Published on Alternet (http://www.alternet.org)
Home > SCOTUS Gave Obamacare a Win. Now the Real Fight Begins
________________________________________
SCOTUS Gave Obamacare a Win. Now the Real Fight Begins
By Kai Wright [1] / The Nation [2]
June 30, 2015
We've come a long way over the six years since Congress began crafting the
Affordable Care Act. We've traveled from death panels to death spirals,
passing through nearly 60 House votes on ways to repeal or gut the law, at
least one election defined by it and two Supreme Court challenges to it. But
finally, with the Court's definitively worded ruling [3] in King v Burwell,
we may have arrived someplace hopeful: the beginning of a meaningful debate
over the law's role in fixing our broken healthcare system.
There is plenty to debate. The right's obsessive focus on Obamacare's repeal
has been maddening for many reasons-the dishonesty that has defined its
critique, the way it has leveraged disturbing ideas about the president's
legitimacy-but among the most frustrating side effects has been its impact
on the urgent work of improving the law. Everyone has been too occupied with
arguing over Obamacare's very existence to truly watchdog its
implementation-and its many potential pitfalls. The law is, still,
predicated on the idea that healthcare is a consumer product rather than a
public good. And even in its most successful manifestation, the Affordable
Care Act will by design leave out millions of people who live in this
country and, their immigration status notwithstanding, depend upon our
health system.
So let's get back to basics: The United States has the most expensive [4]
healthcare system in the world, delivering the least effective results among
its would-be peers of wealthy nations. That's been true for a very long
time. One big reason for the system's colossal failure has been that tens of
millions of people only enter it once they are in crisis-meaning they are
both more expensive to treat and less likely to have healthy outcomes from
that treatment. As the Court's ruling deftly summarizes, the Affordable Care
Act aims to fix this problem by making insurance more cheap, more fair and
mandatory. Is it working?
There's little question the law has worked in its core goal of expanding the
number of people who have insurance. The uninsured rate among non-elderly
adults began dropping as elements of the law took effect in 2010 and fell
off a cliff once it was fully implemented. After years and years of
handwringing over steady growth in the ranks of the uninsured, Obamacare
turned the clock back. The share of our population without coverage dropped
by more than 4 percent last year, a Centers for Disease Control study found
[5], arriving at a lower rate than the CDC has seen since before 1997.
Percentage of adults aged 18-64 who lacked health insurance coverage at the
time of interview for at least part of the year, or more than a year, United
States.
Photo Credit:
CDC/NCHS, National Health Interview Survey, 1997-2014, Family Core Component
But there remain significant political and regulatory fights if we are to
translate this accomplishment into a functioning and equitable healthcare
system. Here are three.
1) Fix Medicaid Everywhere
The right has obsessed over the individual mandate, but Obamacare's real
radical change has been the historic expansion of public health insurance
for the poor. A major reason for the uninsured rate's drap nationally is
Medicaid's expansion in a little over half of the country. In the 21 states
that still refuse to open up their Medicaid programs, roughly one in five
people remain locked out of our healthcare system. Everywhere else, the
uninsured rate has been cut to just over 13 percent.
As I've written, these statistics sanitize political choices that have fatal
consequences [6]. The states that remain outside of the new Medicaid system
are all controlled by Republican legislatures-many of which swept into power
on the back of scare-tactic campaigns focused on Obamacare in 2010 and 2012.
It is shocking just how poor one must be to qualify for public health
insurance in those states. As of January 2015, the median qualifying limit
for parents was 46 percent of the federal poverty level. That means parents
in a family of three who made $10,000 a year were too rich to get help, too
wealthy to have options beyond turning up at the emergency room when crisis
strikes.
This disparity is the Supreme Court's fault. In its 2012 ruling on
Obamacare, it shocked even the law's critics with an out-of-nowhere decision
that Medicaid expansion was optional for states. That means the problem can
be fixed only by forcing political change in the red-state legislatures that
still refuse to acknowledge the existence of the Affordable Care Act. An
election approaches, but it's hard at this point to imagine Medicaid
expansion will be among the defining debates. That's a shame.
2) Make Coverage Meaningful
There is a difference between having insurance and having access to adequate
healthcare. And for the just over 10 million people who have bought
Obamacare plans, there are real questions about whether insurers are
actually providing a fair deal.
Republican critics have advanced the claim in recent weeks that premium
rates are spiking in Obamacare marketplaces. That's at best a partial truth
[7]. Rates have indeed climbed in some places as insurers have searched for
the right price point, but markets vary widely and, overall, most are seeing
only modest increases. In any case, the premium-hike discussion is a
distraction from the real problem.
In fact, during the first two years of the law, insurance companies have
competed fiercely on premiums at the low end of the market. It turns out
that consumers shop the healthcare exchanges much like they do a restaurant
wine list-they go with the second-least expensive option among a bunch of
overwhelming, poorly understood choices. So for insurers, the complicated
business of setting premiums has been about winning at this price point. And
that means shifting the cost of care itself to consumers. This is a trend
that began in the market for employer-based plans and has continued in the
exchanges.
As a consequence, patient advocates reported alarming amounts of sticker
shock in the first year-particularly among patients who most needed care.
Patients with rheumatoid arthritis, multiple sclerosis, autoimmune
disorders, cancers, HIV-all the things that were problems in the old system,
were proving problematic in the new one. "We're really getting a kind of
flood of this particular issue," Brendan Beitry, a case manager with the
Patient Advocacy Foundation [8], told me as patients first started using
their new coverage last summer. "They're contacting us from their
oncologists' office or their doctor's office, or after they've got off the
phone with a specialty pharmacy and they're delivered the blow of cost."
Overall, one in four people with coverage purchased on the exchanges went
without care last year, because they couldn't afford it, according to a
Families USA analysis [9]. Fifteen percent skipped tests or follow up
treatments. Fourteen percent skipped prescriptions. The problem, of course,
is healthcare is not like wine. If the second-cheapest choice is the wrong
one for you, it'll ruin more than dinner.
3) Make Regulators Do Some Regulating
The standard response to the sticker-shock problem has been that consumers
need more information, and the law certainly makes that information more
readily available than it was in the past. But if we're going to keep
treating health as a product, the onus for making it a truly fair and
affordable one will need to be on those who regulate the market, not on
those who shop in it. The morass of co-insurance versus co-pay, of tiered
formularies and providers, of changing and narrowing networks, it is all
designed to conceal the basic fact of cost-shifting from insurer to patient.
That was true before Obamacare and remains true now, and there will be no
substitute for close, aggressive regulation of these products.
Which again brings us to the states that refuse to acknowledge the law's
existence. Health insurance markets are hyper-local, and they require local
oversight. But in places where the political leadership refuses to engage,
there's every reason to believe that oversight is lacking. These markets are
confusing and overwhelming, and thus ideal for disastrous exploitation-see
under subprime mortgages. States have their work cut out in making them
function well, in the best of circumstances. Let's hope we can all now turn
our attention to that massive challenge.
Kai Wright is editorial director of Colorlines.com and an Alfred Knobler
Fellow of The Nation Institute. His investigative reporting and news
analysis appears regularly in The Nation, The Root and The American
Prospect, among other publications, and he is a regular commentator on
National Public Radio and in other broadcast media. His work explores the
politics of sex, race and health. He has closely covered the foreclosure
crisis and the ensuing economic collapse.
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Report typos and corrections to 'corrections@xxxxxxxxxxxx'. [10]
[11]
________________________________________
Source URL:
http://www.alternet.org/news-amp-politics/scotus-gave-obamacare-win-now-real
-fight-begins
Links:
[1] http://www.alternet.org/authors/kai-wright
[2] http://www.thenation.com
[3] http://www.supremecourt.gov/opinions/14pdf/14-114_qol1.pdf
[4]
http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mi
rror
[5] http://www.cbpp.org/blog/historic-coverage-gains-under-health-reform
[6] http://www.thenation.com/article/208977/life-and-death-red-america
[7]
http://www.nationaljournal.com/health-care/the-truth-about-obamacare-s-doubl
e-digit-premium-increases-20150624
[8] http://www.patientadvocate.org/index.php
[9]
http://familiesusa.org/product/many-insured-consumers-non-group-coverage-go-
without-needed-health-care
[10] mailto:corrections@xxxxxxxxxxxx?Subject=Typo on SCOTUS Gave Obamacare a
Win. Now the Real Fight Begins
[11] http://www.alternet.org/
[12] http://www.alternet.org/%2Bnew_src%2B
Published on Alternet (http://www.alternet.org)
Home > SCOTUS Gave Obamacare a Win. Now the Real Fight Begins
SCOTUS Gave Obamacare a Win. Now the Real Fight Begins
By Kai Wright [1] / The Nation [2]
June 30, 2015
We've come a long way over the six years since Congress began crafting the
Affordable Care Act. We've traveled from death panels to death spirals,
passing through nearly 60 House votes on ways to repeal or gut the law, at
least one election defined by it and two Supreme Court challenges to it. But
finally, with the Court's definitively worded ruling [3] in King v Burwell,
we may have arrived someplace hopeful: the beginning of a meaningful debate
over the law's role in fixing our broken healthcare system.
There is plenty to debate. The right's obsessive focus on Obamacare's repeal
has been maddening for many reasons-the dishonesty that has defined its
critique, the way it has leveraged disturbing ideas about the president's
legitimacy-but among the most frustrating side effects has been its impact
on the urgent work of improving the law. Everyone has been too occupied with
arguing over Obamacare's very existence to truly watchdog its
implementation-and its many potential pitfalls. The law is, still,
predicated on the idea that healthcare is a consumer product rather than a
public good. And even in its most successful manifestation, the Affordable
Care Act will by design leave out millions of people who live in this
country and, their immigration status notwithstanding, depend upon our
health system.
So let's get back to basics: The United States has the most expensive [4]
healthcare system in the world, delivering the least effective results among
its would-be peers of wealthy nations. That's been true for a very long
time. One big reason for the system's colossal failure has been that tens of
millions of people only enter it once they are in crisis-meaning they are
both more expensive to treat and less likely to have healthy outcomes from
that treatment. As the Court's ruling deftly summarizes, the Affordable Care
Act aims to fix this problem by making insurance more cheap, more fair and
mandatory. Is it working?
There's little question the law has worked in its core goal of expanding the
number of people who have insurance. The uninsured rate among non-elderly
adults began dropping as elements of the law took effect in 2010 and fell
off a cliff once it was fully implemented. After years and years of
handwringing over steady growth in the ranks of the uninsured, Obamacare
turned the clock back. The share of our population without coverage dropped
by more than 4 percent last year, a Centers for Disease Control study found
[5], arriving at a lower rate than the CDC has seen since before 1997.
Percentage of adults aged 18-64 who lacked health insurance coverage at the
time of interview for at least part of the year, or more than a year, United
States.
Photo Credit:
CDC/NCHS, National Health Interview Survey, 1997-2014, Family Core Component
But there remain significant political and regulatory fights if we are to
translate this accomplishment into a functioning and equitable healthcare
system. Here are three.
1) Fix Medicaid Everywhere
The right has obsessed over the individual mandate, but Obamacare's real
radical change has been the historic expansion of public health insurance
for the poor. A major reason for the uninsured rate's drap nationally is
Medicaid's expansion in a little over half of the country. In the 21 states
that still refuse to open up their Medicaid programs, roughly one in five
people remain locked out of our healthcare system. Everywhere else, the
uninsured rate has been cut to just over 13 percent.
As I've written, these statistics sanitize political choices that have fatal
consequences [6]. The states that remain outside of the new Medicaid system
are all controlled by Republican legislatures-many of which swept into power
on the back of scare-tactic campaigns focused on Obamacare in 2010 and 2012.
It is shocking just how poor one must be to qualify for public health
insurance in those states. As of January 2015, the median qualifying limit
for parents was 46 percent of the federal poverty level. That means parents
in a family of three who made $10,000 a year were too rich to get help, too
wealthy to have options beyond turning up at the emergency room when crisis
strikes.
This disparity is the Supreme Court's fault. In its 2012 ruling on
Obamacare, it shocked even the law's critics with an out-of-nowhere decision
that Medicaid expansion was optional for states. That means the problem can
be fixed only by forcing political change in the red-state legislatures that
still refuse to acknowledge the existence of the Affordable Care Act. An
election approaches, but it's hard at this point to imagine Medicaid
expansion will be among the defining debates. That's a shame.
2) Make Coverage Meaningful
There is a difference between having insurance and having access to adequate
healthcare. And for the just over 10 million people who have bought
Obamacare plans, there are real questions about whether insurers are
actually providing a fair deal.
Republican critics have advanced the claim in recent weeks that premium
rates are spiking in Obamacare marketplaces. That's at best a partial truth
[7]. Rates have indeed climbed in some places as insurers have searched for
the right price point, but markets vary widely and, overall, most are seeing
only modest increases. In any case, the premium-hike discussion is a
distraction from the real problem.
In fact, during the first two years of the law, insurance companies have
competed fiercely on premiums at the low end of the market. It turns out
that consumers shop the healthcare exchanges much like they do a restaurant
wine list-they go with the second-least expensive option among a bunch of
overwhelming, poorly understood choices. So for insurers, the complicated
business of setting premiums has been about winning at this price point. And
that means shifting the cost of care itself to consumers. This is a trend
that began in the market for employer-based plans and has continued in the
exchanges.
As a consequence, patient advocates reported alarming amounts of sticker
shock in the first year-particularly among patients who most needed care.
Patients with rheumatoid arthritis, multiple sclerosis, autoimmune
disorders, cancers, HIV-all the things that were problems in the old system,
were proving problematic in the new one. "We're really getting a kind of
flood of this particular issue," Brendan Beitry, a case manager with the
Patient Advocacy Foundation [8], told me as patients first started using
their new coverage last summer. "They're contacting us from their
oncologists' office or their doctor's office, or after they've got off the
phone with a specialty pharmacy and they're delivered the blow of cost."
Overall, one in four people with coverage purchased on the exchanges went
without care last year, because they couldn't afford it, according to a
Families USA analysis [9]. Fifteen percent skipped tests or follow up
treatments. Fourteen percent skipped prescriptions. The problem, of course,
is healthcare is not like wine. If the second-cheapest choice is the wrong
one for you, it'll ruin more than dinner.
3) Make Regulators Do Some Regulating
The standard response to the sticker-shock problem has been that consumers
need more information, and the law certainly makes that information more
readily available than it was in the past. But if we're going to keep
treating health as a product, the onus for making it a truly fair and
affordable one will need to be on those who regulate the market, not on
those who shop in it. The morass of co-insurance versus co-pay, of tiered
formularies and providers, of changing and narrowing networks, it is all
designed to conceal the basic fact of cost-shifting from insurer to patient.
That was true before Obamacare and remains true now, and there will be no
substitute for close, aggressive regulation of these products.
Which again brings us to the states that refuse to acknowledge the law's
existence. Health insurance markets are hyper-local, and they require local
oversight. But in places where the political leadership refuses to engage,
there's every reason to believe that oversight is lacking. These markets are
confusing and overwhelming, and thus ideal for disastrous exploitation-see
under subprime mortgages. States have their work cut out in making them
function well, in the best of circumstances. Let's hope we can all now turn
our attention to that massive challenge.
Kai Wright is editorial director of Colorlines.com and an Alfred Knobler
Fellow of The Nation Institute. His investigative reporting and news
analysis appears regularly in The Nation, The Root and The American
Prospect, among other publications, and he is a regular commentator on
National Public Radio and in other broadcast media. His work explores the
politics of sex, race and health. He has closely covered the foreclosure
crisis and the ensuing economic collapse.
Error! Hyperlink reference not valid.
Error! Hyperlink reference not valid.
Report typos and corrections to 'corrections@xxxxxxxxxxxx'. [10]
Error! Hyperlink reference not valid.[11]
Source URL:
http://www.alternet.org/news-amp-politics/scotus-gave-obamacare-win-now-real
-fight-begins
Links:
[1] http://www.alternet.org/authors/kai-wright
[2] http://www.thenation.com
[3] http://www.supremecourt.gov/opinions/14pdf/14-114_qol1.pdf
[4]
http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mi
rror
[5] http://www.cbpp.org/blog/historic-coverage-gains-under-health-reform
[6] http://www.thenation.com/article/208977/life-and-death-red-america
[7]
http://www.nationaljournal.com/health-care/the-truth-about-obamacare-s-doubl
e-digit-premium-increases-20150624
[8] http://www.patientadvocate.org/index.php
[9]
http://familiesusa.org/product/many-insured-consumers-non-group-coverage-go-
without-needed-health-care
[10] mailto:corrections@xxxxxxxxxxxx?Subject=Typo on SCOTUS Gave Obamacare a
Win. Now the Real Fight Begins
[11] http://www.alternet.org/
[12] http://www.alternet.org/%2Bnew_src%2B
