Philadelphia Reflections

The musings of a physician who has served the community for over six decades

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Fill in the Gaps?

Soon after the Affordable Care Act was jammed past the House of Representatives, it began to appear President Obama had not carefully read the Act himself. Otherwise, he might not have claimed it covered every uninsured person, or that it mandated every uninsured person to be required to carry health insurance. It plainly did not do either one. In fact, about thirty million people were left without health insurance. Prisoners in custody, for example, needed some version of government-run healthcare but were obviously unsuited for the sort of health insurance covering the average citizen. Unfortunately, there were a lot of them. Disabled persons were eligible for Medicare, but many of them had not applied for it. Indeed, mentally retarded persons were sufficiently different from mentally disturbed ones, or mentally retarded from other neurologic disabled ones, to require a one-size-fits-all national health program to be modified. And anyway, John F. Kennedy with a retarded sister had started a program for retardation which would need to be integrated with other mental programs because it was probably superior to many, whereas the homeless were treated considerably worse to pay for it, when steam grates of cities replaced half a million state hospital beds for mental incapacity. There were said to be eleven million illegal immigrants turned away from overloaded hospital accident rooms. What about drug addicts? What about the awkwardness of the Constitution's Tenth Amendment? These issues had established the tradition this was a problem for state governments to handle, and definitely not the federal branch. Something was needed, but this wasn't it.

As an aside, the Affordable Care Act expanded its eligibility to State Medicaid recipients, who were automatically eligible, but only after they had established their poverty status. So including them in ACA did not really insure the uninsured, it merely included them before they got sick, instead of having the hospital social worker enroll them after they got sick. Therefore, to claim ACA insured twenty million previously uninsured was an exaggeration of language, as was quickly emphasized when half of the states refused to surrender their Medicaid programs to the new federal one. But half of them did yield, and without this dubious enrollment claim, the thirty million persistently uninsured would have even more appreciably dwarfed the twenty million allegedly included. It must be admitted Medicaid was usually a badly underfunded and substandard program, so the program was improved. But this was not exactly the enrollment boast being made. And as for keeping your own doctor, well, just take a look.

So, what is the matter with forgetting about ACA repeal and concentrating reform efforts on the people everyone would concede were falling through the cracks? This would have been an excellent case to make when ACA was fumbling through Congress several years ago. And it still makes a good argument that Obamacare was politically motivated, not an issue the public needed and was demanding. The public perceived something was the matter with healthcare, and they wanted it fixed. But they left it to politicians to determine what was needed, how to work around the Constitution, and how to pay for it. It failed on all three counts.

My view of what really happened has a lot to do with the untimely death of Senator Edward Kennedy and the events leading up to it. A then-graduate student named Jacob S. Hacker had, ten years earlier, been assigned the task of interviewing the survivors of the Clinton health plan, to find out what really happened to cause it to be withdrawn without a vote. He wrote a book, entitled The Road to Nowhere which stated it had been a deliberate plan to introduce different versions of the proposal in the House, and in the Senate. That made it possible to satisfy everybody. It also made it possible for President Bill Clinton to withdraw awkward sections from each bill in the House-Senate conference committee. What the plan had really been all along would stand revealed, too late to change it.

It would be my suspicion the Obama strategy was the same, but Kennedy's death and the Republican replacement -- after the Senate vote but before the House vote -- forced the Democrats to adopt the Senate version, word for word, as the final bill -- so, no conference committee. That may have been the clever political strategy, but it meant the final Obamacare product was something no one wanted, could not live with, and ended in multiple disasters. Whether it is true the Obama administration positively wanted to fail, I am not sure, and do not wish to speculate. But if they are as contrite as they ought to be, bipartisan cooperation in fixing the problem becomes a possibility and is the spirit behind this set of books. More than any other motive, the opportunity presented is unusual and is the occasion for putting the replacement of the Affordable Care Act at the top of my own priorities for health reform. It can be accomplished, and I am not sure the more pedestrian proposals could be.

Originally published: Saturday, December 17, 2016; most-recently modified: Friday, May 17, 2019