Marc Siegel

Opinion columnist

Now that the Senate and House are working to resolve the differences in their tax bills, one question on everyone’s mind is whether the final version will repeal Obamacare’s unpopular requirement that people on the individual insurance market buy a policy or pay a penalty.

I am one physician who hopes it will.

I am not alone. In a survey published by the New England Journal of Medicine in February, only about half of the 426 primary care physicians who responded to its questions wanted to keep the individual mandate.

Why? Because health insurance doesn’t guarantee you access to actual health care. Because too often my patients are trapped by a large Obamacare deductible and are unable to afford to pay out of pocket for the test or treatment I think they should have. Because the orthopedist or diabetes specialist or cardiologist I want them to see frequently doesn’t accept their insurance.

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It only makes sense to mandate a minimum of catastrophic coverage. This kind of mandate would protect patients from sudden bankrupting illness and hospitals from expensive incoming emergencies that uninsured patients have no means to cover. Just as every car on the road needs to be covered by at least basic liability insurance to protect both the driver and others in the event of an accident, the same holds true for health care. But should every basic Toyota owner pay the same as every Ferrari owner just so the latter can pay less for a fancy collision policy? I don’t think so.

Sen. Rand Paul, R-Ky., questions "whether the government can force you to buy something you don't want and for a lot of people it was forcing them to buy insurance that had a high deductible that really did not help them much.” Paul, an opthalmologist, told me in a recent interview that removing the individual mandate (as the Senate bill does) is a way to give the middle class “a little more of a tax cut.” It turns out that 80% of those who take the tax penalty make less than $50,000 per year.

Critics say taking away the mandate will cause premiums to soar, as the few insurers who remain in the market struggle to cover those with preexisting conditions and transfer the costs to the consumer. I would suggest four solutions.

First, if more catastrophic-style policies are available, many who now choose the penalty or feel compelled to buy insurance they don’t want could instead elect this scaled-down coverage. In that case the nonpartisan Congressional Budget Office projection, that 13 million more would go uninsured by 2027, could be a vast overestimation. Second, generous government subsidies could be focused on the 5% of the population who use 50% of the health care, making high risk pools more useful and efficient than previous attempts. Removing the mandate might not save money if that's done, but it is certainly a fairer approach.

Third, the federal government could introduce tax incentives for behavior geared towards reducing health care costs including gym memberships, weight loss programs and smoking cessation. This would certainly save on health care costs. Fourth, it is absurd that the current mandate covers Medicaid as well as private insurance. Medicaid is not something you should have to apply for or be penalized for not having. A Medicaid card should be sent automatically to all who qualify.

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Parts of Obamacare are working, including the attempts to create efficiency and quality driven teams (Accountable Care Organizations), the expansion of Federally Qualified Health Centers (now delivering care to 22 million people) and the popular Medicaid expansion in 32 states. It is no surprise that primary care doctors have not supported wholesale repeal and replace attempts (only 15% favored complete repeal, including 32% of Republican doctors, according to the medical journal survey).

Medicaid is far from perfect; it is filled with waste and last year was 18% of the National Health Expenditure. It needs bridges to job programs built into it, and too many doctors (up to 30%, including me) don’t see new Medicaid patients. The health center I visited in Dunkirk, N.Y., embraced the Medicaid expansion but admitted it lacked the doctors to take care of the newly insured. Medicaid needs to tighten its belt on services while at the same time paying doctors more.

But regardless of Medicaid’s flaws, the GOP was wrong to target it as part of its attempt to repeal and replace Obamacare. That's a main reason the party ultimately failed. The expansion has brought health care to millions who didn't have it before, contributing to the "no" votes cast by rural moderates like Sens. Susan Collins of Maine and Lisa Murkowski of Alaska.

With the Medicaid expansion preserved, the individual mandate scaled back and federal subsidies directed toward those who need them the most, there is a chance to improve efficiency while preserving and even improving basic health care coverage.

Marc Siegel, a member of USA TODAY's Board of Contributors and a Fox News medical correspondent, is a clinical professor of medicine and medical director of Doctor Radio at NYU Langone Medical Center. Follow him on Twitter: @DrMarcSiegel.