We hardly expect to see obscenities in the Gray Lady, much less on the front page, but there it was, almost shimmering in its power: “redistribution”. Esteemed commentator John Harwood took up the challenge by describing how the Obama administration sidled around the dreaded word when selling the ACA to the public in 2010, and ever since, and by exposing just how dishonest this was, since redistribution is such an essential part of the law (NYTimes, 11/24/13, p.1). Of course, a brief essay could only do so much in terms of analysis, and Harwood should be given half a bravo for his frank terminology in pointing out that the cost of health insurance will increase for many of us because we are subsidizing those who are not paying their full cost. The subsidy is mainly channeled to two groups: those who cannot afford coverage, and those shunned by insurers as too risky because of a prior condition. So this is the cost part of the “redistribution”.
But this is only half the story. Once the ACA starts to operate as intended – and, yes, I think it will eventually – we’re going to see the other kind of “redistribution”, one that I haven’t heard much about even from its opponents. I am referring to the redistribution of the care itself, viz. what we are actually paying for with our premiums.
To put it bluntly, the consequences of redesigning the entire marketplace for a commercial service will cause the kind of discomfort that this blog is named for. And, yes, medical care, whatever else it may be, is a commercial service. It remains ruled by the marketplace, and I am confident we will see major changes in how quality medical care is “re”-distributed, probably within two years. Unlike Social Security, which is a universal pension program, health care cannot be standardized into one government-approved delivery system. Social Security exists alongside employer pension plans and private ones, but the end product for all is still delivered in only one form: money. While the amounts may differ, each dollar unit is spent in exactly the same way. For that, one dollar is as good as another.
Not so with health care. What you are paying for is the full “experience” of medical treatment. This is only measured by how you feel when the treatment is over, once you get back to living your life. Which usually means not thinking about your health at all until the body – that pesky thing! – forces you back to the doctor’s office. At that point, the measure of “quality” health care is not only how much you pay for it but also whether the problem is fixed and, of at least equal importance, what the total experience feels like from the patient’s point of view.
There are a lot of components to that experience, among them: the location of the treatment facility; the comfort level at the facility; the amount of wait time; the amount of time with the treating professional; the reputation and level of experience of that professional; the confidence you feel, both during and after treatment, that you are receiving the best care available for you at that time, for that problem. And there’s another part, the one nobody likes to talk about: who else is waiting with you to get treated by those same people.
My feeling is that, once Obamacare gets going, there will be lots of attention paid in the media to finding out the “number ranking” of the providers, and the results will be this: the people who are receiving the most care by the HIGHEST-rated professionals are OVERWHELMINGLY those who are paying more for it. Conversely, the ones getting the most care from the LOWEST-rated professionals are the underclass, who are being subsidized by the taxpayers. This divergence will come about because the market forces that are left untouched, or relatively untouched, under the plan will converge to activate a kind of “counter-redistribution” within the health care marketplace. Of course, this will be totally unacceptable to the progressives, who will raise bloody hell at the continuing inequality in the distribution of a “basic right” in our society.
Thus, the second war of Obamacare. But the combatants will be different this time. The progressives were always waiting for the data to show the divergence because they never believed Obamacare would be able to prevent it. They were always looking to impose the full Cuba-style egalitarianism, namely the single payer system. Rather than “adjusting” the law, they will use the data to try to kill it and replace it with single-payer. The moderate Democrats and (admittedly few) Republicans who want to preserve the law will be the main target of their rage, while the right-wing minority who always hated it will just snipe at both armies sporadically.