Few would argue that a change in our health-care system was desperately needed. The United States has the most expensive health care in the world, spending almost 50 percent more of its GDP than the next highest country, the Netherlands. But we have below-average quality compared with the rest of the industrialized world, according to multiple measures.
We all hoped the Affordable Care Act would usher in a new era, lowering the number of uninsured Americans and decreasing our health care bills. Health care savings were going to pay for the newly insured.
According to the Commonwealth Fund, the U.S. had about 44 million uninsured individuals in 2013 before the ACA. Predictions were that 34 million of them would gain health insurance, but, so far, according to the U.S. Department of Health and Human Services, only 16.4 million have.
In Kentucky, thanks to Gov. Steve Beshear and a near flawless rollout, the statistics were impressive: an additional 82,747 insured through the insurance marketplace and 441,480 through Medicaid.
Yes, Medicaid is government insurance, but when you have no insurance you are thankful for it. For the first three years, the federal government pays for this expansion. After that, federal support will decrease. But the state will never pick up the lion's share. Even without the ACA the federal government pays 70 percent of Medicaid costs in Kentucky — money that stimulates our economy and is hard to turn down.
If Kentucky did not expand Medicaid, the money would still come out of your paycheck, it would just be sent to other states while many Kentuckians went without insurance.
But even staunch liberals now say the system is not sustainable, since the affordability comes not from lowering costs but by shifting the cost to the government through subsidies. According to the Commonwealth Fund, insurance premiums are still increasing 10 to 11 percent a year.
Steven Brill, a health-care policy analyst and reporter, criticizes for-profit medicine. In a January NPR commentary he predicted the system would "snap" within the next few years and said he even "kind of feels sorry" for insurance companies paying higher costs.
The ACA mandates that insurance companies spend 80 to 85 percent of premium dollars on health care. Thus, insurance companies can increase their profit by paying for more expensive health care and then raising premiums. Hospitals are reaping runaway profits because of the decrease in uninsured patients and minimal cost controls and competition.
The stage is set for a fight for a single-payer system. Possibly, this was the plan all along. In single-payer systems, such as Medicare, a single agency organizes health-care financing while the delivery of care remains largely in private hands.
Returning to a free-market system will be more difficult than just saying "repeal Obamacare." The following would have to be accomplished to create a free market:
■ Break up the large hospital corporate oligopolies.
■ Reverse the massive physician employment by hospitals, including the elimination of non-compete clauses.
■ Eliminate payment inequities (as much as 100 percent) for different provider types who provide essentially the same service.
■ Inform patients of the cost of a service. Costs can vary more than five times over among providers.
■ Inform patients of the quality of care. This would be a herculean task, judging from the health-care industry's resistance to publicly reporting outbreaks of untreatable bacteria in their facilities.
■ Repeal insurance companies' anti-trust exemption.
The Supreme Court is considering arguments against insurance subsidies in states that did not set up their own network as Kentucky did. If upheld, that would effectively send the ACA into a death spiral. One outcome may be to rule against the ACA but to stay the ruling. This would prevent loss of life while spurring changes in the law.
How would the ACA be fixed? Returning to the free market is not likely; few legislators have the power or will to enact the above six changes.
The path of least resistance would be to adopt a single-payer system. If this does happen, I hope it will be an option, not a mandate, similar to England where individuals can still opt out. That is if they can afford to do so.