Dear President Trump

I hope you read this letter.  I doubt you will.

I know you’re busy rebuilding Washington, reshaping the international order, and doing a lot of other weighty stuff.  Full disclosure, I voted for you.  Not because you promised to repeal the Affordable Care Act, or because you tweeted at me about it, but because our healthcare system is hopelessly broken and requires an overhaul that does not simply convert over to a single payer system.

Recently you were quoted in an interview with Reuters: “I loved my previous life… I had so many things going… this is more work than my previous life. I thought it would be easier." Yes.  I did too.  Welcome to the frustrating world of shaping health care for a nation.  It should be about making others’ lives better, but instead it is about padding lobbyist pockets. 

There are people who say you’re the wrong man for this job. I am undecided on this.  You’re famous for your hatred of complicated solutions.  They annoy you. They annoy you because you know they’re a waste of time and energy.  Time and energy that can be put into more important things.

You’re also well known for your distrust of experts, who you’ve learned to dislike after years of doing business and listening to boring presentations by people who don’t know what they’re talking about. There are more experts in healthcare than any other area of the economy.  Does that tell you something? I think it should.

If you want any chance of being re-elected next go around, we must get cracking on building the healthcare infrastructure from scratch.  It is not going to be easy, but you already learned this lesson per your statement above.  So how do we streamline health care reform and get ‘er done? 

There are two main problems:  access (coverage) and runaway cost.  The Affordable Care Act provided coverage to many and coupled it with cost control to no one.  This made affordability unachievable for the long-term and things will continue to get worse. 

Congress is currently on the wrong track headed to an empty station.    The general approach of the American Health Care Act is to decrease costs by cutting coverage to the people.  Please go back to the drawing board and start again.  Throwing support behind the American Health Care Act is just flogging a dead horse.  People in this country want affordable healthcare choices and freedom from fear of no access for chronic conditions and unforeseen catastrophic events.  They no longer want to worry about health issues bankrupting them.  Struggling families are one catastrophic illness away from losing their American Dream and that must change.  Step back and take in the big picture. 

Stop focusing on the minutiae.  Instead, start small to overhaul healthcare one phase at a time.  Develop a system which provides immunizations, annual screenings, and simple but necessary medical interventions to every person in the country.  Call it basic care.  You can expand the Community Health Clinic model or utilize the existing Public Health system which is sorely underfunded and underutilized, yet remarkably cost-effective.  Physicians are not required to administer immunizations, take blood pressure, and check cholesterol levels.   Save money by putting mid-level providers in these roles. 

Some basic specialty care could be provided at the public health facilities or community clinics and mid-level specialty providers could fill these positions.  If an individual becomes severely ill or injured and requires more specialized care, needs hospitalization, or surgical intervention, then their catastrophic insurance plan will kick in to cover these needs. 

This is how insurance was created to work, by covering the expense of unanticipated events. Embrace the idea that health insurance should be for:  cancer, heart attacks, car accidents, and other unexpected issues.  The cost of health insurance would decrease considerably if it functioned more like actual insurance and less like a system to reimburse physicians for routine, expected health maintenance.  Third party payers distance patients and physicians from being cognizant of real cost. 

Finally, allow the free market to play a role by giving people options.  80% of healthcare can be handled in a Direct Primary Care practice, where patients pay the physician and enter into a more contractual relationship.  This provides the options many physicians and patients are afraid of losing in a single payer system, an idea that was extremely unpopular in the past.  Health savings accounts could be set up to cover out-of-pocket costs for those who are interested in care outside of the public health system or name brand medications, which are more expensive than generics.

Last but not least, ignore the special interest groups for the time being.  No one else has tried to overhaul health care without kowtowing to them and it is high time someone with big (Ahem) aspirations just went for it.  You are the right person for an unconventional approach.  The Big Four are:  the AMA ($20 million on lobbying in 2016), the American Hospital Association ($20 million), the American Health Insurance Plans (AHIP, $7 million), and Pharmaceutical Research and & Manufacturers of America (PhRMA, $20 million but the industry total was $240 million altogether.)  Special interests cannot help you cultivate the Public Health system or grow the network of community clinics.  Leave them out of it.

I realize the longer this letter becomes, the less likely it will be read, so I will close by saying healthcare is the SINGLE most important task you must accomplish to have any hope of being re-elected.  You have nothing to lose by giving something simple a chance.  The AHCA is trying to pound a square peg into a round hole.  Find the round peg and with it, the right solution. 

Sincerely,

Niran S. Al-Agba, MD

(just google me if you want to talk more)