Politics. There were many harbingers of the pandemic policies that were unleashed upon the country, particularly that part of it that was born after 1990, but none quite does the job like the Affordable Care Act.
With no Cold War to fight, no communists lurking about to threaten liberty; economic growth greased by massive globalization and, after 9/11, free money, it was difficult to discern the differences between the policies of Republicans and Democrats. They seemed to be bound together by an economic nihilism that defined the country not by history and culture but by how rich one (or their friends) could get.
It was not what you would have expected from people who need to face the voters every two, four or six years. Nonetheless, absent clear and present dangers for leaders to, well, lead, they fell into a cycle of bitter culture wars over everything from drug use to TANF benefits to, of course, health care.
Health care was particularly salient, politically, in 2009-10. The massive 1947 bolus of population found themselves in that netherworld between the high health costs of late middle age and Medicare coverage. Funding health insurance coverage at an unprecedented scale fit neatly into those twin domestic goals of reducing unemployment and satisfying a loud constituency.
The law also created and energized a lot of new businesses like SHCR, Livongo and OSCR, with high hopes for “value-based purchasing” and other system reforms the ACA seemed to promise. The economic opportunities extended to businesses like UBER and LYFT that could build a giant car dispatch service on 1099 employees.
Bearing the brunt of the parts of the ACA that constituted a “get-rich-in-3-to-5-years” scheme were the young. Health insurance premiums were and still are unaffordable for the under 40 cohort. The inflation that results naturally from the rain of money that has fallen on health care for a dozen years has forced cash pay without the benefit of price discovery or competition. Until COVID, benefit expense on the SG & A line was an intractable drag on wages.
With the pandemic response in the rearview mirror, it is easier to see now. It is just a question of whether the children figure out how the benefits afforded their grandparents have been denied to them.
Policy. The ACA was not without some good policy, which makes Washington’s addiction to soaring narratives and brilliant photo-ops as they “go big” all the more tragic.
Guaranteed issue was a long overdue mandate to address cherry picking risk. The auto insurance industry offered an effective model of pooling high risks for distribution among insurers. Had the ACA merely required policies be available for all that applied in the individual and small group markets, it would have been a significant victory. High cost individuals could be handled with pooling as they are in some cases.
Extending the similar tax benefits that large employers enjoy to the individual and small group markets is also a net positive. Subsidizing the development of online exchanges has also been beneficial in reducing the friction in these underdeveloped parts of the insurance market.
The problem with doing just these few things is that first, it makes for a short movie. Second, the costs as the market adapted would have been borne by those in middle and late-middle age with higher medical expenses relative to younger, healthy individuals.
We cannot have that.
Power. Official Washington’s utter contempt for the young that began in earnest with the ACA probably culminates with the last two years of COVID-19 response. A young person without health insurance is not ideal but also not usually catastrophic. A 20 or 30-something whose education and/or career was interrupted and required living and working conditions that would normally fire up the American Civil Liberties Union, is another matter. So is requiring age-inappropriate vaccination regimes.
As the ACA was designed in part to protect those in middle and late middle age from economic risk, the slowly being discredited pandemic response was meant to harbor an entire generation from health risk, without regard to the consequences.
Schools were closed not because there was a threat to children, but because there was a theoretical risk to teachers. Restaurants and bars were closed to prevent partiers from spreading the disease to older family members, with little evidence to demonstrate that was happening.
The stubborn resistance on the part of the highly centralized scientific research community to present quality evidence on these life altering and often damaging policies was the “we really don’t care” cherry on the cynical and callous sundae served up to people most at risk for COVID-19. So far gone is the scientific community that the White House plans to announce the availability of a fourth shot before fall (read: election day) without the benefit of an AdComm.
The charge being taken up now is to immunize all those youthful and vigorous vectors of disease. PFE is still on its quest to get an Emergency Use Authorization for >6 years. MRNA is requesting a fourth series for >18 years. Their applications, it should be noted, are for vaccinations designed for the original SARS-CoV-2 version that circulated widely in early 2020, despite being on our third or fourth variant by now.
And then there is this.
The risk of myocarditis may be low but so is the benefit of vaccination, based on two years of data. For many parents even a low risk is intolerable. As an old boss of mine used to say, “unemployment is 100% when you don’t have a job.” Something similar can be said for a parent’s view of myocarditis especially in the face of limited data on long term clinical outcomes.
So, in the end, the parents of children under 20 have something in common with the generation that has been hellbent on destroying them economically. The difference is that one group is thinking of others, the other is thinking of themselves.
Emily Evans
Managing Director – Health Policy
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