Tuesday, May 14, 2013

Jonathan Cohn of the New Republic...

...and Ezra Klein of the Washington Post are two of the best writers I've found on the subject of health care reform.

That's why I read with great interest Cohn's new piece, "My Five Obamacare Anxieties: The Scenarios that Keep this Reform Advocate Up at Night."

Of the five, I think the last is the most significant: "Obama Will Get Smacked No Matter What" (my emphasis):

Here are a few predictions of things that will happen during the first year of Obamacare: Many people will experience long waits before being able to see a doctor. Insurance companies will refuse to cover important treatments that doctors say are necessary. Employers will balk at the rising cost of providing care to their employees. These predictions are certain to come true— because they come true every year. And while Obamacare was designed to address some of these problems, they won’t all vanish overnight.

Perhaps my biggest fear about Obamacare is that the inevitable, predictable troubles become full-blown political firestorms, undermining the entire system. The national Republican leadership doesn’t share the goal of universal health care coverage and neither do Rush Limbaugh or the pundits on Fox. They’ve made it clear they want to get rid of the entire ACA and replace it with nothing at all. You can expect these forces to exploit even the slightest sign of trouble—even problems in the general realm of health that don’t actually have anything to do with Obamacare. “[The administration] own[s] the health care system,” says Mark McClellan, the former administrator of Medicare and Medicaid, who oversaw implementation of Bush’s prescription drug benefit. “And ... they only get the things that go wrong.”

This could have a snowball effect. Insurers could get skittish about participating in the exchanges and stop offering plans. Wavering state officials might come to the conclusion that it’s too politically risky to help federal officials to fix the system and instead let the problems pile up. Individual consumers might decide that it’s too expensive to purchase insurance on the exchanges and opt to simply pay the penalty instead. That’s the true nightmare scenario—that the predictions of doom become self-fulfilling.

That’s why expectations are so important. Starting in January, millions of people will get the kind of affordable, comprehensive, and stable insurance they never could before. This may be quicker to happen in some states than others—and the experience may not always be easy. But it will certainly be an improvement on the current state of affairs. And even those who anticipate difficulties also expect that things will get better over time. “I have described my expectations for 2014 as ‘bumpy,’ ” says economist Gail Wilensky, who was in charge of Medicare and Medicaid under President George H. W. Bush, “but something I assume the country will muddle through.”

And I agree with all of that. I mean, after all, people were blaming Obamacare for all sorts of ills before the darn thing was even passed. You think that will change?

So here's my question: What will follow the near certain bumpy roll-out of Obamacare? 

A return to ... nothing? I don't think so. The previous "system," if you could call it that, was so dysfunctional that health care reform was the most pressing domestic issue in the 2008 campaign before the financial crisis hit. (Hard to remember, but true.)

How about a single-payer system, i. e., Medicare For All? Sadly, no. While that would probably be the most efficient system, the insurance companies are just too entrenched and too powerful. Like it or not, they're here to stay. 

So what does that leave? Obamacare, warts and all. I expect the Affordable Care Act will be pulled and pushed and prodded and tweaked over the years until the U. S. has a system roughly like that of Germany's: cradle-to-grave coverage by the private insurer of your choice which will be heavily regulated (like the utilities) by the federal government. (Seniors will still be covered by Medicare; nobody wants them.) 

It may take a while, but that's where I think we're headed. And, as Martha Stewart would say, that's a good thing.

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