Blog | Monday, July 31, 2017

Agreement and division--the American Health Care Act and what we all want


It's been hard to be a concerned American citizen lately. We are facing huge problems which will become larger in our lifetimes, including the need to take care of our increasing global population and the medical complexity of taking care of people who are becoming older and sicker. There is global climate change, which is hard for all but the most stalwart of partisans to ignore. There is an increasing gap between rich and poor in our nation and in many others, which places the rich and powerful at odds with the much more numerous and therefore potentially powerful poor.

To help guide us through these challenges we have a government so deeply divided on Democrat/Republican party lines that it is mostly unable to do anything creative at all. And we all pay them lots of money to be dysfunctional.

I have been following the activities surrounding repealing and replacing the Affordable Care Act. The ACA (Obamacare) was passed without a single Republican “yes” vote in the senate. The American Health Care Act (AHCA=Trumpcare), if it passes, will do so without a single Democrat voting for it. It has been difficult to write because it has to please all Republicans, including those who feel that healthcare should just take care of itself using the free market and who would happily get rid of any federal subsidies. There does not appear to have been any attempt to make the bill palatable to Democrats or even relatively conservative healthcare organizations such as the AMA.

The most recent iteration abolishes taxes on investment income which is effectively a tax cut for the rich, takes away all federal money from providers of abortions, even if the vast majority of what they do prevents abortions and so may de-fund Planned Parenthood. It offers block grants for Medicaid instead of paying a percentage of Medicaid costs. This leaves states to either pay more for the program or make cuts to services if medical prices go up faster than the consumer price index (which medical costs have done historically.) It reduces subsidies to pay for insurance for many people who are poor which means that many of them will stop paying for health insurance which they will be unable to afford.

The AHCA, as it was written, also would have provided some subsidies for insurance companies which have lost money under the ACA and many of which have either withdrawn from exchanges or increased their rates. In Idaho, I read in our local newspaper, insurance costs are set to increase by 22% this year, which will be very painful for many people. The insurance companies were hit hard since passage of the ACA, because a Republican dominated congress did not appropriate the money promised to the insurance companies in case of shortfalls. People buying health insurance through the exchanges may already be priced out of paying for health insurance, even if nothing is done to “repeal and replace” the ACA. Not only will this leave more people uninsured but rising health insurance costs affect all businesses that are required to buy insurance for their workers, which will either impact their employees' paychecks or even cause the businesses to fail.

The ACA, our present health care system, is like a house whose roof is leaking, and has been leaking awhile. Instead of fixing the roof in the first place we are now wrangling about how to build a new and crappier house. If we don't either fix the roof (which is vanishingly unlikely in a Republican held legislature) or build the new crappy house, we will all be shivering in the corners pretty soon.

But there has been a bright spot in my thoughts about the future. I have been reading Srdja Popovic's book Blueprint for Revolution. He was a member of the group Otpor!, which was partly responsible for mobilizing the people of Bosnia to oust their dictator Slobodan Milosevic. He talks about some of the ways that people can work together to get big things done. The most important step is to find out what issues virtually everyone agrees about and to move on those. Also to maintain a sense of fun and positivity, because that is what feeds people and helps them stay active.

Our communication via the internet, with a new addiction among some of us to reading what we think is “the news” has been both good and bad. One thing that comes of it is that the economy of the internet, which is driven by ads which are equivalent to real money and resources, pushes conflict. There are natural conflicts, but increasingly we are pulled in by more petty conflicts. People who basically agree, share a political party and a vast number of values, enter Twitter or Facebook wars about smaller points and end up mortal enemies. This is exactly how you can get more clicks on your comment or your news story and not at all how you can unite to make good things happen.

There are many things that a majority of American's agree upon. We want to be paid fairly for our work. We want our children to grow up safe and responsible and useful. We want to breathe clean air and have healthy food to eat. We want adequate health care that doesn't stress us financially. We enjoy beauty. We want to end the divisiveness that creates inefficiency in our government so we can further our shared values.

It is likely that if there were leaders who stood up and insisted on ending divisiveness in government, they would have followers of all kinds who would come out in force. Democrats and Republicans, churched and unchurched, black, white and other rainbow colors of people would be willing to march in the streets or sit down to a picnic together.

In a congress that was not divided along party lines a health care bill could be designed that would serve most of our needs. Legislators who populate the fringe would have to convince others of the wisdom of their ideas, but they would not control outcomes as they do now. Bernie Sanders just sent a letter to me and his 50 million other best friends and suggested “Medicare for All” as an option. This will never pass in a divided congress, but might just gain traction if combined with cost saving ideas that would make it palatable to republicans.

In our present political environment I do not know what to do about the AHCA. The progressive organizations who contact me daily by email urge me to write letters and make calls to my congressmen to oppose it. But I don't know that we have any other options at this point than a bill that, if left unchanged, will have long term consequences of reducing health care to vulnerable populations. Left un-fixed, the ACA is going to have some of the same problems, with bloated but cash strapped insurance companies pricing many people out of the market. If the AHCA is terrible, maybe we will get more substantial improvements as people stand up together to insist that they get what they need. Two states (California and Nevada) have already begun the process of assuring their people adequate health care. We need more action like this.

Most of all we need to realize that we are all in this together and that we agree on many more things than we disagree on. The ways in which we disagree are important. Debate, change and consensus making is a valuable use of our energy, but right now we need to also pull together and gently but forcefully insist that our government do the same.

I recognize and respect people who say that Mr. Trump, our frighteningly incompetent president, should not be “normalized” by cooperation. I do not trust that the election which put him in that position represented the wishes of the American people. But deep divisions and lack of cooperation preceded his presidency and brought us to where we all are. It is time that we all, as citizens, begin to visualize what we all want rather than feel complacent in our resistance.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.