Evaluating the Affordable Care Act (1)

This article originally appeared in Capital Commentary, a weekly current affairs publication of the Center for Public Justice.

The deadline for enrolling in health insurance under the Affordable Care Act (ACA) just passed. The numbers are in, and the ACA is a _____________. Well, we really don’t know if it is a success or failure at this point. The deadline is merely a milestone – important on the path that began in 2010, but only a marker on a long road. In this article, I will consider the law in light of the core mission and commitments of the Center for Public Justice. Next week, I will describe likely paths for the law over the next three years.

Three essential commitments frame the work of CPJ: good governance, religious freedom, and public justice.

Good Governance and the Transformation of Public Life. CPJ’s mission states that “We aspire to a United States and a world where citizens and leaders work together to shape public life for the good of all, both nationally and internationally. . . . . As Christians we are called to do more than accommodate the conventional approaches of conservatives, liberals, and pragmatists.”

In this regard, the ACA falls terribly short. Instead of repairing the breaches and focusing on the “good of all,” it has done the opposite. Beginning a year before its 2010 enactment and intensifying since, health care reform has generated unrelenting, vitriolic, ideologically-driven partisan combat. Reasons for this include the complexity of the law (“an ugly patch for an ugly system,” says health economist Uwe Reinhardt), flaws in the ACA itself, an increasingly ideological and intransigent Republican Party for which “Repeal Obamacare” continues as the prime message for the fall elections, and Democratic fear of opening the ACA to change. Moreover, the early 2013-2014 implementation was an abject failure, exposing government itself to ridicule and further undermining public trust in a vital social institution.

Religious Freedom. “The Center's objective is to transform public life by working to establish the proper relationship between government and nongovernmental responsibilities in society, and uphold equal access for and treatment of all faiths in the public square.”

Many have faulted the ACA precisely because they believe that it violates this CPJ commitment. The so-called HHS mandate requires all ACA-compliant insurance (virtually all health insurance) to cover proven preventive health services, including FDA-approved contraceptives. Some religious organizations, especially Catholic hospitals, schools, and charitable agencies, object to contraceptives on theological grounds.

Although the Obama administration carved out an exception to the contraceptive mandate for religious organizations, its definition of “religious” followed a disturbing cultural trend that tends to define religion only in terms of worship and of hiring and serving only co-religionists. This understanding is far too narrow for Center principles. Although the Administration modified the exemption under pressure from Catholic social service and health organizations, it did not back away from its faulty definition of religion.

Public Justice. Affirming that everyone has the right to health care, the ACA’s goals do align with CPJ’s commitment to public justice. The Center understands that economic justice, family policy, and public welfare entail health care sufficient to keep families out of poverty and enable equal citizenship and contribution to community well-being.

In an earlier Capital Commentary article, Leah Anderson reminded us that health care is a legitimate area of government action to assure these goals. The ACA intends to reduce the number of uninsured Americans by more than half. While 2014 is the first major step toward that goal, the key evaluation point is 2017 when Americans will have enough experience with ACA insurance to decide whether they prefer enrollment to remaining uninsured and paying the law’s penalty.

Although it is too early to tally the number of previously uninsured who obtained health insurance, there are short-term success markers: at least three million young people obtained insurance under their parents’ policies. No one can any longer be denied insurance for a pre-existing condition, and there are effective limits on out-of-pocket medical expenses. Moreover, preliminary estimates indicate seven million persons enrolled in private insurance through the “marketplaces” and four million through expanded Medicaid. Even if many had insurance previously and even if many fail to follow through, at least the long-term trend of rising uninsurance rates has been halted and significantly reversed.

The ACA was always estimated to have its full effect in 2017, after three years of the new marketplaces and the new Medicaid. What happens from now until 2017 is crucial to evaluating the ACA, and will be the subject of my article next week.

- Clarke E. Cochran is Professor Emeritus, Political Science at Texas Tech University and former Vice President of Mission Integration at Covenant Health in Lubbock, Texas.