It was Groundhog Day at the House of Representatives Wednesday as it once again voted to repeal Obamacare. All told, House Republicans have voted to repeal, defund or otherwise invalidate part of the Affordable Care Act between 31 and 33 times, depending on how you count. And they're still not done -- Republicans leaders have vowed to make attempts to repeal the law a major priority in the next Congress, too.
But instead of wasting its time and our hard-earned tax dollars -- yes, it cost money to hold all those votes -- on partisan posturing, the House could have passed a lot of legislation that would have tweaked the law or improved our collective health. Some of it might even have made Republicans a little happier with the ACA.
Here are a dozen of our favorite policies -- and seeds of possible bills -- that could improve health, bring down costs, or otherwise improve the ACA:
1. Repeal and replace the individual mandate. The insurance reforms in Obamacare won't work well if people wait to buy insurance until they get sick, but the individual mandate in the law is just one way to make sure healthy people pay into the system. Unfortunately, Republicans (and voters as a whole) aren't very happy with that piece of the law -- they see it as an unnecessary government intrusion in people's lives.
Another way to encourage healthy people to get insurance is to permit a set period of time (a couple of months, say) after a person becomes uninsured to purchase new insurance. If they choose not to become insured (through Medicaid, an employer, or the exchanges provided for under the ACA) within that period, they would lose guaranteed coverage for pre-existing conditions, community rating, and access to the ACA-created insurance exchange subsidies for five years. That would encourage people to buy insurance, but allow people who genuinely want to self-insure the opportunity to opt out. (It's also indisputably constitutional, regardless of what you think of Chief Justice Roberts's decision.)
2. Enact a "public option" in state insurance exchanges. During the debate over the ACA, the Congressional Budget Office estimated that adding a publicly run insurance plan would reduce the deficit by an additional $88 billion over ten years relative to the law as passed, by taking in insurance premiums and paying out less to private insurers through exchange subsidies. That's a significant bit of deficit reduction that won't require tax increases or cutting important services.
3. Repeal corn subsidies. Soda is the number one source of added sugar in the American diet, and sugar contributes to obesity. Drinking one extra can of soda per day can add over 50,000 empty calories per year -- over three weeks' worth of food, with no nutritional content. The sugar used in those drinks is mostly high fructose corn syrup, which, true to its name, is a corn product. We spend $4 billion a year on subsidies to corn farmers -- subsidies which keep corn syrup (not to mention other nutrient-free foods) artificially cheap. Repealing subsidies seems like a no-brainer way to reduce obesity and combat an epidemic that costs our medical system hundreds of billions of dollars each year.
4. Fix the medical malpractice system. Republicans (and a lot of doctors) claim that the medical malpractice system is a big reason for high spending, unnecessary use of medical services, and other problems in the health-care system. But the House is so busy repetitively repealing the ACA it hasn't gotten around to doing anything about it. Unfortunately, there's not a lot of reason to think tort reform will magically solve all the problems that are blamed on lawsuits. States like Texas that have enacted reforms haven't seen a significant reduction in medical spending, the rate at which people lack insurance, or health insurance premiums, or seen an increase in the number of doctors per capita. Maybe if fixing malpractice nationwide doesn't improve the medical system, Republicans will move on to more credible ideas for reducing spending.
5. Enact a carbon tax, or increase the gas tax. A tax on carbon dioxide emissions won't just help prevent climate change -- it'll improve our health. A carbon tax would encourage denser urban development, for instance by making it more expensive to drive to work and to heat large suburban homes -- and pollute the air. Denser development (and the need to find another way to commute and run errands) will encourage people to walk more. Walking is an effective form of exercise, and can help people maintain lower cholesterol, lower blood pressure, and lower body weight, all of which could reduce medical spending.
6. Fix the FDA's post-marketing surveillance system. We've written recently about the problems with letting drug companies take charge of testing their own products. Basically, they have every incentive to keep drugs on the shelf as long as possible, even if those drugs are killing patients. We should establish an independent safety data system that treats all drugs as experimental for their first few years on the market. Making sure our pharmaceuticals don't kill people isn't a liberal or conservative issue -- it's just a safety issue.
7. Require residency programs to train more primary care physicians than specialists. Our medical workforce is upside down. Most developed countries have many more primary care docs than specialists. In the U.S. it's the reverse, with nearly two specialists per primary care physician. Not coincidentally, those other countries' populations are also healthier than ours, and they stay that way while spending less on medical care. There's no reason to keep paying academic medicine to produce more specialists than we need, while millions of Americans don't have a regular primary care doctor.
8. Enact a "meaningful choice" requirement for patients with Medicare and Medicaid. About a million patients each year have cardiac stents placed in arteries in their hearts. Most of those patients don't really understand why they're getting the surgery, though, or how they can expect to benefit. That means they're not making fully informed decisions about their care. Patients deserve better. In order to get paid by Medicare and Medicaid, doctors should have to inform their patients better and do something called "shared decision-making," not just for heart procedures, but for any elective test or surgery. Research has shown that after going through shared decision-making, patients are better informed and tend to choose more conservative options (like lifestyle and pharmaceutical treatment for heart disease, rather than surgery).
9. Pay doctors to have conversations with their patients about how they'd like to be treated at the end of life. Dying is incredibly expensive in the U.S.: an average Medicare patient receives over $53,000 in medical services over the last two years of life, and 10 percent of patients spend over $63,000. Much of that money isn't well spent, because it paid for interventions the patient didn't want. It's time for conservatives to stop the politically cynical shroud waving any time the topic of conversations between doctors and their dying patients comes up. Primary care doctors need to be paid to talk with their elderly patients about how much technological intervention they want at the end of life. Patients deserve access to tools like the videos produced by Dr. Angelo Volandes, at Massachusetts General Hospital, which show patients what it really means to be placed on a ventilator or undergo CPR.
10. Offer insurance exchange subsidies for people with incomes under 100 percent of the Federal Poverty Line. The Supreme Court upheld the individual mandate in its ruling last month, but it struck down the requirement that states expand Medicaid eligibility to all adults under 133 percent of the poverty line. In states that choose not to participate in the expansion, poor adults are in big trouble: while people with incomes between 100 percent and 133 percent of poverty are eligible for subsidies to buy insurance on exchanges, there's no other system in place to provide insurance for people living under 100 percent of the poverty line. Congress should at least offer the same subsidies that higher-income people can get, so the poor aren't left entirely without access to insurance.
11. Fund after-school programs to teach kids to cook. Meals cooked at home are healthier than meals eaten out: they tend to have fewer calories and more nutrients, and they're cheaper. Helping kids learn to cook will keep them off the streets and help them eat better. If kids can help cook, the time cost of preparing a meal is lower for parents; getting kids involved in planning meals can also get them excited about healthier food and build lifelong habits of eating a balanced diet.
12. Require hospitals to make safety data publicly available. The August issue of Consumer Reports contains a remarkable new hospital ranking system: it's based entirely on safety data, not on the beauty contest-style reputation survey used by US News. The picture that comes out of the CR rankings is remarkable: most of the best-known hospitals have disappointingly bad patient safety outcomes, and some are truly atrocious. The magazine only ranked 18 percent of the hospitals in the country, though -- because the rest of them don't report enough data publicly. Congress should require any hospital taking Medicare or Medicaid funds to make reported safety data readily available, including rates of infections, avoidable deaths, unnecessary imaging tests, among other statistics. If Republicans want patients to make better choices about where to get their care, they should make sure hospitals report the kind of information that would help patients make an informed choice.