by Carol A Westbrook
Before you, progressive reader, quit in disgust after reading the title, or you, conservative reader, quit in disgust after reading a few more paragraphs, please hear me out. I'm proposing that we repeal Obamacare (The Affordable Care Act, ACA) but not replace it with another medical insurance program. Instead, I propose that we re-think the entire concept of how we provide health care in this country.
The ACA's stated purpose is "to ensure that all Americans have access to high-quality, affordable health care." Regardless of whether or not you believe good health is a fundamental human right, it is inexcusable for an affluent, first world country like ours not to provide it for its citizens. The good health of our nation is vitally important to its success, guaranteeing as it does a capable workforce, a strong military, and a healthy upcoming generation. However, I have seen the results of Obamacare from many perspectives, including that of a physician provider in a rural community, as well as that of a personal user of both insurance and Medicare. I do not believe the ACA succeeded in meeting its objectives.
It is true that the ACA provided health care insurance for millions of Americans who didn't have it previously, expanded Medicaid for the uninsured, got rid of the pre-existing condition exclusions, allowed our grown adult children to remain on our policies longer, and started the ball rolling on electronic records. These are great results.
To elaborate on these points:
1. Obamacare's requirement that insurance companies determine our health care meant that decisions would be based primarily on the companies' profits, rather than on their customers medical needs. In other words, your insurer determines which provider, lab, or hospital you can use, which drugs it will reimburse, and how much it will pay out for your claims, always with an eye on their bottom line. And every dollar that a business keeps for its shareholders or its executives' salaries is one less dollar that is paid out for your health care. Your illnesses are subsidizing an industry.
2. Medical insurance is not a health care plan. It is insurance, which means it is a shared risk program. By definition, insurance collects money from its participants, and uses this pool to pay for its participants' medical costs. However, if the only people who sign up for insurance are ill and need payout, then there won't be enough money in the pool and everyone will have to pay more, or they their insurance pool can pay only a fraction of the costs. The result is higher premiums and higher co-pays, or company will go out of business. Both things happened with the ACA. We saw Obamacare premiums skyrocket after the first year, and private insurance followed suit. Many insurance companies chose to leave the Obamacare market, and in some areas only one insurer remained, leaving no market cost.
3. Health insurance in the US is traditionally tied to a job. Because of the ACA mandate that businesses with 50 or more full-time employees provide insurance to the full-time workers, many either lost their jobs or had their hours cut so the business' number of employees would drop below the mandate to avoid the high costs. Additionally, many workers have seasonal work, and never had benefits. With lower incomes and some assets such as savings, cars, and homes, these uninsured workers were not destitute, but they couldn't afford the high Obamacare premiums but their income was still be too high for a subsidy. Previously these working poor would take their chances; now, they have to pay tax penalties or buy high-cost health insurance, neither of which they can afford.
4. Obamacare did nothing to contain health care costs, which continue to rise. It's simple economics: with an increased number of insured, leading to increased demand for services in a fixed background of providers, the cost of these services increases. Unlike Medicare, no checks were built into what hospitals or pharmacies could charge.
5. Obamacare required implementation of provisions such as fully electronic medical records, electronic prescribing, and participation in large "accountable care organizations." Such mandates were impractical, unaffordable, or impossible for independent physicians and small practices, especially those in underserved rural areas. Many were forced out of business.
6. The combination of an increased demand for health care in a stable field, along with the closing of many practices, led to people turning to for-profit care centers, pharmacist providers, and poorly trained PA's and nurse practitioners for their care, instead of licensed medical doctors. The result was lower quality health care.
7. For the ACA model to be viable, everyone had to be insured, even those who were in good health, or pay a tax penalty. This makes sense from an insurance perspective, but it is anathema to the American way of life, which maintains that personal health decisions should be your own.
If Obamacare is repealed, then how can we still provide health care in the US? The problem is not the politics, but the health care system itself. Here is how I would do it.
1. The most important step is to lower the actual cost of health care. The US spends almost 20% of its GNP on health care because our insurance pays whatever is asked, even though we don't know what the real cost is! This is twice as much per person as every other first-world country–whose medical services are at least as good as those in the US!
How do we contain these costs? First, I would limit the amount that can be charged for medications, for physician services, for tests and for hospitalizations. Every other country does this, and we do it here, too, for Medicare. This is extremely unpopular with lawmakers, who rely on big money from the pharmaceutical, insurance, and hospital industry lobbies. We need lawmakers who are not influenced by lobbyists.
Next, we should have open, transparent pricing for all drugs and services, so people can comparison shop, perhaps even offering rebates if they save money for their payor.
Third, I would make medical training be tuition-free, and expand the number of physicians and residency positions, thereby increasing the supply of doctors who are comfortable working for lower salaries. Most doctors-to-be are not in it for the money, but find their school debts are so high that they have no choice but take high-paying jobs, forgoing work in a rural or inner-city practice.
Fourth, I would get rid of the middleman. Health care has become a profit center to generate income when money changes hands, or to provide jobs for themselves based on hospital administration and health-related government bureaucracies, many of which are not necessary in order to provide medical care.
2. Medical insurance should not be tethered to employment, which automatically excludes those who are unable to work or cannot get a job–the ones who need health care the most! No other country in the world does it this way.
3. There should be other options for health care coverage in addition to risk pool-based insurance. If health care costs are low enough, many may choose to pay for what they need and use, adding catastrophic coverage only. Insurance costs will become low enough that many will choose to participate; others may join cooperative organizations in which people pool resources and pay out as needed. Still others may choose to pay outright for their medical care. These options will make health care a truly free market.
4. My personal preference is to develop a universal, free health care system, as you find in most other first world countries. One way to do this is to start with Medicare. Currently, all you need is a social security number and be age 65 or older to qualify for basic hospital services (Medicare A), while you can must pay for outpatient care insurance on a progressive, income-based schedule (Medicare B). Supplemental insurance is required to pay for medications and additional services. Medicare tightly regulates how much can be charged for clinical services (but not medication). Why not offer this to Americans of all ages? Many states are considering offering a single-payor solution, but it is unlikely to be viable for our entire country unless other cost reforms are in place–see point #1, above. And for many it may just be too "socialist" to be acceptable.
It is surprising that we have yet to come to terms with the recognition that we all pay for everyone else's health care in some way or another. From the underinsured who use emergency rooms as their primary care doctor, to the uninsured brought to the ED after an auto accident, to the indigent or the mentally ill who are in dire straits, to the elderly person who does not have the resources to pay for medications and is hospitalized–eventually this comes out of our tax money, or indirectly out of our own costs for medical care. Even healthy young adults who never need to see a doctor and eschew buying medical insurance will eventually grow old and die, too, and somehow we have to pay for their care as well. We might as well own up to this and make health care a reality for all.
Adapted from my April 1, 2017 post on Ask-An-Oncologist.com