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The battle for Obamacare

The battle for what would be a revolutionary change in the delivery of US health insurance will be tough and ugly and its outcome far from certain, but the first salvos have now being fired.

Democrats leading the charge for universal healthcare say they have no intention of turning back now, emboldened by the failure on 26 September of a last-ditch Republican effort, following on from two other doomed efforts in July and March, to end the Affordable Care Act (ACA), known as Obamacare.

In defending Obamacare, which was signed into law in 2010 by former US President Barack Obama, Democrats charged that Trump’s latest repeal attempt was aimed at taking away healthcare coverage for the poor in order to give tax breaks to the rich, who would no longer have to pay subsidies to help fund the ACA.

Their stance was buoyed by polls showing a majority of Americans opposed repeal and by an analysis in September from the impartial Congressional Budget Office (CBO) that said many “millions” would lose their cover if the ACA were scrapped. Its figures in July were more specific when it put the number at 32 million by 2026, with 17 million losing cover next year alone.

Ideological battle

As in many other countries, not least in Ireland, politics and health insurance are intertwined but this is even more so in America, where they have always been inextricably linked in a bitter ideological battle over the role of government in tackling society’s problems.

Democrats generally see a central role for government in healthcare coverage, while Republicans mainly believe the government should leave the issue to private insurance companies. They see government subsidies that help Americans to pay for health insurance as akin to ‘socialist’ interference in the industry, an industry backed by powerful lobby groups that pour millions of dollars into supporting members of US congress who back their agenda.

But that ideological debate is now changing as a result of the efforts to kill Obamacare. The ACA is by no means perfect but for the first time, it ensured that pre-existing conditions were covered by insurance companies and insurance became more affordable because of government subsidies.

ACA advocates are also making their presence felt and airing their views like never before. In unprecedented scenes in the halls of Congress at the height of the September repeal effort, hundreds of people, some in wheelchairs, filled the Senate office building to protest. As some chanted “kill the bill, don’t kill me,” police moved in and forcibly removed them, arresting 181 people.

In the end, the repeal effort failed once again when three Republican senators, including Senator John McCain who was recently diagnosed with brain cancer, refused to back the bill, triggering its collapse and angry tweets from President Trump, who made ending the ACA a central pledge in his 2016 presidential campaign.

The failure of repeal now means that the ACA continues to stand as the law of the land. But almost equally significant is the political shift in opinion the law has set in motion and that now makes the introduction of single-payer health insurance a real possibility in the longer term. “The ACA now means that healthcare is seen by Americans as a right,” Mr Chris Jennings, a former senior health policy adviser in the Obama administration, told the Medical Independent (MI). “That’s a major achievement. The door is now open to advances in a way it never was before.”

Indeed, the percentage of Americans who think their government has an obligation to ensure coverage for all citizens has risen from 42 per cent in 2013 to 60 per cent in 2017, according to data published in August in the New England Journal of Medicine and compiled by Prof Robert Blendon, Professor of Health Policy and Political Analysis from the Harvard School of Public Health.

Separately, 56 per cent of doctors registered either strongly support or are somewhat supportive of a single-payer health system, according to a recent survey by Merritt Hawkins, a physician recruitment firm. In its 2008 survey, opinions ran the opposite way — 58 per cent opposed single-payer.

Survive or thrive?

Mr Jennings is someone who has seen the health insurance issue from many sides, having been in the thick of the battle for decades as a health policy veteran of the White House, Congress and the private sector.

He was President Obama’s Deputy Assistant for Health Policy and Co-ordinator of Health Reform and served in a similar capacity in President Bill Clinton’s White House. One of his main achievements during Obama’s presidency was to implement the ACA’s access and delivery reform provisions. But he is the first to admit the ACA is not perfect.

“The ACA is likely to survive, if not thrive. Indeed, from a political perspective, it is stronger than it ever has been in terms of popularity. It is a human principle that one never values a relationship or an object any more than when they fear they are going to lose it. This is what happened during the ACA repeal debate over the last several months. But like any law, in order for it to be sustained in the most rational way, it needs to be strengthened and improved over time.”

The ACA’s achievements are certainly impressive. Apart from covering millions more Americans, including those with pre-existing conditions, millions of young people have also been able to stay on their family’s health plan until the age of 26 years; the elderly are saving hundreds of dollars a year on their prescription drugs; while preventive care, like mammograms for women and wellness visits for ‘seniors’, is covered free of charge.

Some 44 million Americans were uninsured until the ACA was passed seven years ago. Today, it has covered more than 20 million Americans.

As premiums increased, however, consumers loved it less. Annual premiums reached $18,142 (€17,250) in 2016 for an average family, according to the US National Conference of State Legislatures. That works out at $1,500 per month. However, more than half the population of America, or about 156 million people, have health insurance cover through their own job or a family member’s job. In some cases, the employee contributes a certain percentage of their salary towards the premium. 

Millions of other Americans who do not have insurance through an employer are covered through government programmes like Medicare for the elderly and Medicaid for the poor — Medicaid was expanded under the ACA, adding 11 million beneficiaries.

Further coverage?

With the principle of a government role in health insurance now firmly established in the US, as Mr Jennings notes, Democrats sense they have the upper hand. While working to improve Obamacare, they now want to expand that government role so that single-payer insurance becomes a right for everyone.

They are calling this single-payer plan ‘Medicare-for-All’ after the popular government-supported system for older Americans.

“Healthcare must be recognised as a right, not a privilege. Every man, woman and child in our country should be able to access the healthcare they need, regardless of their income. The only long-term solution to America’s healthcare crisis is a single-payer national healthcare programme,” says Senator Bernie Sanders, who is pioneering the Democratic effort.

Senator Sanders, who fought unsuccessfully against Hillary Clinton for the Democratic nomination in the 2016 presidential race against President Trump, has been pushing for single-payer insurance for over two decades. Since joining the House of Representatives in 1991, where he served before his election to the Senate in 2006, Senator Sanders has introduced or co-sponsored 12 bills seeking a single-payer system.

Under the Medicare for All Bill 2017, which the Senator introduced on 13 September, everything from emergency surgery to prescription drugs, from mental health to eye care, would be covered, with no co-payments. Americans younger than 18 years old would immediately obtain ‘universal Medicare cards’, while Americans not currently eligible for Medicare would be phased into the programme over four years. Employer-provided healthcare would be replaced, with the employers paying higher taxes but no longer footing the enormous cost of their employees’ cover.

Private insurers would remain, with fewer customers, to pay for elective treatments such as cosmetic surgery. Doctors would be reimbursed by the government and providers would sign a yearly participation agreement with Medicare to remain with the system.

Senator Sanders acknowledges that the plan would be costly — some estimates suggest a price tag of $3 trillion a year but in making his case, he cites the experience of other countries that provided universal coverage through higher taxes. The average American paid $11,365 per year in taxes, compared with the average Canadian, who paid $14,693, according to OECD data for 2010. But the average American paid twice as much for healthcare as the average Canadian.

On NBC’s Meet the Press programme recently, Senator Sanders also confronted Republicans who say a single-payer system would be too costly. “My Republican friends say that Bernie wants to raise your taxes. They forget to conveniently mention that Bernie wants to do away with the private insurance premiums that you’re now paying… We replace private insurance premiums with Medicare premiums. The average middle-class worker saves money.”

But Senator Sanders knows this will be a tough battle. As far as he is concerned — and experts consulted by MI agree — he is playing a ‘long game’ and these are just the opening salvos, laying the groundwork for a single-payer plan.

“This will be an enormously difficult and prolonged struggle and one which will require the efforts of tens of millions of Americans in every state in this country,” he declared recently. “It will, in fact, require a political revolution in which the American people participate in the political process in a way that we have not seen in the recent history of our democracy.”

As long as Democrats continue to remain united in their efforts and Republicans fail to come up with a better alternative that would keep millions covered, then the momentum is likely to remain with the Democrats as they head into next year’s congressional elections, when they seek to seize back control of either the House or Senate to make passage of their single-payer bill a realistic possibility.

At present, Senator Sanders’s bill has no chance of passage in a Republican-controlled Congress. But after months of behind-the-scenes meetings and a public pressure campaign, the bill is already backed by many senators facing re-election battles in 2018 and by most of the senators seen as likely Democratic candidates in the 2020 US presidential race, including California Senator Kamala Harris, Massachusetts Senator Elizabeth Warren and New Jersey Senator Cory Booker.

Shifting sands

But experts say that if Democrats want to gain ground, they would have to frame the single-payer debate very carefully. Mr Chris Lee of the Kaiser Family Foundation says the level of support among Americans for a single-payer system often depends on what questions they were asked about it.

“We do have some recent public opinion polling looking at what Americans think about a single-payer system,” he told MI. “It shows how malleable those opinions can be, depending on how much information is given and what questions are asked.”

The Kaiser Health Tracking Poll, which he cites, finds that a slim majority of the US public (53 per cent) now favours a single-payer health plan in which all Americans would get their insurance from a single government plan. But, as Mr Lee points out, language often matters in framing questions about health policy.

The February 2016 Kaiser Health Tracking Poll found that when terms were tested on their own, outside the definition of a national health plan that would cover all Americans, the public was more likely to react favourably to the term ‘Medicare-for-all’ (64 per cent favourable) than ‘single-payer health insurance system’ (44 per cent favourable). However, the current poll finds that when the plan is defined as one in which all Americans would get their insurance from a single government plan, support is similar when the plan was referred to as ‘Medicare-for-all’ (57 per cent in favour), as when it was referred to as ‘single-payer’ (53 per cent).

Mr Jennings also agrees that selling a single-payer system could prove extremely challenging. “More Americans are open to a single-payer system and the idea of a simpler, more workable system has appeal. Having said that, what Americans really want is more affordability and accessibility within an improved delivery system. Whatever policy choice can deliver on that promise will be the policy that prevails.

“The advocates of single-payer are right to decry the shortcomings of our current system, including its cost, complexity and unresponsiveness to patients’ needs.

“They are also right to suggest that more aggressive federal and/or state interventions have great potential to help secure these goals. Having said that, Americans are very averse to major disruption. They value their employer-based care. As such, policy options that allow for more choice — like a public option — may become increasingly popular.

“Consistent with that vision may be policy approaches that take advantage of Medicare-secured payment rates and empowering private purchasers to do the same. A classic single-payer approach will be more challenging because of potential for disruption and the amount of revenue that will have to float through the government.”

Continuing challenges

This is also a battle that is being fought on two fronts. While pushing single-payer, Democrats also know that in the meantime, they have to protect Obamacare against President Trump’s pledge to let it “implode”.

Having failed to get Congress to repeal Obamacare, President Trump took his own actions to weaken the law on 12 October. He signed an executive order to make it easier for consumers to buy short-term insurance plans that do not comply with all of the ACA’s provisions, like covering pre-existing conditions,

He also announced he will not make cost-sharing reduction payments (CSRs) this month to insurers selling Obamacare plans.

The Congressional Budget Office has previously warned that insurance companies would likely raise premium prices by about 20 per cent for Obamacare plans if President Trump ended the CSRs, which compensate them for discounting out-of-pocket costs for certain enrollees. Some carriers would withdraw from Obamacare and about 5 per cent of people would live in an area without any insurance options in 2018, the Office estimated, if the monthly payments, which total about $7 billion for 2017, ended.

The effect of both these actions means premiums will become more expensive and critics charge they are essentially aimed at letting Obamacare “implode” by itself over time.

“Having failed to repeal the ACA in Congress, the President is using a wrecking ball to single-handedly rip apart and sabotage our healthcare system,” Senate Democratic Leader Chuck Schumer tweeted.

The 2018 congressional elections will be key to what happens next. If the Democrats fail to win back the House of Representatives, it will boost Trump and Republicans will stick with him. If, on the other hand, Democrats do well, Republicans in Congress will be more likely to desert him and abandon any further attempts to repeal Obamacare.

Then again, it should be noted that Democrats can be a fractious group. When they were last in control of Congress, they only barely got Obamacare across the line. Remaining united has always been a problem for them and whether they will take on vested interests this time round if they win back congressional power remains to be seen.

While Senator Sanders has acknowledged that with Republicans in control of Congress, his bill is unlikely to pass, he has outlined three steps he wants to take in the meantime — passing legislation to get the public option in every state and lowering the cost of prescription drugs.

Meanwhile, Mr Jennings emphasises, the main task facing Democrats and Republicans with elections on the horizon will be to focus on improving Obamacare. “The question is whether the Republicans and the Trump Administration will be able to pivot away from straight-up ‘repeal and replace’ [of Obamacare] to something more like ‘repair and reform’.

“It has already taken too much time to shift to that gear, but I anticipate within the next two years or so we will see some incremental steps in this regard. Even if the ACA isn’t amended and improved, it will survive. The problem will be whether it withers too much over time due to adverse selection and inadequate enrollment. This can easily be avoided through bipartisan, incremental reforms. The challenge is, will the politics allow for it? I am betting yes.”

Perhaps, but the signals coming from the White House so far about Obamacare are not very positive. “The best thing politically is to let Obamacare explode,” President Trump told The Washington Post. The programme is “totally the property of the Democrats” so that “when people get a 200 per cent increase next year or, 100 per cent or 70 per cent, that’s their fault”.

Blame game

But the public does not appear to see it that way. The Kaiser Family Foundation Tracking Poll asked voters in June whether President Trump and Republicans or former President Obama and Democrats would be “responsible for any problems with” the Affordable Care Act “going forward”. By nearly two-to-one, voters said President Trump and Republicans in Congress would be responsible, 59-30, a view shared even by Republicans, 56-35.

Democrats have been outraged by President Trump’s administration’s announcement that it would cut funding for advertising — from $100 million to $10 million — to get people to sign-up for the health law’s coverage.

Democratic leaders accuse the President of deliberately trying to undermine Obamacare to score political points, even at the risk of millions of Americans losing their healthcare.

Yet Obamacare continues to yield positive results. A study published on 26 September by the Cancer Institute at North Carolina’s Duke University found that states that fully expanded their Medicaid programmes for the poor under the ACA cut their rates of uninsured cancer patients by more than half between 2011 and 2014. African-American patients and those living in the highest poverty areas saw the greatest benefit.

A Pennsylvania insurance official also dismissed suggestions that the ACA was already “imploding”. Speaking at a Senate Health Committee hearing, Ms Teresa Miller, Pennsylvania’s acting Human Services Secretary and former Insurance Commissioner, insisted that the notion is false. “I’m not going to sit here this morning and tell you that the ACA is perfect,” she said. “I think we all know that it’s not, but the narrative that the ACA is failing and imploding is just false.”

If that is the case, it will make it easier for Democrats to focus on their primary battle, a long-haul push for single-payer health insurance. California Senator Kamala Harris, who is backing the Sanders Medicare for All Bill, expressed optimism that the recent defeat of the Obamacare repeal attempts was a galvanising moment for Americans.

“I think there’s no question that we have to get to a point where all people have access to affordable healthcare,” she said after Senator Sanders introduced his bill. “As we talk about moving towards a single-payer system, I think there is certainly momentum and energy around it. The recent history on the issue of healthcare is very telling,” she added. “Americans are making it very clear, when they defeated the repeal of ACA, that they don’t want us playing politics with their healthcare.”

Mr Jennings tells MI he is also optimistic of “fundamental changes” that could ultimately make single-payer possible. “We will have many years ahead of us on this and I believe fundamental changes will need a new President. But I’m 33 years in the healthcare business at political and policy level, so I have to be optimistic.”

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