Medicine Drugs

Sorry, there’s a problem with our system

This is the message I have gotten recently while trying to navigate to get new health insurance for my husband and myself as we move to a new state. When I originally went on back in March before open enrollment ended, I got it three times in a row. Finally, I threw up my hands, exasperated, and went directly through my local co-op’s website to buy a plan. The representatives working the phones have been a mixed bag. Some have been very helpful, but I’ll never forget about one woman back in March exclaiming “Wow, you seem to know more about all this than I do!” Not a reassuring message. But the error message that keeps showing up on is symbolic. There is a problem with our system.

The fact is, the Affordable Care Act has done much to help many Americans purchase health insurance who wouldn’t otherwise be able to do so. But as we start to evaluate its successes and failures, we need to realize that the law, while better than nothing, has not failed to fix a fundamentally broken system.

Firstly, the law has been successful at getting people enrolled. More people have health insurance. HHS bragged that more than 8 million signed up for health insurance through the Marketplace after the first enrollment period ended, more than expected and an obvious high point after the failure of the website to launch. It is notable especially that more than 4.8 million individuals enrolled in Medicaid and CHIP

Second, the country had made a major stride forward in protecting those with preexisting conditions from discrimination by health insurance companies. I’ll never forget when I moved to Montana three years ago, three months pregnant, with a gap in coverage. I called Blue Cross to check on my options for a plan before my job’s group coverage kicked in. The woman told me on the phone flat out that I would not get coverage because I was pregnant. The law prevents this and more egregious acts of discrimination.

But the law has failed to fix some fundamental problems. First of all, it is a far cry from universal coverage. About 20 million people chose not to sign up for health insurance, which in many ways overshadows the 8 million who decided to sign up (and let’s not forget that we have yet to see how many of those 8 million enrollees are actually going to pay for their plans, and how many Americans are going to sign up in future years). The reasoning behind those who chose not to purchase coverage was largely cost. The marketplace didn’t reveal costs that seemed all that worth it. Premiums are still hundreds of dollars for many Americans who simply cannot fit that into their current budget. Additionally, the court’s ruling that states need not expand Medicaid (which 24 states chose not to do) made it so that many poor adults without a handicap could not qualify for Medicaid and thus had to forego coverage. Tax subsidies to make plans affordable are available only to those making somewhere between the poverty level and 400 times that amount (about 11,500 for an individual). Adults below the poverty level in the 24 states that did not expand Medicaid remain uninsured. And for those just over 400% of the poverty level, shelling out hundreds of dollars each month for premiums, not to mention thousands of dollars of deductibles, is a hard pill to swallow. Folks like these aren’t poor, by any stretch of the imagination, but they might still not be rich enough to afford health insurance.

Secondly, and perhaps more significantly, the law has failed to address fundamental problems related to complexity and inefficiency. A recent issue of the Economist addressed health-care fraud, reporting that an estimated $98 billion, or about 10%, is added to Medicaid and Medicare expenditures each year due to health-fraud. Up to $272 billion is added overall to the entire health-care system due to fraud. Why? The leviathan-like complexity of the system. Medicare processes 4.5 million claims per day. Medicaid is administered by the state, with no national database. And doctors complain constantly about the complexity of the medical billing system, which makes fraud easier and discourages honest doctors from wanting to participate for fear of making a mistake.

Another less-discussed problem with our current health care system is also related to Medicaid. It isn’t portable. Portability was one of the goals of the Affordable Care Act. The law made it so that you could take your current health insurance with you when you moved. Except if you are covered by Medicaid and CHIP. These programs are not portable, and so they require a reapplication process when you move from one state to another. This makes sense as Medicaid is administered by the states but it is a structural problem that allows for a highly vulnerable population–the poor, especially children–to fall through the cracks with gaps in coverage. A related problem is that CHIP often involves a reapplication process each year which can be held up not only by changes in address but also changes in income. The application process is often complex and time-consuming. Poor and near-poor families should have fewer obstacles to ensuring coverage, especially for their children.

The US spends more on health care than any other country ($8508 per capita) but ranks last in quality when compared to ten other industrialized nations. Even with health care reform, we are still dead last. According to a recent report

The U.S. fares well in providing preventive care and patient-centered care, according to the report. But among its many deficiencies, according to Davis and the report, are a relative shortage of primary care physicians; lack of access to primary care, especially for the poor; a large number of low-income residents who skip needed care, do not get recommended tests or do not fill prescriptions because of cost; high infant mortality; inordinate levels of mortality from conditions that could have been controlled, such as high blood pressure; and lower healthy life expectancy at age 60.

The Affordable Care Act should address some of these problems, but until we lower the overall cost, make the system more efficient, and make it easier for the poor and near-poor to get good health care coverage, the problem with our system will remain.