16 September 2016
Dear Interested Readers,
Some Musings on the Election and a Guide to this Letter
Every four years what has been accomplished over the last four or eight years by the exiting administration is renegotiated. Every accomplishment, as well as every persistent roadblock, becomes an issue during our quadrennial reassessment of national leadership. An extension of that reality is that the whole world holds it breath as we decide who our next leader will be. Our election is an event of undeniable global interest. It easily upstages the G20 meetings, the Olympics, and any planned event that occurs in years evenly divisible by four. The process even upstages natural disasters or other acts of God, although some wonder if its debates can upstage an NFL game. Our elections may be the most covered event in any four year cycle because the outcome really matters for everyone, everywhere on the planet. The world is an interconnected place despite the fact that it is politically inconvenient to be reminded of that fact.
I must imagine that the anxiety and disappointment that I felt over Great Britain’s “Brexit” decision is only a fraction of the concern and vulnerability experienced without voice that a British, European Union member, Japanese, Indian, Brazilian or any other citizen in the world feels in reference to our election. The world is such a small place and America is so great an influence on the rest of the world that a citizen of Israel, Russia, China or you name it, any other sovereign nation anywhere in the world is about as vulnerable to the outcome of our election as is anyone in any of our fifty states. On this small planet we are all riding together in annual circles like commuters on a subway who avoid eye contact as they hang from straps or steady themselves on poles, and stare out at the darkness of the tunnel. The bumps and jerks of the train rock them all back and forth as the wheels squeal on the tracks and they worry individually and in isolation about something they are experiencing together and over which none of them has any control.
We love to call our President the “leader of the free world”. Nativists and isolationists would have the President confine his or her focus to nothing more than our national self interest and use our enormous wealth and power to bully the rest of the world into following our lead. A more “imperial posture” has never really done us much good in the past. Ironically, and in contrast to what some propose now, our greatest moments have occurred when we finally rose to our leadership responsibilities. History suggests to me that the most effective way to protect our national self interest is to be in conversation with the rest of the world and be willing to put the collective best interest of the entire world ahead of what appears to be our immediate self interest. Our “world view” is one of the central issues we debate every four years. We have withdrawn from the world or operated with an imperialistic philosophy before and may again in the future.
Another thing that is also true is that a very astute political position is to be the “candidate of change and unity”, and then imply that the change that would be best would be to change back to where we were before the world last compelled us to change. Anyone looking for a clear message in an election year is on a fool’s errand. Anyone who enjoys the riddles of continuous contradictions in reasoning should love every election year. Journalists and comedians live for the opportunities provided by this extra long “year” that lasts about 18 to 20 months which may explain why the decision process for 2020 will likely begin immediately after the outcome of 2016 is known.
Another big discussion that gets kicked around every four years is whether a conservative or liberal philosophy should be the foundation of our strategic approach to domestic and international progress. It occurs to me that if you are a liberal your illusion and belief is that rational people can work together to collectively plan and execute progress. You believe in the possibility that government done right can improve the lives of everyone. If you are a conservative you are convinced that government never got anything right and that all progress is made by individuals pursuing their self interest or demonstrating their personal commitment to God and country. Your focus is first on the individual and then on the collective with the idea that those who deserve success will find a way to have it. You like the concept of self reliance. Obviously both are wrong and probably in our hearts we all know that we do not have it just right, but we are reluctant to admit the imperfections in our preferred point of view. We fail to recognize that real progress is usually made by a pragmatic process that seeks to broaden the number of enfranchised stakeholders who are in the conversation. The best outcome possible is often a “half a loaf” for everybody. Change that lasts is usually achieved over years of tedious effort. If anyone is quickly getting their way we have lost our balance. We are all vulnerable to the reality that both the “far right” and the “far left” always become authoritarian and then we all lose.
It has been a surprise to me that the continuing process of healthcare reform has not been a significant part of the election conversation. I guess that is what happens when the issues become an unstructured discussion of personal prowess or business and administrative competence that is based on assertions that do not stand up to fact checking. The core issue seems to be what constitutes acceptable prevarication versus what is a lie, rather than a discussion of policy options.
I have not heard any significant mention of healthcare from either candidate since the nominating conventions. In that context many people were startled (some of you sent me emails) by the publication in the New York Times last week of an article that described the departure of Dartmouth from the ACO world. Should that concern anyone? What about the departure of Aetna from most of the exchanges? What does that mean? Are these events that deserve discussion? Do they suggest that the ACA should be amended? Should these events concern those of us who as bleeding heart liberals do believe that we can make a plan that protects all of us? What does it mean that Humana, United and Anthem are making decisions that are similar to Aetna’s? Should these events and the issues they raise about the viability of the ACA concern us as we select a President and decide which party should control the House and Senate? This week’s letter attempts to address some of these issues. This letter will be the first of an intermittent series of letters looking at how the way forward toward the Triple Aim might be impacted by this election.
This week’s letter concludes, as these letters usually do, with comments about nature, Fenway and Foxboro. There is also a reference to the recently departed country singer and common man philosopher, Merle Haggard. I also reflect on always feeling vulnerable and uncertain whenever I think about Fenway as I did this week when my little group that shares tickets for the season was asked by the Sox to ante up several thousand dollars for all of the playoff games. If the inconsistent Sox don’t make it to the playoffs or lose early, the Sox management keeps your money without interest and applies the balance toward next year’s bill. That’s annoying. There is a little more on the Sox and the Patriots at the end of the letter if you choose to read that far.
I was recently in a conversation where the mention of MACRA seemed to generate puzzled looks. As the discussion continued there was confusion about what population health was really all about. If on occasion you are looking for a little background information on these subjects and many others that will impact the delivery of good care now and into the future, let me suggest that you occasionally look at strategyhealthcare.com. My hope is that you will find useful information there and that the links you find in the posts will carry you to other resources. The purpose of the website is to keep you informed in the complex and confusing environment of healthcare and I hope that it will support your efforts to transform the delivery of care where you live and work.
Is It Time For ACA 2.0?
I recently reread an article written by Michael Cohen in the Boston Globe back in April when we were not absolutely sure who the nominees for president would be. I was very sympathetic to his title “Obamacare: an unheralded success” and also was surprised that he had noticed the same thing that I had noticed: healthcare was not an issue that was getting much discussion by Republicans beyond a flat out assurance that it would be abandoned on the first day of a Republican presidency. Over in the Democratic Primary Bernie Sanders and Hillary Clinton were having an ongoing debate that confused most voters about the merits of single payer versus continued efforts to improve the ACA. Cohen’s point was that the health care discussion was a major part of the discussion about “inequality”. His corollary to this observation was that few people really understood or appreciated what had been accomplished by the ACA, better known by what was originally a derisive term, Obamacare. Here is what he said:
Few issues have dominated this year’s presidential campaign more than income inequality. For Bernie Sanders it is the core message in his pursuit of the Democratic nomination. And it is one that has been picked up by Hillary Clinton, who talks of reducing barriers for all Americans.
But not enough attention is being devoted to the government program that is playing an increasingly critical role in reducing inequality: the Affordable Care Act.
If anything, Obamacare has been the red-headed stepchild of this campaign. For Sanders, a single-payer advocate, it doesn’t go nearly far enough. On the Republican side, hardly a day goes by without a presidential candidate vowing to repeal the bill, sometimes on his first day in office.
The remainder of his article was an attempt to enlighten or remind readers of the remarkable accomplishments of the ACA. I loved what he continued to emphasize.
...studies...indicate that Obamacare is making a life-changing difference for actual Americans. According to an analysis by The New York Times, the first full year of the ACA “brought historic increases in coverage for low-wage workers.” Immigrants saw the sharpest rise in coverage. In particular, a third of those who gained insurance are Hispanic — and two-thirds are minorities. The numbers would be higher but or the fact that blacks disproportionately live in red states that have rejected Medicaid expansion.
These are Americans who previously could not afford coverage or were restricted from purchasing even inadequate individual insurance plans because of preexisting conditions. Now they don’t have to put off seeing doctors and can have illnesses treated when they’re sick, not when they can afford it. …
Within that concise statement lies the explanation for the silence on the Republican side. In states they control healthcare inequality is as bad as it ever was for minority populations and the most obvious beneficiaries of the law often don’t vote, and if they do vote they are more likely to pull the lever for a Democratic candidate. One of the confusing realities of this election is why poor white voters, most significantly men without a college education and their families who are also potentially huge beneficiaries of the ACA, are frequently aligned against their own best interest. J.D. Vance, himself a product of this demographic, gives a great explanation for this reality in his wonderful new book, Hillbilly Elegy. I really recommend the book, especially chapter nine, to anyone who seeks to understand this reality that seems so contradictory to rational thinking. I bought both the hardcopy and the audiobook which is a wonderful experience because Vance himself reads it in his mostly Midwestern, slightly Southern Appalachian voice. I was amazed to find that the ebook is available free online!
Cohen’s article as well as articles by many writers and commentators like Paul Krugman, articulates how the law has already improved both the physical and the fiscal health of so many Americans. It is easy to create a long list of real benefits that have been enjoyed by extending care to millions of more people and improving the protection of those who were already covered. With all this benefit the real question is why is the law such a source of contempt and why is there not bipartisan enthusiasm for moving quickly to ACA 2.0 and a fix of those items that experience has shown do need repair? There is a lot to read if you just type “how can we improve the ACA?” into your browser.
Politicians who oppose the law love to allege that the President “lied” six years ago when he told Americans that if they liked their healthcare coverage they could keep it. The assertion that the President “lied” is itself a stretch of the truth motivated by resistance to the intent of the law. What I heard him say was that if your current plan qualified under the mandated benefits of the new law, then you could keep it. Those Americans who could not continue their plan were in plans that were discontinued because of deficiencies or because the employer chose to change the offering. Employers change plans all the time for numerous reasons. Many Americans did not realize that the plans they had and liked were close to worthless because they had many deficiencies that the law corrected, like unreasonable limits on coverage for care. Many of the plans they loved, but had been fortunate enough not to use, could be easily cancelled by the insurer or did not cover preventive care.
No one denies that the ACA could be made better. The first move should be to extend coverage to all Americans which will be hard to do as long as the ACA is a “mandate” where people have the ability to opt out by paying a small fine. If healthcare were truly an entitlement then the majority of the cost would be covered by tax dollars. Bernie tried to foster that conversation and perhaps in time a majority will trust the fact that the increase in their taxes will be more than offset by their enhanced benefit and the reduction they experience in out of pocket expenses. Eventually they may understand that the price they are now paying is a “tax” they do not notice and an economic issue they do not understand.
This last week I was in Napa, California for a meeting of advisers to Simpler and Truven both of which were recently acquired by IBM Watson. Besides the exciting opportunities for care improvement that this new partnership creates, the international flavor and interests of the group (Simpler has long had international operations in the UK, Europe, Asia, and South America. Truven has world wide data on care.) allows me some enhanced understanding of healthcare beyond our borders. Two of the advisers who attended were from the UK. One was a very experienced administrator, both at the central government level of the NHS (National Health Service), as well as at the regional and local levels. The other was a very dedicated former nurse midwife who has also been a regional executive and who now in “retirement” serves on the board of her “council” and is active in the advocacy for better care.
I think the fears that most healthcare professionals and the public have of what an entitlement to healthcare would be like could be easily reduced if there was a more generalized understanding that there is substantial local control and authority as well as opportunity for creative variation within the NHS. The NHS is improving access and quality and as it has improved it has exceeded the quality of British private care. It is not a perfect system and has many growing challenges, but it comes far closer than we do to achieving the call for:
Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time.
I hope that you will read the Globe article by Cohen because it is a terrifically positive analysis of the economic benefits of the ACA for those who are concerned about the problem of inequality in our society. I know that if, like me, you see the ACA as a start and a step in the right direction but not a completed process, you have probably cringed as you read about the departure of Aetna from the exchanges that were created and have served so many quite well. That news hurt, but the announcement this week that Dartmouth, home of Elliott Fisher who in 2006 coauthored the concept of the ACO, will no longer participate in any of the Medicare ACOs felt like a more thematically significant injury. Both realities, the departure of major insurers from some of the exchanges and the departure of several systems from the ranks of the ACOs, deserve closer examination as we seek to understand how to improve the ACA, if there is such an opportunity after the dust of this election process settles. In a subsequent letter I will try to project what might happen if the election produces an outcome that leads to the repeal of the ACA “on day one” as has been promised.
First let’s look at why many of the large insurers are leaving some or all of the exchanges. Aetna recently made the announcement that it will pull out of the exchanges in most states where it has offered a plan; Humana, Anthem and United have also done so to lesser degrees. In his blog Paul Krugman, the Nobel prize winning economist, writes that Obamacare has hit a bump. I agree with his explanations and concerns.
- Obamacare is a system that relies on private insurance companies to provide much of its expanded coverage...
- Many of these private insurers are now finding themselves losing money, because previously uninsured Americans ... turn out to have been sicker and more in need of costly care than we realized. …
- The problem is greater in states that have small populations and/or have governments hostile to reform, where the exit of insurers may leave markets without adequate competition.
To his points I would add that many young people whose premium would have added to the funds to offset the expense of the sicker, newly insured, opted out either without penalty because of their poverty or with too small a penalty because of the efforts of Congress to avoid more appropriate penalties that would have had a political downside and could have precluded the passage of the law.
Krugman describes the fix as perhaps increasing the subsidy both to individuals and to insurers to encourage greater participation and to put more money into the system. An alternative is to reconsider the public option. He believes that from an “economist's viewpoint” both would be sensible repairs, but as he says those repairs seem unlikely because of the gridlocked Congress that we now have. I would add that if we could eliminate waste and improve the delivery of care then perhaps the current resource would be adequate, but that is a difficult outcome to bet on. It falls into the “if pigs could fly” category of solutions. The election is a real opportunity to fix the problem but that would probably require a Democratic president, a Democratic majority in the House, and at least 60 Democratic senators and then for all of them to work together. I am a Pollyanna, but even I do not think that is possible this time around. Gridlock would also be broken if the Republicans won the presidency, retained the House and advanced their majority in the Senate to 60. That also seems like a stretch. So short of a new found bipartisan desire to improve the ACA, these problems will persist.
The other “big bump” and the one with the greatest sting for me was the withdrawal of Dartmouth from all Medicare ACOs. The good news in my mind is that many of the issues that precipitated that disappointing event could be fixed without needing Congress to rewrite or amend the ACA. It seems likely that a President who wanted to foster the movement toward better care through ACOs could have CMS change some rules. Let me ask you to read the NYT article, “Dropout by Dartmouth Raises Questions on Health Law Cost-Savings Effort” written by Robert Pear and published on September 10 that attempts to explain why Dartmouth is pulling out, if you have not done so already.
Just in case you do not have the time, here are some important points
- In its quest to remake the nation’s health care system, the Obama administration has urged doctors and hospitals to band together to improve care and cut costs, using a model devised by researchers at Dartmouth College.
- ... Dartmouth itself, facing mounting financial losses in the federal program, has dropped out, raising questions about the future of the new entities known as accountable care organizations, created under the Affordable Care Act.
- Medicare now has more than 400 accountable care organizations, serving eight million of the 57 million Medicare beneficiaries. Obama administration officials say the new entities are saving money while improving care, but some independent experts have questioned those claims.
- An evaluation for the federal government found that Dartmouth’s accountable care organization had reduced Medicare spending on hospital stays, medical procedures, imaging and tests. And it achieved goals for the quality of care. But it was still subject to financial penalties because it did not meet money-saving benchmarks set by federal officials.
- Since accountable care organizations began operation in 2012, a number like Dartmouth have dropped out of the program, citing financial uncertainties and unrealistic benchmarks for spending. Organizations with higher levels of prior spending had a greater ability to achieve cost savings in the first years of the program, by reducing unnecessary services, so they were more likely to qualify for financial rewards…
I will probably write more about this unfortunate reality next week as I go into more depth describing my concerns and experiences with the concept of the ACO which I still believe has the potential to be a major factor in the improvement process. I decided instead of giving you my thoughts this week to ask Michael Soman, the retired President of Group Health’s Physicians Group, who is a friend, collaborator, Interested Reader, and real smart guy to comment. He was one of the people who wanted to be sure that I did not miss the article and emailed it to me after reading it.
I wrote back to him:
Michael,
I am thinking about writing about this. Dartmouth faced the uphill situation of being damned by previous success. If you were asked for an opinion (which is what I am doing) what would you say? What does this mean to you?
Gene
Michael quickly responded and I have copied and pasted his answer to my question below:
Couple of things, and you don't have to agree and you may not even like it. I am also affected in what I say by big insurers pulling out of the exchanges.
-reinforces that PPACA, while a definite couple of steps forward, is not good enough
-that the well-intended desire to go for incremental change while keeping the key financial stakeholders (drug companies, insurers, suppliers, hospital firms, docs) happy can't fundamentally change the paradigm
-that intelligent academics (like Elliot F) can't predict how margin-sensitive entities will respond to new incentives
-that one of the conundrums of incremental change here is punishing the organizations that were already achieving cost and quality goals
-that the amount of bureaucracy to monitor and administer incremental change is over-whelming and is money not spent on patients
-that the original sin was letting healthcare be a market governed entity in our country
-that we need a single payer and we can dance around it all we want but we must ultimately take the big step, risk the beatings, and do it.
Wow! Well said! I had to pass it along. Let me hear from you, dear Interested Reader. I would love to showcase your thoughts next week especially if you see things from a different perspective or have more to add to what Michael has said. I doubt there will be a substantive debate about the future of healthcare between the candidates over the next two months, but that does not mean that the issues are not important to millions of uninsured or inadequately insured Americans as well as to those of us who are fortunate enough to have good coverage now. We could have the conversation that has not occurred so far in the run up to the election.
At the end of his piece about income inequality, the benefits of the ACA, and the lack of substantive political discussion about healthcare this year Michael Cohen said:
Six years after the ACA took effect, it has, perhaps more than any law passed in the previous five decades, narrowed income inequality, saved lives, and reduced financial anxiety. Imagine if the help it provides could be reproduced with paid sick leave and family leave policies, a higher minimum wage, or affordable child care.
I certainly can salute that sort of thinking. That sort of progress would truly further enhance the greatness of our society. What worries me is that if we are self serving, fearful of addressing complex issues because we did not get a perfect outcome the first time around and continue to use fear to motivate people to allow a more authoritarian approach to social order, we could reverse a lot of the good that has been accomplished over the past eight years. Do not be fooled into thinking otherwise, or become so disgusted that you pass altogether on your opportunity to participate in this most important election.
If We Make It Through November, WIth Apologies to Merle Haggard
This last week my family and I drove out and back across the great central valley of California as we visited the redwoods in the Sierras. I love the valley almost as much as the Sierras which were our destination. I never fail to marvel at the beauty of the farmland, the orchards, the cattle grazing on rolling hills. It is a long valley that is the the origin of so much of what we buy at the grocery store back in New Hampshire. The valley was populated by many of the Okies who were escaping the man made devastation of the dust bowl disaster of the thirties. Yes people, there are consequence to abusing our environment. I always think of Merle Haggard when I cross the Central Valley. He was born, raised and lived most of his life down at the southern end in Bakersfield. This time as I was thinking about what I might write as we made our way across the valley his song “If We Make It Through December” came to mind.
Perhaps you know some of the words of his song:
If we make it through December
Everything's gonna be all right I know
It's the coldest time of winter
And I shiver when I see the falling snow
If we make it through December we'll be fine
When I think about the November election, the unfolding saga of the Sox who at times seem to be unable to hold onto first place, the cosmic question of whether or not the curse of the Cubs will end this year, and the banishment of Tom Brady by Roger Goodell, an act performed to underline the fact that he is the boss, there is a little comfort in knowing that if we can make it through until November (or December) maybe we will be alright. I know that come December I will be sitting by my fireplace with an interesting book while I watch the lake freeze. That feels safe and reassures me that I will survive no matter who gets inaugurated in January. The truth be known, there is really little that I must survive and making it through to this December is almost guaranteed for me and most of my neighbors. Recently I was surprised when a new friend in New London informed me that throughout New Hampshire my new hometown is famous for its large population of retirees. There are so many here like me that some call my little town “Heaven’s Waiting Room”.
When my interest turns from Fenway to Foxboro I feel much more certain about success. I know that the Roger Goodell and the leadership of the NFL suffer from all of the described maladies of pompous and self interested narcissistic management, but I also know that Bill Belichick is a greater intellect and my money is on the Patriots. Those of us who still can’t avoid watching football despite all of its shortcomings know that Belichick is the coach and strategist of the century. I hope that Goodell learns from Belichick that the power exercised for power’s sake is never good. There should have been another way. Did Goodell subconsciously mean to make the Patriots better by challenging Bill Belichick to win without Brady? Will Brady be sitting on the bench if the patriots are 4-0 when he returns? Issues like this, the erratic ups and downs of the Red Sox, and the remarkable year of the Cubs keep my mind busy as I stroll through “heaven’s waiting room” enjoying the heavenly delights of my surroundings.
A miracle occurred last night. When my wife and I boarded our flight from Chicago for the last leg of our journey back to New Hampshire, Big Papi had just hit a long home run but the hometown team was still down 5-2 to the hated Yankees. When we landed in Manchester, I had a text from a friend and Interested Reader telling me that the Sox won the game on a walk off three run homer by Hanley Ramirez in the bottom of the ninth, thus avoiding a three game losing streak that had seemed so likely.
It is good to be home. Life on the West Coast seems disconnected from the rest of the country. All of the sporting events that keep me up late at home are over in the early evening when you are on the West Coast! The night games start at 4:10! The outcome of the Cubs game on Wednesday was in the books by 2:30. The picture in this week’s header is from the Stanislaus River near the Big Trees Park in Calaveras County. Not far from where I was catching fish this last week “49ers” were panning for gold and destroying natural resources in ways that would enrage pioneering environmentalists like John Muir like less than a hundred years before I was born. In some ways it is reassuring that we have survived over two hundred years of abusing the environment with our self interests. December is not that far away. I know we will make it this year. It is making it to December 2017, 2018, 2019, and 2020 that has me worried and keeps me looking for reassurance in wild places.
I hope that you will be out in the wild this weekend gaining the resilience that will propel you far beyond this December and sustain you as you continue your efforts to improve care no matter who wins the election.
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