Tuesday, November 05, 2013


(Um... I'm allowed to use this picture, right? Seeing as how I have no strong feelings for or against the President? I think it's a funny picture and I appreciate the satire, whether intended or not. I promise.)

So, as I've said many times, I'm no fan or opponent of this particular law. Like any piece of legislation (especially one that never went through a conference committee) it's a jumbled mess. What I am in favor of is the idea that everyone deserves health care at least as good as I expect for my family.

All along I assumed this plan was going to be intentionally unwieldy so that eventually there would be no real political choice but moving to a single payer system. A single payer system has proven, time and again, to be the single most effective, cost efficient means of providing health care around the world.

It is also decidedly unAmerican, especially if you cling to the traditional definition of American, which may or may not come sans its initial 'A.'

Since this whole debate began and I've had a chance to read up on it heavily, I've come to realize that there are likely any number of unique, original systems by which the US can keep its love of choice and competition, yet also provide quality basic care to everyone.

TIME Magazine devoted an entire issue to one such option - having the government 'negotiate' prices the way they do with medicare, but allowing insurance companies to compete for business (essentially competing for lowest overhead). This story proves, contrary to popular perception, that Medicare is both the most effective and efficient delivery system in the US (largely due to the volume of care it provides) and that doctors, as much as they complain about medicare patients and threaten to stop seeing them, almost never do (I believe 97% of doctors accept medicare).

There are other options, but their elucidation is for another time and place - since the Affordable Care Act (ACA, Obamacare) doesn't actually address healthcare directly, but only provides insurance.

We can get the problems out of the way up top. First is that whole insurance business. The ACA essentially directs an extra 50 some odd million people into an industry where their presence will do little, if anything to stop the disproportionate rise in costs. Yes, volume will keep costs lower for a time, but the underlying problem of cost inflation remains. Unless the actual cost of care is addressed, it's still kicking the can down the road.

Second, the notion that the government has any say over what plans are offered and which doctors accept which insurance is bunk and sort of mean spirited. Technically, when the President said you can keep your doctor, he was telling the truth. What he didn't mention was that your doctor might not want to keep you. I'm sure its nothing personal, but... you know... these things happen. Likely they have issues with your insurance company, which is not all that difficult to understand. In any event, the President doesn't make decisions for your doctor and he shouldn't have implied he could.

The notion that everyone can keep their plan was also pretty close to an outright lie. The ACA does grandfather in any plan in existence when the law passed. Technically, anyone could keep their plan. However, insurance companies are free to remove plans and make people switch. They do it all the time, law or no law. In this case, moving people to more expensive plans with greater coverage (even if often it costs people less, due to subsidies) makes them more money - and we all know how insurance companies make decisions; it's not about what's best for the customer, but what's best for the bottom line. (That's the main reason I'm in favor of a non-profit health system; it's not perfect, but at least my health isn't taking a back seat to money).

Still, even if the government didn't expect all those grandfathered plans to be dropped right away, for about 3 million people, there is and was a 100% absolute inevitability of having to switch plans - if not this year, then next. The ACA includes a minimum coverage requirement, and the whole idea of "grandfathering" anything means you expect it to eventually go away. They could have been more up front about these realities, but then, of course, there was a chance the bill wouldn't pass. I haven't read the fine print in one of those termination letters, but I imagine the insurance companies aren't going out of their way to vindicate the President and take blame on themselves either.

It's a messy system.

It's easy enough to argue that people on these cheap, bare-cones plans were either taking a huge risk or throwing money away on policies that would have bankrupted them anyway if they had a medical emergency - but the truth is, they weren't told anything clearly up front and this comes as a surprise to most simply because no one was willing to name the hard truth openly and honestly. That is not fair.

Now to provide a little context:

150 million Americans have insurance provided by an employer of some kind, about 50% of the population. An additional 100 million are on either medicare (for those over 65) or medicaid (for those with very little money). There are about 45 million people with no insurance at all, which leaves roughly (and these are very rough numbers) about 15-20 million people buying insurance individually.

It is this last cohort who is really the focus of the ACA. This number may grow a small amount with some very small businesses ending health coverage as a benefit (although businesses with less than 25 employees can get pretty generous tax credits - 35% the first year, 50% afterwards - for continuing to offer coverage). The vast majority of Americans will see no change.

For those 15-20 million people, though, things will get a little dicey. The fact that 45 million other people without insurance may now have access to it, while important in the grand scheme of things, is no comfort to those undergoing upheaval.

In the end, older people (those in the few years before medicare eligibility) are going to come out pretty solid in the process. The ACA limits their premium costs to three times those of healthy 26 year olds (that's way less than most of these people are paying now). The cost for those 26 year olds will be going up. However, most of them have never had insurance anyway, so they don't realize they could have been getting it cheaper all along. The people (and especially families) in the middle, will likely be paying more.

The subsidies will help in some areas (families making under $25,000 a year likely won't pay anything at all), and help less in others (target expenses as a percentage of income are not fixed rules, so some people are just going to be exceptions and pay above 9.5% of their income).

In the end, more people will be covered for more things - and the speculation about outcomes (both positive and negative) is really just speculation until things begin to hash themselves out. I'd imagine 2015 is really when we can start to take stock of what's right and wrong with the ACA.

Yes, people will complain about health coverage. Some might even wish for their previous plan. Although, I think it's a near-universal maxim: "If you're happy with your health insurance, you're probably not using it very much."

The cost side of things is still perilous. As I said, I've been pretty skeptical that this plan was even intended to work out fiscally, let alone could meet projections. There are problems - like states with only one or two insurers entering the marketplace and large insurers avoiding them altogether - but initial premiums are coming in, on average, 16% below what even the White House predicted in selling the bill. That gives me pause to at least see where things are going.

There's also a real possibility for improvement. Assuming some section of the GOP embraces pragmatism in the next couple years, there might be space for reform - to eliminate the obvious problems (like 80 year old single men having pregnancy coverage)* and address future issues (like the aforementioned cost issues).

As for my personal views, well, here is a comment I posted on a friend's Facebook status during the gov't shutdown. I think that sums it up pretty well:

First, I don't support Obamacare, necessarily. I don't think it's effective or efficient, but I'd prefer moving forward and fixing it, rather that starting over. Already, we're seeing the cost on insurance for people on these exchanges much lower than even the Democrats predicted (16% lower, on average). A lot of my neighbors are getting heath insurance for the first time. There're a lot of problems, for sure, but we won't really know what they are until it's implemented. Second, Congress isn't exempted, like everyone else who has insurance provided by their employers, they don't have to change anything because of it - my family and I fall into the same boat. This is a sneaky trick of the tongue opponents are using to make them seem hypocritical. In fact, no one whose employer covers health care (something like 50% of households in the country) is impacted by this (unless their employer stops providing health care altogether). Now, employers stopping health care altogether is why they've delayed implementation for some. I think that's cowardly and wrong. Some huge corporations have made this work already; I'm not sure why the others can't - mostly it's just greed. Home Depot is moving most of their workers to 29 hours a week so they'll never have to comply. This is one of the problems with the law - there's not really a good way to balance public and private funding of healthcare, especially for low-wage workers. Essentially handing free business to insurance companies, which is the foundation of the ACA, is a terrible idea, in my estimation; I'd frankly love to see alternatives proposed, yet the GOP leadership (definitely separate from the GOP itself) refuses to do anything, but look backward. Moderate Republicans in the House have worked on bills that could get majority support (with the help of Moderate Democrats), but Boehner and company won't let them come to the floor because the Conservative wing of the party dominates. They're preventing compromise by making demands the majority of the Congress doesn't agree with. I think the GOP has a really unique place to play in making healthcare work in this country, but the members who really care about improving things are being drowned out by obstructionists.

Two final thoughts:

The failure of the ACA website is embarrassing and shameful. Even for those who can separate the law from its implementation, it is a disaster. The Medicare Part D prescription drug plan rolled out during the second Bush administration is a nearly identical system. Yes, there is a difference between a system run and accessed by gov't and insurance company employees exclusively (as in Part D) from one accessed by the public (the ACA), but not enough difference that you can't learn from past mistakes. You've pretty much lost the argument forever with those people who don't trust the government to "manage healthcare." Even though there's really no management of healthcare involved in the ACA, you have to admit, screwing up a website does not bode well for the future - maybe you can get away with it in 1998, but not in 2013.

Lastly, to those small business owners who are stopping health coverage and NOT giving employees the money you've been spending on their healthcare to help offset their new coverage:

(I'm just clenching my jaw and shaking my head; I really have no idea what to say to you people. For shame! There may be every reason to stop offering coverage, using it as an excuse to cut labor costs is downright cold-hearted.)

To sum it all up: I'm glad more people are getting coverage. I am sorry some people are overwhelmed by the changes. I hope they improve this over time. My family is blessed to pay very little for very good insurance, but I'd gladly pay more if it meant other people could have better care.

*I get the outrage at mandatory pregnancy coverage. For a while I was on an individual plan that was very cheap precisely because I didn't need pregnancy coverage - my plan was about a fourth the cost of a similar one for females. This mandate was clearly a way to keep government costs down. By including everyone in the burden of paying for pregnancies, the costs are spread equally to everyone - those getting the subsidies and those not, but the women most likely to get pregnant are disproportionately getting subsidies, so this move saves the government money.

I've also wondered why my staunchly pro-life evangelical friends are so upset by this. Covering everyone for pregnancy means that there will be fewer abortions. That's just cold, hard facts. Any woman who had cost as a consideration will no longer have that consideration. I consider it good news - and something I'm willing to pay extra to support.


Anonymous said...

You told me you wanted me to post my comments here, Ryan! I hope it helps feed your blog rankings. I don't have time to list how many ways I disagree with your conclusions. Primarily: we do care about people even when we conclude that our taxes will never provide that care, no matter what system the government offers. I reject the conclusion that the I am heartless because I do not endorse gov't provided health care. These poorer folk will be worse off because they will have inadequate care and no jobs because of a tax clogged economy. I care too much for them to want this future for them. (By the way, abortions cost money too. Most are not wanting an abortion because they fear the cost of pregnancy care.)

Ryan said...

I don't think I called anyone heartless. I may have implied that those business owners using this as an excuse to cut labor costs a taxpayer expense are heartless - which is true - but I don't think I said it.

I also don't think I said government health care is a solution to anything. I was hoping to clear up a few of the misconceptions that annoy me in the media (both for and against this thing). There are lots of ways to provide health care for people, both publicly and privately. The truth is, the government does a good job of providing some things. You'll never hear me argue for bigger government - like many, I could likely cut half the spending if you'd give me dictatorial power. I have serious doubts this health care system will work - I don't see how its possible. But I also realize that I don't know everything and this health care system is already performing well in some areas I previously thought impossible. It still doesn't solve all (or even most of the problems), but I'm not going to ignore its successes just because I doubt the overall plan. That's less than charitable.

Ultimately that's what I'm hoping to avoid - the general public persona that the ACA is either the worst thing that has ever happened or that it's the savior of human civilization. It's neither of those things and it's about time we started talking realistically.

As for the abortion thing, well I'm merely responding to what I hear. When I argue than making abortion illegal will not stop abortion, the response is "it will stop some, and any we can prevent is a good thing." Assuming that premise it true - that any fewer abortions is a good thing - which I'll agree with (given a caveat or two), this does stop some. I'm merely pressing people to be consistent in their arguments.