Tuesday, January 16, 2018

The Kentucky Apocalypse

The Commonwealth of Kentucky, best known for its weirdly colored grass, fine bourbon and equestrian pageantry, is about to be destroyed by the Trump administration. Many will suffer and perhaps die because Kentucky obtained a Medicaid waiver to impose additional and often insurmountable hardships on poor people receiving their free health care from the State. Since all I need to know, I learned on Twitter, allow me to share with you some illuminating insights from the Twitterati.

The evil Republican Governor of Kentucky, Matt Bevin, is salivating at the prospect of changing Medicaid as we know it, which obviously means that poor people and especially people of color will be suffering greatly under this plan. You really don’t need to know more, since this should be reason enough to mobilize the worried wealthy, who are tossing and turning in their featherbeds night after night, searching for ways to save the poor. For those who are neither worried nor wealthy enough to really care, here are the ominous provisions of the Kentucky racist, homophobic and xenophobic plan to change Medicaid (it is all these things because it was not only approved, but encouraged by the Trump administration, and we all know what that means).

The most egregious transgression in the Kentucky HEALTH plan is the imposition of work requirements on Medicaid beneficiaries. The first thing that comes to my mind when they say “work requirements” is that sign at the entrance to Auschwitz saying that work makes you free. In Kentucky, the Republicans argue that work makes you healthy. Same thing. So, what are those monstrous work requirements? Medicaid recipients who are not children, who are not below the poverty line, who are not elderly, who are not pregnant, who are not disabled, who are not medically or mentally frail, who are not providing care to children or other disabled individuals, who are not experiencing hardships such as domestic abuse or homelessness or other disruptions in their lives, must spend approximately 4 hours a day in school (any school), training (any training), apprenticing, acquiring useful skills, volunteering in the community, searching for a job or actually working somewhere.

Wait, wait…. Don’t raise your eyebrows and don’t think or say anything. If you are reading this, you are most likely rich, likely white, well-educated and perhaps even male. Medicaid beneficiaries are none of these things. We all know that any of those endeavors could be truly insurmountable hardships for people who are poor, black or Hispanic, uneducated and female. We know that, because we are not racists, misogynists or just plain bigoted SOBs, like the Republicans running Kentucky and that insufferable man running the country (or so he thinks).

Besides, most Medicaid beneficiaries who don’t fall in the exempt categories are already working. The ones who don’t work, or study, or do anything beneficial for themselves or others, are experiencing circumstances beyond their control. Helping them gain control over their lives is not Medicaid’s job because health and wellbeing have nothing to do with socioeconomic circumstances. And even if Kentucky wanted to “nudge” people into, say, getting their GED by funding a special rewards account, the bureaucracy involved in tracking all sanctioned activities, all exemptions and special circumstances is just too daunting for “these people” to navigate. Trust me on this one, I read it straight from the keyboards of Hollywood celebrities and several current and former big health care executives.

The second affront to humanity in the Kentucky plan is to charge poor people premiums for health insurance. Not only that, but those who can’t pay the premiums may be kicked off Medicaid. Granted, the premiums range from $1 to $15 (in lieu of regular copays), and all the exemptions for ill health, frailty and poverty do apply here as well, but that still leaves a sizeable number of poor people who could be denied medical care just because they forgot to pay the monthly dollar twice in a row, or couldn’t afford the higher premium. These highly discriminatory practices targeting the poor are unheard of in other industries or even in the commercial segment of health care itself, where insurance premiums are largely voluntary.

To be fair to Kentucky, there is a mechanism by which people who did not pay their premiums on time can regain their Medicaid coverage, which brings us to provisions reminiscent of the Jim Crow days in the South. The Kentucky plan, you see, has a literacy provision for regaining access to care. This is obviously targeted at people of color and immigrants from what the GOP Leader calls “shithole” countries, which as every wealthy person in Bel Air knows, cannot read or write, as evidenced by the thumbprint (or large X, depending on the State) appearing on most Medicaid applications. I have zero doubt that the Attorney General of the State of California will be taking the depraved Governor of Kentucky, and the Trump administration that enabled him, to court, and I have no doubt that the 9th Circuit Court of Appeals will find in favor of justice and equality, as it always does.

Until then, it seems that some Medicaid beneficiaries in Kentucky may have to sit through torturous health literacy or financial literacy classes, where they teach boring stuff about how to deal with debt, how health insurance works and how one can navigate these treacherous waters. There is no mention of a test or anything at the end, but this still seems like an unwarranted and blatantly racist imposition on “these people”.  Even more outrageous though is that Kentucky is providing incentives, which can be used to purchase gym memberships, for Medicaid beneficiaries to take other classes, such as chronic care management or nutrition or drug addiction coping skills.  What do illiterate people, drug addicts and all “these people” need gym memberships for? It’s like telling them to “eat cake” ….

And on and on goes the Kentucky HEALTH plan, listing one offensive section after another. The problem with this plan, which will live in infamy until the Sun goes supernova, is the cold, heartless and blatantly racist assumption that people who need Medicaid are as capable of functioning in modern society as anybody else. It ignores decades of teachings. It ignores hundreds of years of slavery and Anglo Saxon colonialist supremacy. And it ignores basic Christian values, because Jesus didn’t just sit there giving classes on how to fish. He gave people fish, and it worked great for Him and for His followers, eventually. If you see yourself as the Lord and Savior of huddled masses, you will want to do what Jesus did. If you feel equal to people who need Medicaid, but perhaps a bit luckier at this moment, you will dismiss everything I wrote here as total bullshit.

Tuesday, December 26, 2017

The Power of Silicon Valley

A few weeks ago one man, named @jack, decided that millions of people will be allowed to use up to 280 characters when expressing themselves on Jack’s public square platform. One man decides how many letters each and every one of us, including the “leader of the free world”, can use when we talk to each other. Just like that. Nobody seemed the least bit perturbed by this notion. Another dude, named Mark, decided to ask people for nude pictures of themselves, so he can better protect them from the bad guys. We shrugged that off too. Then, in a most embarrassing exercise in public humiliation, our democratically elected representatives begged three slick lawyers representing these platforms to effectively regulate what people can say or see on “their” platforms.

So here we are, in the land of the free and the home of the brave, where Jack and Mark decide what you can or cannot say, and what you can or cannot hear or see. This, my friend, is the power of “platforms”. In the old days, it used to be that he who pays the piper calls the tune. In the artificially intelligent technology age there are no pipers. He who owns the pipe makes it play whatever the hell he wants it to play. And as Sean Parker, a Facebook founder, elegantly put it, “God only knows what it's doing to our children's brains”. Perhaps God knows, but he is certainly not the only one who knows, because these platforms are built with the explicit intent to get people addicted to and dependent on the platform.

Funded with cash from sexist pigs and harassers, a startup, whose business model is to help other startups “hook” people on trashy little apps, is calling itself Dopamine Labs. “Dopamine makes your app addictive” is their promise. According to the website, they use AI and neuroscience to deliver jolts of dopamine that “don’t just feel good: they rewire the brain’s habit centers” of users to “boost usage, loyalty, and revenue”. “Your users will crave it. And they'll crave you”. At its rotten core, Silicon Valley is a drug cartel, a very clever and savvy cartel who managed to convince the world that its brand of drug addiction is actually good for you and either way, it’s inevitable.

But just getting billions of people on techno-drugs is obviously not the end game here. After extracting trillions of dollars from addicts who would rather go without food and medicine, than go without an iPhone X that costs more than a full blown top of the line computer, the Capos of Silicon Valley Inc. are now realizing that there is plenty more left to extract from the armies of zombies they are creating. "Because I'm a billionaire, I'm going to have access to better health care so ... I'm going to be like 160 and I'm going to be part of this, like, class of immortal overlords. [Laughter] Because, you know the [Warren Buffett] expression about compound interest. ... [G]ive us billionaires an extra hundred years and you'll know what ... wealth disparity looks like."

Ah, yes, health care, the final frontier. When Keytruda (the Jimmy Carter drug) became available, it was considered too expensive at around $150,000, but times are changing. The FDA recently approved the immunotherapy drug Kymriah from Novartis with a price tag of $475,000, although Novartis says it could have charged more, presumably because this drug is a life saver of last resort for small children with cancer.  Next, another CAR-T cell therapy cancer drug, Yescarta was approved by the FDA for adult cancer and Gilead Sciences priced it at only $373,000 a pop (that’s how value-based health care works). At this rate of innovation, it should not be too difficult to project a precise date for the emergence of that immortal class of overlords.

Developing personalized drugs, like immunotherapy, requires mountains of data from millions of people, and this is where the app-addicted public has a crucial role to play. Before the overlords can become immortal, we all need to “donate” our medical data, submit to experimentation, get sick and die, and yes, here and there a few lucky bastards will benefit from therapies their children will never be able to afford. Not surprisingly, Mr. Parker, the aspiring overlord, is now invested in an immunotherapy platform to coordinate research, or something like that. But Mr. Parker is a diversified investor. He has a couple more platforms. One is there to save the world from the AIDS epidemic by providing support to the Clinton Foundation.

The other platform is designed to help us vote. Yes, vote. The guy who promises to show us what wealth disparity really looks like is building platforms, complete with little dopamine jolts and colored pictures of bananas, to teach us all about “civic engagement”, because according to Mr. Parker’s venture buddy “the tools we build in Silicon Valley represent the best hope for fixing our democracy”.  Everything was just fine with “our democracy” until all investments in the Clinton Foundation came crashing down like a house of cards in one fateful night in November 2016, when the overlords were positively robbed by a dopamine-deficient populist mob. In a wholesome democracy, when you pay for a President, you’re supposed to get a President.

Of course “our democracy” has been “broken” in one way or another for upwards of two hundred and forty years, but I think we can all agree that “our democracy” today is less broken than “our democracy” in 1789. There is great utility though, in declaring something to be broken, especially something big and nebulous like “our democracy”, because such declarations are almost always followed by assertions that the diagnosticians of brokenness are uniquely positioned to become the fixers of all broken things. Our health care is broken. Our education is broken. Our justice system is broken. Our economy is broken. Our tax system is broken. Our infrastructure is broken. Our entire goddamn country is broken. Oh, what the hell, the entire freaking world is broken. And Silicon Valley is our only hope.

Silicon Valley has essentially only one product, a very versatile product indeed, but a single product nevertheless. Silicon Valley doesn’t actually make this product. They harvest it by casting gigantic computerized platforms and collecting everything caught in their digital nets, very much like Bubba’s shrimp: “… shrimp is the fruit of the sea.  You can barbecue it, boil it, broil it, bake it, sauté it. Dey's uh, shrimp-kabobs, shrimp creole, shrimp gumbo. Pan fried, deep fried, stir-fried. There's pineapple shrimp, lemon shrimp, coconut shrimp, pepper shrimp, shrimp soup, shrimp stew, shrimp salad, shrimp and potatoes, shrimp burger, shrimp sandwich. That- that's about it.”

Information is the fruit of humanity. You can boil it and broil it to intimidate doctors and manipulate people, to extract immortality (and cash) for you and yours, thus fixing health care. You can sauté it and puree it to terrorize teachers and crush the minds of small children, to generate armies of drones (and cash), thus fixing education. You can sift it, scramble it, steam it, and serve it to nullify judges and juries, to protect property rights (and cash), thus fixing justice for all. You can slice it, dice it, can it and ban it as needed to keep all that cash flowing, thus fixing “our democracy”.

Remember Jack and Mark? Unlike Mark, Jack is allowing users to remain anonymous on his platform. On Jack’s platform, if you see a blue checkmark next to the name of someone, you can reasonably conclude that you are talking, or rather listening, to a “real” person, instead of, say, a Russian bot.  Over time, it became clear that according to Jack, real people are those who are rich, powerful, or have enough “followers” to influence public opinion. Everybody else on Jack’s platform is shrimp. But Jack is an honorable man.

Jack is fixing “our democracy” by revoking the coveted blue checkmarks from some white supremacists. Presumably Messrs. Spencer and Kessler are no longer real.  On the other hand, the multitude of rich and powerful rapists, pedophiles and garden variety perverts, are still very real according to Jack’s superior morality framework.  Mark is fighting the good fight on behalf of “our democracy” in a different way. His platform is pursuing the enemy from without, by tracking enemy advertising paid for with rubbles, not yuans or ryials or euros or dinars or wons or yens, only rubbles, because the legendary KGB masterminds always pay in rubbles (with a return address of Моско́вский Кремль 103073) for all their international spying needs.

Now that “our democracy” is all nice and fixed, the Cartel can apply lessons learned to “democratize” medicine and fix “our health care” too. Health care is rife with old people, old fashioned ideas, and it is scattered all over the place. Nothing a big platform, dripping with dopamine jolts, can’t fix though. Uber for health care. Facebook for health care. Health care is like the iPhone. Information “blockers” will be prosecuted (this one is for real).  Structured data. Metadata. e-Visits. Remote monitoring. Predictive analytics. Population management. This stuff is just begging for a medical platform with hundreds of millions of patients “sharing” their health, their illness and their medical experience with each other, with doctors, researchers and of course the platform overlord and his customers.

You will share your symptoms, your concerns, your treatments, your outcomes. You will “like” CT scans, “star” lab results, and rate doctors, heath insurers, drugs or devices. Perhaps they’ll have a “dislike” button too. You will post videos of your colonoscopy and maybe live stream your telehealth session. You will ask for advice from patients like you and “clap” for the ones you like best. Your cancer remission could go viral. The platform will ensure you see things you care about and shield you from unsettling content. Before you know it, you will feel compelled to check your “health” every 5 minutes, and certainly when your iPhone vibrates with new images from Bertha’s mammogram, or when your Apple “watch” beeps with updates from your fantasy clinical trials league or with an urgent reminder to record your pre-hypertension medication intake so you can receive the coveted 20% discount on Christmas fruit cakes at CVS just in time.

Platformized health care will be cheap, convenient and readily available. And just like communications, shopping, porn, and news, it will be fake, manipulative, addictive and designed to “protect consumers” instead of benefiting citizens, or patients in this case.  Jack doesn’t converse with his buddies on Twitter. Mark doesn’t get his news from Facebook. Jeff doesn’t shop for deals on Amazon. And none of them will be getting medical care from a phone or a watch. You will. Your children will too.

Facebook just introduced a “safe” messenger for children under 13. Parents are supposed to set this up for their babies. Many will do just that. And experts will be exalting the thoughtfulness of the Cartel for creating a less toxic version, suitable for hooking children on the product. Why would a six year old need to message his “friends” online, instead of chasing them in the backyard? Why would a three year old need to watch sickly YouTube videos prepared exclusively for toddlers, instead of playing with alphabet blocks on the carpet? Why would the most powerful 71 year old man in the world self-destruct on Twitter instead of running said world? Why can’t you read an entire book anymore? Such is the power of the Silicon Valley Cartel.

Saturday, August 12, 2017

Only Trump Can Go To Single-Payer

There is an old Vulcan proverb saying that only Nixon could go to China. Only a man who used to work for Joseph McCarthy could set America on a path to better relations with a virulently Communist country. A few years after Nixon went to China, Menachem Begin, the Israeli Prime Minister who represented people believing that the state of Israel should stretch from the Nile to the Euphrates, gave Egypt back all the lands conquered in a recent war and made a lasting peace with Israel’s largest enemy. They said back then that only Begin could make peace with the Arabs.

Today, I want to submit to you that only Trump can make single-payer health care happen in this country. Only a billionaire, surrounded by a cabinet of billionaires, representing a party partial to billionaires, can make that hazardous 180 degrees political turn and better the lives of the American people, and perhaps the entire world as a result. Oh, I know it’s too soon to make this observation, but note that both Mr. Nixon and Mr. Begin were deeply resented (to put it mildly) in their times, by the same type of people who find Mr. Trump distasteful today. The liberal intelligentsia back then did not have the bona fides required to cross the political chasm between one nation and its ideological enemies, or as real as death immediate foes. The liberal intelligentsia today lost all credibility in this country when it comes to providing a universal solution to our health care woes.

Free health care (and free college) are not solutions. These are rabble rousing slogans to gin up the vote, slogans that end up in overflowing trashcans left in ballrooms littered with red white and blue balloons after everybody goes home to get some sleep before the next round of calls to solicit funds from wealthy donors for the next campaign. Providing proper medical care to the American people is a monumental enterprise that engages tens of millions of workers from all walks of life, every second of every day, in every square mile of habitable land, littered with the hopes and fears of hundreds of millions of invisible men, women and children who call this great country their home. This is not something that can be made free. Nothing is free in our times, not even sunshine and fresh air.

For the jaded, the cynically inclined, and those who are simply too afraid to jump off this cliff, and therefore argue that single-payer is not politically feasible, I have a simple question. Did you all think a couple of years ago, that a President Trump is politically feasible?  Okay then. Here is what I believe could be a relatively plausible scenario enabling this one-of-a-kind administration to use its unconventional political capital (if you can even call it that) to get us on the road to making health care great again, greater than ever before.

Step 1: Disaster

The current system, held together with string and duct tape must undergo a seismic shock, preferably a moderate shock and one that does not involve war and famine. The way things look now, the most likely implosion will be the Obamacare individual market. If the Trump administration holds back ransom money from insurance companies (a.k.a. CSRs), or engages in other mischievous behavior, and the individual mandate is not enforced, we may very well have a minor disaster on our hands. In addition, the President's Commission on Combating Drug Addiction and the Opioid Crisis is requesting that the President declare the opioid epidemic a national public health emergency. Put these two together and you see how lots of people are, or will shortly be, in dire need of medical services not currently available to them via existing “insurance” channels.

Step 2: Relief

The opioid crisis will need much more than providing care for its current victims, but we will need a coordinated effort to provide all necessary medical services to people addicted to opioids who are uninsured, or whose insurer is refusing to pay for the extensive programs needed for recovery. People who were able to afford insurance under Obamacare without, or with minimal, subsidies and are now left hanging to dry will also need a solution, and if they are sick, they will need immediate relief. This would be the perfect time to cut through the red tape and institute the Disaster Relief and Emergency Access to Medicare (DREAM) program. The DREAM will open Medicare to the victims of Obamacare and the victims of the opioid epidemic. This will be put in place as a temporary disaster response program, subject to extension of course, until a more permanent solution can be found. I doubt too many people in Congress could vote against such measure.

Step 3: The DREAM

No matter how short lived, all government programs including temporary ones need rules and regulations to execute now, and to be replicated in future emergencies as needed. Besides, any respectable bill needs more than just a title. How do we define opioid addiction? How do we define Obamacare victim? How do they sign up? What do they get? How much will it cost?

Opioid Crisis
  • Congress will appropriate $45 billion for this program for a period of five years to cover administrative costs, medical costs and program analysis costs.
  • Emergency funding will be provided to Federally Qualified Community Centers (FQHCs) to set up a process for opioid addiction screening. FQHCs are non-profit clinics, funded by the Federal government to serve low income populations regardless of ability to pay. All physicians and staff are salaried. The funding will be administered by the Health Resources and Services Administration (HRSA) and defined by the Secretary of Health and Human Services (HHS).
  • Any American citizen or lawful permanent resident will be eligible to access any FQHC and undergo opioid screening as specified by the Secretary at no cost. Individuals eligible for relief, based solely on clinical criteria, will need to provide information about their insurance status. Upon receipt of consent from the individual or legal guardian if the screened individual is a minor, eligibility results and insurance information will be sent from the FQHC to CMS for enrollment in the DREAM program.
  • If the eligible person (EP) is currently covered by commercial insurance, CMS will contact the EP’s insurance plan and require that the plan contacts the EP or legal guardian and obtains proper consent to transfer the EP’s coverage to the DREAM program. Following EP consent, Medicare will become the primary payer for the EP. Medicare at its sole discretion may discontinue eligibility for the EP and the commercial plan must reinstate coverage for the EP at that time. All subsidies paid by the Federal government to the insurance plan, if any, will be paid into the Medicare trust fund for the duration of DREAM participation.
  • The EP will pay to Medicare premiums equal to the last monthly amount the EP paid to the commercial plan. Medicare will cover all opioid related services with zero deductible and zero copay. For other services the EP deductible and copays will be equal to those of traditional Medicare beneficiaries (parts A, B and D). Medicare will end DREAM eligibility for an EP who missed 3 consecutive monthly payments.
  • If the EP is insured, or eligible to be insured, through Medicaid or any other public program, Medicaid or any other public program, will transfer into the Medicare trust fund estimated monthly premiums as calculated by the Secretary for the duration of DREAM participation. Medicaid will become the secondary payer for EPs previously enrolled, or eligible to be enrolled, in Medicaid.
  • If the EP is uninsured and not eligible for public insurance, the EP will be enrolled in Medicare (parts A, B and D), under the same terms as beneficiaries 65 years or older for the duration of DREAM eligibility, except that all opioid related services will be covered with zero deductible and zero copay.
Obamacare Crisis
  • Congress will appropriate $45 million for this program for a period of five years to cover program administration, evaluation and analysis. All other program costs, if any, will be absorbed by CMS budgets.
  • Any American citizen or lawful permanent resident who is not offered employer sponsored insurance, and is not eligible for Medicaid or another public insurance plan, and is not eligible for Federal subsidies on the Obamacare exchanges equal to at least 50% of total costs of the current benchmark plan, or resides in a county where no Obamacare plans are available on the exchange on the first day of the open enrollment period, will be eligible to enroll in Medicare parts A, B and D, at an annual rate of average Medicare spending per beneficiary (MSPB), adjusted for EP age.
  • The Secretary shall publish a list of DREAM premiums for three age bands, 0-21, 22-45, 46-64, no later than one month before the first day of open enrollment for the Obamacare exchanges. All DREAM rates will be assessed and billed for each individual EP. No family rates will be available and no Federal subsidies will be given to DREAM enrollees.
  • The EP, or a legal guardian if the EP is a minor, is responsible for premium payments to Medicare. EP deductible and copays will be equal to those of traditional Medicare beneficiaries (parts A, B and D). Medicare will end DREAM eligibility for an EP who missed 3 consecutive monthly payments.
  • For each program year the Secretary shall conduct and publish comparative analyses of Federal spending on Obamacare exchange enrollees and DREAM program enrollees to inform Congress and the public on the merits of each program.

Step 4: Consequences

See? Wasn’t that bad now, was it? Defining the program is relatively easy and the above is just an abbreviated example. Other details will need to be added, removed or changed, but the main idea here is to open Medicare in the short term to people who are hurting and are underserved by the commercial health insurance markets. There will of course be consequences. First, the Obamacare exchanges will most likely go bust, and we will have to expand the DREAM to allow enrollment of people who will bring their subsidies with them. Second, employers may decide to fund Medicare premiums instead of dealing with health insurance in house. Third, the folks who don’t qualify for the DREAM program may start chomping at the bit, seeing how DREAMers get to choose pretty much everything without breaking the bank. 

Yes, yes, I know. I’m being too clever by half, but surely someone who professes to be the voice of the forgotten men and women, could see his way clear to make this happen. It will, after all, lead to a complete repeal and replace of Obamacare. And for all timid liberals enamored with the poetry inscribed at the feet of Lady Liberty, let’s help the President erect a statue of liberty at the gates to Medicare.

Thursday, August 3, 2017

Is Single-Payer the Right Payer?

As is customary for every administration in recent history, the Trump administration chose to impale itself on the national spear known as health care in America. The consequences so far are precisely as I expected, but one intriguing phenomenon is surprisingly beginning to emerge. People are starting to talk about single-payer. People who are not avowed socialists, people who benefit handsomely from the health care status quo seem to feel a need to address this four hundred pound gorilla, sitting patiently in a corner of our health care situation room. Why?

The all too public spectacle of a Republican party at war with itself over repealing and replacing Obamacare is teaching us one certain thing. There are no good solutions to health care within the acceptable realm of incremental, compromise driven, modern American solutions to everything, solutions that have been crippling the country and its people since the mid-seventies, which is when America lost its mojo. To fix health care, we have to go back to times when America was truly great, times when the wealthy Roosevelts of New York lived in the White House, times when graduating from Harvard or Yale were not cookie cutter prerequisites to becoming President, times when the President of the United States conducted meetings while sitting on the toilet with the door open and nobody cared. Rings a bell?

Single-payer health care is one such bold solution. Listening to the back and forth banter on social media, one may be tempted to disagree. We don’t have enough money for single-payer. Both Vermont and California tried and quit because of astronomic costs. Hundreds of thousands of people working for insurance companies will become unemployed. Hospitals will close. Entire towns will be wiped out. Doctors will become lazy inefficient government employees and you’ll have to wait months before seeing a doctor. And of course, there will be formal and informal death panels. Did I miss anything? I’m pretty sure I did, so let’s enumerate.

Single-payer is going to bankrupt the nation

We have $3 Trillion in our health care pot right now. We have 325 million Americans, men women and children of all ages. First grade arithmetic says we have almost $10,000 per year to spend on each American, the vast majority of whom is either young or healthy or both. For comparison, Medicare spends on average around $12,000 per year for the oldest and sickest population. Last year a platinum plan for a 21 year old cost less than $5,000 per year and this includes the built in waste of private health insurance. So please, tell me again how we can’t afford to pay for everybody’s health care needs at a Medicare actuarial level, which is slightly less than commercial platinum.

And no, we need not increase taxes either. You keep paying what you’re paying. Your employer keeps paying what it is paying. The government keeps paying what it’s paying. But instead of dispersing all that cash to all sorts of corporate entities standing in line with their golden little soup bowls ready to catch the last drop, we put it all together in one big beautiful barrel, and pay for care directly to those who provide care - one pool, one budget, and one accounting system for all. This is a national endeavor. It is irrelevant that Vermont failed and California bungled the whole thing. Do you think California and Vermont could afford to provide for their own armies, air force and navies? I didn’t think so.

Single-payer will cause millions to lose their jobs

Hundreds of thousands of people work for commercial insurers. Claims need to be processed, money needs to be collected and paid out, books need to be kept, customers and service providers need to be supported, computers have to be maintained, audits need to be performed, contracts need t be managed, lots and lots of labor and lots and lots of decently paying jobs. Do you have any idea how Medicare administration works? Or are you under the impression that Medicare runs itself with no human labor? Have you ever heard of Noridian or Cahaba? No? Then I respectfully suggest that you should refrain from opining about the horrors of single-payer.

Medicare is run by private administrative contractors called MACs, each assigned to specific geographical regions and specific portions of Medicare services. In addition to the MACs there are slews of functional contractors that specialize in one or more types of supporting services to the MACs. These are private entities no different from Boeing, Lockheed Martin, Hewlett-Packard, Booz Allen Hamilton, GE and many more. They employ thousands of people and if Medicare becomes our single-payer, there will be more MACs, more functional contractors, and hundreds of thousands more private employees.

That said, it stands to reason that consolidation from many payers to one, will introduce some efficiencies and the total number of available jobs will be reduced, so here is a solution to this potential problem. Currently all insurers including Medicare and Medicaid are offshoring claim processing and in the case of private insurers other functions, including clinical, as well. Change the regulations and bring those jobs back home where they belong in the first place, and offer them to those who will lose their commercial insurance jobs. This administration is especially well positioned to effect such changes to CMS regulations.

Single-payer will take away our freedom

What if Sam’s Club only carried General Mills cereal and Costco only carried Kellogg’s?  What if you had a Costco membership but stopped by another store to pick up some Cheerios and were charged ten times as much as Sam’s Cub sells it for? No it’s not exactly the same, but you get the idea. Would you consider this to be freedom of choice? Or would you rather have one big huge market where all brands sell their products directly to you competing against each other? The latter is how single-payer could work. Freedom to shop for an insurance plan is freedom to shop for your preferred rationing scheme and ultimately your own flavor of death panel.

Traditional Medicare allows you to choose your doctor and your hospital and it pays for all medically necessary services. No commercial plan can say the same unless it’s one of those platinum things nobody can afford. Traditional Medicare can do that because it sets the prices for all health care providers, instead of negotiating with a few preferred vendors. Medicare can take these liberties because it’s big enough and because it’s a Federal program. But Medicare doesn’t pay for everything. That’s why most seniors purchase supplemental plans if they can afford them, and if they are poor enough, Medicaid kicks in as the secondary payer. Being the safety net for the fixed price single-payer should be the sole function of a new and federally administered Medicaid.

Single-payer will destroy our health care

I think American medicine is the best in the whole world. Not because it’s expensive and not due to the corrupt ways in which it’s being financed, but in spite of these things. Finding a better way to pay our medical bills has nothing to do with the quality of American medicine. The concern here is that once Medicare becomes the only game in town, it will unilaterally cut its fee schedules and all hospitals will go bankrupt, all doctors will be driven into homelessness, no new drugs will be developed and we’re all going to die. On the other hand, the Federal government is the sole purchaser of aircraft carriers, stealth bombers, and weaponry of all types. How cheap are those items?  How powerless and decrepit is that industry?

Precisely because of the lessons learned from the mighty military industrial complex, single-payer reform will have to change three things in the structure of our current so-called health care system. First, all hospital consolidation and acquisition of physician practices will need to be rolled back. Second, petty regulations, vindictive carrots and sticks strategies and crude attempts at social engineering by clueless bureaucrats, will have to be dismantled brick by brick. Third, physicians will need to form a union of independent small contractors to negotiate fees and terms alongside the already powerful hospital associations. I have been a longtime proponent of a physicians’ union, even in our current system, to serve as check and balance to corporate greed and government arrogance. A single-payer system cannot and will not succeed without unionized independent physicians.

Single-payer is not the American way

We have been conditioned by large corporations to think that what they do to us is the nature of free-markets, and thus the only way to achieve prosperity for all. I would submit (for the millionth time) that what Apple is doing to the world has nothing to do with Adam Smith’s free markets. The actors in classic free markets must be approximately equal. When sellers are so big that they need artificially intelligent tools to even notice the existence of buyers, there is no free market. When the price of products sold exceeds the lifetime incomes of most buyers, there is no free market. When no one can muster enough moral turpitude to publicly say that if you’re poor, your babies should die, there is no free market. There is no free market and there can be no free market in health care.

There can however be competition. Perhaps not in sparsely populated areas, and perhaps not for highly complex procedures, but there can be competition for most health care services in most places. The uniform single-payer price should be set so that innovative hospitals and entrepreneurial physicians can thrive by charging less and those holding themselves in higher than usual esteem, or those who choose to provide luxury, are free to charge more. If all sellers are small enough, and if the standard single-payer price is fairly negotiated, we will have a real market, because people will shop to save money (in a rewards system like credit cards have) and some will shop for status and vanity.

Will there be a role for private insurance?  There could be, but private insurance should not be allowed to cover any services covered by the single-payer because that would take us back to where we are today. Let private insurance cover stuff nobody needs, but wealthy people like to flaunt, like fresh baked brioche for breakfast after having a baby, or executive physicals in palatial settings, and let those things become frightfully expensive, as these types of things usually are in a free market.

Single-payer will create a new set of losers. Health care executives making tens of millions of dollars every year for no particular reason will be losers. Perhaps they can find new careers at Boeing or Lockheed Martin seeing how their expertise is easily transferable. Health insurance stocks will tank and improperly managed pension funds will also lose bigly. People running for elections will see a major cash cow go dry after the initial struggle is over and done with. There will be powerful losers and it won’t be easy.

But Obamacare has its losers too. Hard working, taxpaying middle class citizens were the designated losers of Obamacare. Some by commission and most by omission, because Obamacare made no attempt to solve the health care problems facing the vast majority of workers with employer sponsored health insurance. That bomb keeps ticking away at a steady pace. The newly empowered Republican Party has nothing to offer either, and I can’t blame them. There is nothing more we can do here. We tried everything else, and now it’s time to do the right thing. It’s the American way.

Monday, July 3, 2017

The Legend of Health Care

Once upon a time, in a kingdom by the sea, broad consensus has been reached, which seems rather weird nowadays. America, you see, was spending too much money on health care for too little in return. We spent almost twenty percent of our GDP on health care, which was much more than any other developed country in the world, but our health outcomes were middling at best. And the costs just kept rising. Something had to be done before health care terminally crowded out every other public need. The Affordable Care Act, Obamacare, was that something. It was supposed to “bend the cost curve” and everybody was supposed to learn that “less is more”.

And so the nation rolled up its sleeves and got to work. Insurance companies were supposed to limit their administrative waste and tightly mange care. Hospitals were supposed to bundle and warrant episodes of care. Doctors were burning out trying hard to cut the volumes of their expensive services, while exercising stewardship of scarce resources (i.e. dollars). Pharmaceutical companies were to be taken to the shed for regular beatings. Patients were educated to choose wisely and seek value for every insurance penny. And in a bizarre remake of Fantasia, the government was cheerfully orchestrating the entire effort with rules, regulations, computerizations and spontaneously generated armies of consultants.

It didn’t work. Not even a little bit. Yes, across the board industry profits and stocks were soaring, as were the loudly lamented loses from sky-scrapping premiums paired with ballooning deductibles (don’t ask, health care is complicated). And yes, Obamacare put a big dent in the “free loader” problem (as the uninsured issue was described to the Supreme Court by the Obama administration), but other than that, everything else was in the “showing potential” or “more research is needed” stage. It wasn’t for lack of trying either. The levels of “disruptive innovation” were positively dizzying. Ever increasing heaps of monies were getting shuffled relentlessly from here to there and back again, amidst vigorous debates on the merits of this or that “initiative”, but for some peculiar reason, not one dollar was ever taken off the health care table.

And then the warm and cozy incubator, where health care expenditures were being raised and nurtured for ages, experienced the mother of all disruptions. Donald Trump got himself elected President. Bluster and bravado notwithstanding, Mr. Trump is a weak President, with no political machine and no support inside the criminal beltway, or the moneyed power-centers that rule this country. The raging crowds that propelled Mr. Trump’s unusual ascent turned back into pumpkins at midnight on November 8th, 2016. He is virtually alone in Washington DC and it seems that slowly but surely the President is realizing that you gotta dance with the one that brung ya.

The Republican Party is now aiming in earnest to take a good portion of government money off the health care table. After seven years of planning, plotting, squirming and howling, the conservative wing of the GOP finally got its hands on the chips’ rake, and they intend to use it. This should not come as a surprise to anybody, but the Obamacare repeal and replace theater can be very instructive in ways that have little to do with a succession of wacky bills that will never become law. For starters, it’s worth noting how beautifully the current commotion validates that Paul Ryan and his fiscally responsible buddies are, and always have been, less than concerned with the infamous 47% of Americans who would never vote for Mitt Romney (but somehow voted in droves for Donald Trump).

Heath Care Hopscotch

Most importantly though, the responses to Mr. Ryan’s slash and burn reform proposals, from both sides of the fake ideological aisle, teach us that we will never be able to “bend the curve” of health care costs through a regular parliamentary process. Never.  And here are some vignettes that might explain why.

When President Obama signed his landmark health care reform legislation, an individual mandate to purchase insurance was included. The mandate was originally proposed by a premier conservative think tank, and copiously derided by the President himself during his 2008 primaries. Once Obamacare became law, the Republican Party took its objection to the individual mandate all the way to the Supreme Court, and when it lost its case there, embarked on a seven years (and counting) quest to repeal and replace Obamacare. Somewhere in the middle of that journey, the GOP fielded presidential candidate Mitt Romney, the first implementer of the individual mandate in Massachusetts (with Paul Ryan, the greatest Obamacare warrior, as his running mate).  How much of the Republican opposition to forcing people to buy insurance had to do with conservative ideology and how much it had to do with political opportunism, and how much it had to do with Mr. Obama himself, is up to you to decide.

Back during the 1995 budget wars President Clinton proposed a “"per capita cap" on federal spending for Medicaid, in which federal payments would be made for each eligible person but with the amount rising each year only according to adjusted inflation increases”. Although the Medicaid cap never came to be, according to then Senate Minority Leader Thomas A. Daschle (D-S.D.) "Virtually every Democrat indicated today that they could support it. In fact no Democrat indicated that he could not support it”. Fast forward twenty years or so, and the GOP proposal to impose inflation adjusted per capita caps on Medicaid is equivalent to the murder of millions of Americans in the eyes of current Congress Democrats, many of whom were also there in 1995.

Heath Care is just a political bludgeon. There are two ideological bookends for the theoretical idea of health care: equality vs. free markets. But when it comes to gory details, and heath care is a cornucopia of goriness, there are no principled positions to be taken. Everything can be twisted and fit into all but the most extreme ideologies (i.e. either everybody has a right to all the care they want or you get what you can pay for) and there are few, if any, people firmly entrenched at each end of the spectrum. Once you acknowledge that there is a morally valid spectrum, you can hop, skip and jump all over the place to serve your immediate political needs, which easily explains the vignettes above and many more acts of intellectual and linguistic chicanery commonly employed in health care policy propaganda.

The Unbending Curve

When the Democratic Party had its chance to bend the curve, they chose to spend more upfront and hope that harassing doctors and managing patients will bend the curve in mysterious ways. Republicans seem more inclined to use brute force to push the curve down at its weakest point, while hoping that the same doctor and patient harassment tactics will counteract the damage caused by any shortages in health care funding.  Whereas Obamacare brought us a flurry of innovations designed to move the system to value-based payments so we can save a few bucks, GOPcare will be bringing us a flurry of equally impotent innovations designed to move the system to value-based care so we can squeeze more quality from fewer bucks. In other words, the more things change, the more they stay the same.

If we want to spend less money on health care, then we need to spend less money on health care.  That pesky curve is not going to bend itself. All industry innovations claiming to save money are simply moving coins from one profit center to another, usually where the profit margins are higher and efficacy is lower or practically nonexistent. Curbing patients’ utilization of proper medical services, which is already lower compared to other developed countries, is a virtuous endeavor. Curbing the wanton rise in prices of said services is either evil Communism, or heartless Capitalism, depending on how the winds blow in Washington DC. The simple truth is that bending the curve means paying less than the industry feels entitled to, and the medical industrial complex shall not be denied. But there is new hope now…

Dollar Store Care

The progressive half of our ruling class seems to have had an epiphany of sorts. Medicaid, you see, is now an array of no frills, managed care, commercial health plans with atrociously narrow and underpaid networks. Medicaid is the Dollar Store of health care and as such it is the ultimate value-based solution. Wouldn’t it be nice if we could put the entire former middle-class on Medicaid and call it universal health care or even single payer? Besides, Medicaid accessorizes very nicely with that new and so very hip universal basic income pushed by progressive billionaires who are sucking up every bit of wealth from every living thing. The conservative half of the ruling class would much rather see a free market of Dollar Stores for health care. The GOP value-based solution is to reduce public funding for health insurance and let the market for Medicaid style commercial plans do its thing unencumbered by the heavy hand of government and the excessive burden of Federal dollars.

The existential question now before us is whether the government will be charitable enough to subsidize our Dollar Store purchases or not so much. There is no longer any debate about the race to a Dollar Store standard of care in America. The goal posts have been moved. Expectations have been reset. Mission accomplished. A win for progressives is Medicaid for all. A win for conservatives is Medicaid for some. The final score: Billionaires 1, America 0. What’s next?

Tuesday, March 28, 2017

Trump Lemonade for Dr. Price

President Trump campaigned on making health care better, cheaper and available to all Americans, regardless of ability to pay. Once Mr. Trump was safely in the White House, the Republican “thought leaders” in Congress were quick to supply him with their stale and superficial “plans” to repeal and replace Obamacare, which were written in protest to President Obama’s policies and were never meant to be implemented. When scrutinized by the rank and file of the Republican Party, it turned out that the Ryan/Price American Health Care Act was neither repealing enough for some, nor replacing enough for others. Nevertheless, Mr. Ryan felt a sense of urgency to ram his pet bill down the throats of not only the opposition party and the public at large, but also the throats of his own party and its rookie President.

The Democratic Party lost no time in whipping up public frenzy against the Ryan/Price bill, and Speaker Ryan lost no time in generating a sense of false urgency to pass his bill now, now, now, because for Paul Ryan this was a once in a lifetime opportunity to begin dismantling the welfare state. From the left, it looked like the bill will be withdrawing billions of dollars in health care benefits from the most vulnerable citizens who also happen to be Trump supporters. From the right, the bill looked like Obamacare Lite because it didn’t throw all the poor people under the bus fast enough.

These were the cards President Trump was dealt. If he signs the bill, he breaks his campaign promises and loses his base. If he comes out against the bill, he confirms the worst fears of all Conservatives and loses Republican support in Congress. There is zero chance for this President to appeal to another set of voters anytime soon, and currently, there is zero chance that even one Democrat in Congress will support anything President Trump proposes, no matter how liberal and beneficial that proposal might be. It was a difficult hand to play, but he played it brilliantly, in my view. Or maybe it was just beginner’s luck.

Right now the Democratic Party and its echo-chamber media are celebrating the defeat of the would-be destroyers of Obamacare. The Republicans are in disarray again. Paul Ryan has been humiliated. Trump, the closer, the grand deal maker, lost big league. Nancy Pelosi declares victory without having to fire one parliamentarian shot. The President in the meantime calls The New York Times and Washington Post reporters and doesn’t sound angry at all. No irate tweets. No below-the-belt punches. No fighting back. No nothing. How weird is that? Think about it. Is this how a beaten Donald Trump sounds like? Nope. That’s how a winning Donald Trump sounds like - calm, collected, magnanimous and low-keyed. President Trump passed his first test.

What’s not next?

According to my Twitter list of health care policy experts, the Big Bad President Trump will now “sabotage” Obamacare so it fails spectacularly, right before the mid-term elections, dragging millions of poor people down with it. Sabotage, espionage, life is good when you are kibitzing from the sidelines. Now why would a Trump administration want to create huge hardships for millions of people right before the mid-term elections? The thought process here is that if Obamacare collapses, the people will blame the Democratic Party, because as long as Republicans do not repeal and replace anything, Democrats continue to “own” health care. Therefore, the GOP will finally have a mandate to get rid of Obamacare any way they see fit, and will likely increase their majorities in both houses in 2018. There is only one little problem with this logic: when things go wrong, most people blame the currently governing administration, not the previous ones, and rightfully so.

Deliberately blowing up the health care system is a criminal endeavor that must be executed in the public eye, because Secretary Price cannot promulgate secret regulations. No administration can afford to do something like this, and expect to survive. Every new President in recent memory insisted that he “inherited a mess”, and every President then gives a State of the Union Address taking credit for fixing said mess. President Trump will be no different. Obamacare may not be in a “death spiral”, as detractors love to decry, but for millions of people, including those who receive generous subsidies, Obamacare is already a monumental mess. No sabotage needed.

Here is a tiny example. Remember that poor 64 year old, making $26,500 per year who, according to the CBO, ended up paying $1,700 under Obamacare and would have had to pay $14,600 under the Ryan plan? Well, that’s only part of the story, because those dollar amounts are just for premiums. Thus a fully subsidized healthy 64 year old is indeed paying “only” $1,700 for the cheapest Silver plan currently available on the Obamacare marketplace (in my zip code). A sicker 64 year old, making $26, 500, with high medical expenses is projected to have over $7,500 in total yearly costs, which is almost 30% of his gross income. I would like to humbly suggest to the Washington DC jet-setters that for this gentleman, there is no difference whether he needs to pay $7,500 or $14,600, or $140,000 or $14,000,000. He can’t come up with any of this. He is uninsured for all practical purposes. The only difference is that under Obamacare, they may have talked him into donating $1,700 to some insurance company.

What is next?

I know conservatives and libertarians abhor the sheer existence of Medicare and Medicaid, but a savvy Secretary of Health and Human Services (HHS) could use the girth and might of these government programs to nurture the reemergence of a relatively free market in medical services, and minor bi-partisan legislation could create a relatively less predatory market in medical products. These two efforts will do more to reduce the price (and costs) of health care than any Obamacare folly or any Obamacare repealing and replacing idiocy. Furthermore, the effects could be framed in terms of freedom, choice, access and even deficit reduction, in addition to quality and affordability for those less fortunate, pleasing people on both sides of the ideological aisle.

Here is my very modest wish list for Secretary Price. All I’m asking for is that from this point onward, we start practicing evidence-based health care reform.
  • Independent Evaluation – Between CMS itself, CMMI, HRSA and other agencies, HHS has billions of discretionary dollars in its budget to try new things, and even more billions to implement statutory experimentations. Traditionally, large sums of money have been spent on health system “transformation” to patient-centered, team-based, coordinated, value-based, managed care (feel free to insert your favorite buzzword if I left something out). Many, but not all, of these “demonstration programs”, pilots, innovation models, etc. include evaluation studies to assess performance and so far the results have been tepid at best, but artfully spun as inconclusive. I want independent evaluations of all CMS funded “initiatives”, and I want programs that do not deliver on promised fantasies to be wound down immediately and the money reallocated to better thought out projects.
  • Practice Research – For the last decade or more, it has been the unequivocal position of HHS that better health care at lower costs necessitates large integrated delivery systems. There is not one iota of bona fide research to support this assertion. And yet, the Federal government has engaged in massive direct and indirect efforts to dismantle the so called “cottage industry” of small independent physician practices. I want CMS to fund several serious comparative-effectiveness studies across various medical practice models before it’s too late and we have nothing left but monopolistic chains for medicine. And I want CMS to follow through and undertake the deconstruction of all infernal medical factories where nobody knows your name, but everybody knows your risk score.
  • Hospital Research – I remember reading something a couple of years ago about someone trying to study the effectiveness of hospitalist care compared to community doctors who are allowed to admit and care for their own hospitalized patients. Hospitalists are another pre-Obamacare “innovation” based solely on hospital profitability arguments. As such, it caught on like wild fire and we have very few community physicians left who follow their patients inside the hospital walls. I want to see that study performed immediately, before the last dinosaurs die off and we forget that continuity and coordination were once built into health care, by default.
That’s it. That’s all I want for Christmas. Disappointed? Don’t be. A comprehensive, well researched report on our health care delivery models (shall we call it The Price Report?) could change the trajectory of health care in America and the entire world. I did not forget about Medicaid, the ludicrous deductibles, the device taxes, the pharma bidding and all those big huge things every pundit is reciting on cable news channels. These are important things of course, but they are temporary solutions at best. Single payer, if implemented tomorrow, is going to implode just as quickly as Obamacare did, and end up rationing care worse than the British system does. The various free market solutions are even more vulnerable to the ominous crescendo of unchecked profit extraction and incompetence engulfing our health care system.

Health care cannot be sustainably fixed in broad political strokes. If we want a real and lasting solution, we will need to step away from the political theater and engage in painstakingly detailed work on fundamentals. Health care is about medicine, and medicine is about applying science to the bodies and souls of people. We know how to do it. We do have the best health care in the world. We just forgot where it is, so now we have to systematically look around until we find it again. Hopefully Dr. Tom Price understands the historic moment he finds himself in.

Thursday, March 23, 2017

A Citizen's Amendment to RyanCare

There are approximately 18 million Americans who purchase health insurance on the so called individual market, on and off the Obamacare exchanges. There are another 14 million or so who could be buying insurance on the individual market, but choose not to buy anything. This puts the total individual market at about 10% of Americans. Half of those are, or are eligible to be, heavily subsided through Obamacare (including those huge deductibles). The other 5% are facing the full brunt of health insurance price increases under Obamacare. Of those, 3% are paying for Obamacare health insurance and getting garbage in return for their money, while the remaining 2% are uninsured. This is the magnitude of the primary problem we are supposedly trying to solve.

The 17% of Americans on Medicare are not upset at Obamacare. The approximately 23% of Americans on, or eligible to be on, Medicaid are not angry at Obamacare either (although the 1% eligible for the Medicaid expansion in states that chose not to expand it, might be angry with their Governors). Some of the 50% or so, who are getting health insurance through their employer, and used to get rather flimsy insurance in the past, may be somewhat disgruntled because the Obamacare imposition of “essential benefits” caused their share of premiums and deductibles to rise, and their ability to choose their doctors to plummet. This is the secondary problem we are supposedly trying to solve.

The American Health Care Act (AHCA) addresses neither problem and exacerbates both.

Three Pronged Care

The proposed GOP solution is “three pronged”. Prong One repeals Obamacare (whatever that means) and replaces it with more widespread, but less generous, subsidies for the individual market and reduces funding for Medicaid, while also reducing Obamacare taxes on corporations and wealthy individuals, including taxes slated to increase the longevity of the Medicare trust fund. Prong Two is a flurry of yet to be determined regulatory relief that the Secretary of Health and Human Services will be supposedly providing at his discretion. Prong Three consists of new legislation, which will require the support of at least some Democrats in the Senate, to relax both the definition of Obamacare “essential benefits” and the regulations on health insurance corporations, so cheaper insurance plans can proliferate across the land (as they did before Obamacare).

The most important thing to understand about the Three Pronged Care proposal is that although the CBO can, and did, estimate the effects of the first Prong, nobody can estimate the cumulative results of all three Prongs, because nobody knows what the second Prong is and because it will take an act of God to make the third Prong materialize. Since we are talking about health care, think of this as some sort of orthopedic, cardiac or transplant surgery. First you cut the patient open, then you remove or adjust the offending parts, and then you put in something new and hopefully better. Coming in after a previous surgeon messed things up is obviously harder, but cutting the patient open and walking away until you figure out if you want to or are able to do more, is hardly a viable option for the patient, and will likely result in a huge malpractice suit (plus a copious prison sentence) for you.

What if Prong One is as good as it gets?

Unfortunately, this is precisely what Paul Ryan and his ragtag coalition are proposing to do with Prong One, whose sole effect will be to add insult to the Obamacare injury. Once we accept the premise that the Federal government has an obligation to help people get health care, the remaining disagreements are just haggling over price. And once we dismiss highfalutin principled rhetoric, the problem with Prong One is that for most people, in absence of Prongs Two and Three, this is just a stingier version of Obamacare. The GOP argument that two imaginary birds in the bush are better than a real bird in hand flies in the face of millennia of human wisdom. On top of that, there is absolutely nothing in Prong One that even begins to address the fundamental problem in our health care system, which is the unit price of health care services. Therefore, premiums and deductibles will likely continue to rise unabated.

In all fairness though, there is a twisted argument to be made that if you cut subsidies and there is less money available, insurers will work hard to lower the price of their products to match what the “market” can bear. That may be true if the reduction in funds affected the entire market, instead of at most 10% (likely 5%) of it, and the least profitable 10% to boot. In “normal” markets, a non-participation rate of 10% percent is certainly sustainable and actually pretty good for the sellers. That said, smaller health insurance vendors currently specializing in Medicaid managed care could step into this niche and offer a commercial product through their existing underpaid networks. If you’re a physician, this prospect should set your hair on fire.

The Free Market Delusion

At some point we will need to collectively disabuse ourselves of the notion that a market in health care insurance could be created without abolishing the provision of health insurance benefits through employment. I know everybody is talking about Flo and the little lizard selling health insurance on TV as the ultimate solution to health care affordability, but that is nothing short of demagoguery. Note that practically all auto insurance is business to consumer (B2C), while health insurance is overwhelmingly business to business (B2B). I suggest you try buying a cow from a feedlot and see for yourself how much negotiating power your consumer status bestows on you in a B2B market. If you want to try a free market solution for health insurance, you would need to do more than just kick a few poor people off their subsidies. You would need to kick 150 million people off their employer health insurance plans. Good luck with that.

I have to admit that there is something compelling about the conservative vision of a portable health insurance product that people buy and carry with them wherever they go. Obviously health insurance that is intended to serve people from cradle to grave cannot be a game of Russian roulette with covered benefits, or as Mr. Ryan refers to it, “patient-centered” insurance. Equally obvious is the fact that State and Federal governments will still have to honor their obligation to help those who can’t afford to purchase insurance for a predefined set of “essential benefits” on their own. Will such semi-free health insurance market deliver the health care affordability we seek? Not likely. The deceptively simple truth is that you cannot successfully tackle the pricing failure in the health insurance market without first taking an axe to our dysfunctional health care delivery system.

The Three Prong Shuffle

Obamacare not only failed to put a dent in health care delivery prices, but arguably made things worse by actively encouraging system consolidation. Under the best case scenario, a heavily modified GOP Prong One plan (e.g. higher tax credits, lower tax cuts for the rich, more money for Medicaid), will not change the Obamacare trajectory one bit and will not provide meaningful relief to people hurt by Obamacare. All this tinkering and re-tinkering with an insignificant portion of the health insurance market is like obsessively unclogging the kitchen sink on the Titanic. The sketchy descriptions of Prong Three, the free market prong, are just too ridiculous to consider at this point, but Prong Two, the regulatory prong, has great potential. After reading the manager’s amendment to the Ryan Make America Poor Again plan, I would like to offer my own citizen’s amendment.
  • New Prong One: Swallow hard and let the AHCA die a merciful death. Extend some temporary relief to the 5% hurt by Obamacare. Give Secretary Price a chance to affect regulatory changes first. Medicare is the de-facto price setter for health care services. The Secretary can affect changes to Medicare fee schedules and payment models that will quickly ripple through the commercial sector. I would start with the RUC and hike the relative value of comprehensive primary care. I would create a monthly CPT code that can accommodate subscription based primary care (not quite what the Direct Primary Care lobby wants, but darn close). And I would engage in a long string of multi-payer initiatives to accelerate dissemination of measures to control unit prices, while leaving behind the naïve and failed attempts to cut utilization.
  • New Prong Two: This is not a purely health care prong, but it is necessary because this is the only way to fix health care in America. Get those tax cuts done, renegotiate trade agreements, fix the education system, get infrastructure projects going, get manufacturing back, drain the swamp, and create lots of opportunities. Introduce specific pieces of legislation along the way to negotiate drug prices, break health system monopolies or at least encourage independent, small and more cost-effective practices to thrive. Keep up a brisk regulatory and deregulatory program to curtail the flow of billions of health care dollars to opportunistic corporations that do not provide care or any other benefits for patients. Think creatively about connecting health insurers’ participation in State/Federal programs to affordability in the individual market (at the very least make it count in Medicaid RFPs).
  • New Prong Three: If all goes well, we can finally do away with Obamacare, which should become automatically obsolete if Prongs One and Two are executed successfully (otherwise Obamacare will be the least of our problems). If the economy catches fire and more people have good paying jobs, and health care unit prices are at the very least contained, fewer people will need subsidies or Medicaid welfare. Make a note to schedule a symbolic full repeal and replace on January 21st 2021. I am certain it will pass with strong bi-partisan support.
Will Washington DC put the horses in front of the cart for a change? Not by choice. However, the good news is that all of a sudden Prong One seems to be on life-support in the House and dead on arrival in the Senate. The excellent news is that President Trump made another promise: "We will take care of our people or I’m not signing it" (it being Prong One, whatever it ends up being, if it ends up being). The disastrous news is that no self-respecting Democrat will engage in any effort to help the President help the American people. That would be too much to ask of our elected representatives.