Look, if you wanted to make healthcare more expensive, you would pay non-profit hospitals to buy competitors and make it harder to build new ones. The United States Government does both. Our government rewards acquisitions and restricts new entrants, incumbent hospitals gain bargaining power. Employers and patients have fewer alternatives, making higher prices easier to sustain. The average annual premium for employer-sponsored family coverage has reached $28,303. Employers and employees pay that together, before deductibles and copays. Medicare encourages consolidation. A hospital acquires an independent physician practice, qualifies it for hospital outpatient billing, and collects higher payments. The physician can remain in the same examination room. The acquisition creates a financial return without requiring better care. As the system acquires more practices, insurers have fewer alternatives. Rejecting its prices becomes harder when excluding it means excluding much of the care local employees need. Congress restricts the physicians who could compete with it. Section 6001 of the Affordable Care Act largely closed the Medicare pathway for new physician-owned hospitals and restricted expansion at existing ones. An independent surgeon can recruit colleagues, raise capital, and design a better facility. Congress still stands between that investment and the Medicare participation needed to make it viable. The hospital buying his practice gets a growth opportunity. The physician building a competing hospital gets a federal restriction. Certificate-of-need laws add another obstacle. Opening or expanding certain facilities requires state permission, and incumbent hospitals use that process to oppose competitors. The business collecting the money gets to argue that the community has no need for another business offering the same service. Governors and legislators who preserve those laws protect incumbent hospitals from competition. Employers and families finance that protection, even though it never appears in the state budget. Many protected institutions also receive substantial public support through tax exemption. With little competitive pressure, scrutiny of that support becomes more important. State attorneys general oversee charitable organizations, including tax-exempt health systems. Their authority varies, but protecting charitable assets and enforcing charitable obligations are part of the job. AGs have ignored those responsibilities for too long. Academic medical centers and tax-exempt health systems operate with far too little accountability for the public benefits they receive. A nonprofit designation does not establish that prices are reasonable, financial assistance is adequate, or acquisitions benefit patients. A hospital’s annual report is no substitute for an attorney general examining its conduct. Federal oversight has failed, too. GAO and the Treasury Inspector General have documented weaknesses in how the IRS evaluates hospital community benefits and the standards used to justify tax exemption. Employers absorb higher costs, charge employees more, reduce benefits, or cut elsewhere. Healthcare consumes money otherwise available for wages, hiring, and investment. Congress can repeal physician-owned hospital restrictions and expand site-neutral payments. Governors and legislators can repeal certificate-of-need barriers. Attorneys general and federal tax officials can enforce the obligations attached to charitable status and tax exemption. Premiums would be lower if lawmakers removed the payment advantages and entry restrictions protecting incumbent hospitals. The bill arrives with an insurance company’s logo. The lawmakers’ names belong on it, too. Can I watch football now? My team is losing, maybe il keep posting…

We regret to inform you that a patient has discovered our drug discount. Naturally, she assumed it would lower her bill. We explained that the discount supports our mission. She asked whether she was part of the mission. An uncomfortable start to the appointment. She suggested that if the manufacturer accepts less money for her medicine, perhaps we could accept less money from her. We assured her that the savings help us serve vulnerable patients. She mentioned that she was a vulnerable patient. Apparently, she had brought her bank statement. We explained that we evaluate the benefit at the institutional level. She asked whether she could pay her bill at the institutional level. At this point, we invited someone from patient experience to join us. She has a compelling story. With her permission, we’d like to feature it in our next fundraising campaign. Her bill remains due Friday.

Your local non profit hospital hospital can buy your physician’s office and receive more from Medicare without improving the care. The waiting-room chairs finally found someone who understood their earning potential.