The purpose of this blog is to educate non-policy people on the content of the Affordable Care Act, discuss the practical logistics of how the law will be implemented, and share my perspective on potential “good” and “bad” of the law. The law is far from perfect, but it is the most significant attempt our country has ever made at reforming our costly and inefficient health care system. In case you are a reader who thinks the entire law is “bad,”.
In addition to speaking gigs, I also do “talk radio” about once a month. The questions I’m asked give some indication of where education on the ACA is lacking. One refrain I’ve heard over and over is that Obamacare is a “government takeover” of medicine. This post explores that concept.
“Government takeover” fears seem to take on several different variations.
Medicine will be a government run entity – doctors will be employed by the government and care will be paid for by the government.
All of the doctors will be employed by the government, but insurance companies will still exist.
The government will dictate what doctors can and cannot do.
The government will make it so onerous to practice medicine that everyone will quit.
If the government has one iota of involvement in any form, it is a government takeover.
So what really happens with the Affordable Care Act? The “government” currently pays about 43% to 46% of all healthcare costs, mainly through Medicare, Medicaid, and the armed services. When Obamacare is fully implemented, it is expected this amount will increase to 49.2%. It is a clear increase, but nowhere near a 100% government-paid program. The private sector will still be responsible for over half of healthcare spending.
How about practice systems? How will the government control this? Most countries pick one payer/provider system and stick with it. Right now, our country has four health care systems:
Government provided/government paid – this is the VA Health System, the armed services, and the Indian Health Service. Doctors in these systems are employees of the government and will stay that way under health care reform. There are many complaints with these institutions, but there are also many satisfied patients. This will not change under health care reform.
Privately provided/government paid – this is Medicare and Medicaid. Many patients are okay with Medicare and those on Medicaid are glad they have something. Doctors don’t like these programs so much because the pay isn’t great and the Medicare/Medicaid watchdogs notoriously look for a reason to not pay the doctor’s fee. Doctors can refuse to participate in these programs, so it technically isn’t government control.
Privately provided/privately paid – this is “regular” insurance. Most people are okay with their regular insurance, but aren’t very happy when it costs a lot of money or when the insurance company denies payment for care they received. Insurance companies in the group market (i.e. employer plans) are required by the government to insure everyone, regardless of health. If not required, insurers would certainly choose to cover only healthy people in order to make more money. In the individual market, insurance companies in most states are not required to insure sick people. Under the ACA, this will change. Insurers will be required to sell insurance to anyone who can pay for it. This requirement would be new government involvement, but comparable to the group insurance market.
Self-insured – these are the roughly 40 million or so people who either cannot afford coverage, choose to go without coverage, or have pre-existing conditions which make it impossible to get coverage. The uninsured are at the mercy of a patchwork volunteer system that is inefficient and expensive to run. Some of the current programs to cover the uninsured are funded by the government (taxpayers) and some through charity (benevolent taxpayers), but the majority of the uninsured are left to fend for themselves. Requiring that people obtain coverage and assisting the low income uninsured in paying for that coverage is part of the Affordable Care Act. This is greater government involvement – making people take responsibility, and assisting individuals in fulfilling that responsibility.
One of the failures of the ACA is that we took a very expensive and complex health care system, and made it more complex. This is the reason that overhead for our health care system is about 30% of the cost of health care. Most countries pay only 5% to 10% overhead because of the efficiencies of one system. Had our legislators attempted that coup, it would have definitely been a government takeover.
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