Everyone had a good laugh when President Trump suddenly announced that “no one knew how difficult health care was going to be” but it may be (unintentionally) the most truthful thing he ever said. Obamacare was a partial solution that reduced the rolls of the uninsured by raising the numbers in Medicaid, creating state exchanges for some, and requiring health insurance for young, healthy individuals who did not want it (or “taxing” them, per the Supreme Court). The Republican’s AHCA is so full of holes in barely merits consideration.
The problems of Obamacare are obvious. Greatly increasing the number of people on Medicaid without increasing the number of doctors accepting Medicaid reimbursement meant theoretical health care, if at all, for many of the poor and sick. State exchanges turned out to be successful as long as federal reinsurance for providers and federal subsidies for consumers were guaranteed to continue to increase indefinitely. And counting young, healthy people as “insured” with a product they never wanted is a unique approach to accounting. So if all this was pretty predictable, why did the Obama administration try it? Why didn’t they go for a single payer option? Federalize healthcare? And why are the Republicans so unprepared to replace Obamacare, if they knew it wouldn’t work and had seven years to prepare to replace it?
“Facts are stubborn things,” as John Adams once said, and here are several facts about health care in America that must be faced directly if we are ever to make any real progress.
- Insurance is not health care. Offering insurance where no health care providers participate is a sick joke. This is the challenge of enlarging Medicaid any further. It was also the challenge undermining the state exchanges, where health care providers are leaving because they can’t make enough profit to justify being in the market. Unless you are willing to “draft” our existing health infrastructure into federal service, you have to address the profit motive, and health care supply and demand. Doctors and hospitals (even non-profits) are a limited resource. Those who still desire to federalize health care need look no further than the VA for a probable outcome, and the TSA for a worst case scenario.
- More Americans get their health care through their work…still. Many policy types hate this fact, and it does cause the complication that those who lose their jobs also lose their health care. But it is a stubborn fact that can not be ignored, and should not be changed just because it is inconvenient to the good ideas of policy makers. Health care has been, and remains, one of the various benefits employers use to attract employees.
- Appeals for empathy are part of the problem, not part of the solution. Attempts to portray any new idea or policy as “killing grandma” simply ensure nothing will change. Hard cases like the “Jimmy Kimmel” challenge are a case in point. To remind, Kimmel’s newborn son had a congenital heart condition who required emergency surgery to survive. He cited this case as an example of the horror awaiting the poor who don’t have their children born at expensive, private hospitals. Perhaps he is unaware of the Emergency Medical Treatment and Labor Act (EMTLA) of 1986, which requires public hospitals to provide life-saving emergency medical care without payment/insurance. So his hard case is already covered in law. Such appeals only provide more smoke and heat, but rarely shed any light.
- Americans are unwilling to adopt healthy lifestyles, and unwilling to accept anything that smacks of health care rationing. This is my most debatable “fact,” but one I think most would admit. Too many American’s approach to health seems to be “leave me alone to eat and drink as I like and do no exercise, but be there with a wonder drug when something goes wrong. If things get worse, continue trying to make me better or just keep me alive no matter what.” In some respects, this is like the economic concept of inelastic demand, in that the health consumer wants the best regardless of cost. Unfortunately, this results in poor health outcomes, elevated costs, and a miracle pill mentality.
- Insurance is a tool that covers catastrophe, period. The concept is you get insurance to cover unforeseen costs which would otherwise be unpayable. If you try to use insurance for more than that, you are misusing the tool, which will backfire. Car insurance covers your catastrophic loss, or repairs if your car is damaged and unusable. It does not cover fuel, or oil changes, or new tires. These are all good things to have for your car, but not for insurance to cover. Why should health insurance cover routine or non-emergency health care issues?
Here is where those facts lead, pointing to the beginning of a solution:
- Accept that many Americans will work, and most will get their health care through their jobs. Do not fight this legacy: treat it as a feature, not a bug. Plug the gap that exists when people leave a job by allowing them to continue their previous insurance at a greatly reduced rate for a period of one year (maximum, not extendable), with the government picking up most of the insurance tab, like a low-cost version of COBRA. This would also facilitate workers changing jobs and careers, which would enhance mobility. The federal government should also establish certain minimum standards for work-provided health insurance, so it does not turn into a bare bones offering which ends up sending workers to emergency rooms for treatment.
- Promote policies which increase access to health care. Remove limitations on health care provided across state lines. Enhance tuition assistance for medical professionals, including reimbursing student debt for those who agree to work in high-need areas or accept Medicaid reimbursement. Provide tax breaks to groups sponsoring wellness and walk-in clinics addressing preventive medicine and routine care. None of these is a panacea, but they are a start at getting more points-of-service for more people.
- Establish a national, catastrophic health insurance program. Everyone is automatically enrolled, but this is the ultimate safety net for those who are one day healthy and the next day near death, as well as those with lingering, debilitating conditions. If you have private insurance or can afford to cover your own costs, you are welcome to do so. Run it as an offshoot of Medicaid, with strict rules on what is covered and how service is rationed. Yes, I said it, rationed. Even those who laud health care in Canada or the UK must admit they ration care.
- Attack health care cost inflation. Limit the opportunity to sue for medical malpractice and the potential damages, perhaps by direct legislation or placing a significant tax on law firms which profit from the same. Slap a windfall tax on excessive profits for health care providers, medical professionals, or pharmaceutical companies; they can avoid this tax by providing low- or no-cost goods/services to poor Americans. Incentivize average Americans to make full use of preventive care by offering a generous tax credit to those who complete a set of routine tests/services (blood test, flu shots/immunizations, blood pressure, physical, etc.,) annually. Consider additional incentives in the form of government payments into health savings accounts for those who address significant health issues (lose 40 lbs, get $ in your HSA). Empower hospital emergency room physicians to reject non-emergency cases; penalize Americans who use emergency rooms for such care by withdrawing their HSA incentives. The emphasis here is to get Americans to try to stay healthy, mitigating future costs for treatment/prescriptions.
- Incentivize states to be the laboratories for new health care policies. Given all the preceding recommendations, there are still gaps for people out of work with health care issues that are neither life-threatening or debilitating. Different states may want to address that gap in different ways. Provide states with block grants that reward programs which identifiable health outcomes (not outputs). Encourage other states to copy successful programs, and defund programs which do not produce such outcomes. If California wants to provide single-payer for its residents, good for them; maybe we can all learn something from that.
- Bury, once and for all, the notion of a US-wide single payer system. Countries which have such systems are struggling to pay for them, they ration care, and they have poor deployment of innovative medicine. While the existing US system is sometimes described as heartless and Darwinian, it still produces the greatest array of medical and pharmaceutical innovation in the world. The trick is to retain the benefit of such innovation, while finding a way to reduce the uneven access to good health care at a reasonable cost. Single payer is not the way there.
I have not submitted these concepts to the CBO for a cost estimate, but there is much here to chew on, and I believe it could be tweaked to come in at a reasonable cost. The status quo pre-Obamacare was morally unacceptable; the status quo today with Obamacare is financially unacceptable. The Republicans attempt to repeal and replace Obamacare is DOA mostly because they tried to do it through an obscure Congressional process known as “reconciliation” which limits what could be in the legislation. You can not fix a comprehensive issue with a limited tool kit. The Republicans need to leave Obamacare alone, fully funded as-is for the next two years, and start over with a complete re-work. During those two years, the successes and problems of Obamacare will be evident to even the most ardent partisan, and can inform the development of a bipartisan way forward.