Category Archives: HealthCare

10 things I’ve learned 10 years after I finished medical school

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Friday’s Random Thoughts: I’ve long argued that the health care system in America is a mess. (How Did Health Care Get to Be Such a Mess?)

These next words from Kevin Tolliver, a physician with a strong exposure to economics and finance, is a welcome addition to the debate. It’s taken a long time to reach the mess we have and it’s going to take a long time and an attitude adjustment among the citizenry if it’s going to get better.

I was once very hopeful that the ABA (ObamaCare) was going to turn the tide toward a better national outcome. But unless the Democrats take over the House of Representatives in 2 months, we’re going to lose any gains we’ve made. There will be an effort in the lame duck session to abolish it entirely. Be prepared to start shouting from the rooftops.

Kevin Tolliver, MD, MBA/Aug 30, 2018

1. Our health care system is broken, and there isn’t going to be an easy way out. Costs are too high and our outcomes too poor. There’s a lot of finger-pointing in how we got to this point, but one thing is for certain — physicians must lead the way to a better system. The heart of health care is still the doctor-patient relationship and that needs to be protected at all costs. Historically speaking, physicians have tended to shy away from the business side of medicine in lieu of caring for patients, but that’s no longer a realistic option. Physician leadership is a must.

2. Nurses are underpaid and underappreciated. Physicians diagnose and develop treatment plans, but the nurses are the ones who carry things out. They’re present for the good, the bad, the embarrassing and whatever else becomes necessary. They spend substantially more time with patients and families than the physician. A competent, compassionate nurse is an invaluable benefit for a physician and shouldn’t be taken for granted. I feel this more strongly with each passing year I work alongside them.

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Here’s What the Average Retiree Spends on Healthcare Each Year Hint: It’s not a small number.

My Comments: As you approach phase two of your adult life, please understand that the economic and financial dynamics can change dramatically.

Retirement is when you have effectively turned off the ‘work for money’ switch and have turned on the ‘money works for you’ switch. That implies you have money and credits in place to pay your bills.

Unless you’re OK with wandering off into the woods to die, health care costs are going to continue and potentially become a noose around your neck. Just know that if you are alive and well today, the day will arrive when you’re not, and in the interim, you’re likely to have a few medical care visits from time to time, and those people do not work for free. Those that do may not provide you with good care.

Maurie Backman Jul 22, 2018

It’s natural to assume that our living costs will mostly go down in retirement, but if there’s one expense that’s likely to rise during your golden years, it’s healthcare. From deductibles to copays to Medicare premiums, healthcare can easily grow to become your single greatest monthly expense — but planning for it can help alleviate some of the stress it causes so many seniors.

So how much money should you expect to allocate to medical costs? The average retiree spends $4,300 on out-of-pocket healthcare expenses each year, according to the Center for Retirement Research at Boston College. Given that the average Social Security recipient collects just under $17,000 a year in benefits, that’s a large chunk of that income to be spending.

Now the good news is that you can take steps to save money on healthcare in retirement. But while you’re optimizing those strategies, be sure to work on boosting your income as well so that you have the means of paying for whatever costs do inevitably come your way.

Make sure you’re financially prepared for retirement

It stands to reason that the more money you have available in retirement, the less worrisome the notion of covering your medical costs will be. And in that regard, padding your nest egg during your working years is really your best bet.

Currently, workers under 50 can save up to $18,500 per year in a 401(k) and $5,500 in an IRA. For workers 50 and over, these limits increase to $24,500 and $6,500, respectively. If you’re 55 years old and are able to max out a 401(k) for the next decade, you’ll add $338,000 to your nest egg, assuming your investments grow at an average rate of 7% a year during that time.

While you’re working on boosting your retirement savings, start thinking about other income streams you might set yourself up to optimize during your golden years. Maybe you have a home you’re willing to rent out or a hobby you can monetize to drum up extra cash. The key is to get a little creative, especially if you’re nearing retirement and don’t have a lot of time to pad your savings the way you’d like.

But don’t forget about Social Security, either. There are ways you can grow your benefits and get more money out of the program to cover your various living expenses, healthcare included.

If you delay filing for benefits past what’s considered full retirement age, those benefits will go up by 8% a year until you reach age 70. This means that if your full retirement age is 67 and you wait a full three years, you’ll boost your benefits by 24%, and that increase will remain in effect for the rest of your life. Fighting for more money at work will also help your benefits go up, since they’re calculated based on your earnings record.

Take good care of your health

While going into retirement with the highest level of savings possible will help make your medical costs more manageable, another important step to take is keeping tabs on your health as you age. All too often, we neglect medical issues because we don’t want to be bothered with waiting at the doctor’s office or don’t want to dish out a pesky copay. But when you let medical problems linger, they tend to escalate, and once that happens, they can become costlier to treat.

Case in point: A nasty cut on your leg might cost you a $25 doctor visit and a $10 bottle of antibiotics. But if you ignore that cut and it gets infected, you could wind up with a $1,200 ER bill. Of course, this applies whether you’re mid-career or on the verge of retirement, but since our health tends to decline as we age, it pays to be even more vigilant when you’re older.

There’s no question about it: Healthcare is a whopping expense that’s pretty much unavoidable for retirees. But there’s no need to let it ruin your golden years. Read up on how Medicare works so you know what to expect from it, save aggressively, and be vigilant about health problems that inevitably arise. With any luck, you’ll be well prepared to tackle those medical bills once your career comes to a close.

Source: https://www.fool.com/retirement/2018/07/22/heres-what-the-average-retiree-spends-on-healthcar.aspx

Medicare open enrollment begins Sunday – and not just for those age 65 and up…

My Comments: Have you noticed a flurry of ads on TV recently talking about Medicare and all the benefits you are entitled to for one easy price per month? I have.

The ads promote the use of Medicare Plan C, also known as Medicare Advantage plans. They are a sop to the insurance industry, giving companies a way to make more money by selling you stuff you may or may not need.

Years ago I decided those extras had little value to me and only lined the pockets of agents and companies at my expense. That’s not to say you might find value with them but as a financial professional, I refused to play the game.

Last year during the open enrollment period, I checked my coverage for Part D, the prescription drug coverage plan. I went to https://www.medicare.gov/, found the spot where you can compare alternatives, and entered the drugs I’m taking for a price analysis. The result was signing up for a different provider and it saved me $85 per month. Not bad.

That being said, if you are already on Medicare or your 65th birthday is around the corner, I encourage you to visit the official Medicare web site. It has good information. Go here: https://www.medicare.gov/

Normally when I write one of these posts it’s to share an article written by someone else. This time I’m simply going to give you two active links to follow if you think any of this is important to you.

Link #1: https://goo.gl/p8nRiF

Link #2: http://flip.it/fg6foM

Remember, there’s also a link just to the right on this page where you can schedule a conversation with me as you wrestle with all this…

How to choose a health insurance policy

My Comments: Having health insurance is critical to maintain your financial well being, much less your long term health. Health care costs in this country are the highest in the world, and the long term outcomes are among the worst.

The budget passed by the House of Representatives includes a significant cut to Medicare, if the media is correct. Why do we keep electing people to Congress who fail to understand their reason for being there in the first place?

Oh, I guess I forgot. They’re there to make money, and the drug companies, the insurance companies, the hospital industry make sure they are properly prioritized.

P.S. – there’s a short window open to get coverage under the ACA. There’s also a short window open to buy a better Medicare Plan D (subscription drug coverage).

Wendy Connick, The Motley Fool Sept. 29, 2017

Given the high cost of major medical treatments, health insurance is a must for just about everyone. But health insurance policies vary wildly in cost, coverage, and other features, so it’s important to choose your plan with your individual needs, resources, and medical history in mind.

Identify your source

If you’re fortunate enough to have employer-provided health insurance, that narrows your options down to the plans that your employer offers. If you don’t have coverage through your job, perhaps an organization or association that you belong to will allow you to buy health insurance through them at a group rate.

Another option is to check your local Obamacare health insurance marketplace to see if you qualify for an upfront premium credit, which would get you reduced premium costs. Even if you don’t qualify for the credit right away, buying your health insurance through the marketplace means you may qualify for it when you file your tax return for the year.

If you can’t, or won’t, get health insurance from any of these sources, you’ll have to fall back on buying a private plan. It will give you the widest range of options, but likely will be far more expensive.

Decide which type of policy to buy

Health insurance policies come in a variety of basic types, although you may not have access to all of these options through your preferred source. Health Maintenance Organizations (HMOs) are a very common type of health insurance policy. With an HMO, you’re required to use healthcare providers within the policy’s network, and you have to get a referral from your primary care physician in order to see a specialist.

Preferred Provider Organizations (PPOs) are also quite common. A PPO health insurance policy has a network, but you’re not limited to in-network care — although using network providers is cheaper — and you don’t need referrals to see specialists.

Exclusive Provider Organizations (EPOs) are a hybrid between HMOs and PPOs. You’re required to stick to the plan’s network, but don’t need referrals for specialists. Finally, Point of Service (POS) plans are a less common option that are essentially the opposite of an EPO. You’re not limited to the POS plan’s network, but do need a referral to see a specialist.

Of the four common types of plans, an HMO or EPO tends to be cheaper than a PPO or POS with the same level of coverage. However, if network coverage is poor in your area, or you’re uncomfortable limiting yourself to network providers, it may be worth paying a little more to get a PPO or POS policy.

High deductible versus low deductible

All things being equal, the higher a plan’s deductible is, the lower the monthly premiums will be. A high deductible means that you’ll have to pay a lot of healthcare expenses yourself before the insurance policy kicks in, but if you have few or no medical expenses in a given year, these plans can be a bargain. Very low medical expenses means that you probably won’t surpass the deductible, even of a low-deductible plan, so getting a high-deductible plan keeps your insurance costs as low as possible while still protecting you in case something catastrophic happens.

If you decide to go the high-deductible route, getting a Health Savings Account (HSA)-enabled plan, and funding it with at least the equivalent of a year’s deductible, is your best option. An HSA plan neatly covers the biggest weakness of a high-deductible health insurance policy — namely, that you’d have to shell out a great deal of money on a major medical expense before the insurance would take over. If you have a full-year’s deductible tucked away in your HSA, you can just use that money to finance your share of the expenses, while simultaneously enjoying the triple tax advantage that an HSA offers.

Comparing coverage

There are two major factors that affect how well a particular plan will cover your medical expenses: the plan’s network and its coverage policies. Even if you choose a plan with out-of-network options, like a PPO, you’re still better off using in-network health providers as much as possible because doing so will reduce your costs. And the rules that a given health insurance policy uses to decide what’s covered and what’s not — and how much the co-pays will be — can make a huge difference in how helpful a particular policy really is for you.

For example, if there’s a rather pricey medication that you take every day, you’ll definitely want to get a health insurance policy that lists that medication on its formulary. If you travel a lot, stick to plans that offer good out-of-area treatment options. And if you already have a primary care physician, you’ll definitely want to pick a plan that includes your doctor in its network.

Finding the best deal

If you’re stuck between two or three different policies and can’t decide which one to choose, try this exercise. Multiply the monthly premium by 12 to get your annual cost for a plan, then add in the plan’s out-of-pocket maximum. The result is the most you would end up spending on health care if you had one or more major medical expenses during the year. Do this calculation for each plan you’re considering, then compare the results. The plan with the lowest total is likely the best deal for you.

Why Sign Up for Medicare If I Have Insurance Already?

My Comments: I’m increasingly asked about signing up for Medicare at 65 or not. This happens as more and more of us are still working at age 65 and expect to keep working for several years to come. This article by Matthew Frankel will give you the background necessary to help your decision.

by Matthew Frankel \ Jul 16, 2017

The standard eligibility age for Medicare in the United States is 65. However, many people don’t know if they need to sign up for Medicare if they already have other health insurance coverage, such as through a job, a spouse’s employer, from their former employer, or through COBRA. Here’s a quick guide that can help you determine if you need to sign up for Medicare when you turn 65 or if you can wait longer without paying a penalty.

How Medicare works with your other insurance

When you have more than one insurance provider, there are certain rules that determine who pays what it owes first and who pays based on the remaining balance. For seniors who don’t have other insurance, Medicare is obviously the primary payer. However, when you have other insurance, it’s a little more complicated.

Depending on the type of insurance you have (group coverage, retiree coverage, COBRA, marketplace coverage, etc.), Medicare can either be the primary or the secondary payer. If Medicare would be a secondary payer to your current insurance, you can delay signing up for Medicare Part B. If your current insurance would become a secondary payer to Medicare, you should sign up during your initial enrollment period, which is the seven-month period that begins three months prior to the month you’ll turn 65.

It’s also worth noting that although I’m specifically mentioning Medicare Part B, which is medical insurance, this applies to Part A (hospital insurance) as well. However, Medicare Part A is free to the vast majority of Americans, so it’s probably worth signing up for Part A whether you’re required to or not. On the other hand, Medicare Part B has a monthly premium you’ll have to pay, which is why it can make sense to delay signing up if it’s not going to be your primary insurance.

Who can delay signing up for Medicare?

So, whose insurance remains the primary payer? In a nutshell, if you have coverage through your or your spouse’s current employment, and the employer has 20 or more employees, your insurance plan remains the primary payer.

If you aren’t sure if your employer meets the “group health coverage” criteria, ask your employer’s benefits manager.

If you do qualify, you can delay signing up for Medicare for as long as you (or your spouse) are still working. Once the employment or your employer-based health coverage ends, you’ll have eight months to sign up for Medicare Part B without paying a penalty, which is a permanently higher premium.

It’s also important to note that regardless of whether you’re still working or not, if you’ve already signed up for Social Security benefits, you’ll be automatically enrolled in Medicare Parts A and B when you turn 65. If you don’t want to keep Part B, you’ll need to cancel it (instructions are on the Medicare card you’ll receive).

Who should sign up at 65, even if they have other insurance?

This leaves a fairly long list of other types of insurance that become secondary payers to Medicare. Therefore, if you’re turning 65 and any of these situations apply to you, you should sign up for Medicare during your initial enrollment period.

• You have group coverage through your or your spouse’s employer, but the employer has fewer than 20 workers.

• You have retiree coverage, either through your former employer or your spouse’s former employer.

• You have group coverage through COBRA.

• You have TRICARE, the healthcare program for military service members, retirees, and their families. Retired service members must get Medicare Part B when eligible in order to keep their TRICARE coverage. (Note: If you’re still on active duty, you don’t have to enroll in Medicare until after you retire.)

• You have veterans’ benefits.

• You have coverage through the healthcare marketplace or have other private insurance. Once your Medicare coverage begins, you’ll no longer get any reduced premium or tax credit for marketplace coverage, and you should drop this coverage as you’ll no longer need it (unless you’re not eligible for premium-free Part A, which is not common).

If one of these situations applies to you and you don’t sign up for Medicare Part B during your initial enrollment period, you could face permanently higher premiums when you do.

GOP confronts an inconvenient truth: Americans want a healthcare safety net

My Comments: Some of my friends continue to decry the notion of socialism. They seem to equate it with communism, a very different animal. It’s too bad they haven’t yet figured out that it’s not a rejection of capitalism. For me, because the word has accumulated so many negatives, not unlike the Confederate flag, I’ve searched for an alternative.

I’m a profound believer in capitalism. But I’m smart enough to know that unfettered capitalism becomes an attack on society, where the have’s get to enslave the have nots.

There are hundreds of millions of people on this planet who benefit from social order, whether it’s rules that tell us which side of the street to drive on, or taxing the population to provide national parks. Where along the lengthy path of human development over time would anti-socialist have us return in their efforts to reject the benefits of social order? And does anyone have a suggestion for what to call it?

by Noam N. Levey – July 28, 2017 – Los Angeles Times

The dramatic collapse of Senate legislation to repeal the Affordable Care Act may not end the Republican dream of rolling back the 2010 healthcare law.

But it lay bare a reality that will impede any GOP effort to sustain the repeal campaign: Americans, though ambivalent about Obamacare in general, don’t want to give up the law’s landmark health protections.

“There may be a whole lot of Americans who are complaining about government, but that doesn’t mean they agree with eliminating the safety net,” said former Sen. Dave Durenberger, a Minnesota Republican and healthcare policy leader in the 1980s and ’90s. “We saw that with Social Security and Medicare in Reagan’s day. Now it is a much broader group of people who rely on those health protections.”

And as the Senate debate this week illustrated, Obamacare’s safety net — both guaranteed insurance for the sick and expanded Medicaid coverage for the poor — proved too valued to tear apart.

That means that, while attacks on Obamacare will probably continue, it’s increasingly unlikely that President Trump or GOP congressional leaders will be able to rip out the law “root and branch,” as Senate Majority Leader Mitch McConnell (R-Ky.) once promised.

The GOP’s failure to dismantle the expanded healthcare safety net also may provide an opening for Republicans and Democrats to cooperate on measures to help Americans who have struggled in recent years with rising premiums brought about, in part, by Obamacare.

“Now the real work lies before us,” March of Dimes President Stacey D. Stewart said Friday, following the defection overnight of three GOP senators who voted against a last-ditch Republican bill to begin unraveling the law.

“Our healthcare system and the laws that govern it are far from perfect, and many opportunities exist to find areas of common ground to make improvements,” Stewart said

The March of Dimes is among scores of patient advocacy organizations, hospitals, physicians’ groups and others who bitterly fought the GOP repeal push, warning of disastrous consequences for tens of millions of sick and vulnerable Americans.

This was not how Republicans had sketched out repeal.

For years, GOP politicians cast themselves as saviors, promising to deliver Americans from a law that former Republican presidential candidate Ben Carson, now Trump’s Housing secretary, once called the “worst thing that has happened in this nation since slavery.”

Demonizing Obamacare, initially a derisive label the GOP coined for the ACA, proved good politics. Republicans scored major victories in the 2010, 2014 and 2016 elections on pledges to roll back the law.

But the successful political message — which built off deep partisan divisions — obscured much broader support for the law’s core elements.

For example, 80% of Americans in a national survey last fall reported favorable views of allowing states to expand Medicaid to cover more poor adults, and of providing aid to low- and moderate-income Americans to help them buy health coverage, two pillars of the law.

The same proportion, according to the poll by the nonprofit Kaiser Family Foundation, liked the law’s insurance marketplaces, which allow consumers to shop among health plans that must offer a basic set of benefits.

Nearly 70% backed the law’s coverage guarantee, which prohibits insurers from turning away people due to their medical history of preexisting conditions.

“As a law, Obamacare got caught up in the politics of the time. It became the symbol of the Obama administration,” said Mollyann Brodie, who oversees polling for the Kaiser Family Foundation. “But the policies themselves have always been quite popular, even among Republicans.”

GOP politicians didn’t have to reckon with that contradiction as they took dozens of essentially meaningless repeal votes while Obama was still in the White House to veto their bills.

That changed after the 2016 elections. No longer was repeal an abstract political slogan.

It was a concrete set of plans that cut insurance subsidies for millions of Americans, slashed hundreds of billions of dollars in federal Medicaid assistance to states and weakened coverage guarantees by allowing insurers to once again charge sick people more for coverage.

That is not what Americans wanted, said Dr. Jack Ende, president of the American College of Physicians.

“No version of legislation brought up this year would have achieved the types of reforms that Americans truly need: lower premiums and deductibles, with increased access to care,” said Ende, a University of Pennsylvania primary care doctor.

Independent analyses of the GOP repeal bills by the Congressional Budget Office and others estimated they would leave tens of millions more Americans without health coverage and drive up costs for many older and sicker consumers.

In the crosshairs were not just unemployed adults whom conservative critics derided as freeloaders, but also poor children, disabled Americans and seniors who worked all their lives but depended on Medicaid for nursing home care.

Altogether, nearly 1 in 4 Americans rely on Medicaid and the related Children’s Health Insurance Program for coverage.

And as the repeal debate dragged on in Washington and in congressional districts across the country, stories of these Americans and others who rely on Obamacare’s healthcare protections brought the safety net to life.

National polls ultimately showed that fewer than 1 in 5 Americans surveyed supported the Republican repeal legislation.

By contrast, 60% of Americans in a recent Pew Research Center poll said that it is the federal government’s responsibility to ensure all Americans have health coverage — the highest level in nearly a decade.

Even many Republican state leaders — including the governors of Ohio, Nevada and Arizona — balked at the congressional rush to roll back the Medicaid safety net. In a bipartisan letter to Senate leaders this week, several of these governors urged lawmakers to turn away from the repeal push.

“We ask senators to work with governors on solutions to problems we can all agree on: fixing our unstable insurance markets,” wrote the governors — five Republicans and five Democrats.

Some congressional Republicans seemed reluctant to give up the repeal campaign. “As long as there is breath in my body, I will be fighting for the working men and women of this country that are being hurt by Obamacare,” Texas Sen. Ted Cruz said after the vote early Friday morning.

And conservative activists continue to demand action. “In Washington, there are no permanent victories or permanent defeats,” said Heritage Foundation President Edwin J. Feulner.

The president, meanwhile, reiterated his threats to “let Obamacare implode,” as he said in a Twitter post after the early Friday vote.

The administration could potentially sabotage insurance markets across the country by refusing to enforce the current law’s requirement to buy insurance or withholding payments to health insurers that subsidize costs for very low-income consumers.

But at the Capitol, Democrats and some Republicans appear willing to begin considering legislation to protect those markets and help millions of American consumers who have seen insurance premiums rise dramatically in recent years.

“Simply letting Obamacare collapse will only cause even more pain,” warned Rep. Kevin Brady (R-Texas), chairman of the powerful House Ways and Means Committee.

Fixing the safety net represents a far better approach than a new push to tear it down, said Durenberger, the former GOP senator.

“Bipartisanship is the only option,” he said.

How Did Health Care Get to Be Such a Mess?

My Comments: trump famously commented that he had no idea health care reform could be so complicated.

There are five principal stakeholders in our health care delivery system: insurance companies, pharmaceutical companies, hospitals, the medical profession, and lastly, we the consuming public.

All five have vested interests they want to grow and preserve, and all five have legitimate claims against the other four. None of them have enough leverage by themselves to either correct or make the system better.

I endorsed the introduction of the ACA because it created another vested stakeholder that by its nature, could put the other five in a subordinate role and slowly cause remedies to surface with the ultimate goal being a better outcome for all of us.

But it was flawed from the start and for political reasons alone, no one had the necessary leverage to fix the flaws. So we are where we are and everyone is still pissed off. The one redeeming thought from the past 8 years is that there is an increasing acceptance in our society that access to health care is a social benefit. The discussion will slowly evolve to figuring out how to pay for it, and by whom, instead of a purely capitalist approach which says, in effect, it’s everyman for himself. Leaving people out in the street to die is not an acceptable outcome for most of us.

I don’t claim to know the answer. But discuss it we must, and that calls for a better understanding of how we got to where we are today. This article by Ms. Chapin is useful in that regard.

By CHRISTY FORD CHAPIN \ JUNE 19, 2017

The problem with American health care is not the care. It’s the insurance.

Both parties have stumbled to enact comprehensive health care reform because they insist on patching up a rickety, malfunctioning model. The insurance company model drives up prices and fragments care. Rather than rejecting this jerry-built structure, the Democrats’ Obamacare legislation simply added a cracked support beam or two. The Republican bill will knock those out to focus on spackling other dilapidated parts of the system.

An alternative structure can be found in the early decades of the 20th century, when the medical marketplace offered a variety of models. Unions, businesses, consumer cooperatives and ethnic and African-American mutual aid societies had diverse ways of organizing and paying for medical care.

Physicians established a particularly elegant model: the prepaid doctor group. Unlike today’s physician practices, these groups usually staffed a variety of specialists, including general practitioners, surgeons and obstetricians. Patients received integrated care in one location, with group physicians from across specialties meeting regularly to review treatment options for their chronically ill or hard-to-treat patients.

Individuals and families paid a monthly fee, not to an insurance company but directly to the physician group. This system held down costs. Physicians typically earned a base salary plus a percentage of the group’s quarterly profits, so they lacked incentive to either ration care, which would lose them paying patients, or provide unnecessary care.

This contrasts with current examples of such financing arrangements. Where physicians earn a preset salary — for example, in Kaiser Permanente plans or in the British National Health Service — patients frequently complain about rationed or delayed care. When physicians are paid on a fee-for-service basis, for every service or procedure they provide — as they are under the insurance company model — then care is oversupplied. In these systems, costs escalate quickly.

Unfortunately, the leaders of the American Medical Association saw early health care models — union welfare funds, prepaid physician groups — as a threat. A.M.A. members sat on state licensing boards, so they could revoke the licenses of physicians who joined these “alternative” plans. A.M.A. officials likewise saw to it that recalcitrant physicians had their hospital admitting privileges rescinded.

The A.M.A. was also busy working to prevent government intervention in the medical field. Persistent federal efforts to reform health care began during the 1930s. After World War II, President Harry Truman proposed a universal health care system, and archival evidence suggests that policy makers hoped to build the program around prepaid physician groups.

A.M.A. officials decided that the best way to keep the government out of their industry was to design a private sector model: the insurance company model.

In this system, insurance companies would pay physicians using fee-for-service compensation. Insurers would pay for services even though they lacked the ability to control their supply. Moreover, the A.M.A. forbade insurers from supervising physician work and from financing multispecialty practices, which they feared might develop into medical corporations.

With the insurance company model, the A.M.A. could fight off Truman’s plan for universal care and, over the next decade, oppose more moderate reforms offered during the Eisenhower years.

Through each legislative battle, physicians and their new allies, insurers, argued that federal health care funding was unnecessary because they were expanding insurance coverage. Indeed, because of the perceived threat of reform, insurers weathered rapidly rising medical costs and unfavorable financial conditions to expand coverage from about a quarter of the population in 1945 to about 80 percent in 1965.

But private interests failed to cover a sufficient number of the elderly. Consequently, Congress stepped in to create Medicare in 1965. The private health care sector had far more capacity to manage a large, complex program than did the government, so Medicare was designed around the insurance company model. Insurers, moreover, were tasked with helping administer the program, acting as intermediaries between the government and service providers.

With Medicare, the demand for health services increased and medical costs became a national crisis. To constrain rising prices, insurers gradually introduced cost containment procedures and incrementally claimed supervisory authority over doctors. Soon they were reviewing their medical work, standardizing treatment blueprints tied to reimbursements and shaping the practice of medicine.

It’s easy to see the challenge of real reform: To actually bring down costs, legislators must roll back regulations to allow market innovation outside the insurance company model.
In some places, doctors are already trying their hand at practices similar to prepaid physician groups, as in concierge medicine experiments like the Atlas MD plan, a physician cooperative in Wichita, Kan. These plans must be able to skirt state insurance regulations and other laws, such as those prohibiting physicians from owning their own diagnostic facilities.

Both Democrats and Republicans could learn from this lost history of health care innovation.

Christy Ford Chapin is an associate professor of history at the University of Maryland, Baltimore County, a visiting scholar at Johns Hopkins University and the author of “Ensuring America’s Health: The Public Creation of the Corporate Health Care System.”