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How did Obamacare change the American health care system?

By Lauren AguirreMarch 17, 2017

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Republicans have been promising to repeal Obamacare for years. And now with their party in power, they have the ability to pass new legislation. Republicans recently introduced their bill that would replace some aspects of the Affordable Care Act. Mary Schumann is the executive director for George Washington University school of nursing and center for health policy and media engagement. She also researches in the field of health policy and policy lead to better outcomes in health care. Schumann discusses the ramifications of repealing Obamacare and facets of the American healthcare system. 

Editor's note: This conversation has been edited for clarity and length. 


How did Obamacare change the American healthcare system?

It changed the healthcare system in some important ways. At a high level, it added a lot of consensus around how to improve the quality of care and that really was a bipartisan effort. That’s both in the dialogue and construction of the Affordable Care Act (ACA) and in terms of how it has moved forward across time. 

It also changed the ways in how we think about how we pay for care. Rather than as a fee for service model, it’s really how to pay for value in health care. That means that hospitals, over time, will end up being paid less if they fail to prevent infections and things like that. Paying for value has continued to move forward and I think if there’s something that’s not likely to be repealed, it would be that piece. People are, I think, in agreement that that has been a good thing. A fee for service model ended up incentivizing wrong behaviors. 

The ACA has also been helpful in non-healthcare sorts of ways. Because through the healthcare exchanges, we have provided people with an alternative way to purchase health insurance. Otherwise, one or the other person in the family had to have a job in an environment, in an organization that offered healthcare. This has given people more alternatives so that people who want to be entrepreneurs, want to be independent consultants, who want to be able to not be tied down to a job that brings health insurance. I think that’s one of the things that has gone unspoken.

What part of Obamacare might be the most disruptive if repealed?

I think it would be hugely disruptive if preventive services went away. When preventive care isn’t covered by insurance, you end up paying double for it down the road. If we don’t interfere upstream as a person’s hypertension continues, as their diet leads to diabetes, as their health deteriorates, the health system pays more for that when something catastrophic happens later on. 

So repealing these measure will end up kicking us two or three times down the road. If you don’t fix the top of the dam, when you have massive flooding, everybody pays and they pay in a lot bigger way than if that had been maintained in the first place. Will it hurt us in the next 12 months if we don’t pay for that? Maybe, maybe not. But will it hurt us in the next three, five, ten years? Absolutely. We’ll pay more.

Why was the individual mandate included in the law?

The importance of the individual mandate was to ensure that the risk pool was increased. You want a good amount of healthy people paying into the pool, not just people who desperately needed that care because they weren’t healthy. It was one means of creating some enforcement of everyone paying into the pool in order for everybody to benefit. Insurance companies just can’t stay afloat if they’re constantly covering very sick people with no one else paying in to balance out those costs.

The reason that Medicare works and Social Security works is that everybody pays into the system. If we are going to be able to afford and someday take advantage of those benefits, we pay in on the front end. And that’s how it works. 

Hospitals are required by federal law to treat everyone that shows up in the emergency room, regardless of their ability to pay. If that person doesn’t have insurance, the cost of their care becomes part of the hospital’s uncollectible expenditures and who pays for that? We all pay for that. While it might be well and good for a 27-year-old to avoid paying for insurance because they think nothing will happen to affect their health, when it does happen them, we all end up paying. We all pay and that patient doesn’t have to pay anything into the system. There are no free rides at the end of the day.

Can health savings accounts be a viable option for coverage?

The idea behind health savings accounts is that you can, instead of putting all of your money into paying for a health insurance plan, you can put that same amount of money into an HSA and then you can choose to spend it when and how you want that on health care. 

Here’s the thing: HSAs are really for people who have a reasonable amount of disposable income. They’re not for people who have very limited means, who are living literally from paycheck to paycheck, where one of those parents are working two jobs at least and where their struggle is to make sure that they keep a reasonable amount of food on the table and so on. How much are they really going to contribute to a health savings account? 

What do you think about a public option or a single-payer system?

I think there are a lot of us, a lot of nurses, who believe that a single-payer system or a public option makes lots of sense. We are the last major industrialized nation that has not done that. If I think back to a comment one of my students from Canada has made, he keeps saying, “I don’t get why you guys are so opposed to this option. It makes all the sense in the world. Everybody should have access to a level of care. Why not?” 

And at the end of the day, a single-payer system is a much less expensive drain on the economy. This goes back to prevention, to population health, to the reduction and delaying of chronic care conditions and so forth and the expense of all those things. If we provide good care, sensible care, from the first dollar on, it ends up costing much less in the long run. I personally think that ti’s time we got our heads in the right place and did this.

What is something lawmakers overlook in healthcare policy?

The tendency is for them to overlook what the population health needs are. There are a lot of things that we need and we do in this country that are for the benefit of the population, not just the individual. So an individual parent might decide not to get their child vaccinated for whatever reason. And most people would say that that is their decision. But if enough people elect to do that, we then have a population health crisis. Where we have a resurge of polio, or measles, or something else. 

Even if enough people don’t get a flu shot, we lose what we refer to as herd immunity by having a sufficient body of the population immunized so that you essentially eradicate the illness. When that no longer happen, everybody is at risk — particularly infants who are too young to get immunized, elderly who are just more susceptible, individuals who are on cancer drugs or chemotherapy who have decreased immunity. What lawmakers tend to focus on is the individual, but a lot of the healthcare we receive as individuals is meant to protect the entire population.