On The ACA: The Fight Of Our Lives — For Our Lives
I remember standing in a crowded conference room gathered around a TV on the morning the Supreme Court was scheduled to issue its ruling on whether the Affordable Care Act was constitutional. The people in the room were all public servants, a mix of appointees and career government types (some both), who’d been quietly preparing for the possibility we would be able to put the measures in the law in place. This was going to be the make or break moment — or so we thought then. In the days before, my boss and I had worked with them and our Governor’s Office to draft statements addressing any possible outcome of the Supreme Court decision.
But we were all pulling for a certain outcome. It was a room filled with nervous hope. You see, most of the people in that room had spent vast periods of their lives trying to help the poor, the needy, the most vulnerable get access to healthcare. The woman who would go on to oversee the rollout of kynect, Kentucky’s healthcare marketplace, Carrie Banahan, had spent her entire life in public service, starting at the bottom of the ladder as a case worker in the field for our Department for Community Based Services decades earlier. Also in the room, Audrey Tayse Haynes, who’d recently been appointed Secretary of our Cabinet for Health and Family Services, and who came out of the Gore team during the Clinton White House (and who was the best Cabinet Secretary I ever worked with, hands down, no contest) before heading into the nonprofit world. I can’t remember if Chris Clark, the IT guru who oversaw the fine details of the marketplace’s technology and design was there, but again, he was a key part of all this and had been working with the Cabinet when it designed the legacy Medicaid system 20 years earlier.
The provisions of the Affordable Care Act were not perfect, but they were still a dream come true for the people in that room, whose lifelong missions had been to get people care, to get people healthier. Government work isn’t glamorous. It is a slog, filled with competing special interests and political pissing contests and more cynics than you’d ever want to be in meetings with. It’s rare that good work will be touted and recognized; your mistakes always will be, usually on the front page of the newspaper, and it’s impossible not to make them. There are never enough resources to go around, particularly in the healthcare world. And so, often, you sit in meetings where people try to figure out how to help some of the people who need it, while being frustrated that you can’t do more, faster, better. To do this work well takes a commitment to the end goal that allows you to cope with all those things and much, much more bullshit.
I can tell you that everyone in that room was committed to that vision: bringing health coverage — good health coverage — to the people of our state. There was no mistake to be made: this would change lives. It might change the entire future of our state.
We were nervous. We were hopeful.
The ruling came down, 5-4, in favor, upholding every major provision, with the exception that the court decided that states must have the right to opt out of Medicaid expansion. That was no small thing, because, of course, the law was designed to expand coverage to the entire population through a mix of tax credits and insurance marketplaces for those uninsured with higher incomes and expanding Medicaid coverage beyond the traditional populations of pregnant women, the elderly and disabled to include people at a certain percent of the poverty level.
But, even so, the room erupted into cheers when the decision was announced. The discussion over what the Medicaid part meant would come, but the good news was very good. We were going to be able to do this.
In the coming months, our team and Governor Steve Beshear’s office kicked into high gear. We studied whether we should do Medicaid expansion, and we began to proceed with designing the marketplace. An independent report showed that Medicaid expansion too good a deal to pass up, in addition to simply being the right thing to do, and everyone worked hard to get the healthcare and advocacy community on board. Over the coming months and years, we would get our insurance industry on board, and even insurance agents, who were extremely skeptical at the beginning. We did public forums and developed videos and did as much education as we could about the benefits of the Affordable Care Act, some of which include:
- No more refusing coverage on the basis of preexisting conditions or charging people more based on health status (smoking, geographic region, family size and age are the only factors considered now);
- No more charging women more than men, and a limit on how much more older people can be charged based on age;
- Standards for coverage, so that essential benefits are covered and insurers can’t get away with selling junk plans;
- No lifetime cap on benefits and a requirement that insurers spend at least 80 percent of premiums on medical costs or pay $$ back to customers;
- Young adults can remain on parents’ plans until age 26;
- No co-pays for preventive health services and free contraception;
- Mental and physical health parity, so behavioral health has to be covered at the same level as physical health, including for Medicaid;
- Creating online marketplaces for uninsured individuals to shop for health coverage, and creating tax credits for certain income levels to make coverage more affordable (as well as providing subsidies for co-pays for some individuals);
- The requirement that most people have health insurance (I see a lot of protest over this piece, but unless Republicans are willing to discuss single payer as an option, it is the only way to do this);
- Expanding Medicaid to low-income individuals, up to each state post-Supreme Court ruling.
There are more, but those are most of the big ones.
We did our very best to put the Affordable Care Act in place in Kentucky exactly as it was designed to be. Because our exchange was one of the only ones that worked right away, we in large part became the people who told the story about how the ACA was working in those crucial early months of the marketplace rollouts. Don’t forget that one of the reasons healthcare.gov had problems is because the law assumed states would build marketplaces, but a lot opted out; the law also assumed most states would want to cover low income people. In fact, most of the provisions that haven’t gone as planned can be chalked up to Republican obstructionism. Anyway, I remember being on a plane in 2014 on my way to the Los Angeles Times Festival of Books for a panel and buying internet access so I could answer about 20 national reporter questions en route, even though I was technically on vacation. We all took this incredibly seriously. This was our dream. We were more than happy to be transparent and take the questions others couldn’t.
(By the way, I keep seeing this criticism about creating the brand. We did extensive research on how to best get past people’s innate fear and anxiety over dealing with health insurance and on attitudes about Obamacare; we were trying to reach people who had maybe never had health insurance in their adult lives. In fact, two-thirds of those who signed up told us just that. We always used the term Affordable Care Act because Obamacare was obviously politically loaded and created by Republicans as part of their consistent misinformation campaign about the law. Why would we go along with that? Our goal was to get as many people covered as possible, so — as the grant required — we developed a brand and strategy that would do that and stay away from loaded or intimidating terms. That’s the whole story. I’m still disappointed the media bought into Obamacare so quickly and used it in place of ACA.)
It worked. We signed up more than 400,000 people in the first open enrollment period. I believe now we’re around half a million people covered who weren’t; our state experienced one of the biggest drops in uninsured rate in the country. Unpaid care in hospitals dropped almost immediately, and is now at an unprecedented low level. Letters and messages and stories flooded in about people getting diagnosed and treated, about how these programs had saved their lives.
Then, in 2015, there was an electoral upset. Our extremely popular Governor, who had put all these reforms in place, wasn’t eligible to run for reelection. And so, in an election with incredibly low turnout and a Democratic candidate people weren’t so enthused for, there was an upset — a millionaire business type who hated the press, refused to release his tax returns, and vowed to end kynect and all the elements of the Affordable Care Act that went with it immediately (stop me if this sounds familiar) was elected. The election seemed to take them as much by surprise as all of us, and so appointments and the takeover were a bit slow. I’d been waffling about whether it was time to leave my job and become a full-time writer. It was getting hard to do both and feel like a living rational being, but what we were doing mattered. The rollout of the ACA was by far the most rewarding thing I was involved in during my government career.
One of the very first things the new Governor did was order us to get our kynect advertising off the air. This was while an open enrollment period was going on. And that made my decision very easy; I simply could not stay and work for people who were going to do their best to undo all the good that had been done.
The ability to purchase insurance off the exchange was the main reason I was able to leave my state government civil service job of seventeen years. I don’t know what happens if it goes away. This year, at least, I was still able to purchase off healthcare.gov. But I am here to tell you that it is entirely possible, without a great, loud protest, that the Republican Congress will do irreparable harm to these reforms with their repeal stunt. The governor here has been slowed in some things, but barreled ahead with others. I believe many of his successes have been in large part due to speed preventing loud enough protests. The Congress is trying to do the same thing.
Like many self-employed people, the ability to have access to good health insurance is what makes this life possible for me. And Republicans are giving every indication they plan to snatch that away, all the things I listed above, without giving much thought to anything but how quickly they can do it. You can destabilize the private insurance market pretty quickly, guys, you’re definitely proving that. But what you aren’t doing is proving that you have given any real thought to policies that would actually improve upon what we have. What you are proving is that tax cuts to the wealthy are more important. And that you would be more than happy to go back to the old way of doing things, where an estimated 3,000 people a month died due to lack of healthcare.
I’m sure I’m going to hear about how dumb Kentuckians are in response to this post. How dumb everyone who voted for Trump is and how the Republicans have tricked everyone into voting against their self-interest.
It’s true they are liars, and that they are callously attempting repeal with no plan for anything that would be an actual replacement for what we have. It’s true that people have been fooled. It’s true that some of those people are dumb and some of them are racists and sexists. It’s also true that in some cases things are more complicated than that. And that obsessing over those points does absolutely nothing to change what’s happening right now.
I believe we can stop this or at least make it much harder. I believe if the GOP actually goes through with repeal, their days in office are numbered. While it would certainly be political capital for Democrats (something we need right now), the impact on people’s lives is not worth that.
You see, I still believe in that vision we all had in that room. I believe that public policy is about trying to help people, the most you can, the best you can. It’s about the road to that more perfect union. The Affordable Care Act was a good start. It saved lives. It’s still saving lives right this second. Trashing it will not fix the problems; it will only create new ones and bring back old ones.
So, no matter who you voted for: Call your representatives and senators. NOW. Today. Tell them you see what Republicans are doing with these late-night votes and talk of high-risk pools (which have been done before and did not work). Ask them how the Affordable Care Act can be all bad if tens of millions of people are now covered who weren’t before. Tell them you want it protected, and you want time to go over the details of any replacement or “improvement.” Call your state-level reps and senators and governors too, and let them know you’re watching how they react to all this.
Remind these people they work for you, and you believe that every American deserves access to quality, affordable healthcare. Tell them that repeal in and of itself is a stunt, and it will not give them the ratings they want. Tell them that if they do this…