Philadelphia Reflections

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

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Without having such intention in the slightest, I find myself writing a four or five volume essay on Health Savings Accounts. The HSA concept originated in 1981, with a letter to me from John McClaughry of Vermont, who was then Senior Policy Advisor in the Reagan White House. He had read my satirical book, The Hospital That Ate Chicago, and also was aware that Senator Bill Roth was working on a tax-exempt retirement fund, now called an Individual Retirement Account (IRA). John asked me if I thought two linked concepts might be of any value in paying for medical care.

Since it was exactly the idea I had been looking for, I began pressuring the American Medical Association, where I was a member of the House of Delegates. Executive Vice President Jim Sammons wrote me he had read my letter three times and still didn't understand "it". But one thing led to another, and the AMA endorsed the Medical (later, Health) Savings Account, firmly intertwined with catastrophic (high deductible) health insurance. The dual concept attracted the notice of people in Indiana and Texas, prompted a book by John Goodman, and was enacted into federal law when another Texan, Bill Archer, became Chairman of the Health Subcommittee of the U.S. House Ways and Means Committee. John McClaughry went on to run for Governor of Vermont, I went back to practicing Endocrinology in Philadelphia, while Health Savings Accounts with high-deductible insurance backup, quietly went on to enlist subscribers in the millions.

And Hillary Clinton emerged with her secret health plan, which I have been given to understand was mostly a national HMO, and later Barack Obama pushed his own version past an obedient Congress. Many young physicians endorsed the motives of the Affordable Care Act, but most established practitioners hate the product. Nobody yet has satisfied me where it was planning to go. Meanwhile, although the dual Health Savings Accounts and catastrophic insurance saved 30% according to the American Academy of Actuaries, it was rather quiet about it; and still grew to thirty million subscribers. Originally most popular in Indiana and Texas, its present leading popularity is in New York and California. How bi-partisan can you get?

So, after discovering I was too old to be included in its coverage, I decided to write a book about it. The book's theme, as you might guess, was the age limits ought to be widened. Soon, a second book was needed to expand its horizons to retirement funding, and a third one to show how easy it was to link it to almost any other age group. The ACA bill got stalled by the death of Senator Edward Kennedy, Nancy Pelosi rammed the Senate version through without any mitigating features the House of Representatives might want to add, the reconciliation was never reconciled, and President Obama was stuck with it. So its flaws had to be examined. But then followed two bewildering Supreme Court decisions, the disastrous computer failures of the enrollment process, and the even worse failure of the Electronic Medical Record. Dr. Robert Wachter wrote a book called The Electronic Doctor , which describes how Mr. Blumenthal diverted thirty billion of the two hundred fifty billion dollars of Stimulus Package to mandatory "meaningful use" of the Electronic Record by doctors, now widely hated by them. For example, numerous fairly young physicians, including my daughter, her husband, and another comrade in a Philadelphia club, dropped out of flourishing practice before they reached retirement age, complaining they just couldn't stand it. The Obama administration tried to patch it up, but now it seems on the verge of collapse.

So, although you can see why I might want to write a book, it was unexpected that I could never complete one as planned. Some unexpected event would come along, invalidating some premise, and I was blocked from one attempted revision after another. The experience taught me just how wonderful the many hidden features of Health Savings Accounts really were, but it sure made it hard to write a book. And, although I twice started a second book the day after I sent the first one to the printer, approximately the same thing happened again. I discovered the HSA's roll-over feature (that had frustrated my hope to join my own plan) effectively solved a much bigger retirement problem. But I had to re-direct because Mrs. Clinton announced she was going to run for President using healthcare as a central issue, once again in secrecy.

As the reader will soon see, lengthening the insurance term limits causes a considerable cost reduction, I had to publish that. But immediately a Supreme Court decision upset my plan. Lifetime health insurance, I had discovered, is much cheaper than insurance in bits and pieces. But now, by golly, I find the possibility is very real for the Affordable Care Act to be thrown out by a new President. So, back to the drawing board. I decided to publish around Obamacare, rather than confront it. Reconciling the unreconciled ACA with Health Savings Accounts would have to become a project, not a book. Meanwhile, the public can evaluate what becomes possible for healthcare financing, if people just leave politics at the door and try to fix the problem.

George Ross Fisher, MD

Philadelphia. December 9, 2016

Originally published: Wednesday, November 23, 2016; most-recently modified: Friday, May 17, 2019