Health care reform after Obamacare

The Supreme Court’s ruling that upheld Obamacare does not mean that the law’s days are not numbered. It is likely that Republicans will sweep this year’s elections and repeal the law before it goes into effect. If the law does go into effect, the Court’s decision that Congress cannot force the states to participate in the Medicare expansion contained in the law means that the complex law is even more unworkable. Gov. Nathan Deal told Georgia Health News that the state had not made a decision on whether to participate in the Medicare expansion. Without major reform, Obamacare will collapse under its own weight, wreaking havoc on the American health care system and the federal deficit as it does so.

The question is what comes after repeal. The status quo of the health industry is also untenable. Reform is badly needed, but it should focus on lowering health care costs through free markets and competition. Obamacare does nothing to lower costs. To the contrary, it increases them and then mandates that people buy the more expensive insurance.

Successful healthcare reform will have several aspects that Obamacare did not. First, successful reform will be bipartisan. The Affordable Care Act was one party’s vision of how the health insurance industry would work. It was crafted in secret behind closed doors and passed by a party line vote that required the procedural trick of using a budget reconciliation to avoid a Republican filibuster. Democrats did not seek Republican input and failed to win a single Republican vote in either house.

Second, successful health care reform must reduce the costs of health care and insurance. If insurance is made more affordable through market reforms, more people will want insurance. The Affordable Care Act essentially ignored competition and the marketplace in exchange for top-down mandates, price controls, and government collusion with the pharmaceutical industry. The result was an immediate increase in the price of health insurance. Many insurers also stopped writing unprofitable policies, resulting in shortages in some markets.

Finally, successful health care reform will simplify and streamline regulations for the industry. The Affordable Care Act, at 2,409 pages, was neither simple, streamlined, nor efficient. It included at least 18 new tax increases, $19 billion in spending through 2013, and created 159 new federal agencies and programs. The bill was so complex that Nancy Pelosi, at the time the Speaker of the House, famously said in a Fox News clip, “We have to pass the bill so that you can find out what is in it.”

Successful health care reform would re-introduce competition into the health care marketplace. There are several ways of doing this. One is to stop the favorable treatment of employer health plans. Currently, premiums for employer-provided health plans are not taxed, but, if a worker wants to buy an individual policy instead of the one at work, premiums are not tax-deductible unless their medical expenses exceed 7.5 percent of their Adjusted Gross Income. If premiums for all health insurance were deductible, it would provide an incentive for people to shop around for the insurance that best suits their own needs.

Another common theme in competition is encouraging states to allow their residents to buy and sell insurance across state lines. The effect here would be two-fold. First, it would provide a larger market for the state’s insurance companies. If the state’s companies offer quality insurance at competitive prices, their sales and profits should increase. Economies of scale would drive down prices.

Second, states that do not have competitive health insurance laws would see their business go to other states. Each state sets it own standards and regulations for health insurance. States that mandate more benefits typically have higher costs for insurance. By allowing interstate insurance sales, citizens of states where insurance is expensive could buy more basic policies in other states. If the insurance companies and state governments see a sufficient loss of sales in highly regulated states, it would encourage reforms to allow them to compete. Otherwise, the insurance companies would go out of business and the state would lose tax revenue.

A third idea is to open more low-cost clinics. In many cases, patients at a doctor’s office never see a doctor for a routine visit. Instead they are treated by a nurse practitioner. In recent years, pharmacies and retail stores such as Wal-mart and Target have opened small health clinics. These clinics are a boon to the working poor because they often do not require appointments, they provide a fast resolution for routine medical problems, and they are much less expensive than an emergency room or traditional doctor’s office. Additionally, these clinics often have extended hours and are open on weekends. For more complex problems, the clinics refer patients to local primary care physicians or hospitals. The Journal of the American Medical Association sees retail clinics as a way to deal with the current shortage of physicians and as a way for every American to have medical care within a few miles.

Partnerships with private companies provide a great resource for helping to lower health care costs that was totally ignored by the authors of the Affordable Care Act. The possibilities can be seen in Wal-mart’s $4 generic prescription plan. The plan, introduced in 2006, was quickly matched by other retail pharmacies. Today, customers of Publix can even get prescription antibiotics at no cost. The downward pressure on prescription prices started by Wal-mart arguably did more to help consumers than the federal government’s prescription drug entitlement and it was accomplished without government mandates and at no cost to taxpayers.

If the goal of health care reform is to cover as many Americans with health insurance as possible, then it is only logical that reform should reduce the price of health insurance as much as possible. Basic economic law states that as price decreases, demand for a product increases. As health insurance premiums go down, more people will buy policies.

One answer to the high price of health insurance is to allow and encourage companies to write no-frills major medical policies. Every time government mandates that health insurance offer a new benefit, the price goes up. Major medical policies don’t cover everything from mental health to Viagra, but they do protect people against the cost of a catastrophic illness. This is all many people want or need. Consumers should be able to choose high deductibles and be allowed to opt out of coverages like pregnancy, preventive medicine, and contraception in exchange for lower premiums. When regulators try to make a policy all things for all people, the result is expensive and prices many people out of the market.

Additionally, health care pricing should be made more transparent. Few people know how much a visit to the doctor’s office actually costs because most people with insurance pay only a predetermined copay, $20 for example. The only way to find out the actual cost of the visit is to look at insurance documents long after the visit. Such a system makes it impossible to compare prices of competing physicians and hospitals and encourages increased consumption. These factors drive up the cost of health care by limiting the exposure of consumers to the true costs.

Similarly, participants in government programs such as Medicaid and Medicare consume health care at prices that are below market rates according to the Washington Post. The deficit from these government price controls is then passed along to private consumers, further increasing health care costs for everyone else. True health care reform must take steps to control the costs of Medicare and Medicaid, while preserving these programs as safety nets for the truly needy. The Republican “Path to Prosperity” budget plan includes provisions to reform Medicare according to Kaiser Health.

One popular provision of the Affordable Care Act is the requirement that insurance companies cover people with pre-existing conditions at below-market rates. The problem is that the rule gives people an incentive to not purchase insurance until they are sick. A better solution to the problem of pre-existing conditions would be to create assigned risk pools at the state level.

In an assigned risk pool, states require insurance companies to accept otherwise uninsurable customers in proportion to the amount of business that they do in the state. Because these policies are high in risk to the insurance company, their premiums and deductibles are higher. This encourages people not to wait until they are sick to purchase insurance. Georgia has long had assigned risk pools for auto and home insurance. Such a proven concept would make sense for health insurance as well.

A final path to lowering health care costs is tort reform. Tort reform involves limiting the ability of patients to sue for medical malpractice. Malpractice lawsuits, sometimes with outrageously large punitive damage awards, have caused premiums for malpractice insurance policies to increase. This higher cost is then passed along to consumers by doctors and hospitals. Tort reform does not prohibit lawsuits or collecting legitimate damages, but it does discourage frivolous lawsuits and excessive punitive damage awards. Understandably, lawyers oppose tort reform and, because lawyers are a Democratic constituency, Obamacare did not address the issue.

Texas passed a tort reform law in 2003. My San Antonio says that before the reform one in four doctors was sued each year. Eighty-five percent of the suits never went to trial, but still cost an average of $50,000 to defend. Cases that went to trial cost $1.4 million each. These costs led to increased insurance costs for doctors and, ultimately, higher costs for consumers.

According to American Medical News, malpractice insurance premiums have decreased by 30 percent since the law was enacted. The state also saw medical license applications increase by 83 percent when compared with before the reform. A spokeswoman for Gov. Rick Perry said, “Comprehensive medical liability reform has improved access to medical care, particularly in underserved areas….”

Mississippi’s experience was similar. Tort reform was enacted there in 2004. In the following years, malpractice insurance rates fell sharply, lawsuits decreased by 90 percent, and doctors stopped fleeing the state according to a 2008 Wall Street Journal article cited on the blog Captain Kudzu.

There is no single answer for how best to reform the health care industry. Solutions should consider economic realities as well as the needs and desires of the American people. Instead of federal mandates, states should be encouraged to experiment with their own solutions. Obamacare, which became law over the overwhelming opposition of the people, does none of that and is destined to fail.

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