Is the Affordable Care Act worth fighting for?

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As a result of the passage of the Affordable Care Act (ACA) during the Obama administration, Americans benefitted from various healthcare reforms such as protection from being excluded from health insurance plans due to preexisting conditions, the ability to be covered under parents’ healthcare plans until age 26 and government subsidization of insurance plans for those who fell under certain income thresholds.

The Trump administration and Republicans in Congress are seeking to “repeal and replace” the ACA, and the current debate among Republican lawmakers centers around exactly how much the ACA should be gutted. Many Republicans clearly see much of the ACA as worth preserving, as evidenced by the party’s rhetorical shifta majority of Americans support keeping reforms like the protection of people with preexisting conditions. The individual mandate remains the most contentious issue related to the ACA.

With this latest push to either abolish or significantly alter the ACA along conservative lines, it becomes necessary to ask ourselves whether the ACA is worth saving and what any potential alternative should look like.

A main thrust of the Republicans’ recently crafted healthcare bill, the Affordable Health Care Act (ACHA), is the abolition of the individual mandate and subsidization of health insurance plans. Instead, people who remain uninsured will be subject to a 30 percent surcharge from insurance providers when they do end up seeking insurance and insurance subsidies are replaced by tax credits. While Republicans are trying to rhetorically frame these two changes as a drastic shift in healthcare policy, it’s clear that they are functionally equivalent to the ACA’s individual mandate fees and insurance subsidies. Americans are still incentivized to attain health insurance to avoid a fine, and taxpayer money is still used to help pay for some American’s plans.

There is much more to the ACHA, but what these two changes make clear is that the ACA has set the status quo for American healthcare going forward. Health insurance will remain a loosely regulated private market where even critical lifesaving care will be run as a for-profit enterprise.

The U.S. is the only industrialized nation that does not guarantee health coverage for its people. Whether it is done through a government-run healthcare system, public-private partnerships that remove the profit incentive from critical care, or individual mandates similar to the ACA’s combined with robust consumer protection, every other developed and many developing nations are able to guarantee a basic level of healthcare access to every single one of their citizens. The U.S., the richest country to have ever existed, is exceptional among developed nations in allowing its citizens to be subject to a for-profit healthcare system.

The negative effects of this on Americans are predictable. A 2014 study found that medical bankruptcy is the primary cause of American bankruptcy cases. Most people who go into bankruptcy due to medical costs had insurance at the time they got sick. Healthcare costs have continued to rise even after passage of the ACA. In countries that have universal healthcare, a bankruptcy arising from medical bills would be a national scandal. Here, it’s commonplace.

The fact that the ACA was not successful in meaningfully reigning in the medical insurance industry’s predatory practices or in lowering medical costs across the board reveals a fundamental sticking point in the debate over healthcare reform: healthcare as a right is considered anathema by nearly the entire American political class.

Conservatives do not believe that a person who is too poor to afford health insurance deserves full access to healthcare services or that Americans should be subject only to whatever protections and reforms a rapacious insurance industry decides to impose on itself.
Democrats, on the other hand, may give lip service to healthcare as a right, but they are overwhelmingly uninterested in expending any serious amount of political capital on instituting the only system that could guarantee universal coverage: single-payer healthcare. Instead, the two parties are content to endlessly bicker over just how much insurance companies should be able to exploit the American people when they inevitably require healthcare services.

The ACA’s reforms were important steps forward, but they represent little more than peanuts tossed to us by a political system that values the profit margins of insurance corporations more than the health of its citizens. While it’s important to fight to preserve the protections that the ACA put in place, it’s even more important to recognize how lacking that legislation was in terms of instituting a sane and humane healthcare system.

When healthcare is a for-profit enterprise, a set of horrible incentives are inevitably introduced into the system. For-profit healthcare does not serve consumers better than other systems, is more expensive than single-payer and does not provide better care than those of other industrialized nations. The fact that working Americans must choose between paying bills and seeing a dentist, or may be forced into bankruptcy by illnesses that would have been treated for free in other nations, is an unacceptable but inevitable consequence of those incentives.