Is Obamacare here to stay, after all? On June 17 the Affordable Care Act (ACA) survived a third attempt to eliminate it via the Supreme Court. The Court ruled 7-2 that the plaintiffs in the case-attorneys general from states around the country- did not have standing and threw out their suit. Though they did not rule on the merits of the case, their decision seems to many to signal a change in the national mood. If that mood holds, what's next for healthcare in the United States, and what values should guide what comes next?
According to the Department of Health and Human Services (HHS), as of June 2021, "31 million Americans now have coverage through the Affordable Care Act." The number of people served by healthcare marketplaces and the Medicaid expansion associated with the ACA have both reached record highs. As of December 2020, "14.8 million newly-eligible people enrolled in Medicaid through the ACA's expansion of eligibility to adults." Overall, according to the June HHS report, "between 2010 and 2016, the number of nonelderly uninsured adults decreased by 41 percent, falling from 48.2 million to 28.2 million."
The ACA also added a number of significant new protections for people with preexisting conditions, among whom are included about 130 million Americans under the age of 65 or nearly half of the nonelderly population. Now, no one can be denied coverage because of a preexisting health problem, and basic standards have been established for what insurance plans must cover.
Clearly, some solid progress has been made in expanding access to affordable healthcare, but significant gaps remain. To date, only 37 states and the District of Columbia have expanded Medicaid to cover adults under the ACA. 13 have chosen not to accept the Medicaid expansion despite generous financial incentives to do so, leaving many of their potentially eligible citizens without coverage. Overall, as mentioned above, more than 28 million Americans are still uninsured.
Given that so many are still without coverage, is it a time to "build back better," as President Biden has declared, and extend coverage to more people? He has called for the restoration of a "public option," a feature that was part of the original version of the Affordable Care Act that would allow customers on the insurance exchanges to purchase a government administered plan similar to Medicare. Others have proposed extending Medicare immediately to all Americans, arguing that a Canadian-style Medicare for All approach would cover everyone while costing us at least a third less than we are currently spending. In between are proposals to extend Medicare gradually to those in their fifties and sixties, or to allow those in counties without many private insurance options to purchase a version of a government administered plan on their state's insurance exchange.
If our goal is to make sure all Americans have access to affordable care, how do we get there, given our divided politics and the resistance of some in the healthcare industry to major changes? Can those of us who favor expanded coverage come to terms with incrementalism, with the kind of slow but solid progress we've experienced over the last decade or so? Would we be wise to ground our advocacy in values-values potentially shared by others-rather than in fixed positions and detailed proposals? Would a values-based approach enable us to reach new people and create a solid majority in support of universal coverage?
In fact, assumptions around healthcare have shifted quite a bit in the last decade. Surveys show that most people like the Affordable Care Act. Many know someone it has helped. Despite all our noisy culture wars and feverish political maneuvering, maybe the time is ripe for a broader conversation about how to extend the ACA's benefits to more Americans. If so, what values should guide that conversation?
Here's a first try at a values-based healthcare to-do list:
Include everybody in coverage. It's the right thing to do, with deep roots in both our religious and secular traditions.
Commit to practical problem solving and go easy on ideology and political correctness.
Listen to everybody involved-especially patients and the providers who work with them directly-and incorporate what they have to say into the evolving plan.
Demand transparency and accountability of ourselves as well as others. Ideas that look good on paper may have to be set aside if they just don't work in the American context. Mistakes must be acknowledged and repaired.
Tap the power of partnership. America is built on partnerships-between government and the private sector, between federal funding and local know-how, between faith-based organizations and overall national, state, and community goals. It's a model that works!
Many critics of Obamacare have grown quieter of late, given the recent Supreme Court decision and the increasing popularity of the program. Is it possible that some are ready for a conversation on how to move forward on healthcare? If so, it's an opportunity not to be wasted!