When I think about the Triple Aim Paul Simon’s song “Slip Slidin’ Away” feels like it has a special message for me. Near the end of the song he sings:
Slip slidin’ away
You know the nearer your destination
The more you’re slip slidin’ away
God only knows, God makes his plan
The information’s unavailable to the mortal man
We’re working our jobs, collect our pay
Believe we’re gliding down the highway
When in fact we’re slip slidin’ away
Slip slidin’ away
Slip slidin’ away
You know the nearer your destination
The more you’re slip slidin’ away
Over the last twenty five years we have made much progress in the journey toward true quality in the care we provide to patients. Across America there are Quality Committees in most hospitals and medical groups. Seventeen years ago Crossing the Quality Chasm taught us that quality has six domains. Now, across America it is likely that a majority of clinicians and medical managers know that care should be:
- Safe: Avoiding harm to patients from the care that is intended to help them.
- Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and misuse, respectively).
- Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.
- Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care.
- Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy.
- Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.
These quality domains and the concepts of population health are fundamental to the future mechanisms of compensation. They are the foundation of the transition of payment from volume to value. Having so many hospitals, groups and clinicians accepting and acting on a shared concept represents an amazing achievement and should be a huge step toward quality care for individuals and better health for communities. But have those gains plateaued short of the ultimate goal?
Over the last twelve years beginning with the 2006 passage of “Chapter 58,” or if you prefer “Romneycare,” in Massachusetts and continuing with the passage of the ACA in 2010 we have achieved a patchwork of some coverage for 90% of the population, but now there is evidence that the uninsured population is growing and the Commonwealth Fund has recently reported that Americans are losing confidence in their access to care. They also report that as many as 4 million working age people have lost their health insurance since 2016. Despite our previous joy with the growing percentage of covered Americans it seems clear that with the continued efforts of the Trump administration to undermine the ACA those victories that we have been celebrating since its passage may be “slip slidin’ away.” As Paul Simon says,
You know the nearer your destination
The more you’re slip slidin’ away
In their fabulous little book Buy-In: Saving Your Good Idea from Getting Shot Down, John Kotter and Lorne Whitehead suggest that a simple majority in favor of a change is a metastable situation that is likely to deteriorate. They advise shooting for much larger pluralities. They assume that majorities are not made up of people with similar profiles of commitment. Of those who vote yes there are some who are solidly sold and are committed to the idea. They are willing to sacrifice to make it work. When the going gets tough they will still be there.
There are others who are sort of for the idea as long as it goes as planned, but will begin to waver and question the idea, and may even withdraw support, as problems arise or conditions change. They are not the biggest concern for the leader of change or the proposer of a new order. The biggest concern is that percent of the “yes” votes in the majority that come from those who were skeptical or sensed some conflict between the proposed change and their own best interest. They went along for political reasons or for reasons of convenience and will be the first to bail.
I had a coach once that liked to say, “When the going gets tough, the tough get going!” Sometimes I would mutter to myself that everyone else beside “the tough” either went home or got lost going in some other direction. There is no question in my mind that among those who have supported the ACA and the remarkable accomplishments of the last twenty five years there are many advocates, but perhaps not a rock solid majority who are forever committed to the Triple Aim. I fear that there are many who are fair weather advocates. They think that it would be nice as long as what is required of them is not too demanding. Finally there are some who barely signed on to the idea. They went along with the concept, and did not vigorously oppose it, but there were other things that they deemed more important. Perhaps they figured it was another passing phase or empty platitude that was best ignored because it would eventually die of its own defects or from the resistance of others.
In eight years the ACA has taken some big blows and is still standing. Getting the exchanges up and running was a managerial challenge and gave naysayers a lot of ammunition. The concept of the exchanges was difficult for many clients to understand and the technical glitches in the software were enough alone to create a near death experience for the new law. Perhaps the biggest disappointment was the decision by the Supreme Court to allow states not to accept the Medicaid expansion, but before the election many of the resistant states were coming around.
I will always admire the courage, patriotism, and humanity of John McCain, even though on many issues I have vigorously disagreed with him. Perhaps the greatest measure of his character, even greater than his vote of conscience that saved the ACA, was the famous encounter with a woman who wanted to pass on defamatory remarks about Barack Obama during the last month of the 2008 presidential campaign. He cut her off and in no uncertain terms told her that Obama was an honest man who loved his country and would make a good president. He did not agree with Obama’s position on many questions, but he would not attack him with lies. John McCain saved the ACA for another day, but the attack continued. The tax law cancelled the mandate. The attack on Medicaid continues and Medicare is vulnerable to crippling changes.
I know many people who believe that things will turn around with the election this fall. They are already anticipating regaining control of the House and are dreaming about a miracle in the Senate. Those are ambitious objectives from a party that doesn’t even appear as organized as a flock of geese. Simultaneously, the world is turbulent and hopefully the president will successfully negotiate a peaceful resolution of the nearly seventy year problems in Korea. The downside of that good act will be to strengthen his position on other issues and improve his favorability.
The Republican control of a majority of state legislatures that control redistricting is likely to continue the advantages of gerrymandered districts and repressive state voter laws made possible by the decision written by Justice Roberts in 2013 that undermined the Voting Rights Act of 1965. The Koch brothers and the Mercers are still in business and are greatly empowered by the Citizens United decision of the Supreme Court. The hill that many Democrats, especially those candidates in the Senate, have to climb is still high.
President Trump could be gone tomorrow and the House and Senate could become controlled by Democrats and the concept of universal coverage could be still challenged by an increasingly conservative court. Ruth Bader Ginsburg is in her mid eighties and has had colon cancer and pancreatic cancer. She hangs on for dear life for women, the poor, and for healthcare. Her mind is strong still, but there is a high likelihood that before the next presidential election she will be replaced by a very young and very conservative justice.
Perhaps the two greatest risks to what has been gained have nothing to do with elections. Those people who have healthcare are paying more and more for the care they get. They see the cost of providing care to the underserved as a burden that threatens their own economic security. The economy only looks strong because the market is high. Why is the market high? It is not because of new and expanding manufacturing. Much of the apparent market strength may be coming from companies buying back their own stock rather than investing in new products and paying workers more. Our capacity to expand the economy may be limited by the inability of companies to find the talent they need. The ability to play a video game on a smart phone is not the same as the ability it takes to manage the production of a new product. Our dream of better healthcare for all may be vulnerable to issues far beyond attacks on the ACA.
Beyond, but connected to a poor economy and the concerns of many for “what about me,” is the complexity of the creation and distribution of care to those in our society deemed as “other.” We have great diversity and amazing superficial civility in many of our largest cities. Our television shows and movies are trying to teach the potential benefits of a post racial society, but the road to the eradication of racial and economic inequality seems longer, steeper, and fraught with more danger than the road to the Triple Aim. All of these forces will impact the future of the ACA and the hopes that we have invested in that vision.
What can we do? As individuals we can speak out and vote. We can wisely focus on what can bring us together and tolerate much of what can so easily divide us. We can demand truth and members of Congress that respect and participate in a return to civility. At home and at work we can practice Gandhi’s suggestion that we be the change we want to see. I fear that perhaps the biggest risk to the future of healthcare is healthcare’s concern for itself rather than those it was created to serve. Finally, we can expect further attacks and perhaps future losses that we will need to process and resolve to survive.
Some more “slipping” may be impossible to avoid, but “slidin’ away” is something that we must be willing to work hard to prevent. The best way to defend against the reality of failure is to recognize it as a possibility. If there is nothing else that we learn from the practice of medicine or the election of 2016, it is that the unexpected can occur to the unaware.
