From the Editor

I am writing this editorial the morning after a surprising, historic United States presidential election that swept into office an unexpected candidate in Donald Trump. My 25-year-old daughter called and asked me to explain how this happened. I’d like to answer that by focusing on issues relevant to healthcare, although that is only a small part of the answer. The Affordable Care Act (ACA) was passed in the senate Dec. 24, 2009, passed in the house March 21, 2010, and signed into law by President Obama March 23, 2010. It was upheld in the Supreme Court June 28, 2012, when it was determined to be a tax and not a mandate, and was therefore declared constitutional. The final ruling was summed up by Chief Justice John Roberts: “The [ACA’s] requirement that certain individuals pay a financial penalty for not obtaining health insurance may reasonably be characterized as a tax. Because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness.” 

The landmark decision cast the Internal Revenue Service (IRS) as the enforcer of a controversial healthcare policy at the same time IRS officials were specifically targeting political conservatives for audits. More than three years after officials admitted to targeting tea party groups for intrusive scrutiny, the IRS remains busy defending itself in a series of court cases. Although President Obama confidently announced (prior to any investigation) there was “not a smidge of evidence” the IRS had misbehaved, officials have now released a list of 426 organizations that were targeted, possibly with the help of the Department of Justice. As the ACA rolled out, the healthcare exchange website debacle lead to the resignation of Kathleen Sebelius, secretary of the U.S. Department of Health & Human Services. She made an ill-fated appearance on The Daily Show With Jon Stewart, during which he challenged her to “sign up for Obamacare” before he could download every movie ever made. The price tag for the website was no joke. The government spent $840 million on Healthcare.gov and its supporting systems, and $175 million to fix it. Importantly, the government exempted itself from HIPAA laws, which was a good thing since the personal health information and financial data of the individuals who signed up through the website were unsecured on it.

In the months following ACA passage, President Obama modified the law with a series of executive actions that were indisputably outside his constitutional authority. To bail out Massachusetts’s malfunctioning healthcare exchange, President Obama and then Gov. Deval Patrick arranged for more than 300,000 state residents to receive temporary Medicaid coverage (without any verification of eligibility) and for the state to get the most generous taxpayer-funded premium subsidies in the country. On Feb. 10, 2014, the administration further delayed the employer mandate, giving “mid-sized employers” (those with 50-100 full-time employees, a category that doesn’t exist in the law) until 2016 to provide coverage and relaxed some requirements for larger employers. In February 2014, when some exchanges were found to be having difficulty determining people’s eligibility, he granted retroactive coverage based on the application date rather than on the date of acceptance. In October 2014, he announced it would not be enforcing the ACA’s “transparency in coverage” provisions, which required insurers to disclose data on enrollment, denied claims, and the costs to consumers for certain services. Lastly, the ACA imposed a health insurance providers’ fee on insurance companies in order to tax the “windfall” they were expected to receive from increased enrollment. In March 2015, by executive action, President Obama expanded this tax to the states because they used managed-care organizations to provide Medicaid services. The states had no choice but to pay the tax or lose their federal Medicaid funds. Texas, joined by Kansas and Louisiana, sued the government in October 2015. Premiums in the ACA’s health insurance marketplaces have been rising since the ACA was passed. Most customers could avoid the price increase by shopping for a cheaper plan. This year, in many states, there won’t be cheaper plans. In addition, in some states, only one insurance company is left participating, so customers will have to take whatever that payer offers. Why is this happening? There was a lot of fine print in the ACA that Congress had to pass “to see what was in it,” as famously stated by Nancy Pelosi, minority leader of the House of Representatives. That included massive payments to insurance companies to keep them afloat for the first few years. Those backend payments are ending, so premiums must increase to cover the deficit. In many of the 32 states with health-exchange plans, insurers have been requesting large price increases and the lower-cost insurers have left. Voters became aware of these cost increases about two weeks prior to the election. Those who are not low-income individuals who pay the full cost of their insurance are going to feel this price increase. I buy my own insurance and, as a business owner, I provide health insurance. Next year is going to be ugly for two reasons: Premiums and deductibles are soaring and the federal government is going to pay higher subsidies for the ACA, which will come from tax dollars. So, my taxes will have to increase to pay for ACA subsidies, in addition to the fact that I am paying a deductible that approaches the cost of a buying a used car every year and on top of a huge monthly premium. Last year in Texas alone, 221,684 individuals were apprehended illegally crossing the border. While nearly a quarter of a million people are apprehended each year, perhaps twice that many are not. Although emotions run high on the topic of immigration, the implications regarding healthcare are enormous. In another controversial executive order, President Obama attempted to protect more than 4 million undocumented immigrants from deportation. The guidance document said they would be permitted to be lawfully present in the U.S., which would make them eligible for work authorization as well as Social Security and Medicare benefits. Although a divided federal appeals court later upheld a state court injunction blocking this, many thousands of them were given green cards by the administration while the injunction was in force, which means the states will need to pay for their healthcare. The median income today is lower than it was in 1999. U.S. labor participation rate is about where it was in the 1970s. On average, Americans claim they can’t trust their government institutions, and they have good reason to feel that way. The people have spoken. Let’s work together to fix this mess and craft some policies that work better for everyone.