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 in 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 give or take a few communicable diseases. Additional thoughts are below:
- Invest and innovate, especially in primary care. We are cost-effective and knowledgeable.
- 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 care for my patients and do my job. Give me control.
- 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?
- 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.
- 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.
- 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.
- 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.
Niran al-Agba is a physician in Washington State.
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