Also in the order are directions to give states more control over implementing health care laws.

Perhaps that order might have been more successfully executed if he had chosen a different Secretary of Health and Human Services than Congressman, Tom Price, MD, orthopedic surgeon from Atlanta. Dr. Price had already demonstrated during his years in Congress serving on the Ways and Means Committee of the House that he had an unique ability to inure himself through questionable relationships with drug companies and other medical industries. It did not take Dr. Price long to decide that he needed to travel like the CEO of a multibillion dollar company as he rang up private air travel bills of more than a million dollars in about six months. What did Dr. Price do while in office to minimize the "economic burden" of Obamacare? He did shorten the enrollment period for the sign up for 2018 and ended the programs to provide advertising and sign up support during the enrollment period. Perhaps he thought that the money saved from these cuts would be a balance for his travel account.

The adventures of Dr. Price have just been a sideshow. Congressional Republicans and the president have been in the center ring of this circus. I soon tired of downloading and reading their “faux” healthcare bills that were announced as a boon to Americans. On closer scrutiny these bills advantaged only the rich and medical device manufacturers whom the ACA taxed to cover the expenses of the ACA. The money was spent expanding Medicaid and helping poorer Americans purchase policies on the exchanges. The support to the working poor made health insurance affordable for the millions of Americans making less than 400% of the poverty level, about $100,000 for a family of four.

What was truly scary was that a bill was passed by the House. Despite the objections of Tea Party Republicans in Congress who thought that Paul Ryan’s bill did not go far enough to hurt low income Americans, Ryan made some changes in his bill and it did pass. You remember the party at the White House that was thrown to celebrate the passage back in March, don’t you? You may have forgotten that that bill got so much push back on the waivers that it offered to members of Congress and their staffs that it had to be redone in May and both bills were sent to the Senate.

The real drama has been in the Senate, but the core characteristics of all the variations that were offered and failed stayed true to the themes that were in Paul Ryan’s original bill. Those themes were: tax relief for the rich, twenty million or so Americans losing healthcare, and future substantial reductions in federal expense by cutting Medicaid under the guise of giving the money to the states to craft the programs that they thought were best for their citizens. The most evasive and, in my mind, despicable and insensitive quote of the period belonged to the speaker himself. When he was queried about how many people would lose their access to care he said that it was alright if 22 million Americans chose not to buy healthcare. He implied that his bill gave everybody the choice and the ability to buy a policy if they really wanted it. To infer that the ability to buy care if you wanted to pay for it was a freedom to be cherished over the access to care that the ACA offered is lame. There is nothing preventing any American for purchasing most things they might want, other than their ability to pay for them. As a free American, I could buy an 80 foot yacht complete with crew, if I had the money.

One positive benefit of the painful last six months is that more and more Americans are learning about the issues of healthcare. As recently as last February as many as a third of American did not know that the ACA, which they liked, was the same as Obamacare which they had been taught to loathe. The twists and turns of the last nine months have demonstrated that the majority of Americans want to be sure that any future legislation should preserve some basic features of the ACA. An interesting thought is that by trying to take many of these benefits away, Republicans have underlined their value for many who were not previously aware of what they had gained and were at risk of losing. Those benefits are explained in many articles which it seems people have read, and they are beginning to understand what is at risk. Here is a list that I have copied from one of those resources.

• Dependants may be covered by their parents' insurance plans until they turn 26.
  
• Insurers may not cancel policies when policy holders become sick.
  
• State health insurance exchanges (the "Health Insurance Marketplace") allow businesses and individuals to compare plans and enroll for coverage.
  
• Insurers may not place a lifetime monetary limit on hospital stays or other benefits deemed "essential" in new policies.
  
• Insurers may not deny coverage to individuals for pre-existing conditions, and must offer the same premiums within the same age and geographical group regardless of gender and pre-existing conditions, except tobacco use.
  
• Individual mandate takes effect, requiring all individuals (with some limited exceptions) to carry health insurance or pay a tax penalty. Subsidies will help low-income people comply with this mandate.
  
• Medicaid eligibility expands to include those earning 133 percent of the official poverty level, including adults without dependants, in participating states.
  
• Subsidies (in the form of refundable tax credits) available on the state health insurance exchanges for individuals with a household income up to 400 percent of the official poverty level.
  
• Minimum standards for health insurance policies enforced.
  
• Employers may not require employees to wait more than 90 days for health insurance eligibility.
  
• Tax credits offered to small businesses (25 or fewer full-time employees, defined as 30 hours per week) for compliance with ACA.
  
• Larger employers (more than 50 full-time employees) will be charged a $2,000 penalty per full-time employee that lacks health coverage.
  

Do you remember all of the resistance to the passage of the ACA back in 2010 that Republicans expressed because it was such a big, complicated bill that no one had completely read or understood? When one looks at the list above things get simple fast. What is taking a little longer for the majority of people who are affluent and/or get their care from their employer (the large majority of the population) is what the bill does for everybody, including them. The same resource outlines those benefits:

• Insurers are required to provide individuals with a standardized, plain-language summary of benefits (which also helps with plan comparisons).
  
• Rate increases of more than 10 percent must be publicly justified; 80 percent of premiums must be spent on actual health care services.
  
• Insurers may not cancel your plan in response to an illness.
  
• Certain types of preventive care must be covered at no additional cost to the patient.
  
• Patients are free to choose any physician within the plan's network and may use an out-of-network emergency room without penalty.
  
• Annual and lifetime dollar limits on care are prohibited.
  
• Patients are granted the right to appeal whenever an insurer denies payment for health care services.
  

Obama’s biggest gaff which the Republicans never let him forget was his statement that if you liked your plan you could keep it. What he should have said, or perhaps meant to say, was that if your employer’s plan was compliant with these provisions or was made compliant with these provisions, you could keep that plan. Most employers made the shift and most Americans never noticed. Many of the plans offered before late March 2013 when these rules went into effect were essentially junk plans that deceived the recipients into thinking that they were safe when they were not. Offering those plans was irresponsible but cheap. When President Trump signed his the first set of executive orders last week attempting to foster “association plans that could be purchased across state lines" he was putting us back on the road toward more junk policies.

The president has one huge partner in fostering the return of junk policies that will eventually erode the essential benefits offered by the ACA. Who might that be? The truth is that you and I are his partners. The prime reason for trying something different that most people understand from personal experience is the cost of their coverage. It is true that eliminating the CSR payments will increase the cost of coverage for many people who get their care from the exchanges and in the individual marketplace. It is true that reducing the number of people with access to care by any of the significant numbers that come from CBO projections will increase the cost of care for all of us. Candidate Trump did not know in 2016 that a law had been passed in 1986 to prevent people from “dying in the street.” Whether he has learned about EMTALA by now or not, he continues to reassure us that we will not die in the street if we repeal Obamacare.

Those individuals who are taken to hospitals or show up with the advanced diseased states that occur when they are denied preventative care or management of their chronic disease are called “bad debt” by the hospital CFO. Who pays for the “bad debt” after bankruptcies and collection agencies fail to squeeze the money from the unfortunate person who could not buy or did not buy the coverage they needed? You pay. At the next opportunity rates are raised to extract the money from those who can pay. All money is fungible. The CFO is responsible to make sure that revenues cover expenses. We all pay more as rates continue to rise and the righteous declare that what is left of Obamacare is a disaster.

Long ago I began to annoy people in the place where I worked by asking the question, “What part of the problem are we?” None of us likes that question because it robs us of some of our self righteous ability to blame others for the state we are in. Doctors and the hospitals and ambulatory sites and practices where we perform our professional responsibilities determine a huge part of the cost of care which is the major reason that the higher premiums we are seeing are required by insurers to stay in business. The nice thing about the question, “What part of the problem am I/ are we?” is that we can fix that part of the problem that lies within the bounds of our agency. We just need to have enough “want to” to tackle the job.

Don Berwick and his colleagues at the IHI have been telling us that the cost of care is a problem for over twenty years. It was a major theme of Crossing the Quality Chasm in 2001. It was the message on the right side of the famous triangle depicting the Triple Aim. It is restated with emphasis in Don Berwick’s description of Era 3. Accepting responsibility for your own part of the total cost of care is step one of not being part of the problem, and it does not require an executive order. I am retired but I have a fiduciary responsibility to three non profit providers of healthcare. At every board meeting I should be asking what can I do there to help us control the total cost of the care we deliver. Whether you are a practitioner, a manager, part of the support staff in the clinic, or working in a cubicle processing claims, and especially if you have a leadership responsibility, every morning as you prepare to begin your day, you should remind yourself that you have the ability to help lower the cost of care and move us beyond the finger pointing and misinformation associated with the concept that Obamacare is a disaster. Look around and ask, “What am I doing today to help lower the total cost of care?”

I doubt that the president understands what to do. The job he seems to have assigned himself is to be the Creator of Chaos-in Chief. In some strange way he seems to believe that creating more volatility, more uncertainty, more complexity (or chaos), and more ambiguity will lead us toward the deals we need to do. His observation that healthcare is too complex is not really right. The ACA was written to move us toward the Triple Aim. We each have a role in getting there. We have the map. Getting to the destination will require us to climb the steep hill of personal and institutional transformation that will lead to a lower cost of care. Lowering the cost of care will speed the arrival of the day when we have universal access that will enable better care for everyone and healthier communities with the resources saved from our current waste of healthcare invested to support improvement in the many social issues that diminish our health.

The ACA is not a disaster, even if some politicians prefer to imply so when they call it Obamacare with a snarl and negative body language. Whether it is called the ACA or Obamacare it is a brave start that points the way to more efficient solutions to our current chaos. The experience we have gained is valuable. It shows us where continuous improvement is needed. We have spent hundreds of millions of dollars on this foundation that needs improvement. Repairing and improving what we have based on what we have learned seems to me to be the right way forward.


My Cup Runneth Over, So Far This Has Been a Wonderful Fall

Late in June I challenged myself to take a quarter mile swim after every walk until it got too cold, and so far I have done it. A wetsuit has be necessary to keep up the project over the last month or so. Wednesday was probably my last swim in the lake for the fall because the water temperature keeps dropping a few degrees with each cold night, and I have no insulating coverage for my head and neck. The water temperature is now in the high fifties which is getting a little cold even with the wetsuit. Yesterday we flew to California to see our new grandson and his big brother. Who knows what the water temp will be when we get back?


There is a fire ten miles to the north among the coastal redwoods near Boulder Creek, and there is smoke in the air. But so far the prevailing winds are blowing the other way and we are fine. When I return next week getting ready for winter will be the main task. The dock is out. The swim platform is out. The sailboat is out. The kayaks and the fishing boat still need attention. There is a cord of wood in the driveway waiting to be stacked. All the lawn gear needs to be removed for the winter. Some years we have had snow by now, but so far, so good this year. I am thankful that up to now the warm weather has allowed me to get away with my procrastination. I know that I am pushing my luck. It is just hard to do yard work when you can walk around or ride around in the midst of the glory of fall. Even a ride to the grocery store is a psychedelic experience as I pass through the tunnel of colorful trees that line the road.


As the header for today’s letter demonstrates we are approaching “peak color” in the Lakes Region of New Hampshire. I must confess that one reason I am behind in the getting ready for winter process is that during the prettiest part of any day I feel it is an error of judgement not to be walking in the glory or riding around back roads in an old rag top open to the sky. We are expecting sunshine and smoke in California this weekend. The sky in New England will be clear. Wherever you are this weekend it is my hope that you will be enjoying sunshine and colorful vistas. If you see something really gorgeous, share it with me. I would love to make your picture the header for next week.