Repeal and Replace: It Doesn’t Need to Be This Difficult

Everyone — patients, doctors, the country — is awaiting a final proposal

I am increasingly pessimistic about where congressional Republicans are headed with health care. 

A detailed, statutory draft of the House Republican plan to repeal and replace Obamacare was leaked last Friday and published by Politico. On Tuesday we were hearing that the proposed legislation is no longer viable or anything they’re working from, which is good — because if the leaked document was an indicator of where things stand and where they are headed, we are in trouble. Let me explain why.

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The leaked plan had enough detail to be analyzed by the Congressional Budget Office, and those scorekeepers have reportedly concluded the proposal is quite costly in budgetary terms. Many Americans would also see a substantial increase in their own medical expenses, if this were to become law.

The leaked bill would phase out the Medicaid expansion that added approximately 11 million individuals to the Medicaid rolls of states opting to participate in that feature of the Affordable Care Act. Instead, each state would receive a set dollar amount per person covered by the program.

This draft would allow insurers to charge older patients five times more than younger patients. My elderly patients are already struggling under rapidly rising health care costs — this change will make it worse.

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That amount would be adjusted based on health status. For example, more would be allocated for state residents who were disabled. This may be a better or more efficient approach, but it will certainly lead to lower benefits and higher costs for certain individuals or certain conditions.

Unfortunately, little in the bill addresses the problem of keeping “gross” spending costs under control, regardless of how the pie of federal subsidies may be divided by any particular state. Already questions have been asked regarding how Medicaid pay for expensive new drugs like those that treat Hepatitis C or other conditions requiring expensive treatments.

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Medicare costs to patients would rise under this bill. This draft would allow insurers to charge older patients five times more than younger patients. Remember the ACA limited that difference to three times. My elderly patients are already struggling under rapidly rising health care costs — this change will make it worse.

Related: Tough Talk, No Action Yet on Rising Drug Prices

The bill would also repeal Obamacare’s requirements for what health insurance must cover. Currently there are 10 categories of health care services health plans must cover — that will change and each state will be able to decide what coverage should require. This provision has raised concern that expensive treatments, such as those for opioid addiction or mental health benefits, would be cut. If state insurance regulators adopt different approaches, we may see a form of “medical migration,” where individuals relocate to one state or another based on what is covered in a standard insurance package.

For individuals receiving subsidies through the existing tax credit mechanism of the Affordable Care Act, things will change. Some simplification would result from basing credits strictly on age rather than on income. And while credits will be more generous for older individuals, that may not fully compensate for the ability of insurers to charge higher rates for older individuals than is permitted today.

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The bill eliminates Planned Parenthood funding, but that may be more of a political point than anything else, and it may be given up in negotiations.

To deal with the pre-existing condition problem, the bill gives states some money to create “high risk pools” for patients otherwise unable to get insurance at a reasonable cost. If those programs are modeled after the best pre-Obamacare programs, like that of the state of Maryland, that may be an improvement to current law. But many of the other state programs, before the ACA, were poorly designed and might not adequately address the pre-existing condition problem.

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We should all wait to see the CBO analysis of any Republican proposal. However, from what I see, they are rearranging the deck chairs on the Titanic. If the Republicans don’t attack the anti-competitive and monopolistic practices that are keeping gross health care costs up — for everything from drugs to simple procedures — the health care “ship” will founder and be unable to stay above water, financially speaking.

It’s with Medicare and Medicaid that the enlarging deficit resides. No Republican or Democratic bill, past or present, has addressed that singular issue. Instead, this bill determines who will get the finite resources available — it picks the winners and losers; and this Republican draft basically piles costs on the elderly and the sick. The system will be unsustainable.

Dr. Ramin Oskoui, a cardiologist in the Washington, D.C., area, is CEO of Foxhall Cardiology PC and a regular contributor to LifeZette.

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