Affordable Care Act (POL 201: American National Government, August 18, 20180

Affordable Care Act

The U.S. Declaration of Independence (as cited by Fine & Levin-Waldman, 2016) grants citizens, “Life, Liberty, and the pursuit of Happiness. That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed” (Section 1.2, para. 2). To protect voters’, the statehood, and unify the states under one government, the Constitution establishes specific powers to balance the state and government. The government is a representative democracy in which elected officials make decisions that align with the opinions and interest of the constituents (Fine & Levin-Walman, 2016). 

Most agree that healthcare is an undeniable right, but before 2010 forty million people were uninsured due to current practices. Democrats and Republicans proposed bills in response to the health care crisis, but the argument remains as to who should be responsible for enacting, funding, and participating in such programs.  The Affordable Care Act (ACA) became law in 2010 and remains a political platform for elections, a target for appeal and reform, a debate topic in the media, and a pressing concern for voters. Some would argue that this disharmony demonstrates a failed government system; however, the ACA is an exceptional example of how the forefathers designed the government to work.

Historical and Constitutional Background

Several attempts at government-based healthcare had been made in the past by different party members. In 1912 Theodore Roosevelt campaigned for national health insurance under the Progressive Party (Geyman, 2018). Richard Nixon advocated for a single-payer health care system which placed responsibility on employers. Bill Clinton proposed the Health Equity and Access Reform Today Act in 1993 which included a requirement to purchase insurance, tax credits, and market reform (Hayes, 2011). Medicare was passed in 1965 to assure that elderly Americans had access to health care, but Medicare only covers approximately ten percent of the population.  John Adams (as cited by Geyman, 2018) said, “Government is instituted for the common good: for the protection, safety, prosperity, and happiness for people, and not for the profit, honor, or private interest of any man, family or class of men” (Geyman, 2018, p. 19).

Before 2010, the health insurance industry had limited regulations, and as a result, forty million individuals were uninsured. This healthcare crisis prompted the creation of the Patient Protection and Affordable Care Act or Affordable Care Act (ACA). The primary goal of the ACA was to provide affordable, quality health care to uninsured Americans. A secondary objective was to establish business regulations to prohibit insurance companies from denying coverage, charging higher premiums, or dropping a member based upon health conditions, or pre-existing conditions (Hayes, 2011). Insurance providers must provide certain preventative screenings free-of-charge for members The ACA removed the previous market standard of annual and lifetime coverage limit caps. The ACA works with state Medicaid programs to offer more affordable coverage to low-income individuals. Since the ACA involves individual participation to be financially sound, individuals who fail to obtain any insurance coverage incur a tax penalty. It is this tax penalty that gave Congress the right to mandate the ACA through the Necessary and Proper Clause and Commerce Clause.

Checks and Balances

A bill must pass through a system of checks and balances through the three branches to become a law. Traditionally a bill is introduced by Congress, referred to a committee and then reported. Once the bill passes the Senate and the House, each appoints a committee to align the bills. The Affordable Care Act (ACT) was atypical. Health reform spanned several committees in the House and Senate, but since the ACA impacted taxes, the bill technically began in the House of Representatives (Hayes, 2011).  The ACA bill had to pass both chambers of Congress to become a law. The Senate proposed its bill on July 15th, 2009. Republicans opposed the bill, but the ACA passed barely with 60 democratic votes. The House passed the Tri-Committee Bill on November 4th, 2009 (Flint, 2013). One would assume that a Democratic president with a Democratic majority in the House of Representatives and the Senate, could pass the ACA easily, but the ACA barely passed.  A Republican Senate seat swung unexpectedly in favor of the bill and on March 23, 2010, President Barack Obama signed the ACA into law. Even if one party holds the congressional majority, the other party provides enough resistance to maintain balance.

The states have a system of checks and balances to keep the government from becoming too powerful. After the enactment of the ACA, several states asserted that the ACA was unconstitutional. The ACA expanded the role of the national government into health care, but it requires the participation of the states to work successfully. The ACA increased the states’ responsibility to implement laws while removing the states’ ability to enact and regulate laws. It was the ACA’s mandatory participation or penalty that went to trial. The state of Florida filed a lawsuit challenging the constitutionality of the ACA. In the case of National Federation of Independent Business v. Sebelius, the Supreme Court ruled that the ACA was a constitutional use of taxation through the Commerce Clause; however, the Supreme Court ruled mandated state participation in the Medicaid expansions was unconstitutional (Fine & Levin-Waldman, 2016). Since state participation was voluntary, thirteen states asserted their independent rights and did not agree to Medicaid expansion. Although the ACA prevailed, Florida won in protecting states’ rights to choose to participate or reject the expansion.

Public Policy, Elections, and Media

The Affordable Care Act was a platform for Barack Obama’s 2008 presidential campaign, and the proposal received harsh criticism. Republicans started a smear campaign which framed the ACA as rationing, anti-capitalistic, and a means for government takeover (Geyman, 2018). The media, “Provided few details of the legislation’s provisions, other than incomplete sound-bite summaries of the most high-profile and controversial among them” (Hayes, 2011, p. 3). While the ACA was not substantially different from bills previously proposed by both Republicans and Democrats, in 2009 frustration over bailouts and the economy prevented a bipartisan legislature (Hayes, 2011). After the ACA passed, the approval and disapproval ratings were equally matched around thirty-five to fifty percent according to individuals polled from March 2010 to November 2012 (Flint, 2013). Even though the ACA was proposed to reduce the 40 billion who were uninsured, the media portrayal that it would be a socialized, anti-American initiative greatly divided voters. As of July 2018, the ACA has a 48% approval rating, while 40% hold an unfavorable opinion (Kaiser, 2018).

The ACA continues to receive criticism, but as of 2016, 20.4 million newly –insured individuals obtained health coverage (Blumberg & Holahan, 2016). Eighty-two percent of those covered by the ACA are pleased with their coverage (Gardner, 2016). But not everyone is content with the ACA. Some are unhappy with the tax penalty received if they do not join the ACA. Hospitals, physicians and those states that expanded Medicaid question the financial stability of the ACA. The consumers who are least satisfied with the ACA are those individuals whose incomes are just above $46,000 and do not qualify for any low-income subsidies (Gardner, 2016).  The continued success of the ACA depends on enrollment, affordability of the plan, and receipt of satisfactory care.

Voting and the Election Process

The Affordable Care Act was on the minds of voters during the 2010 election and as a result, Republicans won 63 seats of the House in the midterm elections (Flint, 2013). A similar phenomenon occurred in the 1994 election after Bill Clinton proposed a national health plan. Support for Bill Clinton’s plan was around 73% until Republicans promoted the proposal as a government takeover. In the 1994 midterms, the Republicans regained the House for the first time in forty years (Flint, 2013). During the 2012 campaign Mitt Romney and Paul Ryan kept the ACA on voter’s minds. Negative aspects of the Affordable Care Act became a platform for the Republican campaign. Obama’s proposed Medicare cuts to fund the ACA became a focus of the Republican Party, stating the cuts would affect the elderly’s benefits. Ryan argued that Obamacare funneled $716 billion from Medicare, which was a tactic used to deter or sway elderly voters (Reiboldt, 2012). Paul Ryan stated, “Obamacare comes to more than 2000 pages of rules mandates, taxes, fees, and fines that have no place in a free country” (Reiboldt, 2012, para. 3). Despite Republican efforts, voters re-elected President Barack Obama on November 6, 2012, and the ACA remained intact.

                During the 2016 election, Donald Trump used repealing the ACA as a platform for his candidacy stating, "Repealing Obamacare is one of the single biggest reasons we must win on November 8" (Bryan & Smith, 2016, para. 9). Trump’s campaign focused on the negative aspects of the ACA  such as increasing premiums and insurance company closures (Bryan & Smith, 2016). Donald Trump proposed his reform plan which involved allowing interstate insurance sales, tax deductions for premiums, and increasing drug provider commerce (Gardner, 2016). Hillary Clinton’s platform included a reform of the ACA including lowering the Medicare age to 50.

The Republican Party tried to appeal the ACA 60 times. In 2017 Republicans presented the American Health Care Act (AHCA) in an attempt to replace the ACA, but the AHCA would have caused 14 million people to lose insurance. By 2020, a total of 21 million individuals would lose coverage (Moniz & Gorin, 2017). A second effort to approve the AHCA was introduced and passed by the House on May 4, 2017, which eliminated taxes imposed by the ACA, phased out the additional Medicaid funding, removed the insurance mandate penalties, but was not presented as 9 Republican Senators were not in favor of the AHCA (Sanger-Katz, 2017, para. 11). The Senate proposed the Better Care Reconciliation Act (BCRA), but it proposed similar cuts as the AHCR also leaving 22 million uninsured. Several Republican Congressional seats were against both the AHCA and BCRA because of how the bills would impact their constituents.

Conclusion

It took nearly a century for the government to pass a national health plan. As of 2016, approximately 21 million Americans obtained health insurance due to the Affordable Care Act. Medicaid expansion within 30 states accounted for 12.2 million.  Some states asserted their power by maintaining the right to stay separate from the ACA Medicaid expansion. The ACA initially passed because both the House and Senate held a democratic majority. Ultimately the fate of the ACA or any health care reform lies in the power of the voter. Whether voters are for change, repeal or satisfied with the current health coverage, the best way to express that opinion is to cast a vote in the elections. If Republicans regain control of the House and Senate in the midterm elections, then appeal efforts may pass. Current repeal attempts have not passed through Congress because the representatives consider the best interest for their constituents. If plans like the AHRA or BCRA pass then millions of constituents could be negatively affected. The passage of the ACA is demonstrative of how the system established by the Constitution works for the state, the government, and voters.

References

Blumberg, L., & Holahan, J. (2016). Early experience with the ACA: Coverage gains, pooling of risk, and Medicaid expansion. Journal Of Law, Medicine & Ethics, 44(4), 538-545. doi:10.1177/1073110516684784

Bryan, B. & Smith, A. (2016, October 30). Donald Trump is going scorched earth on Obamacare in a last-ditch campaign effort. Business Insider. Retrieved from https://www.businessinsider.com/donald-trump-obamacare-2016-10

Fine, T. S., & Levin-Waldman, O. M. (2016). American government (2nd ed.). Retrieved from https://content.ashford.edu/

Flint, S. (2013). Health coverage for America: Signed, sealed, and delivered by the 2012 election. Health & Social Work, 38(1), 3-5. Retrieved from http://eds.a.ebscohost.com.proxy-library.ashford.edu/

Gardner, D. (2016). Election 2016: Where are we with the Affordable Care Act? Nursing Economics$, 34 (5), p. 251-254. Retreived from http://eds.a.ebscohost.com.proxy-library.ashford.edu/

Geyman, J. (2018). Crisis in the U.S. health care: Corporate power still blocks reform. International Journal of Health Services, 48(1), 5-27. doi: 10.1177/0020731417729654

Hayes, K. (2011). Overview of policy, procedure, and legislative history of the Affordable Care Act. NAELA Journal, 7(1), 1-9. Retrieved from http://eds.a.ebscohost.com.proxy-library.ashford.edu/

Jefferson, T. (1776). Copy of the Declaration of Independence. Retrieved from the Library of Congress, https://www.loc.gov/item/mtjbib000159/.

 Kaiser Family Foundation. (2018, July 25). Kaiser health tracking poll: The public’s views on the ACA. Kff.org. Retrieved from https://www.kff.org/interactive/kaiser-health-tracking-poll-the-publics-views-on-the-aca/#?response=Favorable--Unfavorable&aRange=twoYear

Leonard, E. (2011). Introduction: The roles of states in federal health care reform. Kansas Journal Of Law & Public Policy, 20(2), 181-185. Retrieved from http://eds.a.ebscohost.com.proxy-library.ashford.edu/

Moniz, c. & Gorin, S. (2017). What’s next for health care reform under the Trump administration? National Association of Social Workers, 42(3) , 131-132. doi: 10.1093/hsw/hlx031

Reiboldt, Mark. (2012). Healthcare becoming most critical issue in 2012 presidential election. The Journal of Medical Practice Management: MPM, 28 (2), 79. Retrieved from http://eds.a.ebscohost.com.proxy-library.ashford.edu/

Sanger-Katz, M. (2017, April 4). Republican health proposal would undermine coverage for pre-existing conditions. New York Times. Retrieved from https:// www.nytimes.com/2017/04/04/upshot/freedomcaucus-health-care-pre-existing-conditions.html