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A bout 3 years ago, Quicken Loans sponsored The Billion Dollar Bracket Challenge [5]—a contest that promised to award that sum to anyone who could pick all of the winners for every round of the NCAA basketball tournament. Although the probability of accurately predicting the outcome of all 63 games is about one in 9 quintillion—that is to say, the prize had an expected cash value of approximately zero—Quicken needed to assure the public that the winners would be paid. Warren Buffett, America’s third richest man, duly provided this guarantee. I need similar help from Mr. Buffett. I have a plan to give free health insurance to all Americans, but without an underwriter famous for his deep pockets, it won’t seem plausible enough to get off the ground. (Don’t worry, Mr. Buffett, it won’t cost you a penny). My plan, JoeCare, is simple. It is free and it covers everything, with only one catch: It kicks in only after a USD 20 million annual out-of-pocket deductible is met. It’s not impossible that somebody could make a legitimate claim against this policy—just as somebody might pick the NCAA bracket perfectly. But the odds are about the same. Mr. Buffett, a staunch Democrat, is not apt to help me here. After all, with JoeCare in place, the loudest defense of the Affordable Care Act (ACA or Obamacare)—namely, that it cut in half the number of uninsured—is instantly silenced. JoeCare, at no cost, reduces the number of uninsured Americans to zero. Of course JoeCare is preposterous, but if you are unwilling to tag Obamacare with the same label at least with regard to how its supporters count the uninsured, you have not been paying attention. Consider a person of ordinary means holding a health insurance policy with a USD 3000 deductible. That person is, of course, counted as insured. Nonetheless, because of the high deductible, this person might decline to go to the emergency room after an ankle injury, or try to manage an infected finger at home with hot soaks. In other words, despite being nominally insured, this person might opt to forgo timely care that can prevent a fracture from displacing or an infection from spreading. Even with coverage, the costs may be too daunting. For that reason, JoeCare and Obamacare are awfully alike in terms of the access to healthcare they provide. Yet JoeCare can do more than help score rhetorical points in a debate about how to count the uninsured. In a less-ludicrous, but only slightly moreexpensive form, it could be the basis A note from the Editor-in-Chief: We are pleased to present to readers of Clinical Orthopaedics and Related Research the next Not the Last Word. The goal of this section is to explore timely and controversial issues that affect how orthopaedic surgery is taught, learned, and practiced. We welcome reader feedback on all of our columns and articles; please send your comments to eic@clinorthop.org. The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of Clinical Orthopaedics and Related Research or The Association of Bone and Joint Surgeons. J. Bernstein MD (&) Department of Orthopaedic Surgery, University of Pennsylvania, 424 Stemmler Hall, Philadelphia, PA 19104, USA e-mail: orthodoc@uphs.upenn.edu Not the Last Word Published online: 4 April 2017 The Association of Bone and Joint Surgeons1 2017

Not the Last Word: JoeCare: Free Health Insurance Coverage for All