Friday, November 15, 2013

Obamacare's Upstairs / Downstairs Problem

The BBC program "Upstairs / Downstairs" was a look at ossified class society in Edwardian England.  America's healthcare system recapitulates this "insider / outsider" dichotomy by pitting those with healthcare against those without (or with inadequate).  A recent post at the Economist spells this out nicely.
Obamacare was always going to be a hard sell because it is an attempt to fix an insider-outsider problem. At root, its supporters do not think it right for a country as rich as America to be home to tens of millions of people who do not have health cover, or who have such skimpy insurance that they risk financial ruin if they fall gravely ill. 
But ... Republicans have focused on appeals to today’s insiders: warning them that they will be worse off once Obamacare is in force. Those appeals work, because there is something to them. The future of health care in America inevitably involves more rationing and less consumer choice. Indeed it has to. Whether or not you believe Obamacare has a decent chance of putting health care on a more sustainable footing, something has to give. But it is going to hurt. If Obamacare is going to offer affordable coverage to sicker, poorer people without bankrupting the private insurers, then it will have to stick others with the bill. Some will pay more, some will get less, and lots of young, healthy Americans will have to buy insurance for the first time.
The fear of triage, of "rationing," is a winning argument in the Constituency of Fear.  Rather than couching the argument in the framework of "care for all" a la Medicare, the Obama administration has created the ultimate muddle, mixing insiders and outsiders and pissing everybody off.

A better solution, single-payer, Medicare-for-all, would provide a foundation upon which private insurers could build enhanced coverage akin to the enhancements provided through Medicare Advantage.  Instead we have this ridiculous farce.

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