Successes & Failures of 2016 U.S. Elections — Part 17


by Sunil J. Wimalawansa

Less spending and propaganda on advertisements and billboards, and displaying of images of egotistical politicians, singers, and actors at street corners and on hilltops, proactive planning and spending on nurturing human capital, research and development, infrastructure, national security and peace, and education and healthcare would bring prosperity to a country.

“If you would understand anything, observe its beginning and development.”~ Aristotle

Current, failing healthcare delivery system in the United States is out of date: 

( January 18, 2017, Washington DC, Sri Lanka Guardian) To make any advance in healthcare delivery in the United States, this outdated and failed system to contain costs must be changed.  This old-fashioned system is designed to keep people sick and not healthy.  This shortsightedness of healthcare economics may save a bit in the short term, but it escalates costs.  The only beneficiaries are the insurance companies.

Whatever the new healthcare plan put forward by the Republican party, it must include several key concepts and components, including increased market competition, allowing (facilitating and perhaps mandating) insurance companies to provide coverage across state boarders, approval of secure healthcare savings account options for participants, and creating market-driven competitive insurance platforms.  This should be accompanied by making it harder for insurance companies to pull out of individual markets by picking and choosing states in which they want to compete (i.e., placing a financial penalty or regulatory restriction for any insurance company opting out of a market).  

Standardizing premiums and making health insurance affordable: 

Advances in medicine are driving not only improved care and cost but also the care model toward individualized medicine and health maintenance.  Thus, it makes sense that healthcare insurance products be tailored to patient-centric medicine.  Nevertheless, it is essential to control costs.  Any proposed alternative to the Obamacare healthcare insurance model should provide better healthcare and wider coverage at the lowest cost.  This can be achieved in a number of ways and combining different concepts.  One option is to standardize premiums, with stepwise increases to cover higher-than-expected risks.

With this concept, it makes no sense for any insurance company to discourage participants from getting necessary evaluations and treatment.  Yet this is exactly what is happening currently in healthcare insurance coverage in the United States, including private insurance and Medicaid and Medicare.  This cost control is imposed through third-party payers, the gatekeepers.

Amalgamating disease prevention models to new healthcare law is important:

Click on the image to read the previous parts of this series

Over the years, we have not been given the needed priority diseases prevention; mental disorders, chronic disabilities, nutritional problems, and hundreds of environmentally induced disorders.  At the same time, we constantly and deliberately exploit and harm the environment and hope to get away with it.  This is unrealistic and unsustainable.  Many of these harmful actions eventually cause or exacerbate human diseases.

The model of spending more than 80% of our total healthcare funds on treating illnesses will do nothing for disease prevention.  It only increases hospital beds occupancy that currently approaching 100%.  Hospital businesses are thriving, and consequently new hospitals are emerging; this is the classic wrong model of managing healthcare (holding the tiger’s tail!).  Collectively, we have disregarded the wisdom that prevention is the cure.

New model of healthcare is needed: 

Regarding premiums, it makes no sense to penalize healthy participants/beneficiaries, especially those who are healthy and have insurance cover, by charging them higher premiums, shifting to them the premium costs of the sick.  This is unfair and was what happened with Obamacare.  Why would healthy people and those who already have insurance should pay extra?  Although it is a good idea for everyone to have some insurance coverage, it should not be at the expense of one group.  

Here is an example of one option: 

Those who have less-than-average risk (i.e., in good health and no excessive health risks) should be offered a discount (for example, a 15% refund); the majority of people who would be categorized as “normal” (with mild or “expected” risk) should have a standard premium; and those who are moderate or high risk should be offered a premium cost that is 15% and 30% higher than the standard (or a carefully determined percentage from the standard, not an arbitrary value), respectively.

This is an example only; this structure can be expanded and percentages can be varied, to fit the purpose.  Costs greater than those charged for the coverage of “normal” beneficiaries could be covered depending on the income bracket, by a governmental subsidy—At the lower end of the income range, for those below the poverty line can be offer a 50% subsidy, while, those below 50% of the poverty line, 100% subsidy.

In this model that I propose, the excess cost of premiums (the gap) for those with higher health risks should be covered by federal funds directly (as in the case of Obamacare/Medicaid) or through state funds so that everyone in the community pays the same amount in premiums for the same coverage for healthcare insurance, making the expense predictable.  Within this, some variations should be allowed, including options and choices, for companies to make the bidding process competitive to attract customers.

Out-of-the box thinking and planning needed for cost-effective care:

It is essential that an out-of-the box, affordable and accessible, judicious action plan leading to a cost-effective healthcare delivery system is installed in the country.  In the United States, the current cost of healthcare is six-times higher than the healthcare budget of the next closest country.

Therefore, in 2017, the new healthcare plan that is to replace Obamacare must have tangible benefits to quality, accessibility, and cost for the individual participant and the government.  We do not need more expensive care that hardly change the quality of life or life-expectancy; we need cost-effective, affordable and dependable care.

Changing the name of the Affordable Care Act/Obamacare to something else just to fulfill campaign promises would not help Americans.  Creating new sets of laws with healthcare reforms in the United States is a great opportunity to implement major and novel changes: not maintain the same old, failed insurance system-based care.  In the absence of achieving these goals, it will the public again.  With so much of expectations, such a catastrophic failure would anger Democratic and Republican voters, and the independents alike, and they will not re-elect the new administration for another term in four-years’ time.  Thus, the Republicans law-makers must take the introduction of the new healthcare system, very seriously.

In summary, the new healthcare system that will be created must be simple to administer, affordable, easy to understand by ordinary people, easy to shop and register by recipients, acceptable to both consumers and physicians, cooperation and compliance from the participating insurance companies, and incorporation of effective and fool-proof legislation to prevent sabotage and waste.  That would be a winning formula for the country.

To be Continued

Professor Sunil J. Wimalawansa, MD, PhD, MBA, DSC, is a physician–scientist, social entrepreneur, educator, and philanthropist, with strategic long-term vision.  The author can be reached via



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