As the President Elect announced his choice for Secretary of Health and Human Services and for the Administrator of CMS, I could not help but think back to the several times when as CEO of Atrius Health I had gone to the offices of HHS at 200 Independence Avenue SW, just a few blocks down from the Capitol dome. As I was reflecting on those heady past moments of promise for the ACA and the Triple Aim and what the new appointments might mean for those dreams, I was struck by the irony of the fact that HHS is housed in the Hubert Humphrey Building. As one walks past security the first thing that you see carved in stone on the wall to the left is a quote from Humphrey who was perhaps the most most earnest of all liberal senators of the fifties and early sixties.
“The moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped.”
I was mesmerized by the quote when I first saw it. Now it underlines for me how radical Trump’s healthcare choices are. The grim news of Trump’s most recent genuflection to the far right and how incompatible his choices are with the views that he had expressed about preserving what was good in the ACA caused me to think about the words and melody of one of my songwriting son’s older songs which began to roll through my head. I love the title: “Is This The Shape of Things To Come.” Just in case you do not click on the link to hear the song, here are a few of its key lines.
Is this the shape of things to come?
Is this the ground we walk upon?
Is this the way we live and die and carry on?
Is this the day we hoped would come?
Change what you would. What’s the use?
The unmistakable truth:
We’d do it all the same
And somebody out in America
Has found a new belief to push their heart away
With each announcement of a new appointee by President Elect Trump my emotions take a big dip. I almost aspirated my coffee when I read in the New York Times that what had been hinted before would be true. Tom Price, Republican Congressman and Chairman of the House Budget Committee and author of the last attempt and probably the next effort to repeal the Affordable Care Act was to be the Secretary of Health and Human Services.
Congressman Price is an orthopedic surgeon, turned politician, who grew up in small town Michigan, then attended medical school at the University of Michigan. He came south for his residency training at Emory. After several years of orthopedic practice he became a state senator and then a congressman. He has now served the relatively affluent 6th District of Georgia in the northern suburbs of Atlanta for six terms.
He had a successful suburban practice while also running the orthopedic clinic at Atlanta’s famous Grady Memorial Hospital, a hospital where many uninsured and the desperately underserved of Atlanta go when they “are dying in the street.” Grady is the Bellevue, the Cook County, the Jackson Memorial, the Boston Medical Center of Atlanta, and like all of those institutions it is chronically underfunded for the work that it must do. It is hard for me to imagine how a person who has had his professional experience could be one of the most focused opponents of the ACA. To add to my amazement is the reality that he is an enthusiastic coconspirator with Paul Ryan to privatize Medicare.
I had heard many stories over the years about the financial plight of Grady. I know that even though Georgia is one of the states that did not expand Medicaid under the ACA there are fewer uninsured in Georgia since its passage. If you clicked on the link you will learn that in 2010 the uninsured rate in Georgia was 19.7% and in 2015 it was 13.9%. That is without the Medicaid expansion. Congressman Price’s position has held a lot of Georgians hostage to an ideal that has hurt them. Now he has the opportunity to spread the pain nationally.
The case against Dr. Seema Verma for the position of Administrator of CMS is more subtle. Over the last few years she has been successful as a consultant who has helped some of the “red states”, most notably Indiana, that refused the Medicaid extension, to craft programs that achieved some coverage for new Medicaid patients through exemptions that CMS granted as a compromise. With her plan a person who gets Medicaid in Indiana is very likely to have to spend some of their meager resources to prove they have “skin in the game.” The work that Dr. Verma has done is also reflected in the ideas of Speaker Ryan’s crafty document about a “Better Way.” The ultimate goal of such an approach is not universal coverage. The real goal of such a program is a reduction in entitlement expense.
In an article about the appointments, Kaiser Health News summarized Varma’s mindset and the work she did for Mike Pence and Indiana by saying:
Indiana’s unique Medicaid expansion was designed to appeal to conservatives. HIP 2.0 asks covered people to make a small monthly payment to access health insurance. A missed payment can result in six-month lockout from insurance coverage. Those provisions aren’t allowed under traditional Medicaid, but Indiana got special permission from CMS to implement them through a waiver.
Medicine does not have a singular point of view. Many doctors in private practice are worried about reimbursement and feel abused by CMS and commercial payers. Medical Economics has been offering a poll with a simple question, “Does the election of Donald Trump give you hope for your practice’s future?” A few day after the appointments, it was 61% yes and 39% no. This has certainly been a year when we have been mislead by polls, but it will be hard to have a united front to protect the gains of the ACA for the Triple Aim if the majority of practicing physicians do favor the policies of President Elect Trump.
I have seen it written that the repeal of the ACA will differentially affect hospitals and health systems more than physicians. If 10-20 million people lose their coverage over the next year or so, it will certainly put pressure on hospital revenues. Physicians can more easily avoid bad debt than hospitals. Uninsured patients with broken bones from automobile accidents will be still taken off the streets of Atlanta to the trauma bays of Grady Hospital, Dr. Price’s hospital, where they will receive care regardless of their ability to pay. Perhaps President Elect Trump’s plans include repeal of EMTALA, the federal law passed in 1986 that “requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay, but since its enactment in 1986 has remained an unfunded mandate.” Perhaps repeal of this law is in Dr. Price’s legislative agenda, although Candidate Trump promised that no one would “die in the street” from their medical problems while he was president. That is a “low bar” political promise with perhaps a short half-life.
Recently an online news service which many in the business of healthcare read, FierceHealthcare, published an article saying that major industry groups did applaud the appointments of Price and Verma. Obviously Democrats like Senator Chuck Schumer, who will likely be the next Senate Minority Leader, are upset about Price’s appointment and plan to defend Medicare and fight his confirmation as a first step in their political comeback. They are hoping the defense of Medicare and the ACA will be winning issues in the 2018 elections. Indeed the New York Times reports that now only one in four Americans want the ACA repealed. They like it! It is beginning to feel a little like Britain after the Brexit vote when many who voted for exit from the EU suddenly discovered that they really did like a lot of the good things, like open borders, that went with the EU membership that they had just discarded rather thoughtlessly.
So, what’s a body to do? First, do not lose heart. We have not yet seen an end of change. In Lean, when our solutions fail to yield the results that were desired in the “ideal or improved” state, we reevaluate and create “counter measures” through an exercise called an A4. In my opinion the A4 is almost as important as the A3, the original solution process. Progress is hard and first offerings almost always can be improved.
Secondly, as I suggested in last week’s letter, focus on what you can do at home. The tools of continuous improvement like Lean are agnostic to regulations and finance. They can improve the feel and function in any system. The one thing that we can all count on, no matter who is HHS Secretary or CMS Administrator, is that there will be continued downward pressure on revenue which can only be survived by process improvement. If your organization does not have Lean or some other operating system designed to lower operating costs through improvement, it is going to be like trying to cross the desert without a canteen or a compass. Remind yourself of your mission. Visualize how you will be able to continue to serve the underserved. Realize that the best way to take care of your own future is to meet the needs of your patients.
Thirdly, be vocal and join forces to resist the knee jerk repeal of the ACA and all the benefits that it has brought to all of us. Success will require a new bipartisan coalition. America has terminal gridlock that can only be moved by disastrous elections. We can use healthcare as a wedge to break up gridlock if all across America concerned clinicians and healthcare professions are frequently contacting both Democratic and Republican members of Congress to let them know how important improving healthcare is. I agree with David Brooks who envisions one benefit of this horror show (my characterization, not his) as the emergence of a new coalition of centrists across a wide spectrum of issues. That coalition should have as one of its foundational concerns the realization of
Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time.
The Triple Aim should be “the shape of things to come”. That is a “box 3” statement in an A3 for the coalition for an America without gridlock that can demonstrate what Patty Gabow calls “the social solidarity” necessary to get things done. My biggest fear is that “the shape of things” in terms of our ability to work together will not change.
It will be very sad if the result is continued gridlock. We are at a crossroad between continuing what has been or doing remarkable things. To do remarkable things we have to remember the people who need care or need their care to be less expensive.
Hubert Humphrey’s test of government will also be the test of Donald Trump, Mike Pence, Paul Ryan, Tom Price and Seema Verma. It applies to us all of us in healthcare.
“The moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped.”
