602 Chapter 16Chapter 16 || Social PolicySocial Policythe mandate would face government fines. However, individuals who could not afford
to purchase their own insurance would receive federal tax credit subsidies on a sliding
scale (using a complicated formula that would provide the biggest subsidies to the
poorest people and some support to people with incomes all the way up to four times the
federal poverty rate). The individual mandate was one of the most controversial parts
of the bill, but supporters point out that states already require people to purchase auto
insurance if they have a car. During the formulation of the law, it was stated that most
people who were pleased with their current health insurance through their employer
would not have to change anything. However, people with policies that did not meet the
minimum standards of the law would be required to get new insurance policies. This
became a sticky issue for President Obama once the ACA was rolled out.
Other features of the law included incentives to computerize medical records, seen
as a way to reduce medical mistakes, facilitate medical evaluations, and, as a result,
improve the overall quality of care. Integration of technology into medical processes
and record keeping was one of the law’s central cost-control mechanisms. In addition,
a new nonprofit organization, the Patient-Centered Outcomes Research Institute,
would be authorized to engage in “comparative effectiveness research” to identify
the best practices in health care. It would research such questions as which health
care procedures work to make people healthier and which are a waste of money, and
why some parts of the country spend more than twice as much on treating the same
conditions. The ACA would encourage health care providers to adopt identified best
practices. The law was also designed to focus more resources on preventive care to keep
people healthy, so that, theoretically, people would be less likely to get sick and need
further, expensive treatment.
One other goal was that health care had to pay for itself. Obama vowed that the
bill would not “add one dime to the deficit.” With a price tag of just under $1 trillion
over the first 10 years, paying for the bill was a challenge. However, a combination of
higher Medicare taxes, a new investment tax for the wealthy, an excise tax on insurers
for expensive “Cadillac” health care plans, new fees for drug companies and health
insurers, and cuts in Medicare reimbursement meant that the law would actually
reduce the federal deficit by $143 billion over the first decade.^61
Nonetheless, the political battle over health care reform was not over when Obama
signed the bill into law. House Republicans repeatedly attempted to repeal the law. As
discussed in the chapter opener, although these efforts were not successful, the rollout
of the law was very rocky. The national health care insurance exchange, Healthcare.
gov, was supposed to be operational on October 1, 2013, but the system repeatedly
crashed during the first several months of operation, leading to substantial delays and
great frustration for those Americans attempting to enroll. Millions of poor Americans
were not able to get coverage when the states they lived in declined the option to
expand Medicaid to cover everyone whose income was 138 percent of the poverty line
(see Chapter 3 for a discussion of this conflictual issue). Because of the bumpy start,
President Obama granted about a dozen extensions of various deadlines, including
enrollment deadlines for the individual mandate, the employer mandate to cover all
employees for businesses with between 50 and 100 employees (which was extended
until the end of 2016), the high-risk pool that was intended to be temporary, and the
requirement that people who had previously been covered by a substandard insurance
policy get insurance on the exchange (this, too, was extended until the end of 2016).^62
An additional problem is that not as many young healthy people have signed up on
the exchanges as predicted. So some insurance companies, such as Aetna and United
Health, have lost significant amounts of money and are pulling out of many states. This
means less competition and rising rates.Full_17_APT_64431_ch16_572-613.indd 602 16/11/18 11:28 AM