With the Affordable Care Act Here to Stay, What Are the Prospects for Medicaid, Employer-Based Insurance, and Single-Payer?
The Affordable Care Act is a monumental accomplishment. Thanks to its expansion of health care coverage and new regulations, tens of millions of Americans will feel more secure, knowing that they can seek medical attention when they need it and that they will be protected from the insurance industry’s most egregious practices.
But the reform was very much limited by the American terms of the debate, particularly the enduring belief that markets are always more efficient than government (even though our current private insurance system demonstrates otherwise) and the conviction that any changes to the arrangements of the insured cannot fly. The result is a sprawling, confusing, Gorgon-headed workaround, whose beneficial features are difficult for the typical consumer to discern.
Now that the Act has run the Supreme Court gauntlet, how will it affect the structure and politics of health care going forward? Assuming the ACA survives Republican repeal attempts, does it represent a large step toward a single-payer system? What will happen to the employer-provided sector of health insurance? Will health insurance in the United States settle into a pattern of competing private plans? And will some states really opt out of the ACA’s Medicaid expansion and forgo billions of federal dollars?
Prognostication is always a dangerous business—witness the many observers who thought the Supreme Court would uphold the Medicaid expansion but strike down the individual mandate, the opposite of the Court’s ruling. Policy changes of this magnitude are especially difficult to assess, since they take years to unfold, with all the legislative tweaks and developments that are sure to follow. As political scientist Eric Patashnik has pointed out, Social Security was reshaped by decades of amendments and changes before it took the form we know today. A recent Congressional Budget Office report on the ACA admits that the legislation contains so many moving parts, and the changes are so consequential, that prediction is difficult. With this caveat, I offer the following thoughts with modesty.