Can Obamacare Be Made Better?

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Critics contend that the Affordable Care Act is merely a means to further a redistributionist agenda. Obamacare — as the healthcare reform is known colloquially — made numerous tweaks to the insurance industry under the banner of fair coverage, which have resulted in younger, generally healthier individuals paying higher insurance premiums to compensate for the generally higher medical bills run up by sicker individuals. As a result of this change and other adjustments made to the laws governing the insurance industry have made, premiums have risen for a great number of Americans. According to an early analysis from the right-leaning Manhattan Institute, insurance rates on what was once the individual market will increase by 99 percent for young men and between 55 percent to 62 percent for young women.

Yet, despite the rocky rollout of the cornerstone provision of the Affordable Care Act — the individual insurance exchanges, which debuted October 1 with numerous design and software flaws — 3.3 million people have signed up in the first four months of the six-month enrollment period. With just six weeks left before the current deadline, it seems enrollments could match, or at least near, the Obama administration’s target of 7 million. While young people, who are needed to balance out insurers’ risk pools, only account for 25 percent of enrolls, a figure far less than the 40 percent balance the administration has said is needed, and that percentage has crept up slowly. The steadily growing numbers suggest that the healthcare reform could eventually meet its many-branched goal of increasing the quality and affordability of health insurance, lowering the uninsured rate by expanding public and private insurance coverage, and reducing the health care costs of healthcare for individuals and the government. Needless to say, the so-called human benefits are very real.

But with that said, Obamacare critics have by no means been silenced; fixes, better solutions, and repeal are on the lips of many prominent politicians and policy experts who believe the Obama administration should have either gone farther to reform the American healthcare system or that it should have left the American healthcare system alone.

But these theorists, like the Obama administration, are faced with the complex reality of the system. Even before Obamacare was implemented, the U.S. healthcare system included employer-sponsored coverage, Medicare, Medicaid, Tricare, the Indian Health Service, and small-group and individual insurance coverage. Still, 48 million uninsured Americans were excluded or priced out by the traditional system. Given the complexity of the problem, those on the extreme right and left of the ideological spectrum proposed solutions that would scraped all current insurance arrangements, with the liberals pushing for a single-payer system and conservatives advocating for income-related vouchers to be used to help pay for private insurance. Pundits at both ends of the political spectrum have supported these respective solutions. The problem is that while Americans generally opposed the unwieldy fixes of incremental policies, research has shown that Americans really do want incremental change, especially regarding insurance. As Henry Aaron of the Brookings Institution and Harold Pollack of The University of Chicago wrote in a piece titled, “Now’s Not the Time for Liberals to Say ‘I Told You So‘ About Obamacare,” most Americans are reasonably well insured; they like their coverage; and they want it to remain affordable.

So the problems with the implementation of the Affordable Care Act, the complexity of the U.S. healthcare system, and Americans’ mixed feelings on incremental change beget one question: was there a way to make Obamacare better? After all, the reform did make the system more complicated if anything, especially as it was heavily influenced by the demands of various advocacy groups. Plus, the reform came at a high political costs and may not be the most effective policy to universal coverage. It is true that despite the problems caused by the Affordable Care Act, it is actually helping a number of Americans. But according to Robert Kuttner — author of Debtors’ Prison: The Politics of Austerity Versus Possibility and senior Fellow at Demos — half of America’s uninsured will not be helped; those with employer-provided insurance will find their premiums rising, and many fall through the Medicaid gap.

Improving the current reform may not be the only option, but, as the Republican party well knows, no major entitlement program has ever been repealed after implementation.

Kuttner argued that the healthcare reform championed by President Barack Obama could have been better. An incremental approach to a single-payer system could have been a viable option, he wrote in an opinion column published in the Huffington Post. That conservatives were originally responsible for the idea of a public mandate for people to purchase insurance, with a government subsidy for the poor or near-poor, is by no means news. But Kuttner believes that the conservative plan — first pushed by the Heritage Foundation — would have moved the United States towards genuine universal and public coverage. It included the so-called Public Option, which would have allowed individuals under 65 to buy into Medicare. “Since Medicare is so much more efficient than private insurance, over time, the Medicare option (later re-branded the Public Option) would gradually drive out private insurance,” Kuttner wrote. Also on the conservative list were provisions to extend Medicare to young adults and children and to expand Medicaid, which the Supreme Court has made voluntary to the states.

His analysis was not meant to be a proposal for a reform of the healthcare reform, but more a retrospective analysis of what could have been. Plus, Kuttner’s argument that the reform should have put the American healthcare system on the road toward a single-payer system is by no means shared by a plurality of lawmakers. Even he noted that, “Both the conception and the roll out of The Affordable Care Act will set back the effort of liberal Democrats to persuade regular people that government can be a force for the broad public good.”

Any major reform of the current system will be nearly impossible to pass given the problems spawned by the current reform. In addition, the current polarization of Congress will make it impossible for lawmakers to decide upon any reform theme. Lawmakers could either remold the Affordable Care Act to be more in line with the original conservative approval, which as Kuttner writes would lead to a single-payer system. Alternatively, Obamacare could be repealed and replaced with the Patient Choice, Affordability, Responsibility, and Empowerment Act proposed by Republican Senators Richard Burr of North Carolina, Tom Coburn of Oklahoma, and Orrin Hatch of Utah. The plan is strongly reliant on market competition, with notable differences from Obamacare; it would likely cover fewer uninsured Americans, increase premiums for many older adults, shrink Medicaid, decrease subsidies for middle class Americans, scale back protections for people with pre-existing conditions, and allow private insurers to escape many of the consumer-friendly requirements imposed on them by Obamacare. In essence, that plan — known as the Patient CARE Act — is meant to be more financially sound.

The difference between these two plans highlights the political polarization in the United States, and any changes that are made to the reform will be determined by the party with the most power in Congress and the degree to which negotiations play a role in the creation of a final reform. More concerning is the fact that any reform or the current health care reform —  be it a series of incremental fixes or a complete overhaul as the GOP has suggested — will have to solve a series of very important and wide-ranging problems. For any solution to be successful, it will have to deal with the significant number of Americans who are generally happy with their coverage and generally well covered. It will also have to address how to keep insurance coverage affordable for those with pre-existing conditions, which is why individual insurance coverage was mandated by Obamacare; all individuals must purchase policies so that insurance pools are broad enough to absorb the higher medical costs of chronically ill individuals. Plus, the tax increases that must be levied to support the premium subsidies and expansion of Medicaid must be considered.

Both the idea of Medicaid for all and the GOP’s most recent suggestion do not adequately solve these issues, just as Obamacare does not. However, as Aaron and Pollack worte in their piece for the New Republic, “there was and is no alternative to the messy incremental politics that produced Obamacare.”

If Obamacare is only amended, the task list is much smaller — although still daunting. Young people will need to be convinced to enroll; the issue of how tax increases may impact the nation’s productivity will need to be addressed; solutions must be found to deal with doctors who do not wish to take exchange-insurance and with other medical provider issues; and finding insurance solutions for those Americans who fall through the Medicaid gap or those facing staggering premium increases. Solutions have been proposed — like replacing the current fee-for-service system — but there is no quick fix, largely because there is no agreement about how the health care system should operate.

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