Regarded

By PAUL KECKLEY

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!

Paul

By JILL MERRIGAN

Jill Merrigan is the Marketing Manager of Health 2.0.

ANISH KOKA, MD

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.

By DANIELLE OFRI, MD

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.

By Brian JOONDEPH, MD

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. 

By RICHARD GUNDERMAN, MD and JAMES LYNCH, MD

Margaret Edson’s 1999 Pulitzer Prize winning play, Wit, tells the story of the final hours of Vivian Bearing, PhD, an English professor dying of cancer.  Early in the course of her disease, one of her doctors sees the value of her case from a research point of view and asks her to enroll in a clinical trial of an investigational therapy.  In the film version of the play, which stars Emma Thompson, he hands her a two-page informed consent form to sign. 

Wit deals with many timeless features of terminal illness, death, the care of the dying, and the meaning of life, but this aspect of it strikes many contemporary physicians and medical researchers as extraordinarily quaint.  Informed consent remains an integral part of medicine, but the sight of an informed consent form that runs to only two pages – particularly one for an investigational cancer treatment protocol – seems nearly laughable.

Each year, millions of patients and research subjects are asked to sign informed consent forms.  Situations where informed consent should be obtained include blood transfusions, surgical procedures, and participation in clinical research trials, among many others.  The situation is familiar to many – the doctor walks in bearing a clipboard, explains the procedure, and asks the patient and a witness to sign on the bottom line.  The only problem: it is often neither informed nor a real consent.

Consider a more contemporary, real-life case.  A PhD from a science department at a major public university developed cancer.  His physician presented him with the opportunity to enroll in a trial of a new agent under study for approval by the Food and Drug Administration.  He took the 30-page document home with him that night.  The next morning, he and his wife returned, both having reviewed it. 

The expression on the professor’s face could best be described as exasperated.  Here is what he said: “I tried reading this thing several times, but finally I just gave up.  I am pretty smart, but I have enough to worry about with my diagnosis, and this informed consent form is so overwhelming that I simply can’t tell the difference between what is important and what is just legalese.  Would you please just tell me about the study and so we can discuss it?”

Informed consent is a relatively new term, coined in the 1950s in the courts, when patients underwent ill-advised care and suffered adverse outcomes, not knowing that other options were available or that they could have simply declined.  The idea is that patients should have the opportunity to learn about and decide whether to proceed with medical care or research that poses a risk that any reasonable person would want to know about.

The historical rationale for informed consent can be traced in part to the experiments performed by the Nazis during World War II.  In many cases, physicians conducted risky, painful, and sometimes deadly experiments on thousands of concentration camp inmates without their consent.  After the war, resulting military trials led to the Nuremberg Code, which established that medical experiments on human beings could be performed only with informed and voluntary consent.

No one would argue that research trials and medical care should be carried out without consent.  However, the current practice of informed consent has evolved so far from what was originally intended that it might better be described as a mutation.  In fact, it often resembles a monstrosity, no longer serving its primary purpose – to protect patients and research subjects – but instead now protects doctors, researchers, and institutions.

One problem is a faulty assumption that the more information is contained in the informed consent form, the more knowledgeable and therefore more protected the patient will be.  Often every conceivable benefit, risk, and alternative is addressed, as well as financial issues such as who will pay for what, intellectual property rights, privacy protections, conflicts of interest, and language designed strictly to indemnify the institution. 

Two fairly routine informed consent forms that we know run to 33 and 35 pages, respectively.  The first includes a list of 108 side effects that may occur in those taking the drug, including “abnormal blood test results,” “pain,” and “murderous thoughts.”  The second contains a chart of tests performed as part of the protocol, including 15 blood samples, 14 pregnancy tests, 9 thyroid function tests, and 4 symptom-directed physical exams.  No wonder even a PhD can’t understand it.

To repeat, the length and complexity of the forms is being driven less by protecting the patient and more by protecting the institution, should something go wrong.  Rightly or wrongly, people with oversight in such studies believe that if a problem is mentioned in advance, the probability of an unfavorable litigation outcome is reduced.  As a result, informed consent forms are as unlikely to be read and understood as are the byzantine licensing agreements that accompany software updates.

One of the most important goals of informed consent is to protect patient autonomy, but the complexity of the forms makes patients more reliant than ever on doctors, researchers, and institutions to explain the risks and benefits.  Just ask patients why they are being asked to sign the form.  In our experience, many will offer the matter-of-fact reply: “Why, of course, to protect the institution.”  In other words, patients may not understand the form, but they know that its purpose has been inverted.

The bodies that oversee informed consent, known as institutional review boards for the protection of human subjects (IRBs), continue to talk as though patient protection is the goal.  We do not doubt their sincerity.  But the complex process means that the vast majority of patients are operating strictly on trust, and the actual consent too often resembles a box-checking exercise.  If we expect patients to actually read the form, we should present them with something at least a PhD can understand.

Richard Gunderman, MD is Chancellor’s is a professor of radiology at the University of Indiana. James Lynch, MS is a professor of oncology at the University of Florida.

BY DANIEL STONE, MD

The toxic polarization of Washington politics might lead even the most stubborn optimist to abandon any hope for bipartisanship on healthcare. Despite endemic pessimism, the flagging efforts to forge a Republican consensus on “repeal and replace” might set the stage for overdue efforts at compromise. Congress will be tempted to move on to more promising areas such as tax reform and infrastructure funding. That temptation should be resisted. The threat to the nation posed by the current state of American healthcare calls for Congress to resurrect the long lost spirit of bold bipartisanship.

Before considering opportunities for compromise, the obstacles confronting the GOP reform efforts are worth considering.   Republicans face the same stubborn reality that confronted the framers of the Affordable Care Act (ACA): Expensive services cannot be covered by cheap insurance. The cost of U.S. healthcare has simply priced low income and even middle income individuals out of health insurance. Without subsides, they get left behind. The Congressional Budget Office’s estimated that the Ryan plan would result in 24 million losing coverage underscored the political divide: Confronted with unmanageable healthcare costs, most Republicans would opt to reduce public expense whereas Democrats plus a handful of Republican moderates prefer more extensive coverage. The effort of the GOP leadership to split the difference by preserving some residual subsidies and the structures supporting them—“Obamacare light”—remains unacceptable to many on the right. No clear middle ground has yet emerged.

The healthcare cost quandary affects far more Americans than the 3% of the public currently covered through the ACA exchanges or those covered through the Medicaid expansion.  We spend about 17% of GDP on healthcare, or about 7% more than the average developed country. That 7% translates into $1.3 trillion in excessive expense, or about 2.5 times the U. S. military budget. Health outcomes data suggest that we derive no significant benefit from that mountain of wasted resources. Meanwhile, the staggering burden of healthcare cost squeezes employers and makes U.S. industry less internationally competitive. It displaces investment and infrastructure spending. It contributes to U. S. dependency on foreign bond holders to fund the government deficit. In short, U.S healthcare bloat poses nothing short of an existential threat to our economic well-being and our national security. In looking beyond the ACA, we need to consider the costs of the entire system including Medicare and commercial health insurance.

Americans are either seniors now or seniors of the future so we should all be concerned about Medicare. Although its payment system is efficient, Medicare must buy healthcare services in the same overpriced market as the commercial plans. The program’s expenses now account for about 14% of the Federal Budget and will increase by an estimated 60% over the next decade. The Part A trust fund, which pays for hospital expenses, is projected to go broke by about 2030. Republicans have proposed reducing Medicare expense via a voucher program to cap costs. Democrats reject such a program due to concerns that inflation would erode the voucher’s value, allowing low income seniors to be priced out of healthcare.

Democrats and Republicans both complain about the high cost of the commercial health insurance sold to employers and individuals. Democrats focus on the 15-20% overhead devoted to corporate expenses like advertising, executive salaries and shareholder profit, rather than to care.   In contrast to the commercial plans, Medicare’s overhead, absent these costs, runs in the 3-4% range. Allowing access to a Medicare option for younger individuals and employees would allow billions of dollars of commercial insurance overhead to be directed toward productive care. Republicans generally oppose a Medicare option for the public due to their concern that it would increase the government’s role in healthcare.

A healthcare compromise, giving Democrats a Medicare option for employers and exchanges in return for a Republican inspired voucher system for Medicare, could offer a pathway to practical cost savings if the legitimate concerns of both sides were adequately addressed. For Democrats, protection for seniors’ healthcare access in a Medicare voucher system could be achieved by providing a floor to the value of the voucher to serve as a safety net.   One possible means of preserving the voucher’s value would be to peg it to the price of Medicare Advantage programs in specific regions. Under Medicare Advantage, the federal government pays a fixed amount per beneficiary to a private insurer. The insurer then accepts responsibility to provide all necessary services for that price. With effective cost management, these plans are efficient enough to provide seniors with full coverage without paying for a part B “Medicap” plan to cover the program’s 20% copayments, nor additional fees for a part D Drug program. The attraction of these cost savings for seniors has allowed Medicare Advantage to triple its senior population over the last decade. The program now provides care for over 30% of the nation’s seniors.   A voucher system pegged to the cost of Medicare Advantage has the potential to reduce costs while continuing to guarantee seniors access to full coverage. Not only would such a system conserve resources, but recent evidence suggest that Medicare Advantage can improve outcomes and even save lives when compared to traditional fee-for-service Medicare.

The same Medicare options offered to seniors under a voucher plan could be provided to employers and the insurance exchanges as the Medicare Option. Republican could be reassured that the program would limit the government’s involvement in healthcare, as Medicare Advantage programs are administered by private insurers. The care under the Medicare Advantage and other Medicare options would continue to be provided by physicians in community based private practices, not by the government.

Offering Medicare Advantage and other Medicare plans along with the current array of private insurance offerings would enhance competition in the commercial insurance marketplace. If private commercial plans offered better care or more cost effective care, individuals would be free to choose them. When individuals choosing the Medicare Option reached retirement, they could simply keep their same Medicare plan, with government funding replacing the funding provided by their employer. No longer would retirement mean a different plan and possibly different providers. Finally, allowing Medicare Advantage plans to compete in the commercial insurance market would speed the growth of these plans and provide the economies of scale needed to improve the quality of their networks. Areas of the country that lack efficient managed care systems would likely see increased development of systems that could save money for both employers and the public while providing better care.

The opportunity to achieve savings, improve healthcare choices, enhance competition and improve the financial security for Medicare should attract support from a broad spectrum of Americans and from the political leaders of both parties. Nevertheless, achieving large scale compromise would not happen easily.   The insurance companies, pharmaceutical companies and others that profit from the inefficiencies of the current system can be expected to feed partisan antagonisms and fight to protect their stake in the status quo.

In the competitive global economy of the 21^st Century, Americans can no longer afford to pay what amounts to $1.3 billion dollar healthcare tax that yields no demonstrable benefit. The public needs to wake up and pressure the political the leadership to direct their attention away from electoral politics and special interest advocacy and start working toward bipartisan, creative solutions to address healthcare costs.   A trade-off of Medicare Vouchers in return for increased public access to Medicare options offers one possible direction. The national interest demands that Congress and the President begin work on meaningful bipartisan action before it’s too late.

Daniel Stone is a practicing geriatrician in Los Angeles.

By NIRAN AL-AGBA, MD

I remember the first time someone threatened to kill me. It was my day off, so I was not in the clinic that day; a Children’s Hospital specialty group was working there instead, and after a staff member called the police, she notified me.  A father had walked in saying he wanted to kill me for “taking his children away from him.”  Wracking my brain as to this man’s identity, I drew a blank. 

The police found him in a local park a short time later and judged him to be “harmless.”  Somehow, I did not share their reassuring sentiment.  I figured out who the man was, tracked down his mother, and promptly explained the situation.  She provided a recent photograph so my staff could be trained to recognize him and contact the authorities the moment he entered our building.  That photograph still hangs in our “Most Wanted” section of my front office, amongst other pictures which have been added.  Occasionally, I request an updated picture to make sure we are keeping our office environment safe. 

The second time a parent threatened my life was over the phone. 

I was taking call on the weekend for a group of pediatricians.  One of them had evaluated a child for a finger injury and had not quite done their due diligence.  It sounded infected and in need of repair as the father described its appearance over the phone.  I recommended he take his daughter to the local Emergency Room.  He threatened to stab me instead.  I called to warn the ER staff and then notified the other practice.  The response was less than vigorous from my call partners, “you must have done something to upset him.” Their reaction astonished me; “blame the victim” is an unacceptable response to a colleague in this situation.    

When a patient or disgruntled coworker threatens to kill us, that threat should be taken very seriously.  Physicians must become less tolerant. Tolerance is defined as an objective or permissive attitude toward opinions, beliefs, and practices that differ from our own.  In my opinion, the administration of hospitals and some large clinics are far too permissive of violent threats against their staff.  I have heard numerous stories from across the country of physicians being told the patient is always right as patient satisfaction scores reign supreme. 

We have been taught when a patient threatens to commit suicide, we take them at their word.  Why is it any different when our very own lives are at stake?  The idea that physicians, nurses, pharmacists, and ancillary medical staff are expendable is ridiculous and policies must be enacted to protect the lives of medical personnel.

As I reflect on the tragic events that unfolded inside the Bronx-Lebanon Hospital last weekend, it is difficult to comprehend. My first thoughts are for the victims and their families, in particular those who knew Dr. Tracy Sin-Yee Tam.  She was a family practice physician in the hospital that day by chance, filling in for a colleague.  My second thought is to recall a quote from Maya Angelou, “When people show you who they are, believe them the first time.” 

According to the New York Times, Dr. Henry Bello had a background which spelled trouble right from the start.  His life story reveals a chaotic trajectory of bankruptcy, alleged addiction, workplace difficulties, homelessness, and brushes with the law.  He declared bankruptcy in 2000.  In 2004, Dr. Bello was charged with unlawful imprisonment and sex abuse involving a 23 year old woman in Manhattan.  In 2009, there were allegations of unlawful surveillance when he was caught using a mirror to look up the skirts of two women. 

In 2014, he was hired by Bronx-Lebanon Hospital as a family practice physician with a limited medical license and in February 2015 was forced to resign in lieu of termination after an allegation of sexual harassment.  After his resignation, Dr. Bello warned former colleagues he would return someday to kill them.  On Friday, June 30, he exacted his revenge, entering the Bronx-Lebanon Hospital carrying an AR-15 rifle and opening fire — fatally shooting a physician and wounding six others before killing himself.  Something more should have been done about this man to protect the hospital staff and patients. 

This post was not penned to  Monday-morning-quarterback the events of last Friday.   I want to emphasize in the future, these threats should be taken seriously and closely monitored to keep those inside the hospital, medical facility, or clinic walls safe.  Two hours before the shooting, Dr. Bello emailed the New York Daily News to say the allegations that ended his medical career were “bogus.”  He stated, “This hospital terminated my road to a licensure to practice medicine.”  In addition, a week prior to the rampage, he was reportedly fired from his job assisting AIDS and HIV patients by the city.  This was a clear sentinel event and foreshadowed the possibility of something ominous. 

Physicians on the front-lines are facing a battle for their survival, literally and figuratively.  Friday, June 30, I lost a physician colleague in a senseless tragedy.  We do not handle threats haphazardly when they occur in airports, schools, or police stations.  We cannot properly care for a patient when we are in fear for our lives.  It should not be tolerated any longer.  There are many valuable lessons to be learned from the events of June 30th. We need to sit up, pay attention, and make changes.  The loss of Dr. Tracy Sin-Yee Tam and injuries to the other victims should not be in vain; physicians and other medical staff deserve to feel safe in their work environment while trying to save the lives of others. 

My sincere condolences go out to the friends and family of everyone inside the Bronx-Lebanon Hospital that day.  May you find peace, hope, and healing and may we, as collective communities of healers, refuse to tolerate serious threats to our lives, those of our colleagues, and those of the patients we serve. 

By JILL MERRIGAN

We are pleased to announce that Don Rucker, National Coordinator for Health Information Technology at the U.S. Department of Health and Human Services (HHS) will be a featured speaker and a panelist at our upcoming Health 2.0 11th Annual Fall Conference, October 1-4, 2017 in Santa Clara, California.

Jill Merrigan is the Marketing Manager of Health 2.0.

By SAURABH JHA, MD

Any backpacker travelling on a shoestring budget in Thailand knows not to blow their entire budget on premium whiskey in a premium hotel on the first night in Bangkok. Rather, you need to skip the occasional meal, stay in a cheap dorm with random strangers, and drink cheap beer on Khao San Road if you wish to see the country and return home without having to wash dishes in a restaurant in Bangkok to repay the loans. Both Democrats and Republicans seem impervious to a simple wisdom that I learnt when backpacking – you save money if you go for cheap stuff. The operative word here is “cheap.”

Both the Affordable Care Act (ACA) and the Better Care Reconciliation Act (BCRA) impose cost sharing, such as deductibles. Deductibles lower premiums by cost shifting. Because the sick, for obvious reasons, are more likely to meet their deductibles sooner than the healthy, deductibles shift costs from the healthy to the sick, or are a “tax on the sick.” Deductibles also reduce premiums by reducing the administrative loading of insurance – because insurers have fewer small claims to process, administrative costs reduce.

Whatever the morality of deductibles, and they are a trade-off between higher premiums for healthy Peter and higher out of pocket expenditure for sick Paul, a deductible is short-lived if decimated, for example, by a single visit to the emergency department (ED) for vague chest pain which leads to a triple rule out CT angiogram. This is because the charges imposed on the patient before insurance kicks in are the list charges – the dreaded, illogical, evil and, frankly, stupid chargemaster rates. This is not like drinking premium whiskey in a premium hotel. It’s worse. It’s paying ten times the rate for premium whiskey in a premium hotel for cheap beer in Khao San Road.

The chargemaster is a hospital’s list price which hospitals use to show how much charity work they’re doing.

“Look we just did $3000 of charity by giving away ten $100 saline drips, which only cost us $2, for free. Can we keep our Mother Teresa, I mean non-profit status?”

Hospital administrators, in clandestine meetings, use the chargemaster to negotiate with insurers reimbursement for medical services. To give you an example of the negotiation, let’s take Tom, a brash CFO in a hospital in New York who, negotiating with Price, a brasher CEO of Blue Cross Blue Shield, says “see, we charged that poor bastard, Abdul the cab driver, who has no insurance, $10, 000 for a triple rule out CT angiogram, and all we’re asking you for is $1000 for the rich employees at Goldman Sachs who make thirty times Abdul does. Is that really too much to ask for, Price?”

You can instantly see several elements, lunacies actually, about this set up. The higher the list price, the higher the starting point of the negotiation. The more aggressively Tom bargains, the more dollars the hospital gets. The more aggressively Price counter offers, the fewer dollars the hospital receives. If Tom knows that Price is an aggressive, alpha male bargainer, he’s likely to raise the list price of a CT angiogram. If Price adduces from Tom’s swings at the local golf club that he’s a “win at any cost”, Harvard MBA gunner with a Napoleon complex, he’s likely to make a ridiculous counter offer. This is a vicious cycle – logical and illogical in equal measures.

Let’s revisit their imaginary, though not unimaginable, conversation.

Tom: $10, 000 for CT angiogram for uninsured Abdul. For the rich people your plan covers, all I ask is $1000.

Price: No, $200. Take it or leave it.

Tom accepts, but his ego is bruised. Once bitten, twice shy. Tom returns with a vengeance.

Tom: $15, 000 for MRI/ MRA of the brain. That’s what we charged Abdul, that uninsured cab driver straddling the 400 % Federal Poverty Limit (FPL). For your Goldman Sachs’ bankers, all I ask for is $2000.

Price: No, $200. Take it or leave it.

Tom: Did I tell you we’re merging with three other hospitals in New York?

Price: ok, can we make it $1800?

Tom: Price, what difference does it make to you? The Medical Loss Ratio means you can pay hospitals as much as you want – it’ll get counted as “medical expenses.” Those framers of the ACA missed this obvious point.

Price: Tom, it’s not always about the money. Sometimes it’s the ego. Remember, I got bullied at school for not sharing my chocolate.

Tom: ok, $1900 – just because I got bullied at school, too.

Price: Thanks. Please don’t charge anyone else less than $1900 for MRI/ MRA of the brain. I know you might be tempted to because you could feel bad for bankrupting people. I also know Medicare only gives you $500 for MRI/ MRA.

Tom: I don’t feel bad for bankrupting people. You want the “most favored nation” status? That’s fine. Also, I can always use the anti-trust law to keep our negotiation secret. I’ll use a law to our advantage. These regulators are such idiots!

Price: Ha! They’re asses, to be precise.

Tom: Ha! Ha! Yes, asses!

Price: not even that uninsured cab driver, straddling the 400 % FPL. You can’t feel sorry for him just because he’ll be bankrupt. Remember, that’ll violate our treaty.

Tom: You mean Abdul? I wasn’t planning to. We still need to get the $100 he owes us for a saline drip we started just in case he was dehydrated. He wasn’t dehydrated, and he only used 1/3, but that’s not the point. If I must bankrupt that cab driver to keep our legal treaty, I will.

Price: Thanks Tom. No mercy on the middle class uninsured.

Tom: Don’t worry, Tom. There’ll be no mercy on those free riders – even the Democrats are on our side. They didn’t touch the chargemaster.

Price: They need both of us, which is why we supported the ACA. Without your high charges what’s the point of insurance? They need the insurers. They wouldn’t know their posteriors from their elbows without the insurers. Single payer? Bring it on. It’s great opportunity for administrators in private insurance to run the country.

Tom: I agree you guys are invaluable. But we stuffed the Democrats’ mouths with gold. That’s why they didn’t get in a tizzy with the chargemaster.

Price: But what about the Republicans? What if they get a whiff of the chargemaster? They’re an unpredictable lot – they have no principles. I really fear them.

Tom: Don’t worry about the Republicans. Just say “abolishing the chargemaster is a short step to socialism” and their frontal lobe will stop working.

In the phallic war, and eventual financial kumbaya, between Tom (hospital) and Price (insurers) it’s Abdul (unsubsidized middle class) who gets shafted. The chargemaster is American healthcare’s most evil component. It embarks on a feeding frenzy like remorseless sharks. It is responsible for the medical bankruptcies, which seem to cause angst in many who aren’t bankrupt. It’s like a local infection which causes septicemia, so one wonders why undifferentiated bombardment of the septicemia deliberately misses the source of infection.

The chargemaster is still here. How did the ACA miss this elephant in the room?

Healthcare reform is like an Olympic Valsalva maneuver which first leads to a belch then a fart.

That the ACA failed to tame the charges is testament either to the incompetence of central planners or the power of rent seeking. That the BCRA doesn’t even pretend to touch the charges exposes an extraordinary depth of Pavlovian anti-ACA feeling among the Republicans – they’re like a toddler, still mastering sphincteric control, who doesn’t want what his older brother has simply because his older brother has it.

That the policy wonks, health economists, and other quantitative moralizers who, in an unprecedented moral frenzy, have compared healthcare’s re-reform to ISIS and the Iraq War, have proposed little to tame the charges, reveals a troubling level of mathematical puritanism which resides in that no man’s land between absurdity and idiocy. Ideology, particularly when ostensibly supported by statistics, truly guts common sense.

For crying out loud, it’s the costs, stupid. Instead of moralizing about deductibles, “taxes on the sick,” whether healthcare is a right or privilege, personal freedom, and other ideological chicanery, how about lowering the ducking costs, people?

The left believes, rather disingenuously, that costs can be tamed by incentivizing doctors to do the right thing. It’s a Goldilocks aspiration which, far from dealing with costs, has created a Father Bear’s electronic medical records and a Mother Bear’s regulatory overload. Goldilocks ran away before tasting the porridge.

The right believes, rather comically, that costs can be tamed by giving people choice. The latest of this façade in choice is the Health Savings Account (HSA) – where pre-tax, Abdul can put aside money that he’d have used for visiting his relatives in Afghanistan to pay for medical services should he need them.

Let’s bring Abdul back into the story. Say he has a very low premium plan with a super high deductible of $15, 000. Say Abdul decided to go a little thrifty with his Eid celebrations and put $20, 000 over 3 years into the HSA. Unfortunately, Abdul has a dizzy spell, and visits the emergency room, gets a head CT to rule out stroke where some fastidious radiologist reports “please note MRI is more sensitive for acute stroke.” Abdul has an MRI, but also an MRA (because you might as well have a look at the arteries whilst you’re there). Everything is normal.

The unadjusted bill is $25, 000 – $15, 000 for the MRI/ MRA, which Tom used to extract as much money from Price. Abdul pays $15, 000 out of the charged $15, 000. The insurer, thanks to Price, pays $200 of the remaining $10, 000.

Abdul’s HSA is carpet bombed more mercilessly than Dresden. He defers that trip to Afghanistan, again, to visit his family he left behind. He wonders if the chargemaster was invented by the Taliban to fight the Americans.

At the risk of sounding naïve, allow me to make a modest proposal which I believe will be more effective in the long run than both the comically biblical ACA and the biblically comical BCRA.

Here it is. Please don’t be shocked by its brevity.

Jha’s Healthcare Reform in a Tweet:

“Thou shalt not charge un- or under-insured more than Medicare rates for services rendered in any hospital which accepts Medicare.”

Quad Erat Demonstrandum

About the Author:

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