Monday, June 10, 2019

Is Abortion Good or Evil?

Genesis 11:1-9 New Revised Standard Version (NRSV) 1: Now the whole earth had one language and the same words. 2: And as they migrated from the east, they came upon a plain in the land of Shinar and settled there. 3: And they said to one another, “Come, let us make bricks, and burn them thoroughly.” And they had brick for stone, and bitumen for mortar. 4: Then they said, “Come, let us build ourselves a city, and a tower with its top in the heavens, and let us make a name for ourselves; otherwise we shall be scattered abroad upon the face of the whole earth.” 5: The LORD came down to see the city and the tower, which mortals had built. 6: And the LORD said, “Look, they are one people, and they have all one language; and this is only the beginning of what they will do; nothing that they propose to do will now be impossible for them. 7: Come, let us go down, and confuse their language there, so that they will not understand one another’s speech.” 8: So the LORD scattered them abroad from there over the face of all the earth, and they left off building the city. 9: Therefore it was called Babel, because there the LORD confused the language of all the earth; and from there the LORD scattered them abroad over the face of all the earth.

There was a time in America when we were one people. There was a time when nothing we proposed to do seemed impossible. Our communal tower touched heaven and we certainly made a name for ourselves. Since then, a different type of Lord, similarly threatened by our success, has confused our language in a new and more insidious manner to the point where we no longer understand each other’s speech, and a frustrated populace gave up on trying, reverting to primate screeching and screaming instead. It is painful to watch, and it is agonizing to participate in the decaying remnants of our once glorious public discourse.

This is not about who says tomato and who says tomahto. The modern confusion occurs when I say tomato and you hear cucumber. There is no way for us to cook some spaghetti sauce for dinner with my tomato, or tzatziki with your cucumber. I don’t understand why I should chop some dill for the sauce when basil and oregano are the obvious choices, and you have no idea why I’m trying to boil a big pot of water instead of grabbing that Greek yogurt container from the fridge. Salt and garlic are the only things we can agree on, although in vastly different amounts, but nobody can survive on salted garlic. And so, we end up yelling at each other, and eventually we both go to bed angry, exhausted and hungry, each one of us convinced the other one is a hateful idiot and a traitorous saboteur of dinners. The Lord has prevailed.

Today, when I say Socialism, I see a democratic nation with a generous welfare system and thriving private economy, like Sweden or Denmark. You see Cuba or Venezuela, with millions starving in the streets while murderous, mustached dictators are wallowing in palatial riches. When I say Capitalism, I see hundreds of thousands of businesses innovating and competing to serve their customers while creating a land of plenty for all. You see racist, bigoted, exploitative tyranny of a few billionaire owned corporations, employing slave labor tactics to enrich themselves further while the rest of us starve to death. And that’s where the conversation ends, and the yelling commences. There can be no further discussion, no objective analysis, no learning and certainly no compromise. From both our perspectives, this is a fight between Good and Evil. You don’t discuss things, let alone compromise, with Evil.

Abortion

Now let’s discuss abortion, which is perhaps the ultimate example of how fake language acts as a paralyzing venom in service of our predators. If you listen to the public debate now raging on social media and all other media, you would surmise that the battle lines are drawn between two distinct camps. The “pro-choice” camp stating that abortion is Good, without any caveats, and the “pro-life” camp which insists that terminating a pregnancy is Evil, again with no caveats. If you propose to restrict abortion in some cases, you are enslaving women. If you suggest allowing some abortions in special circumstances, you are a baby killer. Both pro-choice and pro-life terms were carefully selected to make polite debate impossible. You cannot be anti-choice or anti-life without being Evil. There is no terminology for anything in between. Oh sure, you can launch into a tirade, but nobody will listen to Evil.

Fake language creates fake realities. Few if any Americans are absolutist pro-life or pro-choice. There is a spectrum of opinions and feelings that was rendered all but inaudible once the screeching, screaming and yelling has begun. Recent polls (grossly tilted towards non-religious people) show that while most Americans label themselves pro-life or pro-choice, only 27% (at most, and likely a lot less) are firmly entrenched at the ends of the spectrum. The remaining vast majority is somehow rendered irrelevant in the current shouting match. If you want to stay relevant in this circus, we call public debate, or rather electioneering politics, you must recite the precise words of the gospel. And when opposing gospel reciters meet, this is what Babel sounds like:

Pro-death: Government has no business telling women what to do with their bodies. My body, my choice. Male members of the old white patriarchy have no say in this debate anyway, because they don’t have a uterus. Besides, the Supreme Court decided this already and we have a constitutional right to abortion.

Pro-coercion: The Supreme Court decision was wrong and must be overturned. Abortion is murder. Plain and simple. You don’t have a right to murder other persons, even if they were not born yet. Killing a baby in the eighth or ninth month of pregnancy, by tearing her to pieces in the womb, and finishing the job after birth if she survives, is infanticide. Is that okay with you?


Pro-death: Do you seriously want to prosecute and jail a twelve years old girl who was raped by her uncle and got pregnant? Do you want to force little girls to carry babies? Those late abortions don’t really happen, except in extreme cases to save the woman’s life. It’s a far-right myth. You’re watching too much Fox News.  So that’s a straw man, but sure go ahead, I’m sure you don’t care if women die and children are jailed. 


Pro-coercion: Oh yeah, you go ahead, lecture me about caring for children, while you massacre hundreds and thousands of babies every year. And if that wasn’t enough, now I’m supposed to finance your Commie holocaust. F*** off….


Pro-death: You’re the biggest hypocrite I’ve ever met, and a liar too. If you care so much for children, how come you refuse to fund public education and early childhood programs? How come you keep sending so many black boys to prison? You’re just a racist Trumpkin, in addition to clearly being a rabid misogynist, and I bet you love putting immigrant children in cages too. You can f*** off yourself… Idiot…


And on and on it goes. Note that both sides put forward reductio ad absurdum arguments, while responding solely with tangentially related ad hominem attacks on their interlocutor. Why is that? Well, maybe it’s because nobody in their right mind can defend imprisoning twelve-year-old rape victims, just like nobody in their right mind can defend terminating a perfectly good baby five minutes before it is due to be born. It is disheartening, but it is also a good sign that we haven’t gone completely mad just yet. Another thing to notice is that on both sides people are either not fully aware of simple facts or would much rather conduct this Babylonian conversation on a fact-free emotional level.

Did you know, for example, that when the Roe v. Wade decision was issued, plenty of progressive voices found it poorly reasoned and even counterproductive? None other than Justice Ruth Bader Ginsburg is on the record saying that “the Court ventured too far in the change it ordered and presented an incomplete justification for its action”. Now make no mistake, RBG is staunchly pro-choice, but the Court may have done more harm than good here, by impatiently stepping out of the judicial lane and into the legislative one, at a time when progress was slowly but surely being made in various States.

Did you know that in Roe the Court asserted that a woman’s right to an abortion is “fundamental”, but only for the first three months of a pregnancy and only in consultation with a physician? After that the State has its own rights to intervene with or outright deny this fundamental right, due to competing interests. Later, in Planned Parenthood v. Casey, the court discarded the medically outdated trimester framework and introduced a dynamic “viability” concept, bolstering the power of States to interfere with a woman’s fundamental right to an abortion, as long as no “undue burden” is imposed on the woman. Neither Roe nor Casey are giving women full rights to terminate a pregnancy whenever and however they see fit. Both Roe and Casey grant States the right to curtail reproductive autonomy of women, if they so choose.

In 1973 the Court decided Roe with a clear 7 to 2 majority. Ten years later, in Casey, the Court splintered into multiple plurality opinions with only one narrow 5 to 4 majority decision to uphold Roe with adjustments in favor of the States. I can’t even begin to guess how the lines will be drawn if an abortion case comes before the Court today. We share this country with one third of a billion other people. Societal consensus on important issues is rare, difficult, and takes decades if not centuries of patient and serious discourse to build. That’s why we have fifty States. We either relearn how to meaningfully communicate and compromise with each other or we will perish in most unnecessary and painful ways.

Wednesday, June 5, 2019

Health Care is a Risky Business

For over a decade Washington DC has been busy with fixing health care. For over a decade, the same government bureaucracy, the same advocacy (read lobbying) organizations, the same expert think tanks, the same academic centers, the same business associations, with the same people hopping around from one entity to the next, have been generating and applying the same “innovative solutions” differentiated solely by their aggrandizing names. The result? Health care is more expensive than ever. More people than ever can’t afford to seek medical care. More doctors are disheartened, to the point of committing suicide. All this while the illustrious transformers of health care are accumulating fame and riches, probably exceeding their own expectations, with no end in sight.

It is no secret that back in 2016 many of us voted for Donald Trump hoping that he will “drain the swamp” or at the very least blow it all up into a spectacular artesian fountain of filth. He didn’t and he won’t. The swamp won. Our special health care swamp is deeper and wider than most, and the Trump administration is making it deeper and wider than ever before.  The single payer lobby is simply proposing to move the existing health care swamp to a bigger and more noxious location, so it has plenty of room to expand in the future. The swampy strategy for fixing health care has always been, and by the looks of it will always be, a game of hot potato. The potatoes are us.

At the core of the guileful verbosity of health care transformation there is nothing more than an elaborate effort to shield corporations, and the governments that serve them, from financial risk. It’s really that simple. We pay our premiums and our payroll taxes, month after month, year after year, and when the time comes, if it comes, they’d much rather not pay the medical bills they are contractually or statutorily obligated to pay. Blame sick people for being sick. Blame the sick for not shopping the clearance aisle. Blame doctors for treating the sick. Blame hospitals for admitting too many sick people, too often and for too long. Punish them for the errors of their ways. Teach them a lesson or two. And most importantly, make them pay until it hurts.

Managing the Health Care Consumer

The most blatant attempt to throw people under the bus is the insanely brazen effort to remake medicine into a consumer industry. Patients, according to the narrative, are empowered when they spend their own money on health care. Increasing deductibles for health insurance, while also increasing premiums and limitting choice of service providers, is how we weaponize sick people in the war against rising health care prices. If enough diabetics choose to die rather than overpay for insulin, prices for the drug will surely go down eventually, because Southwest Airlines will come up with a disruptively innovative version of insulin that will not be as fancy, but it will be cheap enough to spur increased market participation and push Eli Lilly into bankruptcy. Any day now.

The return to pre-1965 days of consumerism in health care for the first $6,000 of medical expenditures was a good step forward, but the road to fully optimized profitability is long and full of terrors. Consumers are like goats. If left to their own devices, they will destroy your landscape in five short minutes. However, with proper guidance and supervision, they will clean and protect your property from the dangers of random wild fires. Managed Care insurance plans, coupled with high deductibles, ensure that consumers do not eat into your nice profits, while consuming enough garbage to keep your bottom line from going up in smoke.

From Volume to Value

Offloading risk to sick consumers is working relatively well by all accounts, but it is not working well enough, and it is not working for beneficiaries of public insurance where the consumer lever is rather short and limp. And so, we push the “provider” lever next. Once patients became consumers, their doctors, naturally, became providers. And just like empowered consumers, empowered providers should have some financial skin in this game. In the current system, you see, providers are just sitting there, placidly watching the register go cha-ching every ten, fifteen minutes like clockwork. If the consumer gets better, fine. If not, also fine. As long as there are no malpractice lawsuits, and the cash keeps flowing, providers are surely satisfied. How do policy makers and garden variety health care experts know this? Simple. It’s called projection.

Moving “from volume to value” does not mean moving from indiscriminate overconsumption to eclectic consumption of excellence. It means moving from lots of variably priced stuff to small amounts of cheap stuff. It means moving from assumed abundance to assumed scarcity. If you can find excellence at the Dollar Store, good for you. If you can’t, well, whatever. Saks Fifth Avenue is out of bounds. And your provider is supposed to enforce those boundaries, at his or her own risk. If you manage to sneak into Saks, your provider will be punished. If you stay where you belong, your provider will be rewarded. Simple. It’s called stewardship.

Global Budgets

This is not fair. Obviously. These very clever risk levers are based on wealth, and since we have massive wealth inequality, the levers are largely discriminatory. Wealthy providers couldn’t care less about adding or removing a dollar from each patient visit. Poorer providers can be driven out of business by a fifty cents difference in “reimbursement”.  Wealthy patients don’t have to become consumers at all. For patients who are not wealthy enough (or poor enough), even the Dollar Store is cost prohibitive. There is too much privilege at the top. The only fair solution is to shut down Saks Fifth Avenue completely. If everybody is forced into the Dollar Store, eventually the Dollar Store will get better. It will become as good as Saks, but at $1 prices, because the wealthy will demand it. Right. 

Shuttering the Saks Fifth Avenue of health care is hard. You can’t just show up at Bayonne Medical Center one morning with a wrecking ball and have at it. Fortunately, the Medicare For All aficionados have a solution: Global Budgets. Once the Federal government controls all health care dollars, they give Saks Fifth Avenue a fixed amount of money to service all their customers for the year. The amount of money is calculated based on Dollar Store costs, with a little markup perhaps, so we don’t appear overly vindictive. Within a few months, you won’t be able to tell the difference between a Saks store and a Dollar Store, except maybe the crumbling façade from a bygone era. That’s how we rid ourselves of inequality and excess privilege, of course.

Remember when Paul Ryan and his evil acolytes proposed replacing the open-ended Medicaid financing model with block grants to States (i.e. fixed amount of Federal money to service all their Medicaid beneficiaries)? There is a one hundred percent overlap between the people who screamed about millions dying in the streets if Medicaid moves to block grants, and the people now climbing the Medicare For All barricades in support of global budgets. Rationing medical care for the poor, or “by ability to pay”, is immoral. Rationing medical care for everybody, regardless of ability to pay, is righteous. Simple. It’s called justice.

A Permanent Solution

It is not surprising that health insurance companies would look out for their bottom line at customers’ expense. After all, these are insurance companies, like home insurance or car insurance, which are notorious for continuously devising innovative ways to minimize current and future payouts. Perhaps it is also not too much of a shocker to see that government is at its best when working to eschew commitments made to its citizens. What should however give you pause is that both government and health insurers seem to have finally found a good way to coopt physicians into doing their bidding. Not all physicians, of course, but more than enough to make a permanent difference in the practice of medicine. Either due to misplaced fear or newfound conviction, your doctor’s prime directive now is to do no harm to the United States Treasury and the corporations for which it shills.

Saturday, April 27, 2019

The Medicare For All Heptagon

I am going to make a prediction here. No matter who we elect in 2020, Bernie or Trump or anything in between, Medicare For All is not going to happen in America. One can run an electrifying campaign on the promise of Medicare For All, or indignantly against it, but this is pure theater on both sides. I don’t know if God can make a rock so big and heavy that even He can’t lift it, but I do know that government can make corporations so big and powerful that even government itself can’t break them.

For decades our government encouraged the health care industry to consolidate vertically, horizontally and obliquely so it can achieve “economies of scale” and therefore lower consumer prices. In the last couple of decades, the government also compelled the industry to computerize its operations, because technology makes everything better and cheaper. Once the resulting monopolistic behemoths were summoned into existence, it was time to nationalize the whole lot, into one super monopoly, with super technology and super economies of scale. The only other example of such government monopoly in America is the Military.

Obviously, our standing armies must be, by definition, a national monopoly, but note that the Navy is not building its own ships and the Air Force is not building its own planes and the Army is not manufacturing tanks. The government is contracting with private suppliers for pretty much everything, from butter to bullets. The Military Industrial Complex is a network of very large and utterly corrupt contractors for the government, yielding more power over foreign and fiscal policy than Congress, the President, and all citizens put together, while delivering practically nothing either on budget or on time. A powerful Military is essential to America’s safety and global success, so we grind our teeth and keep paying. And medical care for hundreds of millions of people is at least as important.

I am not entirely sure how people think Medicare For All is going to work. Are you folks envisioning an angry President Bernie dragging Samuel Hazen into the Oval, wagging his finger at him and making an offer Mr. Hazen cannot refuse? Something like, “I will pay $50 per head and not a penny more, because health care is a human right, and if you want to be a disgusting millionaire or billionaire, go write a bestselling book, like I did…”, at which point Mr. Hazen will be hanging his head down in shame and gratefully take the $50 deal. Upon his return to Nashville, Mr. Hazen will immediately schedule book writing workshops for all HCA department chiefs to compensate for cutting all salaries in half. Yeah… no, that’s not how this works.

Go ask Northrup Grumman or Lockheed Martin or General Dynamics or even Boeing or Booz Allen or any other “beltway bandit” how getting money from the Feds really works. There are well-greased revolving doors between the Pentagon and its contractors. There are stock options and executive positions for high ranking Federal employees. There are 535 people in Congress responsible for allocating budgets, and all 535 are for sale. Most of this infrastructure is already in place for health care too and building the HHS Heptagon shouldn’t take very long. The American President has little to no power over Federal spending, and even less so when it comes to large procurement contracts, as the current occupant of the White House discovered the hard way, during the Lockheed F-35 kerfuffle.

Clearly large health systems will survive and thrive under a Medicare For All law, but how about private health insurance? Future President Bernie says they will all be banned. Is that so? Currently a full third of Medicare beneficiaries are insured and “managed” by a handful of large private health insurers. Medicare is paying those private contractors fixed amounts of money per head for their services. Medicaid is doing the same for most of its beneficiaries, and all military health insurance (TRICARE) is contracted out to the usual suspects. Basically, the vast majority of people covered by public insurance, are really insured by gigantic insurance corporations. Fact: under the hood, taxpayer funded health care is the bread and butter of private health insurance companies.

When future President Bernie and the hordes of uninformed supporting characters in the 2020 elections festival say that private health insurance will be banned, they are lying to you. What will be banned under a Medicare For All law, is your ability or your employer’s ability, to purchase health insurance directly from a private company. Instead, the government will procure contracts in bulk as it sees fit, assign people to them as it sees fit, and pay for these contracts with tax revenue as it sees fit. Just like they pay for battleships, fighter planes, bombs, tanks and such.  The United States Military is known for lots of great things. Value-based purchasing, and cost-effectiveness in general, are not among those things.

Depending on who you ask and what is included in the definition of health care, Medicare For All is projected to cost between three and four trillion dollars per year, which is five times the amount we spend on the Military. This number is calculated based on costs under current law, minus the waste generated by the cacophony of hundreds and thousands of different insurance plans, different health care facilities and their too many to count service and product vendors. The projections do not include the effects of the inevitable massive consolidation of everything health care into a dozen or so Federal contractors, able and willing to demand multi-billion dollars contracts for services worth a few million dollars at most on the open market. Remember the Obamacare marketplace website? Multiply that by orders of magnitude and you have Medicare For All.

Medicare For All is as egregious a misnomer for this plan as the Affordable Care Act was. When they say Medicare For All, they mean Federal government procured health insurance for all. When they say everything soup to nuts will be covered, they mean everything the heavily indebted Federal government thinks should be covered, and can afford to cover, will be covered. When they say health care will be better, more plentiful and much more affordable, they mean please vote for me in 2020. Medicare For All will be built on the largely immovable foundation our government chartered and nurtured for half a century. If you want a glimpse into a Medicare For All future, go look at any Medicaid Managed Care plan in any impoverished southern State, and look at the balance sheets of the associated contractors and sub-contractors.

It doesn’t have to be this way. We don’t need to bulldozer everything we have, and we certainly don’t need to pretend that we can, or that we must. And we need to remember that the proper role of government in a free country is not to manage the health or the care of all its citizens. Free people are not the wards of a State responsible for keeping them healthy, productive and happy. The role of a democratic government is to keep predators, foreign and domestic, including corporate ones, at bay, while providing a sturdy safety net for the few who cannot care for themselves. Let’s do that instead. It will be better, faster and cheaper than the fictional construct called Medicare For All.

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.