Repeal of reform won’t fix our health system

The system we had before health reform became law was simply not working. I think we can all agree on that. A significant number of people oppose “Obamacare.” I can understand that. But repeal doesn’t really solve the problem. Sure, if you think that health reform has or will actually make our system worse than it was before, it seems prudent to undo the legislation, but that brings us back to square one–a system that wasn’t working well for most Americans.

Repeal must only be the first step, to be followed by a far more important next step: How do we improve the health care system? In other words, if “Obamacare” isn’t a step in the right direction, what pray tell, is? This is the area where I’ve not seen much in the way of developed proposals. Sure, John Boehner announced a plan that would eliminate the individual mandate while preserving the new ban on pre-existing condition exclusions, but that only makes for good politics and terrible policy.

When one element of reform is popular and another element is unpopular, it makes people happy when you tell them that you’re going to keep the popular element and get rid of the unpopular one. The problem is that the two elements were purposefully designed to work in concert, according to economic theory and human behavior, to avoid some rather disastrous consequences. Unfortunately, most people don’t think through these types of things, preferring to stop analyzing the situation once they feel happy.

The result of this particular promise would be skyrocketing insurance costs. Why? Because many people would choose not to buy insurance until after they got sick. After all, they wouldn’t be required to buy it when they didn’t need it, and they wouldn’t be prevented from buying it just as soon as they needed it. This practice would undermine the entire principle of risk-pooling and uncertainty upon which the insurance industry rests. As a result, most of the people who bought insurance would be sick, and that would make coverage wildly expensive. John Boehner knows this, but he doesn’t talk about it on television because it wouldn’t be popular.

So, I’d like to see some substance. Call for repeal if you like, but show me your alternative plan for reform. That is, unless you think the system is doing just fine, in which case I’d love to see some data to support that assertion. Either way, I want to hear an explanation grounded in evidence, not just a collection of bullet points that cater to people’s feelings.

Brad Wright is a health policy doctoral student who blogs at Wright on Health.

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  • Sarahw

    The time for talking has just begun.

  • http://www.MDWhistleblower.blogspot.com Michael Kirsch, M.D.

    Brad, where is the evidence that ‘Obamacare’ will lower medical costs and improve medical quality? I agree that it will increase insurance access, but half of these 32 million new enrollees will be in the Medicaid program. The states cannot afford to fund Medicaid even now, and are asking for waivers from Washington. How will they afford to pay for another 15 million patients? In addition, the existing and anticipated ‘quality’ programs (pay-for-performance and various iterations of this) are a sham, in my view. I agree with you that we need evidence. I’m not sure the president has it.

  • http://patientsafety-advocateyourself.blogspot.com/ Cheryl Handy

    Medical insurance isn’t the same as medical care. The government (ObamaCare/Affordable Care Act/Medicare/Medicaid/Govt Insurance Plan X) can’t ensure that sick, dying, suffering people will get necessary medical care. That is the dirty little secret. Care will be rationed, care will be denied, doctors will say no for any number of reasons. It happens every day. People die every day.

    Another political red herring is that those with pre-exising conditions cannot get insurance. Many states have high risk pools. I had no job and obtained insurance through a high risk pool when I had a diagnosis of cancer.

    My question is why doesn’t the AMA, American Cancer Society and other wealthy organizations create high risk pools for those with pre existing conditions? That would demonstrate a true compassion for physicians (who need to get paid) and the patients the organizations purport to care about.

    Governments have zero business being involved in medical care and should stay out of the patient/physician relationship.

    • Jeff Taylor

      ‘Many states have high risk pools. I had no job and obtained insurance through a high risk pool when I had a diagnosis of cancer.’

      Who paid for that, Cheryl?

      • http://patientsafety-advocateyourself.blogspot.com/ Cheryl Handy

        I pay well over $600 a month. I could apply for subsidy but I do not. I pay 90% of all bills. So, I am paying for it. Any other questions?

      • http://patientsafety-advocateyourself.blogspot.com/ Cheryl Handy

        Moreover, I have health insurance and still cannot get health care for a life threatening condition. I have osteomyelitis and dead tibia. I could become septic and die without warning.

        Medical insurance does not equate to medical care.

      • Jackie

        I’ve been covered by the risk pools several times in the past 22 years. I had to pay for the full premium. Risk Pools are created to provide a safety net for those who have pre-existing conditions, have been discriminated agaisnt at work, and/or have difficulty getting coverage through insurance companies. These are the people who need the insurance most, yet they are having the most difficulty getting it.

        Because most insurance is tied to a person’s job, a catastrophic illness makes a person unemployable. And when this patient runs out of the 18 month COBRA – in the meantime runs out of his/her savings – he/she has to go to risk pool.

        Who pays for the risk pool? The patients have to pay for the full premium. Many physicians are shareholders of big medical facilities/insurance companies/pharmaceutical companies. Yes, why don’t the physicians groups create a risk pool for the uninsured/underinsured?

        • Luana

          After COBRA benefits are exhausted, most people can qualify for guaranteed issue plans (also called HIPAA plans) through an insurance company; they don’t have to join a high risk pool. There are 4 other criteria to meet, which most people usually can. They’re about as costly as COBRA; however, usually cost less than a plan in a high risk pool, and have better benefits.

  • Jackie

    It seems very odd to me that while every automobile on the road is required to be ‘insured’, every citizen in the society is not. Aren’t humans more valuable than cars?

    The government should make a ‘liability’ health insurance that every citizen is required to have. Insurance companies can then offer different packages on top of the ‘basic’ one.

    • http://www.nontradmd.com/ Nontrad

      You have the right to not pay automobile insurance by not owning a car. And besides, vehicles are not a proper analog to people. Like you said, “Aren’t humans more valuable than cars?”

      • gzuckier

        Just like you have the right to not get medical insurance, if you will never need medical care.

  • PAULMD

    “The system we had before health care reform became law was simply not working. I think we can all agree on that”

    You lost me there.

    By the way, how many MA, MS, Ph.D., post docs, and employed “health policy” guys are there? I don’t remember this as an option of study when I was in college. The country seems flush with ‘em now. Low hanging non-producing fruit to the machete IMHO. You and I both should learn Manderin and brush up our waitering skills.

  • PAULMD

    @Jackie,
    Sounds easy enough but in practice, every patient, regardless of insurance is essentially a “full court press.” It’s not like forgoing towing or collision or drivers under 25 years of age on your auto policy.

    “Mr. Jones, your policy allowed the coronary stenting that was just done but I’m afraid you did not opt for the ureter stenting ryder policy that we recommended. Enjoy your kidney stone, tylenol may provied some relief…have a nice day.”

    People just ain’t cars. If we were, a large proportion of us would be deamed, “totalled” and would be en route to the crusher.

    To be acurate, New Hampshire does NOT require you to carry auto insurance to register and operate a passenger vehical. You can ask Kevin if you don’t believe me. ;)

    • Jackie

      Well, thanks to some wonderful doctors of mine, I’ve been to the ‘crusher’ and back a couple of times… :)

      Have you looked at the Medicare policy? I have to pay supplemental insurance in order to ‘retain’ my family doctor, my neurosurgeon, and my oncologists.

      Our hospital/clinic started offering weekend hours several years ago. It cut down the ER visits drastically. The system also provides so-called ‘urgent care’ which allows me to see a doctor in the same day when the ‘on-call’ nurse deems it’s necessary.

      Because of my medical history, I used to always get advised to go to ER whenever I contacted the on-call nurse.

    • gzuckier

      Where I grew up you were not required to buy auto liability insurance, provided you put up a cash bond equal to the minimum liability coverage, to be held in escrow (and you do get to keep whatever interest etc. it accrues). Seems reasonable; of course for medical insurance you’d have to put up quite a big chunk of cash, but as with the HSA, it’s still your money and you get to keep the proceeds if it’s not used.

  • http://fertilityfile.com IVF-MD

    The system we had before health reform became law was simply not working. I think we can all agree on that.

    Sure. I can agree with that. But then, where’s the logic? If a system went bad because of too much government interference with the sacred doctor-patient relationship, the proposed solution is —- more government interference? And that’s not called insanity, right?

    There are at least five policy changes that one can logically come up with that will make things a lot better. I respect Kevin’s comment-size limit, so if you can find another venue, invite me and we can discuss it. I’ll gladly walk you through the reasoning. Hint: Think about how we could logically and realistically increase the supply of healthcare providers and set up incentives for providers to make patients happy and satisfied as opposed to the system we have now. Also, what proper incentives would motivate patients to choose actions that benefit the situation as well?

    • gzuckier

      Where exactly did the system “go bad because of too much government interference”?
      US outcomes relative to the rest of the world are BEST in the advanced age brackets where everybody has Medicare, and worst in the younger age barckets.

  • http://patientsafety-advocateyourself.blogspot.com/ Cheryl Handy

    Jackie:
    I have never gone a moment of my life without at least “major medical/catastrophic” insurance. What we don’t need is managed care, well baby, $15 co-pay visit insurance. Some of us would rather pay the “real cost” of the office visit and not the insurance company, inflated cost. (an x-ray of an adult elbow should cost the same at Hospital A regardless of whether the pt has Ins X, Ins Y, Medicare, or personal pay — but the fact is the cost varies and none of us knows the “true cost” of the x-ray.)

    We can all have a “feel good” effect of everyone having health insurance. But it does not change the fact that insurance does not guarantee that people will receive health care.

    The issue needs to be health care – not health insurance.

  • http://abnormalfacies.wordpress.com/ Jim

    The plan was already mangled through compromise, but I agree that striking down the mandate undermines risk-pooling. There’s nothing to debate there; people just won’t buy a plan.

    Sadly, as sick as America is, we don’t want to pay for health care until we need it – badly.

    • gzuckier

      It is sort of bizarre; to hear somebody intone mournfully about how much money we owe China, then promise that they will not rest until individuals can pay less money to Americans for healthcare so that they can spend more money on disposable electronic junk from the Far East.

  • Muddy Waters

    To those who think they are “entitled” to free universal healthcare, you ultimately may get your wish. But, be careful what you wish for. Out of pure necessity, there WILL be death panels, limited access to services (get ready to stand in line), and a significant decrease in overall quality. Just look at the VA hospital. Plus, you will have even less ability to recover damages for malpractice, as there will be no incentives for the lawyers. I, for one, will stop practicing medicine altogether as I refuse to submit to government control. I’m sure there are many others who feel similarly. You can’t have your cake and eat it too. Obamacare might not yet be the breaking point, but it’s a step in the wrong direction.

    • gzuckier

      Descriptions of how the Republicans are handling healthcare in AZ will not scare us.

  • Luana

    “Repeal of reform won’t fix our health system.” You’re right; it won’t. Just like firefighters extinguishing a burning home does not give the family who lives there a new place to live, it attacks the most pressing concern. Obamacare is a fire that needs to be put out. It will destroy good medical care and health insurance, give the country more massive debt, and, if that weren’t enough, it still leaves millions without insurance. What kind of fix is that?

  • imdoc

    IVF-MD is quite correct. We got to the present mess through a series of well intentioned but misguided regulations over the years. Now, we have no price transparency, maldistribution of services, and runaway costs.
    To me, if lost in the woods, go back the way you came rather than hoping for an unexplored shortcut. I do not want an over-arching federal program because we have 50 states which can be test bubbles for different ideas. Massachusetts is at least trying.
    I propose being rid of the legislation causing the trouble: Medicare mandated price controls, tying benefits to employers, and the anti-trust exemptions for health insurers to start with.

    • http://patientsafety-advocateyourself.blogspot.com/ Cheryl Handy

      Oh how happy I would be if we could get rid of Medicare, managed healthcare, and discussions of govt run healthcare. It wasn’t that long ago (30 years) that I could go to a general practitioner or even a specialist & know what the price was. I paid cash. I had major medical through BCBS. There was no big pharm companies running hospitals. I had an actual pt/doc relationship.

      Now many general practitioners are going back to posting prices. And it attracts poor, middle and high income patients who just want to keep the middle man out of the relationship. Indeed, health reform will only get unnecessary players in between the pt/physician relationship.

      Like I have said before – an adult elbow x-ray at Hospital A should cost a certain posted amount. But the fact is that the price is dependent on whether the pt has BCBS. Medicare, Humana. If the pt is private pay, the pt actually pays a premium price! I would love to be a private pay, be sued by a hospital, go to court & argue UCR (usual, customary, reasonable charge) of medical services.

      • imdoc

        Yes, the radiology situation is a good example. Search internet for “cash CT” and see posted prices, then compare to the book prices quoted at hospitals. These free standing cash based radiology services are not targeted to the wealthy. Typically, they cater to uninsured on the lower economic spectrum. So, if these facilities can turn a profit at a reasonable price with no gov’t support there should be a lesson there.

        • ninguem

          Yesterday, I passed a billboard on the Interstate. It was a billboard advert for an imaging center. The MRI prices were on the billboard.

      • http://fertilityfile.com IVF-MD

        Restoring the mutually satisfying patient-doctor relationship is the key to solving our problems.

        There are two ways we, as human beings, can enlist others to help is achieve our goals.

        One is by cooperation, negotiation and free exchange.
        Person A has a health issue and would like Person B to help. They negotiate and Person B accepts what Person A is willing to pay or in case of extreme hardship, person B exercises charity and assists for very little, or even for free.

        The second way is by theft, extortion or the use of coercive force.
        Person A enlists political force to compel person B to help him. Or Person A compels Persons C, D and E to labor in order to pay Person B to help Person A.

        To the extent that we improve our utilization of the COOPERATIVE METHOD to achieve our goals, so will mankind prosper and thrive. To the extent that we rely on the COERCIVE POLITICAL METHOD, so will our civilization deteriorate. The ironic thing is that the more we rely on the second way, the more we will fail to achieve those goals.
        Ask yourself this.
        Has using coercive methods to try and reduce poverty resulted in less poverty?
        Has using coercive methods to try and provide better healthcare resulted in better healthcare?
        Has using violent methods to try and achieve world peace resulted in more peace? (This last one is the most ludicrous concept)

        • gzuckier

          You don’t think a person with a broken leg, let alone a perforated appendix, dickering with an MD for treatment is more akin to being coerced than to bargaining cooperatively?
          Moral issues aren’t the point here, it’s that the beloved “bargaining on a level playing field” free market model doesn’t apply at all. It’s like the stores that jack their prices up sky high in a disaster area. Sure, it’s their right to do so. Can’t make the argument that “the free market is always the best way to allocate resources for the benefit of society” though. Every model has boundary conditions where it brings down, even Newton’s good old F=MA. Economics is hardly likely to be an exception.

          • http://fertilityfile.com IVF-MD

            Sure, I agree that there are certain situations of duress, but there is certainly nothing preventing someone negotiating ahead of time. In fact, in a true free market, it would benefit both parties to have safety mechanisms negotiated ahead of time in case of catastrophe. It would benefit them so much that there might be a market for third-party negotiators who would get paid for helping people forge these agreements. In fact, THAT is what true health insurance is intended to do. Instead today, the concept of insurance has been warped to cover non-emergent routine maintenance. Having “insurance” cover pap smears is like having auto insurance to cover gasoline or oil changes.
            BTW, if you don’t think the free market is the best way to allocate resources in times of disaster, what is your preferred model?

      • gzuckier

        There is nothing stopping a provider from posting a price which is equal to the smallest pittance contracted with the cheapest insurer. The other insurers will not force them to accept more. For that matter, there is nothing stopping a provider from becoming non-participating and posting a price which is whatever they want it to be and letting the patient be responsible for the “cost overrun” over what the insurer will pay. Many do so.

        Ever time I get an EOB from my insurer and see that the billed amount is $400 but the total charge contracted by the insurer is $150 (which is what I am paying in total whether directly through the copay or indirectly through my monthly insurance cost), I am highly dissuaded from just paying my provider directly and cutting out the insurer, even with 25% overhead to the insurer.

        Take Walmart for example. I can get 90 days of my generic diuretic from them for $12 cash now; as compared to getting it from my insurance, for $11. So I do, even though it’s a whole dollar more. Any MDs who wish to follow a similar model, I urge to do so, as that will bring about that direct patient to provider contact they are so nostalgic for.

        Ironically, it’s the insurers now who are posting the prices for various hospitals doing the same procedure now, for their members to see. The hospital doesn’t post the fact that price of an MRI from them is double that of the same MRI at the imaging center a block away, but the insurer now most definitely wants me to know that, and what my copay in each case would be.

        • imdoc

          If there were enough patients around who felt similarly, the cash-based trend would expand. Most cash practices are in larger areas as it is hard to find enough volume of individuals in smaller areas to fill out a practice. The vast majority want to use the benefits provided through an employer and pay only a low co-pay out of pocket.

  • jsmith

    The NY Times has an article by Robert Pear today discussing the disconnect between health insurance and provision of health care.

  • Smart Doc

    “Repeal of reform won’t fix our health system”

    Oh please.

    Repeal the ObamaCare nightmare, passed in the dead of night with no one on earth having read or understood, filled with thousands of unexamined, undebated pages of lies, deceit, totalitarianism, corruption and hyper-regulation.

    Replace with open, non-corrupt, transparent, consumer-friendly reforms that people actually have a chance to read, debate, and discuss.

  • Jackie

    We go to a ‘country’ dentist who charges only about 1/3 of the price the ‘unionized’ dentists in our town charges.

    An old physician in town ( at 80, he’s still the doctor for the volunteer fire department ) used to ‘barter’ with a ethnic restaurant owner. The doctor would get free take-outs or bring his staff to the restaurant – depening on the ‘cost’ of the medical appointments.

    I’ve had some horrific experience with HMO – my first brain surgery had to be contracted out and we were ‘denied’ by the ‘customer service representative’ on the phone. Fortunately my supersivor had some legal experience and helped us get things taken care of. But I remember the tears and sleepless nights I had before my boss’es intervention.

    We are very happy with our current medical care which is also provided by a HMO, but it’s an HMO offered by the insurance company that is affiliated with the hospital system. My doctors have no problem ordering tests or giving me referrals. The problem is that it’s very expensive. Yes, HMOs are expensive because the premium is much higher. But they cover ‘pre-existing conditions’…

    We need to cover everyone in this country. It’s the right thing to to – both ethically and economically.

  • Mickey

    Brad I am in total agreement with what you have said. Let’s put our efforts into making the reform work by fixing what is wrong with it. After all there is no magic formula for a fix but what I don’t understand is why people & Doctors seem to forget that for years now the Insurance co’s have been making all the medical decisions for us & for profit. Even trumping Doctors decisions at the cost of our health. I much prefer someone making my medical decisions who will not gain a profit from it. If you ask me the Insurance co’s are the real “death panels”.

  • jim jaffe

    it is important to remember that most voters think that the system works quite well most of the time, albeit at greater cost than they would like to pay. so while those of us who focus on the issue think the system is either broken — or nonexistent — people healthy enough to participate in American politics see it as merely imperfect. inasmuch as they see more good than bad, they want to hold onto what they’ve got. repeal promises a return to that status quo they’re more or less satisfied with.

    • keepingthyme

      I beg to differ in that I think most voters do not take any amount of responsibilty for their own health care. They either live by the “not gonna happen to me” code of living or they believe that it is the rsponsibilty of health care professionals to just “fix it” and the code of ethics will take care of the bill. We are, overall, a society of opportunists who are always looking for someone else to blame or someone else to take the load.

      No amount of tweeking, changing or repealing legislation will change that mentality.

  • Douglas

    The system we had before cost more and provided less health than any of the systems in most of the world. Our business provides insurance for our employees, and we feel fortunate when the cost only went up 15% a year. Most of the years it was higher.

    Perhaps health care should be a privilage instead of a right, then you could either purchase insurance or lie in the street with your heart attack.

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