We stand watch at Obamacare’s bedside, filled with uncertainty about the timing of its demise and what will follow. There are good deaths and bad deaths—good ones are peaceful and offer time for reflection and fond farewells. Bad deaths are filled with misery and leave behind discord, estrangement and confusion.

Born of compromise

Although the Patient Protection and Affordable Care Act (ACA) passed without Republican support, it did not emerge full grown from the head of Obama. Unlike the Clinton Health Care Reform, the Obama Administration consulted with and received the support (mostly) of the American Hospital Association, the American Medical Society, America’s Health Insurance Plans (AHIP), Pharmaceutical Research and Manufacturers of America (PhRMA), Consumers Union, and many other interested parties. The Obama Administration did not want to resurrect the AHIP-funded Harry & Louise ads that doomed the 1993 Clinton plan. Born of compromise, ACA was a frail child.

Each of the interested parties got something in exchange for their political support. AHIP won the personal and employer coverage mandate and dodged the “Medicare for All” public option. AHA, courtesy of the “out of pocket maximum,” hoped for fewer bankruptcy-driven write-offs. PhRMA escaped negotiated drug prices. AMA’s support bought a long list of free preventative services, like annual physicals and screenings. Consumers advocates won community rating coupled with an end to “pre-existing condition” exclusions.

Rejecting the “single payer” models of the United Kingdom and Canada, the ACA retained private insurance and provider markets, imitating the health care systems of many of our trading partners, e.g. Germany, France, Japan and Switzerland. While private, the payers and providers in these countries are subject to comprehensive price regulation. Read more »