Are the recent calls for a Public Option and Medicare for All an admission the Affordable Care Act (ACA) has failed to live up to its promise after 10 years? After all, there’s still nearly 30 million uninsured, it has “wrecked the individual health insurance market” for the middle class who get little or no subsidy, failed to bend the cost curve, and spurred the dramatic corporatization of our healthcare system.

A Ridgefield family, with a modest income, could spend up to $35k out of pocket (premium and deductible) before their insurance kicks in. Remember the promise “we’ll lower premiums by up to $2,500 for a typical family per year”?

What went wrong? Start with consolidation. Many hospital systems in Connecticut are clearly engaged in “empire-building” where “patients wind up paying more.” Private practice physician groups are disappearing, being acquired by big corporate healthcare.

The price of insulin has escalated dramatically over the years. It is a result of complex regulatory barriers for generics, patent thickets, secret rebates and contracts, spread pricing schemes, and conflicts of interest. Not only are patients being hurt but also independent community pharmacies, which are an important part of the medical neighborhood and perform critical public health functions. Lang’s closed both of their pharmacies in Wilton and Weston due to “unfair business practices by the insurance providers/pharmacy benefit managers (PBM’s)”.

What should Connecticut do? First, reject the public option and single payer. Second, allow innovation and choice. Third, increase healthcare supply by repealing Certificate-of-Need laws. The state has tremendous expertise in the healthcare space and should be aggressively pursuing alternative models of providing coverage. One thing we have learned is using fee-for-service insurance as a payment system for primary care is expensive, inefficient, opaque, and denies freedom of choice.

The Direct Primary Care movement is promising. It’s a direct arrangement between physician and patient with no middlemen. Why not direct pay for outpatient procedures, labs, imaging, and pharmacy? Connecticut should legalize plans that combine true catastrophic insurance, HSA’s, direct pay arrangements, and invisible high-risk/low-income subsidies. The premium savings would help fund substantial HSA accounts over time and, with many new patients now actively seeking value, this will generate both quality improvements and lower costs.

The fundamental disconnect in our healthcare system is we have lost our “traditional role as customers” and assigned it to intermediaries: HR departments, insurers, Medicare, and Medicaid.

Ultimately, “health insurance should be individual, portable, life-long, guaranteed-renewable, transferable, competitive, and lightly regulated.” In 2008, Obama touted special interest support for his plan, but McCain was right. He recognized that Employer Sponsored Insurance (ESI) was the “original sin” of the U.S. healthcare system and almost single-handedly created the pre-existing conditions problem.

Let’s take the tax advantaged money spent on ESI and use it for individual policies. Consider the Swiss, who have universal coverage but through a highly decentralized system of competing private insurers. There is no ESI, no Medicaid, and no Medicare. Everyone just has the insurance plan of their choice.