Premiums have been steadily rising for the last several years. You can't even spot on the graph where Obamacare starts: linky linky
. It rightly deserves criticism for not doing anything about the rise in healthcare costs, but that's just it, Obamacare didn't really do anything
. It basically just kept the status quo, doing little beyond making people sign up for the broken system. Hence the reason it was so heavily supported by industry. Hence the reason it got passed.
There's more to the cost of health care than just premiums though. Deductables and co-pays have gone up, and coverage points have gone down (the dreaded doughnut hole). I wish I'd saved the paperwork they sent me back in like 2012 or whenever that outlined the changes in my plan, but it was literally double on everything, and half the coverage limit. It was almost laughable how much worse it was.
So Obamacare not only didn't fix the basic cost of buying the health insurance in the first place, it also made the additional costs increase as well, while limiting health care choices (in some cases, dramatically). Almost no-one was actually able to "if you like your current doctor you can keep them". Tons of people had their health provider shifted around against their wills, or were tossed off their care and put on public exchanges, and those kept getting shuffled around as the states scrambled to find insurers willing to accept what the states could afford while still staying in business (and tons of them just pulled out of some regions anyway). Which left a lot of the costs passed onto state taxpayers, which you kinda wont find on the federal cost analyses.
It would have just been a bad idea if all it had done was nothing, while imposing additional restrictions and requirements on both purchasers and sellers in the health care market. That it did that *and* made the result even more expensive for most people? Horrifically bad. Hence why just returning us to what we had back in 2009 would be an improvement, even if the GOP can't manage to make any other change at all.
I'm generally in support of this idea. The market could use more competitiveness. I'm still probably more concerned about the rise of the health care networks, the limited selection of treatment facilities in many locations, and the diffused personal costs through insurance. Buying insurance from Wisconsin to use in Vermont isn't going to matter much if virtually every health care provider in Vermont is part of a different network. These sweetheart deals between drug manufacturers, providers, and insurance companies need to be addressed or all the "competition" in the world isn't going to help out. Right now the established industry members are in a position to easily kick out any "competition" because the barrier to entry is so high.
That's part of the issue though. That they have exclusive deals is because of state regulations which protect the "local" industry. If you get rid of that then the health care providers in Vermont can't deny payment from a health insurer from Wisconsin. Heck. Imagine if we managed to break these monolithic health care organizations entirely? You really could pick your doctor and keep him/her, because you'd no longer be required to use health provider A in conjunction with health insurer A, health provider B with health insurer B, etc. That's somewhat of an unholy alliance the way they do that anyway, and something that Obamacare failed to address at all.
And yeah, that is at least partly what causes (and has been for some time, not just because of the ACA) increased premiums over time. There's just no incentive for any player in the game to keep costs low, when they know that the cost to change services is high (or in some regions, impossible).
There's a lot of area for improvement here. And I'll be perfectly honest, that's not the ACAs fault, except to the degree that it didn't address this at all (and arguably made things a bit worse given the contraction of provider options since its passage). This was a major component that the GOP argued for back in 2009, but were more or less ignored (I guess the narrative that the "GOP has no alternative ideas" was more powerful and useful to them than, maybe actually listening to the GOP ideas and perhaps even implementing them).
Again something I'm generally supportive of, but I'm not sure it'll make a big difference in many places, as many individual states have stepped into this gap already. But, I've yet to know the details yet either, so maybe there's something good in there somewhere I'm not aware of. Some more universal limits on malpractice damage caps, extent of liability for data breaches, etc would be welcome regardless. These are major policy drivers at our hospital, and even high caps on damages help with the insurance costs. Insurance providers will not hold back the charges if there's the potential for unlimited liability.
The tort reform is more in the area of punitive IIRC (it's been a while since I did research on the subject, so you'll have to bear with me here). It's one thing to assess a cost in damages to a patient based on a mistake, misdiagnosis, etc. It's a whole different thing when a jury decides to award a massive settlement in some class action suit, where the primary beneficiaries of the suit are the lawyers, with the massive number of folks in the class action getting maybe a few dollars. I don't know if you've noticed this, but one of the more amusing aspects of watching late night cable is all of the commercials advertising for some new drug or treatment for <insert whatever here>, followed by another ad for a lawsuit for everyone who "if you or a family member used <X> and suffered <Y>, call the law officers of <Z>", where <X> is the new drug or treatment they were advertising 6-12 months ago on the same channel.
It's like a never ending cycle. And again, none of the players have any real interest to stop it because they're all making money anyway, since they can pass the costs on to the consumers. And frankly, this has gotten worse
under Obamacare, since the mandates effectively guarantee a market for any crappy drug or medical device that comes down the pipe. Oh. Because the third commercial you'll see is how you can qualify for a free <insert something here> under the Affordable Care Act. And that's a form of the red-green game in action. Everyone knows it's hurting them, but each player does it anyway. I have a friend who rails about the ACA all the time (for many of the same reasons I do). But guess what? When he got something in the mail telling him he was qualified for a free back brace or whatever, he filled out the form and got it. His thinking? He's already paying the higher premiums and other costs for his health insurance now, so he may as well "get his money's worth".
Which is dumb, right? But that's how people play the game when you set up the rules like that. And that drives costs up. If people have to pay out of their pockets for those sorts of things, they will (usually) make good choices. But if it's "free", with them knowing that it's free because they've really already paid for it with their insurance costs, then they'll buy stuff they'd never buy otherwise. How much does this affect things? No way to know. But it is an increase, and every bit matters.
I'm all for doing something about the burden mandated insurance has on people. I'm not convinced however, that removing the mandate is really the answer. Yes, you've made it so that people don't have to sign up for the broken program, but on the other hand you're basically leaving that same program alone otherwise. You're not really fixing the problem, so much as admitting the system is broken. Making people sign up for a bad deal is bad, but plenty of other people are still forced to sign up for it, or go without insurance; which really isn't a good option either.
Sure. Which can be addressed with the idea of opening up competition mentioned earlier. The point is that as long as people have few or no real choices, they have to accept what is offered. The mandate just makes this worse. At least before there existed some market reason to try to draw in health care consumers by offering a good deal to them. With a mandate, that isn't even a consideration. I agree that fixing the things that are broken in the first place is a good direction to go, but I honestly do believe that a heck of a lot of that is how the current insurance based system is set up.
You'd be better off actually doing something to reform the system much more heavily. The fact that people would rather be without insurance says a lot in and of itself about American health care. The thing is, I don't hear (and maybe this is my bad for not paying attention) people talking about addressing major cost drivers. What I see in the Republican plan is more lip service to the politically convenient talking points (more free-market, less handouts, less regulations, etc). The health care companies don't care much either way if this passes, you don't see them lining up for or against it, because it's doubtful it's going to affect their profits much. That isn't surprising because Obamacare didn't change much for them either, so even a "full repeal" of Obamacare isn't going to do anything but keep the status quo a while longer. They're perfectly willing to continue lining their pockets while simply paying off a different political party.
I think one of my main points here is that "health insurance" is not the same as "health care". We ought to have a system where you can obtain the latter without having the former at all. Just do the math on those premiums linked earlier. What's it up to? $18k/year for a family plan on average? Can you imagine if you could just take that money, every year you've paid into your health insurance, and just put it into an interest bearing account? Most families aren't actually spending anywhere near $18k/year on health care. And that's the average of all people in those plans, whether they use them or not. That's a heck of a lot of money that isn't actually going to directly provide health care.
As a conservative, I'm going to talk about market forces and whatnot, but I really do believe that if you put that money back into the hands of those who earned it and let them make purchasing decisions with it, then they'll apply pressure to the health care market to keep costs down. And that'll benefit the entire market, not just themselves. Even the person who didn't save up enough money, or put enough into their health account benefits, because the costs of everything he may want or need is lower as a result. And yes, you'd need to have some mechanism to try to balance the issue of people who wont make any effort to save money, but I think a great start is companies moving to health savings accounts instead of existing insurance plans (not just in addition to them, which is what many are doing now, which basically just means that you're setting aside money to pay the deductables and co-pays ahead of time, which is maybe a step in the wrong direction).
Is that a complete solution? No. But we'd literally be better off if instead of forcing everyone to purchase insurance, which they lose if they don't use each year, we mandated that they put money (some percentage of their income perhaps?) into a health account which they get to keep, can earn interest, and they can use to pay directly for health care. Not that I'm a fan of mandating anything, but if you were going to do a mandate, this would have been a 100 times smarter method.
I'd also completely revamp the insurance model itself, favoring covering only catastrophic health care with insurance. The very concept of comprehensive health insurance is absurd on its face, and the steady rise in costs over time tells us why. Right now though, employers with more than 50 (75?) employees are forced to provide a comprehensive coverage option for their employees if they provide any health insurance at all (yes, this goes all the way back to the mid 70s). Obamacare just takes that mistake and makes it worse with the mandates, but that's more or less at the heart of the problem.
Insurance is only a good method to pay for things if those things are both rare and prohibitively expensive. If the cost is a regular recurring cost, using insurance to pay for it can only increase the cost across the board (and creates incentives for "padding" those services). You'd never buy shoe insurance, right? Because you have to buy shoes fairly regularly and it's not a bankrupting cost when you do. You don't buy clothes insurance, or gas insurance, food insurance, or insurance for anything that is just a regular cost of living expense. You just pay it. What you need insurance for is if you crash your car and it's going to cost you tens of thousands of dollars to replace (or replace the other guy's car). You probably don't have that kind of money lying about, while you do probably have enough to buy some cold medicine, or get a routine checkup, or a flu shot. Those things just don't cost that much, if you were actually paying for them right out of your own pocket. And in fact, if more people paid out of their pockets, they'd cost far less than they do today.
Leave the insurance to pay for serious injuries, or if you happen to contract cancer, or get a brain tumor or something. It should pay for expensive hospital stays and care. What it should not pay for is your monthly supply of medications, and yes, that includes your birth control pills. Same deal. Those would all be much less expensive if they were paid for out of pocket. Most people spend far far less on actual health care each year than they spend on food, and even less than they spend on housing. Why are we paying for this with insurance? It's just dumb.
If you want to fix the cost issue you have to address the power structure. The power to set price points needs to be in the hands of the consumer, not the provider. Right now that's not the case. Sure it's partly a competition thing, there's limited hospitals, limited drug manufacturers (with monopolies over certain drugs), limited insurance providers, etc. You can also use the government: break-up health care networks, do something about pharmacies making deals with drug providers, hospitals, insurance providers, etc. You'll need to address end-of-life care costs to fix the problem, which is trickier. Making people cover their end-of-life costs more out of pocket will never be popular, but those expensive treatment options are much easier to swallow when everyone else is paying the majority of the bill. Until things like that happen, you're just going to be fiddling around with small changes. You're maybe getting costs to increase 90% of what they would have otherwise, in exchange for kicking some poor people out of the system.
Or, honestly, start by eliminating the existing government regulations that more or less force our health care system into those models. We should not just be looking at repealing the ACA. We ought to also look at repealing (or at least seriously modifying) the HMO act. That's the law that gently but firmly forces our health care system into an insurance only model. Which in turn makes creating health care plans (HMO stands for "health maintenance organization", right? Guess what thing it's goal is to create and enforce?), all about groups of health care providers and insurers working as large monolithic players in the market rather than a zillion different players all competing with each other. The requirements of that act nearly force them into as large a scale as possible, meaning that over time, competition has all but disappeared in our health care system.
And yeah, once again, is that a complete solution? Nope. Does is solve everyone's problems? No again. But if you're waiting for "perfect", you'll be waiting for a very long time. I'm happy to settle for a system that is "better", or even just "doesn't create even more problems". That's at least a good starting point, right?
Anyway, TL;DR, it seems like more of the same. People will get up in arms about families being punished by the mandate, or poor people who might be losing coverage, but otherwise all I see is just one more party paid off by the health care industry.
There's no way to be sure what exactly will happen. And yes, I'm cynical as well about politicians and their choices (regardless of party). But at least the GOP is being pressured by people who are by ideology opposed to the "big" nature of our health care and want to go back to a more competitive model. They may not always meet our expectations, but at least there's a chance they will. On the other side there is no pressure to do anything other than feed the money pump at taxpayer and consumer expense. Edited, Mar 14th 2017 5:56pm by gbaji