Repeal and Replace appears again

Former Florida Governor Jeb Bush recently posted his proposed alternative to the Affordable Care Act (ObamaCare).  Although one of the first comprehensive proposals on health care from any of the 2016 Presidential candidates, the Bush proposal continues to ground itself on similar themes and priorities of other proposals.  On his 2016 presidential campaign website ( the Bush campaign declares his plan is build around the key components of innovation, cost savings and increasing state autonomy.  Unfortunately as a clinician I see little innovative in his proposals, recognize that his proposal continues to prioritize acute care over prevention and wellness and predominantly benefits higher income earners at the expense of lower income families and individuals

The key components of the Bush proposal include:

  • Repeal Obamacare, and provide those who presently receive health insurance subsidies a “transition plan” to shift them out of comprehensive insurance to catastrophic health plans.  This would be done via providing individuals with tax credits to buy “catastrophic health insurance plans”.
  • Replace the so-called “Cadillac Tax,” albeit with a policy similarly imposing higher taxes on expensive health plans.
  • Eliminate the mandate that requires large companies to provide their employees with health insurance and instead provide these employers with the option to contribute to their employees health insurance plans.
  • Remove the requirement that health insurance policies require “essential services” and allow insurance companies to again determine what services they will, and will not, cover.
  • Increase the maximum amount that people can contribute to their health savings accounts from $3,350 to $6,650.
  • Shift federal government assistance to states from the current system to a series of “block grants”.

The first, and primary impact, of the Bush proposal would be forcing lower income earners to abandon comprehensive health insurance plans they presently have under ObamaCare and shift them to catastrophic health insurance policies.  Catastrophic health insurance plans are insurance policies that have high deductibles and out of pocket costs before the insurance company pays for anything, provide limited benefits (may not cover prescriptions, preventative care, home health care, etc.) and are only intended form medical disasters.

The benefits of such plans are they have low premiums and are more affordable.  Such plans are economical and possibly a wise affordable option for individuals who are young, healthy and without medical problems.  The disadvantage is that catastrophic plans do not cover comprehensive primary care, often do not cover preventative services and do not encourage health promotion or wellness care.

Shifting healthy individuals into catastrophic plans would likely benefit young, healthy individuals but could dramatically drive up health insurance premiums for comprehensive health insurance plans.  As fewer individuals purchase comprehensive health insurance plans there is a small premium pool to draw from.  Insurers will be forced to increase premiums for comprehensive plans to ensure solvency and profitability.  The increased rates for comprehensive plans will force individuals to drop their coverage, which results in driving premiums higher.

The real world impact of such a shift would be individuals foregoing preventative and wellness care, delaying treating illness or injury and seeking care only when they are desperately in need of care.  Individuals would delay screening exams, immunizations and other preventative services simply because they cannot afford them.  They may wait until their cough becomes a pneumonia before seeking treatment.  A simple examination and treatment plan for a viral upper respiratory tract infection, which could cost less than a $100 rapidly becomes a several thousand dollar hospitalization and convalesce period.

The majority of working families today live paycheck to paycheck to survive.  Such financial constraints force working families to view screening mammography, colonoscopies or immunizations as not being a priority compared to putting food on the table, keeping the lights on and keeping the children clothed.  They also view seeing their primary care provider (if they have one) as an expense that they cannot afford and therefore forego.

Some would argue that shifting individuals to catestrophic health insurance plans would force individuals to have “skin in the game” and be more judicious consumers of healthcare.  The best analogy I can think of is when I have a problem with my car.  I take it to a car mechanic that I trust and ask their opinion of what is needed.  As I know nothing about cars I am really unable to make an informed decision.  I have to decide if I can afford the recommended service or forego it because of the expense.  I can take the car to another mechanic for another opinion but I still am at the mercy of their clinical expertise, and limited by my ability to pay.

Healthcare is no different.

The shifting of individuals away from comprehensive health insurance and into catastrophic plans will perpetuate the current US health system where the majority of healthcare expenditures are on treating emergency or avoidable health complications; and a fraction of healthcare dollars are spent on wellness and prevention.  Our health system is the inverse of every other advanced industrialized nation where prevention is priority and acute care is seen as a system failure.

The end result of our current system is we spend more per capita on individual health care than any other nation, but rank near bottom on many health outcome measures including longevity, access to care, healthcare related complications and overall health outcomes. 

The sad irony of the Bush proposal is that the reliance on catastrophic  health care insurance/delivery drives healthcare expenditures up in the long term, not down.  This model causes our nation to spend billions on treating illnesses and conditions that could have been easily prevented or managed.  Several very strong studies have clearly demonstrated that comprehensive preventative care drives healthcare costs down, not up. (See Here)

The United States has a proven record of the results of health care cost containment through discouraging access and/or utilization of health care.  We have over 50 years of skyrocketing costs, increasing morbidity and mortality and massive health industry profits.  The only successful cost containment strategy must rely on increasing access to care, prioritizing and rewarding prevention/wellness and shifting to an evidenced based healthcare delivery model.  Shifting individuals into traditional catastrophic health insurance plans will succeed at none of these.