The new law does not seek to replace the country’s system of private health insurance with a government-run or “single-payer” system such as Canada’s, the “Medicare for all” approach advocated by some Americans for years, but sharply opposed by insurers and many medical providers. The new plan will not dismantle or fundamentally alter the system of employer-based insurance, as several alternative proposals would have done by replacing the tax-free treatment of employer benefits.
It will begin the work of restraining costs by building on the existing structure of private insurance, Medicare benefits, and other government-sponsored benefits. This market-based approach bears clear resemblance to the universal coverage in Massachusetts. The new federal law seeks to achieve near-universal coverage with a three-part formula. It requires insurers to provide coverage to anyone who wants it. The new law requires everyone to obtain health insurance, thereby broadening the risk pool to include both the healthy and less healthy. The plan provides subsidies to help them buy private insurance.
Despite its relatively straightforward approach to coverage, the law is dense and complex, much like the interlocking system that it seeks to reshape. A look at the new law must include what it means for the health-care system and its component parts: doctors, hospitals, Medicare benefits, Medicaid benefits, large employers and small employers, and states and insurers. The key areas of contention (a mandate to obtain insurance, cuts and taxes, and the change in the way we deliver care) will evolve the uncertain Medicare landscape that lies ahead.