We do not want to go back to sham health insurance plans and denials

Obamacare isn’t perfect, but it’s better than what we had—and what the GOP proposes.

In 2006, I had to try to find health insurance for my son who was no longer eligible to stay on my employee health plan. I went to eInsurance, a website that proudly claimed it was easy to use to compare relevant insurance plans. It was, indeed, easy to use. Put in a few relevant facts—age of the person seeking insurance, location, use of tobacco, and a few other data points—and a spreadsheet came up with a range of plans, including costs. There were thumbnail sketches describing each plan, what was covered, co-pays, etc.

Then-President Barack Obama meets with doctors at the White House.

I was exultant—until I looked at the options in more detail. What I discovered was that finding a health insurance plan was like buying a mattress. If you have ever tried to buy a mattress, you know what I mean—you could go to Bloomingdales, Macy’s, or any of the then-extant department stores or mattress ones and try to compare prices and features and discover that Sealy or Serta or Simmons gave each store different names for their products, making the comparisons impossible.

It was, for health insurance, a maddening experience. If one wanted, for example, to compare mental health coverage—what was covered, how many visits to a psychiatrist or other professional, what the limits were, and so on—it was impossible to decipher. The same for other ailments, for what it meant if one went out of network, what the limits were for hospitalization, and more. And each plan had a “preexisting condition” feature and lifetime limits on coverage amounts. If one got a deadly ailment that required hospitalization or intensive care for a long time, with costs mounting to the millions, busting the lifetime cap, bankruptcy was a near certainty.

The horror stories—such as people denied coverage for care because the insurer claimed that the applicant had not disclosed a preexisting condition as trivial as an ear infection—were legion, and most individual bankruptcies cited medical debts more than any other cause.

Enter the Affordable Care Act, which drew on plans first crafted by conservatives at the Heritage Foundation in the late 1980s. A key was broadening the risk pool to make sure that the mix of healthy and sick people would provide a cushion to lower premium costs by not discriminating on the basis of health—a core principle for fair insurance. And it used capitalism to call for a marketplace—an insurance exchange with a real and easy capacity to compare apples to apples in plans, not apples to tangerines, such as I experienced on eInsurance. This was laid out in a 1989 Heritage study “Assuring Affordable Health Care for All Americans,” with the ideas coming from smart conservative economist Stuart Taylor.

The Heritage ideas were first embodied in a Massachusetts plan often called Romneycare, after its champion, then-Gov, Mitt Romney, enacted in 2006. The next year, as he launched his first presidential campaign, Romney discussed the plan at an American Enterprise Institute World Forum event I attended. It was impressive—a plan built on a statewide insurance exchange with comparable coverage and guaranteed issue, meaning no denial for preexisting conditions. And it added subsidies for poor residents, partly through Medicaid, and an individual mandate with modest penalties for those who could afford to pay but didn’t get coverage, to make the broadest risk pool possible. Romney was very proud of the plan and what it accomplished.

Barack Obama’s Affordable Care Act was built on that plan and the Heritage model—to gain broad bipartisan support. It looked at the outset as if that would happen—until, after months of discussion, Sen. Mitch McConnell (R-Ky.) put the kibosh on Republican buy-in to block any accomplishment for Obama and the Democrats. In the end, as we know, not a single Republican voted for the plan, which had all the bones of the original conservative framework.

I will not go through the details and machinations of Obamacare’s genesis and ultimate passage—readers can read my 2015 Atlantic piece for that. Thanks in part to the drive, brilliant leadership, and perseverance of Sen. Harry Reid (D-Nev.) and Rep. Nancy Pelosi (D-Calif.), the law passed by an eyelash. A public option alongside the private plans in the exchanges would have made an even bigger difference. But Senate Democrats needed every single one of their 60 members to overcome the McConnell-led filibuster against the ACA, and Joe Lieberman (I-Conn.) demanded the public option be stricken.

Obamacare was far from perfect. It was a series of compromises, an inevitable part of the legislative coalition-building process made more difficult by GOP intransigence. And it was not a complete overhaul of the American system of health coverage but an add-on to an already jerry-rigged system of public and private components, with deep imperfections and variations across states.

But it was also transformative, dramatically reducing the number of uninsured, which also relieved pressure on hospitals who had to cover many of them in emergency rooms, providing a safety net for people who developed serious health issues by mandating core coverage and taking away the preexisting condition obstacle, and limiting medically driven bankruptcies. And, in a provision added to the ACA by Sen. Al Franken (D-Minn.), based on Minnesota’s experience, insurers were required to devote 80 to 85 percent of the revenue they got from their customers directly to their care or refund the unused portion. In the first four years, that meant $2.4 billion in rebates to the insured.

After the passage of the ACA, Republicans were left with no good ideas. Their good ones were already incorporated in the ACA. So along with lies—“death panels”—they resorted to ad hominem attacks on Obama. The plan was unpopular at the time, both because the name Obamacare was radioactive for tribal Republicans and because of the lies during its corrosive debate and after. After Obama left the White House and the lies proved to be just that, the program gained dramatically in popularity. Suddenly, people without insurance could get it, people who lost employer-provided insurance and had to turn to expensive COBRA plans had an alternative, and there was an actual honest marketplace.

After that came the promise of a GOP alternative in two weeks—it has been a decade of those two-week promises and “concepts” of a plan. Cheap plans—alternatives to the ACA—flood the market and sometimes give people cash to pay for them. Which is great, until people try to make a claim and find the sham plans are a bait and switch—nothing serious is covered and the preexisting condition barrier is back, most likely along with annual and lifetime dollar limits.

There is no question that ACA premiums have gone up. Health costs are going up overall. And the subsidies added during Covid are set to expire. But extending the subsidies will provide relief for tens of millions of Americans on the exchanges and relieve pressure on the rest of the system—doctors, hospitals, and other delivery systems--by keeping people insured and healthier. And considering that efforts by Health and Human Services secretary Robert F. Kennedy Jr. and his conspiracy-addled cohorts will add pressure to health costs by creating more openings for epidemics and pandemics and eviscerating research into deadly diseases, the protections of the ACA become even more important.

There might be a way out of this, thanks to a bipartisan plan led by Rep. Don Bacon (R-Neb.) and Tom Suozzi (D-N.Y.) that would increase income caps on the subsidies. Whatever works. But what does not work is allowing premiums to skyrocket, leading to people losing coverage—some will die, others will go bankrupt—or allowing some semblance of the GOP chimera built on cash-for-sham plans, harming unsuspecting constituents when they try to make any claims.

Norman Ornstein is a political scientist, co-host of the podcast “Words Matter,” and author of books, including “It’s Even Worse Than It Looks: How the American Constitutional System Collided With the New Politics of Extremism.”

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