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di - 29 Luglio 2011
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“Obamacare” also known as Public Law 111-148; The Patient Protection and Affordable Care Act[1] (hereinafter, “PPACA”), signed into law March 23, 2010, is the most consequential health care law to emerge from Congress since 1965 when Medicaid (federally funded health care for low-income families) and Medicare (federally funded health care for seniors) were created. The PPACA consists of 2,400 pages of legalese, and although its projected cost is at least $940 billion over the first ten years insuring an estimated 32 million additional U.S. Americans, it will nonetheless leave 23 million others uninsured.[2] Why? Because the United States is the only wealthy country in the world that still believes the provision of and payment for health care is a business only, and does not involve the basic moral question that should drive reform – “Do we want to give everybody access to health care?”[3] This intricate legislation can best be understood by grouping its provisions into three categories: (1) expanded coverage, (2) insurance regulation, and (3) taxes and other funding, not discussed in this comment other than with regard to the “individual mandate”.
Expanded coverage under the PPACA is realized by changes to Medicaid and private insurance.[4] The law eases the qualifications for Medicaid by expanding the definition of “low-income” to include a higher income bracket, and by including families without children. Previously, Medicaid covered only low-income families with children. This expansion is expected to provide health care coverage to an additional 16 million U.S. Americans.
By 2014, each State is obliged to institute an online health care insurance marketplace offering five different levels of coverage plans: bronze; silver; gold; platinum; and catastrophic. The health care insurance marketplace is expected to furnish private health care plans to an additional 16 million U.S. Americans who are currently uninsured, if they can afford the cost of the insurance premium.
In addition, employers with more than forty-nine people on the payroll must provide a health insurance plan for employees, and smaller companies with fewer than forty-nine employees that choose to provide health insurance will receive a tax credit.
What happened to the so-called “public option”—that is, a non-profit health insurance plan offered by the federal government?[5] The health insurance industry lobbied strenuously to kill the public option to avoid the threat of a government-run competitor.[6] The industry’s successful lobby was largely due to its public campaign that catered to five U.S. American myths: (1) “It’s all socialized medicine out there”; (2) “They ration care with waiting lists and limited choice”; (3) “They are wasteful systems run by bloated bureaucracies”; (4) “Health insurance companies have to be cruel”; and (5) “Those systems are too foreign to work in the U.S.A.”[7]
It is all socialized medicine out there” is a myth that transcends the United States’ political chasm in which both parties alike, democrats and conservatives, declare that a “European-style, socialized medicine” system cannot work in the capitalistic U.S.
First and foremost, U.S. American health care is not a system at all. It is a market—a market-driven health care, for profit. It is unfettered capitalism at work. U.S. companies like Aetna and UnitedHealth bought non-profit health insurers like Blue Cross and Blue Shield and converted them into profit-making businesses that produced gross bottom-line results, which grew in direct proportion to the company’s selectivity and diligence at denying patient claims[8] and preventive care. Corporations that must fret over quarterly and annual returns find it difficult to justify spending money on preventive care that will not save money for years to come, and certainly not while the insured is covered by the plan paying the bill. U.S. Americans often maintain the same health care plan for less than six years, mostly due to the movement within the employment market where health insurance initiates and concludes with each job, and therefore, many insureds who receive preventive care will terminate coverage before the insurer realizes any financial benefit from its payment for this care.
What is more, because awareness of a preexisting condition can lead to higher insurance premiums—or outright denial of coverage—insureds avoid preventive physical and other examinations for fear of losing their health insurance.[9] In fact, health insurers are often likely to “refuse to pay $150 for a diabetic to see a podiatrist, who can help prevent foot ailments,” the New York Times noted, but “nearly all of them cover amputations, which typically cost more than $30,000.”[10]
Nonetheless, even in the absence of a grand-scale system, in the midst of this U.S. capitalistic market lie two, well functioning socialized medicine systems, Medicare and the U.S. Department of Veterans Affairs. Almost all U.S. Americans utilize Medicare when they turn sixty-five while people in Germany, Switzerland, and other European countries remain covered by private insurance plans for life.[11] This is also true with respect to military veterans who utilize the Veterans Affairs health care coverage and hospitals—one of the purest examples of socialized medicine. So, if socialized medicine is ineffective, then U.S. American seniors and veterans are receiving sub-standard care-but the U.S. has not revamped these two socialized health care systems because they are, in fact, providing adequate care.


1.  Congressional Budget Office, “Cost Estimates for Health Care Legislation,”

2.  50 million U.S. Americans were uninsured in 2010. T.R. Reid, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care 245 (Penquin Books 2010).

3.  During the change of Taiwan’s and of Switzerland’s health care systems, both countries decided that “society has an ethical obligation—as a matter of justice, of fairness, of solidarity—to assure everybody access to medical care.” Id. at 183. As a result, the national debate was waged around ideals like “equal treatment for everybody,” “we are all in this together,” and “fundamental rights” rather than on the commercial implications.
In the U.S., however, the debate for those who already had health insurance focused on self-interest and not on the moral obligation to provide health care to others. And, while 85% of U.S. Americans believe that health care is a basic human right, the public debate is still centered on the economic implications of universal health care rather than on the moral question. Id. at 220.
In fact, to the question, should the rich and poor have the same chance get medical care, Professor Richard Epstein of the University of Chicago Law School, replied, “the correct answer is no. To provide health care for the poor child,” he argued, “other Americans would have to be taxed to pay for the care. That would generate heated and costly political battles. To open the doors to forced redistribution induces the rich to spend more defending their wealth, and the poor to spend more to take it away. Both sides cannot win, and a smaller pie leads to worse health care.” Id. at 223. (quoting Letters, (JAMA March 11, 1998).

4.  See Kaiser Family Foundation, “Focus on Health Reform,” 4/21/10,

5.  The public option was a form of universal healthcare that meant all U.S. Americans would have been covered through an increase in taxes. Every individual would have been required to purchase insurance or to “opt in” to the pubic option—a concept known as the “individual mandate” rule, discussed in further detail below.

6.  The public option was colloquially known as a Medicare-at-any-age program.

7.  Reid, The Healing of America at 229-235.

8.  Id. at 179.

9.  Id. at 188.

10.  Ian Urbina, In the Treatment of Diabetes, 1 New York Times, January 11, 2006)..

11.  Reid, The Healing of America at 230.

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