Sorry, Republican Congress. Health care is complicated

As the GOP is still learning, healthcare is complicated. It was easy to throw darts at the length and complexity of the Affordable Care Act, but the truth is the law hangs together remarkably well and is long for a reason. Meanwhile, some of the GOP’s main proposals are easy looking, digestible concepts that can be explained at the 5th grade reading level. Unfortunately, they won’t achieve their goals or are counterproductive.

Here are a couple that are swirling around this week:

  1. Get rid of mandatory benefits so that people don’t have to buy more than they want or need. After all why would a man need pregnancy coverage or mammography screening? Sounds good, but it turns out that those mandatory benefits only drive costs to a small degree. The main drivers of premium increases are rising provider reimbursements and higher utilization of people with pre-existing conditions who are now able to get coverage. Sure, if you remove coverage for hospitals, doctors or prescriptions premiums will drop, but what kind of insurance would that be?
  2. President Trump is threatening to withhold subsidies that help low-income Obamacare customers pay their out-of-pocket expenses. Sounds like a hawkish budget move. But it turns out the maneuver would actually increase federal spending. That’s because health plans would end up raising premiums and federal subsidies would automatically increase as a result.

There are more examples. Here are a couple:

  • Selling health insurance across state lines. It’s already allowed but no one wants to do it because it doesn’t make economic sense.
  • Rejecting the Medicaid expansion. Some states say they can’t afford it, which is nonsense since the feds pay the vast majority of the cost. If they stop states could just cancel the expansion.



By healthcare business consultant David E. Williams, president of Health Business Group.

Partners buys into Rhode Island: I’m quoted in the Boston Globe

Partners HealthCare plans to purchase Care New England in Rhode Island. Not a surprising move, considering  that Partners wants to continue to expand but is running into roadblocks in Massachusetts. Rhode Island is practically down the street.

I’m quoted in the Boston Globe’s coverage (Partners to acquire R.I.’s Care New England)

“This is a logical move for Partners, which has received strong pushback in its recent attempts to expand in Massachusetts, but is less likely to face the same pressures in Rhode Island,” said David E. Williams, the president of Health Business Group, a Boston consultancy. “The acquisition is geographically close to Partners’ existing network, and they already have a clinical collaboration. Rhode Island regulators will likely appreciate Partners’ financial strength and the stability it is likely to promote.”

By healthcare business consultant David E. Williams, president of Health Business Group.

USPSTF adopts my reasoning on PSA screening for prostate cancer


Which way on PSA?

I oppose over-testing and over-treatment, so I really had to think hard five years ago when I turned 45 and my doctor offered PSA screening for prostate caner. The US Preventive Services Task Force (USPSTF) had just come out against PSA screening, concluding that the harms outweighed the benefits.

Nonetheless (Why I decided to get a PSA screening test for prostate cancer), I did go forward. As I wrote:

I know that PSA is a very imperfect indicator. I definitely want to avoid the stress and possible discomfort of having a biopsy. I’m worried about false positive and false negative biopsy results. And I don’t relish the significant potential for incontinence, impotence, or bowel problems from treatment.

But at this stage of my life I am willing to accept a significant risk of morbidity in exchange for a small reduction in mortality risk, which is my impression of what my choice to have the PSA test means. In 10 or 20 years I probably won’t feel that way. And I hope there will be better detection, follow-up and treatment options by then.

I’m also confident in my ability to make informed choices with my physicians along the way. The PSA test itself was done as part of routine blood work and there was no additional risk from that. My doctor and I agreed that if the PSA is elevated we’ll discuss what to do next. At that stage I’ll also have the chance to do more research and get more opinions if necessary. I’m not automatically going to get into a cascade of follow-up and treatment.

Now the USPSTF appears to be coming around to my way of thinking. In particular, they note that more men are choosing “active surveillance,” i.e., keeping a close watch rather than jumping straight to aggressive treatment.

The choice about whether to undergo PSA testing and what to do once results are in is a great opportunity for shared decision making. And this is what should be encourage.

By healthcare business consultant David E. Williams, president of Health Business Group.

Direct Primary Care: Interview with Dr. Jeffrey Gold


When we think of insurance, it’s usually for things that are rare and expensive. You never want to use your car insurance, fire insurance, or disability insurance and you don’t use file a claim for routine things like changing the oil, buying a fire extinguisher or missing a day of work with a sore back. Insurance works best when it spreads big risks over a large pool of people.

But healthcare is different, and health insurance covers even small, routine things like primary care physician visits. Direct primary care practices change the model because they are paid directly by the patient, not the insurance company. That keeps costs down and increases the alignment between doctor and patient.

I like the idea, and in fact I interviewed an early practitioner of primary care back in 2009, before the Affordable Care Act!

Recently, I spoke with Dr. Jeffrey Gold, of Gold Direct Care in Marblehead, MA. He filled me in on how his practice works and why he’s a proponent of the direct model.

  • (0:10) What do you mean by “direct” primary care?
  • (0:47) How does that feel different from a typical primary care office? Is it the same thing as a concierge practice?
  • (4:58) You don’t accept insurance. Does that affect your overhead and enable you to be more cost effective?
  • (7:08) What happens when a patient goes out of your orbit to see a specialist or be hospitalized? Do you still have to deal with insurance companies then?
  • (9:38) Are there particular kinds of patients that are a really good fit for a direct care model?
  • (11:22) What would be the impact on the overall healthcare system if every patient were a direct care patient?
  • (14:10) Does the Affordable Care Act help or hinder what you are doing? What changes would you like to see in the healthcare law?

By healthcare business consultant David E. Williams, president of Health Business Group.

Trump’s next health care bill: Medicaid for all?

Donald Trump knows almost nothing about healthcare policy. He doesn’t know what’s in the ACA/Obamacare or how it works –just that it’s a “disaster,” and since the abandoned American Health Care Act ran directly counter to his promise to “take care of everybody” it’s fair to assume he doesn’t care about what’s in these laws either. He just wants a big win.

A lot of the populist attacks on Obamacare boil down to the individual exchanges/marketplaces. People complain about high and rising premiums and point their finger at Obama. Frankly, I’m skeptical about many of these complaints. Premiums were rising faster before the exchanges came into being and it was often impossible to get insurance if you were sick or had a pre-existing condition. Also, most Obamacare exchange users receive significant subsidies and many receive help on out-of-pocket payments as well. And let’s remember that Republicans at the state and federal level have been trying to sabotage the exchanges by refusing to set up state exchanges (despite supposedly being in favor of state-level control), not funding risk corridors, not advertising for members, resisting the hiring of exchange navigators, spreading misinformation about the program, and more.

But I say to Obamacare haters: go ahead and unplug the exchanges. They are a Republican idea anyway. Replace them with something better if you can think of it –my guess is you can’t.

Now, what to do with the people who are thrown out of coverage by a shutdown of the exchanges? The Congressional Republican approach appears to be to let insurers sell skinnier policies that more people can afford, while enforcing the retention of popular Obamacare policies like a ban on medical underwriting and allowing people to stay on their parents’ plans to age 26. That won’t work –as they’ll find out if they ever put it in place, and the number of uninsured people will skyrocket.

So here’s a radical idea: kill off the exchanges and let insurers do whatever they please in the individual market. But at the same time make Medicaid available as a cheap backup plan for anyone who wants it. It will be free for the poor as it is today, but others can pay some fraction of the cost based on their income. No need to rely on the Obamacare exchanges in that case. And Medicaid is better than other federal and private programs at keeping costs under control, so it will be a double win. We already see that the Medicaid expansion is becoming popular in Republican led states, so why not just expand it some more?

Obamacare opponents can dress up the Medicaid for All bill however they like. In fact, why not include some of the big GOP “ideas” that will have little to no practical effect and say that’s what made the law work? I’m referring to allowing health plans to sell across state lines, promoting drug reimportation, allowing tax deductibility for individuals’ purchases of health insurance, and expanding Health Savings Accounts.

As I’ve said in the past (Goodbye Obamacare? More like hello single payer!) Donald Trump will have us on the path to socialized medicine faster than you can say Vladimir Vladmirovich Putin.

Images courtesy of Thanamat and Stuart Miles at

By healthcare business consultant David E. Williams, president of Health Business Group.