Not much was overtly said about health system reform during the several hours of election coverage I watched on Election Day. None-the-less, American voters know that how we do health system business is unsustainable.

We can’t keep forking over trillions of dollars every year (mostly through our taxes) to support health care delivery that is poor quality, highly inefficient and leaves our patients in debt. The election news coverage often mentioned inflation and abortion as issues motivating many voters. Both of those, of course, are health care problems.

American consumers have seen health care prices rise into the stratosphere for years, while health care benefits have eroded wage increases. Health care in the U.S. is an economic kitchen table issue because it is mostly funded by the taxpayer, and therefore, like all such issues, will be on every ballot.

Abortion is, by its very nature, a medical procedure and, in many circumstances, such as ectopic pregnancy, an urgent and lifesaving one. Providing for physicians and patients to have the legal protections necessary to make clinical decisions freely will therefore also be on every ballot. But the recently completed election had at least two health reform votes openly on the ballot — one was in the U.S. Senate race in Pennsylvania and the other was a ballot measure in South Dakota.

John Fetterman, the Pennsylvania lieutenant governor who flipped that state’s open U.S. Senate seat from red to blue, overtly put health system reform on the ballot. His campaign website reads: “I believe that health care is a basic, fundamental human right, not a privilege. But health care in America is far too expensive and convoluted. In the richest nation on earth, I believe we have a moral duty to guarantee quality health care coverage for every American and end the disgusting practice of corporations profiting from people’s health and well-being.”

Fetterman proves that politicians in swing states can win while embracing comprehensive health system reform, because that is what the American voters, whether red or blue, know must happen.

Even in red states there is an underlying urge to find a way to fund health care for everyone. Prior to this year, six red states had seen the question of Medicaid expansion come to the vote through ballot initiative. In every one of those states — Idaho, Maine, Missouri, Nebraska, Oklahoma and Utah — the electorate chose to expand Medicaid even though the respective legislatures had already voted it down.

This year a seventh state, South Dakota, saw a similar ballot initiative go to the voters. And again, red state voters passed the Medicaid expansion. Together, these ballot measures will bring a total of about 900,000 low-income people onto the Medicaid rolls across the nation.

Why are these ballot measures succeeding? One analyst suggested three reasons: hearing from neighbors who will benefit, bringing federal tax dollars back to the state and protecting the solvency of rural hospitals and health clinics. Assuming that those reasons reflect the reality of health care ballot measures, I would suggest that more comprehensive reforms of the business of health care can also be accomplished with ballot initiatives.

American taxpayers have been trying to give the gift of universal health care to themselves and their neighbors for 75 years. We want our neighbors to have the care they need. We all want our fair share of federal taxation spent with purpose on improving our lives and those around us.

We see the failure of corporate medicine in rural America and we know that we can’t leave any person or any part of America behind. American voters won’t be done with health care issues until we find a way to deliver better, simpler, and therefore less expensive care to every American citizen.

Joseph Q. Jarvis, M.D., is a public health physician and the author of two books about American health system reform: “The Purple World: Healing the Harm in American Health Care” and “For the Hurt of My People: Original Conservatism and Better, Simpler Health Care.” He is also the executive producer of a soon-to-be released documentary film: “Healing US.”

The healthcare debate like the border wall, immigration policy and Russia collusion has our country completely divided along political lines. But healthcare—unlike the other issues—offers a few major points on which almost everyone can agree:

1. Obamacare has not succeeded in lowering insurance costs for the majority of Americans.
2. Insurance companies have created a disconnect between people and their doctors
3. A fair and free-market for healthcare is non-existent in the United States, due to insurance companies and lobbyists buying off our FDA and politicians.
4. Americans can still end up financially devastated and bankrupt due to major healthcare problems.

It’s due to these four major problems and the complete gridlock in Washington which lead Salt Lake City resident and long-time healthcare professional, Joe Jarvis, to write the book “The Purple World: Healing the Harm in American Healthcare”. We invited Dr. Jarvis on our new Utah Stories podcast to discuss the issue.

Jarvis offers some interesting ideas which are not partisan-based, but instead are common- sense based and “purple”. According to Jarvis (no relations to Jarvik–who invented the artificial heart)–a single-payer health care system would save our country trillions of dollars over the next thirty years. Our federal government could do this by extending Medicare to everyone. Medicare is a much more efficient system than private insurance, says Jarvis.

On a state level, a single-payer program operated by an NGO (non-profit), would negotiate drug costs directly with healthcare providers and drug companies. Either model would cost much less than the estimated current 20% of our GDP on healthcare, said Jarvis. Jarvis and I debated the point over whether or not healthcare is or ever should be “market-driven” in the United States.

I contest Jarvis’ solution for a few reasons. First, when we lived in the U.K. we found a very broken system. The UK government in 2012 was attempting to save 1 billion pounds by telling all doctors that they were not allowed to spend more than fifteen minutes with any one patient. And no patient could bring up more than one ailment at a time.

The result of this policy was that anyone who could afford to see a “private doctor” would do so, and these special “private physicians” were not accepting patients who were seeking state-care. This was because the state-regulated medical care didn’t pay the best doctors enough, and this resulted in a two-tier system.

My primary question for Jarvis is: How would a single-payer system in the United States not end up resulting in the same problems found in the UK and Canada?

Jarvis’ response was that the UK medical care is far underfunded. It’s for this reason that the UK is faced with these problems. The UK needs to spend more on healthcare. Jarvis pointed out that surveys find that people in the UK are far happier with their healthcare than people in the United States. This was verified by a few stories I found from NPR and others.

I also asked Jarvis how a single-payer system would cost less, when the services are offered free for everyone? Wouldn’t a few patients (possibly hypochondriacs) eat up far more resources, which might result in patients receiving limited care?

Dr. Jarvis did not believe this would be an issue. He didn’t believe there were enough people who “want to get their legs poked with needles,” that would drive up costs.

My Conclusion:

As a libertarian, I’m naturally opposed to asking the government to find a solution to this  problem. I would prefer in finding ways to get the government out of the way. But the costs of procedures make it difficult for me to maintain this belief. Life saving procedures can cost in the hundreds of thousands of dollars to keep people alive, so why should only the rich be able to afford care and the poor become financially devastated when choosing to extend their lives?

Dr. Jarvis might have swayed my opinion on the idea of a single-payer healthcare system working in the United States. I will need to do a bit more research on the costs. But if the financial statistics he cites are valid, and a single-payer healthcare system would in fact be cheaper, then it would be a huge equalizing force especially small business owners and entrepreneurs to not need to provide healthcare to their for themselves or their employees.

The Actual Costs of a Single-Payer Healthcare System in the United States

If the overall cost to the American economy of placing everyone on Medicare was that the pharmaceutical companies in the U.S. might be less innovative, due to a decrease in profits, and insurance companies would lose a big segment of their businesses– these costs would be more than made up for with the ability of small businesses becoming more competitive in hiring talented people, which would make for a more fair marketplace.

It’s currently a hugely difficult challenge for small businesses to attract talent due the prohibitive costs of providing healthcare to employees. We know this personally at Utah Stories.

One point of which I certainly agree with Dr. Jarvis, is that something drastic must be done with our current broken healthcare system in the U.S. Lives should not be devastated when people decide to pay out-of-pocket for cancer treatment for loved ones. Further, insurance costs for families who choose to be self employed are far too expensive and continue to rise since Obamacare. Obamacare was sold to Americans based on false pretense. “If you like your doctor you can keep your doctor”; and insurance costs will go down while care would improve. All of these basic points proved to be untrue.

Healthcare As A Right

I pointed out to Dr. Jarvis that if we are going to label healthcare as a right, why would we not also decide then that the availability of healthy, nutritional food should first be a right? Healthcare flows downstream from nutrition and overall health.

Individual healthcare costs are completely dependent upon a person’s lifestyle choices. If the government is going to pay for our healthcare, there should be mechanisms in place to promote better health for all Americans.

A major factor for our healthcare in the US costing twenty-percent of our GDP is because so many Americans eat far too much processed food, high-sugar/fat diets and consume far too much medicine to combat bad choices. Many Americans who spend years consuming medicine, need to take other medicine to combat the ill-side effects of their medication.

Why not treat the root of the problem? Forty-percent of all adult Americans are obese and 20% of adolescents, an all-time high. These basic facts lead to the need for spending massive amounts on diabetes, heart diseases and high blood pressure medications.

I believe we could possibly enact a single-payer system if everyone who used the care had “skin in the game.” Meaning that out-of-pocket costs for most care procedures and doctor visits would still exist for the majority of Americans. Whereas if someone absolutely needed a major medical procedure it would mostly be covered. But there should be mechanisms in place to keep more americans healthier.

If the government is going to be paying for healthcare, I like the idea of allowing citizens to opt-into receiving tax credits for staying healthy. If the government is providing tax subsidies for buying an electric cars, why not provide subsidies to those who walk or bike to work who both help the environment and improve their health? Why not offer tax incentives for those who maintain a healthy weight and lifestyle?

I appreciate Dr. Jarvis coming on the program. Our discussion is a great example of what I hope to accomplish with the Utah Stories Show: We want to facilitate civil and honest discourse with thought leaders and experts to help make Utah a better place.

By Joseph Jarvis | For The Tribune

I don’t know about you, gentle reader, but I tire of the nonsense that passes for political discourse in this country.

For example, the candidates for the U.S. House of Representatives from Utah’s 4th Congressional District just recently met for a debate. During one excruciating segment, both of these esteemed persons, each holding important office at present, took swipes at one another repeatedly over the federal deficit without ever mentioning the sole cause of federal debt, which is health care spending. (Federal revenues are projected to keep up with future federal outlays for all categories of spending with the exception of our massive health care programs, including Medicare, Medicaid, CHIP, etc.)

Not long after exchanging meaningless sentiments about federal debt, the two candidates were actually asked about health care. And again, they failed to address the real issues, choosing instead to snipe at each other over Obamacare, whether it should be salvaged or repealed, ad nauseum. These two candidates, Mia Love and Ben McAdams, either don’t know or don’t care about the basic facts concerning our nation’s single most important domestic issue: our massively wasteful, generally dysfunctional health care system. Wouldn’t it be refreshing if the electorate actually could hear candidates articulating the real issues and proposing real solutions?

But this is our own fault. We, the voters of America, who repeatedly opine that we dislike Congress, nonetheless put up with campaign drivel and generally re-elect our own member of Congress. Let’s change this. We deserve better.

I challenge every Utah voter to reach out to the candidates for Congress in Utah and tell them what you want them to do about health system reform. For those of you puzzled about what you should demand from Congress, here are some facts and ideas:

Americans pay the world’s highest taxes for health care. Two thirds of our nation’s $3 trillion annual health spending comes from the taxpayer. Every other First World nation spends far less and has better health outcomes. The American health care system, compared to other first world nations, wastes $1 trillion per year in health care spending because of poor quality care and inefficiency.

“Coverage” programs like Obamacare are not health system reform. No one needs health insurance, which is the world’s most useless, wasteful, expensive health financing scheme. What every American needs is high-quality health care, and we are already paying enough health taxes to support that. High-quality health care costs less than the shoddy, mediocre care now delivered in the U.S.

We have inefficient, mediocre care in the U.S. because that is what generates highest profits for health care corporations. Our national debt is due to the corporate welfare we the taxpayers are forced to give to the medical industrial complex. Who forces us to make this gift? Politicians from both major political parties. There is not a dime’s worth of difference between Rs and Ds when it comes to the essential features of health policy proposed by each, as the “debate” between Love and McAdams recently illustrated yet again.

Here’s an idea. Tell your congressional candidates that you will not vote for them unless they promise to get the federal government out of the way so that states can attempt real and sustainable health system reform. Call them, text them, email them, flood their campaign offices with demands that they publicly commit to support the State Based Universal Health Care Act of 2018. Just watch how fast these politicians change their tune on health care after the first politician loses office because he/she failed to stop wasting tax dollars on health care corporate welfare.

Link to article and comments: https://www.sltrib.com/opinion/commentary/2018/10/20/commentary-we-need-health/

Healing the Harm in American Health Care

Guest: Joseph Q. Jarvis, MD, MSPH, Author, “The Purple World: Healing the Harm in American Health Care”

America spends more on it than any other country, but we’re not getting better results – and in many cases, our results are worse. The Commonwealth Fund says the reason we pay so much is because of high prices and high administrative costs. Obamacare only made the problem worse, according to physician and public health expert Joseph Jarvis. But Trump’s proposed changes are no better. After decades working in medicine and trying to solve America’s healthcare problem, Jarvis is convinced the answer is radical – we need to completely do away with the health insurance system.

http://www.byuradio.org/episode/f399bdf4-c9fb-4a41-be38-87ae51f836c0?playhead=3146&autoplay=true

By Joseph Q. Jarvis | For The Salt Lake Tribune
Published: 4/23/2018

Yet again Americans have signaled that health care is at the top of the electorate’s agenda, according to a new HuffPost/YouGov poll.

Cost is our principle health care problem, yet elected officials repeatedly offer “reforms” that increase American health care costs, which already are twice as high as the average per-person cost in all other First World countries. All of the federal debt now and on into the future is due to unsustainable and unfunded health care costs.

We have high health care cost because American health financing (the private, for-profit health insurance business model) is incredibly inefficient, with overheads routinely at 25 percent, and because we have a poor quality health care system.

Poor quality care comes in three basic categories: clinically inappropriate care (including, but not limited to, defensive medicine), preventable injury to hospitalized patients (the fifth leading cause of death in the U.S.) and failing to do best practice care consistently. Taken together, the poor quality and inefficiency of American health care business as usual is wasting $1 trillion per year.

Real sustainable reform must change the way we do health care business. Congress is manifestly not up to that reform. Congress, however, may be able to agree to allow states to attempt sustainable health system reform.

Hidden within the Affordable Care Act was a section (1332 State Innovation Waivers) which would have allowed states some leeway in attacking health care delivery problems. Rep. Pramila Jayapal, D-Wash., is preparing legislation that would strengthen the power of states to reform health care systems, and even allow neighboring states to band together to achieve better regional health care delivery. The proposed bill, entitled “The State-Based Universal Health Care Act”, seems like it should naturally receive support from both parties.

During a televised debate with his opponents in the 2010 U.S. Senate race, Sen. Mike Lee stated that he would support federal legislation which would allow states wide latitude in health system reform, even if a state were to choose to enact a single-payer health system. Lee, therefore, should welcome Jayapal’s proposed legislation and sponsor an identical bill in the Senate. I believe that many Republicans would agree that state-based health system reform is a logical step within our constitutional form of government.

I urge all Utahns to carefully inquire of the various candidates for Congress whether they will actively seek the enactment of “The State-Based Universal Health Care Act.” Only those candidates who agree to do so will earn my vote.

Joseph Jarvis

Joseph Q. Jarvis, M.D., is the author of the soon-to-be released book “The Purple World: Healing the Harm in American Health Care.” He is a Salt Lake City public health physician and two-time Republican nominee for the Utah Legislature.

Full Article

https://www.sltrib.com/opinion/commentary/2018/04/22/commentary-real-heath-care-reform-will-have-to-come-from-the-states/

The Deseret News failed to capture the magnitude of U.S. government involvement in health care (In our opinion: Time to tackle government-supplied health care before it gets unmanagable, Sept. 24). In addition to 122 million on Medicare, Medicaid and military health plans, there are millions more on CHIP, state and local government employee and federal employee plans.

Add to that the additional millions who receive VA health care and Obamacare subsidies and the total approaches 200 million Americans with some form of government health care. In addition, remember that private employer health plans exist because of a massive federal tax credit that has propped them up since World War II. No wonder that most of the money flowing into U.S. health care delivery is from taxes. Americans pay the world’s highest health care tax burden. Without public money, there would be no American health care.

This is the health care system that we have chosen for 75 years; we need to stop pretending that somehow we could now choose to have health care without government involvement. We also need to stop pretending that market forces and competition will improve American health care delivery. None of the prerequisites of market economics holds true for health care. Patients are not shoppers because they lack clinical knowledge (no caveat emptor) and are sick and injured, therefore not free to decide whether, where and what clinical services are needed. Sellers of health services are not supposed to act in their own self interest, but should put the patients’ needs first. Positive externality refers to a situation when someone other than the buyer or seller in a market has a legitimate interest in the outcome of a transaction, such as is the case when the general public has an interest in assuring the best care for a patient with a communicable disease. We have massive infusions of tax dollars into health systems because of positive externalities.

Finally, the inverse relationship between price and demand does not hold for health services. No one ever bought an appendectomy because it was on sale. And no diabetic willingly forgoes insulin even if the price skyrockets. Demand for health services is determined by epidemiology, not price. Health care is not a market commodity; the invisible hand of Adam Smith will never save us from our health care woes.

I agree with the Deseret News, Congress has abysmally failed us on health care. Hyperpartisanship is part of the problem, but the massive campaign donations and lobbying power of the medical industrial complex assures that both parties defend business as usual in health care delivery. Cost is our principle health care problem. All of the federal debt now and on into the future is due to unfunded health care costs. We have high cost because the health insurance business model is incredibly inefficient (wasting up to $500 billion per year) and U.S. health care is poor in quality (wasting up to $700 billion per year). We don’t need more money in American health care, we need to reduce the inefficiency and quality waste inherent in U.S. health care business as usual.

Congress might be able to agree to allow states to attempt sustainable health system reform. Seven Democrats have co-sponsored a bill, the State-Based Universal Health Care Act, that would strengthen the power of states to reform health care systems and even allow neighboring states to band together to achieve better regional health care delivery. I believe many Republicans would agree that state based health system reform is a logical step in our constitutional form of government.

I urge all voters to carefully inquire of their congressional candidates whether they will seek enactment of the State-Based Universal Health Care Act.

Joseph Q. Jarvis is a public health physician. He is the author of the recently released book “The Purple World: Healing the Harm in American Health Care.”

For more than a decade, we have witnessed bipartisan failure by Congress to pass meaningful health system reform. Obamacare was neither affordable nor protective for patients; the uninsured who have been “covered” by Obamacare have illusory benefits at an enormous price. The junk insurance now being offered as Trumpcare is just a meaner version of bronze plans. This bipartisan failure is killing Americans, their family budgets and our federal government. Preventable injury to hospitalized patients is the fifth leading cause of death in this country. If the safety record of American hospitals were true of the airline industry a 747 would crash every other week.

Family budgets, already squeezed by low wages, fail to have resources to meet the cost shifting now common in health insurance. Premiums, deductibles, co-payments, co-insurance, point-of-service payments, etc., make care unaffordable for all of the poor and near poor and much of the middle class. GoFundMe for illness and injury cost is now the go-to health insurer of average Americans, and personal bankruptcy is a common outcome.

The federal deficit is growing rapidly and is projected to reach double the GDP within just a few years. All of the federal deficit is due to unfunded health care costs. Mike Leavitt, former Utah governor and former secretary of the Department of Health and Human Services, has said that there is no place on the international leader board for a nation spending 25 percent of GDP on health care. We are almost there. If we don’t change the way we do health care business, America will become a debt-ridden second-tier nation.

Given the critical nature of health policy, candidates for Congress in Utah should emphasize best thinking in health policy ideas. I checked the websites of all Utah congressional candidates who have received at least $100,000 in campaign donations. With one exception, there are no good ideas for health reform.

Reps. Rob Bishop and John Curtis don’t even mention health care on their campaign websites. Senate candidate Mitt Romney and Reps. Chris Stewart and Mia Love want to repeal Obamacare, but fail to mention what comes next, except generally referring to market solutions. Senate candidate Jenny Wilson and House candidate Ben McAdams want to fix or defend Obamacare. House candidate Eric Eliason, while not proposing to repeal Obamacare, recognizes that American health care delivery is in disarray and is looking for data-driven, consensus policy changes. Electing any of these candidates fails to get us past the bipartisan Obamacare/Trumpcare debacle.

The one candidate with a good idea is Shireen Ghorbani, the Democrat running in the 2nd District. She believes that Congress should pass the State Based Universal Health Care Act of 2018. If passed, this legislation would, for the first time, allow states a free hand in addressing health system problems, remove federal obstacles from their path and provide for a mechanism for states to apply for appropriate federal funding to finance health care for all residents. Utah, with lowest-in-the-nation per-person health care costs and some of the best-quality health care systems, surely deserves a chance to take on the task of sustainably reforming health care delivery. But then, why shouldn’t other states likewise have the option to escape Obamacare?

I live in the 2nd Congressional District. Shireen Ghorbani has earned my vote, though I was one of the state Republican delegates who helped Stewart get his first nomination to run for Congress.

As for the race for Senate, I will reserve judgment. Perhaps either Romney or Wilson will show some courage, leave behind the partisan bickering over Obamacare and surprise me by joining Ghorbani in endorsing the State Based Universal Health Care Act of 2018.

Joseph Q. Jarvis, M.D., MSPH, is the author of “The Purple World: Healing the Harm in American Health Care,” which will be released Sept. 4.

Twitter, @DrJoeQJarvis

Link to article and comments: https://www.sltrib.com/opinion/commentary/2018/08/26/commentary-if-you-dont/

My comments (JQJ) are found in parentheses scattered throughout the article.

After years of being a central political question, health care is on the back burner. Both parties contain experts and activists who want to make major changes to health policy. But for now, both parties’ politicians are wary. Democrats are, as usual, more interested in the subject than Republicans, but they are somewhat divided about what to do next and in any case are not yet in a position to enact anything. Republican politicians, meanwhile, seem to have concluded from their failed efforts to repeal and replace Obamacare that the whole issue is best avoided. It is not surprising, then, that talk of a bipartisan deal to shore up Obamacare’s insurance exchanges has petered out.  (Americans are suffering under bipartisan failure of the two major political parties.  Neither party is willing to do what manifestly needs doing in health care policy, preferring rather to look out for its own partisan interest.  The United States needs leadership, not partisanship.  What’s good for Rs or Ds is not necessarily what is for the good of the country.  Health care remains a central question in the lives of Americans and should therefore be at the forefront of what Congress is addressing, now.  Both parties are failing Americans and therefore both deserve a demise.)

But the problems of our health-care system (a system that, among its troubled elements, includes Obamacare and a set of Republican alterations to it) may not be so easily ignored. And Republicans may find that following their instincts — that is, putting the issue out of their minds except when Democrats force it onto the agenda — sets them up for one defeat after another.  (The problems of our health-care system are many and lead to excess death, injury, and financial toxicity in the lives of virtually all Americans.  No other domestic issue is more important.  What American leadership does about health care deserves careful scrutiny by the voters and rejection of the politicians who fail to act.)

It is certainly understandable that Republicans do not wish to relive their 2017 experience of trying to legislate on health care. The chief force working against them was the public’s fear of sweeping change, directed from Washington, D.C., to their health arrangements. That force helped Republicans during the initial debate over Obamacare and would likely help them again if they let Democrats take the initiative on the issue once more. Taken by itself, then, this public sentiment is a political reason for inaction.  (Political reasons for inaction are exactly what is wrong with the lack of health system problems solving.  And no, it was not the public’s fear of sweeping change directed by Washington DC that worked against Republicans.  It was the total lack of understanding about what really is the problem in our health care system displayed by the national leadership.)

It would be another one if Republicans failed to overcome a second force that held them back last year: their own ignorance and lack of preparation. Very few Republicans had a sense of the trade-offs involved in different approaches to protecting people with preexisting conditions, which became as contentious an issue as anyone who had followed health policy would have predicted. Republicans conducted the 2016 campaign without any broadly shared commitment, even a rough one, about how to handle Obamacare in the event they won. President Trump only added to the confusion. During the campaign, he praised other countries’ nationalized health-insurance systems and published a few nonsensical paragraphs he called his “plan.” (Among other things, it called for the creation of health savings accounts, which had already been instituted in 2003.) Republican legislative proposals on health care kept being improvised through much of 2017 and were never clearly explained — especially by the Republican with the loudest megaphone. (Republican legislative proposals were improvised in 2017 and often just silly.  The real problem was and is that the ‘Affordable’ Care Act was never affordable, either for the American family, or for American government.  And every American improvised proposal was increasingly less affordable.)

Democrats and the press were by contrast tireless in making the case that the Republican plans would “take away” health insurance from 15, 22, or 23 million people. These numbers came from the Congressional Budget Office, which based them primarily on its assumption that many people bought health insurance because Obamacare fined those without it. Thus even if the numbers were credible — and there were reasons to think that the CBO had too much confidence in the power of Obamacare’s “individual mandate,” as the organization itself is now in the process of admitting — they meant that most of the people who would “lose” their insurance would be going without it voluntarily. Much of the debate left a very different impression.  (To characterize those without health care financing as people choosing to have no way to pay for needed health care is to ignore the most significant fact about health insurance:  it is useless and wasteful.  The core stupidity of Obamacare was the requirement to buy health insurance or pay a penalty.  Propping up the health insurance business model with the heavy hand of government is, well, stupid.  But that is what both political parties have done for 75 years.  The American people are becoming wise to this policy failure and are increasingly choosing to do away with health insurance.  Who buys a product that is useless and wasteful?  To suggest that Americans who choose to not buy health insurance are choosing to go without health care is, well, even more stupid.)

Undermined by the press, by the public’s bias toward the status quo, and by their own inadequacies, Republicans failed to enact a legislative replacement for Obamacare. Yet they have nonetheless effected some important changes in health policy. Their tax bill eliminated the fines on the uninsured — which will give us a chance to see whether the CBO’s projection of a mass exodus from insurance markets comes true. The Trump administration ended its predecessor’s practice of sending tax dollars to insurers (authorized but never appropriated by Congress) to cover the cost of cutting co-pays and deductibles for low-income policyholders. And it took a series of executive actions, of which the most significant was the liberalization of rules governing short-term insurance plans. Obamacare left these plans largely free of the regulations it employed to reshape most of the market for individually purchased insurance, and so allowing them to grow has the potential to reduce the law’s impact quite a bit.  (The Republicans are stuck in a pretend health policy world created by the heavy donations of the medical industrial complex.  Thus, they are completely unable to see options available for improving health care delivery in the US except those offered up by those who desire to protect the status quo.  Thus, it is not the public that has a bias toward the status quo, but rather it’s the industry which is profiteering from health care business as usual.  Democrats are led into political inaction on health policy by the very same greed for medical industrial complex political donations.)

These legislative and administrative steps have been significant, and they mean that “Obamacare Remains in Place” is not quite the right headline for describing the state of affairs in the wake of a confusing year.  (Obamacare-lite is not any better than the original ACA in delivering high quality, affordable health care to Americans.  I agree that the demise of Obamacare is a prerequisite for real change in American health care.  But I do not agree that steps taken to adjust Obamacare are anything useful.)

In 2012, when the Supreme Court considered a challenge to the constitutionality of the individual mandate, it was taken for granted on all sides of our politics that pulling out the mandate would be tantamount to blowing up the rest of Obamacare. Now the mandate has been pulled out, and while it has turned out to be less important than it seemed, both the substantive and the political importance of its demise should not be underestimated. The expansion of short-term insurance plans could create an alternative insurance market for younger and healthier people who cannot find affordable coverage in dysfunctional state exchanges; their leaving could gradually turn the exchanges into something like subsidized high-risk pools for people with high medical costs. And the mixed signals the administration sent all year about whether it wanted to stabilize or destabilize the exchanges was implicitly resolved in favor of the latter when Congress decided to avoid making payments to insurers in the omnibus spending bill enacted in late March.  (Health care financing that fails to provide financial security during illness or injury–which is what so-called short-term insurance plans are–is nonsense policy. High-risk pools for people with high medical costs are another failed policy from yesteryear which conservatives keep rolling out as if there is some brand new hope that this iteration will finally work.  Stop with the silliness.)

All three of these moves point in the direction of greater instability in the exchanges. And that instability was already quite great in many states. It will now become nearly impossible to assign responsibility for that dysfunction exclusively to one party or the other, as both the original design of Obamacare and the changes enacted legislatively and administratively over the past year play a role. (Obamacare, and the O-lite policies of the Rs during 2017, are inherently unstable because they depend upon the useless, wasteful business model of the health insurance industry.)

So as we look out on the health-care landscape during this lull in the political debate, a few overall trends seem most pertinent. Insurance-coverage levels are certainly higher now than they were before Obamacare’s enactment. Measures vary some, but it appears that just under 90 percent of Americans under age 65 now have health-insurance coverage, while just under 84 percent did before Obamacare was enacted.  (Yes, Obamacare created business opportunity for a failing business model-American health insurance.  But that won’t last, because it is still a failing business model.)

Most of this additional coverage has come through the expansion of Medicaid. The individual market has actually been contracting lately. It shrank by nearly 15 percent in 2016 alone (and preliminary 2017 numbers suggest the decline continued). Employer-based insurance has contracted some as well: There were 3.6 million fewer people in the employer market at the end of 2016 than at the end of 2013, just before Obamacare took effect.  (As I said, the health insurance business model is failing.  So, health insurers are more and more grabbing onto the public revenue streams in health care, such as Medicare and Medicaid.  As with employer-based insurance, this will lead to increasing waste and hollowing out of benefits.)

Increased coverage is the law’s core accomplishment. But it has increased by less than was originally expected, and partly in ways that are accompanied by instability. Obamacare’s exchanges have not lived up to their billing, largely because plans offered through them have turned out to be unattractive, especially to people whose premiums are not heavily subsidized by taxpayers. Premiums have more than doubled in the individual market since Obamacare took effect, even as cost sharing has also increased and provider networks have narrowed. In many states this has set in motion a process by which insurers find it harder each year to attract younger and healthier customers, are forced to raise premiums and narrow their networks as a result, and therefore find it even harder to attract such customers the next year. (Increased coverage is what every major health policy change has targeted for the past 75 years.  Trouble is, that is not what the target for health reform should be.  We have highest costs in the world for health care because we have poorest quality care in the first world coupled with inefficient financing.  Reform must target improving quality and efficiency, not expanding coverage.  No one needs ‘coverage’.  Everyone needs care.  Don’t accept any health policy proposal that doesn’t start with financing care for everyone while assuring optimal quality and efficiency.)

The steps Republicans have taken over the past year have been intended in part to ameliorate these problems and to make it easier for unsubsidized consumers in the individual market to find affordable coverage options. But the reach of these measures has been limited, Obamacare’s core regulatory architecture (which is responsible for the unstable economics of the exchanges) remains in effect, and consumers will keep getting bad news each summer and fall about the next year’s insurance options as long as this goes on.  (The health policy reach of both D and R policy proposals have limited reach because both parties refuse to reject the health insurance business model.  Until we can get beyond that useless wasteful way of paying for health care we can not improve the quality of care or the efficiency of financing.)

These continuing problems with Obamacare’s fundamental economic logic have not brought about a rethinking of that logic on the left. Instead, liberal health-care experts are trying to press their politicians to take the Republican failure to replace Obamacare as evidence of the popularity of Obamacare’s approach (rather than as evidence of the same kind of resistance to change that made Obamacare itself such a political disaster for Democrats), and therefore as a reason to push the same approach farther. The theme of today’s Democratic health-care conversations is that Obamacare did not go far enough, and the internal debate among left-leaning activists is about just how much farther to go.  (No, the internal debate on the left is about whether the time has come to reject the health insurance business model.  And that is the debate the right should be having as well.  Anyone who clings to the useless, wasteful business practices of health insurance is guaranteeing a future federal deficit which will cripple our country.  Fiscal conservatives need to break away from business practices that are financially toxic for American government and families.)

Some propose what are essentially extensions of the reach of Obamacare’s core architecture. The biggest losers under the law have been middle-income families who earn too much to qualify for exchange subsidies but whom regulation has left without good options for coverage. So this winter, Senator Elizabeth Warren proposed legislation that would provide them, too, with subsidies. Under her proposal, no one would have to pay more than 8.5 percent of household income for health insurance. Other proposals (from the Century Foundation and other liberal think tanks) would revive forms of the public-option idea that Obamacare’s architects were forced to drop — for instance, enabling anyone who cannot find affordable private coverage to buy into Medicaid. (All democrats who are defending O-care in these ways are doomed to be in the dustbin of D history in the near future.)

But for some on the left, such proposals do not go nearly far enough, and the lesson of the past decade of health policy is that only single-payer will do. There have been such voices in the Democratic coalition for many years, of course. Bernie Sanders has proposed “Medicare for all” single-payer legislation regularly for more than 20 years now. But when he unveiled this year’s version, he was surrounded by more than half of the Senate Democrats, a level of support never seen before for such proposals. The Center for American Progress, a liberal think tank that has tended to define a consensus for Democratic policy, released a similar proposal in February, which would create a Medicare-like program that would be open to anyone who wanted it, and into which uninsured Americans would be automatically enrolled. (The Center for American Progress is not proposing single payer, but rather a ‘me-too’ look alike intended to capture support for the health insurance business model away from the single payer movement.  Bernie Sanders current proposal is itself an incremental proposal, and therefore falls short of real single payer legislation.  But, thankfully, it is true that increasing numbers of Americans-59% according to a recent survey-believe that single payer health system reform is our nation’s best health policy option.  There should be a serious look at the proposal, from all sides of the American electorate.  Finally, we should all really inform ourselves about what single payer means, and what it proposes.  Sadly, these two authors are not willing to educate themselves or their readers about this most important domestic policy issue.)

Democratic politicians used to fear the political implications of proposing a wholesale government takeover of health insurance, and the massive political price they paid for Obamacare should have made them all the more afraid. Instead, they are allowing the party’s activist base to push them toward such proposals.  (Single payer is not a government takeover of health care.  It is the elimination of multiple payers, and therefore eradication of health insurers, so that one payment source for health care can operate in any given region.  That could be a national payer–Medicare for All–or, my preference, a single payer in each state.  The massive political price paid by democrats what not because of a government takeover, but because Obamacare, being based on the health insurance business model, was incredibly expensive and did nothing to improve health care quality or efficiency.  People knew that they were not getting value for the money they were spending.  Simple as that.)

Yet the dangers have not disappeared. The first involves money. Essentially no effort has been made to explain where the money to cover the gargantuan costs of even extensions of Obamacare’s subsidies, let alone single-payer proposals, would come from. The small handful of left-leaning states that have looked at state-level single-payer reforms have all ended up running away screaming once the costs became apparent, and these would be all the more daunting at the national level.  (Single payer costs less, period.  Anyone who says otherwise, like these two authors, is selling something.  Every other first world nation spends far less on health care and has better quality and more efficient financing.  Were we to have single payer health financing in the US, we would be spending at least $400 billion/year less.  And, with proper emphasis on improving patient care, another $700 billion/year savings could be effected.  Single payer costs less, period.)

Perhaps even worse, at least as a political matter, is the prospect of disrupting the employer-based insurance through which most Americans get their health coverage. The more incremental expansions of Obamacare’s subsidies envisioned by Warren and others attempt to avoid such disruption but cannot fully succeed. The various single-payer ideas would all involve massive disruptions for millions of families. The politics of such disruption has always proven insurmountable for reformers on the right and left alike, and there is not much reason to think that has changed.  (The politics of health system reform requires courageous leaders who place a premium on correctly explaining the problems in American health care to the electorate.  This would include helping all Americans to understand that employer-based insurance has been the biggest waste of tax credits in American history.  Without massive handouts in the form of tax credits employer-based health insurance would never have become the principle mechanism for acquiring health financing in this country.  Time to use tax policy more wisely.)

And even the incremental measures amount to doubling down on the approach that has left the individual market in many states in shambles. Democrats simply have not come to terms with the fundamental failure of Obamacare’s economic model in many states, which suggests that the law’s “captured market” approach cannot create a viable insurance system, even with more money. Subsidizing the entry of higher-income people into such broken insurance systems is not a solution to the problems they confront and could easily be a recipe for greater political disaster for its architects.  (Both Rs and Ds have not come to terms with the fundamental failure of the market approach to health policy.  Health care is simply not a market commodity.  Market forces do not improve health system function.  Buyers of health services are not the all-knowing customers of a market.  Sellers of health services should not be the self-interested profiteers of markets.  Price does not determine demand for health services.  Higher quality does not cost more in health care, it costs less.)

“More of the same” is a strange lesson to draw from the Democrats’ experience of health-care policy and politics over the past decade, and yet that is just what they seem to be taking away from it all. (Single payer is not more of the same; it would be a fundamental step away from the health financing failures of the past.)

For conservatives, this peculiar Democratic blindness poses a perverse temptation. It would be easy to fall right back into what was the familiar groove of Republican health-care politics for decades: criticize the Democrats’ approach and capitalize on its enormous political vulnerabilities while neglecting to propose any serious alternative solutions.  (Republicans are truly bereft of good health policy ideas.  It is time for Rs to stop arguing against a straw man idea of single payer.  It is time for Rs to actually become acquainted with the facts of about health policy.)

That groove is so attractive because the vulnerabilities of the Democrats’ proposals are very great, and Republican politicians tend to think that offering their own proposals only distracts voters from those vulnerabilities. Throughout the Obama years, Republicans in both congressional and presidential races would insist that health proposals of their own would just paint a target on their backs. Calling for the repeal of Obamacare without getting too specific about replacements would, on the other hand, maximize the advantage that the Democrats’ miscalculation had made possible.  (And so we see how bipartisan political failure occurs.  Both Rs and Ds would rather have health policy failures because those failures are political opportunities.  Americans just want to have a national health policy that works for families and government, particularly fiscally.)

The immediate political logic of this approach was sound, and it surely contributed to the GOP’s ability to win elections. But having won them, Republicans have found that their vagueness on health care cedes the policy momentum to the Left and keeps them even from repealing most of the Democrats’ unpopular law, let alone enacting conservative solutions that could solve some basic problems and persuade voters that Republicans ought to be trusted on health care. (What goes around comes around.  Now, we need courageous political leaders who will truly come to terms with the facts and take steps to really reform American health care delivery in a sustainable way.)

Rather than fall back into lassitude on health care, Republicans should continue to advance market-friendly reforms. One advantage they would have if they returned to the issue is that even though they failed legislatively in 2017, in the process they made significant conceptual progress. After two decades of debilitating squabbles between champions of different approaches to changing the tax treatment of health insurance to expand health coverage, Republicans were compelled by the constraints of the budget-reconciliation process to develop a third and entirely distinct alternative that offers more promise. The conversion of most federal health dollars into block grants to the states, combined with the recovery of state control over the regulation of health-insurance markets, allows for a plausible state–federal division of labor in health policy and for state experimentation with various approaches to the formidable problems that bedevil the individual market. (I agree that state-based health system reform is optimal.  However, limiting the options that states have when approaching health system reform is silly.  Let a state that so chooses actually do real single payer health system reform.)

Under such an approach, embodied by the Graham-Cassidy bill in the Senate, the federal government would essentially provide a defined contribution toward coverage, the states would design means of assisting the poor and the sick and would regulate insurance markets, and consumers would have maximal choice and control over any public funds spent on their behalf. (If states are limited to merely regulating insurance markets, then single payer health system reform will not be possible, since that requires eliminating insurance markets.  The Graham-Cassidy bill should be amended to allow single payer health system reform.)

Even given the political constraints of narrow Senate majorities, block-granting Medicaid and Obamacare dollars could allow for extensive deregulation and therefore for the emergence of more-functional consumer markets in the states, rather than a doubling down on the failed model of federally captured markets that yield horrendously unattractive insurance products.  (Insurance products are all horrendously unattractive.  Consumer markets in health care are all non-functional.  Let states get health system reform right; make single payer health system reform possible.)

Conservative health-care experts have developed the fine details of such an approach well beyond the basic structure of Graham-Cassidy in the months since Republicans failed to repeal and replace Obamacare. Should congressional Republicans turn back to health care, they would have a thought-out and plausible legislative vehicle to start from that is suited to the needs of both the health system and the congressional budget-reconciliation process.  (Conservatives need to open their minds to single payer health system reform.)

This decentralizing and deregulatory approach to health policy offers a substantively and politically attractive path for Republicans. But whether it turns out to be more attractive than falling back into the role of pure critics of Democratic health reforms remains to be seen. The future of market-based health economics in America, and perhaps the political prospects of a recognizably conservative Republican party, may well depend on the answer.  (State based health system reform is decentralized, and should be attractive to Republicans and Democrats.  There is no future for market-based health economics; market forces don’t improve health care.  We can do better than continue to pretend that something is true when it manifestly is not.)