Since Pres-Elect Trump’s recent victory, much has been written about the death of Obamacare (or the Affordable Care Act). Most of the stories and opinion pieces have surrounded the political nature of this decision. But the policy aspect of this necessitates a different question—did Obamacare actually fail? This requires a broad, national answer, as well as an individual answer for patients.
Many of the policy-minded pieces have pointed out the difficulty in complete repeal, or even the needed gradations of scaling back. Was it such a failure that it should be eliminated? Just over a month ago, Ezekiel Emmanuel, one of the key architects of the legislation, not surprisingly argued that it did not fail but has been a success that should be built upon. Avik Roy, a conservative health policy analyst, claimed the opposite—not only did it fail, but it would have failed no matter what because it was essentially set up to do so.
But in order to understand their arguments and the question at hand, we need to back up: what is “Obamacare”, exactly? To many, it means little more than the insurance exchanges for individual insurance plans, and Medicaid expansion to broaden coverage. Most of those receiving coverage through the exchanges receive subsidies from the federal government to offset much of the premiums for the health plans. Those have definitely been the most media-covered aspects of the plan, but administration officials continue adding the “Yes but” responses that clarifies the above and underscores the other lesser known elements of Obamacare. Many provisions exist to help those covered by private insurance, such as allowing dependents to remain on their parents plan until age 26 if desired. It provides safeguards against coverage denial due to pre-existing medical conditions. It limits how much insurers can use for profit, thus “ensuring” that they spend a certain amount on actual health-related claims. Accountable Care Organization (ACO) creation provides more coordination of medical care and population health initiatives for patients in certain areas. ACOs and other Medicare pilot projects have the potential for the biggest long-term impact to benefit the system, leading to more efficient and comprehensive care delivery models with payments that rely much more on the value of care provided. All of these aspects are important to keep in mind when we refer to “Obamacare”.
Looking at it from the perspective of the exchanges, it absolutely looks like a failure. News of large premium increases for those receiving insurance through the exchanges have been myriad recently. Multiple large insurers have also fled the insurance exchanges, thus reducing coverage options for many. There are multiple reasons for these failings, both from within the law and from the broader system itself. But if you are one of those individuals or families having to pay for these systemic defects, there is very little comfort in any explanation.
One can argue that from a deeper policy perspective, these issues are not as concerning. The reason for creation of these tools to improve the individual insurance market is because that market was terrible before the law passed. It was horrendously expensive and very difficult to navigate. The idea of the exchanges was to provide an easier experience for individuals and families to buy the coverage they need when they do not get coverage through their employer. Longer term, the hope was that there would be less reliance on employer-sponsored health coverage so as to prevent job lock and wage stagnation. Many thought this was a good idea, many didn’t. Though the exchanges are not as robust as was hoped, and no one wants to pay for large premium increases, they have provided an improved framework to solve the problems they were created to fix. The individual market has improved significantly since before the law passed, and the cost to exchange participants is actually lower than it otherwise would be. The exchanges certainly need work, but they are something to build on.
Possibly the bigger issue is that the term “Obamacare” has become synonymous with health care in general. Any increase in costs or inherent difficulties in the system are believed by many to be secondary to Obamacare. The US health care system is a mess. It was so before Obamacare, it continues to be afterwards, and will likely be so for decades to come. There are many varying opinions on how health care should be structured (which is a topic for another time), but our system was no less messy 7 years ago when the law was being written. Health care costs were growing at a rapid pace without Obamacare, and there is no easy or quick fix to that problem; no single law will dramatically alter the trajectory of our tremendous health care costs.
But again, people don’t take any solace in this as they pay more and more for health care and have less ability to pay for other needs and wants. Hence much backlash at “Obamacare”, which is actually a misplaced attack on health care in general. I don’t blame people for being upset at the system; I share your frustrations as a patient and a physician. But hopefully we can all at least put these problems in proper context to avoid making things worse. Avoiding Obamacare repeal is actually in everyone’s best interest.
The political move by Republicans is to eliminate Obamacare. Even though I don’t like that, I don’t blame them; by definition politicians engage in politics. But the personal and policy perspective would dictate expanding upon it to improve it’s flaws and improve the nation’s health. For all of the negativity it generates, Obamacare is not at significant fault for our current woes. It’s the broken health care system that necessitated the creation of Obamacare that remains at fault.