(Interview 2/2019, oil on canvas 40 ins. x 30 ins.)
Artist Note (2019)
This portrait story looks at the US healthcare system before healthcare reform. It covers how the Affordable Care Act (ACA) or Obamacare changed our healthcare/health access system. We look at where our country is headed in light of calls to lawmakers to address ongoing problems by fixing Obamacare or replacing it with a new system altogether, a “Medicare for all” type system.
To get this overview we will be traveling the mind and writings of healthcare analyst Charles Gaba and others. Nobel Prize winning economist Paul Krugman referred to Gaba as “the invaluable Charles Gaba.” Gaba has received national recognition for his work.
“I just decided to do the numbers myself.” Gaba said.
I like revving up my left brain to digest the data Gaba revels in. But my default is right brain. I notice gradations of color, observe shapes in nature like the way light falls on the planes of a face. I feel sound as it passes through my body. When I flick on the left brain switch, I always learn a lot from reading Gaba’s blog even though he sometimes goes so deep into the weeds, I feel like an ant seeing blades of grass as redwoods.
Healthcare reform, the Affordable Care Act, Obamacare has gone from being a farcical Armageddon– death panels, an additional 16,500 armed IRS agents, microchips planted in people – to a healthcare reform policy that over half the population approves of in the 9 years since the law’s passage in 2010. By 2012 Democratic politicians were skittish about endorsing the ACA because opposition to the healthcare law was so fierce. In 2019, however, the country now finds itself roiled in a pro-healthcare reform debate that 5 years ago would have sunk political careers. Today many millions more are insured because of healthcare reform. Gaba said, “At its peak in 2016-17, around 20-22 million, though it’s dropped down several million since then.”
Healthcare is still very much on the front burner in 2019 but with more people demanding even more reform this time. 2020 presidential candidates are taking positions that would remake our healthcare system well beyond the once villified ACA reforms. Self-described democratic socialist and presidential candidate Bernie Sanders received applause from a conservative audience during a Fox News televised town hall when the hosts polled the audience. "I want to ask the audience a question here. ... How many are willing to transition to what the senator says, a government-run system?" The crowd burst into cheers.
Why the momentum to overhaul our healthcare system? Why now -- even under Fox News’s roof, an organization rated strongly Right-Biased by Media Bias/ Fact Check?
The why is not hard to figure out. The where-do-we-go-from-here is more complicated.
Those with insurance through their jobs are seeing deductibles rise every year. NPR quotes health reporter Noam Levey. “These are the people who've seen deductibles rise astronomically — rising four times in the last dozen years from about $350 on average to $1,350 on average. In some cases, people are seeing $4,000, $5,000, even $6,000 deductibles that they have to pay out of their own pocket before their health insurance kicks in.” People are skimping on medicine, putting off treatment, moving in with friends and family, cutting back on food, and looking for second and third jobs.
In another article, Levey writes “Almost half of non-elderly single households don’t have enough saved to cover a $2,000 bill.”
The New York Times reports on the state-of-affairs today. “High out-of-pocket costs, absurd hospital billing practices and ever-rising prescription drug prices have forced too many people to skip crucial treatments, avoid emergency rooms and ration life-sustaining medications.”
Enter Charles Gaba, the subject of this portrait story. He’s a numbers guy. “I am a data wonk. I like the numbers, the spreadsheets.”
When technical issues derailed the Obamacare website healthcare.gov rollout in 2014, Gaba wanted to know why – on two fronts. “As a website developer, I was really concerned. What the hell happened, and how are they going to fix it?” As a numbers guys, he wondered about enrollment. “I knew they were having problems, but I hadn’t seen any actual numbers. How many people actually signed up given the gravity and seriousness of the technical meltdown? The government wasn’t talking. Either the numbers stank. Or the gov’t didn’t know because the tech side was so screwed up, and they were busy trying to fix it.”
“I just decided to do the numbers myself.” Gaba said.
Gaba’s work attracted the attention of healthcare analysts and journalists. Reporter Sarah Kliff formerly of Vox news wrote, “With no background in health policy whatsoever, Gaba built the country's most trusted source of Affordable Care Act enrollment data."
Healthinsurance.org describes Gaba this way.” Charles Gaba is the founder of ACASignups.net, which has been live-tracking Obamacare enrollments since the exchanges launched in October 2013. His work has been cited by major publications from the Washington Post and Forbes to the New York Times as being the most reliable source available for up-to-date, accurate ACA enrollment data in the country.”
Art As Social Inquiry has been exploring the US healthcare story for the last 11 years by showing how policies and laws play out in real lives. I started my project because as a business owner I was trapped. The only way I could control rising premiums was to take less coverage for more money every year for our very small group – employer-sponsored health insurance. And I was afraid that if I or anyone in the group had big medical claims, the insurance companies would raise our premiums to coerce us into drop the insurance. For-profit insurance companies cannot earn profits if too many people have medical claims cutting into those profits. I wanted to understand what was really going on with our healthcare system. I started asking people I knew how they got insurance. I started the Healthcare in the US portrait story series about access to healthcare.
Now, over 70 portrait stories into the project, I have seen the healthcare/health insurance landscape move from people going uninsured and some even dying because of preexisting condition discrimination. To the implementation of a healthcare law that outlawed such discrimination, required a minimum set of benefits and provided financial help for those who qualify to help them buy health insurance. To repeated failed attempts to repeal the Affordable Care Act. To more successful attempts to sabotage Obamacare. To the rise of high-deductible plans especially for people getting insurance through jobs resulting in delayed treatments, financial hardship and sometimes bankruptcy. To a public interest in a true universal healthcare system that is affordable and comprehensive.
I thought it was time to pause, look at where we came from, where we are, and possible routes moving forward as we reform our healthcare/health insurance system. I am using Gaba’s writings and others’ to steer this review. In the nearly 6 years Gaba has been writing his blog, he has expanded it to include not just numbers analyses. He follows the ACA as it moves through states, the courts and federal executive orders. He breaks down the various Medicare for All proposals floating around. He discusses all things healthcare policy.
Charles Gaba, Health Policy Analyst, Educator, Activist, Blogger, Age 48, Insured
Gaba is now self-employed as a healthcare policy analyst. He was also self-employed in his previous career as a website developer for small business. Not only is Gaba analyzing the healthcare/ health insurance terrain, he’s living it. As a self-employed person he has had to buy health insurance on his own. He uses the Affordable Care Act’s online marketplaces – sometimes called exchanges -- to purchase insurance. He is part of the statistics he reports.
PART 1: Before the Affordable Care Act
In March 2014 The Washington Post asked the question, “So what did America look like before the Affordable Care Act (i.e. in 2010, 2011 and 2012)? Well, a large slice of Americans lacked adequate health coverage, according to a Commonwealth Fund report. About 79 million — more than one in four Americans — either lacked health insurance or were underinsured (defined as those who were insured, yet spent a high share of their income on medical care). “
Out of a population of about 320 million, 79 million of us were precariously situated before healthcare reform happened. One out of six were outright uninsured leaving too many Americans vulnerable medically and financially. People were staying in jobs to hold on to their insurance, a practice known as job lock.
In 2014 Healthcare advocate Wendell Potter wrote for Healthinsurance.org. “The main reason so many of us were uninsured in 2010 was that health insurance had simply become a budget-buster (my link) for many American families. The cost of employer-sponsored family coverage reached $13,375 in 2009, an increase of 131 percent in ten years, according to the Kaiser Family Foundation.”
Gaba says “According to Kaiser, the average full price for an employer family plan was up to $18,687 as of 2017.”
My research writing and painting the portrait stories for Art As Social Inquiry’s Healthcare in the US painting series mirrored the statistics. I encountered people who were rationing oxygen, skipping treatments, using the internet to self-diagnose anything from thyroid conditions to “Is marrying someone for his insurance considered fraud?” I talked to families whose loved-ones died because they cut back on insulin to save money; couldn’t get required colonoscopies needed to monitor a congenital defect; went without a new battery for a defibrillator then died slumped over a car’s steering wheel when the old device failed to jumpstart the heart. When I look at the portraits and remember the interviews, I feel a knot in my chest that sends a lump up to my throat. From there I feel my jaw clench. I’m trying not to cry. I am alone in my office. I could cry. I could cry every day. I just can’t start. I’ll never stop.
The deaths, missed treatments, lack of care for chronic illness, the bankruptcies...the fear and quiet desperation of being uninsured...the fear of losing a job and with it health insurance...the fear of not being covered because the insurer said you lied on a medical history questionnaire...the fear of preexisting condition discrimination...it all had to stop. (And still does in too many cases.) Obamacare was a first step in addressing these dire circumstances.
We can get the pre-Obamacare picture by looking at Gaba’s initial ACA enrollment analysis from his 2016 blog called From the Dept. of No Sh*t, Sherlock. Gaba writes about Blue Cross/ Blue Shield’s report that new Obamacare enrollees were sicker and more expensive to treat.
“There's a bunch of charts and graphs and such in the BCBS report showing the areas and metrics where ACA exchange enrollees are sicker, more disease-prone, more likely to make medical appointments and more expensive to treat than the pre-ACA individual market enrollees and/or Group market enrollees...but really, why is this coming as a surprise to anyone?
“As anyone with two licks of sense already knew well before the ACA's rules on ‘no more denials for having pre-existing conditions’ and ‘no kicking people off over minor technicalities (ie, rescission)’ went into effect, prior to the ACA, insurance carriers were allowed to cherry-pick their enrollees, kicking sicker people (or anyone even suspected of being sicker) to the curb.
“Under the ACA, they can no longer do so; in fact, aside from asking your age, gender and whether you're a smoker, insurance carriers aren't even allowed to ask most medical history/situation questions (ie, they can't ask your weight, whether you have a history of heart disease and so forth). Even if they did ask, they can't deny you coverage based on those factors anymore anyway, and can't charge you more based on gender…the bottom line is that there were tons of warnings and reports (not to mention common sense) indicating that yes, ACA exchange enrollees would probably be a lot more expensive to treat...which is the very reason they had been shunned from the market all those years in the first place.”
Part 2: The Affordable Care Act Becomes the Law of the Land
President Barack Obama signed The Affordable Care Act (Obamacare) into law on March 23, 2010. The Supreme Court upheld the new healthcare law on June 28, 2012. The Affordable Care Act aims to make high quality health insurance more affordable and accessible. The law uses consumer protections, online marketplaces, subsidies, regulations and other reforms to public and private health insurance.
The ACA put in place many consumer protections that traverse a wide swath of the public and private insurance markets. For example, people can no longer be denied health insurance because of a preexisting condition. Young adults can stay on their parents’ plans until age 26. Insurers can no longer impose annual and lifetime limits on consumers and many more protections. Some of those protections are being undermined by the Trump administration. (See Part 3 for details.)
The focus of this section is the individual market, people who buy insurance on their own for themselves and their families. They don’t get health insurance through jobs or other programs. What is the individual market? Why did we need a law to address this group’s health insurance needs?
MIT economist Jonathan Gruber, advisor on healthcare reform for former GOP Massachusetts governor Mitt Romney and then years later President Barack Obama described the Affordable Care Act system as a 3-legged stool where all three legs were necessary for the law to function.
Gaba’s video blog uses Gruber’s metaphor. Presenting Three-Legged Stool: The Motion Picture! is one of the best explanations of how different mechanisms make selling insurance on the individual market doable.
Of the 320 million or so people in this country, Gaba points out that we can understand who is in the individual market by looking at who is not. Here’s who is NOT in the individual market. - Those getting insurance through a job. This is almost half the population if you include the military. Those on Medicaid or Medicare. Those who are a part of the ACA’s Medicaid Expansion provision (about 15 million people.) - Those insured through the Indian Health Service - Those on university student plans - Those on Christian Sharing Ministries plans (not real insurance) Those with grandfathered or transitional policies before ACA regulations went into effect. (A couple million people) - About 800,000 in New York and Minnesota on the Basic Health Program
So who’s left?
Gaba says, “People who buy private health insurance. People who buy insurance for themselves or their families either through exchanges like healthcare.gov or directly from an insurance carrier. About 15 million people are in ACA complaint policies on or off the exchanges.”
What are the exchanges and how do they work? Healthinsurance.org explains,” A health insurance exchange is an online marketplace where consumers can compare and buy individual health insurance plans.”
Health insurance online marketplaces or exchanges are an integral part of the healthcare law’s structure. The online exchanges are where individuals buying insurance on their own become one large buying block. Private insurance companies list their policies online and millions of individuals peruse the policies before purchasing.
Gaba’s 17 minute video explains how the law’s structure works. The ACA’s mechanisms are worth understanding before we get into the law’s shortcomings and the attacks from the Trump administration. Here is a brief overview.
The first leg of the healthcare reform stool is about the insurance companies. They have to sell insurance to everybody without regard to anyone’s preexisting conditions. No discrimination because one is sick. They can’t charge older people a lot more than younger people. (Limited to three times as much.) The insurance policies have to cover a minimum percentage of crucial services and treatments called essential health benefits, and also cover a long list of free preventative services. Lastly, insurance companies cannot put caps on how much they pay out for medical claims in one year or over a person’s lifetime.
These provisions are consumer protections Obamacare spells out for insurance companies. But a good part of our US healthcare system is for-profit. The consumer protections represent money the insurance companies must spend - expenditures that cut into profits. So how do companies stay in business (not that I care but this is the 3-legged stool discussion) if they are required to cover essential benefits and pay sick people’s claims in ways they were not required to do before healthcare reform? More money spent paying medical claims means less profits for insurance companies. The other two legs of the stool put in place protections for insurance companies.
The second leg addresses the enrollee’s responsibilities. (Reminder. We’re talking about people who have to buy insurance on their own not people who get insurance through jobs or government programs.) Gaba explains in his video that people have to sign up for insurance and pay the premiums or pay a penalty. This is called a mandate. (The Trump administration efforts helped reduced the mandate’s penalty to $0 for the time being.) The thinking here is that healthy people along with the sick are paying premiums into the insurance companies’ coffers. Healthy people don’t use the insurance. Their premiums will pay the medical claims of those who do use the insurance. But one day the healthy may become sick. And they will need the insurance. The healthy-turned-sick will need everyone paying into the system as well so they can get their medical claims paid. Thus, the logic behind the mandate.
Another protection for the insurance company is that enrollees must buy insurance during a specific time each year. This time period is called open enrollment. Otherwise enrollees could game the system and just sign up when they got sick. If you search the keyword “open enrollment” on Gaba’s ACASignups.net blog, 105 entries come up for your reading pleasure on the subject.
The third leg of the stool lays out government’s role in healthcare reform. Individuals needing insurance and buying it on the online marketplaces like healthcare.gov can select policies sold by private insurance companies. If their incomes qualify them, these individual can get financial help – subsidies -- to buy those policies. This is good for enrollees and insurance companies. People get money to buy policies. Insurance companies get to sell insurance to people who can afford the subsidized premiums.
Also, the Obamacare subsidies are another way for some people to meet their obligation to buy insurance described earlier as the mandate. (The ACA provided additional financial help for deductibles and co-pays for low-wage earners but the Trump administration eliminated this assistance.)
The government also said that policies had to have maximum out-of-pocket limits. Enrollees couldn’t be on the hook for co-payments, co-insurance and other out-of-pocket expenses with no end in sight. After a certain amount out-of-pocket spending -- depending on the policy -- the insurance companies have to pay 100% of the medical claims.
Another thing the government said as part of the third leg of the stool is that insurance companies have to spend at least 80% of their premium dollars on medical-related expenses. Before Obamacare, insurance companies could spend as much on salaries, administrative costs, investor dividends, etc. as they could make happen. Those payouts are now limited to 20% of premium income.
PART 3: WHERE ARE WE in 2019?
The first two parts of this ACA overview looked at individuals who buy insurance on their own for themselves and their families, how the Obamacare online sites were set up to serve them, and how healthcare reform ushered in consumer protections.
Part 3 tracks how individuals fared under healthcare reform and also opens up its lens to look at the wider population including those who get insurance through jobs, that is, employer-sponsored coverage. In an ACASignup.org blog called SHOW YOUR WORK: Healthcare Coverage Breakout for the Entire U.S. Population in 1 Chart, Gaba breaks down the entire insurance market in a nifty and detailed pie chart.
Let’s not forget that the health insurance most people get is through their jobs. The Affordable Care Act put in place consumer protections for individuals buying single policies but also for those with employer-sponsored insurance.
All policies offered to employees getting health insurance through employment – some 156 million of us –share Obamacare’s consumer protections with the rest of the insurance market. These employer-sponsored plans cannot put limits on how many medical claims a person has in a single year or over a lifetime; must allow adult children to stay on their parents’ plans until age 26; and cannot discriminate against people for having preexisting conditions. It’s worth noting that even those with job-based insurance needing expensive treatments for chronic diseases or medical mishaps were more likely to hit their policies’ annual or lifetime limits before the ACA outlawed such caps. The caps were a way of discriminating against people with preexisting conditions in the employer-sponsored market. (Thanks to @stevedemaio on Twitter for pointing this out.)
The new healthcare law was helping people get health insurance coverage. In a March 2015 blog titled “UPDATED: GALLUP: Uninsured rate drops to 11.9% as of end of March 2015” Gaba writes that the uninsured rate fell “to 11.9% by the first quarter of 2015 from a high of 18% just before the ACA exchanges launched. Gaba adds that the uninsured rate continued to drop to an all-time low of 10.9% at the end of 2016 ( but has since crept back up again to 13.7% according to Gallup). Oregon even saw a whopping 63% drop in the uninsured population.
In the ensuing, years the uninsured rate started to climb especially for individuals buying insurance and not getting subsidies to help pay the premiums. Two of Gaba’s blogs explain why.
On the one hand, Gaba points out in a June 1, 2017 blog that premiums with or without healthcare reform go up due to inflation, an aging population, rising drug prices, etc. He wrote, “It's nearly impossible to compare apples to apples since pre-ACA policies were often ‘mini-meds’ or ‘junk plans’ which barely covered anything...and even the ‘full’ major medical policies often didn't cover mental health, maternity/prenatal care and so forth.” Gaba explains further that many buyers on the Obamacare exchanges qualify for tax credits to help pay the premiums. When measuring cost increase Gaba says, “…it's absurd to measure the ‘average premium cost’ without taking those credits into account.”
On the other hand, in 2016 the Electoral College seated a new president hostile to the Affordable Care Act. Gaba explains how President Trump took steps to undermine the healthcare law’s momentum using executive orders and litigation.
Under Trump’s watch the department of Health and Human Services reinterpreted and rewrote regulations that undermine the ACA’s goals for universal healthcare coverage.
Gaba’s blog title says it all UPDATE: Kaiser study proves it: ACA markets had stabilized until Trump's wrecking ball crashed into them Insurers responded to market destabilization by raising rates.
A new president determined to kill the Affordable Care Act reenergized GOP efforts to repeal the whole law – kill Obamacare outright—and replace it with an anemic substitute. This effort failed.
Other sabotage attempts were more successful. The Trump administration did an end run around current law to reintroduce skimpy or junk policies that do not cover all essential services considered to make up comprehensive insurance. Many unsuspecting buyers were left with massive debt because their junk policies did not cover their medical bills, a practice the Affordable Care Act moved to eliminate but is now back.
And finally in a later Gaba blog, UPDATED: EXCLUSIVE: How much more are YOU paying this year due to #ACA sabotage? Gaba posted this update. “Sure enough, as 2017 dragged out, Donald Trump and Congressional Republicans threw every type of sabotage they could think of at the ACA. Most of the official legislation ended up failing (aside from repealing the individual mandate, though that doesn't formally kick in until 2019), and some of Trump's regulatory sabotage efforts either fell flat or blew up in his face. Even so, a toll was definitely taken...and as I expected, it was those in the middle class who ended up taking it right in the face.”
The middle class especially affected by the sabotage are those individuals buying insurance on their own –known as the “indy market -- but do not qualify for financial assistance according to Obamacare guidelines. Gaba reports that the “ACA-compliant indy market likely down to around 13 million today, mainly due to the premium increases for unsubsidized enrollees forcing them off the market. (The ‘subsidized’ numbers are still around the same.)”
Healthcare reform also affected other groups in the insurance market like Medicare and Medicaid recipients.
Medicare is a gov’t program covering primarily those over 65. Some with disabilities also qualify for Medicare health insurance coverage. While Medicare was not the Affordable Care Act’s focus, the healthcare law put in place provisions to improve services for seniors like free preventive services, lower costs for prescription drugs, and more coordinated care.
Medicaid is a state/federal partnership that covers low-income individuals and families.The Affordable Care Act expanded eligibility for Medicaid based on income but The US Supreme Court made expansion optional for states. Many states chose not to expand their Medicaid programs for political reasons. An individual making about $17,000/year would qualify for health insurance through the ACA’s Medicaid expansion provision. That same low-income childless adult would not qualify for Medicaid under the old traditional Medicaid rules in most of the remaining states that did not expand Medicaid as per Obamacare.
Expanding Medicaid has meant that millions more people gained insurance but gains have been tempered. Gaba notes that “Medicaid expansion enrollment is actually around the same or even lower today, partly due to improved economy/job market (some people have risen the threshold or moved to employer coverage), partly due to GOP undermining the program (work requirements, etc.)
Gaba offers his suggestions for improving the Affordable Care Act in a blog called If I Ran the Zoo. Looking forward Gaba is covering the many healthcare reform proposals emerging ahead of the 2020 presidential elections. They go from fixes for the Affordable Care Act; to plans like Choose Medicare; or Medicare for America that reorganizes health insurance in a big way; to wholesale change like Bernie Sanders’ Medicare for All that eliminates private insurers altogether.
Gaba publishes a Weekly ACA Digest on his blog. Take the week of April 7 – 14. Gaba covers healthcare ground in Ohio, Tennessee, Washington state, Idaho and Colorado. He follows the healthcare issue as it moves through Congress, the courts, and presidential campaigns—all in one week.