In October 2008, during the depths of the financial crisis, I made a risky decision to quit my job in publishing and strike out on my own. Publishing is not a lucrative field, especially when you're self-employed, but I felt bold. I welcomed both the entrepreneurial challenge and the opportunity to also return part-time to teaching--reading, writing, and math--to hardworking immigrant adults, many of them also self-employed.
My decision was possible only because I lived in Massachusetts, where "Romneycare" gave me the freedom to not worry about health security. Sure, I had to work harder than ever earning my living, but because of the Massachusetts health law, I was willing to take the risk. So I gradually built up a modest but reliable independent proprietorship, taught part-time for low pay (simply because I loved it), and embraced my newfound independence with vigor.
In March 2010, when Barack Obama succeeded in bringing a version of Romneycare to the entire nation, I was over the moon. With the Patient Protection and Affordable Care Act, I saw a way for Americans in all 50 states to have the freedom to make choices like I did--not just middle-class people like me who could pay their full premiums, but lower-income folks (like those in my own family and my students), thanks to the ACA's income-related subsidies and, eventually, Medicaid expansion.
Given that the ACA's protections were national, I was able in 2015 to move back to my birth state of New York, closer to loved ones. Knowing I could take my business and my passions anywhere reinforced my conviction that the ACA was not only compatible with entrepreneurship but even nurtured it. I was puzzled by politicians who argued that getting rid of the ACA would give people more choices and freedom. Predictability and sensible minimum requirements for all health insurance plans actually allow me to feel free in other areas of my life--that kind of reliability is invaluable to anyone who is self-employed. And even the businesses that hired me as a freelancer gained--I was purchasing my own benefits (so they didn't have to) and paying both the employee and employer parts of Social Security and Medicare taxes.
As the rhetoric against the ACA escalated during the 2016 presidential campaign, I became worried. Where were the stories of people like me who were thriving in business because of the ACA, of people who no longer had to live in fear because the ACA now protected them and, in many cases, offered them financial support for their insurance? Why was no one discussing that when insurance premiums escalated greatly, it was often in states that refused to accept federal dollars through the ACA's Medicaid expansion? And did people not remember how insurance premiums had been growing even faster before the ACA?
Clearly, we must do more to curb overall U.S. healthcare costs than the ACA or any replacement plan could possibly achieve on its own. Even the most ardent ACA supporters admit that. But now the very real prospect of ACA repeal has injected so much uncertainty into people's lives that they're making perverse decisions for themselves and their families. They're hanging on to jobs they know they should leave, applying for positions they don't want, hesitating to start businesses, and closing down their businesses.
If I've learned one thing in my years working for businesses and then running my own, unpredictability leads to paralysis and stymies innovation and growth. Yet as some lawmakers threaten to repeal the ACA on a daily basis, we have no idea if a replacement will be any better--and there's been no serious response from the insurance industry. Even the most specific replacement proposals are still broad outlines, with very few details to compare what you have now with what you'll get. You wouldn't sign a new mortgage agreement if the banker just said, "Trust me--you'll love the terms." Would you?
This new, uncertain reality is having a chilling effect on the entrepreneurial spirit that gave me such a charge in 2008, when I went out on my own. I, too, have started applying for traditional full-time jobs again--because my sense of what the individual insurance market will look like in a year or more is extremely hazy at best and frightening at worst.
- Will we go back to the days when people must disclose a health history to an insurer in order to obtain coverage? Shouldn't that private information, whether it's chronic low-back pain or a history of breast cancer, be available only to patients and their doctors?
- Will we start providing tax credits or subsidies for insurance only according to a person's age rather than his or her income? After all, it's how much money you have, not how old you are, that determines your need.
- Will lifetime caps on insurance benefits be restored, so that people who are unlucky enough to get really sick risk bankruptcy? For instance, you simply cannot fully treat someone's leukemia with a million dollars.
- Will we make people hesitate to move across state lines, even if that's best for them and their families, because they fear having to adapt to brand-new insurance rules?
This is a small subset of the questions ricocheting through my mind and the minds of entrepreneurs all over America. Promises of "beautiful health care" and "a better way," outlined in only broad terms, send self-employed people and entrepreneurs into a state of paralysis. It surprises me that Republicans, of all politicians, don't recognize this. Telling people not to worry without actually putting the details on the table damages individuals' ability to make smart decisions for themselves and, by extension, harms our whole economy.
The threat of an ACA repeal has put me in the grip of an uncertainty about the future that far rivals any hesitation I felt in 2008, when in the middle of a worldwide financial crisis, I decided to make my own way. That's because then, thanks to the Massachusetts precursor to the ACA, health security wasn't a factor in my decision--I knew I just had to work as hard as I could to make it, and if I didn't, that failure would be on me.
In 2017, in contrast, I am reacting to a sustained and paralyzing lack of detail about what comes next in health care, so that I cannot make personal and business decisions on the merits. Like so many other people, I don't feel entitled to anything but the chance to work hard and make a better life for myself and my family--and the ACA has made that possible. Having that chance, it seems to me, is consistent with values that any political party would want to espouse.