Dear President-elect Trump,

You have stated that one of the first things you will do in office is to overturn Obamacare. You state that you will keep coverage for pre-existing conditions and children to age 26 but beyond that is unclear. Speaker Ryan said it would be “patient centered” but what that means remains to be seen. You now have a former surgeon as head of HHS. If I may, I would like to offer a perspective from a physician who over the course of 40 years has seen a lot of very poorly thought out health reform cause more harm than good.

Part of the reason I voted for you is that you are someone from a  business background and therefore will re-think how the countries problems can be solved. Having the country being run by career politicians has certainly not turned out as planned and nowhere is this more apparent the health care where we aren’t able to even define what is the problem properly.

The main issue with health care has always been exploding costs. Quality was not an issue until costs and quality were tied together. The main drivers of health care costs have been this: The second half of the twentieth century saw an explosion in health care technology. When Medicare was established in 1964, there were no transplants, kidney dialysis, trauma centers, or NICUs, etc., all addressing problems that existed before but nothing could be done about therefore not costing anything. By some estimates, Medicare’s costs were off by a factor of ten. To add to the problem, the countries extreme reluctance to ration care led to pressures to make these same technologies available to everyone. Pressures from the legal system that came down hard on any provider if it was perceived that care was being withheld certainly did not help.

Here’s where we went off the rails. Sometime around the late 80s the idea became established, especially in political circles, that costs were getting out of hand not due to technology, but because the health care system was providing an inordinate amount of high cost, low-quality unnecessary care just to make money. A vendetta started against the fee for service system to replace it with a more controllable quality based reimbursement system. It remains to this day. Whether the politicians did this because they actually believed it or because of political expediency, only they know, although with politicians being politicians I strongly suspect the latter.

Although this was true on a small scale (name me any business where this does not exist) it was nowhere near the amount necessary to justify the types of poorly thought out reform plans that have failed in the past, are failing today, and will fail in the future. Being in private practice has always been competitive and providing a lot of expensive, unnecessary care is not a good way to keep your customers happy, a fact that I know you would appreciate coming from a business background.

From Hillarycare to the private capitation plans of the late 90s and beyond, all these plans failed for the same reason. Obamacare is no exception. Although it did not get a lot of press, and was likely the reason for Obama’s initial claims that families would save money, there were a considerable number of “quality” based health reforms, based on the same false premise that money could be saved if all of that “high cost, low quality, unnecessary care” could be wrung out of the system. Of course, being not true, the exact opposite occurred, and premiums went up. Here are just a few of the other problems that have occurred:

1. The number of health care administrators has exploded compared to the number of providers. This bled money away from actual patient care.

2. Electronic medical records being pushed out prematurely to monitor physicians behavior, causing more problems than it has solved.

3. Increased government interference in the patient-physician relationship where it does belong leading to making problems worse. The opioid crisis is a good example.

4. Physicians avoiding complex, difficult, high-risk or uncooperative patients in an attempt to get better quality scores

5. Physicians becoming more super-specialized as they will only do what they are comfortable doing.

6. Increased physician retirement, burnout, and suicide as they try to deal with an ever changing, sometimes conflicting, set of rules and regulations.

To make matters worse, the old problems still exist, such as our runaway legal system, an aging population, and the effects of irresponsibility. As someone who can now bring a different perspective to the health care problem, maybe you could consider some realistic and workable reforms, such as dedicating 100 percent of sin taxes to health care or instituting loser pays to our civil tort system.

If single-payer is the answer, then most physicians would go along as long as we have a trade union as they exist in other countries. Given your background, I feel we have the best chance we have had in years of solving our problems honestly and objectively and come up with real, workable solutions.

Thank you and the best of luck for your new administration.

Thomas D. Guastavino is an orthopedic surgeon.

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