When Barack Obama was elected President, and long before, the United States was facing a crisis in healthcare. The world’s highest per capita spending on healthcare, soaring premiums, tens of millions uninsured, and medical bills being the leading cause of bankruptcy. President Obama knew he needed to do something, and something he did do. In many ways that is the best description of the Obama care approach to the problems of our healthcare system; do something, anything it does not matter what.
The bill technically called the Patient Protection and Affordable Care Act does four majors things, and hundreds of smaller ones to try and fix the healthcare system.
- The act expanded Medicaid to 133% of the federal poverty level. This is probably the best part of the bill, and will give insurance to the most people who are currently uninsured. There are two problems with this. Firstly, it punishes states like Massachusetts, New York, and Californian that already meet or exceed this standard. Secondly, the states in the south where it will expand coverage the most are refusing to take part in the expansion. This will limit the number of uninsured Americans who get coverage overall.
- This act sets new standards for health insurance coverage. Most of the rules already applied to group policies and were just extended to individual policies. Only 6% of Americans have individual policies; not that they don’t deserve protecting, but a year of debate for 6% of Americans, really.
- The act also set up healthcare exchanges at the state level. The biggest problem with this is there was no reason to do it. The act could have simply allowed people to buy into the federal employee health insurance exchange. Doing it at the state level just gave Republican governors a chance to grandstand. The other issue with exchanges is that a number of states have tried them with no success.
- The most controversial element of the act was the individual mandate. The mandate just made it more difficult to pass the rest of the bill which would have probably have passed easily without it, and had roughly the same effect. As I mentioned before most of the newly covered people will be covered by Medicaid. The mandate’s primary purpose is to make sure the private insurance companies in business the next few years.
The next problem with the act is the hundreds of small provisions in the bill designed to fix every small problem in the system. The way to fix health care is to put out your big reforms, and then wait a few years to see if the smaller problems have been fixed. Outside of that the act’s major problem is that it doesn’t have a comprehensive approach to health care. It throws the kitchen sink at the problem and hopes it work. While there are many specifics in the law I support I have three broad problems with the act.
- Obama care left in place a large number of federal healthcare programs. Medicare, Medicaid, CHIP, Tricare, the VA, and a large number of smaller programs. All of these programs have very specific entry requirements; this means a large number of people will fall through the cracks because they don’t meet these narrow requirements. Combining these into 2 or 3 larger programs with broad entry requirements would ensure less people falling through the cracks.
- Obama care left too much control of healthcare to the states. Look at all the states that have opted out of the Medicaid expansion and refused to set up exchanges. The entire idea of leaving issues up to the states is based on the concept that someone in Kanas City, KS has more in common with someone in Garden City, KS than they do with someone in Kansas City, MO. It also based on the idea that state governments are closer to people than the federal government. I grew up in Illinois and I can tell you people there do not have warm fuzzy feelings about the state government.
- The act does not do enough to rein in healthcare costs. It is based on the idea that universal coverage (which the bill does not provide) will bend down the cost curve. This may or may not be true. (It is based on projections of healthcare economists, a field that is based on the idea that healthcare would be cheaper if no one uses healthcare). The reality is that we are spending 16% of the GDP on healthcare; we need to bring prices down from current levels not just achieving saving of future increases.
Next up: The GOP’s answer to Obamacare.