Why has Obamacare worked?

An Obamacare advertisement at an insurance store in San Ysidro, San Diego, California, USA. Reuters/Mike Blake/file photo

We have just celebrated the 14th anniversary of the announcement of Patient Protection and Affordable Care Actalso known as affordable Care Actalso known as ObamacareHowever many provisions of the law were not implemented until 2014.

In its early years, Obamacare faced sharp criticism from both the left and the right. In reality, right-wing politicians keep saying the same things they said a decade ago, pretending that their fatalistic predictions have not been contradicted by events. But Obamacare has survived, Widespread expansion of health insurance coverage without breaking the budget. Critics on the left complain that it has not produced truly universal health care, and in fact it has not. But it did a lot and became quite popular.

so, Why has Obamacare worked so well?

The point is that Obamacare’s left-wing critics are right. If your goal is to give people access to healthcare, why not give them access by setting up a single-payer system where the government pays the bills? In fact, that’s what we did for seniors when Medicare was established in the 1960s.

HereHowever, a complex system was created that requires people to buy their own insurance, although in many cases the government pays most of the bill. And the complexity of the system, combined with the fact that significant parts of it are run by state governments, some of which are controlled by conservatives who want to thwart Obamacare, means that many people are left behind. : 8% of the population. The American population is still uninsured, although the situation is much better than before the ACA.

Why, then, don’t we opt for a single-payer system? Policy. It wasn’t just about buying the insurance industry and putting it at the center of American health care, although that was part of it. I think what was most important was the perceived need to avoid upsetting Americans who are satisfied with their existing health coverage, mostly those who get insurance through their employers. Instead of reforming our entire health insurance system, Obamacare tried to plug the holes in our system by adding new things. In particular, he attempted to create a labor market in which people who were not covered by their employers could get affordable health insurance.

Many people, especially not just those on the right, expected the effort to fail. I don’t want to go into too much depth here, but the ACA prohibits insurers from denying coverage or charging higher premiums to people with pre-existing medical conditions. This type of regulation can lead to a “death spiral”: fewer healthy people buy insurance, so the risk pool becomes worse, causing premiums to rise, which drives relatively healthier people out, and so on.

US President Barack Obama (right) celebrates the passage and signing into law of the Patient Protection and Affordable Care Act health insurance reform bill at the Department of the Interior in Washington on March 23, 2010, with Vice President Joseph Biden (left) and Vicki Kennedy East The wife of Senator Edward Kennedy is standing behind. Reuters/Larry Downing/file photo

Initially, the ACA included a “mandate” (a penalty for uninsured Americans), but it is unclear how effective the insurance mandate was, and Republicans removed the penalty in 2017.

However, Obamacare didn’t collapse, Why not?

I’ll put it this way: In practice, Obamacare is operating like a single-payer system, and those systems are not subject to death spirals.

First, most of the increase in health coverage came from the expansion of Medicaid, the government health insurance for low-income Americans—single-payer, though less generous than Treatment,

Second, individual purchases of insurance are subsidized in the marketplaces created by the ACA. In fact, 91% of marketplace enrollees received the so-called premium tax credit last year. In many cases these credits cover a large portion of a person’s premium. Furthermore, most importantly, the subsidy does not take the form of a lump sum loan. Instead, the law specifies a maximum percentage of income that enrollees can pay for insurance (that percentage itself depends on their income) and makes up the difference if premiums exceed that maximum.

It’s not quite single payer, but it does mean that the government is the marginal payer, in the sense that even if premiums go up, most people don’t pay more: the government picks up the extra bill. In turn, this means the death spiral basically can’t happen, because even if healthy people drop their insurance, costs don’t increase for most enrollees.

This is smart policy design; Among other things, this protects the ACA from hostile politicians. Shortly after assuming office in 2017, Donald Trump Declared that “the best thing politically was to blow up Obamacare.” And while his effort to repeal the law failed, his administration engaged in sabotage activities, virtually attempting to create a death toll. But subsidies foiled this plan. In 2019, I asked Nancy Pelosi how politicians like her interacted with the smart policy experts who came up with such a robust system. “I’m an idiot,” he replied.

Again, Obamacare has defied the pessimists. But what about the warnings that it would be prohibitively expensive? Despite the coverage expansion, federal health care spending is currently significantly lower than the Congressional Budget Office projected before the ACA took effect. How was this possible?

The then US President Donald Trump attended a meeting on the sidelines of the G20 summit. Photo: Bernd von Jutrzenka/dpa

Part of the answer is that before Obamacare took effect, the uninsured in the United States were comparatively young adults, and young people’s health costs are, on average, much lower than those of older people (who already Were covered by Medicare). Therefore, covering the many uninsured people was never going to cost that much unless the policy design was fatally flawed, which it was not.

Furthermore, the enactment of the ACA coincided with a continued slowdown in overall health care spending growth.

We don’t know exactly why this happened. The ACA included a series of measures aimed at controlling costs, which may partly explain the curvature of the curve. However, it is worth noting that health care costs have stagnated across the advanced world. Technological advances in medicine have changed direction, leading to fewer methods of treating what were previously untreatable and more ways to provide affordable care. And, to some extent, we can see the effect of Stein’s Law: If something can’t go on forever, it will stop. Health expenditure was unable to absorb a growing proportion of national income, so at a certain point insurers and providers began to get serious about controlling costs.

In any case, Obamacare has worked. It didn’t provide universal coverage, but it provided health insurance to millions of Americans, some of whom desperately needed that safety net, and it did so without breaking the bank. Predictions that the ACA would be impractical have been proven wrong. At this point, the only serious threat facing the program—and it is a serious threat—is political: Those who continue to wrongly insist that health care reform will work itself out are ready to intervene to dismantle it. Can.

© The New York Times 2024

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