A green light to target Muslims

Published at Socialist Worker.

A FEDERAL judge dismissed a lawsuit in late February that had accused the New York Police Department (NYPD) of violating the constitutional rights of Muslims in New Jersey by spying on them based on their religious affiliation. Judge William Martini's granting of the city's motion to dismiss Hassan v. City of New York represents a blow to the Muslim community specifically and defenders of civil liberties generally.

The lawsuit, filed by the Center for Constitutional Rights and Muslim Advocates on behalf of several Muslim individuals, organizations and businesses, was in response to revelations that the NYPD had worked with the CIA since 9/11 to conduct extensive surveillance and infiltration of Muslim religious institutions and organizations, community groups, student groups, businesses and even a youth soccer league. Another similar case is still pending in Brooklyn.

Several reporters from the Associated Press (AP) exposed the existence of the secretive spying program, known until 2010 as the "Demographics Unit," and won a 2012 Pulitzer Prize for their reporting on the overreach of the city's law enforcement officials. As the AP reporters documented, the NYPD's spying program reached into nearly every aspect of Muslims' lives. Those targeted for spying were chosen on the basis of their identity.

According to the AP:

Using census information and government databases, the NYPD mapped ethnic neighborhoods in New York, New Jersey and Connecticut. Rakers [a term for undercover officers] then visited local businesses, chatting up store owners to determine their ethnicity and gauge their sentiment, the documents show. They played cricket and eavesdropped in the city's ethnic cafes and clubs.

Without specific evidence of wrongdoing, "rakers" focused on people from a list of 28 countries, most of which were majority Muslim, as well as "American Black Muslims." In 2011, before the story broke, Mayor Michael Bloomberg said "the NYPD does not take religion into account in its policing," and "NYPD spokesman Paul Browne said the department only follows leads and does not simply trawl communities." Browne claimed that the Demographics Unit did not exist, and that the NYPD did not use the term "rakers."

The AP obtained NYPD documents that contradicted all of these claims. It also showed the involvement of Lawrence Sanchez, a veteran CIA officer who "[o]fficials said...was instrumental in creating programs such as the Demographics Unit and met regularly with unit supervisors to guide the effort, all while on the CIA's payroll...After a two-year CIA rotation in New York, Sanchez took a leave of absence, came off the agency's payroll and became the NYPD's second-ranking intelligence official."

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MARTINI RULED that the NYPD's spying operation did not violate the constitutional rights of those targeted. He cited Ashcroft v. Iqbal, a case decided by the Supreme Court in 2009, to argue:

The plaintiffs in this case have not alleged facts from which it can be plausibly inferred that they were targeted solely because of their religion. The more likely explanation for the surveillance was a desire to locate budding terrorist conspiracies. The most obvious reason for so concluding is that surveillance of the Muslim community began just after the attacks of September 11, 2001. The police could not have monitored New Jersey for Muslim terrorist activities without monitoring the Muslim community itself.

Surveillance on the basis of religion or race, according to Judge Martini and the Supreme Court, is constitutional even if it has a discriminatory effect, as long as it is not conducted "with discriminatory purpose." The surveillance is legal because "the motive for the program was not solely to discriminate against Muslims, but rather to find Muslim terrorists hiding among ordinary, law-abiding Muslims."

In the words of Deepa Kumar, a Rutgers University professor and author ofIslamophobia and the Politics of Empire, this is "so deeply racist...It's a form of cultural racism that says that people who practice Islam are sort of 'programmed' to turn to terrorist activities, and this is really the mindset of the NYPD."

Judge Martini didn't deny that the Muslim community was hurt by finding out that their mosques, businesses and other community groups were infiltrated, however. In an Orwellian twist, his decision states:

None of the plaintiffs' injuries arose until after the Associated Press released unredacted, confidential NYPD documents and articles expressing its own interpretation of those documents. Nowhere in the complaint do plaintiffs allege that they suffered harm prior to the unauthorized release of the documents by the Associated Press. This confirms that plaintiffs' alleged injuries flow from the Associated Press's unauthorized disclosure of the documents. The harms are not "fairly traceable" to any act of surveillance.

In other words, the damage done by the NYPD spying is not the fault of the NYPD, which intended to keep the spying a secret from the innocent Muslims they targeted. Rather, responsibility for the harm lies with the Associated Press for exposing it.

"Here you have in one fell swoop...not only the justification for racial and religious profiling, but [also] an attack on the press...and the idea that the press should be watchdogs of the government," said Kumar.

In court testimony in June 2012, NYPD Assistant Chief Thomas Galati of the Intelligence Division said that as far as he was aware, the Demographics Unit hadn't resulted in any leads, let alone stopped a terrorist plot. However, Galati's testimony gave a chilling example of how targets of surveillance were chosen:

I'm seeing Urdu. I'm seeing them identify the individuals involved in that are Pakistani...I'm using that information for me to determine that this would be a kind of place that a terrorist would be comfortable in...Most Urdu speakers from that region would be of concern, so that's why it's important to me.

As the AP points out, "About 15 million Pakistanis and 60 million Indians speak Urdu. Along with English, it is one of the national languages of Pakistan."

In 2007, the NYPD released a report titled "Radicalization in the West: The Homegrown Threat" that places young Muslim men living in the U.S. and Europe on a continuum that begins with "pre-radicalization" and culminates with "ATTACK."

The criteria that qualify individuals for a status of pre-radicalization include "male Muslims," "under the age of 35" and "educated." The report also states that such individuals "do not begin as radical or even devout Muslims," that they may be "unremarkable," "having 'ordinary' lives and jobs" and have "little, if any, criminal history."

The obvious conclusion is that the NYPD views all young Muslim men as potential terrorists.

In this way, it is like a secretive version of the NYPD's stop-and-frisk program, not only chronologically--the programs were established around the same time--but also in theory and practice. Stop-and-frisk swept up hundreds of thousands of predominantly young Black and Brown men, the vast majority of whom were never charged with any crime. Race, ethnicity and religion are treated as evidence enough to be targeted.

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SPYING AND infiltration efforts by the NYPD have had a chilling effect on Muslim communities. According to "Mapping Muslims: NYPD Spying and its Impact on American Muslims," a report issued by a number of American Muslim civil liberties organizations:

Surveillance of Muslims' quotidian activities has created a pervasive climate of fear and suspicion, encroaching upon every aspect of individual and community life. Surveillance has chilled constitutionally protected rights--curtailing religious practice, censoring speech and stunting political organizing. Every one of our interviewees noted that they were negatively affected by surveillance in some way--whether it was by reducing their political or religious expression, altering the way they exercised those rights (through clarifications, precautions, or avoiding certain interlocutors), or in experiencing social and familial pressures to reduce their activism.

As Linda Sarsour of the Arab American Association of New York told Democracy Now!:

[I]t creates psychological warfare in our community. How am I supposed to know if the NYPD was successful in that endeavor [of attempting to infiltrate the Arab American Association board]?...The community right now is in a position where, how do we even know the guy next to us that's praying at the mosque or the guy at the restaurant that's trying to open a conversation with us about something that's happening in Egypt, for example, [is not a police officer]?...And now that we know that the NYPD wants to hear what our sentiment is, people probably don't want to share their sentiment.

Sarsour explained how the revelations work to silence speech before the fact:

[T]he most disturbing of all is our Muslim student associations, who are calling us to consult about how political should their events be...The fact that our students feel like they can't do that because there are going to be NYPD informants, because they can be taken out of context, and because they think something like what happened to Fahad Hashmi is going to happen to them, I think is a valid concern for them to have.

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ACCORDING TO Muslim community activist Sammer Abulaela, the revelations about the NYPD's spying weren't really a surprise to Arab and Muslim communities used to a climate of state-sponsored Islamophobia. In an interview, Abulaela explained:

If the Associated Press stories offered any surprises to the community, it was in the details. We knew we were being watched, but we didn't know that officers were gaining entry into our homes by telling us, falsely, that they were engaged in an investigation regarding a missing child in the neighborhood.

We knew they were listening to the sermons at the mosque, but we didn't know they were counting the number of Qurans on our home bookshelves and noting the promotional wall calendars from the Halal butcher. Personally, I think I expected the language to be a bit more clinical and sanitized...Terms like "Ancestries of Interest," the title of a slide listing 28 ethnic, racial and national identities to be targeted, struck me as particularly brazen and bigoted.

The AP revelations did little but confirm what many in the community had already known. For years, shady characters were suddenly turning up--and then disappearing--inside and outside of Muslim businesses and houses of worship. Community members would speak of local businesses being stalked for weeks by men with tenuous connections to the neighborhood only to have those businesses raided a short time later.

The only thing that ever came of those invasions was a shuttering of the establishments--never as the result of a terror investigation, but due to a loss of business as customers were wary to patronize shops that were clearly compromised by infiltrators and informants wielding the power to arbitrarily smear anyone in their path with accusations against which there is no defense and from which there is no return.

As Abulaela pointed out, the NYPD spying program is in line with U.S. policies since 9/11. In the months following the attacks on the World Trade Center, some 1,200 immigrants, disproportionately South Asian, Arab and Muslim, were rounded up. There have been several cases of Arabs and Muslims living in the U.S. who have beenrailroaded for crimes concocted by the government, while hundreds seized abroad were held for years without trial in Guantanamo Bay.

According to the Migration Policy Institute, the FBI interviewed thousands of immigrants from countries with "a suspected al Qaeda presence."

Under...the National Security Entry-Exit Registration System special registration program, adult males from 25 predominately Muslim countries were required to register and be fingerprinted and photographed at ports of entry or present themselves at immigration offices inside the country for fingerprints and photographs. More than 80,000 individuals were interviewed under the program, and over 13,000 were placed in removal proceedings.

In addition to terrorizing Muslim communities, these government policies fed a climate of Islamophobia in the mainstream press, including providing political space for the far right to gain a hearing, leading to a rise in hate crimes against Muslims.

All of this created a climate of fear and a reality of persecution that caused real harm to Muslim communities, which was felt long before the AP released the details of the NYPD's Demographics Unit.

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MARTINI'S RULING that the harm caused by the knowledge of the surveillance and infiltration of Muslim communities in the Northeast by the NYPD is a result not of the spying but of the reporting on the spying is indicative of the increasingly brazen surveillance state that the US has become.

The U.S. government at all levels has used the threat of terrorism to construct an apparatus of surveillance and repression that is used to target not only Arabs and Muslims, but millions of others in the U.S. and around the world.

When whistleblowers have exposed wrongdoing, the government has gone after the whistleblowers themselves rather than the crimes they exposed. The Obama administration has engaged in an unprecedented crackdown on whistleblowers. Chelsea Manning was subject to treatment that the UN special rapporteur on torture called cruel and inhumane, yet the war criminals she exposed remain free.

Last spring, it was revealed that the Department of Justice had spied on journalists, including from AP and Fox News. The ruling that AP, not the NYPD, is responsible for the damage caused by NYPD spying sets a dangerous precedent that can only further serve to discourage investigative journalism that seeks to shed light on secret government programs.

According to Sammer Abulaela, far from causing harm, such journalism has had the opposite effect:

The revelation of the program confirmed and gave focus to what the Muslim community already understood was happening. Community members who had long remained silent now felt emboldened to speak out against a program that reflected so much of America's publicly rejected racist history. No harm was done by the revelation of this program--all of it was done by the program itself. I'm a bit embarrassed to even have to articulate that point, but if that's where we are in 2014, so be it.

Is Obamacare a step toward single-payer?

Published in Socialist Worker.

NO, NO and no: That's been the Republican Party position on health care reform since the Obama administration's first months in office. No matter how many pro-industry concessions were made in drafting what came to be called the Affordable Care Act (ACA), Republicans never wavered in their all-out opposition.

But increasingly since its disastrous rollout last fall, the ACA has had critics from the left, too--people who oppose a "reform" that falls far short of universal coverage while threatening harsh financial penalties on those who can afford them least unless they purchase the defective products of the private insurance industry.

Groups that criticized the ACA all along, such as Physicians for a National Health Program and National Nurses United, continue to stand for a "single-payer" program--where the government cuts out the insurers and guarantees health care for all under a system similar to the current Medicare program for the elderly, but much better funded and available to the whole population.

Then there are those among liberals and the left who disagree with both sides. They continue to defend the ACA--on the grounds that it is a step toward universal health care.

An editorial in the Nation magazine last month, for example, acknowledged that the ACA came about because Barack Obama and Democratic leaders in Congress "believed [single-payer] was politically unachievable, so they cobbled together a hybrid of public regulation and private insurance that has come back to haunt them."

Nevertheless, wrote the Nation's editors, the left should defend this "hybrid": "Progressives must step in not only as ardent advocates for better implementation of the ACA--a relatively easy task--but also for structural repairs to the law that will make it a better bridge to the truly universal, truly humane and truly functional health care system that America needs...Indeed, winning [the fight for the ACA's effective implementation] will make future reforms all the more possible."

The Nation is wrong. The ACA isn't a bridge to universal health care. It is a cul-de-sac, structured above all else to maintain the central role of the health care industry in general, and private insurance companies in particular.

Achieving universal health coverage and access to care will require dismantling the core of the ACA and replacing it with something else entirely. Making a defense of the ACA in the way the Nation does--as a step in the direction of a single-payer system--cedes ground to the right and is counterproductive to the goal of winning health care as a human right.

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THE CENTERPIECE of the ACA--the "individual mandate" that requires the uninsured to purchase private health insurance policies or face a penalty on their taxes--was first proposed in 1989 by the Heritage Foundation, a prominent conservative think tank. In the 1990s, the Heritage plan was promoted by Republicans, led by former House Speaker Newt Gingrich, as an alternative to the Clinton administration's plans for health care reform.

In contrast to the Clinton proposal--which, while far short of a single-payer system, was considerably more progressive than the ACA--Gingrich and the Heritage crowd proposed a mandate that placed the burden of obtaining coverage on individuals, rather than the government.

Like Clinton's proposal (which never made it to a vote in Congress), Obama's ACA also requires large employers to offer health insurance to employees--the so-called business mandate--although the penalty for businesses is smaller than the cost of coverage and has been delayed for at least a year.

The Heritage Foundation model was later implemented--in Massachusetts, under then-Gov. Mitt Romney, the eventual 2012 Republican Party presidential candidate. Nothing more clearly exposes the hypocrisy and crass opportunism of the Republicans, who from 2009 on have been denouncing health care "reform" from Obama that most closely resembles a model championed by one of its own only a few years before.

The ACA isn't a case of Democrats and Republicans "meeting in the middle" to find common ground between universal health care and the free market. Rather, it is a case of the political spectrum itself shifting to the right--to the point where Democrats occupy space formerly held by Republicans, and the Republicans denounce their former proposals as "socialism."

With the individual mandate at its core, the ACA is, first and foremost, about making sure health insurance remains "based on the private marketplace," as Obama described his law at the Wall Street Journal CEO Summit in November.

But the private marketplace--and the attendant prioritization of profits over care--is the root of the problems with the U.S. health care system. Money comes first in a free-market system, so those without the money to afford a given commodity go without. So it is with health care--and the 30 million people who will continue to go without coverage under the ACA, as well as millions more who will forgo needed care because they can't afford to spend thousands of dollars every year on copays and deductibles.

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IT WAS clear from the start that defending the health industry would be the priority of Barack Obama's health care law. Consider who played a leading role in drafting the legislation.

As chair of the Senate Finance Committee, Max Baucus ended up with responsibility for writing the law--he happened to be one of the leading recipients of donations from the health insurance and pharmaceutical industries.

Baucus brought in Liz Fowler, a vice president for the for-profit insurance giant WellPoint before she left to join Baucus' team. It was Fowler who, according to Baucus, wrote "the 87-page document which became the basis, the foundation, the blueprint from which almost all health care measures in all bills on both sides of the aisle came."

At the end of 2012, Fowler returned from whence she came: She left her post at the Department of Health and Human Services to take a job lobbying for Johnson & Johnson, the pharmaceutical and medical device manufacturing corporation--a perfect illustration of the revolving door between Corporate America and the Washington that ensures government policy meets the needs of the bottom line.

Baucus deliberately excluded voices for single-payer from Senate hearings on the legislation--instead, he had doctors and nurses who supported a radical alternative arrested. Not only did the Democrats exclude single-payer from the discussion, they conceded on even the half-measure of a "public option" among the choices available for the uninsured looking for coverage at the government "exchanges."

But none of that mattered anyway--despite all of the Democrats' industry-friendly concessions, the Republicans continued to oppose the ACA until the end.

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FAR FROM a step in the direction of single-payer, the ACA has made achieving universal coverage much more difficult.

The ACA entrenches the role of private health insurance--"multiple payers" instead of a "single payer"--by mandating the uninsured to purchase coverage or face a penalty. While the law requires private plans to meet minimum standards, coverage sold on the "exchanges" set up under the ACA are grouped into different tiers, and employer-based plans will continue to vary widely in quality.

Hence, health care inequality will persist--and many will go without care, whether they remain uninsured or can't access care because of high co-pays and deductibles.

Had the ACA included the "public option"--alternative coverage administered by the government available from the "exchanges"--it might have been possible to believe that the ACA would have transitioned into single-payer over time, as the public plan outcompeted private plans because of lower administrative costs and other factors.

Single-payer supporters were skeptical of this all along, but it's a moot point now. While claiming publicly to be pushing for a public option, the Obama administration made a deal with industry lobbyists, assuring them the public option wouldn't make it into the final bill. Sure enough, the public option was dropped.

The ACA makes the insurance industry stronger than ever before by handing it more customers and $1 trillion in subsidies over the course of 10 years. Greater revenues will translate into increased political power, which can be used to resist further regulations--and, obviously, any moves toward a single-payer system that would eliminate the private insurers altogether.

The ACA also includes around $500 billion in cuts to Medicare over ten years. This was initially supposed to include cuts to Medicare Advantage--where the government pays private insurance companies to administer Medicare benefits. However, the Obama administration reversed these cuts to private insurers in April 2013, sending insurance company stocks soaring.

Among the Medicare cuts that weren't reversed are a 14 percent reduction in payments to home care health agencies over the next three years, tens of billions in cuts to skilled nursing and hospice services, and some $260 billion in cuts to hospital reimbursements.

On top of all this, Obama offered to raise the Medicare eligibility age from 65 to 67 as part of his effort to secure a "grand bargain" with Republicans to carry out unprecedented austerity.

Even without the eligibility change, these cuts place the elderly and the disabled--those who are eligible for Medicare--at a disadvantage relative to patients with private health insurance, since doctors and hospitals make more money providing the same care for the latter. This, combined with a relative shortage of primary care physicians and the actions of Medicare Advantage plans such as UnitedHealthcare, which recently cut 10-15 percent of doctors in their plan, could reduce access to care for those with Medicare.

Medicaid pays even less to doctors and hospitals than Medicare does, so health care providers serving disproportionately low-income, elderly and disabled populations could face layoffs and even closure.

And all this has been made even worse by state governments dominated by Republicans that rejected the expansion of Medicaid included in the ACA under the U.S. Supreme Court decision in 2012.

If any part of the U.S. health care system could serve as a "bridge" to a single-payer system, it's Medicare. If Medicare's eligibility age limiting the program to seniors were eliminated, allowing everyone to be automatically enrolled in Medicare, this would be a tangible and completely realistic step toward truly universal coverage. Instead of expanding Medicare, however, the ACA cuts it.

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THERE IS one more question that those who believe the ACA will lead toward single-payer need to answer--the impact on a developing sentiment in favor of a pubic health care system like what exists in Canada.

Health care was a major issue in the 2008 election. Opinion polls before the election showed overwhelming majorities supporting a serious overhaul of the health care system. Nearly two-thirds supported the government guaranteeing health insurance for all, even if that meant paying higher taxes.

Michael Moore's film Sicko, released in the summer of 2007, exposed the devastating effect of for-profit health care on the lives of ordinary people. There was a growth in grassroots activism around the country, with doctors, medical students, nurses and other health care workers joining together with patients to demand universal health care for all. By the spring of 2009, with the health reform debate ramping up in Washington,a national day of action brought out single-payer supporters in all 50 states, including over 3,500 people in Seattle.

The shift in public opinion was undeniable. A New York Times/CBS News poll in June 2009 found that 72 percent of people supported "the government's offering everyone a government-administered health insurance plan like Medicare that would compete with private health insurance plans"--essentially, the public option.

The passage of the ACA, with the public option stripped out, took the wind out of the sails of a growing movement and ultimately reversed the trends in popular opinion. Large sections of existing and potential support for single-payer--in particular, among organized labor--were mobilized to support legislation that was antithetical to single-payer. The combination of unanswered Republican attacks on "socialistic" Obamacare and growing disillusion with what the Obama administration actually came up with has corroded support for any government role in health care.

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NOW THAT the law is finally kicking in, it is important that supporters of genuinely universal health care not allow the Republican right to be the only voice criticizing the ACA.

The failures of the ACA are becoming apparent to more and more people--those forced to buy insurance plans with thousands of dollars in co-pays and deductibles and skimpy networks, the 30 million who will remain uninsured, union workers facing cuts to their health benefits as ACA taxes on "Cadillac plans" loom.

The left must be able to recognize the positive measures in the ACA--ending insurance company discrimination against people with pre-existing conditions, the expansion of Medicaid, the requirement that insurance companies spend at least 80 percent of premiums on care and so one--while opposing the core of the legislation that forces millions of people to purchase defective policies from private insurers, thus locking in one of the central causes of the health care crisis.

There is no reason why the left should not demand a rollback of the ACA's reactionary components, like penalties for the uninsured and the tax on good health plans disproportionately held by union workers.

It is up to supporters of true health care reform to put forward an independent alternative--to demand truly universal coverage and access to care. If health care in the U.S. is ever to be made more equal, the movement for single-payer must regain the momentum lost since the passage of the ACA--and fight for health care to be the human right it must be.

Racism, capitalism and contradictions

Published at Socialist Worker.

IN AN interview at Northstar ("Is there a precariat?"), Charlie Post makes the following point:

Workers under capitalism have a dual existence: both as collective producers struggling against capital for control of the workplace, for hours and wages, but also workers compete as each other. They're sellers of labor-power, which gives rise to what the early 20th century Marxists used to call "sectional interests"; divisions along the lines of race, citizenship, nationality, gender, sexuality, etc.

These dual existences depend on one another. Under capitalism, in order to be a collective producer able to struggle, the worker must sell their labor power successfully. On the other hand, collective struggle is often about winning key demands that increase the value of labor power or improve the conditions of its sale. However, there are also contradictions within each of these.

Racism, which must be combatted if white and Black workers are to unite in struggle--and unity among collective producers is essential for victory in struggle--can also work to the benefit of white workers as sellers of labor power in competition with workers of color. Of course, there are countervailing dynamics as well, since the fact that Black workers are paid less drives down wages for white workers, too, but being white clearly has its advantages--if only relative, but isn't relative the key when it comes to individual competition?--as a seller of labor power.

Similarly, white workers gain relative advantage on the job--they're more likely to get promotions, less likely to be fired, etc. I believe that white workers have more to gain by opposing racism and engaging in collective struggle with their Black coworkers (and other people of color), but better treatment on the job is a countervailing force there, too, which encourages white workers to accept racism and even embrace it.

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WHITE WORKERS both benefit from racism, as whites who receive relative advantages or "privileges" if you will, and are harmed by it, as collective producers for whom racism is an impediment to the unity needed to win gains through struggle. The idea that we must argue that white workers do not benefit from racism in order for interracial working-class unity to be possible, and the idea that such unity is impossible because white workers benefit from racism, are both mechanical and one-sided.

Which tendencies prevail, which are dominant, depends on a number of factors. In periods of heightened class struggle, the identity of collective producers in struggle can overshadow the identity of sellers of labor power. This is where there is the greatest opportunity to combat racism, and even see things like unemployed workers rally to support strikers en masse (as in Toledo, Ohio in 1934) instead of taking their jobs.

In periods of defeat, workers are more likely to take on the identity of an individual seller of labor power, as collective struggle ceases to be seen as a realistic option. This is compounded by the pressures of day-to-day survival. Racism takes root more easily.

Of course, consciousness is always mixed, but in different ways and to different degrees: there are racist workers in times of mass interracial struggle, and there are anti-racist workers in times of defeat. There are workers who in practice unite across the lines of race while holding racist ideas, and there are those who hold anti-racist ideas yet do little or nothing to combat it.

Standing over all of this is the long-term, historic mission of the working class, which is to liberate itself. This requires doing away with all oppression and exploitation. But except in revolutionary times, this mission is only recognized by a minority of the working class.

It is up to us to promote the tendencies noted above that move us in the direction of unity in struggle and combat those that move us in the direction of embracing oppression and division.

What caused the Obamacare fiasco?

Published at Socialist Worker 

THE INTRODUCTION of the new health insurance system established by Barack Obama's Affordable Care Act (ACA) has been a technical--and political--disaster.

But the problems aren't confined to crashing websites, and they won't be solved by Obama's promises that the enrollment process will be fixed before the end-of-year deadline for the uninsured to sign up for health plans on the ACA's "insurance exchanges."

Even if the glitches are ironed out, millions of people will face a choice that's no choice at all: Spend thousands of dollars each year on health insurance plans that, because of high deductibles and co-pays, will be even more expensive to use if they do get sick--or pay a fine with their taxes while they remain uninsured.

The fiasco of the Obamacare rollout is a direct consequence of a byzantine law that was bent and twisted to fit the needs of the health care industry, at the expense of tens of millions of people who will find themselves paying even more for even less health care than now.

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AFTER WEEKS of reports that HealthCare.gov, the federal insurance marketplace where the uninsured are supposed to sign up for coverage was plagued by problems, Health and Human Services Secretary Kathleen Sebelius announced last week that fewer than 27,000 people had signed up on the federal exchange in the month of October. An additional 80,000 enrolled via the state exchanges.

As NBC News reported, "The White House had hoped half a million people would have signed up in the first month [HealthCare.gov] was active. The Congressional Budget Office had projected that 7 million people would sign up for private health insurance on the exchange and that another 9 million would get Medicaid coverage" by the end of the open enrollment period on March 31, 2014.

Adding in the 400,000 who signed up for Medicaid in October, the total number of uninsured covered in the first month of the Obamacare rollout is just 3 percent of the total predicted to gain coverage by the end of the enrollment period, and about 1 percent of the nearly 50 million people without health insurance in the U.S.

Meanwhile, millions of people--over 5 million so far, by some estimates--have received cancellation letters from their current insurers announcing that their health plans will no longer be effective as of January 1, because they don't meet the requirements of the ACA. The paltry enrollment numbers prove that only a fraction of those whose policies are going to be cancelled have been able to sign up for new plans via the exchange--meaning they face a gap in health coverage if the exchange system doesn't start working more effectively.

According to ACA supporters, many of those whose plans are being canceled will qualify for subsidies and therefore will pay less, if and when they can sign up on the exchanges.But as the investigative journalists at ProPublica showed, others face higher premiums for coverage that is inferior to their current plans.

The cancellation letters were a further embarrassment to Obama, who sold his health care proposal with the repeated promise that "if you like your insurance, you can keep it. Period." According to reports, the administration expected these cancellations--yet Obama continued to claim otherwise.

As a consequence, Obama's popularity has sank to the lowest point of his time in office--he has a 39 percent approval rating, compared to 54 percent who disapprove of the job he is doing. The same Quinnipiac poll showed a further decline in support for the ACA: "[O]nly 19 percent [say] they believe the quality of their health care will improve in the next year. Forty-three percent say it will get worse."

Facing pressure from Republicans and a revolt inside his own party, Obama held a press conference last week, in which he apologized for the HealthCare.gov problems and announced that the administration would allow insurance companies to continue to offer plans to current customers through 2014, even if they don't minimum standards under the ACA.

This announcement held down defections of House Democrats in support of a Republican-sponsored bill allowing insurers to continue to sell non-compliant plans--but nearly 40 Democrats voted in favor of the bill the day after Obama's press conference.

Obama's concession, however, doesn't guarantee that insurers won't rescind the cancellations. According to the Atlantic, Obama's measure allows, but doesn't require, companies to continue to offer existing plans. It does require insurers "to tell their customers 1) what the new plans cover that their old plans don't, and 2) that these new plans might actually be cheaper for them. In other words, the administration is trying to get the insurance companies to tell people what they would find on HealthCare.gov if it worked."

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ACCORDING TO Sebelius, HealthCare.gov should be working well by the end of this month--at which point one-third of the time available for people to sign up will have elapsed. But it's unclear whether the technical issues will be resolved by then. An analysis sponsored by CNN found that the site is "getting better, but it looks like there's still a lot to do," said Media Temple President Russ Reeder.

So far, the administration has spent $175 million on federal contracts to develop HealthCare.gov. Incredibly, the companies contracted to create the HealthCare.gov marketplace testified before Congress that "end-to-end testing was conducted only in the final weeks before the site went live, and no senior executive at the Center for Medicare and Medicaid Services was designated as the point person for integrating the various components of the system."

Still, as incompetent as it has made them look, it may be better for Obama if the problems with the ACA rollout are chalked up to technical issues. That's better than admitting the deeper problems with the health care law itself.

The Obama administration and congressional Democrats began developing health care legislation determined to bring the medical-pharmaceutical-insurance complex "to the table"--and then made one concession after another to keep them there. The ACA contains some long-awaited regulations on the insurance industry, such as a ban on using "pre-existing conditions" to deny coverage and requirements that plans cover preventative health care.

But the law leaves the main problems of the current system intact because it preserves the place of private profit in a corrupted and wasteful system--instead of making quality, universal care the priority.

Thus, the technical issues are directly connected to the complexity of the system created by the ACA. Different types, levels and costs of coverage are available, and they vary depending on income and what state the customer lives in.

Residents of 36 states must rely on the federal HealthCare.gov site, while the rest have state-level exchanges. Once enrolled, people can choose between different levels of coverage--from Bronze plans, with the lowest premiums, but highest out-of-pocket costs, through Silver and Gold, to Platinum plans, with the highest premiums, but lowest costs if and when policy holders use their insurance. Not only that, but many exchanges include multiple insurance companies, selling multiple versions of plans at each of the four coverage levels.

This creates the illusion of choice, with a bewildering multiplicity of options--but all within a relatively narrow framework that shifts the burden of health care costs more and more onto individuals.

In the future, the "Cadillac tax" on expensive health insurance plans offered through employers will place downward pressure on the quality of existing coverage, particularly for union workers who have bargained for the best coverage over the years. The tax will create incentives for employers to shift more costs onto workers.

For right now, though, another complicating factor is the subsidies for purchasing coverage, which the government offers to individuals earning between 100 percent and 400 percent of the federal poverty line, with amounts varying again by state. These subsidies, which the Congressional Budget Office estimates will total over $1 trillion in the next 10 years, will help make plans on the insurance exchange more affordable--but the money will go straight into the pockets of private insurance companies, which is probably while the stock prices for these companies are up.

Last year's U.S. Supreme Court decision on the ACA allows states to opt out of one important aspect of the law--an expansion of the government-run Medicaid health care program to cover individuals and families just over the poverty line. Fully one-half of U.S. states, led by Republicans, are refusing to accept additional Medicaid funds for the expanded coverage. This will leave even more people--those with fewer means to start with--to negotiate the complicated exchange process.

Managing all of the different options requires the online marketplace to interface with the computer systems of multiple health insurance companies, as well as several government agencies. The system must validate users' information by cross-referencing data entered on the site with records at government agencies, determine the eligibility for Medicaid and/or subsidies, and transmit that information to insurance companies to ensure that enrollment is completed successfully.

Some insurance companies, ever on the lookout for a way to make even more money, have allegedly attempted to take advantage of the confusion caused by the ACA to trick customers into paying more for plans when they might qualify for better, cheaper plans in the federal exchange. According to CNN, the state of Kentucky has fined leading insurer Humana for sending illegal letters saying that "customers had to choose one of two options within 30 days: Either legally extend their current policy through next year or choose a new, more expensive policy that complies with Obamacare. The letter never mentioned buying insurance through the new exchange."

Still, the $60,000 fine won't make a dent in Humana's profits, which totaled some $1.4 billion in 2012. Humana has been sanctioned in other states as well, but without penalties that make it costlier to break the law than comply with it, it should be expected that insurers will continue to make the logical business decision to maximize profits by skirting the law.

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Compare the complexity, confusion and opportunities for insurance company scamming under the ACA to a single-payer system, such as Canada's, where everyone in each province qualifies for government-provided health insurance. Instead of multiple tiers of insurance plans with varying levels of costs, coverage is the same for residents within each province--though those who aren't citizens or legal residents are unjustly excluded.

While universal coverage is available for medical care, the system is not pure "single-payer"--a majority of Canadians buy supplemental insurance for dental, vision, pharmaceuticals and other elements of coverage.

Still, the relative simplicity of this system means that not only is the proportion of the uninsured reduced far lower than the best estimates under the ACA, but there are immense savings on administrative costs. More of health care workers' time can be spent caring for patients instead of dealing with the paperwork associated with determining insurance status and billing multiple insurers.

According to a survey published in Health Affairs two years ago:

[T]he administrative costs of and time spent interacting with multiple payers in the United States far exceeded time spent and costs in Canada with its single-payer system. Physician practices in the United States spent $82,975 per physician per year while Canadian practices spent $22,205 (financials were adjusted for purchasing power). Nursing staff at physician practices in the United States spent 20.6 hours per physician interacting with health plans while their Canadian counterparts spent 2.5. Clerical staff in the United States spent 53.1 hours compared to Canadian clerical staff's 15.9.

A pure single-payer system would save even more time and money. Medicare, which is essentially federal single-payer health insurance system for seniors and the disabled, spends less than 1 percent on administrative costs compared to the major health insurer Aetna, which spends 29 percent, as Time magazine explained in a report earlier this year.

The U.S. continues to spend more than any other country in the world on health care, yet lacks universal health coverage and has poorer outcomes than most advanced industrialized nations.

Despite all its problems, the ACA will, in fact, reduce the numbers of uninsured in the U.S. But it doesn't address the many other aspects of the system that lead to these higher health care costs and poorer outcomes. Instead, Obamacare preserves the role of for-profit insurance companies whose existence is the source of many of these problems.

Fixing the bugs in the ACA won't fix the need for a movement for truly universal health care.

Paying the price for the ACA

Published at Socialist Worker.

The introduction of the "insurance exchanges" set up by the Affordable Care Act (ACA)--the "virtual stores" where the uninsured are supposed to be able to comparison shop for health care coverage--are showing everything that's wrong with Barack Obama's health care law.

The exchange websites have been plagued by problems that won't be fixed for weeks--as a consequence of the byzantine complexity of a 2,000-page law where the priority is preserving the role of the private insurance industry. When the uninsured are able to consider their options, they're finding that the "choice" is no choice at all--sign up for still-expensive health plans that contain all kinds of provisions like co-pays and deductibles that make them even more expensive, or stay uninsured and pay a fine on their taxes.

Part of the rationale for the ACA is that the exchanges would bring younger people, who tend to be healthier, into the system, where their premiums would allow the insurance companies to provide less expensive coverage for older people who need more health care. But there's a flaw in the argument: Instead of healthier people subsidizing health care who have a greater need for it, they're also subsidizing the bottom lines of the health insurance companies.

Gary Lapon asked three young adults about their experiences with the health care system and with the ACA: Spring is a 34-year-old freelance makeup artist living on Staten Island in New York City. She is pregnant; she and her husband are expecting their first child in February 2014.Brian is 27 years old and lives in Washington, D.C., where he works full time at a bicycle shop.Melissa is 32 years old and lives in Oakland, Calif. She currently works in retail in San Francisco.

Brian: Not really. When I have gotten sick, I just try my best to make it go away--ha ha.
I was in a bicycle accident last year and sustained a concussion, even with my helmet on. I didn't go to the hospital; I just talked to my sister, who is a doctor, on the phone for some advice. People tell me that if I'm in another accident and it's bad, I'll wish I had paid for the insurance then. But I seriously can't afford to spend another $100 every month. And even if I could, the cost of the co-pays would keep me from going anyway. Why should I pay for something I can't afford to use?
I was in a bicycle accident last year and sustained a concussion, even with my helmet on. I didn't go to the hospital; I just talked to my sister, who is a doctor, on the phone for some advice. People tell me that if I'm in another accident and it's bad, I'll wish I had paid for the insurance then. But I seriously can't afford to spend another $100 every month. And even if I could, the cost of the co-pays would keep me from going anyway. Why should I pay for something I can't afford to use?

HOW WOULD you describe your current health care situation. Are you insured and do you have access to care? What is that like?

Spring: I'm "self-employed," so I have to pay for individual health care. Because my husband and I were planning to get pregnant, we got the only plan we could afford that has maternity coverage, which is over $300 a month.

About two months after finding out we were pregnant, I got a notice that the health care plan that I have will be discontinued as of January 1, 2014. That's just over a month before I'm due to give birth. Their excuse was that they no longer will cover "sole proprietors"--meaning small business owners with no employees, which I am. We tried to find a new plan to replace this one that included prenatal/maternity coverage, but the cheapest plan started at over $1,000 a month, which is way out of our price range.

Brian: I currently don't have health insurance and haven't for almost two years. My employer is small and doesn't offer health insurance. I'm fairly healthy, although my lifestyle of bicycling everywhere puts me in a vulnerable position.

I was hit by a car in late February of this year and broke my heel. Fortunately for me, it was the driver's fault, and his insurance company paid for my treatment after six months of legal disputes, though I had to incur that debt during those six months. It cost me hundreds of dollars for 10 minutes of care every week. For six months, I was on crutches. Normally I ride my bike everywhere, so a 30 minutes commute via bicycle became a 60 minutes bus ride.

I got calls from the hospital almost every week, with new and confusing bills I had to pay and put on my credit card, which gained interest. Every time I went in for a regular checkup, it was $200 to $300 each time, when I really only had about 5 to 10 minutes with the doctor--from what I hear, that was a good deal. All my bills came to about $10,000 total! I had to really tighten my belt on everything that I did during those six months. It gave me an insight into the industry--even most receptionists had no idea how much out of pocket an appointment would be.

Melissa: I'm uninsured. I got my bachelor's degree two years ago and planned to teach ESL, but ESL programs have taken a huge hit since public schools have faced severe budget cuts, and now I'm left with $36,000 in student loans and meager job prospects, much like others in my graduating class.

The thing is, I was 30 when I graduated, so I'm not eligible to be covered by my parents' insurance like many in my cohort--the Affordable Care Act enables people to remain on their parents' health insurance until they reach age 26--assuming their parents have insurance anyway.

I work in a small retail shop in San Francisco, but since I can't afford to live there, I can't get HealthySF, the city insurance for low- to medium-income people. I've gone back to a community college in Oakland to get training in machining, in the hopes that I can get a job with insurance soon.

HAVE YOU ever gone without care due to a lack of health insurance?

Melissa: Fortunately, I live in an area of the country with some decent clinics. I can go to the Berkeley Free Clinic for some very basic care, but not much beyond that.

I have a genetic condition that, while usually mild, can potentially have serious health complications. The seriousness can be mitigated if the complications are caught early, but that requires me to have an EKG more frequently as I get older. The last time I was due was last year. My grandmother died at 56 from this disorder, and my uncle almost died at 48. That's when everyone in my family got tested, and I found out I had it.

I also wear glasses, which the ACA doesn't cover either. Same for dental. It also has very restricted mental health coverage. It's like they don't care if I'm blind, crazy, and my teeth fall out, as long as the rest of me is fit for work.

Spring: Until this year, I went without health care coverage for as long as I've been a freelancer, which is about eight years. I've never been able to afford coverage for myself, and previously had coverage through employers or Medicaid. Once I became self-employed, I no longer qualified for Medicaid, although my income was low.

WHAT DO you think of our options under the Affordable Care Act?

Melissa: I feel pretty confident compared to most, but I'm no expert. The one thing I do know is that I can't afford insurance through it and I'm going to get fined because of it. And I think that's the case for a lot of people.

Spring: The ACA is very confusing, especially when it comes to what types of coverage an individual qualifies for, and how to go about actually getting coverage. I know that I can't be denied because of a pre-existing condition, and that the income level that qualifies for Medicaid has been raised, and I now qualify for Medicaid. The fact that I have to have coverage or face a penalty is ridiculous, and financially penalizes the poor and those who can't afford it.

Brian: I don't feel totally confident that I know my options. However, I'm sure I will become more well-versed as I go through the process a little more.

I do understand it as a handout to insurance companies. All of the sudden, working people will have to shell out a fair amount of money for private insurance, which have some of the highest profits of all companies. There are good things in the bill, like you can't be denied insurance for pre-existing condition, but that won't matter if you can't afford insurance.

HAVE YOU signed up for insurance via the insurance exchanges? If not, do you plan to?

Brian: I've applied for DCHealthLink.com for assistance. I have yet to hear back, but according to estimates, if I don't get assistance, I'll have to pay $200 per month for the most basic plan. This would be a huge chunk of my monthly income, including my rent and other bills. I've thought about just paying the penalty, because that's $95 a year--for now, I know it will be going up in the coming years.

I definitely will be in a worse financial position than I was before. It will be much harder to nearly impossible to be able to save money for either purchasing a place to live and having a family in the future.

It's hard to say how all this will impact my decision-making. I'm sure I will have to pick and choose the food I get and times that I go out to do things. I really want insurance, and it's really hard to be in a position to have to choose how much I value my health.

Spring: I signed up for insurance via the New York exchange website. It proved to be confusing and very time-consuming, and it used terms that I've never heard before. It also had many technical glitches that made it difficult to complete the application or go back in and update information.

I'm forced to use this option because my current insurance is being canceled as of January 1, 2014, and there are literally no comparable plans available. This is directly connected to ACA, as insurance providers are discontinuing their low-rate plans and waiting until January 1 to roll out new ones. To add me to my husband's employer-provided insurance would be $1,000 a month--way outside our budget.

The best part of ACA is that I now qualify for Medicaid. The worst part is that I won't hear back on my application until as late as mid-December, leaving only a couple weeks before I am cut off from my current provider. With a baby due in February, it is very stressful to have to depend on the government to provide insurance on time, and it leaves me potentially without coverage right before our baby is due.

If anything goes wrong with the application, and it ends up that I am not eligible for Medicaid, I will literally have to find new insurance in two weeks, which is impossible.

Melissa: I've decided I'm going to remain uninsured and pay the penalty. I'm pretty sure I'll have a job with benefits before the end of next year, so it'll probably be a one-time thing for me. But I'd still rather spend the penalty money on something that would actually help me--new running shoes or even a donation to the Berkeley Free Clinic.

I feel like I'm being robbed. My options are to pay for something I can't use or pay a fine for not buying something? That sounds like a scam.

Welcome to new and unimproved health care

Published at Socialist Worker.

THE CENTERPIECE of Barack Obama's health care law--the state and federal Health Insurance Marketplaces, commonly known as insurance exchanges--came online on October 1.

The long-awaited opening of the "virtual stores" for the uninsured to obtain coverage was overshadowed by the government shutdown that began at the same time. The health care law was a factor in the shutdown--House Republicans refused to set aside their attempts to delay or defund the Affordable Care Act (ACA), causing a stalemate over passing legislation to keep the federal government operating.

When the media reported on the new exchanges at all, it was to document continuing problems with the websites where customers are supposed to enroll. Technical experts say the glitches will be worked out in plenty of time for people to start getting coverage on January 1. But the computer troubles were an unpromising start for a system that has been criticized, by the right and the left, as unnecessarily complicated.

As a result, though, no one is looking at the substance of this central element in the new health care law.

When the media get around to that (if they do) and when the uninsured make it through the online enrollment process, they'll find a system for providing insurance that's nothing like what its right-wing critics claim about it--but that's also not at all the great leap forward its supporters say it is.

From before it became law, the Republicans falsely claimed the ACA was a "socialist" (if only!) takeover of the health care system, aimed at putting the government in charge of decisions about your medical care. New enrollees using the exchanges will be relieved--but probably not surprised--to find that they don't have to go before an online "death panel" to determine if they will be euthanized.

But those who sign up online hoping they will find that "the health care system is being fixed, step by step," as Barack Obama promised, will be disappointed.

The exchanges--like other parts of the ACA, including the individual "mandate" requiring people without insurance to purchase a plan through the exchanges or pay a penalty with their annual taxes--are designed to preserve the role of the private insurance industry, not to guarantee access to affordable, quality health care for everyone. The signs of this underlying priority will be visible at every step of the way.

Much more will emerge over time about the ACA and how it will impact the lives of the millions of people now subject to it. Some of those experiences will be positive--because there are positive aspects to the law.

But at its core, the ACA is a market-based reform that maintains the central role for private corporations in the provision of health care. It will deliver millions of new customers and more than $1 trillion in subsidies to private insurers over the next decade. As for those customers, those who do find insurance through the exchanges will be paying hefty prices for coverage with all kinds of holes and limits. And when all is said and done, the ACA is expected to leave some 30 million people without insurance.

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THE EXCHANGES are essentially online shopping centers for health insurance plans. Several states, including New York and California, are running their own exchanges, while many others are relying on the federal exchange.

Users can log on, enter their information, and choose between health insurance options at different prices for different levels of coverage. They can also determine their eligibility for Medicaid, the government-run health care program for the poor--and for subsidies to use toward the purchase of insurance from private companies.

Plans come in four tiers, going from bronze, with lower premiums and higher out-of-pocket costs; to silver; to gold; to platinum, which has the highest premiums and lowest out-of-pocket costs.

However, not all states offer much of a choice. In New Hampshire, for example, Anthem Blue Cross Blue Shield is the only insurer participating in the state exchange, though it will offer 11 different plans.

The ACA originally included an expansion of the Medicaid program to everyone earning less than 138 percent of the official poverty line--state governments would be forced to implement the expansion, or lose all Medicaid funding. However, the U.S. Supreme Court ruled that it was unconstitutional to threaten states with losing all their funding if they refused to implement the expansion. Half of the states have essentially opted out of this important aspect of the ACA.

Nevertheless, the Congressional Budget Office predicts Medicaid enrollment will increase by 7 million next year alone, despite the Republican obstructionism. This is arguably the most positive outcome of the ACA--the expansion of premium-free health care with nominal co-pays to millions of poor people.

But Medicaid expansion is also good for business--private companies that run Medicaid managed care plans expect a big surge in revenue as a result. According to USA Today, "For industry titans such as UnitedHealthcare and WellPoint, as well as smaller, Medicaid-focused plans such as Molina, the Medicaid expansion is expected to bring significant enrollment and revenue growth" in the range of hundreds of billions of dollars in coming years.

There are other components of the ACA that are positive reforms--a requirement that health insurance include a minimum level of coverage with free preventive care, and prohibitions on insurers denying coverage due to pre-existing conditions, for example. Young people may remain on their parents' health insurance until age 26, and insurers cannot charge higher premiums for women--who on average access more health care--than for men.

And for the roughly 10 percent of the currently insured who buy health insurance on the private market, they'll find that the cost is less and coverage is better under the ACA.

But weighing against these positives is the mandate--the requirement that individuals who don't have insurance buy coverage from a private insurer or face a tax penalty.

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THE ARGUMENT for the mandate is that it will offset increased costs to insurance companies while also reducing premiums for those who need a lot of health care, such as older adults and those with chronic diseases--by bringing healthy, young adults into the system. It's a zero-sum game where the big winner is the insurance industry--the ACA reduces costs for older and sicker people by increasing them for younger and healthier people.

The mandate to buy insurance is to be enforced via penalties on those who remain uninsured. In 2014, the penalty will be $95 per adult and half that for a child, capped at $285 per family, or 1 percent of income after the tax-filing threshold, whichever is greater. This penalty will increase each year, reaching $695 per person and a family cap of $2,085, or 2.5 percent of income, by 2016.

So an uninsured individual making $30,000 a year would pay an annual penalty of $300 in 2014, rising to $750 by 2016, while an uninsured couple making $60,000 would pay $400 in 2014 and $1,390 in 2016.

The penalties attached to the ACA are clearly regressive. According to Health Affairs, nearly 60 percent of the approximately 30 million people who will remain uninsured under the ACA--and therefore subject to a penalty--are low-income. More than 16 percent of the uninsured will be Black, though African Americans are less than 13 percent of the population.

Faced with these penalties, the CBO estimates that some 9 million people will purchase health insurance on the exchange next year. This is expected to reach 26 million by 2018--enough to cut the percentage of the population without insurance in half, according to the estimates touted by the Obama administration as proof of the ACA's concrete advances.

What Obama and other supporters of the law don't say is that the newly insured will also be new customers for the private insurance industry, buying plans with premium payments that will flow into the bank accounts of private companies. And that's not all. The insurance industry stands to gain enormous sums directly from the government, in the form of a subsidies system created by the ACA.

In order to help the uninsured pay for plans on the exchanges, the federal government is offering subsidies to those earning between 100 percent and 400 percent of the federal poverty level--this year, that's $11,490 to $45,960 a year for individuals and $23,550 to $94,200 for a family of four.

According to the CBO's estimates, four out of five enrollees will qualify for a subsidy--those who qualify will receive an average of $5,290 in 2014. Obviously, this will make insurance relatively more affordable--although many individuals will still pay hundreds of dollars per month for premiums, and everyone will be stuck with out-of-pocket deductibles that can rise into the thousands of dollars before insurance kicks in.

The subsidies will be paid directly to the private health insurance companies selling their plans on the exchanges. The CBO estimates that subsidies will surpass $1 trillion in the first 10 years after the exchanges kick in.

All this revolves around the mandate for individuals to buy insurance or face a penalty. But corporations get to play by different rules.

Under intense pressure from lobbyists, the Obama administration decided to delay the so-called "employer mandate" for at least a year. This mandate would require companies with 50 or more full-time workers to offer affordable health insurance to their employees, or get hit with a penalty themselves. As SocialistWorker.org reported this summer:

The administration had estimated that the federal government would receive about $10 billion in penalties from companies that didn't abide by the employer mandate. Then there's the money that at least some companies would have spent to conform, but won't have to now--which is money in the bank, at least for another year.

If there were any doubts left about the business-friendly character of the ACA, you only have to look at the big gains in stock prices for health insurance companies after the ACA passed--in anticipation of increased profits from an influx of customers and subsidies.According to Barrons, "The Morgan Stanley Health Care Payor Index has jumped 73 percent during the past two years, with Aetna (AET) up 64 percent and UnitedHealth Group up 45 percent. At $41.59, shares of HCA Holdings (HCA), the nation's largest hospital operator, have more than doubled over that same span."

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THE ACA is incredibly complicated, and the Republican lies, misdirection and hyperbole, willingly echoed in the right-wing media, have made it all even more confusing. To make matters worse, the ACA impacts people in similar situations differently based on where they live.

Let's take, as an example, a family of three earning $12,000 per year. Because their income places them well below the federal poverty level, in states that have accepted the ACA Medicaid expansion, they would qualify for Medicaid and have access to health care at little or no cost.

However, if they live in a Republican state that rejected the expansion, such as Alabama, they will not qualify for Medicaid. In Alabama, a family of three must have income under $4,500 to qualify for Medicaid. But because they earn less than 100 percent of the federal poverty level, a family earning $12,000 a year is too poor to qualify for subsidies on the exchange. They will be exempt from paying a penalty, but will almost certainly remain uninsured.

The Republican opposition to Medicaid expansion is particularly cruel given that the states refusing to implement it, including most of the former Confederacy, are home to disproportionate numbers of the poor and nonwhite uninsured. According to the New York Times:

The 26 states that have rejected the Medicaid expansion are home to about half of the country's population, but about 68 percent of poor, uninsured Blacks and single mothers. About 60 percent of the country's uninsured working poor are in those states. Among those excluded are about 435,000 cashiers, 341,000 cooks and 253,000 nurses' aides.

According to the Times, as a result of state-level Republican obstructionism, the ACA "will leave out two-thirds of the poor Blacks and single mothers, and more than half of the low-wage workers who do not have insurance."

That the Republicans would throw these people under the bus to score political points is yet more evidence of the party's racism, free-market fanaticism and cynical disregard for those at the bottom of society.

But it's important to understand as well that Republican state officials are able to weasel through these loopholes because of fundamental problems with the way the ACA was written.

The ACA does not ensure universal access to health insurance and affordable health care. Some 30 million people will remain uninsured years after its implementation, and health care will remain a commodity, not a right, with private companies having a sickening amount of power over whether people get the medical treatment they need or not.

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THIS IS best illustrated by looking at what insurance plans will be like for those with incomes between 100 and 400 percent of the federal poverty level--people who will therefore qualify for a subsidy when they buy health insurance on the exchanges.

A single adult living in Los Angeles, California making $30,000 per year would qualify for a subsidy of $276. They would still end up spending $210 a month for a Silver plan--one of the middle-tier levels of coverage.

That silver plan comes with an annual deductible of $2,000, which means paying that amount out of pocket for many services--including surgery, ER visits, giving birth and mental health services--before insurance kicks in. If they require a lot of care, total out-of-pocket expenses could reach the capped maximum of $6,400.

Add the subsidized premium payment to out-of-pocket expenses, and a person making $30,000 a year could end up spending as much as $8,920 in one year. That's a worst-case scenario--but the minimum, if they access enough medical care to cover the deductible and full coverage kicks in, would be $4,512.

That's the middle-tier plan. Alternatively, a lower-tier Bronze plan costs less--$151 a month, after the subsidy--but it has a much higher annual deductible of $5,000, which applies to almost all non-preventive care. Out-of-pocket costs are still capped at $6,400, but if the insured happens to get sick and need their insurance, they could end up paying much more with a Bronze plan than with a Silver plan.

So a Silver plan is most likely a better deal for all but the healthiest people. But $210 a month is a lot of money for someone earning just $30,000 in an expensive city like Los Angeles.

Those earning less than 250 percent of the federal poverty level may qualify for additional "cost-sharing assistance" from the government to help pay these burdensome out-of-pocket costs.

For example, a family of four earning $35,325 a year--which is 150 percent of the federal poverty level--would pay a maximum of $118 per month for health insurance, and would have to buy a Silver plan to qualify for cost-sharing assistance. Instead of covering 70 percent of their costs, like a normal Silver plan, government assistance would drop the deductible from $2,000 to $250, and drop the out-of-pocket limit from $5,500 to $2,000.

But even with premium subsidies and cost-sharing assistance, that low-income family of four could pay as much as $3,400 a year on insurance and out-of-pocket costs--nearly 10 percent of their income. That's obviously a hardship for families barely making ends meet.

The obvious effect of high out-of-pocket costs will be to cause many people to avoid seeking care in order to save money--and take the risk of their condition worsening down the line. A recent survey by HealthPocket found that over 40 percent of people would go to the doctor less if they had a co-payment of more than $50 for each visit. Co-payments for non-preventive visits to a doctor under California's Bronze plan are $60 after the first three in a given year.

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WHAT DOES all this mean for real people?

Randi Jones Hensley, who lives in Texas, is still deciding whether to sign up--or bite the bullet and take the tax penalty. As she said:

For my spouse and me, the Affordable Care Act is far from "affordable." We're already operating on a pretty tight budget, with rent, bills, outrageous student loan payments, etc. So adding an expense of a few hundred dollars to our already stretched monthly budget is going to leave us with nothing.

We've been without health insurance for several years, and of course, we would love to have access to health care, but it's hard to imagine paying so much extra money a month when it's really unclear what the coverage will be like and how much co-pays are going to cost us. And with so much of our money going to insurance every month, how are we supposed to put anything aside for the future?

For Hensley and millions like her, the ACA is not a sustainable solution to the health care crisis in the U.S.--which spends far more on health care than any other nation, despite the lack of coverage and access.

While the Republicans rant about the ACA being a government takeover of health care, that's far from the truth. Principally drafted by a former insurance company executive, the law creates a marginally improved regulatory framework for insurance, but maintains the central role of private, for-profit health insurance.

In fact, the framework of the ACA, focused around the exchanges, is based on the health care law championed by 2012 Republican presidential candidate Mitt Romney when he was governor of Massachusetts. Romneycare's mandate to purchase health insurancewas itself based on a plan devised by the right-wing Heritage Foundation--which had been promoted by Newt Gingrich in 1993 in opposition to the Clinton administration's failed attempt at health care reform.

Nevertheless, Republicans have made opposition to the ACA a major focus of their propaganda in recent years, despite the fact that it is a fundamentally business-friendly reform. No doubt one central reason is that Republicans fear the ACA could become perceived as a popular success, like Social Security or Medicare--and earn their Democratic rivals prestige and popularity over the long term.

So the Republican attitude has been total rejection. But the fact that the maniacs of the GOP are determined to deny the poorest of the poor Medicaid coverage and to wreck whatever positive effects might come from the ACA shouldn't blind us to the much bigger problem with the law--that it puts the interests of the health care industry before people who need health care.

Health care is a basic human need, and the only way to ensure this need is met is to make it a basic human right, accessed through a single-payer system in which the government assures that everyone has access to health care.

The ACA will do nothing of the sort. Instead, it will make the health care industry ever richer, while people's needs go unmet.