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The sins of Obamacare

November 4, 2013

Three guys built an easy, alternative website for navigating insurance plans in the Obamacare exchanges. (Click here to use it.) Alex Pareene thinks liberals need to fix the larger problems in Obamacare. I don’t think that is possible in the near term, while every Republican politician is intent on impeding it as much as possible, for use as a political football. In the longer term, I suspect there will be another healthcare political war. That’s because Obamacare commits two mortal sins. And they’re sins of omission, not sins of commission.

First, Obamacare fails to cut through complexity. To anyone who has helped family through the process, one of the more intimidating aspects of a significant medical event is dealing with the financial aftermath. By that, I don’t mean the expense of the final tally, but the accounting work involved. Consider a simple injury that requires a trip to the ER. As example, a friend of mine recently embedded a large, rusty nail in his foot. Given the necessity, he was going to the ER, whether his out-of-pocket expense eventually was $19 or $190 or $1900. (Being uninsured, it ended up more by an order of magnitude!) The problem is that it will be a year before the patient even knows that final tally. The bills will trickle in, from the hospital, the physician, the blood lab, the imaging lab, and other providers the patient never imagined had been involved. Often multiple bills from each. Each bill will seem more complex than the services rendered. Each perplexes over how much actually is due, and how much insurance will pay. For the diligent patient, those weeks of healing also are weeks of becoming an expert in medical codes, billing procedures, and how to deal with insurance companies and medical offices. The less diligent patient both will fail to pay what is owed and unnecessarily pay what isn’t. In either case, there will be times it would seem easier and less painful just to live with a rusty nail in the foot.

Any reform to the medical system that simplifies this would have been welcome relief. Why can’t we have a single charge for most ER visits? Why not a single per diem out-of-pocket for any hospital stay, including all tests, supplies, and care? Why not a single out-of-pocket amount for any covered out-patient surgery? Why do any of these need to generate a book’s worth of itemized billing? Yes, the complexity would remain in the back-end, where provider accounting links to payer accounting. But why can’t simplicity for the consumer be part of what a healthcare system delivers? If Obamacare had promised that every time someone left a hospital or ER or medical office, they would leave with a single, understandable bill, on one page, giving the amount owed with insurance already applied, nothing further to follow, that would have been such a wondrous thing that even its critics would be forced to admit to its benefit. If through clenched teeth. Instead, Obamacare leaves in place insurance policies and medical billing every bit as complex as existed before, still a task for every patient involved.

As its second sin, Obamacare fails to be universal. Many people will lose insurance when they lose a job, will find COBRA unaffordable, and will then suffer a costly medical event before the next exchange enrollment period. Others will simply fail to enroll. Though Obamacare closes some trapdoors that insurance companies would use to shuck themselves of risky clients, it fails to achieve true universality. That takes the wind out of the argument Krugman makes, that Obamacare was the feasible alternative to a universal, single-payer system. If Democrats were willing to give up on universality, there were many alternatives to single-payer that would have significantly extended coverage. Such as lowering the qualifying age for Medicare.

There’s a reason I call these mortal sins. The venal sin is the roll-out of a non-functioning website for the exchanges. The non-sin is what the right wing hates: making it possible for people to acquire medical insurance who previously could not, due to financial or medical circumstance.

The sins I note are what will cause people to wax weary of Obamacare, after it is implemented, after they have grown used to it, and long after the right wing’s current objections seem as dated as their past objections to Medicare. These are the sins that will require yet another political war over healthcare in the future. These are the sins that make me think the Democrats should have aimed for something simpler and more modest.

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