Making Health Care Worse

National Review

As Wisconsin Representative Paul Ryan recently argued, the Affordable Care Act (a.k.a. Obamacare) was sold on “three broken promises.” The administration pledged that its massive health-care-reform law would be paid for without hiking taxes on middle-class families, that it would reduce the cost of insurance, and that it would allow all Americans to keep their existing insurance if they wished.

Ryan is correct: On all these grounds, the administration has made promises it cannot keep. Even worse, however, than its failure to deliver the benefits it advertised is the actual harm that Obamacare policies will cause — policies that will make it harder for the U.S. to develop sustainable health-care reform.


President Obama initially made that pledge during the 2008 campaign. Now that the Supreme Court has ruled that the individual mandate can stand only as an exercise of Congress’s power to tax, the administration will have trouble claiming that it has not raised taxes on middle-income Americans.

Certainly the financial impact that the mandate will have on those subject to it remains the same regardless of how we label it. A 2012 study from the Urban Institute finds that 7.3 million uninsured Americans are too wealthy to qualify for either Medicaid or the exchange-based premium tax credits, which Obamacare makes available to the uninsured who have incomes up to 400 percent of the federal poverty level. That comes to $92,200 for a family of four. The number of such relatively well-off Americans who are uninsured may seem high, but the Urban Institute’s figure is roughly consistent with a 2003 report from Blue Cross Blue Shield, which found that one-fifth of the uninsured in America earn more than $50,000 annually and so are, in effect, uninsured voluntarily.

These families and individuals, though solidly middle-class, are hardly among the “millionaires and billionaires” whom Obama routinely insists should pay more in taxes. And the incomes of many of the uninsured will clearly fall well below the $250,000 that the president promised would serve as the minimum for any proposed tax increases.

But even if we accept the White House’s premise that the mandate is not a tax, many of the actual taxes contained in the Affordable Care Act, though not levied directly on individual taxpayers, will ultimately be passed on to them in the form of higher insurance premiums and higher health-care costs. Former Congressional Budget Office director Douglas Holtz-Eakin points this out in a recent paper.

Though “invisible,” these taxes are real, and they will eat into the paychecks of all Americans carrying health insurance, no matter how modest their incomes. Holtz-Eakin calculates that the premium taxes alone that the Affordable Care Act imposes on insurance companies could add $475 to the annual cost of the average family’s insurance plan.

In short, these new costs and taxes, though in some cases hidden, will increase the cost of insurance for millions of Americans.


Soon after President Obama took office, his transition team set up a website that repeated a promise the candidate had made frequently on the campaign trail: that health-care reform would lower the average family’s health-insurance premiums by $2,500 before the end of his first term. Clearly, this has not happened — and won’t happen.

The president could argue that the promise will be fulfilled once his reforms have been phased in. This would be a convenient claim, since many of Obamacare’s cost-reducing provisions — like the “Cadillac tax” on high-cost insurance plans — aren’t scheduled to phase in until well after Obama’s second term is over. So while it’s possible that the law will lower the cost of health care, voters have no way of knowing whether it will in fact.

Health-insurance costs have already risen significantly since the passage of Obamacare, albeit at a slower rate than before, owing to a stagnant economy. Since the law imposes heavy costs on the insurance industry — through taxes and onerous regulations that force insurance companies to spend more on health expenses — insurance premiums will likely continue to rise.

In truth, Obamacare is largely a coverage expansion, with relatively weak cost controls at the margins.

The end result: Employers and employees alike will find themselves paying more for health insurance. Substantial costs will also likely be shifted from employers to taxpayers as the government defines insurance in ways that make it more expensive.


On the day Obama signed the Affordable Care Act, he repeated another promise that he had often made as he traveled across the country: “If you like your current insurance, you will keep your current insurance.”

But Obamacare left many companies wondering whether it makes financial sense to continue providing their employees with health insurance at all. The ACA levies penalties on certain companies that drop their employees’ coverage, but the penalties may turn out to be less than what they would save by dropping their employees’ insurance — and sending them to the new, taxpayer-funded state health-insurance exchanges.

An August 2011 report from the consulting firm McKinsey & Co. examined this possibility and suggested that “overall, 30 percent of employers will definitely or probably stop offering ESI [employer-sponsored insurance] in the years after 2014.” Corroborating these expectations are internal documents released from several large employers, including Caterpillar, John Deere, AT&T, and Verizon. These companies have calculated that they could cut costs by dropping insurance for at least some of their employees, giving them a raise, and paying the tax penalty. And last week Deloitte, a business-consulting firm, released a study suggesting that one in ten employers plans to drop coverage, with many more considering that possibility.

Even the CBO has estimated that up to 20 million Americans could lose the employer-based coverage they have today.

In a Manhattan Institute report, David Hyman and Richard Epstein point out that Obamacare will also mean that policyholders who keep their plans will find their coverage substantially changed. They’ll face higher premiums. Hyman and Epstein argue that the Affordable Care Act’s protection of existing coverage plans exists “in name only.” They note that while “plan serial numbers may temporarily remain the same,” the core provisions of the Affordable Care Act — especially its “combination of high taxes, large subsidies, and extensive mandatory contractual terms” — will result in substantial changes to most people’s insurance plans. Obamacare’s provisions could “eventually drive most private insurance plans out of business.”


Government spending on Medicare and Medicaid is slowly strangling state and federal budgets alike, threatening to impose either cuts to other critical government functions (such as national defense) or massive tax increases. The promise of Obamacare was that it would not just be budget-neutral but would actually reduce the deficit in the long term. That promise doesn’t add up.

Some budget experts have argued all along that the projected savings from Obamacare were based on a series of gimmicks — reflecting revenues from the CLASS Act (since rescinded) and Social Security revenues (which are paid out later) but not reflecting substantial implementation costs ($114 billion).

Obamacare obscures its true cost also by front-loading revenues while back-loading spending. The CBO scored the bill over a customary ten-year window, but the law phases in its revenue provisions before phasing in its core spending provisions. And so in the CBO’s scoring of the bill, ten years of tax increases are counted against just six years of new spending. The initial CBO score of $940 billion has since been revised upwards to $1.76 trillion by 2019.

Also contributing to Obamacare’s facade of financial sustainability is double counting, which defies common sense: While the law claims $575 billion in deficit reduction through cuts to Medicare, a substantial portion of that amount will then be used to finance the law’s new subsidies for private insurance and Medicaid expansion. Obviously, the savings will not materialize if they are used to fund the ACA’s new coverage expansions. The CBO has noted that without the $575 billion in Medicare savings that the law projects, the ACA will increase deficits by $226 billion through 2019.

The Medicare actuary, meanwhile, expects that some of the ACA’s central cost-cutting provisions will prove unsustainable and will eventually berolled back by Congress.

Some Obamacare defenders cite small demonstration projects whose track record so far is poor. And one significant cost-saving mechanism — the Cadillac tax on high-cost health plans, scheduled to take effect in 2019 — will be resisted strenuously by unions, who persuaded the administration to delay its implementation in the first place.

We should not be surprised, of course, that policymakers, Republican and Democrat, represent their favored polices as all dessert and no spinach when pitching them to voters. And we shouldn’t be shocked when they break their promises. But by focusing on expanding coverage through new taxes and spending without first addressing the drivers of health-care costs, Obama has doubled down on many of the worst aspects of the status quo. He understands that the U.S. health-care system is on an unsustainable trajectory, but his hallmark legislation will only make it worse.

Instead of tackling the nation’s most daunting health-care challenges, the Obama administration has expended political energy — and vast sums — on creating a new entitlement while expanding a broken one (Medicaid). Without large tax increases or cuts to other important programs, the creation of new constituencies for increased government spending will only weaken the nation’s ability to resolve existing deficits.

President Obama has burdened us with bad policies worse than any broken promises. Unless Obamacare is repealed by a future Congress, we’re all going to be paying for those policies for years to come.

— Paul Howard is director and senior fellow at the Center for Medical Progress of Manhattan Institute for Policy Research.

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