The independent news organization of Duke University

Rethinking health care

the voice of dissent

Congressional Republicans failed to pass the American Health Care Act (AHCA) last month, which amounted to the first major defeat of the Trump Administration. While the AHCA would have replaced the Affordable Care Act (also known as Obamacare), it still maintained key provisions of Obama’s signature health care policy reform, thus failing to gain the necessary support of the conservative House Freedom Caucus.

When the Affordable Care Act (ACA) was adopted in 2010, it amounted to the biggest overhaul of the US Healthcare system since the creation of Medicare and Medicaid in 1965. The ACA created health insurance marketplaces, which provide a set of government-regulated and standardized health care plans from which individuals may purchase health insurance policies eligible for federal subsidies. Those subsidies, covering insurance premiums and out-of-pocket costs, depend on an individual’s income as a percentage of the federal poverty level.

The ACA also introduced key regulations aimed to guarantee health insurance coverage for the most vulnerable Americans—who also are the riskiest clients in the eyes of insurers. For example, it forbids insurance companies from denying coverage based on pre-existing conditions. To make those private markets viable in the face of increased regulation, Obamacare introduced individual mandates (taxes) on individuals who do not have coverage or companies who do not provide it to their employees, thus increasing the coverage of poor clients. Finally, Obamacare expanded Medicaid—a health care program of federal subsidies for the poorest Americans—for states who requested it.

Republicans were most opposed to the latter two provisions of Obamacare: the individual mandate and Medicaid expansion. Although their 2017 Health Care reform maintained the logic and broad outline of Obamacare, including the reliance on subsidies and some regulations, it weakened many of its key provisions. According to the widely respected Congressional Budget Office, the AHCA would have led 24 million Americans to lose insurance coverage by 2026 as a result. In my opinion, and in that of Democrats and many moderate Republicans, the AHCA consequently was a bad bill.

However, this does not mean that the concerns of conservatives regarding the failure of insurance markets in certain states—which include insurers pulling out of the market, skyrocketing premiums and the tax burden the mandate imposes on individuals and companies—should be brushed aside altogether. Indeed, what is increasingly evident is that cost of health care itself has become unaffordable for the US economy.

Last Wednesday, I attended a conference organized by the Duke Health Care Policy Forum and Ralph Snyderman, who is the Chancellor Emeritus at Duke University and James B. Duke Professor of Medicine. As the director of Duke Center for Research on Personalized Health Care, Snyderman argued that his research shows it is possible to make health care affordable in this country.

But before talking about health care, he argued, one must first recognize the advances of medicine in recent times. In the 20th Century, with the advent of disciples such as Germ theory, chemistry and physiology, we have come to understand that causative factors lie at the root of disease that we can identify and fix. However, in the 21st century with the advent of disciplines such genomics, proteomics, and micro/nano processing, we now know that at the root of disease lie both a baseline risk proper to each individual and environmental factors.

Theoretically, we could now personalize medicine. At birth, we could quantify the risk that a disease will occur and design a plan to enhance health accordingly, potentially delaying the initiation of the disease until after the patient has died at a very late stage from something else. In the event that a disease has been detected, we could monitor its progression and personalize therapy.

This is key both to health and health care policy, as the longer a patient waits to treat a disease, the greater the likelihood is that the disease is irreversible and the more expensive the treatment will be. The real problem is that the current typical intervention in the US health care system occurs too late, way after the earliest potential clinical detection, at a time when the cost is too high and the likelihood of irreversibility too low.

Why is this the case? Why has the practice of medicine not kept pace with technological progress? Is it not the job of doctors to make sure their patients are safe?

To answer those questions, one must first look at the incentives at the root of our health care system. If you have health insurance today, your insurer will reimburse your health provider based on a fee-for-service system. In other words, your doctor will be reimbursed for every service he or she offers regardless of the quality or value of that service. Therefore, your general practitioner and other specialists you might see have no incentive to coordinate your care, get you engaged in your own health management, quantify your risks, help you set up your wellness plan, track the evolution of your health metrics or follow up with you on a daily basis—all of which are capital steps for personalized health care.

Professor Snyderman argued that the way to reduce the cost of health care would be to replace the fee-for-service reimbursement system with a population-based reimbursement system. A health care provider, such as a health care system hospitals and clinics, would be granted a fixed sum of money for every one of their patients. This would give health care providers the incentive to maximize healthcare outcomes and minimize costs.

Unfortunately, neither the Republican nor the Democratic Party seem to take seriously the potentialities of personalized health care and a population-based reimbursement system. Although Obamacare did create Accountable Care Organizations (ACOs), or health providers who were awarded bonuses in exchange for high-quality personalized medicine, neither this nor the Republican reform mainly focused on that issue.

To solve the problem of health care in this country, policymakers on both sides of the spectrum need to move away from polarized and counterproductive debates around health care and instead come to the table to discuss innovative ways to reduce its costs. Most importantly, they have to face the tremendous business interests that make humongous profits out of the current system and will resist any change to it, ranging from pharmaceutical companies to big health systems.

And they will never face such interests until we, the people, demand it.

Emile Riachi is a Trinity sophomore. His column, “the voice of dissent,” usually runs on alternate Wednesdays.


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