How health care looks in 2030

The Washington Post Sunday - - BUSINESS - EZRA KLEIN

Good morn­ing, class. To­day’s topic, as you know, is “ The Evo­lu­tion of the Amer­i­can Health-Care Sys­tem” be­tween 2010 and 2030. Be­fore we be­gin, ei­ther turn off your iGlasses or make sure they’re not set to holo­graph­i­cally project what­ever you’re day­dream­ing. I did not like last week’s glimpse into Alexa’s sub­con­scious.

As you’re aware, 2010 was a turn­ing point for the Amer­i­can health-care sys­tem: The Pa­tient Pro­tec­tion and Af­ford­able Care Act was signed into law. It was a clunky piece of leg­is­la­tion — the prod­uct not merely of a year of con­gres­sional ne­go­ti­at­ing and deal­mak­ing but also of decades of de­feats and di­min­ished ex­pec­ta­tions for sup­port­ers of uni­ver­sal health care. Af­ter al­most a cen­tury of failed at­tempts to ex­tend cov­er­age to ev­ery Amer­i­can, sup­port­ers gave up on per­fec­tion. Many of them

even gave up on what they con­sid­ered good. They just wanted to get it done. To do so, they em­braced leg­is­la­tion sim­i­lar to what Repub­li­cans had sup­ported in 1993 and 2005.

Of course, that didn’t mean Repub­li­cans liked it. Af­ter win­ning back the House in the 2010 midterm elec­tions, they voted to re­peal the law. As you might imag­ine, this ef­fort didn’t get far in the Demo­crat-con­trolled Se­nate. Shortly af­ter, the Supreme Court re­fused en­treaties to ex­cise the in­di­vid­ual man­date — the re­quire­ment that ev­ery per­son have health in­surance — from the leg­is­la­tion. The law was here to stay.

In ret­ro­spect, for all the sound and fury it caused, the leg­is­la­tion was mod­est. It cov­ered most, but not all, of the unin­sured. It cut the deficit a bit. To give you an idea of its size and am­bi­tion — or lack thereof — when it was fully in place, the leg­is­la­tion ac­counted for about 4 per­cent of the coun­try’s health-care spend­ing. But like a lot of things in Amer­i­can pol­i­tics dur­ing that pe­riod, it was blown out of pro­por­tion. As we know now, the law was the first word in health-care re­form, not the last.

The next big pol­icy change came five years later, when the fail­ure of a mod­est deficit-re­duc­tion bill caused the bond mar­ket to send in­ter­est rates on Trea­sury debt soar­ing. Congress got se­ri­ous about deficit re­duc­tion, and fast. Three months later, the Bal­anced Bud­gets and Sus­tain­able Growth Act of 2015 was signed into law. Among other things, it ended the de­duc­tion for em­ployer-based health in­surance and re­placed it with a re­fund­able tax credit for ev­ery­one, no mat­ter where their cov­er­age came from.

To ap­pre­ci­ate the irony of this, you have to know that this was the core of Repub­li­can JohnMcCain’s health-care pro­posal in the 2008 pres­i­den­tial cam­paign. But Democrats ob­jected to it be­cause it would push peo­ple out of the em­ployer-based mar­ket and into the in­di­vid­ual mar­ket, which was a mess.

Pres­i­dent Obama’s health-care law, how­ever, had re­placed the in­di­vid­ual mar­ket with ex­changes in which in­sur­ers were tightly reg­u­lated — so, for in­stance, they couldn’t turn you away for a pre­ex­ist­ing con­di­tion, or qui­etly cap your ben­e­fits, or sell you a plan that wasn’t re­ally com­pre­hen­sive — and con­sumers were pooled to­gether, so they had bar­gain­ing power, rather than hav­ing to ne­go­ti­ate all on their own. In other words, it took Oba­maCare to achieve McCain Care.

As the em­ployer-based mar­ket eroded, a cen­tral bar­rier fell be­tween the health-care sys­tem we had and the health-care sys­tem we could af­ford. Now that in­di­vid­u­als were see­ing the en­tire cost of their cov­er­age, rather than let­ting the com­pany HR depart­ment do the pa­per­work for them, they found plans that con­trolled costs more ef­fec­tively a whole lot more at­trac­tive. This, in turn, gave in­sur­ers more lever­age against hos­pi­tals and, thus, gave hos­pi­tals more in­cen­tive to work with in­sur­ers to cut costs.

It also cre­ated space in the coun­try for a more sober dis­cus­sion of health care. For many years, ev­ery se­ri­ous con­ver­sa­tion about cost con­trol was de­railed by the dreaded specter of “ra­tioning.” Of course, Amer­ica was ra­tioning the whole time — just do­ing it by in­come, so peo­ple who didn’t have much money didn’t get much health care. When there were hard choices to be made, the coun­try tended to curl into a fe­tal po­si­tion.

In 2009, crit­ics of the health­care over­haul as­sailed a pro­vi­sion to have Medi­care pay for ses­sions in which se­niors could talk with their doc­tors about var­i­ous end-of-life op­tions — in­clud­ing op­tions wherein no ex­pense would be spared to save their lives. End-of-life coun­sel­ing was spun as es­tab­lish­ing “death pan­els.” When the Obama ad­min­is­tra­tion put some money to­ward re­search into which treat­ments work and which don’t, Congress at­tached lan­guage say­ing that Medi­care and Med­i­caid couldn’t use the re­sults to de­cide what they would and wouldn’t cover. Imag­ine that: They weren’t al­lowed to use ev­i­dence.

But in 2019, at the urg­ing of Pres­i­dent Bobby Jin­dal, Congress passed the Health Care Equal­ity Act, the third ma­jor phase of health-care re­form. It ful­filled long-held con­ser­va­tive hopes when it moved Med­i­caid and Medi­care onto the ex­changes and al­lowed se­niors and low­in­come Amer­i­cans to choose be­tween the govern­ment be­he­moths and pri­vate in­surance. But it also opened both pro­grams to all Amer­i­cans — mak­ing them akin to the pub­lic op­tion that Democrats had been un­able to pass in 2010. And as part of the deal, both were given more free­dom to use a flood of com­par­a­tive data in de­cid­ing what treat­ments to cover or refuse, which al­lowed them to fi­nally stop pay­ing for vol­ume and be­gin pay­ing for qual­ity.

Nowa­days, Amer­ica’s health­care sys­tem isn’t per­fect, but it works much bet­ter. And it’s no longer threat­en­ing to bank­rupt the nation. It took sev­eral rounds of re­form, each one build­ing on the last. It was over­due, and it was slow and frus­trat­ing. But at least it got — Dammit, Alexa!

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