Two medical stories are headlined in recent Oregon
newspapers. One is local, but with national implications. The other is national, but with local implications. A common denominator lies beneath both
stories.
In Oregon more
than ten thousand people got inflated tax credits when buying insurance through
the exchange set up under Obamacare. The
excess credits may exceed $100 per month, so some people will have to pay
substantial amounts back to the federal government.
The national news is the death of Thomas Duncan from Ebola
and the infection of several people who treated him. Duncan
was sent home, when he first visited a Dallas
hospital’s emergency room, despite highly suspicious symptoms. After giving conflicting answers to
embarrassing questions raised by this situation, the hospital has hired a
public relations firm and allegedly has prohibited staff members from talking
to the press.
Obamacare may have been a step in the right direction, but a
common denominator underlying both of these stories is its inadequacy and poor
design. Partly due to refusal by many states (including Texas)
to expand Medicaid, tens of millions remain
uninsured. And Obamacare excluded
coverage for foreign visitors and undocumented aliens.
Thomas Duncan,
visiting from Liberia, had no insurance. There is informed speculation that the Texas
hospital had a policy of not admitting emergency room patients who lack
insurance. If this is true, it is no wonder that the hospital would need
to hire a P.R. firm and put a gag rule on its employees.
Obamacare’s basic problem is complexity. Complexity made creation of web-based portals very difficult, and
complexity forces individuals and employers to make choices they are poorly equipped
to make. Much of this complexity flows from
government subsidies, which allow people to purchase insurance, and especially
from the need to document and monitor each person’s continuing
eligibility.
Subsidies are obviously needed. Otherwise poor people who aren’t eligible for
Medicaid would be unable to comply with the Obamacare mandate. And it is obvious that the subsidy for each
individual needs to be on a sliding scale based on that individual’s
income. But incomes can change, thus changing how much subsidy someone is
entitled to and sometimes causing loss of all eligibility. Furthermore, as people’s changing fortunes move them in
and out of Medicaid, the doctors who are
“in-network” for them can change, forcing them to find new providers.
All of these problems---the need to reimburse the government
for excessive tax-credits, the “churn”
as people drop in and out of eligibility for subsidies or for Medicaid, the lack of universal coverage which may have
started an Ebola epidemic in the U.S.---could have been avoided by enactment of
a single-payer insurance system covering all people in the U.S. and financed by
general taxes.
If Mr. Duncan had been covered by such an insurance system,
he might well be alive today and he might not have exposed so many other people
to Ebola.
Under a single-payer system people would still receive implicit
subsidies based on their income, but
this would be taken care of by the existing income tax system under which lower
income people pay less tax and higher income people pay more. The Supreme Court’s highly dubious reasoning
by which it allowed states to opt-out of Medicaid expansion would become
irrelevant, since with universal coverage
Medicaid would no longer be needed. There would no longer be doctors who are
“in-network” or “out-of network.”
A single-payer insurance system would not solve all our problems, but the problems with
Obamacare and the even bigger problems prior to Obamacare suggest we need to
enact one as soon as possible.
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This op-ed has run in The Lund Report.
