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The Caring Economy

Trudy Lieberman [“Wrong Prescription?” Report, July] leads readers on a winding tour of what is wrong with the Affordable Care Act before acknowledging that the legislation has achieved its main objective of significantly reducing the number of uninsured Americans. The A.C.A. prevents private insurers from denying coverage based on preexisting conditions, requires comprehensive essential health-care benefits, enforces strict medical-loss-ratio provisions (insurers must spend at least 80 percent of premium dollars on medical care), takes steps toward instituting value-based payment systems, and infuses a massive dose of federal funding to examine the comparative effectiveness of drugs, equipment, and medical procedures.

Lieberman assails the A.C.A. as “having failed a substantial part of the population it was actually designed to help” while “wreaking havoc on the middle class, much of which had good insurance to begin with.” But a recently released poll by the Commonwealth Fund found that 81 percent of Americans who have coverage through an A.C.A.-established exchange are content with their insurance. The purported negative impacts on the middle class, such as increases in premiums, patient cost-sharing, and spending on drugs, were certainly not triggered by the law. In fact, from the late 1990s to the late 2000s — long before the enactment of the A.C.A. — yearly percentage average increases in premiums, patient out-of-pocket costs, and drug expenditures were higher than today.

Joshua P. Cohen
Tufts University School of Medicine

Whether he naively thought the Republicans would compromise or was merely a closet corporatist all along, President Obama imposed a modified version of Mitt Romney’s Massachusetts plan on the nation. The Congressional Progressive Caucus had had a single-payer health-care plan drafted for years, in the form of H.R. 676, but it was willing to accept a public option as a compromise position. Instead, Obama browbeat the caucus into voting for the A.C.A. — preferred by the much smaller contingent of Blue Dog Democrats — on the grounds that its deficiencies would be fixed later.

When right-wingers argue against the A.C.A., I have to admit that they are correct on many points: high premiums and high deductibles are real problems for many Americans, and subsidies phase out at an income level that barely qualifies as middle-class in many large cities.

It would have been much simpler to lower the age of eligibility for Medicare by five years every year, which would have brought younger, healthier people into the system, resulting in universal coverage within thirteen years. Private insurance companies could have continued to sell Medicare supplements, as they do now. When I qualified for Medicare recently, I felt that a burden had been lifted. Even with my Medicare premiums and my supplemental insurance, which pays my deductibles for almost all services, I am saving $250 per month. Why can’t everyone enjoy this benefit?

Karen Sandness

The Affordable Care Act was a political compromise, not a good health-care policy, as Trudy Lieberman makes clear. “Affordable” is a misnomer, since the cost of premiums was measured only after subsidies were applied. Built into the A.C.A. are provisions to protect insurers, which guarantee that risk is managed, but these will expire in a few years. And thanks to the mismanaged rollout of the online exchanges, 2016 will be the first year that insurers will have data from which accurate rates can be developed.

The United States spends more on prescription drugs than any other nation, but catastrophic care, not drugs, accounts for a greater portion of medical expenditures. Centralizing catastrophic coverage in an expanded Medicare program, including coverage for chronic and end-of-life care, would allow us to spread these costs throughout the national tax base.

Brooks White
Brooklyn, N.Y.

There is an antidote for what ails Trudy Lieberman. National health insurance was pioneered in the United States 120 years ago by fraternal benefit societies, whose members built hospitals, orphanages, and old folks’ homes and received, for pennies per week, sickness and death benefits. These genuinely nonprofit systems, serving one third of American households, could have expanded to national scale.

In 1997, I started the Ithaca Health Alliance and free clinic, whose members were covered for most common emergencies at a cost of only $100 per year. The Alliance was approved by New York’s Insurance Department and the Chamber of Commerce, but in 2011 the IRS forced it to become a charity.

American medical insurance has become a crime, not a crisis, and what we need is a nonviolent revolution to restore nonprofit care with mutual-aid health insurance.

Paul Glover


John Crowley writes, “We — our kind, humankind — are unique among animals in knowing that we will die” [“Dressed to Kill,” Easy Chair, July]. Humans have long made similar unsubstantiated assertions about animals — for example, that we were the only creatures capable of using tools and learning. But New Caledonian crows are adept at using tools, and many songbirds learn complex calls by listening to others of their species.

The brains of birds are far more complex, flexible, and inventive than previously thought — more like those of mammals than reptiles. Much is still unknown about what they see and hear. Perhaps someday we will discover more about what goes on inside their heads, and how they might perceive death.

William Young
Arlington, Va.