The Urban Institute recently reported that some 18 million Americans have gained insurance coverage under the individual mandate, employer mandate and Medicaid expansion of Obamacare, which falls well short of the expectation in 2010 that the gain would be 30 million of the 45 million then uninsured.
Although a Commonwealth Fund survey recently found majority satisfaction with their insurance, a recent Kaiser Family Foundation-New York Times survey found that three-fourths of insured people who had medical bills said they could not afford the copays, deductibles and co-insurance; 26 percent received unexpected claim denials; 32 percent received care from an out-of-network provider that their insurance would not cover; and 69 percent were unaware that their provider was out-of-network resulting in copay sticker shock.
Adopted without broad consensus, subsequent Congresses have sought to repeal and undermine Obamacare.
Viewed as worrisome, expensive extensions of federal power over people’s lives, many object to the individual mandate to buy insurance or pay a penalty and to the increase in complex administrative regulations and enforcement bureaucracy for that mandate and the employer mandate (which requires specified group health insurance for “large” employers).
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So how might a lasting consensus on health care be obtained?
First, a new president should initially seek broad consensus across party lines on what resources are and will be available for and on the ranking of the nation’s spending priorities of national defense; Social Security; replacing/repairing dilapidated bridges, roads, sewer and water lines, aging electrical grid and other infrastructure; education and health care.
With budget priorities established, the president should use Theodore Roosevelt’s “bully pulpit” of direct appeal to the public to keep Congress moving quickly to address each priority.
Second, health care presumably will rank high. Many will call for the elimination of the individual mandate, subsidies, and employer mandate (which the government claims affects only a small percentage of employers).
But most will want to keep the elimination of the insurers’ pre-existing condition exclusion and keep dependent children coverage to age 26.
Third, insurers will protest that without the mandates, people will only sign up when they get sick, causing insurers to go broke, but this might be controlled with a 60-day limited enrollment period each year; by keeping the current ability of insurers to adjust premiums based on certain factors such as age, smoker, and geographic location; and more aggressive government financing of primary care.
The government projects for 2020 a shortage of 20,400 primary care physicians, most severe in high-poverty regions where they are needed most.
Fourth, to address this shortage, correct health problems before they become major, and address expensive hospital emergency department overuse, a broad nationwide system of federally owned or contracted primary medical, dental and mental health clinics may be helpful.
Providers today might prefer less stressful set clinic work hours with attractive salaries, medical school loan relief, and high quality equipment and services.
Clinic services open 24/7 could be at no charge to those eligible for Medicaid and on a sliding scale up to 400 percent of the federal poverty level for people 18 to 65 and for Medicare deductibles and copays, or perhaps Medicare could be available to all for clinic services.
Fifth, for freedom of choice, Medicaid and Medicare could continue for primary care outside the government’s clinic system and for hospital and specialty physician care not available at the clinics.
Regulatory impediments (such as HIPAA) could be removed to such innovations as communal and family meetings with doctors to encourage communal healthier behavior; family and mental health providers’ sharing with each other an individual’s mental health information crucial to treatment and protection of the public; and flexibility for primary care doctors to charge patients directly on a retainer or other basis in place of the administrative burden of billing insurance.
Sixth, for primary, hospital and specialty care not obtained from the clinics, maintain the tax exemption for employer-paid insurance premiums and allow other individuals to deduct up to perhaps $2,000 to $4,000 of the cost of their premiums, which should be lower because of government-financed health care at the primary level.
Achieving consensus on national priorities and how to pay for them, let alone on health care, will not be easy. Enlightened study and leadership are essential.
Daniel O. Jamison is an attorney with Dowling Aaron Inc. He can be reached at firstname.lastname@example.org.