Now that the Republican health care plan has been sent to the dust bin of history, it’s worth thinking about how Obamacare can be improved. While the ACA was a huge step forward in extending insurance coverage, many of the complaints against the program are justified. The co-pays and deductibles can mean the plans are of little use to middle-income people with relatively low bills.

This is a great time to put forward ideas for reducing these costs and making other changes in the health care system. Obviously this congress and president are not interested in reforms that help low- and middle-income families, but the rest of us can start pushing these ideas now, with the expectation that the politicians will eventually come around.

There are two obvious directions to go to get costs down for low- and middle-income families. One is to increase taxes on the wealthy. The other is to reduce the cost of health care. The latter is likely the more promising option, especially since we have such a vast amount of waste in our system. The three obvious routes are lower prices for prescription drugs and medical equipment, reducing the pay of doctors, and savings on administrative costs from having Medicare offer an insurance plan in the exchanges.

Taking these in turn, the largest single source of savings would be reducing what we pay for prescription drugs. We will spend over $440 billion this year for drugs that would likely sell for less than $80 billion in a free market without patent monopolies and other forms of protection. If we paid as much as people in other wealthy countries for our drugs, we would save close to $200 billion a year. We spend another $50 billion a year on medical equipment which would likely cost around $15 billion in a free market.

If the government negotiated prices for drugs and medical equipment its savings could easily exceed $100 billion a year (see chapter 5 of Rigged). It could use some of these savings to finance open-source research for new drugs and medical equipment.

We already fund a huge amount of research, so this is not some radical departure from current practice. The government spends more than $32 billion on research conducted by the National Institutes of Health. It also picks up 50 percent of the industry’s research costs on orphan drugs through the Orphan Drug Tax Credit. Orphan drugs are a rapidly growing share of all drug approvals, as the industry increasingly takes advantage of this tax credit.

The big change would not be that the government was funding research, but rather the research results and patents would be in the public domain, rather than be used by Pfizer and other drug companies to get patent monopolies. As a result, the next great breakthrough drug will sell as a generic for a few hundred dollars rather than hundreds of thousands of dollars. And MRI scans would cost little more than X-rays.


The second big potential source of savings would come from reducing the protectionist barriers which largely exclude foreign-trained physicians. Under current law, a foreign doctor is prohibited from practicing in the United States unless they complete a U.S. residency program. This keeps hundreds of thousands of well-qualified foreign physicians from practicing in the United States. As a result, our doctors earn on average more than $250,000 a year, roughly twice the average pay in other wealthy countries. (There are similar protectionist restrictions which inflate the pay of dentists.)

If we removed this barrier and allowed qualified foreign doctors to practice in the United States, we would likely get their pay down to levels comparable to that of doctors in countries like Canada and Germany. This could save us close to $100 billion a year on our health care bill, at least half of which would be savings to the government.

There is a concern that we would attract more doctors from developing countries. We could easily offset this brain drain by paying these countries enough so that they can train two or three doctors for every one that comes to the United States, thereby ensuring they gain from this arrangement as well. It is worth noting that these countries receive zero compensation now for the doctors they pay to train, but who then practice in the United States.

The third big source of saving would be having Medicare offer an insurance plan in the exchanges. This would ensure both that everyone had at least one good option regardless of where they lived and also that the private insurers in the system would face real competition. In 2010, the Congressional Budget Office projected that a public option would save the government $23 billion a year by 2020 and $29 billion by 2023.

The total savings to the government from these three changes easily exceed $150 billion a year, in addition to large savings that individuals outside the exchanges would see in their health care expenses. This is far more than enough to make the deductibles zero for each of the roughly 10 million people now in the exchanges. That would make Obamacare considerably more attractive.

Of course, if the plans in the exchanges became more generous more people would opt to take advantage of them and we would see people leaving employer-provided plans. That is a problem that we can deal with at the time it happens. (We would need to have a portion of workers’ current payments for employer provided plans go to the government to cover the cost of additional enrollees in the exchanges.) But the way forward in improving Obamacare is to use the market to make our health care system more efficient and reduce the ridiculous rents that now go to the wealthy as a result of waste in the system.