How Obamacare Could Flatline

Employers are doing their best to exploit loopholes in the ACA, and that’s just one of many perils.

David Moberg

(Photo by Chip Somodevilla/Getty Images)

Since it was signed into law in 2010, the Patient Pro­tec­tion and Afford­able Care Act (ACA) has sur­vived a con­sti­tu­tion­al chal­lenge before the Supreme Court and 37 attempts by con­gres­sion­al Repub­li­cans to kill it. Now, as the dead­line for imple­men­ta­tion of the leg­is­la­tion looms, Oba­macare” faces anoth­er hur­dle: mak­ing the ambi­tious, byzan­tine plan actu­al­ly work.

By Octo­ber 1, the Oba­ma admin­is­tra­tion must have the peo­ple and pro­ce­dures in place to admin­is­ter the vast new pro­gram man­dat­ed by the ACA. That could turn into a train wreck,” warns Sen. Max Bau­cus (D‑Mont.) — who, as chair of one of the com­mit­tees writ­ing the leg­is­la­tion, made a wreck hard to avoid. The plan then needs to sign up as many of the 49 mil­lion unin­sured Amer­i­cans as quick­ly as pos­si­ble, espe­cial­ly the young and healthy, to make the new sys­tem finan­cial­ly viable.

Even if the agen­cies involved clear the ini­tial hur­dle of enroll­ment, a host of oth­er prob­lems loom. Fun­da­men­tal­ly, the ACA could fall short of its goal of pro­vid­ing bet­ter and more afford­able health­care for most Amer­i­cans. And at the same time that the new plan pro­vides insur­ance for mil­lions of unin­sured Amer­i­cans, for many oth­ers its imple­men­ta­tion could spell trou­ble: slashed work hours, a pro­lif­er­a­tion of bur­den­some insur­ance plans with expen­sive deductibles, and the dis­so­lu­tion of the mul­ti-employ­er health plans that pro­vide sta­ble insur­ance to many union members.

Obsta­cles to Obamacare’s suc­cess­ful launch stem from five sources: how Con­gress wrote the law, con­tin­ued Repub­li­can sab­o­tage attempts, employ­ers using the law’s pro­vi­sions to cut costs (and hurt work­ers), the reg­u­la­tions the fed­er­al gov­ern­ment is writ­ing to imple­ment it, and con­ces­sions the admin­is­tra­tion made to oppo­nents. Repub­li­cans have stri­dent­ly opposed Oba­macare, and employ­ers have focused on max­i­miz­ing their own advan­tage, but even some stal­wart defend­ers — espe­cial­ly labor unions — are now crit­i­ciz­ing the imple­men­ta­tion of the ACA as falling far short of its lim­it­ed promise.

Holes in the safe­ty net

The effort to string togeth­er a health­care pro­gram around exist­ing insur­ance cov­er­age has result­ed in a safe­ty net full of gap­ing holes. The ACA could have pro­vid­ed much bet­ter insur­ance if it had includ­ed a pub­lic option, as pro­gres­sives advo­cat­ed. Even so, many of the glitch­es in the law could be fixed under nor­mal polit­i­cal cir­cum­stances, but today Democ­rats do not dare intro­duce revi­sions when most Repub­li­cans would seize any oppor­tu­ni­ty to kill the ACA.

Con­sid­er how the law deals with affordability.

The ACA requires busi­ness­es with 50 or more employ­ees to offer afford­able” insur­ance to any­one work­ing 30 or more hours per week — which must cost no more than 9.5 per­cent of the worker’s house­hold income. In addi­tion, busi­ness­es must also pro­vide insur­ance for depen­dents, though poten­tial­ly at an addi­tion­al cost to the employee.

Employ­ers who fail to pro­vide any insur­ance will have to pay a fine of $2,000 a year for each qual­i­fied employ­ee (beyond the first 30). If they pro­vide insur­ance that is not afford­able,” they pay a fine of $3,000 a year for each employ­ee who then obtains sub­si­dized insur­ance from the exchange. (Under the ACA, work­ers who decline their employer’s pol­i­cy as unaf­ford­able must buy oth­er insur­ance or pay a penalty.)

The prob­lem is the def­i­n­i­tion of afford­able.” A medi­an mid­dle-class fam­i­ly of four with pri­vate insur­ance earns about $81,000 a year and spends 9 per­cent of its income on pre­mi­ums, co-pays and deductibles, accord­ing to the White House Task Force on Mid­dle-Class Work­ing Fam­i­lies. This means that, under the ACA, a worker’s pol­i­cy could be deemed afford­able despite cost­ing more than her cur­rent fam­i­ly policy.

More insid­i­ous­ly, the 9.5 per­cent thresh­old applies only to the price of the indi­vid­ual worker’s insur­ance. Insur­ing chil­dren or oth­er depen­dents could raise the cost far beyond 9.5 per­cent. This would make the so-called afford­able plan unten­able for some fam­i­lies. And that could become a big prob­lem. If the work­er rejects this plan as too expen­sive, he will be inel­i­gi­ble for the sub­si­dies for children’s insur­ance through the new ACA state insur­ance mar­ket­places. (Some chil­dren in poor fam­i­lies might get insur­ance through the exist­ing state Children’s Health Insur­ance Pro­grams, even if their par­ents opt out of their employ­ers’ plans.)

Sim­i­lar­ly com­pli­cat­ed rules apply to spous­es, but that sto­ry starts dif­fer­ent­ly: Employ­ers do not have to offer spousal insur­ance, but if they do, the spouse can­not receive sub­si­dized insur­ance on the state marketplace.

The net effect? With the ACA, a fam­i­ly of mod­est means could gain, on paper, afford­able access to health insur­ance, yet be unable to afford it.

Polit­i­cal sabotage

Even with the ACA’s short­com­ings, if it is imple­ment­ed as writ­ten, mil­lions of peo­ple with­out health insur­ance — from those with low to mod­er­ate incomes who can’t afford insur­ance to oth­ers with pre-exist­ing ill­ness­es that insur­ance com­pa­nies will not cov­er — would stand to gain more afford­able health­care. But con­tin­ued Repub­li­can efforts to sab­o­tage the law, large­ly for polit­i­cal pur­pos­es, will great­ly nar­row the ACA’s benefits.

The ACA will expand Med­ic­aid to cov­er all indi­vid­u­als and fam­i­lies with incomes up to 138 per­cent of the pover­ty line. That could cov­er 21.3 mil­lion U.S. cit­i­zens who now lack insur­ance. (Adjust­ing for the poor­er health of its clients, Med­ic­aid is more effi­cient and com­pre­hen­sive than pri­vate alter­na­tives, accord­ing to the Urban Insti­tute.) But Repub­li­cans who want the ACA to fail have seized upon a Supreme Court rul­ing that allows states to opt out of this expan­sion of Medicaid.

In a spite­ful act that Steve Kreis­berg, a health expert with the pub­lic employ­ee union AFSCME, calls pure polit­i­cal the­ater,” gov­er­nors or leg­is­la­tures in some 20 states are like­ly to block this expan­sion for as many as 9 mil­lion needy Amer­i­cans. And they are doing so even though the fed­er­al gov­ern­ment has agreed to pay the full cost for the first three years and a grad­u­al­ly declin­ing share there­after, lev­el­ing off at 90 per­cent in 2020.

After fail­ing to push for the ACA to include a Medicare-like pub­lic option (let alone con­sid­er a more ratio­nal sin­gle-pay­er solu­tion), the Oba­ma admin­is­tra­tion con­tin­ues to retreat on the pub­lic role of health insur­ance. It recent­ly allowed Arkansas to pri­va­tize the oper­a­tion of its expand­ed Med­ic­aid. In a sim­i­lar retreat, unre­lat­ed to the ACA, the admin­is­tra­tion increased its sub­si­dies to give a $71.5 bil­lion wind­fall over a decade to the for-prof­it Medicare Advan­tage plans, even though can­di­date Oba­ma pledged to cut these sub­si­dies as waste­ful spending.

Employ­er loopholes

Ever since union col­lec­tive bar­gain­ing dur­ing and after World War II made employ­ers the pri­ma­ry providers of health insur­ance in the Unit­ed States, busi­ness­es have been of two minds about their role. Some think good ben­e­fit plans help to retain excel­lent employ­ees, but most want to min­i­mize or elim­i­nate the cost of employ­ee health insur­ance. And, under the ACA, many ana­lysts expect some busi­ness­es to drop the insur­ance they now offer and sim­ply pay a fine if that proves cheaper.

Small busi­ness­es (with few­er than 50 employ­ees), as well as qual­i­fied indi­vid­u­als, can buy insur­ance through the ACA man­dat­ed exchanges and receive sub­si­dies. If employ­ers paid work­ers high­er wages in place of pro­vid­ing insur­ance (an unlike­ly sce­nario), some of those work­ers might even fare bet­ter buy­ing the sub­si­dized insurance.

But it appears cer­tain there will be employ­ers who both exploit quirks of the law and con­tin­ue their exist­ing strat­e­gy of shift­ing the cost of health­care to their employ­ees (or the pub­lic) when­ev­er possible.

Employ­ers have sev­er­al ways to game the sys­tem set up by the ACA. First, if pay­ing the fed­er­al gov­ern­ment fine costs less than pay­ing for employ­ee insur­ance, cor­po­ra­tions may opt to pay the penal­ty instead of pro­vide insur­ance. Although only 5.4 per­cent of employ­ers took the penal­ty option in 2011 instead of offer­ing employ­ees insur­ance under Mass­a­chu­setts’ Rom­n­ey­care,” the mod­el for the ACA, the polit­i­cal cli­mate in the state is more sup­port­ive of near-uni­ver­sal health insur­ance than in most states. Rom­n­ey­care, after all, was based on con­ser­v­a­tive pro­pos­als and intro­duced by a finance-sec­tor exec­u­tive-turned-politi­cian. Mod​ern​Health​Care​.com report­ed in Feb­ru­ary that, accord­ing to a sur­vey, only 6 per­cent of a group of large to mod­er­ate-sized cor­po­ra­tions said they planned to stop pro­vid­ing insur­ance over the next three to five years (and pre­sum­ably pay the penal­ty). But if some busi­ness­es gain an advan­tage by drop­ping insur­ance, their com­peti­tors are like­ly to quick­ly follow.

Sec­ond, many employ­ers — such as the Regal Enter­tain­ment Group movie the­aters, Sut­ter Hos­pi­tals, the city of Long Beach, Calif., and the gov­ern­ment of Vir­ginia—have already tak­en steps to restrict some employ­ees to few­er than 30 hours a week to avoid offer­ing ACA-man­dat­ed insur­ance for full- and three-quar­ter-time employ­ees. The Berke­ley Cen­ter for Labor Research and Edu­ca­tion projects that indus­tries employ­ing work­ers at slight­ly more than 30 hours a week are most like­ly to cut hours. These indus­tries include restau­rants, accom­mo­da­tions, nurs­ing homes, build­ing ser­vices, retail, health­care and var­ied ser­vices. Most of the 2.3 mil­lion work­ers who the cen­ter esti­mates will suf­fer cut­backs in hours also earn low wages.

But it is col­leges and uni­ver­si­ties that have so far clamped down most aggres­sive­ly, focus­ing on the ill-paid adjuncts who teach rough­ly half of all high­er edu­ca­tion class­es nation­al­ly. Lind­sey Hewitt, an adjunct lec­tur­er at Oak­ton (Illi­nois) Com­mu­ni­ty Col­lege, esti­mates she could lose half her mod­est income if Oak­ton pur­sues its plan to reduce her course load to the equiv­a­lent of few­er than 30 hours a week. In Feb­ru­ary, admin­is­tra­tors told depart­ment chairs that they should restrict adjuncts to teach­ing two class­es next fall (half of what many pre­vi­ous­ly taught).

Both adjuncts and full-time fac­ul­ty — each of whom is orga­nized in sep­a­rate Nation­al Edu­ca­tion Asso­ci­a­tion locals—fought back at col­lege gov­er­nance meet­ings, and the admin­is­tra­tion and unions reached a ten­ta­tive com­pro­mise to cre­ate a new cat­e­go­ry of adjuncts eli­gi­ble for both longer hours and insur­ance. But many adjuncts will still end up with nei­ther. The whole patch­work was put togeth­er to use extreme­ly low-paid labor and trans­fer costs to indi­vid­u­als and the pub­lic,” says Hol­lace Graff, co-chair of human­i­ties and phi­los­o­phy at Oakton.

Now protests are erupt­ing across the coun­try, reports long-time con­tin­gent fac­ul­ty orga­niz­er Joe Berry, led by the var­i­ous teacher unions and the broad-based New Fac­ul­ty Move­ment (see Mad Professors”).

Many big pri­vate employ­ers appear poised to restrict work hours as well — if there’s no back­lash. In response to hos­tile pub­lic­i­ty, Dar­d­en Cor­po­ra­tion, oper­a­tor of the Olive Gar­den and Red Lob­ster restau­rants, has (for now) backed off from its plan to lim­it hours, but oth­er com­pa­nies are like­ly to endure crit­i­cism or act surreptitiously.

Nobody wants to be the first employ­er to do it, but every­body wants to be sec­ond,” says Ida Hel­lan­der, direc­tor of Physi­cians for a Nation­al Health Pro­gram.

Employers will be tempted to use ACA guidelines as an excuse to shift as much as 30 percent of current healthcare insurance costs from the company to the employee.

Duck­ing costs

As the costs of health­care and insur­ance have risen, employ­ers have shift­ed more of the bur­den to their employ­ees, who now pay high­er shares of insur­ance pre­mi­ums, co-pays and deductibles, and receive reduced cov­er­age. Some cor­po­ra­tions, such as Wal-Mart, rather than offer afford­able insur­ance, have encour­aged their low-wage employ­ees to rely on Med­ic­aid and oth­er pub­licly sub­si­dized programs.

The essen­tial trend of cost-shift­ing to work­ers is exac­er­bat­ed by the ACA,” says Nation­al Nurs­es Unit­ed direc­tor of pub­lic pol­i­cy Michael Lighty. For exam­ple, the famous Cadil­lac tax” on high-priced insur­ance plans will help finance the new leg­is­la­tion, but accord­ing to the Con­gres­sion­al Bud­get Office, it pri­mar­i­ly shifts costs to employ­ees. And con­trary to advo­cates of free-mar­ket health­care, dump­ing more expens­es on indi­vid­u­als will not make health­care more effi­cient and cer­tain­ly will not improve health.

More impor­tant­ly, the ACA sets up four tiers of cov­er­age — bronze, sil­ver, gold and plat­inum — that would pay for, respec­tive­ly, 60, 70, 80 and 90 per­cent of antic­i­pat­ed health­care costs. Employ­ers must pro­vide at least the bronze-lev­el insur­ance, which cov­ers 60percentofexpenses.Meanwhile,the sil­ver, 70-per­cent pol­i­cy serves as the bench­mark for defin­ing how much of a sub­sidy peo­ple will receive for obtain­ing insur­ance on the exchange.

Today, the aver­age pol­i­cy cov­ers 82 per­cent of costs, while the best union plans cov­er 90 per­cent. Employ­ers will be tempt­ed to take ACA guide­lines as effec­tive­ly mak­ing the bronze or, at best, sil­ver poli­cies the new insur­ance stan­dard. That alone could shift as much as 30 per­cent of cur­rent health­care costs from insur­ance com­pa­nies to indi­vid­u­als, poten­tial­ly caus­ing a polit­i­cal revolt among those so affected.

Late in nego­ti­a­tions over the text of the bill, Repub­li­cans insist­ed that all exchanges offer a high-deductible plan, some­times known as a cat­a­stroph­ic plan or con­sumer-direct­ed health plan. Employ­ers like this option because it’s cheap. Younger, health­i­er or wealth­i­er employ­ees may go for it because such plans typ­i­cal­ly pro­vide a Health Sav­ings Account that grows in val­ue if the insured per­son needs lit­tle health­care. Last year, 70 per­cent of major employ­ers sur­veyed offered a high-deductible alter­na­tive, accord­ing to con­sul­tants Tow­ers Wat­son and the Nation­al Busi­ness Group on Health, and 20 per­cent said they would offer it alone this year. Advo­cates say the high-deductible plans turn peo­ple into care­ful con­sumers, putting mar­kets to work to improve health while cut­ting costs.

But a large body of research, includ­ing recent stud­ies by the UCLA Cen­ter for Health Pol­i­cy Research and by Eco­nom­ic Pol­i­cy Insti­tute econ­o­mist Elise Gould, chal­lenges those claims. High upfront costs, typ­i­cal­ly for the first $3,000 in med­ical expens­es, make peo­ple delay or avoid need­ed treat­ment. Often peo­ple do not even take advan­tage of free pre­ven­tive mea­sures or tests, since they may not real­ize the pro­ce­dures cost noth­ing or fear the expense of treat­ing a con­di­tion that a test might reveal.

Delayed treat­ment caus­es more health prob­lems and finan­cial risk lat­er on. Ulti­mate­ly, such plans do not save mon­ey for the health­care sys­tem or improve health. Even worse, high-deductible plans impose a dis­pro­por­tion­ate bur­den on poor­er patients, for whom the upfront, out-of-pock­et expens­es pose the great­est chal­lenge. What’s more, care of the 5 per­cent of the pop­u­la­tion who are very sick con­sumes half the nation’s health spend­ing, and most of that huge expense occurs long after the patient has paid his high deductible charge.

Ear­li­er this year, Prov­i­dence Health & Ser­vices, a non­prof­it hos­pi­tal and health­care sys­tem in five north­west­ern states, began impos­ing a high-deductible plan on its employ­ees. More than 700 work­ers in Olympia, Wash., mem­bers of SEIU Health­care 1199NW, went on strike for five days in March and filed unfair labor prac­tice charges against Prov­i­dence for try­ing to change the con­tract with­out negotiations.

Under the new high-deductible pol­i­cy, Prov­i­dence house­keep­er Deb­o­rah Tip­ton says that she can’t get the ultra­sound scans she needs after thy­roid can­cer surgery. I haven’t gone to a doc­tor,” she says. I can’t afford it. I can’t even imag­ine how much an ultra­sound would cost, and I don’t want to go. There will just be a big bill I can’t afford. I lit­er­al­ly live pay­check to pay­check. They say [the new insur­ance] is afford­able, and I say, If I had your salary, it might be affordable.’ ”

Labor woes

Most unions backed Pres­i­dent Obama’s health reform, even though it meant defer­ring key mat­ters like labor law reform. So Kin­sey Robin­son, pres­i­dent of the small — 25,000-member—Unit­ed Union of Roofers, Water­proofers and Allied Work­ers raised eye­brows in April when he called for reform or repeal of the ACA. Then in May, oth­er union lead­ers, includ­ing Unit­ed Food and Com­mer­cial Work­ers (UFCW) Pres­i­dent Joseph Hansen and UNITE HERE Pres­i­dent D. Tay­lor, pub­licly expressed the crit­i­cisms that union offi­cials have grum­bled about pri­vate­ly for months.

Beyond the con­cern of Hansen, Tay­lor and oth­ers that employ­ers will cut work­ers’ hours to evade their insur­ance respon­si­bil­i­ties, union lead­ers are espe­cial­ly unhap­py with how the ACA has dealt with the health insur­ance pro­grams known as mul­ti-employ­er — or Taft-Hart­ley — funds. The 1947 Taft-Hart­ley law autho­riz­ing these funds aimed to help high­ly mobile or cycli­cal work­ers who might move among small union­ized firms in indus­tries such as con­struc­tion, hotels and truck­ing. Joint­ly man­aged by unions and busi­ness­es, the funds pro­vide insur­ance tai­lored to the needs of near­ly 26 mil­lion par­tic­i­pants. Many funds com­bine active, injured, unem­ployed and retired work­ers from the indus­try. The funds enable work­ers to avoid churn­ing” through chang­ing insur­ance arrange­ments in unsta­ble indus­tries — the very prob­lem that will plague many work­ers under the ACA’s tan­gled rules and diverse qual­i­fy­ing thresholds.

Despite Obama’s pledge that any­one could keep exist­ing insur­ance, the funds feel threat­ened by the ACA, and the unions warn that their mem­bers may not be able to keep the insur­ance they now have and like.

Under reg­u­la­tions the admin­is­tra­tion has writ­ten, the non­prof­it mul­ti-employ­er funds will be pro­hib­it­ed from pur­chas­ing sub­si­dized insur­ance through the exchanges. They will also pay a tax on each pol­i­cy to help pay for the sub­si­dies offered on the exchange. How­ev­er, indi­vid­u­als or small for-prof­it busi­ness­es, espe­cial­ly from low­er-wage occu­pa­tions, could buy sub­si­dized insur­ance through the new mar­ket­places. By obtain­ing insur­ance more cheap­ly than the mul­ti-employ­er plans can (thanks to Oba­macare), non-union busi­ness­es would gain a com­pet­i­tive edge over union­ized firms — and union­ized busi­ness­es or indi­vid­ual work­ers would have incen­tives to leave the fund and obtain insur­ance. So the union los­es one of the main ben­e­fits it offers mem­bers, and work­ers lose a steady source of high-qual­i­ty insur­ance when their employ­ment is uneven.

Although the ACA includes noth­ing that pro­tects the mul­ti-employ­er funds, unions and fund rep­re­sen­ta­tives argue that these funds should count as a qual­i­fied health plan” and be allowed to pur­chase sub­si­dized insur­ance in the state mar­ket­places. So far the Oba­ma administration’s fed­er­al rule mak­ers have reject­ed the funds’ argu­ment. For its part, the AFL-CIO has refused to make any pub­lic com­ment on such prob­lems, reflect­ing the polit­i­cal sen­si­tiv­i­ty of White House allies levy­ing crit­i­cism of Oba­macare, no mat­ter how legit­i­mate. Increas­ing­ly, these issues will com­pli­cate col­lec­tive bar­gain­ing, as they did in UFCW nego­ti­a­tions with the Stop & Shop gro­cery chain in the North­east this spring over con­tin­u­a­tion of insur­ance for many of the chain’s thou­sands of part-time work­ers. In the end, the con­tract pro­vid­ed a large frac­tion of the part-timers con­tin­ued insur­ance under the tra­di­tion­al Taft-Hart­ley plan, but it left many to find cov­er­age under ACA provisions.

The ACA has also com­pli­cat­ed UFCW’s ongo­ing nego­ti­a­tions in Indi­anapo­lis and Cincin­nati with Kroger, whose CEO David Dil­lon told the Finan­cial Times that the com­pa­ny might drop insur­ance for full-time work­ers — now pro­vid­ed through a Taft-Hart­ley fund — if it costs much more than the cost of a fed­er­al fine. In addi­tion to restrict­ing hours of part-time work­ers, cor­po­rate bar­gain­ers have also talked about drop­ping spousal insurance.

In anoth­er twist, some unions may also find that large blocs of their mem­bers, espe­cial­ly those earn­ing low wages, may pay less for insur­ance through the state mar­ket­places than through their exist­ing union contract.

The polit­i­cal fallout

Unions and pro­gres­sives have a tricky line to walk over how much to defend Oba­macare for its good inten­tions and accom­plish­ments ver­sus how strong­ly to crit­i­cize its short­com­ings in pur­suit of robust, pub­lic social insur­ance. In the short run, any crit­i­cism of the ACA will feed into the cur­rent par­ti­san show­down. The prob­lems with imple­men­ta­tion will undoubt­ed­ly become poten­tial polit­i­cal chits for Repub­li­cans to cash in upcom­ing nation­al elec­tions. Repub­li­cans hope to guar­an­tee their vic­to­ry by run­ning against Oba­macare and by block­ing Democ­rats at every turn from deliv­er­ing on their promis­es to reform health­care. If Repub­li­cans win, their health­care alter­na­tive is the repeal of the ACA, fol­lowed by poli­cies that weak­en even pre-Oba­ma pro­tec­tions, such as turn­ing Med­ic­aid into block grants to states and pro­mot­ing indi­vid­ual high-deductible insurance.

But the Repub­li­can cal­cu­la­tion may be off the mark. Though the roll­out of the ACA presents poten­tial prob­lems and polls show luke­warm sup­port for Oba­macare, out­right repeal is not pop­u­lar. A major­i­ty of Amer­i­cans do like some of the more straight­for­ward ACA pro­vi­sions, such as offer­ing birth con­trol and oth­er pre­ven­tive care at no cost, let­ting chil­dren up to 26 years old be includ­ed on their par­ents’ insur­ance poli­cies, ban­ning dis­crim­i­na­tion on the basis of pre-exist­ing con­di­tions, cap­ping annu­al out-of-pock­et costs, and pro­hibit­ing insur­ance com­pa­nies from set­ting either annu­al or life­time lim­its on pay­ments for med­ical care.

And despite the crit­i­cism — war­rant­ed and not — Oba­macare will help mil­lions of Amer­i­cans, insured and unin­sured, and par­tic­u­lar­ly low-wage work­ers — many of whom now can’t afford health insur­ance even when it is offered. By requir­ing employ­ers to offer afford­able insur­ance to most of the work­force, the ACA will expand access to health­care and some­what lev­el the play­ing field among busi­ness­es, elim­i­nat­ing much of a cost-cut­ting incen­tive to not pro­vide any insur­ance. That should help unions stay com­pet­i­tive while offer­ing good ben­e­fits — with the impor­tant excep­tion of the exist­ing mul­ti-employ­er plans described above. The ACA also cre­ates a safe­ty net for work­ers who lose work or are employed cyclically.

The com­plex mix of the ACA’s accom­plish­ments and flaws guar­an­tees that polit­i­cal fights over the plan and the pro­vi­sion of health­care more gen­er­al­ly will not end soon. In con­trast to pro­grams like Social Secu­ri­ty, Medicare and Med­ic­aid — which quick­ly became bedrocks of Amer­i­can pub­lic pol­i­cy, despite the Right’s dreams of undo­ing them — Oba­macare is an unsta­ble, unsus­tain­able com­pro­mise. Most like­ly, it will set the stage for moves either to the Right, with more cor­po­rate and mar­ket dom­i­na­tion and less sup­port for indi­vid­u­als, or to the Left, with a more straight­for­ward social insur­ance through a gov­ern­ment sin­gle-pay­er plan.

In the mean­time, as the ACA’s prob­lems mate­ri­al­ize, the chal­lenge for the Left is to move the coun­try beyond Oba­macare. The strat­e­gy of the Right is to blame [short­com­ings] on gov­ern­ment, but there will also be lots of anger towards the insur­ance indus­try,” says Physi­cians for a Nation­al Health Program’s Hel­lan­der. The key is to be clear that the prob­lems are real, but they were cre­at­ed by pri­vate indus­try, not the gov­ern­ment.” And, to tweak Ronald Reagan’s max­im, gov­ern­ment in this case is the solu­tion. The solu­tion could emerge state by state, build­ing most sim­ply and effec­tive­ly into an improved, more com­pre­hen­sive ver­sion of Medicare for every­one. That may not solve all of America’s health­care prob­lems, but it would be a giant and much-need­ed next step.

David Moberg, a senior edi­tor of In These Times, has been on the staff of the mag­a­zine since it began pub­lish­ing in 1976. Before join­ing In These Times, he com­plet­ed his work for a Ph.D. in anthro­pol­o­gy at the Uni­ver­si­ty of Chica­go and worked for Newsweek. He has received fel­low­ships from the John D. and Cather­ine T. MacArthur Foun­da­tion and the Nation Insti­tute for research on the new glob­al economy.

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