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Five Years In – How’s the Affordable Care Act Doing? A Diagnosis


Five Years In – How’s the Affordable Care Act Doing? A Diagnosis

Carl Finamore

Hard to believe it’s been five years since Congress passed the Affordable Care Act (ACA) on March 23, 2010. The bloviating, vein-popping right-wing still goes ballistic at mere mention of the word Obamacare.

Still, putting aside their senseless distortions and diatribes, not too many of us have cause for celebration except perhaps the top brass from the 1300 or so private health insurers who are raking in enormous profits - health care stocks soared by almost 40 percent in 2013, the highest of any sector in the S&P 500.


As if it weren’t obvious already, 99% must reject any politician who does not support Single Payer healthcare for all. Because almost every politician from the Democrats, Republicans and the Tea Party would never ever dare to disucss this option because of the backlash of corporate sponsorship towards their campaign, voters usually have no viable option available to vote against the status quo. As Thrid Party’s are slowly becoming outlawed so as to prevent a popular outsider from rocking the corporate boat, Americans are suddenly realizing that no one out there represents their interests. If we’re going to discuss “grass roots” organizing, then we have to focus on abandoning the mainstream parties all together, or else all the organizing in the world won’t help us break free from this corporate stranglehold of our government. Perhaps a new party that focused on nothing except universal healthcare, may be the only way Americans can move away from their perpetual reinforcement of their own enslavement as such a party would expose the contradictions between a corporate agenda and the public interest.


Far too many people are just unable or unwilling to question the very premises of that “market based model”.

This is not rocket science… When PROFIT is the motive the health of the individual is not important. Indeed when profit the underlying rationale for providing “health care” the sicker the population, the greater the profits.

That same “market based system” premised on delivering profits to the Capitalists, poisons our water and our air. It destroys our ecosystems. It dumps chemicals and radiation into the environment which we are subject to each day.It bombards us with radio waves and destroys our food supply with GMOs and preservatives and pesticides and other contaminants all because it “profitable” to do so.

That “market based system” premised on the profit motive is making us sick so why on earth would any person think it can make us well?

Now add to that the fact that Obamacare has nothing to do with health care but everything to do with Insurance and is it any wonder it a mess?

Single payer is certainly a start , but if it does not lead to Governments reexamining their roles in ensuring the food we eat, the water we drink and the air we breath is not making us ill , it too is a dead end …


Health insurance companies are the perfect corporate form of parasite: they have zero function except to stand between the provider and patient, and manipulate the system so as to absorb some of the money that exchanges hands between these two. If you add co-pays and deductibles to the insurance premiums being charged, essentially individuals are donating thousands of dollars to these leeches free and clear, in the hope that they will at some time obtain some benefits. ACA forces people to donate money under threat of punishment. It’s an effective rip-off scheme.


Strategy Notes: Even when you say you want “Medicare For All”, be careful what you ask for. We on Medicare also have deductibles and co-pays. Yes, that’s right! Medicare is coverage for catastrophic illness, and even that, only up to a point. We PAY for Medicare Part B, over $100/month now, to cover visits to the doctor and some medical procedures like x-rays, but we get co-pay bills. Medicare coverage for prescription drugs is so dismal that Part D was started just for that and to keep Big Pharma fed. Nursing home care isn’t fully covered, so we have to give up our homes if we own one, to qualify for Medicaid to cover the rest of costs.

Note that the disabled have chronic conditions and live on fixed income that is often at or near poverty levels, but until medical bills hit a high mark, and until we own almost nothing except maybe an old car, we can’t qualify for Medicaid in many states, to supplement and cover the co-pays. Most of us pay more than half our meager income on housing, and rely on food banks. How likely is it we’ll add a doctor’s bill to that, if we can at all avoid it?

We the elderly and disabled on Medicare are not wholly satisfied with it, either. Our high satisfaction ratings are mostly gratitude for not being stuck with the whole bill. Most doctors won’t take new Medicare patients because they feel they aren’t paid enough. We often have to travel far, just like veterans, to get to a community clinic to lower our costs - that’s if our disability doesn’t make travel too painful.

Want more support for single payer? Start addressing the shortcomings in Medicare as-is. Put a limit on out-of-pocket expenses to a very, very small percentage of what’s left of our income, at the very least. Stop the privatization of Medicare billing via “managed care groups” - another ploy to funnel even Medicare patients into for-profit care.


The headline for this article should contain the words “We Told You So.” Virtually every prediction of the problems to expect with the ACA has come true.

Good job on this article.



10 years ago, I was advised that the argument for Single-Payer would sell itself on economic terms. No need to talk about healthcare as a human right, no need to “preach” at people because that is a turn off. That was bad advice. Economic arguments are obscure and most people will not believe that a truly inclusive plan, “everybody in nobody out” will not end up costing them more. The notion that market driven competition is the best way to control costs is so ubiquitous that it is cited as self evident truth.

What moves people and creates conviction are moral arguments. The moral argument of the right is that universal care creates freeloaders who burden others. The answer to that is that any serious illness can reduce any but the richest of us to poverty and we need broadly based social insurance to protect us from the contingencies of life. I don’t hear that argument or any other valid responses being made in support of Single-payer. As a result we are losing on the moral battleground and those who should be our allies tell us to settle for ACA as the best we can do. If we want Single-payer to prevail we have to present it front and center as a battle for human rights. One high standard of care for all and financed by all parts of our economy according to ability to pay. Next we have to want it as badly as the civil rights movement of the 60’s fought for its goals. We have to be very organized and counter culture to have a hope of achieving this. We have to be able to put out of office politicians who will not go along-and that means most politicians now in office. The question for us is not how well the ACA is doing, or whether it will eventually go into a death spiral. The real question is how badly do we want Single-payer to prevail and my estimate is that we are moving backwards. The ACA is a palliative for a broken and unjust system and not enough of us care to make things right.


The shortcomings of “Medicare-as-is” are addressed in HR 676, The Expanded and Improved Medicare For All Act. Summary here.

No copayment or deductible would be allowed for any medically necessary service, procedure or product. That amounts to about 80% of all individual out-of-pocket healthcare spending. This would significantly reduce out-of-pocket expenses for everyone, senior citizens included.

Wasteful and inefficient supplementary programs like MediGap, Medicare Advantage, and Part D drug plans would be eliminated. Privatization schemes in Medicare…and Medicaid…that erect financial barriers to care and foster the commodification of patients in need would be eliminated in converting to a nonprofit healthcare system. Retiree health benefits would be unnecessary. Employer provided health benefits would be unnecessary. An individual’s contribution to the system would be based on income…progressive taxation. The bottom 40% would contribute between 3% and 4% through a payroll tax. The top 60% between 6% and 8%. Household incomes over $225,000 would pay an additional surtax between 6% and 8%. Capital gains would be taxed between 6% and 8%. (If a financial transaction tax is employed, these percentages would be set to their minimums. See Freidman’s funding proposals here [PDF].) Using Freidman’s favored funding proposal, 95% of American household would see significant increases to net income the very first year. (See Figure 2, page 6.)

Currently, about a quarter of Medicare beneficiaries have out-of-pocket medical expenses amounting to around 20% of their income. Imagine reducing that by 15%. By converting to a nonprofit healthcare monopsony, doctors would not have to choose whether they accepted Medicare patients or not, and would have a much more active role in determining disbursement rates and improving quality. Effective cost control methods inherent in a Single Payer system can only benefit healthcare professionals in the long run as they realize a more meaningful, less subservient role in shaping our healthcare system.


Thank you leftover. I’ll follow those links.


PNHP.org is a treasure trove of information on Single Payer healthcare. See their front page for links to FAQs and such.


I disagree. The moral argument…the healthcare-as-human right argument…has failed…repeatedly.
Back in 1990s, the economic argument indeed prevailed. The result was a Medicare-for-All approval rating in the high 60s. Since the Clinton Era, the economic argument has been consistently, and effectively, marginalized by neoliberal politics involving players on both sides of the aisle. Now, after 20 years of the moral argument, the public approval rating for Single Payer/Medicare-for-All wavers around 50%…on a good day. Cosponsorship of Conyers’ perennial introduction of HR 676 has shrunk as well.

The moral argument factionalizes voters. It fractures the solidarity needed to galvanize the public support necessary to build a political coalition to push Single Payer through Congress…and the White House.
The economic argument…
–saving hundreds of billions of dollars in wasteful government spending every year…
–putting real money back into the pockets of 95% of Americans…
–taking healthcare benefits off the negotiating table between employers and employees…
–using proven methods to control costs and improve quality…
–generating enough surplus capital to significantly reduce, or even eliminate the deficit…without cutting other social programs or interfering with military budgets…

…has not been effectively communicated to the public.

The best argument against continuing for-profit healthcare, the argument needed to convince Obamacare® supporters first and foremost, is the economic argument. Remember…it’s Obama who lies when he says ObamaCare® is “making sure every American has the security of quality, affordable health care.” (Knox College 2013.) It’s Obama who denies the existence of an alternate plan based on proven economic principles rooted in socially responsible long-term fiscal policy. It’s Obama apologists that need to change their tune.

In these times of a disappearing middle class, stagnant and regressive wages, growing income/wealth disparity exacerbated by consumer debt, a plan to put real cash back into the pockets of working Americans by giving them the universal healthcare they want must be exploited to the utmost degree. Who doesn’t want to save money? Single Payer financing is actually fiscally conservative. Conservative spending. Liberal Benefits. Aannnd…it strikes a blow against corporatist dominion over the markets and in government. Win-Win-Win.


Yes, the moral argument divides but if you think that the economic argument is convincing I’d like to know who you are talking to. My opinion is that those who are unpersuaded by economic arguments are the very ones who oppose it on moral grounds and do not believe healthcare should be a human right. I wish you were right that there were a large number of individuals who are morally neutral but receptive to economic arguments. All I can say is that in my years of Single-payer advocacy I haven’t found morally neutral but economic persuadable people.


All true. But the current system is morally reprehensible. I find it a bit troublesome that churches cannot muster the moral courage to take public positions addressing the disease.


As I said, the economic argument has not been effectively communicated to the general public. In his six part series examining public attitudes toward Single Payer, Kip Sullivan discovered, among other things, that when pollsters did not clearly explain the economic benefits of Single Payer proposals, support among respondents faltered.

When was the last time, in your experience as a Single Payer advocate, do you remember a CBO/JCT score on Single Payer proposals before Congress? There’s been none since the Clinton Era. Since Gerald Friedman’s funding proposals were published? None. Congressional leadership has consistently avoided the economic argument for decades. Why? Because they know if voters were adequately informed on the cost/benefit analyses…something a little more detailed than “Single Payer saves money…look at Canada!”…they wouldn’t tolerate the ongoing neoliberal privatization of our healthcare system.

Where in the media…even in Finamore’s article…is there any explanation of Single Payer financing? Finamore cites Single Payer advocates, but not one sentence on how Single Payer financing would work, what makes it different from ObamaCare®. Why? Where, in the national media, is there any reporting of the ongoing support for Single Payer in organized labor, (most recently in Tennessee)? It’s not the moral argument that appeals to the rank and file. It’s economics, plain and simple.

Nobody is “morally neutral” on universal healthcare. The American public has always supported it on moral grounds. In fact, if you look at Healthcare Tracking Polls from Kaiser, people appear to be getting tired of hearing about it. Raising the “Human Rights” banner politicalizes the moral argument, resulting in a counterproductive “Us vs. Them” attitude that produces nothing but stagnation.

I live in a Red State…a notoriously Red State. Politicians opposed to healthcare reform here consistently resort to the moral argument to defeat efforts to expand access to healthcare. (Except when it’s their healthcare, which is administered through a system that more closely resembles nationalized healthcare, like that in the UK, than Single Payer.) This forces response from healthcare reform advocates that marginalizes any debate on cost/benefit analyses.

The moral argument has dominated the debate on our healthcare system for decades. That’s exactly what opponents to Single Payer want.


Organized religion, by and large, has consistently supported universal healthcare in one form or another. What obscures their support is the moral argument, particularly concerning women’s reproductive healthcare within the sphere of medical necessity.

The more neoliberal political opportunists exploit public support for less restrictive access to reproductive health services to build acceptance of their brand of reformism, the more organized religion is perceived as backtracking on that general support.

The Catholic Church in America, for example…fierce opponents of reformist exploitation of women’s reproductive healthcare…has formally supported universal healthcare since 1919.


SP, part of the Green party platform … GP candidates show up on ballots - vote for them …


Agree and disagree …

Agree that it is important to make the economic argument - so who do you propose to make it? SP proponents have been making that argument - much of the work done on it has come from PNHP … but don’t be so sure that fleshing out the financing plan would make converts - it certainly didn’t in VT … the devil is always in the details - increased payroll taxes will be opposed by small business and even by those who SP might most benefit - folks just eking by paycheck to paycheck who say “I can’t afford the gov’t taking any more out!”

Disagree that it is not important to make a moral argument - often it is the moral argument that makes folks willing to part with their money when naught else will - I am curious, what “moral argument” is made in your Red State to oppose it?


Agree there are problems that need to be fixed, but you have to remember that it is currently in the hands of a gov’t whose handlers - both Ds &Rs - are pretty much committed to gutting it, but are too afraid to do it outright because of it’s popularity, so they chew away at the edges, making it less and less useful to the beneficiaries, to the point where support for it may be small enough that it can be dropped altogether in favor of the “market approach” …

The best thing to do is vote only for those who are truly committed to it - pretty much leaves out D/Rs …


Well stated. We seem to jump to the conclusion that single-payer is the cure without speaking to the opportunity costs of a system that costs twice what it should while still maintaining to exclude millions from care. Even if we included everyone but kept the same level of spending (17-18 % GDP), the system would maintain its outlier status. Extracting at least a trillion dollars a year through overcharging pretty much precludes solving other problems (education, retirement, etc.) that require investment. With respect to churches, I draw a distinction between statements of principal made once or twice and a serious ongoing conversation. The National Catholic Reporter makes the same point with respect to the Pope’s position on equality and the lack of movement by the Bishops (NCR 11/11/2014: Will Catholic bishops start talking about income inequality?) Practically speaking all churches must weigh the economic ramifications of speaking out. After all, money buys the government too.


Single Payer advocates have to more forceful explaining the details of the economic argument. PNHP and other Single Payer advocates, when they visited the Hill last year to lobby for HR 676, made no mention of calling for a CBO/JCT score on Friedman’s funding proposals. As far as I know, they didn’t even call for Conyers et al. to formally adopt Friedman’s proposals. (Might have changed in the new version…haven’t checked that out yet.) The best way to get more expanded media coverage of the economic argument is with a CBO/JCT analysis. A GOA projection wouldn’t hurt either. The Congressional leadership who allege support for HR 676 are the only ones who can get that done. Advocates need to turn up the heat. We need to turn up the heat on advocates. As far as I know, no Single Payer advocacy group, in publicizing their ongoing strategy for advocacy, have mentioned any call for political accountability. Some detailed coverage from folks like CD would be nice to see.

As I read Friedman’s proposals, the increase in payroll taxes would apply only to individuals. The existing taxes on businesses earmarked for healthcare programs would remain the same. Also, keep in mind that removing the cost of providing healthcare benefits to employees is a significant benefit to employers…large and small. The 3% to 8% increase in payroll taxes that provide workers with universal health care is still less than the 9.5% ObamaCare® defines as “affordable” for limited health insurance coverage. Add to that the elimination of cost sharing…co-payments and deductibles…which has increased at a faster rate than insurance premiums…and a Single Payer system becomes even more attractive to workers, regardless of their political leanings. When it’s explained to taxpayers that any increase to payroll taxes is more than offset by what they pay out-of-pocket for premiums and cost sharing, they begin to smile.

The moral argument has already been decided. Americans support expanding access to healthcare. What they need to know is that doing that can put more real money…after tax income…into the pockets of 95% of Americans.