One of my biggest regrets about the Affordable Care Act is that it really does not improve health care. The Affordable Care Act made some changes to the way we pay for health insurance but we are still stuck with the inconvenient truth that health insurance does not heal people. Hospitals, pharmaceutical, and medical device companies do not heal people either. If we distill health care down to its bare essentials, it is the health care professionals who heal people and I remain unconvinced their job got easier or more effective with the Affordable Care Act.  It might seem obvious but if we are going to improve health care and reform the cost structure then it would make sense that we should focus on the health care professional/patient relationship. The Affordable Care Act took a different tack and seems to be inordinately focused on expanding a flawed third party payer system. From this viewpoint we can see that as much the Affordable Care Act was a political success, it has been a health reform failure. When I started working in the 1970s the third party payer system was still a pretty effective to pay for health care. Forty years later it has declined to the point where it is viewed as one of the major problems impeding health care reform and I am once again thinking self-insurance is a feasible plan. Even when the Affordable Care Act supporters reluctantly admit to the third party payer system failures they cling to the belief that expanding the system is a price they are willing to pay if it expands access to health insurance to the poor.  I do not see a good future for health care reform with an expanded third party payer system. To those people who had their health insurance plans canceled and replaced with higher cost plans, the Act has increased their financial burden. They are the designated Affordable Care Act “losers”. To the poor who were not paying for their health care, it is much ado about nothing. It does not matter to them if the emergency room accepts Medicaid. The financial burden of hospital care was never going to be their problem. The only potential winners are the people whose subsidized insurance is less than their current plans. This dependence on subsidized insurance keeps reminding me of the insurance subsidies in the Farm bill. As I was pondering alternatives to the Affordable Care Act subsidized insurance I ran across the TriHealth pricing page and was surprised with the discounts they offer based on family size and income level. The biggest attraction of the Affordable Care Act exchanges was already being offered by a local hospital. Here is the table from their page.

I am left to ponder one final question. If we have an example of a direct financial subsidy system that does not require the Individual or employer mandate, why did we choose the Affordable Care Act option with its inefficient scheme of subsidized insurance?