Trying to understand some of America’s reaction to the Affordable Healthcare Act

Alright. Time for a brief departure from gardening, and pregnancy, and occasionally work. This is more a post to answer many questions I have had from people across the pond about the now approved Affordable HealthCare Act. Why America needed reform, why some Americans hate it and so on. It is my perspective on that for my fellow countrymen, and also an attempt for me to try to make sense of what seems like the utter craziness around me.

The current system

So to understand the reform, you need to understand the current situation of American healthcare. It is certainly very different to what I, as a naive Brit, has imagined. I had envisioned a healthcare system where if you had a ‘reasonable’ job (and I did  not define reasonable) you could go out and get private insurance for healthcare fairly acceptably within your budget. People who could afford it could choose their insurance, and then those who were insured, once they had paid their premium, got access to top notch and almost unlimited healthcare (I was actually kind of excited to get this ‘better’ healthcare than I had been receiving) . Those who were not insured, had some lower standard healthcare sort if similar to the (usually unfounded) horror stories we hear of the NHS: long wait lines, long distances to travel, limited drug availability – possibly all only available through ER.  I was sort of vague on that. Having lived in the US, it is clear to me that the main things I had misunderstood were this:

-Few people can afford private health insurance out of pocket. Prices for health services in America are ungodly high compared to say, Canada and the UK (have fun googling the cost of a C-section in the respective countries). Therefore, to cover basic services, employers provide health insurance. Employers can get cheaper insurance premiums per person, by agreeing to have all their employers on one scheme – it is in part how companies can provide insurance when individuals often cannot. Economies of scale.

-Therefore, employees often do not get a choice of providers: in both my jobs here, I have been stuck with one option and one company.

-The healthcare provided by the companies, in both my cases has not covered what I would choose in my choice of insurance company. UAB did not cover contraception outside of birth control, nor Wes’ testosterone. UT has very steep co-pays (birth is $1,000-3,500). I understand that I am lucky though, because at 3,500 I reach my yearly max and the baby is covered under that max as long as we are both in the hospital. Some companies charge separate maxes for the mother and baby, meaning the cost of 60% of US births would exceed $7,000. I am generally unhappy with the level of care offered. Some companies do not cover pre-existing conditions (kid with cystic fibrosis? Nope. Previous cancer history? You’re on your own if it strikes again). Some companies have a maximum they will pay out for a given individual. If your cancer treatment exceeds this (as was the case with a lady I met from CA): tough. But you have no decision over whether to choose a company with these exclusions / conditions or not.

-Then, for many, there is no company they work for, and so no insurance. And their only recourse for treatment is (1) pay the inflated US prices, or go to ER. So cancer treatment is out (too expensive / not available in ER). Ditto much preventative care. Care for your child who needs to go to NICU.

-So, I was shocked by the number of categories individuals in the US without healthcare. Examples:

1)The oft cited (by outsiders) / classic case of ‘tramps and immigrants’. But also in some cases:

2)Pregnant women who for whatever reason have to change jobs (it is a pre-exisiting condition)

3)Cancer patients who have ‘run out’ of coverage

4)Children with serious health issues whose parents change jobs (coz, you know, America is in a recession ‘n’ all)

5)Adults with previous health issues that change jobs

6)The self employed, including a man I spoke to today, who chose to be self employed so he could earn money while caring for his mother who had had a stroke and had cancer. So, let’s just say: carers.

and so on. Google it and make your own judgement on the accuracy of figures, but look how many actually qualify for health insurance (some say 10%), how many actually qualify for Medicaid (do not listen if people say it is open to all children and pregnant women – I was turned down!), and how many die each year from lack of insurance: I would go with ~45,000 but again, I let you make your own sense of the figures.

Bottom line: many people are dying within the current system. Both ‘undesirables’ (illegal immigrants / people not wanting to work), and ‘desirables’: me the pregnant university professor, Will the carer, Jane the child born with a hole in the heart whose father lost his job and got another quickly.

The solution

So, a solution has been proposed. I would like to say by Obama, but actually, I think Kennedy first (?) … On the basis that at least categories 2-6 are not reasonable, reforms have been proposed. Including: no pre-existing condition exclusions, and an extension of government covered health insurance. If a company cannot offer you a premium that is a reasonable percentage of your salary (it changes, depending on your situation) the government will pick up the difference. However, there is a problem: some clauses, particularly the first two, if left ‘as is’ will drive up premium prices – which is just generally and all around considered very undesirable. So, there are two twin solutions:

(1) The individual mandate. By forcing everyone to HAVE to buy health insurance (either through their company, or their pocket), if they can afford it, more healthy people proportionally to those needing services will now buy coverage, so there will be more money ‘in the pot’ and premiums shouldn’t experience a massive hike. If you don’t buy it, you pay a penalty. This penalty contributes to the health care system, either by keeping the premiums low, or by covering the ER-emergency care you may recourse to, which as you cannot afford to pay for, goes unpaid for, and so the cost is spread to other people / services, and the insurance companies pay for these (in the main) so it contributes to rising premiums. So: the individual mandate makes sure that premiums are increased as little as possible.

(2) In dealing with the issue that many people are letting healthcare conditions get out of control and into an emergency state: and thus become much more expensive to treat than they are to prevent, and thus as above, are driving up premiums: preventative care has become free. And Medicare has been extended.

So: the solution to many Americans with a lack of coverage is enforced insurance. So that everyone contributes and those lucky enough to remain fairly healthy lose their $$, those unlucky enough to be touched by devastating illness effectively gain $$. Of course, in allowing pregnant women / babies with birth defects / carers / self employed to access these benefits, which requires extending Medicare, you can’t really ‘weed out’ those who chose to take free insurance because they cannot be bothered to have a job. Or women who want to have consequence-free pre marital sex (many Americans get very upset over this. They don’t want to pay for ‘people’ to have sex so regularly get upset at free contraception. But there is no outcry for Viagra / Cialis being covered, so one must assume it is only women they don’t want to have sex without consequences). Or a host of other people you just don’t fancy paying for (personally, I might pick those who engage in dangerous sports, and chose to follow a lifestyle that leads  to obesity… but they generally seem OK in the eyes of the public).

The reaction

Some Americans have gone ballistic. Fair enough: it is not everyone’s ideology that the best health care is a right. My husband’s attitude is this: if you can’t afford healthcare, you don’t get it. When I say ‘what about an adult with cancer? Would you have a preventable death occur because coverage has run out?’. He says ‘Yes. People die Lekki. It is a fact of life. I am not interested in paying to fight that for others’. Well… OK then. I guess that it at least logical. I don’t agree, but I get it. If you want to all the categories of individuals above dying, so that you don’t have to pay for the healthcare of those you don’t want to then yes, oppose the new act. Kinda shocking, but logical.

There are others who think that these deaths, or uncontrolled health conditions, are acceptable if the only alternative is no government interference in the private enterprise of healthcare. Left unfettered, private insurance went the route of the above: the government decided to step in a put a stop on it, to save lives. They either believe that this solution is unconstitutional, or accept SCOTUS’ decision that it is not but believe it is so undesirable, that they would rather people died than see it enacted. OK – again, sad but logical. Stand up and say ‘I believe cancer suffers should die to prevent the travesty that is government interference’. I will accept you as logical but politely disagree that that is a good ideology.

There are some who believe that if saving all categories of individuals above means helping ‘lazy’ people, or people without a job, then that is an unacceptable trade-off. People and children should die so that others do not get health care when they do not have a job. Again, a little shocking to me. But stand up and say ‘in order that people who do not work, and are not married to a worker, do not get coverage paid for by others, I believe the categories above should die’. Cold, but logical.

There are two categories of reactions who deeply confuse me:

-People who get picky about what ‘type’ of person they do and do not want covered. Lindsay said to me (when I couldn’t get contraception): I don’t want to pay for you to have sex. Gina said when I commented that my pregnancy was (albeit briefly) not covered: you chose to have a baby, I don’t want to pay for that decision. OKey doke. But given that in any insurance / universal system we all pay for the bad decisions of others, if you don’t want this, and only want to pay for truly bad luck, why do you want to pay for the consequences of:

-Obesity among those who chose to consume more than the recommended daily caloric intake, and conduct less than the recommended daily activity guidelines

-People who chose to get a suntan

-People who chose to ride a motorcycle, or engage in high risk sports

-People who do not get the recommended hours of sleep per night.

-People who chose to have a high stress job.

To really name but a few. I am baffled by people thinking we don’t ALL (well, nearly all, there are a few health nuts who may not fall into any such category) chose to make decisions every day that are detrimental to our health, and others pay for this.

2) People who get VERY upset when you tell them that they are choosing to let *insert emotive picture* let’s go with: a university professor needing treatment for a brain tumor, whose insurance has ‘run out’, die. VERY upset. ‘How can you say this?? I absolutely do not want any of the categories above (well, often just categories 2-6) to die. Why are you being so rude?? Why are you being so hurtful? Oh I am so upset you think I would let a child die!!’. But it seems to me: they do. For the sake of their constitution, their desire not to pay for certain sections of society, their desire to keep government intervention out or some such they are saying ‘hey, I don’t want to subscribe to a system that provides in these circumstances, and I will let people die as a result. The casualties are worth the greater ideology’.

Then, I *get* it. That is logical thinking. But, as my friend Lizzie explained it to me, I fear some people are doing only emotional thinking. Otherwise they would stand up and say ‘I want to pay for some health choices, but not others and I think I am accurately qualified to decide which ones’ or, ‘I think people must die to preserve my ideology’. Right?


6 thoughts on “Trying to understand some of America’s reaction to the Affordable Healthcare Act

  1. Stacey Cherny

    I can’t help but offer some clarifications:

    The biggest reason employers can offer cheaper plans is because the expense is tax deductible to employers (and a tax-free benefit to employees), but if you purchase health insurance on your own, it is with after-tax dollars. And because it is a tax-free benefit, there is also not much of a market for private health insurance. Eliminate being able to offer it as a tax-free benefit and a robust private market will appear. That would fix several problems you list above, and all by repealing a part of the tax code.

    And part of the reason why costs are so high is because everything is paid with insurance, including silly things like regular checkups. If insurance was just for catastrophic events, costs would come way down. Aside from the hugely expensive bureaucracy of insurance companies being the payer, patients not being even aware of the costs, let alone paying them, allows the costs to get out of control.

    I think the number of deaths due to no health insurance is greatly exaggerated. But even if it isn’t, the reality is that America isn’t rich enough to provide every single resident with the best medical care. Instead of people dying because they can’t afford better care, people will end up dying because the government chooses a particular treatment isn’t cost effective. (You also can’t legislate that people seek care.) Of course, there will always be some people who can afford better treatment and will get it, it will just end up more expense and so fewer people might be in that category.

    As for paying for things we don’t want to pay for, there is a big difference between paying for someone’s contraception or abortion and paying for their bypass surgery because they ate too much. But when you put the government in charge of what is covered, decisions you don’t agree with will always result. If you have private insurance, they will compete on what they do and don’t cover.

    I think there are many good things in Obamacare, but like everything the government does, they’ve managed to create a package that will surely cause more damage than good. At least they didn’t make private medicine illegal, like in Canada.


  2. Steve

    I promised I would no longer comment but this is the absolute last time. The issue is really simple at its core:
    1. solutions are sometimes worse than the problem
    2. The reason some of us are not happy is because we do not like more government in our lives we want less. Government creates more problems (in my opinion) than they solve-plenty of examples of this
    3. individual examples of someone running out of money who has a brain tumor really do not address the issue as a whole (you would not allow testimonials in your research).
    4. We definitely need solutions to the problems of health care, the issue is whether a massive governmental takeover at an expense we cannot afford, is the answer


  3. Lekki Frazier-Wood

    You can comment! I am clearly going to present a one-sided view. Also: I still fail to understand the opposition to the AHA (despite being married to a deep, deep opposer): so I am interested in trying to understand the view.

    I think this is a European perspective (indoctrination?) vs an American one, Steve. My response would be: yes, there are solutions that are worse than the problem, but I am not convinced this is one of them. Individual testimonies are exactly what do count: in (Western) Europe the attitude, when it comes to Healthcare, is: “No [countryman] left behind”. It just takes one story of someone being unable to access the healthcare people think they are deserving of, in a sea of thousands, for reform to be considered.

    I am glad you agree that America’s healthcare needs a massive overhaul. I just do not see any other solution, other than a national healthcare system. I think stopping caps on healthcare payouts (i.e. “sorry you have only reached 1/2 way through your treatment, but we’re not paying any more) is fairly easy to solve without government intervention. So, for that, I can see opposition to the AHA.

    However, if you do not exclude pre-existing conditions (which is one of the main problems, I believe – did you know some women are denied coverage for an emergency caesarian if they have previously had one?), which would reduce restrictions on women that don’t apply to men, and allow people to move jobs freely, and so on… then you have to stop people only getting insurance when they are sick and not paying when they are healthy. So, other than an individual mandate, what option is there? Unless you say to people “If you ever allow yourself a gap in insurance coverage, you are no longer, ever eligible for cover.” But then, you would surely need some kind of expanded Medicare to cover people who temporarily lose their jobs etc. It sucks in some way: but I just don’t see there is any other way.

    Many people against the AHA admit the problems with healthcare in America (for the employed, willing-to-work Americans) must be solved. But I see no other solution.

    As an aside, what amazes me, is that the justification for the incredible cost of procedures in the US – which is part of the problem, no? Less expensive procedures = less caps on spending – , is, in part, the money Industry eventually receives for drug development etc (I know law suits is another huge problem). But I am amazed people accept this: that their money is just going to Industry with no personal say in the matter. Imagine if it was going elsewhere (arms manufacturers? A religious group?): many would be up in arms. I don’t ‘get’ that either.

    To some: the problems of suffering Americans is in and of itself, about the worst thing that can be allowed to happen. To others: government intervention is worse. Each to their own.


  4. Lekki Frazier-Wood

    But I believe that medicine has got so expensive, that some things are inherently not profitable to cover: so no one will cover them. Or you leave people playing probability with their health (I am more likely to get this… over that…), or worse, probability with other people’s health: (my child is more likely to need cover for this than that…) and people will get it wrong.

    I don’t agree there really is a big difference between paying for someone’s contraception or abortion and paying for their bypass surgery because they ate too much…. you are always paying for other people’s decisions. Can we exclude certain types of skin cancer, because people should wear sun screen? And car accidents if the person was speeding? And anything arising from a ‘dangerous’ sport? These are all health decisions we all pay for… I have zero problem paying for contraception. Zero. But, I do have conceptual issues paying for people who do not take care of their health. But, my ideology is that we all have ignorance, we all make mistakes, we all act in the heat of the moment… part of grace and forgiveness is helping people overcome the consequences of this.


  5. Stacey Cherny

    Part of the reason insurance is expensive is because it pays for things that should’t be insurance, like birth control. Things that pretty much everyone needs are not things for insurance coverage. Even C-sections for a second pregnancy when the first was a C-section is pretty much a certainty, so why would a new insurer pay for it?

    Anyway, to understand why ACA is bad legislation, you need to read some thoughtful criticisms of it. It really is true that every time the government gets involved, it makes things worse. I’ve come across so could articles that enumerated all the problems Obamacare introduced. I particularly like the job-killing part where companies with 49 or fewer employees don’t need to provide insurance and 50 or more do. Guess what that will do for economic growth. But there is lots of horrible stuff in there.


  6. Stacey Cherny

    A simple reason why paying for contraception increases rates greatly goes back to the problem that nobody cares what stuff costs if they only pay the copay or nothing, so prices go up. Birth control pills without insurance cost $10 or $20 a month, but I’ll bet anything that they add $50 per month to the cost of insurance for under 40 women! It is just stupid to cover stuff like that. Even routine doctors office visits shouldn’t be covered. In HK, with the most expensive real estate in the world and doctors doing quite well, it costs $20 to $30 for a GP consult. What’s better, paying for that instead of probably paying an extra $100 per month for insurance to cover it? The copays in the US are sometimes more than that. Insurance introduces overhead and also disconnects the consumer from the costs. Encouraging catastrophic-only insurance would get costs under control quickly and combined with health savings accounts (that ACA gutted) would be a quick improvement. But health insurance is a tax-free job perk, so it covers as much as possible. ACA just made it worse.


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