On March 21, 2010, the Patient Protection and Affordable Care Act became law. Known by its nickname – which is either complimentary or pejorative depending on your persuasion – Obamacare permanently changed the landscape of healthcare in the U.S.

As we approach the election, there are two distinct viewpoints on the law – scrap it or improve it. Sadly, many folks base their views of this topic on a limited understanding of the law. And let’s be honest, this group probably includes many politicians.

But we spend 18 percent of our GDP on healthcare in this country. We can’t afford to vote with incomplete information. We voters (and patients and physicians) need to understand exactly what we are voting for or against.

Most everyone understands that there is an insurance mandate under Obamacare. Some know about the subsidies for lower income individuals that help pay for the mandate. They are part of the first key piece of the law – everyone should be insured.

The thinking here is if everyone is insured, we keep people healthier longer. Pay for prevention now and we won’t have to pay to care for uninsured individuals who have advanced disease later. Under Obamacare several provisions make this happen:

  • Pre-existing conditions cannot prevent someone from getting insurance.
  • Employers of a certain size must provide health insurance.
  • Individuals without an employer benefit must purchase their own health insurance.
  • The government subsidizes individuals and households with income below four times the poverty line. Four times sounds like a lot, but for an individual the poverty line is $11,770.

Unfortunately, these requirements do nothing to control costs. One of the biggest complaints since the implementation of the law is about the cost of health insurance.

This is the focus of the second key piece of the law - keeping costs down. It requires that 80 percent of insurance premiums must be spent on actual healthcare costs. Insurance companies that want to increase premiums more than 10 percent must have their rates reviewed to be sure that they are staying in compliance with this aspect of the law.

This keeps the insurance companies from gouging customers. But it does nothing to keep the Pharma Bros and Medtronics of the world from charging exorbitant prices for pills and equipment. It has to anger the insurance companies when they pay three times the cost of a drug here compared to the UK and they can’t get in on that action.

In addition, health insurance policies must cover preventive care. The idea here is health will be maintained longer, preventing the need for more costly care down the road.

A final aspect of the law has to do with Medicaid expansion. Medicaid is a joint federal and state program for children, pregnant women, low-income seniors and the disabled. Obamacare expanded this to cover more individuals whose income falls below 138 percent of the federal poverty level. This aspect is optional for states, and many states have chosen not to participate. In those states, people not covered end up getting care at public facilities, such as the county hospital system here in Texas.

So what questions do we need to ask about this law as we make voting decisions?

Here are a few to start with:

For those who plan to scrap the law – What, if anything will replace it? Will those individuals who were able to get insurance under Obamacare lose their subsidies at once? Will insurance companies be able to drop those with pre-existing conditions? Will the Medicaid expansion be scrapped?

For those who hope to improve the law – What will steps be made to curb health costs? Or will employers (and individuals) be required to bear the brunt of rising costs without means of redress? Will the Medicaid expansion become mandatory for all states?

In the end though, these questions are pipedreams. The biggest healthcare question politicians need to answer is simply: Do you have a plan at all?