So what do I think of the GOP health care insurance reform plan?

by w3woody

It’s more rearranging the deck chairs on the titanic.

First, you need to ignore the politicians and most of the talking heads on CNN. They came out with their predictions that the GOP health care plan would kill millions without ever having read the plan–since the plan had not been publicized or made available to anyone.

Second, you need to realize that the overall GOP plan to reform health care insurance in the United States is to be done in three phases. And like any plan of attack to any problem, the subsequent phases are always subject to revisal or revision. So the current plan is, by design, only 1/3rd of the solution–and the other 2/3rds may never happen or may be substantially changed.

It’s one reason why, while Obamacare (the PPACA as revised and passed to avoid requiring a single GOP vote) was nearly 1,000 pages–and so complex and pass so quickly it inadvertently left Congress without health care insurance (which they quickly fixed later)–the current GOP bill is 1/8th the length.

Third, the GOP bill (which only concentrates on short-term stabilization of the health care insurance market, which is on the verge of collapse in many areas) has some interesting features.

Specifically the Senate version seeks to reshape the curve to preserve the subsidies to the poor for affording health care. It also seeks to relax many of the onerous regulatory requirements which have made Medicaid a disaster to anyone actually stuck on it.


Fourth, and more importantly, the AHCA (the GOP plan to reform the PPACA) is ultimately fatally flawed–and flawed in precisely the same way the PPACA is flawed, in the way COBRA was flawed, in the same way the Clinton health care plan was flawed.

They are all addressing the demand side of the equation–who pays for health care, who receives health care, the limits on how people can receive health care–and do not One. Fucking. Iota. for the supply side of the equation: who provides health care, and how health care providers can be incentivized to innovate and compete.

Now this is not precisely correct: Obamacare did address the supply side. By decimating small family practices by forcing them into Accountable Care Organizations–essentially replacing smaller practices with gigantic health care monopolies. (It did this by requiring all medical services billed to insurance to bill through an accountable care organization–which is just a hop-skip-and-a-jump to forcing self-employed doctors to become employees of large hospital chains.)

Because we all love the competitive excellence of monopolies.</sarcasm>

But the AHCA, as far as I can tell, does fuck all to address the fundamental problem–a problem that has been going on since we started debating how health care is to be provided in this country since the AMA convinced people to see doctors instead of barbers in the mid 1800’s. We’ve been debating the skyrocketing price of health care since the 1930’s when the AMA invented insurance-funded health care out of whole cloth in the 1930’s in response to a New Deal proposal to socialize medicine.

(Insurance-funded health care, by the way, is NOT what we’d get with a “free market”–instead, it was the ACA’s way of providing socialized health care without government involvement, so the ACA could preserve its control over the health care market and preserve their notion of the country doctor with a private practice who made house calls. It’s why even today doctors are seen as the Manor Lord of the hospital–rather than simply as a specialized member of a team of specialists. This is the 100 year old legacy of the AMA, and it’s by design: so much of the back and forth in the supply of health care has been the story of doctors fighting politicians and insurance companies in providing care.)


The fatal flaw of all health care reform going back decades is that the players have fought tooth and nail against innovation in the health care space. Too many large entrenched interests do not want things to change–and if that means a few million people must die receiving substandard care, well, that’s the cost of keeping the current system as it is.

Price transparency, once seen as a cornerstone of Obamacare? Yeah, fuck you.

That’s because hospitals are required to tell the public only what they charge—not the rates that are actually paid by private insurers. Charge information is widely seen as less useful to consumers than data on the actual prices negotiated by insurance companies, especially because high-deductible health plans sharpen consumer interest in insurers’ negotiated rates. Typically, real hospital prices are undisclosed percentage discounts off their charge rates.

Increased competition, especially from retail clinics (such as Walgreens) which would allow walk-up urgent care–and potentially make first point of contact with health care for many ailments widely available, even in poorly serviced rural areas? Yeah, fuck you.

The AAFP opposes the expansion of the scope of services of retail clinics beyond minor acute illnesses and, in particular, opposes the management of chronic medical conditions in this setting. Protocol-based decision and diagnostic models are used in most non-physician led retail clinics, resulting in a missed opportunity to address more complex patient needs.

Translation: we don’t want you seeing a nurse practitioner if you have a chronic condition–and we don’t even want you going to Walgreens to get diagnosed, even if the diagnosis is to be bounced to a hospital which is better equipped to handle your case.

And that’s assuming, by the way, that the state where you live even allows you to receive care from a nurse practitioner and not a fully licensed doctor. Access to Care and Ongoing Battles Over Scope of Practice. (The states in red in the associated map? They have a lot of rural area–meaning if you get sick out in a rural town, you may have to drive for hours to reach someone who can help you.)


Until you address the multiple problems in the health care system which prevents innovation on the supply side–which Democrats have been historically blind to since denigrating Ronald Reagan’s “trickle-down economics”–we will continue to see sky high prices regardless of whatever sort of demand-side insurance reform we implement.

All we’re doing is rearranging who pays for health care, and who qualifies for subsidies. It’s rearranging the deck chairs on the Titanic, assuming that by slight of hand we can allow 100 passengers to sit on 50 chairs at the same time–ignoring the fact that the fucking ship is sinking.

But then, Democrats repeatedly distrust markets–to be a progressive in this day and age requires an inherent and unthinking hatred of free markets. They distrust the chair maker–then wonder why we sailed without enough deck chairs in the first place.

So it makes sense that we continue to refuse to look at the supply side–to consider moves that would, for example, permit Silicon Valley to start innovating in new ways to provide medicine, new and cheaper diagnostic equipment, or to rethink the organization of the health care system as a whole. This leaves us stuck with a model invented nearly a hundred years out of whole cloth to prevent the government from socializing medical care.


Address the fatal flaw, or watch as health care costs continue to rise–predictably–and as health care shortages continue to grow–again, predictably.

The GOP plan? It does fuck all to address this fatal flaw. But so did Obamacare, which makes the GOP plan par for the course.

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