The Case for ACA and Single-payer

Americans already pay for the uninsured — we do it through emergency rooms, which are already very expensive, much more so than the ACA. We don’t turn away dying people for lack of funds, and we haven’t since 1986, and I don’t think America is likely to go back to that, and if you think we should, well, I don’t know how to talk to you.
 
“The Emergency Medical Treatment and Active Labor Act (EMTALA) is an act of the United States Congress, passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA). It requires hospital Emergency Departments that accept payments from Medicare to provide an appropriate medical screening examination (MSE) to individuals seeking treatment for a medical condition, regardless of citizenship, legal status, or ability to pay. There are no reimbursement provisions. Participating hospitals may not transfer or discharge patients needing emergency treatment except with the informed consent or stabilization of the patient or when their condition requires transfer to a hospital better equipped to administer the treatment.”
 
As a doctor friend told me over lunch the other day, a likely consequence of the ACA is that emergency room costs are going to continue to rise, until they get to the point that hospitals either break under the financial pressure or they *do* start turning away dying people, who then end up dying in the street in front of the hospital, and maybe that will finally get through to the general public.
 
“Financial pressures on hospitals in the 20 years since EMTALA’s passage have caused them to consolidate and close facilities, contributing to emergency room overcrowding. According to the Institute of Medicine, between 1993 and 2003, emergency room visits in the U.S. grew by 26 percent, while in the same period, the number of emergency departments declined by 425. Ambulances are frequently diverted from overcrowded emergency departments to other hospitals that may be farther away. In 2003, ambulances were diverted over a half a million times, not necessarily due to patients’ inability to pay.”
 
The main reason some people’s costs went up under the ACA was because their states refused the subsidies that would have made the insurance affordable for them. The whole point was that it was meant to be affordable, hence the name.
 
Since the passage of the ACA, the cost of health care has continued to rise, but MUCH SLOWER than it did before the ACA. Getting rid of the ACA is almost certainly going to cause health care costs to rise sharply. Going in the other direction, to single-payer (Medicare-for-all), is likely to significantly slow the rise in health care costs. Single-payer will both be much lower cost to the nation AND will provide better care overall to all of us.
 
Some insurance companies will go out of business, if they can’t switch over quickly enough to insuring other things, like houses and cars; I’m okay with that.
 
Correct me if I’m wrong, but I’m pretty sure this is all accurate, and are the basics that Americans need to understand.  This Vanity Fair article lays it out in much more detail, with the numbers.

2 thoughts on “The Case for ACA and Single-payer”

  1. I believe that this is not correct:

    “The main reason some people’s costs went up under the ACA was because their states refused the subsidies that would have made the insurance affordable for them.”

    The ACA subsidies are administered by federal tax credits. The states can’t refuse them. What the states were able to refuse was the Medicaid expansion.

    Here is some information about how the subsidies work:

    https://www.healthinsurance.org/obamacare/will-you-receive-an-obamacare-premium-subsidy/

    Here is an LA Times article about states that accepted the Medicaid expansion vs. states that did not:

    http://www.latimes.com/business/hiltzik/la-fi-hiltzik-obamacare-rates-20161031-story.html

    If you buy an insurance plan on one of the exchanges (and I believe this means both the state insurance exchanges, such as Covered California and Kynect) and the federal exchange, you can get a subsidy. There are still some pre-ACA plans in force that are NOT eligible for subsidies because of how they were purchased and the terms of the insurance.

    I would ask anyone who has experienced an increase in health insurance costs how they buy insurance and whether it’s purchased on an exchange. If people have old plans and are complaining about large premium increases “because of the ACA,” the root cause might be “user error.” They may have continued a pre-ACA plan, or they may have opted for a Bronze plan with very high out-of-pocket costs.

  2. P. S. Yes, some kind of single-payer system would be far more efficient than either the ACA or the previous mess. Best of all would be a system that put doctors and other health professionals on salary and had integrated facilities. Paying for medical care on a piecework basis is foolish in many ways, starting with incentives to do more (surgery, testing) than is best for the patients.

    In the US, the Kaiser Permanente system is like this: docs are salaried; Kaiser owns its own hospitals, medical offices, and labs, and has had a good electronic medical records system for a long time. The health plans are nonprofit (the doctor org is NOT a nonprofit). The system has its problems, but has also improved vastly over the last 30 years. My full disclosure here is that I worked for Kaiser for six years in the 90s, and also that I have been a happy plan member since 1990. At this point, I would hate to have to deal with the paperwork of being in another system.

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