Following a heated debate last month that led to the creation and demise of the American Health Care Act, it appears that for the time being, Obamacare will continue in the United States. The 24 million that were projected to lose coverage as well as Democrats are undoubtedly rejoicing, but it is still clear that our current system is untenable and we should expect changes to in the imminent future. The question is: what will those changes be?
Before leaving office, Obama published a piece in JAMA: The Journal of the American Medical Association, about health care reform. He, along with other Democrats, have continued to push for universal health care coverage in this country via Medicaid expansion in every state. Instead of a single-payer model like Canada, however, his argument is that if private insurance companies exist in addition to state-sponsored health insurance, we will have bolstered competition in the insurance market, lowering premiums for the average American. However, while the cost of premiums will decrease, state taxes will most likely have to increase to support Medicaid expansion, regardless of whether the federal government is able to provide subsidies. It is seemingly a lose-lose situation for individual citizens as cost of living would increase, but the long-term benefits of coverage for those at risk of accidents and sudden illness—i.e. all of us—are great.
Certainly, there are ways to reduce costs within health care as well. As a medical student, I am all too familiar with ordering extra tests and imaging “just in case” some improbable pathology is at play. Bundled payment plans are a move in the right direction, as a general framework of testing and procedures for each patient being admitted for hip replacement surgery or exacerbation of congestive heart failure will reduce unnecessary costs. Some may argue that “bundling” eliminates the critical thinking of medicine, but the critical thinking remains in deciding upon what additional measures to take in a sick patient. After all, the diagnoses are frequently the same to subspecialists, but each patient case is unique.
But holding health care entities accountable for patient outcomes to reduce health care costs seems to be a double-edged sword. On the one hand, increased transparency about patient outcomes is useful to consumers who are shopping for providers, but the data is frequently difficult to interpret. Sicker patients tend to have worse outcomes regardless of the skill level of the health care team. In medicine, we routinely see patients with chronic illnesses who are noncompliant with their medications, much to the frustration of the provider. Alternate payment models seem to punish providers for these patients, which could result in preferential treatment of or “cherry-picking” healthy patients while sick patients are neglected. Instead of jumping to alternate payment models, a combination of increased coverage allowing for more visits with primary care providers as well as improved sick leave policies will gradually ameliorate the confounding variables of health care outcomes. These measures will likely take decades and cooperation of the public and private sectors, but again, the long-term benefits for citizens are great.
The 2017 United States government is hyperpartisan, but the continued discussion of health insurance in this country shows that the general populace is hungry for change. The persistence of Obamacare suggests that the constituents of both parties agree that every human has the right to the highest attainable standard of health. Medicare payment reform is already underway with MACRA, the Medicare Access and CHIP Reauthorization Act, and prescription drug reform seems to be likely in the near future. Gradually, we will be able to move towards universal coverage and reducing health care delivery costs. For the time being, it is up to every citizen to stay informed—especially my fellow health care professionals who have the ability to bring change from the front lines.