Yves here. The first book is all about a topic we have discussed regularly: the horrorshow known as electronic health records. The second is about the cost and consequences of fragmented health insurance schemes.
By Lola Butcher, a health care business and policy writer based in Portugal. Originally published at Undark
BOOK REVIEW — “Fragmented: A Doctor’s Quest to Piece Together American Health Care,” by Ilana Yurkiewicz (W. W. Norton & Company, 272 pages).
BOOK REVIEW — “We’ve Got You Covered: Rebooting American Health Care,” by Liran Einav and Amy Finkelstein (Portfolio, 304 pages).
Lana Yurkiewicz’ patient was in the emergency room and fading fast. Born with a severe kidney condition, the patient — she calls him Mitch Garter — required a perfectly timed medication regimen, including a high dose of potassium, to keep his electrolytes in balance. He had been hospitalized nearly 100 times before he turned 25, but this was the first time Yurkiewicz, then a senior medical resident, had encountered him.
She knew he needed potassium, but how much? Clicking into his electronic medical record, Yurkiewicz found tens of thousands of words, entered by many different clinicians, but no clear guidance. “Every medical team seemed to create its own plan and gave different doses and rates of infusion, making it easy to overshoot or undershoot,” she writes.
Using the information she cobbled together, Yurkiewicz calculated that the dose Garter needed was “literally the dose of potassium used in lethal injection.” When she entered the order into the electronic chart, it triggered a warning: “Are you sure?”
Two recent books explore a truth that is obvious to nearly everyone who works in health care and surprising to almost everyone else: Through no fault of their own, doctors often don’t know what they are doing and, even when they do, America’s patchwork way of paying for health care may prevent them from doing it.
In “Fragmented: A Doctor’s Quest to Piece Together American Health Care,” Yurkiewicz, an oncologist and internist at Stanford Medicine as well as a journalist, describes a behind-the-scenes reality that the public rarely sees: doctors scrambling to collect patient records — papers sent by fax, compact discs sent through the mail, electronic notes too disorganized to be useful. “Being a doctor means working in a constant state of being partially blindfolded, grasping at bits and pieces of a patient’s narrative to try to craft a coherent whole,” she writes.
Yurkiewicz’s case that fragmentation is the single greatest problem underlying American health care is convincing — that is, until economists Liran Einav and Amy Finkelstein trump that argument with their start-over-from-scratch proposal in “We’ve Got You Covered: Rebooting American Health Care.” Their focus is on the fragmented way that health care is paid for. It is killing people and, the authors maintain, partial fixes like the Affordable Care Act simply reveal that the foundation of the health care system needs to be replaced. “No matter how much we patch it, the old cracks have always reemerged,” they write. “It’s long past time to tear it down and rebuild.”
In 2009, Congress tried to rebuild one part of the health system when it passed the Health Information Technology for Economic and Clinical Health Act. Until then, patient records were almost entirely in paper form, kept in file folders in a doctor’s office or hospital. When patients visited a new doctor or showed up in an emergency room, getting the often-crucial information about their diagnoses, medications, allergies, and so forth was either cumbersome or impossible. The 2009 legislation set aside billions of dollars to help physicians and hospitals adopt electronic health record technology that, in theory, would allow patient records to be easily shared with caregivers anywhere in the country.
In the past 14 years, almost every hospital and physician practice has adopted computerized charts, and skilled nursing facilities are getting on board. While the electronic record systems work well for storage, they do not always collate patient information in a way that makes it easy for clinicians to use. And because hundreds of electronic medical record vendors use different technology, widespread electronic sharing of patient information has not yet happened. In a 2018 survey at Yurkiewicz’s own hospital, 80 percent of resident physicians said it was “somewhat difficult” or “extremely difficult” to get information about patients transferred from another health care facility.
Computerized patient charts are a godsend in many ways, Yurkiewicz writes; the technology can alert doctors to potential errors, such as her order for Garter’s unusually high dose of potassium, and offer suggestions for addressing specific diagnoses. But the lack of organization inside the electronic charts — and the logistical challenges of accessing information — eat up time that doctors usually don’t have.
Yurkiewicz recalls that, during her desperate search through Garter’s record, she was paged five to 10 times an hour because she was responsible for 14 other patients. She laments that some parts of an electronic record are searchable while others are not. Because clinicians document in different ways, information input by one doctor is not where the next physician expects to find it. “The electronic charts have built the haystack, but they haven’t yet evolved to find the needle,” she writes.
In Garter’s case, she stumbled across the needle only when she was preparing to discharge him. While most of the other doctors who had treated Garter had entered their reports in the “notes” tab of the electronic record, his regular nephrologist had written the doses of potassium to give, by what route, and how often — “the magic formula I had been seeking” — in the “problem list” tab. As it turned out, Yurkiewicz’s orders were effective, but she wonders what a medical malpractice lawyer would have said if things had turned out otherwise. “The lawyer could point out the information was all here; the doctor just didn’t follow it,” she writes.
In subsequent chapters, Yurkiewicz uses her first-hand experiences to illustrate the many frustrations that prevent physicians from caring for patients the way they want to. For example, because many people, particularly those without insurance, do not have a regular doctor, clinicians who treat them in the hospital struggle — sometimes successfully, other times not —to find a physician that will care for them after they are discharged.
Some of her material was adapted from articles Yurkiewicz has published elsewhere, including Undark. While she ties them together under the theme of fragmentation, that framing sometimes seems like a stretch. In a lengthy description of her own father’s life-threatening medical crisis, Yurkiewicz makes a convincing case that many complications stemmed from her father being overly sedated while on a ventilator. But she acknowledges that the doctor who wrote the sedation order and the nurse who followed it acted reasonably, so the anecdote does not advance her argument about the perils of fragmentation.
By contrast, her chapter about how America’s insurance problem wreaks havoc for physicians and patients alike nails the fragmentation argument. When Yurkiewicz volunteered at a free clinic on a Saturday morning, she saw an uninsured patient she thought might have prostate cancer. She offered to do the preliminary urine and blood tests and recommended that he come back to the clinic to discuss the results with another doctor. “But what if they were suggestive of prostate cancer?” she writes. “The layers of follow-up needed were daunting — and unavailable.”
The fragmentation caused by our insurance system is so vast and dangerous that it deserves its own book, and Einav and Finkelstein, economists at Stanford University and the Massachusetts Institute of Technology, respectively, stepped up to write it. The authors argue that America’s piecemeal health care coverage — some people insured through their work, others by virtue of their income level, their age, or their medical malady — is so sprawling and flawed that it must be replaced by automatic free basic coverage for everyone.
About 90 percent of Americans have health insurance, either private coverage — typically provided through an employer — or one of several government-run programs such as Medicare and Medicaid. That means about 30 million people were uninsured as of 2019. (The authors primarily use pre-2020 data to avoid the distortion caused by the Covid-19 pandemic.) Most insurance reform proposals focus on getting those folks insured, but Einav and Finkelstein write that such an approach has been failing for decades.
For one thing, some uninsured individuals are already eligible for government insurance but are unaware of it or do not know how to apply for and maintain coverage. Beyond this segment of uninsured Americans, “health insurance problems extend to most of the remaining 90 percent of Americans who currently have insurance,” the authors write. “Many live with the constant danger of losing that coverage if they lose their job, give birth, get older, get healthier, get richer, or move.”
Indeed, nearly a quarter of Americans under 65 will be uninsured at some point over a two-year period, often because they changed or lost a job. The problems caused by this disjointed approach to insurance, including exacerbating health conditions and even death, have been documented before, notably in Jonathan Cohn’s 2008 book “Sick: The Untold Story of America’s Health Care Crisis — and the People Who Pay the Price.”
The fresh twist from Einav and Finkelstein is that they show how the health care payment system is not just dangerous but also ridiculous. Describing the folly of tying health insurance to employment, they write: “If a worker becomes too sick to work they can . . . wait for it . . . wait for it . . . that’s right . . . lose their health insurance. Precisely when they really need it to cover their medical bills. Kind of a dumb way to set things up, if you think about it.”
The new idea they offer, and it is an important one, is this: Although America has stubbornly resisted universal health coverage, which is standard in most other high-income countries, the myriad patches being made to extend coverage to particular groups of people ultimately reflects the reality that the country wants everyone to be insured.
In fact, the authors assert that this is the empirical social contract under which the nation operates. “From colonial to modern times,” they write, “the record is clear: Our country has always tried to provide essential medical care to those who are ill and unable to provide for their own care.”
So the government requires hospitals to provide emergency care, regardless of the patient’s ability to pay (although not the care required to recover from illness or injury). And, of course, the government provides insurance programs for some low-income people through Medicaid and everyone 65 and older through Medicare.
Beyond that, the government requires coverage for some diagnoses. The most recent example came during the pandemic, when Congress quickly ruled that the government would cover the medical costs of treating Covid-19 among the uninsured. That decision falls in line with other government programs to cover the medical expenses of patients with tuberculosis, Lou Gehrig’s disease, breast and cervical cancer, end-stage kidney failure, and a few other diagnoses.
All those patches have a common origin story: “A particular problem surfaces, generates public outcry, and prompts (limited) policy action,” Einav and Finkelstein write. The unfairness of that squeaky-wheel-gets-the-grease approach is highlighted in their account of an uninsured woman with late-stage breast cancer who qualified for one of the insurance fixes while her mother, who had late-stage lung cancer, did not. The woman “wryly joked that she had won the ‘cancer lottery,’” the authors write. “At least until her cancer went into remission and her coverage then ended.”
That bizarre approach to insurance also leaves people like John Druschitz — another of the book’s many examples — out in the cold. Insured all his life, he canceled his coverage in April 2020 because he was to become eligible for Medicare 23 days later. During that time, he spent five days in the hospital with Covid-like symptoms, but his test came back negative so he wasn’t eligible for Covid-specific coverage. He didn’t know about other programs that might have covered some of his costs and missed the application window. A year after his ordeal, Druschitz faced more than $20,000 in medical bills and a hospital barking at his door.
“Patching the patchwork inevitably leaves gaps at the seams,” the authors conclude, and the only way to fulfill America’s unspoken social contract is to adopt universal health coverage. Their sweeping plan calls for all Americans to receive free basic coverage — emphasis on basic — and the option to buy additional coverage.
Basic coverage, in their view, should cover all primary and preventive care, specialists, outpatient, emergency and hospital care, regardless of a patient’s medical condition. That does not mean seeing the doctor of your choosing at your preferred time and location, and it doesn’t mean a private room. And it does not mean everything gets covered. What about infertility treatment? Physical therapy? Most countries have a formal process for choosing which services make the cut, and the United States will have to have one as well, the authors write.
In addition, to afford free basic coverage for everyone, we will have to create and enforce a budget for how much the country is willing to spend on health care, just as most other countries do. “Remarkably — and absurdly — the U.S. government has never actually had a health-care budget that caps the amount the government can spend on medical care,” the authors write. That explains why, over the past half-century, “U.S. health-care spending as a share of the economy has grown twice as fast as the average in other high-income countries.”
Einav and Finkelstein draw on decades of economics research and examples from other countries to flesh out their plan. The bottom line is that the basic universal coverage they propose would be better for the 30 million Americans currently uninsured; about the same for the 70 million low-income people now covered by Medicaid; and a bit worse — with longer wait times for non-emergency care and no fancy hospital rooms — for the 150 million who currently have private insurance and the 65 million who have Medicare. Even so, as in most other countries, people who could afford to do so would buy supplemental coverage, and nobody would worry about losing coverage, regardless their financial situation.
“‘How can this ever happen politically?’ is surely, by now, echoing from the peanut gallery,” the authors write, acknowledging that universal coverage proposals have been going down in flames for decades. Surprisingly, their answer to this question is the most uplifting part of the book.
For more than a century, prognosticators have been predicting that universal coverage is imminent, and serious attempts to make it happen have been launched by both political parties. Those efforts have all failed, but as the authors recount several near-misses in the U.S. — and the difficult, but ultimately successful, efforts to pass universal coverage in Canada and the U.K. — even the jaded “It’ll never happen here” reader may start to believe that free universal coverage in America will eventually come to pass. “But for a quirk of fate,” they write, “universal health insurance would have been adopted in the U.S. at key junctures.”
Taken together, these two books paint a full picture of the sorry state of American health care — both for patients who need care and the clinicians who want to, but often cannot, provide it. “The story of how we got here is complicated,” Yurkiewicz writes. “It’s a story of misaligned incentives and unintended consequences. But the conclusion is not complicated: our current health care system has failed. The question now is, how do we dig ourselves out?”
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I went into Nuclear Medicine this month for a gastric emptying test. To take that very expensive test, I had to come off all the ‘self-care’ and supplements I’d been using to rebalance my gut to avoid another MRSA infection.
Three hours after completing the test and awaiting results, I get a voicemail on my phone from a technician at Gastroenterology saying, ‘We have your results back from Radiology…. your results weren’t just ‘normal’ (teetering laughter), they were ‘grossly normal’. That was a new one, I had to Google it. What’s ‘grossly normal’ and what does it mean? Left to our own devices in the absence of anything like answers from healthcare (which seems to have nothing to do with ‘health’), we’re treating and dosing ourselves.
I had asked the technician running me through the steps of the test how they evaluate their findings and he vaguely described how the radiologists use a “formula”, that he tried to make sound ‘science-y’ but just sounded like voodoo, like maybe they ‘prayed’ over the images and ‘laid hands’ on them. It didn’t inspire confidence.
The problem with the article is the limited scope regarding who all the players are around patients and their health, further fragmenting the picture. Our own interventions may not be considered ‘legit’, but they’re not negligible. We’re not popping Reese’s pieces by the handful.
This is strange. In my limited experience, test results go to the doctor that prescribed the test, and this doctor decides what recommendations to make. The technician gets a “result”, and he/she may have knowledge about the implications or not, “that was not on the test” during the training. The other thing I know is that the results can be “improbable”, e.g. there is some range of normal results, and above that range something should be done, but you get a result below that range… perhaps something in your conditions violates the assumptions of the test, perhaps something wrong with the equipment… I got it in my blood pressure test two weeks ago.
Speaking of BP: in my 30s I began drinking only spring water because it was unchlorinated and I had blamed my father’s arteriosclerosis on his sensitivity to chlorine. I also was sensitive to chlorinated swimming pools. So for almost 40 years I drank only non-chlorinated water. When the water company was sold to a corporation based in Georgia they stopped delivery service and I once again resorted to tap water. Within 5 years I had developed very high and volatile BP. Started medication, etc. Then about 5 years later we moved to Oregon and again arranged for water delivery. Within less than 3 months my BP was once again normal at 130/70. So just a story, but I think there is something to it.
Do water faucet filters (like PUR etc) that say they remove chlorine work to the level of drinking non-chlorinated spring water?
My guess would be they are pretty effective. I go for purified/spring water because it tastes so good.
The system is so huge, so confusing, so bewildering, that most patients are reduced to psychotics by the time they finally get treated…then they get their bills and become schizophrenic…
Since there aren’t many independent doctors anymore and they are employees of a corporation, my experience is the doctors are pressured to see more patients. Before doctors became employees they would spend 45 minuets to an hour with you. No they are pressured to see a patient for only 20 minuets. You almost get comfortable in sitting down and your appointment is over. It’s like being on an assembly line. Doctors have also become more likely to move on to another place.It seems like to me every time you go to the doctor there are more new faces taking care of you. For the most part the personal contact is gone. In my opinion this has to reduce the quality of care.
Here in Norway 15-20 minutes is the norm and has been since we moved back here.
The patient (me) sits on one side of the desk and the physician on the other side, computer at hand.
There are times the physician will get out if his/her chair, stethoscope in hand, of course, but only if medically necessary.
A bit of an exaggeration but not by much.
Of course single payer system would be better for everyone and would allow controlling the ever escalating cost of healthcare in the US. The Congress should create a law that declare healthcare a human right and mandate the single payer system.
Unless the “money train” stops, money flowing from insurance companies (or any other companies for that matter) to lobbyists, to congress and/or representatives, it’s not going to happen. The pay as you go political system is the root of the problem and it had been since the birth of the US Nation…
Contrast Germany and the UK. Germany has a sick care system but not single payer. UK has NHS. Which one do you think does better?
These two books are looking honestly at our diseased health care system. It has been parasitized by computerized electronic records that make some things even worse with unbearably inefficient information which is not bad enough to kill the industry but bad enough to discourage doctors and make patients worse. The same for our lovely health insurance corporations – they are first class parasites which make the system sick but not quite sick enough to die.
i’ve just started listening Got You Covered. When in the early stages of the book the authors reveal that they’ll be advocating a two-tier health insurance system and doing so in the spirit of Milton Friedman, any hope for advocacy of universal, equitable health care dimmed. I keep on to the end. Maybe I’ll get a happy surprise.
Sounds like a version of Romney/Obama care.
Sorry, one quibble:
The US is the only OECD country that does NOT have a comprehensive health care system. That’s a basic problem.
“Most countries have a formal process for choosing which services make the cut, and the United States will have to have one as well, the authors write.”
The United States already has that formal process, hiding in plain sight. It’s called Medicare. It’s far from perfect, but no country’s system is perfect. Health care will always be — and MUST be — a work in progress. Human rights always are, as long as humans have anything to do with them.
A bit like the blind men and the elephant isn’t it? They each describe a portion of the problem without naming the elephant in the room: Greed.
Yes fragmentation is a huge issue. Just spent a month trying to sort out my elderly parents care in SNF and LTC. Dad needed a WC. LTC doctor said he couldn’t order it and Dads PCP would need to do that . Of course what it came down to was he wasn’t going to get paid to do the documentation for Medicare to get it paid for. Mom got booted from SNF after 30 days despite steady progress on her ADLs almost certainly cause reimbursements were dropping and more profitable patients needed a bed.
Access to a dysfunctional system is surely better than no access, but even the well off are not getting good care in this country.
as Don Berwick has said:
“Every system is perfectly designed to achieve the results it gets”. Ours is designed to make health care execs and shareholder rich beyond imagination. It is working PERFECTLY.
If it is a national responsibility (and at this point it is de facto….the government is already paying for the bulk of medical care) the only solution is to put doctors on salary with no bonus for volume or patient satisfaction and I would add, additional training. Primary care doctors should not make less than neurosurgeons. They cannot be allowed to work for big Pharma or device manufacturers on the side. The government would need to determine where the need is and offer jobs based on that. That means less doctors for Greenwich, Connecticut or Short Hills New Jersey and more for Sandusky, Ohio. Doctors and medical associations and big pharma should not be allowed to pay politicians either. This would be a system not unlike the British NHS which has been quite good. Recently with the conservative neoliberal governments the funding has been cut to encourage people to abandon it and go private. We could do worse than adopt many of the elements of the NHS. Fee for service is fine if we do not want to provide medical care for all Americans. Those that do not have money would need to die. I do not think the American populace has the stomach for that. Paying doctors fee for service is as absurd as paying soldiers in combat fee for service like so much per bullet fired. Paying Pharma fee for service gives us exactly what we are paying for. On the other side we would need to establish a no fault medical malpractice system and take lawyers out of medicine and pharma. And we would need to take lawyers out of personal injury cases since they do benefit and encourage high medical costs in PI and worker’s comp where they can use high medical costs or the threat of them to strong arm the employers and payers into paying higher settlements most of which goes to the attorneys. That would mean dramatic tort reform. Like neurosurgeons who benefit from back surgery especially in workers comp and personal injury cases…..lawyers would be taking a big pay cut. Will this happen? Maybe if the US hits a big depression followed by a revolution and an authoritarian government takes over.
Here’s an example of how the economics of fragmentation have rendered the “mandate” for full coverage of preventive care a joke – less than 6% of adults get all their high priority preventive care, and the government has set a comically low-bar goal of 11%. The people who pay for it don’t give a damn in part because they don’t get the rewards. Written by yours truly.
I can tell you why most adults don’t get “all” their preventive care. A lot of it is unnecessary. I take very good care of my health and my doctor, who is a solo practitioner (and I pay her at the time of service and then submit for reimbursement) does not recommend many of the ACA freebies…which BTW for the most part are NOT freebies under my grandfathered health care plan, hence none of the alleged incentives are at work.
For instance, if you are in an Obamacare compliant plan, you are entitled to an annual HIV test. If you were negative on your last test (and it was >4 months after you had sex) and sexually inactive since then and not an IV drug user or tattoo-getter, that’s a waste.
You are also entitled to an annual Hep C test. Again unnecessary unless you share needles (which includes having gotten a tattoo) or got a blood transfusion.
Similarly, why get depression screening if you are functioning as always???
The list at HHS obscures the fact that “colorectal cancer screening” is a complete misnomer. It = colonoscopy (or the DNA stool test…which then they find something sus-looking you need a colonoscopy, the colonoscopy is NOT covered). But all that is ACTUALLY covered is the doctor having a look-see. If they snip anything, that’s on you. It’s pretty routine to pay $1000 on tope of the “free” part.
On top of that, the US is the only advanced economy to recommend colonoscopies for all adults over 50. Most other countries recommend them only for high-risk groups. For people at normal risk, a cheap (my MD gives it for free because cost to her is $2) fecal occult stool test done annually does just as good a job of catching colon cancer.
Annual exams are valuable for healthy people mainly to get a pretty complete blood workup…which is NOT paid for under Obamacare.
Similarly, urinary incontinence screening for women is overkill. If you aren’t leaking, and you know damned well if you have a problem, you don’t need interventions. Even the American Association of Family Physicians objects:
https://www.aafp.org/pubs/afp/issues/2019/0201/p194.html
They also recommend bone density tests for all women over 60. I have weight trained hard for 35 years and even have palpably denser bones at key muscle/tendon attachment sites like in my collarbone. I tripped over my shoelaces and took a hard fall on concrete which for anyone else would have broken a hip. Instead I tore up my cartilege. I will admit I am an outlier but I am oversharing to establish the point that you are making the assumption with no evidence that the lack of full uptake is due to “fragmentation” as opposed to PCP and patients deciding not to add to the problem of our overpriced medical system by getting unnecessary tests and treatments.
If the main reason you are getting an annual physical is to get your labs, save yourself the doc visit and just get the labs. You do not need a doc order for most blood tests. Got all of my blood work for $105 by going directly to the Quest location. Wellness #2 essential blood test panel bundled 7-8 tests together. Cash payer makes it a lot easier to just get done.
The best essay I’ve ever seen on how to fix the health care system in the U.S.:
https://market-ticker.org/akcs-www?post=231949
2017-03-30 by Karl Denninger
Headings only:
The Bill To Permanently Fix Health Care For All *
“Let’s lay out the parameters for a bill, a fairly-modest update to my two previous missives on this point here and here (note the dates) and which can be easily turned into formal legislative language:
All providers must post, in their offices and on a public web site without any requirement to sign in or otherwise identify oneself to access it, a full and complete price list which shall apply to every person.
All customers must be billed for actual charges at the same price on a direct basis at the time the service or product is rendered to them.
For a bill to be valid and collectible it must be affirmatively consented to in writing, with a disclosure of the actual price to be charged from the above schedule for each item to be provided whether good or service, prior to the service being performed or the good furnished, subject only to the emergency exception below. A bill that is increased, has items added to it after consent is obtained, which contains any open-ended promise to pay without an actual price listed for each service or good prior to customer consent or is issued with no consent at all (including having a customer sign a consent form while under the influence of drugs the facility gave them as occurs in virtually every instance today while you’re being wheeled into the OR) is deemed fraudulent and void.
No event caused by or a consequence of treatment, can be billed to the customer.
All true emergency patients, defined as those who are unable by medical circumstance to choose where their treatment is to take place and require immediate medical intervention to either stabilize their condition, prevent severe permanent impairment or death (e.g. transported by an ambulance, unconscious with no person with medical power of attorney at-hand, having a heart attack in the ER, etc) must receive the same price for the same service as a person who consents to said service.
All medical records are the property of, and shall be delivered to, the customer at the time of service in human readable form (a PDF provided on common consumer computer media such as a “flash stick” shall comply with this requirement.) Any coding or other symbols on said chart must include a key to same in English delivered at the same time. No separate charge may be made for the provision of a contemporary record of a medical visit or treatment other than a reasonable charge for physical media if the customer does not have same with him or her.
All surgical providers of any sort must publish de-identified procedure counts and account for all complications and outcomes, updated no less often than monthly.
Auxiliary services (e.g. medical or dental Xrays, lab testing, etc) may not be required to be purchased at the point of use.
All anti-trust and consumer protection laws shall be enforced against all medically-related firms and any claimed exemptions for health-related firms in relationship to same are hereby deemed void; for private actions all such violations proved up in court are entitled to treble damages plus a $50,000 statutory civil penalty per impacted person.
Any test or diagnostic that carries no exposure to drugs or radiation, nor is invasive beyond a blood draw, may be purchased without doctor order or prescription.
Wholesale drug pricing in the United States must be on a “most-favored nation” basis.
No government funded program or government billed invoice will be paid for medical treatment where a lifestyle change will provide a substantially equivalent or superior benefit that the customer refuses to implement.
Health insurance companies must sell true insurance to sell any health-related policy at all.
All health insurance providers selling true insurance, in whole or part, must provide within their “true insurance” the ability to “replace like with like.”
Medicare becomes just another insurance provider.
Medicaid is repealed entirely.”
Etc.