Let’s Keep Trying to Save the Gains of the ACA

It may seem strange to you, but each time I hear that the president and the Republican leadership are making an effort to resuscitate their attempt at repealing and replacing the ACA, I immediately think of the surprising last scene from “Fatal Attraction,” the terrifying 1987 movie with Glenn Close and Michael Douglas. You may remember that in the chilling last scene Douglas is attacked with a butcher knife by Close. She is obsessed with him and has gone through the full playbook of devious maneuvers as she attempted to trap him in a relationship that he is desperately trying to escape. He defends himself by holding her head under water in a bathtub until it seems that she is dead, and then he turns away. I remember making the mistake of thinking that the action was over. Douglas is exhausted from the fight. He makes the same potentially fatal mistake that the audience makes as he backs off too soon in the aftermath of the struggle. Suddenly Close rises from the bathtub, butcher knife in hand. The audience is shocked and Douglas would have been a dead man had not his wife, whom he had cheated in his affair with Close, suddenly appeared and put a bullet in her chest. Fade to black.

 

Most of us sought a career in healthcare because we had a desire to be of service. The attempt to repeal and replace the ACA has been hard for us. I began to  worry about the fate of the ACA in June when I realized that Donald Trump would be the nominee of the Republican party. There are few things that I care about more than the little bit of progress that we made together with the ACA toward

 

…Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness.

 

Coupled with my worry about the president’s designs on the ACA is the reality of how limited the reach of one individual is. We are individually one among millions and many of those millions see the world through the lens of a very different experience in life. We do not have a universally accepted set of facts upon which to build a consensus about core values in healthcare and on many other issues. The problems we have are further exacerbated by what my friend Patty Gabow calls a “lack of social solidarity.”

 

I am not sure what will remain of the accomplishments of the last 25 years in healthcare by the time a new president or this president takes the oath of office in January 2021. I have learned from years of long runs and long walks that when the going gets tough, like when you are climbing a steep hill, there is some benefit in not looking for the top. It is better to just try to take a strong next step and to lean into the natural resistance of gravity.

 

A key to staying on focus or staying the course is to remain in conversation with others who also share the same concerns. Being patient, long suffering and collaborative has allowed others in other beleaguered movements to succeed. Those of us who believe as Martin Luther King,Jr. did, that healthcare is a human right should take some instruction from the larger cause. We must stay our course through what will surely be a continuing struggle and future disappointments.

 

I think that it is clear that I sustain my own sense of possibility by interacting with others who share the same vision and hopes. I recently got a big lift from the words in Jonathan Oberlander’s most recent contribution that was published in the New England Journal of Medicine, entitled “The Art of Repeal–Republicans’ Health Care Reform Muddle. This article began with a sentence footnoting the writing of Blumenthal and Morone in their wonderful book, The Heart of Power .

 

Presidents have long struggled to translate their promises and aspirations into legislative victory. Harry Truman’s national health insurance program never came close to becoming law. Richard Nixon’s universal coverage plan did not pass. Congress rejected Jimmy Carter’s hospital cost-containment bill. Bill Clinton’s campaign to enact universal insurance ended in political disaster.

 

Yet even judged against this dismal history, Republicans’ March 2017 efforts to repeal and replace the Affordable Care Act (ACA) were an epic failure…Their inability to pass the legislation through the House — where Republicans hold a sizable majority — constitutes a major defeat for President Donald Trump, who came to the White House touting his deal-making skills, and Speaker of the House Paul Ryan, who pushed for a quick repeal bill and whose reform vision shaped its content.

 

Those opening words led to further observations that offered reassurance.

 

An enduring feature of American political institutions is that partisan majorities don’t guarantee legislative success. … The Republican health care reform implosion underscores a crucial reality: 7 years after Obamacare’s enactment, the GOP lacks a viable replacement for it. There can be no repeal without replace — the ACA has changed too much in health policy, and too many Americans benefit from it to return to the status quo ante.

 

His article continued with a denouncement of the errors of thought and procedure that added up to the initial failure of the AHCA. Then he asked the question that has been on my mind as I have fantasies of a mad woman coming back from apparent death popping out of the bathtub with a butcher knife.

 

What will Republicans do next? They could cooperate with Democrats on reforms that address the ACA’s shortcomings, strengthen insurance marketplaces, and make coverage more affordable. But such bipartisanship is probably a fantasy. Republicans failed in their initial attempt to overturn Obamacare; they have not accepted the ACA as a law that should be reformed rather than repealed. Some Republicans favor resurrecting repeal-and-replace legislation. Indeed, at this writing the Trump administration and Congressional Republicans are negotiating changes to try and secure the bill’s passage.

 

…The compromises under discussion between the White House and House Republicans — enabling states to opt out of ACA provisions requiring that insurers not charge sicker persons higher premiums (community rating) and provide essential health benefits (such as maternity services) — could further alienate moderate Republicans who are already uncomfortable with the bill’s effect on Medicaid and insurance coverage. The changes the House bill makes to insurance regulation also could run afoul of Senate budget reconciliation rules. And rolling back the ACA’s popular consumer protections, including those for persons with preexisting conditions, will spark additional controversy. Thus, the prospects of GOP efforts to resurrect repeal and replace remain highly uncertain.

 

Oberlander’s words are a source of hope, but then he reminds me of what I know all too well. There is always the option of “blowing it up” with administrative moves.

 

If Republicans cannot pass repeal legislation, the Trump administration has other options to undermine Obamacare, including weakening enforcement of penalties for not obtaining insurance and eliminating federal payments to insurers that are required to provide cost-sharing subsidies to lower-income Americans for deductibles and copayments. Such actions could explode the individual insurance marketplaces. …President Trump remarked that “nobody knew that health care could be so complicated.” Republicans’ struggles to turn their repeal-and-replace rhetoric into reality underscore just how complicated it is.

 

That is how the article ends. We are back to the realities that existed before reading the article. I am left with the same apprehension I had when I would read a 538 article last fall by Nate Silver predicting that Clinton would win.

 

In my recent discussion of Elisabeth Rosenthal’s An American Sickness: How Healthcare Became Big Business and How You Can Take It Back I said that her description of the problems of our system of care reminded me of the concept of structural evil. Structural evil or unintended consequences can be seen in complex systems even as everyone is following the accepted rules and norms. I got some responses to those ideas.

 

Gene, it has always seemed to me that labelling something evil can free one from the obligation to understand it, which I know is not your intention. From my experience…I have learned that everyone’s behavior is rational and makes sense if you understand their experience, premises and assumptions. To change people’s minds and behavior you have to connect with their interests AS THEY UNDERSTAND such interests, which Kahneman (e.g., Thinking, Fast and Slow)  and the other behavioral economists/psychologists have taught us is often not the same as the interests one would assume from an objective economic rational actor perspective (the election of Trump being a particularly horrible example of this). As you know better than most, and as even Trump seems to understand, HC is complicated because, in part it is so large and important, and so we need new structures informed by a new vision of what the enterprise is about, which has been your mission for a long time. Even with the threatened revival of Ryan & TrumpCare, premised on a massive transfer of wealth from the poor, elderly and otherwise disadvantaged to the top 1%, we shouldn’t lose hope. For example, now that they are in control, the Republicans can’t just rant about the evils of ObamaCare. They must instead show the American people what they want, which is not at all what the majority of Americans want.    

 

This reader is wise. He has been in healthcare for a long time, and he is not giving up. His outlook gives me hope.

Another reader wrote:

 

This week’s comments about blowing up the system reminded me of the similar conclusion reached by Don Berwick perhaps 15 years ago when he presented Escape Fire.  At the time, he was seen as much too radical and it seemed to me that it negatively impacted his influence within the healthcare field.  Now I wonder if he was actually simply too far ahead of his time.

It’s not like I want to see the system implode.  I fear too much suffering by the vulnerable among us, even as I recognize that the “haves” (by which I mean people like you and me) will be just fine whatever happens.

 

Perhaps you remember Don’s 1999 speech at the IHI annual meeting that the reader is noting. Don was speaking just after the publication of To Err is Human and two years before the publication of Crossing the Quality Chasm. The Commonwealth Fund thought the speech was so noteworthy that it published it as a monograph. Fourteen years after the speech a film was produced based on it. Don drew a comparison between a unique event history, the 1949 Mann Gulch fire in Montana and the state of healthcare. A group of firefighters had been trapped by a sudden change in the fire. One of them, Wag Dodge saw that he could not outrun the fire so he fought fire with fire. He found the solution to the threat of the fire within his own experience and ingenuity. He burned an area in front of the course of the fire and then took refuge in the burned area as the fire passed him by.

 

Berwick compared the state of healthcare to the fire and asked the rhetorical question,

“We’re in Mann Gulch. Healthcare, it’s in really bad trouble. The answer is among us. Can we please stop and think and make sense of the situation and get our way out of it?”

 

Last week I celebrated Elisabeth Rosenthal’s description of the “fire” in healthcare. I also expressed some disappointment with her lack of a comprehensive solution for our collective dilemma. Time and time again in her book Rosenthal makes reference to the deteriorating state of healthcare over the past twenty five years. Much of what has happened that is positive was anticipated by Don in the speech. Much of what Rosenthal decries happened despite the message that Don gave us then. Let’s keep trying to save what we have in the ACA.

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