Saving the “Good” in Healthcare Reform: a Thought Experiment

By Jane M. Orient, M.D.,

Some have suggested piecemeal repeal of the most obnoxious features of the Affordable Care Act (ACA). The risk of this approach is comparable to that in cancer surgery: you might not get it all. In 906 pages of arcane statutory language, a lot can be hidden.

I suggest instead that we wipe the slate clean with a total repeal, and then consider reenacting any features that most agree are good. This would be the most efficient method because the list of items is shorter. Much shorter.

The most popular part is probably the elimination of “pre-existings.” You can’t eliminate the uninsurable condition of course, only the insurance company’s ability to deny coverage to people who have it. How would such an isolated law work?

In a free market, coverage for people with pre-existings might well be available, without any law—if insurers could simply charge a premium reflecting their risk, or limit the potential pay-out. The premium, naturally, could be very high. That would be a strong incentive to buy insurance when young and healthy, and resist temptations to spend the premium money on iPods and new cars instead. But for many it is already too late.

The U.S. already has the equivalent of fire insurance for those whose house is burning down. It is called Medicaid. Roll into the emergency room desperately ill, and the hospital will treat you, and probably enroll you in Medicaid—likely after you have spent through any assets and lost your SUV and your home.

To prevent such personal tragedies, how about a law that simply said: “Insurance companies must take all comers, without price discrimination for pre-existing conditions.” This is called “guaranteed issue” and “community rating” (GI/CR).

GI/CR would work well, if insurance were a magical money multiplier (MMM): put $100 in the slot machine, pull the lever, and watch $6 million in medical services pour out. The problem is that if a lot of healthy people who don’t expect to need medical services decline to feed in their premiums, knowing they can always do so as soon as they get sick, premiums will have to escalate rapidly. This is called adverse selection (only sick people sign up), or the death spiral. It has happened every time GI/CR has been tried.

This popular part of ACA is impossible without the hated and unconstitutional individual and employer mandates.

What about doing away with limits on lifetime coverage? Limiting out-of-pocket expenditures? Doing away with copayments? All of these have the same problem: lack of an MMM, such as a money tree or the Philosopher’s Stone that turns base metal into gold. The more we require insurance to pay out, the more money has to be poured in, with the inevitable loss to administrative overhead.

How about “giving doctors incentives to be more efficient”? In a free market, that is called the profit motive. In the ACA, the “incentives” are sticks painted to look like carrots, involving vast new reporting systems, with payments funneled through managed-care mechanisms. The choice is freedom—or ACA bureaucracies. Which of the some 159 new bureaucracies do we want to keep?

What about “affordability” provisions? Since prices are going up, in ACA “affordable” means forcing someone else to pay. It’s a matter of redistributing money from those who earn more than 400% of the federal poverty level (around $88,000) to those who earn less. Americans are divided into winners and losers, guaranteeing constant fights over one’s share of a shrinking pie.

One part everyone might favor is the one about allowing people to keep their insurance plan and their doctor if they like them.

Oh, that’s not in the bill. That was just a Presidential promise. The ACA has rules for “grandfathering” some plans—a good term since they are not expected to have a long life expectancy. ACA also appears to be designed to drive independent doctors out of practice, and it virtually outlaws new doctor-owned hospitals.

If we continue to scour through the ACA looking for isolated good points that will make things better or less costly, rather than worse and more expensive, I predict that our thought experiment will lead to what in mathematics is called the “null set.”

So far I have found no such provisions, zero. Nought, nada, nichts, zilch.

Jane M. Orient, M.D., On Air contributor speaking on Healthcare Reform.  Dr. Orient has appeared on NBC, MSNBC, ABC and many major broadcast venues throughout the US, as well and her Op-eds have been printed in hundreds of local and international newspapers, magazines and followed on major blogs.

Dr. Orient is the Executive Director of the Association of American Physicians and Surgeons.  She has been in solo practice of general internal medicine since 1981 and is a clinical lecturer in medicine at the University of Arizona College of Medicine. She received her undergraduate degrees in chemistry and mathematics from the University of Arizona, and her M.D. from Columbia University College of Physicians and Surgeons. She is the author of Sapira’s Art and Science of Bedside Diagnosis; the fourth edition has just been published by Lippincott, Williams & Wilkins. She also authored YOUR Doctor Is Not In: Healthy Skepticism about National Health Care, published by Crown. She is the executive director of the Association of American Physicians and Surgeons, a voice for patients’ and physicians’ independence since 1943. Complete curriculum vitae posted at

Dr. Orient’s position on Obama’s healthcare reform:  “The Obama plan will increase individual health insurance costs, and if the federal government puts price controls on the premiums, the companies will simply have to go out of business. Obama makes promises, but the Plan will deliver higher costs, more hassles, fewer choices, less innovation, and less patient care.” Doctor Orient resides in Tucson, AZ and can be reached at [email protected]

6 thoughts on “Saving the “Good” in Healthcare Reform: a Thought Experiment

  1. Well put, Dr. Orient.
    Fortunately, the absence of a severability clause in the bill will cause the entire bill be become null and void as soon as the Federal Court finds any one small piece unconstitutional. Then we can start over with a rational plan that outlaws the current type of medical managed care (mistakenly called “insurance”) and allows only health savings accounts and catastrophic insurance, thus allowing the market to operate once more.

  2. Why save Obamacare? There is no good part anywhere in it. It is a fact that when a doctor sees a patient his diagnosis and the patient’s age will be tranmitted by an electronic device to a panel appointed by Obama. The doctor will then recieve a protocol for treatment. If the doctor doesn’t follow that protocol he will be fined $200,000 even if the treatment was successful.
    The second time he doesn’t follow a designated protocol he will go to prison.
    I am a retired surgeon and I know that “cookbook” medicine is bad medicine. What
    you can do to one patient may kill another patient who seems like the one who did well.
    You don’t believe me–about the protocols and fines—- look it up yourself.

  3. I agree. There isn’t enough good in it to worry about salvaging any of it. Our biggest challenge is convincing people in this country of the rightness of paying one’s own way and happily accepting the risks and responsibilities that go along with Freedom. Ultimately, a cow can only support so many ticks…

  4. I agree completely with all that Dr. Orinet has said. Dr. Boyer, would you kindly direct me to the part(s)of the bill that mandate fines/prison for non-compliant physicians? This is truly , in my opinion, the most outageous aspect of the bill and I want to inform others of its impact on physician care. Great position for doctors, right? Don’t prescribe as you think you should and follow some bureaucrat’s directive and you could end up being sued for malpractice! Even if the plaintiff does not prevail, the cost to the physician is enormous. When did the practice of medicine become reduced to a simple formula set up by the federal government? All federla employess including the Congress and the president should have the same “care” we ordinary citizens will have.

  5. I too would like to know what part of the bill Dr. Boyer is referring to. It seems every day we learn a little more about what is in this bill. I just discovered that I will get an income tax increase. Yes, the IRS medical deduction with the 7.5% (of AGI) exclusion is going to increase to 10%. Did anybody tell us that? That’s 2.5% less I will be able to deduct for medical expenses. Also, as a self employed person my self employment tax is increasing. You can read about this at

    I could go on and on with the fun surprises in this bill. I’m with you, Dr. Orient, still looking for the “good” in it.

  6. After reading this article 3 times I still don’t get what Dr. Orient’s point is.
    It is clear she opposes the reform. However, that is pretty much the general consensus, at least superficially. But my frustration is that nobody, including Dr. Orient, offers a workable alternative.
    I guess she is trying to counter the argument of “do away with the bad and keep the good”, by saying that all is bad. However, what is her counteroffer? Should we leave things like they are? Should we move toward universal “one payer” healthcare? If not this, then what?
    A dear wise patient told me not long ago that he didn’t know if this law is going to ruin healthcare, but what he knew is that the system we have now will.
    I read the polls saying that 2/3 of people opposes ACA, yet the same proportion agrees with the general provisions of ACA when presented separatedly. Another says that over 3/4 of seniors oppose univeral heathcare, even though over 90% of them have a highly favorable opinion of Medicare. What am I missing?! Do we really oppose this plan or we just blowing off smoke to get people that we dislike unseated? Perhaps we as a country, are really that simple minded allowing labels to guide our opinions. I say enough of that. We need substance.
    Dr. Orient, I’ll ask you what I ask all my colleagues that appear to vehemently oppose this plan: what do you propose and how do you support it?

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