Readers of this blog and my tweets know that I am a passionate advocate for the Affordable Care Act, or Obamacare if you prefer. It isn’t that I have a Pollyannaish view of the law itself, or the tortured political process that produced it—far from it. The ACA is an imperfect law, created by imperfect people through an imperfect process, with imperfect results. After almost 34 years of experience in Washington advocating with Congress and federal agencies, no one needs to tell me about the difficulties involved in successfully legislating and implementing the kind of sweeping changes required by the ACA.
Yet, I will continue to fight for successful implementation of the Affordable Care Act, warts and all, and against efforts in Congress or by the states to undermine, block, defund or repeal it. Here’s why:
First, my employer, the American College of Physicians, supports the ACA, and I am professionally obligated and personally committed to doing everything I can do to advocate for the policies established by our Board of Regents. If I was unable or unwilling to advocate in support of the ACA, I would seek different employment.
Second, and more to the point, I am proud to work for a physician organization that has championed the cause of universal health insurance coverage for more than two decades now, and which today views the ACA as the best chance this country has had to ensure that nearly all Americans will have access to coverage. That the College would be in favor of a law that has the potential to expand coverage to up to 95% of all U.S. resident should have come as no surprise to anyone who has followed ACP policy.
In May, 1990, ACP said that, “A nationwide program is needed to assure access to health care for all Americans, and we recommend that developing such a program be adopted as a policy goal for the nation. The College believes that health insurance coverage for all persons is needed to minimize financial barriers and assure access to appropriate health care services.”
In 1992, the College editorialized in the Annals of Internal Medicine that, “No one should go without medical care for lack of money. As physicians, we struggle daily against the chaos of illness and injury, whether in the context of clinical, laboratory, or administrative practice. We try our utmost to restore or to preserve health, yet the lack of access to care for many Americans increasingly frustrates our best efforts. In this issue of Annals, the American College of Physicians proposes a plan to ensure high-quality care for everyone.” The editorial was accompanied by a policy paper that proposed specific policies to achieve universal coverage.
ACP later went on to support the Clinton health care plan, and after that plan failed to get through Congress, promoted incremental steps to expand coverage. Then, in 2002, ACP proposed its own plan to get everyone covered through tax credit subsidies to buy private health insurance plans offered through state marketplaces and by expanding Medicaid to everyone below the federal poverty level (sound familiar?), phased in over seven years. ACP’s plan was the basis of bipartisan legislation introduced in consecutive Congress’s by Senators Jeff Bingaman (D-NM), Steve LaTourette (R-OH), and Marcy Kaptur (D-OH). ACP’s proposal was updated in 2008 to recommend giving the states more options to develop their own plans for universal coverage. Then, in February, 2009, ACP called on newly elected President Obama and the 111th Congress to “provide affordable and accessible health care to all Americans.” On January 15, 2010, ACP offered Congress detailed recommendations on the bills making their way through Congress to deliver on President Obama’s commitment to enact guaranteed coverage for all Americans, which later became the Patient Protection and Affordable Care Act (Affordable Care Act). One month before the ACA became law, ACP issued a statement of overall support for the bill, citing the many specific policies in it that were aligned with the College’s own policies.
The version of the Affordable Care Act that passed Congress a month later was almost identical to ACP’s own proposals, going as far back as 2002, to expand Medicaid to all persons at or near the federal poverty level, to require that large employers provide coverage, and to provide tax credit subsidies for people to buy qualified coverage through state-run marketplaces.
So why, then, do I fight for the ACA?
Because it is the position of the American College of Physicians—developed over many decades of analysis, and consensus--that every American should have guaranteed access to health insurance coverage, no matter where they work or live or how much they earn.
Because universal coverage is a moral and medical imperative.
Because the ACA comes close to providing universal coverage.
Because the ACA’s key policies, including tax credits to buy qualified health plans and Medicaid expansion, are identical to the College’s own proposals.
Because if the ACA fails, we will have turned our backs on the tens of millions of our fellow Americans who are at greater risk of living sicker and dying younger, simply because they lack health insurance.
Oh, and one more thing:, this is personal. I have spent my entire professional life fighting to expand coverage for the uninsured, only to see it fail, time and time again, because of unrelenting political and ideological opposition. I first started working as an advocate for internal medicine at the American Society of Internal Medicine in January, 1979. Since then, I have seen the cause of universal coverage fail under successive administrations and congresses. I have seen it fail despite all of the well-meaning reports and commissions that challenged us to do better. I have seen it fail as the number of uninsured has grown, year after year, decade after decade. I lived through the debacle of President Clinton’s failure to achieve universal coverage, and then I saw it put aside for another 16 years, until President Obama vowed to try again. I lived through the contentious debate preceding the ACA’s enactment in March, 2010. I am living through the ongoing political wars to block, defund, or repeal it. I am living through the challenges created by the law’s troubled implementation.
But if I have any influence whatsoever, I am not going to watch it fail this time, not when we are so close to providing affordable coverage to nearly all Americans, the moral and medical imperative described by the American College of Physicians almost a quarter century ago.
Today’s questions: Is the ACA worth fighting for? Why? Or why not?