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To understand the significance of the so-far failed effort to “repeal and replace” Obamacare, we must go back to the origins of the health care reform that Barack Obama and the Democrats carried out in 2009-10. Health care costs had more than doubled in the previous decade, and a million more Americans were losing insurance each year. Something had to be done. Many progressives advocated for a single-payer, Medicare-for-All program, but the Democrats settled instead for a scheme whose origins went back to the Nixon era and the Heritage Foundation – though in this setting the plan could garner no Republican votes. And, for the next six years, the Congressional Republicans tried more than 40 times to repeal it, all attempts stopped in the Senate or were vetoed by President Obama.
What did the Affordable Care Act or ACA – named Obamacare by the Republicans – actually do? Beginning with the declaration that “all Americans should have access to high-quality affordable health care,” it established means to ensure that everyone (except undocumented immigrants) had access to health care within the existing insurance structure.
MORE INSURED
If you were over 65 years of age, you would be eligible for Medicare. Otherwise, if your income was below 138 percent of the federal poverty level, you would be eligible for Medicaid. If your income was above that level, you would be expected to purchase private insurance. You would receive a subsidy to help purchase it, and you would pay a penalty if you didn’t (that’s the “individual mandate”). This type of insurance mandate was first created at the state-level in Massachusetts under then-Governor Mitt Romney.
Insurance companies were required to sell you coverage; they could not charge you any more if you were ill, and the insurance had to be comprehensive, including all “essential benefits.” It could not, for instance, exclude maternity care or mental health coverage. And if your income was below 250 percent of the poverty level, deductibles and co-pays would be subsidized.
As a result, today more than 10 million people who were previously uninsured have private insurance coverage and another 14 million are covered by Medicaid. The uninsured rate has fallen to 8.9 percent, the lowest level in our history.
Then came the earthquake of the 2016 election, giving Trump the presidency and the Republicans control of both houses of the Congress. They are now in a position to repeal at least the financial portions – the taxes and the subsidies and the Medicaid payments – of Obamacare; Democrats can filibuster any change to the structure of the program. But what, if anything, would replace it?
Trump promised “insurance for everybody…much less expensive.” Paul Ryan, the Republican Speaker of the House of Representatives, and his allies instead wanted to go as far as they could in getting the federal government out of the health care business. And, as part of that, they want to replace Medicare coverage by giving each Medicare recipient a limited voucher to use in purchasing private insurance.
Their replacement was the American Health Care Act (AHCA), a plan that was quickly labeled a “tax cut for the rich disguised as a health care bill.” It eliminated the ACA taxes on individuals making more than $200,000 that helped pay for subsidies for the needy. (The AHCA retained some subsidies, but based them only on age, not on income.) It eliminated Medicaid’s safety-net guarantee of coverage and replaced it with a cap of 10 years, the Republican balloon burst. The public outcry, already visible in the angry constituents storming congressional offices across the country, became overwhelming. The plan was withdrawn when the Republican leadership realized that it did not have the votes to pass it. (The House Democrats were united in opposition to it.) As of this writing, there are still efforts by Republicans to revive the bill, possibly in even worse form than before.
RISING COSTS
In other ways, too, the Trump administration can still harm those who depend on Obamacare. It can discourage young, healthy people from enrolling and fail to enforce the individual mandate. It can impose premiums, cost-sharing, and work requirements on those who depend on Medicaid. However, during the eight years since the health reform debate began, the American public has come to believe that access to health care should be available for everyone. Recent polls indicate that 64 percent of Americans, including 86 percent of Democrats and 37 percent of Republicans, believe that government should guarantee health coverage for seniors and lower-income individuals.
So, for the moment, Obamacare has survived, and it continues to help many people, but more than 25 million people are still uninsured. Costs continue to rise twice as fast as anything else we buy. Huge deductibles are becoming common, and we still depend on wasteful, unreliable profit-maximizing insurance companies to pay for much of the health care in this country.
ADVANCING SINGLE PAYER
Many see this as the time to push for a universal Medicare-for-All, single-payer program. Every other advanced country has found a way to cover all their residents while spending little more than one-half what we spend. All rely on government to oversee and regulate health care, including administering the prices that doctors and hospitals charge. Our own Medicare program has shown how such a program can provide reliable coverage while containing costs.
Congress is not likely to act in the near future, but here in New York State, the New York Health Act would extend the principles of Medicare and Medicaid to every resident of the state. Under this legislation, which has passed the State Assembly and has 30 co-sponsors in the Senate – 32 votes are needed for passage – every resident of the state would be entitled to comprehensive coverage for all medical needs. There would be no co-pays or deductibles. The program would be funded through progressive taxes on payroll and non-payroll income, with employers paying 80 percent of the payroll tax.
Studies have shown that such a program, which is similar to that in many advanced countries, including Canada, would cover everyone while costing less than we are now spending. PSC, along with many other statewide unions, is supporting this progressive legislation, and PSC members have an opportunity to reach out to their lawmakers and tell them to support a progressive health care plan for the state.
Leonard Rodberg is professor emeritus of urban studies at Queens College. This article is based on a presentation delivered to the union’s retirees chapter.
