Political PT

Here’s the problem with being a healthcare worker in your 20s who cares about social issues. A lot of the sh*t we’re dealing with today is a result of policy decisions and programs that were implemented either before I was born or when I was too young to care, let alone comprehend what was happening in the world. As someone who cares about health legislation now, that means I have some modern history to learn if I want to form a strong opinion about the state of the country. Furthermore, the only thing hotter than a strong opinion is a smart opinion. I want one of those.

March 23rd, 2010. What were you doing? Probably still recovering from K*nye interrupting Taylor at the MTV Music Awards the year prior. Likely “turning up” to the Billboard number 1 song of the year, TikTok by Kesha, although we didn’t have that mature phrase to describe house parties or car-ride jam sessions until a couple of years later. Were you playing the highly anticipated Call of Duty: Black Ops or getting dropped off at the movie theater by your parents for the third weekend in a row to see Avatar along with every other person in the United States? Did you call your dad’s Blackberry on your iPhone 3 to come pick you up? Unless you were born pre-1990, I can guarantee you weren’t paying that close of attention to the news. At 11 years old, I know I sure didn’t give a flying f*ck about the Affordable Care Act (ACA) being signed into law.

The Affordable Care Act was a piece of legislation that came out of the Obama administration. It was aimed at lowering the cost of health insurance, making said insurance more accessible to low-income citizens, and eliminating the ability for insurance companies to dictate whether or not they could cover costs based on one’s pre-existing health conditions. Sounds pretty great, honestly. But when it passed in the House of Representatives, it did so with a slim margin of 219 voting in favor and 212 voting against (all Republicans voted in opposition and they were joined by 34 Democrats). In the Senate, the vote was decided along party lines, which means the entirety of one party voted one way and the entirety of the other voted the opposite. In this case, all 60 Democrats voted yay and all 39 Republicans voted nay. So it’s clear a lot of folks weren’t into this, and we’ll find out why a little later in this article. Let’s finish hashing out the “what” of it all first.

I think a good place to start is talking about where people get their health insurance. Many people get their health insurance through their employers. This is called employer-sponsored health insurance. Employers negotiate plans with the insurance companies to offer their employees directly, and employees pay a premium (monthly payment) for their plans, usually taken out of each paycheck. That’s how a lot of people in my middle-class suburbia sphere do it. So I’m embarrassed to admit that I didn’t really know how others who don’t have regular nine-to-five jobs get coverage.

Before the ACA, if you didn’t have the option of employer-sponsored health insurance, you had two options:

1. Purchase insurance directly from health insurance companies who quite literally don’t give a f*ck about anything except the money they’re raking in. I do really aim to not shove my opinions down people’s throats in these articles, but these guys really are the worst. They could do things like jack up their prices, deny coverage without regulation, and make people pay higher monthly premiums if they had a pre-existing condition. Things like cancer, diabetes, high blood pressure, asthma, depression, anxiety, oh, and pregnancy. Know anybody with any of those? Also interesting that it seems like the sicker people are, the more money these companies make. Hmmm…
2. Fall into a category of a government-funded health insurance program like Medicare, Medicaid, Veterans Affairs, or the Children’s Health Insurance Program — all of which require you to meet specific criteria.

Those options left a huge gap in uninsured individuals, coming in at 14–16% of the U.S. population. As a feminist who hasn’t quite gotten behind math yet, I had to Google how much 16% of the U.S. population is. Yeah, I didn’t even use a calculator. Tragic. Turns out, the math came out to 53 million people. That is so many f*cking people. My routine bloodwork for my yearly exam would have been $2,000 out of pocket. Giving birth in a hospital without insurance can cost as high as $30,000. So many fcking people and so much f*cking money.

In order to combat this disgustingly high cost of healthcare for millions of Americans, the ACA was designed to make it easier on the pocketbook for people to participate in insurance. After it was signed into law, the health insurance options became the following:

1. See 1. above.
2. See 2. above.
3. Shop for insurance on marketplaces via either federal or state websites. These marketplaces feature plans from insurance companies while providing buyers with government funds to help lower the cost of premiums and out-of-pocket costs. Financial assistance is based on income and household size. Health insurance marketplaces help bridge the gap between those whose income is too high to qualify for Medicaid, but purchasing directly from insurance companies is still a significant financial burden.

The ACA also outlines new minimum standards that all health insurance companies have to comply with, including the majority of plans available outside of marketplaces. It mandates that 10 essential health benefits are included in all health insurance plans. This list includes things like maternity care, substance abuse services, and emergency services. The ACA also declares that insurance companies cannot deny coverage or charge enrollees more due to those incredibly common pre-existing conditions I mentioned above. In addition, premiums can only vary based on age, tobacco usage, location, and family size. Before the ACA, companies could vary premiums based on gender and pre-existing conditions. Super lame.

The ACA also made some changes to Medicare and Medicaid. Medicare got a little finance bro face-lift with some new committees aimed at quality control and reducing costs. They also tightened the belt on reimbursement to providers and hospitals for their services — something that affects the working conditions of every healthcare worker. The ACA also closed the “donut hole,” which was a huge deal for those who had Medicare Part D coverage and had to pay an insane amount of money toward their prescription drugs every year. If you’re interested, it’s easier with a visual, so here’s a video explainer.

While Medicare got the finance bro face-lift, Medicaid went on an ayahuasca retreat and experienced complete dissolution of its ego in the way that a 30-something-year-old white guy does: powerful, but it didn’t quite stick. Before the ACA, the rules for qualifying for Medicaid were kind of wonky. It wasn’t based just on income, and in some states, people making only $12,000 per year were considered making too much to qualify for Medicaid. Yes, you read that correctly. The ACA changed Medicaid so that income was the main qualifier, and it raised the qualifying amount to 138% of the federal poverty limit. In numbers, 138% of the federal poverty limit for a family of three is around $34,000. This means that a parent of three can make up to $34,000 annually and still qualify for Medicaid insurance. The caveat here is that two years after the ACA was signed into law, the Supreme Court ruled that states could opt out of the ACA changes to Medicaid. So, some states still have the old rules, and people who are making dirt income still “aren’t poor enough” to qualify for government-sponsored insurance. If you are curious about how the states have the power to do this, check out my article on the U.S. federalist system.

The last thing I will bring up about the ACA is a great segue into why some people hated it. The original ACA was extremely controversial for this thing called the “individual mandate.” The individual mandate was a requirement by the ACA for all citizens to participate in health insurance. If they didn’t, there was a huge tax penalty.

The idea behind this was the key to how the whole thing works. The government is spending a lot of money to revamp these programs and provide quality standards and financial assistance to insurance enrollees. For this plan to work, they need lots of people — especially healthy people — to enroll in insurance plans. Why? Because insurance is a cost-sharing model.

Insurance companies use the premiums everyone pays them monthly to cover the costs they pay to hospitals when an individual receives healthcare services. Healthy people give a lot of money to insurance companies and don’t have to have a lot of it used on themselves. Sick people are the ones who need a lot of money from insurance companies. Having more healthy people enrolled in insurance helps to keep premiums low because there’s more money circulating in the system to cover the medical costs of people who need them more. Without that, monthly payments have to increase to fill the money pool.

So what’s the problem with this model? Well, I wouldn’t say the model is flawed, but the mandate of it all really pushed people’s buttons. It’s not very American to be okay with the government telling you that you have to do anything — including buy insurance. It’s so un-American that the tax penalty was eventually rolled back in 2017, so now you can be uninsured without repercussions.

What else do people hate about the ACA? An easy one is taxes. A tale as old as George Washington’s wig itself. Some people’s taxes were raised to pay for the transition. Some people experienced changes in their existing coverage because insurance companies had to overhaul their plans to comply with ACA standards. Initially, some lost coverage completely. Some people also experienced higher premiums and deductibles with marketplace plans compared to their old plans. Oh yeah, the rollout was a huge fumble too, I guess. The government website didn’t work, and it was a whole thing.

It’s a doozy, this ACA. There are good parts and bad parts, and some of these parts look a lot different today compared to 2010. I think this one is a really interesting window into what’s behind American individualism, especially when we think about the response to the mandate. What do we value when it comes to paying for healthcare? Do we trust our government? Are we looking for an excuse to not help out our neighbors, banking on the false narrative that doing things for ourselves and only ourselves guarantees us safety? Deep thoughts, man, deep thoughts.

Thanks for reading. Fact-check and sources below.

Ballotpedia – “Affordable Care Act”
https://ballotpedia.org/Affordable_Care_Act

KFF – “Health Policy 101: The Affordable Care Act – How Has the ACA Changed Since It Was First Passed?”
https://www.kff.org/health-policy-101-the-affordable-care-act/?entry=table-of-contents-how-has-the-aca-changed-since-it-was-first-passed

Medicare.gov – “Closing the Coverage Gap—Medicare Prescription Drugs are Becoming More Affordable”
https://www.medicare.gov/blog/closing-the-coverage-gap

KFF – “Explaining Health Reform: Medicare and the ACA”
https://www.kff.org/health-reform/issue-brief/explaining-health-reform-medicare-and-the-aca/

CMS.gov – “Medicare and the Affordable Care Act”
https://www.cms.gov/About-CMS/Agency-Information/Affordable-Care-Act/Medicare-Provisions

HealthCare.gov – “How the ACA Has Improved Medicare”
https://www.healthcare.gov/blog/how-aca-has-improved-medicare/

KFF – “Medicaid and the Affordable Care Act”
https://www.kff.org/medicaid/fact-sheet/the-medicaid-expansion-under-the-affordable-care-act/

Health Affairs – “The Medicaid Expansion: A Review of the Latest Research”
https://www.healthaffairs.org/do/10.1377/forefront.20201029.231522/full/

MACPAC (Medicaid and CHIP Payment and Access Commission) – “Medicaid Expansion”
https://www.macpac.gov/subtopic/medicaid-expansion/

Congressional Budget Office – “Federal Subsidies for Health Insurance Coverage for People Under Age 65: 2022 to 2032”
https://www.cbo.gov/publication/58264

NPR – “Why Do So Many People Hate Obamacare So Much?”
https://www.npr.org/sections/health-shots/2017/12/13/570479181/why-do-so-many-people-hate-obamacare-so-much

House Committee on Education & the Workforce – “Five Reasons Obamacare is a Failure”
https://edworkforce.house.gov/news/documentsingle.aspx?DocumentID=408166

PubMed – “Why do so many Americans oppose the Affordable Care Act?”
https://pubmed.ncbi.nlm.nih.gov/25731135/

The Heritage Foundation – “8 Reasons to Still Hate Obamacare”
https://www.heritage.org/health-care-reform/commentary/8-reasons-still-hate-obamacare

KFF Health News – “Why Do People Hate Obamacare, Anyway?”
https://kffhealthnews.org/news/why-do-people-hate-obamacare-anyway/