Political polarization foreclosed on the possibility of bipartisan compromise to fix the Affordable Care Act, Dr. Jonathan Oberlander says, so expect candidates in the 2020 election to propose “radically different ideas about what the future of American healthcare is.”

Dr. Jonathan Oberlander, a professor of health policy and management at UNC-Chapel Hill, told the audience at Union Square Campus in Greensboro on Tuesday that he was invited by the League of Women Voters of the Piedmont Triad to share his expertise on healthcare reform and help voters make an informed decision in the 2020 election.

“You’ve got a long ways to go, and a lot of speakers and a lot of issues to consider,” he said. “So I’ll see if I can knock off one date for you.”

Because of myriad woes in the US healthcare system, including people facing financial ruin while fighting disease, surprise medical bills and high costs overall, Oberlander said the idea of “Medicare for all” has come roaring back.

“There’s no question that it’s part of a debate in a way that it really hasn’t been since the 1970s,” Oberlander said, noting that the architects of Medicare when it was signed into law by President Johnson in 1965 assumed that it would be only a matter of time before the program expanded from the elderly to cover the entire population.

“And my guess is that the Democratic nominee in 2020 will be in favor either of ‘Medicare for all’ or expanding Medicare, what I call ‘Medicare for more’ — allowing people 50 and older to buy into Medicare, allowing uninsured to buy into Medicare, something like that,” he said.

President Trump, Oberlander predicted, will advocate for a “repeal and replace” plan that is even more severe than the one Republicans unsuccessfully attempted to pass in 2017. On Tuesday, the Trump administration filed a brief in support of a lawsuit against the federal government filed by Texas and five other conservative states seeking to overturn the Affordable Care Act. Oberlander said people should keep a close eye on the suit, which could land in the Supreme Court and lead to the loss of popular provisions like the prohibition on health insurance companies denying coverage based on preexisting conditions.

The sharp divergence between the two parties is a testament to the escalating polarization in American politics, Oberlander said.

“The Affordable Care Act is just one front in a much larger partisan struggle,” Oberlander observed. “One of the frustrating things about the Affordable Care Act is you can imagine a scenario where Democrats say, ‘We love Obamacare, but it’s got problems. Okay, we agree. Let’s make some changes.’ And Republicans say, ‘We hate Obamacare, but some parts of it work. Let’s come together as two parties and let’s make the Affordable Care Act work better and make it more affordable.’ That has not happened. There’s no bipartisanship on this. And the reason there’s no bipartisanship on this is that chasm between the two parties.”

While the Affordable Care Act has succeeded on a number of fronts — outlawing discrimination based on pre-existing conditions and based on gender, and dramatically reducing the number of uninsured people — in other areas, it remains flawed, Oberlander said.

“The Affordable Care Act, if you’re buying coverage in the marketplace, is a pretty good deal if you’re very low income, but if you are not very low income it’s not such a good deal,” he said. “There are millions of middle-class Americans for whom healthcare is still not affordable, and that’s because the subsidies under the Affordable Care Act are not comprehensive enough for middle-class Americans.
“When you hear people say, ‘The Affordable Care Act is unaffordable,’ it’s absolutely the case that for many Americans, health insurance is still unaffordable under the Affordable Care Act,” Oberlander added.

Also, Oberlander said, the online insurance pools created by the Affordable Care Act proved to be more volatile than people predicted, with the cost of plans increasing on average by 21 percent in 2017 and by 32 percent in 2018.

While the law provides that subsidies rise to cover rate increases, Oberlander said, “There are still a couple million Americans inside the insurance marketplace who aren’t subsidized at all, so they bear absolutely the full weight of those premium increases. And outside of the marketplace there are still Americans buying coverage directly from insurance brokers and directly from insurers, and they don’t qualify for subsidies. And they’ve been hit.”

Even with widespread dissatisfaction, Oberlander said it would be “very difficult to take the patchwork healthcare system that we have,” and merge 160 million people with employer-sponsored coverage, those who receive Medicare or Medicaid, and those who remain uninsured into a single plan. And while the majority of Americans say they support “Medicare for all,” Oberlander said support plummets in public polling when respondents are told that the program would lead to delays or rationing.
Many Democratic candidates for president have embraced some form of “Medicare for all,” but Oberlander cautioned that it’s important for voters to press them on what they mean by the label.

As an example, he said “Medicare for all” is generally understood to be different than single-payer healthcare. Medicare, since its inception, has allowed a role for private insurers, who process claims and provide private plans with additional benefits. In contrast, under single-payer healthcare, as exemplified by the Canadian system, there is only one government insurance program, which is administered by each province.

“When you ask Americans about ‘Medicare for all,’ a lot of Americans, what they hear is, ‘Oh, what you’re saying is anybody could buy into Medicare as an option,’” Oberlander said. “The opinion polls will show you that most Americans when you say ‘Medicare for all’ don’t think you’re literally talking about every single American in Medicare. They think it means every American would have a choice to join Medicare, which is very different than saying Medicare is going to replace everything.”

Joking that “there might be two or three people on Medicare in the room” to an audience that drew heavily from area assisted living communities, Oberlander continued, “As you all know… Medicare has lots of benefit gaps and lot of holes itself. And so, most of the plans that are out there in Congress or that presidential candidates are offering for ‘Medicare for all,’ they’re not talking about the current Medicare program; they’re talking about taking the current Medicare program and improving it and adding more benefits to it.”

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