Whenever they read the latest headline pronouncing the dire consequences of "Obamacare," friends and family ask me what I think. As someone who works to implement the Affordable Care Act (ACA), I'm tired of debating it: The public debate has become tangential to the reality of the law.
What do I tell them? I resort to well-trodden but important points: America is the only industrialized country that does not guarantee health care for all its citizens; while the United States spends more on health care than any other developed country, its outcomes are among the worst. People who are uninsured often defer care until they end up in emergency rooms for complications that often could have been prevented had they been accessing primary care. Not only do these enormous care costs bankrupt patients, Americans as a whole still pay for them.
"Health care law projected to cut the labor force" a misleading New York Times headline proclaimed recently. The article itself explains that a Congressional Budget Office report projects that the reduction is among people voluntarily working less since they are no longer chained to their jobs to get health insurance.
"But people have to drop their insurance plans, even if they like them!" people exclaim. Was President Obama ill-advised in repeatedly assuring people that they could keep their existing plans if they wanted? Yes. Is the law flawed for requiring people to change their insurance? No. As one study notes, more than 75 percent of medical bill-related bankruptcies were among people who had insurance. Requiring people to gain better insurance coverage is an achievement – not a failure – of the ACA.
"But what about those who had what they considered to be decent coverage before, and now find their premiums have doubled or tripled?" Their coverage was likely not as decent as they thought – with annual or lifetime limits on coverage that are now prohibited by law. Under the ACA, plans must also cover benefits such as mental-health and preventive care.
The ACA also forbids insurers from charging higher premiums for preexisting conditions or based on gender, and sets limits on their ability to vary premiums based on age (all common in pre-ACA days). While this is fortunate for many, some do pay higher premiums now as a result. Health care is still expensive. The enrollers I work with are highly sensitive to the fact that the costs are a huge burden – but the only way to lower these costs is to get more people insured. And even the most expensive insurance is still cheaper than a hospital stay.
Political compromise created a more problematic law than most hoped for, but that was the only way it could get through Congress. The opponents who made these compromises necessary are now those who vehemently decry the problems that have resulted. Mr. Obama's further delay of part of the mandate that small businesses provide employee health insurance – along with other concessions – seems to have arisen from this fierce climate. There's also the irony of the opposition to the individual mandate: a needed part of a market solution, historically supported by key conservatives.
Insurance companies win as a result of the ACA: They get federal subsidies when people buy coverage. Rather than having a "public option" (part of the initial legislation), private insurers set premium rates. Though there are some new state and federal regulations on this, Americans have to rely on regional market competition to keep rates low. Whether enough young, healthy Americans sign up for insurance to keep the rates low also remains to be seen.
Coverage gaps remain, especially among low-income people in states that chose not to expand Medicaid. Undocumented immigrants still aren't covered and will continue to seek care at emergency rooms at big public cost.
But instead of focusing on these issues, the media has focused so heavily on the initial kinks of the rollout that any constructive conversation has been effectively eclipsed. These initial kinks are not as apocalyptic as they have been made out to be. While the Obama administration should be embarrassed about the botched rollout of the exchange, the exchange itself and its initial bugs do not have much to do with how the law itself will function. The purpose of the exchanges is to get people enrolled in health insurance under the law, and they are doing just that. The huge stress placed on the exchanges shows how great pent-up demand is.
New York has completed enrollments for more than 450,000 people. I have traveled around the state to train staff who enroll people in the insurance exchanges, and they see steady streams of potential enrollees. Most people coming to them for help don't understand their options and are scared and confused by what they've heard. Why wouldn't they be?
Getting the facts straight
The policy is confusing and constantly in flux, and the way it has been communicated does not clarify several key facts: (a) people need to buy insurance or they will be subject to a tax penalty, unless they apply for and are granted an exemption; (b) insurance is expensive, but on the whole it costs less now than it ever did before on the individual market; and (c) many people are now eligible for government assistance in helping to pay for this insurance.
People should have the facts that allow them to contribute to a constructive debate that could ultimately make the law better, but entrenched myths and misinformation have made it nearly impossible to have fact-based conversations.
Among staff on the front lines of implementing the ACA, there is a spectrum of political opinion on the law. But among the hundreds of people that I have encountered through my work, there is a very consistent commitment to helping people and a vested interest in relaying the facts. Some are daunted by the complexity of the system, but many are excited to be implementing this program and educating people on the possibilities newly available to their communities.
As one enroller put it, "I have no vested interest in what plan you choose or even whether you choose to take insurance; my vested interest is in you having the information you need to make an informed decision." If only everybody had the same intention.
Casey Selwyn is a project manager and trainer for CAI Global, an international nonprofit organization dedicated to improving health care and social services for vulnerable populations. The views represented here are her own.