Marc Siegel, MD: Beyond ObamaCare -- My hopes for patients and real, affordable care

House Republicans introduced two bills this week to repeal and replace ObamaCare. They include tax credits to replace subsidies, phasing out the Medicaid expansion, grants to the states and more state control, increasing the scope of health savings accounts and, happily, the end of the dysfunctional individual and employer mandates. More choice, less federal regulation.

Meanwhile, with no visible changes yet in offices like mine, patients continue to come for care and we doctors continue to provide it.

We hope for a less insurance-heavy future because we know your coverage provides a promise we often can’t fulfill. That’s the key: Health insurance is not health care, just as auto insurance is not an automatic ticket to car repair.

Politicians for decades have blurred this distinction and used it to justify expanding the insurance market without necessarily caring for more people in a better way. Remember, this is the same federal government that lamely delivers our mail while Fedex and UPS run circles around it.

Practicing doctors know the truth: Health insurance doesn’t or can’t distinguish between problems (chest pain, fever, blackout) that require an office visit and those (colds, sprains, fatigue) that don’t.

This is a main reason that health care costs escalate out of control: Necessary coverage for a pre-existing condition such as diabetes or even cancer covers not only insulin and chemotherapy, but a muscle spasm or sniffle that the same patient doesn’t need to see me for.

Fear of illness and death drive the market, and patients try to get as much coverage as they can to protect themselves against an overblown sense of risk. Politicians have fanned the flames of this fear to justify regulations and mandates, while insurers use it to justify rising premiums.

ObamaCare didn’t cause this problem, but it has made it worse, joining Medicare as a driver of the insurance market. The Affordable Care Act has added regulations and higher deductibles that have affected employer health coverage (for 175 million people) as well as the individual market (around 30 million) it was intended for. One of my patients fainted and was rushed to the hospital last month (luckily, he was OK), only to be hit with a $1,000 deductible that wasn’t in his company’s policy before this year.

Doctors everywhere will be glad to see the individual and employer mandates go. They are unethical and based on a false premise. Health care may be a right, but health insurance doesn’t guarantee it, since we doctors aren’t compelled to see every insured patient who comes our way and provide every service.

Surgeons, for example, are much slower to operate on patients with multiple medical problems for fear of complications. ObamaCare’s architects argued that screening tests like colonoscopies and mammograms and sexually transmitted disease labs lead to early diagnoses and treatments that save on health care costs. But even if this is true, it is more cost-effective for the government to provide these services directly, or to reimburse insurance companies to provide them, than it is to pile them into an essential benefits package under ObamaCare that everyone pays for in their premiums.

Young, healthy people need emergency health coverage, not high-premium, high-deductible policies. Since 5 percent of the population uses 50 percent of our health services, the individual mandate is on a path toward socialized medicine.

For the worried well, with narrow networks of doctors (a Blue Cross study in 2016 revealed that more than half the state exchanges feed narrow networks) and rising deductibles (the average Bronze plan’s deductible rose over $12,000 last year) blocking usual use (a patient is often afraid to see me at all until her deductible is met, and then she comes in all the time, unnecessarily, once it is), the current doctor’s office is a dysfunctional place of pleas for pre-approvals and reimbursements, nights spent bleary-eyed over computer documentation and too-short decision-making discussions with patients.

No matter what the new health care bill ultimately looks like, it must include catastrophic options that were absent from the ACA. Since federal law prohibits emergency rooms from turning patients away, a baseline catastrophic coverage makes sense. Beyond this, public health is a reasonable justification for providing vaccines free of charge, as well as treatments in an epidemic or disaster.

But basic day-to-day control of health care decisions can be returned to the doctor’s office, where free-market solutions are better suited to innovative biotech personalized treatments of the present and especially the future.

In a TrumpCare future, patients will offer their credit card instead of their insurance card, and they’ll be met with a smile. It will be at least three times cheaper for the government to subsidize those with pre-existing conditions in high-risk state pools rather than the current subsidies for two thirds of people signing up at the state exchanges. National exchanges will introduce more competition and drive down prices. Catastrophic policies paid for at least partly by tax credits (between $2,000 and $4,000 per year per individual earning up to $75,000 in the current House bill), coupled with health savings accounts, will improve price transparency and enable us to guide our patients to more cost-effective choices. Instead of a prohibitive red light turning to green once the deductible has been met, there will be a frugal yellow light on the road to all my patients’ decisions.