As someone unemployed for the first time in thirty years, I’m quickly learning the joys of securing “health care” in the individual marketplace—a reality that millions of Americans face every day without private employer-sponsored coverage, Medicare, Medicaid, or another military or government plan.
The choices on the health insurance exchange are unironically labeled as metals: Bronze, Silver, Gold, and Platinum for the super chi-chi medical services consumer. In the bottom tier, I’m now paying an exorbitant amount for family insurance through the Maryland exchange for what is essentially catastrophic coverage with massive deductibles and out-of-pocket costs.
The government calls these “low-premium” plans, a charade worthy of Catch-22. Pay steadily increasing rates for the privilege of shelling out even more if you actually need medical attention.
This is the “empty your wallet for few actual health services but you probably won’t go broke if you get the cancer” plan. Health insurance that costs as much as your mortgage, except you get no equity and nothing pleasurable or useful out of it.
Of course, one could simply forego paying this extortionist fee for the peace of mind of hopefully not croaking from the financial stress of landing in the ER after an uninsured motorist T-bones you drag racing on the streets of Baltimore because the authorities don’t enforce traffic laws anymore. You can’t fault any American in this position who decides, screw it, I’m not paying for health insurance and taking my chances.
Since I’m the sucker who ponied up, it got me thinking about a feasible way to patch up this hole in the system, especially given the realities of the American health care infrastructure, people’s existing preferences, and the serious limitations of the U.S. government.
Two ideas come to mind, not as complete “solutions,” but as possible avenues for reform:
Create a genuine public option for gig workers, self-employed people, and others without access to employer-sponsored insurance, with reasonable premiums and basic health care services that people can actually use.
Allow the more than 165 million Americans under the age of 65 who have employer-sponsored coverage to keep their insurance if they like it.
This isn’t single-payer insurance. It’s also not the status quo. It is a new arrangement that would acknowledge the reality of how American health care is currently organized yet improve it a bit with a fair and useful new coverage option for those without employer-sponsored or other government-provided insurance.
If this hybrid public-private approach to health insurance sounds familiar, it is. Back in the Obama era, a more expansive version of the Affordable Care Act (ACA) was supposed to do something along these lines. The public option was ultimately dropped from the legislation after opposition from moderate Democrats and industry groups, while Republicans rejected the entire structure of Obamacare. The individual mandate penalty was later reduced to zero, while the ACA’s subsidy structure has been altered and expanded and then reduced again.
The net result of all this political wrangling over Obamacare is a system in which Americans without employer-sponsored insurance find themselves paying increasingly steep premiums while also facing high deductibles and expensive direct payments for actually visiting a doctor or going to a hospital. Not surprisingly, many people forced on to the exchange dislike these plans and can’t afford them.
Perhaps it’s time to bring back debate about the public option.
On the left, the shiny new (old) idea from progressive candidates this election cycle is “Medicare for All,” a nifty slogan that uses the popular health insurance program for seniors as the basis for a government-financed system for everyone. It’s not entirely clear what the right actually wants on health care these days, but it’s some basic combination of more market-driven approaches, more consumer control, fewer insurance middlemen, and more direct payments to doctors and other providers using tax-advantaged health savings accounts.
If you could snap your fingers and go back to the 1950s, the United States arguably would have been much better off establishing a nationalized health care system from the beginning in the aftermath of World War II, much like the United Kingdom and other European nations did.
But that’s not what the U.S. government pursued.
Instead, employer-sponsored health insurance developed into the primary form of coverage for working-age Americans through favorable tax treatment. Later, the government set up Medicare for seniors and Medicaid for low-income Americans, creating a complicated mix of private and public insurance that evolved over several decades.
Unfortunately, you can’t redo history. Institutions develop over time, and policy is path dependent.
The United States, for better or worse, has built a gigantic private health care system with large insurance and drug companies and millions of administrators, hospitals, doctors, nurses, and other workers employed within it. We also have a major public program for seniors that interacts with the system through payment rates, reimbursements, supplemental insurance programs, and private Medicare plans. And we have countless private contracts and institutional arrangements that determine how and when people receive medical treatment.
Changing course on the U.S. health care system is immensely complicated. So the better path forward might be to fix what needs to be fixed without fundamentally blowing up the system, which more radical ideas intend to do.
If more and more Americans under the age of 65 are falling through the cracks of employer-based coverage as the economy changes and can’t afford the costs of individual-market insurance, let’s create a new public pool for them to buy into with reasonable premiums and basic health services that people can access. At the same time, let’s implement some market-oriented ideas to reduce unnecessary regulations, increase price transparency and competition, and discourage excessive tests and other expensive treatments that provide little benefit relative to their cost.
Draw a little from the left and a little from the right. Do something for the millions of Americans left to fend for themselves in America’s health care jungle.
If health care reform is going to build sustained support among Democrats, Republicans, and independents, it will probably need to be a compromise and hybrid plan that can actually pass and be implemented over several years.
Maybe not a platinum plan, but a gold star for normal Americans.
60 years or so ago, insurance was mostly for hospitalizations or catastrophic reasons. Our family doctor had one nurse in his office and no other staff. My mom directly paid the Doc. We were working poor, but my family had no problem paying the bill because it was reasonable. Once insurance starting paying for routine or sick visits, a monster called bureaucracy took over everything. The health care system created lots of jobs to bill payments, process payments, monitor payments, negotiate 100s of different contracts which means prices vary, etc.
Also, I have witnessed the mindset change for people with insurance as most go to doctor for any minor reason which increases insurance premiums eventually. The mindset change also clogged doctor offices causing a shortage of doctors which created urgent care centers (more bureaucracy costs).
Quite frankly, it's a mess. Perhaps the only way to fix it is to return to the old ways which worked. Eliminate all insurance but for catastrophic.
As an aside, you are one of the few journalists remaining who tries to be unbiased. We desparately need folks like you.
FELLOW BALTIMORON HERE. THIS IS THE MOST BALTIMOREY SENTENCE: Of course, one could simply forego paying this extortionist fee for the peace of mind of hopefully not croaking from the financial stress of landing in the ER after an uninsured motorist T-bones you drag racing on the streets of Baltimore because the authorities don’t enforce traffic laws anymore.
I'm in a similar boat. Recently unemployed. We ponied up for COBRA which we knew was going to be expensive, but not DAMN THAT'S EXPENSIVE expensive.