The Ideal Health Care Plan for Everyone

The Ideal Health Care Plan for Everyone

© David Burton 2017

Health Care in 2017


     The first Trump/GOP attempt at replacing Obamacare was stillborn. Their second attempt, euphemistically called the Better Care Reconciliation Act, was released in draft form by Senate Republicans on 22 June 2017. On its surface, this second bill appeared to contain many of the features one might desire in an Obamacare replacement. Is it the Golden Grail - the “ideal” health care plan?

     The undeniable truth is: There is no such thing as an “Ideal Health Care Plan”! The “ideal” health care plan falls into the same category as the Tooth Fairy and Santa Claus – it’s a fairy tale.

     Obamacare, or the Affordable Care Act (ACA) as it’s more formally known, has proven to be a failure and it needs to go. “Obamacare has limited choices for patients, driven up costs for consumers, and buried employers and health care providers under thousands of new regulations. It forced people into expensive plans they did not want and put the government in charge of one of the most personal decisions families will ever make.” (Ref. 1) Patients, with their doctors, should make their own health care decisions free from government interference. The latest Republican plan attempts to address the demands of many Americans for the repeal the Affordable Care Act which has resulted in “skyrocketing premium rates and decreased coverage choices as insurers fled the market.” (Ref. 1) For many Americans, the ACA has proven to be a pack of expensive untruths and broken promises.

     A report put out by the non-partisan Congressional Budget Office (CBO) on the new Republican ACA replacement “estimated that 22 million more people would be uninsured by 2026 under the Senate Republican health care plan than under {Obamacare}, with 15 million more uninsured people in the next year alone.” (Ref. 2) This should come as a surprise to no one! The GOP plan removed the Obamacare mandate requiring everyone to get health care coverage, thereby providing everyone with the option of not purchasing health care insurance. As a result, not everyone would opt to purchase health care coverage and, as the CBO report said, the number of uninsured would go up. But, this is what freedom of choice means! If you don’t want health care insurance, the GOP plan would not force you to buy health care insurance.

     The GOP plan could “result in a reduction of the cumulative federal deficit by $321 billion by 2026, largely due to cuts in Medicaid spending, according to the CBO's report.” (Ref. 2)

     Is the newest Republican attempt to replace Obamacare the “ideal” health care plan everyone is searching for? Not Likely! Was Obamacare the “ideal” health care plan everyone was searching for? Certainly Not! Is there likely to be such an “ideal” health care plan? Guaranteed Not! So, what’s to be done?

     The Republican draft bill is said to be ”better than the status quo because it contains provisions to reduce insurance premiums and promote access to insurance in the short run, cut taxes, and provide major Medicaid reform that will help refocus the program on those most in need.” (Ref. 3) While supposedly better than Obamacare, some conservatives want more – “To undo more of Obamacare’s damage, the Senate should go further by expanding states’ regulatory reform options to encourage continuous coverage and further roll back Obamacare mandates. The Senate should also provide additional Medicaid reforms to improve the program for beneficiaries and taxpayers alike.” (Ref. 3)


     Some of the more significant problems in Obamacare were its “federal control over state health insurance markets {that have} proven to be a costly and painful experiment, resulting in soaring premiums and skyrocketing deductibles for enrollees. One factor {that drove} up costs was Obamacare’s preemption of state authority for insurance markets and its imposition of costly new federal benefit mandates and regulations. This unnecessary move short-circuited the ability of states to adopt different approaches or to modify rules to accommodate changing circumstances.
     “Obamacare’s structure of new federal health insurance regulations and subsidies was designed to provide lower-income individuals in need of medical care with comprehensive coverage at little cost to the recipients. Obamacare also applied those same regulations, but not the subsidies, to the broader individual and small employer health insurance markets.
     “Americans with unsubsidized coverage through individual-market or small-employer policies have borne the brunt of the premium increases and coverage disruption caused by Obamacare’s insurance market regulations. They are the ones most in need of relief from Obamacare. Additionally, Obamacare’s mandates aggravate{d} the cost problem by discouraging young persons from enrolling in coverage, leaving the insurance pools with older and less healthy enrollees and ignoring the needs and preferences of customers.
     “The Centers for Medicare and Medicaid Services (CMS) reported that in the federally supervised health insurance exchanges (39 states), between 2013 and 2017, average monthly premiums increased from $232 to $476—a 105 percent increase. [Emphasis mine] CMS concluded that insurance plans’ high premiums and the lack of affordability in these markets {was} the main reason that individuals are cancelling or terminating their coverage. Between 2014 and 2017, about one million individuals per year dropped their coverage.
     “Soaring health insurance costs {hammered} customers in non-group coverage, leaving those customers to navigate the wreckage of severely damaged individual markets. Health plan withdrawals {were} contributing to rapidly declining market competition and thus restricting consumer choice. In 2018, according to a recent . . . report, about 45 percent of U.S. counties will have either one or no insurers offering coverage in the Obamacare exchanges. [Emphasis mine]
     “Meanwhile, customers {were} discovering that their coverage choices {were} increasingly limited to plans with high deductibles and narrow physician networks.
     “Obamacare’s excessive regulatory regime directly contributed to this state of ffair. . .” (Ref. 3)

     Another destructive aspect of Obamacare was the increased cost of Medicaid. “Medicaid is a means-tested health care and social services program for low-income children, pregnant women, and aged or disabled individuals. {Under} Obamacare . . . Medicaid eligibility {was expanded} to include able-bodied adults without children. Indeed, the Medicaid expansion has accounted for over 80 percent of the net increase in total (both public and private) health insurance enrollment since Obamacare’s coverage provisions went into effect at the beginning of 2014.” [Emphasis mine] (Ref. 3)


     The Republican Better Care Reconciliation Act “takes steps to better target Medicaid’s safety net to those who most need it to ensure that Medicaid reforms work for the long haul and provide access to better care.
     “The Senate bill (like the House bill) would end the open-ended entitlement of states to federal Medicaid funding. It would cap federal contributions to Medicaid spending, with the federal government instead allocating federal monies to state Medicaid programs on a set, per capita basis for the different covered Medicaid populations: children, the elderly, the disabled, and able-bodied adults, including those made newly eligible for Medicaid under Obamacare. The per capita funding amounts for a state would be determined based on average spending by the state for each category of enrollees, with total funding reflecting the number of enrollees in each category in the state.
     “The Senate’s per capita cap funding approach is a major reform, consistent with policies recommended over the years by conservative health policy experts.
     “It represents a major improvement over existing federal payment arrangements and allows states greater flexibility in the administration of the Medicaid program. The per capita approach also offers the benefits of giving states stronger incentives to eliminate waste and fraud in the program; preventing states from gaming federal reimbursement formulas; and better targeting resources to the needy and most vulnerable to improve results.” [Emphasis mine] (Ref. 3)


     On net, the Better Care Reconciliation Act is better than the status quo because it contains provisions to reduce insurance premiums and promote access to insurance in the short run, cuts taxes, and provides major Medicaid reform that will help refocus the program on those most in need. But, to undo more of Obamacare’s damage, Congress and the Administration need to go further by expanding states’ regulatory reform options to encourage continuous coverage and further roll back Obamacare mandates. [4]

     There are still more ways to improve the Better Care Reconciliation Act. For example, improvements could be made to the Medicaid provisions to ensure that the program helps those most in need.

     “First, Medicaid tends to provide less access to providers and poorer quality of care than private insurance. Many Medicaid enrollees cannot find a doctor to take care of them because the reimbursement rates and the regulatory system discourage physician participation in the program. Low-income able-bodied adults cycling on and off of Medicaid as their employment and incomes fluctuate experience disruption in their health care coverage. Enabling those individuals to instead access mainstream private insurance coverage would improve continuity of coverage and access to higher quality care.
     “Therefore, the Senate should convert existing Medicaid and Children’s Health Insurance Program (CHIP) funding for able-bodied adults and children into a premium-support program so those beneficiaries can enroll in private health insurance plans—and thus be able to secure access to the same doctors and medical professionals as their fellow citizens. This would help them obtain the same basic coverage and care as more affluent individuals, while also augmenting efforts to create more stable insurance markets. Such a reform would increase their access to the quality care that they need, and would increase the number of younger and healthier persons enrolled in the nation’s private health insurance pools.
     “Second, an effective per capita approach requires that federal contributions grow over time at rates that are realistic and consistent with achievable expectations for the ability of states to moderate future spending. . .
       - - -
     “. . . {T}he Senate should revise the indexing provisions in the bill to better match them to the historic and projected growth rates of the different beneficiary groups . . .
     “Variations in growth rates largely reflect variations in the mix of services consumed by different groups of beneficiaries. While per capita growth in the cost of acute-care medical services reflects changes in medical technology and practices, growth in the cost of personal care services is almost entirely a product of changes in wage rates. Thus, costs have grown the fastest for non-elderly, non-disabled adults and children because Medicaid is paying mainly for acute medical services for those individuals. Conversely, Medicaid costs have grown the slowest for aged enrollees because the program is mainly paying to provide them with social services (with all of their acute medical care separately paid for by Medicare). [Emphasis mine]
     ”Third, {improvements could be made} to ensure {that} states have the flexibility they need to manage their Medicaid programs. {This could mean} steps {to give states} explicit authority to set and manage eligibility for their Medicaid programs through a range of means such as asset tests.
     “Moreover, {improvements} should ensure that Medicaid focuses—as soon as possible—on the most vulnerable by removing Obamacare’s excess federal funding for newly eligible able-bodied adult recipients. . .
     “Importantly, the Senate should recognize that the current bill’s proposal to give states an option for setting work requirements on able-bodied Medicaid recipients will not be particularly effective.
      - - -
     “Most states will simply ignore the option. Its enforcement is very difficult in a society that provides emergency medical care to all. Medicaid work requirements could be circumvented easily by simply dropping out of the program and seeking emergency medical care when needed, at which point the individual would be re-enrolled in Medicaid, with the potential to repeat the cycle again. There are far better options for pursuing work requirements in other welfare programs that have been consistently ignored by Congress.
     “Repeal the Cadillac Tax. . . .
     “{An improved Better Care Reconciliation Act} should couple repeal of the Cadillac tax with a critical reform of the tax treatment of employer-based health care in the form of setting a limit on the amount of pre-tax contributions to employer-sponsored health insurance.
     “Economists across the political spectrum have long argued that the current policy of providing an unlimited exclusion from taxation for income received in the form of employer-sponsored health benefits is a major systemic driver of health care costs. By its special treatment of employer-based coverage, the policy also undermines portability of coverage, contributes to the opacity of health care costs, distorts health care markets, and limits consumer choice and competition, and is regressive in its application to American workers and their families.
     “A cap is an appropriate correction for these economic distortions. Capping pre-tax contributions would encourage employers and workers to seek better value for money spent on health care without the rigidity of the Obamacare excise tax, which effectively forces employers to limit the scope of health benefits plans. Such a policy would be consistent with the pre-tax funding limits set in law for other employee benefits, such as contributions to retirement savings, group term-life insurance, and dependent care expenses.
     “Moreover, capping the exclusion can be coupled with a reform to let individuals with employer-sponsored benefits choose whether they want to use the existing tax exclusion or the new tax credit. This option would especially benefit lower-wage workers, who likely would benefit more by opting for the tax credit and may be more likely to accept offers of employer-sponsored coverage. Moreover, employers in lower-wage industries may be induced to offer coverage.
     “Finally, {we} should go further in helping Americans save for health care through Health Savings Accounts (HSAs), which allow individuals to save money for their health expenses in an account they own and control, without losing the money at the end of the year. These accounts are a marked improvement over other tax-privileged choices like Flexible Savings Accounts, in which the user has to “use or lose” the money annually. . .
     “HSAs offer two significant advantages. First, account holders are able to exercise more direct control over how their health care dollars are spent and have the ability to pocket the savings from obtaining better value care (as opposed to savings accruing to their insurer). Second, they give Americans both an incentive and a mechanism to save for future health expenses.
     “Two key problems with HSAs limit their usefulness. Individuals must buy a high-deductible insurance policy to contribute to the accounts, and they are limited in their ability to save in these accounts. The {Better Care Reconciliation Act} addresses the latter issue by increasing allowable contribution amounts for HSAs.
     “{An improved {Better Care Reconciliation Act} should go further and permit HSAs to be used with any type of insurance plan, not just high-deductible policies. They also should ensure HSAs can be used as repositories for contributions from public or private sources in order to assist lower income individuals to finance health insurance and medical care. These changes also would ensure neutrality with respect to any incentives for spending on health insurance versus spending on medical care directly.” (Ref. 3)

     An improved {Better Care Reconciliation Act} should create enough incentives for continuous health care coverage—either directly or by permitting states to use a waiver process. This is important to limiting the adverse selection and gaming effects that have driven up premiums under Obamacare.

     In addition, states should be permitted to experiment with different approaches for incentivizing continuous coverage. Additional options should be encouraged, such as allowing states to authorize insurers to prohibit preexisting condition exclusions only for those individuals who can demonstrate continuous coverage during the prior year. Also, there should be flexibility for insurers to impose on those who do not maintain continuous coverage additional cost-sharing requirements (e.g., higher deductibles) for a limited period of time.

     Additionally, Obamacare’s requirement to cover specified preventive services with no cost sharing charged to enrollees should be ended. Prior to Obamacare, plans typically covered most of those services already, obviating the need to mandate coverage. Also, a number of those so-called preventive services are actually diagnostic tests or procedures, and allowing insurers to set patient co-pays is an appropriate way to manage utilization.


     Today (28 June 2017), some nine Republican senators have balked at voting for the current version of Better Care Reconciliation Act. So be it! Let them work to revise the bill to make it more compatible with their thinking. Today (28 June 2017), not one single Democratic senator (out of a total of 48 Democratic senators) has said he/she will vote for the current version of the Better Care Reconciliation Act. This is totally unacceptable! This is nothing more than irresponsible behavior and a demonstration of what is wrong with American politics today. There certainly has to be more than a few Democratic senators who recognize the problems with Obamacare, the need for its repeal and replacement and who should be willing to work with their Republican counterparts to come up with a replacement that they could support. It might not meet all their wants, but it would be better than what they and the American people now have. Isn’t it about time that our politicians in Washington stopped acting like politicians and started acting like representatives of the American people?

     In 1830, Jeremiah Evarts, an outspoken opponent to the forced removal of native American Indians to lands west of the Mississippi, wrote, in reference to the advent of party politics in America, “Now what can we do, when men will act in this manner? . . . The question is already as plain in the Senate as any question of human conduct can possibly be. Not one question of theft, robbery, or murder, in ten thousand, is so perfectly free from all doubt or cavil . . . yet is expected that men will vote by platoons, in regular rank and file, according to party drilling, [Emphasis mine], on this question of public faith. I have never before seen such a commentary on human depravity.” (Ref. 5) With the impasse along party lines over health care here in America, nearly 190 years later, the prescient foresight of Evarts, unfortunately, is all too evident. The failure of America’s elected representatives to compromise and the emergence of unbending partisan politics less than half a century after the signing of the Declaration of Independence began the fight over state’s rights and secession, ultimately resulting in the bloody American Civil War. Where will acrimonious and uncompromising partisan politics take us in this 21st century?

     “It {will be} just as calamitous for Republicans to implement a health care plan without a single Democratic vote as it was when Democrats pushed through the Affordable Care Act eight years ago without a single Republican vote.
      - - -
     “{Senate Majority Leader Mitch McConnell should} - with Trump’s backing and support — . . . reach across the aisle and issue a sincere invitation to Democrats to participate in crafting a fix to the Affordable Care Act, which absolutely needs fixing. This is an opportunity for Trump to do what Obama couldn’t, to put in place a bipartisan health care plan.
     “There are popular aspects of Obamacare — no denial of pre-existing conditions, the ability to keep children covered until age 26 and expansion of Medicaid coverage to the poor — that appeal to many epublicans. And there are aspects of Obamacare — lack of choice, significant increases in health insurance costs and costly and bureaucratic employer mandates — that Democrats know need to be fixed.
     “Health care represents about one-sixth of the American economy. It is too important an issue to be decided by 2018 election calculus. There is a path toward bipartisan compromise. Let’s hope someone — anyone — in Washington has the courage to lead down that path.” (Ref. 6) Democrats must realize that they no longer hold majorities of any kind in the Capitol. If Congressional Democrats wish to serve their constituents and all Americans, they will need to make compromises to ensure that American citizens get what they need, even if it’s not what Democrats want. In a similar vein, Republicans must realize by now, that they can’t railroad an unacceptable health care bill through Congress, even if they do hold majorities in both houses. It is evident that members of their own party will step up and oppose a health care bill that they feel is unacceptable to their constituents.

     The answer to the ongoing and vexing question of what to do about reforming the existing health care law – Obamacare - is for all sides to lock themselves in a room and work out the hard compromises needed to arrive at a less-than-ideal health care plan – but one which fixes the more glaring deficiencies of Obamacare. This less-than-ideal plan will not totally satisfy everybody, but it should satisfy more Americans than Obamacare or the current GOP plan. Our politicians need to abandon their “it’s my way or the highway” approach to their differences and get back to a give-and-take approach to arrive at a meaningful improvement. They need to tackle the health care issue with a “let’s arrive at the best compromise possible” attitude. Unfortunately, “compromise” has become such a dirty word in politics today that nothing is being accomplished. BUT, compromise is the only way to end the perpetual gridlock in our nation’s capital. Nobody can expect to get everything they say they want. Instead, it’s time to consider what’s best for the majority of Americans in the most practical context, rather than continually trying to find some unattainable and unworkable ideal. Our pollical leaders need to be locked away in a room and not allowed out until they have come to a workable compromise health care plan. Failure to agree should not and cannot be an option! Failure to come to an agreement should be viewed as grounds for removal from elective office. The American people are fast becoming frustrated with the seemingly eternal political stalemate in our government – healthcare being just the latest example of this unacceptable behavior by our elected representatives. The electorate wants action, answers, and, most important, the electorate wants fixes and they want them now. What we don’t want is more rhetoric, more obfuscation, and a continuing impasse. Hopefully, there are those in our political rank and file who will roll up their sleeves and find realistic and significant answers to the healthcare dilemma. We urge them to come up with the solutions that can make it through our partisan legislative bodies, be signed into law by the president, and become an affordable and workable health care program.

     Republican Senator John McCain has urged Republicans and Democrats to reach a compromise on health care. When the Democrats rammed through Obamacare, they did it on a strictly partisan basis. Similarly, Republicans did not include Democrats in the formation of an Obamacare replacement. [7]

     “We’ve got to go back and address this issue on a bipartisan basis and we can’t wait until people are without health care,” . . . “We’ve got to have some bipartisanship around here, otherwise we’re not going to get much done.” (Ref. 7)

     In times past, during election years, politicians would take the pledge –“No more Taxes!” Today, they need to take a new pledge – “We'll stay in session until a health care compromise is reached!”

     Obamacare was and is a disaster. The current Republican replacement plan may or may not be a final solution. But, our elected officials can and must reach agreement on what is the best practical Obamacare replacement. They must do it now and not kick the problem down the road.

     Even with the passage of an improved Better Care Reconciliation Act, there will still be significant work remaining to undo all the damage of Obamacare and resolve the problems in the American health care system that preceded it. This cannot be accomplished in one giant step. Future efforts will need to be part of an ongoing process at both the state and federal levels. The health care issue in America will not be resolved in one fell swoop. Congress and future administrations will have to address issues left out of the bill and to correct those unavoidable mistakes that will be made. Costs can only be contained with additional reforms - at both the state and federal levels - that will create more consumer-driven market incentives for medical providers to offer better value care and empower consumers with options to seek better value.

------------------------------------------------------------------------------------------------------ -------------------

  1. Analysis: Fight to save health care bill likely lost cause for GOP , Kimberly Atkins, Boston Herald, Page 10,
    15 March 2017.
  2. Vote on Senate health care bill delayed amid lack of support, Meghan Kendally and Mariam Khan, ABC News,
    27 June 2017.
  3. Better than the Status Quo, Senate Health Care Bill Still Misses Major Opportunities, Edmund Haislmaier,
    Robert Moffit, Robert Rector and Marie Fishpaw, The Heritage Foundation, 26 June 2017.
  4. Here's the latest on Obamacare repeal, Ed Feulner,, 29 June 2017.
  5. American Lion: Andrew Jackson in the White House, Jon Meacham, Random House Trade Paperbacks,
    Page 143, 2009.
  6. Editorial: Work together on health care, J-W editorial staff, Lawrence Journal-World, 28 June 2017.
  7. John McCain suggests a bipartisan compromise must be reached on health care, Rebecca Shabad, CBS News,
    28 March 2017.


  13 July 2017 {Article 299; Govt_73}    
Go back to the top of the page