5 April 2019
Dear Interested Readers,
Solving The Real Problems Behind The Problem We’re Having With Healthcare
I like solving problems, but nothing frustrates me more than a problem that exceeds my skill level. Take tangled fishing line as an example. I can handle small tangles pretty well even while standing in a fast flowing rocky river with water that is waist high, but sometimes you can just tell that what it takes for success exceeds your methods and capabilities. That’s when I realize that I am wasting time and must do something different or risk missing out on catching anything but a cold. Solving the problem between me and catching fish will require doing something more drastic than just continuously picking at the knot that frustrates me. To get on with my fishing I must first climb out of the stream, find a comfortable place on a rock to sit, pull out my knife and cut off the offending and unyielding tangle, and start over by splicing in some fresh line. Only then can I get back to the business of fishing.
Maybe you don’t have any personally frustrating fishing experiences, and can’t apply my metaphor to healthcare. Perhaps as a description of your frustration with the current state of what we once called “healthcare reform,” you might prefer the wisdom of the phrase from the old “Bert and I” routine, Which Way to Millinocket? You know the punchline, if not its origin: “Come to think of it, you can’t get there from here!”
You can’t get there from here nicely describes how I feel when I think about the Triple Aim and the current quality of the political conversation about healthcare. I am more than perplexed by the current state of the process given the fact that meaningful modification of the ACA, or adaptation of a new direction like “Medicare For All” will require much more than just the Democrats winning the presidency and taking control of the Senate while maintaining a majority of seats in the House in 2020. Back in 2010 it was a tough job to pass the ACA when the Democrats had sixty seats in the Senate, “a filibuster proof majority.” The Republicans proved in 2017 that 52 Senate seats was not enough even when they used the “budget reconciliation” path to get around the Senate’s sixty vote cloture requirement. The Democrats were able to use reconciliation in 2010 to pass the ACA, but by using the reconciliation process to pass the ACA, they also made the ACA vulnerable to repeal by the same simple Senate majority vote. When Senate Republicans chose to use “reconciliation” to try to repeal and replace the ACA they learned that even that process was not easy because the reconciliation process has rules, most significantly the “Byrd Rule” that prevents something entirely new or different from being passed using “reconciliation.”
One must conclude that something dramatically new or different would be hard to pass until some moment in the future when one party has control of the House, at least sixty votes in the Senate, and the presidency. That is a high hill for either party to climb, and still does not insure success since a sweeping change will require something that is also as rare as secure control of both sides of Congress and the presidency, and that is unanimity within a party. It was a lack of lockstep unanimity that prevented the Mitch McConnell led GOP from repealing and replacing the ACA. Convincing sixty strong willed individuals to disregard outside influences and vote as told is always going to be hard, especially when almost any change will make some constituent or critical ally in some other issue unhappy.
There is another unlikely path to meaningful healthcare reform, a bipartisan process. It’s not totally hopeless since I think that there is a bipartisan consensus on one aspect of healthcare, and that is that Republicans and Democrats alike must be frustrated with efforts to find any consensus on a solution for this complicated set of interconnected problems. Healthcare easily meets the threshold for the definition of a “wicked problem.” Wikipedia gives us a great one paragraph definition of a wicked problem.
A wicked problem is a problem that is difficult or impossible to solve because of incomplete, contradictory, and changing requirements that are often difficult to recognize. The use of the term “wicked” here has come to denote resistance to resolution, rather than evil. Another definition is “a problem whose social complexity means that it has no determinable stopping point”. Moreover, because of complex interdependencies, the effort to solve one aspect of a wicked problem may reveal or create other problems.
When it comes to healthcare, we should be able to hear Democrats and Republicans say in perfect harmony, “Houston, we have a (wicked) problem!” I give credit to the president who was able to succinctly sum up the reality we face, when during a dramatic moment–which if pictured in a comic strip would feature a light bulb over his head, when he said, “Nobody [Who?] knew health care was so complicated!”
If after all we have experienced since 2009 when Congress began the debate that ended in the ACA, and all of the subsequent reactions and efforts to repeal, undermine, or declare the ACA unconstitutional, we still do not have a bipartisan consensus on the reality that healthcare reform is a complex and difficult problem, we are surely lost. I think it is time for all of us, Democrats and Republicans together, to join in a chorus of voices singing, “…you can’t get there from here!”
I was thinking about this moment in time and the challenges we face, particularly the challenge of the high cost of care, when the memory of a very disappointing moment in early 2009, after Barack Obama’s election and while he was putting together his cabinet, popped into my head. I remembered how disappointed I was to learn that Tom Daschle, the former Democratic Senate Majority leader was withdrawing from his nomination as the Secretary of Health and Human services. I was disappointed for thee reasons. First, I had always been impressed with Daschle as a leader. Second, I was really impressed with his understanding of the problems of healthcare and some of the potential for solutions that he had described in a book that he published just a year before, in February 2008, Critical: What We Can Do About the Health-Care Crisis. Thirdly, I was disappointed that in the end he had made an error in critical judgement that would deny the nation his ideas and leadership. As is true of many books with a political purpose, the introduction was a high point of the book. It begins:
Some years ago, the president of the United States stood before Congress and proclaimed that it was time to guarantee health care to every American. “Millions of our citizens do not now have a full measure of opportunity to achieve and enjoy good health. Millions do not now have protection or security against the economic effects of sickness. The time has arrived for action to help them attain that opportunity and that protection,” said the president, a Democrat. He continued: “People with low or moderate incomes do not get the same medical attention as those with high incomes. The poor have more sickness, but they get less medical care. People who live in rural areas do not get the same amount or quality of medical attention as those who live in our cities.”
That first paragraph sounds like “ditto” for a description of our current situation. The focus on inequality means that the points were definitely the concerns of a Democrat. Daschle continues.
President Bill Clinton might have uttered those words in 1993, but he didn’t. In fact, the presidential speech excerpted above predated President Clinton and his ill-fated attempt at health-care reform by nearly a half-century. The quote belongs to President Harry Truman, and it was part of a speech Truman delivered to a joint session of Congress in 1945 to promote his own, doomed plan to guarantee health care to every American.
That fact made it personal for me. It means that the current situation has existed for my entire lifetime. I was born in 1945, not long after FDR died and Truman became president. The bolding in the next section is mine for emphasis.
Like Clinton, Truman had reason to be confident. His fellow Democrats controlled both houses of Congress, and polls showed that Americans were anxious about the high cost of health care and eager for change. But both presidents underestimated the strength of the forces arrayed against them. Special-interest lobbyists—led by doctors in Truman’s time, and insurance companies in Clinton’s—fanned the public’s fear that government bureaucrats would come between doctors and patients. Additionally, public support had greater breadth than depth. Both presidents’ health-care plans became bogged down in Congress. And when the Republicans triumphed in the subsequent midterm elections in 1946 and 1994, health-care reform was effectively dead. “I have had some bitter disappointments as president, but the one that troubled me most, in a personal way, has been the failure to defeat the organized opposition to a national compulsory health insurance plan,” Truman wrote in his memoirs.
Sixty years and four attempts later, the depressing picture that Truman painted is still an accurate if understated portrait of our broken health-care system. [Make that seventy years and five attempts to reach a modest, partial success.] Millions of Americans go without medical care because they can’t afford it, and many others are mired in debt because they can’t pay their medical bills. It’s hard to think of another public policy problem that has lingered, mostly unaddressed, for so long. Why have we failed to solve a problem that is such a high priority for so many citizens? The answer, I believe, is rooted in the complexity of the health-care issue [Daschle and Trump agree on this!], the limitations of our political system, and the power of the interest groups—doctors, hospitals, insurers, drug companies, researchers, and even patient advocates—that have a direct stake in it.
Here comes the interesting analysis and the subsequent suggestion.
How can we cut through this Gordian knot? I believe that the only way to solve the health-care crisis is to change the way that we approach the challenge.
Pardon the interruption, but remember that sometimes to get rid of a knot you must climb out of the swift water, find a place to sit, pull out your knife, cut out the knot, and splice in some new line. Daschle knows that sometimes bold action, or a new direction is the best approach to a wicked problem. He continues:
In this book, I propose a Federal Health Board, modeled loosely on the Federal Reserve System, to do so. It would create a public framework for a largely private health-care delivery system. Its main job would be to develop the standards and structure for a health system that ensures accessible, affordable, and high-quality care. These standards would apply to federal health programs and contractors and serve as a model for private insurers. The federal government, through programs like Medicare, Medicaid, and the Veterans Health Administration, provides health care to roughly 100 million people. But these programs have disparate benefits, quality standards, and success in cost containment. If an independent board created a single set of standards for all of these programs, it would exert tremendous influence on every other provider and payer, even those in the private sector.
You might say, “Did not the ACA try to do some of those things?” Doesn’t the ACA create a baseline standard of care to which all offerings must comply? The answer is yes, and some harmony in direction has been achieved, but our system is still disjointed and there are still no organizational methods even across publicly funded programs to take advantage of the size of the Federal Government’s purchasing power to lower costs in any aspect of care. As he continues, Daschle adds more information about the benefits his proposal might provide. Again, the bolding is my attempt at emphasis.
Like the Federal Reserve, the Federal Health Board would be composed of highly independent experts insulated from politics. Congress and the White House would relinquish some of their health-policy decisions to it. For example, a shift to a more effective drug or service could be accomplished without an act of Congress or White House political support. This power is not small, and delegation rightly raises concerns. But imagine the outcomes if Congress revoked the Fed’s power to set interest rates and instead took it upon itself to enact them each quarter. It would be a disaster—no less so than the results of decades of mismanagement of our health system. The Federal Health Board I propose would not solve all our health-care problems. Our system is fundamentally broken, and decades of failed incremental measures have proven that we need a comprehensive approach to fix it. Undeniably, it will be difficult to change a system that accounts for more than 16 percent of our economy [that was in 2008, now it is well past 18% and is the largest single factor in our economy]—and has a direct impact on every man, woman, and child in the United States. Moving from the current system to one that guarantees universal coverage will force us to wade into a myriad of complicated details—details that disaffected people, parties, or interest groups can seize upon to derail the entire effort. Nevertheless, the problem is not intractable. With the right approach, including a Federal Health Board, it can be solved.
You can imagine my excitement when I learned in 2012 that Chapter 224, AN ACT IMPROVING THE QUALITY OF HEALTH CARE AND REDUCING COSTS THROUGH INCREASED TRANSPARENCY, EFFICIENCY AND INNOVATION was passed by the Massachusetts General Court and signed into law by then Governor Deval Patrick. Two items in the bill were truly remarkable. The first stated that the annual increase in collective revenue from health insurance increases should not exceed the state’s GDP. The second was the establishment of the Health Policy Commission which on the surface appeared to me to be a state based weaker version of Daschle’s Federal Health Board. Massachusetts has proven that it is possible to have what is essentially universal coverage. It has also proven that universal coverage does not address rising costs which has clearly become the leg of three legged construct of cost, quality, and access, that most threatens the integrity of the whole.
Despite being given no enforcement powers or other “real teeth” I think it is fair to say that the HPC has made some difference in Massachusetts healthcare over the six years since it was established. I served on the advisory board of the HPC, an auxiliary function that provides some voice for insurers and providers for a few years since no employee of a healthcare entity in the state can be on the HPC. Daschle’s Federal Board would have had some teeth as well as both independence and accountability. I think it is still a good idea since it was conceived as an antidote to both the complexity and the self serving conflicts of interests that impede progress toward the Triple Aim. Who knows? Maybe over the next 18 months in the run up to the 2020 election some candidate will dust off Daschle’s idea and give it some new life. I have got to believe it is worthy of a wider discussion. It was a pity that he did not pay his taxes in an era when we could know what taxes our leaders paid. Sometimes history seems like a series of unexpected events with far reaching consequences
Little Children Give You A Different Perspective On Everything
I have been in the California coastal redwoods for this last week, and will not be back in New England until the Red Sox return from their own West Coast adventures which have been a disaster so far. They won one game out of four in Seattle, and then did a ditto, one game in four in Oakland. Their pitchers can only throw gopher balls, and most of their hitters appear to have aged a decade over the winter. They are easily fooled, and most at bats are ending in either pop-ups or strikeouts. The announcers continue to try to provide hope for the faithful, and it is a long strange season, but really? Perhaps the warmer weather that is predicted for the weekend series in Arizona will make a difference. Yes, it’s been cold and rainy in California. The temps here are matching what Accuweather says is happening this week in New Hampshire. That is also strange.
We did not come west for the weather. We are here for the grandkids, and to help their parents. The first week of April is school vacation week, and the preschool/daycare where they go is closed for the week. Both parents have recently gotten promotions, and have agendas that make being on vacation or staying home for the week not a good choice, so here we are.
I would highly recommend the Santa Cruz Children’s Museum of Discovery. Boy were we lucky. We arrived on Grandparents Day and enjoyed free admission. It was five dollars for the four year old, and toddlers under two were free! Both grandsons had a blast banging on things and watching balls being blown through long mazes of transparent tubing. There were plenty of comfortable chairs and benches for grandparents with tired, sore legs. It has been a while since we have really had “the duty.” As my wife is fond of saying, nature knew what it was doing when it gave little kids to people in their twenties and thirties.
Today’s header was snapped on another good area adventure, The Monterey Bay Aquarium. It is a world class show. One really does not need to go to the Aquarium to get a great ocean experience. The town piers in Monterey and in Santa Cruz sport sea lions and you can spy sea otters from many points along the shore of Monterey Bay which runs from Santa Cruz in the North down to Monterey, Pacific Grove and Carmel to the South.
It’s been interesting to watch the evolution of the healthcare in the area over the last dozen years that I have been coming here to visit family. Our experience with the area goes back more than thirty years since it was one of our favorite areas to visit going back to the eighties, long before we had grandchildren, or children in the area. Over the last few years Kaiser has come to town, and its obvious that their presence is putting pressure on the other two large providers, Palo Alto Medical Foundation which is now a part of Sutter Health, and Dignity Health, a Catholic provider of care and the owner of the local hospital. Independent practitioners are being absorbed into these three systems and there seems to be some price competition between Palo Alto (the most expensive system) and Kaiser. It is a market in evolution. The area has free standing surgical centers and birthing centers. The weather generally moves east from California. Over the years it has occurred to me that healthcare changes often follow the same flow patterns.
It is hard to be with grandchildren, and not wonder about the experiences they will encounter in their lives. Will my grandson born in 2017 still be as frustrated in 2089 as I am in 2019? As Former Senator Daschle’s introduction suggests, there were big problems in 1945 that still exist in 2019. I would like to believe that over the next seventy years progress will be made, but when will that change occur, and how? I don’t hear “Where Have All The Flowers Gone?” being played on the radio very often. I guess the “When will they ever learn?” is still an open question.
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
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