Health care clashes

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“Insurance is complicated and health insurance is really complicated.”

That was the pronouncement of Dr. Alison Cuellar, a professor of health administration and policy at George Mason University last week. Speaking at the Jewish Community Center of Northern Virginia as part of a forum on the Patient Protection and Affordable Care Act (ACA), the expansive restructuring of the U.S. health care system signed into law in 2010, also known as Obamacare.


“The problem it’s designed to solve is how close to 50 million Americans don’t have health insurance,” Cuellar said. “The act should get it to half of that.”

The event, co-sponsored by the Jewish Community Relations Council of Greater Washington, was intended to present clear information about how the law affects people and the options it provides for health insurance in Virginia, without all of the conflicting commentary that has surrounded the law since its proposal. Recent polls show many Americans are confused about the basic tenets of the law and what it does.

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“Essentially it was designed to provide access to health care to all Americans,” said Kathy May, director of the Virginia Consumer Voices for Healthcare.

Even after the law was passed and subsequently upheld as constitutional by the Supreme Court, critics continue to assail it and attempt to limit its impact and effectiveness. Most recently, some Republican lawmakers refused to fund the government for 17 days and nearly caused the U.S. to breach the debt ceiling in an attempt to make Democrats and President Obama undo or otherwise cripple the law.


“It’s a disaster, and it’s crumbling before our eyes,” said Dave Schwartz, director of the Virginia chapter of Americans for Prosperity, an activist group founded by the billionaire Koch brothers. AFP has campaigned heavily against the ACA and is working in Virginia to limit how the law will impact the state. “We’re opposing certain parts of the law that we think are particularly bad,” Schwartz said.

As the biggest health care revamp in around 50 years, the law is very complicated, but May explained that it’s possible to broadly break down the ACA into three major parts: namely the new rules and protections for consumers; the creation of state and federal insurance marketplaces as part of the new health insurance mandate; and the federally funded expansion of Medicaid.

While the patient protections apply equally across the country, the exchanges and the Medicaid expansion have been met by state governments with a mixture of approbation and hostility. Some jurisdictions, including the District of Columbia and Maryland, are embracing what the law offers while Virginia and many other states are opting out of participation as much as they can.

When the law was written, states were given the option to create their own health insurance markets for people who did not qualify for health care through their employers or federal programs. Plans to create a backup federal system were also implemented but subsequently ramped up when Virginia and 26 other states declined to create any such marketplace as part of political opposition to the law as a whole. This means the as yet technologically troubled federal health exchange is the only option for those without other access to health insurance. The administration has promised to have the website up and running by December and has pushed back the deadline for individuals to get health insurance to the end of March.

Although Schwartz acknowledges the pre-ACA health care system was seriously deficient, he thinks the new law is only making it worse.

“Obamacare has exacerbated a problem that already existed,” he said.

As conceived in the original law, Medicaid would receive an enormous funding boost so the state-administered program could cover all of the people who make more than the maximum eligibility level to qualify for the program but not enough to afford insurance on the open market with its tax subsidies. However, as part of the Supreme Court ruling on the law, the expansion is optional on a state basis and currently only 29 have accepted the expansion, which is fully funded by the federal government for the first two years and at 90 percent afterward.

“It would help the state budget if we expand our Medicaid program,” said Jeff Connor-Naylor, the program director in the Northern Virginia office of the Commonwealth Institute for Fiscal Analysis (TCI), a nonprofit, nonpartisan policy analysis group. “The Medicaid expansion pays for itself,” he said.

TCI looks particularly at how economic and fiscal policies affect low-income and middle-class residents and provides information and analyses of these issues. As the ACA was designed to provide access to health care for precisely those groups, extensive work on the implications of the law has been an important part of their work, Connor-Naylor explained.

“It would offer coverage to half of the uninsured in Virginia,” he said of the Medicaid expansion. “We think it’s a good deal for the people of Virginia.”

In order to qualify, states must choose to expand their Medicaid program by the end of the year. In Virginia, the legislative commission to determine whether to take the money for the expansion has at this point rejected the idea. “I would tell them to pick it up now,” Cuellar said, “It more than pays for itself.”

Virginia’s government, supported by like-minded activist groups, have maintained that far from being a good idea for people and the economy, Medicaid expansion would actively make things worse.

“The Medicaid expansion is really the part of Obamacare that hurts people the most,” Schwartz said.

The Medicaid system itself is at fault and adding people to it will only make it worse, he explained. Citing a recent Kaiser Health study that found increasing numbers of doctors unwilling to treat patients on Medicaid, Schwartz said wait times will grow and those already in the program will suffer for it.

“People will be more likely to die because it’s a poor system,” he said.

To a certain extent the law acknowledges that could be a problem, authorizing increased payments to doctors who bill the program and funding new community health centers, but Schwartz says it doesn’t matter.

“The problem is that plastic card doesn’t get you much,” he said. “Coverage means nothing if you can’t get good quality of care. The math does not add up.”

According to May, it’s the rejection of that expansion that will cause the most hardship for people in Virginia. There are those who make too much to qualify for Medicaid as it is, but not enough to make enrolling in the exchanges, with the minimum level of care that plans are now required to offer, feasible. “People are going to fall into what’s called the Medicaid gap,” May said. According to some estimates, 250,000 to 400,000 Virginians could fall into that gap. Despite claims by both sides about the effectiveness of the ACA, the wisdom of the disparate approach among states in how they have chosen to respond to it will really only be understood in the coming months and years. Voter satisfaction or displeasure with what their state government chose may only become clear at the ballot box, a system much easier to understand than the insurance market.

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