The election outcome should not have been a surprise. We should have recognized the uncertainty produced by anger and deep divisions on many issues. The “establishment” Republican party seemed to be in shambles. The Democratic party did not recognize that it had lost its traditional labor base. Donald Trump was an unusual candidate who won by presenting himself as an agent of change to a new coalition of voters. He was not encumbered by the rules of the “establishment”, the norms of political correctness or interpersonal civility.
In an environment of fear and anger we are separated in many dimensions by attitudes and opinions that seem irreconcilable. We have lost the sense of community and social solidarity that is necessary to resolve our complex problems.
Donald Trump did not create our divisions and lack of social solidarity, but he understood them and saw the opportunity they offered. This last year and a half of hostile campaigning by both parties has greatly deepened our divisions. Those divisions created a space into which he has deftly stepped. Is he a genius or just a lucky opportunist?
Prior to the election I was concerned that the divisions would be worse post election no matter who won. There was no question in my mind that a Clinton victory would be followed by four years of hassle and resistance that would surpass everything that we have seen since 1992. We are exhausted from a quarter century of political gridlock.
When I began writing about the election I was concerned that healthcare had been lost as a significant issue and was not getting the discussion it deserved. In over four hours of face to face debate between the two candidates healthcare got less than fifteen minutes of discussion. I was worried that no matter the outcome of the election, progress toward the Triple Aim would stall. I wrote to try to imagine a way forward for the Triple Aim that was not dependent on the outcome of the election. I have tried to suggest and describe a mindset for the work of healthcare transformation that would be beneficial no matter what happened in the election.
My “pre work” and realization that a Trump presidency was a real possibility prepared me for a truncated Kubler-Ross process. Having already processed “denial”, “anger”, and “bargaining”, I was ready to quickly move through “depression” and arrive at “acceptance”.
When President Elect Donald Trump visited Washington two days after the election he was asked by the press what his priorities would be. His answer, “Immigration, healthcare and jobs.” He still says that he will attempt to abolish the ACA, but creates confusion by suggesting that he may preserve some parts. It is uncertain what will replace the parts of the ACA that do not survive. The ACA was built on a Republican concept of a public/private partnership. What will be the foundational concepts of its replacement?
His campaign did post a healthcare white paper on his website which I have referenced before. It begins much as you might expect.
In that paper he says:
… On day one of the Trump Administration, we will ask Congress to immediately deliver a full repeal of Obamacare. However, it is not enough to simply repeal this terrible legislation. We will work with Congress to make sure we have a series of reforms ready for implementation that follow free market principles and that will restore economic freedom and certainty to everyone in this country. By following free market principles and working together to create sound public policy that will broaden healthcare access, make healthcare more affordable and improve the quality of the care available to all Americans. (I did not bold the last sentence. That is the way it was written and published.)
There are seven points that emphasize the rights of the individual and a belief in the ability of markets and local government to solve most problems.
- Completely repeal Obamacare. Our elected representatives must eliminate the individual mandate. No person should be required to buy insurance unless he or she wants to.
- Modify existing law that inhibits the sale of health insurance across state lines…By allowing full competition in this market, insurance costs will go down and consumer satisfaction will go up.
- Allow individuals to fully deduct health insurance premium payments from their tax returns under the current tax system. …As we allow the free market to provide insurance coverage opportunities to companies and individuals, we must also make sure that no one slips through the cracks simply because they cannot afford insurance. We must review basic options for Medicaid and work with states to ensure that those who want healthcare coverage can have it.
- Allow individuals to use Health Savings Accounts (HSAs). Contributions into HSAs should be tax-free and should be allowed to accumulate.
- Require price transparency from all healthcare providers, especially doctors and healthcare organizations like clinics and hospitals. Individuals should be able to shop to find the best prices for procedures, exams or any other medical-related procedure.
- Block-grant Medicaid to the states. …The state governments know their people best and can manage the administration of Medicaid far better without federal overhead. States will have the incentives to seek out and eliminate fraud, waste and abuse to preserve our precious resources. [I am not sure that state and local governments do a better job than the federal government with fraud and abuse in other public contracts.]
- Remove barriers to entry into free markets for drug providers that offer safe, reliable and cheaper products…Though the pharmaceutical industry is in the private sector, drug companies provide a public service. Allowing consumers access to imported, safe and dependable drugs from overseas will bring more options to consumers.
The seven points seem to suggest that there are simple solutions to a complex set of problems that have plagued us for seventy five years. The objectives of the Triple Aim could theoretically be met by implementing these seven points if some serious questions are resolved.
- If the mandate is abolished what mechanism will insure the integrity of the insurance pool? Specifically, how will the replacement, in a free market system without a mandate, finance the abolition of lifetime limits and the prohibition of bans on the negative impact of preexisting conditions?
- The ability to sell insurance across state lines is a favorite Republican solution to high healthcare costs. Theoretically insurers will compete for business and costs will come down. How will that work since in many places in America there is no choice between providers that are locally available? Healthcare is a business where traditional market forces have never worked to lower costs. I hope that I am wrong, but this seems like an empty suggestion.
- Replacing subsidies in the exchanges with tax credits for everyone ties the subsidy to income. This will certainly benefit many in the middle class who get no subsidy now. How will it benefit low income patients?
- How will giving money to the states to use as they will to cover Medicaid patients without establishing the criteria of the care that will be provided? How will the program the guarantee that all citizens under 138% of poverty will be covered adequately? The idea places a lot of responsibility on states to do the right thing when at least 18 of them have not expanded Medicaid under the ACA.
- How does the HSA option guarantee that coverage will be affordable or that the funds in the HSA will provide adequate cost support when prices remain high and continue to rise?
- How can we establish transparency and be sure that it will lower costs? Transparency is a laudable goal that we have not achieved. Transparency is necessary for consumer driven care, but it does not insure better coverage and lower costs, especially for patients who have difficulty negotiating complex programs and economic algorithms.
- Buying drugs back from other countries where they are sold for a lower price seems to have many potential problems associated with it. Reversing the decision not to use the government’s leverage as a purchaser of large quantities of drugs does seem like a logical move.
Recently in the NEJM Gail Wilensky wrote an excellent analysis that describes the realities of the legislative process that will make total repeal of the ACA very difficult. That reality does present opportunities for a bipartisan negotiation.There is much that can be done by executive order to impair the delivery of care through the ACA, but even this approach can be resisted by public opinion and a united industry.
The repeal of the ACA will surely cost many of the 20 million new recipients of care the coverage that they now enjoy. How will the President Elect’s constituency respond when they realize they are losing benefits that they have often overlooked or unappreciated? Issues can be avoided during a campaign that become unavoidable when it is time to lead and govern.
More than a decade ago, even before the Triple Aim was a precise concept, I postulated that only Republicans could enact universal care at a sustainable cost and quality that was comparable to the care provided in other advanced economies. I predicted that they would do it when they decided it was necessary for the economy. I also predicted that they would always vigorously resist any attempt by the Democratic Party to introduce reform before they really understood it was good for business.
Steven Brill’s interesting analysis of the ACA, A Bitter Pill, points out that the ACA does a nice job of taking care of business which is a fact that seems lost on the President Elect who has not yet convinced anyone that he has a deep understanding of any political issue beyond the deep anger and insecurity of white men. So far he does not know what he does not know about healthcare. Will he quickly learn that taking care of the health of the nation is a business priority that requires more substance than his seven points?
The low point of the President Elect’s analysis is to lament that we spend a lot of money providing care to illegal immigrants:
Providing healthcare to illegal immigrants costs us some $11 billion annually. If we were to simply enforce the current immigration laws and restrict the unbridled granting of visas to this country, we could relieve healthcare cost pressures on state and local governments.
The paper posted on Mr. Trump’s website ended with the assertion that if elected he will do the job:
To reform healthcare in America, we need a President who has the leadership skills, will and courage to engage the American people and convince Congress to do what is best for the country. These straightforward reforms, along with many others I have proposed throughout my campaign, will ensure that together we will Make America Great Again.
Now, there are two choices for the next four years. We can act like Mitch McConnell did with President Obama, and vow to do everything we can to insure his failure, or we can pledge to do whatever we can to help him deliver the Triple Aim for all of us.
I am hopeful about the future of the Triple Aim under the leadership of Donald Trump, if we can stay in conversation with him and hold him accountable. A Democratic President, either Hillary or Bernie, would have tried hard against great resistance. If Donald and Paul Ryan try at all, and we help them, we could make progress. In doing so we must demand that what gets passed has a chance to really work. The midterm elections are less than two years away, and it is less than four years until the next Presidential election. Like President Obama I will be cheering for President Trump’s success and hoping that he learns quickly. His success will be success for all of us.
