In a recent “Healthcare Musing’s” Friday letter I tried to describe how I planned to contribute to the journey toward equity and the Triple Aim in 2018. Patty Gabow, an Interest Reader, friend, and the retired CEO of Denver Health wrote back:


…I did read this Friday’s [letter] and I thought it was great how you used Lean to think about New Year’s resolutions. I am a big believer in them. In violation of Lean I make a lot which starting a couple years ago I have divided into the categories of Physical, Mental/professional, Spiritual, Family/Social and Societal…it is astounding that at my age I still have so many areas for improvement. Regarding the issue of how we can influence a positive change in the country or health care is something I have been thinking about– its hard but I go back to the saying “That it is better to light one candle, than to curse the darkness.” My approach is to  be in marches, write letters, go to community meetings, make financial contributions and be involved in our governor’s race.


Patty will do more than she is saying. She participates on multiple boards and advisory groups where she is a consistent voice for equity and continuous improvement. Throughout her long career she has been fearless and persistent in her commitment to improving access to care for the underserved. If more of us followed her example, the Triple Aim would be a slam dunk.


Time magazine asked Bill Gates to be the guest editor of a recent edition that was devoted to  “optimism.” I was inspired by reading several of the articles, especially the introductory essay by Bill Gates entitled “The Good News.”


Bill made the case that despite the disturbing and frequently bad news reporting natural disasters and the crazy things that our leaders do, we are not going to hell in a handcart. He used facts to support his argument that things have never been better. Better yet, the trends are looking better everyday. Here are some of the facts upon which he rests his case.


  • In 1990 more than a third of the world lived in poverty; now only a tenth of the world lives in poverty.
  • Since 1990 the number of children in the world who die before their fifth birthday has been cut in half. That’s 122 million children saved over the last 25 years.
  • A century ago it was legal to be gay in about 20 countries. Now it’s legal in over 100 countries.
  • Women now make up 20% of national parliaments around the world.
  • The world is finally listening to women’s complaints about sexual assault.
  • More than 90% of children in the world attend school.


Why, if things are getting better, do we feel like the world is in decline? One answer he offers is that improvements are not keeping pace with expectations. Furthermore, we are more inclined to listen to stories about failure and disaster than reports of success. The media feds us the bad news because those stories get our attention. We tend to focus on what disappoints us, frightens us, and makes us angry. It is also true that if you have needs in a world of plenty, it feels bad to be surrounded by wealth when you are poor. He points out that we are wired to need anger as a motivation for making things better. When we measure where we stand, it seems that we are doing a better job than we think. But, when we look to where we would like to be and focus on how far we must go, it feels bad.


An awful event was recently recorded on video by a concerned citizen with a cell phone. He saw a woman sitting in freezing weather at a bus stop in a hospital johnny just outside the University of Maryland Hospital in Baltimore. We need not only to insure that everyone has insurance coverage, but we also must insure that people get the care they need. Anyone who has ever worked in an emergency room knows that some institutions shun those patients who either don’t have coverage or are socially difficult to manage. None of us know the real story in this case, but few of us would deny that her presence at a bus stop on a cold winter night wearing only a hospital johnny does not represent optimal management.  


My desire is to focus on the positives, so I will report that my hope for 2018 was further expanded recently in the most unexpected way. While reading my local newspaper, The Valley News, I was surprised to see an editorial entitled “ACA Not Dead Yet.”


The year-end holidays overshadowed some rather remarkable news: Despite all the Republican efforts to drive a stake through the heart of Obamacare, nearly as many people signed up for health insurance under the Affordable Care Act during the 2017 open enrollment period as did the previous year. If, as President Trump asserts, the program is “imploding,” he should hope his presidency implodes in similar fashion instead of the manner that appears far more likely.


The numbers tell quite a different story from the one concocted by the president: 8.8 million people signed up during the 2017 open enrollment period, which ran from Nov. 1 to Dec. 15. That compares with the prior year’s 9.2 million, when the enrollment period was twice as long and was widely advertised. More than a quarter of 2017 enrollees were new customers, while 6.4 million returned to to pick a plan or were re-enrolled automatically.


Even these figures do not fully reflect participation, … Eleven states, including Vermont, maintain their own insurance exchanges, which also have been reporting strong enrollment. In several big states, they remain open until later this month. Moreover, many more millions of Americans have gained coverage under the Medicaid expansion provisions of the ACA, … In New Hampshire alone, 43,000 people have gained coverage in that way.


It just feels great to read the acknowledgement of this remarkable achievement in my local paper. From there it got only better and once again underlined a previous point made in these notes:


Ironically, the GOP’s reckless and feckless efforts to repeal and replace the ACA appear to have had the opposite effect: Rather than undermining support for the law, they raised public awareness of it and motivated consumers to sign up, according to polls cited by The New York Times.


The editorial reiterated that the “mandate” was a policy that had originated from the insights of the Heritage Foundation, a conservative Republican “think tank” that had proposed that one of the merits of a mandate was to “encourage personal responsibility.” That was an indirect and more delicate way of say that it was “designed to end freeloading by people who didn’t carry insurance and whose health care costs ended up being paid for through higher premiums borne by people who did.”


The editorial ended by celebrating that the ACA lives despite its abuse:


Essential provisions remain, … People who receive subsidies still get them, and they rise along with premiums. Medicaid expansion is a success story that a number of Republican governors, along with their Democratic counterparts, deem vital…It remains a puzzle why Republicans in Congress appear hell-bent on driving up costs, driving people out of the health insurance market and creating uncertainty in one of the nation’s largest economic sectors….Obamacare ….is gaining the widespread acceptance it needs to become a permanent part of the social safety net.


I wish that we could rest on the laurels of 2017. It feels good to say that the ACA remains largely intact and has a growing popularity with a majority of Americans, but I fear that The Valley News claims victory prematurely. It is becoming clearer with each passing day that in 2018 the battle for the Triple Aim moves from defending “Obamacare” to sustaining the social safety net of entitlements that is so important to the social determinants of health. One fact lost on many is that all of the countries that provide better care than we do for their citizens, do so in part because they invest heavily in the future and welfare of their people with a more effective set of social supports.


My good feelings about 2018 took a hit when I discovered that in a letter dated January 11, 2018, Seema Verma, the Administrator of CMS, granted states the ability to pursue 1115a requests to modify their Medicaid programs to include the requirement that recipients work, be in school, do community service, or be a caregiver to be eligible for Medicaid. The Obama administration had routinely turned down such requests from states, since the ACA had expanded Medicaid to everyone who made less than 138% of the poverty level in the states that accepted the Medicaid expansion. Since Medicaid’s inception in 1965, work has never been a requirement. As an effort to insulate the concept of a work requirement from the court challenges that are sure to occur, Ms. Verma wrote in her letter to the state Medicaid directors that the proposal is presented as something that supports mental and emotional health. The Kaiser News service quoted from her ten page letter:


“Medicaid needs to be more flexible so that states can best address the needs of this population…Our fundamental goal is to make a positive and lasting difference in the health and wellness of our beneficiaries.”


The cynic in me says that Republican job one for 2018 is to cut entitlement spending to reduce the huge budget deficits that the tax cut that was a Christmas present for the wealthy will surely create. What is a reality is that 40% of Medicaid recipients are already working full time, and that the majority of the other 60% are either in school, providing care to someone else, or are just too sick to work. The impact of the waivers will be to allow states like Kentucky, one of the ones that wants the work option, to introduce more onerous sign up requirements making it harder for new enrollees to get coverage. If you would like a picture of life and the dependency on entitlements in the most impoverished “white” county in America,” let me offer you a picture of Booneville in Owsley County Kentucky, where government entitlements like food stamps and Medicaid are the only barrier to starvation and disease for a huge percentage of the population.


So what do we see ahead as we peer into 2018? It’s a very mixed picture. Some of our gains with the ACA are still in place for the moment. The public is getting wiser, and I am hopeful that the energy that preserved some of the ACA will preserve some, or all of the CHIP program. On the downside in the coming year we can expect to see challenges across the entire spectrum of programs for the poor. I wish that 2018 looked like a year on “offense,” but like 2017 it may turn out to be a year when we measure our success by how effectively we defend the accomplishments of previous years. The big vulnerability will be to programs that address the social determinants of health. Our imperfect social safety net is vulnerable to the realities created by the passage of the tax reform bill. Social Security may survive, but Medicaid will likely change for many. Other social programs are even less likely to be defended and many may be shot down as defenders are overwhelmed. On the up side, we have a growing awareness that we could do better, and as the reports from Bill Gates and the Valley News suggest there are many, many working hard to make a difference. It’s not a time for spectators. It is time for anyone who cares about the Triple Aim to mo e into action to both preserve what we have gained, and make a little progress in 2018.