Fixing the Healthcare Fix

The Affordable Care Act — i.e., Obamacare — may have been the most extensive and wide-reaching alteration of American health law since the passage of Medicare and Medicaid in the 1960s, but we should not fool ourselves into thinking that it is anything more than a half measure that is making it more difficult to move real health reform forward.

Individual elements of the law remain popular and should help insurance consumers, but the law as a whole is viewed with disdain by a broad majority of Americans, and it is difficult to see how what essentially is a massive bureaucratic overlay on a broken health insurance system will ever gain the kind of support that still exists for Medicare.

The most recent news — another retreat by the Obama administration on implementation, this one designed to safeguard vulnerable Democrats — is unlikely to help. Instead, it contributes to a narrative of ineffectiveness and inefficiency that has plagued the ACA almost from the beginning.

Let’s be clear: The Republican narrative that paints the ACA as anti-freedom is absolute BS. But so is the Obama narrative that describes a new era of broad access and universality. The law assumed 15 million or so Americans would remain without coverage — a vast improvement, but well short of universal coverage. That said, many of the changes put in place are truly positive and the ACA offered a significant improvement over the status quo.

But it is not the best we can do. While costs are coming down, we still pay double what other modern, industrialized nations do for care even though our health outcomes remain among the worst in the industrialized world. Part of this is our extreme economic inequality — those without money also lack access to good doctors and services — and part is tied to our reliance on a corporate food system that pimps obesity and processed foods and has helped drive up the cost of more natural alternatives.

The American health system is to blame, as well, especially in its reliance on private insurance and a fee-for-service model that creates incentives for doctors to push expensive treatments. These two elements are in tension, to be sure — the insurance companies’ goal is lower payouts (though not necessarily lower costs) while doctors and hospitals charge for every service, every device, every supply, often at absurd rates ($30 for a squib of gel for an ultrasound?) looking to increase their own take.

The system treats care as a commodity — to the benefit of insurers and the large institutional players. Doctors and other providers see fewer benefits, while the medical consumer is left in the dark and the American economy is tethered to the beast.

The ACA offers some incentives to explore alternatives, but it leaves the larger system in place. While there is some evidence that the ACA is “bending the cost curve,” as the bureaucrats say, it can only do so much. So long as we assume that a portion of every dollar spent has to go to a battery of administrators and corporate boards and that our goal is piling procedures and tests upon procedures and tests, costs can do little but continue to rise — even if the rate of increase is shrinking.

Is there a solution? Expand Medicare. Medicare has proven to be the most efficient element of our healthcare system. Its administrative overhead is low and its results are generally positive. Critics will point to its growing deficit, which is real, but not to its primary causes. Medicare treats the oldest and sickest portion of our population, while being funded by a dedicated payroll tax. Expand Medicare to everyone and you unify a fractured system that treats populations differently and carves up risk pools to the benefit of insurers, while spreading costs across a broader and more diverse (health-wise) population.

(We also need to stop paying by the service and instead pay based on the concept of caring for the patient as a whole. I won’t go into detail on this, but there are models for how this might work.)

Basically, we have to redefine health care as a right. It is unacceptable that access to care remains tied to income — the working poor, even those on Medicaid, are forced into an inferior system, either because of ability to pay or because of a de facto medical segregation.

We need to root out profit. The free market in healthcare is not free. Allowing corporate America to continue skimming cash from the top of the medical care industry is wasteful and counterproductive. It redirects money to corporate pockets that, otherwise, could be used to improve care. And improving care should be our goal, rather than building a better insurance system or underwriting a system that treats care as a commodity.

Hank Kalet is a poet and journalist in New Jersey. He writes about poverty and urban issues for NJ Spotlight and teaches writing and journalism at Rutgers University and Middlesex County College (Edison, N.J.). Email,; blog,; Twitter, @newspoet41 and @kaletjournalism; Facebook,

From The Progressive Populist, April 15, 2014

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