Publish date: August 25, 2017
By: Kevin P. Marks, MD, Clinical Endocrinology News

The Affordable Care Act – Obamacare – is not a disaster. It is not a long-term solution, but it is fixable. Now that repeal and/or replace efforts have failed, Congress should intelligently debate which solutions make the most sense and move forward with legislation to fix the health care system.

Before that can happen, Democrats and Republicans need to make certain acknowledgments.

Democrats should acknowledge that the ACA is flawed. Whereas many experts believe a single-payer system is ultimately going to be the best long-term answer, for our country, we’re just not there yet.

The House of Representatives, Senate, and the White House are all under Republican control. Recognize that President Donald Trump’s catchphrase, “America First” effectively translates into “me,” not “we the people.” Just like President Trump, a sizable percentage of Americans oppose paying higher taxes to support the greater good. Their hard-earned taxpayer money is being unfairly redistributed, they argue.

On the other side of the political aisle, Republicans should acknowledge that the ACA is not “a total disaster,” as purported by the president. That’s just not true. The ACA has dramatically reduced the U.S. uninsured population – from 49.9 million in 2010 to 29 million in 2015 (the latest figures), according to the Census Bureau. It cost much less than initially forecast after providing subsidies, assembling accountable care organizations, and providing copayment-free access to a core list of preventive services called the essential health benefits.

Nevertheless, Democrats should acknowledge that the ACA is not affordable. The cost of premiums, copayments, prescription drugs, medical procedures, and subspecialty visits are out of control. Furthermore, Democrats should admit that powerful lobbyists for plaintiffs’ lawyer associations are unwisely influencing their party’s position on tort reform.

So, how can the ACA be fixed? Earlier this year, Republican lawmakers proposed multiple versions of the Better Care Reconciliation Act (BCRA). Unlike the ACA, it really was “a total disaster.” Only 17% of Americans supported the BCRA, according to one poll from NPR/PBS NewsHour/Marist. Further, nearly every major medical organization adamantly opposed it, according to a report from NBC News.

Republicans who despise the ACA often fail to acknowledge what drove up premiums in the first place. Less competition led to higher costs. Republicans shot down the law’s original concept of a “public option.” Nineteen red states refused to expand Medicaid. All these decisions decreased competition in marketplaces.

Now Congress needs to take a deep breath, let go of their hyperpartisan expectations, and listen to these 11 suggestions. How about let’s:

1. Incentivize or persuade more states to expand Medicaid.

2. Create a public option or “public fallback plan” in every state that would compete alongside private plans in the marketplaces.

3. Possibly implement a Cadillac tax on high-cost private plans as recommended by economists.

4. Provide vigorous outreach to the millions of uninsured Americans who are eligible for but not enrolled in Medicaid or the Children’s Health Insurance Program.

5. Invest generously in parent-centered, equitable, high-quality early interventions such as Individuals with Disabilities and Education Act (IDEA) Part C, early childhood special education such as IDEA Part B, and early learning/preschool for young children. High-quality birth-to-5 programs yield $13 for every $1 invested and substantially lower health risks down the road of life.

6. Consider implementing a nationwide sugar tax. Evidence exists that taxing sugary drinks could improve the overall health of the U.S. population which could help to reduce the federal deficit over time.

7. Implement a six-point plan (as originally recommended by Sen. Bernie Sanders [I-Vt.]) to lower prescription drug prices. “Americans pay, by far, the highest prices for prescription drugs in the entire world,” Sen. Sanders notes on his website. He calls for negotiating better deals with drug manufacturers, reimporting prescriptions from Canada, restoring discounts for low-income seniors, prohibiting deals that block generic medications from entering the market, enacting stronger penalties for fraud, and requiring pricing and cost transparency.

8. Expand the role of nurses to filter out which patients need to be seen urgently, and which patients do not need an expensive trip to doctor’s office, urgent care, or emergency department. With appropriate training, nurses can manage behavior change and medication adjustment for chronic conditions; can lead care management teams for patients who are high utilizers of care; and manage transitions of care between the medical home, specialist outpatient, and hospital settings, according to primary care and nursing faculty leaders at the University of California, San Francisco.

9. Bring better accountability to health care by using bundled payments, global payments, and accountable care organizations, while simultaneously improving access and care coordination efforts for people with chronic conditions like mental health disorders and substance abuse, as recommended by the Commonwealth Fund.

10. Expand palliative care programs so far fewer people needlessly suffer and then die in very expensive intensive care units.

11. Enact common-sense tort reform. The overuse of tests and procedures because of fear of malpractice litigation, known as defensive medicine, is indirectly estimated to cost the United States $46 billion annually. According to a 2014 JAMA article, 28% of orders and 13% of costs were judged to be at least partially defensive, and 2.9% of total costs were completely defensive. Most costs were from potentially unnecessary hospitalizations. Survey studies show that greater than 90% of doctors practice defensive medicine, but what separates this perception from careful practice or patient expectations/demands remains controversial.

The main point is this – the Affordable Care Act is indeed fixable. We should not “let Obamacare implode, then deal” as the President tweeted. Whether politicians and other Americans can overcome their hyperpartisan beliefs and expectations remains to be seen.

Kevin P. Marks, MD, is a pediatrician in Eugene, Ore., and a clinical assistant professor at the Oregon Health and Science University, Portland.

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