In the previous article ("Why Support the Imperfect Health Care Reform Law -- Part One"), I made the case that the new Affordable Care Act (ACA) deserves support because of the good it will do for so many Americans and for the health care system as a whole. At the same time, I acknowledged that the law was imperfect and that it will not achieve all we should want to accomplish from reforming the health care system. So, why not go back to the drawing board and try to get it right? The one-word answer is "politics."
Why support such an imperfect law?
This is only the second time that Congress has even voted on a comprehensive reform package. The other was 1965 when Lyndon Johnson persuaded Congress to pass Medicare and Medicaid. The reality is that enacting the ACA was a monumental political achievement, and the probability of passing another one is practically zero.
Why is that the case? First, passing any law is hard because it requires not just a majority in the House of Representatives, but 60 percent in the Senate. Even within a single party, members have different views of the proper role of government and other matters; so, it is hard to persuade a majority (or 60 percent) to coalesce around reform.
This tendency is reinforced by the fact that the over-riding goal for most members is to get re-elected.
Further, the forces against change have compelling reasons to oppose it. They expect to make lower profits and to operate under less favorable rules. So, they are willing to spend a lot lobbying members of Congress to keep a bill from passing. Some of that money also helps members in their re-election efforts.
In contrast, supporters are a diverse group for whom health care reform is not the over-riding concern and who, in any event, tend to have less money to spend.
This combination of factors makes it very difficult to pass any law much less one that accomplishes all the goals of reform. It also helps explain why, when a president and Congress finally do act, the result -- as in this case -- is less than fully satisfying? Then, why not leave well enough alone? Why bother with a reform effort that is sure to disappoint?
Why Reforming the Health Care System Is Important
The U.S. spends too much on health care. Our expenditure rate is 5 to 6 percentage points of GDP more than the second most costly country.
Yet, despite spending all that extra money, many people have no access to appropriate care. Moreover, while the countries that spend less cover all their citizens, 16-17 percent of Americans have no health insurance at all and millions more cannot use their coverage because the only policy they can afford requires more cost-sharing than they can pay.
The quality of care is unreliable even for those with money and/or good insurance. And many health professionals' mistakes are caused by their efforts to cope with dysfunctional features of the present system.
The delivery system itself is deteriorating as a result of the failure to solve the interrelated access, cost, and quality problems. A scary thought: When they become patients themselves, not even doctors can count on getting the care they need or getting it without error.
The need to reform the system goes way beyond the fact that millions of Americans cannot access regular, affordable primary care and other needed services. As the delivery system continues to unravel, no one can be sure he or she will be able to avoid being victimized by its inadequacies.
Why This Reform Law Has Been a Hard Sell
So, why are so many Americans reported to be "angry" at the law's passage. Why do even some progressives oppose it?
One reason is that much of the public is misinformed about the law's actual provisions. It is long and complex, opponents have deliberately misrepresented it, and supporters have not responded effectively. In addition, some people were turned off by the "sausage-making aspect" of the legislative process. Many assume that the legislation itself must be as corrupt as the process that produced it appeared to be.
Further, the law appears to fall short because it won't do all the things proponents touted as the reasons to enact reform. And many of the good things it will do won't occur for several years. Finally, some fear it is a windfall for insurance companies, which will gain millions of new customers.
Instead, the ACA should be seen, not as an end in itself, but as progress along an extended path toward perfecting a delivery system everyone must count on when they get sick.
The new Affordable Care Act deserves support because, although imperfect, it will provide real help to many Americans and permit us to make real progress toward a better health care system. The alternative is to take no action. But that is not an option because the health care system is already unreliable, is deteriorating still further, and will only get worse unless we act to improve it.
For more detail on the need for the law or the politics of reform, see my book, Still Broken: Understanding the U.S. Health Care System.