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Whatever is done on U.S. health care policy, the process should be open, transparent, and unhurried

If we believe that all Americans deserve affordable health insurance, then neither the AHCA nor the current form of the ACA is sufficient.

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.
Dimitri Drekonja

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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Comments (11)

  1. Submitted by LK WOODRUFF on 06/19/2017 - 12:43 pm.

    healthcare continued….

    Everyone needs to be crystal clear that it is the REPs who continue to try to UNdo the ACA, the law of the land per the Supreme Court, and are also now behind this ‘secretive process. Everything this author writes is absolutely true, but it is not the full Senate blocking things or doing things in secret: it is solely the REPs.

  2. Submitted by Constance Sullivan on 06/19/2017 - 03:27 pm.

    Thank you for the clear statement on our current health insurance/health care crisis and the incredibly nasty Republican attempts to make it worse.

    One thing we have to keep in mind: The Republican majority in Congress does not have the faintest idea of what to do about health care. Their goal is simply to take what they see as a gigantic pool of money (Medicaid and Medicare funds) and use it to give tax cuts to the wealthy. If we were to see the Senate’s plan, we would be able to come to that conclusion, as everyone–including Donald Trump!–has done by now with the version passed by the House.

    What will Republicans do, when America is filled with people dying of unaddressed illnesses and injuries in corners of our society? Will Trump supporters remember that their darling president didn’t lift a finger even to figure out how health care works in our country, much less lead the effort to get a good bill?

  3. Submitted by Richard Adair on 06/19/2017 - 09:16 pm.

    View from the private sector

    You have a nice clear voice, Dmitri. Your readers might be surprised to hear how much support for single payer exists among private practice physicians in the Twin Cities. Many of us are sick and tired of trying to care for people who can’t afford what we recommend, or who show up in our offices far past the time when we can prevent the inevitable ravages of high blood pressure, diabetes, or cancer, damage that would have been preventable only a year or two ago. It’s disheartening to consider that the improvements in access to care since passage of the ACA are about to be tossed aside.

    Keep up the good work on this issue, my friend!

    Richard Adair, MD

  4. Submitted by Joe Smith on 06/20/2017 - 07:02 am.

    I agree on openness on fixing the ACA.

    When Obama passed the bill and his top ranking House leader Nancy Peloci said “we have to pass it to find the goodies in it”, I was sick to my stomach. Obamacare expanded coverage for Medicaid (set up for those who can’t work and the young) doubling the amount of folks eligible for Medicaid coverage. What was supposed to be a good thing turned Medicaid into a program that many Doctors would no longer serve, giving those on Medicaid less options for care. The cost overruns are threatening to implode the system chasing Doctors and hospitals away. Another promise was the ACA was going to reduce emergency room visits by the poor, in turn lowering hospital costs (yes, we pay extra to cover non paying emergency visits), that also didn’t happen. Obamacare has doubled the cost to working folks (those actually paying for their coverage) because the young 26-45 year olds didn’t opt in to cover increased costs, not surprising to anyone.

    93% of Americans were covered by their employers, Medicaid or Medicare prior to the ACA. We turned over a system that needed some fixing not an entire overhaul. I personally feel it was the Left’s first move towards single payer Govt run healthcare for everyone….

    The last time congress passed a bill no one read or saw it was a disaster, let’s not repeat it!!

  5. Submitted by Constance Sullivan on 06/20/2017 - 10:38 am.

    Sorry, Joe, you don’t get to distort the truth. The ACA has, indeed, reduced the number of people, and the amount spent on them, in unreimbursed hospital care. A huge drop! Just as planned.

    Also, the expansion of Medicaid has greatly improved the health care of the working poor (not the “undeserving poor” that Republicans sneeringly refer to). The places where Republican governors–like Kasich in Ohio–permitted the Medicaid expansion had great results, but many millions of our citizens in other states where Republicans refused to take the 100%-federal reimbursement for the costs of Medicaid expansion are dying of untreated illnesses. Heartless.

    Let’s also include, if you understand the details of the ACA at all, that the Republican Congress has been diligently working to undermine the program by not funding the risk corridors, etc. so that insurance companies finally decide to leave the exchanges. Plus other stuff.

    The Republicans control this issue by now. They are destroying Obamacare but have no alternative but to shove tens of millions of Americans into the ditch, with no health care.

    And Trump isn’t following this issue. So he can blather on and on in his campaign-style rallies about how he’s fulfilling the promises he made to voters in 2016. But healthcare is definitely something Trump is NOT delivering on!

  6. Submitted by Joe Smith on 06/20/2017 - 04:59 pm.

    Sorry Constance but insurance companies were leaving

    the market long before Trump took over, look it up. The people who pay for their own individual coverage have had premiums increase over 100%, look it up. Coverage for many Medicaid folks are not being accepted by many physicians, look it up. The rate at which people have not been able to pay ridiculous deductibles has sky rocketed, look it up. Living in an utopia feels good but does not improve a terrible healthcare law that Bill Clinton called silly and Gov Dayton said was not affordable.

    • Submitted by Edward Blaise on 06/22/2017 - 09:59 am.

      And your answers???

      Let’s see, you have now ripped the ACA, the ACHA, and any universal coverage plan. That does not leave a lot of room to maneuver.

      Wait, I have one I think you will take a liking to:

      The Heritage Foundation, not exactly a bunch of wild eyed socialists, put some time and thought into the matter and came up with….

      Oh, wait, well, the Individual Mandate…

      All the GOP needed to do in 2009 was to declare victory, state that the ACA is based on conservative principles and let’s move forward and modify and improve as needed to make healthcare work on this conservative foundation.

      But NO, the top priority for Republicans was to marginalize and stop anything supported by this new President.

      Which gets us to today and the dilemma of the current GOP healthcare world: they are against everything and for nothing; so, let’s just have a big old tax cut and move on.

      Yea, that will work….

    • Submitted by Constance Sullivan on 06/22/2017 - 11:16 am.

      It has been the Republican P)arty and its elected officials across the country, who have made it their goal to undermine Obamacare for years. Long before Trump was elected. Were you watching, Joe?

      That undermining has taken place bit by bit, and the public is too distracted to notice what Congress and state legislatures have been doing. Removed this funding, then that funding, and so forth, and you destroy at the very least the stability of market that all health insurance companies need to function at all. They’re withdrawing and have been, not because of Trump–who has NO IDEA of what health carei nsurance is or what Mitch McConnell and Paul Ryan are cooking up for America’s health care.

  7. Submitted by richard owens on 06/22/2017 - 09:17 am.

    Republicans sabotaged pillars of the PPACA.

    Intentionally removing risk corridor payments, removing the individual mandate penalty, refusing to expand Medicaid and cutting all forms of funding from the medical device industry…

    Those all have reduced the risk pool that defines the premium price. SABOTAGE by Rs.

    Also, your oft-quoted remarks attributed to Nancy Pelosi are useless sniping. Your members didn’t want to even read an Obama proposal, they only wanted to add poison pills and / or kill it.

    Thank you for not calling Obama a liar again for simply saying the plan had grandfathered in all qualified plans. “You can keep your doctor” AS LONG AS THE INSURANCE COMPANY WILL SELL YOU YOUR OLD PLAN.

    Most of us knew what was meant by that.

    Meanwhile, we are entering into more civil wars and taunting nuclear powers – another expensive proposition guaranteed to raise debt and not much value for our people.

    True patriots care about their fellow citizens, or OUGHT TO.

  8. Submitted by Edward Blaise on 06/22/2017 - 11:55 pm.


    Paul Ryan quoted recently in conversation with some of his fellow travelers that the ACHA cuts to Medicaid is what he and his buddies dreamed about at keggars in college.

    I have now read the above line several times and basically am speechless on a follow up; so:

  9. Submitted by T Monday on 12/19/2017 - 09:45 am.


    Republicans failed to repeal and replace the Affordable Care Act because of divisions within their own ranks, and because they tried not only to repeal and replace the ACA but also to cut and cap the Medicaid program, generating opposition from many red-state governors and their senators.
    But most of all, they failed because they built their various plans on the false claim — busted by the Congressional Budget Office — that they could maintain the same coverage levels as the ACA and lower premiums and deductibles, while at the same time slashing about a trillion dollars from Medicaid and ACA subsidies and softening the ACA’s consumer protection regulations. Had they succeeded, they would have won a big short-term victory with their base, which strongly supports repeal, but suffered the consequences in subsequent elections as the same voters lost coverage or were hit with higher premiums and deductibles.

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