Tom Roberts Commentary: “Next Steps for Obamacare”

The re-election of Barak Obama and the Democratic majority in the Senate, including our own Jon Tester, has obvious and major implications for the implementation of the Affordable Care Act, also known as Obamacare.
There will of course be some holdouts, including our new state Attorney General, our federal representative and a variety of others who based at least part of their campaign on repealing this wide ranging law. It’s hard to not at least speculate about this profound and prolonged resistance to change. Does it come from some innate human tendency to put up with a bad system because of complacency? Are there existing financial rewards which will be compromised in a new system? Or is there some deeper mistrust and angst over having a black president with his approach to social fairness?
That our current health care system is broken in many ways should be beyond discussion. We spend twice as much money on health care as the next closest country in the world. Over 50 million people, one in six, do not have health insurance which means that they do not get the kind of health care that they deserve. We are totally alone among all first world countries and most second world countries in not making universal health coverage a basic component of our national agenda. We are last in the developed world for longevity, infant mortality, and preventable deaths. The evidence is profound, obvious, and unavoidable. Never the less, there is also the human tendency to rally for the home team. We’re the best, even when we’re clearly not.
Despite all this, people in the US have indeed spoken. Regardless of what our state legislators want, major changes are headed our way and they are coming soon. The federal government will be operating an exchange for Montana starting in 2014. Other states still have until the end of 2012 to make their own choice. Our legislators declined to address this issue in 2011 and won’t have another chance until 2013, so Montana cannot run its own.
The exchange will be a market place where individuals go to buy health insurance. Insurance companies that offer products on the exchange have to provide health insurance to everyone who buys it there. No one can be excluded because of any existing or future medical condition no matter how severe or costly this condition is. This change is almost too large to imagine, given where we are right now. Of course, this only works because everybody has to participate. It’s no longer going to be OK, except in severe economic circumstances, not to contribute at least something towards health insurance.
Individuals and families who now can’t afford health insurance, will be able to afford it by using the exchange. The federal government will pay a major portion of the cost of health insurance for those with lower incomes. Many of these are currently uninsured. But it won’t end there. Lots of people who are now insured through their employers will also be eligible for financial help when buying through the exchange. Businesses with less than 50 people can simply give their employees a little more money to buy a policy on the exchange. They can stop providing employee health insurance with no federal penalty. Businesses with more than 50 employees can do the same thing, but will have to pay something into the insurance pool. Each business will have to do its own calculations based on level of pay and number of employees. But the upshot is that many more than the currently uninsured are likely to be purchasing insurance through the exchange. They will be doing this as individuals and not as part of their place of employment.
Employer based health insurance is mostly a historical accident anyway. It’s beginning to look like this part of our current system is on the way out. Instead of the owner or a benefits manager making the decision, now the actual consumers will start having a choice about what kind of health insurance they want to buy. The health insurance policies offered on the exchange will be easy to compare in terms of cost and coverage. The insurance companies that provide the best coverage at the lowest cost are the ones who will prosper.
Of course, this means that the insurance companies will be asking doctors, hospitals, and others to provide medical care that is based on high quality and reasonable cost. Imagine that! A system that is based on efficiency and best outcomes. Maybe, just maybe we’ll eventually find ourselves in a society where everybody’s’ health and illness is addressed in an organized and thoughtful way. It shouldn’t be too much to expect, and it looks like we are finally on our way there.

Tom Roberts is a physician in Missoula


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