Blog | Monday, December 2, 2013

Functioning health exchanges


There has been a lot of understandable outrage over the troubles plaguing Healthcare.gov, the federal website for purchasing individual or family health insurance under the Affordable Care Act (aka Obamacare). Opponents of the law (Republicans), recovering from their self-inflicted wounds over the government shutdown, see this as evidence of the fundamental unworkability of the law, and of the folly of a “government solution” to a complex problem. Supporters of the law (Democrats) are terrified that the difficulty in buying insurance will dissuade the so-called “young invincibles” (healthy young people who have limited needs for health care services) from buying coverage. If that happens, and only the older and sicker among the eligible population buy insurance, then premiums may not cover the cost of services, forcing insurers to raise rates, which would further dissuade the healthy from buying coverage, setting off a possible “death spiral” of higher rates and fewer people covered.

This is a real problem, and if news reports are accurate, there are lots of fingerprints on the “crime.” The President and The Department of Health and Human Services have promised a fix by the end of the month, and I hope they deliver.

Almost completely lost amid all the yelling and finger-pointing is the fact that each state was supposed to set up its own exchange. The federal health exchange, intended as a default or back-up, is taking on the work originally intended for these state-sponsored exchanges. A map in the New York Times is a reminder that most Republican governors scuttled plans for their own state exchanges, just as they refused to expand Medicaid. Some of these state exchanges have had their own problems, but many are functioning as intended.

I can’t help but wonder about the connection. It seems like Republicans at the state and federal level have done their best to hamstring the implementation of the Affordable Care Act, and are now using the results to say the law was all a mistake in the first place. Seems to me that if your political philosophy is that “government is the problem,” then it is not hard to govern in such a way as to make that seem a reality.

What do you think?

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.