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Health Care After the Election

By Ron Pollack,


This blog was originally posted on

Throughout this election season, there has been considerable debate concerning the future of our nation’s health care system. With the elections behind us, we can determine the key policy directions that will likely shape health coverage and care for the foreseeable future. At least four are worth noting.

First, the Affordable Care Act (aka Obamacare) will move forward. Throughout the primary and general elections, Obamacare’s future was anything but certain. With the President’s reelection and the Supreme Court’s ruling last June, it is clear that this historic law will be implemented, most of it by January 2014.

But while the debate about Obamacare’s future is essentially decided, the hard work of implementing it continues. Ultimately, how well it is implemented will determine whether the law is a success.

Obamacare’s core provisions were designed to ensure peace of mind for America’s families. Irrespective of new family circumstances — an unexpected illness, the loss of a job or a divorce — Obamacare promised that affordable, high-quality health coverage should always be available.

The key measure of fulfilling this promise will be the number of currently uninsured people who gain health coverage. The nonpartisan Congressional Budget Office projects that more than 30 million Americans will do so.

Getting there from here, however, will not be easy. Recent surveys have found that more than three-quarters of those without health coverage are unaware of how the law can help them. So, a robust public education campaign, collaboratively initiated by the private and public sectors, will be needed. Since the first enrollment period begins in October 2013, that initiative must begin soon.

Second, the health care safety net will be strengthened. For low-income adults, the Medicaid safety net is badly frayed, letting many low-income adults fall through. The national median income eligibility level for impoverished parents is only 63 percent of the federal poverty level, a mere $12,027 in annual income for a family of three. For adults without dependent children, the situation is even worse: In 43 states, no coverage is available, even for the penniless.

Beginning in January 2014, states will have the option to raise Medicaid eligibility to 133 percent of poverty, and they will receive unprecedented federal help to do so. From 2014 through 2016, the federal government will pick up all of the costs for covering newly eligible people; thereafter, the federal contribution will gradually decrease to 90 percent. This is a bargain few states will refuse.

Ensuring optimal state Medicaid expansions will require governors to feel secure that the federal government’s fiscal support for Medicaid will remain strong and stable. It is therefore essential that the upcoming federal budget deliberations help instill that confidence and that federal Medicaid funding not be cut.

Third, Medicare’s solvency will continue to be strengthened, and the program will not be converted to a voucher system. According to the Medicare trustees, the program’s hospital trust fund will remain solvent through 2024 — a significant improvement from past projections. But Medicare’s expected budget growth suggests the program needs further strengthening to give current and future beneficiaries a sense of security.

President Obama has emphatically opposed a House-passed proposal to reduce projected Medicare spending by converting it to a voucher system. If such a proposal were offered again, it would likely receive very short shrift. But in the context of a balanced approach to the federal budget, the President and Congress must seriously consider improving the program’s fiscal future.

Genuine opportunities exist to strengthen Medicare. For example, efforts to improve coordination of care for beneficiaries with chronic health conditions can be expanded, thereby improving care quality while eliminating wasteful spending. Since roughly half the people enrolled in Medicare have incomes below 200 percent of poverty ($22,340 for an individual), these and other proposals should focus on improving care, not simply shifting costs to beneficiaries.

Fourth, health system changes to moderate unsustainable health care costs must be strengthened. Bending the cost curve is not only essential to meet new public health commitments, but it is also necessary to keep job-based insurance and other private coverage affordable.

The most recent congressional debates about health care costs have not been constructive. They have focused almost exclusively on shifting costs of public programs to states and consumers — cost shifts that would be difficult to bear and that would fail to meaningfully address system reform.

Instead, we need to move away from fee-for-service medicine to reduce wasteful care. Payment structures must be aligned to ensure that providers deliver the right care at the right time. Pricing should be more transparent.  Preventive and primary care deserve far more emphasis. And consumers need to be empowered to make health care decisions with their providers.

These changes should and will receive greater attention in the years ahead.