The Elections and Health Care Reform: The Uninsured Could Lose Big Time

Last Updated Nov 3, 2010 8:21 AM EDT

This post was updated on November 3, 2010.
The Republicans will now set the agenda in the House. The Affordable Care Act (ACA) could slowly be torn apart -- not by repeal, but by denying the money needed to put its provisions into effect. Rep. (and Speaker-to-be) John Boehner says, "They'll get not one dime from us."

Spending bills traditionally originate in the House Appropriations Committee. A Republican-led committee could refuse, or pare down, the money needed to implement the law -- for example, to provide staff, enable the design of state insurance exchanges, or subsidize policies for the middle class.

Favored groups would almost certainly keep the gains they've won from ACA. For example, seniors would continue to get extra subsidies for prescription drugs. Insurers could still be prohibited from capping the lifetime amounts they'll pay for essential health benefits. Young adults under age 26 might be able to stay on their parents' policies. Note that these changes expand coverage for people and families who have policies already.

Conservatives, though, are targeting the uninsured. Working people under 65, whose companies don't provide medical benefits, could lose their shot at getting health policies they can afford. The Census Bureau reports that 50.7 million people lacked coverage in 2009, an increase of 4.3 million -- nearly 10 percent -- over the year before. Millions more will lose benefits by the time this portion of the law takes effect (or is supposed to take effect ) in 2014.

There's something appalling about watching people with secure health insurance -- members of Congress, workers with company group plans and seniors on taxpayer-subsidized Medicare -- trying to block access for families who are uninsured. To borrow a line from Shakespeare, if you prick them, do they not bleed?

With a defunding strategy, "the nation would be left with zombie legislation, a program that lives on but works badly," says economist and health policy expert Henry Aaron of the Brookings Institution. Resentment and confusion would fester. Fewer people would be covered. A more competitive market for health insurance might not arise. A baby that could have lived will have been maliciously smothered in its crib.

In theory, Democrats should be reaping joy for setting America on the road toward covering its uninsured. But they didn't reckon on the persuasiveness of the lies that Republicans spread about ACA.

For example, they're scared seniors with claims that the law guts Medicare, when in fact Medicare beneficiaries are getting better coverage of prescription drugs. The law takes $555 billion out of future (not current) Medicare spending, mostly in payments to hospitals and other providers. Federal subsidies to private Medicare Advantage plans will be reduced, to bring their cost more into line with that of traditional Medicare. But spending overall will grow. Not a single traditional Medicare benefit has been cut.

Another election ad warned that the law means "higher insurance premiums for hard-hit families." In fact, families earning up to $80,000 will be able to buy coverage for less, thanks to the federal subsidies. For some of the gory details on the deceptive ads, look here.

The Republicans are also mounting a second challenge -- this one through the courts. They're fighting the part of the law that requires the uninsured to buy individual coverage in 2014 or else pay a fine. The lawsuit maintains that a federal mandate for health insurance is unconstitutional. The states could require it, as they do in Massachusetts, but not the federal government.

The Supreme Court probably has four votes for overturning this portion of health reform. The decision could boil down to what the fifth conservative justice, Anthony Kennedy, wants. If the court rules against the mandate, the current and future uninsured will be shafted -- again. They'll be right back where they started before the law was passed.

To cover all of the uninsured, everyone has to be in the pool. Premiums paid by people who are currently healthy will help pay the medical bills of people who get sick. But people in good health -- especially the young -- might not join the pool voluntarily. That's why there has to be a mandate. Without healthy people, the pool collapses.

The new law also prevents insurers from refusing to cover people who have had health problems in the past. The Republicans say they're for preserving this particular change. But they're either kidding you or don't know what they're talking about. Without healthy people in the pool, this part of the law collapses, too.

Two other aspect of health reform are drawing particular Republican ire. The lawsuit challenges the expansion of Medicaid for the working poor. And legislators have vowed to get rid of the Independent Payment Advisory Board, set up to study ways to save money on Medicare. That's right, it's a board created to try to slow down the increase in future federal spending. And yes, the "conservatives" are against it.

On the stump, you heard candidates hollering about the "government takeover of medical care." The government did exactly that in 1964, when it took over the job of providing coverage for another group of uninsured -- namely, older people. Insurance companies wouldn't sell them policies except at exorbitant rates. The government stepped in and created Medicare, which improved seniors' health and well-being and lengthened their lives.

It's particularly sad to see seniors now trying to deny this same chance to the middle-aged and young.

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