No Country for
Sick Old Men

Doc Compares Obamacare with Trumpcare; Differences Are Concerning

March 2017

BY DR. RICHARD WEINER

Patients are coming to my clinic with worries.? That?s nothing new: people have chest pain, or a cough that won?t go away, or a mole that gets bigger, and they go to the doctor.? What?s new is that they worry won?t be able to afford the trip.

Patients are now treating me as a type of insurance agent, one who can divine the future and tell them whether to buy health coverage, and how much.

Call my patient Mike.? Mike has been smoking at least a pack of cigarettes a day since he graduated from high school forty years ago.? He?s overweight, doesn?t exercise much, and is headed toward diabetes.? His blood pressure could be better.

Mike wants me to peer into my crystal ball and tell him what his chances of a heart attack are.? Here?s a crystal ball: http://www.calculators.org/health/heart.php

Most of the tools listed there will give you an answer in the same ballpark, and there?s little mystery involved.? Mike should quit smoking this afternoon, lose thirty or forty pounds, eat more sensibly and take his blood pressure medicine.? (A prescription, by the way that?s free at some grocery story pharmacies and only $4.00 a month at Walmart.? The national economy is safe.)

But Mike wants more that.? He wants me to specify the date on which he will have a heart attack, so he can buy really good health insurance that year.? I tell Mike that when he can tell me when my aging Honda is going to need a new drive shaft, I?ll have an answer for him.

We should be working on blood pressure and serum glucose, weight control and smoking cessation; instead, we are staring at charts of benefits and premiums.

I think Mike should also have a chest CT to look for early stages of lung cancer.? Mike asks if he can afford it.? I wonder if he can afford not to get the scan.

The Affordable Care Act (a.k.a. ?Obamacare?) provides a tax credit based on income and the cost of insurance.? The peak income to receive a credit is $47,000.? The Republicans? proposed American Health Care Act (AHCA or ?Trumpcare?) adjusts its tax credit based on age and income.? The Kaiser Family Foundation analyzed the two plans and found that a 60-year-old who earns $20,000 receives a credit for $13,200 under Obamacare, while a person the same age earning $60,000 gets no credit. Trumpcare, according to the Kaiser review, gives the 60-year-old who earns $20,000 gets a $4,000 credit, while a 60-year-old earning up to $75,000 would get the same $4,000.? In other words, the person with the lower income loses over two-thirds of the credit while the higher earner receives a gift.

Under Obamacare, sicker patients ? the ones who absorb more health resources ? can be charged more, but only three times the rate healthy people pay.? Trumpcare raises that to five times the healthy rate.

If I?m reading this correctly, the old and the sick pay more precisely at the time they can?t afford it.? As safety nets go, this one appears to be badly made.

Yes, I have a good idea of what medical care costs.? I don?t order a CAT scan unless there?s a good reason to think that the study will help the patient.? I don?t order an expensive antibiotic when a generic one will do the same job for a whole lot less.? On the other hand, I don?t want to choose a second-best test or treatment ? or skip it altogether ? because the patient can?t afford optimal care.

About half of Americans get insurance through their jobs.? Sometimes they hold onto a job they don?t like in order to keep the healthcare benefit.? Now they?re frightened that their employers won?t be required to offer insurance.? But under Trumpcare, any change in coverage ? such as quitting or losing a job ? would make them liable for a penalty.? No wonder my patients are worried!

The Congressional Budget Office released an estimate in March that says some 14 million of us will end up without health insurance by 2018 if the Republican plan passes. By 2020 prices will go down for younger people but go up for older people like Mike.

The healer in me wants to tell Mike it?s all going to be okay but I can?t. Our health care is wrapped in overly amped rhetoric right now, more so than ever, and I worry people like Mike will end up paying the price.

I?m lucky. I have insurance and while I?m no longer young, I?m still healthy. But as the hair gets grayer, I reflect that I too will become old and ill and could end up segregated into high-risk pool with steeps premiums and modest benefits right along with Mike and millions of other Americans.

To be honest, that scares me to death.

Dr. Richard Weiner can be reached at

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