Affordable Care Act (ACA) and what needs to be done about healthcare

As Democrats are unwilling to admit that the ACA is a failure and the Republicans have not firmed up any coherent replacement for the bill, I worry we have years of arguing over the color of the deck chairs on a sinking ship.

THINGS THAT HAVE TO CHANGE:

1. Price Transparency: You cannot have any reasonable competitive market when the provider of service doesn't have to tell you how much it costs until after the service is given.

Think of it this way. You are walking along the streets of Montmartre and a street artist begins sketching your picture.  There is a reason they don't ask first. If they ask first, they will have to negotiate prices. If they just draw the picture, they know you will feel the obligation to pay them what they ask because 'the work is already done'. If they were to ask you if you want the picture first, you would ask 'How much?' to which they might reply '30 Euro.' At this point you could say, 'That's too much. Sorry. No, thank you.' The artist will likely lower his price until you can reach a mutual agreement on reasonable cost. Or, if you can come to no agreement, you move on and the street artist finds a new consumer. In healthcare, there is no negotiating prices, at least not between the person offering the service and the person receiving it. The consumer doesn't have the tools to shop around for a less expensive care, at least not at the higher levels of medical care. You find out how much it costs three weeks later when you get the bill in the mail.


2. Price consistency: It should not be that having insurance punishes you. At it is, insurance companies often get charged more than uninsured customers for services. With a deductible, that means you get charged more for having insurance. Not only is this a way for responsible insurance owners to subsidize the uninsured (on top of the tax money that already subsidizes the uninsured), it incentivizes people not to buy insurance. You know what cannot work if people don't buy insurance? Insurance. Especially with a pre-existing mandate.

Worth noting, if price transparency, competition, and consistency existed within healthcare, most non-emergent/serious medical costs could be paid out of pocket. This would not only make the doctor's job easier, but it would ease the burden on insurance companies allowing them to lower premiums and pay out more for serious medical conditions.


3. Tort Reform: This is just necessary even forgetting overwhelming healthcare costs exacerbated by unfair litigation.


4. FREE MARKETS: Despite what you've been told, the American Healthcare Market is not a free market. It has the worst characteristics of a private market without any of the parts of a free market that allow it to 'fix' itself. It's private in the sense that it's not facilitated by the state. Private institutions provide care and pay out vendors privately with a profit model. It doesn't, however, set its own prices. The implementation of medicare, alone, has institutionalized costs via 'coding'. This works for government and insurance, but it does not work for patients. And it eliminates yet another avenue for the consumer to 'shop around' for more competitive care. In fact, in the current healthcare model, you aren't even the consumer. Insurance companies are the consumer.

It is not a 'free' market and the government knows that. In fact, it facilitates that. ACA didn't even remotely deal with these pricing issues or the lack of agency by patients. Instead, it made the problem worse, further marginalizing the patient in favor of insurance companies. Sure, you are covered. But what does that coverage mean? Does it mean real lower costs out of pocket? For tens of millions of Americans, no.


5. No mandate: I know what you are going to say. Without the mandate, we can't cover preexisting conditions. Maybe. Maybe not. Certainly, with the current model of 'insurance-even-for-a-stubbed-toe' it is true. Certainly, while it costs $1200 to take your three-year-old to the ER for a questionable bug bite, you need as many people paying high premiums as possible. But besides the mandate being unconstitutional (despite a bad ruling by the SCOTUS), it is a mechanism for rising costs.

Think of it this way. For ease, let's say the penalty for not having insurance for a family of four is $1000/year. Insurance costs $5000/year in premiums on top of a $5000/person deductible. Like the vast majority of families in America, the likelihood of seeing a cost benefit from your insurance at that rate is very low. So, you are incentivized to take the penalty and cross your fingers, hoping nothing catastrophic happens, as you pay out of pocket for your medical expenses (hey, they even give you a lower rate for being uninsured). The next logical step for lawmakers (as SCOTUS gave them a blank check to penalize your for not buying whatever they want you to buy) is to raise that penalty. However high you raise the penalty, you've given insurance companies all the motivation they need to raise their own prices. If they know your alternative to buying their product is a $3000/year fine, they know they can offer you a $3000/year plan that covers nearly nothing and you have an incentive to buy it because you will be losing that $3000/year anyway. You see?


6. Change the way we see healthcare: Dream with me if you can, folks. Imagine a world where you enter an ER with a questionable bug bite and a triage nurse can look at it and say, 'that is a fire ant bite.' No $1200 bill in three weeks. No two-hour wait so that a doctor and two nurses (all with their own billing) can tell you that it is a fire ant bite.

Or, you go to the doctor and the first question isn't 'Who is your insurance provider?' Instead, you get a flat, transparent rate of, say, $30 for a check-up with reasonably priced add-ons to fit your needs.

What if, instead of subsidizing coverage (whose costs are rising exponentially), we invested in subsidizing care? Hey, we are going to be paying the money anyway. Why not put the money directly into the hands of the doctors providing the care and offer free/reduced price clinics and hospitals for people who cannot afford healthcare? Reform Medicaid to focus on care and not coverage. Cut the bureaucracy. Stop paying $100 for $1 of coverage. And all of this can be facilitated on the state level where people can hold lawmakers accountable, not by DC who can be held accountable for nothing because they weasel around every issue with finger-pointing, buck-passing, and lies.

What if, instead of premiums, we put money we pay to insurers into healthcare savings plans so we get exactly what we pay into it? We become the consumer again, able to shop around and negotiate on our own behalf.


There are a lot of us who oppose ACA who are just as kind and compassionate as those who support it. But we want real options. We want a workable, long-lasting plan that will allow us to keep out 'first in the world' care but cut the insane costs that have risen steadily as it has been taken over by government and insurance companies. Wouldn't you rather an excellent system that is cheaper and better managed than to settle for a bill that is disproportionately hurting the middle class and doesn't deal with cost at all?

If the GOP doesn't implement the kinds of reforms I'm talking about, I will be angry with them too. Something has to be done. Obamacare wasn't it. The bill has helped insurance companies more than anyone else on earth. No amount of tinkering with it can heal the deep and gaping wounds it has inflicted on the healthcare system and the middle class. Let it go. Dream bigger. I beg of you.