Saving the Affordable Care Act

In what is called President Obama’ s most important legislation, the Affordable Care Act, has been under constant fire. The House voted 54 times to end it. The GOP shut down the government trying to kill it. Recent polls show that the majority of  the American people are against it. It is cited as part of the reason the Democrats lost control of the House in the 2010 election and then of the Senate in 2014.

Why?

The Affordable Care Act was developed to curb the abuses of the medical insurance industry. Individuals needing health care coverage that was not available to them through their employer  or through a federal program like Medicare or Medicaid (Medical in California), had to apply to the healthcare insurance companies operating in their area. People found to have had pre-existing medical conditions were faced with very high, almost unaffordable policy options. Companies also asked questions about behavior such as whether someone smoked cigarettes or marijuana, whether one drank and how much and about any previous medical conditions even if they were no longer a problem. The companies would then raise their rates accordingly.

Insurance companies also had caps limiting the amount of claims they would accept. If the patient cost them too much, they could discontinue their coverage.

As many as 50 million were thought to be without any medical coverage. When their illness became too much to ignore, many would wind up in the emergency room of their local hospital making the cost of their treatment even greater. Some could not pay for their treatment theoretically making everyone pay a little more to make up for the loss.

The Affordable Care Act (ACA) came up with a solution. Let individuals without insurance sign up for it through a health exchange in their state. The exchange would let all the health care carriers bid to get the business. This would make their rates more competitive. The companies could not ask about pre-existing medical conditions or lifestyle questions. They had to accept all applicants. But in order for this to work for the insurers, everyone had to get coverage. To ensure that everyone got coverage, fines would be imposed on those who elected to not sign up. Hopefully, with everyone getting coverage, there would be enough healthy applicants to make up for the unhealthy ones who would be sure to sign up.

In order to ensure that everyone could afford coverage, the government promised to give tax credits to those with insufficient means. Those with almost no money would be transferred to the Medicaid program where they would get coverage for free.

We were told that those who do not sign up are being irresponsible causing the rest of us to pay for their medical care, if it is ever needed.

But many people objected. Why should the young and healthy, who might not need medical coverage subsidize the unhealthy? Why should people be forced to buy insurance they didn’t need? And why are some people getting tax credits? Will this be like the Earned Income Credit which has a fraud rate of about $11 billion a year? And does the government have the right to fine or tax the public for non-compliance?

Now that the GOP controls both chambers, it is likely they will try again to force the President to end the ACA.

I think that I have come up with a way to make everyone happy.

First, keep all the favorable parts of ACA including allowing children under 26 to be on their parents’ plan (proving what I have been saying that now anyone under 26 in still a child - that 26 is the new 21 and 18), having no caps, and having state exchanges to bring all the available companies in a competition for this once captive audience. The mandate that businesses of a certain size must offer health insurance to its employees who work at least a certain number of hours a week should remain as would federal coverage still be available to those who cannot afford coverage at all.

The individual mandate should be dropped. People should be able to keep whatever coverage they currently have and those without any coverage do not need to buy it. In return, the private insurers bidding in the state exchanges can reject any applicant with serious, long term and well-documented medical conditions like cancer, heart disease, kidney failure, liver disease, pancreatitis, and AIDS. They could not consider past injuries, alcohol or tobacco use, etc. - just the agreed upon serious pre-existing conditions. Those rejected for serious conditions would be immediately transferred to the federal program, just like those with insufficient income are, except these people would have the same share of cost as they would have through the exchange if they were healthy.

Since private carriers would have no new policies with serious medical pre-existing conditions, they would not need everyone to enroll to make money. And since people would buy insurance only if they chose to and since there would be no federal subsidy through tax credits, the insurers would have to lower their rates to be competitive. Income would not be an issue unless the person were close to indigent and therefore also eligible to federal medical coverage, but with no deductible. There would be no fines for non-compliance because compliance would be voluntary.

But what about the argument that those who choose to go without insurance are being irresponsible? Is a person who keeps himself healthy and never needs medical services irresponsible? If he does need to see a doctor, he will have to pay for it. How is that irresponsible? On the other hand, if a person abuses his body with excessive food, alcohol, tobacco and/or drugs, but has coverage and makes use of it regularly, is he responsible? Does he not cost the ratepayer and the taxpayer more than the person who takes care of himself and needs little medical attention?

I think that with these changes, most of the objections to ACA will disappear and the vast majority of our people will embrace it. Even Republicans.

Seeking a Middle Ground

Now that the GOP controls the Congress but cannot override a presidential veto, the two arms of government must work together. They must find a middle ground that both can live with and might be actually better than either extreme position. Here are our three most difficult issues:

The Affordable Care Act is probably the most contentious issue between the two parties and the electorate, which is split in its support.

Liberals feel that everyone must have health coverage and that business and government should subsidize it. They believe that having coverage must be mandated and backed by mandatory fines to ensure compliance. The mandate is necessary, they believe in order to remove all preconditions as barriers to getting affordable coverage. Further, they feel that those who cannot afford the rates should get government subsidies in the form of tax credits.

Conservatives resent being forced to buy health insurance that they might not want or need. Conservatives resent having the government subsidize payments with tax credits that are based on reported taxable income.

I have a solution that both can live with and would actually improve the current system:

Eliminate the mandates for individuals while maintaining them for businesses of a certain size for employees who work a certain number of hours a week. Individuals not covered by an employer’s group plan or by a federal program like Medicare or Medicaid, should be free to decide whether they want to buy coverage. If they so decide, they should be able to avail themselves of the health exchange which would offer deals from several different insurance groups. The insurers will be free to ask about certain medical preconditions that are long term, expensive to treat and well documented such as cancer, heart disease, type 1 diabetes, AIDS, kidney failure, liver disease, pancreatitis, alzheimer’s, etc. Insurers cannot ask or consider any medical preconditions other than those agreed upon by the decision-makers. They cannot ask about how many drinks we have or whether we have ever had marijuana or broken a leg.

The various health insurance companies will then offer competitive rates for those without any of the identified serious health conditions and refer the rejected applicants to the federal system - Medicare. Medicare will then cover these applicants and charge a share of cost equivalent to the premiums charged the healthy private coverage recipients.

This way the insurers can cover everyone who wants coverage and be motivated to lower their rates to attract more healthy members mindful that individuals will not receive government subsidies which are really also subsidies for the insurers.

Therefore coverage will not be mandatory and there will be no government tax credits saving a lot of time, trouble and fraud. Tax credits are too tempting for many to resist. The Earned Income Credit has an estimated $11 billion in fraud each year. Those who elect to forgo coverage will them be responsible for the health costs should they occur.

Illegal immigration is another sore point.

Liberals feel that if people take the time and trouble to leave their homelands because of the corruption, poverty and resultant violence, and come to our country, we should accept them and help them on their path to citizenship. “Aren’t we all descended from immigrants?” they ask. “Doesn’t the Statue of Liberty say that we want all the poor and huddled masses to come to our shores?” They do not want people found to be here without authority to be deported because it would break up the affected family, including those not yet started. 

Conservatives want the border completely secured so that no one can just walk in. They want those caught crossing, to be immediately repatriated without assignment of an attorney and a court date that will never be attended. Conservatives would like those found here to be deported regardless of their length or quality of stay. They are completely opposed to giving those here illegally permanent residency or citizenship.

I have a slight compromise:

First, completely secure the southern border and our visiting Visa system to stop the flow of illegal immigrants. Deport all those currently being held or any that still get through, almost immediately after apprehending them near the border.  They should not be imprisoned or released to the community for a future court date. People seeking asylum should be invited to do so in their native country before leaving. We have embassies and consulates that could process these requests.

Our government should work with the Latin American countries from which these immigrants are coming. We should develop a new Marshal type plan to make these countries places where people want to live not leave.

We should allow those who have been here for several years and committed no serious crimes or violations to be granted temporary residence status allowing them to live and work without fear of deportation unless they commit serious crimes in the future. They will be able to work for the same wages and benefits as their coworkers receive. Those who have committed crimes here should be deported upon completion of their prison sentences. If they have family here, one would expect them all to move back as that is what families do.

The federal income tax code is a third major issue.

Conservatives want to pay lower marginal tax rates and want more people to pay taxes. The liberals want the rich to pay more in taxes and want to see fewer tax loopholes for the wealthy.

As I have already written in previous columns, I think we should eliminate all itemized deductions and credits for personal income and replace them with a standard deduction (self employed and corporate income would still have itemized deductions). The top marginal tax rate could then be lowered to 35% for income over $1 million as opposed to the current 39.5% for income over $400,000. And all income would be equally taxable, so dividends would be the same as interest and earned income and Social Security benefits. Income is income.

This would satisfy both sides, raise a lot more revenue and would be much easier to administer with a lot less chance of fraud.

How’s that for finding middle ground for three of our country’s most divisive issues? There is reason to hope.

A Change Needed in American Education

We are having serious problems especially in public high school education in America. Where we used to be one of the best educated nations, we are now way down on the list of top countries in this regard. Our high schools are seeing a high drop out rate and the graduates are too often found to be ill prepared for college or for success in the world. What is the problem and what changes need to be made?

One problem has been demographic. Public high schools, especially those in large urban areas, have gone from being places where middle class kids got their education to places where poor minority children go for classes. Los Angeles public school district is now 85% Latino and 95% of the students get free lunch because of their family’s low economic status. Nowadays, parents that can afford it send their children to private or parochial schools rather than the neighborhood school down the street.

As a result, standards have been lowered.

Part of the problem has been inadequate funding for public schools in general resulting in large class sizes giving teachers less time to spend with each student.

Part of the problem has been the learning model which has stressed memorization instead of understanding, recalling instead of thinking.

But I think a large part of the problem is that much of what high school students are being asked to learn is irrelevant or uninteresting or both. Students are not seeing the longterm utility of much of the material they are being asked to remember. How does it help them in their lives?

Today, high school students, especially those who have any college hopes are expected to take certain courses in order to graduate. They must take four years of English including grammar and literature, at least three years of history, including American history, at least two years of a foreign language, three years of science and of math.

The English requirement makes good sense. It is our country’s language and our students should know proper spelling, grammar and diction. They should be familiar with the great works of literature which provide readers with new ideas and ways of thinking. This knowledge will help them throughout their lives.

It is also important to know and understand history. If presented properly, history can be an exciting story of our origins with lessons for the future.

And even though the English language has become the universal language, with people all over the globe learning it, it still seems like at least two years of a foreign language would be helpful. While French and German are no longer quite so universal, Spanish has become one spoken often in the States and might be good to know. I have always been a great believer in the value of   classes in Latin. So much of our language and grammar come from Latin as do so many important languages like French, Spanish and Italian.

But what of the math and science requirements? How many of us have ever had cause to use algebra, calculus, geometry or trigonometry in our daily lives - even once? How many of us remember any of it? Those who go on to study higher math, science, engineering or technology will have great use of these studies, but will the majority?

The same is true for science courses in high school. How often do we use our chemistry or physics knowledge?

What if we offered eighth graders a math and a science survey course. The math course would include basic algebraic principals like writing equations and solving for x in linear equations. The geometry and trigonometry segments would include the basic concepts without all the theorems and corollaries.  The science survey course would cover the basics of biology, chemistry and physics without the details and equations. Some students will show a great interest in pursuing these fields in high school, the rest will be offered alternatives.

The alternatives can vary from hands-on learning such as shop, weaving or auto mechanics to courses like logic, philosophy, psychology, sociology and economics. There could be courses in home economics including financial dealings, hygiene and nutrition. All of these courses are currently being taught in varying degrees in many schools already or once were, like shop and home economics.

I think that these changes would improve student satisfaction and thus increase graduation rates and would better prepare students for the future enabling them to think as well as remember.

But what about college requirements? What if they still require all the math and science for admission? I think that colleges should drop these requirements except for math and science majors. These would have been the students who wanted to take all the math and/or science they can get. One of my daughters had five years of math, including two years of calculus and five of science in high school. She had three years of biology alone. My other daughter had the bare minimum at a school that even offered simplified courses in math and science for her. The former went into nursing but the other is more of an artist, for whom math and science are irrelevant.

And yet most colleges today require applicants to have a full load of math and science and then require additional courses in college. When one of my daughters’ freshman class orientation at college welcomed the students, the speaker predicted that a third of those present would drop out after a year because of the math requirement. How is that helpful?

What is the purpose of education? I think that it helps students learn to observe and gather data and then to reach practical conclusions and recommendations. Education should teach us how best to learn so that we can make the most of our own potential while having a positive impact on the world we live in.  I don’t think that education today is doing that. I think that it is putting up unnecessary roadblocks to learning and growth and failing to teach our students to think and understand.