Scott A. Edmonds, OD, FAAO, focuses his blog on the role of the optometrist in health care reform – moving from primary eye care to primary health care. He is the chief medical officer of MARCH Vision Care, the co-director of the Low Vision/Contact Lens Service at Wills Eye Institute in Philadelphia and a member of the Primary Care Optometry News Editorial Board. 

Disclosure: Edmonds is a consultant for March Vision.

BLOG: Backdoor health care reform

On Dec. 22, President Donald J. Trump signed the “Tax Cuts and Jobs Act” into law. This law, designed and passed by the 115th Congress, is purported to provide a major change in the American tax structure to promote jobs and “rev up” the economy.

This Congress, however, that features a Republican-controlled House and Senate, could not resist the opportunity to meddle with the American health care system in an effort to save face for their numerous defeats in the year-long effort to repeal the Affordable Care Act. This ill-conceived and poorly thought-out effort may gain them a few short-lived points with their conservative base but will ultimately lead to a sicker population that will cost much more to manage in the long run.

In spite of popular opinion, the law does not repeal the individual mandate but rather reduces the dollar amount and percentage of income penalties to zero. The law will continue to require that individuals and related dependents be covered under minimal essential health care coverage.

The Congressional Budget Office (CBO) has concluded that the repeal of the penalty will reduce federal expenditures by more than $300 billion over the next 10 years. This significant savings, however, is from the reduction of the number of citizens covered by health care insurance. The CBO analysis projects the loss of coverage of 4 million by the end of 2019 and an ultimate loss of coverage for 13 million by 2027. Apparently, the 115th Congress believes that this is a simple cost-saving measure.

Many of the millions of citizens that will end up leaving the health care system will be the ones that consider themselves “healthy.” The loss of these people from the insurance pool, however, will make the remaining insured pool “sicker” and more expensive to manage. This will, in turn, increase the cost of insurance premiums and erode the projected cost savings of the CBO.

In addition, if we also take a close look at the “healthy” millions that will no longer have care and apply some public health knowledge calculations, the results are even more alarming.

We know that the percentage of undiagnosed people with diabetes is 9.4%, according to the CDC. The percentage of undiagnosed people with hypertension is 6.2% (Yoon et al.). The percentage of undiagnosed people with dyslipidemia is 16.8% (Najafipour et al.). These people often have no symptoms and will be heavily represented in those that will dis-enroll from our health care system. Taken together, this is 32.4%, or roughly one-third of this population that will go on to develop the natural progression of these undiagnosed and untreated chronic medical problems. The leading three complications of these problems are heart attack, stroke and kidney failure.

The cost of the treatment of any of the three most common complications is measured in hundreds of thousands of dollars per person. Discounting any humanitarian reasons for jettisoning 13 million American citizens from the roles of the insured, these citizens will end up back on Medicaid or Medicare and will wind up costing significantly more than they ever would have if we had taken appropriate care of them on the front end.

As primary care providers, we all do the best we can to identify health risk factors, provide patient education, counsel and refer for treatment. We all need to be concerned about the loss of access to our fellow citizens due to the loss of their health care insurance. We need to follow the details of new laws that affect health care and watch carefully as the details unfold.

Backdoor health care reform would not seem a logical way to resolve the complex problems of American health care. Fortunately, 2018 is an election year. All 435 seats in the U.S. House of Representatives and 33 of the 100 seats in the U.S. Senate will be contested this November. Don't forget to vote!


CDC. National Diabetes Statistics Report, 2017. Posted July 18, 2017. Accessed Jan. 2, 2018.

Najafipour H, et al. Journal of Diabetes & Metabolic Disorders. 2016;

Yoon S, et al. NCHS Data Brief. 2015;220:1-8.