Repeal and replace Obamacare.
This is the Holy Grail that Trump promised (and he said he had a cunning plan during the electoral process). The cunning plan turned out to be "dump the problem on Congress". And it all went downhill from there. They called it the "American Care Act". The Democrats voted solidly against it, so it only took a few Republicans to think it didn't go far enough, or it went too far, and the plan ended up in the "too difficult" drawer.
But it can be done.
First, a few prelimiaries.
Medicare is a healthcare program, paid for out of taxes, that covers people who are 65 or more, certain younger people with disabilities, and people with End-Stage Renal Disease, which sounds pretty dreadful and I hope I never find out what it is. Medicare comes in four parts; A is hospital coverage, B is ... well, read it here. Part A costs you $451 per month = $5412/year. To get part B (which also gets youC and D), you pay $105 per month = $1260 per year. So the whole package is $6672/year.
But there there's "deductibles" (you pay extra if you actually go to hospital), and there's coinsurance (co-pay). Yes, it gets complicated.
55 million people are on Medicare. The Medicare budget in 2017 is $709 billion
Medicaid is for anyone who is low-paid, if you feel low-paid, then google for details, maybe you qualify. 74 million people are on Medicaid; Obamacare expanded Medicaid as of 2014. Oh, and 9 million are on both Medicare and Medicaid. The Medicaid budget in 2017 is $553 billion.
And then there's Obamacare, the Patient Protection and Affordable Care Act, also called the Affordable Care Act or ACA. After you've read that explanation, maybe you can explain it to me, because it's much too complicated for my tiny brain, which probably means that it's *far* too complicated for politicians, who often struggle to comprehend how arithmetic works. Obama said it would cost $94 billion per year, this is disputed. And I can't work out who pays what. No wonder there's controversy. The CBO, which is supposed to be non-partisan, say $134 billion per year. I'll take that figure.
And finally, if you're a Veteran, you can go to The Veterans Health Administration (VHA). The Veterans (VHA) budget is $68 billion
So I added all these up. It comes to $1464 billion, which works out at $4531 per head, since there are 323.1 million Americans (I'm ignoring the detail that some Americans are older than others).
So that's what the government pays - that means that this much comes out of taxation. In addition, there's all the co-pays and deductibles, and additional insurance paymens made by people in these plans, and I haven't even tried to estimate how much that adds to the total, because it's just too complicated. And to that, you should add the money spent by Americans on the various privately-run insurance schemes. Aetna, for example has a revenue of $63 billion, Anthem takes in $85 billion and Met Life gets $70 billion. And that's just three companies of many. I could have included those in my total, but I didn't. I don't need to dip into the healthcare insurance company revenues to make the case I'm making.
How good is American healthcare?
How do you measure how good a healthcare system is? I don't care how many CAT scanners you have, or how much profit is made by the healthcare companies. What matters to me, and what should matter to you, is the outcome. Are you healthier? But it's difficult to measure "healthiness". Do you live longer? Ah, now that we can measure. So I will.
It's always tricky to compare countries, but there's a few things that are comparable. The first of these is the mortality rate for under-fives. In the USA, that's 6500 per million, in the UK it's 4200. Please try to imagine a pile of 2300 dead toddlers.
And there's also infant mortality; deaths per million live births. USA is 5800, UK is 4300. So now imagine a heap of 1500 dead babies.
My older daughter is about to have a baby. It's all very exciting, and eagerly anticipated, but a couple of weeks ago we had a family discussion about "what if". Because giving birth is not without risk. In the USA, there's 21 mothers dying of pregnancy or complications, per 100,000. In the UK, that's 12 per 100,000. So that's 75% more in the USA - I'm glad that my daughter is in the UK!
And life expectancy in the USA is 78.8 years. In the UK that's 81.1, that's 2.3 extra years. Nice!
And on average, 643,000 Americans declare bankrupcy per year owing to medical bills. You break a leg - you lose everyting you own. And each of those 643,000 has a family.
I've compared with the UK, but if you follow the links, you'll see just how poor US health outcomes are compared with a great many countries. Look at the rankings, and ask yourself, why isn't American healthcare the best in the world? Because it really ought to be. Because the USA is a highly educated, prosperous and technologically advanced society, that spends a lot more per head on health care than any other country.
Compare that with the UK.
So that's public healthcare in the USA. And I'd like to compare that with public healthcare in the place I know best, the UK.
The NHS budget is £124 billion, which is $161 billion, and works out at $2453 per head.
For that cost, UK citizens get healthcare, period. And pretty much everything is free (meaning, paid for out of taxation). A medication prescription costs $11, and if you're getting a lot of pills, you can pay $38 to cover all the charges for three months. But there's a lot of people get presciptions for free; I do, because I'm over 65 (also cancer patients, pregnant women, and so on). You also pay extra for dental work; $27 for routine stuff, $73 if you need a filling or root canal. Hospitals are free - I've never paid for any hospital visit. And there's a thing called the "Small injuries unit" which I've been to for a nasty scalp cut and before that for a splinter under my fingernail that I just couldn't get out. A nice nurse cleaned up the scalp cut and then glued it (apparently they prefer to use glue for small stuff). Another nice nurse got the splinter out while I shut my eyes and tried not to scream. In my experience, you turn up and they just deal with it, 24/7. I get free spectacles and have for the last 60 years, although I can pay extra to get designer frames. And when my free biennial vision test discovered excessive pressure in my left eyeball, diagnosis and treatment has been free (a drop in my eye each morning seems to have fixed it).
Oh, and doctor's appointments are free. And I don't see how anyone in the UK could be bankrupted by medical bills.
And I don't think that the UK is exceptionally good. Yes, the NHS is good, but I've heard very good reports of the French system, and Germany was the first country to move to universal healthcare, in 1883.
The American Health Service
So right now, Americans are paying twice as much as people in other countries, for an inferior health outcome.
So let's imagine a service which I'm going to call the American Health Service, AHS. It's free at point of need (with maybe a few exceptions, as above) and it's paid for out of taxation. If it costs the same as in the UK (I'll discuss this later) then that would be $2453/head, $793 billion per year. Which is a saving of $671 billion per year, and if you put that back into the pockets of the taxpayer, that's $2078 per person, which would be $8312 for a family of four. Tax cuts!
So all Americans would get healthcare to a high standard, wouldn't have to raid their income for health insurance, no co-pay, no deductibles, no cap on spending (sorry, you're only covered up to $1m, your insurance ran out, please die quietly now). And no "pre-existing condition". The way it works is, if you're sick, then you get treated.
Sounds good. Sounds very good. In fact, it sounds too good to be true! So where's the catch? How can you get univeral healthcare at cost of about half of what you're already paying?
There's two reasons why universal single-payer healthcare is so much cheaper.
The first is the cost of medication.
A recent Trump tweet said “Now that Ken Frazier of Merck Pharma has resigned from President's
Manufacturing Council,he will have more time to LOWER RIPOFF DRUG
PRICES!” When Trump thinks that drug prices are too high, then maybe they are. Also, drug prices for the same drug in Canada are much lower. But why should Frazier lower drug prices? If there are people willing to pay his high prices, he'd be a fool to lower them.
The reason is monopoly and monopsony. If a company has a monopoly on something important, you can be sure that the price of that thing will be somewhat higher than a situation where there are several companies competing for your business. And, of course, that works the other way round - if there is only one buyer of a product then that buyer has tremendous leverage; that's called a monopsony. So the American Health Service (which doesn't exist, but ought to) would A) be buying in bulk, and that's always cheaper, and B) would be the only buyer, so you sell your Epipen to us, or you you don't make many sales. And here's the price we think we should be paying ... see above.
The second reason is insurance companies.
In an UK NHS hospital there is no team of administrators working out the costs of treating each patient and filling in the necessary forms to claim on the insurance (and the insurance companies are not eager to pay unless it can be shown that the claim is valid). That team of administrators is matched by equivalent teams in each of the insurance companies, checking those forms. The entire cost of the processing of insurance claims is avoided, as is the profits made by those companies. You see, they aren't non-profits working out of the benevolence of their hearts.
The pharmaceutical companies are, of course, aware of this threat and they will fight tooth and nail to avoid having to face a monopsony. No tactic will be too underhand, no "sponsored research" stone will be left unturned. But, you might ask, why doesn't Medicare use its buying power to negotiate better prices? Because your congress won't let them. The Medicare Modernization Act of 2003 (MMA) included a ban on price negotiation. The pharma companies spend more than $100m on lobbying, seeking to persuade lawmakers by hook or by crook to maintain their high (or as Trump puts it, "RIPOFF") prices. That $100 million is a wise investment of a small fraction of the $374 billion that Americans spend on medication per year.
And what of the insurance companies? They will see most of the reason for their existence wiped away. In the UK, there are a few medical insurance companies, but nothing like the American behemoths. And they too will fight like cornered leviathans to maintain their lucrative business. Currently, they're spending over $10m per year.
So that's why it's possible to have a single-payer, universal healthcare system at around half of what the government is currently paying.
"But this is socialism", I've heard people say. Yes, it is. And? It's a service for the whole population, paid for out of taxation. Just like the fire service, the police service, the public school service and the military. I don't hear cries from the anti-socialists "stop taxing us to pay for the military, we'll defend ourselves".
"But it's unfair, I'll be paying for a service used by other people". That's right. The rich will help the poor, the healthy will help the sick. If you're a Christian, then you'll probably approve of this because that's what Jesus wanted. If you're an Atheist, you'll definitely approve of this, because it's the Right Thing To Do.
"But taxes" you might say, if you're Republican. Or also if you're Democrat - no-one actually likes being taxed. Um, no. Because the AHS would cost half of what's currently being spent out of taxes, that leave room for a tax cut once the system is in place. TAX CUT!
"But it's untried, untested, how can we know if it would work?" Look at the 58 countries that already have a universal healthcare system. And these aren't just Western countries like the UK, France, Germany and Italy. They include Burkina Faso, Ghana, Bhutan and Sri Lanka (and I bet many Americans won't be able to find any of those on a map).
The taxation will fall more percentage-wise on the rich; the sick will consume more of the healthcare that the healthy. And that's a good thing.
So I do support the repeal and replacement of Obamacare, but only if it's replaced by something like the American Health Service that this essay proposes.
And there's even something for you, Mr Trump. You can call it "Trumpcare", because as long as Americans get the healthcare that they need, I don't care what you call it.