No, I’m not on about TV.  A & E is the British healthcare term for Accident and Emergency, aka the Emergency Room in American parlance.

My husband is on a BBC kick.  Streaming Internet has given us not only BBC world, included in many cable systems in the U.S., but we can also get real-time BBC radio from Britain.  This includes local talk shows, interspersed with local preferences in music (usually something that was recorded 40 to 50 years ago – I’m not kidding; it’s like going back in time). The DJs go from briskly good natured to extremely sarcastic.

The Brits, bless their brisk hearts, lately have been on about healthcare, or more precisely, the nationalized healthcare available to, theoretically, everyone in Britain, all at taxpayer expense.  This is one of the reasons that taxes in Britain are so high (reference George Harrison’s song Taxman).  This comes up in Prime Minister’s Questions all the time: constituent complaints about everything from bad service, long waiting times and crowded wards to the cost of parking at various healthcare facilities around the country.  It’s sort of like Paul Ryan getting up in the House and complaining about the parking fees at his local hospital.

Where am I going with this?  Obamacare or the Affordable Care Act (“ACA”), of course.  Many objections to the ACA resulted from the idea that it was just a front for nationalized medicine.  The ACA, however, served a real need:  that of providing healthcare for people who either worked for an employer which provided no benefits (there are lot of them out there, especially in small business) or who did not work at all and qualified for Medicaid. One of the more poorly understood aspects of the ACA was that it was an extension of Medicaid.  The Feds would give the individual states increases in Medicaid money to set up “exchanges” of various private insurance companies which would then compete with each other for the consumer dollar.  Theoretically this would bring down health care costs because, 1) fewer uninsured people would show up at the ER and 2) people could get more health maintenance benefits, thus preventing emergencies that occurred because the person in question was uninsured and never bothered with doctors.  To combat the scofflaws who would not bother to sign up, a tax penalty was instituted.

This would have worked had the Obama administration simultaneously been able to remove all employer based healthcare benefits, traditionally where most of the population gets its healthcare. This would have moved the majority of the population into the exchanges, old, young and everything in between.  Instead, the ACA was set up so that it was in competition with employer based programs.  Of course, the employer based programs won hands down; they were much better:  smaller deductibles, better doctor choice, cheaper premiums for the employee.

It also didn’t help that many states would not accept the Fed’s Medicaid money and the regulations that went with it.  The ACA was predicated on the states accepting the money to reduce the real cost of care. This limited the choices in those states that refused to expand their Medicaid programs.

Now, of course, the Republicans vow repeal of all things Obamacare.  Thing is, the ACA has now become part of the landscape.  It cannot just be repealed, it must be replaced.  With what? The Brits can give us (and do, if you listen to local BBC) chapter and verse on their dissatisfactions with the National Health Service: doctors and nurses who are poorly paid, rude service, ill equipped, antiquated hospitals, crowded wards, long waiting periods for specialist care or chronic illness care.  The Canadians, who also have a national health service (and the high taxes that go with it), take side trips to the US to get medical procedures unavailable to them in Canada.

Also, one unintended legacy of the ACA is that health insurance costs have increased across the board; that $500 deductible of five years ago is now a $1500 deductible.  Instead of bringing the basic costs of health care down, everything has become more expensive for everyone.

How to fix this mess?  Good question.  You can bet the Republicans in Congress, they of the bit between their teeth, will come up with something that won’t work.  Instead of taking what is already in place and fixing its flaws, they have decided to reinvent the wheel, mostly because they have to prove that they did not, and will not, cooperate with what’s left of the other side. The other side, however, is not dead.  If the conservatives insist on making sure that the ACA or whatever they’re going to call their version, is a wholly private enterprise program, they will pay for it when the public finds out that, yes, the deductibles went down but the insurance doesn’t cover much either.  The problem is not going to go away.

So.  Whither healthcare?  Is it the responsibility of the state or should it be left to the markets?  What happens to the people who inevitably get left behind by the markets?  Do they go to charity?  If so, who administers the sort of care these people get?  The assumption, and the precedent, is that charity will not be able to provide the same standard of care as the private market.  Should insurance companies be part of private enterprise or are profitable insurance companies by their very nature exploitative? Why does medical care cost so much?  Why don’t insurance companies concentrate on preventative medicine instead of running pricey hospitals that offer amenities like private birthing rooms?  Why are there so many gotchas, i.e.  that the hospital is in your network but the surgeon is not?  Did you have a choice when you walked into the ER with a heart attack? Did you even think about the fact that the doctor and the hospital were on two different insurance networks?  Would you ever think of that?  Seriously?

You know, at least with the National Health Service, you don’t have to fool with the insurance company coming back with a $300,000 bill because your surgeon was not in your insurance network.  You may, however, have died of that heart attack in the A&E because, guess what, you had to wait behind all the other, more severe heart attack cases.  And of course, you would still be responsible for those parking fees.


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