Should states accept health insurance exchanges?

Yes: Supporting the aca system will help reduce costs and corruption

WASHINGTON — The Affordable Care Act of 2010 — widely known as Obamacare — requires states to set up exchanges where individuals and small businesses can purchase insurance.

The purpose of the exchanges is to help implement the reforms. For example, most of the people who will purchase insurance in the exchanges will be eligible for some sort of tax-credit to make their insurance more affordable. Also, the insurance plans must be certified so that they meet the requirements of the ACA.

The ACA also provides for an expansion of Medicaid to households earning up to 133 percent of the federal poverty line. The exchanges can help determine who is eligible for Medicaid or CHIP (the Children's Health Insurance Program), or for subsidies to purchase insurance.

The ACA gives state governments the responsibility to set up exchanges. But a number of state governments have declined to do so, thus leaving this responsibility to the federal government.

In many cases this is for ideological or political reasons — these are Republicans who see their refusal to create the exchanges as an act of defiance against Obamacare.

But defying health care reform in this way will not get them anywhere; they will simply turn the job over to the federal government.

This will disenfranchise their constituents from having a say in how the exchanges are designed. Since states have different laws regulating insurance and different demographicsthis does not seem like a smart move.

Some of these state governments are also rejecting the Medicaid expansion, and federal money that goes with it. This will simply deny many of their citizens access to Medicaid — including 1.4 million people in Texas.

Obamacare will bring some important changes for victims of our healthcare system, some of which are already in effect. Among them:

People with pre-existing health conditions will no longer be denied insurance and important preventive care will be free.

Most insurance companies will be required to cover treatment for mental health and substance abuse.

Most important, an estimated 60 percent of the nation's 50 million uninsured will have health insurance.

But that still leaves tens of millions of Americans falling through the cracks. We also have the most expensive health care system in the world — paying about twice as much per person as in other high income countries, with much worse health outcomes in areas like life expectancy and infant mortality.

Most of the waste comes from higher administrative costs — one study estimated these at 31 percent for the United States, as compared with 16.7 percent for Canada's universal, single-payer system.

The ACA has provisions for reducing costs, and some will be effective; but it will be difficult in a system with hundreds of private insurers who will still find it profitable to expend resources to avoid paying for the sick and injured, and finding healthier groups of people to insure.

The most effective, efficient and equitable system is a single-insurer that covers everyone — as we have in Medicare for Americans over 65.

For this reason the state of Vermont is designing an insurance exchange system under the ACA that will serve as a prelude to a single payer, universal statewide health care system; it is estimated that this will reduce health care spending in Vermont by 25 percent while insuring all residents.