A mean-spirited challenge to healthcare in the U.S

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Photograph: Pexels
Photograph: Pexels

“This bastard has to be killed,” said Michael Greve of the Competitive Enterprise Institute.

“I do not care how this is done,” Greve continues, “whether it’s dismembered, whether we drive a stake through its heart, whether we tar and feather it and drive it out of town, whether we strangle it.”

In language usually reserved for paedophiles, serial killers and invading armies, Greve was quoted recently in the New Yorker, denouncing the Patient Protection and Affordable Care Act, better known as ObamaCare (a term the President has never objected to).

The law, which President Obama signed in 2010, survived one appeal to the U.S Supreme Court regarding its Constitutionality in 2012. Now the law is back at the Supreme Court, trembling in the docks.

 The ACA does a number of things, not just one thing. It is not perfect and its imperfections were made further evident as key provisions were quickly jettisoned for political reasons before the law was signed; like the idea of setting up a “public option”, which in essence would have created a government-run health insurance company (as opposed to a government-run health service, like the NHS).

There are some aspects of ACA that seem not to be questioned, at least for now. It stopped insurance companies from dropping patients if they become seriously ill and stopped them from offering insurance to people without covering “pre-existing” conditions. In other words, health insurers now have to provide insurance for people who need healthcare, not just those who are healthy, which is kind of the point of having health insurance.

It also required most American to purchase health insurance, offering tax subsidies to people who can’t afford it and tax penalties for those who don’t buy it. This is the provision that survived the Supreme Court challenge in 2012, though this very decision also made it easier for individual states to refuse to comply with the law.

It’s important to note here that for somebody like me who had a poorly paid but somewhat professional job in the States (i.e., newspaper reporter), this portion of the ACA would only affect my level of coverage if I lost my job.

I received health insurance, as the majority of Americans still do, through my employer. The employer paid for a portion of the premium each month and I contributed my share directly out of my pay cheque before taxes. The amount I paid into my health insurance went up each year, regardless of whether or not my salary increased.

In my case I had fairly good coverage, meaning I had a wide choice of private practitioners to choose from and, as long as my GP felt it necessary, I could choose to see a specialist.

In hearing about the coverage available through the ACA, however, it’s not great health insurance. Rather it’s providing something for people who had nothing, including many people working minimum-wage jobs for employers who don’t offer insurance, like Walmart.

Be warned I’m talking about purely anecdotal evidence here but the level of coverage provided through ACA is limited to the number of private practitioners who will accept it and people report that both the number and quality of these is low.

This system, which many Brits find “mad”, is actually an unintended consequence of incredibly good fortune. In the post-war years of the American economy, unemployment was low, manufacturing jobs were practically for life and health care cost were such that charity from increasingly prosperous Americans could fill the gaps. This is in contrast to the historic and economic conditions that led Clement Attlee to create the NHS.

So what is it this time for the ACA? The way the ACA was supposed to work is that each state would set up an “exchange” or a marketplace that allowed people without insurance to purchase it. The size of the state exchanges is intended to create an economy of scale that would lower costs for everybody.

This has for the most part worked and healthcare premiums have stabilised or gone down in many cases.

So far, so good and states like California, which setup an exchange, have had a much better experience than the 34 states that refused to establish exchanges. These are mostly states in the South with Republican governors. Residents of these states have been forced to buy insurance on an exchange set up by the federal government.

There are roughly 7.5 million people who have bought insurance on the federal exchange. Remember that number, it’s important later.

The law, in describing who is eligible for the tax subsidies, refers to exchanges “established by the State”, rather than an exchange established by the federal government.

Opponents of the law are now arguing that it’s a violation of ACA to offer those subsidies to people who bought their insurance on the federal exchange, though the law does not forbid this and also requires the federal government to set up exchanges where the state fails to do so.

What opponents are hoping for is that the Supreme Court will rule that the subsidies provided violate Obama’s own law and the 7.5 million previously uninsured people who bought healthcare through the law on a federal exchange should lose assistance.

If this happens many of these people will no longer afford health insurance. As these people drop out of the system premiums across the board will have to be raised to make up the difference and fewer people will be able to afford insurance. In short, the law will unravel.

A quick, short fix to the semantics of the law could clarify the language and the issue would disappear (that’s impossible in this Congress, however).

The opposition is willing to put at risk the newly acquired health insurance of 7.5 million Americans and raise the premiums of many more. A brief filed with the Court by the deans of 19 schools of public health in the United States say the consequence of withdrawing subsides could lead to 10,000 unnecessary deaths.

News stories indicate that the Court is divided on this particularly mean-spirited attempt to repeal the law. Opponents, like Mr Greve quoted above, certainly want to kill the law, fair enough, but they don’t appear to care about the collateral damage either.

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About Stephen Sacco 7 Articles
Stephen Sacco grew up in New York and California and ​holds degrees from NYU and Columbia University. A former journalist, he writes and lives in St Andrews, where he's studying for a PhD. He is also trying to understand this strange form of football that allows you to use your feet.

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