A new Hundred Years’ War? The Affordable Care Act

John J Frey

doi:10.3399/bjgp15X685117

The continuing outright hostility of American ‘conservatives’ regarding the Affordable Care Act (ACA aka Obamacare) must, for those of you in the NHS, call into question the overall sanity of the American people. The struggles to establish the NHS were not trivial, but it got sorted out, and the British got on with it. I remember GPs, during my year in the NHS 35 years ago, asking why it was that Americans could tolerate having so many people uninsured and, of course, I had no answer. I continue to have no answer now, despite the gap being closed dramatically by the ACA over the past 2 years. Last year, there were fewer uninsured people in the US than any time since 1965, when Medicare started to cover the elderly.¹

Every cliché imaginable is applied to the current US legislative process, if indeed it is a process at all: gridlock, paralysis, confrontation, polarisation. And Americans not only seem to tolerate it, but we have reached the point that any behaviour that speaks to the mutual good, like universal healthcare coverage, is suspect and trumped by individualism. One might use the word ‘selfish’, but I won’t. The latest flap about a recent measles epidemic among unvaccinated children has not, for a change, focused on the poor but rather on educated parents who, despite their education, seem grounded in a fundamental mistrust of anything ‘the government’ recommends. They seem as convinced by pseudoscience about immunisation problems as the climate change deniers are convinced that global warming is a glitch rather than a trend. The irony is that the state with the highest percentage of vaccination is Mississippi, perhaps the only time that that state has led the country in any health measure.²

THE TAKE OFF

The beginning of the ACA reminded me of a Boeing 747 taking off at high altitude in warm weather; the runway had to be very long to gain speed and lift. The ACA cleared the runway and for the past 2 years has had to continue to clear other threats that range from the looney right in Congress voting to repeal it — people lost count when the number of times got into the high 50s — to another recent Supreme Court challenge based on four words in a 906-page legislative Act. The court discussion in March will result in a decision in June. Political scientists remind us that Medicare (federal health care for people aged ≥65 years) has spent the past 50 years being revised (the 50th anniversary of its passage is July 2015) and, during that time, no one has sought to repeal it, only fix it.

On the other hand, the ACA seems to be the object of hatred to conservatives who are fixated on an all-or-nothing approach to legislation. One would hope that the 2016 election, 6 years after the ACA was passed and 4 years after its implementation, will be interesting for the lack of table banging in both parties about repealing the ACA and instead, of fixes that improve it. The rhetoric has toned down already in part due to the inevitability of the Act affecting local politics. The largest uptake of ACA enrollees are from among the poor or near poor from Republican districts. The states that suffer from the most health inequity are Republican states and have the most to gain from increasing insurance.

But the Tea Party and Libertarian wing of the Republican Party continue to pretend that their constituents are not getting any benefit, when of course they are. One of the more infuriating examples was a piece on the effects of the ACA on Medicaid enrolment in the past year for the poor citizens in the South. An obese woman who had diabetes and severe dental problems was interviewed about how she was doing after getting on Medicaid. Smiling with her new teeth, she said she was finally able to afford medicine for her diabetes and then, when asked about whether she thought Obamacare was a good thing, proceeded to thank God and say she didn’t trust Obamacare. It is hard to know what to say when presented with responses like that.

COALITION BUILDING

The saying about politics making strange bedfellows is truer with the ACA than most things. The 11 million people who have received health insurance through the ACA are 80% satisfied, both Republicans and Democrats, with their coverage, since most of them had no coverage or had poor coverage to begin with.³ But insurance companies, hospital associations, pharma, and even the American Medical Association, which helped to kill every national health insurance proposal in the 20th century, including Medicare which it labelled ’socialised medicine’, are all strongly supportive of the ACA. Increasingly, governors in Republican states who realise that Medicaid, which is partly financed on the state level, threatens to bankrupt their budgets are seeking waivers and exceptions that will give them cover as they sign up for the ACA. They don’t do it with headline-grabbing speeches but speaking quietly in closed-door negotiations with the federal government and doing the right thing by expanding care for the poor.

The expansion will continue because the economics of health care demands it. Rural and urban hospitals need to have more patients with insurance to guarantee their survival. Safety net clinics can not continue to exist by taking only uninsured patients. Insurance companies can’t compete if their premiums are not lowered by enrolling the low-risk patients as well as the sick. The national embarrassment of trailing Rwanda, Egypt, Macau, and Serbia in not having universal coverage seems less likely to move the US in that direction than the economic liability that threatens governments and healthcare providers. Young physicians who are beginning practice in the ACA era are tired of the bickering and, as all young people do eventually, want their older colleagues to quit whining and get over it: to admit that the ‘good old days’ never really were that good in the first place.

ACCEPTING REALITY

Comparing the biggest piece of social legislation in the US in 50 years to The Hundred Years’ War may seem a bit of a stretch. But that War had numerous treaties and defining battles and its share of heroes. Monarchs, nationalists, and local landowners happily reinflamed the war looking for conquest, only to be followed by another truce. In the end, France and England seemed to have other things to do, like suppressing feuding royalty and establishing nations. It may have ended because 100 years of fighting only illustrated how pointless fighting could be. The only remaining echo may be the Six Nations Rugby Championship every year. Maybe the symbolic end of the Affordable Care War will be a baseball game each summer between Republicans and Democrats.

It is not clear that the ACA battles will continue after President Obama has left office. He has been constantly assaulted by people who don’t like his tact, thoughtfulness, and unwillingness to be bullied. He is not smarmy or duplicitous, which is how we seem to like our politicians these days. Once he leaves office, the hatred may stop, but don’t count on it. The pundit wars, the internecine fighting in the Republican Party, the resistance to seeing government as the protector of the poor and disadvantaged all seem never-ending and enormously discouraging. As the GPs asked me 35 years ago, how can we tolerate it? But we do.

However, for the ACA, the flywheel has started to turn and is gaining momentum. The Fall 2014 enrolment period exceeded government expectations by enrolling 11 million new insured. I spent time at lunch on a cross-country train a few months ago with a 27-year-old college graduate who was working to set up a business in different cities in America. When I asked him about insurance coverage, he said he had just got his through the federal exchanges and was thrilled at the cost and coverage. He was free to try his ideas out without the fear of a broken leg bankrupting him. Freedom to try things has been a characteristic of America that we would like to believe still exists. For him, because of the ACA, it does.