Excerpt reprinted from Undercovered Magazine.

The Affordable Care Act (ACA / Obamacare) has been a polarizing issue since its inception and will continue to be so into the 2020 election. The ACA provides benefits for millions of American families, but the biggest winners, by far, are the private insurance carriers. Whether a candidate or their respective party argues in favor of ‘fixing ACA” or disbanding it altogether, know that they are both fighting to protect one group above all others – the insurance industry.

Healthcare in a Post-ACA World

The single greatest source for unbiased reporting and consumer-driven tools has been Kaiser Health, one of the few remaining non-profit health providers in the country. Kaiser launched several calculators to help consumers understand both their tax subsidy options as well as the effect of purchasing insurance contracts at every level.

Today, they are focused on forwarding concerns of voters who express some of  the same concerns before the ACA went into effect in 2013.

Chart courtesy of Kaiser Health, “Health Reform” https://www.kff.org/health-reform/

Kaiser continues to be a watchdog for consumers, clearly outlining what the insurance industry and our own Health and Human Services agency has not, that our national healthcare crisis has only gotten worse since 2013 when the Affordable Care Act was implemented as a national program.

Pulling Back the Curtain

In June of 2012, I had been hired by a major insurance company that wrote policies for consumers across five states. I was there because the case argued before the Supreme Court, National Federation of Independent Business v. Sebelius, was due for a decision and, if the mandate provision survived, it was my job to help them make up for 36 months of inaction and help them earn readiness certification for the inaugural Open Enrollment in October 2013.  

Live coverage of the SCOTUS decision was broadcast on plasma screens in a lush conference room with state-of-the-art technology where senior executives had gathered to watch the announcement. Clearly they hoped to celebrate the death of what they viewed as a restrictive regulation. The room seemed decades removed from the claims processing floor far below where employees labored on refurbished computers still using unsupported Windows 95 software and critical processes centered around antiquated fax machine technology.

I sat in the back of the room looking at each person fidgeting nervously in oversized leather chairs, their brows furrowed, tight lipped, with the occasional polite nods to each other. They were focused on the screen, knowing that very little had been done to prepare for implementation outside of campaign contributions and lobbying activity after the law since passed two years before. In reality, virtually no preparations had been made at all, so sure were they that the Supreme Court, stacked with Conservative justices, would rule in their favor.

When the verdict was read live, the room erupted into angry outbursts and curses. Even in this sheltered executive area, screams and muffled shouts carried through from junior executives offices and a palpable shutter of fear and uncertainty rippled through the company as all worked stopped.

“The party is finally over,” I thought.

In reality, the Supreme Court decision added a new processing component for these insurance companies that required an overhaul of their databases to provide a seamless hand-off to the IRS. They now needed to add line items for government imposed fines for noncompliance by consumers and new payment fields to accept the advance tax credits from the IRS to pay for monthly policy premiums.

Patient care codes for clinicians and hospitals were also being expanded to ten digit codes geared to properly designate the difference between an injury from a dog bite from a turtle bite. All of this simply meant greater expense for companies like this one wholly reticent to change.

The only employees that faced almost certain job losses where those thousands of minimum wage processors who had been tasked with denying consumers coverage or adding coverage exclusions in the old enrollment process. These conditions were listed over five full three-pages of health conditions deemed as unacceptable financial risks; everything from common seasonal allergies to thyroid conditions and heart disease; both the serious and the seemingly benign. All of these would now have to be covered by insurance contracts and that meant few of the denial processors would be needed in the future.

The real challenge to insurance carriers was having to make up for a decade of inattention to infrastructure, limping by on old technology and, at the same time, actually having to learn about who their consumers really were and do it all in less than a ten months.

The Myth And Miracle of the ACA

For the majority of Americans, the ACA, provides the critical protection for access to healthcare for those who can not otherwise qualify for Medicaid, afford private insurance, or get discounted coverage for chronic conditions. Lifting the restriction for ‘pre-existing health conditions’ coverage by insurers saved millions of Americans from added personal expenses of having to cover medical bills without the help of employer sponsored or private plans. Additionally, expanded access to Medicaid insurance policies for low income working families finally provided some protection for adults as well as children, but only in those states that opted to expand eligibility for working families who earned less than 150% of the Federal poverty level.

The real intention of the law was to rein in costs for the government and bolster the insurance industry with a massive influx of tax subsidies paid for by working Americans.

Understanding the difference between health insurance and access to healthcare has never been a priority for ACA advocates or detractors. They treat the two as inseparable and, therefore, necessary in any conversation about rising costs and the overall strategy to address a crisis issue for families. One side argues the ACA only needs to be refined and strengthened while the other rails against government mandated funding from state and federal taxes.

Both arguments are disingenuous to the real issue many Americans continue to face in a post-ACA era where costs still place a heavy barrier on true access to the health system consumers pay for:

  • Workers with employer-sponsored insurance still cannot afford to use their insurance with high deductibles and added network costs when they need it while employers spend massive amounts of their funds on these group contracts.
  • Small employers who do use the Healthcare.gov SHOP option to provide insurance must do so through an advance of up to 50% of the annual premium cost.
  • Those in the direct ACA Marketplace are actually using their own tax refunds to bring the cost of monthly premiums down instead of collecting their tax over payments as annual refunds.
  • Consumers who opt for the cheaper catastrophic coverage are not fully protected financially and buy policies that offer limited benefits for just a few diagnosed issues.
  • Those with Medicaid and Medicare plans are finding it harder to get access to hospitals that will accept their insurance while physicians themselves find it harder to stay independent and provide patient-centered care.
  • The true cost savings reported through ACA by Health and Human Services come from reducing the payments to doctors and clinics who accept Medicare and Medicaid patients. http://www.healthaffairs.org/do/10.1377/hblog20150625.048781/full/

Let’s be clear on one major point- there is plenty of blame to go around on why the Affordable Care Act isn’t working for families. The law plan started with the same for-profit model that Democrats built upon from the idea borne of The Heritage Foundation, a right-wing think tank, in 1995. From there, Republicans in Congress proposed 98 different amendments that made it even worse. Pharmaceutical companies refused to even hold a conversation about reform, opting to walk away if regulation even came close to price negotiations.

The result of all of this back and forth is the national healthcare package we have today.