Dear Republicans: Stop Blaming Democrats and Make Health Care Great Again

Part 1: The Diagnosis

I don’t want to be a patient in the U.S. health system. Ever. I’m not a fan, as any repeat reader will notice.

But all of us will be patients at some point. Many, if not most of us, already are.

Health care is a fraught issue, publicly, politically, personally.

As HHS Secretary Robert F. Kennedy Jr. has said, a healthy person has a thousand dreams for her life. A sick person only has one.

We have to get health reform right, period. We’re not there yet.

That’s why I still work on trying to fix the conventional “health” “care” system. It’s why I tried so hard, during long years in government, to make it incrementally better. It’s why I started working with employers to build health plans for their workers that are more human, less impoverishing, and less likely to lead to having the wrong knee replaced in the operating room.

It’s also why I’ve invested years running the Alliance of Health Care Sharing Ministries, in a fevered effort to protect people’s right to escape the insurance industry, if they want to.

The system comes for us all eventually, at some point. And if not us, then someone we dearly love.

It’s why this newsletter isn’t merely an escape-the-system manual, but also an improve-the-system manual.

And of course, it’s why I continue offering my former Republican colleagues unsolicited advice, derived from the PTSD and stripes on my back from years of trying (and often failing) to both improve the system and not lose elections.

Yes, yes, I know what they’ll say: it was the Democrats who broke it with the not-so-Affordable, not-all-that-much-Care Act, and their policies are what drove up costs and government intervention and hooked tens of millions of Americans on government subsidies for their health coverage.

Got it. Stipulated.

But this isn’t about them. They’re not in charge.

This is an intervention for Republicans.

I say to my Republican colleagues what I say to my naturopath clients – if you’re focused on someone else as the source of your problems, you’ll never heal.

If Republicans keep blaming Democrats as the reason why they have to take stuff away from Americans — who very much feel they need that stuff — they’ll never win another election.

And let’s focus on our own responsibility here.

America didn’t kick us out of office and give both chambers of Congress and the presidency to Democrats in 2008 — who then passed Obamacare — because we had been doing such a bang-up job on health care.

I was there.

For most Americans under age 65, the most notable accomplishment delivered by Republicans before that was creating health savings accounts.

HSAs let you save for health expenses tax-free, but only a few thousand dollars a year (wiped out after the first overpriced MRI), and only if you have a stingy, high-deductible health plan with unaffordable out-of-pocket obligations.

I guess this was some sort of bribe to get you to buy crappy insurance that, if you get sick, will cost you way more than it’ll save you in taxes.

All to artificially prop up a market for crappy insurance that no one would otherwise want.

A note about Republican attachment to crappy insurance.

America, don’t hate us. There is a reason behind the madness. It’s not an excuse, but it is an explanation.

Republicans are convinced – not without economic reason – that insurance is unaffordable, in part, because people want too much of it – or the government wants too much of it on their behalf.

If everyone wants an iPhone, then Apple can charge $1,200 per, so the theory goes. So if governments would just stop demanding that insurance plans cover so darned much, then the prices would go down.

There is some truth to that. States that have the most mandates on what insurance must cover also have higher premiums, typically by a few percentage points.

Republicans are also not theoretically crazy to be pushing HSA+crappy-plan combos.

People with lower health costs (like under $5,000 or so per year) will break even or do better financially with a maxed-out HSA, coupled with a cheaper bronze plan.

Many people don’t know this and would prefer the gold plan, even if they’re generally healthy (of course, America is not generally healthy, but you get my point).

So, the problem is that nobody wants a bronze plan, where they have to max out an HSA, if they can afford a gold plan without an HSA.

One $10,000 ER visit could tip you over that break-even threshold and have you wishing you had a gold plan instead.

So while Republican economic theory might hold, voters aren’t buying what we’re selling.

Premiums are largely driven by the underlying prices of health care.

And prices are being inflated and distorted by value-sucking middlemen between the creators of value (doctors/hospitals) and the buyers of value (you and me).

The real villains: middlemen

Republicans used to love them some insurance companies. But the romance is over.

They are now rightly calling out the middlemen in this business as the reason why premiums are so unaffordable – insurance companies that act like Bond villains.

Middlemen don’t want price competition because it doesn’t benefit them, but of course, they’re the ones setting the prices with the doctors and hospitals and drug makers.

As long as you’re paying for health care indirectly – through your insurance plan and their contracts with price-gouging, profiteering hospitals – using the prices they negotiated with each other and not with you, you’re getting screwed.

Republicans told you that your high deductible health plan and HSA would make you a price-sensitive shopper that would drive price competition and lower costs for everyone.

But you’re not out there shopping for the best price – you’re being charged the price that your insurer negotiated with the doctor, whether you’ve hit your deductible or not.

In fact, the insurance contract with your doctor actually prohibits you from being charged any other price, even if you both agreed on one.

So HSAs and high deductible health plans don’t facilitate the kind of price competition that results in lower prices, the way Republicans said they would back in 2003 when they created HSAs.

What’s more, the value prop of health insurance was that these insurers could get volume discounts that we couldn’t have gotten on our own. But study after study shows – and now the Trump price transparency regulations reveal that:

The price of care is more expensive with insurance than just paying cash, most of the time.

Also, middlemen don’t have the same goals as you do.

You want to be healthy and pay less when you do get sick. They profit when you’re sick and pay more to treat that sickness. They have no financial interest in improving your sleep, teaching you how to eat like a human, the value of sunlight or purpose or emotional healing.

This is not a match made in heaven.

Ironically though, in our current system, even if there were no middlemen, the incentives are still whacked. Doctors and hospitals, like car mechanics, only get paid when things break down. Their business model, even without middlemen, only works if enough of us are sick.

We buy sick care, not health.

As most of us have learned the hard way, even if doctors instinctively understand the things that keep our bodies working well – sleep, real food, contact with nature, spiritual connection, and so forth – they’re not taught these principles in medical school. They might finger-wag a bit about your weight or stress, but they have no experience or expertise in how to practically support you in taking on those problems successfully – a process that is simple but by no means easy.

Health insurance fails spectacularly to either keep us healthy or to obtain lower prices for us than we could get without it.

In Part 2, I answer that question.