Philadelphia Reflections

The musings of a physician who has served the community for over six decades

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Reflections on Impending Obamacare
Reform was surely needed to remove distortions imposed on medical care by its financing. The next big questions are what the Affordable Care Act really reforms; and, whether the result will be affordable for the whole nation. Here are some proposals, just in case.

In Summary

In Brief Summary. Suggestions for American healthcare reform are made, embracing the full potential of unencumbered Health Savings Accounts, and changing the physical center of healthcare delivery while turning some of the incentives of reimbursement in a better direction. Unfortunately, most of the intent of the suggested changes to the system cannot be appreciated without understanding the history and economics of health insurance, and the complexities of the modern health delivery system. An attempt to capsulize these matters is mixed among the proposed solutions to them in outline. They come from a physician with decades of practice behind him, fifteen of them before Medicare was created. No claim is made of lack of bias. The more important suggestions are:


..1. Health Savings Accounts, linked to debit cards, reinsurance, investment vehicles, and marketing.

..2. Elimination of Co-pay, but increase of deductibles.

..3. Equalized tax-exemptions (for health) for all citizens, regardless of employer.

..4. Reduction of employer domination of employee health insurance choices.

..5. Increased deductibles for elective admissions to the hospital (or decreased deductibles for emergencies).


..6. Revised ambitions for computerized medical records.

..7. Substitution of market-based prices for hospital cost-accounting in DRG calculations and patient bills.


..8. Establish a nation-wide appeals mechanism for both beneficiaries and providers.

..9. Independent negotiation and payment for aggregated hospital indirect costs.

..10. Inter-institutional comparisons of charge-to-cost ratios, indirect costs shifts, and indirect costs.


..(11.) Payment of Last year-of-life costs from an escrow to Medicare, beginning last-year-of life pre-funding.

..(12.) Gradual substitution of whole-life health insurance for term-life health insurance, beginning with first year-of-life post-funding.

..(13.) Encourage migration of office medicine toward the campus of retirement communities. As a beginning, charge some agency with discovering obstacles to moving (independently competing) physician offices to the campuses of Retirement Communities.

Originally published: Thursday, April 25, 2013; most-recently modified: Tuesday, May 21, 2019