With all of the distractions of the past few weeks, ranging from the obscenity of a domestic terrorist attack in Charlottesville to the specter of unstable leaders of nations with nuclear weapons, Americans are still nervously pondering the fate of our health care system.
For-profit insurance companies seem to balk at commitments to the health care exchanges in order to hedge their bets on financial solvency at the expense of the health of America’s most vulnerable citizens. So perhaps we can take a quick overview of where we are at this moment, recognizing that the capriciousness of our government can upend this tenuous situation before the ink dries.
Despite the histrionic exhortations of the president, it would seem Congress, at least for the time being, is intent on leaving the Affordable Care Act, aka Obamacare, in place while it moves on to tax cuts and perhaps the much-needed rehabilitation of our transportation infrastructure. Of course, political and pragmatic realities mean that all of these items are inextricably linked.
Although tax reform is sorely needed, what has been floated in Congress is a simple tax cut, which is different than reform. Wall Street and corporate entities have been hoping for a major reduction in their tax rates to enhance their bottom lines and optimize their stock valuations. However, the size of the original tax cut was dependent on balancing it against the $800 billion reduction in health care costs in the draconian House and Senate repeal-and-replace bills.
The most vulnerable of Americans were saved by two principled women, Sens. Lisa Murkowski and Susan Collins, and a maverick soldier upset with what has happened to our system of governing, Sen. John McCain. Any major tax cut implemented now would add to the national debt, which gnaws at the craw of deficit hawks. Obtaining sufficient votes within the Republican Party now may be a Sisyphean task.
Infrastructure was perceived to be a relative slam-dunk, but the Charlottesville debacle and the moral turpitude of equating protesters with white supremacists and neo-Nazis has probably poisoned the well sufficiently that reaching across the aisle to collaborate and give the president a much-needed legislative win is now much less likely.
Which brings us to what Congress can, and in my estimation, should do to protect the health care of the economically least fortunate, the disabled and elderly Americans. As I have stated many times, the Affordable Care Act is a flawed law that had the prime directive of reducing the number of uninsured Americans. That it did, mostly by expansion of Medicaid.
It also attempted to improve efficiency through structural changes in health care delivery by emphasizing electronic health records and championing value-based care and prevention, rather than the traditional fee-for-service. These strategies, though laudable, have been poorly implemented and created chaos and dissatisfaction among health care providers.
Insurance companies have been opting out of the health care exchanges, which has provided fodder for Trump and others to say Obamacare has failed. But perhaps one should look under the hood before declaring it a total loss.
Insurance companies are not in the business of providing health care coverage. They’re in the business of making money. If they cannot project a profit, they will look for an exit ramp. If the federal government waffles on whether to provide ACA subsidies to poorer subscribers, the insurance companies will bail. And that noncommitment to subsidies was exactly what Trump was threatening just as the insurers were planning for the 2018 sign-up season.
The possibility that insurers would commit to an exchange, incur expenses covering their subscribers and then have a shortfall in revenues because the government reneged on subsidies provided more risk than their executives were willing to take. Nature abhors a vacuum. Business abhors uncertainty. Adios.
So what can our dysfunctional Congress do? Providing market stability is job one. Congress needs to step in and minimize the legal and political uncertainty by providing assurances of federal subsidies for premiums, copays and deductibles. Then it needs to do what we elected it to do: legislate with the proper procedures, or regular order, that prompted Sen. McCain to cast his pivotal vote.
Congress should hold bipartisan hearings with health care stakeholders — the public, AARP, the disabled, minorities, providers, the pharmaceutical industry, unions, insurers and technology companies. Take this collective wisdom and legislate.
As hard as it is to imagine in these tumultuous times, we would have a government of, by, and for the people.
Irving Kent Loh, M.D., is a preventive cardiologist and the director of the Ventura Heart Institute in Thousand Oaks. Email him at firstname.lastname@example.org.
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