n October 24, 1964, famed Minnesota Vikings defensive end Jim Marshall recovered a San Francisco 49ers fumble and sprinted 66 yards into the end zone. Unfortunately, the end zone belonged to his own team. The disoriented Marshall had run the wrong way.
Marshall then made matters worse. Instead of harmlessly running the ball out of his end zone, he threw the ball up in the air in celebration, which by National Football League rules gave the 49ers a two-point safety as well as the return of the football.
President Barack Obama’s bungling of the Affordable Care Act rollout is reminiscent of Marshall’s famous misplay. He has taken the successful passage of the Act, achieved in the blood sport of healthcare policy, and given his opponents political points by presenting the public with malfunctioning enrollment software and by making misleading statements about how policyholders would be able to maintain their existing coverage. In his defense, he has had to play the game with his hands and feet bound.
The Affordable Care Act’s passage was a political miracle given the national stance against “socialized” medicine. The law will expand healthcare coverage to millions of uninsured Americans. It is also designed to rein in medical costs by providing private health insurance in a more structured and efficient marketplace.
But as passed, the Act obligates the purchase of health insurance. Failing to do so means tax penalties. Nowhere is there formal recognition of the fundamental right to health care. As a result, the Act is no more than a smart brace holding up a system already built on shifting sands.
Many American citizens living outside the U.S. don’t fall within the Act’s provisions, an exemption that benefits those who live in countries with national health care systems, such as Italy, but damages those in countries lacking such care, since nothing in the Act helps pay expenses for those without coverage.
Americans who are defined as “residing abroad” will be considered to have minimum coverage, exempting them from enrollment (which won’t stop them from purchasing a U.S. plan if they so choose). By law, residing abroad means either: 1. Having a tax home in a foreign country and qualifying either as a bona fide resident of that country for an uninterrupted period, including a full tax year; or 2. Being present in a foreign country for 330 days over any consecutive 12-month period.
That there is no basic right to health care in the U.S. is reflected in how the law is administered. It is not a federal entitlement program like Medicare or Medicaid. Rather, those who don’t already have health insurance coverage that meets the Act’s minimum requirements must purchase a policy through an insurance exchange set up in their state of residence. Those who are financially able to buy a plan but fail to will face a $95 tax penalty or 1% of their 2014 income (whichever is greater), with penalties increasing annually thereafter.
Health insurance policies under the Act will vary by state, with coverage differing based on the ability to pay. People will also need to pay regular premiums to keep coverage from lapsing. In the event of a claim, forms will require filing and evaluation. Moving from one state to another will leave the insured person responsible for setting a new policy in place. Nothing is automatic.
As I noted in my 2011 column “The Right Thing,” Italy’s Constitution safeguards the health of those within its borders. I learned this clearly after a Vespa accident in Rome in which I tore an Achilles’ tendon that required an operation, a one-week stay in hospital, and 10 days of post-op rehabilitation and medication. When I was admitted, my health card, identifying information and health history were immediately registered. After that my stay was about my care. There was no discussion of insurance coverage or payment; all was covered by the system. It wouldn’t have mattered where in Italy the accident happened, or which hospital I ended up in.
Jim Marshall’s Vikings actually won that 1964 game, Marshall having previously sacked 49ers quarterback George Mira causing a fumble a teammate ran into the correct end zone for a touchdown. Healthcare in the U.S. will never be a winner without the recognition that universal healthcare for one and all is a cornerstone entitlement in a progressive civilization. Anyone who considers a system of insurance policies and tax penalties as sure-footed is someone running the wrong way and destined to lose the ball.