The reactions to yesterday’s Obamacare decision keep coming. We can’t comment on legal reasoning, though for some analysis on that see Jonathan Adler’s piece at the Washington Post and Abbe Gluck’s entry at SCOTUSblog. However, though from a policy perspective we are unhappy about Obamacare—it is a deeply flawed and in many ways counterproductive intervention—the chaos that would have followed a Supreme Court ruling to throw out the exchanges would have been very far from ideal.
Now that the last substantive legal challenge has been settled, the conversation needs to turn to where it should have been all along: given that Obamacare exists, what is the next set of reforms that the health care system needs? Some of those reforms will involve undoing the damage that Obamacare does, but won’t amount to a complete, across-the-board repeal. Others will involve tweaks to Obamacare as the full effect of the law gradually takes hold. Even today some of the most controversial and life-changing features of the law have been delayed—largely because Democrats fear that they are too unpopular.
But the real business of the nation remains what it was before Obamacare was anything more than a line in a campaign speech: figuring out how to make American health care better, faster, and cheaper. The problems with U.S. medicine are well known, and remain true in the ACA era. We pay more than other countries without getting appreciably better mass outcomes. Americans, even with subsidies, have trouble accessing the kind of care they want. Prices are hidden, and many standard medical delivery systems are inefficient and outdated.
There are features in law and policy that makes these things worse, and the sooner we start on the work to transform those features the better. One key area of effort is to apply IT to medicine in order to transform diagnosis, record-keeping, and personal health care. That means updating national record-keeping to the information era, Uberizing health care with universal records so that a patient can walk into a clinic where practitioners can access your total medical history. We need to make much better use of health tracking, monitoring patients’ health and managing chronic conditions remotely. With help from computers, medical personnel with less extensive education and training can provide more complicated and sophisticated treatment without direct doctor supervision. New technology can even empower individuals to do more DIY health care for themselves.
There are other important areas of reform, too. We urgently need to disconnect insurance from employment in a world of shorter-term jobs and more part-time work. Price transparency is a low-hanging fruit, and gives consumers incentives to save and consume care responsibly. Other ways to promote thrift need to be explored. We should reform tort liability both to eliminate excessive and expensive lawsuits and to reduce the incentives to over-treat. Making it easier for foreign-trained practitioners to get U.S. licenses and work visas will lower the cost of care. Allowing, and even encouraging, long-term retirement abroad could help us save on eldercare as older Americans use Medicare to pay for (often cheaper) care abroad. Health care “tourism” to those cheaper locations for those who want it will also save money.
In a healthy medical system, health outcomes will be improving, the costs of most procedures and treatments will be falling, and it will be easier to offer universal access to more benefits because the benefits themselves are becoming more affordable. In a healthy health care system, fewer people should need subsidies to get health care, and the level of subsidy needed should come down as well. For most people insurance should be a method of financial planning (spreading your costs over time rather than paying them in big lumps) plus a safeguard against catastrophic events. It should not be a necessary, and necessarily subsidized, lifeline giving access to a system that is so grotesquely expensive than only the very wealthiest members of society can actually pay for what they need at the prevailing prices.
When you look at it that way, we still have a very long way to go to get to that kind of system. But the good news is we have many of the tools to get there already, if only we have the intelligence and will to use them.