The Affordable Care Act (ACA) was positive legislation bringing medical insurance to millions of additional Americans. But signing up for "Obamacare" forces many to make impossible choices.
ACA subsidies for private insurance were to begin exactly where an expanded eligibility for Medicaid ended. But the U.S. Supreme Court sabotaged that smooth switchover by allowing states to retain original Medicaid without extending eligibility.
In states that did not expand Medicaid coverage, many people therefore earn too much to get Medicaid, and too little to buy subsidized insurance.
The American medical insurance system is not one anybody in their right mind would have intentionally designed. But each step by which it evolved made sense at the time.
Many Americans get insurance through their employer. This was kick-started by wage controls and labor shortages during World War II. Employer-provided medical insurance was not considered wages, even though it was something of value, so it enabled firms seeking to attract more employees to get around the wage limits.
Medicare was enacted in the 1960s for retired people no longer receiving employment-based insurance. Medicaid was created for people whose employment did not provide insurance or who couldn't work and were too young for Medicare.
In addition to Medicare and Medicaid, several additional federal programs insure veterans, native American tribes, and children.
With many kinds of medical insurance, some dependent on income, some on age, some on tribal or military status, many people must find new insurance whenever their income or other status changes.
They "churn" between different insurance programs differing in coverage and other important details. This "churning" is painful for patients and expensive for the government, money that could better be spent on actual healthcare.
Since not all doctors or other providers are "in network" for all insurance programs, when people churn from one type of insurance to another, they may also have to find new doctors.
People buying insurance in the subsidized Obamacare marketplaces can have a terrible time trying to figure out a policy which has their current doctors "in network" and which will cover the medicines they are taking.
It would help if the government would create standardized coverages that private insurance companies can offer, like it already does for those buying "medigap" policies to supplement Medicare.
People buying a medigap policy choose between standard policies A through N, with coverage in each category the same no matter which company they get it from. The companies compete only on price.
An even better idea would be for the federal government to abolish allthe different insurance systems it maintains, displace employer-provided insurance and its "networks," and automatically enroll everybody in a standard medical insurance that must be accepted by all providers.
Costs per patient would be lower, once the system was working smoothly.
The United States, the world's richest country, is the only developed country not providing universal medical insurance.
This multiplies administrative costs, is inefficient, and still leaves millions of people uninsured or insecure in their insurance.
But our current system has great inertia and the private interests that would be injured by changing it have immense ability to block progress.
It probably will be a cold day in Honolulu before we catch up with the rest of the industrialized world.
One possible exception to this gloom comes to mind.
It took Richard Nixon, long a strenuous anti-Communist, to establish relations with the Chinese Communist regime. By analogy, the best person to bring universal medical coverage — often denounced as "socialism" — to the U.S. might be Donald Trump, a severe critic of Obamacare and of socialism.
Given Trump's political clout, he could probably force the politicians in the Republican Party to come along if he came out for universal coverage. He has been urged to consider this by at least one astute friend of his.
But this would require a change of heart, since Mr. Trump has recently egged his congressional allies into major cuts to Medicaid that are expected to deprive millions of Americans of their current health insurance.
When he sees the consequences of these cuts, here's hoping that Mr. Trump will have that change in heart.
(A related opinion column may be found here.)
Paul F. deLespinasse is Professor Emeritus of Political Science and Computer Science at Adrian College. Read Professor Paul F. deLespinasse's Reports — More Here.