Famous question: How do you eat an elephant? The answer, of course, is one bite at a time. And if there ever was a legislative elephant, it’s the deceitfully-named Affordable Care Act, AKA Obamacare.
Republicans have long promised “repeal and replace.” But that mantra not only painted them into a corner, that approach has always been fraught with complications: the ‘replace’ provision suggests that the feds must govern our healthcare choices while ‘repeal’ implies a single-shot excision which is both practically and politically problematic. Obamacare is a cancer entwined in the body politic. Multiple surgeries are likely necessary. Although the Right is often loath to hear it, the Dems also could have enough obstructionist capability to stop the Republicans from enacting all that they want in the first go-round.
But in any case, there are certain things which must be done at some point to dramatically bring down costs, put doctors and patients back in charge, and return us to the free-market and patient-based approach that predominated before the World War II-era wage and price controls opened the floodgates for employer-provided policies.
First, the option to buy individual coverage across state lines is currently absent from the plan when it should have been a primary feature. That choice is an imperative, whether in round two or in a subsequent iteration of round one. Just as car insurance would skyrocket if it included routine items like wiper blades and oil changes, so too have health insurance premiums been forced into the stratosphere by a one-size-fits-all approach which mandates the lunacy of obstetrics coverage for men. Relabeling ‘automobile insurance’ as ‘catastrophic car coverage’ is illustrative. Policies covering accidents costing $100,000 or more can be had for $500 – per year. A free market in catastrophic health coverage would fare similarly. Minor costs are then handled out of pocket.
Second, insurance must be decoupled from employmentfor the free market to function properly.This is easily done by allowing workers the expedient of a choice between their current coverage and any other policy on the market. The ensuing competition among insurance providers would foster significant savings. Employers would simply give insurance dollars to employees with the stipulation that they must maintain a healthcare plan. Most employees under 65 are covered at their jobs. The ultimate goal should be for those individuals and families to choose their own health insurance plan, selected from choices from Spartan to Cadillac. A case can be made that even the plans that workers are currently in would drop in cost to stay competitive. The money remains deductible to the employer and tax free to employees, who may find better coverage at lower cost – and pocket the savings.
Those who were dumped by employers into the Obamacare ‘entitlement’ would then fare better with their own coverage. Entitlements are hard to rescind. But Obamacare was only disguised as an entitlement. Despite the implication that you'd have your medical needs handled, the ACA is government-run insurance – not medicine – and bad insurance at that. The co-pays and deductibles are so onerous that you pay a great number of costs yourself. And if, for any reason, the treatment you seek is not deemed cost-effective or age-appropriate, you may end up in the cold anyway. The focus on whether people will “lose coverage” with repeal of the ACA is irrelevant if coverage is kept in name but care is denied in practice.
The ones mainly benefiting from Obamacare are Medicaid recipients. But there's even a better strategy for them. So third, provision must be made for the poor – and it can be done with dramatically less government involvement.
Any healthcare plan should involve doctors, front and center. But both the ACA and the AHCA are bureaucracy-heavy, not doctor-centric. Fortunately – and amazingly – there’s been a program in place for years which handles Medicaid outpatient care extremely well and at very low cost. The key is involvement by volunteer doctors.
It’s a plan put forth by the Association of American Physicians and Surgeons, the conservative counterpart to the AMA, and it envisions each participating doctor to volunteer four hours a week (typically less than 10% of their time) toward charity care for the poor, something which was commonplace in years past. The payoff for doctors is an elegant quid pro quo: state Medicaid agencies would cover the entire medical practices of these volunteer doctors against malpractice lawsuits. Med-mal coverage is typically more than 10% of a doctor’s net revenue so doctors would save hundreds of millions in premiums and states would save billions in Medicaid costs. It’s an ideal, minimal and appropriate role for government, state only, as they are the medical licensing authorities. They’re also in a position to implement tort reform, as Texas has done, which will further engender savings by reducing frivolous lawsuits and the expensive practice of defensive medicine, where redundant or unnecessary tests are often performed.
These measures would go a long way toward fulfilling Republican promises of restoring US healthcare. Other items, such as risk pools to deal with pre-existing conditions, can be dealt with without undermining the system for everyone else. The process so far has been messy and, for conservatives, disappointing. But there are many in Congress working to make it the best it can be. And Republican efforts so far have been comparatively transparent.
So unlike the process which got us into this mess, we won’t “have to pass the bill to see what’s in it.”