Obamacare’s Empty Victory

By Margaret Flowers, M.D. for The Indypendent

It feels truly Orwellian that progressives are applauding the forced purchase of private health insurance — one of the most hated industries in the United States — while the right is opposing a model that originated from their political leaders. The Affordable Care Act (ACA) is a step farther on the path to total privatization of our health care system, not towards the health care system that most Americans support: single payer Medicare for all.

In the months leading up to the March 31 deadline to obtain health insurance, ACA supporters united around their mission to enroll people. Volunteers knocked on doors and tabled in their communities. Celebrities and athletes tweeted and labor unions ran robocalls. The media buzzed with speculation about whether the ACA would succeed or fail. March 31 felt like election night. And after it was over, ACA supporters clapped each other on the back and celebrated.

Obamacare survived. But now that the law is implemented and the dust is settling, it’s time to question what this actually means for health care and what we should do now.

Before President Obama was elected in 2008, Drs. David Himmelstein and Steffie Woolhandler, two of the co-founders of Physicians for a National Health Program, raised a crucial question in their report, “Our Health Care System at the Crossroads: Single Payer or Market Reform?” They outlined the health care crisis and how past reforms were taking us toward increasingly “threadbare insurance coverage.” Knowing that health care reform would be front and center for the next few years, they argued that as a nation, we had a choice to make. We could stay on the same path toward a market-based health care system or take an evidence-based approach and create national single payer health insurance.

With the ACA, we have now passed that crossroads and are headed down the road to a completely market-based system of privatized health care. This is not something to celebrate. Dr. Adam Gaffney recently wrote an excellent history in Jacobin on the turn we have taken away from the concepts of universal health care and economic justice to a neoliberal model. We are inundated with market rhetoric telling us how wonderful it is to have the choice of shiny silver insurance in the brand new marketplace. Insurance plans are called products and we are consumers of them.

The problem with these public relations messages is that having health insurance doesn’t guarantee access to health care and health care doesn’t belong in the marketplace. As patients, we do not have a choice of whether or not to purchase health care when we need it. Delaying or avoiding necessary care can and does have serious consequences. And we can’t predict how much health care we will need or when we’ll need it. In a market-based system, profits are the bottom line and people receive only the amount of health care they can afford, not what they need.

The ACA is transferring hundreds of billions of public dollars to the private insurance industry to subsidize plans that leave people underinsured, unable to afford care and at risk of financial ruin if they have a serious accident or illness. And even at its best, tens of millions of people will remain without insurance.

Most of the 7.5 million people who purchased health insurance on the exchanges were already insured. More than 80 percent bought the lower-tier silver, bronze or catastrophic plans with the hope that they would not get sick. These plans have the lowest premiums but require that patients pay thousands of dollars out of pocket before insurance kicks in, and then pay 30 to 40 percent of the cost of covered care. The result is that underinsured people will continue to self-ration, delay or avoid care due to cost, as 80 million of us did in 2012.

The ACA includes regulations, but as usual the insurance industry has ways to work around them. Many insurers had caps on out-of-pocket costs waived. Insurers also found a way to “cherry pick” the healthiest customers by leaving cancer centers and major medical centers out of their networks. In fact, most of the new plans have narrow and ultra-narrow networks that shift more of the cost of care onto patients because care outside of insurance networks isn’t covered. And while insurance companies cannot drop individuals when they get sick, they can stop selling their plans in areas that don’t make a profit. Some are already doing this, which means the competition that was supposed to emerge did not. Instead, in 515 of the poorest counties in 15 states, only one insurance company is available on the health exchange. And greater consolidation of the health care system is underway through mergers and acquisitions.

Our public insurances, Medicaid and Medicare, are being increasingly taken over by private insurances in the form of Managed Care Organizations and Medicare Advantage. They compete for the healthiest patients and siphon more of the health dollars for profit, salaries and administration than public insurances. Top advisors to the White House expect our public plans to be rolled into the health exchanges in the near future with subsidies, a plan similar to Congressman Paul Ryan’s voucher proposal.

Nations that treat health care as a public good and not a commodity have universal coverage that costs less and produces better health outcomes. And in polls, some two thirds of Americans support single payer. Now our tasks is to shift the national debate away from how many people have insurance to what type of health care system we support. Efforts to do this are taking place at both state and national levels.

State efforts to educate and organize for universal health systems are using a human rights framework. This started with the Health Care is a Human Right campaign in Vermont that is working to create universal coverage, and similar organizing is happening in Maine, Pennsylvania and Maryland. An essential component of this organizing model is to develop leadership within communities that are uninsured or underinsured. States such as Washington, Oregon, Colorado and New Mexico also use human rights messaging in their campaigns.

State health reform faces significant barriers because federal legislation is needed to allow the creation of a state single payer system. However, state campaigns are essential because they push state health policy to be the strongest it can be and build an informed and organized grassroots movement that can also push for solutions at the national level.

Legislation for single payer health systems exists in Congress. In the House, Congressman John Conyers (D-MI) has introduced HR 676, “The Expanded and Improved Medicare for All Act,” in every session since 2003. So far it has 56 co-sponsors. In late 2013, Senator Bernie Sanders (I-VT) introduced SB 1782, “The American Health Security Act,” in the Senate. National organizations are working together to encourage more members to sponsor them and a national lobby day is happening in Washington, D.C., on May 22.

On a personal level, I have chosen to be a conscientious objector to the ACA. I cannot in good conscience give my support to the very industry I am trying to eliminate. Being a conscientious objector is a decision that people have to make for themselves. So far nearly 500 people have joined me by signing a petition at PopularResistance.org.

Some people speculate that the ACA will bring us to single payer some day because it will fail. This will only happen if we fight for it. Every day that we delay, people suffer and die in this country unnecessarily. Neil H. Buchanan says it best, “The ACA is as good as it gets, when it comes to basing a health care system on private insurance, and it is simply not good enough. Even as the ACA takes effect, therefore, we need to start planning to make it disappear.”

Margaret Flowers is a pediatrician and co-chair of the Maryland chapter of Physicians for a National Health Plan. She serves on the board of Healthcare-Now and of the Maryland Health Care is a Human Right campaign. She is also an editor at popularresistance.org.


  1. John Clay on May 8, 2014 at 6:16 am

    Thanks for the excellent article. These need to start getting regularly published in every newspaper by every citizen who cares about this issue. I managed to get this published in the Tallahassee Democrat. Feel free to plagiarize.

    If we desire periods without health care coverage, prefer to be separated from our cumulative health care contributions periodically (job change/loss) and don’t want those contributions to gain value over time for our health care benefit in old age, then our current use of for-profit, private term insurance is perfect.

    If, on the other hand, we prefer a more cost effective healthcare system designed and funded so that services will be provided in an uninterrupted fashion throughout our lifetimes then private term insurance is unsuitable; for-profit term insurance simply doesn’t, indeed can’t, possess the necessary characteristics to meet those goals. Realizing that, many thoughtful countries have addressed their health care needs by adopting national single payer systems. Tax funded, national single payer systems support world class care, have no gaps in coverage and don’t periodically separate individuals from the benefit of their contributions as our system does.

    Due to reduced agency and health care provider administrative overhead as compared to that attendant the use of multitudes of individual insurance companies, as well as the lack of the mandate to increase shareholder value, single payer delivers health care services at substantially lower costs than we enjoy. Our ongoing health care controversy misses these points entirely and seems akin to passengers of the Titanic engaging in heated ideological arguments about whether the menu should have been Continental European or English and the waiters union or not, oblivious to a heading that would end in a collision with an iceberg. The difference is that the information necessary to make sensible health care system changes is available to anyone who cares to go to the trouble, maintain an open mind and simply search for what works irrespective of individual political ideology.

    With individual lifetime health care contributions in the hundreds of thousands of dollars it’s worth the effort. With health care costs soaring and most of us simply wanting medically necessary healthcare when we need it, the funding structure and financial drivers of our system must be changed so that we are not separated from any of our lifetime contributions. Neither ObamaCare nor the other Republican offerings acknowledge, never mind address, these shortcomings and their serious negative ramifications; that is monumentally shortsighted and flawed.

    The good news is that we already have a proven, successful and cost effective single payer system in operation; fundamentally all we need to do is improve, expand and properly fund Medicare for all of our citizens. House Resolution 676 proposes to do just that and it’s supported by Healthcare-Now and Physicians for a National Health Program. Medicare is large enough to have demonstrated its technical capability at scale and across the country, it has unmatched purchasing power, its superior administrative and cost efficiencies are a matter of public record and its decades of existence doesn’t require plowing new constitutional ground. Using it as the financing vehicle for our entire country’s health care would spread health risks across the maximum population possible. Those are the optimum characteristics one would want in a health care financing and risk spreading system.

    Expanded and improved Medicare would be perfectly suited to the task and would improve our health care, our country, our finances and our lives; all we need is the sense and political will to use it.

  2. Ivan Huber on May 14, 2014 at 3:53 pm

    I am for expanded and improved Medicare for all!

  3. Kristi H on May 14, 2014 at 5:48 pm

    I wish I could join the author as a conscientious objector to the ACA. Unfortunately, as a self-employed individual of modest means, I do not have the resources the author apparently has to draw on in case of a medical catastrophe. I had to choose between my grandfathered HSA plan (whose premiums had tripled in the last eight years, to over 20% of my MAGI), which was likely to be canceled anyway, and the exchange plans, which at least offer me the financial protection of the 9.5% of MAGI premium cap, as long as I don’t earn too much. Without the subsidy (tax dollars to the insurance industry!), the silver HSA plan I chose would have cost me 57% more. And I depend on the HSA for vision and dental care. So I continue to play the health insurance extortion game. In place of a detailed health history, I had to submit a detailed personal financial profile. Craziness. The good news is my husband reached the promised land of Medicare (so we no longer face a $6,000 annual family deductible before actual care); I have 2-1/2 years to go. We had considered emigrating to Canada. We don’t want to leave our country, but the health care situation has pushed us close.

  4. Gerry Hunt on July 30, 2014 at 7:16 pm

    In terms of reason, logic, and arithmetic, the Health Insurance Exchange of the ACA is a perfect vehicle to eliminate private insurers. If you offer comprehensive benefits and lower premium costs as a Public Option, you eliminate some of the health insurers while improving the delivery of medical services. The more benefits and the lower the premium costs, the less the private health insurers will want to play the game. It is every so simple, but the politics of FUD (Fear, Uncertainty, and Doubt) have allowed the insurers to corrupt the marketplace for the past 125 years. There are public resources available to make this happen, if the Legislators were to actually be working for the public Good, but the corrupting influence of the private insurers were astute enough to know that their corrupting dollars would be returned over five fold in the “FREE MARKET”. Their FUD had already earned them control of the “FREE MARKET” because it has never, ever been “FREE”.