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Hillary Clinton
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For decades the AMA House of Delegates has held its semi-annual meeting in the same hotel in Chicago, renting the whole hotel for the purpose. President Obama unveiled his new plan for health reform this year, just as First Lady Clinton did, sixteen years earlier. They both made theatrical entrances, and both gave flawless speeches. Hillary spoke for an hour without notes or mistakes; teleprompters can be hard to see, but Obama ordinarily uses one for his near-daily speeches. The AMA always tries to get advance information, and rumors were circulating that he would have something dramatic to say about tort reform; the rumor was met with delight. Do you suppose, is it possible, he will agree to a cap on awards for pain and suffering? For forty years, the medical profession has been suffering from abusive malpractice suits and has tried out dozens of proposals for reform. For forty years, absolutely nothing has worked except to place a $250,000 "cap" on awards for "pain and suffering". That proposal works, and pretty much works every time it is tried. Do you suppose, do you suppose, we finally have a lawyer President who understands?
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Barack Obama
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The President had a legislative plan to present, and with tort reform promised as the climax of it, the doctors applauded regularly, and laughed at jokes that were a little weak; that's what was expected of them. As he outlined his plan, it seemed a flop but don't be rude. He proposed to spend a trillion dollars on providing health insurance for 16 million of the 42 million uninsureds and intended to pay for it with a trillion dollars worth of cuts to the reimbursement of hospitals and pharmaceuticals, plus taxes on the rich, defined as roughly every person in his audience. And still, they applauded, even good-naturedly joining into one of his cadence counts. He was building to the climax; tort reform was coming. When he started the topic, there were cheers.
Unfortunately, he saw what they meant, and took pains to announce that he was not at all in favor of a cap on "awards", he didn't believe in that. It was pretty easy to hear the boo-ing. When all was said and done, his plan for ensuring everyone amounted to putting 16 million people on Medicaid, the absolute worst part of the present system. The money to pay for it would be provided by the State Governors, who would somehow get it from the Federal Treasury.
And so, Obama lost the chance of a lifetime, the sort of opportunity Kipling was describing as sixty seconds worth of distance run. Of course, he had been surprised and unprepared, but he was performing in front of surgeons and cardiologists, and directors of emergency rooms, anesthesia, and critical care units. There was scarcely a person watching who had never faced a split-second decision involving life and death, in full knowledge that if a mistake was made, a plaintiff lawyer would pounce. It is my opinion -- I sat in that audience for 25 years -- that if he had said he would try his best to get what we want, the profession would have united around his otherwise feeble plan and tried to help him out with it.
What about Hillary's Shakespearean demureness of a generation earlier? Well, the average life expectancy of Americans is five years longer than it was then, so we really didn't miss her plan a great deal. But fundamentally it was the same plan that California doctors devised during the 1960s. It was then called Foundations for Medical Care, but it was essentially an HMO. When the private insurers took it away from the control of physicians, they turned it from success into a disaster; it's still regarded as an antitrust violation for physicians to run one. The California patients loved it when it was run by doctors, hated it when the insurance companies took it away. The last fifty years of so-called health reform have amounted to building bridges without engineers, flying airplanes without pilots -- and delivering health care without the supervision of physicians.
Have a nice time, sir.
Health Savings Plans were designed over thirty years ago, well before the Affordable Care Act. The ACA does include pure catastrophic coverage. But it inexplicably limits such coverage to persons under the age of 30, and over that age, only in hardship cases. The paradox exists: Obamacare in fact imposes high-deductible features to every one of its products but includes too much baggage. The catastrophic options are far overpriced for such limited use. The new regulations should be dropped to remedy that awkwardness. Later in the book, it is of central interest to see how lifetime coverage compares in cost, against a "naked" catastrophic policy costing about $1000 a year. (see below)
Proposal (K): Congress should permit the sale of excess ("Catastrophic") indemnity health insurance, without any specified service benefit provisions or age limitations, with a deductible approximated to exclude most outpatient costs while including most inpatient ones. If future medical science should evolve to exclude an unmanageable proportion of outpatient procedures, the line may be adjusted. If inpatient and outpatient costs fail to segregate roughly around the deductible, a numerical deductible should be abandoned, and wording should be substituted which has that general effect. The designation of payment for emergency care should depend on whether the patient is admitted afterward. Reasonable limits may be negotiated on ambulance costs and other outriders such as expensive drugs and equipment use.
Furthermore, the ACA introduces the interesting concept of an upper limit to cash out-of-pocket costs, which creates a quasi re-insurance effect. That seems like a useful innovation, which mitigates the need to design a special re-insurance program for Health Savings Accounts. The unknown person who devised this idea is to be congratulated for simplifying the problem. Commercial catastrophic insurers are urged to take a look at imitating it, and the Secretary is urged to write regulations which permit the use of it, at the option of the insurer in consideration of the required flexibility of Catastrophic insurance regulation. This is an area where the use of dollar limits (indemnity) is clearly preferable to enumerated service benefits. When bills are large enough to exceed the deductible threshold, they are likely to be paid to institutions, where subsequent non-medical use is comparatively easy to identify.
None of the Obamacare "metal" options is entirely suitable for a Health Savings Account.
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A high deductible is itself a desirable feature, while co-pay or coinsurance, is undesirable. The typical 20% co-pay feature has proven too small to have a restraining effect on usage and would have been dropped as useless, except for one thing. A 20% co-pay will reduce the premium by 20%, a 34% co-pay would reduce premiums by 34%. Therefore, in the heat of a salesman making a pitch, it is useful to be able to adjust the premium to just about anything requested, so the marketing departments usually press for inclusion of a "flexible" co-pay feature. But that is really just a smoke-screen. The effect of a deductible on premiums, on the other hand, is rather tedious to calculate, but its effect on outpatient shopping behavior is striking because a host of small claims are swept away when their price becomes too low to justify expensive individual claims processing. Just think for a moment of the effect: the higher you raise the deductible, the lower you make the premium. I seem to remember a time when the AMA offered a $25,000 deductible for $100 yearly premium. If we had stayed with that approach during the following fifty years, we might be in less of a pickle about rising health care costs.
But, the bronze plan currently has the highest deductible and the lowest premium.
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So the bottom line is this: even the Obamacare "metal" plans demonstrate that the higher the deductible, the lower the premium. With the highest deductible and the lowest premium,
bronze plan is currently the one to choose for linking to a Health Savings Account. It's nowhere close to a $100-dollar-a-month premium, however, and is not at all what I would have designed for the purpose. But if you must have an ACA high-deductible, take this one. And indeed, you probably must. The U.S. Supreme Court decision that it isn't a penalty, it is a tax, has been worked around by saying you have to pay a penalty of 1% of your income, unless the small tax penalty is larger, which it probably seldom will be. A young person might be able to pay the small tax penalty with his first job, but one hopes it will soon creep up on him that he actually has to pay 1% of his income when the happy day arrives he is so unlucky as to get a raise in salary. It's hard to interpret the rumor circulating around that the premium for a Bronze plan will double in 2015. Since by definition, a Bronze plan only covers 60% of the cost, it must be presumed all other plans will similarly double in price. That hardly seems credible, since it would push all Obamacare premiums into the unaffordable range, causing the system to collapse. If you are a gambler, try gambling this rumor is just a hustle, intended to get more people to sign up before it happens, thus allowing enough money to arrive, so it won't happen.
The higher the deductible, the lower the premium.
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The Iron Law of Insurance.
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So the way we would advise using the HSA has three components: 1. Choose the cheapest plan with the highest deductible. 2. Try to build up the HSA to $10,000 as quickly as you can, by contributing the full $3300 annual limit ( or $6000 family unit) even when you otherwise don't need to. 3. Try not to spend the funds in this best tax-sheltered account, unless you don't have any other funds at your disposal when you get sick. Bear in mind it is more favorably taxed than even an IRA.
If your Health Savings Account contains a $10,000 special-purpose fund for unexpected medical costs, compound investment income will make it grow considerably faster when you are young. That's a time when mathematics will make it grow fastest in the long run. Remember, you aren't required to do this, but take my word for it; it will make for much easier lifetime health financing if you can spare the funds.
And by the way, if you can think of any legitimate reason why we should forbid the sale of this type of insurance for any age group whatever, I wish you would come forward and explain it.
In 1965, the most fundamental of economic fundamentals reversed itself. America's international trade balance shifted from positive to negative, has remained negative ever since. It's irrelevant that international currency shifted backward to soften the blow; that's what floating currencies are supposed to do. The era of effortless and largely unchallenged American post-war world supremacy was over. From now on, it was to be everyone for himself, in Medicine as in every other trade.
A new triumvirate, consisting of hospitals, health insurance, and medical schools asserted medical leadership, fought against each other for domination, and consequently found themselves a prized destination for opportunists. The new name of the game was to gain control of the payment system, and through it control of hospitals, and through the control of the doctors. But the sponsors of the earlier system, the employer-based one, were still around, and to a large extent, still, dominate. No proposal for running healthcare could omit physicians from the center of control. Most who attempt it, seek to use medical schools as a surrogate for the practicing profession. However, medical schools are in competition with their alumni by owning hospitals, and the rest of the profession see medical school control as favoring a competitor. They resist it bitterly.
Meanwhile, the doctors had experienced entirely different socialization by going away to various wars, and discovering how little they needed hospitals. As shown in episodes of the TV series Mash, new bonds were formed between a medical band of brothers, operating successfully in tents, not medical centers. This experience comes and goes, but unfortunately, there has been such a succession of wars, the experience gets reinforced. One of the great paradoxes of the present medical upheaval is to see government and insurance doing their best to herd doctors back into hospitals so they can be controlled by salaries, rather than by their patients. And while they seem to have largely succeeded, the ACA ambition to control medical care by control of the payment system is appreciably undermined at its interface between institution and profession. It is always an uphill battle, to defend a more expensive, less satisfying, approach; eventually, it is a losing approach. The oppressive cost of everything, the collision between recessions and inflations, seemed to be keeping everybody under control for the time being. But it would be unwise to assume calm will prevail forever, or that a command-and-control arrangement would continue to work through the hospital, without fragmenting somewhere. In a larger sense, a lot of this history was irrelevant. The people really causing commotion were business leaders with an entirely different agenda; their model was Henry J. Kaiser.
Much of the resulting endgame depends on what Washington will be willing to do. Congress will have its own ideas, but Congress is often in a hurry. What isn't complicated, is often politically difficult, and it helps things along if the public has thought about them first. The Supreme Court gives itself more leisure to think, but sometimes that isn't a pure advantage. The President has more staff, but he can't always control it. Medical cost-cutting turns out to be like closing military bases; it has to be gradual, it has to be spread wide and thin, but it must show early benefits quickly. In its first six years, for example, a lot of people must see some benefit, and very few must see their jobs destroyed. All this can be done, but it can't be done repeatedly. The country cannot afford to keep using up its reserves with noble experiments. World affairs and world economics surely present enough distractions, without inventing artificial ones.
On medical affairs, Congress should learn to listen more to doctors and less to our ancillaries. But for this to happen, doctors will have to become more open about their experiences, rather than electing more doctors to Congress, where they become seen as competitors rather than experts. When Congress finally wakes up to the full dimension of what has happened, everybody is going to need some friends he can trust.
In the final section of this book, we will talk a little about some of the thorny transition problems to be expected. It's not a comprehensive discussion, but a wake-up to the healthcare industry and to Congress, about the complexity of some of the implementation problems they are abandoning to the Executive Branch -- at everyone's peril.
So, come along, let's learn a few hidden things. Start with employer-based health insurance. That's what we had for the past century but hardly noticed it. It even helps to know a little of its history.
A Short History of Employer-based Health Insurance. Instead of starting with Bismarck or some other link to a non-American, let's say health insurance in America began as a proposal of Teddy Roosevelt's during the Progressive Era just before the First World War, a century ago. The American Medical Association had a flirtation with Teddy's national health insurance but came to prefer something like the business community's Blue Cross system, as it eventually evolved during the 1920s. Business scarcely recognized it, but large American companies were beginning to shift control from founding families to stockholders, an evolution which advanced during the next three decades, as a way to extract capital gains taxes to float war debts. To a certain degree, growing shareholder control was a step toward meritocracy; in a human relations sense, it may have been a step backward. The shift extends to only about half of corporations even today. But health insurance and stockholder control of the big companies advanced side by side, scarcely realizing how diminished employer benevolence was undermining the process. We glorified the decline of a semi-feudal system, but we lost something in the process.
American health insurance traces back to President Teddy Roosevelt
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It makes a huge difference whether the boss is a paternalistic owner or the manager of someone else's company. In the first instance, he spends his own money, in the other instance, his only absolute mandate is to generate money for the stockholders. That's a measurement applied to every "good" manager. Plenty of owners were tight-fisted, and plenty of managers were benevolent. Even today, small businesses (less than a billion dollars in assets) are mostly "Subchapter S" corporations, and about 15% of really large "Subchapter C" corporations are still dominated by founding families. But in spite of frenzied rhetoric about the "rich owner", the shift in attitudes is clear; as founding generations move away from active involvement in their companies, they become less involved with employees. They themselves become more like their hired managers. Current investment trends, moving into index fund passive investing, further widen the distance between stockholders and owners-by-inheritance. The "silo effect" of specialized departments further isolates the core business from non-revenue support departments.
Cost-shifting was an early development, transferred from the business to the hospital. The concept originally underlying Blue Cross was that private rooms should produce enough profit for the hospital to support the poor folks in open wards, whereas semi-private rooms just break even. At first, only a handful of ministers and school teachers were in the semi-private category. When hospital finances improved, more working-class people moved into the semi-private category, the wards shrank in size, and semi-private -- became the standard clause in employee contracts. For two hundred years, multi-bed open wards were standard, but semi-private became standard in a single decade. Semi-private nevertheless acquired a charity flavor. The "Blue Cross discount" began to apply to semi-private beds, at the same time semi-private became readjusted to become "standard size" for "service benefits". That is, most employees of corporations started to be cared for at less than actual cost, at the Blue Cross discount-to-business rate, because their contract called for being provided certain services, no matter what they cost. In fact, what they appeared to cost was so distorted by cost-shifting, you couldn't tell who was subsidized. It would not take long for a new standard to be demanded: sharing a room with strangers was so low-class. Private rooms were going to be the only decent thing. Spending other people's money is fun.
And because Blue Cross organizations became dominant during the Second World War, their competitors in cash benefits ("indemnity carriers") greatly resented paying more dollars for the same semi-private room than Blue Cross patients did. Some of this was doubtless a response to wage and price controls during World War II, a way of raising wages without expanding the (taxable) "pay packet". The response of commercial indemnity carriers was to price their premiums on "experience rating", which especially cut into the profit margin of Blue Cross private-bed patients. The way that worked was, the insurer waited a year to see what inflation had done, and made a trailing readjustment in the following year's premium. One unexpected outcome of this price warfare was to make the hospital reluctant to reveal its tentative charges, where the employer demanded to be shown the actual costs of his employees, as well as prices to everybody else. When Blue Cross coverage reached government employees, a new power center gained possession of itemized hospital bills. A new employee representative could easily see how much or how little the government was actually subsidizing charity care. Naturally, as the new source of benevolence, they claimed they were paying too much.
When Group practices, or HMOs, started to pay for healthcare, they too demanded to see comparable bills or at least standardized prices. And so it went, with each new wrinkle in payment. Some people paid listed prices, but big groups could afford to send auditors to look at the books. There had long been a three-tier price list, and now there was a six-tier one because of having list prices and actual payments on each of three levels. Soon it began to seem there might be sixty prices for the same thing. Like a stag cornered by barking dogs, the hospital fended off the payers as best it could. Because of the long period of catch-up following the Great Depression and then the Second World War, hospitals usually needed new buildings and improved wage standards for employees. How were they to pay for this, when everybody seemed to be demanding to get backlogged services at the old prices?
For centuries, hospitals had existed on a system of collecting whatever they could, and delivering needed care as best they were able. Their deficits were covered by public subscription, by religions, and by tightening the belts of the charity-minded hospital volunteers. Sometimes the rich guy who lived in a mansion on the hill would donate, sometimes he wouldn't. Surely, the government had a responsibility to rescue such a deserving charity. The student nurses and the young doctors in white worked for no pay at all. That's right, after I graduated from medical school I worked for four years without a dime of pay. If hospitals overcharged a few insurance companies, well, there was nothing else they could do to keep the doors open. Until health insurance made a significant impact, hospitals ruled medical care. They were the only institutions which seemed to work, all new ideas seemed to come from them, and any new idea which came along was somehow centered within hospitals. Although it wasn't described as such, hospitals began to suffer the disease of conglomerates. If an organization takes on too many functions at once, it performs some of them poorly. Usually, one of the subsidiaries fails and drags the rest of the conglomerate down. That's essentially why the Supreme Court, in the State Oil v. Khan case finally decided vertical integration cures itself and usually does not require antitrust judicial action to break it up. That doesn't mean vertical integration is wonderful; it just has to be shown to be bad before you punish it. Unfortunately, high legal fees unbalance the situation. The corporation can usually afford the lawyers, the individual practitioner can't. Threatening to bankrupt the opponent is now a standard procedure in the courts of Justice.
Disregard for the Tenth Amendment in the 1937 Court-packing incident greatly injured the Tenth Amendment's Constitutional requirement that health and health-related activities should be regulated at the state level. But it also heightened public attention on the Constitutional issue, since hospitals, nurses, doctors, pharmacies, and the Blue Cross organizations were all organized along state lines. Only when the Federal government under Harry Truman began to sound serious about central control of medical care, did health insurance begin to cross state lines, and thus weakened hospital and Blue Cross domination of it. By the time Lyndon Johnson began his piecemeal assault in 1965 with Medicare and Medicaid, the insurance industry had broken healthcare into four "markets":
Large-employer groups. The healthiest groups, and hence the cheapest to insure, became the low-hanging fruit. Union pressure combined with the passage of ERISA expanded and somewhat fragmented the groups, but large employers were first and dominant in the planning.
Small-employer groups. Curiously, this often became the most expensive silo of the markets, because of successful pressure to expand -- even mandate -- benefit packages, and the fact that certain expensive cost generators can be selectively insured when the personnel manager knows them by name.
Individuals. Because of adverse self-selection, "non-group" had the highest marketing costs, and often the highest medical costs. It was possible to eliminate the worst abuses, such as figuratively buying insurance while riding to the hospital in an ambulance. But subscribers to non-group insurance move freely between employers and thus can avoid being dropped from the insurance when they change jobs. What is generally touted as a great disadvantage of employer-based insurance, could easily be called the exploitation of being in a position to select only healthy people for jobs. Insurance companies obviously and regularly "prefer to work with groups". Circumvention wears many disguises. When an insurer tells you this is "his company's policy", be sure to kick him in the shins. His company is part of the problem, not part of the solution.
Executive "Cadillac" plans. are mentioned for completeness, although they could also be grouped with steak dinners and baseball tickets, as mere sales promotion kickbacks for the people who make decisions on behalf of members of a large group. They often had "first dollar coverage", essentially paying for everything even faintly describable as medical care, down to the last penny. It should prompt some concern to learn that health insurance for college professors and politicians is often of this variety. In terms of aggregate medical cost, of course, Cadillac plans are negligible. However, as long as they exist, they light the way for those fortunate who can focus on Henry Kaiser gimmicks rather than the treatment of illness and eventually migrate to the rest of the tax-deductible group.
The general purpose of market stratification is to offer much the same product at different prices. Like other concessions which vice makes to virtue, they constrain admiration for the essential, desirable, feature of insurance in the first place: it spreads the risk and lessens the cost of what is supposedly an unpredictable random health catastrophe. If the insurance industry is really serious about this mission, it would start with one outstanding example of it: catastrophic coverage. Remember, the higher the deductible, the lower the premium. Let's repeat that: the higher the deductible, the lower the premium. Are insurance companies really motivated to have lower premiums? That's like saying Insurance Companies want to lower legal costs in order to preserve the impartiality of the courts.
Almost nobody can withstand a million-dollar illness, but almost anybody can afford a hundred dollars a year. Once you have that minimum feature, you can then start to talk about more expensive, more common coverage -- until we eventually reach first-dollar coverage for non-essentials, at wildly unaffordable premiums. By the way, if you would like to know why I didn't acquire catastrophic coverage back in the days when it was widely available, it was because I already had first-dollar coverage given to me by the University where I worked, I couldn't use extra catastrophic coverage even if it was free. This is no longer pre-1965. Everyone should have catastrophic coverage. Only if he can afford it, should anyone have more than that? Since the logic is beyond dispute, has it occurred to anyone to ask why that isn't the usual case? Read on.
In a way, health insurance suits family plans better than individual ones, because often there is only one responsible working person to foot the bill for everyone. But equally often it is the other way, every ship on its own bottom. Politicians know a no-win situation when they see it, so the matter seldom gets an enduring if arbitrary solution.
So it should be no surprise that responsibility for obstetrical costs has no solution, only expedients in a changing world. It's probably one of the hidden pressures for letting the government pay for it, so we can all forget the issue. Another feature is that it's expensive. The statistic seems high, but 3% of health costs are supposedly derived from the first year of life, and that means $10,000, which really seems quite high. And the report of the first 21 years developing 8% of health costs, also seems high. But something costs that much, and its costs must be paid by someone. As I thought about it, childhood is the reverse of all other health costs, where most people can save money and then spend it. It's impossible to pre-fund newborn costs unless they are paid by some other generation, on the baby's behalf. If that's the case, what would be so bad about grandparents pre-paying a baby's cost?
Furthermore, the grandparents have only recently rejoined the family. In my own case, I had four grandparents like everyone else. But I never met them. I have two great-grandchildren who are almost as tall as I am, and numerous grandchildren who are taller. For decades I have had them to my house for Christmas. All of this seems to relate to my own longevity, and is the destiny of almost everyone else, too.
So this observation is the underlying basis for suggesting we examine generation-skipping for the first year of life. It has the additional advantage of lengthening the period for compound interest to work, especially if the grandparents can save some surplus from Medicare to start the process. If you add that desirable feature to Medicare, you have just about solved a problem where no one else has a clue.
Data from CMS, 2013:
Medicare enrollees: 53 million (+3% per year)
Medicare expenditures:$585.7 billion($11,253 per enrollee x 20 years=$225,000 lifetime)
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APPROXIMATED
a. 1/4 of premiums on half(x 2 programs)=($112,500/4)=$28,000=or $1400 per year over 20 years, plus interest
b. 1/4 of withholding on half similarly =$14,000 total = or $700 per year over 40 years, plus interest
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CONTRIBUTIONS................................................................Death................Perpetuity
Age....................................O...............25.............................65.....................84........................105
Childbirth...........................1800
First-Last Seeding................... 400
Payroll Withholding.........................................................28,000
Seniors Premiums......................................................................................28,000
Total...............................$58,200
------------------------------------------------------------------------------------------------------------------------EXPENDITURES..
ASSUMPTIONS
Childbirth Gift..................................18,000*
Childbirth Escrow............................... 250*
Contingency fund ................................100*
4 Last-years Re-insurance.(200,000)..666
Child Medical Expenses.....................17,000*
Interest on 17,000(age 0-25)................(85,000*)
--------------------------------------------------------------------------------------------------------------------------RUNNING BALANCE
ESCROWED INVESTMENT INCOME @ 7%
Individual Programs:
Child Gift...................250(0)*............$1,125(25)*..$1,625(65)*..$64,000(84)*..$375,000(104)*
Payroll Tax ................0.00(25)..........$28,000(65)...$1,120,000(85)...$35,840,000(104)
Medicare Premiums...0.00(65)..........$28,000(85)...$1,148,000(104)........
Notice: Affordable Care Act, Contingency fund, Retirement provisions -- omitted.
Running Totals=$250(0)..$1,125(25)..$18,000(65)..$90,000(84)..$420,000(104)
Running Balance=$250(0)..$1,125(25)..$28,500(65)..$912,000(84)...$35,840,000(104)
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Total
Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.