Marc Siegel

When President Trump mentioned extending health insurance to everyone this month, it sounded like it could be pie in the sky — until you consider that the insurance he plans on replacing, Obamacare, is struggling under the weight of its own subsidies, regulations and restrictions. On his first day in office, Trump showed he recognized that with an executive order addressing just those issues.

It will certainly be easier to extend a catastrophic-plus style of insurance to more people if that is what the new president has in mind, especially when it is connected to fully tax deductible health savings accounts that will be used by the consumer to negotiate lower prices. Consider that of the 20 million or so who currently receive insurance under Obamacare, 11 million or so are actually the new Medicaid enrollees in states which have expanded the program. Not a pure success for the private Obamacare plans by any measure.

Also consider that the essential benefits package of Obamacare covers the Adderall stimulant for my patient who may not actually have attention deficit disorder but carries the diagnosis and is positive he performs his job better when he takes the medication. It also covers — without a copay — screening sexually transmitted disease tests (though not treatments) for my patient who engages in high risk sex and then wants to be tested for HIV and other diseases (under Obamacare, women are covered for chlamydia and gonorrhea screening and men aren’t, which seems arbitrary). The rest of us who don’t go on alluring websites or hang out late night in pubs help pay for this service. Is this fair? I don’t think so. Obamacare covers women over 40 for mammograms every one to two years, which seems to have no downside until you consider the significant number of mammograms at that age which lead to unnecessary biopsies and surgeries.

The problem is that doctors didn’t decide what was essential, lawmakers did. As a practicing physician, I am glad that the essential benefits package won’t stay the same under president Trump. It won’t be repealed initially. The budget reconciliation process will be used to get rid of the individual and large business mandate taxes and financial drains on the Treasury like the $42 billion in subsidies for the state exchanges.

Here's how to reform Obamacare: Column

Kevin Brady: Our GOP plan to replace Obamacare

As technology develops and medical testing and treatment becomes more and more personalized, it becomes impossible for insurance to cover all of it for all of us without enormous premiums.

Fear rhetoric spouted by politicians may convince us that all this coverage is necessary, but most of us (those without chronic health conditions) would be much better off with a more scaled down catastrophic insurance with a high deductible and a big fat tax deductible health savings account to cover daily health expenses that don’t rise to the level of severe illness. Returning to payment up front for routine health expenses will take a lot of the burden off the physician and will lead to a greater doctor-patient partnership in determining care and negotiating price.

Think of Obamacare as a prix-fixe seven course dinner where by the third course you are already asking for the check. The salad is great, but do we really need the mandatory dessert? The post-Obamacare world should look more like a buffet, where there are many gourmet (high tech) choices and you and your doctor can decide what you need. You will have many more restaurants to choose from (insurers providing policies across state lines) that will compete for your business, and prices will be lower. If you need to eat a heavy meal (pre-existing chronic condition), then the government will pay a substantial part of the check through risk pools. Prior to the full implementation of Obamacare, 35 states offered high-risk pools as a source of non-group health insurance.

Costs may go up for extensive maternity care, mammograms and other services that could see their mandatory coverage scaled back. Government subsidies will be important for true public health preventive services. Medicaid expansion should be maintained though primary control returned to the states and the product made more efficient, as in Indiana and Ohio. Vaccinations are important public health measures that should be part of mandatory insurance coverage.

POLICING THE USA: A look at race, justice, media

Medicare for All should replace Obamacare: Column

Obamacare’s essential benefits package is a chokehold on insurance (individual and small business) that needs to be pried off and replaced with catastrophic coverage for emergency services, true public health needs and hospitalization. Real doctors, beginning with Health and Human Services secretary nominee Tom Price, need to help decide what’s essential and what isn’t. The individual mandate is a noose that isn’t working (young people are less than 30% of Obamacare’s customers). Malpractice reform will help doctors fight the negative urge for defensive over-testing and over-treating.

Replace won’t take place overnight; in fact it may take many months. But in the end we will have a cheaper, more efficient user-friendly health care system that’s far more suited to the personalized health care solutions of the future. We will have to fight through our politician-stoked fears to get there, but we will.

Marc Siegel, a member of USA TODAY's Board of Contributors and aFox News medical correspondent, is a clinical professor of medicine and medical director of Doctor Radio atNYU Langone Medical Center.

You can read diverse opinions from our Board of Contributors and other writers on the Opinion front page, on Twitter @USATOpinion and in our daily Opinion newsletter. To submit a letter, comment or column, check our submission guidelines.