The Default Option

As the 2010 election looms, the rhetoric about health reform is muddled. Repeal of Obamacare is an effective rallying cry for people who dislike the President and/or his policies. However, outright repeal has some big problems, mainly that the default option in our health system is for increasing numbers of uninsured persons even while the health system in unsustainable due to cost.

The U.S. Census annual report on health insurance came out last week and reflects the experience of the nation in 2009, so the baseline or default to which we would return with outright repeal of PPACA. Several points stand out:

• This is the first time since figures were tracked the absolute number of people with insurance declined (255.1 M to 253.6 M)
  
• There were more persons covered by Medicaid than by Medicare, also for the first time (48 M v. 45 M)
• The proportion with employer based insurance is the lowest in percentage terms ever, as is the proportion with government financed insurance

Big picture, if PPACA is repealed, we default into a system described by 3 in 6 Americans with employment based health insurance; 2 in 6 with government provided, either because the beneficiary is low income or age 65+; and 1 in 6 who is uninsured.

PPACA will expand the ranks of the insured, with the expansions roughly equally split by Medicaid and private insurance. We will still face many hard decisions necessary to develop a system that is sustainable due to cost. However, the default places us firmly in the camp of still having to face the same difficult questions about sustainability, but without having taken any steps toward doing so, and with many more persons who are uninsured.

We will never gain control over spending without providing at least some manner of insurance coverage to everyone. PPACA does not reach this goal, but is moving in that way. And it doesn't do enough to address health care cost inflation, but again, is a great deal better than nothing, in one sense because the first steps of PPACA ensure follow up steps.

For many, the cry of repeal PPACA has a pleasing ring to it. The health policy reality if that were achieved is grim.

update: Kaiser Health News has story about how 'repeal' is better as a slogan than a health policy strategy. Update 9/21: still more on lets catch the car.