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So where do we go from here?

Now that the GOP has failed to repeal and replace Obamacare by taking a chain saw to its benefits and coverage, the most appalling thing about this whole fiasco is not the failure itself. It’s the shrug of helplessness with which it was greeted by House Speaker Paul Ryan and President Donald Trump.

After seven years of railing against the runaway premiums and sky-high deductibles that Obamacare has supposedly brought us, the breakdown of the GOP chain saw has left its leadership with no other legislative tools to repair our health care system, no other ideas for cutting the costs of health insurance while preserving the benefits of the Affordable Care Act. All that Ryan had to offer was impotence. “We’re going to be living with Obamacare for the foreseeable future,” he said yesterday, while Trump struggled to salvage something more. Obamacare, he predicted, will “implode” or “explode” within a year—at which point even Democrats will rush to repeal it.

Don’t bet on it, Mr. President. The main reason why you and your pals failed to kill off Obamacare is that it is neither imploding nor exploding. In seven years it has proven its worth for the vast majority of Americans who have come to appreciate and depend on its benefits. And at least some members of your own party know this very well. Opposition to repeal-and-replace came not just from the Freedom Caucus on the right but also from moderate Republicans like Charlie Dent of Pennsylvania and David Joyce of Ohio. While you did all you could—in vain—to satisfy the Freedom Caucusers, who would settle for nothing less than wholesale repeal, GOP moderates could not bear to see their constitutents lose the “Essential Benefits” guaranteed by Obamacare, including such things as preventive care, cancer screening, and trips to the emergency room.

So where do such moderates go from here? I suggest they take their cue from President Obama himself.

Last Thursday, on the seventh anniversary of the passage of the Affordable Health Care Act, President Obama not only identified its major strengths but also frankly stated that it could be improved: “I’ve always said,” he declared,

we should build on this law, just as Americans of both parties worked to improve Social Security, Medicare, and Medicaid over the years. So if Republicans are serious about lowering costs while expanding coverage to those who need it, and if they’re prepared to work with Democrats and objective evaluators in finding solutions that accomplish those goals – that’s something we all should welcome. But we should start from the baseline that any changes will make our health care system better, not worse for hardworking Americans. That should always be our priority.”

President Obama is speaking here to Charlie Dent, David Joyce, and any other Republican member of Congress who truly wants to improve the Affordable Care Act rather than simply wrecking it: who wants to reduce premiums and deductibles for health insurance while expanding coverage as well as preserving the essential benefits. Now that the GOP leadership has lost a purely political battle over health insurance, why can’t moderate Republicans join Democrats in a truly bipartisan effort to build on the ACA?

Doing so will take months of study, hearings, and negotiation. But since we now have seven years of data on the results of the Affordable Care Act, we ought to know exactly what its strengths and weaknesses are.

During the whole of the battle over Obamacare this year, for instance, did anyone ever propose to repeal and replace fee-for-service medicine with team medicine? Yet as Atul Gawande showed eight years ago in the New Yorker (, the difference between the two largely explains why the Mayo Clinic in Rochester, Minnesota, could treat its Medicare patients for half the cost required to treat Medicare patients in McAllen, Texas—with results that were just as good or better. While we can’t abolish fee-for-service medicine by fiat, the ACA already does much to encourage team medicine, and changes in the ACA law—backed by years of evidence—could accelerate this development.

New changes could likewise encourage health care providers to make a single, all-inclusive charge for a course of treatment rather than a list of charges that have to be individually calculated in hospitals and clinics and individually vetted by insurance companies always seeking items to challenge or exclude. If you dine at a restaurant, you don’t get separately billed for the food, the use of a table, the chef’s cooking, and the services of the waiter—though you’re admittedly prompted to tip the latter. But getting treated for just about anything now means getting billed for a list of services. Last month, after having the wax cleaned out of my ears at a clinic in Charlottesville, Virginia, I got a doctor’s bill for $213 and a clinic bill for $175—a total of nearly $400. If the clinic managers and the doctors who work there could operate as a team, they should be able to set an all-inclusive price for wax removal or any other treatment they provide. Doing so would lower the cost of treatment by lowering the clerical costs of multiple billing, multiple calculations, and multiple vetting. (Some doctors’ offices require at least one full-time employee just to handle billing and insurance claims.)

It is also high time that Medicare, Medicaid, and all other health insurers should be allowed to negotiate with Big Pharma over the cost of the drugs they cover. Since Big Pharma develops many of its drugs with the aid of research funded by taxpayer dollars, there is no reason why it can’t be asked to pay us back by lowering its prices.

Another major problem is that doctors and hospitals alike have a built-in conflict of interests. While supposedly aiming to serve the needs of their patient populations, they also feel bound to serve their own needs: performing operations, especially high-priced ones, and keeping hospital beds filled. No federal law or mandate can resolve this basic conflict, but there are ways of mitigating it. In his New Yorker article, Gawande reports that the Mayo Clinic once had a patient whose heart condition could be treated either by an expensive, invasive operation that required several days of hospitalization or by a much less expensive procedure requiring no hospitalization at all. Since only the more expensive option was covered by Medicare, the clinic had good reason to choose that. Instead it chose what was best for the patient. But since we can hardly rely on other health care providers to put their patients’ needs ahead of their own interests, the ACA could and should be revised to at least narrow the gap between these two things.

But first of course Republicans and Democrats in Congress will have to narrow the political gap between their two parties. They can start by asking themselves a tough question: what specific things can we do to lower or at least limit the cost of health insurance for all Americans while preserving essential benefits?