The failure of the Republicans to repeal and replace Obamacare was a disappointment but not a surprise. Sensing there would be no consensus on this I sent a letter to Paul Ryan’s office a couple of weeks ago outlining what I thought a reasonable, comprehensive, patient-oriented, market based health plan would look like. I based it on 35 years of Emergency Medicine practice and practice management in both for-profit and County facilities. I’m fairly certain it never got read.
Before describing my plan I think it important to review for a moment why some sort of replacement is necessary. Obamacare is failing due to its design. It is based on an expansion of Medicaid and was, I believe, constructed to fail. The Holy Grail for Democrats is a single payer, government run health care system. Their thinking seems to have been to enroll large numbers of people in Medicaid, cost free, and foster an entitlement mentality. Then, when the federal subsidies to the states ended there would be pressure on the federal government to do something. That something, they hoped, would be either a bailout of Obamacare with increased federal subsidies, a single payer system, or at least a competing ‘public option’, the bridge to single payer.
Given the election results it is unlikely that Obamacare will be getting any additional federal funds. And it shouldn’t. It is going to collapse and good riddance when it does. People insured under Obamacare do not have insurance. Not really. If you have been enrolled in a managed Medicaid plan and can’t find a doctor to see you, you are essentially uninsured. If you have one of the ‘metal’ plans but can barely afford the premium, let alone the deductible, and are afraid to use it, you are essentially uninsured.
What Obamcare does provide is free access to hospital emergency rooms—at least for the Medicaid members. Since its inception ER patient volumes have risen and the amount of primary care being delivered by Emergency Physicians has become substantial. This, we were told, was precisely what would not happen if the law was enacted. This inappropriate use of the ER further drives the cost up and is hastening the law’s demise.
But even those for whom ER care is free under this plan are still out of luck, in many cases, if they require specialty care beyond the Emergency Room. There are few surgical subspecialists outside large teaching hospitals and trauma centers willing to take call for ER patients, especially those covered by any iteration of Medicaid. They simply cannot afford it.