The “Big Beautiful Bill” is officially known as the “One Big Beautiful Bill Act,” a stunning title for an important and costly piece of legislation.

The title rings wrong in my ears, sounding more like the announcement of a circus act than something that enacts government programs and increases taxes we will pay.

The description may be metaphorical, but I do worry that the name may be more the true representation of the work of the U.S. Congress today than I want it to be — more flash than substance.

As entertaining as politics can be, I do not want the act of governing the USA to be a form of entertainment, especially with a comedic twist.

The “Big Beautiful Bill” is one of those budget reconciliation bills that Congress hopes by some twist of logic will balance the budget of the United States. Of course, we know that it has not worked so far. Our budget performance over the last few decades has resulted in a national debt of approximately $35.3 trillion.

We must understand the budget deficit is not the result of unexpected expenses such as engaging in an unexpected war. We know where the money is going. In other words, our leaders planned for a deficit.

Rather, our leaders promise services but do not pass the budget to support them. Better said, Congress does not require taxpayers to pay for the services. The USA simply borrows and then budgets to service the debt.

And so far, we Americans are going along with the plan.

Except when …

Hands off Medicare, Social Security!

As I understand it, members of Congress spend anxious moments hand wringing in discussion about ways to bring spending in alignment with tax revenues.

The dilemma, as I understand it from the related comments made by those who should know, is the reality that the biggest expenses are entitlements such as Social Security and Medicare.

Their anxiety is rooted in the understanding that a huge public outcry would occur around any thought or idea that implies a reduction in money and services that are going directly to the people.

Taking Social Security and Medicare off the table leaves Medicaid, which we know as the health insurance for low-income families, vulnerable to federal cuts in coverage.

There is an emerging effort to move health care premium support entirely to the states which is great for federal savings but obviously not for states.

The thing about cuts in insurance programs is that people without health insurance still need medical care, a cost which will be borne in the emergency departments of hospitals when the uninsured require care.

Hospitals must provide emergency care under the Emergency Medical Treatment and Labor Act (EMTALA) that requires hospitals to provide such care regardless of ability to pay.

There is no requirement to provide ongoing treatment which common sense informs us will result in people without insurance getting sicker and costing the system more as the patient progresses to the later more acute stages of an illness.

One of my relatives holds the opinion that people without coverage or means to pay should not be given care, a “let them die” point of view.

This relative does not understand that most health care workers who hold professional and ethical standards are constitutionally unable to withhold care in the presence of suffering they can alleviate.

One does not have to be a health care professional to feel the same way.

Less time with patients

We are on the wrong track.

Health care in America is messy with conflicting interests and reimbursement that rewards the wrong behavior, e.g. the less time spent with a patient, the greater the number of patients that can be seen, resulting in more money available for investment, staff, equipment, and profit.

Not great for patients and their satisfaction. The reimbursement system for health/medical care as designed means a patient will only be seen for one problem per clinic visit. More than that takes too much time.

Clinics are reimbursed for one visit no matter how many problems requiring separate investigative tracks are presented. As much as we like to treat the whole patient, two unrelated problems require two visits to the clinic to be adequately reimbursed for the work done on each.

Of course, what I am bemoaning is the “fee for service” part of our reimbursement system. The other common system is HMOs or Health Maintenance Organizations which have a monthly payment that covers all the services ordered. Some HMOs are a provider as well as an insurer of services.

Elected and industry financial leaders treat and pay for the existing system of health care delivery as if there is no other way and/or they have no power to change it.

They think the only way to survive is to starve the care model. Reduce time in direct patient care to increase volume to improve reimbursement only to realize reimbursement still does not keep pace with costs.

People get sick or injured and need professional healthcare. We cannot just stop what health care we are providing, and how we are providing it.

No one should or can starve this system out of existence until there is a reasonable replacement that shifts incentives.

So quit trying.

Reform and innovation can be done without denying medically necessary health care. Obamacare made strides toward incentivizing prevention as a key element in health care without impacting access to care.

Examine systems across the world that are working for patients and providers and in which government is the primary payor.

Take the politics out of American health care.

Do the hard work of identifying the value and benefits of a healthy populace.

That would be “big and beautiful.”