By Dr. Louis Balizet

The future of the Affordable Care Act could go in four very different directions: repeal, remain unchanged, keep and fix, or move on to something else. Let’s look at each one.

Option 1: Repeal.

Dr. Louis Balizet

It’s not going to happen. Even if the Republicans sweep Congress and the White House in 2016, they will almost certainly recoil at the political blowback of depriving 10 million to 20 million Americans of health coverage gained under the ACA. As Ted Cruz warned in July 2013 as he urged his colleagues to repeal Obamacare, “addiction to the sugar” of health insurance will make it impossible to retract once in place.

Too late now, as Cruz warned; the genie is out of the bottle.

Option 2: Leave unchanged.

This is the most likely option, but it’s very problematic. Obamacare’s overwhelming complexity, becoming more apparent with time, threatens to cripple an already daunting health care system. A few examples:

• People who switch plans under the exchanges will discover that they can skip their December premium with impunity – they’re covered in December under their old plan’s “grace period” and in the ensuing January under their new plan. What’s not to like?
• When 2015 premiums are finally divulged, there will be more than a few double-digit jumps (as foretold by preliminary data revealed by the Wall Street Journal in May). How much more will the government be forced to expend for subsidies? Will more purchasers be forced into (quasi junk) bronze plans? Is the beleaguered IRS really going to enforce penalties on the uninsured either this tax year or the next?
• What will happen with the long-delayed and poorly understood employer mandate, due to kick in next year (for companies with over 100 employees) or 2016 (for those with 50-100 employees)? Will it be a debacle to rival the initiation of the individual mandate? If so, can the system survive another such hit?
• Shrinking provider lists, deployed by insurance companies to keep profits intact while minimizing premium increases, threatens to seriously disrupt continuity of care. As an example, one Colorado carrier, Colorado HealthOP, “encourages” its policyholders in mountainous Summit County, plentifully supplied with physicians, to drive 60 miles to Denver for cheaper care.
• The ACA’s legal complexity invites monkey-wrenching by its opponents. The Supreme Court in 2012 allowed states, if so inclined, to opt out of Medicaid expansion. Two dozen Republican-led states have done so, thus withholding Medicaid coverage from 5 million, causing an estimated 7,000 preventable deaths, and creating the new “donut hole” of people making too much for Medicaid but not enough to get subsidies under the exchanges. Recent dueling circuit court opinions regarding the legitimacy of subsidies in federal exchanges promise more opportunities for mischief if the Roberts Court decides to weigh in. Elimination of subsidies in the federal exchanges, coupled with only partial Medicaid expansion, could sound the death knell for nationwide Obamacare; it would devolve into a patchwork program fully available only in a minority of (largely blue) states with both Medicaid expansion and their own state-run exchanges.

Option 3: Keep Obamacare, but fix it (reform the reform).

The ACA is so poorly constructed, and so complex, that fixes are daunting even if there were legislative will (itself unlikely in the extreme).

How do you force Medicaid expansion on states whose governors or legislators oppose it? How do you smooth out the rough interfaces between eligibility categories that are baked into the system? Will the federal exchange be able to replace failed state exchanges, such as Oregon’s? What happens if employer-provided insurance withers and dies as companies, especially smaller ones, find themselves unwilling or unable to contend with the employer mandate and throw their employees, as individuals, onto the tender mercies of the exchanges? What if more companies get religion and object, a la Hobby Lobby, to one or another mandated benefit on theological grounds? Already three Colorado companies are preparing suits to exempt them from providing contraception to their employees. What cost-control mechanism is available now that the Independent Payment Advisory Board is moribund? What about rebellion as hidden costs (such as fees exchanges exact from insurance companies and federal ACA taxes on health insurers) expand and become more apparent? State-by-state innovation is unlikely to improve or substantially replace Obamacare. Vermont is in the vanguard of such efforts and is encountering obstacles, ranging from difficulty in getting Medicare waivers to recalcitrant employers headquartered out of state, that threaten to derail the process.

Obamacare is the Yugo of health policy – poorly designed, unpredictable and hard to fix. The Yugo did indeed provide transportation for many people for a while, but ultimately it disappeared. Leading us to:

Option 4: Leave Obamacare intact while we transition to something better.

Like it or not, Obamacare, with all its failings (termed “glitches” or “clunkiness” by its defenders) is here to stay for the foreseeable future. Shame on us as a nation, however, if we content ourselves with the inadequate, unpredictable status quo. The only alternative is single-payer universal health care, variants of which are the norm in all other developed countries.

The same political forces that created Obamacare and then worked to sabotage it, would seem to argue against the likelihood of such a lurch to the left. However, sometimes things need to get really bad before they get better (think 1941).

Obamacare is shaky and its enemies legion. If Obamacare totters, perhaps we and our leaders will finally see the wisdom of what we should have done in the first place: enact improved and expanded Medicare for all for life.

It would be nice if we could avoid a Pearl Harbor moment in the meanwhile.

Louis Balizet, MD, is a recently retired oncologist from Pueblo. He’s a member of the advocacy group, Physicians for a National Health Program, and a leader of Health Care for All Colorado.