Op-Ed

According to Republicans, Obamacare has been one of the great catastrophes of the Obama era. Many, however, believe it is the key to quality universal care, but Democrats routinely made promises about the bill and its effects that are now under question. And that's why Republicans recently abolished the individual mandate in the most recent tax bill that passed.

But why repeal the pre-existing conditions provision? Allow me to explain.

Effects on Companies and the Market

Basically, what the provision does, is it forces companies to lower the cost of insurance for people with pre-existing conditions to the same price as insurance for people who are completely healthy. While it may seem like a more fair system, it does affect our market.

To a health insurance company, the cost of a patient with a condition is much more than the cost a patient who is completely healthy. It would make sense for the company to charge more for high-risk patients because the services they need to remain healthy do cost more. What is fair to the patient, becomes unfair to the insurance company. While the healthy person may only need a routine checkup every 6 months, the unhealthy person may need weekly check-ups, medication, x-rays, MRI’s, or even surgery.

By forcing companies to lower their prices for people with pre-existing conditions, providers begin to lose money. In order to stay afloat, which would benefit everyone who has insurance, they would have to raise their prices, and because they have to charge everyone the same price, companies raise prices across the board. This leads people without any conditions to be charged much more than they should be.

According to the National Conference of State Legislators, exchange prices are expected to rise an average of 34% for Silver Plans and 38% for the Second Lowest Cost Silver Plan for 2018. This increase in the price continues until individuals and families who can’t afford to pay for them decide to drop their plan.

Increased competition is a combatant of increases in pricing, so the market can regulate itself through more competition.

Unfortunately, because of a lack of revenue for insurance companies, many have gone out of business.

In 2017, there were seven states with only one exchange carrier. Over 50% of all counties in the US, 1,565 to be exact, will have only one carrier this year. Countless other counties will have only two or three carrier options for its constituents.

More people are forced to decide whether they want to pay insane amounts of money for a plan or drop it and lose coverage. If one decides to cancel their plan, the Affordable Care Act has even more in store for them. Not having a healthcare plan is going to cost you. As of 2016, the Obamacare tax was raised to 2.5 percent of your adjusted gross income, although the Trump tax plan eliminates it in 2019. The only alternative to the tax or purchasing health insurance is Medicare.

The way our system is set up, Medicare has reimbursement rates for each procedure set at the federal level. When a doctor accepts a patient on Medicare, they accept payment according to the Medicare reimbursement rates. This means if a procedure costs $200 to do, but the Medicare reimbursement is only $100, the doctor is only getting $100.

Low Medicare reimbursement rates discourage doctors from accepting it. According to a Merritt Hawkins survey, the average rate of physician Medicaid acceptance is 53% in major metro markets and 60% in mid-sized markets. These doctors lose patients and eventually go out of business. A Physicians Foundation survey of America’s doctors found that 62% of physicians were independent in 2008. By 2014 that number had dropped to 35%. The next generation of doctors knows that the money formerly associated with this field is not there anymore.

A report from the Association of American Medical Colleges found that America faces a shortfall of 61,700 to 94,700 doctors over the next ten years.

There is a major consequence of clinics closing down, providers going bankrupt, and a decrease in the number of doctors.

Because the remaining physicians now have many more patients, wait times have gone up an incredible amount. A more widely insured population, coupled with lower amounts of private practice doctors, has driven increased demand for a lower supply of physician services and correspondingly longer physician appointment wait times. A Merritt Hawkins survey found that on average, people waited 24 days for an appointment in 2017, up 30% from 2014.

And this is why so many Republican lawmakers are trying to get rid of the pre-existing conditions provision. If it remains in place, these results will only be exasperated. The repeal of this provision will allow our population more freedom, decrease the price of a plan on the exchanges, and reinstate medicine as a flourishing field with endless possibilities.

Effects on Consumers

Companies have risen insurance prices for everyone to offset the cost of providing care for people with pre-existing conditions. This means that the general population must endure an incredible increase in the price of their healthcare, specifically for employee-sponsored plans. In 2008, the average employer-sponsored family plan cost a total of $12,680, with employees footing $3,354 of the bill, according to Kaiser data. By 2016, the cost of the average employer family plan was up to $18,142 for the year, with workers picking up $5,277 of the tab. This 50% spike over 8 years has hit the middle and lower class families the hardest, as many of them have not been able to keep up with payments and have dropped their plans.

The majority of the 27.6 million non-elderly uninsured Americans in 2016, according to a Kaiser Foundation study, were in low-income families and have at least one worker in the family. The study also concluded that, in 2016, 45% of uninsured adults said they remained uninsured because the cost of coverage was too high. This rise in cost has also affected the income spend of the general population. A study by the Commonwealth Fund, done in 2016, found that the average American family spent 10.1 percent of its income on health insurance premiums and deductibles, up from 6.5 percent a 2006, and increase of just over 55%.

Fewer doctors accept Medicare every year and as a result, emergency rooms are filling up with medicare patients, because they have nowhere else to go.

This creates much longer emergency room wait times for patients. Emergency rooms get flooded with minor injuries such as a sprained ankle or a cut. Because of the losses of private-practice doctors, wait times for checkups has also gone up, as mentioned previously. Patients are now waiting 24 days, up 30% from 2014. If waiting for surgery, this could be a matter of life and death.

As stated before, a major consequence of clinics closing down, providers going bankrupt, and a decrease in the number of doctors is a lack of options in the marketplace. This provides consumers with fewer choices that may cater to their needs. With seven states having only one exchange carrier in 2017 and 1,565 counties with one carrier this year, the population in those areas will only have one or two affordable options to choose from.

If they receive health insurance from their employer, they don’t have any options. This lack of options also affects the types of care present in the market. If a majority of the population only has two forms of care available to them, and neither plan covers dental, for example, the population has no say as to whether they can get dental. If there are 15 options for consumers and three of those have dental coverage, consumers can choose whether they want dental or not, allowing the population to decide.

Even in the worst-case scenario: a single-parent family with no stable income and a child with a pre-existing condition - the child would be covered before Obamacare passed. Any child/dependent was covered under their guardian’s plan up until the age of 24, so it wouldn't affect anyone under that age. Obamacare simply raised that age to 26. Their condition would only start affecting them, from a price standpoint, once they reach the age when they must purchase their own insurance.

Comparisons to Other Nations

There are three characteristics to any healthcare system: universality, quality, and affordability.

In a functioning system, only two will express themselves. Almost all other countries in the world have accepted universality, so one of the other two was sacrificed. The three countries that best show the universal healthcare system are Sweden, the UK, and Australia.

Sweden

In Sweden, they have embraced full-fledged universality. Quality is incredible, although lacking in some parts, such as wait times. The national guarantee of care, Vårdgaranti, lays down standards for waiting times for scheduled care, aiming to keep waiting time below 7 days for a visit to a primary care physician, and no more than 90 days for a visit to a specialist. It does not however, always deliver. A child with psychiatric problems may often wait 18 months for an appointment, according to the Euro Health Consumer Index in 2015. Unfortunately, they have sacrificed affordability, as the taxes in Sweden are some of the highest in Europe. Right now, the tax rate stands at 57.1% for personal income and 25% sales tax. The Swedish government doesn’t really have to worry about military spending either, as the US provides most military services for Sweden.

The UK

The UK has also embraced universality, but has sacrificed quality, as they strive to be affordable for their citizens. Their National Health Service (NHS) has many problems though. They face extraordinary staff shortages and can’t keep up with demand. According to the UK Independent, district nurses declined by nearly 50 percent from 2000 to 2014 and 15 percent from 2014 to 2016. Patients face exorbitant waiting times.

A report from the Patients Association found that "tens of thousands of" patients seeking routine surgeries had to wait over 18 weeks. Additionally, more major operations, such as hip and knee replacements, had average wait times of over 100 days.

Numerous unnecessary deaths occur under the NHS. A study conducted by the London School of Hygiene and Tropical Medicine concluded that around 750 patients a month – one in 28 – pass away due to subpar quality of care, which includes "inattentive monitoring of the patient’s condition, doctors making the wrong diagnosis, or patients being prescribed the wrong medicine."

Australia

Australia’s public healthcare system is universal and affordable, but sacrifices quality. You won’t have to pay for your care, but you will have to wait for it. Your general practitioner usually determines what medical treatment you need to manage your condition and symptoms, not a specialist, as most developed countries do.

If your GP believes you do need to see a specialist, he will send a letter to the local public hospital, which will be reviewed and assessed by the hospital. If the referral is accepted, you will be put on an outpatient wait list to see a specialist. If your situation is urgent, you will be attended to within 30 days, of being added to the waitlist, not from when you first saw your GP. Semi-urgent conditions have a wait of 90 days and non-urgent problems wait one year. Your wait may be longer or shorter.

Urgent surgery might not be assessed for 30 days. A cataract keeping someone from reading or driving might not be removed for up to a year. You will be given an appointment, perhaps not on a day you prefer. Sure, you can change it, but that means going to the back of the line. You will also see the specialist they assign you to. If you don’t like your doctor, you can request a change, but you will have to get back in line for a new appointment. I do, however, support the Australian private healthcare system, which performs with low mortality rates and quality care.