Though Republicans, in control of Congress and the White House, have not been able to deliver their long-promised repeal and replacement of the Affordable Care Act, the debate over what to do with health care in the United States plays a large role in midterm elections across the country.
The spotlight in Washington, D.C., has momentarily focused elsewhere, but the issue still plays a large role in Montana politics and in forums held for the Republicans in their party’s primary for the U.S. Senate.
The candidates are Big Sky businessman Troy Downing, former Billings judge Russ Fagg, state legislator and surgeon Al Olszewski and state Auditor Matt Rosendale.
Each hopes to be the one to run against Democrat U.S. Sen. Jon Tester, who is seeking his third term. The race is expected to be closely watched and hard fought, with money already flowing into the state and advertisements flooding Montanans' televisions and social media feeds.
In forums and campaign messaging, all four have gone after Tester for his vote in support of the Affordable Care Act in 2010, saying it's not lowered health care costs and insurance prices have increased.
Tester has not disagreed there are issues with the Affordable Care Act and called for it either to be fixed or replaced with something that lowers costs and increases access to care for Montanans. But he has voiced concerns over previous GOP plans that would also cut Medicaid spending.
Rosendale and Olszewski have the most hands-on experience with what the changes enacted under the Affordable Care Act, also known as Obamacare, have meant for Montana and its residents, as well as the health care economy here. In his role as auditor, Rosendale oversees the insurance industry in the state, and Olszewski is a Flathead trauma surgeon.
In his practice, Olszewski said he's seen that more people getting insurance coverage hasn't resulted in a decrease in health care costs. In 2016, Montana's uninsured rate had dropped to 7.4 percent, down from 20 percent in 2012. For insurance plans sold on the exchange in Montana for 2018 coverage, rates increased from 13.1 percent to 22.3 percent over the previous year, which also saw increases.
“We have the best health care system in the world,” Olszewski said. “We just have a lousy way to pay for it.”
The fix to that, Olszewski said, is less federal meddling. He said about a third of the costs associated with health care right now are related to fulfilling regulations like patient information to government databases.
“We can rationally go through and reduce regulations that do not deal with patient care; that’s estimated it would reduce the cost of our health care premiums by a third,” Olszewski said.
Olszewski also said the states need more control in regulating what kinds of plans are offered and to allow choice and competition across state lines. He also supports examining the use of a reinsurance pool for high-risk individuals.
Rosendale said it’s more important to make sure people have access to affordable health care than to make sure they have insurance.
That can be accomplished, Rosendale said, by making sure there are alternatives to the current system of accessing care. That includes health-care sharing ministries, where members of a common religious faith pool their money to cover health care costs for their group, and agreements for treatment and payment made between patients and primary care providers without involving insurance. Both of those have been brought to Montana under Rosendale's time as auditor.
“That way people can accomodate their health care needs in a way that addresses their specific budget, their specific heath care needs and their personal choices,” Rosendale said. “Sometimes that can be accommodated by an insurance product, but many times it’s not.”
Rosendale also said more transparency is critical to any health care system fix and there’s no reason medical facilities around the state should not provide the cost of procedures clearly to patients before they receive care. He said that same level of transparency needs to be brought to the pharmacy industry as well.
Fagg also said both health care and health insurance are unaffordable.
“Most middle-income Montanans just cannot afford health insurance and they can’t afford health care, so obviously that doesn’t work. We need a system that people can manage to pay for,” Fagg said.
Moving to a market-based system with competition across state lines is part of the solution, Fagg said. He also sees health savings accounts as a fundamental part of that system “where patients have skin in the game so patients are interested in what things cost and also are interested in outcomes.”
“Right now if you go in and have a knee surgery, you don’t even know what it’s going to cost. And if you asked, the provider can’t tell you what it’s going to cost, so that doesn’t work because you have no skin in the game,” Fagg said.
Fagg said he envisions a “basic plan of maintenance for all of those who through no fault of their own can’t afford health care," and then different levels of health insurance for people to choose from.
Downing said that he feels the health care conversation has become so politicized that people are focused more on scoring political points than finding solutions.
“We’ve politicized this hyper-partisan rhetoric about insuring a broken system and that’s become such a part of the national dialogue and it is just so distracting because nobody is talking about fixing the underlying problems,” Downing said. “Nobody is talking about the actual problems, the actual problems of why health care in America is so much more expensive than anywhere else.”
A restoration of the direct financial relationship between doctors and patients would help reduce costs, Downing said, by eliminating some of the “giant bureaucracy that is this giant health care insurance system.”
Downing also called for examining hospital billing practices, saying they’ve “run amok.” To address high prescription drug costs, he wants to see a deep look at who foots the bill for creating the drugs and treatments and who benefits from it.
“Why is the U.S. paying for research and development for the rest of the world?” Downing said. “I want to make sure if we’re selling something for $100 in Canada we’re selling something for $100 in the U.S..”
The four men also said they wouldn't support continuing Medicaid expansion, and generally called for looking at block-granting federal health insurance programs to give states more control.