Undocumented workers weren’t given eye protection and set out to grind metal. None had insurance. They’d send me (the medical student) in to slowly pick metal flakes out of eyes with a needle.
"Undocumented workers weren’t given eye protection and set out to grind metal. None had insurance. They’d send me (the medical student) in to slowly pick metal flakes out of eyes with a needle." Chaikom/shutterstock.com

I was in Casper, Wyoming when the votes for the Affordable Care Act (Obamacare) slowly trickled in. Wyoming is the reddest of red states—a libertarian dystopia only functional with generous subsidies from the Federal Government. Casper is in the Southeast corner of the state—petrochemical country not too far from Laramie where Matthew Shepard was murdered. Dusty wind was a constant. I lived kitty corner to an oil refinery. Bone tired and aching from an overnight shift in the Emergency Room, I turned the TV on to watch CSPAN.

Quite a few of my patients came from the oil refineries. Undocumented workers weren’t given eye protection and set out to grind metal. At the end of their shifts, they would show up in the ER complaining of eye pain. None had insurance. They’d send me (the medical student) in to slowly pick metal flakes out of eyes with a needle. The hospital had to eat the full cost of caring for these patients, and devoted resources accordingly.

The why of the ACA was fundamentally liberal—all human beings have worth and should be cared for. The how of the ACA was deeply conservative—a lightly modified variant of the Romneycare scheme used in Massachusetts—with a primary mission of keeping the largely useless and lucrative private healthcare insurers happy: Under the threat of financial penalty, all Americans not eligible for Medicare or Medicaid were to buy private health insurance. Subsidies would be provided. The insurers would be forced to make a slightly better product, cover pre-existing conditions, some family planning, and spend at least some minimum amount of the premiums on healthcare. The intention was for Medicaid to be expanded (with Republican state governments successful in blocking this). A whole set of micromanagement of hospitals and doctors was added in, as were deductibles and copays. Undocumented immigrants (like my patients) were excluded.

The Democrats controlled the House, Senate and Presidency. The political fight was intra-party: Should a ‘public option’ be included—a government run-and-owned insurer be formed as part of the law to compete with the private industry providers. The moderate coalition blocked it, in hopes of a bipartisan bill. The votes came in—along party lines. No public option. Everyone forced into the maw of the private insurance industry. The democrats never recovered electorally.

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The House, Senate and Presidency will be in Republican hands in a couple of months. The ACA is high on the to-be-killed list. How to destroy Obamacare and what to replace it with is another intra-party fight—for Republicans. They are in a pickle. The most popular and functional parts of the ACA were also the most liberal components: The Medicaid expansion (where it could occur), the elimination of pre-existing conditions, allowing children to stay on their parent’s plans until turning 26, and coverage for birth control. The conservative parts were the problems: The forcing into private insurance, high deductibles and copays, and the fussy micromanagement of doctors and hospitals with poorly thought out metrics.

Let’s be honest with ourselves: The conservative parts of Obamacare are terrible. Enshrinement of healthcare deductibles and copays? A terrible idea that neither held costs in place and lead to insured people from being financially ruined by needing care. (What is the point of insurance that fails to protect you financially?) The micromanagement with things like satisfaction surveys (borrowed from the beloved car sales industry)? Encouraged avoidance of difficult patients and rewarded worse docs and hospitals. Private insurers are horrid to deal with and have consistently failed to contain costs. No public option? Rapidly escalating costs in the insurance markets. Of course, the murmured plans of the President-elect and congressional leadership are a doubling down of these terrible ideas.

It’s in the bitterest of retrospect I wish we had just gone all the way, added in a public option to Romneycare 2.0, or even bolder, just extended Medicare to become Medicare-for-all when we held the levers of power. The ACA didn’t go far enough, and by reinforcing a crumbling and terrible private-health-insurer-based system wrote its own doom.

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