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The health law at one year: Should we celebrate?

By       Message Claudia Chaufan     Permalink
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View Ratings | Rate It Headlined to None 3/23/11

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On March 23, a year after President Obama signed into law the Patient Protection and Affordable Care Act (PPACA), "the most expansive social legislation enacted in decades," according to the New York Times, it's worth taking a look at Massachusetts.

After all, PPACA was inspired in the Massachusetts health plan, which sought universal coverage through Medicaid expansions for individuals living under 150 percent of the federal poverty level (FPL), partial subsidies for those between 151 and 300 percent of the FPL, a state-based exchange to act as a one stop-shopping place of private insurance plans, and a mandate to purchase one of those plans under penalty of a fine.

And yet, four years after implementation, health reform Massachusetts-style has failed a critical test. As a recent study in the American Journal of Medicine showed, the percentage of personal bankruptcies linked to medical bills and illness, at 52.9 percent, has not decreased significantly, and the absolute number of medical bankruptcies has increased, from 7,504 in 2007 to 10,093 in 2009. How so?

Well, it's not hard to understand why. Health insurance is a means to an end. The end is health care. And skimpy policies with significant, and increasing, out-of-pocket costs are useless when people need care.

And in Massachusetts, skimpy policies are not even cheap. For example, as study authors pointed out, the least expensive individual coverage available to a 56-year-old Bostonian carries a premium of $5,616 and a deductible of $2,000, and covers only 80 percent of the next $15,000 in costs of covered services (uncovered services fall 100 percent on you).

This is not small change if your annual income is around $32,000, or 300 percent of the FPL, so you're not entitled to subsidies (which, mind you, come from taxpayers' pockets).

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But what about at least slowing the increase in health care costs? Fail again. Double-digit increases in premiums have become routine in Massachusetts, and insurers have warned this will continue next year, even as "consumer-driven" policies that shift more costs to individuals multiply.

But would PPACA, a federal program, not control costs of U.S. health care? No, at least if you go by its effect on California, where, maybe to celebrate PPACA's first year anniversary, Blue Shield recently announced its third premium hike since October 2010. An outside consultant found, unsurprisingly, that the planned hike was "reasonable." (PPACA does not forbid insurers to raise their prices; it only demands that they show that increases are deemed "reasonable" by authorities that have little power to enforce their standards of reasonableness anyway.")

And what about the promise that kids with "pre-existing conditions" would not be charged more than other kids? Good luck with that one. This past October HHS Secretary Kathleen Sebelius already backed down on that promise, allowing insurers to charge more to cover sick kids to, according to the New York Times, "persuade companies to offer child-only policies."

And Medicaid expansions, which would enroll at least 16 million individuals? Not a chance, especially after governors throughout the nation begin to implement the creative ideas offered by Sebelius explaining how, as state budgets collapse and nobody bails them out, Medicaid costs can be reduced " by cutting benefits, as noted in California Healthlines.

Wait a minute, you might say. Whatever problems it may have, the law offers (near) universal coverage, no? Out of luck again. The law will leave around 23 million uninsured close to ten years out of its implementation (and over 50 million annually over the next three years). Many of these will be undocumented immigrants, whom the law forbids to buy coverage from the insurance exchanges, even with their own money.

On the bright side, as the failure of the attempt to further strengthen the worst of the U.S. health care system -- for-profit insurance for medically necessary care and trading uninsurance for underinsurance -- becomes increasingly apparent, a space will open up for Americans to demand real health care reform: a publicly financed, privately delivered health care system that provides comprehensive and equitable health care to everybody in the United States: an expanded and improved Medicare for All.

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Claudia Chaufan, M.D., Ph.D., is Associate Professor at the University of California, San Francisco. She is also a member of Physicians for a National Health Program-California (

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