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'Me' Versus 'We' in Obamacare


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To listen to the supporters of the Affordable Care Act, you'd think that the law's only purpose was to deliver health insurance coverage to individuals who did not have it, either because they were too poor to buy it or too sick for insurers to cover them.

Over these many months, the administration has hammered away with messages of "What's in it for me?": closing Medicare's donut hole for seniors unfortunate enough to have sky-high drug costs; keeping your kid on the family policy; giving low-income people large subsidies to buy insurance. There has been little public discussion of how some of the law's provisions benefit the larger community of average Americans.

That point was driven home last week at a panel discussion on the Affordable Care Act held in New York City sponsored by the Hollywood Health and Society Center at the University of Southern California and the Writers Guild of America East. A professor of public health who was in the audience asked why the panelists kept talking about what the law would do for individuals instead of the larger community. "Was Obamacare for me or for us?" she asked.

One of the panelists was the communications director for the Centers for Medicare and Medicaid Services (CMS), which is tasked with carrying out the law and selling it to the public. The CMS representative continued to emphasize the "me" perspective by listing a bunch of ACA provisions designed to appeal to this or that individual.

She avoided the touchy subject of the canceled policies that generated such a fierce backlash a few months ago from people who found they could not keep policies they liked and could afford. Those unhappy people had health plans that did not meet the minimum benefit standards the Affordable Care Act required such as coverage for prescription drugs, substance abuse, hospital outpatient care and maternity services.

Architects of the ACA believe these benefits are essential for good insurance coverage. But the owners of the old policies, many of which omitted these benefits, didn't see it that way. One 58-year-old Beltway lawyer, featured on a recent PBS NewsHour program, shared that she would have to pay some $5,000 more for a new exchange policy, an amount that included more cost-sharing and higher premiums. "The chances of me having a child at this age is zero," she said. "Why do I have to pay an additional $5,000 a year for coverage that I will never, ever need?"

The administration and ACA supporters have not bothered to explain to the woman (and others who were complaining) about how ACA includes cross-subsidization. Last week, the CMS official didn't explain it either. Once again, supporters missed an opportunity to talk about how the ACA includes "we" aspects of the law.

Here's how it works: An older woman doesn't need maternity care, but she has to pay for the coverage anyway. At the same time, a 35-year-old who does need maternity coverage must pay for some things an older woman might need – hospital outpatient surgery for a cataract operation, for example. This cross-subsidization helps make benefits affordable for those who need them.

It's the same principle at work in the Medicare program where cross-subsidization makes it possible to insure very old and very sick people for a reasonable cost. A 65-year-old who is new to Medicare may have very few health needs and cost the system very little money, but his or her premiums help subsidize expensive care that 85-year-olds need.

The administration has not only avoided making this point clear, which might have helped foster a better understanding of the law, but it has now backtracked on the canceled policies. Eager to contain the backlash, the president is allowing people to hang on to the canceled policies through the end of the year. And there's talk of perhaps a three-year extension allowing policies with inadequate benefits to stick around. If that happens, the real casualty will be the loss of the "we" and the cross-subsidization the Affordable Care Act tried to address.

More Blog Posts by Trudy Lieberman

author bio

Trudy Lieberman, a journalist for more than 40 years, is an adjunct associate professor of public health at Hunter College in New York City. She had a long career at Consumer Reports specializing in insurance, health care, health care financing and long-term care. She is a longtime contributor to the Columbia Journalism Review and blogs for its website,, about media coverage of health care, Social Security and retirement. As a William Ziff Fellow at the Center for Advancing Health, she contributes regularly to the Prepared Patient Blog. Follow her on twitter @Trudy_Lieberman.

Tags for this article:
Health Insurance   Medical Education   Medicare/Medicaid   Health Care Access   Trudy Lieberman   Health Care Cost   Pay for your Health Care   Aging Well   Medicare   Inside Healthcare  

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