Dear (Quite Possibly) President Trump

Even the most ardent of Obamacare supporters are now forced to admit that the law has hit a rough patch this year. The opposition to Obamacare is positively gloating with self-congratulatory “I told you so” assessments of the supposedly dire situation. Defenders of the cause are counteracting with the customary deluge of charts and graphs to prove unequivocally that Obamacare is actually turning out better than they expected. Integrity and honesty being in short supply on both sides of this quandary, chances are excellent that no matter what happens next, the American people will lose big time, unless….

If Mrs. Clinton becomes the next President of the United States, Obamacare will survive largely unharmed with a few minor tweaks to address a few minor initial oversights, best summed up by Sara Rosenbaum, a professor of health law and policy at George Washington University: “The subsidies were not generous enough. The penalties for not getting insurance were not stiff enough. And we don’t have enough young healthy people in the exchanges.”  To complete the solution, Mrs. Clinton may very well throw in an option to buy into a Medicaid managed care plan for rural hillbillies (similar to the Arkansas “innovation”), and call it “the public option” to make the lefty wing of her party happy.

If Mr. Trump becomes the next President of the United States, Obamacare will come under vicious attack. Mr. Trump, who is running as a Republican, adopted the GOP “repeal and replace” Obamacare battle cry pretty much verbatim.  On Tuesday, one week before the election, at Valley Forge of all places, the Trump team unveiled its alternative to Obamacare. There was not much under that veil: selling insurance across state lines, health savings accounts, price transparency and Medicaid block grants to states, along with a commitment to retain the preexisting conditions clause and to have a transition period so nobody gets hurt. Team Trump didn’t even try to come up with a serious solution and I’m glad they didn’t, because it would have been incredibly dumb if they did, and because this gives me an opportunity to make my case.

Dear (Quite Possibly) President Trump,

I know you don’t know much about health care, and that’s okay, why should you? You probably know that health care isn’t working well in America. Very few things seem to be working as well as they should or as well as they used to work. This, after all, is why you say you ran for President.

There is unanimous agreement that health care needs to be made great again. The disagreement is on how to go about it. On the campaign trail, you had to come up with something to throw against Obamacare, which is fine, but now you have to actually fix it and those are two very different things, as all Presidents before you discovered to their chagrin, so here are a few Obamacare points to keep in mind.

  • Obamacare cannot be repealed and replaced in one stroke. It’s a lovely catchy phrase, but Obamacare is massive legislation that begot more legislations, such as MACRA (look it up), and thousands of regulations, many already fully implemented, others in various phases of implementation. Money has been spent, mergers and acquisitions have occurred, companies have been funded, contracts have been awarded, people have been hired, and this sea of change is engulfing private and public sectors inside and outside health care to the tune of $3 trillion dollars annually. You cannot change 20% of the economy the first day in office. Not even if you know precisely how you want to change it. And you don’t. My advice here is to settle down for the long haul.
  • Obamacare doesn’t need to be repealed at all. It just needs to be gradually replaced. It’s like renovating the Old Post Office with the tenants living in the building through the entire project. It’s very tricky because the end results are paramount, but the process itself is as important. The tenants, you see, are the American people, and you work for us now, and I assume you don’t want to get fired mid project. We expect you to come in under budget and ahead of schedule, of course, but we also expect no dust or debris in the lobby, no beams crashing on our heads, no interruption in utilities, and very little noise, and you promised not to disappoint us. It’s going to be wicked hard, but we know you can do it, hence our vote.
  • Obamacare is not health care. Obamacare is the two bit façade they slapped on our health care. Fixing health care is precisely like renovating a building. Sure, you have to rip off the cheap paint and plaster, but you don’t start demolishing things like a bat out of hell, do you?First you get engineers to assess the building, its structural integrity, its surroundings and its potential or lack thereof. You get architects to look at blueprints, floor plans, shafts, beams, columns, electric, gas, water, HVAC, etc. You do some market research to see what people want and can afford. Then and only then, you make new plans, you make schedules, you price and choose materials, you bargain and fight, you hire workers, and the fun begins. I’m pretty sure you know what happens if, at any point, you skimp on prep work.
  • Obamacare was put together by political hacks who serve special interests and their lobbyists, and by ideologues who think the American people are too stupid to care for themselves. Obamacare in its totality is a corrupt entitlement system for large health care corporations and for Silicon Valley. If you assemble the conservative version of the Obamacare team of scavengers, your will fail. If you accept the perfidious, back-stabbing, premises of the Ryan plan to gut health care for the people who voted for you, you will fail. If you want to fulfill your promise to the American people, you’ll have to bypass the punditry swamp, put on a hardhat and go down to where health care happens and get your information first hand and free of charge.

Obamacare is irrelevant. Obamacare is at a minimum a distraction and at a maximum an impediment to affordable, high quality health care, because Obamacare misses the point entirely. I am sure you know from personal experience that in America one can get the best health care in the whole world, if one belongs to the privileged elite. What needs to be fixed is the distribution of health care across the nation. Not to disparage your “policy” speech at Valley Forge, but perhaps you should consider that the health care Inferno is nine circles deep, and what you see at first blush is just a hint of the horrors that lay beneath.

  • Health care is too expensive in America because America has become too poor. Health care is too expensive because American workers didn’t get a meaningful pay raise in decades. Health care is too expensive because poor people tend to be sicker and so are their children.  Health care is too expensive because there are too many middlemen and regulators between doctors and patients taking profits for busywork that adds no value. And most of all, health care is too expensive because politicians must pay back for their last campaign, and raise money for the next.
  • Health care is not a “consumer” product or service, and as Bill Clinton said, health insurance is not like auto insurance or home insurance. People don’t want to “shop” for medical care like they shop for hotels or shoes. It is frightening and humiliating to shop for your life or the life of your child. Imagine if you had to do that in a dire situation and understand that all people feel the same way (even the deplorable ones). Price transparency is just a load of crap. It’s one of those empty phrases politicians use to hoodwink voters. You are not a politician, so don’t do it. Just say no.
  • Free market for health care will work as well as free trade is working for the economy as whole. There is no such thing as free trade or free markets. There never has been and never will be. Trade and markets are manipulated and defined by the shrewdest and strongest participants. Sick people of limited means are no match for global corporations that managed to bring our entire government to its knees. Free market health care will leave most Americans with no doctors, no medicine and no care, just like free trade left us with no factories, no jobs and no income. You offered to be our voice, to fight for us and drain that swamp. There is no bigger swamp than health care in America.
  • Just take a look at the disgrace called Medicaid. No, seriously, look at it. Tossing block grants over the wall to states that are even more corrupt than the federal government, and washing your hands of the whole mess, will just make things worse. Remember that the vast majority of people on Medicaid are employed. They are employed in those new and improved crappy jobs that replaced manufacturing. Medicaid is now a penny-vacuuming machine that treats both doctors and patients like trash (with all due respect to your VP). Here is a litmus test for health care plans: would your less wealthy buddies be okay with getting care through Medicaid? Are any doctors you know okay with working for Medicaid? No? Neither is anybody else. You can’t fix health care without fixing Medicaid.

I don’t know how to fix health care. No matter how loudly they scream, how certain they are that theirs is the absolute truth, and how vigorously they wave their illustrious credentials, nobody knows how to fix health care. Nobody. My suspicion is that we are trying too hard. Health care is overmedicated with solutions that have toxic side effects, for which we apply other solutions with even higher toxicity, and before you know it a mild case of the flu starts to look like metastatic cancer. So what should you do on your first day in office? Anything you want, anything at all, anything but health care.

Take your time. Find the real health care still flickering underneath the suffocating layers of Obamacare and its bloated legislative and regulatory progeny. Find real doctors who still care for the health of real patients as they did before health care became a national trough for consultants, lobbyists and other fancy thieves. Beware the experts carrying charts and graphs and big data. Ask Peter Thiel about “big data” and “machine learning” and do trust him on this one. The daunting complexity of health care is largely due to greed, fraud and treachery. If you want to make health care great again, work hard to make health care simple again. 

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33 replies »

  1. Loved the Star Trek comment. Healthcare in the future is zero percent of their economy.

  2. Lost is the discussion is the value to the patient of the service. Value is determined by the buyer of a service. Since the buyer is the government here, what is the value to the government of this exercise?

    Until the patient is spending his own resources as seen fit by him or her, there will be no change in the folly that is HealthCare in America

  3. Re “tons of research and analysis”:
    It amazes me that our policy experts like to ignore the large Rand study on a model that works in “bending the cost curve”. The 2011 link below

    And they point out “high vulnerable” do alright in these types of plans.
    They do point out their study shows a reduction in preventive services, but not clear if this is harmful. Hint: many (most?) net out to a negative (think annual physicals, massive psa testing with an unreliable indicator leading to far too many surgeries). I have noted this Rand stuff before….but no one wishes to incorporate its results in their preferred “reforms”…which all seem hell bent on centralizing power and imposing things on docs and patients…..whereas this shows the benefit of giving more control and incentives to patients for prudent consumption of health care.

  4. I am not promoting “know-nothingism”. I am promoting a measure of integrity and humility, and I am promoting informed decisions.

    There are thousands upon thousands of “moles” on this board and people claim to know how to wack this or that mole. Problem is that even in the fortuitous event where their pet mole is down, a hundred others raise their heads. We call it unintended consequences, but I call it shortsightedness or outright fraud.

    We will not solve health care as long as we have these self-serving so called experts moving hundreds of billions of dollars around based on nothing more than their personal “belief”, political expediency, and hopes of enrichment.

    My suggestion would be to do tons of field research and analysis before we undertake the next harebrained step. That’s all I think I said…

  5. I liked her diagnosis, but not her claim that no one has a clue how to solve the problem. We have plenty of people promoting know-nothingism in our society on all sorts of issues, not just health care. Margolit shouldn’t be lending her voice to all that gleeful pessimism.

  6. You’re right about the existence of edges. I wouldn’t cover stuff like that unless there is a well defined medical problem (feel good sessions with a 5th Avenue therapist, for example, or those posh executive physicals….). On the other hand I wouldn’t punish people for going to the ER. Instead I would make it easier and more enticing to go to a primary care doctor.
    If we have a Medicare FFS type of thing, provider-induced demand would need to be policed (and by provider, I mean those bigger than life hospitals – maybe break them up or something).
    I don’t think co-payments serve any purpose other than to increase complexity of billing and harass doctors. We can maybe use them for discretionary items, such as private rooms, brand name drugs where an exact equivalent exists, rainbow colored casts…. I’m sure there will be lots of haggling and fighting, but if we’re all in the same boat, I think we can pull it off… if our government is on our side, and that’s a big huge “if”…

  7. ….and we agree on which candidate is more likely to “drain the swamp”!!

  8. There is this fallacious argument that we keep making: if someone is wrong on one thing then he/she must be wrong on everything, and vice versa.

    I think Mr. Thiel is right when he calls “big data” and other buzzwords pure and simple fraud, and he is right when he observes that in recent decades tech innovation is just eye candy without substance (and maybe with a sinister touch to it).
    I think he is wrong on many other things, particularly dismissal of higher education without which he would not be where he is, and that entire Ayn Rand thing, neither of which are in any way related to his well informed assessment of the crappy tech that is engulfing us today.

    So yeah, I am okay using his opinion on one subject and discarding his opinion on other subjects. I’m not anointing him (or the other guy 🙂 ) to be my God, so I feel free to pick and choose…

  9. I also vacillate on the importance of moral hazard. But if you think of mental health and services on the edge of cosmetic and vanity care like bariatric problems, then it probably does cause some excess use. The old Rand study found some. I used to think that health care was beset by only three devils: provider-induced demand; moral hazard and third party payers. We might be able to forget moral hazard and hardly see any change. What happens if we charge no co-payments? Have we studied this?

  10. We do agree on that 🙂 But we probably don’t agree on the solution. Having government pull out or step back and let whatever “markets” they created be “free” will not work because due to difference in size of market participants, coercion of one type or another is guaranteed.

    We need better government. That’s all….. Someone needs to do the policing, particularly in today’s very complex, very connected world.

    This is why I don’t understand my “liberal” friends. We have one candidate asking us to accept that corruption in government is an immutable feature that we should not question, and that is the “acceptable” candidate? The Republic will end if we choose to ignore vulgar language and a bad hairdo in the one candidate willing to fight corruption? The doomsday hysteria from corruption beneficiaries and perpetrators is beginning to sound like fear.
    We either solve this at the ballot box on Tuesday, or we solve it in the streets at a later date. There is no third option.

  11. Margalit,
    “Free” means the absence of coercion, (aka voluntary exchange)….and free to the degree possible from govt. bureaucrat coercion or coercion from one party or the other in the exchange. Protection from coercion comes from the judicial system…..property rights, contract law, and criminal law. I agree, Adam Smith and our Founders viewed morals and ethics (in their view based on religion) as essential elements…..and that remains the case. The problem with health care is that the political players who “intervene” to help the weak get captured by the influential players who rig the “fixes” to maximize their profits/protect their turf…….even as they speak eloquently of altruistic/philanthropic goals…..perhaps we agree on that? We saw the same game in ethanol mandates and we are seeing it in the renewables game (cloaked in rhetoric about saving the planet).

  12. Go look at history and see what happened when they allowed credit cards to be issued across state lines….
    Hint: people got royally screwed.

  13. Before we explore less or more, how about we explore “free” and “market”?
    Free from what? Public regulation? If so, smart/strong participants will fare better during any given transaction (even if it is between to individuals). As time goes on, and transactions crisscross and multiply, we have a market and the players are never equal. If we let this proceed on its own, we get Darwin (or Somalia). If we intervene to level the playing field for physical prowess (or lots of guns, or ganging up together…), the market will not look “free” to those who are the target of our intervention, but it will look a lot “freer” to the weaklings… So free is in the eye of the beholder, no?
    If we intervene to eliminate coercion and violence, because strength is not equally distributed by God, can we intervene to eliminate artfully clever crooks, because IQ is not equally distributed? The geniuses will cry foul, I’m sure….

    Not even Adam Smith dared to suggest that markets should be free from morals and ethics… Today it is much harder to discern those things in our markets because they are not markets. They are arenas where wealthy men with no morals compete with each other. We are just marbles in their game…. and I think that’s where Thiel was going….

  14. … where no one has gone before is the PC version in the newer version 🙂

  15. Watch a little Star Trek NG this weekend…. even Mark Twain liked it… 🙂

  16. Why so sensitive to my question? Any rational person has to see there is a continuum from more free to less free….seems you just don’t want to use the phrase “less free” as a descriptor of your prescription for health system improvement. I can understand that as it doesn’t sound good….maybe more regulated works better for you?

  17. Don’t put words in my mouth, “Free markets” is a naive bumper sticker cliche. Private markets, again, get regulated one way or another. Moreover, some markets require more independent regulation than others. And, refrain from going “No True Scotsman” on me.

    Would I assume you’d favor “more free” privatized for-profit air traffic control?

    I’m with Margalit here:

    “Free market for health care will work as well as free trade is working for the economy as whole. There is no such thing as free trade or free markets. There never has been and never will be. Trade and markets are manipulated and defined by the shrewdest and strongest participants. Sick people of limited means are no match for global corporations that managed to bring our entire government to its knees. Free market health care will leave most Americans with no doctors, no medicine and no care…”

  18. Would you agree that there is a continuum of more free to less free markets for any good or service? And assuming yes, do you think the way to improve US health care is to move towards more free or less free? I would assume you think less free is preferable….or am I wrong?

  19. Yes, this is the correct approach, but I disagree that it is complicated.
    The only complicated part is how to bust the near monopoly status of the insurers in most regions (technically oligarchy with one player having over 60% market share). The dominant insurer collects up to 15% of the health spend and cooperates (colludes?) with the major hospital networks to keep them solvent and to keep competitors out (for example, ambulatory surgery centers that charge less). Opening the insurers up to cross state line competition will disrupt this cozy arrangement and drive down costs. The complicated part is to restrict the ability of state regulators to create regulatory barriers and keep imposing state by state mandates.

  20. Sounds like the future Marx and Lenin were pursuing/promising. How’d that work out?

  21. Perhaps, but my guess is that things will turn out differently. If this was your typical GOP candidate, or an Ayn Rand zealot like Paul Ryan, I would agree, but that is not at all the case here.
    BTW, tossing health care to Congress is precisely what President Obama did and with that missed a golden opportunity to do the right thing while he had both houses.

  22. That’s a lot of accounting and bureaucracy…. a lot….. I sort of think there must be a much simpler and straightforward way, no? 🙂
    I also don’t think moral hazard on the patient side is a real problem in health care. I mean nobody is going to get an extra stent or two just because they’re free…. I don’t think…
    The bigger moral hazard I see is from insurers and suppliers (drugs) and tech companies that seem to be piling on plate after plate at the public buffet, and then some…

  23. I’m not going to defend Thiel here, but if we are talking about a distant future like, say, the 24th century Star Trek universe, competition becomes unnecessary, because profits become meaningless when poverty is non-existent, money and accumulation of wealth are non-existent and all material needs of all people have been met. There are no markets in that universe, no economic concepts….. I love Star Trek…. 🙂

  24. Let the insurers in the exchanges do anything they like, including underwriting. Subsidize the poor, the sick and the aged and the kids by income, wealth, executive function, and illness. Subsidze by using refundable vouchers or Medi-Bucks. Let the docs and hospitals do anything they like.

    How to subsidze using the correct indices and criteria are terrific and fascinating puzzles. It has to be done using easily-obtained public data. How to cause vouchers to be valued and saved as if they were money is another complex problem. Vouchers allow the state to be altruistic but also foster shopping when it us appropriate, and assuage moral hazard in patients…especially. if they are refundable in a clever way.

    Both of these problems are key exciting components in health care around the world and could help many other nations if we could solve them. How to we estimate when altruism is needed? How do we cause patients to be aware of costs? How do we cause providers to compete on every level?, from the price of the premium to the price of the procedure? How do we get big Pharma to compete and join the party?

  25. I would ask where the deep knowledge that the policy makers responsible for Obamacare no doubt have, has brought us? Steve – the democrat candidate wants to expand medicaid and will fix high premiums with more tax dollars. In addition to free tuition for folks earning < 125k, she will also give all folks < 10 a pony, or maybe it was a unicorn? Entitlement reform is hard – 'repealing obamacare' is certainly aspirational – but discussing a transition from this to something else doesn't seem irresponsible, and shouldn't be dismissed.

  26. If Trump® becomes President, health policy reform will likely be among the least of our concerns. They don’t teach Article II at Trump® University Skool of Konstitutional Jurisprudence.

  27. Trump has little knowledge about or interest in health care (or anything else really). In general, when in power the GOP ignores the issue. Trump will just be more of the same. At best, he turns it over to Congress. Expect the House to repeal Obamacare another 50 times and the Senate to face filibusters.


  28. “We have to come up, and we can come up with many different plans. In fact, plans you don’t even know about will be devised because we’re going to come up with plans, — health care plans — that will be so good. And so much less expensive both for the country and for the people. And so much better.”

    – Donald Trump, September 14th, 2016 on the Dr. Oz show

  29. “There is no such thing as free trade or free markets.”

    Glad I’m not the only one saying this. Moreover, to the extent markets are “free,” the most venally adroit and asymmetrically powerful Gresham’s Dynamic actors among us are “free” to obfuscate, collude, and capture the markets for their own benefit. This is not exactly news.

    Human socioeconomic affairs get regulated one way or another.

    Oh, and by the way, “libertarian” Peter Thiel (Trump SCOTUS nominee?) is on record advocating Monopoly power — i.e., that “competition” and “capitalism” are mutually antithetical. See his book “Zero to One.”

    “Monopolies drive progress because the promise of years or even decades of monopoly profits provides a powerful incentive to innovate. Then monopolies can keep innovating because profits enable them to make the long-term plans and to finance the ambitious research projects that firms locked in competition can’t dream of.

    So why are economists obsessed with competition as an ideal state? It’s a relic of history.”

    Thiel, Peter; Masters, Blake (2014-09-16). Zero to One: Notes on Startups, or How to Build the Future (p. 33). Crown Publishing Group. Kindle Edition.

    “CREATIVE MONOPOLY means new products that benefit everybody and sustainable profits for the creator. Competition means no profits for anybody, no meaningful differentiation, and a struggle for survival. So why do people believe that competition is healthy? The answer is that competition is not just an economic concept or a simple inconvenience that individuals and companies must deal with in the marketplace. More than anything else, competition is an ideology— the ideology— that pervades our society and distorts our thinking. We preach competition, internalize its necessity, and enact its commandments; and as a result, we trap ourselves within it— even though the more we compete, the less we gain.” (ibid, p. 35)

    Excellent post, btw. I was wondering where you’d been lately.

    PS- Interesting long read article on Medicare: http://harpers.org/archive/2016/11/dont-touch-my-medicare/?single=1