David Coates

Winning in November by Defending the Affordable Care Act Now.

Lindsey Graham’s recent warning that Republicans might yet push for a presidential impeachment serves to demonstrate, if further demonstration was still required, of just how brutal Washington politics could get if his party ends up in control of both Houses of Congress after the mid-term elections in November. In progressive terms, the achievements of the Obama Administration have been, at best, only modest: and yet that modesty does not remove the need to defend them – and to defend them energetically – in the face of sustained Republican attempts to roll them back.[1]

That defense is particularly vital in the case of the Affordable Care Act, which is both the singular domestic achievement of this Administration and the prime target of Republican invective. As many of us are only too painfully aware, the Affordable Care Act is not – and never was – a perfect solution to the many-sided problems of the American healthcare system. But rolling it back in the manner now proposed by its conservative critics would only make those problems worse. So to bolster support for Democratic candidates in November, and to begin to lay the ground for a progressive reform of the Affordable Care Act in the years to come , it is vital that we push back now against Republican criticisms of what they continue to mislabel and disparage as “Obamacare.”

How exactly?

By challenging the Republicans’ core criticisms of the Affordable Care Act.

  • The ACA is not a job-killer as the Republicans like to claim.[2] Nor did the recent Congressional Budget Office report say that the full implementation of the ACA will “kill” 2.3 million jobs by 2021. On the contrary, the report made clear that the Affordable Care Act will not increase either unemployment or underemployment (people working part time who want to work full time). It also found little evidence of employers dismissing workers to avoid having to provide coverage. What the Report did predict was that 2.3 Americans may chose not to work because they no longer need to do so to get healthcare cover from their employer.[3] The ACA will increase their choice. It will not take away their jobs.
  • Far from costing jobs, the full implementation of the ACA may actually help increase employment by slowing the rate of healthcare costs and by subsidizing the purchase of healthcare coverage by the low paid. The effect in both cases will be to increase that part of total national income available for the purchase of other goods made by other workers. If the full implementation of the ACA then does enable some sick or poorly-paid workers to pull out of the labor market entirely or in part, their departure will leave fewer people competing there, so strengthening wage growth (and consumer demand) again. It seems reasonable to expect therefore that the marginal disincentive to work associated with the phasing out of federal healthcare subsidies as income rises (a common feature of all safety-net programs) will be more than offset in the ACA case by the general boost to consumer demand triggered by the subsidies themselves.
  • The ACA will not institutionalize death panels, bring big brother control of your individual healthcare decisions, grossly inflate existing insurance rates or expose private health data to the wider world. All it will quietly do (and is now doing) is make access to adequate healthcare affordable for that wide tranche of Americans currently unable to afford healthcare insurance and so forced back onto an erratic dependency on emergency hospital coverage and free clinics. The ACA is not driving people out of healthcare coverage. It is simply obliging some people to change their particular healthcare plans, often for something better.
  • Nor will the ACA collapse under its own weight – there is no “death spiral” for the Act because enough young healthy people are already enrolling and far fewer than anticipated are choosing to take the fine [4]– and the long-term budgetary implications of the ACA are all positive. A healthier population paying more taxes, helping to bring the long-term trajectory of public debt down rather than up.[5]

Listing the many ways in which the Affordable Care Act is already bringing much needed improvements to the U.S. health care system, and will yet bring more.[6]

  • In spite of the problems associated with the initial launch of the healthcare exchanges, the number of Americans signing up on them for coverage has already reached at least 8 million.
  • Among those not signing up on the exchanges but gaining/retaining cover, we need to count the 2.37 million young Americans enabled by the ACA to stay on their parents insurance until age 26, 1.87 million of whom would otherwise be likely uninsured.[7]
  • The ACA improves access to healthcare for those with pre-existing medical conditions, and for women of all ages, by banning a series of insurance company practices that discriminated against both categories of Americans.
  • People without employer-provided healthcare insurance (a growing proportion of the U.S. population[8]) can now buy insurance on exchanges especially created for that purpose, and receive financial help from the federal government if their income falls below four times the poverty level for their size of family.
  • In states that take up the option, people on the edge of poverty (earning up to 133% of the poverty level for their size of family) become eligible for Medicaid, with the federal government initially picking up all the additional costs involved in making that provision.
  • Senior citizens get help financing part of the doughnut hole in their purchase of prescription drugs (with the hole to be fully eradicated by 2020). In 2011, 3.6 million Americans saved more than 42 million as a result.
  • The ACA contains a number of cost-containment provisions that can only help to lower the trajectory of overall healthcare costs over time. These include changes to payment systems (especially for Medicare), an Independent Payment Advisory Board, and funding for research designed to increase medical efficiency, as well as an increased emphasis on wellness and illness prevention.


Showing that the impact of the Act would have been greater but for opposition from conservatives to key elements of its design & implementation.

  • The impact of the Act on the trajectory of health care costs would have been greater if the original legislation had included a public option, but that element was removed from the original bill in order to win support from blue-dog Democrats and moderate Republicans.
  • The numbers of Americans without adequate health care coverage would have been greater had a conservative majority on the Supreme Court not allowed states to opt out of Medicaid expansion; and had Republican-led state governments not taken that opportunity to refuse the large federal funds earmarked for that very purpose. Twenty-six such states have now rejected expansion, and with it the “federal funds that would finance 100 percent of the expansion costs for three years and at least 90 percent thereafter.”[9]
  • That refusal by Republican state legislators to expand Medicaid coverage will shut out from affordable healthcare anywhere between 5 and 8 million of the most vulnerable and poorly paid Americans.[10] It also creates a genuine “Medicaid Gap” in which people eligible for full assistance in purchasing healthcare coverage on the state exchanges run the risk – if they lose their jobs and end up with income between 100% and 133% of the poverty level – of finding that Medicaid will not step in to make up the loss.
  • The people paying the price of Republican intransigence are the very people most in need of healthcare coverage.[11] The evidence is now clear that the proportion of uninsured Americans aged 18 and over is falling faster in states that choose to extend Medicaid and set up their own exchanges than in states that refused.[12] The evidence is also clear that the proportion of the uninsured who become eligible for federal assistance in purchasing healthcare cover is significantly higher in states expanding Medicaid eligibility under the ACA (at 68%) than in states declining to do so (44%). Indeed, “if the latter states were to extend Medicaid eligibility, 71 percent of their uninsured would be eligible for assistance.”[13]


Demonstrating that – to the degree that the Republicans do possess a coherent alternative set of reforms – those reforms will only make health matters worse.

  • The Republican Party has been very slow to offer a detailed alternative, caught as it has been in the realization that “you can’t achieve the good stuff in the ACA, like coverage for people with pre-existing conditions, without also including the stuff they hate, the requirement that everyone buy insurance and the subsidies that make that requirement possible.”[14]  This silence on policy design is compounded by the fact that the main thing Republicans appear to dislike in the ACA – the individual mandate – was originally a Republican rather than a Democratic suggestion, offered as an alternative to the Clinton health plan in the 1990s.
  • The main plan currently on offer – the Hatch/Coburn/Burr plan[15] – will add to middle-class tax burdens. The plan would use market competition to keep costs down, and level the playing field between employer-provided healthcare and privately purchased health care by capping the proportion of health insurance contributions by both employers and their employees that goes untaxed. Currently 100% does. They propose setting a cap at 65%.  But that would represent a significant tax-hike on middle –class Americans, the very thing Republican lawmakers regularly set their face against doing. The Senate Republican plan would also “likely cover fewer uninsured people, raise premiums for many older Americans, shrink Medicaid…scale back protections for people with pre-existing conditions, and allow private insurers to escape many of the consumer-friendly protections now imposed on them.”[16] It is hardly surprising then that Republican enthusiasm for the plan has quickly wilted.
  • A simple repeal of the ACA would leave the status-quo-ante in place: and that is itself both morally and politically questionable. Are Republicans really in favor of taking young adults off their parents’ healthcare coverage, allowing insurance companies to discriminate against pregnant women and the really sick, or ending subsidies for healthcare for low-income hardworking American families?  In the name of what: the right of young currently healthy Americans to free-ride on the hospital system should they become suddenly and unexpectedly sick? Untrammeled freedom for young millennials is a weak moral basis for rolling back even the modest gains made by the Affordable Care Act: and even healthy twenty-year olds eventually grow old.[17]


Recognizing the limits of the Affordable Care Act, and proposing ways of improving it.

  • 32 million Americans were still without coverage in 2012. The CBO estimated in April that 31 million will still be uninsured a decade from now. They will not get that coverage until/unless we reverse the refusal of states to extend Medicaid availability,[18] or effect a root-and-branch replacement of the ACA with a single-payer system. Currently, 80 million Americans remain either uninsured or underinsured.[19] That cannot be right.
  • The early implementation problems have damaged the credibility of the ACA and continue to bedevil it. Right now, for example, of the six million Americans who have gained Medicaid coverage since last September, at least 1.7 million of them are still waiting for their applications to be processed – some indeed have waited eight months already.[20]  Improvements here are needed fast.
  • Health care costs continue to rise, as is the proportion of that rise falling back on patients (via deductibles and co-pays), with the burden greatest for the chronically ill. Neither trend is satisfactory. We will not pull healthcare costs fully under control without tighter regulation of insurance companies, the breaking of local insurance monopolies, and the replacement of a fee-for-service medical reimbursement system with one based on a per capita basis.
  • The ACA remains unpopular. It is time to reverse that by some honest, detailed and informed talk. It is time to insist that the social contract at the heart of the ACA – that the healthy pay for the sick, and when sick themselves are covered by the healthy – remains a morally desirable one. It is also time to re-emphasize the basic choice that all healthcare systems face[21] – of how to balance conflicting demands for treatment with the necessarily limited resources available to meet them – and to stress again that unregulated market mechanisms are singularly inappropriate for the striking of that balance, given the current level of income inequality.
  • It is time to say too that the case for a singlepayer system remains compelling, and that the ACA should be best thought of as one more stage in the on-going struggle to achieve a healthcare system free at the point of use.


The biggest problem the Republicans have with their opposition to the ACA is that, for all its faults, the Act is actually making a positive difference. The evidence is everywhere. When its prototype was introduced (by Mitt Romney of course!) in Massachusetts, the mortality rate fell.[22] When medical providers combined in the ACA’s Accountable Care Organizations, their spending on Medicare fell. [23] “State health insurance marketplaces that offered consumers very few health plan choices in 2014 are starting to add more insurers,”[24]…and so on.  We can’t afford to let Republicans take us backwards in this key area of social reform, which is why now is the time to push back against the ACA’s conservative critics with all the force we can muster. Hopefully this checklist will be of some value in that pushback.




[1] https://www.davidcoates.net/2014/04/14/dozing-through-the-great-moving-right-show/


[2] https://www.davidcoates.net/2011/01/21/defending-health-care-reform-%E2%80%93-again/


[3] http://www.cbo.gov/sites/default/files/cbofiles/attachments/45010-breakout-AppendixC.pdf


[4] Avik Roy, Sorry, Conservatives: Based on the Latest Sign-Up Figures, There Won’t Be An Obamacare Death Spiral, posted February 14, 2014: available at http://www.forbes.com/sites/theapothecary/2014/02/12/sorry-conservatives-based-on-the-latest-sign-up-figures-there-wont-be-an-obamacare-death-spiral/


[5] http://www.whitehouse.gov/sites/default/files/docs/healthcostreport_final_noembargo_v2.pdf


[6] https://www.davidcoates.net/2012/04/09/taking-the-republicans-to-task-4-on-health-care-reform/


[7] http://www.ncsl.org/research/health/dependent-health-coverage-state-implementation.aspx


[8] Elise Gould, Public Insurance Is Increasingly Crucial To American Families Even As Employer-Sponsored Health Coverage Ends Its Steady Decline. Washington DC: EPI Briefing Paper #238, November 13, 2013: available at http://www.epi.org/publication/employer-sponsored-health-insurance-is-still-failing-american-families/


[9] The Editorial Board, “A Population Betrayed,” The New York Times, October 4, 2013: available at http://www.nytimes.com/2013/10/04/opinion/a-population-betrayed.html


[10] Ibid


[11] Paul Waldman, The Cruelty of Republican States in One Chart. Posted on the website of The American Prospect, October 4, 2013: available at http://prospect.org/article/cruelty-republican-states-one-chart


[12] Dan Witters, Uninsured Rate Drops More in States Embracing Health Care, available at http://www.gallup.com/poll/168539/uninsured-rates-drop-states-embracing-health-law.aspx


[13] Matthew Buettgens et al, Eligibility for Assistance and Projected Changes in Coverage under the ACA: Variations Across States, The Urban Institute, May 2014: available at http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2014/rwjf408158/subassets/rwjf408158_1


[14] Paul Krugman, “Health Care Nightmares,” The New York Times, April 11, 2014: available at http://www.nytimes.com/2014/04/11/opinion/krugman-health-care-nightmares.html


[15] Richard Burr et al, A Republican plan to replace Obamacare, cover pre-existing conditions and lower costs: available at http://www.foxnews.com/opinion/2014/01/27/republican-plan-to-replace-obamacare-cover-pre-existing-conditions-lower-costs/


[16] The Editorial Board, ‘What G.O.P.-Style Reform Looks Like,” The New York Times, February 2, 2014: available at http://www.nytimes.com/2014/02/02/opinion/sunday/what-gop-style-reform-looks-like.html


[17] https://www.davidcoates.net/2013/10/01/exactly-how-is-the-affordable-care-act-an-affront-to-freedom/


[18] Alec MacGillis, Obamacare Will Be a Failure Until Medicaid Expands in Red States. Posted on The New Republic website, March 31, 2014: available at http://www.newrepublic.com/article/117194/obamacare-will-be-failure-until-medicaid-expands-red-states


[19] http://www.commonwealthfund.org/publications/press-releases/2014/mar/32-million-underinsured


[20] Phil Galewitz, More Than 1.7 Million Consumers Still Wait for Medicaid Decisions, Kaiser Health News, June 10, 2014: available at http://www.kaiserhealthnews.org/Stories/2014/June/09/More-Than-17-Million-Consumers-Still-Wait-For-Medicaid-Decisions.aspx


[21] https://www.davidcoates.net/2013/10/09/placing-the-affordable-care-act-in-the-wider-debate-on-healthcare-systems/


[22] Sabrina Tavernise, “Mortality Drop Seen to Follow ’06 Health Law,” The New York Times, May 6, 2014: available at http://www.nytimes.com/2014/05/06/health/death-rate-fell-in-massachusetts-after-health-care-overhaul.html


[23] Melinda Beck, “Coordinated Health-Care Programs Save Millions,” Wall Street Journal, January 31, 2014: available at http://online.wsj.com/news/articles/SB20001424052702303743604579353133811400314


[24] Wonkblog, Obamacare is adding insurers where needed most. Washington Post, June 6, 2014: available at http://www.washingtonpost.com/blogs/wonkblog/wp/2014/06/06/obamacare-is-adding-insurers-where-theyre-most-needed/


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David Coates holds the Worrell Chair in Anglo-American Studies at Wake Forest University. He is the author of Answering Back: Liberal Responses to Conservative Arguments, New York: Continuum Books, 2010.

He writes here in a personal capacity.

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