5 July 2019
Dear Interested Readers,
Unpacking the Conversation about Medicare for All with Lean Thinking
There has been a plethora of articles this week offering analysis of the Democratic Presidential Primary debates. The Washington Post gave us their analysis of winners and losers after night one, and again after the second night. I paid more attention to the healthcare issues than to any other subject. In the end I thought the discussion was a superficial and disappointing review of questions that were fishing for controversy more than clarification. Healthcare was generally considered to have been the big issue behind the Democratic triumph in the 2018 election, and my number one concern this time around is how healthcare will be treated in the 2020 election. I am on the record as being both surprised by, and annoyed by, how little attention was given to healthcare in the 2016 campaign and the debates between Donald Trump and Hillary Clinton.
Now that the first debates are over it is clear that healthcare, and especially the issue of Medicare For All, created the most separation between the candidates, if not enlightenment for listeners. I have been turning all the healthcare issues over and over in my mind. There are many other issues to consider when discussing healthcare than whether or not you favor Medicare For All. The most disturbing possibility after the first debates is that because of the technical complexity of the issues, and a lack of focus and bickering between the candidates, the advantage from healthcare that the Democrats enjoyed in 2018 could be lost in 2020.
In this post I hope to begin a discussion that will be ongoing through the long run-up to the election that will catalog what we all know for sure, what we don’t know for sure and speculate about, and what we know we don’t know… I hope through the ongoing discussion that together we might understand that we must go far beyond universal coverage as our goal. I don’t think that all politicians understand that universal coverage is necessary for health, but insufficient alone as a change that will improve the health of the nation.
Since writing that challenge to myself, it has occurred to me that approaching the issues with a Lean analysis would be a good place to start. Rather than just a focus on Medicare For All which is a proposed solution to a problem that has many facets, why don’t we see if we can consider the reforms that are needed to improve the health of the nation? So what is the reason for action? We have heard many.
Elizabeth Warren focused on the cost of care as a burden for families. That is true, but is that the only reason to reform and redesign a fifth of our economy? Bernie Sanders was pretty succinct about his reason for action in an ABC News interview after the debates.
The United States must “end the international embarrassment” of not guaranteeing health care as a right, Sen. Bernie Sanders, I-Vt., said on ABC’s “This Week” Sunday.
“We need more changes in our health care system, you talk about a public option, many people will not be able to afford a public option,” Sanders said. “What the American people have got to decide is one simple question: ‘Do we create a health care system, guaranteeing health care for all people without insurance companies and drug companies making huge profits and distorting health care in America?’ That is the issue.”
Well, that is his issue and surely the concerns that he and Warren raise are real, but are their concerns all that there is to improve? At times I have heard Sanders and several other candidates go beyond the issues of our tens of millions of uninsured Americans, the high cost of drugs, the opioid problem, and the disproportionate resources that we spend to end up with the worst outcomes of any of the other developed countries, but there is even more to consider. As an example of what has been left out of the analysis, and not considered in the solution, is the growing problem of “burnout” in healthcare professionals.
Sometimes, but without much depth, the conversation does connect our inefficiencies and incompetencies in healthcare to other issues like education, housing, and the need to refurbish our infrastructure. Given the complexity of concerns, let me suggest that our reason for action is that we need to reform healthcare because it is ineffective, inappropriately expensive, fails to meet the needs of many Americans, is dangerous to the health of those who work in the industry, and ultimately unsustainable while further distorting our ability to respond to other important needs. It is a huge problem that is appreciated in poorly connected pieces.
The next step in a Lean analysis is to describe the current state. The current state is hard to separate from the reason for action, but there are some significant realties that need to be considered beyond the cost issues, poor outcomes, burnout, and our lack of universal coverage. Many of these issues are key to reforming our system of care to enable movement toward the Triple Aim.
- Healthcare is not an entitlement in America. Many of those who do not have access to care are fully employed and still can’t afford it. Illegal immigrants are particularly likely to be “uncovered.”
- Rural America has growing areas of inadequate resources.
- Inner city areas have special problems with access to care.
- Access to housing, appropriate food, transportation, and employment that supports existence without subsidies or second and third jobs are huge challenges for many Americans in both rural and urban environments, and the state of these “social determinants of health” is a challenge to their wellbeing.
- We have growing labor shortages in all professional categories. In many systems of care there are vacancies, and patients are left waiting for appointments.
- With the exception of the VA hospitals, and scattered municipal and county hospitals, almost all of our medical assets are privately owned.
- Many Americans do not trust the “government.”
- Americans believe in capitalism and market based solutions, and have significant apprehensions about anything that seems to be “socialist.”
- Americans are charitable, but often reluctant to address the underlying issues that result in a need for charity.
- Medicare and Medicaid do not cover their “costs” by perhaps as much as 30%. As a result commercial rates are inflated to cover the costs of operations for most hospitals. As John Delaney pointed out in the first debate, if everyone was suddenly put on a medicare payment schedule most hospitals would quickly be insolvent.
- Campaigns do not create new programs. After an election a legislative process is required to create a bill which may or may not resolve the problems that were described and debated during the election process.
- Fee for Service payment is the core of Medicare payment despite Medicare Advantage and the slow process of transformation to payment for value through MACRA. Most states pay Fee for Service for Medicaid, although some, like Massachusetts, are transitioning to Medicaid ACOs and risk based finance.
- We lack transparency in all aspects of how we deliver care, the quality and safety records of individuals providers and institutions, and how the cost of care is determined. This makes a “market” for consumers impossible.
I would be delighted for you to add more items to the picture of the current state. My point is that the full reality of where we are is never revealed in the dialog of the campaign, in the questions from the news people running the event, or the 45 second comments that form the rhetoric of the debates. Worse yet, what we get are answers that have all of the earmarks of a “jump to solution.” We can hope that the policies that we are offered are produced behind some curtain after an analysis that includes the bullet points above plus other appropriate considerations, but how do we know? Would it not be better to actually hear these points and others considered in a public discussion? Perhaps the greatest benefit of the ACA has been to educate the public to a greater understanding of the importance of their protection from “pre existing conditions.” Its better parts constituted a giant step forward toward lasting improvements. Its failures are valuable as data to consider in the process of continuous improvement.
If we could catalog the deficiencies of the current moment and accept a common data set about this moment, the next step in a Lean analysis would be a description of an ideal, or failing that, an improved state. The Triple Aim is as good as it gets in terms of a succinct description of an ideal state. It is important to note that if all of the goals of the ACA could have been achieved it would not have delivered us to the nirvana of the Triple Aim. The ACA was a step forward that was taken with the realization that it was a step toward, not an arrival at a destination. The ACA was the product of a great liberal thinker, Barack Obama, who like all liberals believed in the utility of incremental improvement.
Bernie Sanders and Elizabeth Warren are not classical liberals. They are progressives who are further left on the political spectrum than most classical liberals. It has been noted that the further right or left you are, and the more convinced you are of the rightness of your cause, the more you are inclined to use power to address the wrongs that you have identified, and the less interested you are in hearing the genuine concerns of those who do not accept the totality of your sense of the problems and their solutions. The “horseshoe theory” suggests that carried to the extreme, both the far right and the far left move toward an authoritarian use of power. In both fascism and communism you can feel a boot on your neck. I am not suggesting that either Sanders and Warren would become authoritarian despots if elected. I am drawn to some of their ideas, but I am suggesting that some of their supporters have proven to be so committed to the changes they want, by any mechanism, that they are a threat to the harmony necessary to win an election, and could be as great a threat to a real democracy as the politicians they seek to replace. The divisive rhetoric on both sides threatens progress and the stability of our system. Disappointed “Bernie supporters” sitting out the 2016 election because they felt they were “cheated” may have helped to elect Donald Trump.
In Tuesday’s post I mention Adam Gopnik’s new book, A Thousand Small Sanities: The Moral Adventure of Liberalism. Gopnik points out that liberal thought begins with humanism. Humanists abhor human suffering and are committed to equality. Liberals believe that if the conversation continues long enough, public opinion will shift and eventually change will occur, even if all the established authorities of the day like kings or presidents, parliaments or legislatures, and even the courts are stacked against change. Gopnik points to gay marriage, the progressive improvement of the status of women since the late nineteenth century, the abolition of slavery, and the painfully long progress toward equal rights for people of all races and ethnicities as evidence that incremental change eventually can deliver change that sticks. Since liberals are primarily motivated to abolish cruelty, they are willing to change traditions, institutions, customs, and the status quo to achieve that objective. They are for reform without revolution or violence. Only on rare occasions like the American Revolution or Civil War, or the French Revolution, when all attempts at dialog have failed, do they resort to force, and then as soon as possible they end the conflict, and move toward reconciliation without retaliation. Long views are painful for those who continue to suffer, but failed efforts at rapid change are also discouraging and delay the moment of relief.
Having established a reason for action, having completely understood the current state, and having agreed on what would constitute achievable improvement, we are ready to consider solutions that might move us forward. In retrospect the ACA was developed with such a process. There was more than a year between President Obama’s inauguration in late January 2009 and the signing of the ACA in late March of 2010. The product was criticized for its length for political purposes by those who were against any change, just as many of those who had feigned participation in a bipartisan process debated and defeated major ideas like the inclusion of a public option, and then in the end voted against the ACA, even after they had modified it, As we elect a new president, it would be good to consider the political skills that would be necessary to lead us to harvest what has proven to be positive change from the ACA, and then write a bill that would be a broader and deeper challenge to the status quo than what we have now. The “solutions step” of a change process requires leadership. In many ways it is a S.W.O.T. (Strength, Weakness, Opportunity, and Threat) analysis. It considers both the barriers that must be removed, and the capabilities or assets that must be acquired for there to be a chance that the objective can be achieved. This is where unintended consequences, and the potential impact of the unknowns that are known, are considered as well as where strategies for defense against and recognition of the “unknowns that are unknown” are incorporated in the potential solution. The outcome of the exercise is the ability to advance a hypothesis that will be tested. The hypothesis will state that “if we do A,B,C,D etc, then X,Y, and Z will happen.”
The “if … then” formulation is not the end of the process, but ideally it would be the product of a bipartisan piece of legislation that is broadly accepted by citizens and that a majority is willing to test. The ACA did not achieve bipartisan acceptance, but what happened is instructive now as we consider the qualities and skills of a leader who could carry us forward. Implementation of the exchanges was a big challenge. Implementation of the new, and transition form the old, are always huge tests of any social movement. Brown v. Board of Education of Topeka (1954) outlawed apartheid, or if you prefer, the lie of “separate but equal” in public education, but I still graduated from a totally segregated high school in South Carolina in 1963, and South Carolina’s public schools were not completely integrated until the early 70s. Implementation of social legislation is a slow process of managing resistance with reason, and rarely, as was used in Little Rock, a display of force.
My objective in following the presidential campaign closely is not to settle on a candidate who has all the answers now, and then vote for that candidate and his or her solution. My objective is to try to understand which candidate has the humanity and intelligence to lead us through the hard work of evolving a majority opinion that directs us toward a set of solutions that will decrease suffering and loss from the consequences of the declining state of health and healthcare in America. I feel the answers will entail much more than getting rid of insurance companies and the process will go on for a long time. We had a leader that got us started. We need a new leader with many of the same humanitarian qualities who can help us process what we have learned and use those lessons as we continue to move forward together.
I am reminded of the story in the Hebrew scriptures of how David was chosen to replace Saul as the King of Israel. Samuel was told by God to go to the home of Jesse who had many sons and that there he would find and anoint the man who would become king. Jesse introduced his older sons, all of whom were impressive men, to Samuel, but none of them seemed to be the one God intended. Samuel was somewhat perplexed and asked Jesse if he had any more sons. Jesse responded that he had a young son who loved to play his harp while he tended the sheep. He was out in the pasture, and was surely not the person that Samuel was looking to find as a new king.
I do not know if there is a better potential leader who is still out in the pasture. I do hope that as the next year progresses through debates and primaries that we will see the emergence of one candidate who has the ability to lead us through the many changes that will be necessary toward the opportunity of better health for everyone. I am convinced that progress will be made eventually, I just hope that we don’t waste the opportunity to get started in 2021.
A Surprise Meeting on the Road
Summer is really here! I hope that you had an exciting Fourth of July. Our president and his most generous donors certainly had an exciting, though wet day, on the National Mall. I am sorry that my day did not include listening to his anachronistic review of the Revolutionary War. My wife is still chuckling over all of the FaceBook posts about his historical gaffs. Perhaps the speech is evidence that the 25th Amendment, and not impeachment, is what we should be discussing.
Falling as it was on a Thursday this year, I am sure that many of you are still celebrating and enjoying a very long weekend and a well deserved rest. Even as I am writing to you firecrackers are exploding all around and rockets are flying over the lake before they explode in colorful bursts. I hope that you have the 5th and the long weekend off as a great launch to what will be a pleasant summer.
I worry about the wildlife. What must they be thinking with all the noise as bombs burst in the air? We live close to nature here, and every now and then we cross paths with animals that must be having a hard time finding an appropriate habitat. My wife and our cat were surprised by a bear in our yard on Monday. We have woods on either side of the house down to the lake so I guess that the bear was just passing through. My wife and the cat took cover in the house. I was disappointed that I missed the visit. I looked for it in the woods, but by the time I got home from an errand our visitor must have moved on.
My wildlife sightings have been less dramatic, but are very satisfying. When I am on the lake I love seeing a loon pop up near me. It seems that we will not have a new baby loon this summer. The mother loon has been sitting on her nest on the little protected artificial island that the loon society has built for her, but she has been on the nest over a week longer than the usual gestation. A few years ago she sat for an extra fifteen days and the eggs never hatched. Out community is in mourning.
I had a pleasant surprise on my Sunday afternoon walk. I was deep in thought while listening to a great podcasted conversation between Ezra Klein and Adam Gopnik, whose book I quoted above. For reasons I do not understand I looked to my left and saw the deer in today’s header studying me as if I were something of interest. We made eye contact and then stood facing one another for more than a minute. I felt like I was a curiosity to my chance acquaintance. My picture taking did not cause my new forest friend to stir. I was the one who broke the moment. I finally turned and walked away. I imagined that her eyes followed me until I turned the corner and was out of sight. I hope that sometime this weekend you enjoy a walk that is highlighted by a pleasant little unexpected surprise like the one I enjoyed..
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
