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Proletarian issue 78 (June 2017)
Obamacare: going, going ...
Assessing the impact of ‘Trumpcare’.
In 2009, during his first term of office, when the then President Obama unveiled his very modest plan for a US health service almost verging on the humane, the US establishment, especially the drugs and ‘care’ industry, along with its puppets in the press were seen to be frothing at the mouth. Caring for people comes a very distant second to profit in any imperialist country, but the US has perfected the hard-nosed policy of pay up or die into a fine art. The very idea of helping someone without a thought for profit brings forth screams of ‘communism’ from their unified curled lips as if it were something terrible.

The Patient Protection and Affordable Care Act (ACA), aka Obamacare, was kicked, surgically snipped and hacked at during its passage through the US legislative process, so that by the time it found its way onto the statute books its simple description is best summed up as:

“To extend health insurance coverage to some of the estimated 15 percent of the US population who lack it. Those people receive no coverage from their employers and are not covered by US health programmes for the poor and elderly.

“To achieve this, the law requires all Americans to have health insurance, but offers subsidies to make coverage more affordable and aims to reduce the cost of insurance by bringing younger, healthier people into the medical coverage system.

“It also requires businesses with more than 50 full-time employees to offer health insurance.

“The law creates state-run marketplaces – with websites akin to online travel and shopping sites – where individuals can compare prices as they shop for coverage. Some states have chosen not to participate in the ACA, and their residents can shop on a marketplace run by the federal government.

“In addition, the law bans insurance companies from denying health coverage to people with pre-existing health conditions, allows young people to remain on their parents’ plans until age 26, and expands eligibility for the government-run Medicaid health programme for the poor.

“The law aims eventually to slow the growth of US healthcare spending, which is the highest in the world.” (Why is Obamacare so controversial? BBC News, 4 May 2017)

Although this law, since its implementation, has seen jobs in the healthcare sector rise by 9 percent, the claim by its enemies that it is a ‘job-killer’ isn’t without foundation, as many small companies employing 50-100 people have whittled their workforces down to 49 to escape any legal duty to offer even the lowest level of health insurance.

More importantly, though, limited though Obamacare is, it has made an important difference to American working people:

“Obamacare, it turns out, has done a lot of good. It guarantees that people with pre-existing health conditions cannot be rejected by insurers or charged more than others. It has reduced the number of uninsured people by 20 million. It has increased access to primary care, specialty care, surgery, medicines, and treatment for chronic conditions. Patients are less likely to skip needed care because of the cost. As a result, according to studies conducted at Harvard, the ACA is saving tens of thousands of lives each year.” (Trumpcare vs Obamacare by Atul Gawande, The New Yorker, 6 March 2017)

The most popular parts of Obamacare for working-class Americans are inevitably the most despised by the US bourgeoisie, such as:

1. Children can stay on a parent’s healthcare plan (until age 26). This provision will remain under Trumpcare.

2. No one can be denied insurance for a pre-existing medical condition.

3. Companies can no longer charge women more than men.

Nevertheless, the very idea that healthcare spending should be lowered is an anathema to every section of the corporate health industry in the US, which has continued to try and sabotage the programme, even since it was passed into law.

The ACA in practice has been dogged by setbacks in courts and a very poor organisation on many levels, leaving many of the poorest Americans deeming it worthless or still unaffordable. However, despite its faults and shortcomings, it is estimated that 22 million people would lose medical insurance if Obamacare were repealed. Provisions of the law do make some care accessible to those who had previously been totally locked out, and the uninsured rate has dropped by 5 percent since the programme began.

Whilst campaigning to become president, Donald Trump was prone to talking up higher employment, which seemed sweeter to the ears of the unemployed than talk of limited medical aid through cheaper (in every sense of the word) health insurance. Now, with no great jobs revival, the Republicans have already cleared the first hurdle towards eradicating Obamacare from the statute book.

The Republicans have presented a new bill to replace some of the ACA’s main provisions called the American Health Care Act (AHCA), dubbed ‘Trumpcare’. It essentially consists of the repeal of large parts of Obamacare (Trump always says that the new act represents the complete repeal of Obamacare but this is untrue) and includes the following provisions:

1. To modify existing law that inhibits the sale of health insurance across state lines. As long as the plan purchased complies with state requirements, any vendor will be able to offer insurance in any state. By allowing full competition in this market, insurance costs, it is claimed, are expected to go down, and consumer satisfaction is expected to go up.

2. To allow individuals to deduct health insurance premium payments fully from their tax returns. Under the current tax system only businesses can make these deductions, and the stated aim is to allow individuals the same exemptions.

3. To allow individuals to use Health Savings Accounts (HSAs). Contributions into HSAs would be tax-free and would be allowed to accumulate. These accounts would become part of the estate of the individual and could be passed on to heirs, it is claimed, without fear of any death tax. These plans should be particularly attractive to younger members of the more privileged sections of workers, who are healthy and might be able to afford high-deductible insurance plans. However, people in low-paid jobs, the elderly and sick will find little here for them.

4. To require price transparency from all healthcare providers, especially doctors and healthcare organisations like clinics and hospitals. Individuals will be able to shop around to find the best prices for procedures, exams or any other medical-related procedure. In a system where anything and everything is up for sale, it makes sense to know the price beforehand, but if you have no cover or your cover is of the ‘junk’ type reserved for the poorest, this only points out what you cannot afford.

5. To remove barriers to entry into free markets for drug providers that offer safe, reliable and cheaper products. This seems to offer foreign drugs at cheaper prices to Americans, but it is ignoring the fact that capitalist competition cannot but lead to monopoly and the winners of the battle for monopoly will again increase prices. This may appeal to many working Americans who will see it as an increased choice of cheaper drugs with no loss/change of quality.

6. Insurers would still not be allowed to set annual and lifetime limits on how much they will reimburse individuals for ‘essential health benefits’, such as doctors’ services, inpatient and outpatient hospital care, prescription drug coverage, pregnancy and childbirth, and mental health services.

7. Whereas Obamacare mandated that all insurance plans cover certain health conditions and services, such as annual physical exams, prescription drug costs, mental health counselling and women’s health services, under Trumpcare individual state legislatures can allow insurance companies to opt out of any of these.

8. The most controversial provision is that Trumpcare may enable insurance companies once again to charge much higher premiums to people with pre-existing conditions if state legislation permits them to do so. This should not affect people who are currently insured so long as their insurance does not lapse – as it would, for instance, if they are insured through their work and they then become unemployed. Those who cannot afford these premiums may end up uninsured for all or any medical conditions. This may, or may not, make medical insurance cheaper for those who are healthy, but will be a disaster for those who are not.

However, states can only opt out of this aspect of Obamacare if they set up high-risk insurance plans, known as high-risk pools, for individuals who cannot afford traditional insurance. A new amendment provides an extra $8bn to subsidise the cost of insuring those with pre-existing conditions, but experience suggests that the cost to any individual of subscribing to the pool may still be astronomic.

Moreover, the obligation of businesses to provide health insurance for their employees is repealed. We know that many large businesses don’t want to provide health insurance to full-time workers and Trumpcare is their escape card.

Obamacare made a lot of fanfare but delivered very little to the poorest in US society. They remained chained to an insurance system that put comprehensive health cover outside their reach and made a visit to the doctor something to be dreaded for fear of the expense it might incur. With Trumpcare, the poorest are set to lose a little of what they had ‘gained’ through Obamacare, and will gain absolutely nothing. Despite all the shouting about ‘communism’ that accompanied the enacting of the ACA, neither it nor the new AHCA threatens the insurance-based model, which makes US healthcare exorbitantly expensive even as it delivers some of the worst outcomes in the developed world and leaves millions completely uninsured; the profits of the healthcare providers clearly remain sacrosanct to all US bourgeois parties.

Although quality healthcare for all is a basic human necessity, providing even the most basic universal health service conflicts with the need of the ruling class to make profits. The NHS in this country and other rich countries was only set up because the bourgeoisie feared that the working class would follow the Soviet revolutionary example if its living conditions were not improved after WW2. The fall of the Soviet Union has undoubtedly facilitated the present clawing back of benefits that were granted to workers during the post-war period.

Thus we can see that, even in the richest and most apparently ‘civilised’ capitalist countries, complete and free healthcare can never be guaranteed, and why any free provision will always come under attack from privateers. One has only to look at a poor country like Cuba to see how socialism is able to deliver so much more to ordinary people, at a much lower cost, because healthcare planners are able to use the country’s resources directly to meet the people’s needs, without worrying about what will make a profit.

The history of our own health service shows us that the working class has to fight hard not only to obtain a health service in the first place, but then to keep it. Only under socialism can any guarantee be given that healthcare provision will be permanent and that its quality will continue to rise.
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