The Republicans finally get their wish, to repeal Obamacare, and then Trump comes along and wants them to replace it. In fact, some days he seems to want to extend the availability to everyone. And so the Republicans, who have never really had a plan for replacement, are scrambling.

They have now cobbled together several competing plans – the Price plan, the Ryan plan, the Collins plan, and an alleged Trump plan. The problem with any such concoction was nicely summed up in a recent “Wall Street Journal” report. “Sick people are expensive to cover and someone has to pay.

In the abstract that looks like an easy math problem – either cut the number of sick people covered or cut what it costs to cover them. In much of the developed world the solution has been to cover everyone by a single-payer, and keep costs down by controlling prices, as a single payer can do. And by putting some limits on frivolous, unnecessary procedures and tests.

This is anathema to the right since it increases government power. It is socialized medicine. It is price-fixing. It is rationing. Yet it accounts for the fact that health care costs anywhere from two-thirds to half as much in most modern countries as in America and the people in them live longer.

We have apparently made the decision that a few less years of life are better than giving the government more power. But free enterprise hardly characterizes our system. Increasingly health care is provided by monopolies or oligopolies. In any given region, you are probably going to be given little choice but the reigning hospital corporation, the HMO, the provider network, the approved pharmacy.

And then there’s the fact that the middle man is the insurance giant. They add a percentage to the cost of everything for their bureaucratic interposition between you and the doctor. And then there’s the additional anomaly that most people get insurance through their employers in this country, which means if you lose a job or change jobs, you may suddenly be uninsured. Only in America — literally.
The Bernie Sanders wing of the Democrats proposes scrapping employer-provided health care in favor of universal coverage – essentially Medicare for all, from cradle to grave. But they aren’t going to win this fight. So, if Medicare for the old, flawed employer-provided coverage for most workers, and an even more flawed and underfunded Medicaid for some of the poor remain, the fight is over how to cover the leftovers

These are the millions of people too young for Medicare, just eking by with enough to be disqualified from Medicaid and in the kind of jobs that don’t offer medical benefits. Obamacare was designed to cover them, but was flawed. To work, everyone in this pool would have to be required to pay into it. Republicans made that seem like Big Brother taking away your freedom. But, alas, it was simply actuarial reality.

The dirty secret of healthcare is that the sickest of the sick are where the expense lies. The most expensive one percent of patients account for 21% of the expenses. The most expensive 20% account for a huge 82% of the dollars. And the pre-existing condition mandate in Obamacare that Trump wants to keep means that all those costly patients must be covered. But if the healthy 80% opt out, the coverage for the 20% is bankrupting.

One solution is to let the uninsured go without, since they aren’t in protected classes – the elderly, the well-employed. Who cares if a few million nobodies die on the street? To his credit, Trump has objected. So should we all, if only because they won’t just expire quietly – and cheaply. They will go to emergency rooms or put off getting care until they are even sicker and more expensive to treat. It turns out malign neglect is not cost effective.

And this brings us to another problem highlighted by Dr. Atul Gawande in “The New Yorker.” He is a neurosurgeon, but he admits in “Tell Me Where It Hurts” that the present healthcare delivery model is badly askew. Heroic specialties like his, gastroenterology , radiology, and cardiology are richly compensated because every cancer surgery or heart bypass is really expense. So, doctors in those specialties earn an average of $400,000 a year, putting them in the one percent neighborhood.

But it is increasingly apparent that the everyday doctors, like family care physicians, pediatricians, gerontologists, internists who make half as much, are the more important. The surgeons are, in Gawande’s metaphor, firemen who arrive to deal with a crisis. But the others, through patient, month- by-month, year-by-year interaction with, and monitoring of patients can catch the cancer or cardiac problem or diabetes before it goes too far, or prevent it by modifying patient behavior.

And as he points out, 27 percent of patients today have pre-existing conditions that would have made them ineligible for affordable insurance before Obamacare. But, as genetic medicine and environmental medicine develop, virtually all patients will be found to have pre-existing conditions – or predilections for certain maladies that might be avoided or minimized by behavioral modification or detected and treated early.

Without Obamacare or something like it, many more people will get sicker and more expensively treated than otherwise necessary. But without a reorientation of medical rewards too many doctors will enter fire-fighting heroic specialties and too few will become the kind of preventive medicine caregivers who make our long-term health better.

The debate over a replacement for Obamacare is likely to boil down to a thinly disguised case of winners and losers, economic calculations, actuarial tables, a cruel economic calculus based on some people being more worthy of first rate health care than others, an inhumane, laissez faire capitalist, Social Darwinism. Is this really the kind of country we want to live in? Is our hatred of government and taxes so great that we are willing to pay for it with shortened lives and immense suffering for many of us?

It is easy to answer ‘yes’ if we think we aren’t going to be the victims of such a system. But today, another recession or a robot in our workplace, a rogue gene and we or our children or grandchildren are the ones stranded without decent, consistent healthcare. We are the ones waiting for help at the emergency room. Isn’t it time to decide that the price-gouging by the medical/pharmaceutical/hospital/insurance oligopoly is detrimental to our health and that the risk pool for American medicine ought to be comprised of and paid for by all 320 million of us?