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Wednesday, April 10, 2013

Why is the Affordable Care Act (Obamacare) So Controversial?

Fact versus fiction, perception versus reality
By Michael E. Breton

NOTE: Please come to the upcoming forum on Health Care Reform this Saturday at the Cross Mills Library. Click here for details.

What is it about “Obamacare” that makes it so controversial? Progressives tend to believe, as they almost always do, that the problem lies in the lack of understanding by many Americans of what the Affordable Care Act eventually will do to help them. The problem is essentially one of education. 

There is certainly some truth to that position. A continuing flow of information about the health care act has resulted in modest movement of public opinion in its favor.  After all, President Obama was re-elected, in spite of attacks on Obamacare. There has been so much written and said that anyone who wants to can understand the basics of what the act is aimed at doing. How then to account for the continuing vehement opposition?

Let’s look at the other side: conservative Republicans who see this law as such a threat. They portray it as potentially undermining basic American rights. What is more, they assert that we cannot afford it. The concerns conservatives have about Obamacare are largely based on fear, fear that there is not enough medical care to go around, fear that liberals have another agenda (socialism). Why do they feel this way? Can education help?

For the most extremely conservative individuals, a core problem appears to be they view the “facts”, as progressives present them, as somehow doubtful or untrue. In spite of the apparent benefits from the law that many of them welcome, they appear to believe that any movement toward universal health care coverage is a move towards a socialistic system that would undermine their individual freedoms.

There is no truth to the conspiracy fears about Obamacare leading to some form of “socialism”. On the other hand, the next step in healthcare evolution (however long it takes to arrive) may well be a phasing out of private health insurers. Much evidence supports the contention that private insurance is inherently less efficient than a single payer system run by the federal government. Our national experience with both Medicare and Medicaid supports this conclusion. The experience of other industrial democracies also supports it.

And there is that other issue of affordability. Many conservatives appear to believe there will not be enough resources (money) available to provide everyone in the society with adequate levels of care. If insurance coverage is extended to the 10’s of millions of Americans that now are denied access, this will undermine their own ability to access top quality care in the way they feel they are entitled to. Many (not just conservatives) believe that they have contributed to the system what they will, and are entitled to get back in the form of medical services. They believe, correctly, that those at the lowest end of the income scale have not contributed, in taxes at least, what they will need to withdraw in the value of services for health care.

In the first place, the American economy is quite productive enough to support universal health care coverage. This has long been the case. To believe otherwise would be to infer that we are economically inferior in strength to almost all of the Western European democracies, who do provide such coverage and care. Few Americans would accept that proposition.

On the other hand, there is some truth to these fears about lack of resources to cover every member of the society, but only if we make no serious attempt to limit health care cost increases. As Jackie Calmes, reports in the New York Times (April 3, 2013), for each $1 Americans pay directly for Medicare, they will over time draw about $3 in benefits. From this vantage point, almost all Americans are overdrawing the system, not just the poor. The difference is made up from various general revenue sources.

Many commenters promote the view that for both Medicare and Social Security, those drawing benefits are merely taking back what they paid in. Most Americans are well aware that deductions from their paychecks have been made for Medicare and Social Security over their lifetime of work. So it makes sense to them that they are now “withdrawing” from what they contributed. Many believe those that have not contributed should not be able to withdraw.

However, the lowest paid individuals cannot contribute very much to the cost of the health care they will eventually need, precisely because they are so low paid. Low paid workers contribute importantly to the economy and to societal well-being in spite of their low monetary reward. They contribute their time and labor in the best way they can. Because of this, they are entitled to basic societal benefits.

It can even be argued that low paid workers pay a kind of double penalty. First the work they do earns only low wages, which sets limits to any tax they could pay. On top of that, they are denied fundamental health coverage. Those who support the current reality appear to view health coverage as a privilege to be purchased if you are able, and not as a basic right. But when a society is strong enough economically, as ours is, how can we deny basic health care coverage to all and still assert our claim to moral justice?

The conflicts in Congress now, and over time, can best be seen as a process of finding an appropriate balance between legitimate concerns, in this case the rights of the many to universal coverage versus individual freedoms.  Revolutions in science, technology and medical understanding change the economy and our way of living. The laws of the land struggle to keep up. Obamacare, the Affordable Care Act, is an honest and potentially effective effort to bring our social practice more into line with our economic realities and potentials.

What about the imbalance in taxes paid in to Medicare directly and the value of care provided? At the moment there is not a crisis in covering the difference. However, over time the growth of the cost of medical care cannot be allowed to exceed the rate of true inflation in the economy. To think otherwise would be to accept reductions in all other forms of government and private spending over time. Medical care cannot be expanded faster than the economy forever. On the other hand, that which cannot happen, will not happen.

What is most seriously wrong with the American system is its inefficiency. It costs us too much to provide care that is in no way superior to other Western democracies. With improved efficiency, the cost of universal health care is within our means. To provide anything less than universal coverage, given the economic facts, would be morally wrong. We would be denying coverage and care to people who need it and cannot get it on their own, because of their economic circumstance, while we, as a nation, are in a position to give it. Not giving it should be seen as a statement of selfish intent.

So the real question is how to contain medical costs going forward. Here is where the heart of the controversy between the liberal and conservative camps appears to lie. Proponents of the Affordable Care Act point out its provisions for making a start on containing medical costs. They point out that Medicare has a consistently lower cost of providing similar care when compared to the private insurers.

Opponents claim that the cost reduction potential is too modest and won’t do the job. They assert that more stringent measures are needed. In some sense, supporters of the act agree with opponents on this point. Supporters point out that the Affordable Care Act this is only a beginning, only what could be done now, given the political climate. Opponents jump on this assertion as confirmation that supporters want an even more far reaching medical insurance overhaul. And they would be right.

Single payer coverage is certainly a way to achieve greater health care efficiency. This is exactly what the private insurance industry fears.  But most Americans should welcome the greater efficiency and cost savings.

At the moment, we do not have a single payer federal program on the horizon. What we do have is a credible beginning to providing almost universal health insurance coverage, and a reasonable start toward containing health care costs going forward. The Health Care Exchanges that are now being set up in most states, including Rhode Island, should provide affordable access to an adequate level of health care for almost all Rhode Islanders. Exactly how these exchanges will function is still a work in progress.

In Rhode Island, the task of overseeing how the exchanges are set up falls to the Lieutenant Governor, Elizabeth Roberts. 

On Saturday, April 13 (10 am to noon), Lt. Governor Roberts will speak about the Affordable Health Care law and the new Health Care Exchanges at a seminar in the Cross Mills Public Library. 

All interested citizens of whatever political persuasion should try to attend. There is much to be learned. And we would all do well to combine our efforts on behalf of the public good. Open and informative meetings such as Lt. Governor talking can help us do this.