By Ezra Klein
Washington Post Staff Writer
Saturday, January 15, 2011; 7:21 PM
Good morning, class. Today's topic, as you know, is "The Evolution of the American Health-Care System" between 2010 and 2030. Before we begin, either turn off your iGlasses or make sure they're not set to holographically project whatever you're daydreaming. I did not like last week's glimpse into Alexa's subconscious.
As you're aware, 2010 was a turning point for the American health-care system: The Patient Protection and Affordable Care Act was signed into law. It was a clunky piece of legislation - the product not merely of a year of congressional negotiating and dealmaking but also of decades of defeats and diminished expectations for supporters of universal health care. After almost a century of failed attempts to extend coverage to every American, supporters gave up on perfection. Many of them even gave up on what they considered good. They just wanted to get it done. To do so, they embraced legislation similar to what Republicans had supported in 1993 and 2005.
Of course, that didn't mean Republicans liked it. After winning back the House in the 2010 midterm elections, they voted to repeal the law. As you might imagine, this effort didn't get far in the Democrat-controlled Senate. Shortly after, the Supreme Court refused entreaties to excise the individual mandate - the requirement that every person have health insurance - from the legislation. The law was here to stay.
In retrospect, for all the sound and fury it caused, the legislation was modest. It covered most, but not all, of the uninsured. It cut the deficit a bit. To give you an idea of its size and ambition - or lack thereof - when it was fully in place, the legislation accounted for about 4 percent of the country's health-care spending. But like a lot of things in American politics during that period, it was blown out of proportion. As we know now, the law was the first word in health-care reform, not the last.
The next big policy change came five years later, when the failure of a modest deficit-reduction bill caused the bond market to send interest rates on Treasury debt soaring. Congress got serious about deficit reduction, and fast. Three months later, the Balanced Budgets and Sustainable Growth Act of 2015 was signed into law. Among other things, it ended the deduction for employer-based health insurance and replaced it with a refundable tax credit for everyone, no matter where their coverage came from.
To appreciate the irony of this, you have to know that this was the core of Republican John McCain's health-care proposal in the 2008 presidential campaign. But Democrats objected to it because it would push people out of the employer-based market and into the individual market, which was a mess.
President Obama's health-care law, however, had replaced the individual market with exchanges in which insurers were tightly regulated - so, for instance, they couldn't turn you away for a preexisting condition, or quietly cap your benefits, or sell you a plan that wasn't really comprehensive - and consumers were pooled together, so they had bargaining power, rather than having to negotiate all on their own. In other words, it took ObamaCare to achieve McCainCare.
As the employer-based market eroded, a central barrier fell between the health-care system we had and the health-care system we could afford. Now that individuals were seeing the entire cost of their coverage, rather than letting the company HR department do the paperwork for them, they found plans that controlled costs more effectively a whole lot more attractive. This, in turn, gave insurers more leverage against hospitals and, thus, gave hospitals more incentive to work with insurers to cut costs.
It also created space in the country for a more sober discussion of health care. For many years, every serious conversation about cost control was derailed by the dreaded specter of "rationing." Of course, America was rationing the whole time - just doing it by income, so people who didn't have much money didn't get much health care. When there were hard choices to be made, the country tended to curl into a fetal position.
In 2009, critics of the health-care overhaul assailed a provision to have Medicare pay for sessions in which seniors could talk with their doctors about various end-of-life options - including options wherein no expense would be spared to save their lives. End-of-life counseling was spun as establishing "death panels." When the Obama administration put some money toward research into which treatments work and which don't, Congress attached language saying that Medicare and Medicaid couldn't use the results to decide what they would and wouldn't cover. Imagine that: They weren't allowed to use evidence.
But in 2019, at the urging of President Bobby Jindal, Congress passed the Health Care Equality Act, the third major phase of health-care reform. It fulfilled long-held conservative hopes when it moved Medicaid and Medicare onto the exchanges and allowed seniors and low-income Americans to choose between the government behemoths and private insurance. But it also opened both programs to all Americans - making them akin to the public option that Democrats had been unable to pass in 2010. And as part of the deal, both were given more freedom to use a flood of comparative data in deciding what treatments to cover or refuse, which allowed them to finally stop paying for volume and begin paying for quality.
Nowadays, America's health-care system isn't perfect, but it works much better. And it's no longer threatening to bankrupt the nation. It took several rounds of reform, each one building on the last. It was overdue, and it was slow and frustrating. But at least it got - Dammit, Alexa!