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The US Affordable Care Act: Modest Success

Mary Jo Iozzio

Among many other worthy contemporary news on which to comment –like the ongoing and terribly sad plight of refugees and displaced persons worldwide, fleeing their homelands for safe harbor with border neighbors and others much farther away; daily reminders of the fragility and vulnerability of the planet and its inhabitants, exacerbated by global climate change that humans have perpetrated; debates and humiliation for many over equal access to public restrooms; globalization, poverty, and obscene wealth inequity; and both subtle micro-aggressions and blatant racism, sexism, xenophobia, ableism, and heterosexism—some good news can be found with the Patient Protection and Affordable Care Act (signed into US law March 23, 2010, by President Barack Obama and upheld by the US Court of Appeals in the Supreme Court on June 28, 2012).

The current 91.4% of Americans now covered by health insurance extends well beyond the precarious access to physicians in emergency rooms that the uninsured and underinsured, 17.87% of the nation’s population before 2010, relied upon before “ObamaCare” (the Kaiser Family Foundation reports as many as 79 million people –more than one in four Americans!). Today, the Centers for Disease Control and Prevention reports 8.6% (i.e., only 27 million Americans) remain uninsured –56% fewer than the 48 million a mere 6 years ago. As Health and Human Services Secretary Sylvia Burwell applauded this historically lowest rate, she cited the Affordable Care Act (ACA) as driving this success.

This news is encouraging and signals steps toward universal access to healthcare; however, it is a step fraught with polarizing controversy in the cultural climate of today’s United States. Curiously, the US is an outlier on the healthcare map of nations and among developed countries in its capitalist approach to access including, most notably, the ACA’s healthcare exchanges. And although the US spends more per capita than any other nation on health, healthcare in the US remains couched in a business-enterprise model rather than the Human Rights model inspired by the World Health Organization “Constitution” (1946) and the United Nations’ “Declaration of Human Rights” (1948), “International Covenant on Economic, Social, and Cultural Rights” (1976), “Convention on the Elimination of All Forms of Discrimination Against Women” (1979), “Convention on the Rights of the Child” (1990), and both the Millennium (2000-2015) and Sustainable (2016-2030) Development Goals. One of the reasons for the high price of care in the US is industry-driven: research and development of high-tech diagnostic equipment, crisis care over preventive care and office visits with primary care physicians, bulging budgets for duplicate and triplicate administrative offices, and gross profit margins for the industries’ executives and shareholders. The US model advantages the well-heeled and legal who can afford sophisticated care, even as the overall health of Americans falls below its peers on the common measures of human health: based on physically and mentally unhealthy days, self-assessed health status, limitation of activity, and prevalence of chronic disease, the US ranked 27th for females and 26th for males out of 33 peer countries on life expectancy; and ranks worst on obesity rates.

The increase of Americans with healthcare bodes well for an even more radical shift toward what many would welcome: universal access with a single-payer national program (yes, of a socialist kind). Admittedly, this development is increasingly dependent on the November elections and interested lobbies (including the Catholic Health Association, USCCB, and other Catholic organizations). While critics assumed and remain wary of giving away personal choice and institutional decision-making to government agencies and bureaucrats (remember the rhetoric of “death-squads” or mandatory compliance against religious beliefs?), there is little evidence that the ACA has undermined the quality of, withheld care for, or demanded that a medical practitioner perform actions contrary to held beliefs on patients with medical need. And if critics’ fears about the ACA have not materialized then what yet needs to be done to complete enrollment of the remaining 27 million Americans, and to extend the right to more than 11 million resident immigrants and the more than 11 million undocumented persons in the US?

The US can readily support the claims of a “right to health,” a right that requires commitments from local and global communities to develop health policies and provide programs to meet the needs of their populations –especially those disadvantaged by sex, gender, race, disability, and social status. The ACA offers a compromised step in the direction of universal access and a limited single-payer system for those covered by Medicaid, Medicare, or the Veterans Administration. However, with 19 states having opted out of Medicaid Expansion that increases eligibility for economically disadvantaged individuals and families combined with the dizzying array of supplemental plans to the Federal Medicare program, many go without insurance or remain underinsured, unable to fulfill the financial challenges of catastrophic health crises let alone basic care thereby likely to fall further into poverty. Unfortunately, states, the insurance industry, and the business model dodge scrutiny of the unexamined privilege sheltered in privatized access to and capitalist control of healthcare (including the ACA). Alternately, if the US adopted the Human Rights model for health and the UN Sustainable Development Goal #3, such scrutiny could be embedded into the conduct of operations that support the social conditions necessary to “ensure healthy lives and promote well-being for all at all ages,” to relieve, potentially, some of the ills that plague the globe and its inhabitants, and to move from modest to a resounding successful reform of healthcare in the US.