Tuesday, April 2, 2019

What the hell do we have to lose?

If you live or work in Washington DC, your number one health care question is how do I (or my meal ticket people) win the next election. If you live or work in Caruthersville MO, chances are that your most pressing health care question is how do I (or my immediate family members) get a hold of some insulin this month. Theoretically speaking, in a healthy democracy, the answers to both questions would be one and the same. In America, in the year 2019, this is no longer the case.

The Washington jetsetters most aligned with the Caruthersville culture (whatever that means), will pop up on your TV screen promising at least fifty insulin shops on Main Street, all competing for your insulin business, until insulin prices plummet to gas station coffee levels. Not to be outdone, the opposing Washington faction, will promise you free insulin for life, and to sweeten the deal, they will throw in free college for your semi-literate children who couldn’t pass a college entrance exam with a gun to their head. They will also promise free childcare for your grandkids, so just in case your daughter does not make it into that free college and does not become an astrophysicist as planned, she can still pursue her Walmart career.

We are being hoodwinked. We are being robbed. We are being disrespected and infantilized. Stealing our votes has become easier than stealing candy from babies. There are more of us by orders of magnitude than there are of them. They certainly have better and bigger weapons. They are better trained and better organized and have better discipline. We also have collaborators in our midst, who are difficult to spot. Let’s face it, in every conceivable way, Washington DC and its sprawling appurtenances have become what the Court of St. James was to our forefathers.

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Health care is complicated because it has so many degrees of freedom, few of which we can reliably identify. Some degrees of freedom are yet to be discovered, others look independent, but are not, and vice versa. Furthermore, the boundaries of what we call the health care system are ill-defined and in a perpetual state of flux. At our current state of knowledge, deterministic theories of health care systems are not possible, i.e. you cannot infer past states or future developments of the health care system based on its current state, which is why both health care historians and “futurists” consistently fail to produce any valuable insights, let alone solutions.

Option One

The first and most common strategy for changing complex systems is to essentially ignore the complexity, zero in on one’s pet peeve, kick it hard in the shins, and hope for the best. That’s what LBJ did in 1965 and that’s what President Obama did in 2010. One was wildly successful, the other less so. Why? Both LBJ and Obama identified a segment of the population driven into misery and poverty for lack of affordable medical care and passed legislation to have the government assume financial responsibility for their medical care, to various degrees. Both LBJ and Obama faced militant opposition to their proposals. Both had to compromise and twist arms to make it happen.

However, the health care system wasn’t nearly as complex when LBJ acted on it. As luck would have it, LBJ was able to separate a piece of the system from the whole in a relatively clean way and move on that piece and that piece alone. It would take half a century for the ripple effects of LBJ’s kick in the shins to reach all other parts of health care, for better or for worse. By the time Obama got his shot, the health care system became almost impossible to detangle. Almost. Instead of working hard to carve out his pet peeve from the bigger mess, expose its shins, and deliver a blow, President Obama chose to kick the whole system softly in multiple spots, hoping the change will materialize only where intended. It did not.

Obamacare’s main thrust was to provide health insurance to the 45 million Americans who were then uninsured, mostly because they couldn’t afford to buy insurance. If that’s all Obamacare endeavored to do, it would have probably been a resounding success. Instead, Obamacare chose to partially address the uninsured problem directly, while simultaneously attempting to lower the overall costs of health care, so the unaddressed portions of the problem will address themselves. It was too much intervention for the system to absorb at once, particularly since the underlying philosophy was old, unimaginative and empirically proven to be morally and operationally bankrupt.

At the very core of Obamacare is Richard Nixon’s (or rather Edgar Kaiser’s) notion that health care is best when throngs of people, devoid of agency, submit themselves to medical decisions of expert organizations whose job is to minimize the costs of health care. This idea is why we are told that the job of doctors is to “keep” people healthy and be “stewards” of scarce resources, why we need a health system instead of a “sickness” system, and why Obamacare mandated preventive care to be “free” across all health care. This idea is why most Medicaid, large chunks of Medicare and the Obamacare exchanges were surrendered to “managed care” and “accountable” organizations, why fee-for-service is incessantly vilified, and why massive medical surveillance by computers has been instituted.  And this idea is why independently minded private practices had to be demolished.

Remember those vaguely defined degrees of freedom? It turns out some of them had to do with pricing. You want free preventive care? Sure, no problem, just pay a higher deductible. You don’t want to pay a fee for each service? Oh well, then pay a hell of a lot more for each “bundle”. You want a “health” system? Perfect, just pay more for “sickness”. You want billion-dollar precision surveillance of the herd? Easy peasy, just pay more for everything. You don’t like how things turned out? Too bad, because while you were busy pontificating, we all merged ourselves into too-big-to-push-around “health” entities, so take it or leave it, see if we care.

Option Two

The health system we have today is very different than the one we had when Obamacare became law. It has bigger teeth, sharper claws and spectacularly buff muscles, and its grip on our lives has tightened significantly. You can’t close your eyes and click your heels to go back to pre-Obamacare times. You may be able to strip twenty million people of the lousy health insurance they now have, but you can't “repeal” the mergers and acquisitions of the last nine years, you can’t resurrect thousands upon thousands of small practices and pharmacies, and you can’t rip out trillion dollars of computerized surveillance. You can certainly indulge in fantasies of shooting it dead with your Medicare for All silver bullet, but the post-Obamacare health system is no fictional werewolf. It’s a very real animal. You can certainly wound it, but nothing is more dangerous than a wounded beast.

The only way forward is to do what Obamacare should have done, albeit under much more difficult circumstances. You still have around 30 million people with no health insurance, and over 100 million who are underinsured because they can’t afford the new deductibles. You also have small limited opportunities to lower expenditures on certain health related items such as prescription drugs and extra payments to hospitals. You also have a slew of Federal regulations and administrative programs that make everything a bit more expensive, with no added benefits to either buyers or sellers of medical services. Before you do anything though, you must overcome a very painful mental hurdle. Medical care is and will remain very expensive for the foreseeable future, and that’s okay.

We don’t know how to cure Alzheimer’s. We don’t know how to cure diabetes, kidney disease, heart disease and most cancers. These things make medical care expensive. Five percent of Americans use fifty percent of health care funds every year. Fifteen million people use around one million dollars each, in any given year. If these very sick people didn’t exist, or if medicine had nothing to offer them, health care would be affordable for everybody else. Alternatively, if medicine had a fully restorative cure for these and other afflictions, health care would be dirt cheap and life would be much better for everybody. Science will do its thing eventually, and nudging it won’t hurt either, but for now, we need to bite the bullet and pay up.

First, we spend lavishly:
  • Expand Medicaid to 200% Federal Poverty Level (FPL). The Obamacare Medicaid expansion was up to 138% FPL. Where did they come up with that number? The FPL is a joke. No person can live on $6.245 an hour when working full time, which is equivalent to the FPL. Expand Medicaid a little bit more (yes, I just said expand Medicaid).
  • Get rid of the individual market for health insurance. Create locally managed group plans for counties or whatever geographical measures make sense in a given area. Let those groups shop for health insurance just like employers do. This will put to rest all the “preexisting conditions” sound and fury.
  • Subsidize these group plans so nobody pays more than a certain percent of their income and establish parity with current employer sponsored insurance. Yes, it is going to cost money, probably more than Obamacare, but it won’t break the bank.
Now let’s save a few pennies:
  • Do the prescription drugs thing. Don’t reimport from Canada, thus taking advantage of “Socialized” medicine, while badmouthing it with gusto. Grow a pair and take on the drug cartels. If the President can threaten China with tariffs, Mexico with shutting down all trade moving through the border, the EU with dismantling NATO, and North Korea with nuclear annihilation, he can certainly negotiate a better deal for America with a bunch of pharmaceutical sleaze balls, no?
  • Get rid of the “free” preventive care and allow direct primary care, and any cash services that are priced lower than plan negotiated fees, to count against deductibles.
  • Speaking of deductibles, cap those nationally at ten percent of premiums.
  • Incentivize competition in physician services, and discourage shady referral schemes, by paying independent small practices, more than hospitals for the same service. Look at this as a form of reparations for past discrimination.
  • Get rid of all Medicare and Medicaid funded “initiatives” that have no clear purpose or return on investment and disallow anything that is not a direct payment to a medical professional, facility or supplier, from being included in health insurers’ medical loss ratios.
  • Require all sellers of health insurance to submit to yearly value-based performance evaluations and publish the results. This is not about clinical quality. It’s about quality of service, and value-based is the proper term here (for a change).
There is obviously more, a lot more, that we could do, but these are my pet peeves. Other people will have their own. If we keep it simple, and if we are careful when detaching little pieces from the tangled mess that is our health care system, we should be fine. The folks in Caruthersville MO will be getting plenty of insulin, and the wise men and women brave enough to take this or a similar route to solving the health care conundrum, will get reelected in a landslide. The alternative is that in a pointless battle against Obamacare, those who defend the Obamacare status-quo will win in that landslide (regardless of Medicare for All empty promises), because starving people will not trade the piece of stale bread in their hand, for promises of champagne and caviar due to arrive in two years or so, if all goes well.

The President’s political instinct was correct. Health care must be addressed in a positive and generous manner at this exact moment in time, or the party will be over sooner than anticipated (pun intended). Those who advise the President to postpone the discussion are not serving him or the nation well. These are the same people who pushed the stingy and cruel Paul Ryan agenda that brought the house down last year (pun fully intended).

The truth is that right now, nobody in Washington DC has a realistic solution for health care, so why not try something different? What do you have to lose? I mean, seriously... What the hell do you have to lose?

Tuesday, March 12, 2019

Disquisition on Medicare for All

Medicare for all Americans is on the table now. Think about it. The not-in-our-lifetime utopian vision of every progressive liberal, complete with dancing rainbows and unicorns, is now within reach. Alternatively, the socialized medicine Trojan Horse that will turn these United States into a toilet-paper free Venezuela is now before Congress. There are over half a dozen bills in Congress, introduced by serious people with serious intentions, proposing some version of government administered universal health insurance in America.

Whichever ideological camp you’re in, it is a profound disgrace that in America today many people cannot afford basic medical care, as profound a disgrace as having veterans sleeping on sidewalks, as profound a disgrace as having one in five children living in poverty, as profound a disgrace as having Americans going to bed hungry. This was not supposed to happen in our “shining city upon a hill whose beacon light guides freedom-loving people everywhere”. It just wasn’t supposed to be this way in a country founded on the inalienable right to pursue happiness. Regardless of why it happened, whose fault it is, or how to “fix” it, America was not supposed to be this way. It just wasn’t.
"We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America."
Our union is as far removed from perfection as it was in the years leading to the events of April 12, 1861. Whether you obsess over political affairs or social issues, our justice system seems to be established on very shaky and uneven ground. Domestic tranquility must have been some sort of eighteenth century inside joke. Our welfare is anything but general, the much-admired blessings of liberty seem to accrue to the few who do very little to secure them, and things don’t look any better for our children and grandchildren. We can debate the fine legal points, the Articles and the Amendments, but there is no question in my mind that we are failing miserably in at least five out of the six stated goals of our Constitution.

What do all these polemics have to do with “fixing” health care, you may ask. Health care is not a standalone issue. It cannot be debated, let alone “fixed”, in a political, historical and moral vacuum. Our health care woes are one manifestation of a much larger systemic failure of American society. The “concentration of power” in fewer and fewer hands is a calamity that was foreseen by a bitter, desperate man as he lay dying, and promptly ignored by many generations since, including our own. John C. Calhoun stared into his self-inflicted perdition and we stared back at him from the flames.
“At this stage, principles and policy would lose all influence in the elections; and cunning, falsehood, deception, slander, fraud, and gross appeals to the appetites of the lowest and most worthless portions of the community, would take the place of sound reason and wise debate. After these have thoroughly debased and corrupted the community, and all the arts and devices of party have been exhausted, the government would vibrate between the two factions (for such will parties have become) at each successive election … These vibrations would continue until confusion, corruption, disorder, and anarchy, would lead to an appeal to force”.
The tragedy at this point is that we, as an “E Pluribus Unum”, cannot rationally analyze, let alone agree on, either the nature or the cause for our failure to thrive, and as long as that remains the case, we will not be able to “fix” health care, or anything else for that matter. But perhaps there is still some room for discussion at the edges of Armageddon…

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One glaring commonality between all Medicare for All proposals is that they are neither Medicare nor for all. Nobody is proposing to make Medicare available to all Americans, which is rather strange if you think about it. The battle cries of Medicare for All, the ubiquitous #Medicare4All hashtags, are pure propaganda. The proposed plans range from letting a few more poor people buy into Medicaid (not Medicare) to the Cadillac plans of Bernie Sanders, John Conyers and the brand new bill introduced by Pramila Jayapal, including prescription drugs, dental, vision and long-term care, with no premiums, no deductibles and no copays, given free to all citizens, regardless of financial status. In addition to the official bills introduced in Congress, there are lengthy proposals from policy groups touting their superiority and/or soundness compared to all other Medicare for All arrangements. The opposing faction is peculiarly devoid of grand ideas.

The problem with grand ideas though is that, by definition, they must rest on a multitude of assumptions and some assumptions are better than others. You can assume for example, that breaking an egg on a hot surface will get you breakfast. It’s been done trillions of times and therefore one can say that this is a pretty safe assumption, maybe even a fact. You can then be tempted to assume that putting a hot rod through an egg will yield the same results, since the egg is broken and in contact with a hot surface. Now obviously, the hot rod is just a first step, and after extensive tinkering you have a brand-new type of frying pan with an electronic egg breaker embedded in the middle. It costs ten times as much as the frying pan you trashed and it’s only good for eggs, but it does break the eggs, something you never knew was a problem. Oh, and it only makes scrambled eggs, so you save time on complex cognitive tasks.

Obamacare sounded pretty good before it morphed into a pugilistic contest between bureaucracies. Berniecare, sounds pretty good too. I mean what’s there not to like? All health care is free, and we don’t have to pay more than we are paying now for health care. We may even need to pay less, in aggregate. And the payments will be more justly distributed across the population. And every single person, no matter how privileged, will have the same exact glorious health care. Heck I’ve been arguing for a system like that myself. For those interested, I am also arguing for peace on Earth, prosperity, health and happiness to you and your loved ones.

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Despite what hot-headed reformers are trying to tell you, American health care is not worse or scarcer than it is in other developed nations. It is better and more plentiful. The sole problem with health care in this country is that it is not affordable for most Americans. What does “not affordable” mean though? Does it mean that health care prices are too high? Does it mean that we don’t choose our care wisely? Or does it mean that people are too poor? The answer is of course yes and no on all counts. Furthermore, “fixing” any one of the above problems will likely exacerbate the others. Nobody knew health care could be so complicated, obviously, but it is.

Real GDP per household (2.2 persons) stands around $120,000. Median income per household is half as much. We currently spend on average $24,000 per household per year on health care. If every household got a fairer share of GDP, perhaps health care would be less “not affordable”, but even in the most egalitarian scenario, health care would still be a huge financial burden. Medicare for All seeks to shift the health care burden from individual households to the nation. When the nation is faced with burdens of this type, it either goes into debt or cuts budgets. Debt of this magnitude spells bankruptcy down the road, and budget cutting translates into Rationing. Pick your poison.

But maybe we can ration wisely. Maybe we can replace volume with value. Maybe. Either way, when volumes for one service line go down, another service line seems to miraculously become more popular. If we force all service lines to cut down on volume, prices per unit will inexplicably start soaring to keep the topline steady. Then how about combining nationalized health care financing with price controls, as all Medicare for All bills are suggesting? After all, this is working well for Medicare, no? Yes, it is working for Medicare, because hospitals and doctors can charge the difference to private insurers. If there are no private insurers, hospitals and doctors will need to cut their costs. How do most firms cut costs? By letting employees go and/or reducing their salaries.

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Over 16 million Americans are currently working in the health care industry. If you want to cut that mythical 30% that is presumably waste, I can guarantee in writing that before one wasted piece of paper is eliminated, 6 million people will be out of work. In all fairness, a couple of the more radical Medicare for All proposals include income replacement and “retraining” for a few hundred thousand health insurance industry workers envisioned to be displaced, which amounts to a few drops in the disaster bucket. Such massive unemployment will wipe out entire communities, not to mention the stock market, pensions, retirement savings, tax revenues, and safety net budgets. It may also deal the long overdue coup de grâce to the struggling American middle class.

In a service economy, which is what all progressive minds are glorifying now, if you cut spending on services, you shrink the economy, with all attendant consequences. And no, having more money in your pocket to buy more crap from China does not improve the situation one bit. The supreme irony is that when we add the resultant financial aid for those who will lose their health care jobs, and the many more affected by the ripples of our trimmer health care expenses, we will end up precisely where we started, if we’re lucky, which is not very likely. The point here is not to bash Medicare for All plans. The point is to highlight the magnitude of what is discussed. By comparison to Medicare for All bills, Obamacare was just minor tinkering, and look where it got us.

There are only four countries in the world, including our own, that have a GDP greater than our annual health care expenditure. Restructuring health care in America is like restructuring the entire economy of, say, France or the United Kingdom, and then some. The United States is the third most populous country after China and India and has the greatest influx of new immigrants each year. Pointing to how great the Singapore model is working, or how quickly Taiwan transformed its health care system is, forgive me, laughable. If we learn one thing from the Obamacare escapade, it should be that in health care, nothing, absolutely nothing, scales as predicted on paper.

Finally, as hard as it may be for you these days, please remember that smart people, with yards of skin in this game, may disagree with your preferred solution, not because they are greedy, not because they hate poor people, not because they can’t do the math, not because they are evil, and not because they are deplorable or crazed Marxists. So, please, get off your soapbox (I certainly did), look reality in the face without fear or prejudice, start listening to ideas that make you uncomfortable, and understand that pontificating about Medicare for All is as useful as bloviating about free-markets.

Wednesday, February 20, 2019

The Bonfires of Health Care

Let’s burn health insurance down. Greedy corporate bastards should burn. Big Pharma and big hospitals should probably burn too. You know who else is really, really, bad? Wall Street. Let’s burn the banks. And let’s burn Big Tech and the entire Silicon Valley cartel. Let’s also burn Big Agribusiness that’s making us fat and sick. And let’s burn the Oil companies that are destroying the planet, and let’s burn the automakers too. Heck, let’s burn all the globalist billionaires and while at it, let’s burn the White House. Let’s have a cathartic bonfire of all things we passionately hate.

The “scorched earth” military strategy was tried and found true time after time throughout recorded history. Unfortunately, the Geneva Convention banned this useful practice a few decades ago. Not to worry though, the aficionados of all burning things discovered a modern version of the same: the “scorched economy”. Like General Sherman marching resolutely to the sea, the warriors against all things evil are marching from election to election on what will hopefully soon be the ashes of the Great American Economy, and from those ashes the brotherly, egalitarian and perfect in every way, Phoenix shall rise. We simply cannot allow democracy to die in darkness. Hence, we will light the most magnificent bonfire the world has ever seen, and democracy will die in a glorious blaze second only to the Sun itself.

Health care is one fifth of the American Economy, and it is a highly combustible mixture of money, disease, pain, suffering, death, greed, lust, inequality, exploitation, theft, and even murder, along with every other sin known to mankind. It is a good place to start our illuminating destruction of evil. Health insurance companies cannot be allowed to exist. Pharmaceutical corporations must all die, and yes, hospitals should all be shuttered down. Heck, even doctors should be wiped off the face of the earth.

Our government, where we all come together to do good, should provide care to the sick, and preferably health to the healthy. Our government, by the people for the people, should invent new ways to prevent and cure disease. Health care should be given in the comfort of one’s home by artificially intelligent machines. Doctors and hospitals, like walls, are immoral 14th century implements, that can be easily replaced by moral technology, such as drones, sensors and other electronic “things”. Once nobody gets paid to do health care, because government, and because, you know, “technology”, health care will obviously be free. Problem solved. Move on.

To paraphrase Susan Sontag (mostly because one cannot write anything today without some reference to the Third Reich), 10 percent of any population is irrational, no matter what, and 10 percent is rational, no matter what, and the remaining 80 percent can be moved in either direction. In our case, the irrational 10 percent is alternately running for some elected office or serving on expert TV panels on everything, from fighting ISIS to fighting cancer, largely based on ability to quickly skim through Wikipedia articles. And when Medicare for All is deemed necessary to avert climate change, according to a recently introduced House resolution, one is forced to wonder if a Dodo Bird in Every Pot will be the winning electioneering slogan of our times.

Health care according to many well-intentioned people should be a “Right”. Americans have many such Rights enshrined in our Constitution, and the Right to health care seems to fit the bill. We have the Right to free speech for example. Is my Right to free speech exercised the same as, say, Jeff Bezos’s Right to free speech? We all have the Right to Assistance of Counsel if accused of a crime. Is an assignment to a public defender, the same as being able to hire Alan Dershovitz? We have a Right to not be assessed excessive bail. Do you have any idea how many people languish in jails for lack of $50 to post bail? Declaring health care to be a Right is a cheap and very cruel form of demagoguery.

What if health care is not a Constitutional Right, but just a right to a free public service, like say K-12 education? American public education has the largest cost per capita, middling outcomes, rampant systemic inequality, underqualified and underpaid teachers, and a constant stream of flailing Federal initiatives to have no child left behind. Lots of “tech” though, in every failing, illiterate classroom, and more added every day, except in the posh schools of the rich. That’s what a free public service looks like when the foundation is broken. There is little reason to believe that free public health care will be different, once the evil private sector goes up in flames.

Here’s an interesting thought. Would you be surprised to learn that employer sponsored commercial health insurance is the most egalitarian health insurance system around? Do you know why? Because the “decision makers” are required to live within the decisions they make. Unlike salaries and taxation, when it comes to health insurance, the big powerful CEO gets the same exact plan that his secretary gets. Their interests are perfectly aligned in this case. Compare that to free public services, like health care and education, where decision makers are in no way obligated to live inside the “comprehensive” solutions inflicted on everybody else. Think about that. There may be a clue here on how to go about fixing many things in this country.

Once you are safely in orbit around the Washington DC swamp, you will never again have to send you children and grandchildren to a public school, never again have to shop for health insurance, never have to use public transportation, never have to worry about rent, utilities or anything else the “American people” worry about day and night. All the problems you pretend to solve are theoretical. Other people’s problems. Sure, you may be a very good person, genuinely wanting to bestow medical care on all Americans, but it’s not like your little kid is at risk of dying because you can’t afford an asthma inhaler. Theoretical problems tend to generate theoretical solutions. Theoretical solutions seldom work in practice.

Setting everything and everyone on fire and watching it all burn in a semi-religious exorcism of all that is and has been evil in America, is not the same as having your own plump derrière baptized by the flames.
We who are about to be sacrificed in your self-aggrandizing arsonist rituals, categorically refuse to fuel the bonfires of your fake revolution.

Saturday, February 3, 2018

Ambergan Prime

Dear primary care doctor, Jeff Bezos is about to devour your lunch. All of it. And then he’ll eat the table, the plates, the napkins and the utensils too, so you’ll never have lunch ever again. Oh yeah, and they’ll also finally disrupt and fix health care once and for all, because enough is enough already. Mr. Bezos, it seems, got together with two of his innovator buddies, Warren Buffet from Berkshire Hathaway and Jamie Dimon from J.P. Morgan, and they are fixing up to serve us some freshly yummy and healthy concoction.
Let’s call it Ambergan for now.

This is big. This is huge. It comes from outside the sclerotic “industry”. And it’s all about technology. The founders are no doubt well versed in the latest disruption theories and Ambergan will be a classic Christensen stealth destroyer of existing markets. When the greatest investor that ever-lived combines forces with the greatest banker in recent memory and the premier markets slayer of all times, who happens to be the richest man on earth, all to bring good things to life (sorry GE), nothing but goodness will certainly ensue.

Everybody inside and outside the legacy health care industry is going to write volumes about this magnificent new venture in the coming days and months, so I will leave the big picture to my betters. But since our soon to be dead industry has been busy lately bloviating about the importance of good old fashioned, relationship based primary care, perhaps it would be useful to understand that Ambergan is likely to take the entire primary care thing off the table and stash it safely in the bottomless cash vaults of its founders. It’s not personal, dear doctor. It’s business. Ambergan will be your primary care platform and you may even like it.

I am not sure what Mr. Buffet is contributing to this venture, other than cash and the warm bodies of his employees to pilot the venture. As to Mr. Dimon, he could probably run a modern analytics-based, risk-assuming health management entity, a.k.a. insurance company, while blindfolded and with both hands tied behind his back, so he may be useful in the short term. Let’s face it though, the most interesting actor here is Mr. Bezos and his Amazon platform of everything. Whatever else happens, it is probably safe to assume that within the next ten to twenty years, most people will be getting much expanded primary care services directly, and almost exclusively, from Amazon.

Amazon is a transactional platform, where people buy and sell things that Amazon does not make, and often does not even stock. With its more recent forays into TV, movies and music, Amazon also has some experience selling, mostly subscription based, services to consumers. As strange as it may sound though, most Amazon profits come from a very different source. Amazon Web Services (AWS), a computing platform (cloud) service, mostly for businesses and governments is a modest part of Amazon revenues, but a huge contributor to its profits. This lay of the Amazon land practically begs for a little cross pollination, and health care may very well be the ideal vehicle for that.

Cloud services like AWS are essentially eliminating inhouse professionals and expertise in maintaining the basic infrastructure of computing, outsourcing it all to Amazon. Rings a bell? You can almost see the Amazon ads for its primary care services, telling hospitals that they should concentrate on their core business, which is cutting people open and stitching them back together, and leave routine care to Amazon’s primary care platform, expanding or shrinking just in time to match organization demands, with guaranteed uptimes of 99.99999%, and so forth. And you can almost see the direct to consumer ads too, can’t you? Sure you can. You know you can.

A few days ago, before the Ambergan announcement sent the health care markets into a tailspin, Amazon hired a top doctor from one of those trendy primary care corporations that like to misrepresent themselves as Direct Primary Care (DPC).  People speculated that Mr. Bezos, who previously invested in another failed DPC organization, may be ready to try his own hand at fake DPC for his own employees. Meh…  It didn’t sound right to me, because with or without Ambergan, the Amazon stars were already aligning towards a massive thrust into health care, from the bottom up, as any good disruptor usually does.

A few weeks ago, Amazon offered us an opportunity to invite Jeff Bezos into our bedroom. No, he won’t interfere with anything. You won’t even know he’s there. He’ll just sit quietly beside your bed and watch you sleep, until you ask for something, if you do, and if you don’t, that’s fine too. It’s called Echo Spot and other than being unusually cute, the camera/microphone device that looks a little like an old-fashioned alarm clock, is just another extension of the Alexa line of surveillance/service products that run your home and your life, which is precisely what an ideal primary care doctor is supposed to do, i.e. keep you healthy, where health is defined as  “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”. 

You will subscribe to Ambergan Health. You will be monitored by Alexa in your home and maybe a future tiny Echo will let Alexa go outside with you. Perhaps they’ll throw Apple a crumb here to keep an eye on you when you leave your home, although it’s becoming increasingly unclear why you should. When you feel sick, you will summon a doctor on your Echo screen, and eventually he will appear preemptively before you get inconvenienced by any symptoms. You will be examined, diagnosed, treated and monitored in your home. And this should take care of most needs of most people most of the time. Not only is this a good start, but it’s a foundational step, and a perfect place to practice, because you can’t cater to complex needs if you have no idea how to care for simple needs.

Will there be room for marginal plays in drug pricing and maybe devices or exclusive contracting with delivery systems, as most experts (who drove health care into the ground) seem to think? Maybe, but negotiating lower prices for bulk purchasing is neither unique nor disruptive. It does sound like Ambergan will begin by deploying its services to its own employees, but make no mistake, this cannot be about creating yet another middling scheme for self-insured employers. If that’s all Ambergan is, there will be no innovation and no disruption. This must be about the entire health care market. This must be about doing to health care what Amazon did to retail. Amazon didn’t kill retail by restricting consumer choice to idiotic narrow networks of starving suppliers. That’s the Walmart model. Amazon decimated retail in precisely the opposite way. This is a business venture gunning for large market shares, and yes, I know it’s not seeking profits right now, but the entire Amazon retail bonanza started without profit and it remains mostly so to this day.

If you’re a primary care doctor, soon you will be able to have your own little storefront on Amazon, instead of or in addition to some strip mall or non-descript medical building. You will have to provide specifications for your services and cash will be king. Remember those new interstate licensing compacts? That will help here and so are the ever more relaxed telehealth rules and regulations. How about the recent rise in burned out doctors and cash practices? It’s almost like this was meant to be.

For the initial enterprise offering, substitute doctor farm for server farm and you get the AWS of medicine. For the end result, add another layer to the AWS, and substitute each doctor in the farm for say, detergent or movie, and you get the grand idea. Since everybody is shopping for substitutable services, this is the perfect insertion of the high-volume retail model into the high-profit AWS model.

Ambergan need not buy clinics, employ doctors or contract with systems, although it might start out that way. It just needs to get as many doctors as possible on the Amazon Health platform and have them compete, while people review and rate them into oblivion or success. The Amazon platform IS the network, and there will be terms, conditions, stars and promotions. There certainly are many legacy obstacles to overcome, and perhaps that is why Amazon couldn’t or wouldn’t go it alone. Throwing highly regulated markets wide open requires two strong lobbying arms, and a federal government willing to play fast and loose. The stars are indeed perfectly aligned for the first true disruption of our health care since 1965.

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.