What's Wrong With American Health Care?

The Best in the World?
Despite the fact that Americans spend much more on health care than any other nation and have demonstrably worse outcomes, you still hear people say, "American health care is the best in the world." But plenty of people are NOT happy with the high prices they pay when they go to the doctor or with the expensive and sometimes dangerous drugs they are prescribed or with the constant fear of losing their health insurance, upon which access to healthcare depends, when they lose their jobs.

What's wrong with American healthcare? Personally, I'm almost totally disillusioned with our so-called "health care system" which isn't a "system" at all but a patchwork of insurance companies, big health care corporations, disconnected provider organizations and monolithic charity operations, all with their own goals and all looking for health care dollars. Lots of our hard-earned money is poured into these institutions, which are supposed to provide us with health care. But mostly it provides them with profit and us with an insecure, inefficient and frequently ineffective means of receiving health care services.

INSURANCE MODEL DOES NOT WORK

Let's start with insurance. Why is insurance used as a mechanism for paying for healthcare? It doesn't work. Insurance works only when the object or event against which we have insurance is something that is not likely to happen. Insurance against a flood or someone slipping on your front sidewalk or some other unlikely event means the insurance company can take in more than it pays out without much trouble. But everyone needs health care services from time to time, some much more than others. Insurance companies have responded to this by trying to eliminate anyone who might be very expensive. That makes sense for them, but does not serve the societal goal of making sure everyone has access to the care they really need.

Should all Americans Have Access to the Care They Need? The above statement assumes that Americans DO believe everyone should have access to health care, but I'm also aware that there are people who do NOT believe this. I think the reason they don't think everyone should get the health care they need is because they have spent their lives with the insurance model and with the Republican idea that business solutions are always good and government involvement is always bad. They have never questioned whether insurance companies should be involved in our health care. In other industrialized countries, government-funded health care ensures that everyone can access health care services. It works for them and it would work for us too if we could get over the nonsensical idea that government can never be part of the solution to a national need. As a society, we have accepted government-funded fire and police services, and government involvement in public roads and infrastructure. Why is healthcare different?

INEQUALITY OF SERVICES

Maybe some people oppose government-funded health care because they do not want everyone to have the great medical services they have. In America, we have big-time inequality of health care services. The well-insured get all the services they need, and more, while the uninsured and poorly-insured may be unable to get even life-saving treatments, let alone regular trips to the doctor. This leads to distortions in our so-called health care system.

Medical Services Go Where There are Lots of Well-Insured People Let me explain. I grew up in Flint Michigan during the 1950s, when the auto industry was booming. In the post-war years, Flint autoworkers were able to get great company-paid health insurance through union bargaining. Subsequently, lots of doctors settled in Flint, and hospitals had all the latest equipment. As the years went by, this meant some people (the union auto workers) had great access to care and anyone else did not. Providers typically love the well insured and offer as many services as possible for them, while seeking to avoid those without insurance or with skimpy coverage. Beginning in the 1970s, the auto industry went into decline and, although my father made Buicks for over 40 years, they no longer build Buicks in Flint. The huge factory complex where my Dad worked is just an urban ruin now. But due to the large number of retired auto workers who still have union-sponsored insurance, there are still numerous health care providers located there, in a city full of abandoned homes and rampant poverty. As they continue losing insured customers, many of these providers will move on to other locations where there are more people who have great health insurance. Flint, like other poor areas, will be left with abandoned health clinics and people who have no health care. The distribution of health care services is not related to medical need, but rather is heavily represented in geographical areas having a large, well-insured population.

GAMING THE SYSTEM

Insurance companies have been creative in finding ways to eliminate subscribers who might be costly. Originally, they just dropped anyone who ran up too many health care bills. Then Congress said they had to take everyone when supplying insurance to employer groups, so within groups, they could not pick and choose who to insure. But if a person switched to a new policy when they changed jobs, they could be excluded based on health status. That led to "job lock" where people with a sick child or spouse were afraid to change jobs because they would lose their insurance. Various state and federal laws tried to do away with this too and made health insurance through your job more secure, but still dependent on the largesse of your employer to continue providing it. As costs rise, more employers opt out or pass on most of the growing cost to their employees.

Why is there an "Individual" Market? But some people are self-employed or operate a small business, and these are among our most creative and productive citizens in terms of growing our economy. These people too would like to have access to health care. Insurance companies created the concept of the "individual" plan so they could examine the person's health prospects and the health of any family members who would also be insured. If any might prove to be expensive, insurance companies responded by either quoting extremely high rates or just turning down the applicant. Have you ever wondered why insurance companies can't "pool" ALL their subscribers into one pool? Pooling is supposed to be how insurance "works" - you spread the risk by having a large group of subscribers and base rates on the "pooled" group. But insurance companies don't do this. They deliberately fragment subscribers into as many small pools as they can, along with turning down anyone who applies as an individual who might be expensive.

SELF-EMPLOYED EQUALS UNDERINSURED OR UNINSURED

My husband and I were self-employed and operated a small business through most of our 48 years together. We were constantly scrambling to find some source of health insurance we could afford. For a while we had "association" insurance - we joined a business organization that offered a group policy. This was a good option for a few years, but the rates kept rising until it became obvious that we would reach a point where we could no longer afford to pay the premiums. Our health insurance was so expensive, it cost more than our mortgage payment and grew to cost even more than our mortgage and car payments combined -- in fact, it was our single biggest expense! That made me wonder when to stop paying. Every month meant writing a big check to an insurance company and mostly seeing nothing in return. We had a large deductible, so we always had to pay from our pocket when we went to the doctor until the deductible was used up, which it mostly never was. Wouldn't I be better off to stop paying now and put the premium money in the bank and use it to pay for services when I received them? That's the question I asked myself every month. The minute I stopped paying, all the money I'd already given the insurance company would be for nought, gone into the black hole called insurance company profits and doing me no good at all. In desperation, we called our agent to see if we could get a cheaper plan. The agent didn't bother calling us back. I guess we were just a small customer and he didn't really care how paying for health insurance (NOTE: not "health care" but "health INSURANCE") was bankrupting us.

Throughout our married lives, we bounced from one bad plan to another. From one expensive plan to another. That's how it is for people who don't work for a big company that provides good group coverage. That's a lot of people, maybe more all the time as increasing numbers of people work free-lance, on contract, part-time or just change jobs frequently in our continuing poor job market.

Insurance companies claim they are providing Americans with healthcare, but they are really providing themselves with huge profits off the fears and insecurities of the American people who continue to buy their flawed products (and now are being FORCED to buy their products by the Affordable Care Act, also known as Obamacare). Insurance companies are so entrenched in our country that most people don't even question their role.

PROFIT-DRIVEN PROVIDERS

Health care in America is a commodity, although it is paid for through a labyrinth of organizations, each skimming off their share of health care dollars. In America, you do not have a right to health care; you must purchase it, usually through a middleman, the insurance company. Although medical doctors, through their organization, the AMA, initially opposed insurance as a payment mechanism when it first appeared during the World War II years, thinking it would reduce their control over medical services, they later embraced it and even offered their own plan, the Blue Cross companies. In the beginning, these operated with a "social insurance" model with the stated purpose of pooling subscribers to spread costs, and they were non-profit. But that has changed, as the medical profession pursued the dollars they could collect from the well-insured and decided to ignore everyone else. Most of Blue Cross companies today are for-profit and even if they are ostensibly non-profit, they operate the same as the for-profits. Today we have a system where providers provide what insurance companies will pay for. Doctors like to pretend they are independent and are offering the treatments that are best for their patients, but aren't they really just doing what the insurance companies dictate?

No Insurance? No Service! Doctors have embraced health insurance to the point of not wanting to serve patients who lack insurance, even if those people have cash to pay for services. Like their patients, they have lived with the insurance model for so long, most have adjusted to it. Their prices are now so high (another by-product of insurance and the extra layer of costs it adds) that they don't believe anyone can or will pay them without insurance. How ironic! My cash is no good - I must have that precious insurance card to get in the door.

WHAT'S THE PRICE FOR A MEDICAL SERVICE? NO ONE KNOWS

Cash customers have no easy way to figure their expenses when they need medical care. Providers don't really have a "price" for their services anymore, since their payment is determined by the insurance companies. Cash customers, when they are served at all, are usually given a higher price than the insured. This is even more pronounced with hospitals, which also receive whatever Medicare or insurance companies will pay, so most hospitals do not have a list of charges. Again, they simply jack up the price for uninsured patients, who — contrary to all the propaganda that the uninsured do not pay for services — DO receive a bill and ARE expected to pay it. Granted, many can't pay it, but the uninsured do not get a free ride and most are uninsured, not because they are too irresponsible to purchase health insurance, but because they CANNOT GET IT or cannot afford it. Remember, not everyone has employer-provided group insurance and the "individual market" is a swamp of overpriced bad deals.

Social Responsibility? Health care used to have a heavy "social responsibility" overtone, with many religious organizations operating hospitals or clinics. Where I live, we have health organizations with names like "Providence," "St. John," "Mercy" and "St Joseph" that used to have a social mission to provide people with health care, but now are profit-driven. Yes, it costs money to operate hospitals and they cannot stay in business if they don't take in money, but shouldn't we question why medical care has gotten so expensive and why we continue to tolerate a system that excludes so many people from access to care? How is this progress?

WHO SHOULD PAY? WHO SHOULD GET PAID?

Most countries of the world have opted for government-funded health care, and their citizens like it. In Great Britain, people are so fearful of any attempt to privatize their National Health Service that even Conservative Prime Minister David Cameron had to promise he would never take away their universal health care. Canadians regularly make fun of our backward health care, and I have read two novels (one written by a Canadian) in which the plot revolves around insurance companies having hit men eliminate people who cost too much. A bit extreme maybe, but it's in the interest of insurance companies to eliminate these folks as customers or to find ways to not pay for their care. Why not hire some thugs to do away with kids born with fatal diseases or accident victims who will require lifelong care? Insurance companies are all about making money, not providing care.

Are we too arrogant to study the successful medical systems in other countries? Only "made in America" will do? Private insurance tied to people's employment is a ridiculous way to provide health care and only WE don't see it!

Doctors as "Slaves?" Doctors generally oppose government-funded care for all and recently I've heard one of the stupider reasons from Senator Rand Paul (who is a doctor). He claims that universal health care would force doctors into a kind of slavery because he claims that they would be forced under law to provide services to whoever needs them even if they can't pay and doctors would thus be forced to work for free.

First, there are some situations in our present system that already do require medical care facilities to provide stabilizing treatment in emergency cases. This is under a kind of half-hearted belief that we should not just let people die when treatment is right in front of them and could save their lives. So Emergency Rooms already have to provide some services, but that does not mean the doctor does not get paid. Rand Paul mistakenly ties the responsibility to the doctor, but clearly under a national policy of universal health care, the onus is on the government to provide (and pay for) needed services. I doubt doctors in Canada and Great Britain think of themselves as slaves.

Doctors Try to Maximize Income The real reason doctors oppose government funding is they fear they might make less money under such a system. But doctors have already lost the ability to dictate fees for their services - insurance companies took over that role long ago, and the government also influences pricing through Medicare. Doctors once considered it a duty to take care of people who came to them for help, and did not instantly demand to see an insurance card before treating someone. But now we have Rand Paul whining about being forced into "slavery" at the mere thought of treating someone who does not have insurance. Ironically, in a government-funded system, the doctor would always get paid.

Government-funded health care is "free" to those who need it, but it is not "free" to society. What it does is take the principle of "pooling" to the highest level and puts all Americans in the same pool, spreading risk evenly throughout society, and paid for with taxes. When you have a big income, you pay more. When you have a small income, you pay less. But you always get the service. It eliminates the insecurity most Americans feel about their health care. When you only get health care when you can pay the insurance premium and/or you continue to have a job that provides insurance, it leaves you with a lot to worry about.

WHO GETS WHAT SERVICES?

Eliminating insurance companies and giving everyone the same set of covered services would eliminate the inequality of care we now have. Everyone would get services, regardless of employment status or income. There would be no incentive for providers to seek out some patients and try to avoid others based on their insurance status.

But what services would everyone get? There needs to be an overall design to health care, an agreed-upon level of services that actually provides benefit to patients, not just profits to hospitals, doctors and drug companies. Today, we have a smorgasbord of high tech procedures and new expensive drugs that are often just variations on older cheaper drugs. The profit motive produces ever more potential services, treatments and drugs for which we can spend money. Which are really worthwhile and for whom? These questions need answers, and I can't provide them here.

Runaway Costs

But I will use the "R" word - Rationing. Yes, we need to ration services based on what works and what has the most potential to keep people healthy. We need to make sure all children get the care they need to grow up healthy, and we need sensible, but not unlimited, expenditures for late in life and end of life care. We should eliminate overtreatment and futile treatment and take away incentives to provide ever more services that are expensive but accomplish little or nothing. We should not allow any million dollar drugs and treatments, as these are not financially feasible. We need central planning to initiate mechanisms for bringing down the overall cost of health care and improving the outcomes of what we do medically. We MUST do this if we are to actually provide necessary health care to all Americans.

Screening is NOT prevention Even screening tests are oversold, as if they will keep us from getting the disease they are screening for. Mammograms are touted as "breast cancer prevention" but they are no such thing. In fact, the exposure to radiation involved actually CAUSES cancer! Assuming the machine used is correctly set and the technician operating it is well-trained (and these are often not valid assumptions), the exposure is small, but it does add up; the effect of readiation exposure is cumulative. Screening tests are promoted on the idea that early detection means a better chance of effective treatment, but there are other opinions on this which hold that often early detection makes no difference. However, it DOES lead to unnecessary (and expensive) biopsies and treatments for an anomolous finding that may not be an actual problem. A tiny spot seen on a mammogram may never become cancer, but may be treated aggessively (and expensively) anyhow. Treatments can trigger side effects requiring more treatments. Women can end up having a breast removed. Men having surgery for prostate cancer risk impotence. Are these questionable treatments really in our best interests, or just in the interests of those who profit from them?

Are "Preventive" Services Worth Their Cost? Speaking of preventive care, Obamacare (see the section below), which became law in 2010, makes insurance companies cover "preventive care" completely. Given the profit-driven nature of healthcare in America, this leads to aggressive promotion of screening programs which further runs up the already exorbitant premiums we are forced to pay. Some of these services may have some value for some people, but where does this philosophy end? So-called "preventive care" is another oversold service that is offered precisely because there is insurance to pay for it; benefits to patients is a secondary consideration. If you doubt this, I recommend Dr. Gilbert Welch's book, Overdiagnosed (See link to my review of this book below).

IS HEALTH CARE WORTH WHAT WE PAY FOR IT?

In all the forcing of people to pay for insurance so they can have health care, have we ever asked the question: Is it worth it? Do we get something equal in value to all the money it costs when we go to the doctor, the clinic, or the hospital? It seems to me that most of the time I've sought out a doctor, I've gotten little or no relief from the problem. Doctors are quick to put you on some maintenance drug that you must take forever, and I can't help but wonder if this is because 1) it means you have to keep coming back to get your prescription renewed (and they get their fee) and 2) because they receive gifts and flattery from the drug companies who "educate" them about the drugs they prescribe.

If you go to the doctor for a pain in your hip, you will get a battery of expensive tests that probably reveal nothing and maybe a prescription for some expensive drug you must take forever and, after spending a ton of money, you still have the pain in your hip. You may also later have a bunch of side effects from the expensive drug you must take forever, but, hey, the doctor can prescribe more expensive drugs to counteract those effects. Who hasn't had an older family member who has a dresser-top full of pill bottles, but has no idea why he's taking any of the stuff in the bottles? I am determined that this will NOT be me!

Hospitals are supposed to help us, but thousands of people get infections in the hospital or are victims of medical errors leading to more sickness and more expense. Hospitals get MORE money when they make people sicker! Do doctors suggest surgery far more often than it makes any sense? Isn't it posible that this is because surgery is what they do and it is very profitable? Of course, medical people will say that patients demand services and prescriptions and doctors merely give them what they want. But I seriously doubt that. I think doctors just don't know what to do about a lot of the health complaints that people have and they fall back on writing a prescription, ordering tests or doing surgery that is lucrative for them! They are not healers; they are technicians. Over my lifetime I have lost most of my respect for them. They make a lot of money for the little benefit they provide and the unpleasant and financially disastrous experiences they put us through.

Scammers Sell "Insurance" That Doesn't Pay For Anything Millions of self-employed people have discovered that insurance can be so thin it barely rises above the level of a scam. And sometimes it IS a scam. Unscrupulous salesmen preying on peoples' fear of being without insurance sometimes sell plans that are actually just discount programs but sold as insurance, or that turn out to not actually pay for much of anything. I once got stuck with a $2500 bill for a few hours in the Emergency Room which I expected my "insurance" to pay, but for which it paid nothing. I was, however, paying a hefty monthly fee for this so-called "insurance." My own negative experiences have led me to feel much of "insurance" is actually just a rip-off. Like other Americans, I have paid their exorbitant premiums because I did not want to be without coverage and put up with the sneers of those with great employer-paid coverage who claim it is "selfish" to not buy insurance. Do they really think the self-employed or minimum-wage worker has any access to the great coverage they have? Doesn't the excessive use of medical services by the well-insured run up the cost of premiums? Just who is being selfish?

THE PROOF IS IN THE NUMBERS

Then there's the matter of our poor health outcomes compared to other industrialized nations. A report by the Robert Wood Johnson Foundation and the Urban Institute looked at 19 developed countries and how well their health care systems kept people from "preventable deaths" through providing necessary treatments. The US ranked DEAD LAST!! Not surprising for a country where the only people with a right to health care are prisoners (that's right, if you are in jail, the state must pay for your medical care); the rest of us have to have an insurance card to get served, then we still have to hope our expensive insurance will actually pay for our treatment. Canadians and Europeans with government-funded health care live longer than we do and their babies don't die as frequently as ours do. The US ranks 31st in life expectancy (tied with Chile!) and 34th in infant mortality. The only group of Americans who rank higher than average in life expectancy are Americans over the age of 65. That may well be because if you reach that age, you have Medicare and are no longer dependent on private insurance for your health care.

WHAT'S WRONG WITH THE Patient Protection and Affordable Care Act?
(also known as ObamaCare or "the ACA")

Forcing People to buy Health Insurance In 2010 Congress passed into law a health reform bill supported by the Obama Administration. President Obama campaigned on health care reform and, as President, he pushed a bill that would keep insurance companies in charge and require all Americans to purchase health insurance, known as the "individual mandate." Along the way, he compromised away the best parts of this plan, including a "public option." Actually, as the "public option" shrank under the objections and compromises of the committee hearings, it would not have provided any real option to expensive for-profit insurance anyhow. In its final state, it was going to consist of small state-run plans that had to operate like private insurance and would only be available to people who did not have a plan at work. What we end up with is continued reliance on health insurance companies for our access to health care, but now we are forcing everyone to buy insurance from for-profit companies that have failed to get the job done in the past. Are these insurance companies going to change their tactics now? Why would they?

Are you Poor Enough for a Subsidy or an Exception? Actually, it isn't "everyone" in these plans anyhow. Like the Massachusetts bill (the Mitt Romney plan) upon which it is based, the Obama plan allows for exemptions for people whose income is too small to afford insurance premiums and provides subsidies for lower income people to buy insurance or let more people qualify for Medicaid. Many states, especially those with Republican governors, have decided not to expand Medicaid (thanks to the Supreme Court decision that said states can decide to opt out) which will leave poor people in those states with no options since most will not meet minimum qualifications for buying insurance on the exchange. Some states may do better than others, but all require a bureaucracy to decide who gets subsidies or who can get Medicaid, and those who qualify have to continually show that they are still poor enough to qualify. There's not much security in that.

In fact, this "reform" act does not provide any kind of health care security. People who supposedly can afford the premiums may find themselves in situations where they cannot continue paying. Their income may vary (free-lancers, contract workers, seasonal workers) or they may be hit with large unexpected expenses. Some, with money short at the end of the month, will just quit paying for health insurance. After all, food and shelter needs come first. That will mean paying a fine (even if the Supreme Court decided it is a "tax," it works just like a fine), and, of course, they also lose access to health care. Other people exempted from paying the fine but not qualifying for Medicaid or a subsidy, will also be without access to health care. How is this reform?

Keeping Our Young People Dependent and Burdening Parents There are some helpful parts of Obamacare, but overall it will not solve our health care problems. The provision that requires insurance companies to let subscribers keep their children on their policies to age 26 is the wrong solution to the problem of young people who can't afford insurance. It drags out childhood for young adults and is a burden on parents at a time when many want to reduce expenses and retire. It might be welcome to wealthy parents, since their offspring tend to have extended childhoods anyhow (with Mom and Dad paying for four years or more of college and a good launch in life), but to the average working family, having to pay for health insurance for their sons and daughters to age 26 could be a big financial hit. Insurance companies do not provide this coverage for free. It is expensive to add anyone onto most employer-provided plans. On my last job, I had my husband on my plan until he qualified for Medicare. It did not just double my premium - it MORE THAN doubled my premium! Insurance companies do not really like to provide "family" coverage and have been moving away from it. Because some people in group plans through big companies get to add family members for little or no cost obscures the fact that adding anyone to a health insurance policy is going to cost someone. If you buy your own insurance or work for a small employer, the someone who is going to pay is you.

Spouse and Child Coverage: It Will Cost You Your employer may subsidize the cost of insurance for YOU, but not for your spouse or children. If you insure them, with many small group plans you will pay the entire amount of their coverage. If you were unlucky enough to be in the miserable "individual market" before Obamacare, you might have found you could not even add your spouse or new baby to your policy if there was a pre-existing condition. People who work for the government or a large, prosperous company with great group coverage might be surprised to know that other people who work for a living and pay for health insurance were denied the possibility of providing their spouse — or children — with coverage. For people in that predicament, Obamacare provides relief. Insurance companies have to insure your family members, no matter their health condition. However, they will charge you plenty for doing so and the high cost of treatment is still there; that will be reflected in the high insurance rates we are all going to pay. Insurance companies are not in the business of making health care cheaper. On the contrary, their presence in the process ALWAYS makes it more expensive.

Parenthood is Now Unaffordable The cost of insuring a new baby is actually causing some young couples to put off parenthood. A New York Times story in 2016 on medical debt (I Am Drowning — NYT, Jan 11, 2016) included reader comments. One woman wrote that she and her husband divorced because of the huge cost of health insurance for herself and their children. Divorcing meant one of them and the children could qualify for Medicaid. There was also this:
Health costs have killed my dream of having a child. My fianc� and I pay nearly $20,000 a year for health care (with insurance); a third person�s (i.e. a baby�s) premiums and bills would sink us.

We find ourselves in a world where we are all held hostage to the ridiculously high cost of health care, so much so that it means some couples can't afford to marry (or stay married) or have children. This is what handing control over healthcare to insurance companies and a profit-driven medical industry has done to our country. Are we creating a society where only the wealthy can afford to have children?

Reducing/Limiting Costs? The high cost of insuring spouse and children remains a feature of our so-called health care system under Obamacare, which was supposed to save us all money. Obama's original plan when he was a candidate was to require health insurance only for all children, but, under the law as passed (requiring insurance for EVERYONE), just who is supposed to pay for the children? If husband and wife each get their own insurance through their jobs, can the children, who might be expensive to add to either of their plans, buy their insurance on the exchange? Wasn't there supposed to be a maximum you would have to spend? When you add up the cost of HIS insurance, HER insurance and the CHILDREN's insurance, how much of your family income is that? And don't forget to add in the out-of-pocket expenses because of the high deductibles and copays on those plans on the exchange. I think American families will continue to see a large proportion of their income going for health insurance and health care regardless of provisions that are supposed to limit the cost for families. The deductibles alone can be bankrupting for some families. The law does little to reduce the cost of health care itself and that cost will always be reflected in the cost of health insurance.

AFFORDABLE??? Ha! Ha! Maybe the worst thing about this health care law is its name -- "AFFORDABLE Care Act." As long as we have insurance companies in charge of our health care and no controls over which services should be provided as part of an effective healthcare system, our health care will never be "AFFORDABLE." The capitalist model means more companies coming up with more medical services and products that cost ever more money, with no brakes on what they can charge. Health care services, like rents in New York City, are just too damn expensive!

Is This the Best We Can Do? I wish President Obama had used his obvious intelligence to analyze the problem a bit further and use his charm and oratory skills to show and persuade Americans that government-funded health care is really the only solution to our long-time healthcare hell. I wish he had worked even harder for a system that would actually bring health care equality to all Americans. Instead, he never challenged the insurance companies or the drug companies and he gave them all the seats at the table in the apparent belief that this plan was the best we could do. President Obama was too much of a pragmatist and not enough of a visionary on what is possible. It is disappointing that we did not get something better than the so-called "Affordable" Care Act" which is anything but "affordable."

My comments on Obamacare

Website Problems Yes, the Obamacare architects shot themselves in the foot with that disastrous rollout, which was NOT an auspicious beginning. I spent over 20 years working in IT, including some big software projects, and I know failure is common. I've seen projects end up getting scrapped because they didn't work or the client didn't like what he got. However, health care reform will succeed or fail, not on the quality of a website, but on whether people can actually get and keep good health insurance that they can actually afford, and that actually covers enough of their costs to be useful. Websites can be fixed; bad policy is a much more difficult problem. Obamacare has continued to be vilified because of unintended consequences and failure to fix the basic problem that health care costs too much and insurance only makes it more expensive.

"If you like your insurance, you can keep it" President Obama famously told Americans they could keep their health insurance under Obamacare, but it turned out that some people who had non-group insurance have had their insurance canceled, and some of them publicly complained about it and Obama-haters siezed upon it as evidence that Obama lied. Well, it seems to me that this is just more proof of how little anyone in this big country of ours (including the Obamacare authors) really ever understood about the so-called "individual market," that insurance hell to which those of us without job-based group converage were consigned. Insurance companies could always do whatever they wanted (charge as much as they liked and cover as little as possible). As I said earlier in this rant, why would they sudenly change? I doubt that many of those being canceled actually "liked" their insurance (certainly not, if they ever had a major illness), but some may have had lower premiums than an Obamacare "bronze" plan if they were healthy, had never made many claims and had bare-bones coverage. In fact, most of those who were purchasing individual coverage can buy better coverage on the exchanges, but they may have to pay more for it. Obama didn't lie, he just didn't understand that people in non-group plans (the very people suffering with high prices and poor benefits) were at the mercy of the insurance companies who could always find ways to cancel their coverage. These canceled policies, along with rising premiums on the exchanges, are indications of the extent to which insurance companies are still in charge.

COVERAGE ? -- Oh Yeah, We Got Coverage, But Have We Got Health Care?

Campaigning for President in 2016, Hillary Clinton stated that Obamacare has taken us to "90% coverage" with health insurance. The "individual mandate" forces everyone to purchase health insurance or pay a fine. So, 90% of us have COVERAGE. What exactly does that really mean? COVERAGE means making monthly payments to a for-profit insurance company for an insurance product that will probably come with deductibles (as high as $10,000 and even higher for some) and copays on each visit to the doctor and each prescription. A 20% copay on a $5000 drug you must take every month means it is still unaffordable for most people. Paying for COVERAGE provides only a chance that you will actually get the health care you need. It is a huge gift to insurance companies and requiring such COVERAGE is a huge burden on the American people.

COVERAGE is NOT health care!!!!

Premiums, Deductibles, Copays Rise and Become Unafforable Insurance companies are going to keep raising the premiums for people who buy on the exchanges (who already have to pay those big deductibles before their insurance pays for anything). Paying these premiums will be a big monthly expense for many, reducing the income they have left for necessities like food and shelter. But the premium is not the end of their medical expenses. People who have been prescribed a drug that some greedy drug company has decided to reprice to an astronomical level may find thier copay for that drug so unaffordable they will be unable to remain on the drug. But they STILL must pay their health insurance premiums or face a fine. This kind of "insurance" is not providing healthcare security.

Medical Bankruptcies are Still Happening In Massachusetts where they had a law similar to Obamacare before Obamacare, medical bankruptcy rates did not go down much, and there is growing evidence that medical bankruptcies are continuing since Obamacare has been enacted. The out-of-pocket costs can be so high that many people still find the bills piling up when a family member is sick. The Bronze plans are so skimpy (paying only 60% of covered services) that they are not really worthwhile and leave people exposed to bankruptcy. But, under the Affodable Care Act, you MUST purchase insurance.

Is Change Possible? Hillary's surprise rival for the nomination, Senator Bernie Sanders, was the first person to run as a Democrat in many, many years to support ACTUAL universal health care for all Americans as a right. Universal health care was once a staple of the Democratic Party platform, until it was replaced by "everyone should have health insurance." The Republicans, of course, generally oppose anything but "free market" medicine (as if that were even possible in health care, which is not the same thing as buying a refrigerator or some other optional consumer purchase). In either case, no one seems to be talking about ways to reduce the overall costs. Unaffordable health care is unavailable health care. It seems both parties have been seduced by the special interests who profit from keeping insurance companies in charge of our health care.

Would electing Bernie actually have gotten us what all polls show most Americans want, true universal, government-funded health care? Well, no, because most members of Congress owe their election to financing from billionares who don't want us to have what every other advanced nation on earth has, so it does not seem likely that they will pass universal health care. But I supported Bernie because he is right that we must replace insurance companies with publicly-funded health care for all. Change will come when lots of Americans send Congress the message that we want a health care system that is fair and (truly) affordable (not just labeled "AFFORDABLE Care Act.").

Repeal and Replace? Republicans who vow to "repeal and replace Obamacare" will do no such thing. They will find repeal more difficult than their slogans make it seem and they have no replacement. Healthcare as it operates in the US is extremely complex, but very important to all of us. Obamacare has provided access to care for many people despite its shortcomings, and its sudden disappearance would cause much harm. President Obama had good intentions when he signed the ACA into law, and it does represent an important step in securing universal healthcare: the admission that the federal government should guarantee that ALL Americans, regardless of income or health status, have access to health care.

CONCLUSION: WE NEED REAL CHANGE IN OUR HEALTH CARE SYSTEM

Real Help? Only If You're Over 65 In the summer of 2010, I turned 65 years old and finally got Medicare and as long as I have it, I feel — for the first time in my life — a sense of security about my access to health care. Medicare is not dependant on having a job with benefits or the ability to pay monthly premiums, but is a right for every American over age 65. But I've had to worry about my daughter, who, like her parents, has chosen the free-lancing life and had been doing without health insurance. She finally (at my urging) logged on to the New York state health care exchange website (she lives in NYC) in January 2014 and, after going in circles on the website which did not handle her self-employed income in any manner that made sense, calling the help line and waiting on hold for a solid hour and finally connecting with a lady who was very helpful. Going through the maze, this phone help got her to a point where she was shown to be eligible for Medicaid. She signed up for a "Medicaid HMO" plan with no monthly premium. Other People may find they'll be paying a high price for only 60% coverage (with a bronze plan) and also have a big deductible.

What Should Struggling Young People Do? I am guessing there are still many young people who are doing without insurance. Yes, Congress passed a health care reform bill, and it is helping some people, but I fear that little has actually changed. It turns out that even my daughter, who got the no-cost Medicaid HMO, found herself STILL going to a public clinic for health care because the big insurance company operating that HMO could not direct her to a health care facility that actually takes the insurance card they sent her! This is a new low for even as sleazy an industry as health insurance. Shame on you, State of New York! Why are you letting them get away with this?

My daughter also told me that she and her millennial friends (late 20s, early 30s) are not happy with Obamacare because the deductibles are so high that they still have to pay every time they see a doctor plus pay insurance premiums. My daughter says even her Medicaid plan did not provide any benefit better than she had by just going to Bellevue Hospital for care. She said it DID let her use the Bellevue pharmacy for prescriptions that she could get for no charge, but otherwise did not help her find actual medical providers. Her friends say the copays for doctor visits and prescriptions are higher than the cost of programs like the one Bellevue always had, where a clinic visit costs just $20 and provides access to excellent doctors. Some feel NOT signing up for Obamacare and just paying the fine is a better choice than paying for a plan on the exchange.

It's interesting that these younger people have the same complaints I had as a buyer of "individual market" insurance (costs too much, pays for too little, not worth it). A system of low cost or free clinics would better serve young people and others struggling to make ends meet than something as complicated, burdensome in terms of having to explain a variable income, and ultimately as expensive as Obamacare. BUT... if younger, healthier people don't sign up (because they feel not signing up is in their own best interests), then plans on the exchange can go into a "death spiral" of high costs for insurers who will have to continually raise premiums, leading many to quit offering Obamacare plans at all. Obamacare is not sustainable.

The sad truth is that healthcare itself is still too expensive and Obamacare does nothing to bring down the cost; it is designed to serve the healthcare industry, not the American people. Health security for most Americans is still a mirage, perpetually out of reach.

Profit-Driven Insurance Companies are Still in Charge As health care has sunk more and more into the profit-driven morass of Corporate America, it is taking in more of our dollars and giving us back services that are too expensive and too ineffective because they are motivated mainly by profit, not by doing what is best for people. Healthcare as a product delivers very poor value for what it costs and our poor health care outcomes are the proof.

I am angry that I live in a country where people go bankrupt because they got sick. People die because our stupid method of funding care through health insurance means millions of Americans are left out and don't get the care they need! I will continue to protest against our inefficient, ineffective and overpriced health care system as long as it is not fixed and I have breath left to complain. Considering the extent to which Washington has sold out to the Healthcare Mafia (big insurance and drug companies and the AMA), I'm not optimistic that I'll live to see health care equality in America.