I stood in line at 6:45 Sunday morning to purchase donuts at a very popular local donut shop — Spudnutz — at Lake Okoboji. The line of donut-seekers stretched far out the door. I did not receive donuts until 7:50 a.m. I waited more than an hour for donuts. (Yes, very good donuts). Nine people were working in that donut shop that once housed an auto mechanic shop.

If either the Senate bill or the House bill that was intended to repeal and replace the Affordable Care Act (ACA) became law, I fear none of those nine hardworking people would have health-care coverage in the future. For many of my patients and for, I believe, the employees of Spudnutz, I give thanks for the defeat of the Senate “skinny” repeal legislation.

The fallout from the middle-of-the-night vote in the U.S. Senate defeating the “skinny” repeal of the ACA includes statements from Republicans saying that the states need to be given the flexibility to decide health care for the residents of their states or saying able-bodied individuals ought to work with the expectation that they could then have employer-based health insurance. Both statements reveal that Republicans do not know nor do they care about the health coverage for poor and middle-income Americans.

The ACA gave each state the ability to decide whether to run a state-based Exchange, gave each state (via a Supreme Court ruling) the ability to expand Medicaid or not, continues to give each state the power to determine insurers in the individual market, and finally gave each state the ability to administer the Medicaid program even though the federal government is paying 90 percent of the costs of the expansion.

In Iowa, these state-determined elements of the ACA allowed Governor Terry Branstad’s administration and the Republican-run Legislature to quash establishing an Iowa-specific Exchange, to trash talk the ACA at every available opportunity, and to withhold assistance to what was our new startup cooperative insurance entity, CoOportunity Health, when it failed. The Republicans are now gladly propping up Medica, the only remaining health insurer in the Iowa individual marketplace. All the while President Trump continues to threaten to end insurance subsidies, which would further destabilize the individual market not only in Iowa but across the country.

Iowa chose to expand Medicaid, for which I applauded them. Governor Branstad and the Iowa Legislature then chose to turn the entire state Medicaid operation over to three for-profit managed-care companies. I argued strongly against for-profit corporations taking this role. (See previous blog posts, including March 2015). These companies suffered a cumulative loss in the first year of $224 million, for which the state of Iowa was billed only an additional $10 million. I do not know how much the federal government was billed. In addition, both patients and providers have complained about how the managed-care companies have administered Medicaid in Iowa.

Nineteen states chose not to expand Medicaid, thereby withholding health-care coverage for more than 4 million U.S. residents.

In Iowa, a well-run state Exchange with the full backing of the state government, combined with state assistance for CoOportunity Health in the manner and amount that Medica is now receiving state assistance, would have led to a much more stable individual insurance market. Additionally, I believe a state-administered Medicaid program, the type of program we had prior to the managed-care corporations taking over, would have been a much better use of taxpayer dollars and provided a better system for both patients and providers.

I believe there is every justification in calling the Iowa experience with the ACA “TerryCare,” with its state-imposed limitations.

Given Iowa’s experience and that of the 19 states that chose not to expand Medicaid, a belief that states neither had the power nor used the power to affect the ACA is simply wrong. It also calls into question whether states should be given more flexibility regarding health-care coverage decisions.

I do believe able-bodied individuals should work; I also believe that, under a Republican plan for health care for those on the lower rungs of the income ladder, their usual jobs would not have health insurance as a benefit, or their options for health insurance would be limited and cost far too much. The current systems of Medicaid for individuals working at the very lowest-paying jobs and government subsidies for individuals at the next-higher level of paying jobs are not only desirable but are necessary.

As we move forward in this fight for health reform, I think our goal should be to keep affordable, accessible health care for employees such as those working at Spudnutz. The “skinny” repeal would not have allowed for such coverage.

Hopefully, a bipartisan approach will bring stable and ongoing health care to Americans. There are currently many thoughts, plans, and ideas floating around in Washington. Please see the blog entry titled Health Reform and Nick Bath, March 2017, for some solid ideas.