In a recent essay Michael Dowling, the CEO of Northwell, the massive health system with 21 hospitals in metropolitan New York and Long Island, points out that the most frustrating aspect of the current healthcare debate is that “it is ideological and not practical.” He describes the debate as “…contentious, tumultuous and exhausting to keep up with.” These comments set the stage for his central contention that through it all and no matter the outcome, “…leaders must remain vigilant in our commitment to provide care to those in need and preserve our mission to improve the health of our communities.”
Dowling’s comments resonated with me. He is right to point out that the debate in Congress is not really about what will achieve
…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.
The debate is not about how to achieve universal coverage or even directly about how to lower the cost of care. It is a debate about the proper function of government. It is a debate about what each of us can expect, or is entitled to receive, as an individual in the wealthiest country the world has ever known. It is a debate about how to preserve and protect a great natural resource, the health of the nation. It is a debate about taxation. It is a debate about states’ rights. It is a contest between political philosophies. Healthcare has suffered the same “partisan divide” that complicates decisions about trade policy, immigration policy, foreign policy, education policy, and the continuing debate about all entitlements. It has not been a discussion about “how best to…”
One might ask how we got to this point. The attempt to answer that question would certainly precipitate another round of debate and finger pointing, which is why Dowling suggests a more productive use of our time despite the fact that “…potential changes to the law [repeal or replacement of the ACA], such as those that would undo Medicaid expansion and roll back coverage protections for the sick, could be calamitous to patients and public health.”
Dowling prefers to see the debate as part of a fundamental renegotiation of the respective roles of federal and state government. That debate has been going on in one way or another since before the ink dried on the Constitution. It is his idea that the current administration favors “…a New Federalism [that] seeks to limit the role of Washington in not just healthcare, but in science, education, social services, law enforcement and government policy. New Federalism will drive budgetary priorities and it will continue to shape the debate on healthcare.”
I disagree somewhat with Dowling’s belief that their “is no ill intent behind these philosophies.” I contend that we each have a responsibility to project the likely outcome of our philosophies into the future. The projection of the “New Federalism” into the future looks to me to result in more global warming, a sicker population, greater income disparity, a more divided nation and a further unwinding of the American Dream for many of our citizens.
Perhaps the problem lies in the numbers and in the belief in the permanence of the status quo. Tversky and Kahneman would say the problem is not in our stars but in our biases. Let me try to explain.
At this moment a solid majority of Americans have acceptable access to care that comes to them from their employers and have no need to pay much attention to the current debate because they feel secure in their access to the care they need at an expense they can afford. On a recent flight from San Jose to Atlanta I was sitting next to a Google engineer who was flying with several of his colleagues to where they were creating a new data center. Our conversation turned to politics and a review of his healthcare which he said was the best money could buy and was free to him. After I learned that his brother in law is 41 and awaiting his second kidney transplant the discussion changed.
His brother in law has had lupus for many years. He has been unable to work, probably has “dual eligibility” and gets his healthcare through a combination of public payment from Medicare and Medicaid in a California program called CalDuals. It had not occurred to this very intelligent man that his family has a stake in the long term outcome of the current healthcare debate. If we multiply this intelligent man’s failure to connect the dots between the current debate and his brother-in-law’s condition we can begin to understand how hard defending something that seems to be an issue for a minority of people can be. He sees his brother in law as someone from his own social class who has a serious medical problem, not as an unworthy “welfare recipient.” The attitudes of many, like this fine man, are “anchored” in the reassuring bias that they are just fine and any change could compromise their own position.
It is hard for my engineer and for the majority of people who are comfortable with the coverage supplied through their employment to realize that what they have is vulnerable to changes beyond their control. They do not realize that none of us will have real insurance that protects us from anything that might occur until all of us have the assurance of care that is universal. The most obvious beneficiaries of the campaign for “healthcare for all” have been those who do not have employer based coverage. Those who must buy coverage as individuals, who are Medicaid recipients, or the working poor collectively are a minority. Extending care to them is always going to either require the covered majority to recognize their own potential vulnerability to the loss of their coverage through employment or for the majority to have empathy for their uncovered neighbors. It would be wonderful if the covered majority recognized the collective benefit of a healthier community, or at a minimum could recognize that an economically unsustainable system of care could eventually deny them care.
The consistent mantra of those who want to replace the ACA is that an unfettered market can lower the cost of care and that local control can reduce the abuse of the system by those who receive their care through public resources. Dowling is more optimistic than I am about the corrective potential of the market. He says:
There is power in allowing market forces to self-correct some of the excess in healthcare delivery and consumption. Institutions and organizations breathe in and out continuously — centralizing for operational efficiency, decentralizing to get closer to the market and consumers’ needs.
I totally agree with his position on devolving more control to the states:
Yet devolving responsibility for healthcare to the local level, taken to the extreme, runs the risk of unleashing unintended consequences that would continue to whipsaw the American healthcare system and bring uncertainty and hardship to millions of Americans.
I also totally agree with his position that:
“…it should be clear to all open-minded individuals that we need to move beyond the political gamesmanship in Washington to a substantive discussion on how we can modify healthcare policy in ways that will preserve access to those most in need and stabilize the insurance markets…It’s easy to say you want to tear something down. It’s more difficult to come up with a better replacement. Repeal and replace is the wrong approach: Congress should be fixing what was broken with the ACA while strengthening and maintaining what works. It should be a renovation job, not a demolition.”
The remainder of Dowling’s piece is about what we should be doing. His first suggestion is to get everybody covered. That is the responsibility of lawmakers. It should be a practical exercise in finance and not an opportunity to push ideology. Here is my compilation of his “to do” list.
- Now is the time to change course and focus on the aspects of the law that directly affect patients’ health. Lawmakers must look at the current situation and ask how they can cover everybody. How can they expand access to care and how can they finance it?
- How can we bolster reimbursement to sustain the provider system?
- Like Don Berwick in the call for Era 3, Dowling calls for more focus on what we measure. He thinks that we should seek to reduce the list of critical indicators to “the 10 that are most important for strengthening patient care and focus on them.”
- Recognizing that lifestyle choices largely dictate how healthy we are, what demands can we place on individuals to take more responsibility for their own behavior?
I think there are several other “bullets” on Don Berwick’s Era 3 list that could be added to Dowling’s list. Focusing on both sets of recommendations could help us survive the tension of the moment and begin to be more positive at a time when despair is an understandable emotion.
9 Steps to Era 3
- Stop Excessive Measurement
- Abandon Complex Incentives
- Decrease Focus on Finance
- Avoid Professional Prerogative at the Expense of the Whole
- Recommit to Improvement Science
- Embrace Transparency
- Protect Civility
- Listen. Really Listen.
- Reject Greed
Dowling gives us a warning and a reminder of our responsibility:
If lawmakers fulfill any or all of their promises to alter the health law — freeze Medicaid expansion, rescind the mandate on coverage for essential health benefits or avoid covering those with preexisting conditions — healthcare providers still have an obligation and responsibility to care for anyone who comes through our doors, irrespective of whether they’re insured.
He predicts that hospital expenses will be much higher if the ACA is repealed and federal funding for Medicaid expansion is cut, putting stress on states. He asserts that many hospitals would not survive the stress; they would be “absolutely ruined.”
Over the past several letters I have expressed many of the concerns that Dowling articulates more convincingly from the position of his enormous responsibility. We also see a similar course of action that is advisable for providers to follow while waiting for the resolution of the repeal and replace uncertainty. Again there is a high level of similarity with Don Berwick’s advice.
- Eliminate waste.
- Ensure you are treating patients in the most-efficient and cost-effective setting.
- Continue to grow efforts around population health management and value-based care.
He adds:
…continuing to focus on improving people’s lifestyles and behaviors, strengthening our ties to the community and using data analytics to target at-risk populations will remain integral factors in producing positive patient outcomes. We cannot just retreat from these endeavors. On the contrary, we must invest in them even more.
Dowling’s closing sentences underline what is perhaps the key responsibility of leaders during times of uncertainty. He urges us to be transparent and communicative with staff:
It’s also imperative to maintain engagement among staff. When faced with uncertainty, many people have a tendency to pull away or let anxiety hinder their performance at work. Leaders have a responsibility to prevent and mitigate that as much as possible by enhancing communicating with them.
