The ACA is Constitutional, but Still Terrible

The Supreme Court upheld (on narrow and clever grounds) the Affordable Care Act. So, for those of us who had our fingers crossed that we could start over, we’re going to have to look to our elected officials for help. To be certain, the health care system in the United States has some problems. Some of those problems are huge and pervasive. The ACA is the epitome of everything that sucks about compromise: nobody gets what they want and you run the risk of the outcome carrying the worst traits of the proposed solutions.

The left wants to fix everything right now. The right wants the federal government to have no part in it.

Neither of those are viable alternatives, and what congress ended up with in the ACA was a deal with the devil. The left sold its soul to the health insurance industry for some short-term gains to coverage levels. In exchange for some platitudes from the health insurance lobby, congress handed them millions of new, mostly healthy customers, a demographic known to health insurers as “free money.”

In typical American fashion, once we agreed there was a problem, we demanded an immediate fix, without regard for the long-term consequences. With a bit of patience, we could have something both better and easier.

To be certain, I’m no big fan of big government. I’m skeptical. I’m fairly certain that the primary role of big government is to generate inefficiencies that are then paid for by taking money from people who, largely, have no idea what it is being taken for.

Still, I’d prefer, if we’re going to do it, that we do it the right way. The federal government needs to either get its nose out of the health care market or it needs to go in all the way.

So what’s the better, easier solution? An iterative approach. We currently have a Medicare system that works reasonably well. It’s expensive, sure, and it is not without its own issues, but as health care goes, Medicare is a pretty good safety net. Medicare has an eligibility age. Currently, that age is 65. This means that medicare currently serves around 40 million people.

So let’s talk to CMS. Tell them that we want to add 4 million people to Medicare. We give CMS three directives: 1) tell us what age we need to drop Medicare eligibility to in order to make that happen, 2) Make any and all preparations that are required, including budget requests or other congressional acts, 3) Tell us when you’re ready. Then we send CMS to work, letting them take as long as they think they need. Once they’re done, we drop the age and wait. We react to whatever unforeseen problems that influx causes, and then we repeat that process, adding another 4 or 5 million.

This process can continue until we have 100% coverage in Medicare or, in other words, until we have a single-payer system.

This provides some huge benefits: first, we’d be growing within our capacity. We’re not trying to fix things all at once and running into problems scaling federal services. Second, it allows for periods of time in which uncooperative legislatures refuse to participate, but it does so without endangering the eventual goal — if you think there’s a political party with the clout to take federally funded healthcare away from an age group once they’ve given it out, you’ve lost your mind1.

This plan isn’t without its issues. Specifically, that it could take a while — maybe a decade or more — to get where we need to be. Second, there are going to be growing pains. One such growing pain will almost certainly be a tipping-point — the point at which Medicare has sucked up such a huge percentage of Americans that private health insurers are no longer viable.

This latter concern is possibly farther off than it might seem at first. Consider that some of the most expensive patients are the oldest ones. We’d be taking some of the private industry’s customers, yes, but we’d be taking loss centers not profit centers. At first, this would be a boon for health insurers. There’s also the possibility that this gradual change would allow health insurance to shift from being a primary source of funding to offering supplemental funding for optional, experimental, or other care deemed inappropriate by Medicare.

Still, there may come a point that health insurers simply don’t have a pool big enough to swim in, and Medicare suddenly has to take on a larger-than-planned-for influx. This is something that should be a part of the CMS evaluation at every step: can health insurers survive after our next expansion? If not, we need to plan for our next step to be the final step.

Simply put, we need to treat healthcare like an engineering problem, not like a political, moral, or ethical problem.

Until then, I suppose we deserve what we get.


  1. Contrast with the ACA, which is a giant political football, just begging for a Republican congress to repeal or neuter.