Diagnosis for Democracy
Insights into the State of Our Union
A Blog by Rob Tenery, MD


Where Does the Congress Go from Here?

By Rob Tenery, MD on August 9, 2017

Based on the latest out of Washington, unless the Senate Republicans can ‘pull a rabbit out of their collective hats’ the chance of replacing Obamacare is highly unlikely at this time. Even if they come together, any Senate Republican plan will have to be reconciled with the plan submitted by the House of Representatives before a new health care bill can be sent to the President.

It seems everything that comes out of Trump’s mouth and through his tweets are criticized by one constituency or another. One point he made that shook even his own followers was suggesting turning to the Democrats for possible answers to fix of the Obamacare (ACA) legislation.

Trump is known for throwing out ideas just to get the discussion started. However, he may have been making a very important point--- for all its flaws there are parts of the ACA legislation that have allowed millions of new lives to be covered.  To repeal the law without an alternative that would include those lives is a political ‘death pill’ come the next election.

For all the claims of keeping the same doctor and capping the rise in premiums, the designers of the ACA legislation knew that without an effective way to bring in more funding, their legislation was doomed to failure. Deny all they want, these same designers knew the easiest way out of that dilemma was to slip into a single payer system, as the private carriers pulled out of the market. Although there is scattered support for a single payer system, the majority in this country still favor our current system.

The Democrats have decided for ‘all its warts’ the ACA is better than anything the Republicans could come up with. The Republicans, trying to back up their campaign pledges for the last six years, are pushing for repeal and replacement. Unfortunately, both sides are not budging from their positions and the public is paying for it. Most predict the ACA will die its own death as the private providers dwindle down.

Whether he realized it or not, Trump may have been on to something when he suggested asking the Democratic leadership for contributions. There are several significant stumbling blocks that have created the problems both Parties face.

By covering more lives through the expansion of the Medicaid programs, taking the coverage away from those patients is not only unpopular, but wrong. However, continuing to pay for these extra lives, when or if the government subsidy runs out, is a problem that many states feel they can’t afford to take on.  

Another concern that should be addressed is to encourage the private carriers to come back into the market by allowing them to compete across state lines. Thus, spreading their risks through larger segments of the population.

The third concern is how to bring more dollars into the delivery system. Supplements to insurance companies to shore up some of the losses on premiums, as suggested in the Senate’s Republican proposal, encourages the private payers, but only adds to this country’s entitlement commitments.

The real dollars that could turn some of the increasing deficits around is now held by the healthy uncovered who are not already in a federal entitlement program or covered under private plans.

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As of December 2016, the American Hospital Association reported that since 2000, hospitals of all types have provided more than $538 billion in uncompensated care to their patients. This does not include uncollected expenses to the doctors and other health care providers.

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These are the individuals who have chosen not to buy coverage that were targeted in the Individual Mandate clause of the ACA.  Because the penalties were relatively inconsequential, many just paid the small fine rather than join the ACA programs or purchase private coverage. Now, it’s even worse with Trump’s Executive Order to not enforce the Individual Mandate penalty.

A possible solution would be to create a whole new category of health care insurance covering the costs of catastrophic events that would not be picked up under any of the existing federal program. Cancer policies, costs of dialysis patients and mandatory liability coverage for drivers are existing examples.  Those who chose to take on the risk of a significant injury or illness without protective coverage would be mandated to pay for the premium for catastrophic insurance coverage.

There are those who would argue this is unfair and infringes on one’s right to choose. The counter is individuals’ obligation to society and to those who would take care of them in the event they were faced with a catastrophic medical event. With unpaid debts and declaring bankruptcy, who ends up adsorbing these costs? The heath care professionals, the facilities where the care was given and ultimately the taxpayers. And who gets off the hook?

The answer seems obvious! All patients and potential patients should come on board and pay their fair share. Or the liberal policy makers, if and when they are in control again, will gladly take over the system for us. Our Congressional leaders must hear from us if this message is going to influence them. Right now, representatives of both Parties seem more focused on the next election than keeping the best health care delivery system in history.

Don’t say you weren’t warned!





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