When I opened my Sunday paper this week, I was delighted to see two healthcare related articles on the front page. The first article written by Nora Doyle-Burr, a staff writer for the paper, was entitled “Health care a pressing issue in 2020 for many Upper Valley voters.” This is not really news. I hear lots of conversations about healthcare wherever I go. Sure, some of what I hear is directed toward me by people who are apprehensive about changes in their care and think I might be able to explain what is happening. More often than not, the comments and concerns that I hear are not directed to me, but rather I am eavesdropping on a conversation at a social gathering. Sometimes I am listening to the concerns of a friend who has a medical problem that has brought him/her in close contact with our dysfunctional system of care that seems less empathetic, less focused, and much more difficult to navigate than they had expected or desired. The majority of thoughtful people seem to recognize that things must change. The concern is how will that change affect them. With those personal experiences in mind, I was very interested in reading what my neighbors had revealed as their concerns to Ms. Doyle-Burr.
The other article on the front page, “Americans’ struggles with medical bills are a foreign concept in other countries” written by Noam M. Levey, was imported from The LA Times, and is part of an ongoing series in the Times on the increasing economic burden of copays and deductibles associated with employer provided insurance. Both articles are ripe with things worth repeating and considering. I highly recommend The LA Times article and series to you, but will focus on the opinions from the Upper Valley. There is evidence in both articles that getting to universal access while reducing the cost of care to the consumer represents a challenge that troubles many voters.
The article written by the local reporter included the names and comments of nine Upper Valley residents. There was no attempt to make the article statistically relevant. Since three of the people being interviewed are retired, or semi retired physicians, and another manages a home care program, there may even be some bias. Even thought this is not a statistical study, their comments are very interesting and capture the range of concerns and opinions that I hear from my neighbors.
The first “neighbor” interviewed was Liot Hill, who is a Democrat who serves on the Lebanon City Council. Lebanon, population of about 14,000, is the largest community in the Upper Valley, and is the home of the Dartmouth Hitchcock Medical Center. Councillor Hill is a Democrat, and so far, she is neutral in the primary. She was pleased with the time spent on healthcare in the last debate. She was once a Republican before she got involved in politics by working on Howard Dean’s campaign back in 2004. She is 41 and has not had health insurance for ten years because she can not afford it. We are told that her older daughter has coverage through her college plan and her younger daughter is covered by Medicaid. I will let her speak for herself. Ms. Doyle-Burr quotes her as saying:
“This is an issue that hits home for families and businesses. They’re speaking my language. I manage my health in a different way. “Most of all, I’m incredibly lucky that we are healthy…”
After introducing the issue of the uninsured with Ms. Hill as the spokesperson for a population that can’t afford insurance, Ms Doyle-Burr states.
New Hampshire voters seem to agree that the current health care system needs fixing, with a good number thinking they’d like to move to a single-payer system of some kind, but they’re not in agreement about how to get there and how fast…Given Trump’s previous failed push to repeal the law when Republicans had a congressional majority, much of the political chatter this election cycle has been about Democratic proposals with more clarity and more drastic reform.
The next three comments are from physicians. She uses their comments to provide some facts and details for her readers about the political questions to be considered by voters.
Dr. Ken Dolkart is 65, but he still practices internal medicine part-time, and is also teaching a class on current issues in healthcare at Osher@Dartmouth, a lifelong learning institute. His comment was:
“All of these (Democratic) plans are reflecting efforts to have genuine and comprehensive reform. All of them are better than what we have now…”
Doyle-Burr provides us some insight into his political preferences:
Though Dolkart said he “loves Bernie” and the way Sanders has shaped the conversation about health care, he thinks Warren might be more effective right now. He also said he likes Harris, from a “political point of view.”
He does not, however, like former Vice President Joe Biden’s health care plan, which aims to tweak the Affordable Care Act, which became law during Biden’s time as vice president under President Barack Obama.
“I think Biden is too locked-in to his prior life and prior decades,” Dolkart said. “America is ready to move beyond that.”
She then gives her readers some up to date statistics from the Kaiser Family Foundation:
Nationally, about 53% of Americans are in favor of Medicare for All, according to polling by the Kaiser Family Foundation. Support is broader, ranging from 74% to 77%, however, for other proposals such as optional Medicare for All, a Medicaid buy-in or a Medicare buy-in for ages 50-64, according to the foundation.
You should click on the link which will take you to a data rich slide deck from Kaiser. The survey is a little out of date in that it reflects opinions from April. The most important point is that the answer given to a question is a function of how the question is asked. (slides 5,6). When people who support a national program of universal coverage are asked to rank what is important to them (slide 8), an interesting cascade of priorities emerges.
- Covers all All Americans-89%
- Simplifies the health care system-79%
- Eliminates monthly premiums-56%
- Eliminates out-of-pocket costs like co-pays and deductibles-56%
- Shifts what people pay for health care to taxes-45%
- Eliminates private health insurance companies-38%
Dr. Bradley Truax is a 70 year retired neurologist/hospital administrator who writes a weekly blog on patient safety and co-teaches the Osher course with Dr. Dolkart. He said:
The downside of the more moderate proposals is that they may not be able to achieve the administrative cost savings that a Medicare for All, single-payer system could, and they also likely would fail to attract enough people to adequately share the risk.
Dr. Truax also favors Medicare for all because a smaller group wouldn’t have as much leverage in negotiating with pharmaceutical companies, which is currently not allowed by law. Truax likes Bernie Sanders’ plan, but he favors Elizabeth Warren whom he considers more electable.
Johanna Evans is 31. She lives in Lebanon. She has managed the campaign of a Democratic state legislator, but now works at Dartmouth. Ms Evans told Ms Doyle-Burr that she thinks it’s time for the party to focus on policy and move past the electability issue. She “leans left” and would like everyone to have basic access to health care. Doyle-Burr adds:
…[she] thinks that people also should have access to additional coverage based on their lifestyles and needs. For example, she said, athletes might have greater needs for orthopedic services than the average person, and they should be able to get the care they need to continue those pursuits.
The quote from Ms Evans focuses on the variable needs of patients:
“Completely abolishing private insurance doesn’t make sense. Americans “don’t all have the same health care needs.”
While she wasn’t sure which candidate she will support in the primary, Evans prefers someone in the middle, like Harris or Booker, “where we want the party to end up.”
Don Kollisch is presented as a semi-retired family medicine doctor who has been actively involved with the Granite State chapter of Physicians for a National Health Program for over 30 years. So far he does not support a specific candidate. His opinion is that moderates’ plans that would offer a public option of some sort, but allow those who wish to keep their insurance plans to do so are “misleading the public.” Ms Doyle-Burr sums up his position with a quote:
“My organization does not support any candidate,” said Kollisch…However, the group does support those who are in favor of Medicare for All, “where ‘all’ means everybody.” That’s the only way, Kollisch said, to achieve “true equity” and “true savings.”Right now, Kollisch said the candidates in this category appear to be Sanders and Warren…
Our next citizen is Laurie Harding, a former Democratic member of the New Hampshire House who represented Lebanon, but now is co-director of the Upper Valley Community Nursing Project, which helps seniors receive the care they need to stay at home. She favors moving to a single-payer system. Her comment was:
“I’m looking at the candidates very carefully to see who’s got that [a single payer system] as a goal but who in fact is going to be very thoughtful and deliberate about the steps to get us there…[I’m] looking very closely at Amy Klobuchar [who has said that getting rid of private insurance is a bad idea] because I like her approach to difficult issues. She’s got a progressive vision, but is really very thoughtful…”
Eric Bunge is 58-year-old who lives in Etna, New Hampshire. He is originally from Minnesota, and he favors Klobuchar. He works across the Connecticut River in White River Junction, Vermont as a project manager for a local theatrical group. Bunge and his wife are both uninsured. The policies they can buy on the exchanges created by the ACA are still too expensive for them, but he also has apprehensions about Medicare for all. His comment about Klobuchar was:
“She doesn’t get the kind of press that I think her record, intelligence, willingness to work across the divide warrants.”
Based on his experience with the expense to him of the ACA exchanges he is concerned about costs. He asks:
“What does that mean? Would there be unintentional consequences of health care skyrocketing? Should the government really be paying for all of these things?”
Perhaps one of the most interesting individuals that Doyle-Burr interviewed was Curt Jacques. He is the owner of West Lebanon Feed & Supply. He was the subject of an interesting healthcare policy article that Doyle-Burr wrote in July 2017. Jacques is a Republican who did not vote for Trump. Like many New Hampshire Republicans, he will be registering as an independent in 2020, but would be able to vote in the Democratic Primary next February. He offers his employees a high deductible policy, and then helps cover their premiums and deductibles based on their length of service. As is true for many people in New Hampshire, he is worried about the government getting more involved in health care even though what he must do now to cover himself and his employees is not good either. He is apprehensive about going all the way to Medicare for all:
“I think that we need to do baby steps on health care…It’s “still a burden for us…”
Doyle -Burr continues with his comments:
…none of the plans proposed by the Democrats appeal to him. “I’m afraid that more government means more money (and) more regulation (that will) slow the process down…”
Doyle-Burr goes on to explain
[He] would support efforts to get pharmaceutical costs under control. He’d also like to see a wellness program that would teach people to “eat better, live better (and) be more smart about your own health…”
The last Upper Valley resident to weigh in on healthcare was Dave Shinnlinger, who teaches industrial arts at a local regional high school. Despite getting his healthcare through a union negotiated contract he was open to a single-payer system.
“Anything that provides more access to health care for my students, their families, and our community is a good thing. Health care for all is an idea I’m willing to sacrifice some personal benefits for if it comes to that, but I am optimistic that we would all benefit from nationwide health care.”
Doyle-Burr finished her article with another comment from Liot Hill, the Lebanon city councilor who despite her middle class economic status is one of the nearly 30 million Americans who does not have health insurance. Ms Hill told Doyle-Burr that her vote is up for grabs. She likes what she’s hearing from Warren, Buttigieg, Booker, Harris and Biden. In many ways her last quote is typical of what I hear when I eavesdrop on conversations in this once “red,” then “purple,” and now increasingly “blue” corner of the Granite State:
“I’m not a single-issue voter. There are so many issues — from the climate, expanding the promise of the American dream to everyone regardless of what they look like or who they love or where they live.”
I like that attitude, and I think that it is hard to conceptualize that we won’t fix a system where Ms Hill and 30 million other Americans can’t afford to buy care, and is so expensive to use that many people still don’t get care even when they are “covered.” It leaves one thinking that as good as the ACA was meant to be, it is not enough. The ACA pointed the way, but it is now time to take what we have learned and apply that knowledge to the continuing march toward the Triple Aim. The feed store owner is right to be apprehensive, because without a willingness from all of us to participate in an operational transformation that is designed to reduce waste in all of its forms, the cost of care will rise. If we don’t get the costs down as we expand access, even if we were all as generous as Dave Shinnlinger, we will not be able to address the “so many issues” to which Ms. Hill refers that are complexly connected to the health of our communities.
“There are so many issues — from the climate, expanding the promise of the American dream to everyone regardless of what they look like or who they love or where they live.”
