The electorate’s collective corpus had not even started to cool after the November elections when Mitch McConnell, Senate-Majority-Leader-In-Waiting, said there would be no repeal of ObamaCare. This has not, however, stopped speculation on how Republicans, now that they are actually center-stage again, could repair this most unpopular reform.
Our health care industry is broken, and seriously so. If we are going to start fixing it (to the extent that it is redeemable at all, and that is very debatable), we should take a few small steps and one giant leap, all of which Republicans could do as part of detangling the tentacles of ObamaCare that reach into Americans’ lives without warning, welcome, or invitation.
First, the small stuff.
1. Axe Coverage for Annual Physical Exams
No less an authority than ObamaCare architect Ezekiel Emanuel now claims that no generally healthy adult should have an annual physical exam. We’ve known for more than 50 years that they are clinically worthless and financially wasteful. That did not stop Emanuel from ensuring that the statute compels every health plan to cover an annual physical at no cost to the patient at the time it’s administered (it’s “free” YAY!), but at a cost of almost $7 billion to everyone. In fact, I’ll argue now that they should not be covered at all for generally healthy adults. Going to the doctor for no reason should not be subsidized recreation.
2. End All Support for Workplace Wellness Programs
Workplace wellness doesn’t work, wastes money, and encourages employers who ought to know better to waste time and money playing doctor. In a policy clash worthy of the Keystone Cops, employers heeding ObamaCare’s workplace wellness exhortation are now being sued by the Equal Employment Opportunity Commission for violating a statutory pre-existing condition, the Americans with Disabilities Act.
Killing workplace wellness itself will stifle the ability of employers to penalize employees, and it should end any thought of subsidizing workplace wellness for small businesses. This will also finally, thankfully, mean the end of the wellness industry’s fraudulent mantra that wellness saves $3.27 for every dollar invested. That study is so bad that it should be retracted. Congressional hearings on doing away with wellness could help produce that result.
3. Cover Only Preventative Services the U.S. Preventive Service Task Force Rates With an A
The USPSTF is the closest we get to an honest data broker when it comes to evaluating clinical prevention. No health plan should cover any service it grades less than A, and, frankly, no health care provider should be able to market services that are not A-rated. Provider economics are the only reason to promote prevention to generally healthy adults, because it is how health and hospital systems find new customers, the so-far medically un-accosted, who can get shoved onto the “get-more-care-it’s-good-for-you” treadmill. Just because something is “health care” doesn’t mean it is good for you.
4. Don’t Just Punish Smokers with Higher Premiums
The problem is that it’s not the only, or even the best, indicator of downstream health risks. If we are going to encourage risk-based pricing in health care (and why wouldn’t we, given that we do so in every other form of insurance?), then let’s go all-in and set premiums based on credible risk profiles. You can exempt people with inherited or idiopathic disorders, but most of a person’s avoidable health risk in life comes from daily choices regarding diet, exercise, stress management, and substance use. You think eating all the time, never exercising, and boozing it up four or five nights a week is fun? Good: pay a health insurance premium that reflects your reality.
Now, the big one.
5. Peel away the Health Care Industry’s Favorable Tax Status
Make health-care premiums taxable as income if employer-based and not deductible at all otherwise. Then, layer by layer, rip away 501(c)(3) status from health plans, hospital and health systems, and the not-so-not-for-profit “patient advocacy” world, which is just a subversive playpen for drug and device companies. This make-believe world of benevolence is a charade. Let the states regulate these entities like utilities, with public hearings on rate increases and full disclosure of operational and financial matters. Extravagantly paid hospital executives have mastered the art of institutional, clinical, and fiscal opacity while scooting around on private jets and disclosing as little as possible on their Internal Revenue Service 990 Forms. Some faith-based health systems even refuse to list the charity care they’ve provided on their 990 on the grounds that they are part of a “church,” and don’t have to answer the question.
The American Heart Association, funded in large proportion by the pharmaceutical industry, last year published workplace screening guidelines that violated its own clearly stated conflict of interest policy, and let a vendor who would directly benefit participate in the drafting. Also on this luminous writing team was the former head of the American College of Sports Medicine, which, like many in the fitness community, wants further medicalization of exercise, to the point that it should be physician “prescribed” and, then, of course, paid for by someone else. Why don’t we just let health plans buy everyone’s groceries?
In fact, Congress should go a step further, and place a federal excise tax on all health care services, from office visits to surgeries to drugs. You want to see a market (re)form overnight? Stop tax-coddling this not-to-for-profit wasteland and make people feel the impact not only of their health-care choices, but also of their lifestyle choices. When there is virtually no disagreement that up 30 percent of our total medical care spending is inappropriate, there might be no quicker way to upend it than to make lousy choices more costly.
American health care suffers from so many maladies that is hard to know where to start, and it is impossible to envision an end game. But it is long past time to shatter the idol’s feet. At every reform effort since the passage of Medicare and Medicaid 50 years ago, we’ve heard that there is a light at the end of the tunnel. Efficiency, safety, effectiveness, and transactional honesty are just ten more years and another trillion dollars away.
But, in fact, there is no light, and the tunnel is without end. And there will never be a light if we cannot wrap our heads around the idea that the medicalization of every aspect of our lives is itself pathological. As we near the point where we spend nearly $10,000 per person per year on health care, it is increasingly clear that this addiction so deeply permeates our culture, across all demographic lines, and major surgery might be the only way to fix it.
