We live in interesting times. This holds true for all of us, but it’s particularly relevant for those in the health care field. For me, a physician with an interest in health policy, every day brings new twists and turns to a saga that has roots that stretch to before I was born: the saga of providing and paying for American’s health care.

Before addressing current events — which move so quickly that they may not be current when you read them — it’s important to know a few facts about the American health care system.

1. We are the only modern industrialized country that does not provide universal health insurance. Other countries utilize a variety of payment methods (single-payer, mixed public-private coverage, national health service — but all provide universal insurance).
2. We spend more than any industrialized country. This was true long before the Affordable Care Act (ACA) was signed in 2010; in fact, it’s been true for decades. We currently spend nearly TWICE per person than the comparable country average expenditure ($9,451 vs. $4,908).
3. We get worse results. By most measures (life expectancy, infant mortality, disease burden, preventable hospital admissions, etc.) we are not just a bit worse — we are substantially worse than comparable countries.
4. The percentage of uninsured Americans is at a historic low (10 percent). The historical trend has been downward — with a steep drop from 19 percent to 10 percent from 2010 to the present.
5. Lastly, being uninsured is not good for you. Studies consistently show that those without health insurance skip or delay care, don’t take recommended treatments, have more preventable hospitalizations, and have higher mortality. In addition to the health consequences, the financial costs are also high: Those without insurance have higher rates of bankruptcy and worse credit reports.

Secret Senate process

Knowing these facts is key to understanding the current plan to replace the ACA with the American Healthcare Act (AHCA), which has passed the House and is on track to be brought to a Senate vote in late June or early July. Interestingly, the Senate has opted to keep the legislative process secret. There have been no hearings, no testimony from health-care or health-policy experts, not even a draft of the bill to read.

The Congressional Budget Office (CBO) will soon be asked to score the financial and health coverage impact of the bill — but the score will be released just days before the final vote. As such, the effects on 1/6th of our economy, and millions of Americans, will be largely unknown. Based on the House version of the AHCA, we do know that the main features of the bill are: a reduction in premium assistance for low-income Americans, elimination of the mandate to purchase insurance, steep reductions in Medicaid spending, and tax cuts that will benefit high-income Americans but decrease funding to Medicare.

The Medicaid reductions are particularly noteworthy, since then-candidate Donald Trump was unambiguous during his presidential campaign, tweeting that he “was the first & only potential GOP candidate to state there will be no cuts to Social Security, Medicare & Medicaid.” Since 80 percent of Medicaid spending goes to fund health care for children, the disabled, or the elderly, these cuts are particularly problematic. These are not groups that can simply seek employment and purchase coverage on their own — they are among the most vulnerable of society.

Uninsured rate would soar

The net effect of these features of the AHCA, if it passes, would be over 20 million Americans losing health insurance, and an overall increase in insurance premiums, particularly among the poor and elderly. This would be the largest increase in the uninsured rate in American history, coming after historic gains.

Unfortunately, even if the Senate does not pass the AHCA, the state of the U.S. health care financing system is not good. The ACA was an imperfect law. As such, it would have greatly benefited from the usual legislative process of addressing flaws that emerged as it was implemented. This did not happen. Instead, there has been a concerted effort to undercut the law. Multiple states opted to not expand Medicaid enrollment, and successfully sued to avoid doing so. Funds to stabilize insurance premiums in parts of the country with high rates of illness and thus high costs (so called “risk corridors”) were frozen by language added to a spending bill (a so-called “rider”) that passed in 2014, severely hampering the ability of the government to cushion insurance rate spikes in hard-hit areas of America. When people talk of the ACA “collapsing,” the reality is that it is shuddering (but still standing) under multiple attempts to blow up the foundation.

Two other options

Where do we go now? Passage of the AHCA will raise insurance rates and increase the number of Americans without insurance. Continuing under the ACA while the party in power continues to try to destroy it will eventually lead to a similar situation, as insurers raise premiums in the face of uncertainty and decreased governmental support. Two other options remain: continue with the ACA, but with bipartisan attempts to improve it (better subsidies, re-institution of risk corridors, attempts at cost-control, etc.), or develop a completely new system. If we believe that all Americans deserve affordable health insurance, then neither the AHCA nor the current form of the ACA is sufficient. Only a significantly reworked ACA, or a new system, could do so. In either case, given what is at stake, it is imperative for the process to be open, transparent, and unhurried. Most important, we need to acknowledge that other countries have managed to achieve universal coverage for far less money, and consider following their example.

Which path we take appears to be in the hands of the Senate. Within weeks, they will vote on a bill that will have far-reaching impacts; hopefully their constituents will have let them know how they would like them to vote.

Dimitri Drekonja, M.D., M.S., is an infectious diseases physician at the Minneapolis VA Health Care System, and an associate professor of medicine at the University of Minnesota. The views expressed are his own, and not necessarily representative of the VA or the University of Minnesota. He is also a member of Minnesota Doctors for Health Equity, a group that acts to advance health equity through legislative, community, and institutional engagement. 

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