Is Trumpcare Dead? Was It Ever Really Alive?

Is Trumpcare Dead? Was It Ever Really Alive?

Senators Mike Lee and Jerry Moran said yesterday that they would not vote for the Better Care Reconciliation Act, effectively killing the legislation.  As anybody who has been following this story would have predicted, President Trump reacted publicly on Twitter on Tuesday morning, vowing to let the ACA marketplace collapse and then rewrite the plan later.

Senate Majority leader Mitch McConnell attempted a quick punt this morning, calling for an immediate Senate vote on the House bill, a trick card that if it worked, would give Republicans two years to work things out.

Unfortunately for McConnell, it probably won’t.

The White House sees the failure as saying more about the political establishment in Washington than itself, which shouldn’t be all that surprising. Caught up in the drama of the Watergate-Russia emails-Trump family narrative, major media outlets like the Washington Post and the New York Times see a historic defeat rather than a temporary setback. That may or may not turn out to be true. Predictably, conservative commentators and the alt-right believe the defeat says more about the mainstream media and the Deep State than it does about the Trump Presidency. For their part, Democrats clearly think they have found their issue and can be expected to continue to exploit it using legislative Viet Cong tactics (attack on social media, melt into the jungle, lob snarky public Molotov cocktails) to punish Republicans and keep the story on the front page.

One thing is clear. Instead of repealing and replacing Obamacare, the GOP now has to rewrite and replace its own plan. Doing that would be difficult under the best of circumstances, but in the current climate in Washington it is difficult to see how it would be possible without a major shift in the political landscape.

All of this is bad news for hospitals and health plans and a frightening development for consumers, although not the really bad news some had feared. The President’s threat to let the insurance marketplace die and then “figure it out” sounds good as a rallying cry to the troops on social media, but is not the kind of thing that investors and CEOs like to hear.  Realistically though, at this point everybody knew that the uncertainty would likely continue through the year (best case) or a year or longer (worst case) as the gridlock in Washington plays out. As depressing and frustrating as it is that the uncertainty will continue, by this point the industry is used to it. Insiders will continue to look for ways to minimize risk and for business opportunities to capitalize on the uncertainty.

Trump’s plan to allow the insurance exchanges to collapse is the kind of confrontational talk Trump and his advisors relish. In theory, the idea could work. There are in fact signs that it already is, as major insurers leave the marketplace and consumers hesitate before committing to expensive insurance policies.  In reality, however, the collapsing exchanges will create a political crisis that is even worse than the current one for the administration, with news cycle after news cycle dominated by stories of terminally ill cancer patients and parents with children with horrible diseases and no insurance coverage. At this point, it will be difficult for the party doing the collapsing to point at the other side and say “It was them. They did it!”

Moderates see some sort of brilliantly crafted compromise as the obvious solution. In any place and time other than Washington in the year 2017 that would probably be the case. Unfortunately, despite what you’re hearing, it probably isn’t going to happen. Extremists on both sides are unlikely to accept anything less than complete and total victory.  With the President on hand to reliably blow up negotiations with ill considered tweets and taunts, all of the pieces are in place to ensure that the  healthcare reform story continues season after season.

If you are a person with a serious pre-existing condition or somebody facing a life threatening health condition, you can be forgiven for feeling extremely unwell right about now. Will you be able to pay for your drug prescriptions next year? Will you even be able to buy insurance coverage next year?  If you are able to buy insurance, will that insurance coverage be worth the paper it is printed on? If by some miracle, you are in fact able to buy insurance coverage, will some insane person take it away from you at some later date in time?

John Irvine is the editor of the Health Care Blog. He can be followed on Twitter at @thcbstaff. He can be reached by email at

Regulatory Capture Tests the New Administration

Regulatory Capture Tests the New Administration

The bipartisan 21st Century Cures Act charges HHS / ONC to deal with two issues that previous laws (HIPAA and HITECH) and the Obama HHS left in-progress: information blocking and longitudinal health records. ONC needs to deal with these two issues at a time when there are calls to delay or rescind some Meaningful Use regulations, in an administration that does not favor regulations, with some vendors already starting to ship Meaningful Use Stage 3 EHR products, and while the budget for ONC is still undetermined. ONC can’t be too careful.

Judging by the agenda, the July 24 21st Century Cures Act Trusted Exchange and Common Agreement (TFCA) Kick-Off Meeting is a step in the wrong direction. Listening to the “health IT stakeholders” is a prescription for advancing the interests of the health IT stakeholders instead of dealing with patients and physicians as the stakeholders. Framing the issue as “National Trust Frameworks and Network-to-Network Connectivity” is a recipe for continued ineffective interoperability as the “stakeholders” line up for another round of regulations that promote rent-seeking middlemen with catchy names like Direct Trust, and CommonWell.

National trust frameworks work when the institutions being trusted are fairly uniform, like the banks participating in money transfers or police searching law-enforcement databases. But healthcare institutions are way more diverse than banks or police departments. Some, like a psychiatrist’s practice or a small group are hardly institutions at all. Patient-centered care means networking institutions as diverse as a mom-and-pop long-term-care facility and the massive VA hospital and Medicare bureaucracy. Patient-centered care must support family caregivers like me, trying to keep my 91-year-old mom from becoming somebody’s procedure. Patient-centered care means we have a plan for longitudinal health records as an outcome rather than attempting to regulate technological process like “network-to-network connectivity”.

“National Trust Frameworks and Network-to-Network Connectivity” for the first high-profile ONC meeting is a framing that continues the failed policies that brought us state health information exchanges, DirectTrust, and other uninvited middlemen to the physician-patient relationship.

Interoperability and longitudinal health records are an outcome sought by physicians and patients. When a patient says to a provider: “Please allow X to access all or part of my record via the Meaningful Use API until I say otherwise”, the patient is exercising a fundamental right regardless of who or what X is. (API =Application Programming Interface) There is no role for a trust framework in patient-directed exchange. There is no need for coercive patient identity matching in patient-directed exchange. There is effectively no cost to the patient in patient-directed exchange via API. There is no legal basis for information blocking in patient-directed exchange via API. Just like a patient giving a provider a postal address to send records to, it just works, and the provider doesn’t get to say: “I don’t trust that address, so I’m blocking this request.”

Longitudinal health records are enabled by patient-directed exchange because the patient is able to tell any of her providers: “Let X access my health record.”, where X is a longitudinal health record service that the patient has chosen. X could be a primary care doctor, a web service, or even an artificial intelligence like IBM Watson. Various doctors, service providers, and institutions could decide for themselves whether to access a longitudinal health record at X and if they decided that they don’t want to use X the patient might go elsewhere. This is no different than a merchant deciding to accept American Express or ApplePay. They have a right to decline the customer’s choice but they risk the customer going to another provider if they do.

But is there a need for interoperability that is not directed by the patient? Surely it’s convenient if a doctor can just ask around for who might have records about a patient without bothering the patient to remember them all. This is similar to what police do when they stop your car. They ask you for some identifying information and go poke around various databases to see who might have some information about you. Police access the various databases on the basis of their role whether you like it or not. The police don’t tell you where they are accessing your information and they don’t need your permission to access it. The police and the databases they are allowed to access are part of a trust framework. It’s more or less a national trust framework. It’s definitely useful. It’s also coercive. It also means that people might not trust the police, a problem that police often cite with regard to serving undocumented people. There’s that patient ID thing again.

Medicine is not law enforcement and caregivers are not the police. Assembling large databases of patient records and then managing access on the basis of trust frameworks creates an illusion of interoperability, as nationalized health systems like the UK NHS have shown. It may seem more efficient than asking the patient: “Where can I find your health records?” but it’s bound to fail because the participants in medical interoperability are much more diverse than police.

If not a police analogy, then maybe the trusted intermediaries are like the three credit bureaus that help merchants figure out where a person has credit relationships without asking the person to list their current relationships. That’s a good model for driving interoperability toward a valued outcome (credit) and a good consumer experience (don’t ask me for a list of all my relevant accounts). Merchants are supposed to ask for permission before requesting your credit report from a very limited number, three, of regulated intermediaries. But there’s no trust framework like the mythical one in healthcare because the merchants don’t get to take that credit report and ask the various banks and other merchants listed for more details about you without explicit and separate authorization, for example, auto-pay. So yes, there are reasons to introduce trusted and regulated intermediaries into the interoperability solution but they need to be in the service of a specified outcome, like credit, and the person still gets to decide if the merchant-to-merchant link is authorized, like auto-pay, on a case-by case basis regardless of any trust framework.

It’s time for ONC to treat patients and their caregivers as the primary stakeholders in health information interoperability. Let’s focus the new ONC on patient experience and outcome. Trust frameworks are not a solution to either information blocking or longitudinal health records. The July 24 meeting could be a good place to start but I don’t see either patients or physician advocates on the agenda – just would-be middlemen looking for regulatory capture.


The Most Important Questions About the GOP’s Health Plan Go Beyond Insurance and Deficits

The Most Important Questions About the GOP’s Health Plan Go Beyond Insurance and Deficits

Ending healthcare for those who need it will not make them or their problems disappear. On the contrary, the GOP plan will shatter American families and the economy. Nothing magical happens if we stop caring for the elderly, the ones who need vaccinations, the small infections that can be treated for $2 worth of antibiotics, the uncontrolled diabetics, and those with contagious diseases who clean our schools’ offices and homes. They don’t just get healthy.

As George Orwell said in Down and Out in Paris and London, “the more one pays for food, the more sweat and spittle one is obliged to eat with it.” Cutting care only exacerbates illnesses, infection, disability, the effects of age and the costs to society. The burdens continue or increase but the cost is shifted to American families, businesses, and states.

Fifteen years ago, one of the authors showed that lost productivity from workers caring for Alzheimer’s patients cost US businesses over $60 billion a year. Employee-caregivers, usually at the peak of their responsibilities and corporate experience, quit, prematurely retired, were constantly distracted, or engaged in presentism (e.g., at work but focused on mom burning down the house). Business cost were incurred by the need to replace workers, extra training of replacement workers, and increased pressure on other workers to cover for caregivers. The more expensive the employee, the longer and more costly the search and the longer the time to get them up to speed. But that study examined just a miniscule number of patients and workers compared to the tens of millions of people affected by the proposed GOP bill. As noted, it’s not only those needing care, but our society and our families that must deal with the elderly, ill, disabled, under and uninsured, children not receiving even ordinary care, people not being screened for preventable illness, and countless others.

Extrapolating from Koppel’s tiny study to the US population and businesses reveals the GOP bill will cost the nation trillions of dollars in losses and extra costs. It will devastate state budgets, and explains why GOP governors are among those leading the resistance.   Consider these facts:

  • Most every nursing homes (SNF— Skilled Nursing Facilities) depend heavily on Medicaid, the program that will face the largest cuts by all of the GOP plans. What will happen to the millions of our elderly, disabled, and infirm? The lawns and parks of Washington DC and the 50 state capitals could hold only about 5% of them, where, of course, they would die without care.
  • 75 million Veterans receive care via Medicaid. In fact, less than half receive care via the VA health system because some don’t qualify for various reasons or live too far from a VA facility to for primary care.  Many vets instead rely on Medicaid. Over thirty states and the District of Columbia chose to expand Medicaid to cover more people — especially veterans.
  • Ironically, while President Trump campaigned on a pledge to force lower drug prices, the GOP plan gives greater freedom to drug companies to set prices. Freeing the FDA to accept less rigorous clinical trials on medications and medical devices is supposed to lower costs. Drug and device companies will be given greater latitude to define “proxy end points,” a term that means they don’t have to really show the drugs’ or devices’ long term effects, e.g., if a drug is shown to shrink cancer tumors after, say, 2 months, the company need not continue the trial for another 9 months—where there’s a good chance it might show the tumors return, or the drug fails, or that the drug or device harms patients through other means. More directly, getting products to market with less testing does not lower the prices of drugs that have been on the market for years and are now being up-priced by a few thousand percent—which is the case with many of the recent pricing scandals. In fact, the GOP committees on drug pricing just cancelled hearings.
  • Hospitals and medical schools depend on many of the programs cut by the GOP plan. The Association of American Medical Colleges(AAMC) “predicts that the United States will face a shortage of between 40,800-104,900 physicians by 2030.”   Cutting training and research dollars will not increase the number of doctors or the good they can accomplish. While about 5,000 doctors offer concierge medical care for fewer than one million family members of multimillionaires, that will leave the remaining 319,000,000 of us scrambling for care. Googling “WebMD” is not a substitute for health professionals.
  • This GOP bill forged a rare unity among medical societies, addiction physicians, hospital associations, nursing homes, and almost anyone else involved with healthcare. In contrast, big Pharma and the medical device companies win regulatory freedoms and tax cuts. They seem less hostile to the bill.
  • Not providing birth control will mean millions of more abortions and unwanted babies. Those children born will not disappear, but rather will need care to become productive members of society. This is an additional burden on the American public and taxpayers.
  • The largest growth area in the US labor force was and is healthcare. There are about 13 million healthcare workers in the USA, of which about 3 million are nurses, 800,000 are physicians, the rest are pharmacists, technicians, respiratory therapists, nurses’ aides, etc. In contrast, there are only about 15,900 miners in the entire USA who are involved with extraction, mining machine operations or earth drillings. Mining jobs have declined for decades because of extraction technology (e.g., mountain top mining and bigger drilling machines), natural gas, pollution concerns, etc. In contrast, even in mining communities, it’s often healthcare jobs that are available. Cutting healthcare jobs is a surefire way to increase unemployment. It will destroy entire communities. Even West Virginia has about 81,000 healthcare workers whereas it has only a few thousand active miners.
  • Finally, returning to the costs borne by businesses and society: People denied healthcare are more likely to need caregivers. In 2015, the average age for caregivers was about 49 years old, 85% of which provided care for a relative. 60% of caregivers were employed within the last year while they provided care to someone, while 56% of them worked an average of 34.7 hours per work. 43.5 million adults “provided unpaid care to an adult or a child.” Many caregivers are still at an age where they must work, are forced to make accommodation with their jobs, and their extra labor receives no monetary compensation.
  • The caregiver role is seldom short-term: “three in five care recipients have a long-term physical condition (59%), more than a third have a short-term physical condition (35%), and a quarter have a memory problem (26%).” The unforeseeable end to their role as a caregiver creates a twofold effect on them as their labor remains unaccounted for in the GDP. Unpaid family caregiving costs the nation approximately $470 billion in 2013. For Walmart alone (not exactly the company with the highest paid workforce) the economic value estimate totals more $477 billion.

Offering poorly designed or no health insurance to Americans will not make their problems disappear. Instead, we are left with more costly health problems. Sicker Americans, in addition to paying incomprehensibly large medical bills, will be forced to exit the workforce early–increasing financial burdens on business and families.

Perhaps most important, the GOP plan copies Obamacare in not really confronting healthcare prices. Instead, it only denies insurance, allowing largely unchecked the dizzying array of prices. As Bret Stephens writes, the same blood test in California can vary from $10 to $10,169; a lower back MRI in the USA can range from $199 to $6,221. A more dramatic comparison is the cost of care in the US vs. other nations, where US costs are usually 3 to 5 times higher. In the US, average angioplasty prices are $31,620, whereas in the UK, they are $7,264.

The CBO looked at the loss of insurance and the transfer of wealth to the super rich–both staggering. Yes, there were some deficit reductions from denying healthcare to millions. As we try to show here, however, even those “savings” will backfire horribly for the American government, our citizens and our economy. Neither we nor the CBO address the inhumanity implicit in the proposal health plans. For that there are other metrics.

Ross Koppel is a professor at the University of Pennsylvania. Yasmine Martinez is a senior at Vassar College.

Which Is More Efficient: Employer-Sponsored Insurance or Medicaid?

Which Is More Efficient:  Employer-Sponsored Insurance or Medicaid?


An old disagreement between Uwe Reinhardt and Sally Pipes in Forbes is a teachable moment. There’s a dearth of confrontational debates in health policy and education is worse off for it.

Crux of the issue is the more efficient system: employer-sponsored insurance (ESI) or Medicaid. Sally Pipes, president of the market-leaning Pacific Research Institute, believes it is ESI. Employers spend 60% less than the government, per person: $3,430 versus $9,130, per person (according to the American Health Policy Institute). Seems like a no brainer.

Pipes credits “consumerist and market-friendly approaches to health insurance” for the efficiencies. She blames “fraud,” “improper payment,” and “waste” for problems in government-run components of health care.

But Uwe Reinhardt, economist at Princeton, counters that Medicaid appears inefficient because of the risk composition of its enrollees. Put simply, Medicaid recipients are sicker. Sicker patients use more health care resources. Econ 101.

The points of tension in their disagreement are instructive.

Is ESI free market?

The term “consumerist” instinctively appeals to competition and choice, elements we value in free market. However, health care can’t be compared to shopping for single malt in airport duty free, deciding between Talisker 18 and Glenlivet 21.

ESI is hardly an assortment of private units functioning autonomously and competing with each other. ESI has been carved by so many regulations that the government figuratively runs through its veins.

Do you wonder why insurers in ESI don’t surcharge a family with a child with Tetralogy of Fallot? That is increase their premiums astronomically or deny coverage because of a pre-existing condition.

Goodness of heart? No, it’s because of the government.

This means that young fit joggers are subsidizing the costs for the unfortunate child’s complex cardiac surgery. Insurance is redistribution.

Risk adjustment: Comparing apples and oranges

Failure to adjust for comorbidities makes it difficult to make comparisons in quality, value and performance.

Not only are Medicaid enrollees sicker, they are poorer and less empowered. A priori they are a more inefficient group to deal with than the employed middle class.

I’ll hazard a guess that Sovaldi (medication for hepatitis C) won’t increase Microsoft’s health care bill as much as the state of Illinois’. One, of course, would not credit Microsoft’s cost savings to greater efficiency through clever free market insurance design.

However, in policy discussions comparisons between apples and oranges are commonplace.  Life expectancy and infant mortality are used to compare U.S. health care to countries such as Cuba or France, when adjudicators well know, or should know, that there is more nuance. Using metrics which can be affected by social determinants of health is misleading.

Is Medicaid an island?

There are no islands in health care.

It’s important not to make the same logical errors with Medicaid as with ESI.  Medicaid is not an autonomous government unit. Its recipients aren’t sent solely to safety net hospitals. For most parts Medicaid recipients share the same system as folks on ESI; a system which, arguably, has been sculpted by ESI, for better or worse.

This means there’s interdependence between ESI and Medicaid, or between a government-regulated/ government-subsidized system and a government-regulated/ government-funded system.

Interdependence would be suggested by cost shifting, where costs of seeing Medicaid patients are shifted to ESI. Even if there is no convincing evidence of cost shifting, as Reinhardt cautions but Pipes disagrees with the caution, this interdependence is not diminished. Providers, or hospitals, might happily see Medicaid patients knowing they can still enjoy good returns from ESI, without purposely shifting costs to ESI, or other forms of insurance.

Politics, Ideology and Medicaid

Medicaid is more than a system of reimbursing physicians. It has become an ideology. Any criticism of Medicaid leads to the unfortunate conclusion by some well-intentioned individuals that the purpose of critique is to send the poor to workhouses and let them die – de facto eugenics. No rational discussion can be had when people shout “Republican reforms kill.” The mob clouded the judgment of Pontius Pilate – and that was before Twitter.

Good intention does not mean access, though. Medicaid recipients have a problem of access. This is because Medicaid pays providers far too little whilst simultaneously imposing far too much red tape. Poor access is fiercely countered by some policy analysts and their fierce counter is fiercely countered by practicing doctors who actually see patients on Medicaid.

Regardless, paying providers the least when caring for the sickest, poorest and most disenfranchised section of society does no favors to that section of society.

Medicaid pays a cardiologist, with years of training, $25-40 for a consultation to manage a complex patient with multiple comorbidities, on polypharmacy, where the cardiologist must indulge in shared decision making and also ensure the patient adheres to statins.

For comparison, my personal trainer charges me $80. There’s no shared decision making – he tells me to do “burpees” and I must abide or face his wrath.

Serve and volley at the margins

Both Reinhardt and Pipes cite several studies supporting their point of view. One wonders whether policy wonks truly can form opinions solely from evidence since it’s so easy to cite evidence to support one’s prior convictions and subconsciously disregard or criticize the methodology of studies which refute our convictions.

For example, outcomes are often used to adjudicate the efficacy of treatments and healthcare systems, and the same constituency which flags poor outcomes when comparing the US healthcare to Sweden’s asks that these outcomes not be used to assess the efficacy of Medicaid. I agree with them as strongly as I disagreed with their use of life expectancy to judge American healthcare.

Disagreements are common because economics is not a hard science such as physics. It does not so much get us to the objective truth as it does to the action at the margins through methodology that is not as robust as the physical sciences, yielding different results on different occasions.

Who is correct, Reinhardt or Pipes?

In a sense both.

Reinhardt is right. Medicaid recipients are not the same as those enjoying ESI.

Pipes is right. Medicaid has structural issues. It pays physicians too little compared to ESI.

This begs the question which reimbursement corresponds to the fair market price in health care: Medicaid or ESI. We will never know because health care has not operated as a free market, and never will. And ESI does distort the price signals as do mandates and virtually everything else.

But here is the important point: ESI is going nowhere. Neither the most left-leaning Democrat nor the most right-leaning Republican has the courage to rid health care of ESI.

What’s the objective truth? Which system really is more efficient?

The truth lies in the answer to this: Would ESI deliver the level of care enjoyed by ESI recipients with paucity of cost sharing that Medicaid recipients face to Medicaid enrollees at a lower cost than Medicaid?

For Medicaid recipients cost sharing should be zero otherwise it defeats the purpose of a safety net. But remember we want them to have the same level of care as ESI for a true apples-apples comparison.

It’s practically impossible to conduct a randomized controlled trial to answer this question. Nor does empiricism suffice. All quantitative analyses have assumptions. With regards to assumptions I can do no better than paraphrase Groucho Marx: “Those are my assumptions, and if you don’t like them … well I have others.”

Importance of disagreements

The current system does not have many genuine alternatives. Single-payer is out as is a genuine free market. As politicians don’t wish to talk about costs because of political expediency, all we are arguing about is which part of health care has the most administrative cost/ informational loss. This is at best a marginal argument. To resolve this argument I would encourage more dialectic between partial truths.

But if Medicaid truly is a high risk pool, and I believe it is, then it should be treated as the other high risk pool – Medicare. Which means that the poor and sick, the uninsurable, should be covered by the Federal government through general taxation. I would suggest a “Medicare for the Poor” which offers the same benefits as traditional Medicare. This would allow the states to balance their budgets better and concentrate on local infrastructure, such as parks, police and public libraries.

Summary of key points

  1. It’s more cost-efficient treating healthier patients.
  2. Accurate adjustment for comorbidities and social determinants of health is key for any comparisons in health care. This is (never) seldom achieved.
  3. There’s interdependence between employer-sponsored insurance and Medicaid.
  4. No one knows true market prices in health care because it’s not a free market.
  5. Economic analysis yields information about the margins, until the next analysis.
  6. The poor should be covered by the Federal government through general taxation.

About the Author:

Saurabh Jha is a contributing editor to THCB. He can be reached on Twitter @RogueRad




The Entertainment Presidency: A Primer For Health Care Professionals

The Entertainment Presidency: A Primer For Health Care Professionals

Many physicians have expressed dismay at the conduct of US president Donald Trump.  But whether colleagues find his politics objectionable or congenial, his conduct bold or vulgar, and the man himself an imbecile or a genius, it is important for healthcare professionals to understand that the Trump presidency is a predictable consequence of our times.  In particular, it is an entirely natural outgrowth of the forms of media that characterize our age.

The Medium Becomes the Message

In 1964, media theorist Marshall McLuhan famously declared the medium the message.  McLuhan argued that the consciousness of a people is more profoundly shaped by media themselves – for example, Gutenberg’s movable print, radio, or television – than by the content they convey.  To understand the character of a presidency, McLuhan would argue, we need to shift our attention from specific policies to the media by which the president operates.

When candidates Abraham Lincoln and Stephen Douglas engaged in their famous 1858 debates for an Illinois Senate seat, broadcast media had not yet been invented, and the newspaper dominated.  As print media, newspaper articles could examine a candidate’s position on an issue in great depth, and 19th century debate audiences expected candidates to develop real arguments for their policies.  As a result, each of the Lincoln-Douglas debates was formatted to last three hours.

Today’s media prefer sound bites.  In fact, McLuhan argued that the medium of television operates “at the speed of light.”  It permits “no continuity” and “no connection.”  Instead, he said, with television, “It’s all just a surprise.”   In contrast to the time Lincoln took to carefully craft his arguments, a television president might be expected to rely less on argument than on astonishment, not taking the time to trouble himself over non-sequiturs and contradictions.

Those baffled at Trump’s trajectory must concede that he has mastered the media of our age, especially television.  He became a national media phenomenon largely through his role on “The Apprentice,” where he starred between 2004 and 2015, and from which he boasted that he had earned $214 million.  It has also been widely reported that Trump relies far more than any of his predecessors on television as his principal window on the world.

McLuhan predicted that television would breed a culture of spontaneity and impatience.  He likened the situation to the left and right hemispheres of the brain.  The left expects everything to be “connected, logical, and goal-oriented.”  But the ascendancy of television brings a shift to the right, which makes “the old left hemisphere world, which is our educational and political establishment, look very foolish.” 

A television president might look foolish to the traditional educational and political establishment, but he might also make those establishments appear foolish to a television-saturated public.  The modus operandi of such a president would be not reasoned argument, for which the medium of television has little tolerance, but the creation of associations, in much the same way that an advertiser might brand products.

Statecraft Becomes Show Business

This point was amplified by another media theorist, Neil Postman, who contended that television is a supremely visual medium that rejects ideas.  In his 1985 book Amusing Ourselves to Death, Postman argued that “It is in the nature of the medium that it must suppress the content of ideas to accommodate the requirements of visual interest; that is to say, to accommodate the values of show business.”

In effect, Postman carries McLuhan’s central point even further, arguing that the medium becomes not just the message but our “dominant means for construing, understanding, and testing reality.”  Recognizing that appealing to the emotions of the television audience is far more important than any rational argument, and that the medium is suited to nothing better than entertainment, a television president would naturally emphasize show over substance.

What would a generation of viewers – or even a second or third generation – reared on television expect from its president?  To answer such a question, we need but imagine a person who has read little but watched a million television commercials.  Such a person, Postman wrote, would “expect political problems to have fast solutions through simple measures,” and would think that “complex language is not to be trusted” and that “all problems lend themselves to theatrical expression.” 

Twitter Becomes Twaddle

These liabilities are only amplified when we consider what would likely constitute an entertainment president’s preferred medium for messaging: Twitter.  With a 140-character limit on tweets, such messaging richly rewards the ability to further simplify the message, placing an even greater premium on what entertains, or even better, outrages.  The goal is not so much to inform or persuade but to grab and keep tight hold of the public’s attention, at which Trump has exceled.

At the core of McLuhan’s and Postman’s critiques lies a charge of immaturity that could also be leveled at a Twitter presidency.  Both men died before Twitter was invented, but they would likely echo journalist Clive Thompson’s 2008 assessment that the new medium has elevated narcissism to “a new, super-metabolic extreme – the ultimate expression of a generation of celebrity-addled youths who believe their every utterance is fascinating and ought to be shared with the world.” 

No one can predict with certainty the ultimate verdict of history on the entertainment presidency.  We can, however, characterize with great confidence the irresistible effect of contemporary mass media on the messages transmitted to us through political discourse.  Some people hate Donald Trump.  Others love him.  But all health professionals can agree that he has high entertainment value, and given the media that dominate our age, such a presidency is all but inevitable.

Shopping For a Health Insurance Plans Again. Seriously? 

Shopping For a Health Insurance Plans Again. Seriously? 

On the golf course, my son Jason has an uncanny ability to hit any tree within earshot of his intended target line. It’s fait accompli in his book. And his reaction is always the same: “seriously!”

The same is his plight with health insurance. Though a self-employed healthy single male with a successful career and no need for government assistance in buying coverage, he just got this letter from his insurer:

“The last seven years within the health insurance market have led all of us to decisions we have never before considered. It has remained a very challenging environment as the debate over the 2010 Affordable Care Act (ACA) continues today.
At TRH Health Insurance Company, we have arrived at another critical decision point, which, unfortunately, will affect you. This letter (and the enclosed notification letter as required by the ACA) is our notice that we will not be offering plans in the non-subsidized marketplace in 2018. Your current plan remains effective through December 31, 2017.”

It’s the third time in five years he’s been dropped. Though paying his premiums dutifully and shrinking his coverage to reduce his monthly cost, his premium has increased more than 10% every year. And he’s healthy.

As the GOP Senate leadership weighs its options in moving toward a Repeal of the Affordable Care Act and its replacement, their greatest political risk is the potential that up to 22 million will lose their insurance coverage per the Congressional Budget Office’ most recent score. They have bet their political calculus on stories like Jason’s, one of 18 million in the individual insurance market whose premiums have skyrocketed. More than 8 million of these get a subsidy to buy their policy because their incomes fall below 400% of the federal poverty level. Those subsidies are likely to go away. For the rest, like Jason, it’s a crap shoot. Individual insurance plans that feature less coverage, narrow networks, high premiums, high out of pocket costs and the high likelihood the underwriter will cancel the policy the next year is standard fare. Or, they just choose to go without.

The July 4 recess gave Senate Majority Leader McConnell a week to tweak the BCRA to get the requisite 50 votes needed to pass a bill. Repeal of the individual mandate, major cuts to Medicaid programs and tax breaks for insurers, drug and device manufacturers and higher income households are still in. The proposed sweeteners fall into two buckets:

  • Bucket One: Changes to funding for special programs: To accommodate a few Senators, $45 billion to fund the opioid addiction program is being added and delays in cuts to Planned Parenthood are on the table.
  • Bucket Two: to accommodate insurers so they don’t raise premiums too high or exit the individual market altogether: the addition of a six-month waiting period on coverage for those who let their coverage lapse, allowing consumers to use funds from their Health Savings Accounts to pay their premiums, and a provision to allow states to determine their own medical loss ratio requirements for individual and group insurance plans.Stabilizing the individual market so people like Jason can get a plan that’s affordable and predictable is complicated. But these are the realities:

The regulatory constraints imposed by the Affordable Care Act on insurers are flawed. Medical loss ratio requirements of 80% for the individual market and 85% for the group market are too high, especially when coupled with elimination of caps on life-time limits, coverage of pre-existing conditions, inclusion of all 10 essential health benefits in every plan and age-rated risk bands set at 3:1 instead of 5:1 as plans had operated previously. Insurers are advancing some of the most innovative ways to address chronic disease management in innovative arrangements with providers, so lawmakers should revisit how they define “medical loss” (which is an unfortunate term to describe medical care). And the penalty for non-coverage is too low incent young invincibles to buy coverage. That’s why the marketplaces attracted more sick and older than the government’s actuaries expected. Coupled with higher administrative costs associated with individual health plans, it’s a non-starter for insurers. Tackling the individual market for insurers is only part of the issue facing insurers: flaws in the ACA’s oversight of insurance extend beyond the individual market.

  1. Insurers have no obligation to provide coverage to any segment in the population if it’s not profitable to their businesses. Insurance companies, whether investor-owned or not -for-profit plans like the 36 Blues operate in the interests of their owners. Even provider-sponsored health and co-ops have the same obligation: to spend premiums cautiously and cut unnecessary costs. All take risks in underwriting the plans they sell, adjust their premiums annually to cover medical inflation and utilization costs, modify coverage to reduce costs and purge their enrollments when higher-than-anticipated costs or utilization shows up in their claims data. The insurance business is complicated and risky. Like hospitals and post-acute providers, health plan operating losses are common, and margins are thin. But unlike hospitals, they can choose to cover who they wish and suspend services if they can’t make their numbers work. Hospitals don’t have that luxury.
  2. Americans want coverage but most don’t trust insurers. The majority of Americans associate coverage with access to physicians and hospitals they prefer and protection against personal financial ruin if they are in the 5% who experience an accident or contract a disease requiring expensive care. Most think insurance is too expensive and don’t understand why premium hikes are high across the board. Most think insurers will drop anyone who’s too risky or costly to the plan and most don’t see any difference between a plan sponsored by a medical group or health system and one owned by investors. Insurers know this: they struggle to make their cases to legislators, providing ample data to support their premium increase requests, denial policies and results of the population health programs they sponsor. But trust in health insurance companies is negative though the majority think coverage is necessary. Go figure. For lawmakers, satisfying the public’s growing aversion to escalating health costs and sensitivity to insurance premiums is not easy.
  3. Large Insurers have done well since passage of the ACA despite its flaws, while others have been hurt. Like other industries, scale is an advantage. While it’s difficult to access data about the financial performance of non-publicly traded health plans, financial data from the Big Five (Aetna, Anthem, Cigna, Humana and United who control 44% of the insurance market and have a market cap approaching $300 billion) show the advantage of scale. Since passage of the ACA, the market capitalization for each has more than doubled. EBITDA (earnings before taxes, interest, depreciation and amortization—a measure of operating profit) have steadily improved with recently stalled at Cigna and Humana and basic EPS (earnings per share) have improved annually for 4 of the 5. (See The Keckley Group analysis of financial reports from the Big Five for 2010-2016 below). All insurers have tightened their operations and lowered their administrative costs. Many have purged their plans of the riskiest populations precipitating decisions like withdrawal from the individual market and exchange marketplaces. Almost all have invested in sophisticated information systems and coding to optimize their rebates from the reinsurance pool (CMS announced Friday that 445 of 709 would get something back, and larger plans fared well). And most have diversified into non-insurance ventures to mitigate their insurance risks long-term. Example: in the June 19, 2017 Bloomberg Businessweek, United Healthcare Optum’s 3-page ad touts its capabilities in Data and Analytics. Pharmacy Care Services. Population Health Management. Health Care Delivery. Health Care Operations. The data show that plans with the largest enrollments have fared considerably better than others, in spite of the ACA’s flaws and current uncertainty about what’s ahead.

The bottom line is this: insurance as we know it seems destined for radical change. The largest plans seem advantaged by the uncertainty around the Repeal and Replace efforts in DC and they’ll be stronger and bigger. Smaller plans will not survive. Some will focus exclusively on Medicare and Medicaid managed care. Some will carve out certain populations of high risk enrollees. Some will transform themselves into diversified health services companies. And, for the foreseeable future, regardless of what becomes of the BCRA, they will raise their premiums above medical inflation because we’re getting older and the costs of our drugs, technologies and hospital stays are increasing.

This scenario puts lawmakers in a precarious position: by conceding to insurer demands of fewer restrictions on the policies they sell, they expose citizens to coverage that’s cheaper but less comprehensive. And eliminating the mandate to buy coverage means large numbers of healthy young adults might forego coverage, take their chances and pay the penalty. It’s an irony: Americans see the need for coverage but it leaves a bad taste in our mouths.

Jason and I talked about his situation. He’s compared notes with his buddies: they’re confused about their own insurance. Matt runs a successful business: he says he knows how to predict and plan for every expense in his business…except healthcare. Bret works for a big company: he’s counting on it to continue his family coverage and figure it out.  And Jason’s looking for a new plan but skeptical about his prospects. He doesn’t want or need a government subsidy and he doesn’t understand how the partisan rancor in Washington fixes anything. He’s too young to think about health issues everyday but he’s forced to think about it every year. Especially now that he’s another statistic in the displaced health insurance marketplace.

For Jason, having to find coverage and paying a higher premium for less coverage is like hitting trees on the golf course: it’s fait accompli. Seriously!


The Keckley Group analysis of financial reports from the Big Five for 2010-2016


Join Our Free Webinar About Advancements and Challenges in Patient Matching

Join Our Free Webinar About Advancements and Challenges in Patient Matching
Join Health 2.0’s Matthew Holt and Indu Subaiya in discussion with Adam Culbertson, Innovator-In Residence, HIMSS; Abel Kho, Associate Professor of Medicine and Preventive Medicine in the Feinberg School of Medicine at Northwestern University; and Tom Leary, VP of Government Relations, HIMSS. We’ll be talking about the challenges, such as technical and political hurdles to matching patients. Additionally, hear about current projects underway to advance this challenging problem.

Electronic health records (EHRs) offer the promise of improved healthcare coordination, lower costs, and improved patient safety. To achieve these benefits providers need to be able to share patient health information, and systems must be able to match patient data from disparate health data silos. Currently, mistakes in patient matching are a substantial contributor to adverse medical events, and correcting mismatched patient records can be as high as several hundred dollars per record. More important than monetary costs are the potential cost in human lives and subsequent legal cost due if a patient receives the wrong treatment. Given the substantive impacts poor patient matching can have on care delivery, population health analyses, and research, it is important for organizations to be able to quantify their patient matching algorithm’s performance and compare the results to industry standard benchmarks and performance metrics.
Click here to register for the free webinar on Wednesday, July 12, 2017, 10am PST.
We will be discussing topics like this at the at Health 2.0’s 11th Annual Fall Conference, which will be held on October 1 – 4, 2017, in Santa Clara, California.

Jill Merrigan is the Marketing Manager of Health 2.0.

The BCRA Is An Improvement Over Obamacare. Here’s Why..

The BCRA Is An Improvement Over Obamacare. Here’s Why..

Dr. Jha writes on these pages in typically stirring fashion about his views on the recent health care kerfuffle and rightly so fingers what the real focus of our efforts should be: Cost.  He ends by slaying both sides because of their refusal to confront the hospital chargemonster – the fee schedule hospitals make that remarkably only really applies to the uninsured.

Unfortunately, the solution proposed ensures hospital fee schedules for the uninsured are no greater than Medicare reimbursements, which is far from perfect.  Consider that the Medicare reimbursement for a stent placed to an ischemic limb is in the range of $15,000.  While this makes for a less daunting bill for the uninsured, in reality for the vast majority of folks that are uninsured $15,000 is about as far away as $150,000.

But my major disagreement with the good Dr. Jha relates not to his attempt to slay the chargemaster, but his underappreciation for the attempts made in the GOP bill to control health care spending.  A conservative mantra about the why of health care costs focuses on the existence of deep pocketed third party payers that make costs opaque to patients.  Attempting to have patients understand what they’re being charged has been conservative dogma, and there are a number of studies that suggest patients with health saving accounts are more cost conscious when they interact with the health care system.  Dr. Jha glosses over this important point – This is the Republican attempt to bend the cost curve!  And at least to this physician who’s lived through the last eight years, a plan that has a considerably greater chance of success than any number of failed acronyms designed so far by enlightened theorists from the Acela corridor.

The policy experts are hard to convince about HSAs, and point to the above chart as evidence of the uselessness of HSAs.

Our major problem clearly relates to the small number of patients (5%!) that account for 50% of all healthcare spending.  Patients that spend within their deductibles, I am told, aren’t why health care is expensive.  But this argument seems to imply that that the low lying fruit lies in the sick 5%, rather than the relatively healthy 95%.  This is bass ackwards – looking for cost efficiency gains is certainly possible for the 42 year old man who walked into my office today, a full year after dying while shopping at a PETCO.  He had no medical history prior to falling flat on his face in aisle 3.  A nurse who happened to be nearby started CPR, a police officer responding to the 911 call happened to have an defibrillator which found a shockable rhythm and delivered a shock which allowed the patient to make it to a neurointensive care unit where he was cooled to limit injury to his brain.  On waking, multiple incessant bouts of a ventricular arrhythmia – an electrical storm – followed that required not one, but two emergent procedures performed after hours on separate days.  A team lead by electrophysiologists finally mapped the source of his electrical storm and extinguished it.  The intensity of care that was delivered in this case is matched only by the cost of all of this care.  This is care that won’t be seen in life expectancy or infant mortality comparisons that would give you the false impression that Cuba or Chile are more appealing countries to get sick in.

Critics of the current system will point out that even if overall life expectancy and mortality statistics are blunt instruments, a more granular look at mortality rates for conditions that should be preventable – so called amenable mortality – also do not give favorable reviews to American health care.  A recent Lancet analysis that accounts for amenable health care conditions still ranks the United States behind the usual cast of European countries but also finds itself tied with Estonia, and behind Qatar and Kuwait.

Those puzzling over a model that finds Andorra and Iceland(#1 & #2) as countries that are ostensibly the best at preventing disease, won’t be surprised to hear that I think the methodology used to generate this list borders on useless.  Simply assigning cause to mortality can be difficult.  Attempting to ascertain which deaths may have been preventable with societal intervention with some degree of certainty would seem to be a tall task.  But there is no amount of complexity that seems beyond the data scientists of the 21st century.  Take ischemic heart disease – a disease that accounts for 7 million deaths world wide.  The WHO takes the stance – largely based on correlative studies – that a large percentage of cardiovascular mortality is preventable.  The actual percent preventable is again more feelings based on correlation with some experts stating 50% of deaths may be prevented with increased attention to diet and exercise.  Never mind that we don’t know what a good diet is, and the evidence from randomized control trials of diet would suggest at most a modest effect of diet on cardiovascular events.

Even if we were to agree about the strength of the link between diet and cardiovascular mortality, is it reasonable to think that cheesesteak-loving Philadelphia will be amenable to cheesesteak reduction strategies?

Perhaps even more importantly, the diseases that are amenable to reductions in mortality change over time.  Chronic Myelogenous Leukemia (CML) used to be a diagnosis associated with a 5 year survival of 31%.  The discovery of Gleevec – a daily pill – revolutionized the treatment of this disease. Five year survival now stands at 69%.  Andorra and Iceland, by dint of size and economic scale, contribute little to the development of the next generation of wonder drugs and therapies but do accrue all the benefits of such a system.

The cost of such innovation is not cheap.  The cost of care delivered to all out of hospital cardiac arrests in the hopes that one 38 year old will walk out are massive.   It is easy to see why we spend so much on so few.  But should we be looking for savings in those with the greatest potential for improvement?

I’d argue strongly that it is the remaining 50% of care provided to 95% of the population – statins for primary prevention using a calculator that overestimates risk and would expand the pool of statin takers inappropriately by millions, ER visits for chest pain that take a test first, ask questions later policy, and 90% of MRIs for back pain.  This is the type of care that desperately needs primary care physicians with time to parse and avoid this type of low yield, expensive utilization of health care resources.  And it is with this in mind that I get on my obligatory soapbox whenever anyone asks to suggest that the Direct Primary Care movement (which involves direct flat monthly payments between patients and physicians to cover the vast majority of outpatient care needs) is an important part of the solution.  I’ve written before about how Obamacare doesn’t work particularly well with the DPC movement because the generous essential health benefits and the individual mandate results in physicians having to convince patients to pay $50-$100/month on top of the $400/month they are already paying for that wonderful high deductible bronze plan.  The BCRA is a win for DPC because it takes away the individual mandate, allows skinnier catastrophic only plans and allows for HSA’s to be used for monthly subscription type payments to physicians.  For those without the income to fully fund HSAs. state subsidized HSAs with nominal $5-$20/month patient payments would prove to be a cost efficient way of delivering high value care to those who need it the most.

The biggest issue Democrats have with the GOP attempts to reform health care as it exists relates to federal subsidies.  Support from the federal government in the House version for buying health insurance was in the form of flat tax credit based on age.  This happened ostensibly because small government conservatives like Paul Ryan, and Rand Paul believe any federal subsidy to insurance companies or patients raises the cost of health care.  Market-based proponents of universal health care are supportive of expanded subsidies to provide a safety net and the Senate Bill is reflective of these concerns.  The Senate version of the health care bill (BCRA) simply builds on the ACA infrastructure to provide premium tax credits that are less generous but (like the ACA) are based on age, income, and cost of insurance plans in the local market.

At 100% of the FPL ($11,880) premium payments would be capped at 2% of income –  ~$23/month.  If a plan with a premium less than the median value of plans locally were chosen, the monthly cost would be even less.  Someone in their 20s at 350% of the FPL ($41,580/year) would pay no more than 6.4% of their income in premiums ($260/month), while someone in their 60s at 350% of their FPL would pay a maximum of 16.2% of their income in premiums ($655/month).

High risk individuals with pre-existing problems have always been a tough lift for the individual market, and the ACA dealt with this by not allowing insurance companies to risk adjust – a so called community rating.  This had the effect of raising insurance costs greatly and saddled young, healthy individuals in the pool with higher costs – a fact not lost on the healthy insured who saw entering the market as a bad deal, and stayed out of the marketplace – choosing instead to pay a fine for not having insurance.  This was the problem of adverse selection that the BCRA hopes to solve by creating high risk pools and allocating fairly large sums of money specifically to help states lower the out of pocket cost of care for these individuals. The hope is that these direct federal subsidies for high risk patients will protect and stabilize the larger individual market. (Alaska appears to have done this successfully, funding the plan through a tax on health insurance companies).  The BCRA would allocate $50 billion in the first 4 years and another $60 billion over the course of 8 years for this same purpose.  It is hard to decide if these are appropriate amounts, but scale and context is provided by the national high risk pool that existed under the Obama administration prior to the ACA coming online in 2014.  At its peak enrollment, ~100,000 patients were enrolled in this plan with an average premium of ~$32,000.  Even tripling the number of currently high risk uninsured patients to 300,000 would still mean that the proposed funding would be greater than what was allocated per patient in the national high risk pre-ACA pool.

The CBO thinks little of any of these machinations – the coverage numbers change little whether there was a flat tax credit or expanded tax credits as present in the senate bill.  It would seem that the only way to get a good CBO score would be to impose a strong individual mandate with heavy subsidies for insurance companies, which effectively doubles down on the ACA approach, and does nothing to actually lower the cost of healthcare.

The current debate about the GOP bill, which looks and smells a lot like the ACA, misses the point  as it is designed to do by those having the debate.  The goal of those on either side is to win at all costs – and in this case the party under siege, the Democrats, have weaponized the debate in order to provoke moral outrage.  It is virtually impossible to discuss Medicaid reform at this point because anyone supporting alternative paths that don’t involve greater federal subsidies for insurance companies is guilty of manslaughter.

The debate we should be having should focus on how to make the Medicaid program financially sustainable, expand access, and improve the quality of healthcare.  The only way to achieve this is to decrease the cost of health care – a goal that won’t be achieved by simply making hospitals charge medicare rates to the uninsured.  The Senate Bill attempts to create a robust individual market that safeguards patients from catastrophic medical bills, expands individual choice and personal responsibility with HSAs, and expands subsidies for those that need it.  There will be losers in an alternative path, and it should come as little surprise that organized medicine, the American Hospital Association and health insurance plans,are vehemently opposed to any plans that would threaten their stranglehold on the nation’s wallet.  I think we can do better, and current reform efforts that put patients in charge of their healthcare dollars with additional help for those that need it seems a reasonable step forward.

Should Doctors and Nurses Be Patient Activists?

Should Doctors and Nurses Be Patient Activists?

When the eminent physician Dr Cliff Cleveland wrote his memoir about his years in medical practice, he entitled his book, “Sacred Space.” Yes, it’s a bit sentimental, but he pays rightful homage to the idea that that relationship between patients and their doctors and nurses is something exceedingly precious. Medical professionals appropriately go out of their way to keep that space neutral, private and nonjudgmental, because patients are often at their most vulnerable.

A patient of mine recently told me about a genital symptom that was bothering her. She’d had it for two years, but had been too embarrassed to bring it up. We had to build up our trust bit by bit, until she felt comfortable revealing it to me. Happily, it was something easily treatable. It’s situations like these that remind me how critical it is to protect this space.

Like most doctors and nurses, I try to keep the outside world firmly outside the exam room. I don’t talk about politics, religion, money, or sports. I don’t even gripe about the mayor. Most medical professonals avoid political activism for the same reason. But could that reticence be harmful to our patients?

I grappled with this over the past few weeks, as the House passed its American Health Care Act and then the Senate put forth its Better Care Reconciliation Act. As one detail after another was revealed, I began to worry about my patients. The cuts to Medicaid would do real damage to them. I had a number of fragile patients in mind who could die if their care was disrupted.

What would I do, I asked myself, if I started to notice a dangerous side effect of a medication that my patients were taking. The answer, of course, is easy. And it wouldn’t even be a question; it would be an obligation. If I see a threat to my patients’ health, it’s in my job description to speak up.

The ACHA and BCRA suddenly seemed like the same thing—a threat to my patients’ health. Yes, I value political neutrality, but this no longer seemed like politics to me. It was a medical threat.

When the Ebola threat was on the horizon, medical professionals geared up even before it arrived. (As it happened, it was my exam room that was chosen as the “Ebola room,” so was stocked with gear and had a window cut into the door so staff could observe patients without putting themselves at risk.) And although the epidemic was ultimately safely contained, out staff was completely prepared when the fourth and final US patient with Ebola was admitted to our hospital.

If I suspect that one of my patients is suffering abuse at home, I am obligated—in fact, legally mandated—to speak up.  If I suspect that my patients’ health will be harmed by legislation, I believe we are equally obligated to speak up.

Whether a medical threat is from a virus or a medication or a natural disaster or legislative action is ultimately irrelevant. If our patients could be harmed, then medical professionals have a duty to weigh in.

I wrote an op-ed for the New York Times to that effect, that doctors and nurses need to speak out about the ways this legislation could harm their patients. And that was about as far into the waters as I felt comfortable wading. But the editors decided to title the piece “Time for a Doctors’ March on Washington.” From the outpouring of response that I received, it seemed like medical professionals were ready to gear up, just was we’d done for Ebola. It was time to take a step beyond the exam room.

Along with filmmaker Catherine Stratton and her talented colleagues at Resistance Media Collective, the HouseCalls Campaign was created. We decided that there needed to be an organized effort to bring the voices of practicing clinicians to the ears of Senators have little clue about the realities of healthcare.

I’ve thought long and hard about whether this violates my commitment to political neutrality with my patients and I’ve concluded that it does not. I do not discuss these efforts with my patients, and I continue to keep the exam room as neutral as possible. When patients bring up politics—which they do frequently these days—I steer the conversation back to their medical issues because that is my job as their doctor. When I leave the hospital, I start calling Senators about BCRA because that is also my job as their doctor.

Right now it is estimated that 20,000 Americans will die each year because of the loss of insurance coverage and Medicaid from BCRA. To me, that’s a clear medical threat to our patients. It’s a medical emergency, and medical professionals need to behave as such.

Danielle Ofri, MD, PhDis an internist at Bellevue Hospital and an associate professor of medicine at NYU School of Medicine, as well as editor in chief of the Bellevue Literary Review. Her newest book is What Patients Say, What Doctors Hear and her TED talks include Deconstructing Perfection and Fear, A Necessary Emotion. Her current efforts are focused on the HouseCallsCampaign.

Repeal and Replace. Repeal and Replace. Repeal …

Repeal and Replace. Repeal and Replace. Repeal …

Repeal and replace.  Simple enough on the campaign trail.  We heard this promise in 2010, when voters gave the House to Republicans.  We heard it again in 2012, when voters gave them the Senate.  Despite controlling Congress, Obamacare remained the law of the land.  Candidate Donald Trump, along with most Republican members of Congress, promised repeal and replace last year.

Republicans now have their largest electoral majority in nearly a century, and repeal and replace is spinning its wheels, like an old Pontiac stuck in the snow.

Some think a grand bill is still possible, particularly Senate majority leader Mitch McConnell.  Others are skeptical.  Senators Rand Paul and Mike Lee favor a two-pronged approach: repeal first then repeal later.  Herein lies the problem.  Republicans can’t agree on anything.

Democrats had no such problem in 2010 when they passed Obamacare.  The Bernie coalition didn’t get a single-payer plan as they wanted.  Some wanted higher Medicaid reimbursement for their states, as in the “Cornhusker Kickback.”  But they came together and passed Obamacare, each Democrat getting most but not all of what he wanted.

There’s nothing similar on the Republican side, which is why repeal and replace, as a single bill, is spinning its wheels.  Whether in the House or the Senate, any bill provision that pleases conservatives will lose moderate votes, and vice versa.  So no grand unifying bill will emerge as there won’t be enough Republican support for passage.

It’s all much like a carnivore and a vegetarian trying to plan a meal.  Add meat to the dish, pleasing the meat-eater, and the vegetarian won’t touch it.  Make it veggies and tofu, and the meat-eater will grab a burger instead.

This is why separating the two bills is the only reasonable option at this point.  Two casseroles, one with meat and one without.  Something for everyone…but separate.

There are enough votes for a repeal.  The House has voted on and passed such a measure several times.  If the Senate cannot currently agree on a replacement plan, just repeal now and replace later.

What could go wrong with that?  Plenty.  Congress is famous for making promises it doesn’t keep.  Budgets are a great example.  How many times did a Republican Congress pass a bloated budget or continuing resolution, or raise the debt limit, only to tell everyone that “next time,” they will put their foot down and show fiscal restraint?  It’s like Lucy pulling the football away from Charlie Brown each time despite promises to the contrary.

If they vote for repeal only, it won’t go into effect immediately.  There will be a phase-out period of several years.  Individuals, business, and particularly insurance companies need time to adjust.  Insurance is based on actuarial risk, predicting the future.  Businesses and individuals financially plan based on the rules of the game going forward.  An individual might delay elective surgery or have it sooner based on future insurance coverage.  It’s the same for businesses investing in additional employees or capital equipment based on potential future employee insurance expenses.

A replacement, while not necessary immediately, needs to be forthcoming in order to allay the uncertainty that is poison to businesses, the insurance industry, and the financial markets.  And the timing of the repeal process provides a deadline, one of life’s great motivators.

Once repealed, the clock begins ticking for replacement.  But Congress will at least have a clean slate.  Rather than applying Band-Aids and duct tape to the failing Obamacare plan, they can create a new plan from the ground up.  They can even bring along some Democrat involvement, at least among those few willing to work for the benefit of the country rather than sucking their thumbs, criticizing and complaining about Trump and Republicans.

That’s fertile ground for new health care delivery plans, whether a two-tiered approach or more of a free-market plan with expanded health savings accounts and vouchers for those in financial need.  It is far easier to create a new plan without trying to fit a replacement into the framework of a failing existing plan.

Like it or not, the health care ball is now in the Republican court.  They made promises to American voters and were given congressional majorities to stop the Democrat agenda and fix longstanding problems, whether immigration, taxes, regulations, trade, or health care.  They will rightly be blamed or credited with whatever they do.  Or don’t do.  At least by voters.  The media will criticize Republicans for simply existing, but fortunately, they don’t decide elections, as they painfully learned last year.

There is no argument that Obamacare is failing.  As some suggested, it could be allowed to continue and implode, but the resulting chaos will be hung like an electoral noose around Republican necks.  They can fix it.  Hand-wringing and indecision are not fixes.

It comes down to three options.  One is to do nothing, enabling the continuing destruction Obamacare is wreaking on Americans.  Two is continuing the no-win debate on a replacement option that has no hope of passing Congress – or, if something does squeak through Congress, it being little better than the mess it’s replacing.  Three is to use the congressional majority, nuking the filibuster and Byrd Rule if necessary, repealing Obamacare entirely.

That would leave Congress with a clean slate – an opportunity not to fundraise and kiss the rear ends of lobbyists and donors, but to do their jobs and legislate.  All members of Congress have given interviews and speeches, debated the issues.  Surely, they have ideas on how to deliver health care to the American people.  Time to do it.

If they fail, voters may say “meh” in 2018 and beyond.  Any guess what Democrats will replace Obamacare with if they are handed the reins of power?  Single-payer.  Medicare for all.

Let’s go, congressional Republicans.  You wanted to be put in the game.  Time to show America why you are better on the field than on the bench.

Brian Joondeph is an ophthalmologist based in Denver. He is a frequent contributor to THCB.