Well, it’s done. He is the President. Yup. Trump and his coterie of billionaire country rapists are now our official leaders. How does it feel? Like you could benefit from several hours on a bidet? I feel your pain.

As most of my readers know, especially if they’ve clicked on the “Books by” link on my Facebook site, I write and have two published works of fiction, Zendoscopy (a serio-comic coming-of-age tale) and Spacebraid and Other Tales of a Dystopian Universe (sci-fi fantasy stories). What many may not know, however, is that I’m a retired M.D. An ob/gyn, to be precise about it. I spent 16 years in clinical practice, and then segued into administrative medicine, taking on several roles during the balance of my career: senior health plan executive, market medical director for a large health plan and, ultimately, heading up physician, hospital, and ancillary provider peer review (medical quality of care management) for 13 western states for a very large insurance company. Along the way, I also did some teaching in a university-affiliated ob/gyn residency program. Having worked in these several sectors of our health care environment, I’ve developed some pretty strong opinions about where health care should be heading. And folks, lemme tell ya, it ain’t a goin’ in that direction today.

At first, I thought I’d provide you with a historical review of how we got to where we currently find ourselves but, as I began to write, I realized I could fill far more paragraphs than anyone would want to assimilate on the subject. So, instead, here’s a considerably shorter review with my take on it all.

The pre-mid-1980s 80/20 insurance plans and employer-based health care model provided coverage that encouraged people to ask for everything and physicians to provide it…and more. This led to uncontrolled costs and opened the door for so-called “managed care”, a model that promised evidence-based health care with cost controls and some inevitable loss of choice for patients. Big business saw an opening and stepped in to run it, leading to substantial abuse in the name of bolstering corporate profit. The promise of better care at lower cost was sacrificed on the altar of stratospheric executive pay. Health care, quite simply, became an immoral, profit-centered business.

The Affordable Care Act (the “ACA”, or “Obamacare”) was an attempt to deal with the problem and provide coverage for the millions of Americans who lacked health insurance. It is important to remember that the basic idea from which grew the ACA was, in fact, a Republican plan and was even implemented in Massachusetts by then-governor Mitt Romney. But the version known as the Affordable Care Act was the specific plan promoted by our nation’s first black President, and as Senator Mitch McConnell famously articulated, nothing proposed by President Obama would ever be approved by Republicans, including the formerly articulated Republican health care plan. The racism inherent in the Republican position was obvious and odious.

President Obama’s offering included a “public option”, essentially a program of universal coverage provided through an alternative that would, in effect, compete with the private health care system. This was a non-starter for business-protectionist Republicans, who screamed “socialized medicine” and forced Obama to drop it. As a result, the ACA ultimately passed on a straight party-line vote without the one component that would have led to truly comprehensive coverage availability for everyone. The ACA as enacted was far from perfect but it was a compromise that Republicans could at least say didn’t eliminate the insurance companies from the health care market, and it did allow more than 20 million people who formerly lacked insurance to gain coverage. Other benefits of the ACA are well known and I won’t take time to delineate them here.

Now, the Republicans, who’ve tried some sixty times without success to dismantle the ACA, see their chance finally to kill it. But as in all the years since its adoption, they have been unable to present a viable alternative. What they’re learning is that health care does not operate according to simple market-based supply and demand rules. Demand for health care is relatively inelastic – everyone needs it eventually and, often, unpredictably. To drop 20 million or more from the insurance roles will only cause them to delay care, become sicker, and then seek care in emergency rooms, where treatment is outrageously expensive and, to a great extent, paid for by taxpayers in the form of government expenditures and increased direct health care costs. It isn’t more cost effective than covering people through insurance and, being wasteful of resources and inefficient, it makes no sense to abandon the ACA with this as the inevitable result.

What is the answer? No matter how distasteful it is for the right wing, the ONLY viable answer is universal coverage, sometimes referred to as “Medicare for all”, although it would likely differ in some respects from Medicare. It would, in essence, be a federally funded program that could use private insurance companies as fiscal intermediaries under contract for reimbursement. Everyone would be covered by a safety net assuring a basic standard of care. Those who could afford it could purchase upgraded levels of coverage from the insurance companies, say, for cosmetic or advanced infertility treatment. We would abandon the dysfunctional employer-based health care model, with funding (as now for Medicare/Medicaid) coming from tax revenues. It would not be more expensive per capita than what we are paying now in premiums.

That’s a somewhat oversimplified view of what needs to happen, but I’m confident in predicting that it won’t happen anytime soon. Entrenched interests will see to that. But how long will we be able to justify our present system or whatever the Republicans may try to implement when we’re confronted by the well-functioning universal coverage systems of other Western, developed nations? Our present system, with its fragmented incentives of patients v. doctors v. hospitals v. insurance companies v. drug companies is an utterly unnecessary disgrace with higher costs and worse health outcomes than most if not all Western European countries. But we won’t get what we need until we all stand up for it. This will take a degree of political awareness and activity sorely lacking today in the American public, many of whom voted against their own best interests in the recent Presidential election.

Maybe those folks will eventually wake up and realize they’ve been conned. If so, I hope it happens before the suffering becomes too severe. Say, in time for the next midterm elections.