The Affordable Care Act (ACA), commonly referred to as Obamacare, was the first major effort in recent history to counteract these trends. It made inroads into the problem by improving access to health insurance for large portions of the population that had previously been ineligible or unable to afford it. Increased subsidies provided financial assistance to poor and middle class individuals. Parental coverage was extended to the age of 26. And preexisting conditions could no longer be grounds for denial or increased premium rates. This legislation also mandated minimum coverage, meaning that insurers could no longer offer plans that lacked basic provisions for care.
Trump may not have realized until recently but healthcare in America is, and has been for years, a very complicated issue. There are employer plans, private insurance, VA programs, Medicare, Medicaid, and CHIP, in addition to state run programs that don't always work together and sometimes even compete with each other. There is also the discrepancy in Federal and State standards which can be more or less restrictive. Environmental and social factors should also be taken into account when considering the state of health, and healthcare, in our nation.
It should also be taken into account that the vast majority of our healthcare system is a for profit industry. What this means at the most basic level is that insurers are primarily concerned with the generation of profits, not the well being of those they cover. Their desire is to create the greatest amount of revenue with the least amount of expenditure. Since revenue, on some level, is limited by the laws of supply and demand reducing expenditure is the easiest way to increase profits. While streamlining office procedures can reduce some expenditures that greatest portion of insurer expenses are for covered services which leads to the logical conclusion that, to increase profits, there will be a decrease in services. In fact, generally speaking, insurance will seek to cover the least amount of claims possible. This is evidenced by the pre-ACA practice of denying coverage or only offering extraordinarily high premium rates to those with preexisting conditions (i.e. those who would necessarily require more than the bare minimum of services).
Trump's solution, which appears to have failed at this time, would have reset much of our system to pre-ACA levels. However, instead of rehashing the few pros and many cons of his plan, I would like to instead take some time and envision a brighter future for American healthcare.
In its ideal form a healthcare system should be one that's primary goal is the short and long term full body health of all covered individuals. Whether it is a minor stomach bug or a chronic, debilitating illness every individual should have access to the appropriate doctors, medicine, testing, and treatments for their condition. By full body I mean not just physical care but also care for the mental and emotional well being of a person. This access should be regardless of the age of the individual or cost of care. All of this boils down to creating a plan that has the goal of patient health, the scope of full body care, and equitable access for all.
Of these three areas the goal is the easiest to solve. Our current system, as mentioned above, is concerned primarily with profits rather than patient health so it fails the first test. Next is the debate of private sector nonprofit or government run. The problem with private sector nonprofit is an issue of stable funding and ideological differences. Many nonprofits receive government funds already or must rely on private donors. Should a nonprofit's funding fail it is those they cover who will suffer. Member contributions can provide some stability but income differences can make this inaccessible to those without funds to contribute. Ideological differences, on the other hand, can take many forms. As a few examples, a Scientologist run network could exclude all mental health services, a Catholic run program may offer no forms of contraceptive (even pills and condoms), a new age philanthropist could start a service that insists all illness must be cured by targeted meditation and offer no other services. These are extreme examples, but patients should not be limited to one philosophy of care, and should especially not be influenced by religious ideals (I will discuss this more when I talk about access). The government, on the other hand, should provide neutral ground for medical philosophies and should also have a stable funding base. As for the question of State vs. Federal I would argue that the Federal government is in the best position to institute minimum standards while the States would be allowed (from their own tax revenues) to institute and provide greater coverage if, where and how they choose.
A trickier subject is scope of care. There are obvious things that should be covered such as preventative care, cancer treatment, etc. And there are things that obviously should not such as cosmetic surgeries not prompted by an injury or other elective treatments. But then come the gray zones. How crooked do your teeth need to be before braces are covered? If you need glasses how much of the frame cost should be covered? And what about alternative treatments? Acupuncture? Massage? Chiropractic? In general I would allow physicians the flexibility to prescribe the treatments they feel are best for their patients and to make the call on whether a procedure is purely cosmetic or medically necessary. For the most difficult of decisions, such as cases for treatments that are alternative or still in testing, I would suggest a review panel but only if said review panel was able to give decisions without requiring patients to suffer through excessive waiting periods. The problems that have been discovered with the VA serve as an excellent cautionary tale on this front. In general I would insist upon basic coverage for medical, dental, vision, and psychiatric care. This would include prescription coverage, emergency services, lab work, maternity and pediatric care, rehabilitation services, etc.
Finally we come to equitable access for all. What I mean by all is every American regardless of age, race, national origin, religion, sex, gender, sexual orientation, familial status, you get the picture. Now obviously every person's health status is different. Not just for the obvious differences I've stated above but also due to environmental circumstances, unique genetic traits, socio-economic conditions, and the list could go on. When I talk about equitable care what I mean is that every individual's experience with the health care system should be the same. The poor black family living in a rural, economically depressed region should be able to get the same care and individual attention as a rich white family living in New York. If someone wants to pay additional money out of their own pocket for elective procedures that is their choice, but no American should ever have to choose between filling a prescription and putting food on the table. On the flip side, just because certain treatments are offered does not require an individual to take advantage of them. There are millions of Catholics who choose not to use birth control even though surely many of their medical plans cover it. A Scientologist is not obligated, unless they are seen as a danger to themselves or others, to seek psychiatric care. And if someone believes that meditation will heal all ills that doesn't negate their access to traditional medicine. However, this must also mean that health care professionals can not use religious or moral exemptions to get out of discussing, let alone providing, medicine that would be considered a normal part of their professional activity. If too many providers in a particular area exempted themselves from certain treatments it could cause an undue burden on patients and limit their access to the health care they deserve. Also, as a professional, patients expect to be able to trust them to give the best medical opinion, which should be the case even when that opinion conflicts with a personal view.
When we talk about healthcare too often we obsess about the dollars and cents. The reality is that much of the developed world provides universal healthcare to their citizens. Some of these systems work better than others but we can not deny the fact that they work and that their citizens are better off, as a whole, because of it. I will paraphrase a quote I saw once from a Canadian about their health care system:
I don't see anything wrong with paying a few extra dollars so that an 8-year-old across the country can have heart surgery
Too bad we can't all have this outlook on life.
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