9 November 2018
Dear Interested Readers
Where From Here?
I finished the Strategy Healthcare post for November 6, Election Day, with the following statement:
I am hopeful, not optimistic, that this election will initiate a set of events that will protect the positive principles of the ACA, and be a step toward the opportunity to use what we have learned to build programs and pass legislation that move us closer to the Triple Aim. I am afraid to be optimistic because no one will know what comes next until today’s vote is tallied. If it turns out that a majority of voters likes this administration because it has put money in their pockets, likes its approach to North Korea and Iran, likes the way it has protected our borders by turning away women and children, likes its stance on climate change, applauds its abandonment of public education, and believes fear, rather than opportunity, is the key to progress, then I want to be prepared to see the day as a battle lost, but hope it’s not the end of the struggle.
A small majority for progressive ideas in the House would be a delight. Capture of both the House and Senate would be evidence of a new day coming. I want to be resilient even if the day ends in disappointment. I believe that “down ballot” victories in the elections for schools committee, town and county government, and state legislative positions can form a foundation for future statewide, congressional, and presidential victories…
We now know that the House belongs to the Democrats and that the ACA will survive in some form for at least another two years. The Democratic Party’s control of the House offers real protection for the ACA, but if that’s all we think about then opportunities will be missed. Forty percent of voters told political pollsters that healthcare was their most important concern, and the Democrats ran with that idea in mind. It is a very broad idea and my guess is that it meant many different things to different voters. When I say that healthcare is my number one issue do I mean that I want to see universal coverage? When you say that healthcare is your number one issue it may be that it is the cost of coverage that is your concern because you already have coverage for your self and your family, but it’s too expensive. Your employer keeps taking more and more money out of your paycheck for the same coverage that you have always had. Your neighbor may be focused on yet another component of care, the cost of her prescription drugs while her daughter is concerned about access to infertility care. The point is that there is still a lot of work to be done, much to be decided, and many trade offs to consider. I doubt that we all mean the same thing when we say that healthcare is our number one concern.
Several years ago it occurred to me that we would never have universal coverage until both major parties considered it to be a necessity for the defense of a better future and our ability to compete internationally. I wish that the thought had been that we would have universal care someday because everyone considered it a human right, but that seemed naive. What seemed more realistic was the idea that we would have universal coverage when business realized that employer based programs were too expensive and undermined their ability to compete. That idea was fuelled by learning that General Motors was spending more on healthcare for its workers than it was spending on the metal in their cars. I later expanded the thought to imagine that taxpayers would eventually understand that keeping people healthy, educated, housed, employed, mentally fit, off substances, and out of jail led to lower tax bills. I felt a little greasy for those thoughts, but I have “been to the theater” and know that aligning good public policy with self serving objectives always trumps doing something under the rubric of “its the right thing to do.”
Just as I know that the forty percent of voters who said that healthcare was the most important issue in the election were not all thinking the same thing, I also know that the ACA we now have is not the one we tried to implement on January 1, 2014. It is even true that the ACA that was primarily implemented in 2014 is not the one that was signed into law by President Obama on March 23, 2010. The ACA that House Democrats will try to preserve when they assume power in January is also not the ACA that Donald Trump began to dismantle with executive orders during his first week in office, or the ACA that existed before the tax reform act was passed in December 2017 and removed the ACA’s mandate.
Perhaps a quick review of some high points related to the original ACA and how it has been maligned is indicated to make my point. You may disagree, but this is how I view the origin and the history of the ACA. The ACA is a “path dependent” piece of conservative legislation that tests the idea of whether or not private enterprise, the power of the market, public subsidies for the poor and elderly, and the insurance principle of “community rating” can all be brought together to cover most Americans with a health insurance product that can reduce the cost of care and improve quality by harnessing market forces. The basic idea arose at the Heritage Foundation, a conservative think tank, in the late eighties after Ted Kennedy and the Democratic party abandoned efforts to do universal healthcare paid for by taxes.
Community rating throws us all in the same risk pool without concern for preexisting conditions and therefore requires that the cost of care be spread over most of the population, not just those who are sick. The mandate was meant to support that reality and without it we can expect rising individual costs as those who are healthy chose not to either “pay or play.” A politician who says that he/she will protect access to coverage while doing away with the mandate believes in “healthcare alchemy.”
The other major thesis of the ACA is that insurers, physicians, and medical institutions will compete for patients and gain market share by using innovation and improved medical management to improve quality, take waste out of care processes, and lower the cost of care. It was assumed that a competitive market would spread to medical suppliers and producers of pharmaceuticals as institutions and individuals competed for larger markets. New customers would be available for this competition through expansion of the eligibility for Medicaid and public support of the individual market, for which the states and individuals would receive subsidies. For those over 138% of poverty and incomes that were below 400% who did not have access to healthcare through their employer, there would be subsidies to purchase commercial policies through the “exchanges.” It was a plausible plan that was processed with compromises that were written into the law to gain Republican support, like the elimination of a government “option” on the exchanges. Despite compromises and its consistency with over twenty years of Republican ideas, the Republicans strategically chose to vote against it. It has always been my bias that the reason for the resistance was limited to only one component of the whole system of thought, the cost of extending care to those who could not buy it or have an employer buy it. The finance of healthcare through the ACA is a “public/private” joint venture, and who wants to pay for someone else’s care? The answer is that the “who” who is willing to pay is anyone who recognizes that the success of our society is a collective endeavor that suffers when anyone is left out. It has been my sense for a long time that our successes with quality and cost will be limited and marginal until we settle the core question of whether or not we have a collective responsibility to give every person access to care and make that what we all mean when we say healthcare is our number one issue.
We all can remember the drama of the ACA’s passage using the reconciliation process after Ted Kennedy died and was replaced by Scott Brown, a Republican. The next big attempt to derail the legislation was the appeal of the law to the Supreme Court in 2012. The mandate and the law were ruled to be constitutional, but the requirement that every state participate in the expansion of Medicaid was not supported by the decision. That partial victory for the opponents blocked access to care for tens of millions of potential beneficiaries. Acceptance became a state by state process.
There have been some dramatic moments where governors and legislators took political risks in “red states” to find compromises that would then be presented to CMS as a request for support or waivers that would enable the expansion of Medicaid in their state. As of election day 2018 thirty three states had “accepted” the expansion either by the governor, the legislature, or by a ballot question. In 2017 Maine voters approved a ballot question accepting the Medicaid expansion after the Republican governor refused to do it, but then the governor refused to honor the mandate. The drama continued on Tuesday when Maine elected a Democratic governor who may finally implement the Medicaid expansion that the voters approved. Kaiser News has given us a map that shows how this election has expanded Medicaid in several states. Things are looking better in Idaho, Utah, and Nebraska where ballot questions passed. Things may be better soon in Maine, Wisconsin, and Kansas where new Governors will probably make a difference. The only down note on election day was in Montana where the Medicaid expansion was repealed for 96,000 people because the renewal would have been financed by a tax on cigarettes and e cigarettes and the tobacco industry spent millions to defeat the initiative. There is a slim hope that the legislature will approve another funding source.
The dramas in the states are important and will surely continue. What is harder to judge is what will happen as the Trump administration continues its efforts to undermine the ACA with executive orders and administrative moves. The ACA expanded care and it also established what the policies sold on the exchanges had to cover. The president’s orders create the possibility that “junk policies” with limited benefits and coverage could be sold to patients who may not have other options. Cutting the enrollment period in half, slashing the budgets for the guides who help people navigate the exchanges, and limiting the budgets to inform the public about the open enrollment period are all measures taken to undermine the ACA. Nothing threatens the ACA more than the continuing possibility that the Supreme Court will find that minus the mandate the ACA is no longer constitutional. A Democratic majority in the House can not protect the ACA or us from that possibility.
The Democratic control of the House is a start, but it is not a guarantee. The ACA was always an exercise in innovation and an experiment to test the idea that “the market” could give us something that might move us closer to the Triple Aim. We may be able to protect what is left of the ACA, but we will not be able to fix it or to move on to something that might be better without either a change of heart from its opponents or a recognition of the potential benefits to business and the country that something better would offer.
There are other options. Individual states could decide to “go it alone” and reinstitute mandates. The Commonwealth Fund has explored this idea. The collaboration that Amazon, Berkshire Hathaway, and JP Morgan have launched and Atul Gawande is leading may prove that the market can do something better even though it is hard to imagine a private effort being scaled to provide universal coverage. Then there is you. What can we do as individuals and as participants in larger practices and institutions? We can redouble our efforts to eliminate waste, innovate, and demand that all care be patient centered, safe, efficient, effective, timely, and equitable. We can refuse to be part of any system that does not adopt movement toward the principles of practice that support the Triple Aim as its mission. It may be true that “the care we save may be our own.” The cost of care is the sum of all of our decisions. Choosing wisely and improving our critical thinking can contribute to lowering the cost of the care for individuals, businesses, and taxpayers.
The next two years will probably not be the era of negotiation that the president referenced in his news conference this week when he tried to imply that having the Democrats win the House supported his objectives. This twisted reasoning seemed to be based on his confidence in his abilities as a negotiator, or more likely in the fact that admitting a defeat exceeds the limits of his personal development. He is a self proclaimed genius who has no rival in “the art of the deal.” What he does not consider is that wise people don’t do deals with people they can not trust. Any Democratic politician who trusts the president is not ready for prime time. I do believe that there are earnest, compassionate members of the Republican minority in the House and the Republican majority in the Senate who will engage in doing the work that the country needs to have done. There should be every effort to reach out and create a bipartisan coalition for better healthcare. Before the election Democrats had no leverage, and they could not draw like minded Republicans toward a shared objective. Perhaps now after the mood of the country has been tested at the ballot box there will be a few brave Republicans who are willing to test Mitch McConnell’s and the president’s ability to cause them pain. The possibility of healing and change has been improved by this election.
The Democratic strategy for healthcare over the next two years should include patience, the long view, continuous collaboration, graciousness as a risk taking exercise, and a willingness to take small steps toward some bipartisan objectives. A willingness to collaborate and put the public’s complex needs and agenda ahead of purely political objectives will demonstrate to voters that giving the Democrats a greater authority to improve healthcare in 2020 would be a wise move.
Seeking Peace and Tranquility
It has been a turbulent week. There were events to initiate hope and events to remind us that frustration, horror, and even death can intervene in our lives at any moment. This week my wife and I got a phone call to inform us that a dear friend’s hope that her cancer was quiescent after treatment was replaced by the challenge of knowing that her cancer has returned.
Thursday morning I poured myself some coffee and opened the New York Times on my iPad to see if there was finally a winner in the Georgia 6th Congressional District, Newt Gingrich’s old district and the district that Dr. Tom Price left for his brief tenure as the Secretary of Health and Human Services. I know the district well. My mother and father lived there until my mother’s death. They had moved to this area of the northern Atlanta suburbs to be close to the support that my sister and her family could offer as my mother’s health deteriorated. I have several other close relatives who live in the area.
I had made political donations to the Democratic candidate, Lucy McBath, and she had been leading by a small margin, but the Republican incumbent had not yet conceded. What I saw before I could find the result was the report of the most recent mass shooting that had occurred overnight in Thousand Oaks, California. Last week the victims of the latest gun abomination were older adult worshipers at the Tree of Life Synagogue in Pittsburgh. Wednesday night the victims were a deputy sheriff who tried to stop the mayhem and young people out for drinks and dancing at the Borderline Bar and Grill. After reading about the Borderline in what has become boilerplate journalism where all that is needed is to fill in the blanks with date, place, and number of victims, I did discover that Lucy McBath had won by 2,934 votes. Her personal story has a common denominator with the events at the Borderline Bar and the Tree of Life Synagogue. Lucy McBath had been a Delta Airlines stewardess for thirty years before tragedy made her a gun control activist. A Newsweek piece announcing her win describes the source of her political motivation:
McBath, 58, was a former flight attendant with Delta Airlines for 30 years before switching to politics. She has said she was motivated to run for office after her son, Jordan Davis, was shot and killed at a Florida gas station in 2012 when he was 17-years-old. His shooter, a white man named Michael Dunn, was complaining about the loud music he was playing in his car before firing 10 bullets into the vehicle.
One young black man shot at a filling station in 2012 probably did not get much more attention than a few minutes on the local TV. Last week the shooting of two black people at a Kroger’s grocery store in Kentucky did not get much attention. How many people must die in a single event to make it a newsworthy event? A mass shooting is now defined as four or more. How many must die to make gun violence an actionable problem?
I do not know about you, but I need to return to nature on a regular basis to have any chance to manage the stresses that come our way everyday. Sometimes just sitting and looking at a piece of art or a picture can be a source of relief. I have discovered that the drone videos published by my neighbor are almost as good as a “walk in the woods.” Today’s header is yet another screen shot from his work. The scene is located about three miles from my house.
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
