We've heard a lot of hype, on both sides, about the healthcare reform bill President Obama signed today. But how will it really affect our future? Here are five dystopias it may save us from, and one it could cause.
Oh, and there are spoilers in this post. Watch out!
So the House of Representatives passed The White House/Congressional Leadership Reconciliation Bill (H.R. 4872) on Sunday, and President Obama signed it today. (There are still procedural hurdles in the Senate, but it's basically a done deal, by all accounts.) So now it's all over except for the court cases, giant stacks of regulations, and the inevitable followup bills.*
You can read the whole text of the bill here, and there's a great comparison with the previous House and Senate bills here (PDF). So what does the bill actually do, in its final form, and how could it make our future more or less dystopian? Glad you asked. Here are some dystopian scenarios that the bill makes less likely:
1) The mutant plague.
An affluent country in which 30 million people only have access to health care through emergency rooms and a few other sources is a scary situation. When such a huge slice of your population isn't getting basic screenings and preventive care, it's like a welcome mat to weird diseases.
It doesn't take much imagination to picture a scenario where a new epidemic sweeps through the uninsured population, gaining too much traction for public health officials to be able to cope with it by the time it reaches the rest of the country. But even if you discount a 28 Days Later/I Am Legend** type scenario, it makes basic sense that even people with health insurance are healthier if those who currently lack it get proper treatment.
Under the bill that President Obama just signed into law, insurers will no longer be able to deny anyone coverage based on a preexisting condition, or end coverage for existing customers using a process called "rescission." And there are no more lifetime limits on how many benefits you can receive. If your employer doesn't provide coverage for you (or doesn't pay enough of the cost) you'll be able to buy insurance on a state-run "exchange," where insurers compete to offer the best coverage at the lowest cost. And if your income is below a certain threshold, your insurance premiums will be subsidized.
Also, there'll be no more "doughnut hole," where Medicare drug coverage stops after a certain cost level and then resumes after a "catastrophic" cost level. Also, Medicaid doctor visits, including things like immunizations, will pay at the same rate as Medicare, meaning doctors will suddenly be a lot more open to seeing Medicaid patients for those things.
And the law eliminates Medicare co-payments and deductibles for preventive services, and phases in a similar requirement for private health plans. Plus here's a pretty good list of some of the other things the bill will do to improve preventative care and rural health care, among other things.
So how could improving access to health care services, and especially to preventive care, help to stave off the zombie apocalypse? Well, it means more of the population will be getting checkups, which means nasty diseases are likelier to be caught early. Assistant Secretary of Health Howard K. Koh, MD says that healthcare reform will have a net-positive effect on public health generally, because so many more people will have access to preventive care and immunizations. Koh cites a recent study saying 100,000 people die in the United States every year because of lack of access to basic preventive care, like flu shots.
So even if you already have great insurance, you''ll be healthier because other people will have it now. And you're less likely to be eaten by super-plague-mutants.
2) The vanishing middle class, as society splits into the rulers and the undercity.
It's a staple of dystopian science fiction — the world divided into the privileged few, who live high above the smog belt in their shiny penthouses, and the downtrodden rabble, who live in the streets below. Usually there are sewer mutants too.
And a world in which fewer and fewer people can afford decent health coverage, because insurance is getting more and more expensive and selective, is a big piece of that dystopia. So is a world where people are driven into bankruptcy and lose their homes because of catastrophic health care expenses. And a world where health insurance companies are making billions in profits, based on their ability to avoid providing care, is definitely one in which a few lucky people are ascending into the evil penthouses.
In the short term, at least, this law will be good for the insurance companies — you'll be required by law to buy health insurance from them, after all. Talking to Business Week, Phillip Seligman with Standard & Poors Equity Research says the new law will be a net positive for managed care organizations because they'll gain so many new members, providing economies of scale.
But there's at least a decent chance that these exchanges, where insurance companies compete to offer the best deal, will drive down prices over time. There's also a lot of leeway for the administrators of the exchanges to kick out insurers who raise prices or abuse customers, until they fix their wagons. And even though we didn't get a "public option" where the government competes with those insurers, a regulated marketplace seems like the next best thing — and some observers think it could lead to the introduction of a public option down the road.
The bill also includes some new taxes on high-income Americans that will make some steps towards reducing the gulf between "haves" and "have nots" — including higher Medicare payroll taxes for individuals making more than $200,000 per year, excises on super high-end "Cadillac" health plans, and businesses that don't offer sufficient insurance for their employees. These taxes will mostly hit the wealthiest Americans, and depending on how you feel about progressive taxation, they're either a step away from dystopia or a step towards one.
In any case, the future dystopia where most people live in the gutter and a few people live in the heavens has just gotten a wee bit less likely.
3) Corporate serfdom.
It's sort of related, but a common theme in dystopian science fiction is the world where you belong to a corporation, body and soul. Think Jennifer Government by Max Barry, where your last name is the name of the company you work for. In such a world, usually, your fashion choices are severely constrained and sometimes the evil company is just called The Company or The Corporation. The only way out of corporate serfhood is to die. Etc. etc. etc.
And obviously, a world where you can't quit your corporate job for fear of losing health insurance is one where you're a little bit serf-y. This has long been a secret tax on entrepreneurs, since leaving a big company and starting your own small company has meant going without health coverage.
And then there's the Kafka-esque corporate bureaucracy thing. If you're like me, you've only had the occasional brush with obstructive government bureaucrats — but frustrating conversations with health insurance company bureaucrats are a constant fact of life. The health insurance behemoths spend jillions of premium dollars paying a small army of people to figure out ways to deny coverage or make your life more complicated, and it's a horrendously inefficient system. You can spend hours on hold, being transferred, filling out stacks of forms, getting transferred again, and generally being circle-jerked around. It's like a parody of Brazil.
The new law won't completely eliminate this delightful process, but it'll reduce the scope for companies to behave this way massively. No doubt insurers will still have their own idiosyncratic views of what's "medically necessary," but at least they'll have a new level oversight in these exchanges. And given how much energy the bill spends on measuring what forms of care result in higher quality care and which are totally useless, we could soon have more actual clinical info with which to argue for treatments that really do make a difference.
It's just a wee step away from a world ruled by evil corporations.