World Politics

Beyond Insurance Reform: An Assessment of Obama's Achievement

 Rose Ann DeMoro

[The author is  also a leader of the AFL-CIO, the US trade union organisation. This essay appreared in

Executive Director, National Nurses United, AFL-CIO and California
Nurses Association

Posted: March 23, 2010 08:07 PM

Passage of President Obama's healthcare bill proves that Congress can
enact comprehensive social legislation in the face of virulent rightwing
opposition. Now that we have an insurance bill, can we move on to
healthcare reform?

As an organization of registered nurses, we have an obligation to
provide an honest assessment, as nurses must do every hour of every day.
The legislation fails to deliver on the promise of a single standard of
excellence in care for all and instead makes piecemeal adjustments to
the current privatized, for-profit healthcare behemoth.

When all the boasts fade, comparing the bill to Social Security and
Medicare, probably intended to mollify liberal supporters following
repeated concessions to the healthcare industry and conservative
Democrats, a sobering reality will probably set in.

What the bill does provide

-Expansion of government-funded Medicaid to cover 16 million additional
low income people, though the program remains significantly under
funded. This limits access to its enrollees as its reimbursement rates
are lower than either Medicare or private insurance, with the result
some providers find it impossible to participate. Though the federal
government will provide additional subsidies to states, those expire in
2016, leaving the program a top target to budget cutting governors and

-Increased funding for community health centers, thanks to an amendment
by Sen. Bernie Sanders, that will open their doors to nearly double
their current patient volume.

-Reducing but not eliminating the infamous "donut hole" gap in
prescription drug coverage for which Medicare enrollees have to pay the
costs fully out of pocket.

-Insurance regulations covering members' dependent children until age
26, and new restrictions on limits on annual and lifetime on lifetime
insurance coverage, and exclusion of policies for children with
pre-existing conditions.

-Permission for individual states -- though weakened from the version
sponsored by Rep. Dennis Kucinich -- to waive some federal regulations
to adopt innovative state programs like an expanded Medicare.

All of these reforms could, and should, have been enacted on their own
without the poison pills that accompanied them.

Where the bill falls short

-The mandate forcing people without coverage to buy insurance. Coupled
with the subsidies for other moderate income working people not eligible
for Medicare or Medicaid, the result is a gift worth hundreds of
billions of dollars to reward the very insurance industry that created
the present crisis through price gouging, care denials, and other

-Inadequate healthcare cost controls for individuals and families.
1. Insurance premiums will continue to climb. Proponents touted a
"robust" public option to keep the insurers "honest," but that proposal
was scuttled. After Anthem Blue Cross of California announced 39 percent
premium hikes, the administration promised to crack down with a federal
rate insurance authority, an idea also dropped from the bill.
2. There is no standard benefits package, only a circumspect reference
that benefits should be "comparable to" current employer provided plans.
3. An illusory limit on out-of-pocket medical expenses. But even in the
regulated state exchanges, insurers remain in control of what they offer
and what will be a covered service. Insurers are likely to design plans
to attract healthier customers, and many enrollees will likely find the
federal guarantees do not protect them for medical treatments they
actually need.

-No meaningful restrictions on claims denials insurers don't want to pay
for. Proponents cite a review process on denials, but the "internal
review process" remains in the hands of the insurers, and the "external"
review will be up to the states, many of which have systems now in place
that are dominated by the insurance industry with little enforcement

-Significant loopholes in the much touted insurance reforms:
1. Provisions permitting insurers and companies to more than double
charges to employees who fail "wellness" programs because they have
diabetes, high blood pressure, high cholesterol readings, or other
medical conditions.
2. Permitting insurers to sell policies "across state lines", exempting
patient protections passed in other states. Insurers will likely set up
in the least regulated states in a race to the bottom threatening public
protections won by consumers in various states.
3. Allowing insurers to charge three times more based on age plus more
for certain conditions, and continue to use marketing techniques to
cherry-pick healthier, less costly enrollees.
4. Insurers may continue to rescind policies, drop coverage, for "fraud
or intentional misrepresentation" -- the main pretext insurance
companies now use.

-Taxing health benefits for the first time. Though modified, the tax on
benefits remains, a 40 percent tax on plans whose value exceeds $10,200
for individuals or $27,500 for families. With no real checks on premium
hikes, many plans will reach that amount by the start date, 2018,
rapidly. The result will be more cost shifting from employers to workers
and more people switching to skeletal plans that leave them vulnerable
to financial ruin.

-Erosion of women's reproductive rights, with a new executive order from
the President enshrining a deal to get the votes of anti-abortion
Democrats and a burdensome segregation of funds, that in practice will
likely mean few insurers will cover abortion and perhaps other
reproductive medical services.

-A windfall for pharmaceutical giants. Through a deal with the White
House, the administration blocked provisions to give the government more
power to negotiate drug prices and gave the name brand drug makers 12
years of marketing monopoly against competition from generic competition
on biologic drugs, including cancer treatments.

Most critically, the bill strengthens the economic and political power
of a private insurance-based system based on profit rather than patient

As former Labor Secretary Robert Reich wrote after the vote "don't
believe anyone who says Obama's healthcare legislation marks a swing of
the pendulum back toward the Great Society and the New Deal. Obama's
health bill is a very conservative piece of legislation, building on a
Republican (a private market approach) rather than a New Deal
foundation. The New Deal foundation would have offered Medicare to all
Americans or, at the very least, featured a public insurance option."

Unlike Social Security and Medicare which expanded a public safety net,
this bill requires people -- in the midst of the mass unemployment and
the worse economic downturn since the Great Depression -- to pay
thousands of dollars out of pocket to big private companies for a
product that may or may not provide health coverage in return.

Too many people will remain uninsured, individual and family healthcare
costs will continue to rise largely unabated and private insurers will
still be able to deny claims with little recourse for patients.

If, as the President and his supporters insist, the bill is just a
start, let's hold them to that promise. Let's see the same resolve and
mobilization from legislators and constituency groups who pushed through
this bill to go farther, and achieve a permanent, lasting solution to
our healthcare crisis with universal, guaranteed healthcare by expanding
and improving Medicare to cover everyone.

Leaders of the National Nurses United have raised many of these concerns
about the legislation for months. But, sadly, as the healthcare bill
moved closer to final passage, the space for genuine debate and critique
of the bill's very real limitations was largely squeezed out.

Much of the fault lies with the far right, from the streets to the
airwaves to some legislators that steadily escalated from deliberate
misrepresentations to fear mongering to racial epithets to hints of
threatened violence against bill supporters.

For its part, the administration and its major supporters shut out
advocates of more far reaching reform, while vilifying critics on the

Both trends are troubling for democracy, as is the pervasive corruption
of corporate lobbying that so clearly influenced the language of the
bill. Insurers, drug companies, and other corporate lobbyists shattered
all records for federal influence peddling and were rewarded with a bill
that largely protected their interests, along with a Supreme Court
ruling that will allow corporations, including the health care industry,
to spend unlimited sums in federal elections.

Rightwing opponents fought as hard to block this legislation as they
would have against a Medicare for all plan. As more Americans recognize
the bill does not resemble the distortions peddled by the right, and
become disappointed by their rising medical bills and ongoing fights
with insurers for needed care, there will be new opportunity to press
the case for real reform. Next time, let's get it done right.

Rose Ann DeMoro is executive director of the 150,000-member National
Nurses United