Obamacare Insurance Exchanges Will Help -- Especially in Vermont, Where They Are a Step to Single Payer Insurance for All

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Mark Weisbrot
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The Affordable Care Act (ACA) of 2010, widely known as “Obamacare,” requires states to set up exchanges where individuals and small businesses can purchase insurance. The purpose of the exchanges is to help implement the reforms. For example, most of the people who will purchase insurance in the exchanges will be eligible for some sort of tax credit or subsidy to make their insurance more affordable. Also, the insurance plans must be certified so that they meet the requirements of the ACA.

The ACA also provides for an expansion of Medicaid to households earning up to 133 percent of the federal poverty line.  The exchanges can help determine who is eligible for Medicaid or CHIP (the Children’s Health Insurance Program), or for subsidies to purchase insurance.

The ACA gives state governments the responsibility to set up exchanges. But a number of state governments have declined to do so, thus leaving this responsibility to the federal government. In many cases this is for ideological or political reasons – these are Republicans who see their refusal to create the exchanges as an act of defiance against Obamacare.

But defying health care reform in this way will not get them anywhere; they will simply turn the job over to the federal government. This will disenfranchise their constituents, including state insurance companies, businesses, and citizens, from having a say in how the exchanges are designed.  Since states have different laws regulating insurance and different demographics (including age and income distribution), this does not seem like a smart move.

Some of these state governments are also rejecting the Medicaid expansion, and the federal money that goes with it.  This will simply deny many of their citizens access to Medicaid (e.g. 1.4 million people in Texas).

Obamacare will bring some important changes for victims of our broken health care system, some of which are already in effect. People with pre-existing health conditions will no longer be denied insurance, and important preventive care will be free.  Most insurance companies will be required to cover treatment for mental health and substance abuse. Most importantly, an estimated 60 percent of the nation’s 50 million uninsured will have health insurance.

But that still leaves tens of millions of Americans falling through the cracks. We also have the most expensive health care system in the world -- paying about twice as much per person as in other high income countries, with much worse health outcomes (life expectancy, infant mortality). Most of the waste comes from higher administrative costs – one study estimated these at 31 percent for the U.S., as compared with 16.7 percent for Canada’s universal, single-payer system. The ACA has provisions for reducing costs, and some will be effective; but it will be difficult in a system with hundreds of private insurers who will still find it profitable to expend resources to avoid paying for the sick and injured, and finding healthier groups of people to insure.

The most effective, efficient, and equitable system is a single insurer that covers everyone – as we have in Medicare for Americans over 65. For this reason the state of Vermont is designing an insurance exchange system under the ACA that will serve as a prelude to a single payer, universal state-wide health care system. It is estimated that this will reduce health care spending in Vermont by 25 percent while insuring all residents. The people of Vermont deserve congratulations and support for their years of grassroots activity that could make this a reality as early as 2017.  The only reason we don’t have this nationwide is because of the corrupting power and influence of the pharmaceutical and insurance corporations. If Vermont succeeds, other states and then the federal government could follow, as happened in Canada.


Mark Weisbrot is co-director of the Center for Economic and Policy Research, in Washington, D.C. He is also president of Just Foreign Policy