“What will TUCA (The Unaffordable Care Act) look like one year from now?”  This is one of the most common questions I hear.  As many times as I have answered it, I think it might be worthwhile to do so in a blog.  There are two answers, really.

Scenario #1

TUCA will do precisely what it was intended to do:  inject economic chaos into the medical marketplace, driving prices for insurance and healthcare through the roof, so that people will beg for the sequel…single payer.  There is no doubt in my mind that this was the intention of the authors of this bill, several of which were the corporate players who would benefit from this insanity.  While it is worthwhile to understand various provisions of TUCA, detailing its shortcomings without assigning malevolent intent to its authors is naive, I think.  This legislation was meant to “crash” the system.  That is its purpose.  Unaffordable care and insurance are its goals.  This is a medical economic false flag from which only Uncle Sam can rescue us.

Scenario #2

As prices for insurance skyrocket as a result of TUCA, people will act and adapt.  One course will be for individuals and families to increase their deductible exposure if they have insurance in an attempt to keep their premiums in check.  $5,000 or $10,000 deductibles will be commonplace.  Others will drop insurance altogether, figuring that at $2500/month (typical premium payments in high-priced states like Romney’s Massachusetts), they could bank this money and in one year have a $30,000 cushion for whatever health expenses might come along.   

Both the new uninsured and the new high-deductible players will be doing something the medical marketplace is increasingly gearing up for:  spending their own money.  People spending their own money tend to ask the same question before buying:  ”how much is it?”  Those physicians and facilities not willing to reveal their prices upfront will lose these patients to those who are price-transparent.  Those who are price-transparent will compete with each other for these patients.  This new and vibrant medical marketplace will cause the price of medical care to plummet.  The price disparities between the transparent doctors and facilities and those otherwise will become even more stark.  This medical price deflation will slow if not utterly destroy the push for single payer as the price crisis movement could paradoxically be derailed by this market competition.  After all, low cost, high quality means no crisis.  This is why cost was never addressed in the original TUCA debates, only “coverage.”

Anything that state governments can do to slow the implementation of TUCA down will increase the likelihood that scenario #2 takes place, as more time will be available for the development of a vibrant market.  Refusing to expand Medicaid is one critical part of the pushback against TUCA.  Various lawsuits filed regarding the constitutionality of TUCA could also play a slowing role (probably less helpful).  

One of the most interesting slowing (if not derailing) strategies I have heard about comes from Ohio, where, two legislators have figured out a simple way to capitalize on the fact that the states, not the federal government, retain the power to regulate insurance companies in their state.  Very simply, any insurance company that accepts a TUCA insurance subsidy, would be prohibited from writing any new policies in that state until that subsidy was returned to Washington.  Creative ideas like this at the state level will buy the free medical marketplace a little time to perhaps finish off TUCA.  

I actually think that scenario #2 is more likely than single payer scenario #1.  One of the reasons I am optimistic is that the track record of the state is so bad in all areas, I am inclined to believe that they won’t even get their false flag right.  For all their attempts to control healthcare from D.C., the unintended consequence may be the creation of a competitive marketplace.  They would have been much more likely to achieve single payer I think if they had tried to create a competitive marketplace.  The state, after all, does nothing well or efficiently and more often than not delivers unintended consequences.  TUCA may very well ration and kill before it fades away, but I think the seeds of its own death are within the bill itself.

G. Keith Smith, M.D.