How the Affordable Care Act dropped the ball, and how Medicare for All can pick it up

Since it was signed into law on March 23, 2010 by President Barack Obama, the Affordable Care Act (ACA) has achieved many wonderful things for the American public and had many successes. Nearly 20 million individuals living in the U.S. have gained health insurance since 2010 between the open of insurance exchanges and the expansion of Medicaid. In particular, states that made the choice to expand Medicaid saw large drops in the number of their uninsured residents. It virtually eliminated the ability of insurance companies to deny care or increase insurance premiums based solely on the existence pre-existing conditions. On that same note, it eliminated lifetime and annual coverage limits. These regulations were 100% necessary in a time when insurance companies were essentially dictating the care (or lack thereof) to patients

The ACA’s focus on preventative care was another giant step in the right direction. Formerly, our system functioned as a “disease treatment” rather than as a “disease prevention” model of care. Prior to this, insurance companies used treatment of preventable diseases such as cervical cancer, HIV, diabetes, as something of a profit booster for their shareholders. Focusing on covering preventative diagnostics at no cost such as mammograms, colonoscopies, well-woman visits, provided an excellent way to lower our overall costs long term by catching disease early. The ACA also required insurance companies to close the “gender rating” gap and allowed young people to stay on their parents’ insurance until they are 26 years old

Dropping the Ball

While the list of ACA’s accomplishments is impressive, we must acknowledge the ways in which it did not go far enough:

Insurance companies continuing to remain in the game is completely detrimental to patients. As an Emergency room Physician Assistant, I see patients from all socioeconomic walks of life, some with health insurance and some without health insurance. For the patients with private health insurance (including exchange insurances), many are faced with the dilemma of picking and choosing what they can and cannot afford to have ordered while they are in the ER. Over the years, I have had patients come in for emergent issues (often requiring admission) and tell me things like “No, I can’t afford that, I’ll just go home and take my chances” or “How much does that blood test cost? I’ll just have the x-ray instead.” They explain to me that while their insurance company will cover a portion, they will ultimately end up with a bill that they cannot afford. Others inform me that they have not yet reached their inflated deductible, so they will be required to pay a significant amount, if not all of, the tests and medications that are ordered. As a practitioner, I find this frustrating for both the patient and for myself as the person trying to provide them with appropriate care.

While private insurance exists, companies will always increase premiums and offer high deductibles. Many blame the hike in premiums on the ACA and they are not entirely wrong, but they are also not placing blame where blame is due. Although placing federal regulations on insurance companies was and still is necessary, they will always find a way around this in an effort to increase their profit margins. Health insurance is a for-profit industry, right? It would logically make sense that any for-profit company will find a way to minimize losses and maximize profits. However, let’s not forget that, thanks to the individual mandate, companies like Aetna, United Healthcare, Anthem, Cigna, Humana, have added millions of customers since the ACA went into law. A combination of the individual mandate, a hike in premiums, and many states offering only plans with high deductibles, has led to massive profits for these companies. On the flip side, in states where these companies sensed losses coming, they were able to drop out of exchange participation, virtually leaving exchange participants with only one or two options in those states. 

Medicare for All

While the ACA was able to expand Medicaid coverage to individuals at 138% of the federal poverty level and exchanges were able to offer coverage “options” to millions more individuals, it ultimately failed to provide affordable coverage to everyone. By continuing to leave for-profit insurance companies in the driver’s seat, many individuals were left with a difficult choice: pay a fine or choose a high deductible insurance with a high premium. A patient told me recently, “My husband makes too much for me to qualify for Medicaid, but we don’t make enough money to be able to afford the monthly premiums on the options in the exchange.” We are missing a large chuck of the individuals that, like this patient, fall somewhere in the middle: above the poverty line, but still do not make enough money to afford inflated premiums. This indicates the absolute necessity of a universal option.  

In May of 2016, Physicians for a National Healthcare Program (PNHP) revealed a fiscally plausible plan on how a universal option could be achieved. You can read the plan here: Beyond the Affordable Care Act: A Physicians’ Proposal for Single-Payer Health Care Reform. Ultimately, leading to a decrease in premiums and out of pocket costs. This proposal, drafted by the PNHP would focus on a shift to a non-profit, preventative care approach to healthcare coverage, which would lower our costs long-term. This would essentially take the “cost of care burden” off of patients, allowing them to accept treatment when they need it. It would also continue to focus on a “disease prevention” approach rather than a (more costly) “disease treatment” approach.

This past week, Reuters released a new poll which found that 70% of Americans now support the idea of Medicare for All. This indicates a growing support for the concept of universal coverage. With strongly Progressive candidates (like Ben Jealous here in Maryland) gaining support, we are now poised and ready to make plans (like the one proposed by PNHP) a reality.


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  • Kristy Fogle
    published this page in Blog 2018-09-06 08:50:53 -0400