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September 20, 2024
Dear Interested Readers,
He Has “Concepts of a Plan”
The most interesting moment for me in last week’s debate between former President Trump and Vice President Harris was when the questions moved to healthcare. I have found that the healthcare consultancy, “The Advisory Board,” has posted in its “Daily Briefing” blog a very thorough review of the questions asked to both candidates about their healthcare positions and policy proposals. First, there was a discussion of abortion during which former President Trump told one of his most outrageous lies about the postnatal “execution” of unwanted babies. The Advisory Board reported:
During the debate, Trump claimed that “every legal scholar, every Democrat, every Republican, liberal, conservative, they all wanted” the issue of abortion “to be brought back to the states,” adding that “it’s the vote of the people now. It’s not tied up in the federal government. I did a great service in doing it. It took courage to do it. And the Supreme Court had great courage in doing it,” referring to the court’s decision overturning Roe v. Wade.
Trump also claimed that Democrats favor the “execution” of babies after they’re born, adding that Harris’ pick for vice president, Minnesota Gov. Tim Walz (D), “says execution after birth … is okay.”
One of the moderators, Linsey Davis, corrected Trump, saying, “there is no state in this country where it is legal to kill a baby after it’s born.”
Trump was floundering. Having shot himself in the foot with his responses about abortion, the moderators offered him the chance to sound thoughtful or shoot himself in his other foot. The report from The Advisory Board continues by referencing Trump’s disdain for the ACA and reporting the exchange with the moderators about whether he has a “plan” for its repeal and replacement with something better.
…Trump said that the ACA is “lousy health care. Always was. It’s not very good today,” adding that he “inherited [the ACA] because Democrats wouldn’t change it. They wouldn’t vote for it. They were unanimous … If they would have done that, we would have had a much better plan than [the ACA].”
Trump said he was then faced with the choice, “do I save [the ACA] and make it as good as it can be? … Or do I let it rot? And I felt I had an obligation, even though politically it would have been good to just let it rot and let it go away … I saved it. I did the right thing. But it’s still never going to be great. And it’s too expensive for people.”
When moderators asked Trump about his statement that he will keep the ACA in place “unless we can do something much better” and whether he has a plan to replace the law, Trump said he has “concepts of a plan,” adding that “if we come up with something I would only change it if we come up with something better and less expensive. And there are concepts and options we have to do that. And you’ll be hearing about it in the not-too-distant future.”
Knowing that he told over 30,000 lies while president, you need to be skeptical when Trump vaguely promises something better in the future. I guess that the former president is hoping that most voters have forgotten that with the control of both Houses of Congress, he almost succeeded in repealing the ACA in 2017 as he tried to replace it with a very deficient substitute. That effort failed when John McCain returned after his initial treatment for his brain tumor to cast his vote against Trump’s bill with a dramatic thumbs-down gesture. Lisa Murkowski and Susan Collins had already voted against the bill. Had McCain voted for it, the vote would have been 50-50. Mike Pence would have voted with the Republicans who had gone along with the totally inadequate “plan” and it would have passed. McCain’s vote gave Trump a 51-49 loss. It was one of the most dramatic moments in politics that I have ever witnessed.
The key phrase to remember from Trump’s stumbling presentation of what he would do with the ACA was his statement that he had “concepts of a plan.” Just in case you did not realize how lame that answer was he added.“…if we come up with something I would only change it if we come up with something better and less expensive. And there are concepts and options we have to do that. And you’ll be hearing about it in the not-too-distant future.”
If you want a preview of those “concepts of a plan” I would refer you to my discussion of the healthcare section of “Project 2025.” in the Healthcare Musings letter of July 19, 2024. The day after the debate one of my favorite commentators, Nobel Prize laureate Paul Krugman, commented on just how farcical Trump’s comment was in a column entitled “Here’s Why Trump Was Forced to Say He Has Only ‘Concepts of a Plan’”
Krugman began his column with a phrase that I like to use–exceeded expectations. That was in reference to the Vice President’s performance. His corresponding opening comment about Trump was not so flattering.
Kamala Harris exceeded my expectations in her debate with Donald Trump on Tuesday. I knew that she was smart, but for whatever reason, many insiders have questioned her political talent. I assume that her remarkable skill at baiting Trump into one trap after another has ended those questions.
Trump, by contrast, was who he has always been. He essentially sounded the same as he does at his rallies — except that this time TV viewers experienced his ranting raw, not sanewashed by summaries that make him sound more coherent than he is.
Next Krugman reminded us of Trump’s outrageous comments (seeded by J.D, Vance) about Haitian immigrants stealing cats and dogs to eat, but that was not where Krugman wanted to make his point. Krugman then continued:
For policy wonks like me, however, the most remarkable moment in the debate probably came when Trump was asked whether he had a plan for health care reform, and his answer was: “I have concepts of a plan.”
Bear in mind that health care coverage is a crucial (in some cases life-or-death) issue for many Americans. Furthermore, health care — unlike, say, grocery or gas prices — is an issue on which public policy can make a big difference.
Further along, after reviewing Trump’s ill-planned and poorly executed attempt to repeal the ACA in 2017–thank you John McCain–Krugman continued:
I do think he has shown pretty clearly that he’s generally unwilling to roll up his sleeves and get into the nuts and bolts of policy, but I don’t think that’s why his promised alternative to Obamacare has never appeared. The truth, I’d argue, is that he’s blowing smoke when he claims to have even “concepts.” That is, neither he nor anyone around him has any real clue about how to do better than the A.C.A., which is a much smarter piece of legislation than many people ever gave it credit for.
Krugman ends with the sort of statement that is the equivalent of “the Emporer has no clothes.” I think that Krugman may share my frustration with how Trump has been able to announce dreadful ideas without much effective pushback from wiser voices on his side of the political divide. Krugman ends by expressing his doubt that either Trump or his camp can ever develop a plan that is better than the ACA.
No, very likely, the reason Trump has never produced a health care plan that wouldn’t deny coverage to millions of Americans is that he and those around him don’t know how to do that. Indeed, if they’ve thought seriously about it at all, they might have realized that they’d probably just end up reinventing the A.C.A.
So, am I saying that Trump has probably been faking it all along, that he has really never had an idea about how to improve on Obamacare? Why, yes.
If Trump can’t do it, can anybody? I hope so. Perhaps in our political climate, we can only aspire to incrementally refine the ACA,, but that does not mean we can’t do better. Perhaps to do better we need to use the new tool of AI.
On Monday, while driving back the eighty miles from an appointment with my Neurologist at the Chelmsford office of Atrius Health, I noticed that Sean Illing had a new release on his podcast, The Gray Area. It was a long conversation with historian, philosopher, and author Yuval Noah Harari. I first became aware of Harari through his very well-received book, Sapiens; A Brief History of Mankind which was published in English in 2014. His most recent book is NEXUS: A Brief History of Information Networks From the Stone Age to AI.
The podcast was a 90-minute conversation about truth, the fragility of democracy, and the growing concerns about and possible benefits of AI. At one point in the conversion, Harari referred to the moment in time when Google’s AlphaGo defeated the world’s greatest “Go” player. According to Harari, “Go” is the most difficult and complex game in the world. Harari pointed out that AI won because it evolved a strategy that had never been used before by a human. According to Harari, since AlphaGo won, many “Go” experts have adopted the strategy introduced by AI.
As I was listening, it occurred to me that if Trump had only “concepts of a plan” and if the ACA is the best humans and our politics can do, perhaps AI could join the quest that Dr. Ebert conceptualized back in 1965 when he wrote:
“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”
Since, after searching for 59 years, we have not been able to find the formula for healthcare to facilitate organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population, I decided to see if ChatGPT might be able to do the job. If AI in the form of AlphaGo could win at Go with a creative approach, what might AI do if given the task of solving our healthcare finance and operating problems? So I asked ChatGPT a lengthy question
American healthcare is expensive and has poor access and outcomes that are worse than other developed countries. What changes in finance and operating systems might improve the access, cost, and quality of American healthcare?
ChatGPT said:
The U.S. healthcare system is widely criticized for its high costs, limited access, and often suboptimal outcomes compared to other developed nations. To address these challenges, changes in financing mechanisms and operational systems are essential. Here are several strategies that could help improve access, reduce costs, and enhance the quality of healthcare:
1. Implement Universal Coverage or a Public Option
- Universal Healthcare Models: Many developed countries with better healthcare outcomes than the U.S. have adopted some form of universal healthcare coverage. Systems such as single-payer models (e.g., Canada) or multi-payer systems with robust government involvement (e.g., Germany) ensure that all citizens have access to healthcare without financial barriers. This approach could reduce administrative complexity and provide coverage to uninsured and underinsured Americans.
- Public Option: A public option, which would allow individuals to buy into a government-run health insurance plan (e.g., an expanded version of Medicare), could increase competition in the private insurance market and provide a lower-cost alternative for coverage. This approach would help reduce costs for both consumers and providers by leveraging the government’s bargaining power to negotiate lower prices for healthcare services and prescription drugs.
2. Shift Toward Value-Based Care
- Value-Based Payment Models: Shifting from a fee-for-service system (which incentivizes more procedures and tests) to value-based care (which rewards providers for improving patient outcomes and lowering costs) could enhance the quality of care while reducing unnecessary spending. In value-based models, healthcare providers are reimbursed based on the quality of care they deliver rather than the quantity of services. This approach is already being tested through Medicare’s Accountable Care Organizations (ACOs) and bundled payment initiatives, but broader adoption could lead to more systemic improvements.
- Integrated Care Delivery: Promoting integrated care models, where providers work together across specialties and disciplines, can help prevent fragmented care, improve coordination, and reduce duplication of services, ultimately lowering costs and improving outcomes.
3. Price Transparency and Regulation
- Greater Transparency: Price transparency in healthcare is currently limited, leading to wide variations in the cost of services. Increasing transparency by requiring hospitals and insurers to disclose prices upfront would empower consumers to make informed decisions and could promote competition among providers, thereby lowering costs.
- Regulating Drug Prices: Prescription drug prices in the U.S. are among the highest in the world. Allowing Medicare to negotiate drug prices, as is done in many other countries, could significantly reduce costs for both consumers and the healthcare system as a whole. In addition, policies that cap out-of-pocket expenses for medications (such as the $35 cap on insulin introduced by President Biden) could improve access and affordability.
4. Expand Telehealth and Digital Health
- Telehealth Expansion: The COVID-19 pandemic demonstrated the potential of telehealth to expand access to care, particularly in rural and underserved areas. Expanding reimbursement for telehealth services and investing in broadband infrastructure in rural areas could improve access to care and reduce healthcare costs by minimizing the need for in-person visits for routine consultations and follow-ups.
- Digital Health Tools: Integrating digital health tools (such as wearable devices, remote monitoring, and artificial intelligence) can help providers manage chronic conditions more effectively and prevent costly hospitalizations. These technologies can empower patients to take a more active role in managing their health, improving outcomes while reducing the burden on healthcare providers.
5. Address Social Determinants of Health
- Invest in Social Services: Research has shown that addressing social determinants of health—such as housing, nutrition, education, and transportation—can have a significant impact on health outcomes and healthcare costs. For example, ensuring stable housing for vulnerable populations could reduce hospitalizations and emergency room visits. A more holistic approach to healthcare, which integrates social services with medical care, could lead to improved outcomes and lower costs.
- Preventive Care and Public Health: Prioritizing preventive care and public health measures, such as vaccinations, screenings, and lifestyle interventions, could reduce the incidence of chronic diseases like diabetes and heart disease, which are major drivers of healthcare costs. Expanding access to preventive services through public health initiatives could improve population health and reduce the need for costly treatments down the line.
6. Reduce Administrative Overhead
- Streamline Administrative Processes: The U.S. healthcare system has significantly higher administrative costs than other developed countries, largely due to the complexity of insurance billing, claims processing, and regulation. Simplifying and standardizing billing systems could reduce administrative overhead for providers, allowing them to focus more on patient care. Universal or public insurance options could also reduce the complexity of navigating multiple private insurers.
- Electronic Health Records (EHRs): While electronic health records have been implemented in most healthcare settings, their interoperability remains limited. Improving the interoperability of EHRs would allow for better information sharing across providers, reducing duplication of tests and improving the coordination of care.
7. Enhance Primary Care
- Invest in Primary Care: Strengthening primary care services can improve the overall health of the population and reduce the need for expensive specialist and hospital care. Countries with robust primary care systems, such as the UK and the Netherlands, tend to have better health outcomes and lower overall healthcare costs. Increasing the supply of primary care physicians through loan forgiveness programs and incentivizing medical students to enter primary care could improve access and reduce costs over time.
8. Incentivize Health Savings Accounts (HSAs) for Preventive Care
- Encourage Preventive Health Spending: Health Savings Accounts (HSAs) could be expanded and incentivized for preventive care. HSAs allow individuals to save pre-tax dollars to pay for medical expenses. However, making preventive care expenses fully reimbursable and expanding the range of services covered could encourage more people to invest in their long-term health, reducing future costs.
9. Reduce Hospital and Provider Consolidation
- Combat Monopolies and Consolidation: The consolidation of hospitals and healthcare systems has led to reduced competition and higher prices. Encouraging antitrust regulation to prevent monopolistic practices and promote competition in the healthcare marketplace could help reduce healthcare costs without sacrificing quality. This might involve limiting large hospital mergers or requiring competitive bidding processes for certain healthcare services.
10. Health Equity and Disparities
- Addressing Health Inequities: Reducing disparities in access to healthcare based on income, race, or geography is critical to improving outcomes. Policies that target underserved populations with tailored healthcare services, such as community health workers, mobile clinics, and enhanced Medicaid coverage, could address some of these gaps and improve overall population health.
Conclusion
While no single solution will fully address the challenges of the American healthcare system, a combination of reforms targeting finance, operations, and social determinants can lead to substantial improvements. Implementing universal coverage options, shifting toward value-based care, improving price transparency, and investing in both primary care and preventive health are essential steps to ensure better access, lower costs, and improved outcomes for all Americans.
My reaction was wow! Did AI just summarize sixteen years of Healthcare Musings Friday letters or read Crossing the Quality Chasm? The only problem that it did not explicitly address was our workforce shortages. Perhaps, the answer to our workforce problems is embedded in the totality of ChatGPT’s suggestions. It did suggest loan forgiveness programs that might encourage medical students to consider working in rural or other underserved areas. It is possible that the total package of changes offered by AI which includes more coordination of care, and greater patient involvement in self-care that prevents and facilitates the management of chronic diseases coupled with better utilization of our IT infrastructure could allow better leverage of our existing workforce. It is true that eliminating unnecessary hospitalizations and procedures that are unnecessary and add no value would relieve some of the pressures on our hospital-based nurses and our specialists. Perhaps the answer to our workforce issues is a better workplace that eliminates overuse and misuse of our medical resources.
It is interesting to consider that we may have all the medical professionals that we need if they were working in a more efficient operating system that wasn’t driven by fee-for-service payment. Can you imagine former President Trump leading the development of policies that would favor the possibilities that ChatGPT suggests? In truth, if he has “concepts of a plan,” it is unlikely that his plan would be a more efficient system of finance and operations and would likely exclude many Americans from the care that they currently enjoy. I suspect that his “concepts of a plan” is just another lie. Vice President Harris’s platform is not that far off target when compared to the analysis and recommendations of ChatGPT which I accessed for free.
Former President Trump has concepts that he hasn’t revealed, but the healthcare proposals in Project 2025 and the Republican Presidential platform are diametrically opposed to what ChatGPT recommends. If you would like to contrast the Democratic Platform, Republican Platform, and the recommendations of Project 2025, I refer you to Healthcare Musings For August 30, 2024.
The election is only 46 days away. The pollsters still suggest that either candidate could win. Healthcare is on the ballot whether the candidates are discussing it or not. The evidence that I can see suggests that if Trump wins with his “concepts of a plan,” if he has one, or if he continues his past strategy of neglecting the ACA, he will move us further away from the Triple Aim. Nothing that Trump has said and nothing in the 900-plus pages of Project 2025 should give you hope that his concept of a plan has any possibility of improving the social determinants of health or providing universal access to quality healthcare for millions of Americans. My “concept of a plan” will be a vote for the Harris-Walz ticket.
Observations This Week
I have been having a lot of contact with the healthcare system recently. I have been wearing night splints for a year and a half to control carpal tunnel symptoms. My symptoms are worse. My hands are numb when I walk with my crutches, or when I ride my bicycle. Numbness in my left hand can persist for a long time, and I am left-handed. Since I will be on crutches after my knee replacement in December, I am hoping to get my left hand fixed before the knee surgery. I don’t want to let the problem go much longer for fear I might lose some functionality.
I took the picture in today’s header on Monday when I had a Neurology appointment to discuss the feasibility of carpal tunnel surgery. As I was waiting to be seen, I wondered why no other patients were also waiting. Perhaps, the answer is that when a system is not working well there are substantial variations in flow and experience.
On Tuesday. I had an appointment with a podiatrist at Dartmouth Hitchcock Medical Center to discuss foot discomfort that has plagued me for over forty years. I had seen a nurse practitioner in podiatry a couple of months ago because of painful calluses over the volar surface of the head of my fifth metatarsals that was worse on the right than left. She helped me a lot by removing a lot of callus and then surprised me by saying that I should see the podiatrist.
It took over two months to get an appointment, and then to my surprise, again the waiting room was full of empty chairs. My visit was informative. It turns out that I have a congenital bilateral inability to properly pronate which may have contributed to my problems in my lower extremities because proper pronation when walking or running decreases the stress of the impact of each stride.
Since I have run and walked over 80,000 miles over the last fifty years, the podiatrist who is also a marathon runner, told me that it should be no surprise that things are wearing out. Thankfully he didn’t advise a surgical repair, but he did believe that replacing my “off the shelf” orthotics with something that is customized for me, might be beneficial. I am all for that plan, but why is the waiting room empty when it takes over two months to get an appointment? Again, I am left with the idea that systems under stress, be they medical systems or physical systems, don’t perform optimally.
What I did notice driving the 25 miles north to Dartmouth versus the 80 miles south to Chelmsford is that as you go north you are driving into fall. There is already a lot of color along the road north. There was very little color when I was headed south.
Fall is upon us. We had a beautiful week with clear skies, low humidity, and temps in the high seventies. We hit 80 on Monday. Cooler, cloudier weather with a little rain is the prediction for the weekend. With temps in the high forties and low fifties at night, the water in the lake is getting colder. I am doing my daily swim in a wetsuit. The great thing about swimming is that it doesn’t pound your joints. I guess that I should have swam more and run less over the years. To bad that we can’t ask for a “do-over” in life.
Since there are no “do-overs,” I hope that you make the most of your weekend and that your fall will be full of exhilarating colors against a background of clear skies.
Be well,
Gene
