A few thoughts on the ACA-  Let’s not throw out the baby with the bath water

What a year so far for Obamacare.  Not just the website.  Hardly a day goes by without someone being interviewed on the news channel with the latest criticism.  Republicans are crying for repeal of the law.  Democrats are trying to cautiously defend the bill, yet distance themselves as much as possible from the negative consequences.  The lawsuits seem never ending.

We hear about only two possibilities– repeal the Act or leave it alone.  And partisan lines are drawn.

I would like to look at this lengthy complicated Bill in terms of the merits of the individual components.  My premise is simply this:  Let’s keep the good things and let’s re-engineer the components that are failing.

During times like these it is easy to forget some of the truly outstanding features of this Act:  Parents can now cover their children on their plans until age 26.  Pre-existing conditions were eliminated.  Lifetime limits were banned.  Insurers now have to follow the 80/20 rule.  The “Donut hole” in Part D Medicare has been improved.  Pay for performance to deliver true value is a part of the new system.  There are many others.  These are very needed changes.

Market vs Mandate—  Looking at the big picture in the evolution of health care, it is important to differentiate what must be legislated and what should be left to the market.   Personally, I have always been a strong advocate for the market but I also realize there are certain things that a market cannot fix.  One of these is universal coverage…. a free market will never give away something for nothing.  Another is a standard benefit package.  These two issues must be mandated.  Let’s briefly look at these two.

As a business principle, insurance only works if all play.  By definition, those who do not need the coverage are subsidizing those who do.  Thinking back in my career I have paid health premiums for almost  30 years.  For 29 of those 30 years all I had done was routine physicals and tests.  One of those years I had open heart surgery.  How I wished I could have just paid the premium for that one year…. just think how much money I could have saved!  Yes, those who do not need the insurance will always subsidize those that do.  Therefore, health insurance needs to be mandated in order to be successful.  Just look at automobile insurance.  Liability insurance is required in all 50 states… by the way, this was done through individual state laws, not Federal.  We need a better system to have all play, with the appropriate penalties for those who don’t.  The concept of the ACA is good here… the logistics need to be fixed.

The benefit package mandated by the ACA is far more rich than we can afford.  We are all concerned about spiraling health care premium costs come this fall.  We simply cannot afford all of the benefits provided in this bill.  Incentives have to be better aligned with a greater emphasis on individual patient responsibility.  As Americans, we have to decide what we are willing to pay.  This is no small issue, but the current costs can be FATAL to the ACA.

Almost everything else can be left to free competition in a free market.  Mandating the market can be a very destructive thing, but the ACA has at least taken a stab at the two most important mandated issues.

Medicaid expansion has a very mixed experience.  So far this year in my consulting I have been in 28 states, about half have accepted the Federal mandate, and about half have not.  In ALL of the states I have heard criticism about the status of Medicaid in their particular state.  The issue here in my opinion is the need to reform Medicaid, regardless of whether  a state accepts the Federal plan or not.  Appropriate incentives need to be incorporated into Medicaid that will enhance quality, satisfaction, cost and patient compliance and engagement.

The Exchanges are proving interesting…. in order to keep monthly premiums to a minimum most are opting for the high deductible plans.  In many cases, the deductible exceeds what the person has in the bank.  This is a catastrophe waiting to happen.

So there does need to be a lot of work done on the ACA.  This is but a small fraction of what I could report.

If the bill is repealed, we all have to remember that all of the good things I mentioned early will also be repealed.

Let’s examine this bill not as Republicans or Democrats, but rather as concerned American citizens.  Face it, everyone in this county is either a present or future patient.  We will all live in the system we create.

Let’s work together and keep what’s good and fix what’s needed to be fixed.

To your health !!!!

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