The Obama administration's decision to give big employers another year before they are taxed for not providing health insurance for their workers looked like the opening Republicans had been waiting for. As they had been saying, Obamacare just doesn't work and now the administration is admitting it.
But it hasn't gone down that way. Rather than call for the repeal of Obamacare or at least its employer mandate, business groups praised the administration for giving the relative handful of large employers who don't already provide insurance (about one in 20 in Arkansas) more time to figure out the complicated system of rewards and penalties in the Affordable Care Act and decide if they will insure their workers or pay the penalty.
It was, to be sure, an embarrassment for the administration because it was at least a recognition of the immense complexity of the law, a necessity when the president and Congress decided that the only politically conceivable way to achieve universal coverage and some measure of reform and cost control was to try to perfect the Rube Goldberg system of employer-based insurance that emerged in World War II and afterward. It also will give the Health and Human Services Department more time to develop the insurance markets for individuals and employers and perfect the regulations.
The year's delay also provides encouragement, if any were needed, for the Republican House of Representatives to continue the charade of voting regularly to repeal the Affordable Care Act. The reform remains fairly unpopular, the negatives consisting of people who do not believe the government should guarantee access to medical care for people who cannot afford the care or the insurance, people who believe (correctly in my view) that a government program like Medicare would have been much superior to patching the employer-based private insurance system, and people who already are insured and believe the propaganda that their coverage might be affected. (It will be in many instances. Their insurers can no longer cap their medical reimbursement during the year or over a lifetime or curtail their coverage or increase their premiums for a lingering health condition.)
Still, it's the best PR for the Republicans. The worst thing that could happen would be to succeed and actually repeal Obamacare. Suddenly, Medicare recipients, who opposed the reform because they were led to believe by advertisements in 2010 that it would cut their benefits, would suddenly lose benefits and see their prescription drug expenses rise. Hospitals, doctors (especially family doctors) and other providers would lose the prospect of ending charity care. Millions of low-income working families would lose coverage. Millions of people who had lost coverage owing to pre-existing conditions would lose it again.
Ross Douthat, part of The New York Times's stable of "civil" and "thoughtful" conservative columnists, saw the administration's mandate delay as an affirmation for liberals and conservatives alike who have long recognized that the system of employer-based health insurance is what is wrong with health care in America, responsible for the roaring cost of health care and a shortage of competitiveness in U. S. industry. There was some truth in his analysis, but how would he replace it? Somebody else's problem.
Obamacare is a political arrangement, perhaps the best Congress could concoct in the political environment of 2010 or of anytime the past 20 years — or the next 20. "Medicare for all" ceased to be an option as a replacement for a private insurance industry that had become one of the most powerful players in the country. Obama, like all his party's candidates for president in 2008, concluded that the only route was to broaden private insurance coverage by mandating for individuals who didn't have employment coverage but without undermining employment insurance. Without an employer mandate (for those with 50 or more full-time workers), the individual mandate and government premium assistance would encourage big employers to pull back their coverage. Congress thus constructed a complex network of thresholds, penalties and reporting to make that work.
But soaring medical costs in the United States — far and away the highest in the world — and terrible distortions in the health-care system are not the work of employment-based insurance but rather of the reimbursement system for government and private insurance, which has been run by an adjunct of the American Medical Association since the days of the Reagan administration.
You haven't heard of it — the Specialty Society Relative Scale Update Committee, known as the RUC. A committee of medical specialists each year determines the relative reimbursement rates for some 9,000 medical procedures, based on a number of factors, so that an office visit with family doctors and pediatricians is around the bottom and complex surgeries at the top and far away. Washington Monthly has a superb article about the cartel this month.
You want to be a doctor? Get a specialty. The rewards are far greater. So, we have a huge shortage of general practitioners.
The reimbursement and the fee-for-service systems together have stimulated the growth of needless medical procedures, overall health-care costs and premiums.
Obamacare didn't address either of those problems, which is why the AMA endorsed it, but it actually will tackle them obliquely. Congress probably will not let it occur, but the law creates an advisory panel that could recommend lower reimbursement, or none at all, for needless or unworkable procedures. It gives a boost to family doctors. And it deftly suggests that states or programs might try something else besides fee for service, such as bundled care, to see if it works. Arkansas, of all places, is trying it, so far with great success, but no one has dared admit that it is Obamacare.