There is a lot of uncertainty about what Covered California will look like beyond 2017. One of the key issues at stake is how much premiums will be after federal reform. Increasing rates in healthcare are actually due to a variety of factors and the folks at California Healthline do an excellent job of breaking this down. One of the key implications with rising premiums in the era of the Obamacare is that the tax credits have also increased, which is intended to help with the offsetting the costs. However, since this is part of the larger conversation about the role of government in insurance policies, I thought I would chime in with a couple of questions that people continuously ask.
First, there is the question about why healthcare is so expensive in the first place. When I was in graduate school, I remember sitting in this big huge lecture hall and listening to Thomas Bodenheimer explain in a no nonsense way the reasons for this rise in costs. This changed my thinking and had a lasting impression on me. It is complicated indeed, and multifaceted. There is the cost of healthcare technology, which is always increasing and mostly coming from publicly traded companies that have a responsibility to their shareholders for profit. Next, is the cost of providers, especially in disadvantaged areas where there is a large provider shortage such as in Fresno County. For example, people here can expect that not all providers will choose to cover publicly insured patients, whether Medi-Cal or as part of any subsidized exchange. When they have the option to treat people with higher reimbursement rates for their services, they will opt for those patients to help them keep the doors open.
Next is the question of why people are not getting the care they need if they have access to insurance. Often, when private providers limit their access to only private pay patients or only limited hours for public paying patients, it results in an overburden of Federally Qualified Health Centers and County hospitals to provide the bulk of the care for the publicly insured. This also means that there is no incentive for those providers to bring down any costs in their care because the reimbursements are not enough. I have personally heard private doctors say they often lose money providing certain treatments to patients they know they are unlikely to get reimbursement for, simply because it is the right thing to do.
Lastly, people ask why they should pay for other people to receive federal subsidies for their care if they don't work for it. In fact, we have seen a trend since the 1970's of not only wage stagnation but a sort of "race to the bottom" in the level of benefits employers provide to their employees. This downward trend has left a bulk of the working population without insurance. Before the Affordable Care Act, many owners of small businesses with pre-existing conditions were shut out of both the private and the public health insurance systems. I know several who have been making enough to keep themselves afloat, but not enough to ever be able to afford a healthcare premium or pay out of pocket. I know several small business owners who saw preventive care in this country for the first time after the affordable care act, because they qualified for Medi-Cal. It is hard for people to conceptualize how someone could qualify for Medi-Cal and be working, but the working poor make a large part of our county. In fact, in 2013, there were an estimated 354,800 Californians working full-time and year-round, still under the federal poverty level. This isn't counting the millions that are living underemployed (working less than full-time). "Handouts" are actually the government doing the work of companies who have foregone the days when worker fringe benefits were a requisite.
It is my assessment that many things will change in the price and access to care with any new health legislation, but some of the core issues around healthcare cost and access will remain unless intentionally addressed