Mr. Trump (now that he is President-elect we need to show “Donald” some respect) has recently said that he may keep the Affordable Care Act (Obamacare) ban against denying coverage for preexisting conditions as well the extension of parental policies to 26 -year-old children because “everyone seems to like those provisions”. As President-elect Trump begins to soften his bombastic, total opposition to Obamacare (and replace portions of “the Wall” with a fence) the 1.2 trillion dollar question becomes, “what is he going to do next?”
Since passage of the ACA 20 million Americans have gained health insurance coverage. 63% of that gain was produced by expansion of Medicaid in the half of our states that choose that federally subsidized route under ACA. The other 40% of increased coverage came from the federally subsidized premiums on policies purchased through health insurance exchanges. Not every state established health insurance exchanges, and those states that did establish exchanges were twice as effective in getting people to enroll in health insurance.
The “individual mandate” that was resisted so fiercely by Republicans as “another government tax” was originally composed by Governor Mitt Romney and became law in Massachusetts years before the ACA passed. The ACA 2014 “individual mandate” was a $95 fine if you did not obtain coverage, and it proved to be fairly ineffective. In 2016 that fine goes up to $695 (or 2.5% of your taxable income), so it may prove more of an incentive this year. (1)
What about the rest of the ACA? We shall see, but just tinkering with the ACA (“repeal/replace” or “fix”) raises the concern that we may waste a lot of time and energy getting entangled in the trees while losing sight of the forest.
Can we get REAL about health care reform, or do we just continue arguing about health care insurance? It just so happens that a physician colleague of mine wrote a succinct, clear, eminently quotable Op Ed column about that question in our local paper yesterday! (2) I am going to shamelessly plagiarise* it.
“We have given providers incentive to ration care and collect data while ignoring non-provider stakeholders responsible for major system expenditures.”
. Like: big pharma that advertises directly to consumers for great profit
. medical device companies with excellent, high-paid, effective lobbyists
. health insurance companies with more lawyers, consultants, lobbyists, and way more overhead than Medicare.
“We seem determined to jump through ever more hoops to limit provider options while the rest of the industry revels in the lack of any kind of market control.”
“Resources that used to represent [provider] profit or ability to retain staffing are now spent on fighting insurance claims and bolstering hospital advertising budgets.”
New payment-bundling schemes with buzz words like “pay for value”, “pay for performance”, and “population basis” will “transfer unprecedented financial risk to providers.”
“Constraints placed on health care providers cannot adequately repair our system.”
What actions can repair our system according to Dr. Urbach?
. “expanding the public option should not be politically toxic” when 50% of Americans are already covered by government
. reforming malpractice tort law to save big dollars by reducing the costs of “defensive medicine”;
. having thoughtful discussions about appropriate use of resources at end of life;
. allowing Medicare to negotiate drug and device costs;
. devoting adequate medical resources to the mentally ill rather than putting them in jail.
“We must stop pretending that exerting ever more financial pressure on our doctors, nurses, and hospitals (while ignoring bigger fish) will get the job done.”
Now, Dr. Urbach is not a disgruntled primary care physician who is whining about poor reimbursement and non-appreciation of his skills and talents. He is an experienced, well-respected cardiologist, a specialty near the top of the payment and prestige pyramids, who shared these reflections on the occasion of his son’s graduation from medical school. He prays that his son and his peers “will not only make themselves into great clinicians, but that they will also do what my generation of providers largely failed to do – make themselves into a courageous political force that can effectively force comprehensive reform of the heath care system by demanding sacrifice from all stakeholders, not only the caregivers.”
And I say, Amen.
1. New England Journal of Medicine, 375;17, October 27, 2016, p.1605
2. Cape Cod Times, November 14, 2016. “Let’s get real about health care reform”; David Urbach, MD
* “When you copy one person’s words, it is plagiarism. When you copy many persons’ words, it is research.”