The Affordable Care Act: Visible vs. Intended

Current coverage about the Affordable Care Act misses the forest in favor of the trees.

The Federally run health insurance exchange for residents of those states that wouldn’t build their own insurance exchange is a curious creature. (I refer to it as a single exchange, but my understanding is that there are about 30 exchanges all hosted on the same web site, each for residents of a single state.) It’s very visible, so it was big news when its launch went horribly last fall, but it shouldn’t have to exist.

The primary purpose of the Affordable Care Act is to make sure all Americans are covered by health insurance. It’s expected that most Americans will be insured under insurance earned by the principle breadwinners in a household. There are parts of the law that penalize employers above a certain size who fail to insure their employees adequately. Smaller employers are also encouraged to provide health insurance, but because “being a small business owner is hard and prone to failure!” they get an exemption until they’re successful enough to have enough employees. After employers, retirement plans, Medicaid,and Medicare are presumed to cover most remaining Americans.

There are incentives for states to increase eligibility for Medicaid, and as most of us have heard, many Republican governors have demonstrated their disdain for government spending and the Federal government by refusing to accept those incentives, as if they know those incentives will sharply and quickly disappear, leaving states to absorb an increased cost. Yes, the incentives to states are scheduled to end after a relatively short time, I think five years. Then again, remember when George W. Bush’s tax cuts were extended as their ten-year life ended, even though we had fought two unexpected wars during that decade? It’s not unheard of for popular Federal programs to be extended.

By design, the uninsured would be those:

  • with too much income to qualify for their state’s Medicaid program
  • not covered by a spouse’s or partner’s plan
  • who work for employers too small to be forced to provide coverage and too something to do so because it’s the right thing to do
  • who might be self-employed and not affiliated with any guild or trade association that offers a plan to their members

I’d love to see the demographic numbers about usage of the Federal exchange — or the state exchanges, for that matter. How many users are self-employed? How many are employed by small businesses? How many might have been covered by Medicaid if their state had expanded eligibility as suggested by the Affordable Care Act? Finally, how many states will eventually stand up their own health exchanges, perhaps even using the same software as one of the current successful exchanges (sorry, Oregon!)?

We shouldn’t need the Federal health insurance exchange. Instead of whining about what it represents, why not focus on how many other options have to fail before it’s used?

How many employees are covered by employer health insurance that wasn’t offered for the first time until after the ACA passed? How many are covered because the ACA force insurers to be more tolerant of some pre-existing conditions or other factors formerly used to increase insurance rates?

That should be the focus of ACA coverage, not the performance of the device of last, last resort.

Says me, anyway. I freely admit that my ideas aren’t popular enough to get me elected as dog catcher, let alone a government policy maker or law maker.


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