The basic premise of the complaint, as I understand it, is that the infrastructure is not as far along as some would like, which may lead to confusion when major elements become effective next year, that Americans remain ambivalent about the bill because they don’t know what it does for them and that this lack of enthusiasm – coupled with continued GOP opposition – will yield a bad result in Congressional elections next year.
Their concerns lack merit, reflecting a basic inability to stand back as things work themselves out. The state pools begin operation October 1, selling insurance coverage that begins next year. Most of these pools will be operated by the federal government because of GOP opposition in many states, an outcome that should be welcomed by liberals who tend to favor programs run from Washington, particularly when states they deem unfriendly are involved.
The pools will doubtless get a lot of press, but will be fairly irrelevant to the majority who continue to be covered by private employment-linked insurance. The key to their success is whether enough young health people enroll to keep the premiums modest despite the medical needs of older, sick people who are presumed to be ready to break the doors down at the outset.
Everyone, starting with insurers who’ll have to make an educated bet in setting initial rates, is wary about this question because no one really knows what’ll happen.
In a broader political context, it’s worth remembering that the rules are still being written to implement the Dodd-Frank financial services reform bill, whose enactment preceded Obamacare and was written in response to a problem, the financial meltdown, deemed more acute than the need for health reform. Our government moves slowly in implementing such complex issues – and properly so.
There have been more than a few positive developments in the health world since enactment of Obamacare, though I’d be the last to suggest causality. One is that medical costs are rising more slowly than they were a few years ago and more than a few observers think this trend won’t be totally reversed as the economy improves, which probably will have more impact on the next election cycle – or two – than how the health law works.
Another is that a growing percentage of physicians are now on payrolls, which should make them amenable to the inevitable protocols that will come from the creation of accountable care organizations and expansion of evidence-based medicine. Professional ethics notwithstanding, there’s a growing probability that your doctor will be an employee of an organization that will have an incentive to squeeze out duplicative or unneeded care. Such enforcement was more difficult in the past when most physician reimbursement was based on how many services were delivered.
There’s also a growing realization that GOP suggestions of having us shop for care simply can’t work now because of a lack of price transparency. Patients, particularly sick patients with extensive needs, cannot find out what care costs before they receive it. Steven Brill’s extraordinary expose of hospital billing, augmented by the recent release of Medicare data, demonstrate incredible disparities in hospital charges, which still cannot be translated into what a particular procedure will cost a particular patient. Anyone who wants to play the cost-estimate game should prove this point here.
As a result, the public is somewhat more aware of their vulnerability and the need for large, sophisticated organizations to protect them.
The GOP has also found that Obamacare was cleverly crafted so that repeal would actually raise the deficit, which gives the repeal faction heartburn.
There’s yet to be an American election where health policy played a major role. That precedent won’t be broken anytime soon. Irrespective of the specifics, Obamacare is providing incentives for major changes (like wider use of electronic medical records) that could make the system work a lot better. Celebration may be premature, but this is not a time for hand-wringing.
For 16 years, Jim Jaffe worked for House Democrats who served on the Ways and Means Committee, apprenticing with Representatives Green, Gibbons and Gephardt before working for Chairman Dan Rostenkowski.