14 April 2017
Dear Interested Reader,
What’s Inside and Coping with the Suspense Awaiting for the “Explosion of the ACA”It is spring, the season of rebirth and renewal. Soon, in New Hampshire we will see buds on our trees. I anticipate the visual pleasure of the soft pastel colors. Spring must be nice in Washington this week while Congress takes its Easter recess. The reporters at the big newspapers tell us that
very few members of Congress have scheduled town meetings back in their constituencies during the Easter recess.
This week there were numerous articles describing how the president, with the help of Tom Price and Seema Verma at HHS and CMS, can undermine the ACA. If you thought that the efforts to repeal the ACA were over, you may be in for a surprise. Tax reform is harder than repealing the ACA. If the government is going to lower your taxes and reduce its revenue, it needs to get out from under the expensive obligations that are driven by the ACA. The tax realities and perhaps the sting of having a signature initiative fail are causing the president and the Republican leadership to try again to negotiate a repeal and replace package that can capture enough Republican votes to get out of the House. One wonders, “Will it ever end?”
Uncertainty is an uncomfortable state. One’s hopes rise and then fall before rising and falling again in the midst of the emotional exhaustion of too much caring. We suffer as we anticipate losing much that has been gained from the great efforts of so many people over so many years. It is hard to imagine a future that will feel like the slow torture of thousands of cuts to millions of people.
We are not a poor third world country. We have an abundance that exceeds the wealth of every other nation on earth. We have more than enough of everything for everybody. We are a country of basically good people. Most of us would go out of our way to help a neighbor. We all worry about the future our children will experience.
We are a country with a huge problem. We can not manage ourselves. Our collective ineptitude in our domestic affairs has denied us the bounty of our technology. Despite our wealth and our desire to be good, we have not discovered how to insure the fair and equitable distribution of the resources that will perpetuate our collective best interests. Our issues with healthcare are a concern, but so are our issues with the environment, the future of science, the future of intellectual freedom, and the future of education.
Despite our greatness we tolerate a collapsing infrastructure, homelessness, underemployment, and the frustrations of widespread public health problems like the opioid epidemic. We tie ourselves in knots over issues like the use of bathrooms that will surely look ridiculous in hindsight a few years hence. We are about to let our impressive medical resources, our technical advances in healthcare, and the collective health of our communities deteriorate like our roads, public buildings, schools and other critical shared infrastructure because of incompatible philosophies and visions of how to live in the present moment. History would suggest that nobody’s God intervenes to solve problems that should be within our collective ability to solve for ourselves. We appear to be unraveling when we should be rising to new heights.
To avoid a greater sense of despair in these difficult times I have been self medicating with good reading. Gaining insight through the thoughts of others seems to me to be a good way to tolerate the back and forth, on again, off again rhythm of the “repeal and replace” debate about the future of our healthcare. In the past I have enjoyed many of Michael Lewis’ books like
Moneyball,
The Blind Side, and
The Big Short. His most recent book is
The Undoing Project which I would recommend whether or not you know who Amos Tversky or Daniel Kahneman are.
I’ve read great books by Kahneman, Cass Sunstein, Richard Thaler, and Dan Ariely in an attempt to gain greater personal knowledge about behavioral economics because it feels like the concepts have a lot to do with patient engagement and professional motivation. Behavioral economics and our irrational errors in decision making are just interesting subjects in their own right. Lewis’ book assumes no prior knowledge and is a great “first read” on the subject if one has no background in the field. Chapter Eight is a fascinating discussion of how the concepts explored by Tversky and Kahneman relate to medical practice. Their work is foundational to understanding how to reduce medical errors and improve medical decision making with or without artifical intelligence. I hope the folks at IBM have given the book to Watson to read.
An “Interested Reader” suggested that I check out the
New York Times review of Elizabeth Rosenthal’s new book, American Sickness. I did and you should too. I bought the book and you can be sure that I will give you my own review soon. Rosenthal is a physician who has been a frequent writer in the
New York Times and is now the editor of the
Kaiser Health News. The book deals with the complex question of why healthcare can not self correct as a market. That may not be a big concern to you, but it is the most significant reality that must be addressed if we ever hope to reign in the cost of care to a sustainable level.
The piece that triggered the thinking for the meat of this letter was “
Michael Dowling:The health reform debate is about conflicting ideologies — Leaders, don't let that deter your strategy.” The article appeared in
Becker’s Hospital Review, one of the ubiquitous online publications that fill my inbox every day. Becker’s is an industry “throwaway” like
Medical Economics or
Modern Healthcare that frequently has an article of interest.
Ater review Dowling’s thoughts with a little of Don Berwick and my own ideas thrown in, the letter concludes with reflections on spring, the Marathon and family. I ask for your tolerance of a grandfather’s reflections at the conclusion of this week’s letter.
The core of last week’s letter has been revised and was posted on the
strategyhealthcare.com site on Tuesday. It fits nicely as a set with this week’s continuing focus on strategy in uncertain times. Even if you completed all of last week’s letter I hope that you will check it out and perhaps circulate it to colleagues. I feel that it is important to get as many voices as possible into the conversation about what should be the future of healthcare.
Where We Should FocusIn a
recent essay Michael Dowling, the CEO of
Northwell, the massive health system with 21 hospitals in metropolitan New York and Long Island, points out that the most frustrating aspect of the current healthcare debate is that “
it is ideological and not practical.” He describes the debate as “
...contentious, tumultuous and exhausting to keep up with.” These comments set the stage for his central contention that through it all and no matter the outcome, “
...leaders must remain vigilant in our commitment to provide care to those in need and preserve our mission to improve the health of our communities.”
Dowling’s comments resonated with me. He is right to point out that the debate in Congress is not really about what will achieve
...Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness.The debate is not about how to achieve universal coverage or even directly about how to lower the cost of care. It is a debate about the proper function of government. It is a debate about what each of us can expect, or is entitled to receive, as an individual in the wealthiest country the world has ever known. It is a debate about how to preserve and protect a great natural resource, the health of the nation. It is a debate about taxation. It is a debate about states’ rights. It is a contest between political philosophies. Healthcare has suffered the same “partisan divide” that complicates decisions about trade policy, immigration policy, foreign policy, education policy, and the continuing debate about all entitlements. It has not been a discussion about “how best to…”
One might ask how we got to this point. The attempt to answer that question would certainly precipitate another round of debate and finger pointing, which is why Dowling suggests a more productive use of our time despite the fact that “
...potential changes to the law [repeal or replacement of the ACA], such as those that would undo Medicaid expansion and roll back coverage protections for the sick, could be calamitous to patients and public health.”
Dowling prefers to see the debate as part of a fundamental renegotiation of the respective roles of federal and state government. That debate has been going on in one way or another since before the ink dried on the Constitution. It is his idea that the current administration favors “
...a New Federalism [that] seeks to limit the role of Washington in not just healthcare, but in science, education, social services, law enforcement and government policy. New Federalism will drive budgetary priorities and it will continue to shape the debate on healthcare.”
I disagree somewhat with Dowling’s belief that their “
is no ill intent behind these philosophies.” I contend that we each have a responsibility to project the likely outcome of our philosophies into the future. The projection of the “New Federalism” into the future looks to me to result in more global warming, a sicker population, greater income disparity, a more divided nation and a
further unwinding of the American Dream for many of our citizens.
Perhaps the problem lies in the numbers and in the belief in the permanence of the status quo. Tversky and Kahneman would say the problem is not in our stars but in our biases. Let me try to explain.
At this moment a solid majority of Americans have acceptable access to care that comes to them from their employers and have no need to pay much attention to the current debate because they feel secure in their access to the care they need at an expense they can afford. On a recent flight from San Jose to Atlanta I was sitting next to a Google engineer who was flying with several of his colleagues to where they were creating a new data center. Our conversation turned to politics and a review of his healthcare which he said was the best money could buy and was free to him. After I learned that his brother in law is 41 and awaiting his second kidney transplant the discussion changed.
His brother in law has had lupus for many years. He has been unable to work, probably has “dual eligibility” and gets his healthcare through a combination of public payment from Medicare and Medicaid in a California program called
CalDuals. It had not occurred to this very intelligent man that his family has a stake in the long term outcome of the current healthcare debate. If we multiply this intelligent man’s failure to connect the dots between the current debate and his brother-in-law’s condition we can begin to understand how hard defending something that seems to be an issue for a minority of people can be. He sees his brother in law as someone from his own social class who has a serious medical problem, not as an unworthy “welfare recipient.” The attitudes of many, like this fine man, are “anchored” in the reassuring bias that they are just fine and any change could compromise their own position.
It is hard for my engineer and for the majority of people who are comfortable with the coverage supplied through their employment to realize that what they have is vulnerable to changes beyond their control. They do not realize that none of us will have real insurance that protects us from anything that might occur until all of us have the assurance of care that is universal. The most obvious beneficiaries of the campaign for “healthcare for all” have been those who do not have employer based coverage. Those who must buy coverage as individuals, who are Medicaid recipients, or the working poor collectively are a minority. Extending care to them is always going to either require the covered majority to recognize their own potential vulnerability to the loss of their coverage through employment or for the majority to have empathy for their uncovered neighbors. It would be wonderful if the covered majority recognized the collective benefit of a healthier community, or at a minimum could recognize that an economically unsustainable system of care could eventually deny them care.
The consistent mantra of those who want to replace the ACA is that an unfettered market can lower the cost of care and that local control can reduce the abuse of the system by those who receive their care through public resources. Dowling is more optimistic than I am about the corrective potential of the market. He says:
There is power in allowing market forces to self-correct some of the excess in healthcare delivery and consumption. Institutions and organizations breathe in and out continuously — centralizing for operational efficiency, decentralizing to get closer to the market and consumers' needs.I totally agree with his position on devolving more control to the states:
Yet devolving responsibility for healthcare to the local level, taken to the extreme, runs the risk of unleashing unintended consequences that would continue to whipsaw the American healthcare system and bring uncertainty and hardship to millions of Americans.I also totally agree with his position that:
“...it should be clear to all open-minded individuals that we need to move beyond the political gamesmanship in Washington to a substantive discussion on how we can modify healthcare policy in ways that will preserve access to those most in need and stabilize the insurance markets...It's easy to say you want to tear something down. It's more difficult to come up with a better replacement. Repeal and replace is the wrong approach: Congress should be fixing what was broken with the ACA while strengthening and maintaining what works. It should be a renovation job, not a demolition.”The remainder of Dowling’s piece is about what we should be doing. His first suggestion is to get everybody covered. That is the responsibility of lawmakers. It should be a practical exercise in finance and not an opportunity to push ideology. Here is my compilation of his “to do” list.
- Now is the time to change course and focus on the aspects of the law that directly affect patients' health. Lawmakers must look at the current situation and ask how they can cover everybody. How can they expand access to care and how can they finance it?
- How can we bolster reimbursement to sustain the provider system?
- Like Don Berwick in the call for Era 3, Dowling calls for more focus on what we measure. He thinks that we should seek to reduce the list of critical indicators to “the 10 that are most important for strengthening patient care and focus on them.”
- Recognizing that lifestyle choices largely dictate how healthy we are, what demands can we place on individuals to take more responsibility for their own behavior?
I think there are several other “bullets” on Don Berwick’s Era 3 list that could be added to Dowling’s list. Focusing on both sets of recommendations could help us survive the tension of the moment and begin to be more positive at a time when despair is an understandable emotion.
