9 August 2019

Dear Interested Readers,

 

Focusing the Conversation in Order to Make Progress

 

Dr. Ezekiel Emanuel is the brother of Rahm Emanuel, former congressman, Barack Obama’s first chief of staff, and later two term mayor of Chicago. Dr. Emanuel was a major participant in the drafting of the ACA. His 2014 book had a lengthy title, Reinventing American Health Care: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System.  Some say that he is the principal architect of the ACA. Despite his identity as a healthcare policy advisor to Democratic leaders, in 2017 the Republicans engaged him in discussions about how to repeal and replace the ACA.

 

Dr. Emanuel, who was a target of much Republican abuse during the debates leading up to the ACA, remains a staunch defender of the ACA. He also considers it to be a piece of social legislation that time and experience has demonstrated is ready for modification and improvement. In the article noted above about his attempt to collaborate with Republicans in 2017 written by Juliet Eilperin and Amy Goldstein and published in the Chicago Tribune in March 2017, the authors document Emnuel’s attempt to have a bipartisan conversation with Paul Ryan, President Trump and other administration officials about how to maintain the core benefits of the ACA, even as they were determined to “repeal and replace” it. They attempted to explain his action:

 

In his 2014 book Reinventing American Health Care, Emanuel wrote that “beginning in 2020 or so, the ACA will increasingly be seen as a world historical achievement, even more important for the United States than Social Security and Medicare has been. And Barack Obama will be viewed more like Harry Truman – judged with increasing respect over time.”

 

While Emanuel is partisan, he also is pragmatic, and he has consistently maintained that the sprawling law needs improvement. He has argued that it should be altered to further expand insurance coverage, contain health costs, improve the health plans’ affordability, and address the inconsistent caliber of health-care delivery in the United States.

 

I added the bolding for emphasis of what remains as the core challenges, and what should be the core issues to be discussed in the ongoing Democratic debates. There have been several problems with the debates so far. To name a few:

 

• The news organizations seem to be asking questions designed to produce controversy and viewer excitement rather than clarification.

 

• The candidates justifiably seem interested more in their own survival than engaging in a discussion that will inform the public about the issues.

 

• Neither the journalists or the politicians seem to grasp the extent of the complexity of the current internal current state of healthcare or fully appreciate its external connections to almost every other economic and social issue worthy of their attention. 

 

• There has been little attempt to continue the education of the public about what the ACA has accomplished, or how the gains of the ACA are vulnerable to a continued Trump presidency. 

 

• The debates have not explored the gains made by the ACA that must be compared to potential benefits in any program that replaces it.

 

• There has been no discussion of healthcare finance that contrasts the impact on patient care of Fee For Service payment with value based reimbursement.

 

• There has yet to evolve a consensus about how to prioritize the issues in need of improvement within healthcare, and how to prioritize healthcare within the larger list of issues that face the nation.

 

• There is not a consensus on the question of how to win the presidency. Should the focus be on the performance of Trump or on what might be offered as an alternative to “Trumpism” and the anxieties that support it?

 

I am sure that the list is longer. My point is that the discussion so far has had more emotion and posturing than useful content. The Democrats are frittering away their opportunity to present their knowledge of and commitment to the tenets of the Triple Aim. 

 

Zeke Emanuel is not a household name despite his authorship of multiple books, and his pivotal role in the creation of the ACA. I believe that he has much to teach us as we seek to become better consumers of political positions on the future of healthcare. We all know the advice that “those who do not learn history are doomed to repeat it.” I have always modified that thought just a little because what it is trying to imply is more for me than just using history to avoid the disasters of the past. It implies to me that we should approach history with the objective of trying to accurately understand what has happened, and then effectively apply that information to our current issues and projects as we build on past successes and failures for continuous improvement. If that is our objective, Zeke Emanuel is the perfect guide.

 

We are fortunate to have healthcare policy people like Emanuel who have an interest in learning from history. Dr. Emanual like David Blumenthal who is the President of the Commonwealth Fund is a student of our century long struggle to improve health in America. Both were advisers to President Obama and were involved in the evolution of the ACA, and both continue to analyze their experience for “lessons learned” and offer their experience and analysis to us as advice for the next iteration of change.

 

What follows is lifted from three pieces that you can read that offer Emanual’s thoughts beginning with an interview with Harold Pollack, who is also a healthcare policy expert and is a professor at the University of Chicago.  The interview was published in the Washington Post over five years ago, shortly after Reinventing American Health Care was published. The second piece is an opinion piece by Emanuel published in Stat earlier this year on the ninth anniversary of the ACA, and a couple of months before the Democratic debates. The third piece is an op ed from the New York Times that Emanuel published just like week in response to the failure of the debates to produce meaningful dialog about the core issues. Last week I gave you a link to an NPR interview with Dr. Emanuel that covers much of the same ground as the NYT op ed. only The NPR piece is only about five minutes long and is worth your time even if you pass on the articles.  

 

The Pollock interview from five years ago would be good prep reading for all the Democratic candidates because Emanuel reviews the failed efforts of Truman, Nixon, and Clinton to reform healthcare, and contrasts them with the more successful efforts of Wilbur Mills and Lyndon Johnson in 1965 resulting in the passage of Medicare and Medicaid. Obama did know the history and tried to use its lessons, but even that knowledge and intent were not sufficient to produce a bill that was bipartisan and free of design flaws. Emanuel even suggests that the plan offered by Nixon and resisted by Ted Kennedy was a more encompassing piece of legislation than the ACA. It’s been a while since I have read the book, Power, Politics, and Universal Health Care (2011), written by Stuart Altman who was on NIxon’s staff and a key policy maker, and co authored by David Shactman. It is my memory that they suggest the same idea, that Nixon was an advocate for a very progressive healthcare program which may seem strange in these times when we expect that Republicans are trying to undermine healthcare reform. Emanuel goes on to outline how Senators Olympia Snowe and Charles Grassley argued for and obtained significant modifications to the ACA in committee, and then voted against the bill after their demands were written into the law. Click on the links attached to their names to understand what they think now. 

 

The biggest take away from the 2014 interview for me is Emanuel’s clarity about the differences between policy formation and policy implementation, and the importance of effective communication internally and then with the public. Emanuel is very specific about the different skill sets required for each piece of the total process. As I read the interview, I asked myself, who among the current Democratic candidates speaks in a way that suggests to me that they understand these political and operational realities? Who among them is willing to be pragmatic enough to preserve what we have, astute enough to negotiate improvements, and has the political skill to oversee communication, legislation, and implementation of a path toward something better while simultaneously defeating Donald Trump? Perhaps it is the format of the debates; perhaps their websites are still in evolution; perhaps their town hall techniques and interview skills are still evolving, but so far it seems they all offer flawed claims that they are the one for the job. I am not convinced that any of them really fully understand what would be required for success. 

 

Emanuel begins his March 22, 2019 piece in Stat by also looking back to 2009. It is a “perspectives” piece. His perspective is clearly that both coverage and cost has improved compared with 2010, but there is still much that needs to be done, and if there was the political will, much could be accomplished yielding great benefit for everyone, no matter what their political affiliations are. 

 

Even before the Affordable Care Act became law, about 90 percent of the conversation and criticism of it was about coverage. Little has been said about its ability to control costs.

March 23, the ninth anniversary of the ACA’s passage, presents a good opportunity to examine its legacy on cost control — a legacy that deserves to be in the foreground, not relegated to the background behind the exchanges, Medicaid expansion, and work requirements.

 

He presents data to suggest that costs were more affordable in 2018, by hundreds of billions of dollars on an annualized basis, than the CBO predicted they would be as the ACA went into effect. 

 

Fast forward to December 2018, when that same office [the CBO] released the official tabulation of health care spending in 2017. The bottom line: cumulatively from 2010 to 2017 the ACA reduced health care spending a total of $2.3 trillion.

 

Related: Coverage for pre-existing conditions lives on, even though the Affordable Care Act seemed doomed…In 2017 alone, health expenditures were $650 billion lower than projected, and kept health care spending under 18 percent of GDP — basically a tad over where it was in 2010 when the ACA was passed. It did all of this while expanding health coverage to more than 20 million previously uninsured Americans.

 

Compared to the 2010 projections, the government’s Medicare bill in 2017 was 10 percent ($70 billion) less, and spending for Medicaid and the Children’s Health Insurance Program was a whopping $250 billion below expectations (partially — but only partially — due to the failure of some states to expand the program). The actuary had predicted in 2010 that employer-sponsored insurance would cost $1.21 trillion in 2017, but it came in at $1.04 trillion, a difference of $170 billion for that year.

 

Some may argue with the numbers, and nobody discounts the threat that still exists in the courts to the ACA as a whole, but it’s hard to deny to the dramatic accomplishments of guaranteed coverage at community rates despite pre existing conditions that the electorate now seems to understand. Emanuel doesn’t celebrate where we are as much as he suggests that we should heave a sigh of relief based on where we would have been if the ACA had not changed the predictions of the CBO. As he says:

 

One reason the ACA’s enormous success in cost control goes unappreciated is that no one experiences the difference between projections and reality. What could have happened is intangible. All we feel is what actually happens.

 

At least three trends make it hard for Americans to appreciate these lower costs. First, employers are foisting more of the cost of health insurance onto employees. Employees’ share of health premiums has gone up 32 percent since 2012 while the employer portion has gone up just 14 percent. Second, drug prices are rising and Americans are finding copays for them more and more onerous. Third, more and more Americans are enrolled in high-deductible health plans. For them, a $2,000 or $3,000 deductible is stressful even if they never actually pay it.

 

Understandably we are less appreciative of our collective benefit, and much more aware of our sense of personal expense and vulnerability. Nothing brought this fact home to me more clearly than my own recent experience with the healthcare system. I was premature in reporting to you that my five hour hospital stay for an outpatient laparoscopic hernia repair under anesthesia was about $9000 with almost everything covered by my wife’s excellent Federal Retirees Blue Cross benefits. To my great surprise a month later a second bill showed up for an additional $17,000 of which my portion was $3000. It seems that Dartmouth Medical Center does split billing and the first bill was for physician services and the second bill was for institutional expenses. Fortunately for us, my wife and I can easily write a check for $3000, and just grouse about it. What if we were not financially secure? It is a reality that many Americans who think they have great coverage don’t really know what they really have until it is tested. Many of those people are among the 40% of working Americans who would need a loan if presented a bill for $400. Yes, we still have a healthcare cost problem even though its not nearly as bad as it would have been if we had never passed the ACA.  Emanual wants us to fully understand both the financial benefits we have from the ACA, and our continuing need for cost improvement:

 

Hence the most likely explanation [for why healthcare costs have come down] has to be the ACA. It changed how physicians and hospitals are paid, shifting toward more value-based payments. It required reducing wasteful and expensive readmissions and encouraged efficient redesign of care. And it spurred the private sector — insurers and employers — to try their own payment reforms, such as reference pricing, to control costs. Indeed, the latest data suggest a real slowdown in utilization of health care services. It will take health economists a few more years to sort out all the contributing factors.

 

The ACA has helped bend the cost curve. But we should not rest on this $650 billion savings success. We can do more.

 

As he continues, he identifies rising prices for drugs, medical devices, and hospitalizations as continuing threats. His solutions include centralized negotiations on drug prices. He advocates upper limits to what hospitals can charge. He suggests a future emphasis on Medicare Advantage type plans.  He believes that we will benefit from better antitrust enforcement to limit hospital acquisitions and mergers as ways of keeping hospital charges from going ever higher. His conclusion:

 

Despite constant criticism and occasional sabotage, the Affordable Care Act has successfully expanded health insurance coverage — even though it included individuals with pre-existing conditions — and controlled runaway health care costs. We need to build on its tremendous cost-control success.

 

Based on the show at the first two Democratic debates, I am not sure that any of the participants had read Emanuel’s Stat article, or if they did, they must have said, “Yes…but” in response to Dr. Emanuel’s advice. He is not deterred by the fact that they are not buying what he is selling, or if they are, deem it too complicated to pass on to the tens of millions of interested listeners to the debates.  

 

It seems like the Democrats are attempting to emulate Trump’s debate strategy to get the nomination. He got elected by being brash, rudely interrupting other speakers, and undermining the points of other Republicans with misinformation and outright lies. We now have some practitioners of those arts on the Democratic platform. Could it be we have come to believe that the ability to use force and disruption is a better predictor of success than orderly process and respect for others even on a debate platform? Dr. Emanuel’s third piece and the radio interview that I have offered for your review were presented as responses by Emanuel to the misdirection of the first two Democratic debates.  He begins with the obvious observation:

 

As this week’s Democratic debates made clear, the party is divided on how to improve health care for Americans. Bernie Sanders, Elizabeth Warren and others are for a single-payer Medicare for All system. Joe Biden, Pete Buttigieg, Amy Klobuchar and others want an incremental approach building on the Affordable Care Act.

But candidates who are battling over plans like Medicare for All (Mr. Sanders) versus Medicare for All Who Want It (Pete Buttigieg) versus Medicare for America (Beto O’Rourke) versus BetterCare (John Delaney) — and many others — are having the wrong debate. Instead, they should be competing to find the best ways to tackle affordability — an issue they can all agree on and President Trump has done nothing about.

 

With that statement he points out that they have all “jumped to solution” without fully dealing with the explanation of why we are having difficulty getting to universal coverage, and why a significant number of reasonable people are concerned that if we were to wake up tomorrow with any of the solutions that are being debated, we would have a financial and operational disaster on our hands. 

 

He has his own solution:

 

Democrats are deeply concerned about achieving universal coverage. The simple way to do that is not through a single-payer Medicare for All plan, which faces daunting political opposition. Instead, they can get coverage for most of the remaining 28 million or so Americans with auto-enrollment. Changing some existing policies, like harmonizing the income eligibility standards for Medicaid and the insurance exchanges, would enable the government agencies, hospitals, insurers and other organizations to enroll people in health insurance automatically when they show up for care or other benefits like food stamps.

For the other 295 million Americans who have some form of health insurance, the problem is high costs. Even with health insurance, high premiums, deductibles and co-pays, surprise hospital bills and exorbitant drug prices inhibit people from accessing care and taking their medications, threaten to drain their savings, or even force Americans into bankruptcy. Democrats need a plan to deal with this problem.

 

He is a policy guy and policy guys have opinions and suggestions. He has four suggestions to improve affordability:

 

• First, we need to address drug prices. The United States has just over 4 percent of the world’s population, and yet it accounts for nearly half of global drug spending…He estimates that effective negotiations with drug companies yielding a 10% savings could save at least $53 billion.

 

• Second, hospital prices are soaring and must be contained….A recent RAND study indicates that, on average, hospitals now charge private insurance companies 141 percent more than Medicare. The main culprit behind this price escalation appears to be the mergers of hospital systems, which creates local monopolies. Researchers at Yale calculate that capping prices for inpatient care for private insurers at 120 percent of Medicare would save about 20 percent of those costs, approximately $90 billion per year…

 

• Next, we need a policy that targets wasteful insurance billing practices…14 percent of health care spending was related to billing and insurance-related administrative activities…we spend nearly $500 billion a year on billing and insurance processing. Based on comparisons with other countries, about half of that is classified as “excess” — a polite way of saying waste. The simplest approach is to empower an independent commission to create a clearinghouse for processing all medical bills with uniform standardized electronic formats for all insurers…Health economists suggest this could yield savings that are more than 3 percent of expenditures, about $90 billion per year.

 

• The fourth option is to push even harder on switching from fee-for-service payment to value-based alternatives…Ultimately, it is doctors who write orders and decide on a patients’ suite of tests and treatments…There are many ways to incentivize this shift, but probably the easiest is for the government to require every insurance company that receives any government funds…to require more than 50 percent of their payments to physicians be some kind of value-based payment within three years.

 

It sounds simple. Sign up the uninsured. Set some limits. Change a few arcane practices. Improve business practices to reduce waste. Utilize the government’s leverage for negotiation. Get rid of Fee For Service in favor of value based reimbursement. Ten billion here, 20 billion there, and before you know it costs are down and everybody is covered. I know what you are thinking, “Like all of the other ‘plans,’ the devil is in the details.”

 

I salute Dr. Emanuel for his work over the years. I know that there are many who do not like his ideas or his style, but I think that he is doing us a favor to offer us his opinion and some ideas for discussion that might get us off “stuck.” I do believe that there are abuses from the drug industry, insurance companies, and wealthy corporations and individuals, but I do not believe a civil war against the status quo is a productive path to the Triple Aim. The status quo needs to be modified, and those that abuse the system should be held accountable, or at least find that their advantage has been taken away. We must systematically work to modify the rules of engagement in the business of healthcare so that we can have a more affordable and inclusive system of care in the near future that is built on our past accomplishments.

 

It will not be easy to work for a consensus among Democrats, or even more desirably, evolve a marginally bipartisan process, but it is not the time to force a solution. It is the time to review past efforts. Discuss lessons learned. Renew respectful engagement with the hope of producing sustainable outcomes. All of these actions will require exceptional leadership. The call from a new responsible leader should be followed by a response from all of us who will support the work of finding a better way that is both inclusive of all who live in our land, and good stewardship of our personal and collective assets. If we could move forward on those broad objectives, we would be on a road to sustained greatness.  

 

It Was A Great Day For A Parade

 

Today’s header is a picture that I took trying to capture the feel of our 95th Annual “Hospital Days” Parade. It was a big weekend of community fellowship and fun. Local dignitaries offered themselves up as targets for dunking on the town green. Little children collected candies from the marchers in the parade. The ferris wheel turned offering great views from the top, and I am sure there was enough action on the “Tiltawhirl” to dislodge some poorly digested hot dogs that seemed like a better idea going down than coming up. 

 

A new tradition was set. In the past we crowned “Miss New London.” A few years ago social progress led to a name change, and we began crowning “Ms. New London.” This year after the votes were counted (votes= dollars donated), we continued to expand our consciousness and inclusiveness by crowning “Mr. New London.” Floats, musicians on flatbed trailers, cattle marching down Main Street in yokes, old convertibles carrying dignitaries who were waving to the crowd, a jazz and gospel singer piloting a Segway while singing, and the town moderator on an ancient high wheeled bicycle that he deftly maneuvered up and down Main Street, all added up to a great day that fostered a sense of community cohesiveness that one might hope will last a year until the next event. 

 

August is flying by as the Sox sink lower in the standings. I remind myself on a daily basis that there are many more important things to consider and care about than baseball. Whatever you plan to do, wherever you plan to go, I hope that you will have a great August weekend that will renew you for the challenges ahead. 

 

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