Things I’ve heard about the Affordable Care Act

As the date for the implementation of “Obamacare” looms closer and the congressional GOP tries for the umpteenth time to defund it, talk about the ACA has increased in the general public. I’d like to share some things that I’ve heard in the blogosphere, on facebook, in the media, and in conversation with people and offer my take as both a nurse in training and a citizen.

Obamacare is causing businesses to cut hours

While it is true that part-time work seems to be a paradigm of the new economy, this is a trend that started long before the ACA and before Obama even became president. Many businesses have been cutting hours back in order to avoid having to offer workers benefits for years. This personally happened to me back in 2006, long before Obama and the ACA. I used to work for a corporation where it was standard practice to automatically schedule any non-mangerial employee below the minimum number of hours required for enrollment in any benefits package. But more to the point, healthcare costs (for both individuals and employers) have been rising disproportionately for a very long time now–that’s one of the many reasons we enacted healthcare reform in the first place. So it’s somewhat disingenuous to claim that this is all the fault of the ACA.

Obamacare is going to bankrupt the country

Well, despite the fact that the CBO has repeatedly projected the the ACA will save us money in the long run, this idea still persists. But more to the point, I think that a lot of people don’t realize that the number one cause of bankruptcy in this country is medical bills. Medical bankruptcy is a HUGE problem and a huge drain on the middle class. The previous model of care we were delivering was financially unsustainable. In other words, medical care before the ACA was already bankrupting us. Plus, like it or not, the ACA is going to be a boon to the economy. In fact, the stock market loves it. There will be a slough of new jobs in healthcare, insurance, construction, financing–it will have a positive ripple effect through the country. Increasing the number of insured people in our society means that we’ll need more nurses, more lab techs, more pharmacists, more of all the administrative personnel that work in healthcare.

Why should I have to pay for the healthcare of other people?

Well, the short answer is that you already do. It’s medically unethical and quite illegal to refuse someone medical treatment. Many hospitals have charity funds to help cover the costs of uninsured patients, but those funds are often severely limited. So how do hospitals make up the difference? They pass the buck to the paying customer. Part of the reason why healthcare costs are escalating so sharply is precisely because uninsured patients are draining the system and the paying customers with insurance have to pay more to make up the difference. In other words, the more uninsured people there are, the fewer paying customers there are, placing more of the the burden on the few remaining people with insurance. So you already subsidize the healthcare of other people, you just never realized it.

If I’m young I don’t need insurance

Well, that’s all great–until of course you need healthcare. There’s this idea that a lot of young people have that health insurance = being sick, and since young people don’t get sick they ergo don’t need health insurance. A more accurate phrasing would be health insurance = healthcare, something that young people need just as much as anyone else, albeit for different reasons. While it’s true that most young people aren’t likely to get cancer, it’s also true that young people are much more likely to be in horrible accidents: motor vehicle accidents, athletic injuries, other forms of trauma, etc. So yes, you’re less likely to suffer end stage renal disease, but you’re much more likely to break a bone or suffer trauma, which requires healthcare. So unless you want to be one of those uninsured people draining the system and increasing the problem, you need health insurance. There’s even an option in the ACA that young people can choose that only covers catastrophic health problems if that false sense of youthful invincibility is impossible for you to shed.

Obamacare is going to cause small businesses to close down

The argument here is that, facing stricter taxes and having to provide health insurance to all employees, places are going to go out of business. To the ear that initially makes sense. But remember how healthcare costs have been increasing disproportionately? Yeah, employers are going to face rising costs no matter what. Even if the ACA magically disappeared tomorrow, they would still be facing rising costs. So if the ACA succeeds in decreasing costs it should basically come out as a wash for employers. Sure, they have to pay more to cover all employees, but at the same time the costs to cover them should come down, basically balancing it out or representing an increase of only a few percentage points. And if a 3% increase is enough to run you out of business, I’d have to question your solvency anyway regardless of the ACA.

This is all just part of Obama’s socialist agenda

I really think that most people in this country don’t truly know what socialism is, and that they already take part in it everyday. Anyone who went to or sends their kids to public schools is technically a socialist. Anyone who supports a publicly funded military is technically a socialist. In reality, this is actually the least socialist plan ever. The insurance exchanges that are part of the ACA are capitalism to the hilt: they introduce a vastly greater degree of competition into the health insurance market, which, as any capitalist would normally decry, will drive down the prices. In fact, in many states the exchanges are already lowering prices.

Obamacare is a plan to crash the economy and make everyone dependent on government assistance

I’m not sure where this conspiracy came from, but if you think about it for a second it really makes no sense. What pays for all of those government programs? Tax money. So if the plan is to cause massive unemployment and force people to become reliant on the government teat, the tax pool drastically shrinks and we’re no longer able to afford the very government programs these people think Obama wants us to become reliant upon.

I shouldn’t be forced to buy something

Ah, the individual mandate. I can definitely see why a lot of people would argue against essentially forcing people to buy a product, no matter how much money it saves. If the idea is to lower costs and make healthcare more affordable and accessible, then why the mandate? If the exchanges lower costs, wouldn’t healthcare then become more affordable, and wouldn’t more people choose to buy it of their own free will? It’s impossible to say. But the SCOTUS already ruled that it’s constitutional, so it’s a moot point. It seems like a bizarre argument when you consider all of the other things people are forced to participate in. It’s illegal to drive without car insurance, but I don’t hear anyone saying, “I should be allowed to drive without insurance, it’s my risk to take–down with car insurance!” But beyond that, why are the only two choices fund it or completely gut it? There’s no gray zone. Fine, let’s have a debate about the mandate, but what about keeping everything else? I’m sure most people, regardless of political affiliation, wouldn’t argue that denying people with preexisting conditions coverage is a good thing. I’m sure most people wouldn’t argue that dropping people once they become sick is a good thing. I find it hard to believe that anyone would argue that lowered costs are a bad thing, or that the exchanges lowering the prices are a bad thing. Don’t people want more options? Don’t they want to be able to compare plans side by side, apples to apples?

***

Personally, I think the whole individual mandate is something worth debating. But the other components of the bill have merit and shouldn’t automatically be dismissed. I think the biggest mistake here has been a total lack of dialogue with the American people on the part of the administration. The only thing most people know about the ACA is that it’s coming–and that’s it.

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8 thoughts on “Things I’ve heard about the Affordable Care Act

  1. Great write-up! Even though I don’t agree with all the points you’ve made here, it’s good that you’re trying to start an informed and intelligent discussion.

    Just touching on a few things that contradict what I’ve read/understood:

    – The mandate is a bit like car insurance, with a major difference being that car insurance *protects other drivers.* The legal and social impetus is primarily to ensure payment in case someone damages your property, or vice versa. Health insurance is much more person-centric protection, not so much public. (Arguably it MAY help protect others from picking up the tab when a person skips out on a $150,000 med bill … But that’s a long, roundabout, and probably not realistic outcome of the current revisions.)

    – Re: high costs and paying for the healthcare of others:

    1) You say that “It’s medically unethical and quite illegal to refuse someone medical treatment.” This is NOT a true statement. While doctors are generally responsible for treating any patient in a critical/emergency situation, they are perfectly within their rights to refuse to treat someone under most other circumstances — nothing unethical or illegal about it.

    Yes, doctors do have a unique career in the degree of responsibility and the amount of “altruism” that is expected of them. They are not, however, indentured servants who can be forced to work under government (or any other) mandate. Doctors are just people — people who have jobs, and who spend 18 hour days *working.* We can’t force them to work without reasonable compensation, and some of the new insurance laws would put them such low rates that accepting Obamacare patients would bankrupt their practice. And I don’t mean bankrupt in the sense they won’t be able to drive a porsche anymore. Those who aren’t independent practitioners still get the short straw making $20/hr after paying taxes, malpractice insurance, etc, a sum that unfortunately is not commiserate with the decade of school they spent paying to get trained. Either way, we can’t be upset when doctors (or any other individual) declines to accept the terms put forth by the government. If they don’t want to accept Medicaid or Medicare or Obamacare patients, *they don’t have to.*

    ha okay that turned into kind of a rant. Anyway,
    2) also I’m pretty sure it’s not as simple as patient doesn’t pay, hospital cranks up costs to eat the difference, paying patient gets a bigger bill.
    Maybe look into the role of insurance companies in this whole “health care revolution” –pharmaceutical and device manufacturers, too — especially how their business tactics drive up costs across the entire system. If you’re really into the political process, check out congressional records on Thomas (thomas.gov) and how these groups (e.g. Big PhRMA et al) beat down beneficial provisions and beef up their own finances…while stealthily showing only the “pro” side to the public.

    1. Wow, thank you very much for the thoughtful reply. I appreciate this kind of feedback very much!

      With regard to some of your rebuttals:

      1) I wasn’t really trying to compare car insurance to medical insurance directly as insurance programs, but merely as an example of a compulsory program. I probably should have been clearer on that. I suppose that healthcare is more concerned with the individual, but I think that the “person unable to pay massive hospital bill” scenario is a lot more common than you think. Plus, I tend to think of a healthy society as an economically productive one.

      2) I should have delineated that I was referring specifically to the hospital system with my argument about refusing people treatment. I’m perfectly aware that there are plenty of scenarios wherein providers aren’t legally compelled to treat people. However, the hospital system is the major source of debt and high cost in this argument, so it was what I was referring to.

      It’s a slippery slope when you start talking about “reasonable compensation.” What constitutes that? Who gets to decide what “reasonable” is? Do I get to as the customer? Does the doctor get to as the provider? It seems like that term is completely subjective and impossible to universally define.

      I think it’s also a little unfair to start talking about malpractice insurance. That’s not an ACA problem, and it’s not even a medical system problem–it’s a legal one. Our legal system is what has allowed malpractice to become what it is today, so I’m not quite sure that the ACA has to do with any of that.

      What new insurance laws are you specifically referring to? I’m also a little unclear on how you arrived at the $20/hour figure. It seems, at least to me, that with approximately 40 million new customers, there would more money available for reimbursement and payment–not less. I also feel compelled to mention that there’s a program for people who work in public service jobs that eliminates debt. So long as you make good faith payments for 10 years, the rest of your debt is forgiven.

      I don’t quite understand the whole “indentured servant” argument either. The mandate doesn’t force providers to work–they’d be working regardless of any mandates. Nor does the ACA specifically change how doctors deliver healthcare. It’s not like there’s going to be a government employee in every hospital room, directing the physicians on how to care for patients. In fact, there are a lot of incentive programs built into the ACA for physicians. Thanks to the PQRI, physicians who generate above average health outcomes for patients get a $$ bonus.

      3) I definitely would never try to argue that pharmaceutical companies are innocent lol. But you’d be surprised how hospitals sneak in higher costs. That band-aid you got? $8. And I can assure you that that isn’t what the hospital paid for it. A lot of times it really is simple for hospitals to bump up costs whenever and however they want. I’d be hesitant to blame device manufacturers. Yeah, devices cost a lot, but it’s EXTREMELY hard to get one in a lot of places. I have literally seen doctors and nurses get into shouting matches with insurance companies who didn’t think that an assistive device was necessary and didn’t want to pay for one.

      When you dig below the surface of all the provisions in the bill, what the ACA is really all about is accountability. It’s about setting standards for all the systems involved in healthcare delivery and it’s about rewarding positive or improved patient outcomes.

      1. Thanks for the equally thoughtful and in-depth reply. Given that this topic is more complex than can be deconstructed in a blog comment, I’ll point to an incredibly perceptive yet concise report by the economist John H. Cochrane. It sums up the many practical concerns — and shortcomings — of ACA policies: After the ACA: Freeing the market for health care (http://faculty.chicagobooth.edu/john.cochrane/research/papers/after_aca.pdf) He points out realities that have somehow been overlooked — about proposed ideals of medical “quality” and “need,” plus more straightforward economic issues. (“Government-imposed efficiency is, to put it charitably, a hope without historical precedent.”)

        As for physician payment cuts, my concern is that it is a direct hit to the people who — with these new regulations — we will need the most. Aside from the fact that physician salaries are a ridiculous and unfounded place to seek out ‘savings,’ new laws will have a negative impact on patients by 1) short-term driving a physician shortage, and 2) long-term turning away the best and the brightest (a whole other discussion for another day, but let’s be real — if we want to attract the best and the brightest, we have to make it worth their while). Also, I say indentured servants because the providers are very much in danger of having their autonomy revoked by people who do not have the slightest understanding of medical practice (politicians). “Best practices” are WILDLY undefined, and vary considerably on a case-to-case basis. For a panel to even attempt to outline what doctors should and shouldn’t do in each given scenario is ridiculous — we simply don’t have the evidence to support it. For example, let’s say the gov’t looks at the data and says the best approach to diabetes treatment is X. That “data” is going to be based on a trial with carefully selected patients and applicable to a select population. An individual patient is likely to have a range comorbidities and issues that can make any given treatment X a less than optimal approach. Some people tolerate certain treatments better than others, but the physical reality is that not all conditions have a clear go-to treatment — This is a major flaw in the gov’t definition of quality of care.

        Along those same lines… From the outside, the plan to “reward” “above average health outcomes” may sound terrific — it is, however, a wildly oversimplified approach to medicine. For example, one variable that influences patient outcomes is patient compliance and (through various related factors) patient education/SES. Doctors who treat the “healthiest” and the most educated patients will inevitably have “better” outcomes. Those who are willing to take on a large number of poor or minority patients will be “punished” for doing so — Their outcome numbers will be in the toilet. There’s talk of compensating for that in various ways, but really, Do you want your doctor to be more concerned about taking care of you — or about pleasing the government number crunchers? Let’s not even get started on how these outcomes are measured, btw.

        From strictly financial perspective, docs are about to get screwed in a lot of ways, one example being: “…under the rules of the exchange, a patient can go up to three months without paying premiums and still not get their coverage formally dropped by an insurers—but the insurer isn’t obligated to pay claims incurred during the second and third month if that person isn’t paying their premiums for that time…Those rules could mean that doctors end up eating the cost of the care they have already provided, or have their receivables stay unpaid for longer stretches of time.”

        Anyway — I highly suggest the Cochrane article. Even if the beginning doesn’t lock your attention, try and give it a full read. If nothing else, it will give you some things to think about.

      2. Well, I’ll start off by saying I trust economists about as far as I can throw them.

        I think, quite simply, the reason why I cant support the argument you’ve put forth is that it presumes that without the ACA, there’s some mythical place where physicians can practice in total independence, which isn’t at all reality.

        You asked if I want my doctor more concerned with my health or with satisfying a government number cruncher, but that’s really no different than the current paradigm. Swap “government number cruncher” with “insurance company” and you’ve got basically the same scenario you’ve just described. Quite frankly, personally, I’d rather have my physican beholden to a not for profit government agency than a for profit insurance entity, which is currently the way it works. You can argue all you want about government dictating health care, but right now it’s the insurance companies who dictate your medial care (unless you’ve got the cash to pony up) an that’s proven to be unequivicably unsuccessful.

        Best practices really aren’t that hard to define. You go where the evidence takes you, and it really is as simple as that. Practices are always being updated and replaced as newer information comes in. That’s the basis of science itself.

        As for the argument about incentive programs, obviously there are a ton of variables involved. To my knowledge, any physican can appeal any decision that’s been made regarding incentives or penalties. This would require all providers to keep proper documentation of treatments and services rendered, which shouldn’t even be an issue if you’re a reputable physician.

        I really don’t know what to say about the insurance exchange payouts other than there really isn’t anything that was previously stopping physicans from not receiving payment for services rendered. People walk out on paying bills all the time, regardless of what the law is.

        I know that previously you argued that physicians are just people doing jobs, but really that’s a rather simplified way to look at it. They aren’t just people doing jobs. Medicine isn’t a job you can’t just do on your schedule. Healthcare doesn’t just take place during bankers hours. Anyone going into the medical field is perfectly aware of the sacrifices required. Sick and injured people don’t take vacations. You’re always on call. This whole argument feels like a firefighter complaining that they have to run into a burning building; it’s what they signed up for quite frankly.

  2. I’m having your RWCRFM card revoked. (Right Wing Conservative Republican Fundamentalist Moron) Consider yourself reported. 😉

    I have never had an issue with Obamacare. If it makes health care affordable to my family, I am all for it. As it is health care would run us around 5-600 a month for a lousy plan. Twice that for a good plan.Needless to say, we do not have coverage. Now consider just for a moment…every single politician that screams into their bullhorn about how Obamacare will be the end of the world as we know it, has gov’t health care.

    I think one point you missed about current health care is, you can pay in for years, and then you get sick with something that will actually cost your insurer money, and they can…and do find a reason to drop you. Just like that, out in the cold, and on your own with no recourse. Cold blooded bastards.

    I like the idea of insurance, pay money in to alleviate a disaster later, but these companies even when they do work with you, don’t always live up to their expectations. For example say your house burns to the ground, will you get the amount of $ you are insured for? No, they have these people in their employ called adjusters, they come in and devalue your home and possessions and offer you considerably less than you were insured for. Brilliant business plan, if you are a scam artist. The concept of insurance is a good one, the reality is they will screw you over. Best bet if your house burns to the ground, get a lawyer before you agree to anything. Also document all of your possessions with pics/video, keep them in a fire proof box.

    With all of that said, I did have a good experience with an insurance co. when the wife crashed the car, they not only acted quickly and professionally, but paid us way more than I was expecting. So, it isn’t all bad out there. (the wife was fine)

    As far as the mandate that everyone gets coverage…I am torn on that one. I see it as unconstitutional, but I think seatbelt mandates and helmet laws are as well. That doesn’t keep the gov’t from making us comply. I don’t like it, but at the same time don’t see much I can do about it, besides complain.

    1. I’m glad your wife was ok!

      I hear what you’re saying about how insurance is actually delivered. Totally unethical, yet perfectly legal. I very much the idea that you can’t be dropped or denied coverage thanks to the ACA.

      I always get some good laughs from the hypocrisy of the GOP in congress. Here they are, talking about too much government, government never solved any problems…and yet they accept lifetime government healthcare AND a lifetime government pension. It’s ridiculous.

  3. I hear this a lot and have written about this as well. Even from the peer-reviewed research I get at college, it discusses the level of politics involved with the ACA. Unbeknownst to many citizens, that “evil and disgusting” GOP in this country actually attempted several times to pass healthcare reform.

    Seriously.

    The Democratic party (at the time was a minority) voted “nay” each time. Much of these bills didn’t get past the various committees. After reading some of these bills, it was clear they were different from the ACA. Let me explain: the ACA simply perpetuates the status quo. How, you ask? It get’s more people on medicaid, and it “makes” it law that you buy health insurance. Public or private health insurance leads to gross inefficiency. There are some good things with the ACA! Tort reform? Great! Stopping pre-existing conditions and bias? Great! Were they the first to come up with these ideas? Absolutely not.
    The GOP, actually wanted to change…fundamentally….how healthcare is financed instead of through public and private insurance.
    The GOP does care when people get sick. They do care about others and their fellow citizens. What they do not like is how they attempted several times just to be shot in the back from their fellow citizens.
    The GOP is simply angry that Democrats accuse them of wanting sick people to die, mock their attempts and stab fun that they “never came up with a plan,” when it’s simply not true. Mocking your opponents or attempting to accuse them of not caring is part of the problem we have in this country.

    Cognitive dissonance works both ways

    1. I don’t remember where, exactly, but somewhere in another post or maybe on another blog I talk about a distinction between conservative politicians and conservative citizens. In general, I believe that republicans in the government act in ways contrary to how many regular citizens who self-identify as republicans feel. My reasoning here is money…without a need to win election cycles or to draw campaign donations or pressure from lobbyists, the average citizen is much freer to live a life much more closely aligned with common sense and reason. And this goes for democrats as well as republicans. In truth I think this country is a lot more moderate than anything else; congress as it currently stands is not really a representative body anymore; it’s simply a stockyard of corporate shills on both sides.

      So when I hear people say, “the GOP don’t care when you get sick,” what I REALLY hear people saying is, “POLITICIANS don’t care if you get sick.” None of my conservative friends are heartless or unsympathetic. But I truly, honestly, believe that most politicians don’t really care whether you or I get sick. They’ve got their money, they’ve got their power, and they’ve got a cushy lobbying job in the revolving door system of congress when it’s all over. They’ve won. They don’t need to appeal to you or I or anyone else anymore.

      And to be fair, I believe that this logic can be applied to the ACA as well. Do I think that Obama pushed for it because he can’t sleep at night knowing how many people get dropped from their coverage? No, of course not. The ACA is one more corporate handjob from the government. The only difference is that if it works, we little folk benefit from it as well.

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