Saturday, February 25, 2017

Is Obamacare the best bad idea ever?

When the Affordable Care Act was being debated and ultimately passed, I was not happy.  I wasn't happy with the hyper-partisan political process and, more importantly, as an insurance guy, I wasn't happy with the proposed model.  But, eight years later, I believe this has turned out to be the best bad idea ever.

The Bad
Insurance is all about balancing risk with cost.  It's basically counting cards in blackjack.  If you do it well, you can charge people collectively reasonable and layered rates based on the risk of occurrence of a claim.  Insurers try and limit subsidization of higher risk groups by lower groups to provide more desirable rates to customers that are less likely to file a claim.

The certitude of a claim (i.e. a "pre-existing condition") completely breaks the model and stops it from functioning.  The only way to counter-balance that is finding a group of equal weight that has a virtual certitude of never filing a claim and somehow splitting the difference.  The ACA did that through the individual mandate.  The math works out, but it's hardly equitable.  And that's why costs have gone up.

And unlike something fairly straightforward, like Auto Insurance, health care issues aren't limited to a single clear point in time.  Often they are chronic and progressive, creating an ever-mounting cost spiral.

In fact, it's my belief that an insurance-centric model as the primary means of access to health care is a lousy idea.  Since insurance is predicated on the hope you never actually use it, the model is inherently at odds with the needs of the populace and modern medical practice, which places greater value on regular check-ups and screenings to prevent more serious conditions.  Nevertheless, that's what we've got.

The Good
The mission of our federal government is to "promote the general welfare."  I don't see anything more plainly fitting that scope than the health of our populace, our workforce, and our fighting force.  The ripple effects of a debilitated population to productivity are staggering.  Plus, expecting people to suffer when we have the means to alleviate it is simply inhuman.  So, creating a system that provides access to care for 12 million people who needed it most but couldn't get it, is fundamental to our duty to our fellow citizens.  We've raised the standard of fundamental support to people, and that's a victory we should all be proud of.  Cortez burned his ships, and none of us can go back now.  We are marooned together in this strange new land.  Now, we have to figure out how to make a life here.

The Ugly
The one reason above all that I have come to support the ACA is this:  eight years later and Republicans are still talking in bumper stickers.  Ridiculous statements like "health savings accounts" and "let the free market decide" show that they clearly don't have a clue how to fix it.  If the Democrats had not shoved the ACA down all of our throats, a courageous move that cost them dearly in congressional seats afterwards, we would still be dithering about slogans like "portability" and "tort reform" while people died.  We can only hope we can find another batch of brave souls to tackle Social Security someday soon.

The Next Steps
Whether the ACA survives or not will be up to Republicans in Congress.  We'll have to wait and see.  The ACA has problems, no doubt, but they will be hard-pressed to deliver on promises without throwing a lot of people under the bus.  I sincerely hope that they aren't that reckless.

What I hope happens next is this:  Congress uses it's power to direct hospitals and doctors to reduce actual COSTS of care to the point where insurance is no longer the primary way to see your doctor.  You can fiddle with the insurance models all you want, it's all still the same pile of money, just shuffled around differently.  You've got to dictate that hospitals provide the basic services at accessible prices for routine and regular care.  Then, maybe, the models can handle the rest.

No comments:

Post a Comment