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Eric Patashnik Provides an Overview of the Affordable Care Act
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Из курса от партнера University of Virginia
Public Policy Challenges of the 21st Century
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Healthcare Systems and Insurance Markets
Professor Eric Patashnik examines healthcare reforms, weighing costs, benefits and the efficacy of alternative approaches, including 'Obamacare.'
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- Professor Gerry WarburgProfessor of Public Policy, Assistant Dean for External Affairs
Frank Batten School of Leadership and Public Policy
Whether you like the healthcare reform or not, whether you
believe it's an appropriate expansion of the welfare state or a gross overreach,
it's very important to understand what Obamacare does and does not do.
What it does do or attempts to do is to expand coverage to some 32 million
additional Americans at the cost of over $900 billion dollars over a decade, and
it does it through the individual mandate, through the creation of health insurances
exchanges, through the expansions of public programs like Medicaid.
It regulates the private insurance mandate to try to say that insurance companies can
no longer deny coverage for people who have preexisting conditions for example.
It pays for this by cutting payments to the hospitals,
by raising taxes on high premium insurance plans and
the medical industry, as well as more affluent Americans.
And it creates some pilot programs in an effort to improve care and reduce costs.
This, of course, has been a enormously controversial law.
I believe this is the most controversial domestic policy law
since the Civil Rights Act of 1964.
It has engendered opposition at the elite level, at the grass roots level.
It has engendered opposition that has shaped election outcomes,
that shaped debates during the last presidential election, and
I believe will continue to shape debates for the foreseeable future.
We forget today that Social Security as well was extremely controversial.
People think that Social Security is a bipartisan consensual program and
that it always was.
That's false.
Social Security was enormously controversial in 1935, and
the struggle over its consolidation did not end, really, until the early 1950s.
Fifteen to twenty years it took until Social Security became an entrenched,
accepted part of the American state.
I believe it is quite possible that the struggle over the entrenchment of
Obamacare may continue for some time.
And its outcome will depend on who wins elections.
It will depend on public opinion.
And it will, of course, depend significantly on facts on the ground and
whether the program ultimately achieves its goals at reasonable costs.
There are clearly both winners and losers from Obamacare.
According to one of the economists who helped create Obamacare and
therefore not an arm-length analyst, Jon Gruber, a prominent economist,
about 80% of Americans will be largely unaffected by Obamacare.
But that means there are only therefore about 14%
of Americans that are clear winners, which includes the currently uninsured,
who gain access to an affordable policy.
And some potential losers as well, people who have higher quality health plans with
no annual cap, as well as people who will be able to switch plans, that,
but they will have a plan that's very similar.
You might think if you look at this pie chart that this policy therefore should be
overwhelmingly popular because after all, 80% of
Americans are largely unaffected and there are some winners who outnumber losers.
That would be a mistake as we know, however.
The reason, of course, are several.
One is even some of the people who are winners have uncertainty.
They don't recognize that they're going to be better off.
Disproportionally, many of the people who are in the 14% include poorer Americans,
more minority Americans, Americans who are currently at the margin of society.
They are people who do not speak with loud voices.
Of the people who are going to be held harmless,
there are people who are much more influential in politics.
And even if those people are, in fact, subsequently hold harmless,
they're subject to uncertainty because they don't know for
sure they're going to be held harmless.
And when it comes to healthcare, people want, understandably, guarantees.
And as we know,
there are no guarantees given the way this program has been rolled out.
If you look at public opinion polls, if you ask, are people actually more willing
to pay more taxes to cover the uninsured, are people willing to do this?
Actually, a majority of Americans say no.
So, people want the uninsured covered, but public opinion suggests that
of a desire for Americans to pay for it themselves is not a majority of Americans.
That also helps explain why this policy is unpopular.
Obamacare, whether you agree with it or not, is a highly redistributive policy.
Its intended purpose is to help those who do not health insurance,
have health insurance, who include not only those who
have preexisting conditions, but also less affluent Americans.
It is a more redistributive policy than Social Security, for example.
The rollout, the implementation of the Affordable Care Act,
has been nothing short of disastrous.
Here is a screenshot that all too many Americans saw for
weeks during the initial rollout.
The system failed.
One of the most major implementation failures of
any government program in the last half century.
It ranks, although in a different way,
with the failure of the space shuttle that blew up upon launch.
This is one of the great debacles of American public policy.
Not to say the policy might not yet succeed, but its initial rollout
fed into perceptions of incompetence and distrust in government.
What we know is that these problems were recognized before the time.
People in the government knew that this was going to be a heavy lift.
Suffice it to say, some of the leading advisers to President Obama recognized
that the government was not ready, was not ready to successfully implement this law.
And what we've seen is that continued over time, a majority of
Americans have an unfavorable view of the Affordable Care Act.
Over 50 to 53% of Americans on the up or down vote are not positive about this law.
That's not to say public opinion might not change over time.
But currently, it is the case that a majority of Americans have an unfavorable
view of the Affordable Care Act.
Of course, it's not,
these views are not randomly distributed across the electorate.
Overwhelmingly, Democrats are much more supportive of the law
than are Republicans, and Independents are in the middle.
This debate over Obamacare has become highly controversial,
highly politicized along partisan lines.
I should just say in, in, in, where do I think we're going?
What made Social security finally able to succeed?
Was that a Republican president?
Dwight Eisenhower decided that the program needed to be accepted and embraced.
Social Security had some Republican support when it was originally passed.
That's very different from Obamacare.
Obamacare had no Republican support.
And reb, Obamacare is much more redistributive.
So this is a program that started as a partisan program, and
the question will become, can it, over time, grow into a program that
most Americans are comfortable with, that people see it working,
that people adjust to it, that people recognize that it's expanding coverage?
I believe that the jury is still out on that and we do not know yet, and that that
is why this will continue to be at the center of our debates in the coming years.
It is an opportunity for young people,
who have been largely absent in the debate over Obamacare, very much to be involved
on any side of it because I believe its fate has not yet been written in ink.
Okay.
Very briefly, I just want to mention that we often think about
the Affordable Care Act as only trying to expand health insurance coverage.
Actually, it's a massive law, a thousand-page law,
and it has many different goals.
Another goal, an area that I've been researching,
is the effort to improve the quality of healthcare.
We know that a lot of healthcare is wasteful,
that a lot of treatments have not been shown to be very effective.
We know that doctors, for example, don't always have the best information that
they need in order to determine what treatments work best.
One of the things that the Affordable Care Act does is tries to invest
new taxpayer money in research studies to learn what's the best treatment for
heart disease or diabetes or arthritis.
Because some studies suggest that half of all medical care in
the United States is not based on adequate medical evidence.
And that's one of the reasons why we spend more than any other country in
the world on healthcare and our results are not uniformly better.
We have a lot of waste in the system.
So, in addition to expanding coverage, another unanswered question is,
will we be able to eliminate some of the waste in healthcare?
Will we be able to get better value for our money so
that healthcare costs do not continue to rise, so that middle-class Americans who
are not receiving the, the raises from their employers that they would like
will begin getting better take home pay so that we can control healthcare costs?
Can we begin having a taming of the cost of Medicaid so
that we have more money to invest in education, in infrastructure, and
all the things that we need to do as a society to prepare for the 21st century?
At the center of our debate about healthcare is really then not only
about caring for patients, it's also about the future of our economy and
the future of our ability as a nation to care for our fellow citizens, but
in a way that is fiscally responsible.
So I will stop there and be happy to take some questions.
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