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What “Obamacare” Should Have Been

Doctors doing what they should

A young friend who is writing a research paper on the Affordable Care Act has been picking my brain about it… so I wrote out my thoughts on what it should have been for him. Here’s my very personal opinion.

A substantial proportion of those opposing “Obamacare” opposed it because it did not go far enough, and the compromise legislation was not health CARE reform, but merely health INSURANCE reform. Granted, there are very good provisions in it, such as the pre-existing condition clause, but the bill doesn’t really address health care access and cost reduction. The big loser there was the loss of the so-called “public option”, which would have offered citizens the option of buying into a tax-payer supported insurance similar to Vermont’s VHAP insurance (one of the best and most comprehensive Medicaid-supported state insurance programs in the country).

Obamacare So Far

What many have been trying to get on the table for decades is the establishment of a national health system. The U.S. is the only industrialized nation in the world without one. One of the best is in Costa Rica… a tiny Central American country that is touted as one of the best places for American retirees to relocate to, taking their Social Security and Medicare dollars with them.

Lee Iaccoca, the former CEO of Chrysler who brought the company back from bankruptcy 20-something years ago, stated in his autobiography that the lack of a nationalized health service in the U.S. was THE biggest stumbling block for U.S. manufacturing to compete in the global market.

Consider the savings to employers: no need to fund in-house insurance management; no constant searching for the best insurance deals; no loss of productivity because employees are coming to work sick because they can’t afford the deductibles/co-pays to see a doctor or get a prescription filled; lower employer taxes (nationalized health would replace employer-funded plans AND Medicare); removal of health care benefits from union contracts.

What would a national health service look like? Ideally, like one, large, extended health clinic. Doctors would be able to choose to be employed by the service [for a flat salary], to set up in private practice, or a mix of the two [say 20 hrs/wk to the service plus private practice hours]. Hospitals and clinics would be able to make the choice between service and private. Nurses and other support personnel would make the same choice to be employed by a provider in the national service or private practice.

To understand the benefits to health care professionals, and where potential savings in overall health care costs can occur, let’s take a look at what a doctor in private practice needs to fund with his/her fees: 10-12 years of student loans; malpractice insurance for himself and his practice; the overhead for office space; salaries for nurses and office staff; medical and office equipment; medical billing [either a service or software & trained in-house personnel], advertising [yes, advertising. Yellow pages, Internet and so forth]. Oh, and a living wage for himself. Plus his own health insurance.

Nurses today are increasingly required to carry malpractice insurance on themselves; employing practices no longer insure them against malpractice in the performance of their duties at the clinic/hospital. Nurses need to be paid a high enough salary to cover that, paying off their 4-6 or more years of student loans, plus a living wage. As there is a nurse shortage in the U.S., salaries are going higher and higher to compete for this limited resource.

Even nurse’s aides are required in most states to be licensed, which requires post-high school educational expenses.

For hospitals and clinics, look at the private practice expenses and multiply them a thousand-fold… and add in the constant expense of building maintenance, expansion and renovations to meet the ever-changing demands of new therapies and changing demographics [example: a hospital in an area that had a high birth rate due to the families of manufacturing employees has an extensive labor and delivery department, plus a state-of-the-art neonatal intensive care department and a large pediatric wing. It now finds itself caring for more geriatric patients and far fewer maternity and pediatric patients because the factory closed and all those families have moved away. It needs more general beds, expanded emergency, cardiology, oncology and renal/dialysis departments. It needs to do massive renovations because the population it serves has changed, along with recruiting specialist doctors and nurses for those expanded departments.]

So, what would be the savings within a national health care system?

First, student loan forgiveness for health care professionals who join the system. There is already such a foregiveness provision in place for doctors who commit to serve in isolated areas of the country and overseas that have a desperate need for medical services, like Native American reservations. This would cover everyone from doctors to medical record specialists – anyone who has needed and paid for post-high school education and training for their health care profession.

Second, elimination of malpractice insurance for providers who are 100% national service. The service would self-insure. The service would also have the power and authority to investigate and censure any provider it employs, up to and including stripping their license to practice. There could be caps applied to malpractice suits… with medical care provided for a victim of malpractice already through the national health service, such suits would only be for pain & suffering, loss of income and non-medical life accommodations.

Third, oversight would bump up to the national level rather than state, saving the states from having to fund oversight boards. Licensure would be at the federal level, eliminating the need for providers to obtain [and pay for] multiple licenses to practice in another state if they move.

Fourth, centralization of medical and prescription records [yes, pharmacies and pharmacists would also be part of this system]. The benefits of this alone are so far reaching. Briefly: no doctor/pharmacy-hopping for prescription-drug addicts; reduce the costs of supporting medical records for all providers; availability of a person’s full medical record to every provider who sees them; prevention of conflicting prescriptions; revenue from private providers who opt to be included in the medical record system.

Fifth, single-payer. All services provided by the system are paid for by the federal government. No need for service providers to bill multiple insurance companies and patients.

Sixth, reduced prescription costs. Currently drug companies charge astronomical prices for patented drugs to cover the costs of their research and development [some of which is frequently paid for by federal research grants], testing and FDA approval process, manufacturing, sales to thousands of pharmacies and marketing [which includes not only advertising to the public, something that used to be banned and should be again, but all those drug reps who visit doctors and hand out free samples, pens, breakaway hearts, intro to insulin kits and so on]. Consolidate or eliminate the marketing. Consolidate purchasing for service pharmacies. Expand the FDA approval process to include the actual testing of proposed drugs by the CDC, ensuring truly unbiased test results and a consolidation of the infrastructure to support testing.


Seventh, eliminate regional duplication of services. For example, Rutland cannot support another hospital. We don’t have the population to require one. On a smaller scale, right now we have all these individual primary care providers with separate offices or clinics. Under a national health service, these individual practices can be combined into a single primary care clinic. Right now, when we take Felix to the pediatricians, we see whichever of the doctors are in-house that day – they all have access to his medical record, they review it before walking in the room, and they are all interchangeable. With elimination of duplication, primary care clinics and even specialist clinics would function the same way. This eliminates the expenses of maintaining multiple doctor’s offices and clinics.

Eighth, better allocation of human resources. A national health service can offer incentives to providers in provider-dense areas to relocate and practice in areas of the country that currently lack providers. There are states in the upper Midwest where people have to travel two to six hours to reach a doctor, much less a hospital.

Ninth, the power of bulk purchasing. This applies not only to the cost to the service in purchasing equipment and supplies in bulk for all its providers, but also to the manufacturers of that equipment or supplies. A manufacturer could reduce its advertising and sales overhead by contracting the majority of its output to the national service. This would also allow for the standardization of provider equipment and supplies. Inventory management and shipping would shift from the manufacturer and individual practices to the centralized national health service.

M. Turner – Her Story

A national health service would ensure that no one in the United States would lack access to basic medical care or necessary specialist care. It would eliminate Medicare, Medicaid and VA medical services, because it would cover care for all citizens, regardless of age, income or prior military service. Veterans would be able to live anywhere, instead of having to live within manageable travel distance from a VA medical center.

Cosmetic surgery is not a necessity. You get to pay for your own nose jobs, botox injections and liposuction. Reconstructive surgery is a necessity. The service would provide repair of a deviated septum to relieve sleep apnea, surgical procedures to reduce morbid obesity and “cosmetic” reconstructive surgery for burn victims. Prosthetics for daily living would be covered. Chiropractic care would be covered. Yes, non-emergency surgeries would probably be scheduled like… oh, wait, that already happens… oops.

A national health service does not mean that private insurance and private practice doctors will go away. There will be people who want to buy their own insurance to cover medical care above and beyond the national service, and there will be doctors who want to get rich, or who want to deal with only a limited number of patients or don’t want to be part of a “practice” that will control a provider’s schedule. The insurance field will contract, but it won’t go away completely. Private practice providers will still need malpractice insurance, their patients will still need private insurance, their offices will still need liability insurance and so forth.

What there will be is a reduction or elimination of the political influence of insurance and drug companies. With a true national health service in place, there will be no need for lobbyists and campaign donations that currently buy Congressional votes to block true health care reform.

How can we finance this? Redirect the current payroll taxes for Medicare. Institute a 1% tax on all employers, corporations and wage earners. Close the tax loop holes that allowed G.E. to pay no corporate income tax last year. Tax capital gains as income [currently capital gains, which are the income derived from investments and playing the stock market, is taxed at a flat 15% - this is why Mitt Romney only paid 17% tax on his income in 2011, in spite of that income being in the millions.]. Reduce the budget for the Pentagon – Congress has allocated larger budgets to the Pentagon than they have requested since 2010. Eliminate tax-exempt status, period [a true non-profit will have very little or no "profit" to be taxed. Only those "non-profits" who raise monies in excess of their program expenses will have corporate income to be taxed.]. Revise the federal tax code. Fold the federal departments dealing with Medicare, Medicaid and veterans’ medical services into the national health service.

Take note of the hammer and sickle at the base

This is what so many of us want. It is what got torpedoed under Bill Clinton and what we didn’t get with Obamacare… because Americans have been brainwashed against “socialized” anything and Congress has been sucking at the teat of the insurance companies, the drug companies and the medical associations for decades. Every primary care doctor I have talked to supports a national health service, and would love to work for one.

I would love to have one. Then I wouldn’t be trying to pay off thousands of dollars in deductibles and co-pays under Medicare.

Oh, and this would also streamline the process for determining disability for SSI and SSDI. Primary care physicians and specialists working in the system could be trained to determine disability under federal guidelines, thus eliminating the entire cumbersome infrastructure currently in place. They could certify temporary or permanent disability and kick that certification immediately to federal safety net programs including food stamps, Social Security, housing services. It would tighten the safety net for disabled citizens, including veterans. It could help reduce homelessness by eliminating all the hoops a homeless person has to jump through to get housing assistance, SSI, SSDI, veteran’s benefits…

Yes, it is a massive social program. It would require a massive national effort to implement. But it can solve so many of our problems. Pulling in referrals for mental health service from schools could have put the Connecticut elementary school shooter into therapy four years ago… and could have saved the lives of those twenty children.

Aftermath at Sandy Hook



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One Response to What “Obamacare” Should Have Been

  1. Omribar Dan

    December 29, 2012 at 3:24 am

    An intriguing scenario, and a proposed program for health care reforms that is certainly worth taking a serious look at again… if we could mobiliize sufficient political support from the voters at the grassroots level, how much time and what other kinds of resources do you think will be needed to get this started… but since EVERYONE seems to be affected, maybe this should be dealt with, at least in terms of the bill to be passed, as a non- partisan consensus?