This paper presents a critical examination of the Affordable Care Act (ACA), arguing that it serves primarily to consolidate power within healthcare and insurance cartels rather than improve access or affordability. The author analyzes the influence of the American Medical Association (AMA) and the Relative Value Scale Update Committee (RUC) in setting healthcare prices, the role of the McCarran-Ferguson Act in exempting health insurance from antitrust laws, and the conflict of interest demonstrated by policymakers. The paper proposes both top-down and bottom-up policy interventions, including presidential executive action and grassroots mobilization through the Libertarian Party, to dismantle cartel influence and reform the ACA.
The Affordable Care Act (ACA) was recently signed into law in America. This public policy impacts all citizens of the USA and has been controversial from its inception, not only because many people who were promised by the President that if they liked their plan they could keep it ended up having to get a new plan at a higher rate, but also because the very individuals who promoted the policy demonstrated a clear conflict of interest in doing so (Cesca, 2010).
The financial impact of the policy has been serious. Rates have increased, and people who cannot afford to buy health coverage are taxed if they do not buy it. Moreover, the Act asserts that "healthcare is a right, not a privilege" (Rak & Coffin, 2014, p. 317). However, by "enforcing" everyone to exercise that "right," it stops being one and instead becomes a "tax" burden on American families who may have reasons for not wishing to purchase health insurance. At the same time, research has shown that the ACA does little to reinforce the practice of primary care physicians and instead only directs more money to specialized care, further destroying the pool of and accessibility to primary care physicians (Goodson, 2010). This essentially means that more people seeking health care will be required to pay more for specialized care. The ACA has, in effect, institutionalized practices that benefit specialized providers at the expense of patients and primary care practitioners.
As Rosenbaum (2011) indicates, the Affordable Care Act was a "watershed in U.S. public health policy" because of its aim to reduce the total number of uninsured citizens by over 50 percent, resulting in coverage—whether through insurance or Medicaid—for 94 percent of all Americans (p. 130). Through this Act, touted by supporters as a reform, health care providers are guaranteed payments that before were simply not available for 25 percent of municipal hospitals "which handle mostly the poor" (Schorn, 2006). Thus, for both non-profit and for-profit hospitals, the ACA has guaranteed better consistency with regard to client payment fulfillment. Understanding how the ACA came into being reveals even more clearly the driving motive behind this "reform."
The ethical principle that underpins this critical perspective is that of justice. Justice demands that the Affordable Care Act be exposed for what it is and that it be overhauled or vastly reformed so as to allow individuals who do not want to purchase health insurance to opt out without fee or penalty. The current system violates individual autonomy while enriching the very institutions that claim to serve the public interest.
Matthews and McGinty (2010) provide explicit documentation of how health care services have become a profit-driven arena, directed by secret panels—cartels—which provide guidance for groups like The Centers for Medicare and Medicaid Services. They describe the mechanism: "Three times a year, 29 doctors gather around a table in a hotel meeting room. Their job is an unusual one: divvying up billions of Medicare dollars" (Matthews & McGinty, 2010). This panel operates under the title of Relative Value Scale Update Committee (RUC) and essentially sets the "pricing" of health care services, indicating how much health care providers should be compensated for their work.
RUC oversees approximately half a trillion dollars worth of Medicare money in the sense that committee members determine who gets a significant cut. According to DeBronkart (2013), RUC is nothing more than a "giant cabal" under directorship of the American Medical Association (AMA). Dr. Lee Hieb (2012), former president of the Association of American Physicians and Surgeons, has reported that the AMA has not only openly endorsed the ACA, it is "firmly behind this egregious bit of expensive and health killing legislation." Hieb notes how the AMA has become firmly embedded in the formation of government policies, providing since the 1980s an ever-increasingly complex coding system which health care providers are "required" to use when they bill insurance companies or government agencies. The AMA essentially has total control over how physicians interact financially with their clients—which is precisely what the ACA reinforces in an even more stringently codified way.
Because RUC has advised allocating more government money to medical "specialists," Medicare coffers have been depleted (Sanghavi, 2009). Thus, the effect of collusion between AMA and government is, ultimately, exploitation of government's pocketbook. But exploiting the pocketbook to the extent that it is completely emptied does not help anyone in the services industry. What is wanted are perpetual profits at perpetually increasing rates—in short, a "fix" (Sanghavi, 2009). Since the "fix" only exacerbates the problem, a "patch" is needed. The answer to this exploitation is more collusion: the ACA is a law that now requires everyone to "pay into" the system, meaning the pocketbook is then raided and divided by RUC. That pocketbook is now being reloaded annually with more money than ever before.
People who did not want or need health coverage have no choice but either to buy in or pay the penalty "tax" for not buying in. To make matters worse, the 1945 McCarran-Ferguson Act is a virtual shield for the health care cartel, in that it exempts it from antitrust laws. Theodore Roosevelt, the famous "trust buster" in U.S. history, would be hard-pressed to break the trust that the health care cartel has developed—so entwined is it with the body of government off which it feeds. The system is essentially that of a host with an ineradicable parasite attached deep within its structure.
Price-fixing, which is essentially what RUC does for the health care services industry, is illegal in America. As Kurt Eichenwald (2000) described in detail in his book The Informant, the FBI will go to great lengths to "nab" price-fixers. Yet one can only surmise that the current system of government in the U.S. is operated by individuals who are openly breaking the law and not being punished for it. The cartels appear to understand that the "law" proper does not apply to them, since they are so entwined with the executive, legislative, and judicial branches of government—branches which oversee, craft, and enforce the law.
The decision maker who will receive this policy brief is Senator Rand Paul, a possible future Presidential candidate and supporter of Libertarian ideals. The policy requires the attention of the Paul camp because it illegitimatizes the health care industry as a whole by exposing it to charges of extortion, hypocrisy, and strong-arming. Nursing is about helping people at an affordable cost, not at a cost that will make them wish they could receive care in another country. The ACA not only hurts patients, it also hurts nurses and doctors who act as primary care givers, as they are also targets of the AMA, which wants to replenish the government's wallet and then divvy out more funds for "specialized" care givers.
As an aftereffect, the law, which is said to be helpful to the average American because it provides "better" care at lower cost (Rosenbaum, 2011), actually only gives the health insurance cartel an excuse to raise rates (since it now has to cover more liabilities). This in turn prompts government to "overhaul" the legislation in an attempt to pacify the insurance lobby. The famous promise of the President to citizens that they could "keep their plan" if they liked it was quickly broken precisely for this reason. Any way one looks at it, government has become the servant of special interest groups—in this case, the health care cartel and the health insurance cartel. What government does not serve in any sense of the word is the working class citizen it purportedly aims to "protect."
Citizens feel themselves caught in the middle of a health care "crisis," as they are the ones least represented in this tug-of-war. The ACA demonstrates that nothing has changed in America in the past hundred years. The Federal Reserve Act of 1913, which gave the power to print the nation's money to a small, private cartel of bankers, showed how powerful a group of focused and determined people can be when they unite themselves with persons of authority in government. The Affordable Care Act, which is said to protect citizens just as the Federal Reserve Act was said to do (both have done nothing but rob citizens of their wealth and their freedom of choice), has ushered in a new era of cartel dominance—only this time, it is not one but two groups (health care and health insurance) vying for the hard-earned dollars of Americans.
The main challenges of addressing this issue are that it will pit Paul, conservatives, and Libertarians against a powerful health care cartel, which does not want anyone to rock its boat. The cartel is elitist, wealthy, and influential. Targeting them the way that Teddy Roosevelt targeted the major trusts (to become known as the "trust buster") will likely have political consequences—good if the busting of the cartel is successful; bad if the bust fails. Garnering support from constituents may be easier than the actual contest that awaits Paul in Congress or from the cartel, which has powerful influences in and around the White House. Depending on how effective Paul and the Libertarians are at redirecting the current two-party system to one more inclusive of alternative, grassroots perspectives, the challenges will change from time to time. Overall, the biggest challenge is to make a big, bold political statement in which Paul "calls out" the fascistic nature of today's government.
The primary options and interventions for Paul are the following: First, he should run for President and win the election. Second, once in office, he should suspend the ACA immediately and allow citizens to make up their own minds in a free society what they wish to do regarding health care. Third, he might consider nationalizing the insurance industry. If insurance companies do not want to cover specific types of individuals because such types are precisely the ones who are likely to need coverage, matters must be taken in hand and the insurance companies taken over by a government committed to helping others rather than to making profit. If that option is not viable, an alternative may be to oblige insurance companies and health care agencies to lower their rates all the way across the board. This would undoubtedly set off a chain reaction of necessary rate lowering in all industries as the market is so interconnected; if one trust is busted, they all must be.
The best course of action would be for Paul to be elected President and for him then to issue an Executive Order. This will allow Paul to bypass Congress and the lobbies which control it. Americans will thank him even though he will make enemies of some powerful organizations. There is certainly precedent for issuing an Executive Order to overhaul an unjust system. This course of action relies upon overwhelming grassroots support and a massive electoral base. If Paul can manage to make the overhauling or abolishment of the ACA his main platform, it is possible that he could ride a tidal wave of support into the White House.
The success of this policy can ultimately be evaluated by the extent to which the AMA is reformed and the ACA abolished or restructured. Health care costs should not be influenced by individuals who stand to benefit from raising rates or arbitrarily obliging all citizens to purchase coverage whether they like it or not. However, throughout the incremental stages of the policy, evaluations will be necessary. From the top-down approach, this evaluation would start with Paul himself: Is he serious about taking on the cartel? Is he serious about running for President and making this the basis of his platform? Once he has committed to this course of action, the next steps are to gather advisors around him who can help organize the campaign.
"Libertarian Party mobilization strategy"
"Dual-approach implementation feasibility"
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