The Absence of Civic Responsibility

This post has been updated.

by Chelly Massey-de Bock

The current controversy surrounding the repeal and replacement of President Barack Obama’s signature healthcare legislation, the Affordable Care Act (ACA), also known as Obamacare, is not surprising. For more than a hundred years, American presidents, whether Democrat or Republican, have struggled with the issue of healthcare and  health insurance. President Theodore Roosevelt was one of the first. From his great-grandnephew Franklin D. Roosevelt through Presidents Truman, Kennedy, Johnson, Nixon and Clinton, virtually all tried to find a solution to this important social issue. They did not succeed, although President Lyndon B. Johnson came closest by establishing Federal programs such as Medicare and Medicaid.

A consensus developed, however, that the government was responsible to provide American citizens with health insurance, or at least those citizens not covered by insurance policies offered through their employers. Therefore, it was not uncommon in the Sixties or Seventies for politicians from both parties to accept the principle of universal or national health insurance. For instance, in 1973 Sen. Jacob Javits, (R.-NY) introduced a bill to eventually expand Medicare to all Americans.

Implicit in the bi-partisan efforts was the acknowledgement that American citizens merited government subsidised coverage. This has long been the prevailing viewpoint in Western democracies such as France, Great Britain, Germany and the Netherlands. But the aforementioned countries’ governments realized earlier than the US that their citizenry needed universal health insurance, and passed relevant laws to achieve this. For example, Great Britain passed the National Health Care Act in 1946, France passed a similar act in 1945,  and the Netherlands passed-under German occupation, its first national health law in 1941. The German occupying forces were in control of all levels of the government, and they made it mandatory for everyone under a certain income level to obtain health insurance. Germany itself was the first European country to pass national health laws, in 1883.

The ACA finally achieved what many Administrations could not do: make accessible universal health care the law of the land, and turning it into an entitlement. And because of our unique values and social and political conditions, the system based on the ACA is the best we can get right now-we should retain the good and try to improve it.

The current GOP-dominated Congress, in close collaboration with President Trump, however, recently introduced a new health insurance bill, the AHCA by claiming it to be an improvement on President Obama’s much maligned Affordable Care Act. Meanwhile, Democratic and Independent Senators decry it as an attack on the poor and middle classes, claiming that the act will effectively end their health insurance and proper health care. Currently, the proposed bill is under consideration in the Senate.

Many have heard about the most egregious parts of the bill, such as making it possible for states to apply for a waiver. This waiver would allow insurance companies to charge older Americans, women and people with pre-existing conditions much higher premiums, effectively making insurance unaffordable for these groups, all currently prohibited by the ACA. The law also stipulates the establishment of high risk pools, which consist of people expected to be significant users of medical services. These risk pools, according to the calculations of the Congressional Budget Office(CBO) will be severely underfunded.

The bill eliminates funding for prenatal care and preventive care, and guts Medicaid, thereby annulling a key Trump campaign promise. Other promises included preserving health insurance for people with pre-existing conditions, while reducing health insurance premiums. Also, during the 2016 Presidential campaign, President Trump made a promise to stay away from Medicaid. All of these protections are on the verge of being revoked.

By removing the obligation to purchase health insurance, known as the individual mandate, President Trump and the GOP are voiding the protective provisions of the ACA, even if they wanted to preserve them. In fact, the only way to make health insurance even remotely affordable is by creating a pool of all people, including the healthy and the young, as well as the sick and elderly. If you allow the first group to withdraw from this pool, health insurance will become unaffordable for the second group.

Speaker Paul Ryan has said that this bill will improve access to health insurance, offer more choices to the American people, and lower their premiums. What is becoming clear instead is that the AHCA will make health insurance affordable only for the healthy and the wealthy. It will make health insurance more expensive than it currently is. It will become virtually out of reach for middle-class Americans with pre-existing conditions and the working poor-in short, for those who need it the most. Millions of Americans will lose their health insurance.

However, we have to weigh our options. First, does  our current health insurance system need to change? The ACA is not working as it was originally intended, and as President Obama promised it would. Indeed, many doctors do not want to contract with insurance companies that provide policies through the Marketplace, where citizens sign up from the ACA. In some states, many insurance companies are pulling out of the Marketplace altogether, and premiums have skyrocketed.

It should be noted, and emphasized, that a great deal of the present insecurity is caused by the President himself, who, by threatening to withhold federal subsidies, and the GOP pledging to “repeal and replace” Obamacare, has made insurance companies react this way. Blue Cross Blue Shield of Georgia, for instance, has “proposed to raise rates an average of a 40.6 percent. Blue Cross said that if policy in Washington weakens the exchange it may even pull out of the Obama care market altogether.

We now come to the crux of the issue. If we agree that the ACA in its present form is unsustainable, yet the AHCA is much worse, what are we to do? What are other Western industrialized countries doing, democracies such as the UK, Germany, France, Belgium, the Netherlands, Scandinavia, Canada, Israel, and Australia? Can we learn something from their example?

It seems that the US is an outlier among Western, industrialized countries. It has long had an aversion to compulsory government-run health insurance. America has a tradition of limited government, and of classical liberalism-the government is there to build and maintain infrastructure, to take care of the military defense of the country, but generally limit its regulatory power, and leave citizens to fend for their own.  

Americans take pride in their self-sufficiency.  With the advance of modern medicine, however, and the ever increasing expense for healthcare, politicians on both sides of the aisle have come to a begrudging acceptance of government assistance in ensuring that every American is covered. The Democratic Party has been a strong advocate of universal healthcare in the past, and of the ACA now.

At present, a single-payer health insurance system remains unrealistic. A move towards single-payer insurance would imply a massive overhaul of the current health law-the ACA-, for which there is no political majority. It would also imply “taking out” the health insurance companies. They will not go down without putting up a big fight.  The health insurance companies pour a great amount of money into the political campaigns of candidates supportive of their industry. Many candidates might be swayed by the promise of big contributions to their reelection campaigns.

Also, single payer health care would require taxes to be raised. There are different suggestions as to how this should be done, the options being raising the VAT, raising payroll taxes or raising income tax. To campaign on a message of (massive) tax raises would be a very toxic message for candidates to campaign on in the US, and there is not even remotely a political majority to push such an ambitious health insurance overhaul through-nor any desire to do so on the part of the Republican Party, which is currently in control of all levels of government.

For the US, single payer health care is currently one bridge too far. The ACA has achieved on one count at least what President Obama envisioned; accessible healthcare for most Americans. On count number two, affordability, the current results are less rosy. A clear majority of Americans want to keep Obama care, even though they complain about the premiums. The best path forward would be for Republicans and Democrats to work together to make the necessary amends and modifications to the ACA in order to achieve that second part of the formula, affordability, until such time when the government as well as the public may be ripe for single-payer health care.

Government does have an obligation to help people receive quality, affordable healthcare, for all people, including the most vulnerable. Healthcare is a unique commodity. Our citizens’ health and their very lives are at stake.

Let us work together therefore towards the goal of making all Americans achieve the best possible healthcare, according to their needs, without the burden of ever increasing premiums, medications that become pricier every year, and out-of pocket expenses that continue to grow as well as deductibles that continue to rise. And let us show the world that we cherish our citizens’ and legal residents’ health and lives just as all other Western democracies do. It is time to join the company of civilized nations.