Welcome to the Decade From Hell, our look back at an arbitrary 10-year period that began with a great outpouring of hope and ended in a cavalcade of despair.
In 2007, the next president of the United States made a characteristically grand promise: America would have universal health care within five years. “We can have universal health care by the end of the next president’s first term, by the end of my first term,” said then-candidate Barack Obama to a hall full of union workers in New Jersey. His pledge might have seemed absurd coming from a candidacy not premised on “Yes, we can.” Even after Obama was sworn in and started to come to grips with the realities of passing a bill, the idea of universal coverage persisted. In June 2009, while laying out his priorities for the health care bill, Obama said, “It’s time to give every American quality health care at an affordable cost.” As late as 2011, a year after the Affordable Care Act was enacted, Ezra Klein described it as “near-universal health care.”
There are at least 72 million Americans who can tell you from personal experience that this was not accurate. In 2019, 28 million people are completely uninsured and 44 million more are underinsured—that is, their health insurance is too expensive to use. Each year, millions face gaps in coverage when they switch or lose jobs, or when they get kicked off Medicaid. Tens of millions struggle to afford their prescriptions. A third of Americans report often delaying or declining care because of cost. Though we may have understood “universal health care” to mean everyone having some kind of health insurance in 2009, our pundit and political class now acknowledges that just having insurance isn’t enough, especially when the cost of care is so high. The implication is clear: The ACA failed to bring the affordable care it promised to its intended beneficiaries.
The last decade’s misadventures in health care reform—the fight to pass the ACA; the unhinged response of its opponents; the efforts, successful and unsuccessful, to undermine the law; and the rapid, unprecedented rise of a movement to replace it with something far bigger and more radical—holds a clear lesson for the future. Passing a bill crafted with industry approval and based on ideas originated with the Heritage Foundation and Mitt Romney—and then insisting that it’s the most progressive thing since the New Deal and we should all be grateful for it—set the party up for the single-payer movement that’s happening now. If only this had been its intention.
You Might Be a 2010s Progressive If You Remember These Stories: Death panels. “Keep your government hands off my Medicare.” Betsy McCaughey. “If you like your plan, you can keep it.” Were we ever so young? These are the cherished memories and memes we have of the fight to pass the ACA (which, yes, mostly happened in 2009) and the deranged opposition that persisted after its passage, all the way through the catastrophic 2010 midterms. Astroturfed activists, as well as organically mad old white people, showed up to town hall meetings to scream “Tyranny!” at Democratic members of Congress because of their plan to bring the health care bill Romney enacted as governor of Massachusetts to the rest of the nation—the very accomplishment that, at one time, entitled Romney to think of himself as a viable presidential aspirant.
But with Romney’s claim to fame forgotten, his Republican friends accused Obama of plotting a “government takeover” of health care. The ACA could not claim to be so bold: It established a market for private insurance, regulated private plans so that they had to cover things like preexisting conditions, and made modest expansions of Medicaid. None of these things involved the government taking over any aspects of health care or health insurance provision, let alone establishing a British-style system where the government actually runs the hospitals—not that this prevented American conservatives from using Britain’s superior system as a frightening bogeyman. I attended an event at UCLA in early 2011, at which a local Tea Party activist claimed that in Britain, cancer patients get thrown out on the street. (I told him I was British and this doesn’t happen. I imagine he changed his whole political outlook thenceforth.)
In reality, the ACA was not nearly as radical as all the unhinged Republican responses to the law suggested. The bill banned insurance companies from discriminating on the basis of preexisting conditions; Medicaid expansion saved lives, at least in the states where it was permitted; allowing people to stay on their parents’ insurance until they’re 26 is infinitely preferable to not allowing them to do that. The subsidies on the marketplace help some people—though they also don’t work very well, and the abrupt cliff for subsidies at 400 percent of the poverty level leave many people paying far more than they can afford.
Nevertheless, premiums are now almost double what they were in 2009, and deductibles are twice as high for employer-sponsored insurance. The worst plans have deductibles as high as $13,800 for a family plan. On the ACA marketplace, a family of four making just over $100,000 would pay $15,275 to cover the whole family on a silver plan, with an out-of-pocket limit of $16,300. Should that family experience a high amount of unexpected health costs—by means of a severe illness or an accident—and meet that limit, more than 30 percent of their income would go to health care costs. The prospect of extreme economic dislocation, or destitution-level indebtedness, remains a reality for ordinary people who face serious health care crises.
While the ACA was born with some of these problems, others were thrust upon it. In 2012, the Supreme Court struck down one of the key mechanisms for increasing coverage: Medicaid expansion. The bill sought to fill coverage gaps by expanding Medicaid for those with incomes up to 138 percent of the poverty line, above which people would be eligible for subsidies on the ACA’s insurance exchange. The Supreme Court’s decision allowed states to opt out of this expansion. There are 14 states that still opt out; one of those states, Texas, has one-sixth of all uninsured people in America. In those states, people below 100 percent of the poverty line aren’t eligible for Marketplace subsidies either, leaving them almost no way to get health insurance.*
But the experience of the more sensible states shows that even Medicaid expansion doesn’t provide universal coverage: 11 percent of Nevadans, 8 percent of Arkansans, and 7 percent of Californians were uninsured in 2018. In Minnesota, which has a comparatively low uninsured rate of 4 percent, a 26-year-old man named Alec Raeshawn Smith died after rationing his insulin, which he couldn’t afford because he was uninsured. According to the Kaiser Family Foundation, approximately two million adults are in the “coverage gap” between Medicaid eligibility and ACA marketplace subsidy eligibility. Clearly, something else—perhaps unaffordable premiums—explains why many of the 28 million uninsured have not simply purchased health insurance.
A 2012 post from the Center for American Progress Action Fund, the political activity arm of the Democratic Party’s favorite think tank, is a revealing look into the Obama-era mind-set that led to this cobbled-together compromise law. Romney, the post notes, claimed to oppose the ACA, yet—get this—the law he passed in Massachusetts “provided much of the foundation for the Affordable Care Act.” This is supposed to be a dunk on Romney for flip-flopping and not an indictment of the ACA for lacking any truly cutting-edge liberal policies to animate it. Indeed, the post laments that “[j]ust a few years ago, this approach was not at all controversial among conservatives” and that the “Center for American Progress Action Fund finds this sharp turn to the right troubling.” If only Romney had remained a moderate Republican, like Obama!
A decade after those acrimonious town halls, keeping the ACA intact is among the most conservative things you could propose to do. The most right-wing Democrats support “improving” the law in ways they rarely specify. The health care industry front group that exists to fight Medicare for All also pushes this line. A bill recently offered by Democrats in the House would merely reverse some of the Trump administration’s tampering with the law, along with repairing some of the original bill’s minor glitches. Republicans, electorally stung by their 2017 efforts to repeal the law, now go out of their way to avoid talking about it at all—preferring to see courts, packed by their lifetime-appointed judges, do the dirty work. This month, the 5th U.S. Circuit Court of Appeals ruled that the individual mandate was unconstitutional, in a lawsuit brought by conservative states led by Texas, the state with the highest number of uninsured people. This left it to the lower courts to decide whether that means the entire law should be thrown out—an absurd legal argument that may nevertheless turn out to be the undoing of the whole law. Increasingly, Republicans recognize that most elements of the ACA are far more popular than the law itself; many ran swiftly away from their attempts to get rid of protections for preexisting conditions in the 2018 midterms.
Earlier this year, Trump briefly claimed he was Looking Very Strongly at a new repeal bill, but as with most of the half-formed but incredibly strong urges that bubble up to the surface of his minestrone brain, he has since stopped talking about it. The Heritage Foundation, a jobs program for young Brooks Brothersed men named Prentis or Chardley whose wet dreams are made of kicking single mothers off Medicaid, has its own repeal plan that it hoped would form the basis of Trump’s next attempt. That plan successfully alienated both right-wingers, who thought it wasn’t bloodthirsty enough, and moderate Republicans, who saw it as jeopardizing patients with preexisting conditions. Dead on arrival, this plan is all but forgotten. (The president’s current health care push centers on hospital price transparency, something that should obviously already exist but that would not help patients “shop around” for cheaper care, because that idea is obviously not to be countenanced.)
When Heritage released its plan, the group’s domestic policy study director told CNN that the Republican health care plan needed to address Americans’ concerns: “They want to make sure that they and the people they love don’t lose access to coverage or care if they get sick. They want lower costs, and they want better choices.” It should not shock you to learn that its proposal would not do that. Allowing insurers to sell whatever kind of useless junk plans, plans that don’t even cover hospitalization or drugs, does nothing to ensure Americans have lower costs, better choices, or coverage for sickness. But tellingly, Heritage has to pretend that this is what it wants. Knowing the dire state of health care in this country and the anger, anxiety, and torment that infuses most Americans’ interactions with the health care system, even Washington’s most vicious Chardleys have to couch their nonsense in the language of access and affordability, instead of liberty and the Venezuelan perils of government intervention.
The ACA dramatically lowered the rate of uninsured people, yet millions remain uninsured. It saved thousands of lives and failed to save thousands more. Premiums are higher, patients are saddled with larger deductibles, and drug prices are a national disgrace. Hospitals sue patients for money they’ll never have, based entirely on fraudulent pricing, leading to some patients being imprisoned. It is clear that the ACA left a repulsive system of profiteering in place and that nothing adequate to the needs of ordinary Americans can be built upon this system. You almost couldn’t have designed a better way to prove this.
The complete shift in how we talk about health care—going from Democratic institutions describing how uninsured people game the system for free health care to even moderate Democrats acknowledging the gap in the ACA by proposing a public option, and a majority of the country supporting a single government insurance plan—is remarkable. This is thanks, in large part, to a grumpy old socialist from Vermont, who took on the party’s anointed establishment hacks to champion Medicare for All, pushing this more radical policy idea toward the mainstream. But none of this would have been possible without the ACA’s failure to achieve its goal of making health care either affordable or universal. Thanks, Obama.
* This article originally stated that people below 138 percent of the poverty line in 14 states that opt out of the Medicaid expansion aren’t eligible for Marketplace subsidies.