Last weekend marked the thirteen-year anniversary of the administration of former U.S. President Barack Obama getting the landmark Affordable Care Act (ACA) passed by Congress and signed into law. Since then, the ACA, billed as “Obamacare”, has brought nearly 30 million uninsured Americans under the healthcare insurance umbrella. It also survived challenges in court and notably its individual mandate, which requires tax authorities to levy a punitive fee on those who fail to buy health insurance policies, was upheld by the Supreme Court in 2012. Attempts by the administration of former President Donald Trump to gut the law by attacking its key provisions also failed in the Supreme Court, and today there is a far greater sense of inclusivity, accessibility and justice so far as healthcare insurance regulation is concerned.
My encounter with the ACA when I first took up the role of this newspaper’s U.S. correspondent, in early 2010, was twofold. Firstly, it was the most dramatic event happening in Washington when I landed there on a wintry February morning. While the context of U.S. healthcare might not have been directly relevant to India, the sheer intensity of the conflict and negotiations around the Obama administration’s campaign to get it passed on the Capitol Hill captivated global audiences and made it an obvious story for me to cover daily. To me, and perhaps to some readers of the coverage that we provided of the ACA’s tortuous path through Congress, it was astounding that to get to the final lap and across the finish line, the White House had to ultimately yield to the demands of Republican Congressman Bart Stupak, a long-time opponent of abortion, who insisted on including the Hyde Amendment, an anti-abortion-funding provision within Medicaid, in the ACA Bill.
Second, I was directly impacted by the restrictive nature of the previous healthcare insurance, as the ACA had not yet been passed into law when I arrived. Members of my family with any health issue, howsoever minor and transient, were denied healthcare policies owing to a breathtakingly broad definition of “pre-existing condition”, which included, bizarrely, even the “condition” of pregnancy. Further, almost without exception, hospitals and doctors were recommending an ever-expanding use of expensive testing and medication regimens, unlike, say the U.K., where these are relatively less prescribed. This made healthcare doubly expensive, putting it entirely beyond the reach of the poorer sections of the population.
The ACA was remarkable for the paradigm shift that it brought about in this deeply-entrenched system of insurance companies, hand-in-glove with healthcare providers. Overnight, it broke their system of minimum patient support and maximum user out-of-pocket payments. It was a shining example of how vested interests, no matter how deep their pockets and how insidiously they were able to lobby with lawmakers to preserve the status quo, could be ousted by enlightened leadership that took the fight to their doorstep yet made compromises to get the bill passed.
What was immediately evident at the time of the ACA’s passage, and is still relevant today, is the fact that in line with the traditional balance of power between the federal and state governments in the U.S., the latter still retain a great amount of autonomy in setting policy positions so far as the healthcare sector is concerned. The same applies to reproductive rights, specifically the ability the U.S. states to now deny women the right to abortion in the wake of Roe vs Wade being overturned by the Supreme Court.
Regardless of the setbacks that the ACA may face in the years ahead — and it has survived the sharpest of legal attacks already — it will always be a seminal legislation impacting the daily lives of the common people in the U.S. That it became emblematic of Mr. Obama’s “Yes we can” campaign reflecting the power of the individual’s voice was a bonus for the Democrats that still shapes their political prospects.
narayan@thehindu.co.in
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