Those exultant cheers you heard last week were business organizations, like the U.S. Chamber of Commerce, celebrating the Obama administration’s decision to delay the “employer mandate” provisions of the Affordable Care Act (ACA).
This section of the “Obamacare” law requires employers with 50 or more full-time workers to provide health benefits or pay a penalty. While the Chamber said that businesses needed “more time and clarification of the rules” before the employer mandate goes into effect, it’s no secret that business groups and conservatives are pushing for repeal.
|As conservatives and business groups continue pushing to dismantle health-care reform, it’s time to push back for something better than an employer-based private insurance system.|
The Chamber claims it is not an intransigent defender of the status quo, but that it wants reform that is simple and builds on the “strengths of the current market-based and employer-sponsored system.” This stance is self-contradictory in two major ways. First, the ACA takes the form it does precisely because it builds on the current employer-provided private-insurance system. Second, the goals of simplicity and continuity with the current system are utterly opposed to each other. Any reform aiming to build on the current foundation will inevitably take the form of a wildly complicated Rube Goldberg machine.
Health-care reform efforts since the 1990s have tried to address the main problems of the employer-provided private-insurance system—lack of universality, non-portability of benefits, heavy administrative costs, etc.—while keeping the basic structure intact.
The “employer mandate” extends employer-provided insurance to the uninsured (though it doesn’t reach the unemployed or their families). The “community rating” prevents private insurers from discriminating against high-risk individuals (i.e., those with “preexisting conditions”). The “individual mandate” gives insurers a compensatory gift by requiring everyone to have health insurance or pay a penalty. (That includes low-risk individuals, who are coveted by insurers, who might otherwise forego insurance.) Add in subsidies for low-income individuals and you have the basic formula for Obamacare.
This formula is so unavoidable, if one takes employer-provided private insurance as the starting point, that the conservative Heritage Foundation came up with it in the late 1980s. “There was a time when conservative think tanks employed genuine policy wonks,” notes Paul Krugman, “and when asked to devise a Republican health-care plan, they came up with—Obamacare!”
Such reforms may be an improvement, but they leave fundamental problems unsolved.
The reforms result in a multi-tiered system: a minority with pretty good employer-provided insurance—many with bad-to-terrible employer-provided insurance, many with similarly bad individually purchased insurance—alongside those covered by Medicare or Medicaid, and those still left uninsured. The dizzying array of private insurance plans, meanwhile, guarantees enormous “health” costs that have nothing to do with delivering health services or improving health outcomes. The shape of health-care reform tells us a lot about the intersection of economics and politics in the U.S. today. Interests and ideology play big roles.
The design of the ACA, especially the individual mandate, was a tribute paid to the insurance industry to get it to accept reform. As sociologist Theda Skocpol has argued, the U.S. system is crowded with vested interests—insurers, pharmaceutical companies, hospital chains, etc.—that have to be mollified for any reform to go through. (In this sense, both the ACA itself and the Obama administration’s recent retreat reflect the political power of these interests.)
|Being resigned to nothing better than Obamacare is a near-guarantee of ending up with something worse. Beating back the business offensive against health-care reform requires a grassroots movement determined to fight for something better.|
The barriers to reform, however, do not come only from on high. “Anti-government” ideology has a mass following in the U.S. That makes it relatively easy for conservatives and business groups to exploit fears of a “government takeover.” Bending reform to mollify business interests does not neutralize this reaction; in fact, it leads to accusations of government-sponsored “crony capitalism.”
Business groups and conservatives clearly feel emboldened by the Obama’s latest retreat, but this doesn’t necessarily mean they’ll end up getting what they want. There are good arguments that turn the tables on everything business groups pretend to want.
If they really wanted simplicity, a single-payer system would be much simpler than any employment-based system. If they really wanted efficiency, public social-insurance systems have far lower administrative costs than private insurance. If they really wanted continuity with the existing U.S. system, then we should just eliminate the age restrictions from Medicare.
Ultimately, the fate of health-care reform will turn not on who has the best argument, but on a test of political strength. A single-payer system may be a longshot right now, given the power of business and the deep roots of “free market” ideology in the U.S. Being resigned to nothing better than the ACA, however, is a near-guarantee of ending up with something worse. Meanwhile, beating back the new business offensive against health-care reform requires a grassroots movement determined to fight for something better.