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Bioethicist: Obamacare is Here to Stay. Now Let’s Fix It.

Image: A woman walks in front of a New York City hospital

Obamacare is here to stay but that doesn't mean the US health system doesn't need more fixing, argues Art Caplan. Eric Thayer / Getty Images file

The Affordable Care Act is here to stay.

The only chance Republican critics (and the critics are all Republicans) had to kill it was to have the Supreme Court strike it down.

But the Court found the program constitutional and its financing mechanism of using federal tax subsidies to bolster the affordability of state insurance programs legal. The jig is up. With millions now covered, pulling away their insurance through legislation would be political suicide.

Continuing the war against Obamacare without Obama to kick around and with support for the program growing makes no sense. Aside from the growlings of some presidential wannabees trying to stir the conservative base, the Affordable Care Act has a great prognosis.

All that said, Obamacare has some real problems. It is too bad the President’s political opponents spent so much time trying to nuke the whole thing. They would have been better off pointing out the flaws and getting political credit for working to fix them.

The biggest problem with the Affordable Care Act is that it is insurance reform, not a guarantee of care. If there are no obstetricians in the rural county where a pregnant woman lives, then all she can do is hope to find a midwife and bite on her insurance card if the pain becomes overwhelming. We need a plan to get more primary care health care providers into the field fast and more innovative approaches to delivering primary care such as telemedicine.

The biggest problem with the Affordable Care Act is that it is insurance reform, not a guarantee of care.

The Affordable Care Act has blind faith in evidence as the key to cost containment: If tests and therapies are studied long enough we will figure out what works and stop doing what does not—thereby keeping costs contained. Ummm, don't think so.

Tell it to the folks building proton beam centers on every corner despite a lack of evidence. Tell it to those trying to discourage the overutilization of mammograms in middle-aged women with no history of breast cancer. Tell it to those still taking vitals on patients who are within hours of dying.

Evidence alone will not drive or shift behavior especially if there is evidence that medicine and the lawyers who sue them can make a lot of money insisting on doing things regardless of whether they work. Better cost-containment strategies are needed lest we wind up spending the entire gross national product on health care but without any roads or bridges to permit us to go to the hospital.

Obamacare does nothing to fix Medicaid.

Lastly, something has to be done to fix Medicaid. It pays doctors poorly and that cuts a lot of really poor people and children out of health care. But the real problem is that Medicaid has been hijacked by the middle and upper class to pay for granny’s nursing home care.

What was a program to help the poorest of the poor, the disabled and kids is now a boondoggle for lawyers telling the rich how to hide assets so as to avoid having to pay the bill for long-term care. Obamacare does nothing to fix Medicaid. It does nothing to address the growing need for long-term care. With an aging population and Alzheimer’s on the rise we must not continue to ask poor children to pay that bill.

Obamacare lives. The President has had his day in court and won not once but twice. There is no chance of a legislative assassination of the program. That is good news but not great news. There is a whole lot more that needs to get done if Obamacare is to give all Americans adequate health care.