Philadelphia Reflections

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

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REPLICATED COPY of Foreword 11/24/16 07:31 pm


Without having such intention at all, I find myself writing a four or five volume essay on Health Savings Accounts. The concept originated in 1981, with a letter to me from John McClaughry of Vermont, who was then a 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, in which 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 linked to catastrophic health insurance with a high deductible. It 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, but Health Savings Accounts with their linked high-deductible insurance quietly went on to enlist subscribers, in the millions.

And then 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 plan through an obedient Congress. I have been given to understand many young physicians endorse the Affordable Care Act, but most established practitioners hate it, and nobody yet has successfully explained to me what it was really all about. 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 it grew to thirty million subscribers, originally in Indiana and Texas, without much general notice. Curiously, its present leading popularity is in New York and California.

So, I took it up again, but after discovering I was too old to be included in its coverage, decided to write a book about it. The book's theme, as you might guess, was the age limits ought to be widened. That seemed harmless enough, but politics started to heat up. The ACA bill was 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. 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. 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, which is consequently 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.

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 the intended completion. When I realized just how wonderful the hidden features of Health Savings Accounts really were, I felt I had to publish a different sort of book. And, although I started a second book the day after I sent the first one to the printer, approximately the same thing happened twice more before the President's term expired. 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 the central issue, once again in secrecy. When I subsequently discovered, lengthening the insurance term limits causes a considerable cost reduction, I had to publish that, but immediately turn to address a Supreme Court decision. 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, so it became impossible to complete the third book before knowing what was going to happen to subscribers, age 25-65. But I decided to publish what I have, anyway, because including everything else except the Obamacare collision, gave such enormous promise, the unfinished book might prove to be of value in filling the gap. So, if I live that long, the reader may look forward to still another volume devoted to the central but undefined issue, reconciling the unreconciled ACA with Health Savings Accounts. 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. November 29, 2016

Originally published: Thursday, November 24, 2016; most-recently modified: Monday, June 03, 2019