… maybe that’s just what the doctor ordered!

How many times during the campaign did we hear the Republicans say “repeal and replace” Obamacare on Day One?  I must admit, in the few weeks since the inauguration, I was fully expecting President Trump to sign some executive order summarily repealing the ACA.  Now we hear from the Oval Office that it may be at least a year until the final legislation is out.  There will be no imminent replacement, and the President is talking more about “repair” instead of “repeal and replace”.  What gives?

Personally, I’m relieved.  As health care approaches 20% of our total GNP, a rash solution might not only adversely effect millions of patients, but also could be catastrophic to our entire economy.  But something needs to be done, and soon. Our health care system is out of whack.  Costs are increasing at an alarming rate that exceeds the profit margins of most organizations.  The present solution is to pass it onto the consumer by increasing the deductibles and the co-pays.  Premiums are skyrocketing with no end in sight.  Although more people than ever have access to health care, many simply cannot afford to use what they purchased.  And although we have the most costly program in the world, our outcomes are far from the best.  In fact, a report this December by the CDC showed that the life expectancy of the average American actually DECLINED last year.   We simply cannot afford NOT to have a sustainable health care solution.

Even as a historical Republican, I must concede that much of the ACA has been a good thing.  I have written that two thirds of the bill is great, but the other third is a deal-killer.  We need to selectively keep the good and jettison the bad.   I was pleased when Trump announced in December, even before taking office, that he wanted to keep both the elimination of the pre-existing condition exclusion and the ability to insure our kids to age 26.  Those are two very sound aspects of the ACA that should be retained with any viable health care solution.  But there is much more work to do.

So we hit the pause button.  I like it.

I thought back on a pearl of wisdom I acquired during my residency training, when a very senior physician (in my youthful eyes), told me that the best medication we have for our patients is “Tincture of Time”.  He was right.  “Tincture of Time” can be one of our best clinical options, particularly when we are not sure of the diagnosis.  Time can be our friend, especially if it leads to a better ultimate outcome.

A lasting solution to our health care dilemma deserves to take time.  There are no simple solutions:

First, we must better understand the difference between what is left to the market and what must be legislated.  Industry phenomena like consolidation, transparency, and consumerism will proceed REGARDLESS of what is ultimately decided in Washington.  These are a direct consequence of the marketplace.  A prime example is Pay for Performance.  Although a part of the ACA, it is market-driven.  Consumers will pay, especially when it is their own money, based on perceived value regardless of any health care legislation.  Having said that, its implementation may be better managed through appropriate legislation.

Critical to any solution is to better control health care costs.  This trend is simply unsustainable for our country.  If we do not get a better handle on costs, we will not be able to afford health care as a society.  And that means making some tough choices.  Any cut in health care costs is a pay cut for some component of the industry.  Who in the industry will volunteer to be first for that?

We need to reconcile the “insurance mandate”.  It is not a question of popularity.  Insurance only works when everyone plays.  Whether it’s health care insurance or home/car insurance, the unafflicted will always pay for the afflicted.  If insurance is optional, only those with the highest risk will purchase it, ultimately resulting in adverse selection and subsequent rises in premium.  That’s precisely what we saw in 2016, when health care premiums rose over 100% in some markets.  Somehow, we need to enlarge the risk pool.  Whether it is a tax or a mandate, something needs to be done to get everyone in the pool. Only then can premium costs be managed.

We must better determine the benefit structure.  Every benefit carries an incremental cost to the total program.  How do we determine the most appropriate allocation of our precious resources?

We need to tackle the Medicaid expansion issue. There are several innovative models in different states.  Let’s implement true best practices into the final plan.

Finally, and maybe most importantly, this time gives us an opportunity to construct a true bipartisan solution.  Every one of us, regardless of political affiliation, is either a present patient or a future patient.   We will all ultimately receive care in the very model we are presently designing. We are all in the same health care boat.

Just as in the practice of medicine, “Tincture of Time” can be an opportunity to craft an even better solution.  Let’s keep the best of the ACA; let’s get rid of the worst.  Let’s come together as Americans and truly make American health care affordable and “great again”.

I’m optimistic.  I welcome applying the “Tincture of Time”.  Let’s all put on our “big peoples’” pants and move ahead together as Americans dedicated to achieving the best health care in the world.

Maybe it’s just the quiet before the storm.  Or maybe it’s just what the doctor ordered.

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