The Politics of US series: Obamacare

Eighth in a 10-part weekly series. The Politics of US looks at polarizing topics to help deepen understanding of the issues – and respect for those with differing views. This installment looks at why Obamacare is so controversial, and costly.

Follow us on Twitter @CSM_politics. Review the previous seven installments, from guns to illegal immigration, here.

In this week's edition:

1. Cover story: Obamacare's ups and downs, as seen by a Republican doctor
2. Briefing: Where 'Obamacare' stands in 2016
3. By the numbers: Which country spends the most money on health care?
4. Civics 101: Why conservatives challenged the constitutionality of Obamacare
5. The candidates: Where Clinton and Trump agree on US health care policy
6. Engage: Discuss the Affordable Care Act, just don't call it Obamacare (or maybe you should)
7. Quizzes and lists: How much do you know about health care reform?
8. Our picks: '11 mind-blowing facts about American health care dysfunction' – and more

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Obamacare's ups and downs, as seen by a Republican doctor

Daniel Derksen, who drafted part of Obamacare, has had a front seat to the implosion of Arizona's private insurance marketplace. But as a rural health expert, he also sees how it's helped.

By Francine Kiefer, Staff writer

Daniel Derksen knows only too well how polarizing Obamacare can be.

In 2012, he was leading an effort to build a health insurance marketplace for New Mexico under the new law. The state’s Republican governor, Susana Martinez, and Dr. Derksen – also a Republican – were committed to standing up a robust, competitive marketplace that would be run by the state, not the federal government.

Initially, things went pretty smoothly for this family physician and health-policy expert. Derksen, who had actually drafted part of the Affordable Care Act, had secured a first round of federal funding for the state’s marketplace exchange. He was readying his proposal for a second round of funding.

But as the Supreme Court moved toward a landmark ruling on the constitutionality of the law, conservative critics in the governor’s administration began to question him. With tensions mounting, Dersken handed his funding proposal to New Mexico’s secretary of human services.

“Obamacare’s not coming in the door,” said the secretary, throwing his proposal on the floor and storming out of the room, according to Derksen. 

Read more

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BRIEFING: Where 'Obamacare' stands in 2016

By Francine Kiefer, Staff writer

Given the polarizing nature of the Affordable Care Act, aka “Obamacare,” it’s not surprising that the two main presidential candidates have opposite takes on it. Here’s a review of the law and what could happen with it.

Q: Why is Obamacare in trouble?

The Obama administration announced Monday that consumers who buy private insurance under the law’s federal marketplace exchange will face an average 25 percent increase in premiums for a benchmark “silver” plan, though most people will qualify for tax credit subsidies to help pay for the price hike. It’s increasingly clear that the next president will have to address the instability of the federal exchanges.

The premium increases follow the exit of big private insurers and co-ops from many of the exchanges set up under Obamacare. Analysts cite several reasons for the insurer exits, including inexperience with the marketplaces, the end of certain federal support for the insurance companies, and an imbalance among those covered: too many sick participants, not enough young, healthy ones. That has been costly for private insurance companies, who have cited hundreds of millions of dollars in losses.

Read more

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BY THE NUMBERS

Also see The Upshot's interactive map of where uninsured Americans live within the US at the county-level. 

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CIVICS 101: Why conservatives challenged the constitutionality of Obamacare

By Christa Case Bryant, Staff

Not a single Republican voted for the Affordable Care Act (ACA), which a Democrat-controlled Congress passed in March 2010. Two years later, conservatives challenged the law's constitutionality in a landmark Supreme Court case, NFIB v. Sebelius. The case focused on the law’s requirement to sign up for a minimum level of health insurance or pay a financial penalty, known as the individual mandate.

The main question was: Does the constitution give Congress the authority to establish such a requirement? The court examined two provisions under which Congress could claim this authority: the power to collect taxes and to regulate commerce between states. Both are found in Article 1, Section 8 of the Constitution.

The first clause, about taxes, seems relatively straightforward: “The Congress shall have power to lay and collect taxes, duties, imposts and excises, to pay the debts and provide for the common defense and general welfare of the United States; but all duties, imposts and excises shall be uniform throughout the United States…”

The third clause, known as the Commerce Clause, gives Congress the authority to “regulate commerce … among the several states.” Essentially this gets to the debate over the balance of power between federal and state government, as Cornell’s Legal Information Institute explains. 

In its June 2012 decision, the Supreme Court determined that the Commerce Clause did not provide legal justification for compelling Americans to buy a minimum level of health insurance or else face a financial penalty.

“The individual mandate… does not regulate existing commercial activity. It instead compels individuals to become active in commerce by purchasing a product, on the ground that their failure to do so affects interstate commerce,” the ruling read. “Construing the Commerce Clause to permit Congress to regulate individuals precisely because they are doing nothing would open a new and potentially vast domain to congressional authority.” 

However, the court upheld the individual mandate, but for a different reason: it argued that the financial penalty amounted to a tax and thus fell within the bounds of Congress's constitutional authority.

"In this case … it is reasonable to construe what Congress has done as increasing taxes on those who have a certain amount of income, but choose to go without health insurance. Such legislation is within Congress’s power to tax," the ruling read.

Subsequent Supreme Court cases challenged other aspects of the law, including whether it violates the religious liberty of employers opposed to providing contraception.

(Editor's note: This section was corrected to clarify the court's decision on the individual mandate.)

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THE CANDIDATES: Where they stand on health care

We encourage you to contact the Monitor on Twitter @csm_politics or by email csmpolitics@csmonitor.com if you can improve our chart!

Sources: the Jill Stein campaign, the Hillary Clinton campaign website, Reuters, MSNBC, the Donald Trump campaign website, ProCon.org, Fox News, Donald Trump's Twitter account, Politico, ISideWith.com, Ballotpedia, CNN

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ENGAGE: Living Room Conversations and AllSides.com

Look at health care from different perspectives and discuss with people who agree and disagree with you.

• Why some people use the term "Affordable Care Act" while others say "Obamacare."
• Do we have "health freedom"? Are "big pharma" and "big health" getting in the way?
• Let's discuss health care with friends and family, even when we disagree - here's how.
• Dig deeper into health care with these policy proposals and news coverage from the left, center and right.
• Discuss health care in the classroom following this lesson plan that reflects and respects different perspectives.

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QUIZZES & LISTS

1. How much do you know about health care reform? Take our quiz.

After surviving a shaky legislative birth, significant public opposition, and legal challenges that went all the way to the US Supreme Court, President Obama’s signature achievement, comprehensive health-care reform, went into effect in 2014. How well do you know the reform law and the underlying issues? 

2. 'Between Two Ferns' and the 8 wackiest Obamacare ads targeting Millennials

The program is complex and its benefits are difficult to reduce to a sound bite. So several advocacy groups ditched traditional messaging and created attention-getting, even wacky marketing campaigns in the hopes of generating social media buzz and getting more young adults to sign up for insurance. Here are some of the stranger pro- and anti-Obamacare ads targeting Millennials.

3. HealthCare.gov: Five questions about the problem-riddled rollout

The rollout was so rushed that, even after the launch, the site's computer code still had placeholder language, tech experts say. The site also did not have the capacity to handle the flood of visitors it received, making it operate slowly and crash often. Here are five questions about what happened after the launch on October 1, 2013.

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OUR PICKS: Recommended reading and viewing

1. "Football Team at the Buffet: Why Obamacare Markets Are in Crisis," The New York Times

… many of the most important problems can be understood if you think of an Obamacare marketplace as a particular kind of restaurant: an all-you-can-eat buffet…. The appeal of your business — and the risk — is that all people pay the same price, whatever their appetite. That is fine if you charge $15 and feeding the average customer costs $10. But you can be in deep trouble if your buffet suddenly becomes the favorite hangout of the high school football team. Once a bunch of growing teenage athletes start dropping by after practice, they can ruin your business. Those very hungry customers will pay $15, while eating $40 worth of food.

2. "11 mind-blowing facts about American health care dysfunction," Vox (video)

• One in every six dollars in the US gets spent on health care.
• An estimated 210,00 patients are killed annually by medical errors – that’s the equivalent of 10 jumbo jets crashing every week.
• Americans pay (way) more for the exact same drugs.

3. "America’s Bitter Pill," a New York Times review of the 2015 book by Steven Brill 

In Brill’s account of the Affordable Care Act, the insurers got a fair shake, uninsured and underinsured patients truly benefited, hospitals and pharmaceutical companies and medical equipment companies were left free to charge exorbitant prices, while the general public was left with no real strategy for cost containment. In other words, Brill is impressed with the expanded coverage provided by Obama­care, and depressed about the cost of care. Despite the cynical title, this is a surprisingly triumphant book.

4. "Selling Sickness: How Drug Ads Changed Health Care," NPR

Prescription drug spending is the third most expensive cost in our health care system…. In a decade and a half, the use of prescription medication went up 71 percent. This has added about $180 billion to our medical spending…. It used to work like this: Doctors decided what to prescribe. Drug companies — through medical advertisers — tried to influence doctors. Patients did what they were told…. Today, drug companies spend $4 billion a year on ads to consumers…. The Nielsen Co. estimates that there's an average of 80 drug ads every hour of every day on American television. And those ads clearly produce results… By taking their case to patients instead of doctors, drug companies increased the amount of money we spend on medicine in America.

5. "Our diagnosis as doctors – ObamaCare is about to collapse," by three MDs who are Republican members of Congress, Fox News

The dwindling number of ObamaCare supporters repeatedly point to the fact that 20 million more Americans have coverage now than before ObamaCare. The vast majority of those 20 million, however, have been dropped into a failing Medicaid program…. It is a top-down system that has Washington dictating terms to the states that ignore the diverse needs of communities across this country. That is not a recipe for success, and studies have shown that Medicaid’s impact on the health status of enrollees is negligible. Regardless, 31 states expanded their Medicaid programs under Obamacare. However, it is not going as promised. According to Dr. Brian Blase at the Mercatus Center, there are 50 percent more enrollees at a cost of 50 percent more per person than originally projected. These massive, unanticipated costs will only become more unaffordable in the coming years.

6. "Where Clinton Will Take Obama Care," op-ed by Phil Gramm, the Wall Street Journal

The Achilles’ heel of ObamaCare today is the same weakness that felled HillaryCare – the coercion required to force millions of young, healthy people into the exchanges where they can be exploited. Why the Republican majority in Congress has never forced a vote on health-care freedom, giving families the right – promised by President Obama and his Democratic allies – to choose not to participate in ObamaCare and to buy the health care of their choice independent of the exchanges, remains the greatest mystery of the 114th Congress.