We last talked about the Affordable Care Act/Obamacare in July 2013 (great links!), as parts of it were still being rolled out. Three years later all of its major provisions have begun to operate and experts are starting to get an idea of where the law has been successful at achieving its goals and where results have been disappointing and why.
Non-experts like us have a hard time getting any sense of it at all. Obamacare is only dimly-understood by most Americans. The law had to be grafted onto the existing, highly-complex American health care system, so it is very complex. The law’s affects also are nearly invisible to most Americans, largely by design. Complexity and invisibility left a huge opening for clever propagandists to trash the law and attribute every negative development as the beginning of Obamacare’s imminent collapse.
This is a bummer for a lot of reasons, not the least of which is it makes it hard for us to see through the complexity and opacity to draw our own conclusions about the law’s good parts and bad parts (both exist). To help us out a bit, I will start our meeting on Monday evening by reviewing two key contextual points:
- The major problems/shortcomings of the status quo ante health care system that Obamacare was designed to fix; and
- How the ACA was supposed to do that.
Then, we can go one of several ways. We could discuss each major part of Obamacare in turn, such as the state insurance exchanges, the law’s many new consumer protections, and Medicaid expansion. As we talk I can sketch out some of the latest good news/bad news in each area. Or, we could go big picture and explore whether the ACA has succeeded so far at its three big, broad goals: Achieving near-universal health insurance coverage, controlling health care costs, and improving the quality of medical care. Very ambitious goals.
As we talk, I think it is very important for us to do two things that news stories on Obamacare implementation almost never do.
- Look at the entire law – not just some piece of it that has experienced recent good or bad developments; and
- Compare its results to a realistic alternative – either one based on where our health care system was heading before Obamacare or to Republican alternatives (to the extent they even exist – see links).
If you want we can get into GOP alternatives and Hillary’s plans to protect Obamacare’s gains and fix its flaws or expand it. And, yes, there is yet another lawsuit probably heading to the Supreme Court that is aimed at one of the ACA’s major provisions and bringing the whole thing crashing down.
There’s one more thing. The ACA’s shortcomings are particularly tragic, and not just because health care matters so much. Unlike other laws Obamacare cannot be amended at all because Republican lawmakers will not allow it. They want the ACA to collapse so they can “repeal and replace it.” To my knowledge, no major law has ever been held to this standard, expected to work perfectly in its first iteration. Major laws are amended all the time to correct mistakes and adapt to new conditions and unanticipated or even unanticipatable problems. For example, Medicare’s basic fee structure was completely overhauled less than 10 years after its 1965 passage because it wasn’t controlling costs very well, and the program has been modified thousands of times since then.
So, however brilliant or dumb the Affordable Care Act is, we are stuck with it as is. Any insufficiencies in the law (or unexpected adaptation by consumes and businesses) must either be addressed administratively or left to fester, or, if a GOP-controlled Congress is elected, solved or ignored their way.
DISCUSSION QUESTIONS –
- Review: How was Obamacare supposed to solve the major problems in our health care system?
- The Parts: How has implementation of each major moving part of Obamacare gone? What caused any failures and how was implementation of the law adjusted to compensate?
- The Whole: Can we declare overall success or failure (or making good/bad progress) on the 3 major goals of ACA: Helping the uninsured, making HC more affordable, improving quality of care?
- The Divide: Do liberals and conservatives define “success” differently?
- The Future: What’s next in U.S. HC reform?
- Latest GOP lawsuit.
- Dem/HRC plans to fix/expand?
- GOP plans to repeal/replace?
SUGGESTED BACKGROUND READING –
- A tutorial on ABCs of Obamacare.
- NYT in 2014: Yes ACA is working, but with some caveats. Recommended.
- The ACA is succeeding. The evidence keeps piling up. Either.
- It’s doing way more for the poor than expected.
It’s a mixed bag or it’s failing:
- Progress has been mixed. Recommended. The state exchanges are worryingly fragile.
- It has failed (Conservative POV):
The Future –
- Your must-read! In this month’s JAMA Obama himself outlines progress made to date and next steps in HC reform. (I’m sure Donald Trump’s journal of the AMA article will be published shortly.)
- Key point: Liberal and conservative goals for HC reform are fundamentally different (click thru here to access recommended WSJ article).
- GOP alternatives:
NEXT WEEK: Does the “historical Jesus” matter?