Reconsidering the Affordable Care Act: The Debate among Democrats

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December 7, 2014; The Hill

Given the Democratic debacle in the mid-term elections, the recriminations have been flying about President Obama’s decisions and non-decisions on major policy issues during this term-and-a-half in office. Since the election, there has been a vibrant reconsideration of the President’s healthcare reform strategy. Although Republicans still seem to have a thing about the Affordable Care Act, led by Texas Senator Ted Cruz and his Tea Party allies in the House of Representatives, the two most notable statements have come from prominent Democratic senators.

Ruing the Democrats’ losses at the polls, New York Senator Charles Schumer said in late November that Americans needed “middle-class programs” that would have led to “better wages and more jobs” and were not clamoring for changes in their healthcare. It’s not clear that Schumer was much in touch with the Americans who actually were clamoring for changes in their health insurance coverage, burdened as they were by ever-increasing health care costs and limitations or exclusions of coverage by the big insurers. Always interested in the cameras, Schumer’s statement got plenty of attention and press coverage, though it has been widely criticized, declared “deeply wrongheaded” by economist and New York Times columnist Paul Krugman. Since Schumer was a frequent presence on #ACAworks campaign platforms, his comments have been criticized by Obama insiders, who noted that, to their knowledge, Schumer never raised his strategic concerns with the President. Nancy Pelosi concluded that there were 14 million reasons—14 million being the number of Americans who have received health insurance coverage through the ACA—why Senator Schumer might be wrong.

Outgoing senator Tom Harkin (D-IA) raised a more substantive concern in early December. In contrast to Schumer’s obsession with electability as the purpose of public policy, Harkin questioned whether the Affordable Care Act was designed and structured as well as it should have been, suggesting that the willingness of the administration and Congress to make compromises in response to the concerns of centrist Democrats led to an overly complicated bill. In a reference to the Democrats’ numerical advantage in Congress in 2009, which could have led to the enactment of a number of important pieces of legislation—for example, comprehensive immigration reform—if President Obama had pressed for action, Harkin said that Congress and the administration should have pushed for “single-payer right from the get-go or at least put a public option would have simplified a lot…We had the votes to do that and we blew it.”

Although the press harped on the notion that Harkin was suggesting that the nation would have been better off had the ACA had not been passed, Harkin was really arguing that the administration should have held out longer and harder against the legislation’s opponents in favor of single-payer or the public option. He clarified his position in a phone call with reporters: “What I was trying to say is that I thought, and I still think, that a single-payer system would be the best system for America. It’s cheaper. It would save us a lot of money. Much more understandable. More much efficient and effective.”

New York Times columnist Tom Edsall noted two problems in relationship to the Schumer critique, though they relate to Harkin’s more substantive criticisms of the ACA, too. The first is that, even though most legislators deep down know that healthcare reform is essential and the ACA, as complicated as it might be, is a big improvement over leaving millions without health insurance, Republicans are unlikely to behave rationally and work with Democrats for technical improvements to the legislation. Rather than working on fixes to the legislation, opening up the ACA to modification would possibly “eviscerate” the legislation. The second is that 28 of the 60 Democratic senators who voted for the ACA in 2010 are no longer in office. In Edsall’s mind, that works toward Schumer’s favor in a potential shift of the party’s attention away from healthcare and toward jobs and income for the middle class, Schumer’s electoral algorithm. However, more in line with policy concerns, those losses mean that the Democratic cohort that Harkin believes would have supported the public option, or even potentially a single-payer system, in 2009 and 2010 just isn’t there any longer.

On the ground, while helping people sign up for health insurance, Louisiana nonprofits report that one of their biggest challenges is “battl[ing] misinformation and misconceptions about the [Affordable Care Act] program.” In Miami, Miami Dade College is making health insurance navigators from the Health Council of South Florida available to MDC students. “With all the misinformation that was out there, and quite frankly a lot of it was just noise, we thought it was important for our students and their families and our community that we offer this service,” explained Joe Pena, MDC’s director of federal relations. Simply countering the misinformation about what the ACA does and who benefits—it’s the middle class, as well as the poor—is a challenge for nonprofit healthcare advocates. 

For working families that were unable to obtain or afford health insurance prior to the ACA, health insurance reform has helped the American middle class address a significant financial need that had driven many families out of the middle class. It is unfortunate that nonprofit health insurance navigators have to address the public’s health insurance misconceptions, but also those of Senator Schumer, whose priority appears to be more about winning elections than carrying out policy change.—Rick Cohen

  • R. Scott Dixon, CPA

    Very good reporting. The ACA of course needs revisiting and will continue so as we go along. What works and what doesn’t? The individual shared-responsibility mandate and the market exchange concept is a home run. The employer mandate is causing the most confusion and resentment among employers. Releasing the form of health reimbursement arrangement (HRA) heretofore widely used and commonly known as “employer payment plans” from the “market reform” provisions would go miles. It may have been unintended in the first place to subject such reimbursement plans to the prohibitive market reform provisions. In the end, we will have a program that is uniquely American and that works for us but will take some time.

  • Dianne Saunders

    Mr. Cohen –Perhaps you don’t know who the middle class really is? ACA has hurt huge sectors of the middle class, particularly the working, lower middle class.

    2015 and 2016 will be a rude awakening for many lower middle class workers. The FIRST THING that happened with AFA was a significant increase in premiums for working middle-class people. Then last month, for the start of our firm’s 2015 plan year, our premiums went up another 30%. So, my small employer shopped around and changed plans. My out of pocket expenses have jumped tremendously with the new plan. Prescription copays are triple what they were before ACA. We are now also paying a good portion for radiology, lab work, etc., and our hospital deductibles went from $400 to $5000.

    For middle-class, mid-life workers, this is a huge change. Furthermore, with ACA, the itemized medical deduction rose from 7% of AGI to 10%, and section 125 caps lowered from $5000 to $2500. So there is little/no tax break for working lower middle class people. We work, the government taxes us.

    Any middle class working person pays the brunt, always, of social services. ACA is just one more way the government can gouge working people to support those who are unable to work (elderly) and those who just don’t want to work.

    I feel it’s yet to be proven that providing coverage is not the fix. Making coverage AFFORDABLE is what’s needed. There is simpply nothing AFFORDABLE about the Affordable Care Act. The proof is in the pocket, where elected officials seem more than willing to take from working class people in order to .provide social welfare with our hard earned dollars.

    If you want some hard facts, I sent a multi-page letter to my elected (democrat) representative when ACA was being debated a few years ago. The elected representative never got back to me. Painful, perhaps, to admit that ACA is another burden for working people.

  • R. Scott Dixon, CPA

    Good points. Ultimately employers will be out of the health insurance game altogether. Companies do not need health insurance, employees do. It will be easier for employers to deal with all this with their employees once the TWO “market reform” barriers are restructured.