Better care is unlikely. As it is now primary care docs get reimbursed based on quantity, not quality. With quantity increasing there will continue to be drops in quality, along with budget cuts that further reduce the quality. E.R. waits are also slated to increase pretty drastically as well. What we NEED to do is, instead of 'fixing' the current system, we need to start fixing people. A major part of the problem is corporate corruption, especially with drug companies. We are also a country that jumps to medication over common sense things like EXERCISE. Our culture is not in need of more high-end health care, we are in need of a cultural shift to increase prophylaxis in the form of exercise. The other issue is our food production, which is also adding to our healthcare costs. The chemicals and crap we consume are terrible in this country. If we were able to change these, then maybe just maybe somewhere down the line we could make universal health coverage work. Healthier people = less crowding, cheaper insurance premiums, lower taxes, etc.
Yes, doctors in the majority of hospitals in the US are currently paid on a fee-for-service basis as opposed to receiving a salary; they get paid for each test they run. The concern is that this leads to the temptation to run unnecessary tests to increase their earnings. While I don't think that this is a rampant practice there is evidence that it makes up a significant portion of tests; some hospitals have tried switching to paying doctors salaries even before the Affordable Care Act got involved and it led to up to a 40% reduction in tests run in some places without any corresponding dip in patient care. Public databases of hospital services show huge disparities in cost of treatment over even short distances, e.g. two hospitals in the same city where one charges roughly $38,000 to treat pneumonia where another charges about $14,000. I'm sure the more expensive hospital has some good arguments for why it charges more but clearly it isn't strictly necessary. The new reimbursement system (which by the way applies to only patients on Medicare) is to reimburse the hospital for a defined period of care as opposed to reimbursing the individual tests and treatments which (hopefully) will reduce that disparity.
How will ER waits increase drastically? People without insurance can go to the ER and the hospital gets shafted on the bill. So the only change is that the exact same number of people will need to go to the ER but that hospitals will actually get reimbursed for a few more of them than they used to.
We certainly do need to fix the current system exactly because it is corrupt; drug corporations, insurance corporations and yes even hospital corporations. It's not that these are bad people out for themselves though, some are sure, but the corporations in a large part are taking advantage of the current system to remain competitive and keep investors happy. I agree that the people also need to be fixed; exercise, eating better, not going to crazy medical treatments to fix their problems for them, but hopefully this will help do that by giving them greater access to primary physicians who will hopefully in turn better educate people to take care of themselves. Part of that is also changing how doctors treat patients but that's a battle for a different day because we have to get them in the room first.
Not to mention insurance coverage provided by the government has never really worked, what makes us think it will work now?
The Affordable Care Act is *NOT* government health insurance. It's true that Medicaid is being expanded slightly to include individuals making up to 133% of the poverty level (~$15,000/year in the contiguous 48) but the majority of health insurance access being granted is to private health insurance that already exists in the system. The big change their is the creation of online exchanges where rates can be more easily understood and compared to increase competition in price.
There will be a lot of people that will not only opt to not take the insurance, but will also just plain not pay the penalty as well. We will still be footing the bill on all of them but without them paying a portion. Hell there are people that qualify for medicaid that don't even bother getting it because they just don't care; they know they can't get denied by the E.R. so they just rip up the bill when it comes.
Again, its not actual insurance, so they're simply opting not to buy their own insurance on the exchanges. Since the penalty is part of their taxes they don't really have the option to not pay it since they'd then be guilty of tax evasion. So the only change here is that instead of people not paying for insurance, using up expensive medical resources for free rather than cheaper medical resources earlier on, and not being penalized for it (which is the current system), if people don't pay for insurance and don't pay the penalty and still use up those resources the government can now come after them for it.
And why wouldn't they get insurance? With the exchanges it becomes incredibly affordable, with subsidies available to those making 100-400% of the poverty line (in the contiguous 48 ~$11,500-$46,000 for an individual, higher if you have dependents) making it even more so.
For many the penalty wouldn't even be worth dodging, for the first year its at 1% of income over the filing threshold with a cap at the average cost of bronze-level insurance on the exchanges for the year in question (currently ~$3,300). Furthermore if there is no health coverage available for under 8% of your income you are exempt from the penalty.
So for example lets say you make $100,000 a year and are filing as a single individual. Your penalty if you didn't buy insurance would be $902.50 for the year. Someone making this much will probably have health insurance but if they don't want it then that's not exactly a kick in the junk to pay.
$100,000 - $9,750 = $90,250
$90,250 * 0.01 = $902.50
Let's say they're making the median US income ($42,693 in 2012), their penalty would only be $329.43.
$42,693 - $9,750 = $32,943
$32,943 * 0.01 = $329.43
What about a family making the median US household income ($51,017 in 2012)? $315.17 for the year.
$51,017 - $19,500 = $31,517
$31,517 * 0.01 = $315.17
Granted, this is only the first year and the penalty rate is slated to go up over the next couple years so let's take a look at it at it's peak of $695 ($2,085 for a family) or 2.5% of income over filing threshold (takes effect in 2016, adjusted for inflation thereafter). Let's assume a somewhat bleak scenario where median income is stagnant and doesn't change (although if the debt ceiling isn't raised maybe stagnant would be phenomenal instead of bleak).
Same people:
$100,000 - $9,750 = $90,250 $2,256.25/year
$90,250 * 0.025 = $2,256.25
$42,693 - $9,750 = $32,943 $823.575/year
$32,943 * 0.025 = $823.575
$51,017 - $19,500 = $31,517 $787.925/year
$31,517 * 0.025 = $787.925
It's certainly high but it doesn't seem prohibitively so, particularly considering we've lived through tax hikes of this level in recent years without great impact. Certainly taxes compound so its not in a vacuum, but this is also assuming that they are opting not to buy their own health insurance, which is ultimately what the goal is with the changes to the system and the implementation of the exchanges.
... I'm going to stop here because this post developed a mind of its own. *octo3*
