The future of Trumpcare really had us wondering last week. For some reason the Marx Brothers came to mind:

Groucho: Well, if you look at it, it’s a barn. If you smell it, it’s a stable.
Chico: Well let’s just look at it.

Regardless of your political leanings, it’s safe to say that Trumpcare was likely to be painful for many. (Probably for the big D too.)

Most would agree that Obamacare, while good for many, still needs tuning. However, I really don’t understand the intense drive to suddenly upend the system in one pop, other than to remove the name “Obama.” In science we change one variable at a time and see what works. Why not try that with healthcare too?

I also think lumping so much under one word may be at the root of our problem. What exactly is “healthcare”? It’s everything from vaccines, to vitamins, to Ebola readiness, IUDs, trauma care, botox, chemo, addiction therapy, dialysis, organ transplants, assisted suicide… Google “CRISPR” to get your head really spinning about our future health.

So if by chance, there is some path from my fingers to decision makers during this stalemate, I’d ask they first divvy the word “healthcare.” Then go slow and chew bite by bite.

I’d also lose all the age based thinking. A 35 year old with cystic fibrosis, uncontrolled diabetes, or 20 years of smoking is a lot different from Serena Williams. Why does under 18 equal pediatric? Where did 26 come from for kids to stay on parents’ insurance? And why does over 65 mean “now we care”?

If I was chief legislative cat herder, I’d grab any of these below and see which could fly its own:

1. 1. Societal bang for buck
      What in medicine has ripple effects far beyond the patient? Cover those first independent of age or income. I’d include addiction rehab, smoking cessation, vaccines, tubal ligations and vasectomies for starters. Could that be one bill? No need to kill the ACA even. Controlling the blast zone of a single meth user, and helping him or her to become a contributing citizen can easily pay for itself. I’ve studied this and seen it first hand.
      Add more bang for buck services as the public sees fit.
   2. Refined emergency coverage
      EMTALA already keeps you from being rejected at the ER gates. However, I’d like to see coverage for emergency care become diagnosis dependent.
      If you’re hit by a drunk driver, I’d like my society to help you get you back on your feet. New Zealand goes further and covers all trauma. Nice people there. However, in my preferred world, if you’re the drunk driver in an accident, your medical bills are on you and your private insurer. If you’re uninsured, then tie medical care with rehab. We’ll pitch in when you’re ready to sober up.
      Heart attack, covered. Second heart attack and still smoking?… on you; unless you commit to “smoker’s rehab.”
      Pneumonia, covered. Sinusitis in the ER at 3am?… on you. Grow up.
      Of course, the definition of an “emergency” has lots of grey, which I’d leave for the states to decide. If California wants to cover Cal Poly students who land drunk in an ER, so be it.
   3. Likely to resolve with or without medical assistance
      Strongly encourage telemedicine and other direct pay models (like Pre-R). Using any kind of insurance for these problems just amplifies our bloated system. Ingrown toenails, poison oak, calf pain after a soccer tournament…? (You’d be amazed.) If you walk into an ER for any of those, they’re on you.
   4. Encourage savings
      To nudge toward more direct pay healthcare I’d like to see extra tax incentives for HSAs. Today they’re a write-off, but not enough to make very exciting or interesting, especially for low income folks. Why not triple or quadruple the write-off, and increase yearly limits to really incentivize such savings? Vanessa and I love ours.
   5. High risk or self destructive behavior
      Private insurance required. No Red Bull inspired injuries should be covered by taxpayers… no matter the age. If the ski resort doesn’t check speed-freak Jimmy’s insurance before entering the half-pipe, then care for his broken femur is on them. Same for climbing walls, ice rinks, pools etc. I suspect our % uninsured would plummet with fun-based incentivization.
      How about extending that idea to cars and boats? Lump health insurance with required vehicle insurance, since vehicular trauma is a huge source of medical expense.
      How about requiring smokers to show proof of health insurance at the CVS for their next carton?
      How about for gun ownership? If you get shot with your gun by your toddler:
      • A) Bad parenting.
      • B) That shouldn’t be on taxpayers’ dime.
      • (I know… 3rd rail… crash, burn, forget I said it.)
   6. Federal medical board
      Every state has it’s own medical board which greatly limits where doctors can practice. No need to aggressively and contentiously shut them all down, but if one federal medical board would gather all our credentials in a single database, that could really improve coverage in underserved areas. State medical boards would then be freed up to assure patient safety. I’d be happy to fly to rural Virginia in a pinch, or answer questions there by telemedicine, but currently can’t because I don’t have a Virginia license.
      (If you’re not in medicine you likely don’t realize the wackiness of state medical licensing. I used to advise ER residents to spend more time choosing a state than finding a job, because the licensing in each state can take so painfully long.)
   7. Price transparency
      GoodRx and Pre-R have changed my practice patterns, because I now have access to prices. Real time price transparency needs to exist for doctors and for patients, because fiscal well being is completely connected with mental and physical wellbeing.
   8. EMRs
      Hire Google, Facebook, Microsoft to build one that works and that all hospitals will use… please! That it remains a struggle to gather records from neighboring hospitals using competing EMRs is absurd.
   9. 10. and 11. Med-mal lawyers, insurers, pharmaceuticals
      Oye… I’ve no clue. They always win. I know that’s a copout.

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Someone will comment “universal healthcare!” or “single payer!” Maybe, you like Bernie. I actually do too. However, “healthcare for all,” while noble, I suspect is a setup for failure… unless bundled with “retirement for none.”

Plus it would also be a massive sudden disruptor. Frankly, I just don’t see an economical, feasible, logical way to equitably offer the full buffet of medical services to 300+ million people, especially with increasing life expectancies. In addition, free care does not mean better care. I’d rather we take more steps to help people to keep themselves healthy.

I’m further pushed away from socialized medicine by the lessons of big oil. Vanessa, being from Venezuela, has made me consider the word “free” far more than I ever did previously. In Venezuela, despite their rapid inflation, food shortages and crime, they continue to have “petrol for all.” To this day, even while citizens are struggling in food lines, you can still fill your tank for less than a cup of coffee; not even a high dollar Starbucks blend! As such, when you’re happy in Venezuela, you go for a drive. When you’re depressed, you drive. Angry, drive. Bored… you guessed it.

Point being that anything free is easily taken for granted, squandered and abused. Everyone in emergency medicine sees and knows this lesson too. Because of EMTALA, ERs today are high dollar clinics that sometimes care for actual emergencies.

“Healthcare for all” to me is more than pie in the sky; it’s cholesterol in the arteries. And it eventually leads to emergency department visits for Tylenol prescriptions.

Obamacare was complicated progress with big flaws. However, I’d rather keep incrementally refining and testing.

Enough rant. Sorry.