Never in the field of human conflict did so few fight so long to keep so many from having the benefit of health insurance. Apologies for the paraphrasing of a famous Winston Churchill quote from World War II, but it serves my purpose, given the startling ruling of a federal judge in Texas that the entire Affordable Care Act is unconstitutional.
Headed into 2019, a full decade since Barack Obama became president and proposed a market-based health insurance expansion, we are still arguing about whether everybody should have it, or whether government should be involved.
Building a solid, affordable health-delivery system for all Americans is important business, and the Affordable Care Act gave the country an opportunity to come together for a common purpose. Instead, it has been used as a cudgel in a foolish, partisan conflict.
“It’s unbelievable,” says Jonathan Weiner, the health policy expert at the Johns Hopkins Bloomberg School of Public Health and even-handed Obamacare explainer. “It’s exhausting and sad. Health care should be high up on everyone’s list as a priority.”
I mentioned Churchill at the outset because he and others in the United Kingdom had this figured out 75 years ago. Here’s what Churchill, a member of the Conservative Party, told the Royal College of Physicians in London in March 1944: “Our policy is to create a national health service in order to ensure that everybody in the country, irrespective of means, age, sex, or occupation, shall have equal opportunities to benefit from the best and most up-to-date medical and allied services available.”
The U.K.’s National Health Service was formed in 1948.
Seventy years later, and the U.S. is still wrestling with the concept of affordable care for all. The ruling in Texas is another marker in this tired fight over extending insurance to the 50 million Americans who did not have it and who proved a costly burden to the rest of us who did.
Republicans of all stripes fought at every turn to keep the ACA from becoming law, and then fought to repeal it. When that did not work, they turned to sabotaging it. They financed lawsuits. They filled conservative airwaves with dire warnings about the law and predictions of its demise. And, in what Weiner characterized as “the biggest case of political malpractice I've seen in my life,” 25 Republican governors refused to take federal money set aside under the ACA for Medicaid expansion. It was a cruel denial of insurance for their poorest citizens.
“It's hard to estimate exactly how many, but hundreds of people die every month because they do not have an insurance card," Weiner said two years ago.
On Saturday, he noted that several of those Medicaid-resistant governors have smartened up.
“In the current 2019 open enrollment period, we have 36 states plus the District of Columbia with ACA Medicaid expansion or some similar alternative,” Weiner said. The Kaiser Family Foundation now lists 14 states that still have not expanded Medicaid. “No surprise,” Weiner notes, “Texas is one of these holdout states.”
Despite all this resistance against something fundamental to any society that considers itself civilized and organized — and despite the election of a president driven to undo everything Obama — the ACA has reached millions and become popular, even among Americans represented by its most steadfast opponents. More and more people understand and welcome its benefits.
“That’s not to say there isn’t room for improvement, there always has been,” Weiner says.
Consider Maryland, where the ACA has been embraced from the start. The Republican governor and Democratic legislative leaders worked together to avoid projected huge increases in premiums this year. While the Trump administration continued to sabotage the ACA — by, for one thing, greatly reducing the budget to advertise the 2019 enrollment period — Maryland increased its marketing effort. Headed into the final week for enrollment, the number of people buying private policies through the state’s ACA marketplace was still growing.
Maryland shows that fixing the ACA works. This ruling sends it back into a dark age of confusion and uncertainty about its survival.
Vincent DeMarco, president of the Maryland Citizens’ Health Initiative, called the judge’s ruling in Texas “a horrible decision that will hopefully be overturned.” In the meantime, he’s looking for the Maryland General Assembly to make more improvements to the state’s ACA exchange with, for one thing, a “health insurance down payment plan” that, DeMarco says, will further reduce uncompensated care and attract younger Marylanders to the pool. His group also has a plan that, he says, would reduce the costs of prescription medications.
The ACA stands, for now, despite the judge’s ruling in Texas. But, while optimists see cooler, smarter heads prevailing and saving the law in the coming years, it’s hard to tell where this will go. “It’s pretty amazing that we are here,” Weiner says, “but emblematic of the crazy state of our politics.”
One of these days, we are going to get past crazy.