To fix Obamacare, Trump needs to 'go small'

President-elect Donald Trump will enter office in January facing several tough issues. None bigger than what to do with the monstrosity that is the 2700 plus page Patient Protection and Affordable Care Act ("ACA" or ObamaCare").

While we squabble over how to repeal, replace, or even just amend Obamacare, a pink elephant sits not so quietly in the room. Obamacare's core premise has failed. While more Americans are covered, health insurance is far from affordable, and taxpayers are fronting the bill. The next step down this line is a massive single payer system. Would the return on this type of giant investment be worth it?

Leaders from both parties have historically attempted to cure the nation's health care ills with big solutions. Starting in 1965, when President Lyndon B. Johnson first went big into government run health care with Medicare and Medicaid. At the outset, Medicaid was only to cover people getting cash assistance. Today, a much larger group is covered, amounting to 70 million people, over 20 percent of our nation's population.

In the 2003, President George W. Bush doubled down on more government involvement in our seniors' care with the passage of Medicare Part D and its unprecedented entitlement of prescription drug benefits.

The results? More Americans get their health care coverage from these two programs than any other source. Also, more Americans complain about the care and coverage they receive from these two programs than at any other time in their history. And, oh yes, while mostly absent from this year's debate, Medicare and Medicaid both sit on the not so distant verge of insolvency.

Then there is Obamacare. The big government solution now almost universally viewed as a complete failure. Just ask President Bill Clinton, who once called it the "craziest thing in the world." Ironically, he too attempted to pass a gigantic nationalized health care program in the 90's.

So how does Trump win with "Trumpcare"? Simply put: he goes small and cost-effective. With the goal in mind of helping more Americans in need of treatment get access to variety of options, he can scale individual expectations to levels of care and coverage.

First, unlike his predecessors, our new president is doing something small but very meaningful. He's listening to the folks actually charged day-to-day with taking care of us: our doctors. "Doctor" Ben Carson's significant involvement in the campaign and transition provide evidence.

Doctor Kevin Campbell, a renowned cardiologist, President of K-Roc Consulting, and a nationally recognized television contributor sees the role of doctors in Trumpcare as crucial:

"The most important thing that physicians can learn from the ACA debacle is that we must be involved in change. During the years leading up to the ACA, most physicians ignored the movement and we simply thought it would just 'go away.' Now, we have a chance to come to the table in Washington, DC and be a part of the process."

A doctor driven solution will reignite the value of entrepreneurial providers starting small independent practice groups, rather than their current subservience to big health systems and insurance. A doctor incentivized to get and keep patients in their own practice will need to market cost-effective options. Just look at the many billboards or ads for cosmetic doctors, including their frequent use of "Groupon," and other market driven approaches to increase access for all incomes.

This also means marketing a better patient experience. Who doesn't want fewer appointment cancellations and shorter waiting room lines?

President-elect Trump is also seeking to shrink rather than increase regulation. The cornerstone of his policy is to repeal the McCarran-Ferguson Act, opening up insurance carriers to compete and offer coverage solutions across state lines.

Dr. Campbell sees the wisdom in this as well:

"Some small changes could have a big impact—if we allow insurers to compete across state lines, they will be forced to provide better service for both doctors and patients."

Next, President-elect Trump wants people to save first, spend later on their health care. His plan to increase the limits for health savings accounts ("HSAs") incentivizes health care consumers. They can keep more of their saved, tax-free dollars to be proactive toward their wellness, while also preparing for a "hospitalization" rainy day.

Freeing up Obamacare dollars toward HSAs will push the door open toward another Trump initiative. Making Medicaid a state focused program again. Rather than the central planners in the Department of Health and Human Services, state level leadership will allow access to block grants to target the specific needs facing their poor uninsured residents. This makes sure that those who truly can't afford coverage get the care they need.

Finally, for the very few parts of Obamacare that aren't broken, why fix them? In this spirit, Trump announced recently that he is open to keeping ObamaCare's consumer friendly exclusion over pre-existing conditions, and the policy that adult children can stay on their parents' healthcare until they are 26.

Contrary to popular opinion, the pre-existing exclusion and ObamaCare's individual mandate are not irrevocably intertwined. If the law's minimum insurance thresholds are removed, new groups and new products will form to offset the sicker population in the pool with healthier consumers.

Go big or go home? Maybe with the wall…but let's hope for Americans tired of failed, big government health care solutions, not with Trumpcare.

Commentary by Bryan Rotella, founder and CEO of nationwide health care law firm Rotella Legal Group. He previously worked for two Ohio governors and has advised presidential campaigns on healthcare issues. Follow him on Twitter @RotellaLegal

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