In a typical politician’s fashion, “Trump’s Ten Weeks of Lies”

By: Ahmed Baba

Ten weeks. We are now in the double digits of what has felt like the most tumultuous first weeks of a new presidency.

Ten weeks of lies. Ten weeks of failed policy attempts. Ten weeks of Trump.

President Trump went into this week still trying to shake off the disaster that was week nine. Obamacare replacement attempt, failed. Trump-Russia investigation, confirmed. Republican party, fractured. How was President Trump going to handle this?

Did Trump clean up his act and try to repair the division within his party?

Did Trump prove he has nothing to hide and cooperate in the investigation into his campaign’s potential collusion with Russia?

Of course not. In typical Trump fashion, he learned nothing from his mistakes. He doubled down.

Here is every action President Trump, and his administration, took during his tenth week as President of the United States:


Tenth Weekend (March 25–26)

The Blame Game

Donald Trump and House Speaker Paul Ryan — Nov. 10, 2016 (AP Photo/Alex Brandon)
  • Fresh off of his tremendous week of losses, President Trump started his tenth weekend off with some comforting words for American’s worried about the future of their healthcare coverage. There is nothing more relaxing than your President telling you your healthcare system is going to spontaneously combust
There is no evidence to support the claim that Obamacare will explode
  • This is when things got interesting. On Saturday, Trump sent out this tweet

And…This was Jeanine’s opening statement

This was in stark contrast to Trump’s supportive words for Paul Ryan after the failure of his healthcare bill.

  • After blaming the Democrats, President Trump had some bitter words for his fellow Republicans in the Freedom Caucus, whose rebuff of the GOP’s Obamacare replacement doomed it to an early grave
This wouldn’t be the last time he swung at his own party this week
  • As Trump was spending yet another weekend at Mar-a-Lago, The Washington Post reported that “for the eighth weekend in a row, President Trump has visited a property that bears his name. He has done so on 21 of the 66 days he has been in office”

Tenth Week (March 27–31)

Monday March 27

Sketchy Nunes

House Intelligence Committee Chairman Rep. Devin Nunes, R-Calif., looks down on the right of the committee’s ranking member, Rep. Adam Schiff, D-Calif. Wednesday, March, 15, 2017 (AP Photo/J. Scott Applewhite)
  • Last week, House Intelligence Committee Chairman Devin Nunes (R-CA) brought himself under fire after briefing President Trump (who Nunes is currently investigating for ties to Russia) on intelligence reports that contained the “incidental collection” of communications between the Trump transition team and foreign entities. Nunes, who was also on the Trump transition team, briefed Trump without first briefing ranking member of the Intel Committee Rep. Adam Schiff (D-CA). Trump took that info as “vindication” for his wiretapping lies, even though it is far from it. This week, the heat turned up. Nunes told CNN he was on White House grounds when he reviewed the intelligence reports, leading many to question whether his source was the White House itself. This was the first of many developments throughout this week, that pointed directly to coordination between Rep. Nunes and the White House he is investigating
  • The Senate Intelligence Committee said they will question President Trump’s son-in-law Jared Kushner as part of their investigation into potential collusion between Trump’s campaign and Russia. He will be questioned specifically on his secret meeting with former national security advisor Michael Flynn and Russian Ambassador Sergey Kislyak in December, as well as his correspondence with a Russian bank
  • Attorney General Jeff Sessions held a press conference where he used fear tactics and dangerous myths to push a Sanctuary City policy change that would do local communities more harm than good. He threatened to strip their funding
  • Trump picked Jared Kushner to lead a team to fix government bureaucracy with business ideas
  • Democrats forced the delay of a vote on Supreme Court nominee Neil Gorsuch
  • After the revelation that Nunes met his source at the White House, Democratic House Minority Leader Nancy Pelosi and ranking member of the House Intelligence Committee Rep. Adam Schiff (D-CA) called on Devin Nunes to recuse himself from the Trump-Russia investigation
  • President Trump ended the day with some tweets trying to discredit the Trump-Russia investigation, continued his assault on his own party, and signaled he would try and reach out to Democrats if the GOP would not cooperate

Tuesday March 28

Obstruction Of Justice

Former acting Attorney General Sally Yates (AP Photo/Carolyn Kaster)
  • Former acting Attorney General Sally Yates made headlines once again this week. In January, she was fired for ordering Justice Department lawyers to not defend Trump’s Muslim ban. Before she was fired, she was the person who originally warned the White House of Michael Flynn’s lies regarding his discussions about lifting Russian sanctions with Russian Ambassador Kislyak. Letters revealed that the White House tried to prevent Yates from testifying in the Trump-Russia investigation. The White House would’ve had to invoke executive privilege, which is the ability of the President to “shield executive branch confidences from disclosure.” Interestingly enough, the hearing she was scheduled to testify at was canceled by non-other than House Intel Chairman Devin Nunes. Many pointed to this as an example of Nunes coordinating with the White House to try and shield the President from Yates’ damaging testimony on Michael Flynn’s contacts with Russia. It also served as a way to avoid the invocation of executive privilege
  • Rep. Walter Jones (R-NC) called on Rep. Devin Nunes to recuse himself from the Trump-Russia investigation. He’s the first Republican lawmaker to do so
  • President Trump signed an executive order further dismantling Obama’s climate policies
  • USA TODAY reported that “The president and his companies have been linked to at least 10 wealthy former Soviet businessmen with alleged ties to criminal organizations or money laundering”
  • Speaking of ties to former Soviets, Trump ended his Tuesday trying to deflect away from the Trump-Russia scandal, tweeting out once more about Hillary Clinton’s alleged ties to Russia
1. She isn’t president 2. She isn’t under FBI investigation for potentially colluding with Russia
  • President Trump’s approval rating dropped to an all time low of 35%

Wednesday March 29

Nepotism

Donald Trump kisses his wife Melania Trump as his daughter Ivanka Trump watches after giving his acceptance speech during his election night rally, Wednesday, Nov. 9, 2016 (AP Photo/John Locher)
  • Ivanka Trump is becoming an official federal employee, working as an unpaid assistant to her father President Trump. Critics cried nepotism, but with what was revealed later on in the week, it appears there is a bigger issue at hand with this situation than family favoritism
  • House Intelligence Committee Chairman Devin Nunes could be facing an ethics probe for unauthorized disclosures of classified intelligence when he revealed the details of the “incidental collection”
  • For the third time, Republicans in the House voted down a measure that would’ve forced President Trump to release his tax returns
  • Amid legal battles and rampant conflicts of interest with his first DC hotel, President Trump’s company is pursuing a second DC hotel
  • Sean Spicer snapped at female reporter, and veteran White House correspondent, April Ryan, telling her to “stop shaking your head” after she asked about the Trump administration’s perception problem and how they will deal with the Trump-Russia scandal
  • The Senate Intelligence Committee, who plans to question 20 people, held their first press conference on the Trump-Russia investigation. Chairman Richard M. Burr (R-NC) and ranking Democrat Mark Warner (D-VA) promised a thorough bipartisan investigation
  • Scott Pruitt, the head of the Environmental Protection Agency, moved late on Wednesday to reject the scientific conclusion of the agency’s own chemical safety experts who under the Obama administration recommended that one of the nation’s most widely used insecticides be permanently banned at farms nationwide because of the harm it potentially causes children and farm workers.”
  • It wouldn’t be a Wednesday in Trump’s America without at least a couple more tweets bashing the fourth estate

Thursday March 30

Declaration Of War

President Donald Trump in the Oval Office of the White House in Washington. Friday, March 24, 2017 (AP Photo/Evan Vucci)
  • We saw the gradual escalation in President Trump’s rhetoric towards the Freedom Caucus throughout the week, but on Thursday, he took it up about 10 notches. In a stunning move President Trump declared war on the Freedom Caucus, calling on his supporters to vote out members of his own party

Later in the day, he began to call out Freedom Caucus members by name.

  • Speaker Paul Ryan warned his fellow Republicans that they need to unify in order to prevent Trump from potentially making a deal with Democrats on healthcare
  • It was revealed that 2 White House officials provided the “incidental collection” intelligence reports to Rep. Devin Nunes…The very same intelligence reports Nunes briefed the President on. This revelation made it clear that the White House gave the reports to Nunes in a coordinated attempt by President Trump to vindicate his wiretapping lies
  • Former national security adviser Michael Flynn expressed his willingness to testify before federal and congressional investigators on the Trump-Russia scandal if he is granted immunity
  • Politico reported that “the Energy Department’s international climate office told staff this week not to use the phrases ‘climate change,’ ‘emissions reduction’ or ‘Paris Agreement’”
  • The Senate Intelligence Committee held their first hearing on the Trump-Russia scandal, and it was distinctly different from the House’s. It was informative and not deadlocked by partisanship
  • North Carolina repealed the transgender ‘Bathroom Bill’
  • Seattle sued the Trump Administration over their threat to strip ‘Sanctuary’ cities of funding

Friday March 31

Immunity

President Donald Trump, accompanied by, from second from left, Chief of Staff Reince Priebus, Vice President Mike Pence, White House press secretary Sean Spicer and former National Security Adviser Michael Flynn, speaks on the phone with with Russian President Vladimir Putin, Saturday, Jan. 28, 2017, in the Oval Office at the White House in Washington. (AP Photo/Andrew Harnik)
  • After it was reported that Michael Flynn was seeking immunity, President Trump urged his former national security advisor to go forward with it. Trump also called the Trump-Russia investigation a witch hunt
  • The Senate Intelligence Committee rejected Flynn’s request for immunity, stating that it was “wildly preliminary”
  • Rep. Adam Schiff chimed in for the House Intelligence Committee, stating that it was indeed far too early for immunity to be discussed. Schiff said he would need to see details of what Flynn was going to say
  • “Ivanka Trump and Jared Kushner, President Trump’s daughter and son-in-law, will remain the beneficiaries of a sprawling real estate and investment business still worth as much as $740 million, despite their new government responsibilities, according to ethics filings released by the White House Friday night.” With Trump’s enormous business empire, this causes numerous conflicts of interest since these two will be advising the President and also have financial ties to their business empire
  • The Trump administration released financial disclosures for White House staff
  • ProPublica reported that “Tom Price Intervened On Rule That Would Hurt Drug Profits, The Same Day He Acquired Drug Stock”
  • According to civilian monitoring group Airwars, there has been a significant increase in civilian deaths at the hands of US-led coalition airstrikes in Iraq and Syria since Trump has taken office. In March alone, the US has allegedly killed almost 1,000 civilians, surpassing Russia’s civilian death toll for the first time. This was three times the amount the Obama administration killed in his final month in office
  • In regards to Michael Flynn seeking immunity, it has been speculated that this is indicative of him seeking protection for a larger crime and he is gearing up to take down a bigger fish with his testimony
  • Some bonus tweets for you. On Saturday morning, Trump took to Twitter once again to try and discredit the Trump-Russia story. This time, he took aim at Chuck Todd and NBC

Another wild one. President Trump has declared war on the Freedom Caucus. By taking aim at his own party, he puts them in danger in 2018.

The Trump administration’s actions surrounding the Russia investigation are beginning to look like a coverup.

And all the while, Trump continues to create more circumstances where he could be in violation of the emoluments clause.

Trump’s reckless approach served him well on the campaign trail, but it will be his downfall in the White House.

President Trump has changed nothing for the good of America…(cont.)

The FBI’s Secret Rules

26-10-15-1

President Trump has inherited a vast domestic intelligence agency with extraordinary secret powers. A cache of documents offers a rare window into the FBI’s quiet expansion since 9/11.

terrorists-won

Domestic Investigations and Operations Guide

The rulebook governing all FBI agents’ activities, in unredacted form for the first time. This is the 2011 edition, which remains the baseline document today, although the FBI recently released some updates from 2013.

SEE DOCUMENT

Hidden Loopholes Allow FBI Agents to Infiltrate Political and Religious Groups

Cora Currier
Beneath the FBI’s redaction marks are exceptions to rules on “undisclosed participation.”

National Security Letters Demand Data Companies Aren’t Obligated to Provide

Jenna McLaughlin, and Cora Currier
Internal documents suggest the FBI uses the secret orders to pursue sensitive customer data like internet browsing records.

Despite Anti-Profiling Rules, the FBI Uses Race and Religion When Deciding Who to Target

Cora Currier
The bureau still claims considerable latitude to use race, ethnicity, nationality, and religion in deciding which people and communities to investigate.

In Secret Battle, Surveillance Court Reined in FBI Use of Information Obtained From Phone Calls

Jenna McLaughlin

Secret Rules Make It Pretty Easy for the FBI to Spy on Journalists

Cora Currier
Rules governing the use of national security letters allow the FBI to obtain information about journalists’ calls without going to a judge or informing the targeted news organization.

Annotation Sets

  • Bureau Hid Doubts About Reliability of Stingray Evidence Behind Redaction Marks


  • CIA and NSA Dossiers Are Available to the FBI in the Absence of Any Crime, Raising Privacy Questions


  • FBI Spy Planes Must Abide Rules When Looking Into Homes


  • On Campus, the FBI Sometimes Operates Outside Restrictions


  • To Probe the Digital Defenses of Targets, the FBI Turns To a Special Program


Confidential Human Source Policy Guide

Detailed rules for how the FBI handles informants. Classified secret. This unreleased September 2015 document is a major expansion and update of a manual from 2007 on the same topic.

SEE DOCUMENT

The FBI Gives Itself Lots of Rope to Pull in Informants

Trevor Aaronson
Agents have the authority to aggressively investigate anyone they believe could be a valuable source for the bureau.

When Informants Are No Longer Useful, the FBI Can Help Deport Them

Trevor Aaronson
The FBI coordinates with immigration authorities to locate informants who are no longer of value to the bureau.

How the FBI Conceals Its Payments to Confidential Sources

Trevor Aaronson
A classified policy guide creates opportunities for agents to disguise payments as reimbursements or offer informants a cut of seized assets.

Annotation Sets

  • How the FBI Recruits and Handles Its Army of Informants


Counterterrorism Policy Guide

Excerpts from a guide for agents working on counterterrorism cases, which functions as a supplement to the FBI’s main rulebook, the Domestic Investigations and Operations Guide. Classified secret. Not previously released. Dates to April 2015.

SEE DOCUMENT

Undercover FBI Agents Swarm the Internet Seeking Contact With Terrorists

Cora Currier
The FBI’s online activities are so pervasive that the bureau sometimes finds itself investigating its own people.

Based on a Vague Tip, the Feds Can Surveil Anyone

Cora Currier
Low-level “assessments” allow the FBI to follow people with planes, examine travel records, and run subjects’ names through the CIA and NSA.

The FBI Has Quietly Investigated White Supremacist Infiltration of Law Enforcement

Alice Speri
Bureau policies have been crafted to take into account the active presence of domestic extremists in U.S. police departments.

Annotation Sets

  • Disruptions: How the FBI Handles People Without Bringing Them To Court


Confidential Human Source Assessing Aid

A document bearing the seal of the FBI’s Anchorage field office that gives tips for agents cultivating informants. It is classified secret, and dates from 2011.

SEE DOCUMENT

DIOG Profiling Rules 2016

A 2016 update to the Domestic Investigations and Operations Guide’s policy on profiling by race, gender, and other factors.

SEE DOCUMENT

Guidance on Guardian Assessments 2013

A 2013 unclassified communique from the FBI’s counterterrorism division explaining the database checks and other steps to be taken as part of low-level investigations.

SEE DOCUMENT

National Security Letters Redacted

An unclassified internal FBI document explaining the rules for national security letters, orders that the bureau uses to obtain certain information without a warrant. The document is undated but contains references to another document from November 2015.

SEE DOCUMENT

We All Want Healthcare To Cost Much Less — But We Are Asking The Wrong Questions?

We All Want Healthcare To Cost Much Less — But We Are Asking The Wrong Questions ?

Imagine this: Healthcare — the whole system — for half as much. Better, more effective. No rationing. Everybody in.

Because we all want that. And because we can. This can be done. Let me tell you how.

I’m an industry insider, covering the industry for 37 years now, publishing millions of words in industry publications, speaking at hundreds of industry conferences, writing books, advising everyone from the U.N.’s World Health Organization, the Defense Department, and the Centers for Disease Control to governments around the world to, probably, your local hospital, your doctor, your health plan.

The economic fundamentals of healthcare in the United States are unique, amazingly complex, multi-layered and opaque. It takes a lot of work and time to understand them, work and time that few of the experts opining about healthcare on television have done. Once you do understand them, it takes serious independence, a big ornery streak, and maybe a bit of a career death wish to speak publicly about how the industry that pays your speaking and consulting fees should, can, and must strive to make half as much money. Well, I turn 67 this year and I’m cranky as hell, so let’s go.

The Wrong Question

We are back again in the cage fight over healthcare in Congress. But in all these fights we are only arguing over one question: Who pays? The government, your employer, you? A different answer to that question will distribute the pain differently, but it won’t cut the pain in half.

There are other questions to ask whose answers could get us there, such as:

  • Who do we pay?
  • How do we pay them?
  • For what, exactly, are we paying?

Because the way we are paying now ineluctably drives us toward paying too much, for not enough, and for things we don’t even need.

A few facts, the old-fashioned non-alternative kind:

  • Cost: Healthcare in the U.S., the whole system, costs us something like $3.4 trillion per year. Yes, that’s “trillion” with a “T”. If U.S. healthcare were a country on its own it would be the fifth largest economy in the world.
  • Waste: About a third of that is wasted on tests and procedures and devices that we really don’t need, that don’t help, that even hurt us. That’s the conservative estimate in a number of expert analyses, and based on the opinions of doctors about their own specialties. Some analyses say more: Some say half. Even that conservative estimate (one third) is a big wow: over $1.2 trillion per year, something like twice the entire U.S. military budget, thrown away on waste.
  • Prices: The prices are nuts. It’s not just pharmaceuticals. Across the board, from devices to procedures, hospital room charges to implants to diagnostic tests, the prices actually paid in the U.S. are three, five, 10 times what they are in other medically advanced countries like France, Germany, and the U.K.
  • Value: Unlike any other business, prices in healthcare bear no relation to value. If you pay $50,000 for a car, chances are very good that you’ll get a nicer car than if you pay $15,000. If you pay $2200 or $4500 for an MRI, there is pretty much no chance that you will get a better MRI than if you paid $730 or $420. (Yes, these are real prices, all from the same local market.)
  • Variation: Unlike any other business, prices in healthcare bear no relation to the producer’s cost. None. How can you tell? I mean, besides the $600 price tag on a 69-cent bottle of sterile water with a teaspoon of salt that’s labeled “saline therapeutics” on the medical bill? (Yes, those are real prices, too.) You can tell because of the insane variation. The price for your pill, procedure or test may well be three, five, even 12 times the price paid in some other city across the country, in some other institution across town, even for the person across the hall. Try that in any other business. Better yet, call me: I have a 10-year-old Ford F-150 to sell you for $75,000.
  • Inefficiency: We do healthcare in the most inefficient way possible, waiting until people show up in the Emergency Department with their diabetes, heart problem, or emphysema completely out of control, where treatment will cost 10 times as much as it would if we had gotten to them first to help them avoid a serious health crisis. (And no, that’s not part of the 1/3 that is waste. That’s on top of it.)

So who’s the chump here? We’re paying ridiculous prices for things we don’t necessarily need delivered in the most inefficient way possible.

Why?

Why do they do that to us? Because we pay them to.

Wait, this is important. This is the crux of the problem. From doctors to hospitals to labs to device manufacturers to anybody else we want to blame, they don’t overprice things and sell us things we don’t need because they are greedy, evil people. They do it because we tell them to, in the clearest language possible: money. Every inefficiency, every unneeded test, every extra bottle of saline, means more money in the door. And they can decide what’s on the list of what’s needed, as long as it can be argued that it matches the diagnostic code.

That’s called “fee-for-service” medicine: We pay a fee for every service, every drug, every test. There’s a code for everything. There are no standard prices or even price ranges. It’s all negotiated constantly and repeatedly across the system with health plans, employers, even with Medicare and Medicaid.

We pay them to do it and the payment system demands it. Imagine a hospital system that bent every effort to providing health and healthcare in the least expensive, most effective way possible, that charged you $1 for that 69-cent bottle of saline water, that eliminated all unnecessary tests and unhelpful procedures, that put personnel and cash into helping you prevent or manage your diabetes instead of waiting until you show up feet-first in diabetic shock. If it did all this without regard to how it is paid it would soon close its doors, belly up, bankrupt. For-profit or not-for-profit makes little difference to this fact.

If we want them to act differently, we have to pay them differently.

Paying for Healthcare Differently

But wait, isn’t that the only way we can pay? Because, you know, medicine is complicated, every body is different, every disease is unique.

Actually, no. There is no one other ideal way to pay for all of healthcare, but there are lots of other ways to pay. We can pay for outcomes, we can pay for bundles of services, we can pay for subscriptions for all primary care or all diabetes care or special attention for multiple chronic conditions, on and on, the list of alternative ways to pay for healthcare is long and rich.

There are now surgery centers that put their prices up on the wall, just like McDonalds — and they can prove their quality. There are hospital systems that will give you a warranty on your surgery: We will get it right or fixing the problem is free.

Look: You get in an accident and take your crumpled fender to the body shop. Every fender crumples differently, maybe the frame is involved, maybe the chrome strip has to be replaced, all that. So there is no standard “crumpled fender” price. But it is not the first crumpled fender the body shop has ever seen. It’s probably the 10,000th. They are very good at knowing just how to fix it and how much it will cost them to do the work. Do you pay for each can of Bondo, each disk of sandpaper, each minute in the paint booth? No. They write you up an estimate for the whole thing, from diagnosis to rehab. Come back next Thursday and it will be good as new. That’s a bundled outcome. It’s the body shop’s way of doing business, its business model.

There are new business models arising now in healthcare (such as reference prices, medical tourism, centers of excellence, “Blue Choice” and other health plan options) that force hospitals and surgical centers to compete on price and quality for specific bundles, like a new hip or a re-plumbed heart.

Healthcare is a vast market with lots of different kinds of customers in different financial situations, different life stages, different genders, different needs, different resources, yet we have somehow decided that in pretty nearly all of that vast market there should be only one business model: diagnostic-code-driven fee for service. Change that, and the whole equation changes. It’s called business model innovation. If we find ways to pay for what we want and need, not for whatever they pile onto the bill, they will find ways to bring us what we want and need at prices that make sense. That’s called changing the incentives.

Already Happening

Is this pie in the sky? No, it’s already happening, but in ways that are slow and mostly invisible to anyone but policy wonks, analysts, and futurists like me. The industry recognizes it. Everyone in the healthcare industry will recognize the phrase “volume to value,” because it is the motto of the movement that has been building slowly for a decade. It’s shorthand for, “We need to stop making our money based on volume — how many items on the list we can charge for across how many cases — and instead make our money on how much real value, how much real health, we can deliver.”

Self-funded employers, unions, pension plans, and tribes are edging into programs that pay for healthcare differently with reference prices, bundled prices, onsite clinics, medical tourism, direct pay primary care, instant digital docs, team care, special care for those who need it most, all kinds of things. The Affordable Care Act set up an Innovation Center in the Centers for Medicare and Medicaid Services, and the government has been incrementally pushing the whole system more and more into “value” programs.

Are We There Yet?

So why hasn’t it happened yet? Why aren’t we there yet?

Because it’s hard, it’s different, and it hurts. And there is a tipping point, a tipping point that we have not gotten to yet.

It is very hard to loosen your grip on a business model as long as that business model pays the bills. We built this city on fee for service, these gleaming towers, these sprawling complexes, these mind-bending levels of skill and incomprehensible technologies. To shift to a different business model requires that everybody in the healthcare sector change the way they do everything, from clinical pathways to revenue streams to organizational models to physical plants to capital formation, everything all the way down. And it’s all uncharted territory, something the people who run these systems have not yet done and have little experience in. It’s guaranteed to be the end of the line for some institutions, many careers, many companies.

So far, the government “volume-to-value” or “value-based-payment” programs are incremental, baby steps. They typically add bonus payments to the basic system if you do the right thing or cut payments a few percentage points if you don’t. My colleague health futurist Ian Morrison calls these programs “fee for service with tricks.” They do not fundamentally change the business model.

Private payers such as employers have only gradually been getting more demanding, unsure of their power and status as drivers of change in this huge and traditionally staid industry. Systems such as Kaiser that have a value-based business model (so that they actually do better financially if they can keep you well) still have to compete in a system where the baseline cost of everything they need, from doctor’s salaries to catheters, is set in the bloated fee-for-service market. So movement is slow, and we are not yet at the tipping point.

Back to Who Pays

This is not a libertarian argument that everyone should just pay for their own healthcare out of their own pocket and let the “free market” decide. The risks are far too high, and we are terrible at estimating that risk, financial or medical. All of us are, even your doctor is, even I am. A cancer can cost millions. Heck, a bad stomach infection that puts you in the hospital for 10 days could easily cost you $600,000. Bill Gates or Warren Buffet can afford that, you and I can’t.

We need insurance to spread that risk not only across individuals but across age groups, across economic levels, and between those who are currently well and those who are sick. For it to work at all, the insurance has to be spread across everyone, even those who think they don’t need it or can’t afford it. You drive a car, you have to have car insurance, even if you are a really safe driver. You buy a house, you must have fire insurance, even though the average house never burns down. You own and operate a human body, same thing, even though at any average time you hardly need medicine at all.

If we are to have insurance for everyone, we need to subsidize it for those who have low incomes — and this has nothing to do with whether they “deserve” help, or even with whether healthcare is a right. It’s about spreading the cost of a universal human risk as universally across the humans as possible. At the same time, such subsidies need to be given in a way that helps people feel that they are spending their own money, that they have a stake in spending it wisely. This is not simple to do, but it can be done.

This is also not necessarily an argument for a single payer system. Single payer, by itself, will not solve the problem. It doesn’t change the incentives at all. It just changes who’s writing the check. What the system needs most is fierce customers, people and entities who are making choices based on using their own money (or what feels like it) to pay for what they really need. This forces competition among healthcare providers that drives the prices down. That means the system needs variety, a lot of different ways of paying for a lot of different customers. If we can figure out how to do that in a single-payer system, well then we’re talking.

Obviously the ultimate customer in healthcare is the individual, since medicine is about treating bodies, and we have exactly one to a customer. But the risk is too high at the individual level, and the leverage is too low.

So employers, pension plans and specialized not-for-profit mutual health plans whose interests really line up with the interests of their employees or members can act as proxies. They can force providers of healthcare (hospital systems, medical groups, labs, clinics) to compete for their business on price and quality. They can refuse to pay for things that the peer-reviewed medical literature shows are unnecessary. They can pay for improvements in your health rather than just fixing your health disasters. They can help their members and employees become fierce customers of healthcare with information and with carefully-titrated incentives.

Here’s one example of an incentive: A payer says to its members, “You need a new knee? Great, fine. Here are all the high-quality places you can get that done in your area. You can choose any that you like. But here’s a list of high-quality places in your area that do it for what we call a “reference price” or even less. Choose one of those places, and we will pay for everything from diagnosis to rehab. You can choose a place with a higher price if you like, but you’ll have to pay the difference yourself.” With reference prices, the employee or member partners with the payer in becoming a fierce, demanding customer, and prices for anything treated this way come crashing down.

Both payers and individuals, by being fierce customers, can force the healthcare providers in turn to become fierce customers of their suppliers, forcing pharmaceutical wholesalers and device manufacturers to bid on getting their business. “This knee implant you are asking us to pay $21,000 for? We see you are selling it in Belgium for $7,000. So we’ll pay $7,000 or we’ll go elsewhere.” The “price signals” generated by fierce customers reverberate through the entire system.

What’s the look and feel?

“Healthcare for half” sounds to most people like a Greyhound bus station with stethoscopes, like flea market surgeries, and drive-through birthing centers. Paradoxically, though, a lean, transparent system catering to fierce customers of all types would feel quite the opposite, offering more care, even what might feel like lavish care, but earlier in the illness or more conveniently. It might mean a clinic right next door to your workplace offering private care on a walk-in basis, no co-pay, even your pharmaceuticals taken care of — or you could choose to go elsewhere to another doctor that you like more, but you have to schedule it and pay a copay for the visit. Why will providers make healthcare so convenient and personal? Because if they are paid to be responsible for your health it’s worth the extra effort and investment to catch a disease process early, before it gets expensive.

It might mean, when your doctor says you need an MRI on that injury, getting on your smart phone to conduct an instant spot auction that allows high-quality local imaging centers to bid for the business if they can do it in the next three hours. It might mean, if you are in frail health or have multiple chronic diseases, being constantly monitored by your nurse case manager through wearables, and visited when necessary or once a week to help keep you on an even keel. It might mean your health system not being so quick to recommend a new knee, and offering instead to try intensive physical therapy, mild exercise and painkillers to see if that can solve the problem first (Pro tip: It often does).

Changing the fundamental business model of most of healthcare will be difficult and painful for the industry. But if we look to other countries and say, “Why do their systems cost so much less than ours? Why can’t we have what we want and need at a price we all can afford?” — this is the answer.

Change the way we pay for healthcare, not just who pays, and we can rebuild the system to be at the same time better and far cheaper.

Joe Flower is an independent healthcare analyst and futurist, http://www.ImagineWhatif.com. His latest book is How to Get What We Pay For: A Handbook for Revolutionaries.