As we were creating a cartoon about the complexity of the current health care payment system, we noticed media reports on common misunderstandings of the Affordable Care Act (ACA). The most recent was in the Michigan news weekly Bridge, which noted, “In Michigan, some counties with the highest Medicaid expansion and ACA usage gave Trump some of his largest victory margins …”
People have been known to vote against their own interests for the sake of broader principles, a tendency that politicians are happy to exploit. However, on the chance that voters were misled on simple facts, we bring you the following educational cartoon, put together lickety-split to be of service before the ACA can be repealed!

A few slightly more detailed facts:

• Obamacare is the Affordable Care Act (ACA). Strictly speaking, it’s the Patient Protection and Affordable Care Act.
• The ACA was the result of a series of compromises, but its goal was to provide health insurance coverage, either public or private, for anyone who did not have coverage through an employer-provided plan. In the past, options for the planless who were not eligible for public insurance (Medicaid, Medicare, TRICARE, etc.) included buying “individual” insurance on the private market at great cost, paying for COBRA through a recent employer at great cost, paying for care in cash at great cost, or going without.
  The ACA succeeded in insuring 20 million Americans. Of the 27.2 million (non-elderly) Americans who remain uninsured, 11.7 are eligible for financial help. For information about health insurance for the elderly, see the final bullet point below on “Medicare.”
• The ACA bans insurers from refusing coverage to people with pre-existing conditions. In the past, people were refused insurance for reasons ranging from the tragic (had suffered from cancer) to the ridiculous (tested negative for a medical problem).
• Because young and/or healthy people would naturally wait until they needed care to buy insurance, the ACA mandates that everyone have coverage. This ensures that the risk pool is not made up solely of very sick people who need expensive care.
• In the past, only the poorest of the poor were eligible for Medicaid, except for certain special (and temporary) categories, like children or pregnant women. The ACA required states to expand Medicaid to people whose income was at 133% of the federally-determined poverty line or below. Following a challenge, the U.S. Supreme Court conceded that states did not need to expand Medicaid. Many states (green on our map) nevertheless did so because generous federal subsidies are offered for the purpose. But states that did not expand Medicaid caused many of their residents to remain trapped in the “donut hole” that existed pre-ACA: their income was too high for Medicaid, but too low to afford private insurance. It is worth noting that the decision to expand now rests solely with the states; those who blame the feds for the donut hole are blaming the wrong government.
• The ACA reduces premium costs up front, by providing tax credits for households whose income is 400% of the federal poverty level. If an applicant’s income is considered too low for tax credits, that person is funneled toward their state’s Medicaid program.
• Many people insured by public plans were unaware they were benefiting from Medicaid expansion, because their plans bore state-specific names that did not include the word “Medicaid.” Some examples: Husky Health Connecticut, MassHealth, Healthy Michigan Plan, Washington Apple Health, and many more. These state plans are Medicaid.
• The ACA allows children to remain on their parents’ plans until the children reach the age of 26. William Shatner’s 1978 Saturday Night Live skit is referenced here purely for the nostalgic amusement of your cartoonist.
• The ACA requires that free preventive care be included in all insurance plans.
• We can identify and acknowledge many drawbacks to the ACA, many of which are continuations of problems that existed pre-ACA or resulted from compromises made in response to opposition challenges. But even political opponents who have been fighting like cats and dogs can agree on what’s wrong and how to fix it. Insurance premiums do keep increasing, just as they did in the past; however, the absence of an ACA cap on premium increases exacerbates the problem. Correspondingly, tax credits arguably should be adjusted to accommodate unaffordable higher premiums. This is purely a political problem and should be addressed accordingly. High-deductible plans are a reasonable choice for people who do not expect to use much care, but can be financially devastating for those who find themselves in need of medical attention. The answer, again, is to adjust the tax credit and premium caps to make better plans affordable to more people. Insurance does not guarantee health care, it is true. While the ACA contains provisions to increase access from the provider side, those preparations will require years to bear fruit. More immediate creative solutions are clearly needed. Finally: big government. This is a philosophical objection that begs for its own cartoon. Stay tuned!
• Where is this all leading? Medicare for all. Medicare is the federal health insurance program for people who are 65 or older. “Medicare for all” suggests extending this insurance program to all Americans in a national single-payer health insurance plan – the kind favored by a majority of Americans. This proposal does not necessarily involve a centralized authority that employs providers and directs all medical care. Rather, it proposes combining the entire population into one insurance risk pool in order to take the greatest advantage of potential savings, particularly from administrative spending, which currently accounts for one of every three health care dollars spent in the U.S. Much more information on single-payer systems is widely available. We suggest starting with Physicians for a National Health Program.

We hope that The Affordable Care Act/Obamacare 101 has been useful to you. Please respond on our Facebook page if you have ideas for future cartoons on this subject – or any other!

Image credits

• The photo in Frame 3 is “The White Angel Bread Line” by Dorothea Lange from the collection of the National Archives.
• The dinosaurs in Frame 4 are from Free Microsoft Clipart.
• “Birthday Candles” in Frame 6 is a photograph by George Hodan shared in the Public Domain.
• The “Vulcan salute” icon in Frame 9 is shared under a Creative Commons license.
• The cat and dog strolling together so companionably in Frame 10 are in a photo taken by rijaij and shared under a Creative Commons license.
• The “Medicare for All” poster in Frame 11 is taken from the website of Sen. Bernie Sanders.