As the presidential primaries and political season rolls along, it is clear that we have collectively chosen to take a long holiday from facts and reason. This week individual market insurers announced they were preparing their premium requests for 2017. Citing a recent Blue Cross/Blue Shield (BC/BS) analysis describing greater acuity and higher costs associated with new Affordable Care Act (ACA; Obamacare) enrollees, they warned that the requested new rate hikes will be a high number.

The Republican candidates immediately declared the ACA “a total disaster” and then threw some red meat to the crowd vowing “to repeal and replace” with absolutely no coherent plan supporting the sound bite. While I have no expectation that anyone is listening, I still felt compelled to point out a few “facts” as we approach the 6^th anniversary of the ACA.

Why did the ACA come into being? Seemingly forgotten, but when Obama took office, 40-50 million Americans had no health insurance. It was, in fact, a national scandal for the wealthiest country on earth. Forty million Americans received no preventative health care, skipped non-negotiable medical appointments (including prenatal care), failed to refill prescriptions, sought care episodically in wasteful/expensive emergency departments, presented to the hospital in more acute condition, or, if they were patriots, died quietly at home about 10 years earlier than the insured.

And, just in case anyone is unclear, there are no Saint Andy of Mayberry Hospitals that write off those unpaid bills. Accounts receivable are passed onto paying customers with a mark-up on your medical bills and historically high inflation of your health insurance premium costs.

Because of the ACA, the uninsured rate in America is now at an all-time low of 9%. Since its inception, 9.1 million Americans have become insured through ACA health care exchanges with the help of government tax subsidies, another 9 million through the exchanges but unsubsidized and about 11 million receiving coverage via expanded Medicaid eligibility. That number would be even larger, but 20 states ignored obvious health and economic benefits and refused Medicaid expansion (paid for by our Federal tax dollars) so ambitious governors could have a better shot at national office.

For mathematically challenged state officials, that is 30 million new people insured over just the past couple of years. That is the entire population of New York and New Jersey. It is the entire combined population of South Carolina, North Carolina, Georgia and Tennessee. As far as meeting its goal of providing insurance coverage, the ACA stands along with Social Security, Medicare and The New Deal programs as a testament to the potential greatness of our country.

“Hey, but hey, the premiums are going up. It’s a total disaster.” Almost certainly true. The premiums are likely going up. Why?

The explanation is found in the characteristics of the newly insured.  Blue Cross/ Blue Shield, the largest individual insurer in the country, have analyzed the new enrollees since the opening of the exchanges in January, 2014. They were “shocked” to discover that the new enrollees were different than their old enrollees and more expensive to cover.

The new enrollees in 2014 and 2015 were significantly more likely to have hypertension, diabetes, depression, and coronary artery disease. The post ACA enrollees were 242% more likely to have HIV and 140% more likely to have Hepatitis C compared to the enrollees who already had individual coverage. During their first year of coverage these new enrollees had substantially more inpatient admissions, outpatient visits, medical professional bills, prescriptions filled and emergency room visits.

The conservative Republicans were quick to pounce. Obamacare was nothing but a redistribution of resources from deserving workers like themselves to a bunch of freeloaders taking advantage of the system. To quote George Orwell, “All the pigs are equal, but some are more equal than others.”

Really.

These findings demonstrate EXACTLY why the ACA was necessary. Prior to the ACA, sick people with pre-existing conditions were systematically excluded from the individual insurance market. In a Kaiser Foundation Health Survey in 2013 before the guaranteed coverage provision of the ACA went into effect, 49% of adults said that they or someone in their household had a pre-existing condition. One quarter of those reported being denied insurance, being charged an exorbitant premium or staying at a job just for health coverage.

Without the ACA, most of these families stood no prayer of obtaining health insurance. Moreover, they faced the risk of catastrophic health expenditures. Not all the homeless are con artists. Some are hardworking citizens who’ve been stripped of all their assets due to illness or injury. In Atlantic City, Springsteen’s everyman says simply, “I’ve got bills no honest man can pay.”

Sadly, neither the Blues, nor the Republican candidates, could find another convenient demographic which would allow them to demonize these new enrollees or recommend a wall to hide them behind. Other than pre-existing conditions, the new enrollees looked just like employer-insured members. Bottom line, the ACA enrollees are citizens just like you and I, but unlucky to have gotten sick or old.

What has happened was the most predictable outcome of the ACA. Far more predictable than the number who would enroll. Premium rates were bound to rise for the pre-ACA enrollees as their insurance pools were forced to accommodate a mass of people with pre-existing conditions. The old, lower insurance rates, were the product of cherry picking the healthiest pool members who required the least care. By the way, in addition to keeping rates low, cherry picking also helps generate healthy profits for the insurance companies.

The only way to make the infusion of so many people with pre-existing medical conditions tolerable to the insurance system and its rates was to balance them with an even larger infusion of low-risk enrollees who were also new to the system. The insurance expenditures required by the new high-risk enrollees had to be offset by income from a huge number of new low-maintenance enrollees.

That was accomplished by the popular provision of allowing young people to remain on their parents insurance until age 26 and the less popular individual mandate to have insurance coverage with or without government subsidy support.

The individual mandate hasn’t been under constant judicial attack because of hurt constitutional sensibilities. It is under attack because it’s the key to ACA success. Without the individual mandate, millions of low risk young immortals would abandon their health coverage in favor of beer money. Conservative policy makers understand that the popular provisions of the ACA are not affordable without the individual mandate. They wisely strategized to attack the ACA through the courts (rather than through new legislation) so they would have political coverage if the ACA was dismantled.

“Repeal and replace” is fool’s gold. Other than a single payer system, there is no alternative plan that provides insurance coverage for 30-40 million uninsured Americans. Providing coverage to so many people previously excluded because of pre-existing conditions would come with a cost. However, the cost is not as large as one may anticipate. The insured are already paying for unreimbursed care and unreimbursed care costs were going up dramatically.

One of the goals of Obamacare was to “bend the curve” of health-care inflation, which has grown faster than the cost of any other sector. The ACA implemented a wide range of reforms designed to improve care and bring more cost-consciousness into the system. The ACA turns incentives upside down. Instead of a hospital acquired infection or readmission generating new billable treatments, Obamacare changed reimbursement to penalize hospitals with high readmission rates. Sure enough, hospital medical errors and readmission rates are down. Ultimately, more preventative, timely and careful health care will improve outcomes and save money. See my previous post on the improving infant mortality rates in S.C.

As predicted, health-care inflation has not only slowed since the introduction of the ACA, it has dropped to the lowest level since the government started recording it. Of course that isn’t a “fact” that has changed anyone’s mind. Conservatives have pivoted from the absolute ideological certainty that health-care inflation would rise in the wake of Obamacare to the absolute ideological certainty that the drop in health-care inflation has nothing to do with Obamacare.

There is no fact or logic that will mitigate conservative opposition to Obamacare. Even if they know they’re wrong, politics is a Texas Hold’em poker games and they’re all-in against the ACA and it’s too late to blink. But for everyone else, it’s time to forget the tired political slogan of “repeal and replace.”

There is much that can still be done to make the American health care system better and something less than the most expensive in the world. Realign our priorities regarding primary and preventative care versus specialty care. Eliminate environmental health hazards and reverse the trend towards obesity.  Control exorbitant pharmacy costs. Crucify pharmaceutical CEOs who price gouge lifesaving or disease preventing medications. Restrict direct to the public drug and medical device advertising.

Support NIH-sponsored research to conquer the diseases of the 21^st century. Regulate for-profit hospitals like you mean it. Lock up fraudulent doctors, dentists, pharmacists, medical device salesmen, nursing home hucksters and hospital administrators and throw away the key. Or, turn them over to the villagers when they’re convicted of treating patients for cancer who don’t actually have it or putting in defective artificial hips because you could get a deal on the batch.

I realize that none of these are modest proposals. However, all of them are better than abandoning a well-conceived, effectively working and reasonably priced health care law that has brought improved health care to more than 30 million people. The same number of people who live in Portugal, Belgium, Denmark and Norway combined. The ACA is one of the greatest public health achievements in the history of the United States.