Douglas Hough
Point-counterpoint on Obamacare:


Douglas Hough
John Geyman

John Geyman

Even before the Supreme Court took up the Affordable Care Act, Obamacare was a polarizing plan, with fierce opposition and rabid support.

During its short life, it withstood a legal challenge in 2012 before the Supreme Court, a partial government shutdown over the issue in 2013, and several votes by the Republican-controlled House to repeal it, and that doesn’t even include the latest ruling by the high court.

The Supreme Court’s ruling will only add to the argument that Obamacare is the most controversial piece of legislation in decades, and the most impactful.

Below are two experts who give pro and con opinions on the Affordable Care Act.

Obamacare has had a positive effect on Americans

By Douglas Hough

Douglas Hough

One prediction by Obamacare opponents has been that increases in required coverage will force health insurance premiums to soar. It hasn’t happened.

— Douglas Hough, associate director of the MHA Program at Johns Hopkins University’s Bloomberg School of Public Health

Obamacare is the program that Americans love to hate. Since its passage, the Affordable Care Act has been unpopular. Tracking polls by the Kaiser Family Foundation have found that support for (and opposition to) the law has fluctuated between 33 and 53 percent, with no real trend.

At the same time, Americans have expressed strong support for many specific provisions of the law, including banning insurers from denying coverage for those with pre-existing conditions, allowing children to stay on their parents’ insurance plan until age 26, and requiring companies with 50-plus employees to offer health insurance.



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Opponents have painted the ACA as a giant step toward socialized medicine, a job killer as small businesses refrain from growing above 50 employees to avoid having to offer health insurance to their workers, and an affront to individual liberty through the individual mandate to purchase health insurance. However, as behavioral psychologists and economists have demonstrated, events rarely play out as dramatically as people expect. So, Obamacare will never be as bad as opponents fear or as good as supporters hope.

Nevertheless, I would argue that Obamacare has, on net, been good for Americans. Here’s why.

Now, 11 million Americans who were uninsured have health insurance. The percentage of Americans who are uninsured has fallen from 18 percent to 12.9 percent, the lowest ever recorded. This is the true bottom line. Despite massive problems with the enrollment website and the intransigence of 22 states in not expanding Medicaid, the program has worked. To deny that, is to deny reality.

The increase in health care costs has slowed. Despite predictions that the ACA would accelerate health care inflation, just the opposite has happened. Government actuaries have determined that health care spending has slowed by 0.5 percentage points. PriceWaterhouseCoopers estimated that the growth rate of health care expenditures will dip even more in 2016. Costs are not going down, but the cost curve is being bent.

One prediction by Obamacare opponents has been that increases in required coverage will force health insurance premiums to soar. It hasn’t happened (although some individuals have seen their premiums increase dramatically). A study by the Commonwealth Fund found that premiums for employer-sponsored, single-person health insurance plans rose 5.1 percent per year from 2003 to 2010, but only 4.1 percent from 2010 to 2013.

Employers are not abandoning the health insurance market. A survey late last year by the Employee Benefit Research Institute and the Society for Human Resource Management found that only 1 percent of employers were planning to drop health benefits for their employees in 2015, with no difference between large and small employers. Employers were changing benefits structures (such as higher deductibles and copays), but these were trends that were evident long before Obamacare.

Providers are being forced to become more efficient. Obamacare has catalyzed a movement to transition the health care delivery system from one that is paid based on volume (number of visits, procedures, hospitalizations) to one that is paid based on “value” (outcomes, patient satisfaction, population health). For instance, Medicare is no longer paying for re-admissions of beneficiaries within 30 days of initial discharge. As a result, re-admissions have dropped from 19 to 17 percent.

This trend could revolutionize the industry by shifting the focus of physicians and hospitals from treating the sick to keeping people well.

People are taking more responsibility for their health care. Here is the true irony in the debate over Obamacare. The individual mandate that everyone must buy health insurance is the touchstone for opposition to Obamacare and is the one component of the law that has spurred the sale of torches and pitchforks. The irony is that the individual mandate is a conservative idea.

In 1989, Stuart Butler of The Heritage Foundation presented “The Heritage Plan,” which included as one of its four major components: “Mandate all households to obtain adequate insurance.” This idea was based on two principles: “Health care protection is a responsibility of individuals, not businesses,” and “there is an implicit contract between households and society, based on the notion that health insurance is not like other forms of insurance protection.” That is, “each household has the obligation, to the extent it is able, to avoid placing demand on society by protecting itself.”

The concept was integral to two bills introduced in Congress by Republicans in 1993, and to the health care reform bill enacted in Massachusetts during the governorship of Mitt Romney.

The conservatives got it right — for a reason that they did not consider. By requiring people to buy health insurance when they are healthy and not thinking about potential illness, they will be better off in the long run from their own perspective. Thus, an individual mandate is actually what economists call “welfare enhancing” rather than welfare reducing.

Obamacare is not perfect. It has many inherent flaws, like not addressing the hard issue of reducing health care costs, and the rollout has been rocky. But, on balance, the Affordable Care Act has made Americans better off.

Douglas Hough is a guest author for Bankrate. The views, opinions and positions expressed by this guest author are those of the author alone and do not represent those of Bankrate’s. The accuracy, completeness and validity of any statements made within this article are not guaranteed. Guidance contained in this article is general and broad in scope, intended only to assist you with financial decisions. Because this article does not consider your personal financial situation, Bankrate recommends that you seek the advice of financial, accounting and legal advisers who are fully aware of your individual circumstances before making any final decisions or implementing any financial strategy.


Obamacare has been a failure for Americans

By John Geyman

John Geyman

Obamacare is good for corporate stakeholders and Wall Street, but bad for ordinary Americans. We urgently need more fundamental health care reform.

— Dr. John Geyman, professor emeritus of family medicine at the University of Washington School of Medicine in Seattle

Supporters of Obamacare, the Affordable Care Act, correctly argue that it has done some good things since its passage five years ago, including dropping the uninsured rate from 18 (percent) to 12.9 percent, allowing some 11 million Americans to gain health insurance through the new health insurance exchanges or Medicaid expansion, providing limited reforms of the insurance industry (especially the elimination of pre-existing conditions as a reason for denial), and allowing parents to keep their children on their policies until age 26.

But it is failing to meet its promises of cost containment, affordability and improved quality of care. It will never assure coverage for all Americans and is unsustainable in the long run. It is flawed by political compromises and trade-offs from the beginning that favor corporate stakeholders in the medical-industrial complex over the needs of patients and their families.

Major reasons for failure and unsustainability

  1. Though improved for some, access to care remains inadequate.

    Private insurers have narrowed networks across the country to the point that millions of people have to change physicians and hospitals, breaking up continuity of care. Out-of-network care creates financial hardships for many patients.

    About 4.3 million people remain without Medicaid in 22 states that opted out of Medicaid expansion. Because of low Medicaid reimbursement, a third of U.S. physicians in 2012 didn’t accept new Medicaid patients. Given the best case for the ACA, 26 million Americans will remain uninsured in 2019.

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  1. The ACA does not control health care costs.

    There are no significant price controls under the ACA. Insurers still have wide latitude to set premium costs and cost-sharing requirements. Hospital systems are expanding and consolidating. With increasing market shares, they can set their own prices and are gaming the system by up-coding reimbursement of services delivered.

    The drug industry was helped by the ACA’s ban on negotiated drug prices and imports of drugs from other countries. The cost of specialty drugs, such as those for cancer and hepatitis C, is going through the roof. For-profit emergency rooms are being set up all over the country with increasing profit margins. Federal subsidies to insurers, as a major cost to taxpayers, will total more than $1 trillion between 2015 and 2024.

  2. Health care costs are still unaffordable for most Americans under the ACA.

    Even for the many people newly insured under the ACA, insurers impose increasing cost-sharing through deductibles, copayments and out-of-pocket costs that leave many insured unable to afford necessary health care.

    According to the Commonwealth Fund, almost one-half of Americans in 2014 said they have trouble affording health care. A recent study by the Pew Research Center has found that 55 percent of households are “savings limited,” with less than one month of their savings liquid. Some 43 million Americans have an account in collection for medical debt, and almost 2 million (mostly insured) Americans go bankrupt every year because of unpaid medical bills.

  3. Despite its promises, the ACA has not yet significantly improved quality of care in the U.S.

    Although we spend twice as much on health care as most advanced industrial countries, we have worse outcomes than most, due to lack of universal coverage, care forgone due to access barriers, shortages in primary care, insufficient scientific rigor in assessing services and drugs that are brought to market, and an out-of-control health care system committed to profits over service to patients.

    We now have an epidemic of underinsurance, with insurers permitted to sell limited benefit policies with little actual coverage. The so-called “value-based payment systems” being developed under the ACA are mostly rudimentary process measures unrelated to health care outcomes.

    Electronic health records, encouraged by the ACA, have been disappointing in terms of their impact on quality of care, with vendors customizing their systems to competing users that don’t talk to each other. The Patient-Centered Outcomes Research Institute (PCORI), established by the ACA with the intent to oversee and set guidelines for urgently needed comparative effectiveness research, was hobbled from the start by its lack of clout in setting coverage and reimbursement policies without buy-in from corporate stakeholders.

  4. Excess bureaucracy and waste with the ACA.

    The bureaucracy of the ACA, dealing with some 1,300 private insurers competing in newly expanded, subsidized private and public markets, churning of coverage from year to year and ongoing problems in determining eligibility for coverage and subsidies, has become an administrative nightmare for patients, physicians, taxpayers and the IRS, even as the use of electronic health records has become widespread.

Summing Up

In short, Obamacare is good for corporate stakeholders and Wall Street, but bad for ordinary Americans. We urgently need more fundamental health care reform. There is a simpler, more efficient, affordable and fairer fix — a single-payer system of universal coverage for all of comprehensive care of proven value, improved Medicare for all — with full choice of physicians and hospitals, coupled with a private delivery system, financed with progressive taxes, costing most Americans and employers much less than they now pay.

Dr. John Geyman is a guest author for Bankrate. The views, opinions and positions expressed by this guest author are those of the author alone and do not represent those of Bankrate’s. The accuracy, completeness and validity of any statements made within this article are not guaranteed. Guidance contained in this article is general and broad in scope, intended only to assist you with financial decisions. Because this article does not consider your personal financial situation, Bankrate recommends that you seek the advice of financial, accounting and legal advisers who are fully aware of your individual circumstances before making any final decisions or implementing any financial strategy.


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