Whither Obamacare?

Most readers of this blog are unaware that I am a retired physician. In 1977, after finishing my specialty training in ob/gyn and a fellowship in family planning and the treatment of sexual dysfunction, I entered the private practice of medicine. Eight years later, I left private practice to become the gynecologist for the student health service of a large university. From there, I went on to take control of a troubled clinic near Los Angeles International Airport, my predecessor having been summarily fired for moral and ethical indiscretions. Moving on from this clinic, I subsequently pursued a career path that led me to chair the ob/gyn department for a large managed health care plan, progress to become Executive Vice President of Medical Affairs for an HMO/PPO organization, and move to two other organizations before landing in my final job with a major health plan and insurer for which I spent the last fifteen years of my career. In this latter job, I was primarily focused on the management of quality of care in our physician, hospital, and ancillary provider networks. I relate all this to make the point that I’ve seen health care from just about every possible angle during the course of my professional life, and it has afforded me significant perspective on where we’ve been and where we ought to head.

This blog piece cannot hope to address the entire problem of the health care mess we face in the U.S. Simply stated, U.S. health care costs exceed by a large margin those of other western European countries and our outcomes (infant mortality, for example) lag woefully behind those same countries. The often stated (by Republicans, at least) mantra that we have the best health care in the world is, simply, not true, and it’s a national disgrace.

The Affordable Care Act (aka, the ACA or Obamacare) was implemented in the attempt to address some of the myriad issues confronting our health care environment. Note that I’m not calling it our “system” here because, in reality, we don’t have one. What we do have is a patchwork of medical care models that operate inefficiently and make almost no one happy.

The only viable permanent solution to the problem is universal health care coverage, a model into which many with vested interests will have to be dragged kicking and screaming. How might such a model work?

First, it would be sort of like Medicare for everyone. A baseline safety net would be established so that everyone would be covered for essential services. Yes, it would be a government program, but we know that Medicare works and works well. This would get the private insurance companies and their confusing plethora of care plans out of the business of providing basic health care. We would allow them, however, to sell supplementary policies for people who could and would want coverage for additional types of services including, just for example, certain plastic surgical procedures and advanced reproductive technologies. We could also use private insurance companies as the fiscal intermediaries for our model. Competition between companies to provide this service would incentivize efficiency and help to hold administrative costs down. Coverage guidelines would be centrally set, as they are for Medicare, and without the current, nonsensical variation we have now based upon company whim and, largely, state legislation.

Unfortunately, President Obama threw in the towel during the partisan and special interest haggling that went on as he fought for the ACA. The process, however, ended up producing a program that has had beneficial effects for many who now have coverage they formerly lacked. Admittedly, it has hurt a few and, worse, not succeeded in providing care for some people at all.

Democratic nomination seeker Bernie Sanders is militantly vocal about wanting universal health care but, unfortunately, although I agree with his sentiments on the matter, he’s a bull in a china shop and probably not electable. Even if he were to be elected, he probably could not create the revolution he seeks, as Congress will not be coerced. The better bet, although it would be slower to play out, is Hillary Clinton’s approach. She advocates incrementally improving on the ACA. Admittedly, this is not as exciting as a revolution, but it’s far more likely to take us in the desired direction. Furthermore, this is the only approach with any prospect of long term success.

Finally, if a Republican wins in November, it’s unlikely that he (not she — Fiorina has no chance) will be able to fulfill the oft-repeated pledge to kill the ACA. Some 17 million people now have insurance that they didn’t have before and, among other benefits, pre-existing conditions are now not allowed as coverage exclusions. In general people are happy with their coverage under the ACA, and killing it would be disastrous for Republicans. Would, say, a Ted Cruz or Marco Rubio really take all this away with nothing else to offer and risk incurring widespread public wrath? Unlikely.

So, although this discussion has been brief, it does point to a direction for the future with respect to health care. Bernie is too militantly cranky and the Republican Congress is not likely to respond in any functional way to him. If we want to straighten out what’s wrong, we have to support Hillary. She’s the only one who both makes sense and has an approach that might work.

BUT, having said all this, I will also say that health care isn’t the only issue of importance in the process of selecting a Democratic Party candidate. Hillary Clinton carries some real baggage with her: Her vote in support of enabling George W. Bush to invade Iraq, her e-mail kerfuffle, and her lack of ability to rally the support of younger voters and, in particular, that of younger women, are major concerns. Bernie Sanders, also not without his own baggage, nevertheless has drawn remarkable support from younger voters, but he does not have the same level of support that Clinton has from voters of color. Sanders is saying things that positively need to be said, if a bit too bombastically. His blow-things-up rhetoric is unlikely to play well with Congress, and he really should bury his repeated statement that he’s a democratic socialist. It’s not a problem for many that he is one, but his flaunting of the label is most assuredly hurting him among many voters whose support he’ll need if he’s to win in a general election.

The bottom line is that both Sanders and Clinton are on the correct side of the issues and, despite their individual drawbacks, either would be far better than the reactionary Republican opposition. But if health care is your main concern, Clinton definitely has the edge over Sanders as the person who is most likely to take us in the direction we need to move.


1 thought on “Whither Obamacare?

  1. Jnana Hodson

    Your views are appreciated. If only the other side of the political aisle had been willing to admit there was a problem in the first place, maybe we would have had a shot at a better solution than we were able to achieve. Still, despite its many shortcomings, it was a step in the right direction.
    Now, to make it better rather than going back to two aspirin and a glass of polluted water.


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