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mon t m e d s o c .c om
2) Health-savings accounts. Long a staple of those
who favor less government regulation, HSAs have been
touted by some as the cure to so-called "high-deductible"
plans. Similar to a college 529 or 401(k), an HSA would
allow earners to put away "pre-tax" dollars that could
then be spent on care. Proponents of this approach say
that it will help patients better understand the true cost
of care, give them more control over what to spend,
and the freedom to decide on when to spend it. Critics
charge that HSAs will still do nothing to help lower
costs for the sick, and further shrink the disposable
income of the economy's lower earners. Economic
experts, for the most part, have had mixed feelings about
HSAs. They are an intriguing idea, but only part of a
3) Allowing insurance companies to charge young
people less and older people more. Under the ACA,
insurers are forbidden from charging older patients more
than three times the cost of what they charge the young.
One solution that has been proposed involves raising
that cap to 5:1, which would ease pressure on the market
but runs the risk of being politically unpopular. Given
that politics has been called 'the art of the possible,' the
fate of this particular option remains to be seen.
4) Establish "high-risk pools" for the costliest
patients. An alternative answer to the individual mandate
would be the establishment of government-subsidized
plans to help cover the cost of the sickest Americans.
Without droves of young people paying into the system,
these "pools" have been projected to require as much
as $25 billion from Washington over a 10-year period.
While tempting on paper, this may require raising taxes,
never an easy sell in today's current environment. Also,
high-risk pools have had a poor track record of success
overall, leading some to question their utility as a broadbased solution.
5) Restructuring Medicare and Medicaid. This is
likely to be the least politically-popular of the options;
the idea of converting Medicare to a "premium support"
model has long been discussed on Capitol Hill. Instead
of government-backed, guaranteed health insurance,
seniors would have to choose a private plan, with
Medicare picking up at least part of the cost. Current
iterations under discussion guarantee no changes for
those already enrolled, or for those 55 and older at the
time the law would be passed. Again, this would require
a 'sea-change' in the thinking of Americans, whom polls
have consistently shown favor keeping Medicare the way
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And let's not forget the cost of prescription drugs, which have
also spiraled out of control. Any renewed push to overhaul the
nation's healthcare system will need to address this, as well.
Hold On to Good Parts of ACA
Moving beyond the above options, our incoming leaders
have promised to keep the most popular parts of the ACA, such
as the ban on not only denials for pre-existing conditions, but
lifetime limits on insurance, as well as allowing young people
to stay on their parents' plans until age 26. What's unclear is
how to pay for this. Continued prohibition of 'rescissions,' or
dropping one's insurance in the setting of illness or injury, has
also been promised. However, the devil is always in the details,
and healthcare is no exception. For example, an examination of
the fine print reveals that all of the above are true-as long as
there is no break in coverage. But enter the market after a break,
or an open-enrollment period ends, and you may be out of luck.
Tax credits and high-risk pools may help, but no one has been
able to elucidate just how they will be able to bring down costs.
Many have theories, but there were theories about the ACA, too.
So how will this be different?
The answer, ultimately, is no one knows. In other words, as is
so often the case when politicians are involved, stay tuned.
M C M S P H Y S I C I A N 13 W I N T E R 2 0 1 7
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