Six years on, the health care “reform” law continues to be very controversial. This far-reaching law affected almost every aspect of the health system and has had significant economic effects as well. We like to periodically review where we are in watching the effects unfold. The most visible parts of the law were those intended to expand coverage and help everyone have health insurance. The three major prongs to achieve this were a Medicaid expansion, an employer mandate, and an individual coverage mandate, with the creation of health insurance exchanges to facilitate finding coverage for individuals and subsidies to make it affordable. In addition, a number of “coop” health plans were subsidized to also supposedly create affordable options. The Medicaid expansion turned out to be non-mandatory–the Supreme Court ruled the feds couldn’t force the states to expand. Nonetheless, we have seen a dramatic growth in people covered by Medicaid. You could consider this a success, unless of course you are worried about the effects on state and federal budgets. And it likely has deterred people from seeking employment or working full-time for fear of losing Medicaid eligibility. The coop health plans are disappearing rapidly, costing the federal government lots of money in non-repaid loans. The employer mandate appears to be working, unless you again notice that part-time employment is up dramatically and full-time down; and as Goldman Sachs has recently noted, this is likely due to the mandate. And as was predicted all along, individual coverage through the exchanges has consistently seen premium increases well above personal income growth, GDP growth or inflation and for 2017, many insurers are leaving the exchanges and consumers in many states will experience very dramatic premium increases. And we still have a very large pool of uninsured, most of whom simply don’t see why they need insurance; and who is to say they are wrong. So the coverage expansion is working just great, exactly as promised by the Administration and Democrats in Congress who passed this abomination.
Providers are thrilled too–feeling completely overwhelmed by meaningful use and “quality” measurement programs and underpaid by Medicare and Medicaid. Physician job satisfaction is down and more than ever doctors feel they are forced to spend too much time on matters that don’t relate to patient care. I don’t mean to be unduly pessimistic, and full disclosure, I thought this law was a mistake from the start, so I am likely to always look for evidence that it doesn’t work–confirmation bias affects us all. But the law has demonstrated exactly what my and others primary concern was. The idea that any group of humans, especially the geniuses who occupy the White House and Congress, is capable of anticipating all the consequences of such a complex change to an already very complicated system, was complete nonsense and as good a demonstration of hubris as you could ask for. Despite ample warning of the likely problems, these geniuses plowed right ahead with a law that is likely to end up making things worse for consumers, patients and providers in the long run. Better to have some humility and be incremental, test initiatives before doing a hundred simultaneously with no idea what the impact will really be. How to fix it now is a real nightmare.