As a solution to the conundrum of the failing health care system, I propose the HHO plan built on the foundation of provider-to-patient health care and the return of control back to payers. The proposed congressional bipartisan debt commission would be an excellent option for making recommendations to Congress, urging it to allow the needed changes for a revamp of our healthcare system {2}. This commission will not realistically be able to implement the necessary cost-saving changes across all systems that affect health care, such as health insurance, Big Pharma, advertising, and malpractice; however, it could legislate changes and contracting pertinent only to the HHO plan. This would minimize the legal, political, and public opinion challenges from special interest groups that benefit from the current system. Congress has already legislated the Center for Medicare and Medicaid Innovation (CMS Innovation Center). A hospital/health care system, without any need for further congressional support, can apply to the CMS Innovation Center for a trial study based on HHO plan fundamentals. Such studies would include select hospitals with the ability to adjust to local needs. These trial studies are the first step in getting the health care system headed in the right direction. The implementation of the HHO plan will require ample effort and patience—it’s a cliché, but we have to take it “one step at a time.” It has been said that the present system is just too complex but if our government can build an aircraft carrier and go  to ( and return from) the moon, it should be able to handle an individual’s health care as well as many countries around the world that have far less resources than we do.

Specifically, I advocate the division of medically indicated care into basic, lifesaving, catastrophic, and elective categories using International Classification of Diseases (ICD-10) and Current Procedural Terminology (CPT) codes. This will allow the differentiation of payer sources, patient choice regarding benefits desired, and employer and government choice regarding benefits provided. The HHO plan will allow all to pay for what they need and want. Rather than being a completely new system that would eradicate every trace of the old system, the HHO system would be a blend of already tried and tested payment models in a coordinated effort to leverage the advantages of each. The following discusses the division of care.

Basic care (a right). Basic care is reserved for unexpected minor episodic illnesses and injuries that can be treated `in a primary or urgent care setting. On average an individual sees a doctor about 3-4 times a year.  More often if you are an infant, elderly, female or have insurance.  Many patients go for years between office visits, especially if uninsured but that is not recommended. Basic preventive care (e.g., yearly exam, immunizations, and Pap smears) and urgent care (e.g., treatments for simple lacerations and simple fractures) also fall under the basic category.  Such care would be billed according to the predetermined level of the service (e.g., $50–$250 for Levels 1–5, which would reflect the appropriate complexity of a visit) and not by codes. Advanced preventive care  would be paid for by an all-inclusive set yearly fee paid for by a lifesaving contract (refer to next section).   Direct deductions (i.e., no billing, insurance, or cash {rare exceptions with surcharge) payments) would be made from patients’ pretax health savings account (HSA). Minimizing provider billing offices will result in lower cost to the patient. It may be argued that many of the poor do not have an HSA account but the fact that the government will be depositing money into it for those in need would be an incentive to get one just like they are likely to already have an Electronic Benefits Transfer (EBT) card. There should also be an option to tailor the EBT card to also function as an HSA account and thus patients would be less likely to “lose” the HSA card. HSA card numbers also may be on file in the provider’s office and hospital just like a credit card number may be on file. Level 1, and even level 2, bills may be equal to a current insurance copay. Patients can use funds from their HSAs, flexible savings accounts (FSAs), or Electronic Benefits Transfer(EBT) cards to pay for basic care. Credit or debit card payments (with surcharges high enough to discourage their use of cash back rewards and to reimburse processing fees) would be acceptable if one did not have any other method of payment; the credit card or debit card would then be paid off with post-tax dollars which would discourage its use. This payment option would be made available to a foreign visitor with no HSA option. The use of the HSA to pay for basic care has the same benefits as the current  use of a high-deductible insurance plan with HSA benefit. The federal government would deposit funds into the HSAs of individuals with  too low of income to cover anticipated basic care needs. With individuals rather than insurance companies paying for basic care, there would be competition to provide the best and most affordable treatment options among HCPs and entities. All patients would pay the same amount as predetermined by the service level, and unused HSA funds would accumulate in individuals’ accounts. This system can also be used to encourage positive  health care decisions, such as preventive care and lifestyle changes.  If the balance of an HSA falls to zero, basic health care can still be made available. If an issue is non-urgent and care is sought at “off-peak” times, a discount or possible pro bono services may be offered if the care is truly needed. On a limited basis, for urgent care, the HSA balance may also be allowed to fall to the negative (with non-interest-bearing loan against the HSA until additional funds are available). In special circumstances, health care and financial counselors may need to step in when patient needs exceed expectations. Telemedicine is a good option for minor ailments and can be very cost effective. AI has tremendous potential for answering basic questions, however, it needs to be used with caution when personal health is at risk. There may be a specific AI driven triage website that can be vetted to provide trusted basic medical information including when a telemedicine, office, urgent care, or ER visit is warranted. There needs to be various competitive options available for basic care that are affordable and user friendly for people of all income levels. In this model you pay for what you get, and basic care should be available for all. With patients paying directly for basic care health care companies can deal directly with the patients using normal economic principles rather than with the biased insurance company’s’ policies. This  should significantly assist healthcare provider clinics in start-up phase.  Any willing provider, health service company or pharmacy should be able to deal with patients directly and not “blackballed” by an insurance company, monopoly, pharmacy benefit manager or health care network regarding payments or control. This payment model would encourage very cost-effective independent provider offices and pharmacies that are slowly disappearing with the current insurance-based payment model. Providers or groups of providers would have the option to offer basic care plans directly to patients, employers, or government, however there should be no outside administration fees.

The purpose of requiring HSA payments for services is to help individuals regain control of their health care spending and limit unnecessary discretionary visits.  It is vitally important that all pay the same amounts of money for the same services (currently, payments are different based on individuals’ various insurance plans or other options for payment) to ensure the same incentives and disincentives for care and to eliminate patient selectivity by providers while minimizing the “dumping” of undesirable patients from one system to the next or the poaching of desirable patients by systems. Normal supply and demand principles should prevail.   Health care visits are necessary for everyone, especially when there is benefit in prevention, early diagnosis and treatment. It is almost unbelievable that people  visit a hospital emergency room (ER) for minor ailments, aches, and pains because they either have no insurance, no one will see them because of their insurance, or they cannot get a prompt appointment with their primary care provider. They may also pay little to nothing for such extremely expensive ER visits if they are on Medicaid and have no financial incentive not to enjoy the 24/7/365 convenience. On the flip side, those who are held responsible for their ER bill may elect not to visit the ER when they should because they are responsible for falsely elevated ER bills with current hospital cost shifting policies. The long ER wait times do at least partially limit unnecessary visits. However, they can be very detrimental in the event of a true emergency needing lifesaving care. ERs may differ in their bills and that is where competition plays a role and if the hospital is non-profit, there is current governmental support which should be used to help the individual patient and not the hospital.

How would you feel if car repair shops had different rates for everyone ranging from $0 to very inflated rates depending on whether certain car owners are indigent or have a better bargaining agent than you do?

All funds in HSAs should be investable to encourage the building up of unused value. However, no additional funds would be allowed to be deposited when an account balance reaches a certain dollar amount to limit undeserved tax shelter benefits—just like the current rules stipulated for 529 educational accounts. After HSA funds have been used, funds can be replenished. Under the HHO system, employer deposits into HSAs would be the default practice unless an employee opts out, just like current employer-sponsored 401K plans. There could even be possible links between the pretax 401K plan and the HSA. HSAs would be used to fund all medically indicated care including hospital/health care system plans and insurance policies designed to cover medically indicated care. Individuals over the age of 65 (Medicare age) will be able to take money out of the HSA plan and they will have to pay taxes for any prior interest earned like with the 401K plans. While we want to simplify health care payments, we also want to limit the ability to game the system. Building up in value of the HSA account would be appreciated by the approximate 50% of the population that uses very little if any formal medical care. It is reasonable to anticipate that  percentage would rise with personal responsibility for payment of basic medical care.

The RAND Health Insurance Experiment of 1971 to 1986 showed that cost sharing reduced health care spending with minimal effect on overall health. The use of the HSA to pay for basic care leverages the benefits proven by this experiment. There is question as to whether low-income individuals will forgo necessary care if they are required to use their own HSAs to pay for such care. While this is certainly a possibility, we would nevertheless all have the same incentives and opportunity for care under this policy. Education on the importance of health care will go a long way in truly equalizing access to health care for all.

The level-of-service payment model for basic care sounds simple but does not address realistic criticisms such as inflation, competition, comorbidities, or procedures dealt with during the same visit. Inflation can be tackled by periodic increases in prices for a specific level of service. Competition can be dealt with by hopefully a decrease in the scheduled rate. Different providers may charge a different rate for the same level of service. With reasonable rates, there will be little room for discounts. The issue of multiple problems can be dealt with hopefully by an increase in the level of service or discounts, such as a 50% discount for a second service (as we provide for a second cosmetic procedure done at the same procedure). However, we must watch for possible “mining” for problems. Providers on salary would be less likely to look for any additional unnecessary problems and with direct patient payment any unnecessary  “extras” should be caught. Provider payment for a consultation or procedure would be based on time or by relative value units (RVUs). There would also be a mechanism for change in value in the future if an RVU for a service changes or a new procedure were to become available. Years ago, I was asked by a member of the RVU Update Committee (RUC) to determine what “relative” value I would place on new plastic surgery procedures compared to the other procedures on the list. There was no mention of price; I was only asked to compare the different procedures’ “relative value.” I was also asked whether any of the other procedures were not listed correctly on the master list. Comparing the relative value of procedures I do personally is easy, but it is difficult to compare procedures done by different specialists. Even in the same specialty, relative values may change significantly over time and with the advent of new techniques. Take carpel tunnel surgery for example.  This common procedure presents multiple variables for treatment. A variable affecting its relative value is if it’s done in the office under local anesthesia, which can be done now, or if it is done under general or regional (Bier’s block) anesthesia in a hospital OR or surgical center, as was the case in the past.

Lifesaving care (a right). Lifesaving care is usually supplied in a hospital or hospital ER and includes advanced preventive (e.g., colonoscopy done at an outpatient clinic) care as well as acute care, such as for heart attacks, strokes and severe trauma. The individual, employer or government (for those with financial need) would pay a set, all-inclusive fee adjusted for age, sex, and ZIP code directly to a local hospital/health care system or network for the care provided. An increased fee for negative lifestyle choices  such as smoking should be considered.  This fee would vary among systems to allow for competition. There could also be an option to include surcharge payments for extended provider networks to include additional local facilities or more distant/highly specialized sites such as Mayo Clinic. The purpose of direct payments to a hospital/health care system or network is to minimize the significant health insurance and administrative expenses for all and mitigate copays, coinsurance, deductibles, prior authorizations, and insurance denials. Payments are to be used for healthcare and a reasonable profit to ensure continuation of the hospital/health care system. Referral for lifesaving care would initially be made by a HCP or ER practitioner, and any ongoing chronic care would be acquired through similar direct referral and appointments would be made with the appropriate clinics. Care would be approved based on medical indication and best practices by unbiased HCPs and not an insurance company. There would be no denial of essential (not elective or cosmetic) care if standards of care were met. There should be national standards. There will be a peer review of cases as needed to ensure care standards are met. If someone wished to appeal a medical decision, they would obtain a second opinion through medical consultation. Hospital and health care systems profits and loss ratios would be monitored and regulated as needed by the government to limit any financial gain that would limit needed patient care. When appropriate care is given appropriate profits would be expected.

Specialty Clinics of Excellence associated with the treatment of chronic care (e.g., chronic care management companies or clinics owned  and operated by the hospital/health care system) issues and various specific diagnoses, such as diabetes, high blood pressure and heart disease, cancer, and psychiatric disorders including depression would not have HSA payment requirements and would be funded by lifesaving care payments. There is a need for everyone to have, or at least be assigned, a primary care provider so as to have available a route to access specialty care, monitor progress or follow up from.  A telemedicine service including triage will be an integral component of the lifesaving care contract. An Accountable Care Organization (ACO) is a good example of what can be used as a basic framework to implement the lifesaving component of the HHO system.

Catastrophic care (a right). This form of care is usually supplied in a hospital or tertiary care center or chronic care specialty clinic and is a subset of lifesaving care for patients who have the most extensive health care needs (e.g., over $250,000). Examples include organ transplantation and aggressive precision (tailored to the individual and can be adjusted for the genome of the patient or genetic sequencing of the tumor) treatment for metastatic cancer. This group of patients continues to expand, as new, extremely expensive treatments and medications are being made available every day, and the general population is seeing increased longevity, and more people can benefit from such treatments. As a result, insurance companies have used focused advertising to minimize the provision of insurance payouts for this group of patients. High-deductible plans are also used to preselect subscribers who do not feel they will need care. Health insurance companies offering health club membership benefits in their plans as an incentive for subscribers are immediately advantaged, as such benefits attract healthy subscribers who are not likely to require catastrophic care. The long-term health benefits of an increase in exercise levels are a bonus for patients, but only an indirect benefit for insurance companies that generally only look year to year at a unique individual’s financial risk.

The redesigned system based on the HHO plan would lead to decreases in costs for providers that would be passed on to the payers and not increased profits. Governmental savings would be used to help cover those in need.  The implementation of the HHO plan would need to be paired with effective federal negotiations and legislation to deal with all overpriced providers, CEOs, and suppliers of health care, including increasingly powerful health insurance companies, Big Pharma, pharmacy benefit managers, and private equity groups who don’t have patients’ best interests at heart.  Savings realized by eliminating advertising budgets will potentially enable discounts on health care services, including drugs and devices as well as decrease unnecessary care. HCPs will be able to count on direct payments from individuals or contracting with institutional or government payers of health care rather than advertising to individuals. The government will deal with contracts for catastrophic care, since payment will be its responsibility.

The federal government should deal with catastrophic health care in a similar manner that it treats other catastrophes, such as hurricanes, floods, and tornados. The individual health care catastrophe is just as important and in need of help as the natural disaster ones. The federal government is in the best position to negotiate with the overpriced suppliers of health care services. It has experience with Medicare and Medicaid.  With the implementation of such policies and the HHO plan, hospitals and health care systems would not lose money from treating patients with catastrophic health care needs. It is important to emphasize here that ethically, the health care system should not make money from these patients either, as it sometimes does with the current health insurance fee-for-service system. These patients are unfortunately treated like Yo-Yos in that insurance companies do not want them. Hospitals and HCPs do, but only if they have favorable traditional insurance and not Medicaid or Medicare that are paid by DRG’s.  Transferring the financial risk for catastrophic care from individuals (usually through health insurance) to the government is reasonable, being that we are a society which  has the resources to be able to do so as well as the fact that most of these patients eventually end up with government payment or at least support for their expenses. The emotional and social burden of a catastrophic medical event is enough to deal with; there is no need to add possible financial ruin and/or bankruptcy to the mix of concerns.

An acquaintance of mine recently required heart, bilateral lung, and kidney transplants and had to be hospitalized for three months in the ICU. This caused him to rack up millions of dollars in bills. For most patients with a traditional health insurance policy (even one that has no cap or a maximum out-of-pocket expenses), the financial risk, when combined with expenses not covered by insurance, is too great to cover personally. With shrinking subscriber pools and increasing costs, the financial risk has even become too great for small insurance company pools and employer self-funded plans. If health care payments were made by capitation, a smaller hospital or health care system would not be able to financially survive treating such patients. This is where the government, which can institute shared risk by all, would help not only with payment of health care expenses   for these patients, but with lowering costs. It has already historically, been accomplished as we have seen done with Medicaid and Medicare payments. As stated above, the government is in the best position to address the health care crisis with direct payments to hospitals/health care systems for catastrophic care rather than legislate unfair cost shifting, unfunded mandates or even clinical care issues.

Elective care (a privilege). This form of care is usually supplied by a specialty clinic or surgical center. It includes all forms of acute and chronic care that are not lifesaving but are medically indicated (e.g., breast reduction, abdominoplasty, and joint replacement). Examples also include hearing, dental, vision and chiropractic care as well as acupuncture. There is already rationing of elective (and some necessary) care by insurance companies and breaking out elective care from medically indicated care would allow standardization of differentiation. The payers: individual, employer, or government (on behalf of those in need) would optionally fund one of various health insurance policies that would pay claims on a bundled payment or DRG basis. The bundled or DRG payment would be based on a group average.  Several well-defined standardized health insurance policies would be available under the HHO plan similar in concept, but not content, to the present options A-N for the Medicare medigap plans to allow payers to choose the desired benefits. Contrary to current practice under the redesign, elective care would be defined by CPT codes and paid by DRG’s.  An option may even be available for all medically indicated care to be covered. However, that would be an extremely expensive option. Sadly, It is exactly what we now expect with our current healthcare system. There should be a surcharge for lifestyle choices such as smoking. 

This system would simplify underwriting, control costs and foster competition between insurance companies and providers. Everyone will initially be eligible for insurance plans with no preexisting condition clauses; however, if an individual refuses the initial coverage or opts for a break in coverage, a surcharge or delay in benefits (this is elective care) would apply if they want eventual coverage. It should be noted that elective care is an extremely broad category and includes many items that different patients, social groups, communities and special interest groups may feel should be covered as a right or moral responsibility. The intention is that, with optional health insurance, unexpected and for many, unaffordable events will be covered. The range of health insurance plans should vary enough that, if coverage for a specific unexpected event is desired, then an individual should be able to buy an insurance policy or rider (like jewelry with a homeowner’s policy) with that benefit. No federal government guarantees of coverage would be put in place for elective care since fundamentally, such care is meant to be elective. The determination of a procedure or treatment’s category of care would have already been made. The elective insurance would be much less expensive than previous traditional policies, given its limited and well-defined benefits. Additionally, it would be less costly to administer reimbursements via bundled or DRG payments, and there would be no need for such plans to cover basic, lifesaving, or catastrophic care. Non-medically indicated procedures (e.g., cosmetic surgery) would continue to be self-funded. Referral for elective care would be made by a primary care provider. The definition of elective care is medically indicated as well as being unexpected, not that the patient can electively have anything they want done.

 The premium for care would be determined by age, sex, and ZIP code as well as benefits desired. Another variable affecting the total cost of the insurance premium would be possible deductible, coinsurance or copay (these options would only be needed for elective care and potentially drug/device benefits).  Payment for care would be based on the least expensive qualified provider rates in a subscriber’s area to foster competition, and subscribers would be given the option to pay any differences in price for a higher-priced provider. A discount on insurance premiums may also be obtained if subscribers wish to extend the potential distance to their providers by up to 250 miles (farther distance allows for potential  use of a less expensive provider) or even across the country. This would not be any different than traveling to get a better deal on a new car! Remember: These policies would apply to elective care, not urgent or emergency care.  Such policies would allow choice and competition at their finest, just like on the Amazon marketplace.  These insurance plans should be available and sold nationally and not limited by the state you live in. Plans however may be limited by the insurance company service area.

Premium services such as a custom lens for cataract surgery can be dealt with by an added surcharge. Insurance companies would be allowed to not only compete to sell policies but also contract with providers to get as good a deal as possible on a whole palette of elective care procedures. High-volume outpatient surgical centers, especially those that deal with joint replacement, breast reduction, or cataracts, would be in an excellent position to bargain with the various insurance companies.

Physical and occupational therapy are good examples of care that can be essential or elective. Quite literally all areas of physical and occupational therapy can benefit from the use of information sheets or handouts that patients can use themselves or with the help of a health care provider. These can and should substitute when appropriate for costly, lengthy, and protracted sessions given by a physical or occupational therapist for elective therapy. Yes, patients may not use them but that is the patient’s choice. Should we as a group ( insurance or government) cover care that can be done by a patient themself.  Specific courses of essential therapy, like postoperative therapy, should be included in the fee for the related procedure if such courses are needed and  expected. The fee paid the therapist would be based on the average number of visits needed. Some patients may need more or fewer sessions, and this should be determined by therapists. Peer review as appropriate is required to ensure that clinical guidelines are met. The current policy of mandating a certain number of hours of therapy a day to keep a patient in a rehabilitation facility encourages unnecessary care—care that could go toward patients who need it. Rehabilitation care by therapists is certainly indicated and necessary in specific cases but the care should be for specific patient needs rather than having a group of patients in wheelchairs do barbell arm exercises to meet insurance requirements to stay in a rehabilitation facility. This is not the best use of a therapist’s expertise or rehabilitation dollar. While patients might see benefits from such exercises, they should be incorporated in a general wellness program that would not need the expertise of a physical or occupational therapist. Essential therapy sessions should be included in a lifesaving care plan, but optional therapy sessions should be included if desired in an elective care policy. When you need optional therapy, it may be best to use a physical trainer individually or one that is guiding a group self-help program.  I had one patient who sees a physical therapist on a routine basis instead of getting a personal trainer since their therapy is “covered by insurance.” This should never be an allowable expense covered by insurance and the therapist is also to blame.

Another example of elective care is having a panniculectomy ( surgical procedure to remove skin and fat from the lower abdomen)after massive weight loss. It is certainly medically indicated but not lifesaving. The surgical risks of panniculectomy are limited. However, if a panniculectomy as an elective procedure is insurance-covered  and a patient wishes to pay an additional surcharge for a total body lift, the risks of bleeding, slow wound healing, and hospitalization increase. Generally, additional steps to a panniculectomy procedure are  for cosmetic reasons. However, if there is a complication or hospitalization is needed, the total medical bill for the procedure increases. Should these additional expenses be covered by an insurance company or should there be patient responsibility?

Tertiary care must be made available to all as needed. Usually, tertiary care is available at major universities and other large institutions. We need competition to improve care, not to fund a system that profits only from the already wealthy. What could be better than having Mayo Clinic compete with Massachusetts General Hospital, Johns Hopkins, Stanford and the Cleveland Clinic to lower costs and provide better care? This also goes for cancer care, as Mayo Clinic competes against M.D. Anderson, Dana- Farber and Sloan Kettering for patients and prestige. Tertiary care centers would have the ability to provide not only tertiary care but also basic and elective care plans.This would mean they could opt to function as an insurance company for elective care. This would work best if the tertiary care center is non-profit. Rules for the HHO plan would need to be upheld to qualify for catastrophic care payment. The tertiary care center could potentially have four income streams: basic, lifesaving, catastrophic and  elective care.

For the HHO plan to work, and have widespread impact, the government needs to step up support from not only a legislative standpoint, but also a financial standpoint. Support is needed to back startup systems until they can compete with existing health care systems. It is equally important that the HHO system and traditional systems do not work side by side under the same organization competitively, since the traditional system will, at least initially, be much better at revenue generation. However, the HHO system will be much more sustainable in the long term. Salaries offered to HCPs, which are often artificially inflated under the present system, will need to be competitive initially to entice them to work under these startup systems. As the HHO system expands there will be an increase in productivity with greater efficiency. Physician salaries will eventually decrease with the increased use of physician extenders. It is more efficient, and politically accepted, to increase productivity of a provider by having them supervise a productive assistant than to decrease their pay. Presently, not only are health care systems bidding against one another for a limited number of essential providers, but the need for traveling providers, especially nurses and specialty care physicians, has also added an unsustainable and exorbitant cost being shouldered by health care entities. Programs that help practitioners pay back medical school loans can be useful in provider recruitment but that benefit then ends when the obligations are met. Provider shortages in critical areas are often long-standing and all too often insurmountable.

Under the Affordable Care Act (ACA), Congress set up a provision as previously noted to allow the CMS Innovation Center to evaluate proposals for cost-effective changes in health care delivery. The HHO plan would be a good candidate for that program. Use of the Social Security Act Section 1115 waivers would also be a potential source of help in the implementation of the HHO plan. The different sources of funding, from federal and state to employer and patient, do complicate any health care reforms. Initially, there will certainly be significant and unavoidable overlaps between basic, lifesaving, catastrophic, and elective care, with corresponding challenges regarding referrals and payment. The integration of the HHO system may develop individually, horizontally, or vertically with private or government ownership, partnerships, or networks. Nevertheless, incentives to promote the reciprocity of health care systems should be encouraged, and if not, intersystem payments should be dealt with on a fair, wholesale basis. Nonprofit ownership would be the best option if altruistic not-for-profit entities actually exist in healthcare.  However, realistically, there will be a mix of ownership, which does corroborate our free enterprise ideals. Ideally, however, tertiary care centers dealing with catastrophic care would be altruistic nonprofit or government-controlled entities and work with all systems. An important point is that affordable health care can be made available if an individual, or employer, pays only for the care wanted and needed without cost-shifting and unfunded mandates. The HHO plan will work well if all catastrophic care is funded by Medicare, thus ensuring that the risk is shared by all. Otherwise, it is not only unfair but also expensive to determine if my catastrophic needs are more than yours.

As the HHO plan expands, elements of the present health care system will be kept in place. Its cost-effective HHO components benefiting patient care will survive, and its costly non- direct health care elements will eventually fade away due to diminishing employer and government support. Better and less expensive options will satisfy the health care obligations of employers,  government, and organized labor. The HHO plan’s growth and implementation can advance rapidly by partnering with emerging health care entities that are ready to discover the benefits of implementing a direct-to-consumer (i.e., without insurance) model. The important issue is not how, when, and where integration will occur but that the favorable cost-saving and access issues are not overlooked in the process. Ideally, there would be a specific date for transition, but this is unrealistic, given all the moving parts of the health care system. Transition will be in stages. There may be a need for patients to submit their own claims to their insurance company (with the necessary information provided by their PCP) if the provider has already switched to an HSA payment system. Eventually the traditional health insurance plans will be replaced with the less expensive HHO plans. 

The HHO plan would achieve, for Democrats, basic, lifesaving, and catastrophic care for all and elective care for most, as well as, for Republicans, cost control. The stale debate between community-based health insurance ratings (everyone paying equally) versus actuarial fair health insurance ratings (everyone pays differently based on their individual health care risk) will conclude with the hybrid HHO plan. Community-based payments will be used to pay for lifesaving and catastrophic care, and actuarial fair payments will be used to pay for basic and elective care. While the HHO plan may not solve the health care crisis, it can be the impetus for meaningful political discussion. Only individuals’ support backed by bipartisan federal legislation can enable the fundamental changes needed to overhaul the health care system.

{1} US Health Expenditure as Percent of GDP 1960–2021, Preeti Vankar, Sep. 19, 2023. Statis.com.

{2} The Federal Debt Tops $34 Trillion and Some in Congress Want a Commission to Find Ways to Tackle It, Jan. 18, 2024. Associated Press.