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Forty Years!

After graduating law school, I went to work for Boston Legal Services, where as a young lawyer I tried cases on behalf of individual clients with few resources and no political power, in Roxbury, Dorchester, the South End and East Boston.

One of my clients who had been laid off came to see me and explained that he’d just gotten a job and then a notice cutting off his family’s Medicaid coverage. He said “Don’t worry about me I can get my care through the Veterans Administration because I’m a disabled Vietnam veteran, but can you do something for my wife and kids?” I said “Sure, this must be a mistake, no sane society would cut off your family’s health coverage just when you get a job; I’ll get it taken care of”. After a lot of legal research, I had to come back to him and report to him, “This is crazy, but that’s what our laws are, and I’ll try to get it changed”. I thought it would take at most a year to get this changed; it’s taken 40 years of my work life. This fundamental flaw in the American health care system changes as of today. It’s taken over 100 years of our country’s history since President Teddy Roosevelt’s first proposals as a candidate in 1912 were developed, but on January 1, 2014, this is about to change and affordable coverage will be offered to every American. This is the most important change in health policy in this country since the passage of Medicare and Medicaid in 1965. It will allow the United States to join every other Western industrialized country in offering health coverage for all its citizens.

Let me just tell you a couple more stories both on why I got hooked and stayed with it, what the Affordable Care Act does. After a couple of years of really hard legal work, I got quite sick with a then little known disease that the doctors had a really difficult time diagnosing; they were afraid it was leukemia. They finally diagnosed, and it wasn’t, but it took three months of recovery to fully get back to work. My employer kept me on salary and paid for my health insurance the whole time. Several years after, a new client came in. She was a college grad working as a secretary who developed a serious but treatable condition that left her temporarily unable to work just as I had been. Her employer had laid her off, so she lost her health coverage. While she had unemployment insurance to help pay her rent and food bills, she had no money left over to pay for her medications and doctor visits, let alone the cost of insurance, for which she would have been ineligible anyhow due to her pre-existing condition. At just the same time, the newly elected Governor of Massachusetts and the state legislature terminated medical coverage to a large group of low-income individuals of which she was one.  In California we call this group, the MIAs. I sued the Commonwealth of Massachusetts on her behalf and lost that case. Later when I moved to California, the state’s Governor and legislature did the exact same thing in 1982.

It was about that time, I concluded that “If you can’t beat ‘em, join them” and went to work for the California legislature to work with a dynamic young legislator who was trying to change these laws. Working with both Democratic and Republican lawmakers, California actually got quite a lot done to cover pregnant women, to stop hospitals and doctors from denying emergency care to people with no health insurance, and to stop health insurance plans from denying, terminating or jacking up the cost of health insurance to small employers with an employee who comes down with an expensive condition like a heart attack, cancer, AIDs, a disabled child or even pregnancy.

Over the last thirty years, California policy makers have tried many approaches with many different legislative authors to cover the uninsured. Some were known as single payor (Canadian style coverage); some were employer mandates (employers must offer coverage); some combined employer, individual and government contributions, known as “shared responsibility”; some were for catastrophic coverage. These efforts most recently culminated in the bi-partisan Schwarzenegger-Nunez proposed legislation of 2007-08, California’s version of the Massachusetts reforms, know as Romney Care. California was never able to muster the financial resources and political will to cover the uninsured in large measure because of California’s 2/3rds vote requirements for new revenues and spending.

California now has over 7 million residents who are uninsured at some point during the year, that’s nearly one out of every five children and adults under age 65 (20%), and the numbers and percentages get higher and higher nearly every year since the mid 70’s. Our nation has almost 50 million uninsured, that’s over one in seven of our nation’s citizens under 65. Over 80% of the uninsured are in working families, and they don’t get private coverage at work, and they don’t qualify for public coverage (Medicaid) in their states.

About seven years ago, Governor Mitt Romney signed into law “RomneyCare”. Since its implementation, Massachusetts now has 98% insured, a 2% uninsured rate. About three years ago, President Obama signed into law the Affordable Care Act (ObamaCare), which is pretty much a carbon copy of RomneyCare, maybe a little better around some of the edges.  It fills the gap for individuals not covered through their work and not eligible for either Medicaid or Medicare.

What are the problems Congress was trying to solve? It’s both affordability and coverage. Private health insurance for the average American family costs as much as our nation’s minimum-wage salaries. In other words, a minimum wage worker would spend his or her entire salary buying private health coverage for the family.

What’s in the Affordable Care Act? First, expanded public insurance (known as Medicaid) for the lowest income working poor, (that’s the MIAs, the low wage workers, the working parents and their families I referred to earlier),[1] and private individual insurance made more affordable through tax credits for the non-poor, that is for individuals with moderate and middle incomes not covered at their place of work.[2] Second, protections for individuals and small employers so they cannot be denied coverage due to a pre-existing condition like cancer or pregnancy and a large purchasing pool, known as the Exchange or Marketplace, which negotiates premiums on their behalf. And third, a responsibility that every American enroll in either public or private coverage[3] so when you get very sick, you will get care in a hospital or at a doctor’s office.  The hospital and the doctor will get paid for your care, and you and your family won’t end up in a medical bankruptcy losing the funds you have been putting away for retirement, a home down payment, your child’s college education or a new car.

Why should we care about the uninsured? Without health coverage, access to doctors, specialists and prescription drugs is very difficult and inordinately expensive for the uninsured; it causes costly and avoidable hospitalizations as individuals delay care until there really is no other option than the local emergency room.

The ACA has some flaws that will need fixing and adjusting, but it’s a good solid building block for our nation’s futures. Each state will make its own decisions as to how the Affordable Care Act is implemented for their citizens so there will be wide variations from state to state.

Why should you care? First, not all of you are working on Wall Street, not all of you are earning six figure salaries right out of college or grad school. In fact, most of you don’t and won’t — at least not right away. Some of you will be artists; some will start up small businesses and become entrepreneurs; some will wait tables and some do construction; some will work in child-care; some will become farmers, and others may start with part time and seasonal jobs. These are all occupations and types of businesses with high rates of uninsurance. All of you will get sick; all of you will have accidents, and most of you will have or adopt and raise children, and they’ll need medical care too.


Lucien Wulsin Jr., ITUP Executive Director

Dated: October 1, 2013 – the Launch of Covered California


[1] Every state sets it own criteria for Medicaid, ranging from 25% of the federal poverty level (that’s less than $3,000 a year for an individual) in a state like Texas to 300% of the poverty level (over $33,000 a year for individual) in states like Vermont and Massachusetts. The Affordable Care Act pays for the upgraded Medicaid coverage in each state up to just a bit less than $16,000 a year for an individual. After the US Supreme Court decided that the Medicaid expansion was optional with the states, many states with Republican Governors are implementing the Medicaid expansion. Some states with policy makers engaged in massive resistance to the implementation of ObamaCare are not taking the offer of 100% federal match to expand their Medicaid programs. This resistance was the same resistance when Medicaid was first established; it erodes over time as the benefits of reforms become obvious. One state, Arizona, took almost 20 years to implement its Medicaid program.

[2] The tax credits under the Affordable Care Act pay for the difference between an individual’s contributions and the actual cost of coverage.  At the lowest end (e.g. $16,000 a year) an individual may pay 2% of income for coverage, and the tax credit makes up the difference. At the higher end, a family of four earning $95,000 a year would contribute up to 9.5% of their income for coverage, and the tax credit pays the rest.

[3] Each individual picks their level of preferred coverage (this can vary between 60 and 90% of expected medical expenses), their own health plan and their doctors. Young persons and those with financial hardships may prefer the option of catastrophic coverage, which is also offered to them.

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