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Commentary: ACA is much more than individual mandate

This article first appeared in the St. Louis Beacon, April 16, 2012 - As we await the Supreme Court’s decision on the constitutionality of the Affordable Care Act (aka Obamacare), it may be useful to review some of its more positive features.

Conservatives have called it an attack on freedom, and its detractors often say the system that we have is fine, calling the changes socialism.

All other Western democracies have universal health care, though the institutional arrangements differ. These health systems insure each and every person. The American model, however, at least for adults of working age, is based on insurance by employer.

Changing jobs can significantly affect coverage. When one’s employer does not have health benefits, a person has to purchase on his or her own without the benefit of a group rate. Many either cannot afford to do so or have to pay a significant percentage of their income to receive coverage. And a pre-existing condition can be sufficient for an insurance company to deny people coverage.

As for other U.S. options: Medicaid covers the very poor but does not cover single people who are not elderly or disabled. And while Medicare is for those 65 and over, many seniors purchase optional supplement plans and Medicare Part D drug coverage. Thirty million Americans are uninsured.

We have some of the world’s finest hospitals and doctors, but income strongly affects quality of care. For instance, if you look at infant mortality, one of the standard measurements of national health, the U.S. does not fare well.

Private insurance companies, which offer or administer America’s health care,  are profit-making entities that reward executives with heady compensation. The insurance companies (often in accord with the employers’ plans) can deny coverage for various procedures or impose significant co-pays.

Some rail against the idea of government bureaucrats enforcing government health care. But, today, bureaucrats at insurance companies call many of the shots. Interestingly, under the Affordable Care Act private for-profit insurance companies would remain in charge of our health care.

The focus of much of the opposition to the Affordable Care Act is the mandate requiring everyone to have insurance. Those without insurance can now receive care at hospitals on an emergency basis, and that has a cost for others. Plus the uninsured have no preventable health care. How does this system figure into American concepts of freedom or equity?

Other features of the ACA are supported in public opinion polls. These include:

Already in effect

  • Young adults allowed to stay on parents’ coverage until age 26.
  •  Health care plans must cover preventive care without co-pays, e.g., mammography, pap smears

To take effect in 2014

  • Lifetime and annual policy coverage caps are eliminated.
  • Insurance is extended to the uninsured by expanding Medicaid and providing state exchanges to control costs for others.
  • Companies of more than 50 workers are required to provide health insurance benefits.
  • Tax credits are provided to small businesses to help obtain insurance for employees.
  • Discrimination based on pre-existing conditions is eliminated.
  • The Medicare Part D prescription drug doughnut hole is gradually closed. (The act already provides a 50 percent discount for brand name drugs for those who have already hit the doughnut hole.)
  • Women will no longer have to pay more for the same insurance policy a man has.
  • Nursing mothers will have a right to reasonable break time and a place to express milk.

Under the ACA, private insurance companies and drug companies do not lose their favored place. There is greater regulation, to be sure, as well as greater coverage. 
The bill passed in 2009-10 after a partisan fight. Only a few Republicans supported it. Republican presidential candidates have spoken against it at every turn; and Democrats by and large have not gone out of their way to defend it. Ironically, key elements of the Affordable Care Act such as state-based exchanges were proposed by the conservative Heritage Foundation in 1995, and some prominent Republicans supported a mandate then.

Those voices are now largely silent.

During the fight against “Obamacare” and now, Republicans have generally proposed no alternative. How would they handle pre-existing conditions, the doughnut hole in elderly prescription drug coverage or health care for children under 26?

The Massachusetts health plan, enacted while Mitt Romney was governor, contains a mandate and was a model for the Affordable Care Act. Romney says it was a one-state solution and each state should find the plan it deems suitable. In these stringent times, state plans are unlikely; and, even if some did enact plans, health care would be a case of "where you sit is what you get."

Republican Rep. Paul Ryan’s budget calls for a major restructuring of Medicare as we know it and could temper the current safety net. If the Supreme Court decides against the Affordable Care Act, perhaps Republicans will develop their own proposals beyond changes to Medicare. Time will tell.

Lana Stein is a professor emerita of political science at the University of Missouri at St. Louis.