The Looming Policy Questions Obamacare Doesn't Touch

Despite the nation's laserlike focus on the Supreme Court and the Affordable Care Act, we shouldn't pretend that the White House's law is the only game in town.

The pending Supreme Court decision has brought attention to the Affordable Care Act (ACA) to a near boil once again. The country is almost perfectly divided on the law along partisan lines, signaling that the law has become a symbol of ideological and partisan differences that have little to do with substantive disagreements about the details and the merits of the legislation itself.

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Decisions about the future of the ACA in the Court or by the next president and Congress will have enormous consequences--for one thing, it is hard to imagine returning to a world where we leave fifty-plus million Americans uninsured. But it is a mistake to treat the ACA as the only game in town when it comes to big, looming health policy questions. In fact, what is unique about the current era is how many big questions about future directions may be up for grabs. The answers to these questions will profoundly shape the future of American health care.

First, there will no doubt be a debate after the election about converting Medicaid into some form of a block grant program. The fundamental issue: should we as a nation guarantee health coverage to most low-income people as a matter of national policy, or is it better to leave that decision to each of the states? Resolution of this issue could radically change health coverage for more than 60 million low-income and disabled people, and affect both state and federal budgets.

Likewise, we can expect a big debate about converting the always politically volatile Medicare program to a premium support or voucher program. The big question: will Medicare remain a defined benefits program, or switch to a defined contribution program instead? How would the all-important details of that work?

The insurance and delivery system are changing rapidly. We don't really know, with real evidence, if the changes that are occurring offer new models to provide more cost-effective care, or instead represent a further consolidation of power and money in the marketplace that will drive up spending in the long run. We do know that what we call insurance is changing, with a steady growth of high deductible plans and more cost sharing for consumers. While conservatives do not like what they call Obamacare, the form of private insurance they have always favored, with much more skin in the game for consumers, is gradually prevailing in the marketplace.

Beneath the surface, while these policy questions crystallize in Washington, the nature of health care utilization has been changing. The slow recovery, coupled with greater consumer cost sharing in health insurance, have caused people to go to the doctor and the hospital less in recent years, resulting in a slowdown in historic rates of the otherwise inexorable increase in health spending. Official estimates now are that the gap between increases in health spending and growth in GDP will be a full percentage point smaller than previously expected over the next ten years: health spending is now projected to grow 1.4 percent faster than GDP rather than 2.4 percent.

We do not know for sure if this projection will come true, because we don't fully understand why the slowdown has occurred. The government models credit reductions in Medicare spending in the ACA for much of the longer term slow down. My guess is health utilization will pick back up as the economy strengthens, but if we are seeing a "new normal" many of the ugliest projections about health costs will need to be reevaluated.

Finally, there is the election itself, which could certainly usher in changes in direction and philosophy in health in the White House and Congress. So yes, the ACA may be the most important health policy turn coming up. But it is not the only one.