In Congress speech, Trump got healthcare right. But now what?


Who could possibly argue with what President Trump said last night?  

Here are a few direct quotes:

“Expand choice, increase access, lower costs, and at the same time, provide better healthcare. …

“The way to make health insurance available to everyone is to lower the cost of health insurance; we should help Americans purchase their own coverage, through the use of tax credits and expanded Health Savings Accounts. …

“Give our governors the resources and flexibility they need with Medicaid to make sure no one is left out.”

These are admirable goals. There are two key problems:

{mosads}Many members of Congress would not have given the same speech. The president’s phrases like “health insurance available to everyone,” and “help Americans purchase their own coverage,” and, the one that surely caused blood boiling, that we should give governors the “resources and flexibility they need with Medicaid to make sure no one is left out.”


In “The Hill” a few days ago, I proposed principles for health reform; the president’s, “make sure no one is left out” is surely among them. However, the leaks that have come from the Republican plans do the opposite: shrink Medicaid and shrink subsidies.  In fact, Freedom Caucus Chairman Mark Meadows (R-N.C.), came out against the draft plan as it wasn’t tough enough and created “a new entitlement program” through its refundable tax credits. 

Hardly “make sure no one is left out.”

Even if the Republican Congress agreed with the president’s words, there is no way to pay for a plan like this, right? Wrong. The money is there.  We waste one-third of our healthcare dollars — about $1 trillion per year, with the largest amounts on administrative inefficiency (how many times do you need to be asked your address?), overuse and duplication of tests and procedures and high prices such as drugs. If we could save just 10 percent of the waste, we could pay for the uninsured. What can we do?

1) Reduce excessive spending to save.

We waste $192 billion on over-treatment, i.e. doing procedures and tests that are unnecessary. In West Virginia, for example, a patient is seven times more likely to have a heart procedure than in San Francisco, but the patients in West Virginia are no sicker and do not have better results, implying that many in West Virginia did not need the procedure in the first place and were “over-treated.”

There are a number of possible reasons for this overtreatment, but a prominent one is that the doctors doing these procedures are paid per procedure — the so called “fee-for-service” model of health care.  

Fee-for-service has got to go. A good way to attack this problem is to pay physicians a salary (plus bonus for quality). The salary could be at the level they are now making (the savings in doing too much would dwarf the salary expense.

The best health systems in the country including the Mayo Clinic, Cleveland Clinic and Kaiser Permanente salary their physicians. Why not the rest of us?  

2) Drug prices.

As part of the attack on paying too much, how about this one: The government is not permitted to use cost in the decision of what to pay for. This is ludicrous and must be changed. To echo the president’s words, the Congress should permit Medicare to negotiate for prescription drug prices.  Bringing the management of a large group of patients to the bargaining table is done in virtually every other developed country; we should too.

3) Electronic health records.

At present, difficult as it may seem, physicians — usually on the forefront of innovation — shun Electronic Health Records (EHR), which are difficult to work with and reduce efficiency.  But the benefits are legion: improving quality and cost, reducing administrative expense and attacking fraud and abuse.  

The technology is here. The Centers for Medicare and Medicaid Services should spend real money to make EHR’s physician-friendly. Rand estimates $81 billion in eventual yearly savings.

4) Attack chronic disease.

Reducing readmissions, unnecessary admissions and Emergency Department visits could reduce the cost of chronic care by 10 percent. The budget for Medicare Home Health is $89 billion per year. The concept for how and where to care for a patient should be revised.

One might think that there are real problems with physician shortages to care for patients with chronic disease; the National Academy of Medicine has a different view — that new ways of caring for patients, with “task shifting” from physicians to nurses and Grand-Aides can save the physicians for what they alone can do.

In sum, the president laid down a strong set of goals; I would argue they are achievable — but these can only be accomplished if both sides of the aisle rise to applause at the same time and get to work.

Arthur Garson, Jr., MD, MPH, MACC is the director of the Health Policy Institute at Texas Medical Center.

The views of contributors are their own and not the views of The Hill.

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