I was just 18 when I first heard this question, but even then, in the context of the late days of the Carter Administration, it registered with me as a first-time voter, and, I know, with my parents and older relatives during a Reagan/Carter debate in 1980:
“Are you better off now than you were four years ago?”
In the context of those years, everyone knew what Reagan’s question meant—and people—regardless of political leanings, responded to it. Inflation was high, energy prices had soared, interest rates neared 20 percent, and our 52 hostages had been held for nearly a year in Iran. President Carter’s own description of “a national malaise” seemed apt, though I've never bought the idea that he or any other President is entirely responsible for every national circumstance.
When I heard the same question asked by Mitt Romney in his recent address to the Republican National Convention, I had to think a little longer, because the economic and political equations had changed so much. Let’s see . . . just refinanced at around 5%, energy is expensive but our car gets good mileage (Carter's administration set up the first auto mileage standards), economy is rough but improving.
With the possible exception of college tuition, the one really enormous economic change from the first time that I considered the ‘are you better off?’ question 32 years ago is the incredible impact of healthcare and health insurance cost increases on the budgets of governments, businesses, and households nationwide. Compared to 1979, the ability of those under 65 who do not qualify for Medicaid to afford appropriate healthcare can only be measured in our nation's incredible rate of 45 million uninsured, including a growing number who no longer receive healthcare benefits at work.
Though some criticize President Obama for putting healthcare reform “ahead of jobs,” I can’t fault either him or Congress for getting on with the business of healthcare reform. To me, the development and passage of the Affordable Care Act represents a huge boost to the health and economic circumstances of many, many Americans. And, while its major provisions won’t be in place until 2014, it has set in place a series of positive changes:
· It puts healthcare insurance in reach for some 32 million of our 45 million uninsured, including 11 million with untreated behavioral health problems. That's a feat that no business, no entrepreneur, and no amount of private investment could accomplish. Come 2014, these folks are definitely better off, though perhaps not today.
· It puts in place a set of essential health benefits that will ensure that all plans offer an array of services that includes mental health and substance use care benefits that are at “parity” with medical benefits. While neither the EHB or parity regulations are perfect, they definitely represent progress made in the past four years. Definitely better off.
· It will help unemployed and low-wage workers, both of which have little chance of paying for health insurance on their own. When one considers that the cost of family healthcare coverage can easily top $20,000 annually (premiums and out-of-pocket costs), the Medicaid expansion and insurance subsidies offered by the ACA will meet the needs of a growing number of Americans whose employers do not provide health insurance benefits. It will help those “in between” jobs too. Surely, even a low wage job or a spate of unemployment would feel a little better, a little more hopeful, for workers who know that they’re still meeting the health needs of their loved ones. And, even the substantial cost of insurance is likely less than the cost of a single ER visit that leads to a costly hospital stay.
· Over the longer term, the ACA is the only credible alternative for exercising some control over healthcare costs—no other serious solution is in sight. By opening access to lower cost sources of regular care and by promoting wellness, the ACA is much more likely than our current approach—doing nothing—to lead to meaningful change in the upward trajectory of healthcare and health insurance costs.
And, who could claim that the cost of health insurance is not already a major factor in businesses’ decisions about investments, benefits, jobs—or in their decisions to source products in other countries? I don’t buy the argument that, minus the ACA, substantially more Americans would have gone back to work in the past couple of years—the big drag was the foreclosure crisis and the collapse of the housing market, not the costs of healthcare, which have been with us all along. Nor do I believe that the ACA’s tax on employers that don’t offer insurance represents a major deterrent to creating new jobs. More than a few employers, I expect, will recoup any additional cost the way already do today—by splitting the difference in employee wages, limiting wage increases, and trimming other costs.
In all, I believe that the Affordable Care Act offers ample reason to feel that Americans, including those with behavioral health needs, are better off today—and likely far better off in the future—than they were four years ago at the start of President Obama’s term. By targeting the growing impact of healthcare costs, the costs of caring for the uninsured, and the rising costs of insurance premiums in everyone’s budgets while launching payment and delivery-system changes, he’s put the ACA in position to make a big difference. Now, to see it through . . .