Authors note: This is post was from an article I submitted to the Wall Street Journal as a proposed OP-ED in October 2013. The article was not accepted as it didn’t meet their needs.
When I was eighteen years old, my mother died at the age of forty-eight of congestive heart failure. When I was twenty-two, my father died at the age of fifty-three from a heart attack. What we had in common was poverty, lack of a family doctor, no preventative health care or health insurance nor the means to pay for any major medical emergency. Admittedly, few people had insurance in those days, circa 1958-1962. In later years, as I went through four major illnesses and three major surgeries, my family and I were fortunate to have both great health insurance and Medicare, great doctors, and the benefit of the great strides in medical science.
This lifetime perspective, contrasting my parents’ early death, with my own extended longevity, influences my thinking, as I, like most Americans, watch the national debate on the Affordable Care Act (ACA), or Obamacare, and the defunding of government, as a means to repeal the ACA. The debate grapples with the reality that today, like my parents then, we find tens of millions of Americans without health insurance nor the means to avail themselves of life-saving medical care and technology.
As an interested observer of a variety of fact and opinion on matters of national and international import, in print, broadcast media, and the internet, I have been struck with the need to express an opinion on the national debate on the ACA and the Republican effort to delay or defund the ACA as a condition for continuing government operations. I interpret a major part of the conservative argument against the ACA to be that the public is against the health initiative and the press headlines support this contention. I see it differently as I process the vast collection of information and opinion on the ACA.
Counter to these headlines, I base my view largely on the results of two major, frequently cited polls, that ask a cross-section of Americans, Republicans, Democrats, and Independents, whether they support or oppose various aspects of Health Care Policy that are components of the ACA. Rather than focus on the single question of being for or against the ACA, for reasons I will describe, I view the aggregate of responses to the component questions as being far more meaningful than the response to the single question of being for or against the ACA as a whole. Examination of the polling results in the Table below one finds very strong support for 12 of the 13 components of the ACA, the only component not gaining favor is the so-called Individual Mandate, that all citizens obtain Health Care. I also note in the Table the overall result against the ACA legislation as a whole- the typical result that generally makes the Headlines.
Polling Results on the Key Features of ACA Amongst Democrats, Republicans and Independents
|Reuters/Ipsos Poll June , 2012||Kaiser Health Tracking Poll March 2013|
|Dependents Coverage to Age 26||63% For||76% For|
|Ban on Denying Coverage for Pre-existing Conditions||82% For||Not Asked|
|Disallow Policy Cancellation After Sickness/Guaranteed Issue||86% For||66% For|
|Creation of Health Insurance Exchanges||80% For||89% For|
|Ban on Lifetime Caps||80% For||Not Asked|
|Regulations to Insure Comparable Coverage||68% For||Not Asked|
|Mandating Companies with 50 or more employees to provide coverage||73% For||57% For|
|Subsidies to Help the Poor||75% For||76% For|
|Expanding Medicaid for Family Incomes Under $35,000||64% For||71% For|
|Tax Credits For Small Businesses Providing Insurance Coverage||Not Asked||88% For|
|Closing Medicare Donut Hole||Not Asked||81% For|
|Increase Medicare Payroll Tax for Upper Incomes||60% For||Not Asked|
|Mandate All Citizens Obtain Health Coverage*||59% Against||60% Against|
|Support for the Overall Legislation*||55 % Against, 45% For||40% Against, 37% For, No opinion 23%|
As I write this, I have the added benefit of a recent article from the New York Times of Oct. 5, 2013, titled, “A Federal Budget Crisis Months in the Planning.” The article describes how a coalition of Conservative activists met shortly after President Obama’s second inauguration and laid out a grand strategy to repeal Mr. Obama’s Health care law. The Times listed various groups in the coalition that arose from this meeting [hereafter referred to as the Kill Obamacare Coalition (KOC)] to include the Heritage Foundation, the Club for Growth, Freedom Works, Tea Party Patriots, and Freedom Partners Chamber of Commerce link to the Koch Brothers, Charles and David.
In recent days, we have seen how the KOC grand strategy has led to the government shutdown in an attempt to defund and/or delay or repeal the ACA. The Times article states ”With polls showing Americans deeply divided over the law, conservatives believe that the public is behind them.” The Times article goes on to quote Michelle Bachman, a congresswoman from Minnesota, founder of the House Tea Party Caucus, on the eve of the government shutdown, “This is exactly what the public wants.”
With the Individual Mandate being the only ACA component disfavored by the public it is revealing to analyze the juxtaposition of the Heritage Foundation, a key member of KOC, being the original dominant proponent of the Individual Mandate, with its current role leading the crusade against the ACA, with a special focus opposing the Individual Mandate.
KOC is prominently represented in the coalition by the group called Heritage Action for America, the political arm of the Heritage Foundation headed by Michael Needham. Needham’s role in KOC was extensively chronicled in the Wall Street Journal on Oct. 12 in an article by Stephen Moore of the WSJ staff. The Heritage Foundation itself is now headed by former Republican U.S. Senator Jim DeMint from South Carolina who has turned the Foundation into one of the most active opponents of Obamacare.
For perspective on this turnaround, we turn to the Heritage Foundation Paper titled, Lecture #218, October 1, 1989, titled “Assuring Affordable Care for All Americans.” The author of the paper is Stuart M. Butler then Director of Domestic Policy Studies at the Heritage Foundation. In the paper, Butler states: “As many as 37 million Americans lack adequate Insurance against health care cost, and many others who have insurance still dread the financial impact of a serious disease.” Toward a plan to overcome this national problem Butler proposed two key concepts:
- Direct and Indirect government assistance should be concentrated on those who need it most. Help should be provided to those who cannot afford protection.
- Mandate all households to obtain adequate insurance.
In rationalizing the proposed mandate Butler stated: “Thus we find many individuals and families, particularly among the young, who decide to use their income for other objectives than health care insurance, even though they have the means to obtain insurance without cutting back on other necessities, … They are playing Russian roulette with their continued good health. The household mandate assumes that it is the family that carries the first responsibility. …there is an implicit contract between households and society, based on the notion that health insurance is not like other forms of insurance. If a young man wrecks his Porche and has not had the foresight to obtain insurance we may commiserate but society feels no obligation to repair his car. But health care is different. If a man is struck down by a heart attack in the street, Americans will care for him whether or not he has insurance. If we find that he has spent his money on other things rather than insurance , we may be angry, but we will not deny him services-even if it means more prudent citizens end up paying the tab.”
One must note that this latter concept (of not denying medical service in emergencies) was ingrained in 1986 legislation, the Emergency Medical Treatment and Active Labor Act (EMTALA) and was co-sponsored by Republican Senator Robert Dole and Democratic Congressman Pete Stark, passed by a Democratic House and Republican Senate, and signed by President Ronald Reagan. The Act mandates that any hospital participating in Medicare (or receiving funds from the Department of Health and Human Services) must provide emergency services to anyone, including illegal immigrants, whether they can pay or not. Accordingly, very few hospitals are exempt from this EMTALA requirement.
There is considerable evidence that EMTALA (due to so-called free riders) has led to cost-shifting (or hidden tax) primarily through higher rates for insured individuals with hospitalization insurance. Harbage and Nichols (2006), of the New America Foundation, in a paper titled, “The Hidden Costs All Californians Pay in Our Fragmented Health Care System” estimate that this cost-shifting due to free riders “amounted to $455 per individual or $1,186 per family in California each year.” Professor Matt Harman, in a WEB article titled “EMTALA and the Costs of Providing Health Care to the Uninsured” citing data from the American Medical Association on unpaid care, estimates a 13% added cost to insurance premiums in Texas versus a national average of 8%. The hidden tax posed by EMTALA could thus be viewed as the basis for Butler’s ringing endorsement of the Individual Mandate. Governor Romney incorporated the Individual Mandate in Massachusetts Romneycare to overcome the costs of EMTALA and attributed the idea to former House Speaker Newt Gingrich who in turn got the idea from Butler and the Heritage Foundation.
In following the KOC campaign against Obamacare by the coalition described by the NY Times, it is a fact that one of the features of the ACA most railed against is the Individual Mandate-most ironically the feature given legs by the Heritage Foundation as described above. In contrast to the concepts of young free riders being a financial drag on Emergency rooms, described so graphically by Butler in the Heritage paper, KOC through Freedom Works and Jim Demint’s National Town Halls, have introduced the concept that young healthy workers will unjustly be forced to subsidize their sicker elders, thus treating young people unfairly. Butler, who remains at Heritage as the current Director for Policy Innovation, states his reversal and now opposition to the Individual Mandate as arising from the following: a) It is unconstitutional b) It forces people to buy expensive comprehensive coverage rather than catastrophic coverage c) It forces individuals to buy insurance without a requirement. Of course the Supreme Court has since ruled the ACA is constitutional.
One of the most extensive analyses of the Individual Mandate is a paper by Eibner and Price of the Rand Corporation titled “The Effect of the Affordable Care Act on Enrollment and Premiums, with and Without the Individual Mandate.” They address the notion of unjust treatment of young healthy workers by observing that “because younger individuals are more likely to be low-income, the ACA subsidy schedule is disproportionately generous to younger, lower-cost people”. The provision that individuals under age 26 can remain on their parent’s insurance further mitigates any perceived unfairness. The ACA’s provisions for levels of insurance labeled bronze, silver, gold, and platinum with the bronze plan being limited coverage, along with the subsidies and insurance on parent’s plan through age twenty-six, largely mitigates any concern for expensive comprehensive coverage cited by Butler as a basis for his reversal of opinion on the Individual Mandate. Matt Miller, in the Washington Post, August 21, 2013, in an article titled “The GOP’s Obamacare Youth Hoax” observes that 20 million youth between the ages of 19 and 34 get health insurance through their employer and effectively pay the same rate as their elders for the same insurance and have done so for decades without a peep from anyone about this socialistic unfairness. Butler’s original anecdote, quoted above about the Porche owners wreck versus the man struck down on the street by a heart attack, remains a solid argument why mandated insurance should be a requirement. Others have opposed the Mandate because it is socialistic. Yes, it is, but so is the Mandate imposed by EMTALA.
With respect to costs under the ACA Exchange Policies, one of the key findings of the Eibner-Price Rand study is the conclusion “With our methods we find a 9.3% increase in the average premium per covered life when the mandate is repealed” primarily “due to a change in the composition of enrollees.” Their overall conclusion states “Our analysis demonstrates that the individual mandate is important to achieving the goal of near-universal coverage for all Americans.”
Jonathon Gruber, a professor of economics at the Massachusetts Institute of Technology was a key architect of the Romney Massachusetts health reform insurance legislation and an advisor to Democrats and the Obama administration during the build of the Affordable Care Act. Gruber has been quoted as comparing Obamacare with Romneycare by saying “the two were the “same (expletive deleted) bill.” In an August 2013 Massachusetts poll conducted by the Massachusetts Medical Society Physicians Group and reported on by Healthwatch, 84% expressed satisfaction with their healthcare. In a 2008 paper in the Journal of Economic Literature, titled “Covering the Uninsured in the United States,” Gruber introduces a metric of new government spending per new insurance enrollee called “bang for the buck.” His modeling indicates that with the mandate the total government cost per enrollee is $3,659 and without the mandate, the cost is $7,468–essentially a factor of two. The huge difference is due to the fact that government spending will be roughly the same, with or without the mandate, but 12.5 million fewer people will gain coverage without the mandate.
The KOC effort to kill Obamacare with a focus on this alleged unprecedented unfairness is an incredible irony and is undoubtedly the reason that the Individual mandate is the one component of the ACA that is not supported by a majority of those polled. The Times article indicates that the Koch brothers, through Freedom Partners Chamber of Commerce, have disbursed more than $200 million in the KOC effort. The campaign has featured young people enticed into demonstrations featured by “Burn Your Obamacare Draft Card” rallies, inferring that the Individual Mandate is unfair to youth –comparing it to the military draft.
As the effort to Kill Obamacare (KOC) proceeds, along with the government remaining shut down along with the threat of default due to a failure to lift the debt ceiling, this writer is reminded of a recent cartoon. An elephant is standing beside an oncoming train that is labeled “Obamacare”. A portion of the track has been removed in the train’s path and the reader gets the image of the oft-repeated claim that Obamacare is headed for a train wreck. However, the frame with the elephant shows the elephant with a crowbar and other tools by which the missing segment of track has been removed-assuring the impending train wreck. The KOC effort is determined to create an Obamacare Train Wreck. My plea to KOC conservatives is: “Please put away your crowbars.” Your misguided efforts are leading us to a national train wreck.