Things about Obamacare that liberals don't want to discuss

Trudy Lieberman,Harper's Magazine - It’s bad enough that the A.C.A. is fattening up the health-care industry and hollowing out coverage for the middle class. Even worse, the law is accelerating what I call the Great Cost Shift, which transfers the growing price of medical care to patients themselves through high deductibles, coinsurance (the patient’s share of the cost for a specific service, calculated as a percentage), copayments (a set fee paid for a specific service), and limited provider networks (which sometimes offer so little choice that patients end up seeking out-of-network care and paying on their own). What was once good, comprehensive insurance for a sizable number of Americans is being reduced to coverage for only the most serious, and most expensive, of illnesses. Even fifteen years ago, families paid minimal deductibles of $150 or $200 and copays of $5 or $10, or none at all. Now, a family lucky enough to afford a policy in the first place may face out-of-pocket expenses for coinsurance, deductibles, and copays as high as $13,200 before its insurer kicks in.

Of course, these out-of-pocket caps can be adjusted by the insurer every year, within limits set by the government, and there are no caps at all for out-of-network services, which means that some providers charge whatever the market will bear. In the post-A.C.A. era, you can be insured but have little or no coverage for what you actually need.


The A.C.A.’s greatest legacy may finally be the fulfillment of a conservative vision laid out three decades ago, which sought to transform American health care into a market-driven system. The idea was to turn patients into shoppers, who would naturally look for the best deal on care — while shifting much of the cost onto those very consumers. In large part, this scheme was the brainchild of J. Patrick Rooney, whose Indianapolis-based Golden Rule Insurance Company specialized in selling policies to only the healthiest customers.

Rooney, a vegetarian who wore plastic rather than leather shoes to avoid killing animals, pioneered the marketing of high-deductible catastrophic insurance policies, which could be coupled with tax-advantaged saving accounts to pay for non-catastrophic health-care costs. These medical savings accounts made perfect sense to a free-market ideologue like Rooney, even if they were initially regarded as a screwball invention that ran contrary to the basic concept of comprehensive employer-based insurance. Rooney channeled millions of dollars from his company’s political action committees to the campaigns of G.O.P. legislators. He walked the halls of the U.S. Capitol himself, sometimes making as many as ten thirty-minute visits a day to congressional offices.

... Rooney and his G.O.P. allies (with, it should be said, Democratic acquiescence) moved American health insurance in a direction contrary to that taken by most every other nation in the developed world. It is also contrary to the needs of those unlucky enough to get sick. Whereas insurers once asked policyholders to pay a nominal $25 or $50 for a doctor’s visit or a CT scan, they now require them to foot as much as 25 or even 50 percent of the bill. What looks like a reasonably priced policy, at least in terms of premiums, can bring on sky-high bills and serious debt in no time.

For employers, of course, these policies are a bonanza: every dollar insurers save by shifting medical costs to consumers will lower the tab that employers pay for coverage. In 2011, Helen Darling, who was then head of the National Business Group on Health (which describes itself as the “only non-profit organization devoted exclusively to representing large employers’ perspective on national health policy”), was quite frank about this equation. Moving from copays to coinsurance, she said, amounted to “a more subtle way to increase what the consumer pays. We are clearly seeing a march toward a more aggressive consumerist system.”