Sue Lani Madsen: Fixing coverage mandates a good first step in reforming Obamacare

Consumer-driven, patient-focused health care is the goal as Republicans methodically work through the process of reforming the reform. But it’s hard to feel like the consumer is driving anything in the health insurance market.

Switzerland is a favorite model for free-market advocates, although its health insurance market is also regulated to protect consumers. Health policy expert Avik Roy, writing in Forbes magazine in 2012, said “the consumer-driven Swiss health care system achieves 30 percent lower per capita health care costs and universal coverage while providing reasonable quality of care.” In other words, it works.

Yet even in Switzerland, there have been referendums to move to a single-payer system to reduce administrative costs. It’s been rejected by voters each time, most recently in 2014. The Swiss like their system that gives them convenient access to doctors, the latest medical technology, and outcomes to please anyone. Good health care trumps a bureaucratic focus on paperwork.

There are no single-payer public option plans like Medicaid or Medicare in Switzerland. There is no employer-purchased health insurance. Everyone is under a universal mandate to purchase insurance. Employers focus on their business, and your insurance plan is none of their business.

Obamacare incorporated the universal mandate of the Swiss system, but without the competition. There are about 40 different major medical insurance companies in the U.S., give or take any recent acquisitions and mergers, serving a population of nearly 319 million. The Affordable Care Act established one-size-fits-all mandates on coverage, and the only competition is on costs. There’d be less vehement objections if people could buy coverage that matches their needs and values.

In contrast, 8.35 million Swiss citizens have over 90 health insurance companies seeking their business, competing on cost and coverage, with some, but fewer, mandates on what plans must include. Swiss citizens have a range of choices as expansive as the coffee menu at a great espresso stand.

In Washington, we’re buying coffee out of a gas station vending machine.

In 2017, Washington citizens had a total of 13 health insurance companies competing in the state, only nine offering plans on the exchange. There’s now less competition after California-based Kaiser Permanente purchased Washington-based Group Health. By Swiss standards, there should be 79 companies serving us in Washington. That would be real competition.

The black-and-white, repeal-and-replace rhetoric has always seemed misleading. The challenge for Republicans is keeping their promise to repeal Obamacare without losing what has worked.

The ACA revolutionized health care in 381,517 unread words of legislation and over 11.5 million words worth of regulations. Some inevitable problems buried in all those unread words have already been quietly fixed in bipartisan efforts by Congress, in small bills that took care of specific issues.

Republicans have learned from those successes. In a conversation last month, Rep. Cathy McMorris Rodgers confirmed House Republicans are working the problem with what she described as three buckets. The first bucket includes negotiations underway to provide market stability, following the universal health care principle of “first, do no harm.” The second bucket is regulatory relief for critical issues that can be fixed administratively. The third bucket will be a series of smaller, more transparent bills to put new and improved health care reform in place.

Republican-introduced bills for replacement plans in the past six years were destined to die. With a Republican White House and a Republican Congress, it’s time to reform the reform. Twenty million more insured is waved like a victory banner in every defense of Obamacare. And it is good news, it really is. Now it’s time to talk about the 28.5 million still uninsured and the unsustainable cost trajectory of the ACA.

The latest Republican plan was introduced last week in the U.S. Senate. The Patient Freedom Act of 2017 follows patient-centered principles long laid out by Republicans as the alternative to bureaucracy-centered Obamacare.

The process for repeal and replace will be at a steady and deliberate legislative pace, no matter how fast the White House wants the bucket brigade to move. Shifting to a patient-centered health insurance market is key to addressing the millions still uninsured in 2017.