The Murky Future for US Health Care

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Republicans vow to repeal Obamacare, but President-elect Trump has injected confusion by claiming that the replacement will provide health insurance for all. But many health experts fear what comes next, reports Dennis J Bernstein.

By Dennis J Bernstein

All eyes are on the Republicans and Obamacare, as the dominant GOP now proceeds toward dismantling President Barack Obama’s signature healthcare policy plan, formally known as the Affordable Care Act. What they plan to replace it with is still anybody’s guess.

I spoke recently to public health care expert and single-payer advocate Dr. Don McCain about the debate, the negatives and positives of Obamacare, and what kind of health care system we need in the U.S. to really attend to the medical needs of all people.

McCain, a senior health policy fellow with the group Physicians for a National Health Program, said recently about the current debate, “President Obama meeting with the Congressional Democrats, and Vice President-elect Pence meeting with the Republicans are being touted as a strategy efforts on the two opposite sides of the health care reform debate. But are they really opposites?”

Dennis Bernstein: What do you mean by that? Aren’t they opposites? It does seem like the Democrats are on one side, and the Republicans are on the other.

Dr. Don McCain: That’s certainly the way they framed it. Of course, they passed Obamacare. The Democrats passed that even though it was a Republican plan. And now the Republicans claim it’s a Democrat plan that has to be repealed. Yet, what are they talking about, as far as reform is concerned? They are talking about tweaking our current system. Well, that’s all that Obamacare did.

We have a highly dysfunctional system, fragmented, with extreme administrative excesses. And a system that doesn’t function very well because it leaves people with insurance in debt. It leaves too many people uninsured and takes away choices for our health care providers, through these narrow networks that are increasing in prevalence.

The Democrats did improve that, but the improvements were very small compared to what needs to be done. The Republicans would turn around, and maybe repeal some of those things, and then introduce their own tweaks. But these are all only tweaks to our current, highly dysfunctional, wasteful, fragmented system.

So the opposite would be an integrated, universal system that provides healthcare to everyone, and eliminates this profound administrative waste. And gives people their choice again. Of course, that’s a single payer, national health program commonly known as an improved Medicare For All–fixing Medicare, and providing it to everyone.

DB: Well… the Republicans would say that’s a budget buster, that’s a big government program, that’s socialism, and ultimately it will be a disaster.

DM: Of course, it is paid through taxes but we already… two-thirds of our health care is already paid for through the tax system. In fact, we pay more in taxes for health care in the United States than other nations pay for their entire health care system.

So tax isn’t the problem. Getting the tax right is the problem, and we’ve got to make it much more equitable through progressive taxes where everyone can afford to pay the taxes that we would need to run the system. But it doesn’t bust budgets.

In fact, the efficiencies of a single payer system actually slow down the increases in health care costs. So we would not be having these high increases every year. Yeah, there’s been slowing for a couple of years, but they haven’t really fixed the fundamental defects, whereas through a Medicare-like system, they do control healthcare costs, much more effectively. So we would all be ahead and we would all have health care.

DB: … Let’s do a compare and contrast: Under Obamacare, how does the U.S. system compare to, say, Europe?

DM: It is much less efficient [with] extreme administrative waste. We pay about a trillion dollars a year in just administration of our system. It’s because it’s this fragmented system of multiple programs, and other reasons, for the excesses. We could recover about one-half of that trillion dollars, and redirect it into health care. They don’t have that in the European systems. They have much more efficient financing systems. None of them pay near what we do, in administration.

DB: And, in terms of actual health care?

DM: The health care systems… the health care delivery systems are pretty comparable. There is a difference and that is that many people in the United States, either because they are uninsured or underinsured, they have excess deductibles that they cannot afford, are unable to access our system. Whereas in the European nations [and] Canada there’s no problem with access.

Yes, there may be some delays in some countries, but that’s mainly for elective care. Any urgent care is taken care of right away and so, overall, the performance of their systems is superior. Commonwealth has done a study a few times of eleven nations and we always fall in last place, the eleventh, as far as the functioning of our healthcare system.

DB: And, what is your concern if the Republicans simply dismantle Obamacare? Will it matter… [if they don’t] have any program to put in its place? What do you think is going to happen here?

DM: It will matter because many of the people who gained insurance under Obamacare will lose it. And they will do virtually nothing to control our increasing health care costs. So overall, it would be worse. …

If they eliminate the subsidies and yet, as they said, they’ll continue the right of anyone to buy insurance regardless of pre-existing conditions…. [Then] the insurance model breaks down, because sick people buy insurance. Healthy people don’t until they get sick. Then insurance will be affordable for no one.

DB: So, what happens in terms of your own experiences as a medical doctor? What have been your struggles and how might they be mitigated so that you can spend your time doing health care, instead of being a businessman? Talk about that. What does that look like?

DM: It really happened with the managed care revolution in the ‘80s, where the insurance companies basically gained the right to contract with doctors, and, of course, they contract with patients by selling them insurance plans. But this physician contracting, they have used to try to slow the race that way, while they continue to ratchet down on the way physicians can provide care to their patients.

So the reimbursement rates do not keep up with inflation. The prior authorization requests that you have to go through make it more and more difficult to get care for your patients.

And now [with] these narrow networks, they’ve made it extremely difficult to get the specialists that your patient needs, because they are not in these networks. So we’re losing choice in care.

And then the hassles, the computers. The computers are designed to assist the insurance company, and assist the government bureaucrats. But they are sure a headache, because they come between the physician and the patient.

Computerized records are a good thing, but the way the computers are being used, it’s increased the hassle factor. And, in fact, physicians now, over 50% of physicians are experiencing burn out, from a Mayo study.

DB: Wow. Now, before we let you go, I want to talk to you about something that’s personal to me. I know you’re a medical doctor, but dental care is very much a part of medical care. I don’t know the exact figures for how many people don’t have medical care now, but more people don’t have adequate dental care. I mean, I have a health plan here at KPFA, Pacifica. But it’s a joke. It’s gone with the second cleaning.

DM: That’s correct. In our proposals for health care reform, we include dental care. Because that’s a very basic, essential health service. And we think it needs to be part of the national health care program.

DB: But, again, it is interesting that in this country … I mean, I remember traveling as a student, and traveling in England, and having a massive toothache. I walked into an office and they took care of me. And I was done. I didn’t get a bill.

DM: Right. That’s the way it should be.

DB: And how would you explain it in this context–Health care is a human right?

DM: Yes. In fact, [on January 3rd] JAMA, The Journal of the American Medical Association, the editor-in-chief wrote an editorial and they’re allowing access for free, that says “healthcare is a right, and as we reform health care, we have to accept that fact.” And it’s a very interesting editorial, and your listeners should look it up.

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