Jerome Groop­man and Pamela Hartzband

The New York Review of Books - - Contents - Jerome Groop­man and Pamela Hartzband

An Amer­i­can Sick­ness: How Health­care Be­came Big Busi­ness and How You Can Take It Back by Elis­a­beth Rosen­thal. Pen­guin, 406 pp., $28.00

Get­ting Risk Right: Un­der­stand­ing the Science of Elu­sive Health Risks by Ge­of­frey C. Ka­bat. Columbia Univer­sity Press, 248 pp., $35.00

Not long ago, a rel­a­tive called us for ad­vice about a hospi­tal bill. A pub­lic in­ter­est lawyer in New York, he had de­vel­oped chest pain when ex­er­cis­ing and con­sulted his in­ternist, who or­dered a stress test with an echocar­dio­gram. To his re­lief, no ab­nor­mal­i­ties were found. Distress came later, when he saw that the hospi­tal had charged some $8,000 for this test. De­spite hav­ing ex­cel­lent in­sur­ance, he was in­formed that he was re­spon­si­ble for $2,000 of the total.

The bill seemed ex­or­bi­tant to us, and we sug­gested that he con­tact other med­i­cal cen­ters in the city to find out what they would charge for the same ex­am­i­na­tion. To his sur­prise, he dis­cov­ered that prices ranged from about $1,200 to $6,000. When he called the billing of­fice at the hospi­tal where his test was per­formed and asked why the echocar­dio­gram was priced at such a high level, he did not re­ceive a clear an­swer. Frus­trated, he in­formed the hospi­tal that he de­clined to pay. This re­sulted in sev­eral veiled threats, but he coun­tered that he would con­tact the at­tor­ney gen­eral of New York about what he be­lieved was abu­sive pric­ing with­out jus­ti­fi­ca­tion. Af­ter much backand-forth, his in­ternist in­ter­vened on his be­half, and the hospi­tal dropped the de­mand for the $2,000 dif­fer­ence. This story points to the ex­tra­or­di­nary predica­ment of our cur­rent health care sys­tem. Since the im­ple­men­ta­tion of Pres­i­dent Obama’s Af­ford­able Care Act (ACA)—and the manda­tory cov­er­age it brought—most pa­tients need­ing a pro­ce­dure such as an echocar­dio­gram can count on some form of in­sur­ance. But Oba­macare put no con­trols on the pric­ing of drugs or clin­i­cal care, leav­ing the profit-driven health in­dus­try mostly in­tact.1 As a re­sult, pa­tients are too of­ten re­quired to pay large out-of­pocket costs while in­sur­ance pre­mi­ums have con­tin­ued to rise. Most pa­tients nav­i­gat­ing the fi­nan­cial shoals of our health care sys­tem do not have rel­a­tives who are doc­tors to ad­vise them, nor are they lawyers; and many do not have in­sur­ance poli­cies as gen­er­ous as our rel­a­tive’s.

Now, if the Trump ad­min­is­tra­tion and a Repub­li­can-led Congress are suc­cess­ful in their ef­forts to re­place the ACA with “a free mar­ket so­lu­tion,” largely stripped of reg­u­la­tory re­straints, the sit­u­a­tion could get much worse. In May, the House of Rep­re­sen­ta­tives passed its ver­sion of a bill (called the Amer­i­can Health Care Act or “Trump­care”) aimed at dis­man­tling Oba­macare, and the Se­nate has been craft­ing its own bill. The Con­gres­sional Bud­get Of­fice has es­ti­mated that the House bill, if en­acted, would leave 14 mil­lion peo­ple unin­sured as soon as next year, and 23 mil­lion by 2026. Fur­ther­more, this plan would make it even more costly for the need­i­est pa­tients to ac­cess care.

At the cen­ter of both our flawed cur­rent sys­tem and its dis­as­trous pro­posed re­place­ment is a more fun­da­men­tal re­al­ity: health care in the United States is enor­mously costly, of­ten in ways that are baf­fling not only to pa­tients but to doc­tors them­selves. In An Amer­i­can Sick­ness, Elis­a­beth Rosen­thal, a physi­cian turned jour­nal­ist, first at The New York Times and now at Kaiser Health News, sets out to ex­plain how we got here. The book takes its struc­ture from the way doc­tors record clin­i­cal notes, de­lin­eat­ing a “chief com­plaint,” the “his­tory of the present ill­ness,” then a di­ag­no­sis, and fi­nally a treat­ment. But here the sick pa­tient is our health care sys­tem. With health care re­form be­com­ing one of the main is­sues of the cur­rent ad­min­is­tra­tion, An Amer­i­can Sick­ness could not be more timely or alarm­ing. Rosen­thal iden­ti­fies the “chief com­plaint” as an Amer­i­can med­i­cal sys­tem that “has stopped fo­cus­ing on health or even science. In­stead it at­tends more or less sin­gle-mind­edly to its own prof­its.” Who among us hasn’t opened a med­i­cal bill or an ex­pla­na­tion of ben­e­fits state­ment and stared in dis­be­lief at ter­ri­fy­ing num­bers? Who hasn’t puz­zled over an in­sur­ance pol­icy’s rules of co­pay­ments, de­ductibles, “in-net­work” and “out-of-net­work” pay­ments— only to sur­ren­der in frus­tra­tion and write a check, per­haps un­der threat of col­lec­tion?

Rosen­thal con­tends that the be­hav­ior of the health care mar­ket does not match that of other com­modi­ties. In­stead, she points out, it de­fies eco­nomic logic:

More com­peti­tors vy­ing for busi­ness doesn’t mean better prices; it can drive prices up, not down.... Economies of scale don’t trans­late to lower prices. With their mar­ket power, big providers can sim­ply de­mand more. . . . Prices will rise to what­ever the mar­ket will bear.

The

Amer­i­can sys­tem was not al­ways like this. Rosen­thal gives a lu­cid and re­veal­ing his­tory of Amer­i­can health care be­gin­ning with re­li­gious in­sti­tu­tions min­is­ter­ing to the sick and dy­ing in the nine­teenth cen­tury. Ab­sent ef­fec­tive treat­ments like an­tibi­otics and anes­thet­ics, ther­apy was not very costly, and re­cov­ery largely de­pended upon the body’s nat­u­ral sys­tems of re­sis­tance and re­pair. In the early 1900s, as clin­i­cal knowl­edge and treat­ment ad­vanced, med­i­ca­tions and surg­eries were de­vel­oped, and costs in­creased. The ques­tion for hos­pi­tals at the time was how to cover ex­penses, not how to make money. The archetype for to­day’s in­sur­ance plans, de­vel­oped at the Bay­lor Univer­sity Med­i­cal Cen­ter in Dal­las in the 1920s, was never in­tended to gen­er­ate profit. It be­gan when the hospi­tal ac­cu­mu­lated large num­bers of unpaid bills for its ser­vices and de­cided to of­fer the lo­cal teach­ers’ union a deal: for six dol­lars a year, mem­bers “who sub­scribed were en­ti­tled to a twen­ty­one-day stay in the hospi­tal, all costs in­cluded.” But there was a de­ductible: the in­sur­ance took ef­fect only af­ter a week of hospi­tal costs pegged at $5 daily.

Bay­lor’s plan spread across the coun­try and was given the name “Blue Cross.” The aim of this in­sur­ance was to pro­tect pa­tients from bank­ruptcy and to sus­tain hos­pi­tals and the char­i­ta­ble re­li­gious groups that sup­ported them. Em­ployer-based health in­sur­ance arose as a “quirk of his­tory.” The fed­eral govern­ment ruled in 1943 that no taxes would be levied on the money paid for em­ployee health ben­e­fits. “When the Na­tional War La­bor Board froze salaries dur­ing and af­ter World War II,” Rosen­thal writes, “com­pa­nies fac­ing se­vere la­bor short­ages dis­cov­ered that they could at­tract work­ers by of­fer­ing health in­sur­ance.” Af­ter the war, in many other coun­tries, a na­tional health care sys­tem came to be re­garded as a pub­lic good. But in the US, many viewed govern­ment-based health in­sur­ance as a form of so­cial­ism, and de­spite sev­eral at­tempts, pro­pos­als for such a sys­tem never could pass Congress.

As more Amer­i­cans gained cov­er­age, for-profit in­sur­ance com­pa­nies sprang up to com­pete with the non­prof­its Blue Cross and Blue Shield. The “Blues”—which co­or­di­nated their ef­forts start­ing in the 1940s and for­mally merged in 1982—ac­cepted ev­ery­one, and all mem­bers paid the same rate no mat­ter how old or how sick they were. (By the 1960s, more than fifty mil­lion Amer­i­cans had hospi­tal cov­er­age from Blue Cross.) “Un­en­cum­bered by the Blues’ char­i­ta­ble mis­sion,” Rosen­thal writes, the pri­vate in­sur­ers “ac­cepted only younger, health­ier pa­tients on whom they could make a profit.”

In the 1970s and 1980s, the rise of for-profit in­sur­ance com­pa­nies like Aetna and Cigna made it dif­fi­cult for the Blues to com­pete. In 1994, “hem­or­rhag­ing money,” Blue Cross and Blue Shield be­came for-profit as well. “This was the fi­nal nail in the cof­fin of old­fash­ioned no­ble-minded health in­sur­ance,” Rosen­thal writes. The for-profit Cal­i­for­nia Blues “gobbl[ed] up” their fel­lows in a dozen other states and, re­named Wel­lPoint, emerged as the sec­ond-largest in­surer in the coun­try. Pre­mi­ums rose rapidly. “Wel­lPoint’s first pri­or­ity ap­peared no longer to be its pa­tient/mem­bers or even the com­pa­nies and unions that used it as an in­surer, but in­stead its share­hold­ers and in­vestors,” Rosen­thal writes. This truth is of­ten ob­scured; in­sur­ance com­pa­nies mar­ket them­selves in the me­dia as care­givers, con­fus­ing the pub­lic, but they are not. The com­pa­nies are fun­da­men­tally in­vest­ment

ve­hi­cles, max­i­miz­ing prof­its to boost share­holder value.

Be­fore the Blues turned into for­profit com­pa­nies, they spent 95 per­cent of pre­mi­ums on med­i­cal care. To in­crease prof­its, the Blues, along with other in­sur­ers, now spend as much as 20 per­cent of their pre­mi­ums on mar­ket­ing, lob­by­ing, and ad­min­is­tra­tion. In con­trast, Medi­care, the fed­eral pro­gram for se­niors that en­joys wide­spread pop­u­lar­ity, de­votes nearly all of its fund­ing to health care and only 1 to 2 per­cent to ad­min­is­tra­tion.2

Rosen­thal’s in­dict­ment ex­tends well be­yond in­sur­ance com­pa­nies. She looks care­fully at hos­pi­tals, and the reader learns how they have been trans­formed by mar­ket­ing con­sul­tants and ad­min­is­tra­tors with busi­ness de­grees to gen­er­ate large prof­its, though many still en­joy a tax­ex­empt sta­tus as “non­profit in­sti­tu­tions”—mean­ing that they pay “al­most no US prop­erty or pay­roll taxes.” In­stead of profit, tax-ex­empt hos­pi­tals call it “oper­at­ing sur­plus.” In 2011, the US govern­ment cal­cu­lated that hos­pi­tals were get­ting an an­nual tax ad­van­tage of $24.6 bil­lion. Steven Brill, who high­lighted the preda­tory pric­ing that oc­curs in cal­cu­lat­ing costs of care in Amer­ica’s Bit­ter Pill (2015), recently listed the yearly pay of the CEOs of large hospi­tal sys­tems, which of­ten amounts to many mil­lions of dol­lars. Rosen­thal points out that “total cash com­pen­sa­tion for hospi­tal CEOs grew an av­er­age of 24 per­cent from 2011 to 2012 alone.” Rosen­thal’s case study is Prov­i­dence Port­land Med­i­cal Cen­ter in Port­land, Ore­gon, founded by nuns in the 1850s. A cen­tury later, Prov­i­dence, as other hos­pi­tals did, be­gan charg­ing pa­tients for each ser­vice ren­dered. The hos­pi­tals hired ad­min­is­tra­tors to “up-code” physi­cian ex­am­i­na­tions and di­ag­noses in such a way as to max­i­mize rev­enue. Prov­i­dence then de­cided to stop pay­ing salaries to physi­cians and treated them in­stead as in­de­pen­dent con­trac­tors, turn­ing each doc­tor into a “busi­ness.” A series of merg­ers and ac­qui­si­tions fol­lowed, cre­at­ing a giant hospi­tal-based net­work that dom­i­nated ge­o­graphic regions and had rev­enues in the bil­lions. Rosen­thal notes that Prov­i­dence still presents it­self as a “not-for-profit Catholic health care min­istry,” in­vok­ing the tra­di­tion of its found­ing nuns. But it

com­prises a weird mix of Mother Teresa and Gold­man Sachs: one day it is do­nat­ing $250,000 to help build a new teach­ing hospi­tal in Haiti to re­place one de­stroyed by the 2010 earth­quake, and the next its new off­shoot, Prov­i­dence Ven­tures, is an­nounc­ing the launch of a $150 mil­lion ven­ture cap­i­tal fund, led by a for­mer Ama­zon ex­ec­u­tive.

As Rosen­thal high­lights, when doc­tors are turned pri­mar­ily into busi­ness­men, there can be egre­gious abuses of the sys­tem. Medi­care tightly reg­u­lates re­im­burse­ment for cataract surgery, and in 2013 it re­duced pay­ments to oph­thal­mol­o­gists by 13 per­cent for sim­ple pro­ce­dures and 23 per­cent for com­plex op­er­a­tions as the tech­nique be­came more ef­fi­cient and re­quired less time:

Many eye sur­geons made up for Medi­care’s in­creas­ingly stingy cataract pay­ments by charg­ing com­mer­cially in­sured pa­tients more, lead­ing to some stag­ger­ing prices. Wendy Brezin, a Web de­signer in Jack­sonville, Florida, had cataract surgery billed at $17,406. John Aravo­sis, a po­lit­i­cal blogger, was stunned to be billed over $10,000 for each eye.

Rosen­thal also writes of a plas­tic sur­geon who closed a cut on a girl’s face with three stitches and sent a bill to the fam­ily for $50,000. This kind of abuse is a be­trayal of the pro­fes­sion and should not be tol­er­ated.

But Rosen­thal de­tracts from her story by re­peat­edly in­vok­ing un­founded stereo­types of physi­cians. She de­scribes pathol­o­gists as “quiet, an­ti­so­cial types.” The train­ing of anes­the­si­ol­o­gists is “not ter­ri­bly dif­fi­cult.” Rosen­thal quotes a re­mark from an anony­mous source re­gard­ing anes­the­si­ol­o­gists over­see­ing the care of mul­ti­ple pa­tients and billing for this work “while sit­ting in the lounge mon­i­tor­ing their port­fo­lios.” She as­serts:

When I left medicine in the 1990s doc­tors com­monly com­plained that they made less per hour than plumbers. To­day, they seem more in­clined to com­pare (neg­a­tively) their com­pen­sa­tion to that of sports stars like LeBron James or ti­tans of com­merce like Lloyd Blank­fein, the CEO of Gold­man Sachs.

In an other­wise se­ri­ous and well­re­searched work, th­ese hy­per­bolic char­ac­ter­i­za­tions are gra­tu­itous and dis­ap­point­ing.

Some of Rosen­thal’s med­i­cal ad­vice is in­ac­cu­rate. She in­cor­rectly claims that “neu­ro­surgery to re­move a brain tu­mor is never an emer­gency.” Tu­mors can press on the brain (some­times due to bleed­ing) and cause a her­ni­a­tion, a life-threat­en­ing event in which the brain is squeezed on top of the spinal cord. This is an emer­gency that ne­ces­si­tates urgent neu­ro­sur­gi­cal in­ter­ven­tion.

In the pre­scrip­tive sec­tion of the book, Rosen­thal of­fers some use­ful poin­t­ers on con­test­ing med­i­cal bills. As we sug­gested to our rel­a­tive, she rec­om­mends

con­tact­ing the hospi­tal armed with com­pa­ra­ble test charges and alert­ing a med­i­cal so­ci­ety or state agen­cies to pos­si­ble abuse. (A sur­gi­cal spe­cialty so­ci­ety got the plas­tic sur­geon to re­duce his bill from $50,000 to $5,000 for the three stitches.)

How­ever, she stum­bles in the ad­vice she gives on in­ter­act­ing with your physi­cian. In a sec­tion called “In Your Doc­tor’s Of­fice,” Rosen­thal writes:

Here are some ques­tions ev­ery doc­tor or health­care provider should be able to an­swer for you at a doc­tor’s ap­point­ment:

1. How much will this test/surgery/ exam cost? “I don’t know” or “It de­pends on your in­sur­ance” is not an an­swer. The doc­tor should give you a ball­park range with the cash price at the cen­ter where he or she refers.

When a pa­tient seeks med­i­cal care, the doc­tor must lis­ten and ex­am­ine to for­mu­late a di­ag­no­sis and rec­om­mend treat­ment op­tions. In many clin­ics, ap­point­ments have been shaved down to some twenty min­utes. Time is pre­cious and should be spent on clin­i­cal care, rather than search­ing and quot­ing price lists. To be sure, in­for­ma­tion on cost is im­por­tant, but ac­cu­rate es­ti­mates can be dif­fi­cult for both pa­tients and doc­tors to ob­tain. The “cash price” of­ten bears lit­tle re­la­tion­ship to what the pa­tient’s ac­tual cost will be be­cause of the wide vari­a­tion in de­ductibles and other specifics of each in­sur­ance plan. How­ever, an ad­min­is­tra­tor in the clinic, or a web­site, could ap­pro­pri­ately pro­vide as­sis­tance.

Im­por­tantly, there may also be un­in­tended con­se­quences of fo­cus­ing the doc­tor–pa­tient in­ter­ac­tion on money. As Paul Krug­man, the No­bel econ­o­mist, has em­pha­sized, pa­tients should not be un­der­stood as “cus­tomers.” Doc­tor­ing, he avers, is not the same as sell­ing cars. In­deed, we value our health dif­fer­ently than ob­jects we pur­chase for util­i­tar­ian or lux­ury rea­sons.3 Re­search in cog­ni­tive psy­chol­ogy in­di­cates that re­peat­edly cue­ing the physi­cian to view pa­tient care as a mar­ket ex­change risks pro­mot­ing self­ish be­hav­ior and erod­ing es­sen­tial as­pects of our pro­fes­sion that con­trib­ute to high-qual­ity health care, in­clud­ing pride in work, sense of duty, al­tru­ism, and col­le­gial­ity.4

A re­cent na­tional sur­vey from the Mayo Clinic of some 6,800 physi­cians re­vealed that more than half, many of whom are salaried, re­ported feeling “burned out.”5 Com­ment­ing on this find­ing, a lead­ing cog­ni­tive psy­chol­o­gist, Dan Arielly, and his coau­thor, Dr. Wil­liam Lanier, point out that this feeling is largely at­trib­uted to the trans­for­ma­tion of the health sys­tem into “a sort of ‘fix­ing-peo­ple pro­duc­tion line.’” This in­dus­trial ap­proach has caused loss of physi­cians’ au­ton­omy as well as mi­cro­man­age­ment of their use of time and how they make de­ci­sions. The re­sult is a change in the na­ture of the re­la­tion­ship of doc­tors and their pa­tients, veer­ing to­ward a “mar­ket” trans­ac­tion rather than a com­mu­nal re­la­tion­ship. The time to dis­cuss not only the pa­tient’s phys­i­cal mal­ady but its ef­fects on other im­por­tant as­pects of his life—time that al­lows doc­tors and pa­tients to forge per­sonal bonds—has been all but elim­i­nated.

In his book Get­ting Risk Right, Ge­of­frey Ka­bat of­fers in­sight into why the health care de­bate is so fraught and why it is so dif­fi­cult to reach con­sen­sus:

Dif­fer­ent groups—sci­en­tists (who them­selves fall into dif­fer­ent dis­ci­plines with dif­fer­ent points of view), reg­u­la­tors, health of­fi­cials, lay ad­vo­cates, jour­nal­ists, busi­ness­men, lawyers—are shaped by dif­fer­ent back­grounds and mo­ti­vated by dif­fer­ent be­liefs and agen­das. De­pend­ing on the is­sue at hand, the in­ter­ests of th­ese par­ties may con­flict or may align and re­in­force one another.

In the case of the Af­ford­able Care Act, each group force­fully lob­bied Congress and the Obama White House to pro­tect its own share of the pie. In order to craft a bill that would pass Congress in the face of such po­tent lob­by­ing, the Obama ad­min­is­tra­tion caved in to the phar­ma­ceu­ti­cal in­dus­try, omit­ting pro­vi­sions that would con­strain drug prices. Sim­i­larly, the in­sur­ance in­dus­try was given con­sid­er­able lee­way in set­ting pre­mi­ums and de­ductibles in ex­change for agree­ing to of­fer poli­cies that re­quired es­sen­tial ben­e­fits like ma­ter­nity and pre­ven­ta­tive care, and that did not dis­crim­i­nate against pa­tients with pre­ex­ist­ing med­i­cal con­di­tions. And to sat­isfy lawyers the ad­min­is­tra­tion did not pur­sue any se­ri­ous tort re­form in mal­prac­tice cases.

A painful com­pro­mise nar­rowly passed by a Demo­cratic Congress, Oba­macare achieved sev­eral laud­able

goals: pro­vid­ing cov­er­age for tens of mil­lions of pre­vi­ously unin­sured Amer­i­cans; en­sur­ing care of pre­ex­ist­ing con­di­tions; al­low­ing young adults to stay on their fam­i­lies’ poli­cies un­til age twen­tysix; sub­si­diz­ing pre­mi­ums for those of mod­er­ate in­comes; and ex­pand­ing Med­i­caid cov­er­age for the poor, dis­abled, and el­derly in many states. But it failed in one cru­cial re­spect, as Rosen­thal ob­serves: “The ACA did lit­tle . . . to con­trol run­away spend­ing.”

In the fi­nal sec­tion of her book, Rosen­thal sets out a series of pos­si­ble re­forms to re­duce the cost and chaos we now en­counter. She rightly ar­gues for greater trans­parency in the pric­ing of tests, like the echocar­dio­gram our rel­a­tive re­ceived. Pa­tients should have easy ac­cess to web­sites that show com­par­a­tive charges among dif­fer­ent hos­pi­tals. Rosen­thal also pro­poses cre­at­ing a na­tional body of ex­perts to as­sess the “cost ef­fec­tive­ness” and “value” of tests and treat­ments, like that in the United King­dom, which sets ac­cess to th­ese el­e­ments of care. We find this idea mis­guided. Paul Dolan and Daniel Kah­ne­man have ob­served that the method­ol­ogy used to cal­cu­late cost ef­fec­tive­ness is deeply flawed. And as Ashish Jha, a widely re­spected health pol­icy re­searcher, recently noted, em­pir­i­cal data largely fail to sup­port the no­tion that pay­ing for “value” im­proves out­comes for pa­tients.6 Fur­ther, much of the prac­tice of medicine ex­ists in a gray zone where there is no one right an­swer for ev­ery­one. In­stead, there is con­tin­ued dis­agree­ment among dif­fer­ent groups of ex­perts about what is best. Ka­bat ex­plains in Get­ting Risk Right that ex­perts have their own bi­ases, of­ten ide­o­log­i­cal rather than fi­nan­cial. He de­bunks

the sim­plis­tic no­tion that the “con­sen­sus among sci­en­tists” is al­ways cor­rect. This is a widely in­voked cri­te­rion or short­cut for de­ter­min­ing who is “right” in a sci­en­tific con­tro­versy. How­ever, the re­sults of a sci­en­tific study should not be ex­pected to line up on one side or the other of a neat yes/no di­chotomy. Un­for­tu­nately, the science is not al­ways clear-cut, and the con­sen­sus on a par­tic­u­lar ques­tion at any given mo­ment may not be cor­rect.

The

Amer­i­can Health Care Act (Trump­care) has been framed as “freedom of choice,” with min­i­mally reg­u­lated com­pe­ti­tion in the health care mar­ket. As a re­sult, pa­tients of limited fi­nan­cial means will be at the mercy of unshackled in­sur­ance com­pa­nies. Some peo­ple with pre­ex­ist­ing med­i­cal con­di­tions may be un­able to get af­ford­able in­sur­ance, while an es­ti­mated 14 mil­lion low-in­come Amer­i­cans who now de­pend on Med­i­caid for health in­sur­ance will no longer qual­ify. Per­haps un­sur­pris­ingly, re­cent polls have con­sis­tently shown that, how­ever dis­sat­is­fied they are with the cur­rent sys­tem, a wide ma­jor­ity of Amer­i­cans are against re­peal of Oba­macare.

Repub­li­can se­na­tors have been work­ing be­hind closed doors on their ver­sion of Trump­care and may try to rush it to a vote as soon as the CBO can an­a­lyze its ef­fects on health care costs and cov­er­age. In early June, Se­na­tor Claire McCaskill, Demo­crat of Mis­souri, de­cried the lack of open de­bate about “a bill that im­pacts one-sixth of the econ­omy.” Even if it doesn’t pass the Se­nate, the Trump health re­form has led to new un­cer­tainty in the health in­sur­ance mar­ket, with some in­sur­ers with­draw­ing from the ex­changes set up un­der Oba­macare.

What is a fea­si­ble step to be­gin to rem­edy our costly and chaotic health care sys­tem? Many in­dus­tri­al­ized na­tions, in­clud­ing Ger­many, Ja­pan, Bel­gium, and oth­ers, have uni­form ne­go­ti­ated na­tional fee sched­ules for hospi­tal ad­mis­sions and clin­i­cal en­coun­ters with doc­tors. Medi­care also does this. Fur­ther­more, Medi­care markedly de­creases ad­min­is­tra­tive costs for both doc­tors and hos­pi­tals, com­pared to pri­vate in­sur­ance. A pub­lic op­tion like Medi­care that pro­vides vi­tal ser­vices and de­votes nearly all of its funds to pa­tient care, ac­tively com­pet­ing in the mar­ket­place with pri­vate in­sur­ance, would be a wel­come step in the right di­rec­tion.7 This could achieve a goal un­met by ei­ther Oba­macare or the Trump­care plan: to re­move money as the cen­ter­piece of our health care sys­tem and re­store the es­sen­tial com­mu­nal re­la­tion­ship that sus­tains pa­tients and physi­cians alike. —June 15, 2017

Don­ald Trump

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