9 June 2017 Dear Interested Readers, What’s Inside This Letter, Amazing Events, and A Question for You Let’s start with the question. Have you written a senator yet to express your concerns about their deliberations over the fate of the ACA? Now it is the Senate’s turn to decide what to do with the Republican campaign promise to repeal and replace the ACA. Will they try to pass something as onerous as the AHCA that the House passed on May 4? Maybe they will try their hand at coming up with new ideas that could be called TrumpCare. There is no doubt that the Republican leadership in the Senate has a dilemma to face as it becomes their turn to weigh in on what to do with or to the ACA. I remain very concerned that the opponents of the ACA will try to cobble together a collection of implausible ideas and blatant misconceptions and contradictions that will enable them to pass something that will fool much of the American public into thinking that they care about the health of everybody while they take hundreds of millions of dollars a year out of Medicaid. The bulk of this letter is a continued attempt to rally you to exercise your constitutional right to petition your government and inform a senator of your deeply held opinions about the importance of universal access to cost effective quality care. Last week I published the letter that Dr. Patty Gabow, the retired CEO of Denver Health, was sending to Senator Lamar Alexander, the chairmen of the Senate’s Health, Education, Labor and Pensions Committee. I also challenged you to follow her example. I have mailed my letter. I hope that yours is also in the mail. If you missed Dr. Gabow’s letter or want to read the edited comments that I wrapped around her letter, let me recommend that you click this link to the Tuesday blog, Strategy Healthcare that is coupled with this Friday “Healthcare Musings” letter. If you are interested in my letter, read on. I am retired and had the luxury of listening to James Comey’s public testimony before the Senate on Thursday morning and then listened to the various commentaries on the radio and television for most of the rest of the day while I was working on this letter to you. I am old enough to remember Senate hearings all the way back to Joseph McCarthy. Even as a child of nine the few clips that I saw of the Army-McCarthy hearings on our TV that only received one channel, led me to distrust the junior senator from Wisconsin. I had bad vibes during the Watergate hearings, and it was deja vu all over again as I listened to the former FBI director accuse the president of lying and revealing that he himself had “leaked information” about his concerns with the hope that it would precipitate the naming of a special counsel. The most bizarre moment of the day was Senator McCain’s apparent conflation of the investigation of Hillary Clinton’s misuse of an email server with the investigation of the Russian attempts to disrupt the election. The exchange with McCain confused Comey and may be evidence that McCain’s years have caught up with him. The senator did attempt to explain himself after the event with a written statement that was more coherent. The day will most likely be one that is remembered in history. Comey’s language was full of nuance and I have heard some commentators and politicians who say there is evidence in Comey’s testimony that the president attempted to obstruct justice. Others who heard the same testimony said that so far there is no evidence of obstruction. For me the most important testimony from Mr. Comey was the fact that he believes that he was fired because of the continuing investigation of the Russian interference in the election. The president strangely said as much himself. All that is missing now in comparison to Watergate is whether there are tapes of the one on one conversation in the Oval office between the president and the former director. The weather in New Hampshire has been cold, cold and wet, cold, wet and windy, and finally nice. The letter finishes with a good reason to look forward to the summer with hope. Senator Alexander, Please Read My Letter. Hours before James Comey appeared before the Senate Intelligence Committee, David Leonhardt published an editorial in the New York Times entitled “Uh oh, Health Care Edition.” The editorial began with a couple of challenging paragraphs. James Comey’s testimony today will reveal President Trump’s blatant disregard for the rule of law, and Nick Kristof’s column offers an excellent preview.
I realize it will be hard to pay attention to any other political story this week, but I urge you to find the extra attention span, because there is another important, disturbing story developing: The chances of the Senate taking away health insurance from millions of people seem to be rising. Well, that got my attention. Leonhardt went on to say that as the world watched Comey’s testimony Mitch McConnell would be hard at work to get a Senate version of the AHCA ready for a vote before the July 4th congressional recess. The president wants to move on to other issues and must check off healthcare to have the money he wants to give back to his voters from healthcare taxes. Leonhardt says that McConnell is saying that it will be “hard to do something” while he is setting the stage for dropping the blade on the ACA. The strategy is to talk like nothing can happen soon and then to throw the “Hail Mary” that wins the game while the Democrats are thinking that they have won or that there is a long time left to play. The Democrats do not seem to recognize that we are near the end of the game and that it is sudden death time, not early in the third quarter. Or as Leonhardt sums it up: The whole game is distraction. The only way that the House could pass such an unpopular bill was to keep people from focusing on the substance of the bill, while rushing it through, and the Senate now seems to be following a version of that strategy.
Before showing you my letter to Senator Alexander we should give some consideration to Leonhardt’s warning and and assess what is likely to occur between now and July 4, the deadline that Mitch McConnell and the president seem to have given themselves. As you may remember the Democrats took over a year to craft the ACA. There were extensive hearings and many questions were considered and vetted in the various committees. Despite over seven years to prepare for the moment, the Republicans are not ready for their moment of action. I can think of several reasons why they seem like deer in the headlights of an oncoming 18 wheeler at this moment. Perhaps they never really believed that they would ever get more than an opportunity to throw rotten eggs and overripe tomatoes at the ACA and therefore never coalesced around a viable alternative plan. Do not imagine that their lack of something to offer to responsibly replace the ACA will prevent them from pursuing the more important objective of killing the ACA. Perhaps, since the self described objective of many senators like Mike Lee, Rand Paul and Ted Cruz was always to get government out of healthcare and take back tax money that was supporting the exchanges and the Medicaid expansion, there never was a logical reason to develop and offer an alternative. New Hampshire is the home of the “live free or die” mantra that is so appealing to many conservatives and libertarians. The slogan is proudly displayed on license tags and on many other flat surfaces, except strangely not on motorcycle license tags even though you are free not to wear a helmet. There are many other places around the country where the same sentiment is embraced, if not displayed. Another explanation for no real plan may be a corollary to the president’s famous epiphany, “Nobody knew that healthcare was so complicated.” If that is true perhaps seven years, or as the Bible might say “seven times seventy years” would never be long enough to come up with a plan that provides everyone with adequate care without the involvement of the government and using tax money. If it can’t be done, then the challenge quickly becomes how to win enough votes to pass something that enriches a few while damaging the health of many. Listening to the video of the president’s pronouncement that healthcare is complicated is well worth the two minutes it will take you. The president freestyles from implying that something wonderful is coming to pondering whether or not to just let Obamacare die over 2017 and 2018. What he is implying is that he can and will starve the ACA to death because he controls Tom Price’s ability at HHS to neglect its proper maintenance. Back in 2009 the process was open and available to Republican participation in the committees of the Senate and people like Alexander, Grassley and Hatch did have an opportunity to at least comment on what they did not like. Some of their comments and suggestions were put into the law to win their support, and yet they voted against their own contributions. Some of the same bargaining went on between very liberal and more moderate Democrats. The “public option” died in the final version of the ACA because of just this sort of legislative bargaining. The public option was in the House version that was lost when the reconciliation process of passage was forced by the loss of a filibuster proof Senate majority when Scott Brown took Ted Kennedy’s seat. The process this time around does not look like it will occur in standing Senate committees where Democrats are minority participants. The bill is being written in haste by a select committee that has only Republican men, no Republican women, and McConnell will try to force it to produce something in the next week or so. The deadline is tight. If the CBO is to be able to have time to “score” the bill before the Senate votes prior to its July 4th recess, then the rough bill needs to get to the CBO pronto. Let’s examine the committee that is really writing the bill. An article from the New York Times on May 8 describes the committee. The politically vulnerable senators (those up for reelection in 2018 in states that did expand Medicaid), all Republican senators who are women, the one senator who is a physician and wants a more compassionate bill, and the only black Republican senator, Tim Scott of South Carolina, are not on the committee. My assumption is that they were not invited because of their concerns about an outcome that might make a positive difference or minimize the projected damage that the AHCA will surely inflict. Here is the committee. The Republicans’ working group includes Mr. McConnell and three other members of the Republican leadership: John Cornyn of Texas, the majority whip; John Thune of South Dakota, the chairman of the Senate Republican Conference; and John Barrasso of Wyoming, the chairman of the Senate Republican Policy Committee, who has been a point man for the party on health care.
The group also includes three committee chairmen: Mr. Hatch; Senator Lamar Alexander of Tennessee, chairman of the Senate health committee; and Senator Michael B. Enzi of Wyoming, the head of the Budget Committee.
The other senators in the Republican working group are from states that have expanded Medicaid under the Affordable Care Act: Tom Cotton of Arkansas, Cory Gardner of Colorado, Rob Portman of Ohio and Patrick J. Toomey of Pennsylvania. What is happening in that committee is unknown since the work has been done in “secret”, or “behind closed doors.” It seems that even the press is confused. An article in the New York Times on May 26 by Jennifer Steinhauer and Robert Pear reported that McConnell was skeptical about his ability to get anything done. On June 6 McConnell brought all Republican senators behind the closed doors as staffers gave a PowerPoint presentation of the work so far and then sounded more positive later in the day after he and Paul Ryan met with the president. I am reminded of the line from the old country song that made Charlie Rich famous: Oh, no one knows what goes on behind closed doors Unlike Charlie, when I think about what goes on behind closed doors in the Senate and at the White House I do not smile. I cringe and have low expectations which is why I followed Patty Gabow’s example and wrote a letter. What we have learned in the last week might suggest a slight change in strategy. We must act fast. We can not rely on the usual process in the standing committees like HELP and Finance to provide time to thoughtfully respond to what will be proposed. It does remain true that a good person to reach out to is Lamar Alexander. He is on the select committee, he is an honorable and experienced legislator, and he is on the record asking for a deliberative process as you will read in my letter. There is a lot of wiggle room in what he has said, and he is only one person; but if McConnell is able to bring the bill that we have not yet seen to a vote before July 4, he can only lose two votes. Three Republicans holding out for something better saves Medicaid and a little bit of what has been achieved with the ACA. I’m hoping Senator Alexander will be one of those votes. Here is my letter. June 8, 2017
Senator Lamar Alexander
455 Dirksen Senate Office Building
Washington, D.C., 20510
Dear Senator Alexander,
I am a retired physician who was the CEO of a large, multispecialty group practice, Atrius Health. Atrius Health was one of the original Pioneer ACOs and is a national leader in quality metrics as it provides care to more than 700,000 patients in Eastern Massachusetts. Atrius Health has a long experience in value-based reimbursement and is the legacy medical practice of the Harvard Community Health Plan. For almost fifty years I have been deeply committed to the search for effective ways to lower the cost of care while improving the care of the individual and the population at a sustainable expense and under conditions that adequately support all the professionals that provide the care.
I was very encouraged when I read Robert Pear’s May 6th article in the New York Times identifying you as one of the thirteen senators that Senator McConnell had named to produce the Senate’s version of the American Health Care Act. I had been reassured when I discovered in an article written in USA Today in March describing your concern for those who might lose their insurance because of problems with the exchanges when the House Republicans seemed to be unable to come to consensus on their bill:
With health care reform stalled, Sen. Lamar Alexander announced Wednesday he intends to file legislation that would provide temporary relief for millions of people who live in areas where there are no insurers selling policies on the federal health insurance marketplace.
Alexander’s proposal would let people who get government subsidies to buy insurance use that money to purchase any state-approved plan on the private market if there is no insurer selling policies on the federal exchange, or marketplace, in their area.
I was pleased to read your “tweet” of May 4 after the House passed the American Health Care Act without waiting for the CBO to score it.
“I congratulate the House on passage of its bill. The Senate will now finish work on our bill, but will take the time to get it right. My own goals for a Senate bill include: 1) rescuing the thousands of Tennesseans and millions of Americans who will be trapped in collapsing Affordable Care Act exchanges with few or even zero options for health insurance in 2018 unless Congress acts; 2) lowering premium costs, which have increased under the ACA law; 3) gradually giving states more flexibility on Medicaid program, but doing it in a way that does not pull the rug out from under people who rely on Medicaid; and 4) making sure that those with pre-existing conditions have access to insurance.”
When I read your statement I could imagine the possibility of bipartisan support for a bill that met the criteria that you set. I was disappointed, but not surprised, to read the CBOs report in late May after they were finally able to score the House bill. As someone who has worked for many years with the hope of someday seeing every American having access to care, I was devastated to learn that in 2026, as a result of the bill, there would still be more than 50 million Americans without coverage. That fact seems inconsistent with the sentiments expressed in your tweet. I fear that you are being pushed away from your pledge to “take the time to get it right” by the president and Majority Leader McConnell’s timetable to “get healthcare done” by the July 4th recess.
I am impressed that even with intense disagreement over the role of government the objective of better healthcare for all Americans has been a bipartisan goal during most of the last sixty-five years. President Eisenhower believed we could use a public private partnership to achieve better outcomes than our European allies had with “socialized medicine.” Richard Nixon not only opened China, he created the EPA and launched HMOs. Scholars at the conservatively oriented American Enterprise institute evolved the principles that formed the basis of the “connector” in Massachusetts when Mitt Romney was governor and its contributions are easy to see in the ACA.
I was a student at Harvard Medical School in the sixties where the dean, Robert Ebert, wisely said:
The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.
We have been searching for that “conceptual framework and operating system that will provide optimally for the health needs of the population” for more than fifty years. The committee that you are on has an opportunity to make real progress toward the lofty goal of the “Triple Aim” that evolved from Dr. Ebert’s observation. You have a chance to offer real leadership that will bring us closer to
...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.
It is my hope that you will continue to demand the time to produce an effective bill that will truly serve the health needs of all Americans and be a barrier to the passage of a sham bill like the House’s AHCA that tries to find a way to look like it is good for the health of the nation while damaging so many people in a poor business tradeoff that enriches the few while undermining so many of the people who do the hard work of this nation. I also hope that you will seek to open up the process of writing the bill and invite not only the input of your Democratic colleagues but also the testimony of the many people who do have a deep understanding of how complex healthcare is.
Thank you for your service to the country, your stated commitment to finding a way to a better answer, and for the opportunity to provide input to your process.
Respectfully yours,
H. Eugene Lindsey, Jr., M.D.
The strategy is to remind remind the senator that he said, “The Senate will now finish work on our bill, but will take the time to get it right.” His criteria for a good law are straightforward.
- rescuing the thousands of Tennesseans and millions of Americans who will be trapped in collapsing Affordable Care Act exchanges with few or even zero options for health insurance in 2018 unless Congress acts
- lowering premium costs, which have increased under the ACA law
- gradually giving states more flexibility on Medicaid program, but doing it in a way that does not pull the rug out from under people who rely on Medicaid
- making sure that those with pre-existing conditions have access to insurance.”
If he can stick with those objectives, then progress might be possible. Mrs. Loon Is On Her Nest The header for today’s letter contains the view from my deck. It is a beautiful picture that was taken by my wife last weekend near the end of day, just after heavy rain and wind had passed through, and not long before the next front arrived. You can’t see it in the picture, but just below the purple sky toward the elbow of trees on the far shore is where the loon pair have a little floating island that is about four feet by four feet and is maintained in pristine condition by the State of New Hampshire. The island is necessary to protect the eggs from predators and people. The wildlife authorities have a floating sign there that advises that we stay away. There is a line that floats in the water like the ones that divide swimming lanes in a pool. New Hampshire does offer loons universal access and quality care as part of its population health management plan for them, and the plan is working. “Social solidarity” exists in New Hampshire when it comes to loons and the great outdoors. Solidarity works, there may be as many as a thousand loons in New Hampshire now. Every year we hold our breath to see what will happen to our loons. Some years we have a baby loon. Many years it’s all for naught. Rarely there are two babies. I have my fingers crossed for a successful outcome this year, and most evenings I drift by in my kayak to check out how things are going. She has been sitting there for at least five days and the usual gestation is 25-28 days. We should have an answer by the time Congress goes on its break. If Mitch McConnell delivers something before the fourth, it is most likely not going to be good for the Triple Aim and Senator Alexander will not have stuck to his promise to take as long as it requires to get it right. I hope that this weekend after you get your letter in the mail there will be sunshine and much for you to see and do in the great world outside where there are loons and many other wonders to see. | 
