Tuesday, November 15, 2016

A Vote For TrumpCare

The world is not going to end.  We witnessed a revolution earlier this week.  The people have spoken and they chose the anti-establishment, street smart, government shrinking candidate who bucks the status quo.  We find ourselves in uncharted territory, with an unpredictable President-elect, who has unclear plans for healthcare.  Here is what we do know.  Mr. Trump is a successful entrepreneur.  Forbes describes the entrepreneurship pathway as having no clear story line, but a “sense of chaos, hectic decision making, and moments of great fear and doubt.” Improving our broken healthcare system will involve decision making in the face of great uncertainty.  Mr. Trump has a well-developed tolerance for this sort of ambiguity and is likely the right man for the job. 

Mr. Trump won over the white working-class individuals in small rural areas.  Sluggish economic recovery in these areas played a significant role in his unanticipated victory.  It is these disenchanted individuals watching the American Dream slip through their fingers who voted for Mr. Trump.   Those same people want the freedom to buy the insurance they need, and not what the bloated government shoves down their throats.  25% of the population lives in rural areas yet only 10% of the physicians practice there.  Physicians are leaving the system in droves, closing their patient panels, and not keeping up with demand, thereby threatening patient access in these isolated locales. 

Independent practices have a better chance of survival than they did just a few short days ago.  Do not sit idle.  My son, who is in the second grade, was asked to write down his thoughts on this election. “If Hilary Clinton is elected, I will die.”  His teacher insisted he use facts to back up his dramatic statement.  “If Hilary Clinton becomes President, she will close my mom’s clinic, we will not have enough money for food, and I will die.”  While this is not exactly the conversation that took place over family dinner, my son did understand healthcare would change dramatically following this election.  You should have seen him on election night when the network called Pennsylvania for Trump, but that is another story for another day.  Private practice physicians must seize this opportunity to be involved in the “make things great again” conversation. 

Hillarycare was a known entity with a foregone conclusion.  Trumpcare remains a bit of an unknown.  His “plan” for healthcare was revealed a little more than a week ago, ironically, at Valley Forge.  It encompasses dropping the insurance mandate and allowing purchase across state lines,  making health savings accounts accessible, price transparency, Medicaid block grants to the states (which has certainly worked well for Head Start) to encourage policy innovation, and protecting coverage for those with pre-existing conditions.  The blank canvas is full of possibilities, which is markedly better than the universal health care plan we could have been facing had the outcome of the election been different.  

Every clever “fix” for healthcare so far has had unforeseen adverse consequences.   Providing marketplaces for consumers to shop for insurance did not improve health; instead, it padded the pockets of insurance company CEO’s, lobbyists, and administrators with special interests.  The statistics on rising insurance premiums could not have been released at a better time to facilitate a Trump victory.  I am overjoyed at the possibility disingenuous CMS employees and lobbyists for the American College of Physicians could be out of jobs.  As for MACRA, I hope it goes down with the Affordable Care Act ship altogether.  Physicians want to practice at the top of their skill set, without needless oversight by administrators telling us what is “best practice.”  

The system Mr. Trump is inheriting is full of obstacles.  Patients are disgruntled about paying exorbitant premiums they can ill afford.  Even Bill Clinton chimed in, “The costs are going up, coverage is going down, it’s the craziest thing in the world.”  Maybe not the craziest thing.  I say a man getting elected to the White House without having any previous political or military experience while most of the polls were predicting his loss is fairly extraordinary.  

Admittedly, there are no easy solutions.  My best advice is for him to familiarize himself with the game, the players, the field, and the score, and then develop his own blueprint for healthcare.  Most importantly, get back to the basics.  One hundred years ago healthcare started with fundamentals:  the physician, the patient, a stethoscope, and a conversation.  People were arguably as healthy then as they are today.  My additional thoughts are below:

1.      Invest and innovate, especially in primary care.  We are cost-effective and knowledgeable.

2.      Stop penalizing physicians who do not use Electronic Health Records.  Physicians are doing two hours of paperwork for every one hour of patient care and hiring ancillary staff to support this unnecessary infrastructure.   Let me do my job. 

3.      Shrink or Decentralize the Centers for Medicare and Medicaid bureaucracy.  None of these people are practicing health care providers.  Why are they in charge of 18% of the GDP, when they know little of practice on the front lines?

4.      Encourage innovation and competition amongst insurance companies.  If you want a low deductible, your children covered until they are 26, and exemption from pre-existing conditions, then pay for it.  If you want only catastrophic coverage, and pay for routine maintenance as you go, then pay less and save the extra money to go on a cruise. 

5.      Redefine high “quality.”  Reward physicians when they spend more time with patients, are more accessible, and able to prevent expensive hospital admissions and readmissions.  Eliminate patient satisfaction scores, immunization rate scores, and outdated HEDIS measure goals. 

6.      Require Medicaid recipients to contribute to their health insurance, on a sliding income-based scale.  Require small copays for insurance plans including Medicare and Medicaid.  Even a small personal investment ($3) for a visit has been shown to increase value in the eyes of the consumer. 

7.      Allow Medicare to negotiate with drug companies.  Pharmaceutical companies have been getting fat and happy while Americans have just been getting fatter and more ill. 

Our problems in health care have little to do with the patients or the physicians; rather it has to do with corruption of our administrators and nonessential healthcare players.   Beware of the snake oil salesmen touting their latest “solution” for the health care conundrum; instead, look to physicians with boots on the ground caring for real patients to provide tangible answers. 

The undecided policy agenda of Mr. Trump held the most promise to save private independent practices everywhere.  Time will tell if this gamble will pay off.   Now is the time to roll up our sleeves, get to work, and embrace transformation.  Success is where preparation and opportunity will meet.  I hope he leaves no stone unturned. 


  1. One of the ways to fix health care would be to combine the free market, personal responsibility, and Medicare.

    To accomplish this, let us keep more of the money we pay, or our employer pays, for our health insurance. Why does our employer or why do we give 100% of our monthly premiums to health insurance companies who then decide which treatment they will pay for with our money? Not only do insurance companies receive 100% of our premiums (often $20,000+ per employee annually) we (the patient) also pay large co-pays and office visits payments. Instead, could we create a system where employers send 50% of employees’ health care premiums to their employees’ health care savings account (HSA) and 50% to a new version of Medicare (coverage for everyone not just the elderly) instead of giving 100% of our premiums to health insurance companies?

    Using the 50/50 health care plan, health care costs would be reduced, risks could be managed (you are covered by Medicare if you deplete your HSA), and everyone would be covered. There would be no disagreements with insurance companies over services or payments. Patients and doctors would decide the treatment that is necessary and the patient would pay for the services through either their HSA or if their HSA was depleted then payment would be through the new Medicare. All preventative care would be paid through Medicare, so people would be encouraged to take good care of themselves. This would encourage more patient engagement and responsible behavior, and better patient-doctor relationships. The payments would be as easy as sliding your HSA card or app (like a credit card or ATM card or app) through a card reader at doctor’s offices. The payment would be made and you would receive a printout/text/email of the services, the costs, and the remaining balance in your HSA.

    Currently, if you lose your job, then you might pay enormous sums under Obamacare for health care or you become part of Medicaid (if you are poor enough) or Medicare (if you are old enough) programs. It would be helpful to have a HSA to draw upon when unemployed in addition to Medicare and Medicaid. For example, if the health insurance premiums your employer pays for you cost $20,000 annually and you worked for 30 years, then you could potentially have $300,000 ($20,000/2 * 30) in a health savings account. HSAs would be portable and preventative care would be paid through the 50% that goes to the new Medicare. The new Medicare would also cover the indigent or others who do not have and/or have depleted their HSAs with the 50% of the premium Medicare would receive in addition to the current payroll taxes that go to Medicare. This would also help shore-up Medicare too.

    The Affordable Care Act/Obamacare requires everyone to purchase health care coverage from the same health insurance companies who have gotten us into this mess. If the government can require everyone to buy health insurance, then the government should regulate the health insurance companies by banning health insurance companies from being traded on Wall Street and mandating that health insurance executives/employees may not be paid more than $1 million per person annually. Obamacare should not be a windfall for insurance companies and their employees.

    Using the 50/50 health care plan, when you reach 75, you can use your HSA as a supplement to your pension or 401k/retirement. This would encourage everyone to take great care of themselves, since preventative care is paid through Medicare and if you take good care of yourself then you could have a large HSA to help you when you are older.

    We need to go in a new direction for health care coverage…a direction that does not include the unnecessary middleman/insurance companies. The 50/50 health care plan eliminates the insurance companies so patients and doctors can engage directly with each other for better health care for everyone and at a lower cost.

  2. Thank you for reading and commenting. I cannot disagree with your ideas. I think they are good. You are absolutely right that government should regulate insurance companies if they are going to in turn regulate us. It has been a windfall for everyone except the physicians and patients. Keep reading!!! More to come...

  3. Most people in America, including the rural white folk who voted in DJT, cannot afford to put money into HSAs. If they had thousands of dollars for HSAs, they'd happily pay for health insurance. Our employers do not provide us with health insurance or HSAs because those benefits cost money and low-income disposable labor is not worth it. When it is offered they know we don't get paid enough to take advantage, or if we do, they find ways to keep us from accessing benefits.

    The idea that the Republican Party, after an unprecedented victory in all branches of government, is going to unleash a can of industry regulation is beyond a pipe dream. It's a little silly. Unregulated free-market capitalism with it's attendant income stratification and consolidation of resources, including healthcare resources, is their economic policy. Their problem with the ACA is not that it gives insurance companies more customers, but that it provides the poor (which includes masses of urban blacks, immigrants, single mothers, pre-existing conditioners and other undesirables) with free or discounted healthcare at the upper classes' expense. The ACA was a pro-business compromise to avoid single payer healthcare (read: the dreaded socialism) but still help the uninsured get access.

    It worked. I know so many people, including myself, whose lives were dramatically changed by getting access to healthcare through the ACA especially mental healthcare.

    Dr. Al-Agba's son is celebrating that his mom's clinic won't close while other peoples' sons are worried that their parents will be deported, killed by xenophobic marauders or lose access to the healthcare that keeps them able to be parents. I'm so disappointed that this is her position. I understand that much of a pediatric practice's caseload is funded by Medicaid. The chance of a Republican Congress improving Medicaid payments is less than 0. Sometimes I wonder if the American folken enjoying our countrysides know which side their bread is buttered on. :(

  4. Thank you for reading and sharing your thoughts. We disagree, however there is a time I echoed your feelings on this matter. There are still 30 million people uninsured in this country, who need access to AFFORDABLE healthcare. I do not have all the answers, but we would have had universal health care with HRC. Basically, my clinic (and many others) is providing high quality healthcare to numerous children on Medicaid and now it has a chance to survive. As a physician in private practice, I am struggling and all four of my children see that, especially by the end of each month. None of us in medicine are supporting deportation of immigrants, murders, or decreased access to care. We are supporting access for affordable care for hardworking families and their children. Keep reading... and sharing your comments. :)