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Health Care Reform: Both Democrats and Republicans Miss the Mark


Larry Altshuler, MD, director of oncology intake services, hospitalist, internist, Southwestern Regional Medical Center

I am nonpartisan. I don’t really care whether it is a Democrat or a Republican that tries to reform health care; I just want to see whatever reform is instituted to be designed to improve patient care and achieve quality outcomes. Unfortunately, both sides of the political spectrum have missed the boat, and their proposals won’t soon achieve either of these goals.

I am not a fan of ObamaCare, but not for reasons most people oppose it. The Affordable Care Act  (ACA) had great goals: providing insurance for everyone, improving preventive care, covering those with pre-existing conditions, and removing various caps. The major problem with the ACA was how to pay for it; all these goals are extremely expensive. The measures legislated, including increased taxes, penalties, and mandates did not work, which is why premiums, copays, and deductibles have increased substantially and many insurers have dropped out of the exchanges. 

That being said, now the Republicans have their chance for reform. But their initial proposal will face the same major problem as the ACA; how to pay for it. What they have done is simply proposed different ways to pay for health care than the ACA did. Of course, by halting Medicaid expansion or giving states block grants, and by not subsidizing millions of Americans who presently rely on subsidies to get insurance, they will obviously save some government money, about $337 billion. However, the Congressional Budget Office report states that premiums will continue to rise around 20% until 2026. And of course, millions of Americans will not have insurance.

The essential problem is that they both primarily address how to pay for health care, but don’t truly address how to decrease health care costs to begin with. In fact, they assume those costs will come down automatically with the different ways to pay for it. They are wrong, as already seen with the ACA.

Just think… if health care costs are decreased, there would be additional money to subsidize those without insurance, as well as lowering premiums, without having to raise taxes. Unfortunately, that aspect is really not being addressed, especially by the Republicans, who think competition and more choice will decrease costs. If that was the case, it would have happened before the ACA was passed, and in fact was one
reason the ACA was legislated.

So how do we address lowering costs? Remarkably, it can be done rather straightforwardly. First, we need to address unnecessary medical care, which has been estimated to be at least 30% of health care costs. That equates to almost $1 trillion per year; even eliminating 50% of unnecessary care would provide enough money to subsidize the uninsured and it is significantly more than the $337 billion saved by the Republican plan (and over 10 years, not 1!). It would also lower costs for Medicare and insurers, thus resulting in lower premiums, etc. Best of all, it would automatically improve the quality of care.

A second need is to reverse the heavy predominance of specialty care over primary care. Primary care physicians (PCPs) are disappearing rapidly because of greater overhead and less reimbursement. The reimbursement in medical care goes proportionately more to specialties, testing, and procedures, leaving PCPs with little means to increase income. The countries that have the most cost-effective outcomes have a predominant primary care base. This is not surprising because US studies consistently demonstrate that primary care provides better outcomes at lower cost than specialty care. But again, that is not the direction US health care has traveled.

Legislation should also aim to decrease pharmaceutical costs. We all know that the US subsidizes the rest of the world’s medication needs since the government is not allowed to negotiate lower prices. But it is more than this: 50% of the medications used in the world are used by Americans. Yet once again, we have poorer outcomes than other countries. The reason? We overuse and misuse medications and ignore other methods that can provide longer lasting relief.

Fourth, we must focus on prevention and adequate treatment of chronic diseases, which eat up the majority of health care costs. Government demonstration projects to do so have mostly failed but a few small projects have succeeded. The latter are the ones that need to be expanded.

Fifth, we need to reform medical malpractice.  Simply capping rewards does nothing to eliminate costly frivolous lawsuits and more importantly, does nothing to prevent repeat errors. Defensive medical practice is estimated to cost 11% of the health care dollar. By establishing medical courts with knowledgeable judges, nonbiased experts, and evidence-based information, both doctors and injured patients can obtain justice, without a high price tag.

Again, none of these potential solutions are adequately addressed by either political party. They’ve truly missed the boat and are basically “treating the symptoms and not the disease”. Until they address the underlying drivers of high health care costs, true health care reform that will benefit all Americans will not be a reality.  

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