Magazine article The New Yorker

Health Caring

Magazine article The New Yorker

Health Caring

Article excerpt


--Jeffrey Toobin

The Affordable Care Act, President Obama's perpetually beleaguered health-care initiative, received a jolt of good news last week. As the first deadline for coverage in 2014 drew near, the Administration announced that the number of people who signed up had passed six million. That's short of the original goal of seven million, owing largely to the disastrous launch of the federal Web site last fall. The methods for tallying beneficiaries, like everything else about the law, are being disputed, and regional disparities remain severe. Still, it's clear that the law is helping a lot of Americans. Three million young people remain on their parents' health-care plans; more than eight million uninsured people are eligible for Medicaid; and, according to the Department of Health and Human Services, more than a hundred million people have received preventive-care services, like mammograms and flu shots, at no cost.

Those gains have been achieved amid a political controversy that has at times seemed almost unprecedented but which in many ways replicates the example of two of the law's forerunners, Medicare and Medicaid. Those programs were born together in the summer of 1965, but their paths quickly diverged. Medicare, providing health insurance for all Americans over the age of sixty-five, proved popular almost immediately: after the rollout, about nineteen million people signed up, more than ninety per cent of those eligible. Medicaid, covering the poor of all ages, is financed jointly by the federal government and the states. The first year, only twenty-six states agreed to participate, and the program didn't include all fifty until 1982, when Arizona, the final holdout, joined.

The broad outlines of the debate over the A.C.A. have also been clear from the beginning. Republicans have mostly tolerated the portions of the law that benefit the middle class, including the guarantee that young people can remain on their parents' policies until they turn twenty-six; the prohibition on denying coverage to people with preexisting conditions; and the elimination of lifetime limits on the amount of coverage an individual can receive. The real controversy, as with Medicaid five decades ago, centers on health care for the poor. Ideas such as the requirement that everyone obtain insurance, with subsidies for people who can't afford it; the mandate that insurance companies offer coverage to all comers; and the incentives for states to expand the number of people covered by Medicaid have meant political war. And the partisan divisions have been much more entrenched on these issues. As of a few weeks ago, the Republican-controlled House had voted fifty times to overturn all or parts of the law--though the votes were largely symbolic.

The legal attacks, while less noisy than those in Congress, have been more effective. Two years ago, in the epic case of National Federation of Independent Business v. Sebelius, the Supreme Court upheld the heart of the law. But seven Justices (all except Ruth Bader Ginsburg and Sonia Sotomayor) also rewrote it to say that states could opt out of the Medicaid expansion. Twenty-four states have done so, the same number that originally resisted Medicaid. As before, many of them will eventually opt in. …

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