We’ve got a whole host of things that we’ve talked about on how to do this. The [Patients’ Freedom to Choose Act], it saves the states billions in terms of cost.
Q: Do you have any optimism that Congress can work together in a bipartisan way to address some of your concerns with the existing law?
A: No. This isn’t fixable in the way that they have it. To make this fixable, you have to take out the individual mandate, you have to take out the employer mandate, and you have to go to a system of risk reallocation on the insurance industry. If you want to really cover people with pre-existing illnesses, what you have to do is keep the insurance industry from cherry-picking. And what they tried to do is to get everybody covered so you could actually indemnify the whole population.
Our other problem is we’re spending money. You know, if we spent a lot of money on prevention that actually worked, we would in fact save some dollars. But we haven’t created a situation where the insurance industry is interested in keeping you as a long-term insuree, so, therefore, I don’t have any incentive to work on your wellness. Now they’re doing a little bit of that, but they’re not to a great extent. And if you knew you could buy your health insurance over a period of 20 years and be with the same company and they’d actually help teach you, get the things that are going to lower your risk and your cost, they’d both save money.
So there are all sorts of things, but what we’ve done is we’ve abandoned the thing that we use in the rest of the country to allocate scarce resources, and that’s market forces. Ask yourself why the best hospitalists in the country get paid the same as the worst. Well, why wouldn’t we want to incentivize and pay for higher quality and pay less for poorer quality and poorer outcomes, to the point where we promote excellence rather than mediocrity? But we don’t do that.
Q: What’s the next step for Republicans in trying to push forward some of your own ideas?
A: We’re going to take our [Patients’ Freedom to Choose Act] and we’re going to modify it somewhat and we’re going to introduce it and have, you know, “Here’s what we believe. You all believe this, we believe in individual freedom and personal responsibility and accountability,” and we’re going to try to do that. That won’t go anywhere because we don’t have the votes to have it go anywhere. What we’re going to wait for if the court cases. My suspicion is the president loses the court case when it gets to the Supreme Court.
Q: Do you believe the entire act will be struck down or just the individual mandate?
A: No, no. I think the entire act will be struck. The bill doesn’t work without the individual mandate because you don’t get enough revenues in to cover what—and the bill is scored so stupidly anyhow. I don’t know if you know much about government budgeting, but this thing’s a farce in terms of its cost. It’s going to cost fully $600 billion to a trillion dollars more in the first year  than they’re saying it will.
Q: What’s your view on accountable-care organizations?
A: Accountable-care organizations (ACOs) aren’t going to work, and let me tell you why they’re not going to work: because the ACOs are going to be grouped in the large metropolitan areas and you’re going to have less competition rather than more. And so what you’re doing is you’re seeing hospitals buy physician practices, and then they’re going to get into this accountable care, and what they’re going to find is it’s not going to save them any money because you’ve got less competition.