Moving Obamacare Forward

Obamacare did a lot, but in rough terms, these are its most important features:

(1) replacing our previous system — in which uninsured people received no healthcare until they were literally hospitalized, and then hospitals were forced to treat them without compensation — with universal coverage (through subsidies);

(2) expanding Medicaid so that anyone up to 138% of federal poverty line qualified (varies locally but this basically covers individuals making $16k or less or families making under $28k — an expansion that reaches over 10 million people);

(3) no discrimination based on pre-existing conditions;

(4) moving away from fee-for-service towards managed care — i.e., we pay based on outcome, not based on number/complexity of procedures;

(5) moving records into online/digital databases (massive undertaking; prior to Obamacare, one study showed that less than a quarter of medical records were online).

It’s worth noting that House Republicans didn’t even try to take away 3, 4, or 5. They aimed for 1 and 2, and couldn’t get the votes. So, much of what people call Obamacare is either uncontroversial or politically pretty sturdy.

But, assuming we live in a world where people still want to improve healthcare, there’s a lot to fix that has nonpartisan appeal. Here are a few:

(1) from the author of Obamacare, one of its mistakes was making it harder for smaller practices to compete with big players (https://www.wsj.com/articles/i-was-wrong-about-obamacare-1469997311?mg=id-wsj); as the author puts it, we should encourage competition and embolden small players to innovate;

(2) work with states that haven’t accepted the Medicaid expansion to get them over the line (just like the Obama administration did in a pilot project in Indiana) — this would extend insurance to millions of people who couldn’t otherwise afford it;

(3) as of now, in order to be a “qualifying plan”, an insurance plan needs to cover a fairly long list of things — this is good in theory, but it’s one of the reasons premiums have gone up, and what we’re seeing is some people are being squeezed by those costs. Paring back some of the requirements — without cutting particularly important benefits — could make insurance more affordable;

(4) healthcare is fundamentally local, and there should be flexibility for states to deviate from national standards in order to support programs like this: http://healthaffairs.org/blog/2016/12/20/how-to-build-sustainable-community-health-programs-in-the-united-states/;

(5) doing more to make patient data electronic and easy for patients to access even when they change their doctor (HIPAA took strides in this direction but it’s worth looking into doing more).

These are all nonpartisan, helpful things that could make the healthcare system better and more affordable, and they’re worth getting in exchange for a few strategic compromises. A good example is the individual mandate. Conservatives hate it because they don’t think the federal government should tell individuals that they “must” buy health insurance. But it shouldn’t matter to Democrats all that much because many people are exempt from the individual mandate’s penalty provision, the penalty provision is basically unenforced anyway, and the evidence has overwhelmingly shown that subsidies — not penalties — drove the increase in enrollment. It’s also worth looking into rolling back Obamacare’s tax increases on parts of the healthcare system (like insurance) which are driving up costs and making it hard to cabin premiums — those revenues can be collected elsewhere.

Not saying these are perfect or comprehensive but they’re all worth discussing. And that’s what I think we should be doing — discussing and trying to figure out how to make things better. Maybe that’s a bit naive but it’s the world I’d like to live in.