The Coming Evolution of Obamacare

Updated August 30, 2013.

Florida and Texas are the largest of 27 states that either have said they won't establish a state run medical insurance exchange or have yet to decide what they are going to do about that pivotal part of the "Patient Protection and Affordable Care Act," now and forever nicknamed Obamacare.

Another part of the act, Medicaid expansion, finds the states even more conflicted  The Supreme Court has ruled that part of Obamcare is voluntary.  Florida and Texas lead the south in near solid opposition, and most states haven't decided, despite the generous terms on offer if they do.  The 17 million Americans now without health insurance, who would be newly eligible for Medicad, will have to cool their heels in emergency rooms a while longer.

On another front, over 1,700 businesses  have received waivers postponing their participation in Obamacare until 2014.  It seems clear that its roll out will be slow.  Even after tardy businesses begin to comply it is quite possible that many will opt to pay a fine rather than offer their employees health plans that conform to Obamacare regulations. 

Far from being dismaying, these developments are just what the doctor ordered for we who advocate a single payer federal system. They will let Obamacare evolve as follows:

1) Employers, already disposed to do so, will continue to shed or emasculate employee medical benefits the better to compete locally and globally.  The penalties for not complying with Obamacare are not apt to rise at all, while the costs of health insurance will continue up.  In time paying the fines will be the more sensible route.

2) In tandem with the decline in employer medical benefits, iinsurance exchanges -- whether federally, state or jointly run -- will gradually become the market places where most Americans buy health insurance.

3) Medicaid will expand gradually, but inevitably, as state intransigence wanes in the face of withering public outrage.  This will save the Feds gobs of money in the near term while laying the blame for heartlessness where it belongs. 

4) Gradual Medicaid expansion will buy the medical professions time to recruit and train caregivers from around the world to meet the expanding need. This would alleviate what could have been a  biding war for suddenly scarce skills and a consequent steep rise in medical costs that might have proved fatal to Obamacare while in its cradle.

5) Medical insurance offerings will become standardized into a menu of plans easy to understand and compare, leading to markets competing predominately on price like retailers at Christmas time. This will squeeze profits more effectively than any number of costly regulations, and will lead the insurance industry to depart the medical insurance business except as contractors for the Feds. 

6) As with flood insurance, hurricane insurance in Florida and earthquake insurance in California, government will fill the vacuum by popular demand.  The five medical insurance programs -- Medicaid, Medicare, Obamacare, Tricare (for the military) and the Federal Employee Health Benefit Plan (Civilcare?) -- run by the Federal Government will thus come to insure nearly all Americans.

This outcome may not be called "a single payer system," but it will look, act and quack like one.  In a generation these systems will converge and a Health Security Administration will take its place along side the Social Security Administration within the Department of Health and Human Services. This will be called socialism, more black UN helicopters will be seen patroling our boarders and we will be accused of being just like Europe.  And not a moment too soon.

Of course it will be far from socialism.  Most of us will still have to select a plan from among insurance company offerings.  Most of us will choose among benefit plans offered at work either as primary insurance or as a suplememt to Medicare.  Others will shop through state exchanges especially if you work for a comany with fewer than 50 employees.

Doctors and other medical providers will still practice separately or in privately organizaed groups.  Hospitals will still be free to be non profit or for profit corporations.  We will still be constrained by which doctors and hospitals are acceptable to (cozy with) our insurers. The system will look a lot more like Germany's, which also keeps a role for insurance companies, than England's, in which medical resources are deployed by the state.

Obamacare will also like a Republican proposed plan, which was developed by the Heritage Foundation, a conservative think tank, in response to Hilliary Care/.  Yes, you understood right: Obamacare was first proposed by the Republicans under a different name.  Wonder what happened?  Join the crowd.