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Stephen M. Davidson Headshot

It's Maddening

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Predictably, as October first approaches, the level of attention focused on the Affordable Care Act has grown both in volume and intensity. While the administration encourages uninsured Americans to get ready to sign up through the Health Insurance Exchanges, opponents once again argue for repeal or, failing that, for starving the implementation process for funds, hoping it will fail for lack of the resources needed to make it work.

As one who has written about health policy for many years, I find the opposition to be nothing less than maddening. Some, like Sen. Ted Cruz, are just nasty and cynical. As Gail Collins pointed out, he wants to kill the act because it is bound to be popular and, therefore, hard to take away from people later on. Others continue to spew falsehoods about the law -- either they have not taken the time to inform themselves of the facts or they just don't care what the facts are. It is maddening because the issues are serious, they affect us all, and those guys treat it like a game in which the only prize is a government job for themselves in the national legislature where, historically at least, the object was to pass legislation.

While the law is hard to master because it is long and has many parts, most of the ideas are pretty simple and have been around for a long time. What follows is an attempt to set the record straight on the assumption that not everyone is taken in by the cacophony from the far-right chorus.

The first point to make -- and the place where the debate should begin -- is that reform is critically important to the future of the American health care system. One reason, of course, is that millions of Americans have not had insurance and, therefore, have lacked access to beneficial medical services. In addition, U. S. health care spending, which already is the highest in the world by far, is still growing, thus making it harder both for employers to continue to provide good coverage to employees and their families and for individuals to buy insurance even when their employers offer it. Finally, quality of care is too unreliable. Quality measures vary widely from state to state. Even doctors, when they or their families are patients, have trouble getting the care they know they need.

These are serious problems and the continuing failure to deal with them makes them worse. In 2010, the president and his Congressional allies were able to pass the ACA which, while not perfect, addresses all of these problems in ways that are reasonable. If fully implemented, the health care system will improve and we will all benefit.

What are some key provisions? Practically all Americans must obtain health insurance (the "individual mandate"). Those who have trouble paying for it may be eligible for subsidies to help. Moreover, insurers must provide coverage for all who seek it, even those with prior medical conditions, and except for age, may not charge individuals more because of personal characteristics, even factors that increase the risk of needing care. Thousands of young adults up to the age of 26 are still covered on their parents' insurance policies while they continue as students or look for a job with coverage. According to estimates, in 2012, almost 13 million people received rebates totaling more than $1 billion because private insurers spent more than the maximum permitted by the law (85 percent for large-group insurers; 80 percent for those in the individual and small-group markets) on overhead, executive compensation, and profit instead of on medical services and efforts to improve quality of care. Health insurance exchanges should make it relatively easy for individuals to compare competing insurance policies and to choose the one that is best for them. And many provisions encourage reform of the way care is delivered and paid for to increase quality and save money.

Opponents claim that government will "play doctor" (without identifying provisions that could lead to that conclusion); that the law takes away personal freedom (though it is not clear how or what freedom); and that it will cost people too much (though early indications are that premiums will be lower than expected). They also claim it will add to the federal deficit even though the CBO has long estimated not only that it will actually be reduced, but also that repealing the law, as the House has voted to do more than 40 times, would add $109 billion to the deficit. While the administration and others valiantly try to answer them, the growing list of false charges causes lots of damage. One result is that recent surveys show that many disapprove of the ACA (although most tend to want lawmakers to "do what they can to make the law work as well as possible"). Many do not understand it very well - partly because, if they already have insurance, it may not affect them directly or because they are confused by the "facts" the far-right makes up.

The new law is not perfect, but Senator Cruz is probably right that it will be hard to take away from people when they see the good it does.

(My new book, "A New Era in U. S. Health Care: Critical Next Steps Under the Affordable Care Act (Stanford University Press, 2013) has more detail about the law.)