Graham-Cassidy is Dead. It’s Back to the Drawing Board. Why Not a Two-Tier System?

Remember back in 2012 when then Vice-President Joe Biden told us, “Bin Laden is dead, General Motors is alive”? The good old days. Also around the time Senators John McCain and Lisa Murkowski promised to repeal Obamacare. Along with a bunch of other Republicans seeking reelection to Congress.

Fast forward to 2017. The new catchphrase is “GOP is dead, Obamacare is alive.” At least their credibility is dead. Buried in the rubble of broken campaign promises. Not only Obamacare repeal, but also tax cuts, immigration enforcement, balanced budgets, reduced spending, and so on.

Repeal and replace, as a promise was simple enough on the campaign trail.  We heard this promise in 2010, when voters gave the House to Republicans.  We heard it again in 2012, when voters gave them the Senate.  Despite controlling Congress, Obamacare remained alive and well.  Candidate Donald Trump, along with most Republican members of Congress, promised repeal and replace last year.

Eight months into the Trump administration, Obamacare is still kicking. Congress had three bites of the apple this year and each time came up with a worm instead. This week was their third attempt to fix Obamacare. Not the promised repeal, instead only financial window dressing to keep Obamacare alive in some shape or form.

Graham-Cassidy didn’t even earn a Senate vote this week after three promised GOP defections. Too bad they didn’t vote. Senator Richard Shelby thought a vote was fruitless saying, “Why have a vote if you know what the outcome is and it’s not what you want.” Why? How about getting the Senators on record with a yea or nay vote? Votes that they could be reminded of during their next campaign.

Once again, the do-nothing Congress has squandered a once in a generation, or lifetime, opportunity to advance a conservative agenda. Instead after 8 months, they have little to show for their control of the executive and legislative branches of government. Obamacare remains the law of the land.

Republican lassitude is not lost on voters, as Luther Strange learned this week. Senator Bob Corker noticed too, choosing to do nothing as a private citizen rather than as a U.S. Senator. Congress may not want to repeal Obamacare, but the voters do.

Many want a simple repeal, similar to what Congress passed multiple times, certain that their virtue signaling repeal bills would be slapped down by an Obama veto. Now that the veto threat is gone, so are the votes for repeal. It won’t happen. Neither will the IRS ever be abolished, or the Departments of Education and Energy be closed. All conservative pipe dreams but far from the reality of current Washington, D.C.

Obamacare remains in a death spiral. Another year of double-digit premium increases, some families paying more for their Obamacare insurance premiums than they are for their mortgages. Not to mention rising copays and deductibles, and narrowing physician and hospital networks. All making medical care unaffordable for many Americans, even though they have insurance.

What’s next? Waiting in the wings is Bernie Sanders’ “Medicare For All” bill which has the support of 17 Democratic senators, more than a third of their caucus. On the House side, John Conyers has his own version of single-payer with 119 cosponsors, more than half of the Democrats’ House caucus.

America is already drifting toward single-payer. Medicaid, Medicare and the VA System are all single-payer health insurance plans. Or more accurately, government-run healthcare systems. Obamacare is following this path. A third of counties have only one Obamacare insurer. It’s not far from what we have now to a true single-payer plan. And the Democrats are ready and waiting to take advantage of Republican chaos and an imploding Obamacare.

Perhaps this was the plan all along. It was then Senator Obama who once said single-payer is the goal, but “we can’t get there immediately.”

If President Trump cannot get anything done with his own party in Congress, maybe he calls his new buddies Chuck and Nancy. Just as John McCain always extolls, “reaching across the aisle.”

Suppose Donald, Chuck and Nancy cook up a two-tiered system, something for everyone? A public option and a parallel private option. Just as most developed countries have. The public option covers everyone. Think of Medicaid for all. A bare bones catastrophic coverage plan available to all Americans. With minimal or no out-of-pocket costs to patients but with the tradeoff of long wait times for care and limited treatment options.

The private option allows individuals to purchase medical insurance or actual care directly, what they want and need, nothing more. Insurance without mandates and regulations. No subsidies, tax breaks or government assistance. Pure free market.

Think of K-12 schools. Public schools available without cost to all students. For most a good education. And a private school option for those who desire and have the means. Pay the private cost or default to the public option and pay nothing.

Pros and cons to each system, but both are separate and distinct, each doing what it’s designed to do. Rather than an amalgam of both systems, which is what we have with Obamacare, Graham-Cassidy, skinny repeal or whatever the witches and warlocks of Congress conjure up.

Something for both the right and for the left. Free market for the right. Universal coverage for the left. Perhaps the only way to get past the current logjam in Congress. If Republicans continue to twiddle their thumbs and do nothing, they may soon find themselves in the minority. Leaving Bernie in charge.

If the Democrats control Congress, make no mistake, they will pass single-payer. No defections. They will change procedural rules such as the filibuster if necessary. And they will accomplish what the Republicans are unable to.

In the meantime, Obamacare is alive and it’s the GOP on life support.

Brian Joondeph is an optometrist based in Colorado.

14 replies »

  1. We should all remember two observations: *) the Medicare eligible population is in the process of doubling between 2000 & 2030 and *) the level of poverty within our nation’s citizenry is doing nearly the SAME ! See “OUR KIDS — The American Dream in Crisis” by Robert D. Putnam, 2015. He is also the author of “BOWLING ALONE,” 2000.
    Health Spending in 1960 as a portion of our national economy, GDP, was 5.0%. By 1970, it was 6.5%. Last year it was 18.2%. The Paradigm Paralysis of our nation’s healthcare is strangling our nation’s economy as well. We are headed to bankruptcy on the back of health spending. So far, there are no LEVERS within our nation’s healthcare reform that will solve the cost and quality problems of our nation’s healthcare.

  2. I think I support this, although please elaborate a bit.
    But only as an experiment. We don’t know what we are doing. We don’t need big synoptic changes yet. Every management and policy thing we have done so far has failed…but we grind on, in the science, making thrilling progress.

  3. Maybe a two tier will improve on the multi-tier system now.

    My objection to two tier is if it’s framed in law. When the wealthy and influential are separated from the commitment and funding for single-pay then those “wait times” will only get worse – the “let them eat cake” for health care. There will need to be something that prevents providers fleeing to the upper tier.

  4. I’m not sure you’re ever going to see Washington outlaw the private option. Singe payer will translate to a two-tier system, although I doubt it will be framed that way ..

  5. So how do providers decide which system they will serve? I’m guessing the private system pays better.

  6. My intent for a two tiered system is simple. Universal coverage for everyone at little or no cost, with the trade off of limited availability meaning wait lists. And a government free private system for those with the means and desire. Without the wait for care. Lastly something that both sides of the political aisle might agree on.

    Last point important since O-care passed w no Repub votes and so far no Dems have supported any Repub plan. A two tiered system gives each side something they want.

  7. The problem with quoting a conservative publication which quotes a Canadian conservative publication is credibility.

    Wait times in Canada is complicated and regional. You can look here for non-biased information: https://www.cihi.ca/en/wait-times-for-priority-procedures-in-canada-2017

    Canada sets benchmarks then attempts to meet them. Of course everyone wants a procedure instantly, but in Canada there’s no co-pay or deductible, and hardly any Canadian sees the U.S. system as a solution. There is also a private medical industry in Canada as well. Canada daily works to balance cost and necessity – like every good conservative would. But if you don’t like the Canadian system choose another, I’d take the German model as well.

    So how would a two tier system under your vision reduce wait times and give better care? Do you not think that insurance companies set limits on drugs in this system? My wife recently got a script for a fungal drug that was $1600. Her insurance intervened to have the doc justify that – is that not prudent? In the end my wife knew the drug was not necessary (at that price) and went with another treatment. As usual docs don’t care about cost.

    Here’s an interesting article if relevant.

    So I’m not sure of your intent for a two tier system; improve health care delivery and cost for everyone, or protect the ability of rich people to get timely care.

  8. Much like the ACA. How many times was “the secretary shall determine” in the bill? Hundreds of time. Legislation by whim?

  9. Whatever public option there is would be funded by everyone via taxes, just as Medicare, Medicaid and VA are funded now. So yes the “private bunch” would still be paying for the public option even if they chose private care.

    Lines are already there. The wait for some specialists is months now. What if these specialists choose not to take public insurance and only take private insurance or cash. Fewer specialists, demand exceeds supply and the lines get longer.

    Check with Canada for wait times. Something like 20 weeks from GP referral to specialist treatment. For elaboration… http://dailycaller.com/2017/07/07/waiting-and-waiting-for-medical-care-in-canada/

    Limited options mean the government entity providing the insurance may decide that the newest drug for disease X is too expensive and is not on formulary. Or they may decide that if your BMI is greater than Y then you can’t have a joint replacement. These restrictions are already in place in other first world countries with such a system.

    I’m not a fan of sitting in waiting rooms but yes I sit with all the “public types”, whatever that means.

  10. So doc, which tier are you going to be serving?

    “with the tradeoff of long wait times for care and limited treatment options.”

    Tell us how you’d create those long lines? How long would the wait times be and how would you triage the line? What does “limited” options even mean?

    Trouble with the school comparison is the private bunch still has to pay school taxes for the public bunch.

    Doc, you got a problem with sitting in the waiting room with the rest of us “public” types?

  11. With or without the ACA 2010, the cost and quality problems of our nation’s health spending and healthcare quality are continuing to worsen unabated. There is absolutely no reason to believe that the Paradigm for solving the scientific mandate to manage Complex Healthcare Needs can also be applied to the humanitarian mandate for each citizen’s Basic Healthcare Needs. The paradox described by Baron C.P. Snow (also an M.D.) in 1959 continues unabated. We must recognize that the social capital necessary to fuel a community’s COMMON GOOD and its healthcare services also continues to decline unabated. There is absolutely NO health insurance arrangement that will solve that problem. I recommend a modern day application of the Federal Smith Lever Act of 1914 to healthcare, community by community. It could be up and running in 6 months for a cost of @1.00 per citizen, annually. The “Design Principles for Managing a Commons” should be applied.