Where Does The Real Controversy Lie?
The Democratic position on healthcare and the philosophy expressed in Paul Ryan’s “A Better Way” and the brief paper that the Trump campaign had on their website agree on more than you might expect. Both sides focus on the immediate need of lowering the expense of healthcare. The differences are in the path to solution. A close reading of what is available leads to the conclusion that everyone says they are for something that is like the Triple Aim.
Republicans loathe the individual and employer mandate. Democrats don’t like the mandate either, but they accept the mandate as technically necessary and the only responsible position that would create universal coverage through the marketplace.
Republicans put their trust in the power of the market and competition. They believe in “privatizing” care by giving public support to the needy and elderly to blend with their own resources to use in the marketplace. The question is whether the combination of public and personal resources will be enough to buy “Triple Aim” care or whether many will just op to be uncovered. Republicans also believe that state governments are closer to the site of care and should be where resources and regulations are managed.
The two parties have philosophical differences about how change should occur. They see priorities differently in a world of scarce resources and competing needs. They have different opinions about the urgency of universal coverage and the liability of accelerating costs.
Both Donald Trump and Bernie Sanders recognized the desire for real changes that would decrease income inequality. I do not know whether Donald Trump has any knowledge of the goals of the Triple Aim and how it intersects with the economy, but when I read what he and Paul Ryan have written and what they pledge, I see different words that add up to the “Triple Aim.” The differences between the two parties are all in the “solution space.”
I think that it is not too early for the leadership of healthcare enterprises to begin to contemplate how they will respond to the predictable actions that President Elect Trump will take as soon as he has taken the oath of office. I heard two speakers at the recent Kyruus conference on access abandon what they had planned to say when they expected a Clinton presidency and recast their presentations to a series of guesses about what a Trump presidency might mean.
I also recently attended the quarterly meeting of the Advisory Council of the Health Policy Commission of Massachusetts. The “feel” of the Advisory Council agenda was substantially altered by the uncertainty of what a change of direction in Washington will mean in Massachusetts. What Donald Trump might do was also the subject of an extended discussion at the board meeting of the Guthrie Clinic which serves a community and region where many of the patients voted for Donald Trump with virtually no understanding of how their vote might modify their future access to care.
What Do the Experts Expect?
The authorities agree; Donald Trump will absolutely support the repeal of the ACA, and will do anything that is within his administrative power to limit its effectiveness on “day one” of his presidency as he has promised. The mandate is what Republicans object to most. Trump persists in saying he will abolish the mandate even though it is structurally necessary for any attempt to use insurance as a pathway to universal coverage without reference to prior medical problems and with no lifetime limits. How the conflict between abolishing the mandate and preserving universal access to insurance will be resolved remains to be seen.
Beyond the certainty that the ACA will be repealed, opinions diverge somewhat as to how the drama will play out. Repeal of the whole bill is probably impossible because the Republicans do not have the sixty votes in the Senate that would be required under the Senate’s current rules to bring the bill to an up or down vote. The ACA was passed by a “reconciliation” process and the same process could be used to repeal the majority of the bill and render what it does not repeal relatively ineffective. Last year a repeal bill was passed and vetoed by president Obama. Most experts suggest that last year’s bill will be refiled on “day one” of the Trump era.
There has been an incredible amount of investment in the ACA made by private investors and corporations as well as by state and federal government. Experts say it will take a year and a half to bring the ACA to a halt after it is repealed. There will be confusion during that period. I assume that soon many organizations will be busy deconstructing their efforts to comply with the ACA and focusing on new strategies to try to figure out how to survive without the income they were enjoying from newly insured patients.
Lastly, the “play out” of the shift in healthcare finance that will begin on “day one” may result in dramatic changes in Medicare and Medicaid. There will be millions of people who either voted for Donald Trump or did not vote for Hillary Clinton (more than 42% of eligible voters, almost 100 million people did not vote) who are at risk of losing their access to care as the fallout of Trump’s fulfillment of his promise to abolish the ACA. How they will express their surprise and anger could be a big issue in the 2018 election. Mitigating the damage to the members of their base who will lose care that they want will be a political problem to be solved by the Republican leadership.
Beyond Repeal to Replace
Many experts have suggested that Paul Ryan’s, “A Better Way” will be the core of the bill written to replace the ACA. If you do not want to read the 37 pages, you can listen to Speaker Ryan explain his ideas by clicking here. We all know now that Trump has also indicated that several of the provisions of the ACA will be retained. He likes keeping young adults on their parent’s plans until age 26. He also likes the abolition of lifetime limits of payment and the ban against exclusion because of a pre existing condition. He has not indicated that he understands that removing the mandate for patients and employers to participate creates a huge potential instability in the insurance market when retaining these benefits. Without a new solution to resolve the absence of a mandate, many people expect chaos. What will happen remains unknown but the problem does create the possibility for bipartisan dialogue during the repeal debate.
The Ryan plan shifts responsibility for Medicaid to the states through grants. It abolishes the subsidies that support low wage workers in the exchanges and replaces them with tax deductions. Ryan favors big changes in Medicare. Trump has said conflicting things but Medicare will be another place where productive conversations may occur. Medicare could be modified by combining parts A and B or alternatively privatizing it and giving vouchers to the elderly to assist in their purchase of insurance from private insurance. It is possible that the age of eligibility will rise from 65 to 67. Medicare Advantage and its risk based finance are very popular with Republicans.
A key Republican plank in the replacement of the ACA is the purchase of insurance across state lines. There is much debate about selling insurance across state lines. Even though it is now possible in a few states there are many who are convinced that it is an empty box offering no real benefit. I think it will be part of the package that will be passed, but then it will be ignored. The sum total of repeal and replace will likely be a direct reduction in revenue for most hospitals and provider groups if for no other reason than that there will be fewer customers in the market place. It is unclear what it will do to the business investments that have been made by the industry and its suppliers.
My Skepticism
As a society we have been looking for over seventy five years for solutions to the complex challenge of providing everyone with quality healthcare at a cost we can collectively bear. Now our President Elect is prepared to lead us in a different direction without much more assurance than the assertion that he can “fix it”. In healthcare what needs fixing is cost, access and quality.
Much has been written about the President Elect’s personality. Many explain the conundrum of his behavior as a manifestation of narcissism or say he has a borderline personality. Whether those concerns are real or not, his own presentation of facts and his analysis of his ability to contribute to solutions to the problems that he will recognize suggests that he demonstrates the Dunning-Kruger effect. I learned about the work of Dunning and Kruger while reading Daniel Kahneman’s book on behavioral economics. They did experiments that documented that people with limited abilities often think that they know more than they really do. Some have suggested that those who believe in people who overestimate their own abilities have some derivative of the Dunning-Kruger effect. I guess we could call it Dunning-Kruger “by proxy”.
I anticipate that things that will not work eventually will fail and there will be new downstream problems. I asked myself and the other attendees at the the meeting of the Advisory Council of the Health Policy Commission what Massachusetts would do when the support from the federal government for Medicaid falls even further below the true cost of care than it is currently. At this time the shortfall in Medicaid and Medicare resources is covered in most entities by cost shifting from commercial insurance. Will that be possible in a collapsing insurance market? Will the taxpayers and employers of Massachusetts pay more to continue the spirit of universal coverage when the Ryan/ Trump ideas reduce resources? It will test our priorities.
What Can We/You Do?
As a collective effort we can encourage thoughtful consideration and debate of unintended consequences. Continuing to question the managerial and governmental capabilities of a Trump presidency and the soundness of his ideas are an absolutely responsibility of a “loyal opposition”. We should seek to form a bipartisan coalition of the “reasonable”. We must move past the time when “progress” can only occur on any issue if one party controls the Presidency, both houses of Congress and the Supreme Court. The Constitution envisioned debate and discernment. I believe that as we look into the abyss of the alternative, the leadership of both parties must participate and compromise while using all the skills of interest based negotiation. After the knee jerk repeal of the ACA there will be a real opportunity to focus on what replaces it without causing a collapse of healthcare.
Never before has there been a greater need for all of us to focus on how we lower both our operating costs and our prices. Unless we replace the certain reductions in revenue with efficiency, the burden of cost on individuals, state government and employers will result in empty beds and empty offices for the wrong reasons. MACRA was passed with more than a 95% bipartisan majority. Commercial insurers and employers like value based reimbursement. We all need to speed our transition from volume to value.
Physicians need to be willing to collaborate in ever more creative and effective ways with other healthcare professionals. Don Berwick has given us great advise for these times with his call for Era 3 in healthcare. We can still work for the Triple Aim after the ACA is repealed. I believe that the flame of commitment still burns in the hearts of most people who dreamed of being in healthcare when they began to plan their lives. There is nothing like a threat to what we hold dear to rekindle the flame.
