Here’s How Trump Will and has Already Started to Change Obamacare

16832291_1114393575356967_1937264909174955317_nBut the effect is already being felt. Consider, an article written by Peter Orszag, the Ninth Circuit Court of Appeals in San Francisco on Feb. 9 upheld the restraining order on President Trump’s immigration ban. A key argument used by the States of Washington and Minnesota was the negative impact of the ban on higher education, but an important corollary is the impact on medical care in the U.S. While the world waits for a final decision on the matter, potentially from the Supreme Court, it’s critical to look at the potential ramifications of the ban.

Regardless of the ultimate ruling, the travel ban has already had significant consequences for people from the seven targeted majority Muslim countries and American citizens. Doctors are among those people directly affected – and that has big implications for health care delivery in U.S. hospitals, particularly those in rural America and inner city safety net hospitals. Physicians who are citizens of these nations who were traveling outside the country at the time of the ban have been detained or refused access to the U.S.

Larger-scale, lasting effects of a ban on the graduate medical education system are likely to be even more severe and may further strain an already overstretched health care system and affect the care of communities across the U.S. Indeed, the president of the American Medical Association already has written a letter to the Department of Homeland Security, explaining how the ban could affect those who are already underserved by limiting doctors from other countries.

As physicians involved with educating and training the next generation of doctors, we see dire consequences for health care delivery in our country if the travel ban is reinstated. There is a looming deadline that even though the ban has been temporarily lifted, the timing could not be worse for international applicants hoping to train in the U.S. While new resident physicians typically begin on July 1, the match process that allots positions occurs much sooner. On Feb. 22, residency program directors must submit their rank list of which applicants they would like to have in their program.

Therefore, without clear signs that travel for foreign applicants will be possible by July, program directors who want to protect their training program from staffing shortages may decide against ranking these applicants. The loss of a single incoming class of international medical graduates will significantly decrease the number of residents in training and physician capacity in hospitals and health care systems across the U.S.

Graduates from outside the United States constitute 26 percent of the U.S. graduate medical training. These foreign medical graduates usually fill resident training positions that are left vacant after medical schools match U.S.-based students to residency programs. Why is this and what are we doing wrong in this country not to fill the training spots?

Therefore, foreign graduates typically do not take spots away from graduates of American medical schools, but instead provide medical care in hospitals that will otherwise be understaffed. These include rural hospitals around the country, where it is especially hard to recruit physicians, and safety net hospitals serving the poor.

Consider the effect on primary care and that even if all current residency positions could be filled with U.S. medical school graduates and eliminate the need for any additional resident physicians from outside the U.S., the projected demand for physicians in the near future will still not be met.

Physicians in graduate medical education provide a significant proportion of all health care in the U.S., with teaching hospitals accounting for 40 percent of charity care (US$8.4 billion annually) and 28 percent of Medicaid hospitalizations. Without sufficient residents to care for patients, teaching hospitals are ill-equipped to maintain this role for the poorest patients and may not continue to meet this critical societal need.

Physicians who are both foreign-born and U.S.-born and trained outside the country constitute more than a quarter of all practicing physicians in the U.S. While the country of origin of these doctors is not often reported on a country-by-country basis, a recent interview with the Association of American Medical Colleges reported 260 physicians in training were from the seven targeted nations last year.

Expanded travel bans could dramatically increase that number as, between 2008 and 2010, 16 percent of these international medical graduates taking a required licensing exam were from Middle Eastern countries. It is predicted that the most severe effect will be felt as a drop in primary care providers. These international physicians also disproportionately work in primary care fields that are the hardest hit by the ongoing U.S. physician shortage crisis.

Currently, primary care programs have 50 percent of their residency slots filled by nonallopathic students and international medical graduates, whose absence could cripple primary care capacity.

Having a primary care doctor leads to increased access to care, reduced emergency department visits, decreased hospitalizations and improved management of chronic conditions, and decreased acute care utilization can lower overall health care spending. Similarly, general surgery has seen a 13 percent decrease in U.S. graduates in the specialty; however, this shortcoming has been buffered by influxes of international medical graduates. Delays in scheduling operative cases have also been associated with increased health care costs, making adequate numbers of surgeons another cost containment strategy.

Without international physicians entering the graduate medical education workforce, it would require substantial changes to maintain the current level of physician staffing in health care systems, such as replacing physicians with midlevel providers which may further inflate health care costs.

While physician shortage is a challenge for many communities across the U.S., the pain will not be distributed equally among all Americans. Minority and low socioeconomic status patients are more likely to suffer from increased physician shortages, are most likely to be impacted by increased wait times to get care, and stand to lose the benefit of having a primary care doctor that has also shown to confer benefits to at-risk populations.

President Trump’s immigration ban has the potential for immediate ramifications for the hospital and health care system workforce in the U.S. Long term, decreases in the number of international medical graduates in training will result in fewer primary care physicians and general surgeons, just as the country is likely to need more.

This immigration policy can have significant adverse impacts on health care delivery and the health of Americans. These consequences should be critically considered in related immigration and travel ban policy decisions moving forward.

There is something really flawed in our education system if we can’t educate and train sufficient physicians, nurses and ancillary staff to care for the patients in our own country.

Consider other effects on health care if Trump and the GOP get their way and repeal the Affordable Care Act. Promises made by Donald Trump and Republicans in Congress to repeal and replace the Affordable Care Act are proving to be more complicated than they sounded on the campaign trail. With reality now setting in, what’s most likely to happen?

I expect to see Republicans stage a dramatic early vote to repeal, with legislation that includes only very modest steps toward replacement — and leave most of the work for later. Next, the new administration will aggressively issue waivers allowing states to experiment with different approaches, including changes to Medicaid and private insurance rules. At some point, then, the administration will declare that these state experiments have been so successful and that Obamacare no longer exists.

In other words, the repeal vote will be just for show; the waivers will do most of the heavy lifting. I predict something like this will happen and I am pretty sure of this outcome because of two core challenges that stand in the way of Republicans’ replacing the ACA through legislation: the need for so-called community rating and the need to have 60 votes in the Senate to pass a comprehensive new health-care law.

First, consider the importance of community rating. It is one of the basic building blocks needed to create a workable private insurance market — whether Democrats or Republicans are doing the building. If your insurance covers a pre-existing condition but at a cost of, say, $100,000, that doesn’t really help. Community rating requires that your premium be the same as that of other people in your area, no matter how unhealthy you are.

With community rating in place, the next step is to recognize how easy it is to game the system: People can just wait until they get sick, then buy insurance at the community rate. To discourage that practice, the system needs to give people some strong incentive to purchase insurance before they get sick. The Affordable Care Act used an individual mandate; most Republican plans instead propose a requirement for continuous coverage. That is, people enjoy access to community-rated premiums in the future only if they have kept themselves insured over some period of time in the past.

Given the costs involved, subsidies are also needed to ensure that low- and moderate-income households can afford the coverage. This overall structure means that younger, healthier people implicitly subsidize older, sicker people.

Such are the inescapable constraints imposed by community rating. Community rating could be discarded, as Mark Pauly of the University of Pennsylvania has argued. Pauly instead proposes that insurance companies be allowed to vary people’s premiums according to their health status, and that general revenue be used to pay sicker people’s higher premiums. This would require substantial new taxes, however, which is presumably a nonstarter in a Republican plan. In any case, it would only make the transfers to older, sicker people more explicit.

The second challenge is more nakedly political: Without a substantial change in Senate procedure, a bill to fully replace the Affordable Care Act, including changes to insurance rules, will require 60 votes. Republicans have only 52, so at least eight Democratic senators would need to be persuaded to go along. This is a much tougher assignment, especially since the administration will already be calling in legislative favors on ongoing confirmations, the debt limit, tax reform and other issues.

The Republicans’ desire to hold an early partisan vote repealing the ACA (through the reconciliation process that requires only a simple majority in the Senate) seems too strong to resist. The repeal will probably be set to become effective in the future, perhaps 2019 or 2020.

This vote will probably be closer than many people think, given the concerns that some moderate Republican senators have expressed about repealing the ACA with no replacement ready. Some far-right Republicans may also balk at anything less than a full immediate repeal. For the White House, however, the closeness of the vote will be a feature rather than a bug, because it will create the impression that the vote is significant.

The repeal legislation will probably include some modest steps toward replacing the ACA, but these will be mostly symbolic measures such as allowing insurance companies to sell across state lines (which by itself would do little to lower people’s premiums). The hard work of a creating comprehensive replacement is then likely to get bogged down in legislative muck.

But the administration can use its expansive waiver authority to allow states to experiment with both Medicaid and the individual insurance markets. As these 50 flowers bloom, President Trump could at some point declare victory and assert that the ACA has been sufficiently reformed.

This approach, whatever its potential substantive shortcomings, provides a major political benefit: The administration would not necessarily own the many problems that inevitably would remain. In response to any particular complaint in a specific state, the administration could simply shrug its shoulders and direct the inquiry to the relevant governor.

This outlook assumes that the Republican leadership in Congress isn’t willing, or lacks the votes, to change the Senate’s traditional rules, and that a comprehensive replacement for the ACA will indeed require 60 votes. If that changes, all bets are off.

This Week’s Outline of GOP plan to replace ACA has few surprises

Shannon Muchmore sums up the “progress or lack of progress in health care reform.

  • An outline of the Republican plan to replace the Affordable Care Act was leaked Thursday after a meeting among Senate Republicans, The New York Times reports.
  • The document is a blueprint modeled after the House Republican’s plan called A Better Way, with age-based tax credits to help people buy insurance and more reliance on health savings accounts.
  • President Donald Trump said in a tweet early Friday that repeal and replace of the ACA is “moving fast” and House Speaker Paul Ryan said earlier this week he expects legislation to be introduced possibly as early as next week.

The GOP plan leaked Thursday contains few surprises but does leave out some key areas. It makes no mention of changing Medicare into a premium support plan, which Ryan has supported but Trump has been wary of.

The plan also makes no mention of how it would be paid for. Bloomberg has reported, however, that the GOP may be considering capping the tax breaks on employer-sponsored health insurance. This would be a major tax policy change. Policy analysts tend to support the idea but it could be a tough sell for lawmakers eyeing reelection.

The plan does address Medicaid, and essentially guts the expansion put forward by the ACA. It would roll back the generous cost sharing for states that expand eligibility and give states either a fixed sum per beneficiary or a block grant. Either way, far fewer people would be covered, leading to more uninsured and without access to care. Medicaid, even though I hate the reimbursements to physicians for the health care that they provide to their patients for those who need health care and can’t afford third party insurance.

“This would mean fewer people could afford health insurance and that the health insurance would likely cover less,” says Larry Levitt, senior vice president at the Kaiser Family Foundation.

Under the plan, states that expanded eligibility for Medicaid would see their supplemental federal funding rolled back. The program would also be converted from a federal-state program that pays for all the health care beneficiaries get, to one where Washington sends a fixed amount of money to each state for each Medicaid enrollee.

To help people who don’t get insurance through their employer buy coverage, the bill offers age-based tax credits that start at $2,000 for individuals under age 30. It would rise to $4,000 for those over 60. Those credits are unlikely to cover the full cost of a plan that pays for routine health care, but could potentially pay for insurance that protects against a catastrophic health event.

Levitt says those credits are less generous than the subsidies offered under Obamacare. This could be unpopular, even among fellow Republicans. A handful of GOP governors in expansion states have said the move has improved healthcare access and their state’s economy.

One of the most politically explosive pieces in the draft of legislation, which is currently unnamed, is defunding Planned Parenthood, a move that some Republicans see as too dangerous. According to the draft, no federal funds could go to a “prohibited entity.” The bill includes abortion provider in its definition of “prohibited entity.”

Congress returns again and Republican leaders will push for legislation to be introduced as soon as they receive more guidance from the Congressional Budget Office, which is scoring some of their proposals.

So, is there any news about the Trump Care Act? Not Really.

Remember my suggestion…..modify Obamacare to retain the good parts, modify the parts that don’t work and figure out how to pay for the system that doesn’t financially “screw” the young healthy workers who presently shoulder the financial burdens with outrageous premiums and even worse deductibles. Even physicians don’t want to get rid of all in the Affordable Care Act. One of the biggest impediments to an affordable health care system that covers everyone is sustainability. In the next few weeks I will report on the advances or frustrations in the GOP/Trumpcare healthcare system and attempt to out line what would really happen if Obamacare is repealed as well as a true plan for a successful sustainable health care system…..Really???!!!???!!!


No Fake News Here-So Where is the Health Care System After 4 Weeks of the Trump Presidency?

16406937_1098787356917589_7943843917564142116_nI think we are all sick and tired of the media pointing out President Trump’s faults and inadequacies and Trump pointing out the media’s lies and ability to makeup fake news. Therefore, I thought that I would only report the real news.

The leader of one of the U.S.’s largest health insurance agencies—who has been saying for months that ObamaCare is on the ropes– said Wednesday that statistics indicate that the law has now entered a “death spiral.” Aetna’s CEO Mark Bertolini told The Wall Street Journal that the health law’s market is nearing failure because healthier people have dropped out while premiums continue to climb.

Health insurer Humana announced it is leaving the law’s public insurance exchanges for next year as it regroups after ending its proposed combination with rival insurer Aetna. Humana Inc. covers about 150,000 people on exchanges in 11 states.

The Trump administration took steps Wednesday intended to help calm jittery insurance companies and make tax compliance with former President Obama’s health law less burdensome for some. The administration’s actions signal a change in direction.

For consumers, the proposed rules mean tighter scrutiny of anyone trying to sign up for coverage outside of open enrollment by claiming a “special enrollment period” due to a change in life circumstances such as the birth of a child, marriage, or the loss of job-based insurance. Also, sign-up season will be 45 days, down from the current three months. For insurers, the curbs on special enrollment periods are a big item. The industry claimed that some consumers were abusing special enrollment by signing up when they needed expensive treatments, only to drop out later.

Aetna is considering reducing its presence in the markets set up by ObamaCare, Bloomberg reported. The insurer already reduced its footprint in four states after losing $450 million last year. Insurers also would gain more flexibility to design low-cost coverage tailored to younger people. In another move aimed at consumers who move in and out of coverage, insurers would be able to collect back premiums from customers who had stopped paying, then tried to sign up again for another year.

Separately, the IRS is backing off from a tighter approach to enforcement that was in the works for this tax-filing season. Under the law, people are required to have health coverage or risk fines from the IRS — a penalty usually deducted from a taxpayer’s refund. That underlying requirement remains on the books, and taxpayers are still legally obligated to comply, the IRS said.

But the agency is changing its approach to enforcement. Originally, the IRS had planned to start rejecting returns this year if a taxpayer failed to indicate whether he or she had coverage. Now the IRS says it will keep processing such returns, as it has in the past. Many of the law’s supporters consider the coverage requirement essential for nudging younger, healthy people into the insurance pool to keep premiums in check.

Hours after his inauguration President Trump signed an executive order directing federal agencies to look for ways to ease requirements of the 2010 health care law. The IRS said in a statement that it is following through, but “taxpayers remain required to follow the law and pay what they may owe.”

It was also recently reported by Yasmeen Abutaleb that U.S. healthcare costs to escalate over next decade. The cost of medical care in the United States is expected to grow at a faster clip over the next decade and overall health spending growth will outpace that of the gross domestic product, a U.S. government health agency said on Wednesday.

A report by the U.S. Centers for Medicare and Medicaid Services (CMS) cited the aging of the enormous baby boom generation and overall economic inflation as prime contributors to the projected increase in healthcare spending.

Overall healthcare spending will comprise 19.9 percent of the economy in 2025, up from 17.8 percent in 2015, the report forecast. The pace of growth in U.S. spending on health is expected to pick up in 2017, increasing 5.4 percent over 2016. That compares with an estimated 4.8 percent spending uptick in 2016. Spending for 2016 was estimated at $3.4 trillion.

When the final numbers are in, the growth in prescription drug spending for 2016 is expected to have slowed to 5 percent from 9 percent in 2015. However, CMS has forecast growth of 6.4 percent per year between 2017 and 2025, in part because of spending on expensive newer specialty drugs, such as for cancer and multiple sclerosis.

The projections for 2016 to 2025 were made assuming that the Affordable Care Act (ACA), former President Barack Obama’s signature healthcare law widely known as Obamacare, would remain intact. It does not take into account likely changes to the law.

The Republican-led Congress and President Donald Trump have vowed to repeal and replace the ACA, but a viable replacement plan has yet to emerge. Trump signed an executive order on his first day in office last month to freeze regulations and enable government agencies to take other steps to weaken Obamacare.

The ACA expanded Medicaid, the government health insurance program for the poor, in more than 30 states and set up private healthcare exchanges that enabled previously uninsured people to buy health insurance. After high enrollment between 2014 and 2015, Medicaid and private health insurance spending were expected to have slowed in 2016.

But spending on Medicare, the government health insurance program for the elderly, is expected to grow between 2017 and 2025 as a larger elderly population requires more medical services.

The overall insured rate of the population is expected to reach 91.5 percent in 2025, up from 90.9 percent in 2015, the report said.

So, what are the Republicans doing about it?? House Republican leaders shared general descriptions Thursday with rank-and-file lawmakers of how they’d propose replacing President Barack Obama’s health care law, with little detail. Highlights are based on a document distributed to legislators obtained by The Associated Press and interviews with lawmakers, aides and lobbyists:

MEDICAID: Phases out Obama’s expanded Medicaid coverage for more low-income people that 31 states accepted, which is nearly completely financed by federal funds. States could continue covering current beneficiaries for an undefined “limited period,” but the extra federal money would expire. The 19 states that didn’t expand would get additional money. In the future, states could decide to receive Medicaid money based on the fluctuating number of beneficiaries in the state and other health factors, or a lump sum.

OBAMA’S INDIVIDUAL MANDATE: Penalty for not buying coverage would end immediately. During transition away from Obama’s system of subsidizing most people who buy insurance on online marketplaces, younger people could get slightly bigger subsidies than today and those for older people might get smaller. That’s an attempt to draw younger, healthier people into insurance markets in hopes of stabilizing them that’s opposed by groups representing seniors like AARP.

TAX CREDITS: Available for people not covered by employers or government agencies. Paid in advance, refundable so people with little or no tax liability would get an IRS check. Higher credit for older people, not based on income. Not usable for plans that cover abortions.

TAXES: All or some of the Obama overhaul’s tax increases on high-earners, health care companies and others would be repealed. Taxes could be levied on the value of employer-provided health coverage exceeding $12,000 for individuals, $30,000 for families.

HEALTH SAVINGS ACCOUNTS: People could contribute more than current annual limits of $3,400 for individuals, $6,750 for families.

HIGH-RISK POOLS: States would get federal money to help people with costly conditions to afford coverage.

MEDICARE: Proposes no changes.

COSTS: No estimates provided.

So, will these ideas work?

First: House Republicans are debating a plan to replace the Affordable Care Act that would give consumers tax credits to buy insurance, cut back on Medicaid and allow people to save their own money to pay for health care costs.

The outline plan is likely to take away some of the financial help low-income families get through Obamacare subsidies, and also result in fewer people being covered under the Medicaid health care program for the poor. “In general this is going to result in fewer people covered nationwide,” says Caroline Pearson, a senior vice president at Avalere, a health care consulting group.

Republican leaders distributed the skeleton proposal at a meeting of the House Republican Conference in the Capitol on Thursday. Lawmakers now have an outline to bring with them to their districts for the Presidents Day holiday weekend, where they may face constituents with questions about what is going to happen to their health care. The plan is based on one outlined last summer by House Speaker Paul Ryan.

Rep. Bill Huizenga, R-Mich., called the 18-page outline “guideposts and a road map.”

“We know the direction we want to go and sort of the destination,” Huizenga said outside the meeting.

Lawmakers who attended the meeting said the plan is to repeal the Affordable Care Act with a bill similar to one that passed in 2015 but was vetoed by then-President Barack Obama. That proposal would have repealed all the taxes and subsidies associated with the health care law and would have killed the mandate for individuals to buy health insurance by getting rid of the tax penalty used to enforce it.

This Congress could either first pass a repeal bill and then a replacement bill, or include replacement elements in the repeal. The meeting Thursday centered on “principles and goals on where we’re going in patient-centered care,” said House Ways and Means Committee Chairman Kevin Brady, R-La., after the meeting.

“We’re talking about repealing, replacing and starting to return control of health care and restoring the free market,” he said.

Most of the plan is silent on how much money lawmakers want to put behind their proposals, so it’s impossible to know exactly how generous the plan is and how many people it would cover.

The elements of the plan include replacing the subsidies that help people buy insurance through Obamacare exchanges with fixed tax credits to buy coverage on the open market.

The major difference between the two is that the Obamacare subsidies increase as premiums rise so that consumers are responsible for the same premium amount, which is tied to their income. The tax credits proposed by Ryan are not tied to income but rise as a person ages and insurance rates increase.

“The important thing on the tax credits is that they’re not income adjusted and we don’t know how big they are,” Pearson says. She says it’s unlikely they’ll be as generous as the Obamacare subsidies. “This likely means that low-income people will have difficulty affording individual insurance,” she says.

The outline distributed by Republicans repeatedly mentions that people will be able to buy so-called catastrophic coverage, which has limited day-to-day benefits but protects people when they have a serious illness or accident that requires a lot of health care.

The plan also calls for expanding health savings accounts, which allow people to save their own money tax-free to pay for health care costs. It calls for the limits on HSA savings to rise from $6,750 per family to $13,100.

HSAs are a favorite among conservatives because they encourage people to save and plan for their health spending and to shop around for price. Democrats have criticized the focus on HSAs because they only help people who have extra money to put away and give a bigger tax cut to people with higher incomes. Something that I have also pointed out in my blog.

The Republicans’ plan also calls for a major restructuring of the Medicaid health care program for the poor. It would repeal the Medicaid expansion that most states adopted under the Affordable Care Act, which allowed able-bodied people with incomes just above the poverty line to become eligible for Medicaid coverage.

And it would cap how much the federal government spends per person per year. Right now, Medicaid pays all health care costs for those who are eligible.

“This is a potentially significant incentive for states to get serious about efficiency,” says Paul Howard, director of health policy at the Manhattan Institute, a conservative think tank.

Howard says states currently have an incentive to increase their spending on Medicaid, because it boosts the amount of federal money they get. Ryan’s plan would make Medicaid either a block grant program, where states receive a fixed amount of money, or it would be a per capita benefit, where the federal government would give the states a set amount for each beneficiary. States could still offer Medicaid to those who became eligible under expansion, but the states’ share of the costs would be higher than it is under the Affordable Care Act, likely making it too expensive for many states to do so.

Finally, the Republican plan would offer states pools of cash to come up with ways to expand insurance access to more people.

At this point Senator Rand Paul ran out of the meeting disgusted with the lack of any real plans and no real progress in developing a real working plan.

In thinking of the Health Savings Accounts I thought of this article which examines the perplexing psychology of saving for health care by Oivind Hovland.

Spending your own money on health care might mean that you’ll be more frugal with it. That’s the theory behind health savings accounts; a decades-old GOP concept that’s sparking renewed interest on Capitol Hill as Republican lawmakers look for ways to replace the Affordable Care Act.

HSAs are like personal savings accounts — with a difference. As with a retirement account, money put into an HSA can be invested, and any growth in the fund accumulates tax-free. Withdrawals can be made at any time, and they are tax-free, too — but the money can be used only to pay for certain medical expenses, such as health insurance deductibles, or for copays for hospital care or a visit to the doctor.

Currently, HSAs are only available to people who have high-deductible health plans, meaning they usually pay a few thousand dollars for medical care each year before their insurance kicks in to pay its share. While HSA participation is growing, only about 20 million people out of the 176 million who have health insurance participate in these savings accounts, according to a 2015 report by the Association of Health Insurance Plans.

Why don’t more people who are eligible for HSAs have them? For one thing, not everyone has money to contribute upfront. But psychologists and behavioral economists point out that even many people who have the extra cash on hand confront big psychological barriers to saving.

“How we think and feel is directly tied to our ability to make ‘good’ financial decisions,” says Alycia DeGraff, a board member and secretary of the Financial Therapy Association. DeGraff says when faced with financial decisions about the future, many people simply get stressed out.

“These stressors can become so overwhelming that … we can become debilitated and ignore the situation altogether,” she says. “Or we can practice any kind of defense mechanism — entitlement, suppression, overcompensation, isolation, etc. — to try and deal with [it].”

This may explain, at least in part, why middle-class Americans are pretty bad at saving money in general. Only about half of us have money in any sort of retirement account. And those of us who are parents have only saved, on average, enough to pay for about one year at an in-state college for our kids.

Saving money is hard. It means setting aside what we want now for something we think we’ll want or need later. And we live in a culture that offers a lot of pretty, shiny, things to buy RIGHT NOW.

Plus, we all pretend we won’t get old or sick.

“People are predictably irrational,” says Dr. Mitesh Patel, especially when it comes to money. He’s a behavioral economist, physician and assistant professor at the University of Pennsylvania’s Perelman School of Medicine.

But many of us really hate to lose money, Patel says, which is what makes the concept of HSAs is so appealing. For example, he and his colleagues published a study last year in the Annals of Internal Medicine on what motivates people to lose weight, and found that the way a financial incentive was framed made all the difference.

The researchers observed three groups of people for 13 weeks. They told one group to walk 7,000 steps a day. About 30 percent of the group did so. Meanwhile, people assigned to the second group were told they’d be paid $1.40 every day they walked 7,000 steps. About 35 percent of the second group did so.

Here’s the kicker: Each person in the third group was paid $42 upfront and was docked $1.40 each time they failed to meet their goal. Forty-five percent of that group met the assigned goal, Patel says. People hate to lose money.

Another way to encourage more saving might be to make HSAs operate more like the 401(k)s that required people who didn’t want to participate to actively opt out of the plan — rather than requiring people who want to contribute to opt in. “This creates a path of least resistance,” Patel says.

Of course, setting up and overseeing such a plan would likely cost the government some money, he notes.

People with HSAs do use less health care than those without such plans, a recent study from the Employee Benefits Research Institute suggests. But it’s unclear whether they actually improve their health. Prescription drug costs went down for people enrolled in HSAs in the EBRI study, but emergency room visits went up — particularly for lower-income families.

Then there’s the issue of figuring out how much you, as an individual or a family, would need to save for health care — it’s not easy to find out the average price for a medical test or procedure in your town, let alone how much that price varies from doctor to doctor or hospital to hospital.

“If you want to save for a house, you can pretty much figure out the math,” Patel says. “But if you go to a doctor, they don’t give you a menu for prices.”

To really increase their health savings — or any savings — we’d all need to change our mindset, says Degraff, the financial therapist.

“People would have to first take a dose of reality and get real about their future selves,” she says. Naturally, we think our future selves will be “better, healthier, more financially secure,” she adds. But, for many of us, health and income eventually decline with age. We need to save more now for later.

HSAs can be useful, Degraff notes, but only for those who have enough cash to pay their day-to-day expenses — plus a little left over.

“A lot of people don’t even have a regular emergency fund savings,” DeGraff says, “especially those that are already struggling to pay for health insurance.”

Will the Republicans ever come up with a plan that works? Not sure that they will get it right, but next week I will review the elephant in the room: Mr. Trump and what he could actually do to health care.

Let’s continue with non-fake news.

The AMA Holds Funeral Service for Physical Exam; and Is Technology Changing the Way we Practice Medicine?

16684123_1106335246162800_8399871417867272601_nI was troubled last year when my daughter came home from her new primary care doctor and was she angry. Her new doctor asked her some questions, never looked at her, touched her, listened to her heart or lungs, felt her pulse but scheduled her back for a second visit for her travel vaccinations. And yes we received a huge bill since we have a very large deductible health care insurance plan. Even more of an insult was the new premium that my daughter received from her insurance company increasing her premium by 125%. Hard to believe how the young employees can pay for their healthcare- their insurance premiums as well as their health care visits, medications, laboratory teats, etc.

I thought that this week after such weird goings on in the political arena, (are all of our politicians crazy?) that we all needed a little laugh. But article written by Dr. Glaucomflecken (name withheld due to potential the innocents laughing out loud) brings up some serious thoughts about clinical medicine, especially considering my daughter’s experience and the more and more similar experiences that my own patients relate to me almost daily.

The American Medical Association held a large funeral service today in honor of the Physical Exam, which passed away earlier this month after a decade long battle with obscurity. The funeral was well attended by nurses, medical doctors, and trainees from all over the country who wished to pay their respects. The service began with an hour-long tribute to the highlights of a centuries old career diagnosing illness, with special recognition given to the following: (these are all part of the physical exam, which is/or has previously been taught to every future doctor in medical school, but now it seems that the technology seems more important)

S3, S4, and “murmurs,” whatever those are

Palpating the point of maximal impact

Percussing the lungs

Percussing in general

Measuring liver span

Actually putting your own finger into the rectum to examine it

Doing that thing where you have the patient swallow some water then feel their thyroid

Femoral pulses

Reflexes not involving the knee

Cranial nerve I

Pinprick test

Temperature sensation

Any part of the exam where human contact is involved

Following a display of the Physical Exam’s most prized possessions, including a stethoscope, reflex hammer and a little vial filled with coffee beans, several health care providers gave moving eulogies in remembrance of an old friend.

Tim (60-year-old internist): “I’ll miss you dear friend. My intimate knowledge about you was my only defense against the onslaught of millennial EMRs and imaging studies. I could always count on you to show me findings that, although might not have any clinical significance whatsoever, could at least be used to humiliate a resident for missing it.”

Lucy (24-year-old resident): “Dear Physical Exam, we never really knew each other. You were already pretty old and inconsequential by the time I started medical school. However, I still sometimes put on my stethoscope and listen to the strange thuds, beeps, and boops coming from inside the patient that used to be important. Hell, I’ll even write about those crazy sounds in my progress notes like I’m a real 1950s primary care doctor. But then I look at the telemetry and think to myself, technology is pretty awesome. Lolz!”

So, in which direction are we going and is it in the correct direction? Is technology, our computers, drones and robots with all the complex algorithms controlling the future of our lives and our health care? Consider the following article.

Will Algorithms Erode Our Decision-Making Skills?

Algorithms are embedded into our technological lives, helping accomplish a variety of tasks like making sure that email makes it to your aunt or that you’re matched to someone on a dating website who likes the same bands as you.

Sure, such computer code aims to make our lives easier, but experts cited in a new report by Pew Research Center and Elon University’s Imagining the Internet Center are worried that algorithms may also make us lose our ability to make decisions. After all, if the software can do it for us, why should we bother?

“Algorithms are the new arbiters of human decision-making in almost any area we can imagine, from watching a movie (Affectiva emotion recognition) to buying a house ( to self-driving cars (Google),” Barry Chudakov, founder and principal at Sertain Research and StreamFuzion Corp., says in the report. But despite advances, algorithms may lead to a loss in human judgment as people become reliant on the software to think for them.

That’s one of the conclusions made in the report. It included responses from 1,300 technology experts, scholars, businesspeople and government leaders about what the next decades hold for the future of algorithms.

One of the themes that emerged was “humanity and human judgment are lost when data and predictive modeling become paramount.” Many respondents worried that humans were considered “inputs” in the process and not real beings.

Additionally, they say that as algorithms take on human responsibilities, and essentially begin to create themselves, “humans may get left out of the loop.” And although some experts expressed concern, others gave reasons algorithms were a positive solution and should expand their role in society.

Here’s a sampling of opinions about the benefits and drawbacks of algorithms from the report: Bart Knijnenburg, an assistant professor in human-centered computing at Clemson University: “My biggest fear is that, unless we tune our algorithms for self-actualization, it will be simply too convenient for people to follow the advice of an algorithm (or, too difficult to go beyond such advice), turning these algorithms into self-fulfilling prophecies and users into zombies who exclusively consume easy-to-consume items.”

Rebecca MacKinnon, director of the Ranking Digital Rights project at New America: “Algorithms driven by machine learning quickly become opaque even to their creators who no longer understand the logic being followed to make certain decisions or produce certain results. The lack of accountability and complete opacity is frightening. On the other hand, algorithms have revolutionized humans’ relationship with information in ways that have been life-saving and empowering and will continue to do so.”

Jason Hong, an associate professor at Carnegie Mellon University: “The old adage of garbage in, garbage out still applies, but the sheer quantity of data and the speed of computers might give the false impression of correctness. As a trivial example, there are stories of people following GPS too closely and ending up driving into a river.”

Amali De Silva-Mitchell, a futurist and consultant: “Predictive modeling will limit individual self-expression hence innovation and development. It will cultivate a spoon-fed population with those in the elite being the innovators. There will be a loss in complex decision-making skills of the masses.”

Marina Gorbis, executive director at the Institute for the Future: “Imagine instead of typing search words and getting a list of articles, pushing a button and getting a narrative paper on a specific topic of interest. It’s the equivalent of each one of us having many research and other assistants. … Algorithms also have the potential to uncover current biases in hiring, job descriptions and other text information.”

Ryan Hayes, owner of Fit to Tweet: “Technology is going to start helping us not just maximize our productivity but shift toward doing those things in ways that make us happier, healthier, less distracted, safer, more peaceful, etc., and that will be a very positive trend. Technology, in other words, will start helping us enjoy being human again rather than burdening us with more abstraction.”

David Karger, a professor of computer science at MIT: “The question of algorithmic fairness and discrimination is an important one but it is already being considered. If we want algorithms that don’t discriminate, we will be able to design algorithms that do not discriminate.”

Daniel Berleant, author of The Human Race to the Future: “Algorithms are less subject to hidden agendas than human advisors and managers. Hence the output of these algorithms will be more socially and economically efficient, in the sense that they will be better aligned with their intended goals. Humans are a lot more suspect in their advice and decisions than computers are.”

Isaac Asimov inspired roboticists with his science fiction and especially his robot laws. The first one says:

A robot may not injure a human being or, through inaction, allow a human being to come to harm. Artist and roboticist Alexander Reben has designed a robot that purposefully defies that law. “It hurts a person and it injures them,” Reben says. His robot pricks fingers, hurting “in the most minimal way possible,” he says.

And the robot’s actions are unpredictable — but not random. “It makes a decision in a way that [I] as the creator cannot predict,” Reben says. “When you put yourself near this robot, it will decide whether or not to hurt and injure you.”

Though it may seem like a slightly silly experiment, Reben is making a serious point: He’s trying to provoke discussion about a future where robots have the power to make choices about human life. Something that we need to consider seriously as we see driverless cars and the possibility of the “robot-car” choosing whether the passenger deserves to live!!!!!

Reben’s robot is not very elaborate. It’s just a robotic arm on a platform, smaller than a human limb and shaped a bit like the arm on one of those excavators they use in construction — but instead of a shovel, the end has a pin. (And in case you were wondering, each needle is sterilized.)

“You put your hand near the robot and it senses you,” Reben explains. “Then it goes through an algorithm to decide whether or not it’s going to put the needle through your finger.”

I put my finger beneath the arm. The waiting is the hardest part, as it swings past me several times. Then I feel a tiny sting when it finally decides to prick me.

Reben created this robot because the world is getting closer to a time when robots will make choices about when to harm a human being. Take self-driving cars. Ford Motors recently said it planned to mass-produce autonomous cars within five years. This could mean that a self-driving vehicle may soon need to decide whether to crash the car into a tree and risk hurting the driver or hit a group of pedestrians.

“The answer might be that ‘Well, these machines are going to make decisions so much better than us and it’s not going to be a problem,’ ” Reben says. “They’re going to be so much more ethical than a human could ever be.”

But, he wonders, what about the people who get into those cars? “If you get into a car do you have the choice to not be ethical?”

And people want to have that choice. A recent poll by the MIT Media Lab found that half of the participants said they would be likely to buy a driverless car that put the highest protection on passenger safety. But only 19 percent said they’d buy a car programmed to save the most lives.

Asimov’s fiction itself ponders a lot of the gray areas of his laws. There are a total of four — the fourth one was added later as the zeroth law:

  1. A Robot may not harm humanity or by inaction allow humanity to come to harm.
  2. A robot may not injure a human being or, through inaction, allow a human being to come to harm.
  3. A robot must obey the orders given it by human beings except where such orders would conflict with the First Law.
  4. A robot must protect its own existence as long as such protection does not conflict with the First or Second Laws.

In Asimov’s stories, the laws are often challenged by the emotional complexities of human behavior. In a screenplay derived from his famous I, Robot, the protagonist is a detective who doesn’t like robots because one had saved him in a car crash, but let the girl beside him die based on a statistical determination that she was less likely to survive.

Still, scientists in the field as a kind of inspiration and talking point often cite Asimov’s laws as we move toward a world of increasingly sophisticated machines.

“The ability to even program these laws into a fictional robot is very difficult,” Reben says, “and what they actually mean when you really try to analyze them is quite gray. It’s a quite fuzzy area.” Reben says the point of making his robot was to create urgency — to put something in the world now, before machines have those powers in self-driving cars. Will they transform into machines that can truly think and make decisions to “take over the world?”

“If you see a video of a robot making someone bleed,” he says, “all of a sudden it taps into this viral nature of things and now you really have to confront it.”

Wow, I am almost scared to consider all this. We have telemedicine and all, or most of the new regulations in medicine and more important, the new requirement that the patient’s health care, social, preventative care and planning needs to be inputted into computer Electronic Medical Records. Protocols have already been put into play to determine the care of the patient, how many days that the patient is allowed in the hospital as well as “suggestions” for appropriate care. Don’t get me wrong there are great advances in technology with activity trackers, patches that measure blood glucose, and more, which can help plan the patient’s healthcare. I think we have to be careful that we forget the diagnostic basics of interaction with our patients and the importance of listening, seeing, touching, yes even smelling and using the basic instruments, the otoscopes, stethoscopes and then utilizing the technologies at our convenience, to reaffirm our diagnoses.

The Big Business Disrupters and their Influence on Health Care.

16298392_1090247417771583_9185795102683978035_nI bet you thought that I meant President Trump as the disrupter. Although he is becoming the great disrupter I really was referring to Uber and others. My wife and I were in New York City this past weekend and it still amazes me how Uber as well as its competitor Lyft has changed the taxi cab business that others like Yellow Cab and Diamond Cab has for decades controlled.

Disruption is happening at different speeds for different industries shouldn’t lead those industries where it’s happening slower to assume it’s not happening. The worst thing would be to feel like it’s not hitting your industry and to wake up in five years and find out that, actually, the fundamentals have changed. The other thing is, disruption is not all negative. For some players, disruption represents huge opportunity and upside. Whereas, for others, it’s really about containing the damage.

Look at the effect of the Minit Clinics, and the Walmarts and the Mega Drug Stores offering vaccinations and healthcare in their clinics and stores. Walgreens has more than 400 in-store Healthcare Clinics and CVS Health had more than 800 MinuteClinics and by the end of the year 1,035 clinics with plans for 1,500. Today,

About 10.5 million patients a year visit more than 1,800 retail clinics in the U.S., according to a recent report by Manatt Health Solutions, the healthcare division of law firm Manatt, Phelps & Phillips. Traditional provider organizations have also joined the fray.

I was more concerned when I saw 2 more articles.

First there was: Wal-Mart launches new primary care clinics in South Carolina- Lauren Sausser wrote last year that Gov. Nikki Haley and two high profile health care advisors boarded a private plane to Bentonville, Ark., more than a year ago for a closed-door meeting with Wal-Mart executives. They hoped to convince the largest retailer in the country to launch a new primary care strategy in South Carolina.

Healthy Connections Checkup-The South Carolina Medicaid agency launched a new program called Healthy Connections Checkup on Friday. It will provide preventive screenings and family-planning benefits to an estimated 300,000 residents who fall below 194 percent of the federal poverty level. The program is less comprehensive than traditional Medicaid, but it will cover adults who are ineligible for the regular low-income health insurance program.

It’s also much less expensive to administer. Healthy Connections Checkup costs the state approximately $300 per person per year, compared to at least $3,000 a year for regular Medicaid.

“We’ve put public health and prevention and screenings front and center where it should be,” said Medicaid Director Tony Keck. Critics argue that the program is well intentioned, but that it will not benefit uninsured patients who are truly sick because it only covers the cost of screening, not actual treatment. Keck replied, “There are many, many organizations that see people for free or for a reduced cost. When we find people who need care and aren’t able to pay for it, we can connect them.” “We told Wal-Mart, ‘We think this is perfect,'” said Tony Keck, director of the state Medicaid agency, who attended the meeting.

And then there were the articles about Uber: Uber-a-docs: Changing the healthcare landscape for better or worse? Meg Bryant wrote last year that there was a time when a person could ring up the doctor’s office and arrange for their physician to see them in their home. The image of the black bag-toting doctor was ubiquitous in primary care. But that changed as the healthcare system evolved and medicine became more high-tech. Now, the house call is trying to make a comeback via a slew of apps that promise convenient, same-day diagnosis and treatment at a fixed price.

But one question lingers: Is it the best way to use physicians’ time and skills? Some say house calls are time-sucks “House calls are inherently inefficient.” “House calls for physicians are more convenient for patients and they allow the doctor to avoid the overhead of a physical office,” Harvard health policy professor Ateev Mehrotra said via email. “However, they are inherently inefficient because the visit reimbursement has to cover both time of the doctor in the visit and the travel time.”

Physician Jason Parkinson, who launched a solo practice offering house calls in New York City in 2007, agrees. Writing in the online magazine Quartz, Parkinson says up to 60% of his day was spent traveling between apartments in two neighborhoods and to and from the pharmacy or his apartment for supplies and vaccines. While a typical primary care doctor can see about 30 patients a day in the office, the maximum number he saw in a day was eight. “Doctors already spend roughly 40% of their day documenting and doing other administrative tasks,” he wrote. “To waste the other 50-60% of your day traveling between patients is a 50-60% reduction in efficiency.”

Parkinson adds: “Short of teleportation, the doctor house call will always be an irresponsibly massive reduction in primary-care efficiency.” He has since co-founded a digital healthcare service called Sherpaa, which provides online consultations for patients. Triage is essential for success. Andrew Chomer, vice president of marketing for Uber-offshoot Pager, acknowledges the concern, but believes there is a sustainable model for house call apps.

“If it was just a house call service, that time is kind of inoperable,” Chomer tells Healthcare Dive. Pager’s doctors use Uber to get to and from patients, so travel time is frequently used to follow up with patients or for a telehealth call.

Pager’s platform offers three possible care paths. As soon as they hit the button on the app, the user is connected with a nurse who assesses what the problem is and the level of care that is appropriate. If the issue can be handled by a phone call or videoconference, then it is triaged to telemedicine. If it can’t be resolved via phone or internet chat, the next step is to consider a house call. If Pager doesn’t feel the problem is within the scope of its services, the patient is referred to a specialist or emergency room. The company, which operates in and around New York City using its own medical practice, has partnerships with Weill Cornell Medicine and New York Presbyterian Hospital.

Pager marketing VP says about 60% of calls are handled by telemedicine and 40% are house calls. Chomer says about 60% of calls are handled by telemedicine and 40% are house calls. Overall, about 10% lead to referrals. Pager, which fielded “in the tens of thousands” of calls from individual and enterprise clients last year, boasts a 99% customer satisfaction rate.

Triage is essential if physician house call businesses are going to succeed, says Gorkim Sevinc, managing director of Johns Hopkins Medicine Technology Innovation Center, who doesn’t want to see healthcare “commoditized like a cab ride.” Not all health concerns require an actual doctor visit, so the question is “how do we become a little bit more smart about deciding who should be seen and who should not be seen?” he says. Not every house call app provides a filtering process. Sevinc also worries the rise of house call services like Pager, Mend, and Dispatch Health will erode the traditional patient-doctor relationship.

“The biggest thing about a primary care [physician] and a patient is to start to establish trust and have a relationship between them,” he says. While these apps are great and they fill a certain demand demographic (the individual can’t venture out, they need to see someone right away), in most instances “I would prefer to go to my PC because I have an established relationship with them,” Sevinc adds. “How am I going to establish a relationship when I am swiping left and right on an app?”

As more of these apps spring up across the country, there are other concerns, too, such as patient safety. “Some of these services that are talking about being able to sew someone up at their kitchen table — is that a sanitary environment? Is the lighting good? Is the proper equipment available to handle some type of medical emergency that might occur?” urgent care expert Alan Ayers asked ABC 7 in Denver.

Spared no expense? Patient access is also an issue. On the one hand, house calls lower the barriers to access by allowing anybody to request a doctor and have them there quickly. On the other hand, most, if not all, are not covered by insurance and require cash payment upfront. For an in-patient visit, Pager charges $50 the first time and $200 for each subsequent visit. Other companies report fees in the $150-$200 price range.

The issue comes back to value and the best use of doctors’ time, says Sevinc. “If I’m paying out of pocket for this, if my insurance is not covering it, what is that sweet amount that I am okay with paying that is also value enough for the physician to actually travel to me?

Triage is essential if physician house call businesses are going to succeed. The insurance picture may be changing. According to Chomer, Pager is in the process of becoming in-network with some “well-known” carriers and expects to roll that out in the third or fourth quarter of this year. The company is also looking at possible opportunities with Medicare and Medicaid in the future, he says.

According to Healthcare Finance News, the American Academy of Home Care Physicians estimates that home-based primary care could save Medicare between 20% and 40% by preventing unnecessary ER visits. If you figure that one diverted ER visit saves about $1,500, then that would offset 10 house calls, the group said.

That still doesn’t resolve the basic question of whether house calls are an efficient use of primary care doctors. “Everyone talks about Uber for healthcare, which is great,” says Sevinc. “Healthcare needs to be modernized, and a lot of startup companies are trying to do this, but we need to do so without lowering the value of our healthcare providers.”

So, now there is a suggestion that Uber can use this strategy to get into other markets. While dozens of startups today look to Uber as a template for how to bring on-demand convenience to a long-standing market, one “Uber for healthcare” startup has an advantage. Its cofounder Oscar Salazar, who helped build the first Uber prototype, knows a thing or two about the $46 billion-plus valuation company first-hand.

Pager announced, Uber Cofounder’s ‘Uber For Healthcare’ Startup Raises $14 Million, last year that it had raised $14 million from Ashton Kutcher’s Sound Ventures and New Enterprise Associates, with existing investors Goodwater Capital, Lux Capital and Montage Ventures rejoining. The money’s aimed at expanding the New York City-focused service to new markets including San Francisco and Los Angeles and building out the product.

While services like ZocDoc and Doctors On Demand have made it possible for customers to find and book doctors more easily by computer or phone, Pager tries to take the process further by making your appointment instant and for a flat fee. A first-time urgent care visit is $50, and $200 after that. A physical is $100 and a phone consultation $25.

The parallels to Uber are peppered throughout Pager’s product. The service finds and verifies doctors for its network and bills you automatically over a linked credit card. There’s a $10 cancellation fee if you bail on an appointment after more than 5 minutes. And because the service is out of network for now, it favors those for whom convenience can come at a premium to healthcare network costs. That’s why it’s no surprise that Salazar is involved. Since building the prototype of the Uber app with billionaires Garrett Camp and Travis Kalanick, Salazar’s become something of an on-demand Uber exporter. He’s got a cofounder title with Ride, an app to bring Uber-like convenience to carpooling. Last month he linked up with another startup to work on an “Uber for trash.” Salazar doesn’t work full-time or daily at any of these startups.

“I don’t build companies, I help people build companies,” says Salazar. “It’s part of my strategy to work with companies like Uber, because I can do my job faster and I want to have value to add.”

As Salazar helps with high-level product issues and builds out technical teams, it’s up to operators lesser-known than Kalanick to execute at each one. At Pager, that’s the job of CEO Gaspard de Dreuzy. “Pager is focused on delivering a broader range of care options on demand” than exist today, de Dreuzy says. “It could be a tele-consult via phone or messaging, or an in-person visit in the home, or a referral to the right specialist. We like to think of ourselves as the Amazon for healthcare.”

Eventually, Pager will build partnerships with national providers to improve their own customer reach, says new investor and NEA partner Mohamed Makhzoumi. That’s where Pager’s vision may translate into large numbers of users, as its technology helps push the rest of the industry to improve its tech. Otherwise Pager’s pricing and pitch could come off—as Uber once did—as a service of convenience for the well-heeled.

The influence of Salazar’s background helped with investors and with the product. It also helps Pager stand out among dozen of startups striving for attention. But Salazar himself makes it plain that he’s not helping any of his startups score major Uber partnerships trading off his reputation at Uber HQ.

Salazar’s already got a new area where he’s looking for an “Uber for X”: education. “ They all share a narrative, Salazar says. “All the projects I’m involved in have a social impact. That’s where startups can change the world faster.”

What’s the secret of those incumbents that do survive—and sometimes even thrive? One aspect surely relates to the ability to recognize and overcome the typical pattern of response (or lack thereof) that characterizes companies in the incumbent’s position, i.e. the disruptors. This most often requires acuity of foresight and a willingness to respond boldly before it’s too late, which usually means acting before it is obvious you have to do so. As Reed Hastings, the CEO of Netflix, pointed out (right as his company was making the leap from DVDs to streaming), most successful organizations fail to look for new things their customers want because they’re afraid to hurt their core businesses. Clayton Christensen called this phenomenon the innovator’s dilemma. Hastings simply said, “Companies rarely die from moving too fast, and they frequently die from moving too slowly.”

How about the announcement that Forward, a medical office startup founded by CEO Adrian Aoun, announced its arrival to the world on Tuesday, Business Insider reported. Aoun, a former Google employee, is joined by ex-pats from prominent tech companies Uber and Facebook and has received investment funding from the likes of Peter Thiel’s Founders Fund and Marc Benioff. The service, currently offered in San Francisco, costs $149 a month in lieu of insurance and/or a co-pay, Tech Crunch reported.

According to Business Insider, Forward’s take on care delivery twists the concept of concierge care, a model some detractors believe favors wealthy individuals. Forward’s services boast a smattering of services, including basic screening, blood tests, wellness services, wearable monitoring as well as access to an artificial intelligence system.

Armed with the bells and whistles of a modern tech startup, Forward is adding to the growing list of companies seeking to disrupt the care delivery system. As the industry attempts to shift patients away from over-utilizing hospitals and lead to more of an outpatient/preventative care model, patients are being seen on a spectrum of acuity. This is markedly different from the traditional fee-for-service model. Therefore, companies are looking to make fiscal gains while offering access to high quality care services across the acuity continuum. For another recent example, Oscar opened a primary care clinic in Brooklyn for its members.

“Healthcare is not a repair shop but an ongoing relationship,” Aoun was quoted in USA Today. This quote shows exactly how care delivery providers are beginning to think about customers in the long term. As a fee-for-service model is slowly chipped away, provider-patient relationships will be increasingly important as that could help fuel a doctor “brand loyalty.”

It looks like these companies are strategically evaluating the needs and the ability to make a profit and deliver a service that the average and even the above average potential patient is willing to pay for. And with more insurance companies and government agencies realizing the efficiencies and cost savings, more will consider funding these services. I think that these disruptors, which, strategized and established these healthcare alternatives back in the Obama years, that President Trump’s business background and bias for reducing regulations and allowing the business community to grow will stimulate more startup alternative systems to flourish as the demand grows.

Women’s Health as an Investment and Their Value

16298661_1091212851008373_7978367349692312767_nToday I sat in awe as I watched and listened to the musical- Beautiful, The Carol King Musical at the hippodrome theater in Baltimore, Maryland. The talent was amazing and the tail of Carol King, the intelligent lyricist, composer and singer was inspiring, a lady who skipped 2 grades in school.What an inspiring woman and what a great role model for all women, especially after reading the report that girls are less likely to identify their own gender as brilliant than boys are, even at age 5. One question is whether it’s the girls who need to change their thinking about innate intelligence.

Also reflect on Washington, D.C., Friday , December 20, where the 45th president was sworn into office. Reporters were fanned out across the U.S. Capitol, New York City and elsewhere to provide comprehensive coverage of Trump’s inauguration, and provided coverage of that night’s inaugural balls, the first family’s fashion and, of course, the historic first dance. A day after President Donald Trump was sworn into office, women descended on the nation’s capital for the Women’s March on Washington. The Women’s March on Washington sent a bold message to our new government on their first day in office, and to the world that women’s rights are human rights and elsewhere. We stand together, recognizing that defending the most marginalized among us is defending all of us. If President Trump is as smart as his supporters say he is and he and his Cabinet should learn from the women and their message. Look at these maps showing the involvement both in the United States and around the world of women marching to bring awareness to their causes.



What group makes up half the global population? Women. Who makes about 80 percent of health-care decisions for their families? Women do. Women also have different bodies and medical needs than men, and innovation in health-care technology for women requires financial investment.

Yet big investors tend to put money into solutions to problems that they can relate to. And most venture capitalists are male. By one account, only approximately 20 percent of VC firms funding early-stage biotech companies have any women’s-health-focused technologies represented in their portfolios at all. The top twenty VC firms most active in health care made upwards of 1,500 investments in the last decade, but only roughly 80 of those were in women’s health.

Aid programs that provide women opportunities to better their health, education, and well being have effects far beyond a single individual. A woman multiplies the impact of an investment made in her future by extending benefits to the world around her, creating a better life for her family and building a strong community.

  • 99% of maternal deaths occur in the developing world.
  • Adequate health care, a skilled birth attendant and emergency care help prevent maternal deaths.
  • 1 in 5 girls in developing countries who enroll in primary school never finish.
  • When 10% more girls go to school, a country’s GDP increases on average by 3%.
  • 1 in 7 girls will marry before they are 15 in the developing world.
  • Girls who stay in school for seven or more years, marry four years later and have two fewer children.
  • Women make up nearly 52% of the global total of people living with HIV.
  • Current approaches to preventing mother-to-child HIV readmissions are 98% effective.
  • Women make up 43% of the agriculture labor force. However, women are less likely to own land, and own fewer amounts of land when they do.
  • When women have the same amount of land as men, there is over 10% increase in crop yields.
  • Women comprise only 18.9% of the world’s legislators.
  • Countries where women’s share of seats in political bodies is greater than 30% are more inclusive, egalitarian, and democratic.

More female entrepreneurs and investors are focusing on largely unmet medical needs: their own.

Women are the health-care industry’s biggest customers, due in part to their need for reproductive care, and make 80 percent of the health-care decisions for their families. Tired of having their conditions misunderstood or dismissed as “bikini medicine,” they are starting up and investing in female-focused companies, many of them in digital health, a market valued at $55 billion in 2014, according to KPMG.

“Obviously women have unique health experiences that men don’t,” says Halle Tecco, who was a co-founder of venture-capital fund Rock Health and is now an adjunct professor for digital health at Columbia Business School. “It is a huge market.”

And therein lies the rub: More than 90 percent of investing partners at the top 100 VC firms are men, research by startup-tracker CrunchBase shows. People invest in ideas that they feel comfortable with, and that’s why women are leading the charge on female health, says Albert Wenger, a partner at Union Square Ventures in New York.

“There is a bias that results from the fact that a lot of venture investors are male,” Wenger says. “We are five white guys who are exhibit A in the non-diverse case. It’s just the reality of it.”

That’s changing, but slowly. Female health is attracting more investors of both sexes. Nine digital-health companies focused on women who raised $82 million through the third quarter of last year, up from $29 million in 2014, according to Rock Health, whose board and investment team are mostly female. One of them, Progyny Inc., raised $34 million from investors including Kleiner Perkins Caufield & Byers and TPG Biotech.

That amount pales in comparison to the $4.5 billion that poured into digital-health companies overall. So women are once again trying to shrink the gap by investing in female-focused enterprises.

In April, Cindy Whitehead, who raised $100 million for Sprout Pharmaceuticals Inc. before it was bought by Valeant Pharmaceuticals International Inc. for $1 billion, started another company, The Pink Ceiling. It will make investments and do strategic consulting for companies working on women’s issues.

“It was an advantage for me to be a woman leading Sprout,” which made the first pill for low sexual desire, Whitehead, says. “Women shared their stories with me. We did a year of diligence and just by listening I had such a better appreciation of the devastation for women.”

Being a woman is less of a bonus when raising money for a women’s health business.

“I had to get past the locker-room jokes and giggles to get to a serious and frank scientific discussion” with potential investors, Whitehead says. She “adapted by understanding how fiercely I needed to come out of the gate with science.”

Wenger’s Union Square, an early backer of Twitter Inc., saw a clear need for Berlin-based Clue, which helps women track their menstrual and fertility cycles. Wenger says the business case was strong: More women are going to have easy access to a smartphone than to birth control, and that creates an opportunity to educate women about their bodies and contraceptives.

That pitch didn’t appeal to everyone, says Clue founder Ida Tin, whose company has raised $10 million and has 5 million users.

“One thing is understanding something intellectually, another thing is having that experience which is anchored in your body emotionally,” Tin says. “Sometimes people would say, ‘You know it’s really interesting but I can’t use the product myself. I only invest in products that I can use myself.’ And that’s of course the problem if all are male investors.”

The solution? More female investors. Tecco has invested in EverlyWell, a direct-to-consumer at-home testing business, and recently joined the advisory board at startup Celmatix, which uses data analysis and genomics to improve woman’s chances of conceiving. Women lead both companies.

With women becoming more financially independent, and living longer than men on average, “this a huge business opportunity,” says Anula Jayasuriya, a doctor who oversees a women’s health-care entrepreneurship and investment fund, EXXclaim Capital. She has invested in Wildflower Health, whose Grow application enables women to track the health of their families and tap into resources provided by a health plan or other sponsor.

The proportion of VC deals involving companies founded by women has doubled since 2006, yet is still only 18 percent, according to data from Pitchbook, which tracks private equity, venture capital and merger and acquisition activity.

Besides a lack of female mentors and investors, Whitehead thinks women’s health suffers because issues are often assumed to be psychological.

“We have a lot of preconceived notions where we reflexively assign issues to biology for men, and to psychology for women,” she says. “We’re under-serving men that way, too.”

Hormones are a key marker of disease that are consistently overlooked by medical professionals, says Heather Bowerman, who started Dot Laboratories in 2014. The company makes hormone test kits that rely on saliva samples, which can be sent through the mail to a lab. Users track the results over time using a mobile app.

Having that data at their fingertips can help patients choose the right contraceptive, as well as treatments for disorders such as polycystic ovary syndrome or PCOS, a market that’s set to double to $10 billion by 2020, Dot Labs says.

Research is revealing the breadth of the differences between the sexes, with genes, hormones and gender roles influencing the course of conditions such as heart disease, dementia and depression.

With more women involved in the health business, the foundation is there to capitalize on such discoveries.

“The wheels have been set in motion now for a very, very positive development in terms of increases in female investors, female entrepreneurs, female-founded business that will build long-term success,” Wenger says.

untitledwomens-health-2aBut more important is that this new Administration realizes the value of women, in business, in health care, as leaders and more importantly in this Administration. What a signal President Trump could send if he and his confidants could add a new cabinet position…the Secretary of Women’s Affairs and Diversity. What a message this could send that maybe this Administration was aware and sensitive to the values of one of the most important groups of important voters, purchasers of goods, business owners, professionals, etc.

I am trying to give the Trump Administration the credit for getting elected and the hope that their change may make a positive change to-Make All America Great….Again. Instead of the media, the GOP and the Dems being angry and threatened each other, maybe we need to work together and really make America wonderful and yes, great!

Trump Signs Executive Order To ‘Ease The Burdens Of Obamacare’ And This Is Probably What’s In The GOP Obamacare ‘Replacement’

16114130_1085270604935931_2092200022696161157_nAs promised, President Trump got to work on Day One, spending some time in the Oval Office in between the inaugural parade and a trio of formal balls.

Trump signed an executive order Friday night directing government agencies to “ease the burdens” of Obamacare while the new administration and Congress work toward repealing and replacing the Affordable Care Act.

White House Chief of Staff Reince Priebus presented Trump with the order, which he described as: “An executive order minimizing the economic burden of the Patient Protection and Affordable Care Act pending repeal.”

It’s not clear what kind of relief the executive order envisions.

Repeal of the Affordable Care Act and its consequences were on the hot seat as senators questioned Rep. Tom Price, MD (R-Ga.) Wednesday about his fitness to serve as Secretary of Health and Human Services.

“I have serious concerns about your qualifications for the department you hope to lead,” said Sen. Patty Murray (D-Wash.), ranking member of the Health, Education, Labor, & Pensions (HELP) Committee, at a hearing on the nomination. “Just last week you voted to begin the process of ripping apart our healthcare system without any plan to replace it, even though [it’s estimated that] 30 million people will lose their coverage.”

Wednesday’s hearing was a “courtesy” hearing before the committee, which is not tasked with sending Price’s nomination to the Senate floor for a vote. That responsibility falls to the Senate Finance Committee, which is scheduled to hold a formal confirmation hearing and vote on the Price nomination next Tuesday.

Price maintained that if he were confirmed, he would fulfill president-elect Donald Trump’s promise of healthcare for everyone. “The principles that I think are absolutely imperative for the healthcare system is one that’s affordable for everybody, one that provides access to health coverage and care for everybody, one that’s of highest quality, that’s responsive to patients … one that incentivizes innovation, and that insures choices are made and preserved by patients,” he said.

Access was a word that Price returned to frequently when he was asked if he would guarantee that certain groups would not lose healthcare coverage under a replacement for the ACA. “It’s incredibly important that we have a system for every single American to have access to the kind of coverage they need and desire,” he said in answer to another question.

Access to health insurance is not an exact match for President-elect Donald J. Trump’s promise of health insurance for all, a point hammered home by Vermont Sen. Bernie Sanders, the independent who challenged Hillary Clinton for the Democratic nomination. “I have access to buying a $10 million home. I don’t have the money to do that,” Sanders said.

Democratic senators also pressed Price on potential conflicts of interest, specifically his healthcare stock trades, several of which been the subject of media coverage. Price maintained that many of his stock trades are done through a broker so he is not always aware of them, and that he has disclosed any relevant trades as required by the House Office of Government Ethics.

In response to questions about his purchase of stock in six pharmaceutical companies shortly before introducing a bill blocking a regulation that would likely have hurt those same companies, he noted that “My opposition to having the federal government dictate what drugs are available to patients is longstanding.”

The House Republicans have promised to reveal to the public what kind of health care reform they want instead of Obamacare. In anticipation, I thought a preview of conservative health policy ideas was in order.

Before anyone gets too excited, the House GOP task force handpicked by Speaker Paul Ryan (R-Wis.) to tackle the thorny issue of “replacing” Obamacare isn’t going to introduce legislation or anything like that.

Rather, Ryan will issue a broad outline, which will differ somehow from all the other broad outlines congressional Republican leaders have tossed off since 2009, when the debate over the Affordable Care Act began.

It’s only been seven years, so they’ll surely tell everyone what they really want to do, how much it’s going to cost, how many people it will cover, etc., at some point. Next year? Or maybe 2018? (House Republican leaders are still ahead of their Senate counterparts, who don’t appear to be making any effort to define an Obamacare replacement.)

What we already know from news reports — and history — is that the contents of the House GOP proposal likely will be cribbed from previous Republican health care plans, like the ones touted by President George W. Bush in 2004, by Sen. John McCain (R-Ariz.) during his White House bid in 2008, by then-House Minority Leader John Boehner (Ohio) in 2009 and by presumptive Republican presidential nominee Donald Trump this year.

untitledblog1GALLUP The plummeting uninsured rate is one of the Obamacare problems House Republicans seek to remedy.

Because these ideas are all old and warmed over, they’ve all been analyzed ad nauseam, which makes it possible to evaluate the Ryan-backed plan — or at least get a sense of its general impact — before it even comes out.

When Ryan introduces this framework next week, we will return to the subject and give it another look. And if the House GOP has managed to find a way to cover more people than Obamacare at a lower cost with fewer regulations and no mandates, caps will be tipped.

The Huffington Post’s take on the likely components of the House plan assumes that the Affordable Care Act is fully repealed before any new policies are put into place, because that is the explicit goal of the Republican Party. As such, we compare the status quo, which is Obamacare, to what the GOP plan might do to it, including taking health coverage away from 24 million people — not to the world before the ACA.

And with that important note, here’s our review of conservative health policy’s greatest hits:

Get rid of the lines!

The idea: Let health insurance companies sell plans to consumers “across state lines” to increase competition and choice.

The problem: This policy has always been a Trojan horse. The notion is to deregulate health insurance by allowing companies to avoid states where rules require them to cover things like diabetes and autism — and then set up shop in states without those mandates.

And while allowing health insurers to go back to selling plans with meager benefits might be good for healthy people who won’t use their coverage, it’s bad for sick people and for states with more rules. If a healthy person from state A buys a skimpy plan from state B, insurers in state A lose a healthy customer, which is bad for business and could cause rates there to rise.

Insurers aren’t clamoring for this. One big reason is they’d have to assemble networks of medical providers in any state where they had even one customer, which is a lot of bother. Also, it’s actually been tried in Georgia and a few other states — and literally no insurance company has participated.

High-risk pools for the sick

The idea: Take care of people with the greatest health care costs by enrolling them in so-called high-risk pool insurance that’s government-subsidized. That way, they’re covered and everyone else’s premiums go down because regular insurance no longer pays for the costliest patients. It would also be nice if we could reward the patients who take good care of themselves, exercise, don’t smoke, are not obese and therefore don’t drain the finances of the health care system, insurance companies and the government.

The problem: This could actually work, if it were adequately funded (think of Medicare, which is sort of a high-risk pool for the elderly, people with disabilities, and kidney-failure patients). Except in the five decades since the first high-risk pools came to be, they’ve never been adequately financed, and it’s hard to see Republicans setting aside a lot of money for government-funded health care any time soon.

Make the sick pay more

The idea: Allow insurers to vary premiums, charging more to people with medical problems or at high risk of developing them. That way, healthy people wouldn’t have to pay as much for their coverage.

The problem: For a start, the whole purpose of all kinds of insurance is for many people to pay in so that few people can get benefits when they need them. Getting rid of what’s called underwriting — basing a person’s health insurance premiums of their health status and medical history — is one of the most popular things to come out of the Affordable Care Act/Obamacare, and for good reason.

To a lot of people, jacking up premiums on someone because they just got sick or used to be sick or might someday become sick seems unfair or even cruel. Plus, most of us — if we’re lucky — will live long enough to go from being the healthy person to the sick person, meaning we’d all become that customer paying more at the time we need it most.

Tax health insurance more

The idea: Alter the tax code to reduce or eliminate an existing preference for employer health insurance.

The problem: Starting around the time of World War II, the federal government decided that if your employer provides health insurance, then the premiums won’t count as part of your income. One goal of this decision was to boost job-based coverage — and it did.

But most economists believe the tax break creates an artificial financial incentive to provide employees with generous coverage, causing them to consume more health care and eventually drive up prices for everybody. It also disproportionately benefits middle- and upper class people, who have the kinds of jobs that provide benefits, over the poor.

The solution, economists say, is to limit the tax break or, better still, eliminate it entirely. The Affordable Care Act actually includes a provision that would accomplish this, although Congress last year voted to postpone its implementation and the change may never take effect.

The risk of messing with this part of the tax code is that it could make insurance more expensive by taxing it’s cost, which could weaken the foundation of the employer coverage system. This would force people to look elsewhere for insurance.

That’s not such a big deal with Obamacare in place, since the law’s exchanges theoretically make private plans and Medicaid available to everybody, regardless of pre-existing conditions or ability to pay. But without the exchanges or some other similar mechanism for universal coverage, some people who lose employer insurance would end up without any coverage at all.

Lower prices for younger people (and higher prices for older people)

The idea: The ACA limits how much more health insurance companies can charge older customers to compared to younger ones to 3:1. This tends to make coverage relatively more expensive for young adults than before Obamacare, so some Republicans have proposed raising the ratio to 5:1.

The problem: It’s sort of self-evident: Older people, who typically have higher medical costs and greater need for insurance, would see rate increases. It’s roughly the opposite of what the ACA did.

Health savings accounts!

The idea: Letting people sock away money and spend it on out-of-pocket medical costs tax-free encourages saving and makes patients more like consumers who shop around for the best prices. A popular Republican proposal is to expand the use of these products and to let people pay health insurance premiums pre-tax, too.

The problem: These are great as a tax shelter and a way to buy the cheaper, high-deductible insurance that comes with it — if you can afford to save money, which most Americans demonstrably can’t. What’s more, the evidence suggests that patients make terrible shoppers. It’s very hard, if not impossible, to get reliable information about what medical procedures cost. Lay people often aren’t in a position to know even what questions to ask. And no one comparison shops during an emergency.

Make Medicaid better by shrinking it

The idea: Reduce funding for Medicaid, then give the states way more leeway to run the program as they see fit.

The problem: Medicaid is the largest single provider of health coverage in the U.S. It covers even more people than Medicare does, and the program as a whole is very expensive. States, which administer the program and kick in a bunch of the money, struggle to find adequate funding and usually must seek federal approval to alter benefits and eligibility.

To conservatives, the solution is obvious: Slash spending and let states make big changes, like dropping entire categories of enrollees, on their own.

But if you significantly reduce the amount of money devoted to Medicaid, you significantly reduce the number of people you can cover and the kinds of benefits you provide.

Medicaid is already underfunded. It’s expensive because there are so many beneficiaries on it — including a lot of pregnant women, people with disabilities, and frail elderly in nursing homes, who are costly — not because it’s buying lavish care or full of waste. And it’s not like these people could get insurance some other way. By definition, the people on the program are either very poor, have disabilities, or both.

Smaller subsidies for fewer people

The idea: Health insurance is expensive, so giving people money — usually in the form of a tax credit — can help them afford it.

The problem: This actually is one of the most consequential parts of the Affordable Care Act. But the questions are: Who gets the money, and how much do they get? GOP plans that feature tax credits offer substantially less assistance to a lot fewer people, and some of them target that assistance based on age, not income. That would leave a portion of the neediest with little to no help and offer subsidies to higher-income households that may not need them.

Coverage for (some) people with pre-existing conditions

The idea: The pre-Obamacare market allowed insurers to reject customers based on their medical histories, and now they must accept anyone. Republicans don’t want to keep that, but they want to look like they are by proposing a guarantee that people who already have insurance won’t lose it if they get sick.

The problem: For one thing, federal law already offered a version of this guarantee even before the Affordable Care Act. More importantly, this could lock out anyone who doesn’t have coverage — because they can’t afford it, because they don’t think they need it — forever, leaving them uninsured when the time comes they actually need medical care.

Turn Medicare into a voucher program

The idea: Give seniors vouchers — a.k.a. “premium support” — and let them shop around for an insurance plan they like.

The problem: Today Medicare is a single government program that guarantees a fixed level of benefits; private insurers can offer alternative plans, but those policies are subject to strict rules that result in coverage that’s no less generous than what the existing program offers.

Conservatives would prefer a system with more freewheeling competition among plans. The idea has been kicking around for a long time and, in some versions, traditional Medicare remains an option for seniors who want it. But the theory for the change is always the same: Competition would hold down costs better than the existing program does.

Or so the thinking goes. The problem with the theory is that Medicare is actually doing a pretty good job of holding down costs now.

Critics worry, plausibly, that voucher schemes are simply a roundabout way of giving seniors less health care. That’s particularly true when the sponsors of such plans have traditionally envisioned their plans yielding big savings that likely wouldn’t be possible unless the insurance seniors had provided much less coverage than it does now. Critics also worry — again, with reason — that traditional Medicare would not survive long in such a scheme, forcing all seniors to take private insurance.

Curb malpractice lawsuits

The idea: Limit jury awards in medical malpractice lawsuits

The problem: The medical malpractice system gets a lot of bad press, and deservedly so. Many well-meaning physicians operate under clouds of suspicion, particularly in high-risk fields like anesthesia and obstetrics.

Meanwhile, research suggests the system doesn’t serve patients particularly well, because only a relative handful of people harmed by medical negligence actually bring cases to court and win.

That’s why even some liberals have called for reforming malpractice laws in ways that would compensate more of these people while simultaneously introducing new safeguards that would deter negligence — and, ideally, avoid other kinds of adverse medical events as well. Systems like that already exist in some parts of Europe.

But the usual conservative solution is simply to slap a limit on how much juries and judges can award in damages.

In this scenario, lawyers would be less enthusiastic about bringing cases, since their contingency income from winnings would be much smaller. In the absence of other reforms, the victims of malpractice would have even fewer sources of compensation than they do now.

And while limits on awards might reduce spending at the margins, since physicians would be less inclined to order up extra tests and practice other kinds of “defensive medicine,” most analyses have suggested the impact on the nation’s overall health care bill would be modest. But I disagree with this assessment because you can’t expect physicians to change their treatment of patients with the continual treat of litigation. Just listen to the attorneys advertising on television and the Web promising to sue and get you big bucks if you have “any problems.”

It would also be nice, but I don’t think it will be on the GOP’s vision and mission to lower the cost of education our future physicians. So, we will have to be satisfied with more care by physician assistants and nurse practitioners.

Now lets see what really happens and see how accurate I am at predicting the future of health care and whether the GOP can deliver the substitute for the Affordable Care Act/Obamacare.

Here They Go Repealing the Affordable Care Act. And How Is That Going?

15977995_1081116692017989_1435982330398986180_nFirst, as the GOP and the Democrats in Congress continue their battles, let me say that the childish behavior that both sides are exhibiting truly is an embarrassment. No wonder nothing ever gets done in our government or takes so long and wastes so much money. The disrespect shown to the President-Elect and his Conferees is embarrassing and childish. Congressman Lewis of Georgia, and his statements that President –Elect Trump is not a “legitimate president” is unbelievable as well as the Democrats still looking for excuses for Hilary Clinton’s loss- hacking, emails leaked, Russian influence, the Chinese! Doesn’t anyone understand that the election, the Electoral College, the Constitution has determined that Mr. Trump won the election and he is now our President-Elect? And let us not forget the GOP, who is threatening to repeal the Affordable Care Act/ Obamacare as they are drooling with the idea of embarrassing President Obamacare- and without an alternative healthcare system to cover our patients.

So, now the latest round in the epic health care battle has begun…and continues as the GOP Congress has approved the first step toward dismantling the Affordable Care Act. By a near party line 227-198 vote, the House approved a budget Friday that prevents Democrats from using a Senate filibuster to derail a blueprint that would repeal and replace President Barack Obama’s signature healthcare law. Nine Republicans joined all voting Democrats in opposing the budget. The Senate approved the measure last Thursday. It does not need the president’s signature. Friday’s passage was critical because it takes 60 votes to end filibusters, while Republicans have a 52-48 Senate majority.

Now, Republicans in Congress must decide which parts of Obamacare to end and how to help protect up to 30 million people who received coverage under the ACA’s provisions and its Medicaid expansion. Many in the party have split over how to reform the nation’s $3 trillion-a-year health care system. Still, President-elect Donald Trump has urged Republicans to pass the budget and concurrently find a replacement plan. “The ‘Unaffordable’ Care Act will soon be history!” Trump tweeted Friday. He takes the presidential oath next Friday.

Tammy Luhby reports that after decades of circling each other, the Democrats gained the upper hand in 2010, making their philosophy of universal health care coverage the law of the land. They called it the Affordable Care Act. Now the advantage lies with the Republicans, who suddenly have the opportunity to advance their brand of universal health care access. The names of the repeal legislation floated over the years provide insights into their priorities. The Empowering Patients First Act. The Healthcare Accessibility, Empowerment, and Liberty Act. The Patient CARE Act.

Senate Republicans took their first major step toward repealing the Affordable Care Act on Thursday, approving a budget blueprint that would allow them to gut the health care law without the threat of a Democratic filibuster. The vote was 51 to 48. During the roll call, Democrats staged a highly unusual protest on the Senate floor to express their dismay and anger at the prospect that millions of Americans could lose health insurance coverage.

One by one, Democrats rose to voice their objections. Senator Maria Cantwell of Washington said that Republicans were “stealing health care from Americans.” Senator Ron Wyden of Oregon said he was voting no “because health care should not just be for the healthy and wealthy.” The presiding officer, Senator Cory Gardner, Republican of Colorado, repeatedly banged his gavel and said the Democrats were out of order because “debate is not allowed during a vote.” The final vote, which ended just before 1:30 a.m., followed a marathon session in which senators took back-to-back roll call votes on numerous amendments, an arduous exercise known as a vote-a-rama.

The approval of the budget blueprint, coming even before President-elect Donald J. Trump is inaugurated, shows the speed with which Republican leaders are moving to fulfill their promise to repeal President Obama’s signature domestic policy achievement — a goal they believe can now be accomplished after Mr. Trump’s election.

The action by the Senate is essentially procedural, setting the stage for a special kind of legislation called a reconciliation bill. Such a bill can be used to repeal significant parts of the health law and, critically, is immune from being filibustered. Congress appears to be at least weeks away from voting on legislation repealing the law.

Republicans say the 2016 elections gave them a mandate to roll back the health care law. “The Obamacare bridge is collapsing, and we’re sending in a rescue team,” said Senator Michael B. Enzi, Republican of Wyoming and the chairman of the Senate Budget Committee. “Then we’ll build new bridges to better health care, and finally, when these new bridges are finished, we’ll close the old bridge.”

Lets look at how Republicans Can Repeal Obamacare Piece by Piece Peeling away pieces of the law could lead to market chaos and Republican leaders say they will work closely with Mr. Trump developing legislation to repeal and replace the health care law, but it is unclear exactly how his team will participate in that effort.

On Wednesday of last week, Mr. Trump said he would offer his own plan to repeal and replace the law “essentially simultaneously.” He said he would put forth the plan as soon as his nominee for secretary of health and human services, Representative Tom Price, Republican of Georgia, is confirmed. The Affordable Care Act has become ingrained in the American health care system, and unwinding it will be a formidable challenge for Republicans. As I have pointed out, more than 20 million people have gained coverage under the law, though premiums have risen sharply in many states and some insurers have fled the law’s health exchanges. The budget blueprint instructs House and Senate committees to come up with repeal legislation by Jan. 27.

Senator Bob Corker, Republican of Tennessee, and four other Republicans had sought to extend that deadline by five weeks, to March 3. But late Wednesday night, Mr. Corker withdrew an amendment that would have changed the date. “We understand that everyone here understands the importance of doing it right,” he said. He described the Jan. 27 date in the budget blueprint as a placeholder.

Senator Rob Portman of Ohio, another Republican who sought to delay the deadline, said: “This date is not a date that is set in stone. In fact, it is the earliest we could do it. But it could take longer, and we believe that it might.” The House was planning to take up the budget blueprint once the Senate approved it, though some House Republicans have expressed discomfort with voting on the blueprint this week because of lingering questions over how and when the health care law would be replaced.

A vote on the measure in the House did come on Friday. In its lengthy series of votes, the Senate rejected amendments proposed by Democrats that were intended to allow imports of prescription drugs from Canada, protect rural hospitals and ensure continued access to coverage for people with pre-existing conditions, among other causes.

In the parlance of Capitol Hill, many of the Democrats’ proposals were “messaging amendments,” intended to put Republicans on record as opposing popular provisions of the Affordable Care Act. The budget blueprint is for the guidance of Congress; it is not presented to the president for a signature or veto and does not become law.

As the Senate plowed through its work last Wednesday, Republicans explained why they were determined to dismantle the health care law, and they tried to assuage concerns about the future of coverage for millions of Americans. “This is our opportunity to keep our campaign promise,” said Senator Roger Wicker, Republican of Mississippi. “This is our opportunity to help the president-elect and the vice president-elect keep their campaign promises and show to the American people that elections have consequences.”

Senator Johnny Isakson, Republican of Georgia, said that while working to repeal the health care law, “we must also talk about what we replace it with, because repealing it without a replacement is an unacceptable solution.” Republicans do not have an agreement even among themselves on the content of legislation to replace the Affordable Care Act, the timetable for votes on such legislation or its effective date.

Senator Susan Collins, Republican of Maine, said on Wednesday that she agreed with Mr. Trump that Congress should repeal the health law and adopt a replacement plan at about the same time. “But I don’t see any possibility of our being able to come up with a comprehensive reform bill that would replace Obamacare by the end of this month,” she said. “I just don’t see that as being feasible.” (Ms. Collins also supported pushing back the deadline to come up with repeal legislation.)

As Republicans pursue repealing the law, Democrats contend that Republicans are trying to rip insurance away from millions of Americans with no idea of what to do next. The Senate Democratic leader, Chuck Schumer of New York, called the Republicans’ repeal plan “irresponsible and rushed” and urged them to halt their push to unravel the law.

“Don’t put chaos in place of affordable care,” he said.

While the Republicans have yet to issue a detailed plan to replace Obamacare, many of their proposals share common traits. CNNMoney lays them out for you as a guide to the Congressional battle that lies ahead.

  1. Universal coverage vs. universal access:

A primary goal of Obamacare was to make sure all Americans — or nearly all — obtained health insurance. It created insurance exchanges for those seeking individual coverage and expanded Medicaid for low-income adults. It offered a mix of incentives and penalties to entice people to sign up.

Republicans have a different take. Rather than emphasizing coverage, they back making health insurance more accessible. They promise to lower the cost of premiums to make coverage more affordable so that more people can buy policies.

  1. Comprehensive benefits vs bare bones coverage:

Obamacare requires that insurers cover lots of benefits that were hard to find in the individual market beforehand. Think: maternity care, mental health and prescription drugs. Under Obamacare, Americans can get preventative services, such as annual check-ups, cholesterol screening and certain vaccines, for free.

The law also provides other protections for Americans. It caps how much consumers paid out of pocket each year and ended insurers’ practice of placing a dollar limit on how much they paid annually or over one’s lifetime.

Related: How Trump’s health secretary pick would replace Obamacare- this I already covered in a previous post. Go back and read it again.

Republicans argue mandating such comprehensive benefits drive up cost. They want to give consumers more choice. They say Americans should be able to pick the benefits they want — why should a 55-year-old couple pay for maternity benefits?

This increased flexibility will likely mean lower premiums, though it could also mean higher deductibles. But that’s okay with Republicans, who tout the concept of consumer-directed health care. The more people have to pay out of pocket, the wiser spending choices they’ll make, the thinking goes. If people have to shell out $75 for a blood test, they’ll think twice about whether they really need it or they will shop around to see if they can get it cheaper elsewhere.

  1. Premium subsidies vs. tax credits:

Under Obamacare, the federal government provides a helping hand for low- and moderate-income enrollees in the form of premium subsidies, which are officially tax credits offered in advance. The less you earn, the higher the subsidy. More than eight in 10 Obamacare enrollees get premium subsidies, which lower their cost to less than 10% of their income.

The Republican replacement plans also provide tax credits to cover premiums. But the size of the Republican credits would be based on age, not income. Younger enrollees would get less than those age 50 and over.

Also, to help pay for coverage, Republicans would encourage the use of a favored tool: health savings accounts. HSAs allow people to sock away funds tax free for medical expenses. But higher-income Americans, who can afford to contribute to them, mainly use it. Think of it most people don’t have the pre-tax dollars or the knowledge to purchase HSAs. They are paying mortgages, rents, car payments, cell phone payments, the cost of raising children and putting their kids through school, food and other insurance, etc.

  1. Pre-existing conditions ban vs. continuous coverage:

Obamacare barred insurers from discriminating against those with pre-existing conditions. Insurers could not reject those who had been sick, nor charge them more.

Republicans say they would protect people with pre-existing conditions — if they’ve maintained continuous insurance coverage. That means if you have a gap in coverage — say, because you left your job and couldn’t afford coverage on the individual market — you might not be protected.

Those who are uninsured and sick may be charged more or may have to look for coverage through state high-risk pools, which had a very troubled history before they were essentially disbanded after Obamacare’s individual exchanges opened in 2014.

  1. Taxing high-cost employer plans vs. capping tax deduction:

Many lawmakers on both sides of the political aisle want to rein in the cost of employer-sponsored insurance plans, which cover 150 million Americans. These plans often offer rich benefits packages, which employees like to utilize, driving up the nation’s health care spending.

Obamacare called for instituting the so-called Cadillac Tax. It would impose a 40% levy on the amount of employer premiums above $10,200 for individual and $27,500 for family policies. The idea is to have employers limit their benefits packages to a certain level, slowing the growth of health care spending and usage.

But even though the Cadillac Tax is in President Obama’s landmark health reform law, it is not universally endorsed by Democrats. In fact, Congress came together to push back the date the tax is to go into effect to 2020, from 2018.

Republicans, on the other hand, would limit costs in employer plans by capping the tax deduction for premiums. The rationale is that this will force employers to provide less generous policies so their workers don’t get socked with a tax bill.

  1. Medicaid expansion vs fixed grants:

In keeping with its universal coverage philosophy, Obamacare aimed to expand Medicaid to all adults with incomes below 138% of the poverty level. Prior to Obamacare, most enrollees were low-income children, pregnant women, parents, the disabled and the elderly. The federal government enticed states by covering 100% of the cost of the newly eligible for three years and lowered reimbursement to 90% over time.

Republicans have long favored turning Medicaid into a grant program. They would either provide states with a set amount of funds, known as a block grant, or provide a certain amount of money to cover each enrollee, which is called a per-capita grant. This would help curtail the growth of Medicaid spending and make it a more predictable cost for the federal government. But consumer advocates worry that funding caps will restrict the number of people who can enroll and the quality of care they receive.                                                                                                                     House Speaker Paul Ryan has said that Republicans will “definitely” put a replacement for ObamaCare on Donald Trump’s desk before the end of April. Or perhaps we should say “replacements.”

The biggest mystery in Washington these days isn’t Russian spies or whom Trump will tap for the Supreme Court. The real head-scratcher: how Republicans will replace ObamaCare.

Initially, the GOP was planning to eat dessert first. They were going to repeal the law, bringing the political and tax benefits at once, but delay the actual elimination of benefits for at least two years while they worked out a plan.

But an uproar among conservatives who sensed danger from creeping repeal and Trump’s apparent agreement sent Congressional policy wonks back to the drawing board.

And now Kentucky Sen. Rand Paul vowed last night that he would reveal a bill to replace ObamaCare next week. Paul, a Republican, tweeted a photo of the first page of the bill he titled the “Obamacare Replacement Act.” He added: “Done drafting the bill & will be discussing on CNN Sunday AM and all week next week!”Last week, Paul was the lone Republican to vote against the budget which would repeal the Affordable Healthcare Act after expressing his displeasure because it endorsed huge budget deficits. He wasn’t the only one to have expressed anxiety over dismantling the law without a replacement to show voters.                                                                                                                                                 Sen. Susan Collins, R-Maine, said she wants at least to see “a detailed framework” of a GOP alternative health care plan before voting on repeal. She said Republicans would risk “people falling through the cracks or causing turmoil in insurance markets” if lawmakers voided Obama’s statute without a replacement in hand. The budget “gives us the tools we need for a step-by-step approach to fix these problems and put Americans back in control of their health care,” House Speaker Paul Ryan, R-Wis., said after the vote. Congressional Republicans have made annulling Obama’s law and replacing it a top goal for the past seven years. GOP rifts and an Obama veto prevented them from achieving anything other than holding scores of votes that served as political messaging.                                                                                                                            President-elect Donald Trump also made targeting Obama’s statute a primary target during his campaign. At his news conference Wednesday, Trump — who’s supplied few details of what he wants — said his emerging plan will be “far less expensive and far better” than the statute. And I say-show me!                                                                                           Many Republicans have insisted on learning how their party will re-craft the nation’s $3 trillion-a-year health care system before voting to void existing programs. There are internal GOP chasms over Republican leaders’ plans to use their bill to halt federal payments to Planned Parenthood and pare Medicaid coverage. There are also disagreements over how to pay for the GOP replacement, with many Republicans leery of Ryan’s proposal to tax part of the value of some health insurance provided by employers.                                                                    “Repeal and eventually replace” seems to be dead, at least for the time being.     Slow-walking the repeal had obvious political benefits. First, it would have allowed Republicans to avoid major disruptions in coverage as they built consensus around a new plan. Second, delaying the fight over what to put in its place would have left lots more bandwidth for Republicans to take up other policy priorities like taxes, border security and infrastructure. Third, and perhaps most importantly, twinning repeal and replacement is risky business and again remember my advice, as in Pottery Barn, you break it you buy it and the GOP will take the blame!

Also, remember the analogy about choosing a restaurant. If a group is trying to decide where to dine and is given three options, say the new Indian place, Applebee’s or “something else,” “something else” is an easy winner. That’s because everyone in the group believes their preferred outcome still might be obtained.

Ryan’s initial plan was, essentially, just to get Republicans to agree that they wanted to go out to dinner in the first place and then start the debate about where to go once everyone was in the car.

Once you start talking about the specifics of ObamaCare’s replacement, you start jeopardizing votes for the repeal itself. Maine moderate Sen. Susan Collins and Nebraska conservative Sen. Ben Sasse both want the law repealed, but do not necessarily agree on the replacement. The GOP can only afford to lose two votes in the Senate on repeal, and running a concurrent replacement dramatically increases the chance of defections.

In what would be one of the most ambitious legislative undertakings in memory, Ryan and his team planned to put forward not one “comprehensive” plan, but rather a suite of related bills as a replacement package. This is a reversal of decades of congressional practice in which important or complicated legislation, like ObamaCare itself or two failed bids to reform immigration are heaped into enormous piles. Republicans had good fun with Democrats over the length of ObamaCare: some 2,700 pages of indecipherable Beltwayeze.

But both parties knew the secret to passing unpopular or controversial things was size. Written correctly and with enough stuffing you could hide a black bear in one of these bills. In the old days, bills were crafted in legislative backrooms and delivered with no time to be reviewed by the members or the public. Lawmakers could vote for one of these nasties and then go home and tell the good people of their district the story they wanted.

Now, there is scrutiny at every stage. Closed-door meetings turn into leakfests on social media. Activists and journalists pore over draft language and voters respond in real time to various outrages they see in the plans.

In a nod to the new reality, Ryan is proposing a series of smaller bills passed one at a time. It’s also a nod to the fact that Republicans can act alone to repeal, they will need Senate Democrats’ help to replace.

The risks are still substantial. Democrats will have many more opportunities to obstruct the majority so the possibility of a legislative quagmire is real. The safety net here is that if Democrats and dissident Republicans succeed in blockading key components, the leadership can fall back to delayed replacement. Whatever happens, though, the next three months promise to bring a wild, wide-ranging fight over the law. Ryan and his Senate counterpart Mitch McConnell are tasked with avoiding what happened eight years ago where early momentum for ObamaCare stalled and eventually turned into a politically bruising slog.

As they say in Triadelphia: You know how you eat an elephant? One bite at a time.