October 11, 2024

Dear Interested Readers,

 

Incrementalism Has Replaced Transformation As A Strategy To Improve Healthcare

 

If you are a regular reader of these Friday letters, you know that I have bemoaned the fact that unlike 2008, 2012, 2016, and 2020, with the exception of abortion and other related issues of women’s health, healthcare has not been a top tier political issue like the economy and immigration. It is possible to find policy suggestions in the 900 pages of Project 2025 and in the published platforms of both parties, but until queried at the one debate between Trump and Harris, neither candidate was saying much about healthcare at their campaign rallies or in their ads. 

 

The closest thing to newsworthy about healthcare in the last month has been Donald Trump’s “concepts of a plan” gaff when he was questioned about what he would do about the ACA during the one debate that did occur after Kamala Harris became the Democratic nominee. If you want to review my thoughts on the debate and Trump’s “concept of a plan” I would refer you to the section of Healthcare Musings on September 13 entitled “Reflections On Childless Cat Ladies and Illeagal Immigrants Consuming Pets” and September 20 entitled “He Has ‘Concepts of a Plan.’”

 

While I have complained that the candidates are not discussing healthcare, I have been silently disappointed by the fact that I had seen little about the election in our standard medical journals like The New England Journal of Medicine. That lack of discussion of the election ended last week with the publication of an article and an interview with Jonathan Oberlander of UNC about the implications of the 2024 election outcome for our health policies. The article is entitled “​​Health Care Reform and the 2024 U.S. Elections — Low Visibility, High Stakes.” The associated podcast is entitled “Interview with Jonathan Oberlander on the implications of the 2024 U.S. elections for health care reform”.

 

The interview is about nine minutes long and is well worth the time it will take you to hear it. Over the years I have enjoyed reading several articles in the NEJM on healthcare policy and politics written by Dr. Oberlander. He is a professor of social medicine and of health policy and management at the University of North Carolina at Chapel Hill. He begins with some ideas about why we haven’t been hearing much on the stump about healthcare. As usual, I have bolded points that I think are worthy of your notice and reflection. 

 

Abortion and reproductive health have emerged as a major focus in the 2024 U.S. presidential campaign…

While reproductive health has drawn the spotlight, less attention has been paid to other health policy issues such as the uninsured and underinsured populations, health care costs, and Medicare. Medicaid, too, has drawn scant notice, despite seeing disenrollment of more than 25 million people since 2023 owing to the expiration of the continuous-coverage provision of the Families First Coronavirus Response Act of 2020.

Issues such as the economy and immigration are predominant, reducing the visibility of health care (apart from abortion). But there is another explanation for why neither Democrats nor Republicans have offered sweeping reform plans: the success of the Affordable Care Act (ACA), which was strengthened by policies adopted during the Biden administration. In the ACA’s shadow, both parties lack a clear plan for future health care reform. U.S. health politics has, for now, returned to incrementalism, with proposals that promise small changes rather than transformation — and if the election produces divided party control of the White House and Congress, the prospects for transformative change will be further constrained.

 

Oberlander continues with a review of what Trump talked about in the 2016 election and tried to do during his first term. Oberlander emphasizes that not only did the attempt to “Repeal and Replace” the ACA fail, it probably made it stronger.

 

Repealing Obamacare was a centerpiece of Donald Trump’s first campaign for the White House in 2016, and as president, he supported congressional Republicans’ 2017 efforts to roll back the law. Those efforts ultimately failed, and the GOP’s controversial repeal-and-replace drive actually made the ACA more popular while helping Democrats regain a majority in the House of Representatives in the 2018 elections. In 2024 — with higher enrollment in ACA insurance plans and more stability in the law’s insurance marketplace, more states having adopted Medicaid expansion, more favorable public opinion, and longer public exposure to popular benefits such as protections for persons with preexisting conditions — the ACA is stronger politically. Twenty-four million Americans are enrolled in Medicaid as a result of the ACA’s expansion, another 21 million obtain insurance through its insurance marketplace, more than 60% of Americans view the law favorably, and in recent years the uninsured rate fell to record lows.

 

What Trump’s administration did do was to try to undermine the law through the use of its administrative powers. Oberlander suggests that Trump’s lack of success at repeal and replacement, and the fact that the ACA and its principles have gained wide support since 2014, have made healthcare a subject that he would prefer not to discuss. 

 

Trump has therefore not made ACA repeal a priority in this year’s campaign. Still, he has given mixed signals — on the one hand expressing regret that congressional Republicans had not voted to “terminate” Obamacare and indicating an openness to alternatives, and on the other hand declaring that he is not “running to terminate the ACA” but wants to make it “much better.” 

 

We know that what candidates say they will do or don’t say they will do often differs from what they do when in office. So, Oberlander speculates about what to expect from Trump if he is re-elected

 

If Trump wins the presidency and Republicans gain majorities in the House and Senate, what would they do? It could be tempting for Trump to unravel Barack Obama’s signature legacy by renewing ACA-repeal efforts. But not only would that be perilous politically, Republicans lack consensus on any replacement for the ACA — a problem that helped doom their past repeal efforts (and one underscored by Trump’s acknowledgment that he has only “concepts of a plan”). Seared by the fallout from those misadventures, Republicans may forgo sweeping plans to dismantle Obamacare.

The GOP could instead attempt to eliminate specific ACA policies or weaken its insurance market regulations. Another option would be to take administrative actions to undermine the ACA, such as reducing outreach efforts designed to boost insurance enrollment — a strategy the Trump administration employed after legislative repeal failed in 2017. 

 

Oberlander describes a strategy that would be easier for Republicans and less likely to create an uproar from those who are not paying close attention to the damage that could be done by a Trump administration through executive action and failing to extend the market subsidies that Biden implemented when the subsidies run out in 2026. There is a potential political downside to anything Trump might choose to do. Oberlander says:

 

Republicans could also undermine the ACA simply by doing nothing: the enhanced subsidies enacted during the Biden administration that make insurance plans in the marketplace more affordable for consumers are set to expire in 2026 unless Congress acts. But letting those subsidies expire — which would increase premiums for many people and thereby reduce health insurance coverage — could trigger a political backlash.

 

The Republican theory and preference for healthcare is that it should be “market-driven. They definitely want to reduce, not expand, spending on Medicare and Medicaid. Oberlander gives us an overview of what Republicans are likely to do if they get the chance: 

 

Beyond the ACA’s insurance marketplace, Republicans could expand use of health savings accounts. They could also pursue large reductions in federal funding for Medicaid, given their concerns about Medicaid’s expense and enrollment growth and the need to offset the costs of proposed tax cuts in order to satisfy congressional budget rules. As Republicans discovered in 2017, however, Medicaid is a popular program with sympathetic beneficiaries — pregnant women, children, persons with disabilities, older Americans — and an influential political constituency, including hospitals and governors, that opposes funding cuts that could substantially increase the uninsured population. A Republican Congress could additionally seek to revive work requirements for some Medicaid enrollees, another policy that was promoted by the Trump administration. On Medicare, the GOP could seek to accelerate enrollment in private Medicare Advantage plans. Republicans also have called for repealing the provisions allowing Medicare to negotiate some drug prices that Democrats enacted in the 2022 Inflation Reduction Act — though any increase in Medicare beneficiaries’ drug costs would be deeply unpopular.

 

I am sad to say that Oberlnder sees little enthusiasm among the Democratic leaders for efforts to “transform” healthcare with sweeping progressive programs like Medicare for All. Oberlander discusses the change that has occurred in Kamala Harris’s position since her short campaign for the Democratic nomination for the presidency in 2019 and early 2020 before dropping out.

 

Meanwhile, Democrats are formulating their own incremental agenda. When Kamala Harris ran in the 2020 Democratic presidential primary, she proposed extending Medicare — including private insurance plans offered through the program — to all Americans. Harris has subsequently retreated from that plan, and she has not made enactment of a new Medicare-like public insurance option or lowering of the Medicare eligibility age to 60, reforms backed by Joe Biden in 2020, a centerpiece of her current campaign. Instead, Harris has spoken of efforts such as curbing prescription-drug costs, building on provisions of the Inflation Reduction Act, and providing medical debt relief. The political appeal of such policies lies in their promise to make health care more affordable for Americans, including those with insurance. But they do not constitute an ambitious reform agenda.

 

Oberlander speculates that the Harris campaign is reading the realities of the shift in the concerns of individuals to have their personal medical expenses reduced.  Therefore, it is more likely that a focus on out-of-pocket costs, the cost of medications, and the cost of participation in the ACA will be better received than the stretch required to offer something totally new like “Medicare For All” or a “public option.” After his speculations, he offers us his prediction of what Harris will try to do if elected.

 

So what would a Harris administration do in health care policy if it had Democratic majorities in Congress? In addition to measures related to prescription drug costs and medical debt relief, it could seek to pass legislation to close the coverage gap for low-income persons living in states that have not expanded Medicaid eligibility under the ACA. Democrats would also prioritize extending the ACA’s enhanced premium subsidies. In addition, a Harris administration could consider reviving Democratic plans to improve Medicaid coverage of in-home and community-based services and expand Medicare to cover dental, hearing, and vision benefits.

 

I agree that if enacted that bundle of changes would not represent a “transformation,” but I do believe that with Democratic majorities in the House and Senate, there is a possibility that some or even all of those ideas could incrementally build on the accomplishments of the ACA.

 

Unfortunately, it is quite possible that even if Harris is elected. The Democrats could lose control of the Senate. A New York Times article published yesterday shows polling that suggests that Democratic Senator Jon Tester of Montana is significantly behind in his attempt to hold his seat.  If the Republicans take control of the Senate there is little likelihood for even incremental improvements in federal healthcare programs and policies. So, our best possible outcome with further improvements that will expand the ACA to more Americans, and offer some relief to those who still have onerous uncovered costs depends on Democrats winning the presidency, regaining the House, and holding onto their slim control of the Senate.

 

Oberlander points to one huge health-related issue, global warming, that is also getting very little discussion during the run-up to the election, other than the lies being distributed by Trump about biases in the distribution of disaster recovery funds. Oberland ends his discussion with a statement that to my ear sounds almost like an endorsement of Harris’s form of incrementalism as our best outcome if improving healthcare is the objective.

 

Despite the predominance of incrementalism, there remains a stark partisan divide on whether U.S. health policy should build on the ACA’s successes or pursue policies that would jeopardize its coverage gains. Though health care reform has garnered only limited visibility in this campaign, the stakes of the 2024 elections for its future are high.

 

Well, after months and months without saying much about healthcare the New England Journal published a second article online about the healthcare implications of the election. The online article is entitled “Implications of the 2024 Election Outcome for U.S. Health Policy.” The authors, Robert J. Blendon, Sc.D., John M. Benson, M.A., and Natalie B. Le, A.L.M., are affiliated with Harvard’s T.H. Chan School of Public Health and Harvard’s Kennedy School.

 

The authors begin with a stark statement of the stakes in this election:

 

This report focuses on how the outcome of the upcoming 2024 election could have a profound effect on federal government policies affecting health care, medicine, and public health in the future. This is the case because the U.S. political system has become so polarized in its performance that government health policies would differ substantially depending on which political party was in the majority. Over the years, our political system has changed in ways that result in elected officials’ paying more attention to the views of their party’s adherents than to the public as a whole with respect to policy decisions. That means that the health policies that are adopted after this election are likely to reflect the policy views of whichever party is in the majority in Washington.

 

The authors continue by saying that there are more conservatives and more liberals with fewer legislators who identify as moderate. They also say that there are fewer moderates in the electorate. Their conclusion:

 

These divisions have widened over the past several years and will affect the outcome of a whole range of socially related health issues that will be decided by elected officials after the election.

 

Their report is based on a large survey of attitudes held by potential voters.  

 

The report is divided into six sections that describe the following findings: the top issues in the 2024 election; the public’s underlying values that could affect the election and future health policies, overall and according to political party identification; the public’s views about health-related policies, including differences according to party identification; public confidence in key health institutions and professionals that could have an effect on governmental decision making after the election, overall and according to party identification; public support for increases in future health spending, as seen from the perspective of both Democrats and Republicans; and the overall implications of the outcome of the 2024 election for the future of health policy.

 

Top Issues in the 2024 Election

Polls suggest that voters at the time of this election are mostly pessimistic about the country’s immediate future. Their concerns are more immediate issues that directly affect their families as well as the country as a whole. Nearly three fourths of U.S. adults say they will vote on the basis of which candidate or party will have the biggest positive effect on the economy or their own personal financial situation. Also, voters’ decision making is influenced by how favorably or unfavorably they view the major presidential candidates, Kamala Harris and Donald Trump.

Polling before the 2024 election showed that the economy, abortion, immigration, inflation and cost of living, and the state of democracy and corruption are the top five policy issues for voters in the upcoming presidential election. Health care is a second-tier issue among registered voters, but abortion is now among the top policy issues, having risen in prominence in the past few months. 

 

Their database ranks the issues that concern voters:

• Economy  21%
• Abortion 14%
• Immigration 12%
• Inflation and cost of living 7%
• State of democracy and corruption 7%
• Foreign policy 3%
• Equity and inequality 3%
• Health care 2%
• Middle East, Israel, and Palestinians 2%

 

They also asked about healthcare issues:

 

• High healthcare and drug costs 46
• Large medical bills 13
• Need for government to pay for home care for seniors and the disabled 9%
• Medicare 8% 
• Problems with access 7%
• Problems of the nation’s uninsured 6%
• Problems with poor quality 6%

 

There is a wealth of data in the article which you may want to review, but sadly the authors end up with a conclusion that is not much different than the opinion that Oberlander expressed in his article. They write:

 

Apart from abortion, health and health care will not be a dominant issue in determining the outcome of the 2024 election. But the outcome of the election will substantially affect the future of health care, medicine, and public health during the next 4 years. This is the case because of the very wide differences between the political parties on what they believe the future role of the federal government should be in this area…

Bipartisan actions will include some level of effort to increase funding for Medicare and veterans’ medical care. But Republicans are likely to support efforts to encourage more Medicare beneficiaries to join private Medicare Advantage plans, and Democrats will support the existing Medicare program and its expansion. In terms of efforts to control health care costs, Democrats would entertain more proposals for regulation of prices by the federal government, whereas Republicans will have a number of proposals to encourage more competitive market forces without relying on increased government price regulation.

 

Most of us believe in the wisdom that “If you can’t make it better, don’t make it worse.” We probably won’t experience transformational progress in healthcare over the next four years. Incremental progress may be all that we can hope to achieve. it is very possible that the election will produce a divided Congress, and progress toward progressive objectives like the Triple Aim will be unlikely at least until the mid-term 2026 election. The election is less than four weeks in the future. There are very few undecided voters which means that the party and the candidate that can best turn out their loyal voters will probably be the winner. If you care about the future of healthcare please vote!

 

I’m Back From My Travels

 

During the first part of last week, my wife and I enjoyed seeing our Northern California family, and then we headed to Southern California to visit old friends who have recently moved from Santa Fe, New Mexico to Laguna Woods in Orange County which lies between Los Angeles and San Diego. I have been to L.A. and San Diego several times over the years, but I have only been to Orange County twice. I visited the area way back in 1958 to go to Disneyland and Knott’s Berry Farm as a teenager with my family and then in the mid-seventies to attend a meeting of the American College of Cardiology in Anaheim where I presented a paper on “silent ischemia.”

 

I have long considered the area to be the “red part” of California. Nixon’s San Clemente retreat lies on the coast between LA and San Diego. In the 60s and 70s, the beaches of the area were popular for surfing and rock music. The area also has a reputation for evangelical “megachurches.” Since I avoid freeways, shopping malls, and megachurches, there had been no compelling reason for me to visit the area until our friends moved there. All I knew before we arrived was that they were enjoying living in an “over 55” planned community. I had no idea what it would be like. 

 

Laguna Woods surprised me. I was not expecting it to be one development that was a whole city of about 18,000 people with a mean age of 74.5! Not seeing children, adolescents, or even adults in mid-life is sort of a startling experience. The only people I saw who were under 55 were either landscaping workers or were working as clerks in stores or as waiters and waitresses. I would not survive in Laguna Woods because all of the houses apartments, and “memory units” looked very similar, and the roads led to a daunting maze of large and small buildings set in a park of flowering trees and well-manicured yards and gardens that all looked the same.

 

There were many swimming pools, pickleball courts, golf courses, and shopping centers that were separated by wide eight-lane streets that were filled with people going here and there in highly polished BMWs, Lexuses, Audis, Teslas, and other high-end-looking cars. People were hurrying to art lessons, bridge clubs, and other interesting ways to pass the day as they awaited promotion to the next world. What struck me as bizarre was that I saw no schools or playgrounds as we took short trips to restaurants and to a very comfortable “performance venue” where we were entertained by a band composed of talented musicians who looked old enough to qualify for housing in Laguna Woods.

 

You can see the band in today’s header. They are the “K-Tell All-Stars.” To my surprise, their “Ultimate 70s Show” was quite good. They have been playing shows in California long enough to be been inducted into the California Music Hall of Fame last April. Who knew? California is its own world with many curiosities that you probably wouldn’t see anywhere else. That is a misstatement. California is several worlds. Some people believe it should be six states. My favorite Californias are the coast from Big Sur going north to Oregon and the Sierras.

 

It occurred to me that I did not see a hospital and no one looked sick. Almost everyone appeared to be quite comfortable economically and were enjoying life. What I couldn’t understand was why I felt that I needed to leave and get back to a more familiar and less perfect environment. I guess that I don’t fit very well into a utopian environment. I seem to need a world where uncertainties, imperfections, and occasional medical procedures produce unexpected challenges. I don’t know if there is an afterlife or heaven, but going to Laguna Woods makes me worried that I won’t do well in paradise. 

 

In one of my father’s sermons, he told a story about a man who was knocked unconscious in an auto accident. To his surprise, when he woke up he was in a great resort. Every time he wanted something, his desire was immediately satisfied. The service was spectacular. The first few days were quite relaxing, but after a few days of having every desire immediately addressed by a willing servant, he realized that he was getting bored with the whole routine. He decided to speak to the concierge about the excess of service that left him bored. At the concierge’s desk in the lobby, he was told to just relax because there was nothing that he needed to do. He was frustrated and tried to explain that he wanted to do something. Again, he was told that there was nothing he needed to do or worry about. The man became quite frustrated and angry and shouted at the concierge, “Having nothing to do is like being in hell!” To which the concierge replied, “Where did you think you were?” 

 

Now at home from California, I have plenty to do. The yard needs to be readied for winter. The furniture on the dock needs to be stored. The boats need to come out of the water, but those things will have to be done by someone else or wait for a while since I had the first of two carpal tunnel surgeries done yesterday to be followed in a couple of weeks by surgery on the other wrist. The carpal tunnel surgery is to prepare me for my total knee replacement which is scheduled for the first week in December. My wrist symptoms have increased since I have been walking with crutches following my back surgery in March. My goal is to get all of my medical/surgical needs met before my eightieth birthday next July. Perhaps, when all the surgeries are behind me I will take another trip to California and see if I have changed my mind about living in paradise.

 

Wherever you are, and whatever challenges you face, I hope that you will enjoy this long fall weekend. The colors here are reaching their peak. 

Be well,

Gene