If your loved one  is seriously ill or injured and can’t pay for health care, should America provide what she/he needs? If health care costs are beyond the reach of many Americans,  should government take action? If you answer “yes”, the next steps are about how to achieve the goals; and it’s time for fact based solutions to the problems of American health care.

Prior to passage of the Affordable Care Act,  (Obamacare) the status of American Health Care was as follows:

• American spending was over $8000 per person per year, by far the highest in the world and  double the norm for the world’s wealthiest nations.
• Every other developed nation covered its entire population with some form of health benefits while we had 47 million uninsured Americans.
• Our life expectancy and infant mortality put us near the bottom of rankings of developed nations.
• The law required hospitals that receive Medicare and doctors working there  to care for anyone with a health emergency regardless of whether the patient had insurance or was  willing to pay.
• Emergency care for the uninsured was subsidized by raising prices to those who do pay.
• Insurance companies denied coverage to patients with pre-existing conditions or set impossibly high rates for them, putting them on the road to medically induced bankruptcy.
• Employers were dropping health benefits or raising employee’s share to unaffordable levels. Wages stagnated. Jobs were lost.  Some corporate planners found the cost of Canadian taxes that include health benefits to be lower than the combination of American health benefits and taxes.

Obamacare is a uniquely American approach to gradually covering everyone by 2020 while reducing spending.   It builds on our existing system with these basic elements.

• No more freeloading – every person is required to have insurance so costs for uninsured patients will no longer be passed on to others.  Individuals who can afford part but not all of an insurance premium will have government assistance to keep the premium below 9.5% of their income.
• Medicaid is expanded to cover those with very low or no income. The cost of that is substantially offset by reducing supplemental Medicare payments to hospitals with large numbers of uninsured patients.  (North Carolina put doctors and hospitals in a bind by rejecting 100% federal payment for Medicaid expansion while accepting the Medicare cut.)
• All but very small employers must provide part of the premium for employee coverage.
• Health care providers are encouraged to form “Accountable Care Organizations” (ACOs) which, like HMOs, can accept  premiums and take full  responsibility for care of patients.
• Payment reforms reward hospitals and doctors for improving outcomes,  patient satisfaction, and  costs. They can also be penalized for poor results.
• A variety of other reforms such as elimination of pre-existing condition exclusions make it easier to get and keep insurance .

Despite constant press coverage of Obamacare’s problems, early results are promising. The rate of increase in health care costs has declined significantly as has the number of uninsured.  Competitive pressure on high cost hospitals and medical practices is rising and at the same time work to eliminate complications and reduce health care errors offers financial rewards. Quality is improving without huge cost increases.

Meanwhile, our problems persist and hostility to Obamacare runs high, especially  among Americans who want a smaller and less active federal government.  Where should we go from here?  A constructive answer lies in the long-ignored section 1332 of the Obamacare law allowing waivers for innovation.  States can extensively change most provisions of the law beginning in 2017, as long as they maintain comparable levels of coverage and don’t raise the cost to the federal government.  Conservative ideas like privatization of Medicaid and liberal ideas like a single payer system are all on the table for state-level innovation.  President Obama and a bi-partisan group of legislators wanted to make this opportunity available even earlier but congress would not agree.

Now is the time for state governments to plan the changes that they want and for President Obama to reach out to governors with offers to support innovation.  With the states acting as laboratories, we can continue to evolve more effective ways of delivering economical health care for all Americans.  Our leaders should disband their circular firing squad and demonstrate creative teamwork.