The future of Obamacare
Donald Trump has been elected. We will continue to have a Republican House of Representatives and Senate in Washington. What does that mean for health and health care in the United States?
Since its inception, the Republicans have railed against the Patient Protection and Affordable Care Act, more commonly known as the ACA or Obamacare. This could be expected since it was passed unilaterally by a House and Senate controlled at that time by Democrats. Although the idea was based on a plan originally conceived by a Republican-leaning think tank, it was hated from the beginning by the party not in power at the time. Now that party is in power, and what can be expected?
Despising something and doing something about it are two different things. Think of a dog chasing a bus. If it catches the bus, then what? We have heard the phrase “repeal and replace” frequently without seeing a consistently structured plan. The majority party now can finally do something, but what? How different and how effective can they be?
Attention must be given to three aspects of health care; cost, quality and access. Obamacare was flawed from the start because it concentrated mainly on financial access, especially insurance. Americans were required to obtain health insurance coverage either by themselves, through an employer or through the government. This was intended to do two things: give financial access to more people and stop the cost of care for the uninsured being passed along to the insured in the form of higher charges for those who could pay. Cost shifting by health care providers commonly was in the form of charges at least 25 percent to 33 percent higher than needed. Health care functioned as surrogate tax-collectors, overcharging many to cover costs of others.
However, Obamacare’s mandate to obtain coverage didn’t indicate the cost of insurance. It relied on competition among insurers to keep costs in check, but this left out health care providers. Health care providers realized a bonanza under Obamacare. More people were covered and fewer bills were unpaid. However, providers did not reduce their charges accordingly. In fact, ever-increasing charges became one big reason for insurance costs to continue to increase. People objected, but the increasing costs were a big issue before Obamacare. In fact, the “good old days” weren’t so good either. Health insurance costs were ever increasing, and employers and citizens were caught in a trap of insurance costs increasing faster than inflation. The lack of a focus on costs and provider charges became a major flaw in Obamacare, and we heard many complaints about the cost of coverage under the plans offered because of Obamacare.
Incorporating action on costs would have required joint action by our Congress and President. This was not to be. Hence, Obamacare, without Congressional willingness to improve it, was doomed.
Quality was mildly addressed by Obamacare. The American health care system does not produce the best results: several other countries have far better outcomes on many measures such as life expectancy, maternal and child deaths and disease rates. In fact, our system that often focuses on episodic, expensive, high tech and esoteric care kills many patients. Medical errors and poor care are not uncommon. Any look at health care should incorporate consideration of the value of the care that is paid. For those who say this is not a role for the government, consider that over one-half of all care already is paid by the government, and taxpayers have a right to expect the biggest possible bang for their buck.
Going back to access, consideration of the supply of providers is a key for two reasons. We need enough providers distributed throughout our population to assure that people have a provider available to them. Hopefully, more providers could lead to some price competition and help reduce costs. The supply of medical personnel and facilities was not addressed.
Can a Republican develop a replacement for Obamacare? That is debatable. The tremendous forces of lobbyists representing medical professions, facilities, pharmaceuticals and insurance will fight to assure their place on the gravy train. These are among the best funded and most effective lobbyists in Washington and our state capitals. They will make action by Congress difficult.
A better solution might be to declare Obamacare a failure, but keep it through a long sunset period and improve it through cost, quality and access measures. Then a victory for the people might come about.