24 March 2017

Dear Interested Reader,

What’s Inside and Waiting to See What Happens in Washington

It has been a busy and dramatic week in Washington. So far it has not been a mountain top experience for either Paul Ryan or for President Trump. They have been working hard all week to find the 216 votes that Ryan needs to get the AHAC passed despite the increasingly obvious tensions within the Republican Party. The duo has been working hard because they know that a failure to broker a deal within their own ranks would be a huge setback for both of them.

The healthcare struggle would be enough for a tough week, any week, but this week has been a circus with acts in three rings vying for our attention. The opening act for the circus featured James Comey in the center ring on Monday with his testimony before the House Intelligence Committee. As long as he was testifying all eyes were on him. I was startled to see how tall Comey is. The video clips of Comey striding through the halls of the Capitol on his way to the hearings make it easy to see that he stands head and shoulders over other people. He is 6’8” tall. As a child I was a fan of Fess Parker whether he was playing Daniel Boone or Davy Crockett. Comey looks a little like Fess Parker and has that quiet, no nonsense presence that also reminds me of Parker’s characterizations of famous Americans. Parker was a real presence and only 6’5”.

I hope that as time goes by Comey will have a happier personal outcome than Davy Crockett experienced at the Alamo. Because of his questionable management of the investigations of Hillary Clinton that may have cost her the presidency and 24 million people their healthcare, Comey metaphorically slumped a little and proceeded with caution in his testimony, but he left no doubt that the FBI was investigating the election related activities of the Russians and was checking out who may or may not have collaborated with them in their effort to undermine the election. That announcement must have raised some concerns among those who now have offices in or near 1600 Pennsylvania Avenue. He suggested that there was evidence that unfriendly things the Russians did may have been coordinated with actors from the Trump campaign during our election. Comey definitely provoked the president and delighted the Democrats by saying that no one, including former President Obama, had wiretapped Trump Tower. Was that a makeup call for the damage that he did last year with Hillary’s emails?

There was a nice flow to the week’s Capitol Hill entertainment. After Comey moved out of the spotlight, in walked Neil Gorsuch for his act. Gorsuch seemed to imagine that with a lot of smiling and big hugs from his wife and handshakes all around he could finesse the hearings with lot of pleasant double talk and his Cary Grant leading man good looks. He presented no Robert Bork like combativeness, and he tried to say more than Clarence Thomas, but not enough to give Democratic senators reasons to not vote for his confirmation. His strategy was too conservative. His performance was less than convincing. Yesterday, Chuck Schumer played his cards. As minority leader he will take a page from the Mitch McConnell playbook and filibuster Gorsuch’s nomination. Schumer is playing political poker. If he can hold all 48 Democratic Senators in line then he has some leverage. If Schumer is successful, and if the Republicans really want a full Supreme Court with a conservative majority, Schumer will have forced them to change the rules so that they can confirm his appointment with a simple majority which may carry a negative potential for them at sometime in the future. It is too early to tell, but perhaps Schumer will become a political Belichick.

As Gorsuch was having his fifteen minutes in the limelight with his future to be determined by a round of political Russian roulette, Speaker Ryan moved into center ring for the main act of the week. He has traveled a long way since last spring when he was denying his support to Donald Trump as he pursued the nomination, or since last fall when he wavered in his support of the candidate as a man of questionable integrity as revealed by the “Access Hollywood” tapes. Now Donald and Paul are a team. Ryan is hoping that the president’s “art of the deal” skills will magically resolve the standoff within his own party between the far right “Freedom Caucus” and the “Tuesday Group” of Republican moderates. This week he has been willing to offer the Freedom Caucus almost anything, including the mandated benefits of the ACA, if they will go thumbs up.

Unfortunately for the deal making speaker and his “world class” negotiations accomplice, the president, giving concessions to the arch conservatives may be eroding support among the moderates who were also not so happy about the appearance of the whole deal. Alas, yesterday afternoon the Speaker had to retreat from his theatrical goal of the House passing the AHCA on Thursday, the seventh birthday of the ACA. Gone is his dream that Thursday March 23 would be the beginning of the end for the ACA. Despite the fact that rules were changed so that bargaining could continue right up to the moment of the vote, by Thursday afternoon he did not have a winning hand. There will need to be some more arm twisting of his skeptical colleagues if he is to enjoy the gratification of the repeal of the ACA.

I am surprised by Ryan’s demonstration of arrogance or optimism. Did he really think he could ram through the AHCA before anyone recognized what an awful piece of legislation it is? He should have known better. He must have known he was up against the “Freedom Caucus” and its leader Mark Meadows on the right. One wonders how much thought he gave to the fact that this is the same group that drove John Boehner out of the speakership in 2015 which is how he got the job. Now Meadows may soon also have Ryan’s scalp on his belt. If Meadows folds, millions of people need to worry about losing the mandated benefits that they enjoyed under the ACA, like routine medical care, maternity care, emergency care and treatment for substance abuse. Each day is an adventure, so everything could change by the time this letter goes out at three o’clock today. As I said, it has been a busy week in Washington.

As the header on today’s letter suggests, I took a nice walk on the waterfront in Boston this week. On Tuesday I was in Boston for a retreat meeting of the combined Boston Medical Center Health System boards. I arrived early with the idea of meeting an “Interested Reader” downtown for a cup of coffee and then had a couple of hours to enjoy walking before the meeting started.

I was excited about the meeting. It was my first meeting since recently joining the Faculty Practice Foundation Board of BMC. I consider it an honor to be asked to serve and a huge opportunity to try to make a small contribution to an important provider of care to the underserved. As Paul Ryan and Donald Trump were negotiating with Mark Meadows about how much damage they would be willing to do to America’s poorest people to get his vote for the AHAC, the leadership at BMC was meeting to formulate strategies to protect the real recipients of the president’s and speaker’s callous disregard and lack of empathy, the most disadvantaged members of our community.

The main section of this week’s letter is a review of some of my thoughts and observations from the BMC retreat about the future of medical practice during the Republican war on Medicaid, and an overview of the uphill climb that faces Massachusetts as it battens down the hatches in preparation for whatever will follow the ACA. Will the brave spirit of “Romneycare” survive the challenges?

The letter is about 25% shorter this week. I hope that represents an improvement, and is not just an expression of my inability to keep up with all that is happening. Despite the economy of words, I did save enough verbiage to conclude the letter with observations about spring, football jerseys, stolen and recovered, and the simultaneously occurring dramas of March Madness, the final weeks before the playoffs of the NBA and the NHL, and the return to Fenway Park of the Red Sox.

Did you take a look at strategyhealthcare.com this week? I hope so. I also hope that you have pointed out the website to a friend as the place where they can sign up to receive these weekly letters.

Transformation Is Going To Be Hard, But It Will Happen

Nothing is a clearer demonstration of the fact that Paul Ryan’s AHAC is more a thinly veiled attack on Medicaid than an attempt to repeal and replace the ACA with something better than is his attempts to gain the support of the “Freedom Caucus.” The president and the speaker are caught between their promise to their base to make the repeal of Obamacare job #1 and the reality that despite all of its imperfections the ACA is a remarkable initial piece of social legislation that more and more people are finally recognizing for the lives it saves and improves everyday.

It was not long ago that the president was acknowledging the benefits of the ACA that should be preserved. The newly revised AHAC takes deeper whacks at Medicaid. It also sacrifices for all Americans the benefits that are required in every policy. Margot Sanger-Katz has explained the losses in her New York Times article, “Late G.O.P. Proposal Could Mean Plans That Cover Aromatherapy but Not Chemotherapy.” Here is the list of items that would not be necessary to include in a slimmed down post AHAC policy. One could perhaps pick off of a list like ordering from a menu.

• Ambulatory patient services (doctor’s visits)
  
• Emergency services
  
• Hospitalization
  
• Maternity and newborn care
  
• Mental health and substance abuse disorder services, including behavioral health treatment
  
• Prescription drugs
  
• Rehabilitative and habilitative services and devices
  
• Laboratory services
  
• Preventive and wellness services, and chronic disease management
  
• Pediatric services, including oral and vision care
  

Passage of a law that allows stipped down policies would be a huge step away from the dream that someday everyone will have

...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.

What the last minute attempts to get the AHAC through the house reveals is that access, quality and lowering the cost of care are not the objective. Lower taxes are the objective and the big winners will be those who get their care from their employer along with a six or seven figure income. The losers will be the underserved and the safety net institutions like the Boston Medical Center and the other practices and institutions who are challenged to solve enormous problems everyday with limited and shrinking resources.

The Massachusetts governor is a Republican who understands the enormous challenge that the AHCA will place on the land of Romneycare. Since the passage of Chapter 58 in 2006 Massachusetts has been the state with the highest percentage of its citizens enjoying adequate health coverage. Covering 98% of the population has been in part achieved through the Medicaid expansion. Medicaid is the largest item in the state’s budget. It currently is spending over 35% of all tax dollars on Medicaid. Last year Massachusetts negotiated with CMS for a waiver that would provide over 50 billion dollars over the next five years to move all of MassHealth, the Massachusetts Medicaid program, from fee for service payment into value based payment through ACOs. If the AHCA is passed and the projected revenue losses are realized, will the taxpayers of Massachusetts be willing to make up the 2 billion dollar loss of revenue? If not there will be several hundred thousand citizens in the state who will lose their coverage and institutions like the BMC will be facing huge challenges.

The BMC retreat I attended this week was a proactive response to the ambiguity of the challenges it faces. The program was called “Leaning into the headwinds.” As I was getting grounded in the realities of the moment, I thought the implied metaphor was an undercall. A more appropriate title might have been, “Surviving a hurricane.” One attendee who is probably a sailor was quick to point out that if you are on the right tack and know how to use the wind you can go a long way with a nice steady headwind.

The last ten years since the passage of Romneycare have been difficult for the BMC. There was a misconception that the need for extra support from taxpayers would be reduced after the passage of Chapter 58. Soon there were deficits in excess of a hundred million dollars annually, but under the leadership of Kate Walsh since 2010, things have remarkably improved.

The BMC has always been a huge asset to its community and to the world. It was founded in 1855 as the nation’s first municipal hospital. It made a big difference in my medical education. When I was a student at Harvard Medical School the Boston City Hospital hosted medical services from all three Boston medical schools. I learned how to suture in the Boston City EW on a very busy Saturday night. I did my first unsupervised history and physical on a BCH ward, Peabody One. Nobel Prize winning research has occurred in its labs. Hundreds of thousands, if not millions of patients who had no resources have received the care they needed through this wonderful institution since its founding one hundred and sixty two years ago. We live in strange times when such a valuable and venerable asset is at risk when it has never been needed more.

There is one bright spot in the BMC’s recent history. It is the recipient of a 25 million dollar gift from the Greyken Family to establish a center for study and treatment of opioid dependence. Michael Botticelli, former director of the White House Office of National Drug Control Policy and former director of substance abuse services for the Massachusetts Department of Public Health will be leading the work. It is almost unbelievable that the brilliance of an opportunity like the Grayken Center is clouded by such an onerous and unreasonable potential setback as the AHCA’s impact on Medicaid. The most vulnerable citizens in the country and institutions like the BMC do not deserve such a threat.

As the presentations and conversations proceeded, I was impressed with all of the strategic thinking that was presented. The leadership of the BMC understands the challenge and they correctly understand that their response must be a deep and dramatic process of transformation.

Governor Baker is predicting as much as a two billion dollar loss from what was reasonably expected to come to Massachusetts between now and 2022. Much of that 2 billion dollar shortfall will need to be made up by innovation and the transformation of care delivery in the hospital and ambulatory practices of the BMC and the community practices that use its services. I do not think this is a fair or reasonable challenge, and it would be a tragedy if it was only happening to the BMC, but it will be happening in every institution and practice that provides care to the underserved who briefly had a reason to hope for better health and the improvement of the inequity of care through the promise of the ACA. The thought of it all is enough to make one want to cry, but as I looked around the room at the other attendees I saw no tears. I saw determined, cleared eyed people and heard their strong voices as they described their commitment to the challenge.

I am not a prophet, but I am a person who believes that despite the current challenge a better world does lie ahead. I was impressed that despite the fierce “headwind” the BMC has set a strategy of clinical transformation built on the wisdom of population health, programs to improve the social determinants of health, the elimination of waste, and the improvement of clinical processes, all focused on improving the health of the community. If any institution is ready for the challenge, the BMC is. CEO Kate Walsh said it nicely:

We lead the nation in many areas despite the headwinds we face, and have set out to make Boston the healthiest urban population in the world by 2030.

What Kind of Spring Is This?

Monday and Tuesday were pretty nice, but oh, was it cold as the North wind did blow on Wednesday and Thursday. My “AccuWeather Forecast” is calling for snow and cold mixed with frozen rain, sleet and generally lousy weather for most of the next week. What is nice and does generate hope for better things to come is that now that we are have passed the vernal equinox and have daylight savings time; it is still light at seven in the evening!

I was paying no attention to March Madness until the South Carolina Gamecocks upset Duke to make it to the Sweet Sixteen. Any time South Carolina beats Duke at anything the world almost comes to an end. The victory last weekend over the hated and perennially successful Blue Devils has been officially labeled as the number one moment in all of the history of Gamecock basketball. Hopefully that moment will slip in the standings to number two if they beat Baylor tonight.

Also slipping up on me as I wander the country roads of New Hampshire trying to log my 15,000 steps each day is that the Celtics are pushing the Cavaliers for first place in the NBA East. Who would have ever thought that was a possibility? Will wonders never cease? Well maybe. The Bruins were sailing toward the playoffs but have hit a bump in the road just as they were knocking on the door of renewed success. I am not a big fan of hockey, having spent the first two decades of my life where water never freezes outdoors, but I would like to see the Bruins have a little success for the pleasure of my hockey loving friends.

It seems ironic that as we wait for opening day at Fenway and the beginning of what we hope will be a pleasant journey to October baseball, and as we anticipate the dramas of the NBA and NHL playoffs, the biggest story on the sports pages in Boston is the return of “the jersey”, or rather both jerseys. I do not understand. We never heard that Brady’s jersey from Super Bowl 49 was missing until the jersey from Super Bowl 51 was found in Mexico in the company of 49. How strange is that? But there is joy in beantown as both have now returned home and will soon be reunited with the “GOAT”, the “greatest QB of all time.”

There is much to ponder as you get out for your exercise this weekend. Take your pick of the options. What will happen to the AHCA? Has Paul Ryan gone too far in his attempts to get his vote? Under what circumstances does the president ever prefer facts over prevarications? Will the Sox win the World Series? Should you walk 15,000 steps a day to live longer, or to just feel good?