President-elect Trump says he is open to considering which parts of the Affordable Care Act (ACA) – or Obamacare – should be kept and which should be killed. Dr. Tom Price is a terrific choice for Secretary of Health and Human Services; he and his colleagues in Congress now must get down to work.

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Price has fielded his own plan, with similarities to House Speaker Paul Ryan’s plan. Regardless, we must keep our collective eyes on what the outcome should be: affordable, quality health care for all Americans. As a physician and policy person, I make the following suggestions.

Kill or change it considerable:

Any mandate is unpopular, to say the least. However, losing the individual mandate and keeping the elimination of the pre-existing exclusion (see below) requires new mechanisms to be developed to incent patients to have health insurance.

Having insufficient numbers of healthy people sign up doomed Obamacare. There have been a number of approaches to incentives, including: The uninsured get an open enrollment period, and if they do not sign up for insurance, they face pre-existing condition exclusions and higher prices for insurance.

Have insurance available to all which covers only catastrophic care, funded through health savings accounts.

Make health insurance cheaper. In a previous post, I suggested ways to do that and finally create subsidies that consider the entire out-of-pocket expense, rather than just covering the premium and leaving a person who makes $24,000 a year with a totally unaffordable $4,000 deductible.

It is vital to get the incentives right, perhaps by permitting several states to try them, as suggested by the “Health Partnership Act” years ago. I strongly agree that states should be able to take important roles in deciding about health care.

As unpopular as it could be, if in response to all the incentives, healthy people do not buy insurance, the individual mandate may actually have to be increased.

States will need organizations such as exchanges that could be privately funded. The federal government should set reasonable guidelines, with metrics for coverage, and get out of the way. These organizations must manage both Medicaid funding via a block grant and federal funds for subsidies to buy commercial insurance.

They should promote portability and be as seamless as possible whether a person is funded by Medicaid or federal subsidy for insurance. Regulations for mandated benefits in Medicaid as well as commercial insurance should be examined for cost and effectiveness. Selling insurance across state lines should be promoted if costs are demonstrably lower.

Remember the goal:

Affordable health insurance for all — that’s 1-9 percent of income for all health-related expenses, not just the premium. Finally, a well-tested transition plan must be put into place so that millions of Americans are not left without coverage.

In order to provide funding for state innovation, the Independent Payment Advisory Board, Centers for Medicare and Medicaid Innovation, Cadillac Tax, Workforce Commission, and the prevention / public health fund should be discontinued.

These funds should support each state to take the lead in decreasing cost, improving quality and optimizing health workforce. A similar approach should be made for Medicare. Representatives from states and Medicare could meet yearly to share best practices, as proposed 10 years ago in the “Health Partnership Act.”





Permit Medicare to consider cost in coverage decisions. Currently, Medicare is not permitted to consider cost and the ACA expressly prohibits the use of cost effectiveness in decisions of what to pay for. These prohibitions make little sense. Very few people would buy anything without considering price. Additionally, Medicare is prohibited from negotiating prices with pharmaceutical manufacturers. One of the major reasons other countries have less expensive drugs is because they negotiate prices on behalf of large segments of their population.

Keep these aspects of it:

Elimination of the pre-existing condition exclusion. This has always seemed draconian, but before Obamacare, this was the only thing that motivated healthy people to buy health insurance. We need new ways to incent people to buy insurance (see above). For those who remain uninsured, the safety net should be strengthened with increased federal funding for community health centers.

Coverage of children to age 26. According to an analysis of this provision, adding young adult coverage would increase average family premiums by as little as 0.7 percent while allowing 1.2 million young Americans coverage under their parent's' plan through an employer or the individual market.

Insurance provisions: eliminate lifetime and annual limits on health insurance; insurance companies must spend at least 85 percent of their premiums on health care services.

Value-based payments to health systems and physicians, moving away from fee-for-service payment where the hospital and physician are paid for every service performed, thus tending to overtreatment.

Legal issues. There should be more screening for fraud and abuse, and finally, tort reform must take place. The current system does not work for patients, and it must be improved.

In conclusion, there is much to be said for beginning with the goal of quality health care for all Americans, and enacting the best ways to achieve the goal. Whether the ACA remains or a new act is drafted is a question for the bill drafters.

Much of the prior proposals actually contain features that have been introduced by both parties. In any event, this is a time for Republicans and Democrats to work together and show the nation that this next Congress and the new President can do important work.

Arthur Garson, Jr., MD, MPH is the director of Health Policy Institute at Texas Medical Center.

The views expressed by contributors are their own and not the views of The Hill.