Health Care

Obamacare Isn’t Paving the Way to Single-Payer

A woman reads a leaflet at a health insurance enrollment event in Cudahy, Calif., in 2014. (Lucy Nicholson/Reuters)
Its failures have made the folly of government-driven health care obvious.

This week the first congressional hearing on Medicare for All took place in the House Rules Committee. The following day, the Congressional Budget Office indicated that the transition to a single-payer system “could be complicated, challenging, and potentially disruptive.”

As a physician I wholeheartedly agree. And I don’t believe we are ever going to get there.

Ten years ago, when Obamacare was first being put together, many people — including yours truly — warned that the new law was a big step in the direction of single-payer. This was because it relied so heavily on government overreach, control, and subsidy, and locked patients into a unified form of insurance that covered many services you might not need (so-called essential benefits). In order to maintain profitability, insurers had to increase premiums, copays, and deductibles and shrink provider networks to the point where the insurance became completely dysfunctional. It seemed only a matter of time before the government would have to take the whole system over and provide coverage for all directly, as in Canada.

But then something happened that the Obamacare architects weren’t expecting. More than 6 million people a year, most of them under 35 and relatively healthy, decided to take the tax penalty rather than pay for an overstuffed policy they didn’t need. More and more insurers dropped out.

Then President Trump signed a tax bill that eliminated the penalty for failing to buy Obamacare-compliant insurance. Though Obamacare still exists, patients are now no longer coerced into it, and the Trump administration has used this sudden opening as an opportunity to add more choice with short-term skinny plans, association plans, and expanded direct-care models. These free-market solutions fit a health-care system with exciting new emerging treatments in the worlds of surgery, cancer immunotherapy, and genetics. I believe that coverage more suited to an individual’s needs may actually lead to more people choosing or being able to purchase private insurance than before.

So the dysfunction and unaffordability of the Affordable Care Act has brought us farther away from single-payer, not closer. The health-care solutions of the future are more and more high-tech, expensive, and personalized, requiring creative payment plans including installments, expanded health savings accounts, or payments that vary according to how well a patient responds to treatment. One-size-fits-all insurance is becoming less useful all the time.

The failures of Obamacare have helped inform both doctors and patients about what we wouldn’t like or want about single-payer coverage: restricted access to doctors and treatments, long waits, underpaid providers, higher taxes.

Nine years after Obamacare was signed into law, the employer-based health-care system, which provides coverage for over 170 million people, is still the bedrock of health insurance in the U.S. In fact it has never looked as good as it does now, compared with Obamacare’s woeful attempts to plug the holes in the individual market. As a physician who sees patients daily, I am more convinced than ever that a single-payer system would destroy the heart of the system by banning private insurance. Luckily, this is never going to happen here in the U.S., no matter how much Senator Sanders and others may want it to.


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