Congressional Republicans and the president can’t seem to coordinate their activities to “repeal and replace” the ACA, or get much of anything done. Their inability to deliver on their promise to give the public something better than the ACA is a surprise, since they have been saying for seven years that the American public deserved something better. Their inability to offer a better alternative has not caused them to change their battle cry. At any moment since 2010 and right up to today, if you asked any of them what they thought of the ACA they were all are likely to use the same words, “It’s a disaster.”

President Trump wasted no time trying to deliver on his campaign promise to get rid of the ACA. He signed executive orders during his first hours in office that were step one in his promise to offer relief to his voters from the horrors of the ACA, ASAP. His first order said that his administration would “seek prompt repeal” of the ACA which it called an “economic burden.” The order directed the Secretary of HHS and other agencies to “waive, defer, grant exemptions from, or delay the implementation” of any part of the law that places a fiscal burden on the government, businesses or individuals…in the order are directions to give states more control over implementing health care laws.

Perhaps that order might have been more successfully executed if he had chosen a different Secretary of Health and Human Services than Congressman, Tom Price, MD, orthopedic surgeon from Atlanta. Dr. Price had already demonstrated during his years in Congress serving on the Ways and Means Committee of the House that he had an unique ability to inure himself through questionable relationships with drug companies and other medical industries. It did not take Dr. Price long to decide that he needed to travel like the CEO of a multibillion dollar company as he rang up private air travel bills of more than a million dollars in about six months. What did Dr. Price do while in office to minimize the “economic burden” of Obamacare? He did shorten the enrollment period for the sign up for 2018 and ended the programs to provide advertising and sign up support during the enrollment period.

The adventures of Dr. Price have just been a sideshow. Congressional Republicans and the president have been in the center ring of this circus. The various bills that Republicans have introduced advantaged only the rich and medical device manufacturers whom the ACA taxed to cover the expenses of the ACA. Each bill sought to reduce the federal support offered to the underserved in the ACA. The most common mechanism offered was to switch Medicaid to “block grants,” ostensibly to offer the states more local flexibility. At times repeal and replace seemed likely. A bill was passed by the House. You remember the party at the White House that was thrown to celebrate the passage back in March, don’t you?

The real drama has been in the Senate, but the core characteristics of all the variations that were offered and failed stayed true to the themes that were in Paul Ryan’s original bill. Those themes were: tax relief for the rich, twenty million or so Americans losing healthcare, and future substantial reductions in federal expense by cutting Medicaid under the guise of giving the money to the states to craft the programs that they thought were best for their citizens.

The most evasive and, in my mind, despicable and insensitive quote of the period belonged to the speaker himself. When he was queried about how many people would lose their access to care he said that it was alright if 22 million Americans chose not to buy healthcare. He implied that his bill gave everybody the choice and the ability to buy a policy if they really wanted it, and maybe 22 million Americans would exercise their option to go uncovered as a matter of choice. To infer that the ability to buy care if you wanted to pay for it was a freedom to be cherished over the access to care that the ACA offered is lame.

One positive benefit of the painful last six months is that more and more Americans are learning about the issues of healthcare. As recently as last February as many as a third of Americans did not know that the ACA, which they liked, was the same as Obamacare which they had been taught to loathe. The twists and turns of the last nine months have convinced many Americans that any future legislation should preserve some basic features of the ACA. By trying to take many of these benefits away, Republican attempts to repeal and replace the ACA have awakened Americans to the benefits of “Obamacare.” Those benefits are explained in many articles.

Most Americans like the benefit of their children staying on their policy until they are 26. There is peace of mind in knowing that your insurer cannot cancel your policy when you get sick. It is really nice to be able to compare policies to better understand what you are buying. Many people did not know that prior to 2010 their policy probably had lifetime limits on many of the benefits. They like that they cannot be denied coverage or charged more for a “pre-existing” condition. They did not initially appreciate that the law required that they be offered the same premiums as others within their locality or age group, unless they were a smoker.

No one likes the “mandate” that they buy insurance or pay a fine, but now they understand why one is needed. Experience has now taught many of them that they can trust that they will be shielded from excessive increases in cost by subsidies if they are in a household making less that 400% of the poverty level, as long as the ACA remains the law. They are thankful that they are now eligible for Medicaid if they earned less than 133% (because of the way it is calculated, actually 138%) of the poverty level, and are lucky enough to live in one of the 31 states that accepted the medicaid expansion.

In the context of recent Republican offerings and the “bipartisan” negotiations to preserve the CSR payments, many Americans are now learning that the best part of the ACA for them was the guarantee that their policy meet certain standards of coverage. The potential compromise may erode that benefit if states are allowed to have more flexibility in the benefit design of their Medicaid programs. The president’s executive orders regarding access to birth control and creation of “association” policies across state lines also threaten the assurance that policies meet minimum  standards.

Do you remember all of the resistance to the passage of the ACA back in 2010 that Republicans expressed because it was a complicated bill of over 2000 pages that no one had completely read or understood? When one looks at the list above things get simple fast. What is taking a little longer for the majority of people who are affluent and/or get their care from their employer (the large majority of the population) is that the bill does provide benefit for everybody, including them. Everybody is entitled to a summary of benefits to enable their decision making even among plans purchased through their employer with different payroll deductions. At least 80% of the money paid to insurers must be used to provide care. In the past many plans kept more than 30% of the premium to fatten their profits. Everyone gets the guarantee of much of their preventative care without extra expense. Everyone is protected from annual and lifetime limits on coverage, and enjoys the right to appeal a denial of payment form the insurer. These are real benefits.  

Obama’s biggest gaff, which the Republicans never let him forget, was his statement that if you liked your plan you could keep it. What he should have said, or perhaps meant to say, was that if your employer’s plan was compliant with these provisions, you could keep that plan. Many of the plans offered before late March 2013 when these rules went into effect were essentially junk plans that deceived the recipients into thinking that they were safe when they were not.

Candidate Trump did not know in 2016 that a law had been passed in 1986 to prevent people from “dying in the street.” Whether he has learned about EMTALA by now or not, he continues to reassure us that we will not die in the street if we repeal Obamacare.  Those individuals without coverage who are taken to hospitals or show up with the advanced diseased states that occur when they are denied preventative care or management of their chronic disease are called “bad debt” by the hospital CFO. Who pays for the “bad debt” after bankruptcies and collection agencies fail to squeeze the money from the unfortunate person who could not buy or did not buy the coverage they needed? We all pay.

Because the cost of care determines the cost of insurance, the president has one huge partner in fostering the return of junk policies that will eventually erode the essential benefits offered by the ACA. Who might that be? You and I are his partners. The prime reason to consider  trying something different from the ACA that most people understand from personal experience is the rising cost of their coverage. Long ago I began to annoy people in the place where I worked by asking the question, “What part of the problem are we?” Doctors and hospitals determine a huge part of the cost of care. The nice thing about the question, “What part of the problem am I/ are we?” is that we can fix that part of the problem that lies within the bounds of our agency.

We have recognized the cost of care as a problem for decades. It was a major theme of Crossing the Quality Chasm in 2001. It was the message on the right side of the famous triangle depicting the Triple Aim. Accepting responsibility for your own part of the total cost of care is step one of not being part of the problem, and it does not require an executive order. Whatever your role in healthcare, and especially if you have a leadership responsibility, everyday you have the ability to help lower the cost of care and move us beyond the concept that Obamacare is a disaster.

The president has made himself the “Creator of Chaos-in Chief.” In some strange way he seems to believe that creating more volatility, more uncertainty, more complexity (or chaos), and more ambiguity will lead us toward the deals we need to do. His observation that healthcare is too complex is not really right.  The ACA was written to move us toward the Triple Aim. We each have a role in getting there. We have the map. Getting to the destination will require us to climb the steep hill of personal and institutional transformation that will lead to a lower cost of care.  Lowering the cost of care will speed the arrival of the day when we have universal access that will enable better care for everyone and healthier communities with the resources saved from our current waste in healthcare invested to support improvement in the many social issues that diminish our health.

The ACA is not a disaster, even if some politicians prefer to imply so when they call it Obamacare with a snarl and negative body language. Whether it is called the ACA or Obamacare, it is a brave start that points the way to more efficient solutions to our current chaos.  The experience we have gained is valuable. We have spent hundreds of millions of dollars on this foundation that needs improvement. Repairing and improving what we have based on what we have learned seems to me to be the right way forward.