28 April, 2017

Dear Interested Readers,


What’s Inside Plus Opponents of the ACA Come Back for Round Two

It may seem strange to you, but when I heard that the president and the Republican leadership were making an effort to resuscitate their attempt at “repeal and replace,” I immediately thought of the surprising last scene from “Fatal Attraction,” the terrifying 1987 movie with Glenn Close and Michael Douglas. You may remember that in the chilling last scene Douglas is attacked with a butcher knife by Close. She is obsessed with him and has gone through the full playbook of devious maneuvers as she attempted to trap him in a relationship that he is desperately trying to escape. He defends himself by holding her head under water in a bathtub until it seems that she is dead, and then he turns away. I remember making the mistake of thinking that the action was over. Douglas is exhausted from the fight. He makes the same potentially fatal mistake that the audience makes as he backs off too soon in the aftermath of the struggle. Suddenly Close rises from the bathtub, butcher knife in hand. The audience is shocked and Douglas would have been a dead man had not his wife, whom he had cheated in his affair with Close, suddenly appeared and put a bullet in her chest. Fade to black.

Despite the fact that “Fatal Attraction” spontaneously popped into my head earlier this week when I read that the very conservative Freedom Caucus and the more moderate “Tuesday Group” had worked out a mutually acceptable compromise with the president and Republican leadership that might have revived the repeal and replace process, I was not really surprised the way I was when Glenn Close popped out of that bath tub with her ten inch butcher knife. I had suspected all along that the Republicans would eventually renew their attack on the ACA. The president needs to make something happen, anything happen, even if it hurts many in his base and undermines the “greatness” of America. The Republican leadership is embarrassing itself by its inability to agree on how they will repeal the ACA and what will replace it. Just as I am finishing this letter I hear that they have failed yet again and are now pulling “Zombie Care”, as Stephen Colbert called the latest attempt, in favor of a deal with the Democrats to keep the government “open and in business” past Friday.

It must be hard for the Republican leadership and all of its presidential candidates to admit that they can’t do what they have said for seven years that they must do. They do not have the ingenuity to accomplish the repeal and replacement of the ACA with something that would be considered acceptable by the majority of Americans. President Trump has even a bigger problem than Paul Ryan. Ryan has not been as specific as the president about “how great” the replacement would be, nor has he bragged as much about his ability to negotiate real success. Ryan has focused on how bad the ACA is. As Nancy-Ann DeParle and Phil Schiliro, two former Obama White House staffers who worked on the ACA, point out in a recent New York Times op ed piece, “How Trump Could Save Obamacare, and Help Himself,” the president is in a deeper hole because of his penchant for bragging and the way he hates to be wrong. Lately he has had to back off on China, the “wall”, and NATO, and has been frustrated by the courts in his attempts to block “undesirables” from entering the country. With tongue in cheek they offer advice:

…[Trump’s] endorsement of the House Republican bill last month ended in one of the biggest embarrassments of his first 100 days. And the new attempt this week to revive the effort might have a similar fate. So he shouldn’t let his past criticisms preclude him from pivoting from “repeal and replace” to “repair and rebrand.”

A rebranded Affordable Care Act would be consistent with the vision Mr. Trump offered during the campaign. Then, he promised that everyone would be “beautifully covered,” with “much lower deductibles,” and “taken care of much better than they’re taken care of now.” He said he wouldn’t cut Medicaid and would provide coverage for those who can’t afford care.

Their advice is for the president to shift from “repeal and replace” to “repair and rebrand.” They present a set of very compelling points beginning with a review of healthcare before the ACA and a list of many of its accomplishments that are needlessly at risk. They complement the president for his self acknowledged competencies.

“Repair and rebrand” would take advantage of Mr. Trump’s background as a businessman and his interest in expanding the private sector. What the Affordable Care Act needs most is more customers — and federal officials taking actions to increase enrollment, strengthen private plans and ensure the marketplaces will function properly. With a few smart adjustments, this will foster a virtuous cycle of lower costs and expanded competition and coverage options for millions of working-class voters.

He could claim all of the success that flowed from the rebranding of the ACA from Obamacare to Trumpcare. He has done it with real estate. Why not do it with legislation? Many in his base who desperately need access to care would love him for the accomplishment. He could also convince the nineteen states that have not expanded Medicaid that it’s a deal they should not pass up. He is a self proclaimed marketing champ. Since he carried the majority in almost all of those “red states” he should be able to convince them that expanding Medicaid is the right thing to do.

This week’s letter must contend with our continuing concerns about the future of healthcare in the midst of political turmoil, despite the fact that perhaps you are tired of the subject. I begin with an examination of another excellent article in the New England Journal of Medicine by Jonathan Oberlander entitled “The Art of Repeal--Republicans’ Health Care Reform Muddle.” I continue by offering further reflections on Elisabeth Rosenthal’s An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, which was the prime subject of last week’s letter. If you missed last week’s letter, read the abridged and improved form on strategyhealthcare.com. I know that I make the same plea every week, but it is a great way to get into the conversation. Any comments or opinions, pro or con, will be published on the site.

The last section should not be a surprise. Despite a couple of cold days of fog and heavy rain spring is here! Fishing season has begun. If you keep up with the Boston television news, perhaps you saw the report showing Governor Baker putting some big rainbows into Jamaica Pond. As today’s header shows, we have big rainbows in New Hampshire. Rainbow’s are not natural East Coast inhabitants, but they are a good example of the joys that immigration can offer. Oh, the Cubs are also playing the Sox and I am a little nervous after they were whacked twice by the Yankees.

Let’s Keep Trying

Most of us sought a career in healthcare because we had a desire to be of service. Some of us wanted to be nurses, some doctors, and others were delighted to realize that healthcare was a very complex endeavor that needed people with a wide variety of skills and that healthcare had a place for our gifts. The last year has been hard for us. For me the worry began in June when I realized that Donald Trump would be the nominee of the Republican party. There are few things that I care about more than the little bit of progress that we made together with the ACA toward

...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.

I was quite worried about the slim threat that he presented to the goals of the Triple Aim. I could not imagine the election of a Ted Cruz or a Marco Rubio who had both been more focused and effective in their objections to the ACA, but Trump seemed like a real threat. I think that if you reread these letters from last fall you will find evidence to support that memory.

What frustrated me then, as it does now, is the reality of how limited the reach of one individual is. We are individually one among millions and many of those millions see the world through the lens of a very different experience in life. What is increasingly clear is that we do not have a universally accepted set of facts upon which to build a consensus about core values. With different sets of facts we get different answers when we apply our minds and hearts to the search for solutions to vexing problems. The problems we have are further exacerbated by what my friend Patty Gabow calls a “lack of social solidarity.” It seems that the quantity as well as the importance of universally accepted values are in a decline. It is easier to say what makes us different from our neighbor than what concerns us all.

There has been a lot written about the president’s first one hundred days. Based on those first one hundred days I am more worried by his next one thousand three hundred and sixty days. I am not sure what will remain of the accomplishments of the last 25 years in healthcare by the time a new president or this president takes the oath of office in January 2021. I have learned from years of long runs and long walks that when the going gets tough, like when you are climbing a steep hill, there is some benefit in not looking for the top. It is better to just try to take a strong next step and to lean into the natural resistance of gravity.

A key to staying on focus or staying the course is to remain in conversation with others who also share the same concerns. Being patient, long suffering and collaborative has allowed others in other beleaguered movements to succeed. The struggle for human rights has made painful progress over many centuries and has survived many setbacks because those who believed in the importance of equality have never given up the struggle. Those of us who believe as Martin Luther King,Jr. did, that healthcare is a human right should take some instruction from the larger cause. We must stay our course through what will surely be a continuing struggle and future disappointments.

I think that it is clear that I sustain my own sense of possibility by interacting with others who share the same vision and hopes. That is why I write these letters. That is why I begin each day looking for the wisdom of others. Each new “discovery” provides me a lift and gets me through another one of the next thirteen hundred and sixty days. I recently got a big lift from the words in Jonathan Oberlander’s most recent contribution that was published in the New England Journal of Medicine, entitled “The Art of Repeal--Republicans’ Health Care Reform Muddle." I have never met him, but every time I see his name in print I am an eager reader. This article began with a sentence footnoting the writing of Blumenthal and Morone in their wonderful book, The Heart of Power.

Failure is a familiar outcome in U.S. health policy. Presidents have long struggled to translate their promises and aspirations into legislative victory. Harry Truman’s national health insurance program never came close to becoming law. Richard Nixon’s universal coverage plan did not pass. Congress rejected Jimmy Carter’s hospital cost-containment bill. Bill Clinton’s campaign to enact universal insurance ended in political disaster.

Yet even judged against this dismal history, Republicans’ March 2017 efforts to repeal and replace the Affordable Care Act (ACA) were an epic failure. Less than 3 weeks after introducing the American Health Care Act (AHCA), the Trump administration and House GOP leadership withdrew the bill from consideration without holding a vote in the full House of Representatives. Their inability to pass the legislation through the House — where Republicans hold a sizable majority — constitutes a major defeat for President Donald Trump, who came to the White House touting his deal-making skills, and Speaker of the House Paul Ryan, who pushed for a quick repeal bill and whose reform vision shaped its content.

Those paragraphs made me feel good! To that opening wisdom he added the observation that offered further reassurance.

An enduring feature of American political institutions is that partisan majorities don’t guarantee legislative success. It’s not unusual for members of Congress to vote against a president from their own party. Ryan and the Trump administration calculated that House conservatives would ultimately vote for a bill they did not fully support because there really was no choice: they wouldn’t wound a new Republican president or miss a long-awaited opportunity to repeal Obamacare. That proved to be a colossal miscalculation...Republicans somehow managed to cram legion political mistakes, strategic miscalculations, and legislative defeat into just 17 days. The Republican health care reform implosion underscores a crucial reality: 7 years after Obamacare’s enactment, the GOP lacks a viable replacement for it. There can be no repeal without replace — the ACA has changed too much in health policy, and too many Americans benefit from it to return to the status quo ante.

I felt a lot better after reading that analysis! His article continued with a withering denouncement of all of the errors of thought and procedure that added up to the initial failure of the AHCA and then he asked the question that has been on my mind for the last month.

What will Republicans do next? They could cooperate with Democrats on reforms that address the ACA’s shortcomings, strengthen insurance marketplaces, and make coverage more affordable. But such bipartisanship is probably a fantasy. Republicans failed in their initial attempt to overturn Obamacare; they have not accepted the ACA as a law that should be reformed rather than repealed. Some Republicans favor resurrecting repeal-and-replace legislation. Indeed, at this writing the Trump administration and Congressional Republicans are negotiating changes to try and secure the bill’s passage.

...The compromises under discussion between the White House and House Republicans — enabling states to opt out of ACA provisions requiring that insurers not charge sicker persons higher premiums (community rating) and provide essential health benefits (such as maternity services) — could further alienate moderate Republicans who are already uncomfortable with the bill’s effect on Medicaid and insurance coverage. The changes the House bill makes to insurance regulation also could run afoul of Senate budget reconciliation rules. And rolling back the ACA’s popular consumer protections, including those for persons with preexisting conditions, will spark additional controversy. Thus, the prospects of GOP efforts to resurrect repeal and replace remain highly uncertain.

This is music to my ears. It certainly is a source of hope that could propel me through another day or week or perhaps a month, but then he reminds me of what I know all too well.

If Republicans cannot pass repeal legislation, the Trump administration has other options to undermine Obamacare, including weakening enforcement of penalties for not obtaining insurance and eliminating federal payments to insurers that are required to provide cost-sharing subsidies to lower-income Americans for deductibles and copayments. Such actions could explode the individual insurance marketplaces. ...President Trump remarked that “nobody knew that health care could be so complicated.” Republicans’ struggles to turn their repeal-and-replace rhetoric into reality underscore just how complicated it is.

That is how the article ends. We are back to the realities that existed before reading the article. In a way I am left with the same apprehension I had when I would read a 538 article last fall by Nate Silver predicting that Clinton would win.

Last week’s letter which was a weaving of a discussion of Elisabeth Rosenthal’s An American Sickness: How Healthcare Became Big Business and How You Can Take It Back and some free association from me about structural evil elicited a few concerned responses from interested readers. One reader wrote:

Gene, it has always seemed to me that labelling something evil can free one from the obligation to understand it, which I know is not your intention. From my experience...I have learned that everyone’s behavior is rational and makes sense if you understand their experience, premises and assumptions. To change people’s minds and behavior you have to connect with their interests AS THEY UNDERSTAND such interests, which Kahneman (e.g., Thinking, Fast and Slow) and the other behavioral economists/psychologists have taught us is often not the same as the interests one would assume from an objective economic rational actor perspective (the election of Trump being a particularly horrible example of this). As you know better than most, and as even Trump seems to understand, HC is complicated because, in part it is so large and important, and so we need new structures informed by a new vision of what the enterprise is about, which has been your mission for a long time. Even with the threatened revival of Ryan & TrumpCare, premised on a massive transfer of wealth from the poor, elderly and otherwise disadvantaged to the top 1%, we shouldn’t lose hope. For example, now that they are in control, the Republicans can’t just rant about the evils of ObamaCare. They must instead show the American people what they want, which is not at all what the majority of Americans want.

I totally agree. I felt immediately better after reading these words. This reader is wise. He has been in healthcare for a long time, and he is not giving up. His outlook gives me hope. I just get down and a little out from time to time and need a slap in the face to get back on track.

Another thoughtful reader wrote:

This week’s comments about blowing up the system reminded me of the similar conclusion reached by Don Berwick perhaps 15 years ago when he presented Escape Fire. At the time, he was seen as much too radical and it seemed to me that it negatively impacted his influence within the healthcare field. Now I wonder if he was actually simply too far ahead of his time.

It’s not like I want to see the system implode. I fear too much suffering by the vulnerable among us, even as I recognize that the “haves” (by which I mean people like you and me) will be just fine whatever happens.

That comment was also very helpful. I did remember Don’s very moving speech from the IHI Annual gathering of 1999. Perhaps you remember Don’s concern about healthcare at that time. It’s been almost twenty years. He was speaking just after the publication of To Err is Human and two years before the publication of Crossing the Quality Chasm. The Commonwealth Fund thought the speech was so noteworthy that it published it as a monograph. Fourteen years after the speech a film was produced based on it. A Wikipedia review of the film remarks:

Dr. Berwick draws a parallel between American healthcare and a 1949 Mann Gulch fire in Montana. Just as the healthcare system lies perilously on the brink of combustion, the forest fire that seemed harmless at first was waiting to explode. A team of fifteen smoke-jumpers parachuted in to contain the fire, but soon they were running for their lives, racing to the top of a steep ridge. Their foreman, Wag Dodge, recognized that they would not make it.

Dodge had invented what is now called an “escape fire,” and soon after it became standard practice. As Berwick says in the film, “We’re in Mann Gulch. Healthcare, it’s in really bad trouble. The answer is among us. Can we please stop and think and make sense of the situation and get our way out of it?”

Last week I celebrated Elisabeth Rosenthal’s description of the “fire” in healthcare. I also expressed some disappointment with her lack of a comprehensive solution for our collective dilemma. Time and time again in her book Rosenthal makes reference to the deteriorating state of healthcare over the past twenty five years. Much of what has happened that is positive was anticipated by Don in the speech. Much of what Rosenthal decries happened despite the message that Don gave us then. The reference by the Interested Reader to Don Berwick’s speech and the message of the speech do put this moment in time in perspective. We still face the same challenges:

We’re in Mann Gulch. Healthcare, it’s in really bad trouble. The answer is among us. Can we please stop and think and make sense of the situation and get our way out of it?”

The Joys of Spring

This last week has been pretty typical for Spring. Some days near 80 and some days when you can see your breath when you are out for a walk. April 15 is the official start of trout fishing in New Hampshire, but as the weather and my schedule interacted I did not get out on the water until this last Monday. There is nothing like the joy of getting down all of my fishing gear from the attic where it has been resting since last October. My hands were trembling with joy as I assembled my old friends and assessed any needs for repair or renewal. After everything was deemed ready, I took my favorite kayak down from the rack where it had been resting for almost six months, and I was ready to go.

I have a lazy man’s approach to fishing when I fish in the lake behind my house. It is about 20 feet from my deck to the little beach from which I launch my adventures. I do love to cast flies when I fish in streams, but on the lake I am a troller. I was not always a troller, but it is just so much easier than casting when the fish are not rising, as they will later in the year when bugs are hatching.

I have a simple methodology. I let out about 25 yards of line and then peddle my kayak around looking at all the beauty of spring. Wood ducks and loons greet me on the water and occasionally I see a hawk or an eagle circling above or high in a white pine or birch along the shore. I always tell myself that it makes no difference whether I catch anything, but I know that is a lie.

I justify my sloppy approach to fly fishing by saying that the real skill is not in all of the repetition of casting but in how you “land” the fish. There are not many sensations that generate more physiological “electricity” than suddenly realizing that a fish has hit your line. Focus and patience are required to complete the exercise of landing the fish who suddenly has gone from the pleasant expectation of a tasty morsel to the reality of a world in crisis.

I can relate to that sudden reversal of fortune. What the fish does not know is that I am just looking for a relationship and really mean no harm. My goal is a “selfie” like the one showing my left hand holding the fine and plump 14 inch rainbow in today’s header. I joke that after the picture, I give my new friend a brief lecture on the downside of impulsive behavior and then let her/him go. I hope that they understand that the experience was a gift for both of us. The next fisherperson they encounter may want to see how they look in a frying pan.

I had almost completed my tour of the lake with nothing to show for my efforts. I was already into the recitation to myself that whether or not I caught a fish made no difference. I had enjoyed a great evening on the water when my line went “thwang” and then “zing.” Someone wanted my attention. Both the fish and I were a little rusty in our interaction. For the longest time I was not sure what was on my line. Was it a bass or was it a rainbow? I hoped it was not a lowly dace. Finally, my fish jumped out of the water and revealed its identity. After a few more minutes of gentle coaxing my new friend was in my net and we had a photo op. It was a great way to start another year on the water.

Rainbow trout are an interesting subject. They arise from a relatively small area on the West Coast and have been spread throughout the world where they are bred in hatcheries and then deposited in local lakes and streams. In 2010 Anders Halvorsen published an interesting book, An Entirely Synthetic Fish: How Rainbow Trout Beguiled America and Overran the World. Ironically the title of the book sounds almost as reactionary as a Trump complaint about Muslims and Mexicans. It’s a touchy subject since I know that the state of New Hampshire puts about 1500 new trout into my lake every spring. Who knew that a fish could be an example of how complex our lives and our world have become?

Clearly there is a lot that you might ponder if you take a walk or decide to go fishing this weekend. Whatever you do, if it is possible to take a friend along, be sure to do it. I will be in and out. I sat in the fog at Fenway on Wednesday night to watch the Sox lose to the Yankees and then watched them lose again while typing this letter to you. I hope that they will have a better showing against the Cubs over the weekend.

Be well, take care of yourself, stay in touch, and don’t let anything keep you from making the choice to do the good that you can do every day,

Gene