expensive), combined with the worst health outcomes of all rich countries — highest rates of infant mortality, shortest life spans, largest portions of populations never seeing a doctor and receiving no preventive care, most expensive uses of emergency rooms.

We could not and cannot continue with this travesty of a healthcare system.

The Affordable Care Act is a modest solution.  It still relies on private insurers — merely setting minimum standards and “exchanges” where customers can compare policies, requiring insurers to take people with preexisting conditions and not abandon those who get seriously sick, and helping low-income people afford coverage.

A single-payer system would have been preferable. Most other rich countries do it this way. It could have been grafted on to Social Security and Medicare, paid for through payroll taxes, expanded to lower-income families through Medicaid. It would have been simple and efficient. (It’s no coincidence that the Act’s Medicaid expansion has been easy and rapid in states that chose to accept it.)

But Republicans were dead set against this. They wouldn’t even abide a “public option” to buy into something resembling Medicare. In the end, they wouldn’t even go along with the Affordable Care Act, which was based on Republican ideas in the first place. (From Richard Nixon’s healthcare plan through the musings of the Heritage Foundation, Republicans for years urged that everything be kept in the hands of private insurers but the government set minimum standards, create state-based insurance exchanges, and require everyone to sign up).

The moral imperative.  Even a clunky compromise like the ACA between a national system of health insurance and a for-profit insurance market depends, fundamentally, on a social compact in which those who are healthier and richer are willing to help those who are sicker and poorer. Such a social compact defines a society.

The other day I heard a young man say he’d rather pay a penalty than buy health insurance under the Act because, in his words, “why should I pay for the sick and the old?” The answer is he has a responsibility to do so, as a member the same society they inhabit.

The Act also depends on richer people paying higher taxes to finance health insurance for lower-income people. Starting this year, a healthcare surtax of 3.8 percent is applied to capital gains and dividend income of individuals earning more than $200,000 and a nine-tenths of 1 percent healthcare tax to wages over $200,000 or couples over $250,000. Together, the two taxes will raise an estimated $317.7 billion over 10 years, according to the Joint Committee on Taxation.

Here again, the justification is plain: We are becoming a vastly unequal society in which most of the economic gains are going to the top. It’s only just that those with higher incomes bear some responsibility for maintaining the health of Americans who are less fortunate.

This is a profoundly moral argument about who we are and what we owe each other as Americans. But Democrats have failed to make it, perhaps because they’re reluctant to admit that the Act involves any redistribution at all.

Redistribution has become so unfashionable it’s easier to say everyone comes out ahead. And everyone does come out ahead in the long term:  Even the best-off will gain from a healthier and more productive workforce, and will save money from preventive care that reduces the number of destitute people using emergency rooms when they become seriously ill.

But there would be no reason to reform and extend health insurance to begin with if we did not have moral obligations to one another as members of the same society.

The initial problems with the website and the President’s ill-advised remark about everyone being able to keep their old policies are real. But they’re trifling compared to the wreckage of the current system, the modest but important step toward reform embodied in the Act, and the moral imperative at the core of the Act and of our society.

The Republicans have created a tempest out of trivialities. It is incumbent on Democrats — from the President on down — to show Americans the larger picture, and do so again and again.