"A larger irony is that the ACA is about as far from a government takeover of health care or the “final leap to socialism” (as Michele Bachmann sees it) as one can imagine. Such hyperbole is now about a century old. In 1917 insurance executives raised the fear of “Prussian” or “Bolshevik” medicine. In the 1940s the American Medical Association fabricated a quote from Lenin—“socialized medicine is the keystone in the arch of the socialist state”—to punctuate its Cold War campaign against public health insurance. During the early debate over Medicare in 1961, Ronald Reagan warned that “you and I may well spend our sunset years telling our children and our children’s children what it once was like in America when men were free.” These scare tactics usually worked. The power of southern segregationists in Congress doomed much of the New Deal’s timid universalism. Deference to the AMA virtually immobilized health reform in the 1940s and 1950s. Job-based coverage emerged as the next-best bet, while public policy retreated to occasional efforts to mitigate its failures—most notably with the passage of Medicare and Medicaid in 1965. Since then efforts to appease health care industry interests and avoid the “socialized medicine” label have routinely turned good intentions into bad policy or legislative shipwrecks. Republican pollster Frank Luntz’s now-infamous 2009 memo “The Language of Healthcare” set out the basic talking points that would later pepper Ted Cruz’s filibuster: any public program or option is a slippery slope to “government takeover” and national health systems (insert Canadian or British horror story here) that stifle innovation, encourage malingering, and ration care—either by forcing patients to wait or by pulling the plug."
"In terms of coverage, efficiency, and equity, the ACA is a far cry from a single-payer system. Some hope that it might push us along that path (either through its sheer failure or by incremental tinkering with its provisions), and some fear that it might block the way (by marginalizing the remaining uninsured or simply poisoning the well for future reformers). In either case, the ACA is better than nothing and it has already had a real impact. Health care costs are falling. While slower spending is largely attributable to a slow recovery from a long recession, it also reflects the rollout of some of the ACA’s cost-containment provisions and the response of private insurers to the threat (and now the reality) of modest health reform. And the uninsured are finding coverage. Thanks to the ACA’s requirement that insurers allow children to stay on their parents’ plan until they are twenty-six, the uninsured rate among young adults has fallen for two consecutive years. None of the economic calamity predicted (or pined for) by congressional Republicans has come to pass. The law actually imposes little obligation, cost, or uncertainty on employers. Ninety four percent of firms affected by the ACA’s employer mandate already provide coverage voluntarily. There is no empirical evidence that the ACA is a “job killer” or that employers are gaming the mandate (now pushed off to 2014 anyway) by ducking under the fifty-worker threshold or cutting workers back to part-time status. The promise for the future is substantial. The combination of insurance regulations and state exchanges provides coverage options for millions of uninsured Americans. Most of those finding insurance via the ACA will qualify for subsidies that reduce the costs of that coverage. And the ACA will enhance the health security of those who are already covered by checking the capriciousness of private insurers and providing a softer landing for those who lose a job or job-based coverage."
"At the root of our ongoing health crisis (both the unconscionable rate of uninsurance and a level of spending nearly double the OECD average) is our reliance on jobs as a means of distributing and paying for health coverage. This is an historical accident, which began as an ad hoc arrangement to evade Second World War-era wage and tax regulations by offering employees non-monetary compensation."
"The ACA’s second major flaw is its deference to the states on key aspects of eligibility and access....Despite the fact that the expansion will be paid for largely with federal dollars (full federal funding through 2016, no less than 90 percent after that), fully half of the states have passed on meaningful participation (twenty have turned the idea down flat and five more are undecided). Not surprisingly, the states that have thumbed their nose at the ACA are among the nation’s poorest and—with a midwestern inroad–closely follow the contours of the old Jim Crow South. According to a recent analysis by the New York Times, state-level recalcitrance will leave two-thirds of poor blacks, two-thirds of single mothers, and half of all uninsured low-wage workers ineligible for Medicaid and therefore unable to afford coverage offered by the insurance exchanges. This regional unevenness blunts the ACA’s impact by limiting its reach where is most needed. It leaves the fate of a federal law in the hands of fickle and deeply partisan state legislatures."
..."the ACA’s third major flaw: its inability or unwillingness to displace private insurance. In this respect, one baseline assumption of health reform has remained unchanged since the 1930s: we already pay for national health insurance, we just don’t get any of the benefits. As a consequence of incremental timidity, we spend as many public dollars on health care as any of our democratic and industrialized peers. We then spend as much again in private dollars–for a per capita bill more than double the OECD average—and claim precious little (widespread insecurity, lousy health outcomes, and high costs) in return."
" ...any reform that simply lards new coverage options onto the old system of private insurance will be hard pressed to realize any real efficiencies or savings in the long haul. Propping up the current health care system—or pushing more people into it via individual or employer mandates—does nothing to address the administrative waste, actuarial complexity, or naked profiteering that created our health care crisis in the first place."
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