2 August 2019
Dear Interested Readers,
What Have We Learned So Far From Listening To The Democratic Debates?
This last week we entertained some old friends from Massachusetts. We were neighbors. We attended the same church. We share many fond memories of watching our children grow up together. For many years, from the late eighties until the early two thousands, we spent the Labor Day weekend together with other families at a camp on Lake Winnipesaukee.
Our friends are very accomplished and have always been involved in civic and charitable activities. The husband’s field is economics, and in his research he has explored the effectiveness of public programs to support the underserved. Can you think of a better person with whom to listen to the Democratic debates? To my surprise, my friend was very straightforward about one curious reality, the healthcare debate made little sense to him. The problem was not that he was an opponent of the ACA. Like me, he fears further administrative and judicial attacks from the Trump administration on the ACA. He has always supported the idea of extending access to healthcare to everyone. He is open to the idea of a single payer. He believes healthcare is too expensive, but the debates have not clarified much for him. He understands John Delaney’s supposition that an immediate shift to Medicare for All would lead to a revenue reduction for hospitals that could push many into insolvency. He understands that unions have vigorous negotiated healthcare benefits for their members, and that some may be reluctant to give up those hard won benefits, but how do all of these loosely connected facts and attitudes add up to a practical program that can become a workable piece of social legislation?
He understands the politics and the economics. He understands the need to give everyone the care they need to optimize their health. He knows that the health of the nation is challenged by unresolved social issues, and that we are in the midst of an epidemic of ‘diseases of despair,” and he also knows that the current finance mechanisms of healthcare are wasteful and unsustainable. What he does not understand is how the solutions being debated will solve the complex and sometimes contradictory problems that we face, or how we will ever decide whom among the many debaters is the one to lead us through what will surely remain a contentious process after the election. This is a very confusing moment for my friend, and if a fellow with a Harvard PhD in economics is having trouble making sense of the situation, and if you think that you understand what is going on, the most likely reality is that you don’t know enough to be confused.
It occurred to me as I was listening to the debates that everyone of the candidates seems to think that “their ideas” would work, but despite many attempts, none of them have successfully convinced a majority of voters of the efficacy of their “plans.” Kamala Harris did try to articulate both a healthcare plan and an implementation process this week, but her effort did not go well. Marianne Williamson while warning Democrats that they should give up their wonkiness when dealing with issues like the Flint, Michigan water pollution, and by inference all issues including healthcare, introduced a sad reality. Williamson said,
“If you think any of this wonkiness is going to deal with this dark psychic force of the collectivized hatred that this president is bringing up in this country, then I’m afraid that the Democrats are going to see some very dark days,”
In an article written by Fredreka Schouten and published by CNN, the author points out that Williamson’s admonition to avoid wonkiness and focus on positively and understandably addressing the anxieties of the middle class can be extended to every subject that was debated, and especially to healthcare. Harris’s attempt at defending her plan against Joe Biden and others came across as another exercise in “wonkiness.” Harris’s efforts were not well received, although to me, a wonk, her ideas do make some sense. If you go to Harris’s website, and read the content there, her ten year “implementation” of Medicare For All seems plausible, if you are a “wonk.”
So where do voters go with their fears and concerns? It is easy to see why the Republicans have failed to deliver a solution that would move us toward the Triple Aim even when they controlled the House, the Senate, and the Presidency. Their philosophies and ideology don’t grant them enough degrees of freedom to solve such a complex problem. Any system they would build does not necessarily have universal coverage or a provision for guaranteed insurability without regard to pre-existing conditions as plausible objectives because they are reluctant to use public money that would result in a need to raise taxes. They reluctantly accept the concept of a “public/private” partnership to fund healthcare, but their tax policies do not allow them to expand the “public” support from current levels, so new funds can only come from individuals and employers. The many millions who currently have care or need care through the expansion of government support would by necessity lose their care, as it is in conflict with another Republican objective, which is to reduce money for “entitlements” in order to fund their tax reductions. Should Democrats focus more on the fact that they are dedicated to finding humane and fair solutions to healthcare and other complex issues like immigration, climate change, and economic inequality, rather than pouring on undeliverable promises in the form of half baked ideas unsupported by plausible concepts of finance and implementation?
Because of their commitment to private enterprise Republicans would never concur with a fundamental change like a single payer system that would substantially change or eliminate the need for commercial insurance. What the debates have revealed is that the majority of Democratic candidates are getting nervous about the political backlash that might occur if they signed on to the thesis of Sanders and Warren that private insurance, as we have known it, should go away because things are too bad to fix by just tweaking our expensive, complicated, and moribund system of healthcare finance that is built around commercial insurance. A core objective of the ACA was to gradually reform and standardize commercial insurance benefits, and to lower the cost of care through competitive markets. Many Democrats are terrified that any attempt at “radical change” would result in a backlash that would deny them the ultimate prize of defeating Trump. They may be right. Fear of failure, not a lack of evidence of “high crimes and misdemeanors,” is also what prevents most Democrats from supporting the initiation of the impeachment process that seems to be the only path available if the objective is to prove that “no one is above the law.”
Over five hours of contentious debate occurring over two nights, and without resolution of any issue, or the effective transfer of any new information, or the emergence of any new insight, left my friend and me limp with exhaustion. Listening to bickering that leads to no resolution, and simultaneously is depressing, because, as Elizabeth Warren observed, the conversation was giving Republicans and Trump a lot of talking points, is emotionally draining and worse than watching your favorite team lose a big game by beating themselves with unforced errors. Amber Phillips of the Washington Post captured much of the sense, or nonsense, about healthcare on the first night of the debates in her column entitled “Democrats’ intense Medicare-for-all debate, paraphrased.”
In my Tuesday post I published a link to an op ed by David Blumenthal and Sara Collins of the Commonwealth Fund that I kept thinking about during the debates. I think that they offered plausible suggestions that would result in our ability to quickly get to universal coverage. Their suggestions, based on observations of the other advanced countries that offer universal coverage at about half our cost, deserve being reviewed. Here they are again.
- First, European countries that rely on private plans simplify things tremendously by standardizing the benefits that all private plans offer. This cuts down on the inefficiency and waste that arise when everyone’s plan covers different things at a different price.
- Standardized benefits also simplify things for people and reduce the time they have to spend choosing among plans, as well as ensure that they are covered for health services essential to their health and well-being.
- So that no one is bankrupted by their healthcare costs, European countries place limits on what people have to pay…if they are very sick or have a chronic illness, out-of-pocket costs are capped at 1% of income.
It was easy to discern that except for Elizabeth Warren and Bernie Sanders, the other candidates were frightened by the power of commercial insurers to sway public opinion with a campaign of fear designed to exacerbate the basic distrust of government that many Americans possess. Republicans could easily use such a campaign of fear and misinformation to undermine any attempt at real reform and simultaneously deny Democrats the presidency. I am sure the death of the Clinton attempts at healthcare reform in the early nineties that was executed by the very effective “Harry and Louise” campaign that the insurance companies financed and directed, was an easily accessed memory for the more timid debaters who were seeking to advance their own possibilities while undermining Sanders, Warren, and Harris.
Our system of commercial insurance is flawed by complexity that adds no value to the consumer. As Elizabeth Warren astutely observed, “The basic profit model of the insurance companies is to take in as much as you can in premiums, and pay out as little as you can in healthcare coverage.” If you clicked on the last link and watched the YouTube collection of Elizabeth Warren’s quotes from the debates, it is easy to see why a panel of fourteen New York Times columnists gave her the highest score for “night one.” She is passionate and communicates her ideas without hesitancy. Can you imagine her ferocity in a head on debate over healthcare with Donald Trump? The panel of Times columnists covers the spectrum of political opinion and includes liberals like Nicholas Kristof and conservatives like Peter Wehner. The winner of the Times analysis of “night two” was Corey Booker.
While I was trying to extract some meaning from the barbs being exchanged by Democrats in their fight to demonstrate that they were “the one,” I found myself thinking not only about the ideas of Blumenthal and Collins, but also thinking about the presentation that I heard earlier this year by Troy Brennan of CVS, who did predict that we would end up with a system that was much like Medicare Advantage.That was the idea at the core of Kamala Harris’s plan. My conclusion to all my conjectures was that there is a plausible path forward, and Harris was closest to the right answer. As I said earlier, she does a better job explaining the transition process from commercial insurance to Medicaid For All on her website than she does in a debate where information must flow in less than one minute sound bites in the contentious environment of a host of others intent upon promoting their own possibilities.
I believe that in time the single payer concept that Sanders and Warren vigorously defend will be achieved, but I also believe that it will be a long and contentious process, perhaps even longer than the ten years that Senator Harris imagines. Moving beyond just saying that healthcare is a right to making that essential entitlement a sustainable reality will require much more education for the majority of Americans. There was a little bit of truth in what every debater said. What we are looking for is not the dominance of one opinion, but the discernment of consensus about a path forward, and the careful choice of a leader with the skills to move us a little further along from concept to implementation. When I look at the 20 current debaters it is still far from clear to me who that leader for uncertain times is. Let me try to create room for creative thinking by beginning an incomplete list of points to consider as we attempt the next steps on our journey.
- The ACA was an remarkable and innovative piece of legislation despite the fact that Joe Lieberman and a few other senators who were protecting the interests of insurers prevented it from having a public option. Even though the ACA remains at risk, a majority of Americans have a growing appreciation of what it has done. The ACA has moved us to the place where a majority of Amercians do believe that healthcare is a human right, as long as that principle works in their personal favor.
- Universal Coverage is theoretically an achievable objective, soon. Collins and Blumenthal give a plausible set of recommendations to achieve that goal. Finding a politically acceptable way to finance universal coverage and describing a path to move from where we are to the new reality is the real challenge. The candidates should stop selling their concept without clarity about its finance or path to implementation, and continue to build the honest case for the benefits to everyone to be part of a system that is closer to the ideals of the Triple Aim.
- Unions enjoy serving their members by negotiating generous employer funded health benefits that are managed by commercial insurers. Now that the ACA has “standardized” expectations and benefits that policies must honor, the major concern is the continuing shift of uncontrolled costs onto the consumer and the general increase in cost to employers and taxpayers.
- It is quite possible that many employers would be delighted to give up their responsibility to negotiate with insurance companies. Troy Brennan’s contention was that employers would prefer to have a fixed cost in terms of a tax to support a single payer public program rather than the resources, time, and uncertainty of negotiating coverage with insurers. Their tax benefits for providing coverage have largely ceased to be worth the effort. If a public option existed, it could be an alternative that they would favor their employees using.
- Cost is the unaddressed issue in the debates and the biggest challenge to the achievement of the Triple Aim. Zeke Emanual addressed this nicely in an NPR interview aired yesterday. Remember, the first “A” in ACA stands for “Affordable.” That objective eludes us. John Delaney may be right, since Medicare and Medicaid pay less than 80% of current costs, a sudden shift to Medicare For All would be a challenge to the finances of all healthcare organizations. Sooner or later healthcare is going to realize that year over year big increases in premiums to cover system waste and inefficiency is no longer a viable strategy.
- In a transition to a “Medicare Advantage For Those Who Want It,” commercial insurers would have a chance to offer products through Medicare as they do now. Although it is not an obvious part of Bernie’s plan, it seems likely that there would be an opportunity for some insurers to offer “wrap around” products as they do now even if we went all the way to Medicare For All.
To that list I would add that the need to move from fee for service payment to population health based risks contracts is never discussed. Perhaps that is really too “wonky.” But, costs are unlikely ever to be controlled in a system that does not include some risk for providers. Harris did not mention it, but Troy Brennan does. A Medicare Advantage type solution would significantly favor the continued evolution of the expertise necessary to evolve programs of care that deliver better outcomes and better quality for a lower cost of care than Fee For Service Medicare. That is the wisdom that is already built into MACRA.
I hope to add to this list as the conversation continues. It feels as if one of the impediments to a more informative discussion is the debate format. There is no substitute for listening to the candidates express their thoughts without the harassment of other “debaters” trying to gain attention by manufacturing a sense of disagreement. It is likely that many of the candidates will withdraw before the September debates in Houston. Perhaps with a smaller number of participants we will see some progress. As crazy as the process has been so far, I am eager for the next round. Will Tom Steyer successfully buy his way into the next round? We will see.
Can You Believe That It is Already August!
It was very hot in Boston over the last couple of weeks. My favorite television weatherman informs me that this July was the hottest July on record for Boston. I sit a hundred miles north of Boston, and although it has been a little humid and in the high eighties, I am not complaining about our weather. Most of our recent days have been sunny, the air is usually light, and if I do feel a little warm, I hop in the lake, or I take a little sail in a light breeze.
The Red Sox are fighting for my attention. It seems their only hope for the playoffs is as a wild card, and after losing four straight games they are headed back to New York to play the Yankees while trailing Cleveland by five games, and Tampa Bay and Oakland by over three games. It’s not hopeless, but it is far from certain. I gave the Sox two nights off from my attention while I watched the Democratic debates. If they continue their slide, no amount of attention from their fans will make a difference.
A big signal that fall is closing in on us fast is the beginning of the NFL “preseason.” Those “practice games” started last night with the “Hall of Fame Game” in Canton, Ohio with a 14-10 Denver win over Atlanta . Patriot fans have been flocking to Foxborough (or Foxboro if you prefer, as does the Post Office) all week to watch Tom Brady prepare for his twentieth season. It’s amazing to realize that Tom will be 42 tomorrow (born August 3, 1977) which makes him significantly older than at least two of the Democratic candidates for president, Pete Buttigieg (January 19, 1982), and Tulsi Gabbard (April 12, 1981).
My random observations add up to my usual summer time advice. It’s our sweetest, but shortest season, so make everyday count, rain or shine. The weather prospects for this weekend in my little town are great. It is also a festive weekend known as “Hospital Days.” This year is the 95th annual repetition of Hospital Days. It is a celebration of summer that raises money for our little critical access hospital that is affiliated with Dartmouth. There are concerts, raffles, a golf tournament, a mini-triathlon, a carnival with rides for children on the town green, and the big parade that is the grand finale! It’s a real small town celebration, and I expect that one or more Democratic presidential wannabes will also be dropping by.
Whatever is in your plans for the weekend, I hope that you will include a little exercise in the fresh air. Summer is slipping away. We have just five weekends until the fall so that our challenge is to treasure and effectively use each one.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
