No one likes Obamacare

January 2, 2014
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People are always interested to know, when I tell them I write about health care, what I think of Obamacare.

My answer usually is this: “The Affordable Care Act is so massive, it's just about impossible, if you know what’s in the law, to entirely love it or hate it."

I could just as easily say this: "No one is happy with this law."

We all know conservatives don’t like Obamacare. Republicans have been warning about Obamacare-induced death panels, death spirals and the death of America as we know it since before the law was passed. And after it was passed, the Republican-led House has staged 40-some votes to repeal all or part of Obamacare.

“Obamacare will destroy the private-insurance market, incentivize businesses to cancel current health coverage for their employees, create physician shortages, and force Americans and states into total dependency on the federal government,” wrote Jim DeMint and Mike Needham, both of the Heritage Foundation, in a Wall Street Journal op-ed that encouraged shutting down the government to stop funding for the law.

Perhaps more surprising is that liberals don’t like Obamacare either. Many of them wanted Obama to push for a national, Medicare-for-all health insurance program. At the very least they wanted a public option insurance plan to give the health insurance industry some real competition. But that provision didn’t make it into the final version of Obamacare.

“Obamacare is awful,” wrote liberal filmmaker Michael Moore in a New Year’s Day op-ed in the New York Times. “The Affordable Care Act is a pro-insurance-industry plan implemented by a president who knew in his heart that a single-payer, Medicare-for-all model was the true way to go.”

Indeed, looking back nearly four years after Congressional debate over Obamacare, I see lots of ways in which critics of the law got a better deal than they thought (or said) they would, while many proponents of the law are now disappointed.

Consider that health insurers like Indianapolis-based WellPoint Inc., which in general worked against the law, now enjoy a government decree for nearly all Americans to buy their product. (I can tell you the newspaper industry would kill for a mandate for all Americans to buy its product. And I suspect every other industry would, too.). Obamacare gives its insurance mandate teeth by taxes on those who don’t buy insurance and by fairly sizable tax subsidies for many who do. Those subsidies are set to total $100 million a year by 2017, Moore noted.

Consider that hospitals, who thought they would see a flood of newly insured patients, are now trying to cut their expenses to deal with Obamacare’s slower-than-expected growth in reimbursements from the Medicare program. (Other factors hurting hospitals right now are federal sequestration, Indiana’s decision not to expand Medicaid eligibility, as called for by Obamacare, and a decline in patient visits, which appears to be induced by the nation’s long bout of joblessness and by the rise in high-deductible insurance plans.)

Consider that hospitals, doctors and even drug companies like Eli Lilly and Co.—all of which supported Obamacare because of its expansion of insurance coverage—are now seeing their services and products cut out of some insurance plans, as insurers switch to narrow networks and narrow formularies.

Consider that health savings accounts and high-deductible health plans—which were marked for extinction by the incoming Obama administration—are now, thanks to the bronze plans on the Obamacare exchanges and Obamacare’s Cadillac tax on employers, on their way to becoming the dominant type of health insurance plan across the country.

Consider that labor unions, some of Obama’s staunchest supporters, will likely not be able to keep their health plans going in the future. Some unions have even called for the outright repeal of the Affordable Care Act.

Why does all this discontentment matter? Because it means that health reform is by no means done. If anything, the Jan. 1 implementation of the bulk of Obamacare is just the beginning of health reform.

I don’t ever expect a repeal of the Affordable Care Act—even if Republicans take control of the Senate and the White House by 2017. Instead, I expect liberals and conservatives to engage in a pitched battle to twist Obamacare’s basic architecture into something more to their liking.

Liberals will still find it hard to attack Obamacare outright. But they could certainly re-start their anti-insurance rhetoric, blasting health insurance companies for the real-world effects of their narrow networks, high deductibles and high premiums. That could give them traction on introducing a public option.

Conservatives will find it hard to stop predicting Obamacare’s impending doom. If they did, however, they would discover that the bill has given them a chunk of what they wanted—proliferation of health savings accounts, the extension of tax breaks to individuals (not just companies) for buying insurance. They could try to scale back the highly prescriptive nature of the regulations on the Obamacare exchanges and open those marketplaces across state lines—both in the name of expanding choice and competition. They could also take a shot at repealing Obamacare’s individual mandate tax.

I also expect conservatives to try to extend the logic of Obamacare—tax subsidies for private insurance—to Medicare (as Rep. Paul Ryan has already proposed). In response, I expect liberals to try to keep the program roughly as it is, while expanding Obamacare's modest provisions for reducing health care spending and, possibly, giving Medicare the power to negotiate prices with drug and device companies.

Obamacare, for all it changes, leaves a lot of things the same in American health care. Both liberals and conservatives can find things in the law they will fight to preserve, and other things they will fight to overturn.

So, now that Obamacare is here, let the real health reform debate begin.

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  • The ACA debate everyone's missed
    Best analysis I've seen. Risk for ACA is to end up an orphan law, abandoned by its mother the left for single payer, and never accepted by right who was its intellectual father.
  • Obama
    Obama supporters will go hysterical over this well sourced list of 504 examples of his lying, lawbreaking, corruption, cronyism, etc. http://danfromsquirrelhill.wordpress.com/2013/08/15/obama-252/
  • silly headline to this blog posting
    Millions like Obamacare. Those who benefit from it. Like those with preexisting conditions suffering from a private system that wisely, but cruelly, denied them coverage. Same for those who could not afford to buy coverage that was worth anything since it was riddled with exclusions, high deductibles, and benefit limits. And don't forget those with mental health conditions, who often did not have coverage at all for their treatment, and if they did had to worry that benefits would be denied; now mental health benefits have to be provided on a parity with benefits provided to those who suffer from a heart problem or diabetes. Are "people" happy with Obamacare? And there are those in business and government who like what the law will do in terms of cutting federal spending and business expenditures for health care. Certainly it is not perfect but it was a legislative compromise that did what was politically possible at the time. Not like the system wasn't broken. So, the headline takes a complex law that touches and does nothing to tell readers why they should keep an open mind.
    • To Mark Barnes
      Fair points all around, particularly on the problems with the existing system. I would point out, however, that the headline did not say, "No one likes any part of Obamacare." But taken as a whole, as viewed by the dominant schools of thought out there, I think it's fair to say that no one likes this law. All sides would like to change it. Does my headline overstate that situation a bit? Probably. But headlines are, almost by definition, overstatements.
    • Going forward
      By actually providing access to health insurance coverage to millions of uninsured folks, the ACA has shifted the focus of the conversation from "can we/should we provide insurance to (nearly) all citizens" to "how do we responsibly provide this insurance." This is a dramatic change. It has opened a debate that is important. What role should the market play in providing insurance coverage and what role should the government play? It is a topic to which all can contribute ideas. I'm looking forward to the coming debate.
      • not totally true
        Your statement "consider that hospitals, doctors and even drug companies all supported Obamacare" is simply flat out wrong. I'm in the medical profession with a hospital-based practice and I haven't heard one person saying they supported Obamacare. Are there some portions of it that are better for all in the long run?...Sure. But I think most hospital and doctors would have liked to have seen a more bipartisan solution to the problem. If you're using the AMA as your guidance for doctors, I need to inform you of something. The AMA realistically represents the most-left leaning physicians and not the overwhelming majority. Ask 10 doctors and you will find maybe 1-2 who think the AMA represents his/her positions politically on health care. It's not just politics here, it's that the AMA is significantly disconnected from the super majority of physicians in every aspect. http://www.cmaj.ca/content/183/11/E713
        • To Dave Kelleher
          Very good comment, Dave, as usual. The shift you identify is, indeed, dramatic, even if it still leaves much to be debated over cost, quality and access. Thanks a lot.
        • To gojeepdog
          I did have the AMA, AHA and PhRMA in mind, although I am aware the AMA is not nearly representative of doctors' views as it once was. Still, I don't remember any doctors groups being vocally opposed to the law during the Congressional debate. And I can't think of a single doctor I've ever talked to who did not want to see insurance coverage expanded. Am I wrong on those points?
          • Obama
            Next fight: Defund the NSA
          • No One Likes Obamacare?
            Once Obamacare is made mandatory, the ruling class will love the economic control the Smart-chip within the bill will provide for them. Is it possible that The Affordable Health Care Act was never designed to be affordable? Is it possible that it was purposely designed by the Ruling Class to profit from the penalties they knew would be generated by employers who could not afford health care for their employees? There is evidence that the Ruling Class own both the IRS and the Federal Reserve. There is also evidence they rob other accounts that are designed for institutions such as The pentagon, Social Security and other retirement investments and that most corporate insurance companies are owned by the Ruling Class, therefore, they win whether or not people sign up for Obama care. Their insurance corporations take in billions, but only pay out millions. Is Obama Care just another revenue stream for them? The 3rd Reich was a trial run, the 4th has now begun; http://www.focusonrecovery.net
          • Don't be so fooled JK
            Don't let Obama fool you that easily, JK. Just because insurance coverage is expanded doesn't mean it's good insurance from a physician/hospital perspective. I'd rather take care of the occasional uninsured patient and most others who have commercial insurance rather than a bunch of watered-down "insured" Obamacare exchange patients that pays us and the hospitals jack and makes us work twice as hard to make the same income. Just because something (such as insurance coverage) is broadened doesn't necessarily mean it's a good thing for all parties affected. I think you're analyzing this too simplistically. All we're doing is major cost-shifting where the middle class and above will be paying a stiff amount more to support Obamacare.
          • ACA Is Bringing About Needed Debate
            I think most people were naïve to think that the ACA was going to be a "turnkey" event. Changing the country's woefully expensive and disproportionate health care system is going to be a long term process and the process will be wrought with missteps. I would hope all the critics of the ACA would begin to identify steps to begin addressing the weaknesses that are being revealed by the ACA's poor implementation. I am hoping the President will offer some legislative recommendations in his state of the union address but I am sure I will be disappointed. But I can hope all sides and parties can begin to get really serious about working together to make the overall system more efficient and effective.
          • DeMint op ed
            DeMint says, "ObamaCare will destroy the private-insurance market..." and "it will destroy what's left of our personalized free-market health system...." The free market system has not worked well for most customers shopping for health care. It is very expensive and certainly not transparent. The notion that decisions should continue to be made between me and my doctor is a fiction. Insurers play a big role. It amazes me that so many people let ideology trump their own actual experience.
          • Lack of facts
            Republicans are doing everything they can do to hassle patients, doctors, pharmacies now and blaming it on Affordable Health Care Act. Changes can be made; many of the things wrong were added by GOP to get passed. ER visits will drop dramatically, which having worked in one, I can tell you MANY pts used because they didn't have insurance to go to their own docs.. Taxpayers had to pick up those very expensive tabs. Now, the insurer will have to pay. Additionally, state docs are being prevented from practicing medicine as they were trained because of new scrutiny from pharmacists and insurance companies, under new laws. Blaming it on Affordable Health Care Act, which is not true. It is already law.. instead of complaining, work to change parts of it that aren't taxpayer friendly.Gov Pence screwed up big time by not accepting increased Medicaid, which the feds and not state would have paid for.this is ALL an attempt to cause more friction.. who loses? All of us.. those who would have been eligible for increased Medicaid, taxpayers, and receiving heavy criticism, even from his own party on a federal level. His incompetence has received natl attention. Just who is running this state? Clear many voters have been deceived on so many levels. Parts of it I would certainly like to see modified, but nothing says that cannot be done.. so many middle class will benefit from this. Minimum workers who couldn't get insurance from employers now have a chance to get it.AS one who has spent my life working in both mental and emergency health care, can tell you that so much info put out there is deceptive and tainted, and sabotaged buy embittered politicians. Give it a chance, then propose changes once it is clear who is behind many of the bad aspects. You don't pronounce the patient deceased because he/she has a few broken bones, that were added after the accident by those who wanted him dead.
          • Good luck
            Good luck on finding any psychiatrist who takes Obamacare---or hospital---or doctor. That is the problem those who have Obamacare are running into---lack of providers.

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