Dear Mr. President-Elect, about that Ryan Plan Thing


The American people, myself proudly included, chose to send you to Washington DC to do their bidding. That’s what happened on November 8th 2016. Everything you hear now from the elite punditry is aimed at obfuscating this simple truth. Forget about dainty glass ceilings, we the people were able to break through the fortified ramparts erected by entrenched money and power and exercise our right to govern ourselves. I would caution the smug intelligentsia against underestimating the wisdom of the people once again, and I would caution you against forgetting who sent you there and why we did so. We now know we have the power, and what the people giveth, the people can taketh away.


The ecstatic welcome you received from Paul Ryan and Mitch McConnell the other day looks more like an act of violence than one of true reconciliation. Fair weather friends are usually there because they want something, and in this case they want to highjack the people’s agenda and replace it with their own conservative garbage. Mr. Ryan in particular has been proposing bogus alternatives to Obamacare with alarming regularity. Similar to Obamacare, Mr. Ryan’s health reform plan is based on belief in his own superior intelligence and devoid of any evidence that it can indeed work. Unlike Obamacare, the Ryan plan is also based on the assumption that helping the poor get poorer and the rich get richer is the ultimate role of government.

A few days before this historic election, I used your Old Post Office renovation project to highlight the big picture facets of health care in America in ways you can easily relate to. It will be very helpful if you read that first, believe me. From reading your latest Obamacare repeal and replace literature, I am starting to think that you are about to swallow Mr. Ryan’s fantasy hook, line and sinker. I would like to remind you that on the campaign trail you promised to replace Obamacare with “something terrific”. In keeping with tradition, the GOP Better Way may be great for GOP corporate donors, but for us, it is anything but terrific.

Have you read Mr. Ryan’s plan, Mr. President-elect? I suggest you do, and I suggest you ask your old friend Chuck Schumer to bridge an introduction to Bernie Sanders, who is perhaps the only other elected public servant not beholden to lobbyists and special interests. If I had to summarize the difference between RyanCare and Obamacare I would say that whereas Obamacare is providing people with a government defined set of health care benefits, RyanCare is proposing to make a government defined financial contribution towards purchase of health insurance. This difference extends to all insurance including Medicaid and Medicare, with RyanCare essentially dismantling Lyndon Johnson’s 1965 landmark legislation. I know you’re now in the “take the lumps out, son” phase, but some lumps were just meant to be taken as is.


While Obamacare and RyanCare differ on how they finance health care services, they are unsurprisingly similar when it comes to controlling health care delivery costs, because this portion of both nightmares was dictated by corporate lobbyists and special interests. When you leave medical decisions in the hands of millions of people interacting with hundreds of thousands of doctors in unique ways, the result is utter chaos, or what we call freedom. The Obamacare lieutenants decided early on that the best way to exert control over costs is to industrialize health care.  You have to admit that this sounds pretty tempting. Industrialization has made lots of things cheaper and often better and more reliable. The conservative Ryan plan, which is by definition dismissive of workers and non-wealthy people in general, went all in with this aspect of Obamacare.

But here we are attempting to industrialize people. Not only is this impossible without enslaving humanity as a whole, but these futile attempts at industrialization are costing us a fortune. This is the fundamental round-hole-square-peg paradigm plaguing both Obamacare and RyanCare, because insurance prices are driven by the prices of goods that are being insured and you cannot have affordable insurance prices for unaffordable products. During the 2008 election season, President Obama made fun of Mrs. Clinton’s proposal to mandate that everybody buys health insurance, because it would be like trying to solve homelessness by mandating that all homeless people buy a house. A couple of years later he did precisely that. RyanCare on the other hand is turning health care into a food stamps program.

Here is the most important piece of health care information you’ll ever need: When you go to a doctor who runs his or her own small business, you pay half as much as when you go to a doctor that is employed by a large health conglomerate, and you get better care to boot.

To be fair, consolidation of health care started decades before Obamacare, but the Obama administration trifecta (the 2009 Stimulus, the 2010 Obamacare and the 2015 MACRA) made consolidation of health care providers pretty much mandatory. In a perverse and illogical way, this set of laws ensures that excessive health care prices are baked into this cake in perpetuity. In particular, the bi-partisan and fairly new MACRA legislation represents a complete regulatory capture of medicine, its transition to indentured servitude to moneyed interests, and hundreds of billions of health care dollars wasted.  Get rid of MACRA Mr. President-elect. Replace it with what Sen. Tom Cotton suggested on the floor right before the Senate voted on it. You do that and you are 90% where we need you to be.

The other day I listened to your favorite negotiator, Mr. Carl Icahn, and his description of how excessive regulations are killing our industries by discouraging capital investment in new machines, which in turn suppresses productivity growth, leaving stock buybacks the only venue for CEO enrichment. Health care is different. In health care, regulatory capture mandates the purchase and expensive operation of machinery that is designed to kill productivity, which leaves consolidation to gain market power, the only revenue enhancing alternative. MACRA is the final, and still removable, nail in this coffin. Whatever you do with Obamacare, if you leave MACRA in place and allow the passage of the 100% lobbyist crafted 21st Century Cures Act, it will all be for naught. To put it in construction terms, if your remodeled Obamacare is the building, MACRA and the Cures Act, are the termites and black mold devouring it from within.

Words that Go Bump in the Swamp

I know the President of the United States sets the tone, but cannot possibly be delving into policy details. Unfortunately, Mr. President-elect, policy details is where corruption lives. You may not be bound by allegiances to money and power, but your political appointees will be. Big league. They will come to you with executive summaries, both written and verbal, so here are three of the most common, most potent and most dishonest health care buzzwords. You should never use them, and you should never use advice from any swamp dweller that is using them, because these are code words for defrauding the public and we, the public, know that, and we are watching carefully. As simple as that.

Patient-Centered – Every calamity in health care is patient-centered. Every time you hear or read patient-centered, repeal and replace it with “circular firing squad”. The most common usage is to demand “transformation to a patient-centered model of care”. Now, you’re a smart man, think. What the hell does that mean? Try these: guest-centered resort, golfer-centered club, gambler-centered casino. See what I mean? People who pitch patient-centered ideas are known as “thought leaders” or “industry experts” and are invariably looking to fleece either doctors or taxpayers or both.

Patient-centered means big health systems using big computers to collect and analyze personal information of patients and target them for certain services that optimize payments and revenues for the system. Very much like the RNC campaign software worked to target voters for you. You think that system was voter-centered? With that answer in mind, perhaps it would be a good idea to remove that patient-centered reference from your website and fire whoever put it there. You are supposed to be the authentic one, remember?

Value-Based – This is a very simple one to understand, because as a businessman, you should know what value-based pricing means, and you should know that it is not something that has the buyer’s welfare in mind. You should also be cognizant of the fact that value-based schemes are intended to enable wealthy patrons to purchase better stuff, while the masses are kept content with generic, cheap stuff. This may work well for socks, but this is not how health care can or should operate. There is no such thing as generic versions of coronary bypass surgery, or buy-one-get-one-free dollar-store stents.

Value-based care is the key to the regulatory capture of medicine. Its sole purpose is to herd doctors and the working class into cheap, substandard systems of health care, and use the leftover money to enrich a vast array of special interests, ranging from insurance companies, think tanks, Silicon Valley vultures, and all the way to software developers in India and computer manufacturers in China. Like all fraudulent schemes to steal hundreds of billions of dollars, this is a huge and very complex subject, but for now you just need to beware people carrying value-based health care solutions. Treat them like they were carrying the plague.

Transparency – I heard you read this term from the teleprompter in a speech about health care. I know you didn’t put it there. Please, stop. President Obama promised the nation that his will be the most transparent administration in history. It ended up being the exact opposite. You said many times during your rallies that you are struck by how smart the American people really are. You were correct in that assessment. We may not look smart, or sound smart, but we are smart and you, of all people, should sympathize with our predicament. We know that a promise of transparency is only necessary if the enterprise is a secretive sham. When you promise transparency in health care prices, we know that we are about to be brutally beaten, raped and robbed. Transparently.

Bottom Line

We did not vote for you because we fell in love with the Republican Party elitist agenda. If that were the case we would have elected Mitt Romney in 2012 or Jeb! 2016. We picked you precisely because we recognized that the conservative agenda, much like the progressive agenda, is an anti-working people agenda. We know what “defined contributions” are. We know what “vouchers” imply. We know what “skin in the game” means for us. And we know what the synonyms for “modernizing” Medicare and “block granting” Medicaid are. Thanks, but no thanks. We didn’t take much of your campaign-trail bluster literally, but we took your promise to be our voice seriously. Consider this a friendly reminder from the deplorable balcony. Godspeed Mr. President-elect!

Categories: Uncategorized

28 replies »

  1. Agree Steven, sheer fantasy by those who worship on the alter of “competition”.

    Insurance sets premiums by actuarial tables of their risk mix. They claim just 15% for profit and overhead. Providers don’t (won’t) want to negotiate, to any great degree, and drug companies have us (and Congress) by the balls. Hospitals won’t cut prices due to large overheads. Who’s going to go first? “Competition” for providers does not give a lot of room to pay them less, and with most markets already with insurance coverage how is a company to leverage into any market promising lower prices?

    So where is all this room for “savings” from “competition” that will be meaningful to the “ordinary working person” with premiums and co-pays and deductibles going up.

    Get the health care lobby money out of DC and there may be hope – lacking that, the Republican (and Trump supporters) delusional fantasy will continue to give false hope.

  2. It is good that you blame the employers, but why not blame third party as well and government that created the third party mess? While you are doing that why not blame the individual that purchased the insurance in the first place.

    You can only hold the physician responsible for his own fees. Asking much more is crap. One can find out a lot of prices by using the old fashioned telephone and in that way one can find the least expensive provider and save money.

  3. I do indeed also blame the self-funded employers. Presumably, they could allow disclosure of the reimbursement rates THEY ARE WILLING TO PAY while the insurer providing ASO services just writes the checks on the employer’s behalf. Different employers reimburse at varying percentages of the usual and customary amount. They could make price discovery much easier for employees and their family members if they wanted to.

  4. “This is all sheer fantasy and will never happen. Taxpayers pay for almost half the health care delivered in the US ”

    I wonder if Steve Findlay has noted that the more government gets involved (including paying for a greater and greater share of healthcare costs) the higher the costs are? This is not a call for no government involvement rather a call for common sense.

  5. I’ll make it easy for you. Call up a small group that uses a surgicenter and find out how much Medicare will pay to the doctors and facility for a colonoscopy. Then call up your local hospital. You will find that the payment to the hospital very significantly greater.

  6. If you do that he should know that individuals from the left, right and libertarians of all stripes have a lot of philisophical agreement on this issue. To date healthcare reform has involved corporatism more than anything else.

    The real difference will be to meld the left’s desire for single payer run by government with a more libertarian approach where people are subsidized by government and have choice. (I know this is rather simplistic.)

    The difficulty arises when one deals with the underlying philosophy behind egalitarianism and meritocracy.

  7. I would like to add that the insurance policy is purchased by the patient, not the doctor so why hold the doctor responsible? The employer is more responsible if he bought the insurance for you in a third party payer setup. You don’t seem to mind third party payer that much. Why not blame all the employers?

  8. I Love this idea. I have been thinking about how to get this input to his people, but I am relatively new to this commenting on policy thing. Email me?

  9. Agree on principle. But I don’t think that sentence on his websites means anything. It is the same thing that appears in the Ryan plan and we (or at least I) know that one is just pure fraud.

  10. Barry, these prices are set by insurers, not by doctors and not by hospitals. The Medicare fee schedule is public and so are the Medicaid ones. I think a bunch of insurers do post prices on their websites now. Either way you look at it, the ball is in the payers’ court on this one, so why harass doctors?

  11. Bernie said today that he will be happy to work with the new President to help working people… so there’s that.

    I merely picked the best item on the shelf of Democracy. Time will tell… My previous choice was indubitably perfect and it didn’t work out so well, so I’m ready to be surprised again.

  12. We should band together and make sure it gets, if not to him, to someone that can influence policy… The Health Care Blog Advisory or something…. Hey, now that I’m typing it….. that may be a really good idea guys and galls…. think about it…..

  13. I voted for President Obama twice. He left health care to his Congress. That’s how the ACA was drafted and that’s why we didn’t get a public option. Trying something new now…

  14. Thanks, Gregg. My biggest worry now is that while everybody is busy freaking out over Trump, Paul Ryan is in a position where he could fulfill Ayn Rand’s most ardent dreams…

    Brace yourself now 🙂
    This is why, I am thrilled that Steve Bannon is in the White House.
    [resist the impulse to type stuff about Bannon that you picked up on CNN, Huff Post, NYT or whatever… Do your research first. I’ve done mine months ago,,, :-)]

  15. Ah, my dear Steven, if we could sit down for a few minutes, I suspect we would agree on 99% of issues….

    The alternative to “industrialized” is not “free market” wild, wild west. Medicare has done a great job of “regulating” FFS. Unfortunately it weighted the menu in favor of powerful specialties. We could clean that up and move forward. Medicare also agreed, again in a bow to power, to pay “facility fees”, we can clean that up and move forward. We can then brainstorm on how to let doctors innovate in their own practice, in their own way, from the bottom up, unshackled, sit back, learn, and move forward. We can let patients go wherever they want to go (traditional Medicare) and reward good care and good service (like real DPC), because nobody wants bad care, nobody. Have Consumer Reports fairly research, evaluate, rate and whatever. Learn from that and move forward.

    All the other monstrosities, of forcing people to buy and use garbage technology, of issuing 5000 pages of regulations on how to give or take a few hundred dollars to/from each doctor ($3 per visit is at stake!!!) is insane. No business, in any industry, would last more than a week if it did accounting this way.

    We cannot possibly get value from a health care system after the bureaucracy is helping itself to 25 cents on the dollar, off the top. What we are now doing is a tragedy. We accept the extraction of money to unearned profit and meandering around the halls with a clipboard, and try to do something with what’s left over. Inevitably, we ask patients to accept less and we tell them that less is actually more and that this really means “value”.

    Where are the damn value-based EHRs? Where are the value-based population management software packages? Where are the value-based consultants? Where are the value-based organizational structures invented by CMS seemingly every Friday at 4pm Eastern? Where is their “skin in the game”? Why is it that poor people always have to donate that pound of flesh or skin or bone or whatever? Why is everybody getting filthy rich in health care if we are so strapped for cash? Why are Medicaid managed care plans laughing all the way to stock exchange?

    We don’t need more transparency Steve, we have plenty already…..

  16. As usual, an engaging post from Margalit–my favorite health policy libertarian! But amid the clever presentation and refreshingly unconventional ideas, there are some very flawed notions, unproven approaches, and unrealistic scenarios.
    The main idea (and I may have this wrong) seems to be to do away with almost all structure (“industrialization”) and regulation and let doctors practice medicine as they see fit, and pretty much charge what they want (especially if they have small practices, because somehow they will charge less). (Will they do less–cheaper and reduce unnecessary care?)
    This is all sheer fantasy and will never happen. Taxpayers pay for almost half the health care delivered in the US (Medicare, Medicaid, VA, military, government employees). Insurers/health plans act as an enforcer of quality and a check on spending in FFS medicine in the private sector. Pretending either is unnecessary or could be done away with in our current system, and that doctors can or should be free of accountability, is just not realistic at all. Doctors essentially work in a public trust, quasi utility environment. And let’s not forget that most make a pretty good living doing so, with average incomes that (adjusted) exceed those of any other industrialized nation.
    That said, I would concur that we have failed as a society, to date, to hold doctors accountable in a way that maximizes their productivity and the quality of care, preserves their sanity, restrains cost growth, and does no harm.
    Why? Because it’s damn hard to do. MACRA is far from perfect but it has evolved from 15 years of initiatives and effort. It garnered bipartisan support for a reason. And the AMA and other doc groups came around to buying into it for a reason (in large part to limit the damage to the profession from more draconian price control measures).
    To suggest that we should not try to enhance (a) “patient-centered” care (yes, I know it’s ill defined and has been co-opted as a buzz term); (b) value-based care (management-speak meaning GET BETTER VALUE IN A SYSTEM WITH 30% WASTE OR THE HEALTH SYSTEM AS WE KNOW IT GOES BUST IN ABOUT 25 YEARS); and (c) transparency—is just, again, not grounded in reality.
    These ideas/approaches won’t solve all the problems in health care. But they all play a useful role as we begin the long and painful reengineering of the health system that we should have no illusions will ever be less regulated by government ….even as a new conservative (or whatever?) administration very likely probably seeks to ramp up competition.

  17. Wow Margalit! A beautifully constructed piece.

    While I did not proudly stand and support the hologram of Trump, I admire the warranted shot over the bow of a reminder for him to claim his independence and drive something forward that truly addresses the healthcare conundrum. Yet, nothing has been or recently offered to suggest he warrants your trust.

    I offered my thoughts here: https://acowatch.me/2016/11/14/as-the-trumpcare-pivots-begins/

    And in 2012 before Obama’s re-election with some admitted ‘energy’ took on RyanCare are well: https://acowatch.me/2012/08/14/ryancare-v-the-affordable-care-act-bring-on-the-death-panels-for-grandma/

    I hope you’re right… but as someone who’s been at this dance managing hospitals, health systems, academic medical centers, IPAs, PHOs, and MSOs since the mid 70s, I’m not as optimistic as you are. Our healthcare borg is both resilient and hungry for ‘more’.


  18. The fundamental problem with the ACA is that it does not address healthcare costs that are more than $1 Trillion higher in the US than in any other developed economy. Part of the reason for Trump’s election is that people continue to see rising out of pocket costs and narrowing networks whether they’re getting insurance through the ACA or not.

    Fiddling around with the mandates and the exchanges does nothing to address the consolidation of pricing leverage resulting from the HITECH mandates and hospital EHR-centered policies of the past 7 years. Fiddling around with the mandates, exchanges, and private insurance regulations without real practice innovation will lower costs only as a result of rationing and will probably increase health care disparities to-boot.

    The most hopeful aspect of Trump’s healthcare plan https://www.greatagain.gov/policy/healthcare.html is: “The Administration’s goal will be to create a patient-centered healthcare system…” To achieve a patient-centered healthcare system, the new administration will need to undo the HITECH policies that give hospitals and EHR vendors veto power over practice innovation.

    Patient-centered healthcare needs patient-centered health records.

  19. Rep. Ryan, I must have been out sick that day in Ayn Rand Skool Econ 101 class where it was taught that simply GIVING citizens federal tax money (aka “premium support” vouchers) so they could buy “affordable” (albeit otherwise unregulated) commercial health insurance was a “conservative” notion. Help me out here.

  20. You voted for him. This is what you are going to get. Trump, like most people in the GOP isn’t that interested in health care. He will leave this up to Ryan and friends.

    ” When you go to a doctor who runs his or her own small business, you pay half as much as when you go to a doctor that is employed by a large health conglomerate, and you get better care to boot.”

    Evidence for this? Might be true for primary care, doubt it, but likely not true for specialty care. Also not true for hospital care. Rather than solo practices, which you seem be suggesting, I think larger private practice models where the physicians themselves own the practice is probably the best, but still difficult to prove they are cheaper.


  21. Dr. Palmer, while I hear and understand what you’re saying, there are also numerous cases that do lend themselves to pricing including most surgical procedures, imaging tests, basic labs, PT, physician E&M time in 15 minute increments, etc. Patients who go to a retail clinic see transparent prices for the menu of basic services they offer but we never see similar posted prices in a primary care doctor or specialist’s office. Why not? It’s probably because of the confidentiality agreements demanded by insurers to preclude disclosure of actual contract reimbursement rates. More and more patients have high deductible health insurance plans these days and it’s more important than ever for them to ascertain what their out-of-pocket exposure will be before services are rendered at least to the extent possible.

    For hospitals, they should be able to quote a price for a day in a standard semi-private or single room or a day in an ICU bed or an hour of operating room time. Cardiac monitoring could also be priced per day, half-day or other appropriate time unit. If you call most hospitals, they can probably tell you precisely how much they charge to park your car in the garage or parking lot but they can’t or won’t tell you what anything else costs. Even recognizing the difficulties you cite in pricing many services, how do hospitals justify presenting patients without insurance a bill that can easily amount to 10 to even 20 times what they routinely accept as full payment from insurers? It’s obnoxious. When these hospitals aren’t killing us with infections, they’re killing us financially. I think they could do a lot better if they really wanted to and if management made it a priority.

  22. “When you go to a doctor who runs his or her own small business, you pay half as much as when you go to a doctor that is employed by a large health conglomerate, and you get better care to boot.”

    Margalit, as usual, excellent post. I do hope Mr. Trump is reading. You summed up the MOST important point above. Thank you.

  23. There aren’t that many natural groupings and make-sense packages for us to quote prices very often. I agree that we should try to do this, but what if we quote a price for a sepsis patient–say a staph skin infection that has gone bad with fever and stiff neck–and we discover diabetes? Are we not supposed to work up the diabetes? We have to sometimes go laterally.

    It’s not just in the physical side of health care either….I wouldn’t have a clue how to quote a price for someone with bipolar disease or a suicide attempt. There are whole vistas of problems where this is not feasible….deep vein thrombosis with ? PE, rehab medicine, metabolic diseases that are poorly known like homocysteinemia, inappropriate ADH (low Na values), masses and lumps that present without a clue as to whether they are benign or malignant, even simple things like psoriasis. How could we quote a price for this if we do not know how fussy the patient is going to be or how complete a remission his circumstances demand? How would you go about giving a quote for the care of a Crohn’s patient?

    You can’t quite think of medicine as you would a car mechanic, although even these guys mostly do not stick to their estimated prices. Lawyers too…often miss on their estimates.

  24. Margalit, in your desperation for a health care system that is pro “working people” you have made a terrible mistake. It’s akin to electing Hitler because you want the trains to run on time.

    There will be so much collateral damage from this election, because of the people Trump owes, that your “victory” and vengeance against the Democratic Party for not nominating Bernie will be hollow, and hurt many more than those wanting a better health system.

  25. I agree on getting rid of MACRA, at least for primary care. In fact, we may need a whole separate simplified business approach just for primary care that could include balance billing. I think there is a much more legitimate need for decent electronic record systems in hospitals and for specialists who practice within a hospital setting where multiple doctors are often involved in a patient’s care and they need to know what each other is doing or has done in real time.

    As for transparency, as a patient, if I’m responsible for paying all of at least part of the bill, I want to know what it’s going to cost me ahead of time before services are rendered and I want to know whether or not a more cost-effective high quality provider may be available as a an alternative. Price discovery is taken for granted in every other area of commerce. Healthcare should be no different.