Life in 2017 has been surreal. We wake every day as though in a nightmarish dream that we hope to soon end so that we can get back to the real world. The latest episode ended last night when the Republicans narrowly failed to continue the charade of “Repealing and Replacing Obamacare” while really seeking to cut subsidies to the middle and lower classes to provide tax cuts to the super rich. We recognize their actions as a charade because none of their “replacement” proposals addressed the cited problems with the ACA of high premiums, high deductibles and dearth of options in many rural communities around the country. Instead, their focus has been on undoing the expansion of Medicaid (where much of the money is) under the guise that the program is unsustainable. (The GOP is notorious for only being concerned about spending when it applies to social programs.)
To anyone paying attention the real problems with healthcare in this country are the rising costs of medical treatment and prescription drugs; problems that existed long before enactment of the ACA. Indeed, the ACA was crafted specifically to address these issues. In the US, medical care is largely paid for via medical insurance and insurance companies have shown that they can negotiate lower prices for medical care to benefit their own coffers. The working hypothesis was that by getting more people insurance coverage that encouraged preventive care and getting the insurance companies to compete for the increased customer base via the state exchanges, that medical costs would be lowered; they would pass along most of the savings to the consumer; and people will be healthier because they would have access to earlier and less costly treatment. The result in turn, would lower the overall expenditure on health care. Hence, the mandate to buy insurance, expansion of Medicaid and the minimum provisions and non-deductible preventive treatment requirements for health insurance policies sold.
Notwithstanding the demagoguery of the Republicans for the past seven years the ACA, or Obamacare as they cynically named it, has succeeded in expanding coverage and slowing the rise of medical costs. High deductibles and rising premiums, however, are still a problem in many areas. The probable causes for this are varied. The failure to expand Medicaid by many GOP controlled state governments that left many people without coverage and access to subsidies on the exchanges is a main culprit. The penalties associated with the mandate, though designed to increase over time, were initially set too low and were too sporadically enforced so that fewer young and healthy individuals signed up leading to a less healthy covered population is another. This lead to higher costs and subsequent higher charges by insurance companies. Immediately after the inception of the ACA the GOP led congress cut funds allocated to stabilize the insurance markets as they were forming. They also filed lawsuits attacking the legitimacy of subsidies causing further insecurities in the insurance industries. More recently, failure to enforce the increasing penalties associated with the mandate, threats to withhold subsides and talk of “letting Obamacare fail” has only added to the market instability. All of these actions work against the success of the ACA.
In a democracy such as ours trying to influence medical costs via secondary or even tertiary controls (enacting policies that influence insurance companies to influence medical costs which are impacted by equipment, supplies, research, etc. …) is a process that requires constant monitoring and a commitment to make it work. This is a seeming impossible task given the current political environment.
Single Payer, the approach endorsed by all other major industrial economies in the world, would provide more direct influence over medical costs but would represent a further expansion of a government program; an anathema to GOP orthodoxy. So where do we go from here? It is clear that there can be no consensus on HealthCare, particularly when the there is no consensus on the objectives and the relative priorities thereof. Until we elect enough people who will in good faith “…provide for the common defense and promote the general welfare” we are doomed to watch the ongoing circus in Washington and living in this continuing nightmare.