by Seth J. Baum, MD

Sporadically during the presidential debates we hear discussions that attempt to resolve issues. One of the most contentious one relates to healthcare, Obamacare specifically. Few would argue that we are better off today than we were prior to the institution of the Affordable Care Act. Those in favor point to the process of change, “Sometimes things must get worse before they getter better”, they incant. Those opposed argue by citing the extraordinary rise in deductibles, loss of physician choice, and the burgeoning power of insurance providers to determine which patients are permitted to receive particular medications, procedures, or diagnostics. Both sides have positive and negative aspects to cite. As a practicing physician in national leadership roles, and as a patient on far too many occasions, I have an unenviable advantage in evaluating the process. This is what I see.

Obamacare plusses include the elimination of preexisting conditions, portability of healthcare, and expanded coverage opportunities for the lower middle class. Negatives include the massive deductible and premium hikes (rendering the practical utilization of insurance unaffordable for enormous numbers of Americans), loss of physician choice, and perhaps worst of all an unprecedented shift of power to the insurance providers. Doctors now spend much of their day fighting to enable patients to receive the care they require. Often the fights become so tedious that insurance providers win by attrition. This often leaves patients unprotected and powerless. So what is – or are – the solution(s)?

During the last Republican debate Rubio and the media ridiculed Trump for presenting a presumably simplistic view of his solution. To paraphrase Trump, eliminate state boundaries for insurance providers and let competition do its thing. He added that Obama’s pre-existing condition law would remain, and that no American would be permitted to die on the street. Kasich on the other hand proposed a more complex solution in which, stated more simply, doctors would be held to two standards, cost containment and the provision of top-quality care. Although Kasich’s proposal emphasizes the role of doctors in the economic burden of healthcare, yet doctors are responsible for only a tiny fraction of healthcare costs, let’s still examine these two positions.

With Kasich we need to understand the metrics for “quality” of care. This is not a simple matter. In fact, some studies have already shown that, counter intuitively, the more satisfied patients often have the worst outcomes. Measuring quality it turns out is extremely complex. A simple and accurate assessment tells us that quality of care is really no different from everything else in our world, “You get what you pay for.” Things that cost less are typically worth less. We all know this, yet somehow in the context of medical care we think things should be different. One of the reasons for this misapprehension is the vastly higher cost of healthcare in the US compared to what is found in many other nations. Of course, not considered in this equation are the costs of litigation, medical malpractice insurance, and defensive care, as well the burgeoning cost of hospital infrastructures. CEOs of hospitals can earn millions of dollars a year. Include the vast and growing group of management teams also earning extraordinary sums of money and you will witness one of the greatest wastes in healthcare. Thus, waste is a preeminent problem that is typically overlooked. Another flaw in Kasich’s system is an unavoidable inherent conflict of interest: doctors earn more money by providing cheaper care. In other words, withholding care leads to bonuses. Kasich would counter by arguing that the requirement of quality will assure this doesn’t occur. But I’ve just told you that quality is so difficult to measure that studies have already demonstrated worse patient outcomes in the setting of “better” quality of care. So Kasich’s slope is slippery, and as a physician and a patient I admonish everyone to examine his proposal with more seriousness than a mere glance.

What about Trump? Can competition win the day? In many ways I believe so. Withdrawing the insurance industry’s unfair advantage and forcing competition into the system will do what it always does; provide more opportunity for the consumer. In this case, that’s you and me, the patients. As for not permitting anyone to die on the street, I couldn’t agree more. We in medicine have always provided free care for the indigent. No one in the media seems to recognize this, but such is the case. And what would enable us do so even more frequently would be permitting doctors (as all other businesses are allowed) to deduct such care as an income loss. Why doctors cannot currently do so is beyond me. And as for pre-existing conditions, of course we need to keep that in place. No one but the insurance industry should refute its importance. And who will pay for it? Akin to Trump’s wall, the insurance companies will. They will be forced to. What disturbs me most about this debate though is that a simple plan is viewed as vacuous while a complex one, thoughtful. Sometimes the simple solutions are best. And absent a political or professional agenda I must assert that this, I believe is one of those conditions.