Despite the Affordable Care Act’s (ACA’s) problems, it has offered many desirable components-and this why I believe we would be better off fixing the ACA than starting over. In order to fix the ACA, Americans need to understand the problem and they need to understand the components that go into a solution. I am going to do my best to make this simple, this may drive policy wonks longing for details nuts. However, throughout my career in healthcare, I have drawn simple pictures and made generalizations to explain complex concepts. People can get lost in details and never understand the concept if we don't remove those barriers. That is the point here, to help people to conceptualize and understand the larger problem even if some details are left out.
Simply put, funding for healthcare comes from different buckets and is distributed by different gatekeepers. Let's just say that the money for all healthcare services went into one giant tub. If that were to happen, we would know how much money we had as a nation for use, and how much we could spend on healthcare. That would make healthcare spending much easier to understand because it would be similar to a budget. However, that is not what happens.
With the ACA, people sign up for “health exchanges,” each of these exchanges is a different bucket they drop their money into, (because of changes made to the original language of the ACA, people could also "opt out" by paying a small fine). The opting out caused those buckets to be leaner then they might have been had more people been made to buy into the exchanges -even if they were healthy and felt that they didn't need insurance coverage.
Other, similar buckets are available through employers, and even more buckets are available through the federal and state government programs and still others through state-based waiver programs. Medicaid, Medicare, Tricare, waivers, and "insert your insurance company's name here", are all just buckets for the funding that pays for healthcare.
How these funds are doled out, is dependent upon the rules of the federal and state governments, and the risk of profit loss to the insurance companies. Policy writers, lawyers, and bean counters, work within the laws mandated by the state and federal governments to ensure that they provide services required and that they withhold services that are not required, so that they manage the risk of profit loss. A big part of the failure in implementation of the ACA had to do with poor risk management.
To stay in the game, insurers cannot afford to lose too much money, even though this system is rigged in their favor. Risk, (or profit loss) must be spread between the healthy and the sickest. In order for this to work out to the insurance company's benefit, it is especially important that healthy people pay into the system more money than they take out. This is the case for all insurance, so the idea that this risk unique to healthcare is untrue. All insurance depends on those who never use it to pay into it.
From my perspective there are 10 things we can do to improve the health care system immediately, or at the very least start healthier conversations to that end:
1. Require all people to purchase insurance.
2. Incentivize the insurance company through a time-limited carrot and stick approach to enrollment.
3. Focus on prevention-based care.
4. Require the cost of care be driven down through penalties and incentives to correspond with benchmarks for quality.
5. Re-evaluate the workforce distribution, allowing people to work the fullest extent of their education and training.
6. Reward people (incentivize) who improve/maintain health.
7. Offer fair provider reimbursement across the board based on patient need, not based on healthcare provider or type of insurance.
8. Disrupt and reform the pharmaceutical industry.
9. Establish state and federal bioethics committees under the Health and Human Services division to guide bureaucrats in forming health policy.
10. Be honest with Americans. For example (if this is the case), “Yes, this is a tax and this is what you get for it”.
Healthcare has been made a partisan issue, an issue that pits the poor against the wealthy, middle class against the vulnerable. Healthcare and the cost of healthcare affects us all no matter the door that it comes through; hidden in the pandering of partisan rhetoric, is the fact that healthcare in America is more expensive than it needs to be, is less accessible that needs to be, and is a solvable problem with the right motives, minds, and desire for change.
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