Fix Health Care, Not Insurance

I’m sure President-Elect Trump doesn’t want to hear from me. But I have plenty of suggestions about what to fix in our health care system. Of course I’m not an actuary, but I’m an educated consumer of health care and a widow of a doctor, who has been writing about this subject since 2007. I’ve spent a decade looking at what Obamacare did right and wrong, and now that it is about to be repealed, here are my thoughts on how to make it better.

I’ll start out by saying that in my lifetime, insurance has made things worse. The biggest culprit of our health care crisis is the insurance industry, which destroyed the relationship between patient and payer. Back in the day, you went to the doctor and paid the bill at the door. If you couldn’t afford care, you tried to keep yourself healthy. That doesn’t happen anymore, because we all have insurance. Actually, those high Obamacare premiums are a good thing in one way — they focus people on staying out of the system.

But some people, unfortunately, can’t stay out. We’ve got to divide the nation again, but this time between people with preventable, lifestyle-related conditions who should be held accountable for those conditions, and people with pre-existing conditions acquired through no fault of their own.


  1. If you’re going to keep competition in the health insurance industry — which I think is wrong — at least make the industry adopt common forms and standards, and make all the software systems used in the industry interoperable. A huge, indirect cost of health care is paperwork. Every doctor’s office has at least one person, often several, who does nothing but billing and collecting.
  1. Related to this is another, less palatable but more effective solution: single payer or Medicare for all. This does not mean socialized medicine, because that single payer could be a private corporation. All it means is a further lessening of the interminable paperwork that drives up costs and drives down quality of care. It also means more central control and more opportunity to spread innovation broadly throughout the system. In the past eight years, I’ve seen Medicare evolve in very interesting and effective ways, most notably by forcing hospitals to prevent re-admissions by refusing to pay for them!
  1. Divorce health care from employment. Several reasons for this. First, workers with good health insurance are less inclined to take care of themselves because they know they “have insurance.” Second, small businesses who cannot afford to insure their employees in a world of constantly escalating premiums simply don’t hire full time people anymore. Allow individuals to buy their own policies, and provide subsidies so they can afford them. The world of work has changed enough to make this necessary.
  1. Keep mandatory insurance, and make the fines higher. Obamacare has made it cheaper to go bare and pay the fine than to pay for insurance.
  1. Means test Medicare. Or raise the age on which we get on it, commensurate with the rise in the age of Social Security benefits.
  1. Move further into digital health for remote patient monitoring and patient compliance. A high cost of care is lack of compliance, and there should be a penalty for that. If you are prescribed a high blood pressure drug and you don’t take it, and you have a stroke, you pay a fine. Some 95% of us have smart phones, and there’s no reason why patient compliance can’t be monitored that way.
  1. Invest in smoking cessation and other prevention programs. One of the best parts of Obamacare is the prevention piece, and that should be kept. However, it should also be strengthened. Currently in the US, people are moving slowly to better eating habits and at least thoughts of exercise, and that’s because most people have high deductibles and can’t afford the doctor. This encourages them to stay healthy.
  1. Cap the amount of care a person can get at end of life. Most health care dollars are still spent on the last six months, performing tests and procedures that do not add value and may further reduce quality of life. Many hospitals and doctors are still unwilling to admit that they can’t keep life going forever, and to have the tough conversations with family members. An expansion of palliative care would also contribute to less costly end-of-life issues.
  1. Expand public health programs that educate patients. Most patients go through life blissfully unaware of what’s coming in the future for them, and they don’t really want to know. The most successful programs for counteracting drug addiction and smoking are lurid and graphic. We shy away from representing those unpleasant truths, but some people need to be “scared straight.”
  1. Keep the parts of Obamacare that work: pre-existing conditions and staying on your parents’ policies until you are 26. You won’t get re-elected if you don’t.
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