With the appointment of Rep. Tom Price as Secretary of Health and Human Services, it looks like the Trump administration is gearing up for an effort to repeal the Affordable Care Act (ACA). (I don’t call it “Obamacare” because I don’t want to be associated with many of its critics who use that label.) I cannot imagine that they will fail. In the short run, this is going to wreak havoc in many people’s lives. What about the long run?
The ACA is uniquely American in two ways, both dysfunctional. It is uniquely American in putting the delivery of what is supposed (at least by liberals) to be a public good—health care—into the hands of private, profit-oriented organizations. Instead of taxing us to finance some level of health care for all, the government requires us to buy insurance from private companies. But since the whole point of a national program is to provide health care to those who cannot pay, government must subsidize these payments to private companies.
Even if market fetishists are right that this is somehow more efficient than a national single-payer system, this arrangement poses serious constitutional issues. Chief Justice John Roberts raised exactly the right issue when he asked why the federal government hadn’t just created a single-payer system, since that would have been at least constitutional. The answer, of course, is that such a system would not provide some corporate sector an opportunity to “maximize shareholder value.” Creating such opportunities—private prison systems, outsourced wars, Medicare Part D, Charter schools—seems to be the primary function of government these days.
The ACA is also uniquely American in its implicit assumption that all issues are financial issues. The ACA most decidedly is not health care reform. It is health care financing reform. And, as usually happens when government undertakes to reform the financing of some endeavor, the rich get richer, and the rest get screwed. But leaving this aside….
We really need to discuss how health care should work in the US. Is it a good thing that our health care system is focused on lengthening people’s lives at the end, often just extending suffering and despair? Should we focus on treating disease or on preventing it? What kinds of medical care, if any, really should be accessible to everyone, regardless of ability to pay? And so forth. These are the issues we need to discuss before we figure out how to pay for health care.
I think we avoid these issues largely because we fear that they will force us to look too closely at our own mortality. In any case, I don’t imagine that we will confront them after the repeal of the ACA, or that anything the Republicans come up with will be any better. Currently, the Republicans seem mostly to be arguing about whether they must repeal and replace at the same time, or might repeal first and replace later. Maybe they won’t get around to replacing at all.
Don’t get sick in America, I guess.
You're right in your assessment but one feature of the ACA was to create "benefit designs" that would promote primary and preventive care and consequently reduce serious illness that would eventually save costs. (Think diabetes chronic care vs the cost of the untreated disease)Simply put. The U.S. has a disease/illness system not a Health care system. All the untreated illnesses eventually costs us all when the cost of unpaid emergency and acute care gets passed on to everyone else. Because the real national health systems (medicare, Veterans, Federal employees) negotiates fees`a la HMOs and PPOs the burden on everyone else such as employers and individual insured was unsustainable. Some health care mathematicians/underwriters/actuaries will surely point this out. The political points have been made. They won the election. Now, I hope someone will just do the math.
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