The other night I watched 60 Minutes and heard Steven Brill and Leslie Stahl report on how Obamacare is doing at this point. There was an air of naiveté and associated helplessness or a sense of victimization by “systemic evil” that was at the core of this segment, although everything I heard was true and the segment ended with a flicker of hope.
Before going further let me introduce Steven Brill to those of you who may not know him. Brill is 64, and as his Wikipedia page notes is an accomplished “American journalist-entrepreneur.” You may remember the Time Magazine Special Report which he wrote, published on March 4, 2013, entitled “Bitter Pill: Why Medical Bills are Killing Us.” That edition of Time was one of their best sellers, ever. This last week Time released another Brill cover story as its January 19th issue, “What I Learned From My $190,000 Open-Heart Surgery: The Surprising Solution For Fixing Our Health Care System,” which is largely excerpted from Brill’s new book, published last week, entitled America’s Bitter Pill. The 60 Minutes program that aired Sunday night feeds off of the book and all of Brill’s previous publications, which are also summarized in the book. America’s Bitter Pill has been favorably reviewed by the New York Times. It was not as favorably reviewed by Malcolm Gladwell in the New Yorker and was defended against Gladwell’s criticisms by Brill himself in an interview with the Huffington Post.
Most agree that on the one hand Brill has brought humanity to the complexity of healthcare with the story of Sean Recchi from Ohio, a 42-year-old self-employed small-electronics businessman, who had no insurance and who was stuck with an up-front $83,900 bill for the treatment of his non-Hodgkin’s lymphoma at MD Anderson Cancer Center in Houston, and with Brill’s own story of a $190,000 bill for resection of his own aortic aneurysm at New York-Presbyterian Hospital. The reviewers suggest that in the book Brill gives a good replay of the political dealings that produced the Affordable Care Act (ACA), although he just gave that subject a brush-by on the 60 Minutes airing. [I must admit that I have not yet read the book, just the Time articles, past and present. I have just ordered my copy of Brill’s book from my small-town bookstore and will have it in a day or so. We must not forget the little guys in the age of Amazon, but that is a different story.] Brill does laud the ACA for expanding coverage to people like Mr. Recchi and he gives great criticism to the Medical-Industrial Complex whose lobbyists he accuses of being the origin of the deal that provided ten million new patients as new customers at going rates which taxpayers can’t support.
What does get discussed on 60 Minutes, in the recent Time article and therefore in the book is Brill’s acceptance of the empathetic reality that no matter how rich or poor we are, when we are sick we share a common trait. Not only do we suffer pain the same and bleed the same no matter what our net worth is, but we will do anything – including assuming economically fatal doses of personal debt – to survive. The cost of care becomes a second-level priority. I have seen this time and time again. It is the reason why medical expense has been the number one cause of home loss and bankruptcy. Even Brill is willing to give the ACA credit for improving access to care and for doing away with the burden of prior medical conditions as a barrier to coverage. He just presents it as a deal done with the devil, much like the Faustian plotline in Damn Yankees or the legend of the deal that Robert Johnson, the blues master, made with the devil at the crossroads down in the Mississippi Delta.
My own reading of events says that Brill is not all wrong. President Obama was well aware of all the failed attempts to create healthcare as an entitlement, beginning with Roosevelt and running through Hillarycare. He was also aware of the compromises that led to Bush’s ability to pass Medicare Part D and Romney’s ability to pass Chapter 58 (Romneycare) in Massachusetts. The first step in the crafting of the ACA was to win acceptance from the AMA, the American Hospital Association, the nation’s health insurance industry, big Pharma, and many of the companies that manufacture the stuff of healthcare. As Brill points out it was not a government takeover of healthcare, it was a first step in the transformation of healthcare in America and it was an expensive first step where pragmatic assessments of reality played a big role in the decision-making. It was a step that realized transformation is a process that may require a generation or longer, but also realized that the uninsured needed relief now.
I have always imagined that the path to both educational reform and healthcare transformation and universal coverage would be a downhill slide once the majority of Republicans and business interests decided that an ignorant and ill workforce was not in their best interest. Similar reasoning by Nixon and Kissinger had opened China to the West despite its persistent strange form of Communism and human rights violations.
So step one was to get everybody (business and professional interests as well as the uninsured/uninsurable) on board and to do that in the context of what was already in place, a fee-for-service economics system in a strange public (Medicare, Medicaid, VA, CHIP)/private (employers based, private pay) partnership. To do that no one could lose money and new recipients had to be funded either by direct government subsidy or by indirect private subsidy through the acceptance of community rating in a way that most consumers did not or would not understand [Gruber was not all wrong, just not that smart himself in terms of politics].
It is my strong belief that the deal was worth it because – as Mr. Brill’s own activities point out – the real agents of change will be a combination of unsustainable economics, increased transparency, and the American habit (noted by Churchill) of “doing the right thing after trying all the wrong things.” If there is any concept our history supports it is that we are a nation capable of collective learning if we can just engineer or survive the right crisis. We play real good defense in the “red zone.”
Brill loves to jump to solution. He did it a few years ago in a book about education and he seems to be doing it again in healthcare. Again he is not all wrong. He is just not so clear on all of the complexities of how healthcare works, nor on the history of what has been done/tried over the last 80 years with the clock starting at the time of the New Deal. Doctors have tried running their own insurance companies. I am not a defender of insurance companies, but I did work in a limited-network, prepaid, self-insured practice for a quarter of a century and that construct has its problems even in most mature forms as seen in Kaiser and perhaps to a limited degree at Geisinger.
The issue that Brill misses (at least on 60 Minutes: he may address it in the book) is that we are already in the midst of a great transfer of risk from insurers to providers and patients through ACOs with global budgets and with “consumer-driven care” (a very deceptive term for driving more cost to the middle-class consumer who in any economic system regarding any commodity ends up being the payer eiher through taxes or through a personal bill, because of cost shifting). Insurance companies are very good at understanding actuarial risk. Providers, even as smart as the CEOs he uses as examples (Cosgrove at Cleveland Clinics, Corwin at New York Presbyterian, and Romoff at UPMC) are not as good as their even higher-paid counterparts at the big insurers. Doctors need to understand “performance risk” and “total medical expense” which are key to a fully developed ACO system. We have a very long way to go, because to be successful with ACOs we need to re-engineer our processes to remove waste and improve performance, and that requires us to be open to new methodologies of care while vigorously pulling knowledge about transformation into our practices.
Brill does give evidence that he understands a fair market will be key to lowering the cost of care. I reject the idea that the market for healthcare can’t serve the issues of quality and cost improvement the way the market serves consumers in banking, high tech and almost every part of our consumer society. Cost trends can be reversed. As many have suggested, price transparency and consumer knowledge are key to a market that works. In the deal with the devil at the crossroads, Obama and company got short-term relief for many who have suffered for a long time and they set up a long-term process to facilitate a transition that could be orderly if all parties accepted the reality that if something is unsustainable it will not go on forever. A good strategy for the Medical-Industrial Complex is to ask itself, “How can we use our vast resources to construct a new and reasonably profitable course into the future?”.
I am a total believer in the idea that a deep understanding of the Triple Aim leads one to realize that seeking to create value for consumers within the concepts of process improvement and innovation to remove waste can also include justifiable profits for the Medical Industrial complex, cost relief for payers (employers, taxpayers and individuals), better care for individuals, and the collective possibility of a healthier nation. It will just take a little more work, a little more time, and a little more collective learning than Mr. Brill proposes, but I bet he knows that I salute him for keeping an important conversation going.
