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.
n 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.
4) Our entire economy gets turned over to health care spending, plus maybe defense.
This is the one that keeps me up at night. Health spending, as a percentage of GDP, has been skyrocketing in the U.S. for the past decade or so, despite a bit of a slowdown. No, seriously. I'm not kidding. This dire chart keeps me laying awake at night sometimes:
It goes without saying that this is an unsustainable trend — and if health spending really reached 50 percent of GDP by the middle of the century, we'd basically all just be working to pay our doctor and hospital bills. This trend affects both the federal government and private employers, both of whom are faced with the same problem: keeping people healthy and coping with common diseases is getting more and more expensive all the time.
Why has healthcare gotten so expensive? This is a question with no easy answer — if you want a giggle sometime, read the meeting transcripts of the Medicare Payments Advisory Commission (an advisory body so toothless, the word "toothless" is practically part of its name.) The most recent transcript, for the March meeting, actually starts out with one of the commissioners declaring "my head hurts."
There are many explanations for skyrocketing costs, though: Fancy new technologies save more lives, but they're also tremendously expensive. Doctors perform extra tests to cover their asses, or just on the off chance they find something. We have too many specialists and not enough primary care doctors — if you happen to live in a place with a spinal surgeon, you're a thousand times more likely to have a particular type of spinal surgery than if you live in the next county over, as a fascinating publication called the Dartmouth Health Atlas illustrates. Health insurance companies work hard to reduce their "medical loss ratios" — the percentage of premium dollars they spend on providing actual care. We don't spend enough on prevention, and we spend too much on fixing messes we could have prevented. We eat too many Big Macs and smoke too many Camels. And so on, and so on.
So, I hear you asking, isn't the new health care reform bill likely to increase spending, what with the federal government paying for more stuff?
Hopefully not. The bill includes a lot of cost-cutting measures, some of which could also improve the quality of health care over time. For one thing, the huge giveaway to private insurers taking part in the Medicare Advantage program is being scaled back — there'll no longer be such huge subsidies to cover patients whom vanilla Medicare would have covered for a lot less. Some of the oversight in those insurance exchanges may include making sure insurers are being "prudent purchasers" of health care. There's also a new pilot program on "bundling," in which hospitals get a flat payment for ten common conditions, instead of getting paid separately for each procedure or test they do. (Bundling already exists, to some extent, but this would expand it somewhat.)
Just having more young, healthy people in the risk pool for insurance may help to bring costs down a bit, because young people will pay premiums without incurring as many costs.
The old "toothless" Medicare commission is replaced or supplemented with a new body, the Independent Payment Advisory Board, which would come up with legislative proposals to reduce Medicare spending if it rises faster than a certain target rate by 2013. The IPAB isn't allowed to come up with proposals that would "ration care," but can find ways to streamline services or reduce overpayments.
The bill also puts pressure on doctors to take part in Medicare's quality-measurement program, which has been voluntary up till now — and that could yield more data that allows the government to cut spending a lot more. People talk a lot about "evidence-based medicine" as one of the keys to cost-cutting, and it's really true. We waste money because we don't know what works.
As Princeton health-care economist Uwe Reinhart tells Ezra Klein, insurance companies will no longer be spending 40 percent of their premiums on marketing and administration and brokers, thanks to the exchanges. But Reinhart mostly just sees the new law as a good step towards reducing costs, because it allows us to gather actual data on health costs and outcomes. "When McAllen, Texas, became the poster child for high spending, suddenly the Wall Street Journal jumped out to say that its spending was justified! The only way to answer that is to have the really good research to say this isn't justified."
Of course, we don't know yet if the new law will reduce costs, or whether the cost of insuring so many more people will actually drive costs up. (Plus the law doesn't fix Medicare's Sustainable Growth Rate system, a mechanism which cuts doctors' Medicare payments every year, and that's going to be an expensive fix.) But the experts, including the Congressional Budget Office, are optimistic about savings at this point.
5) The Fast Food Apocalpyse!
You want scary? This is scary.
It's like Russell T. Davies' worst nightmare: Millions of people eating junky food at chain restaurants, without having the least inkling what they're putting in their mouths. But no longer.
As food blogger Marion Nestle pointed out, the new law includes a long-awaited provision requiring national calorie labeling on menus for any restaurant with 20 outlets or more. That means you'll know exactly how many calories your hamburger or salad contains. (According to the Associated Press, a chain-restaurant Caesar salad has 800 calories, which is sort of alarming.) And apparently the restaurant industry actually lobbied for this change, so they wouldn't have to deal with varying state and local laws.
Just having the calorie counts listed plainly on every restaurant menu could make people healthier, in some small way.
But it's not all good news. There's one dystopia that the new law makes more likely:
The Socialist Totalitarian state
Could the new healthcare reform law eventually lead to the government taking over the healthcare industry completely? Sure, it's possible. A lot of people are not so secretly hoping that will happen. We could find ourselves living in 1984, or Brazil, or any of a number of other statist dystopias where the government controls everything. Although it's a bit hard to envision the leap from subsidized health insurance to Room 101.
But if you want to think of ways this new scheme could turn dystopian, it's not that hard. The government could use access to affordable health care to control people — already, young people are going to have to pay higher premiums than older people. And what if, in a cost-cutting measure, the government eventually decides that smokers must pay higher premiums? Since it's their own fault that they're at higher risk for emphysema and lung cancer. That's not in the law now, but it could be added at some point in the future.
Even if we don't get the public option at some point, the law certainly gives the government more of a role in regulating the health insurance industry — for example, there's an "essential benefits plan" that specifies exactly what sort of care, at minimum, your insurer will have to offer you.
So yes, this is a definite step towards a world where the government runs the health care industry, and this gives the government functionaries a greater degree of control over your life. You could imagine a future where the federal government uses access to health care as an instrument of social policy — maybe if you criticize President Obama (or his successor, perhaps) your Platinum health plan might suddenly be downgraded to a Bronze one? This isn't something that's in the current law — but maybe (if the Democrats get 70 seats in the Senate and a 100-vote majority in the House, say) this could happen.
And of course, if you're a dedicated conservative who doesn't believe the government has a role in helping to solve problems like lack of access to healthcare, and you hate progressive taxation and government programs generally, then it's all dystopian. As with most things, it's all in your point of view.
* The last major revision to federal health policy, the Balanced Budget Act of 1997, spawned years of annual bills tweaking and unraveling some of its provisions, including the beautifully named Balanced Budget Refinement Act of 1999. It's just like the Balanced Budget Act, only more... refined. Possibly with nice tea cups, or those little finger sandwiches.
** And yes, I know that the diseases in those movies are actually caused by medical science. So maybe healthcare reform will turn us all into zombies?