21 March 2013

Obama's Affordable Care Act: a Law with No Spirit

Self-portrait, 2013. Photograph by Franetta McMillian copyright 2013.
 
By Franetta McMillian
 
(Franetta McMillian describes herself as  “a full-time writer, sometime artist and part-time retail drone living between Newark, Deleware and Avondale, Pennsylvania.” Most recently her stories and poems have appeared in Broadside Review and Possum Garage Press. This report, significant for its personalization of the real-world impact of what has come to be known as Obamacare, shows she's also a talented journalist. It is her first formal contribution to Outside Agitator's Notebook.)

IT WAS MY employer's annual benefits enrollment period that put the Affordable Care Act of 2010 back on my mental radar again, not that it had ever really left.

Many large companies (though most are not as graceless about it as Wal-Mart, Applebee's and Papa John's) are looking for creative ways to "control costs" and "empower" their employees to "take charge" of their health. What this usually means is saddling employees with higher premiums and co-pays or slashing labor hours so these companies are no longer obligated to provide health coverage at all. They will do the bare minimum to follow the letter of the law — which in this case is all they can follow because the Affordable Care Act has no spirit.
 
Though the law was trumpeted as a way to expand coverage to many who do not have it, as it is currently written it will not even come close to accomplishing that lofty goal. Obama's intentions may have been noble, but the law serves too many and the wrong masters, resulting in "reform" so diluted, it's barely reform at all. Like I said: no spirit.
If you really want an idea of how big a nightmare the Affordable Care Act will be in the real world, read  Obmamacare: A Deception It's not exactly a quick read; it's technical and often tedious, but then again, the Affordable Care Act itself is some 2000 pages long. I doubt even members of Congress read the whole thing.

The Affordable Care Act requires every American who can afford it to buy health insurance. If you can't afford insurance, the government will provide you with a tax credit to help you do so. The poor and the near-poor (those whose income falls within 138% of the federal poverty level) will be part of the new expanded Medicaid. Sounds reasonable, doesn't it?
 
But take a closer look. The amount you are required to pay for insurance is determined by your modified adjusted gross income, which is a different beastie than the more familiar adjusted gross income you use to determine your federal and state tax obligations. For many the modified adjusted gross income is higher, which means you may not be as poor as you think.
 
My modified adjusted gross income fluctuates from 200% to 300% of FPL, which means the government says I can afford to spend 4% to 9.5% of that income on health insurance. That's approximately the amount of a car payment. Good thing I don't have a car payment now, but that's not saying I won't have one in the future. Oh well. If I do, I can live on beans and rice; I've done it before.
 
Okay, let's go buy insurance!
 
The new health care exchanges will offer four levels of coverage. The platinum and gold levels are way out of my league and our government will do little to help me with the cost of those even though they provide the most comprehensive coverage. So I'm stuck at the silver and bronze levels. Silver only offers 70/30 coverage with a $2050 deductible. Bronze is worse with 60/40 coverage and a deductible nearly twice as high. All plans cover up to $250 for preventative care — the annual physical with basic labs — and my pre-existing hypertension won't lock me out of purchasing a plan. However, since there is no cap on what the insurance companies can charge for a policy, there's no telling how costly that plan will be. Oh yeah, and I'm in my early 50's, the age when things slowly begin to unravel even for the healthiest of us. That's going to add some cost, too.
 
The government's help, the so-called advance tax credit, is based on the cost of a silver level plan in my state and my modified adjusted gross income. Since there is no way I can precisely know what my income for 2014 will be, that credit will be based on my income for this year (2013). If, by chance, 2014 brings me loads of freelance work and a couple of especially lucrative short story sales, thereby increasing my income significantly, I will have to pay back all or part of that credit when I file taxes in 2015. And on and on. It could get messy. Uncle Sam may giveth, but if he thinks he's giveth too much, he will certainly taketh away.
 
Let's say 2014 brings me worse fortune than the current year, enough to get me bounced into Medicaid. Well, that's not exactly unconditional love either. I may get some semblance of care, but should I die of whatever ails me, the state will be allowed to recover the costs of my medical treatment from my heirs, who aren't exactly rolling in dough either.
 
I don't want to sound like a total hater here. The law does bring some significant improvements. Everyone with insurance is covered for a yearly physical. Insurance companies must spend at least 80% of premiums on actual healthcare. Children can stay on their parents' plan until age 26. People with preexisting conditions can no longer be turned down and there is no longer a lifetime cap on benefits.
 
However, there are no established legal limits on how much those now mandatory insurance plans can cost and no price controls on the actual cost of treatment itself. (For an especially frightening — and utterly exasperating — examination of healthcare pricing check out Steven Brill's piece, Why Medical Bills are Killing Us.) There isn't even a guarantee a doctor or hospital will accept your insurance for non-emergency care once you've mortgaged your arms and legs to buy it. This especially holds true for bronze level plans and Medicaid.
 
Even if your bronze level plan is accepted, the bills can pile up very quickly. A few years ago I was unlucky enough to have an illness that required several surgeries. Fortunately, I had decent insurance for most of the course of my treatment, but even then, I racked up thousands of dollars in incidental costs due to deductibles and co-pays, not to mention several thick manila folders of paperwork. (Which, incidentally, I still keep just in case I get a surprise bill. No kidding. I once got a bill for injections nearly two years after the fact.) If I'd had a bronze level health plan, those nickel and dime charges could have easily ballooned to the high tens of thousands, and I would still be paying those bills today and for several years to come.
 
As it stands, the Affordable Care Act barely lives up to its name. It is an expensive and needlessly clumsy piece of legislation that will give private insurers lots of bang with your bucks. Hopefully it won't be so expensive and clumsy that it will sour Americans on the ideal of universal healthcare or erode our dwindling faith in government past the point of no return.
 
Thing is: it didn't have to be this way. Obama could have just said, "Medicare for everyone!", and I bet the majority of Americans would have understood. Yes, that would have been expensive too, but at least we wouldn't have been throwing our money in the street because Medicare works. And if it's one thing I've learned during my short time on this earth, it's that it's always cheaper in the long run to do the right thing. And safeguarding the health of your citizens is the right thing to do. I believe it dovetails nicely with the "general welfare" clause of the Constitution.
 
I suppose you could argue that with the Affordable Care Act Obama managed to legislate the idea of expanded coverage and greater access to care where others had failed. Though the legislation is flawed, this line of thinking goes, we can always go back and patch the holes later. But I fear an idea so poorly executed from the start may prove worse than no idea at all.
 
(Original reporting by Franetta McMillian copyright 2013, reproduction rights conditional upon crediting author and linking to Outside Agitator's Notebook.)

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