A year after the passage of the Patient Protection and Affordable Care Act, even supporters of the reform legislation are second-guessing what might have been had it been shaped a bit differently. Opponents, meanwhile, are seizing on the Administration's waivers of certain provisions to claim that that this shows what a monstrosity the ACA truly is.
Of course, that's twaddle. The ACA does have shortcomings -- many of which I explained in this space while it was all coming together. But, like ex-union boss Andy Stern, I agree with Joe Biden that the reform law is still a "big f---- deal," and that its full implementation will transform U.S. healthcare.
One of the more surprising second-guessers is Sen. Max Baucus (D.-Mont.), who said he wished there were stronger cost controls in the reform law, because the lack of them has given ammunition to the ACA's detractors. Baucus, of course, is the chairman of the Senate Budget Committee, which did more than any other Congressional committee to carve the legislation into its current form. He, as much as anybody, should be aware of the intense special interest lobbying that made cost control so problematic.
Then there's the ever-popular (on the left) public option. Lefty comedian Bill Maher said on his HBO show that he wished President Obama, during the reform debate, had been as ballsy as Wisconsin Gov. Scott Walker has been in trampling on public-sector unions. If Obama had proposed a government-run, single payer system, Maher said, perhaps he could have gotten the other side to compromise on the public option.
Washington Post blogger Ezra Klein, one of Maher's guests, wasn't buying it. If Obama had even whispered the term "single payer," Klein said, reform would have been DOA (again).
Second-guessing has not been confined to the Democratic side. The Republicans believe it's politically smart to attack positions they previously supported when the Obama Administration takes those same positions.
For example, the administration has granted waivers to 1,000 mini-health plans that cover 2.6 million people so that they don't have to provide coverage worth at least $750,000 this year, as the ACA requires. The government has also granted a waiver to Maine so that insurers operating in that state don't have to spend at least 80 percent of individual insurance premiums on health care. Other states are angling for similar waivers. Previously, the Republicans favored these policies; now they say it shows the law is flawed because it requires so many exceptions.
The Republicans have also argued that the reform law is a federal usurpation of states' rights. But when Obama proposed recently that states be allowed to opt out of the ACA's core provisions if they could find a way to cover as many people without raising government costs, Republicans immediately rejected the idea. While they welcomed the flexibility for states, they said that the proposal still required them to achieve the goals of a "flawed" statute, such as near-universal coverage at what the Republicans say is an unaffordable cost.
Well, the law does have problems. Some waivers, for example, were necessary because issues like mini-plans weren't considered during the reform debate. Some individual plans were "grandfathered" so they didn't have to accept children with pre-existing conditions. And the federally financed, state-administered high-risk pools for people who are deemed uninsurable have attracted far fewer takers than anticipated. That's probably because they were inadequately funded, so insurance in them costs too much.
But, despite these drawbacks, I still believe that the ACA -- when viewed in its totality, including the many provisions dealing with reform of the healthcare delivery system -- is going to have a very large and a mostly positive impact on healthcare. It will be several years until these effects are fully felt. But when they are, we'll be very glad that the Democrats stuck to their principles (after swallowing some unpleasant compromises) and voted for healthcare reform.
Image supplied courtesy of Wikimedia Commons.