Blog | Thursday, July 20, 2017

Health care reform is still a dog


Back in March, I made some observations about the American Health Care Act, the bill to “repeal and replace” the Affordable Care Act (ACA) that was ultimately passed by the House of Representatives and both hailed and disparaged by the President. Some of the naked political calculus that facilitated the passage of such a truly despicable bit of legislation was the belief that the Senate would somehow rescue the Republican Party from itself and restore something “beautiful.” Well, it is now pretty clear that the Senate bill, cynically dubbed the “Better Care Reconciliation Act of 2017, was no better than what the House threw over the fence.

The bill retained essential “features” of the House version: less funding for Medicaid, fewer constraints on bad behavior of insurers, leaner subsidies for the uninsured to buy insurance, and repeal of the mandate to buy insurance for those with neither employer provided insurance or eligibility for Medicaid or Medicare.

I think Paul Krugman explained pretty well why the current plans to dismantle parts of the ACA don't work. The ACA is based on a few interdependent ideas:
1. For insurance to be useful, it has to have certain features, like broad benefits and inclusion of people with pre-existing conditions
2. To avoid the insurance “death spiral,” everybody has to be in the risk pool. Otherwise, only sick people would buy insurance, thereby pushing up the price and making those who are relatively healthier drop coverage, driving up the price further and driving more healthy people away, worsening the problem
3. To facilitate getting everyone in the risk pool, subsidies are provided to those who can't afford the premium

Remove any one of these and the system collapses. We are likely to end up with fewer people insured and worse coverage for those who buy insurance. As is true of the House bill, the Senate bill did nothing to address the real challenges facing our health care system today, access, quality, and affordability. As the President might say: “Sad.”

What do you think?

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.