More to Come With Obamacare

About Obamacare: there’s much more to come – maybe good and maybe bad or confusing depending upon your individual perspective (not political). A couple of things or more are certain. It’s here to stay. You voted for it; you get to keep it. The Act, known officially as the Patient Protection and Affordable Care Act, is too much enacted and now embedded to reverse, totally stop, even with defunding, which will never occur. Sen. Ted Cruz whose filibuster helped shut down the government for a couple weeks was right. Once it’s here you can’t do much about it. But it was too late anyway.

Tinkering around the edges might relieve some anxiety, but the reality is that the Act itself provides 2,700 pages of new law in which the Secretary of Health and Human Services is directed to create what has already become thousands and thousands (at least 10,000 by one report). Tinkering by President Obama assisted by both Democrats and Republicans has, without official congressional action, changed the section that required Congress and their staffs to participate in the exchanges even though they get insurance through the federal government. An executive order postponed the corporate insurance policy mandate by one year and the President has hinted (though unlikely to act) that there may be relief for some who lost their insurance policies.

However you cut it everyone must, by law, in 2014 have medical insurance. Period. It’s mandatory unless you get an exemption for which there have been issued at least 1,200 for at least a year. There’s a penalty, called a tax by the U.S. Supreme Court if you do not. The Internal Revenue Service will enforce it. In the meantime, there are a couple of direct falsehoods and at least one truism to deal with.

The first is that when President Obama said if you like your policy you get to keep it was not true. He said it to get support for the law as in “Look. It doesn’t affect you. It will only affect them. Why oppose this?”. It was pointed out to him in 2010 by Republicans, but he said it didn’t matter because they were going to get a better policy. He has apologized for this although it was a deliberate falsehood. The second falsehood was that the Act had to be initiated by October 1 of this year. The fact is that the Secretary of HHS has discretion. Also, officials knew that it wasn’t ready for launch. There shouldn’t have been any surprises.

The truism to deal with  is Rep. Nancy Pelosi’s now famous statement that “We have to pass it to see what is in it.” That’s both true and false. Few legislators read the Bill and few appeared or appear to know what’s in it. However, the behind the scenes drafters and crafters and the executive branch knew. On the other hand, because the Act delegates to the HHS setting up the rules and regulations, few knew what that might bring. Regulations are still being issued.

In the meantime, we’re three years into the Act and eventually the sign-up screw ups will be resolved. Everyone will have health insurance or pay the fines, penalties, or taxes. Some will be happy; some will not. Whether it will reduce the cost of health care or not isn’t known. Hospitals and other health care providers have standards and regulations to meet that will be and are costly and filled, according to what insiders tell me, with red tape. Most of these have to do with tracking, coordinating and reporting and evaluating individual care. That’s over and above the electronic medical records requirements. There are financial rewards and punishments attached to the outcomes.

Delays in implementation have already cost some hospitals. Reimbursement for “free” care has already been cut although patients affected haven’t gotten insurance policies. Estimates of the number of people losing their existing policies ranges from 3 to 5 per cent of the population to 30 per cent. It’s millions anyway and the postponement of the mandatory corporate side is expected to swell the numbers.

From the public standpoint, the point of reform was to make certain that the uninsured get coverage. That was the simple view, but all acts have consequences and the Act hasn’t been fully implemented yet. As I wrote: there’s much more to come including dealing with a physician shortage although this will very likely be handled by putting more responsibility on nurses and physicians assistants. There are provisions in the Act for this.

To wrap this up, some people have proposed jumping directly to a single-payer system. Medicare for all. That’s actually the system President Obama preferred. At this point, there won’t be a simple “jump.” Besides that there are two essential problems with this and they are linked. One is that if our Medicare or Medicaid system is now a financial liability, what will happen financially if the system is applied to every single one of the estimated 305,000,000 million citizens (and maybe non-citizens)? What services would have to be restricted, redirected, curtailed, controlled and for and to whom for that system to work? It is easy to say that other developed countries  have this, but it is necessary to look at what “this” is. This deserves discussion, but ours is a huge and diverse country used to a certain independence, and the question will be “will Americans accept such a centralized and strictly controlled system?”

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