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Notes -
What will the future of the US healthcare system look like?
The current system is a patchwork of primarily employer-sponsored healthcare (60% of non-elderly Americans), the ACA marketplace (offering government-approved plans through private insurance companies), Medicare for the elderly, and Medicaid for the poor, disabled, and children. About 8-9% of the population is uninsured. Prices are higher and health outcomes worse than comparable developed countries.
Obamacare attempted to reduce the uninsured population by, among other things, implementing Medicaid expansion to all adults under 138% of the federal poverty level and granting tax credits to help defray the cost of marketplace plans (for incomes up to 400% of the FPL). During COVID, these subsidies were increased and expanded to higher income levels, but Congress allowed them to expire this year, resulting in average premium increases of ~114% for about 22 million people, although an additional vote is scheduled this month.
In addition, low-income adults utilizing expanded Medicaid will be required to demonstrate 80 hours of work per month starting in 2027. Mike Johnson framed this as kicking out unemployed young men mooching off the system - even the old welfare queen trope has been de-DEIified. Georgia already implemented a similar work-requirements program as part of their Medicaid expansion in 2023, resulting in the bulk of the money going to administrative costs and only about 9k out of 250k low-income adults enrolled.
As a result of all of this, the uninsured population will likely increase this year, which may even cause premiums for people with health insurance to rise due to a death spiral effect - if more people are uninsured and can't pay their medical bills, the costs may be shifted to covered patients.
The above article takes the pessimistic view that the system is unlikely to improve significantly, because tying healthcare to employment is such a nice perk for employers (the system started during WW2 when companies offered health insurance as a replacement for wage increases due to federal wage freezes). European or Canadian style universal healthcare certainly seems less likely than ever.
Assuming that this person is correct and that ACA enrollment is increasingly becoming dominated by early retirees I would expect the enhanced subsidies to be reinstated fairly quickly A. because Bill and Shelly vote in midterm elections and B. because doing so is easier (and maybe cheaper) than expanding Medicare eligibility to 55+ or whatever.
I've already said that Mike Johnson's crusade against gamer NEETs on Medicaid is a smoke and mirrors show to distract from the fact that unless we undo the ACA's Medicaid expansion (which mostly covers the working poor), there isn't much we can tweak in terms of eligibility that will actually cut costs.
An unfortunate occurrence in the last few years is that the Great Recession through Covid era of stagnation in healthcare spending has ended and healthcare spending is again growing faster than the economy, such that we're rapidly heading for healthcare spending making up 20% of US GDP.
The above is why I assume that we're nowhere near a universal system. No country with such a system spends as much of their economy on healthcare as the US does. Germany is the closest and the US spends about 50% more of its GDP on healthcare than Germany. For reference, if we moved to a German level of healthcare spending we could nearly triple the defense budget (which is currently about 3.5% of GDP). For another fun comparison, what we spend on healthcare now is pretty similar to the entire revenue of the federal government. Put simply, I don’t think that the US has either the capacity to bring healthcare spending in line with other OECD countries (which would require mass firings and/or salary cuts that would hit a well-educated and engaged chunk of the electorate) or the ability to raise taxes enough to cover said spending, so I assume that the system will remain largely as-is.
Even if you’re cynical enough to regard health insurance companies as make-work programs for bureaucrats, they’re a necessary evil because they’re also the paypigs that keep the whole thing afloat. Privately insured patients are the only ones that medical providers actually make money treating (Off the top of my head, Medicare patients are close to break-even, Medicaid patients are a net-loss, and of course the uninsured are near-total write-offs.) and unlike House representatives are able to impose payroll taxes on corporations and the upper-middle class without getting kicked out of office in the next midterm.
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