Why 'Repeal and Replace' Will Never Work

By Robert F. Graboyes - U.S. News

"Repeal and replace" is a misguided strategy for getting past the Affordable Care Act and moving toward a focus on health rather than insurance cards. It is hopelessly utopian, strategically suicidal, emotionally deadening, operationally hollow, and needlessly partisan. Here's why:

Utopian: Like the Affordable Care Act, "repeal and replace" assumes some enlightened Congress and president can muster the wisdom, altruism and ability to reinvent one-fifth of the economy. One new law would sweep away the old and fix the problems that preceded it.

Suicidal: A "repeal and replace" coalition would see no victories for years. Doing so requires a unified plan, House and Senate majorities, the presidency and the will to stave off lobbyists for years. An "repeal and replace" bill would require proponents to lay aside divergent philosophies and parochial interests. In reality, once announced, Affordable Care Act supporters and lobbyists would demagogue any such bill to death in a day’s time. "Repeal and replace" resembles the British during the American Revolution: bright red uniforms with shiny brass buttons, tight geometric groupings marching onto an open field and guerrillas behind trees cutting them to pieces.

Deadening: Affordable Care Act backers look beyond the law to a bumper sticker reading "Universal Coverage." Like it or not, for them, widespread insurance cards are all that matter. If "repeal and replace" had a bumper sticker, it would read: "Hey folks, Let’s sell health insurance across state lines, broaden pooling through association health plance, add in some health savings accounts, allow high-deductible policies, and equalize the tax treatment of employer and individual insurance policies; Also, a little malpractice reform and some electronic health records might be nice, too. How about it?"

It’s painful to watch "repeal and replace" proponents lumbering through their talking points, sounding like the disclaimers at the end of Nexium and Lunesta commercials

Hollow: Like the Affordable Care Act, "repeal and replace" plans do little or nothing to solve the great structural problems of American health care: wasteful Medicare reimbursement formulas, slow and skewed drug and device approvals at the Food and Drug Administration, hospitals’ resistance to innovation and protectionist state medical boards.

Partisan: "Repeal and replace" is as partisan and ideological as the Affordable Care Act, alienating potential allies who are otherwise reachable. The real divide in health care is between what I call "fortress and frontier." The fortress fears risk and protects insiders. The frontier tolerates risk and allows outsiders to compete.

Health care in 2014 is where computers were in 1964. A half century ago, technological changes began streaming out of garages (the frontier) to upend the world of million-dollar mainframes (the fortress). Even 25 years ago, Siri, Skype, Kindle, Google and Street View would have sounded like outlandish science fiction.

Health care is poised for a similar transformation. Today, FDA-approved prosthetic hands cost $30,000 to $40,000; at the same time, a consortium of amateurs called e-Nable creates 3-D printed hands for around $10 in materials plus a few hours of assembly time. 3-D printed kidneys, livers and hearts made from the patient’s own cells are nearing reality. Wireless technologies enable providers to constantly monitor patients’ body readings. Artificial intelligence can mine enormous masses of data to detect patterns of illness and treatments that doctors’ intuition could never find. Our knowledge of the human genome will soon make it possible to fit custom-made drugs to a single person’s DNA. And right now, smart phone-based telemedicine is beginning to bring inexpensive, quality medical coverage to underserved communities, such as rural areas and inner cities. But fortress institutions are slowing the pace of these miracles.

Instead of a right-of-center "repeal and replace" effort, a better approach would be a coalition defined by philosophy — not party — devoted to identifying and removing hundreds of obstacles to innovation.

Allies will appear in unexpected places. Silicon Valley is full of left-leaning medical innovators and would-be innovators who eloquently plead the case for allowing health care innovation. Google should be a massive player in health care, but recently, co-founder Sergey Brin said health care is "just a painful business to be in … the regulatory burden in the U.S. is so high that I think it would dissuade a lot of entrepreneurs."

Brin should know. His wife, Anne Wojcicki, is CEO of 23andMe, a company that experienced the full force of the fortress. 23andMe provides $99 home genetic tests that give consumers information on more than 250 aspects of their personal DNA. In 2013, the FDA ordered 23andMe to cease its services, saying, in effect, that people are not entitled to possess their own genetic information. Left-leaning millennials enraged by regulatory threats to their beloved Uber ride-sharing are likely to favor unshackling 23andMe, too.

The film “Dallas Buyers Club” perfectly illustrates the fortress (the FDA and medical professionals denying terminally ill patients a chance at life) and the frontier (the film’s protagonist daring to distribute the life-extending drugs).

In many states, medical boards block telemedicine, international medical graduates, migrating doctors from other states and independent practices for nurse practitioners. Hospitals milk Certificate of Need to block would-be competitors.

Instead of "repeal and replace" with its far-in-the-future hopes, a decentralized, aisle-straddling attack on these obstacles could begin today.

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