Senator Alexander, Please Play the Right Tune

Hours before James Comey appeared before the Senate Intelligence Committee, David Leonhardt issued a warning in an editorial in the New York Times entitled “Uh oh, Health Care Edition.”

 

James Comey’s testimony today will reveal President Trump’s blatant disregard for the rule of law…I realize it will be hard to pay attention to any other political story this week, but I urge you to find the extra attention span, because there is another important, disturbing story developing: The chances of the Senate taking away health insurance from millions of people seem to be rising.

 

Mitch McConnell was hard at work getting a Senate version of the AHCA ready for a vote before the July 4th congressional recess while we watched Comey testify. Leonhardt notes that while McConnell says it will be “hard to do something” he is busy setting the stage for dropping the blade on the ACA. The strategy is to talk like nothing can happen soon and then to throw the bomb that wins the game before the Democrats realize there is no time on the clock.

 

The whole game is distraction. The only way that the House could pass such an unpopular bill was to keep people from focusing on the substance of the bill, while rushing it through, and the Senate now seems to be following a version of that strategy.

 

We should give some consideration to Leonhardt’s warning and and assess what is likely to occur between now and July 4, the deadline that Mitch McConnell and the president seem to have given themselves.  Despite over seven years to prepare for the moment, the Republicans are not ready for their moment of action. Do not imagine that their lack of something to offer to responsibly replace the ACA will prevent them from pursuing the more important objective of killing the ACA. The absence of a viable plan that can fulfill the president’s boast that Republican plan will make everybody very happy may be a corollary to the president’s famous epiphany, “Nobody knew that healthcare was so complicated.” If that is true perhaps seven years, or as the Bible might say “seven times seventy years” would never be long enough to come up with a plan that provides everyone with adequate care without the involvement of the government and using tax money. If it can’t be done, then the challenge quickly becomes how to win enough votes to pass something that enriches a few while damaging the health of many.

 

Back in 2009 the Democrats took over a year to craft the ACA. The process was open and available to Republican participation in the committees of the Senate and people like Alexander, Grassley and Hatch did have an opportunity to at least comment on what they did not like. Some of their comments and suggestions were put into the law to win their support, and yet they voted against their own contributions.

 

The process this time around will not occur in standing Senate committees where Democrats are minority participants. The bill is being written in haste by a select committee chosen by McConnell. The deadline is tight. If the CBO is to be able to have time to “score” the bill before the Senate votes prior to its July 4th recess, then the rough bill needs to get to the CBO pronto.

 

An article by Robert Pear from the New York Times on May 8 describes the select committee. The committee has zero diversity. The politically vulnerable senators (those up for reelection in 2018 in states that did expand Medicaid), all Republican senators who are women, the one senator who is a physician and wants a more compassionate bill, and the only black Republican senator, Tim Scott of South Carolina, are not on the committee.  My assumption is that a more diverse committee was nixed because such a group might want to take the time to produce an outcome that might make a positive difference or minimize the projected damage that the AHCA will surely inflict.  

 

What is happening in that committee is unknown since the work has been done in “secret”, or “behind closed doors.” On June 6 McConnell brought all Republican senators behind the closed doors as staffers gave a PowerPoint presentation of the work so far and then sounded more positive later in the day after he and Paul Ryan met with the president.  What we have learned in the last week suggests that we must act fast. If McConnell is able to bring the bill that we have not yet seen to a vote before July 4, he can only lose two votes. Three Republicans holding out for something better saves Medicaid and a little bit of what has been achieved with the ACA. I’m hoping Senator Alexander will be one of those votes.

 

Following Dr. Patty Gabow’s example, I wrote a letter to Senator Lamar Alexander.

Here is my letter.

Dear Senator Alexander,

I am a retired physician who was the CEO of a large, multispecialty group practice, Atrius Health. Atrius Health was one of the original Pioneer ACOs and is a national leader in quality metrics as it provides care to more than 700,000 patients in Eastern Massachusetts. Atrius Health has a long experience in value-based reimbursement and is the legacy medical practice of the Harvard Community Health Plan. For almost fifty years I have been deeply committed to the search for effective ways to lower the cost of care while improving the care of the individual and the population at a sustainable expense and under conditions that adequately support all the professionals that provide the care.

I was very encouraged when I read Robert Pear’s May 6th article in the New York Times identifying you as one of the thirteen senators that Senator McConnell had named to produce the Senate’s version of the American Health Care Act. I had been reassured when I discovered in an article written in USA Today in March describing your concern for those who might lose their insurance because of problems with the exchanges when the House Republicans seemed to be unable to come to consensus on their bill:

With health care reform stalled, Sen. Lamar Alexander announced Wednesday he intends to file legislation that would provide temporary relief for millions of people who live in areas where there are no insurers selling policies on the federal health insurance marketplace.

Alexander’s proposal would let people who get government subsidies to buy insurance use that money to purchase any state-approved plan on the private market if there is no insurer selling policies on the federal exchange, or marketplace, in their area.

I was pleased to read your “tweet” of May 4 after the House passed the American Health Care Act without waiting for the CBO to score it.

“I congratulate the House on passage of its bill. The Senate will now finish work on our bill, but will take the time to get it right. My own goals for a Senate bill include: 1) rescuing the thousands of Tennesseans and millions of Americans who will be trapped in collapsing Affordable Care Act exchanges with few or even zero options for health insurance in 2018 unless Congress acts; 2) lowering premium costs, which have increased under the ACA law; 3) gradually giving states more flexibility on Medicaid program, but doing it in a way that does not pull the rug out from under people who rely on Medicaid; and 4) making sure that those with pre-existing conditions have access to insurance.”

When I read your statement I could imagine the possibility of bipartisan support for a bill that met the criteria that you set. I was disappointed, but not surprised, to read the CBOs report in late May after they were finally able to score the House bill. As someone who has worked for many years with the hope of someday seeing every American having access to care, I was devastated to learn that in 2026, as a result of the bill, there would still be more than 50 million Americans without coverage. That fact seems inconsistent with the sentiments expressed in your tweet. I fear that you are being pushed away from your pledge to “take the time to get it right” by the president and Majority Leader McConnell’s timetable to “get healthcare done” by the July 4th recess.

I am impressed that even with intense disagreement over the role of government the objective of better healthcare for all Americans has been a bipartisan goal during most of the last sixty-five years. President Eisenhower believed we could use a public private partnership to achieve better outcomes than our European allies had with “socialized medicine.” Richard Nixon not only opened China, he created the EPA and launched HMOs. Scholars at the conservatively oriented American Enterprise institute evolved the principles that formed the basis of the “connector” in Massachusetts when Mitt Romney was governor and its contributions are easy to see in the ACA.

I was a student at Harvard Medical School in the sixties where the dean, Robert Ebert, wisely said:

The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.

We have been searching for that “conceptual framework and operating system that will provide optimally for the health needs of the population” for more than fifty years. The committee that you are on has an opportunity to make real progress toward the lofty goal of the “Triple Aim” that evolved from Dr. Ebert’s observation. You have a chance to offer real leadership that will bring us closer to

…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..

It is my hope that you will continue to demand the time to produce an effective bill that will truly serve the health needs of all Americans and be a barrier to the passage of a sham bill like the House’s AHCA that tries to find a way to look like it is good for the health of the nation while damaging so many people in a poor business tradeoff that enriches the few while undermining so many of the people who do the hard work of this nation. I also hope that you will seek to open up the process of writing the bill and invite not only the input of your Democratic colleagues but also the testimony of the many people who do have a deep understanding of how complex healthcare is.

Thank you for your service to the country, your stated commitment to finding a way to a better answer, and for the opportunity to provide input to your process.

Respectfully yours

H. Eugene Lindsey, Jr., M.D.

 

The strategy is to remind the senator that he said, “The Senate will now finish work on our bill, but will take the time to get it right.” His criteria for a good law are straightforward.

1) rescuing the thousands of Tennesseans and millions of Americans who will be trapped in collapsing Affordable Care Act exchanges with few or even zero options for health insurance in 2018 unless Congress acts

2) lowering premium costs, which have increased under the ACA law

3) gradually giving states more flexibility on Medicaid program, but doing it in a way that does not pull the rug out from under people who rely on Medicaid

4) making sure that those with pre-existing conditions have access to insurance.”

 

If he sticks with those objectives, then progress might be possible. I have recently discovered that the Senator likes to play the piano and he is pretty good. I hope that he plays the right song for healthcare.

 

 

 

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