America is in denial about the depth and breadth of the problems with its health-care system. While there is much discussion of rescinding the Affordable Care Act (Obamacare), there is nothing being discussed as a substitute that begins to address the underlying problems. Denial is an awful thing. Denial can be catastrophic.
What are we in denial about? An aging population? Sort of. Skyrocketing Medicare costs? Our ability to become more cost-efficient? Sure. But at the end of the day, what we are most in denial about is the hidden extent to which we are all subsidizing Medicare. Our ability to provide health care has become so advanced that our aging population is living longer with chronic, expensive health issues. We are not addressing, in a reasonable way, the problem of covering the costs of an aging population, and hospitals are taking matters into their own hands. That is creating a bigger problem for the rest of the population.
A hidden Medicare subsidy you are paying
The true promise of the Affordable Care Act, which was much more well intentioned than most believe, was the insurance mandate and the resulting expectation of millions of young new insurance customers. But young people aren’t stupid. Even without the negative press, the cost of insurance under the ACA simply didn’t strike people as being worth the investment. The combination of high premiums and high deductibles meant that younger, previously uninsured recipients would rarely receive real benefit.
Insurance under the ACA actually started to behave more like catastrophic coverage. But even under that description, the cost was too high. Why? Because the premiums didn’t just cover the cost of catastrophic coverage for young, healthy people. The premiums also had to subsidize coverage for chronic illness in middle-aged and older people. In many cases these preexisting conditions were uninsured (and uninsurable) until ACA. And they represent the most expensive of all patient classes. High costs were a big part of the unraveling of Obamacare. Yet those costs were necessary to subsidize the part of the ACA (preexisting conditions) that even Donald Trump has said he wants to keep. Hence the denial.
While the very young—20-somethings—quickly recognized the extent to which they would be subsidizing others under the ACA, the public hasn’t yet come to grips with the Medicare equivalent, which has been going on for years (some would say decades). Right now all of us under 65 are subsidizing Medicare just about every time we seek medical care. Some of us understand this relationship and are quietly complicit, while this dynamic has created a systemic dysfunction that is becoming increasingly more evident.