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After the American Health Care Act

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DANIEL STONE, MD

The late UCLA Professor Richard Brown, once commented that the Clinton healthcare initiative failed because the status quo was everyone’s second choice. Some of that logic applies to today’s failure to vote on the AHCA. Additionally, no one ever lost money betting against the rollback of an established entitlement program.

The Republicans opponents of the ACA have not yet faced the fact that the reason coverage is so expensive is because the care is so expensive. You can’t have cheap insurance for expensive services. So, something “better and cheaper” was a never more than a slogan. That slogan showed the AHCA to be the bait and switch that it was.

Health insurance has evolved to serve two purposes; to protect against health related financial catastrophe and to finance care. The ACA, with its high deductibles does a better job with the former than the latter. (Although opponents give short shrift to the mitigation provided by the provision of preventive services without charge.) It will be hard to satisfy the diverse collection of stakeholders with anything much different.

This is another illustration of the fact that anything approaching universal coverage is challenging for the developed world’s outlier on healthcare cost. Medicare has around 15% lower costs than commercial plans. The only practical way out of the cost vs access quandary is to harness the commercial insurance overhead/waste/profit and direct it toward coverage.

So, to paraphrase Keynes, in the long run, we’re in both single payer and dead. It’s just a question of whether we’re all dead first or just some of us.

JOHNATHAN HALVORSON

My immediate reaction is that now they are going to nibble at the ACA for 4 years. I’d actually have preferred the House passed this monster of a bill, which the Senate would have rejected, and then had to answer for it in 2018.

Energy and Commerce committee is not going to rewrite the AHCA now and is instead turning to CHIP reauthorization (where they may sneak in ACA cuts) and exchange stabilization.

MICHAEL MILLENSON

I think Jonathan Chait’s piece in NY Magazine addresses a lot of the substantive issues very well, particularly noting high up the opposition of a broad array of conservative experts.

Let me comment briefly on a small political point. Trump issued an ultimatum asking for a vote, just like you’d do if you last paid attention to how Congress works during 8th-grade civics class. But, clearly, when it became clear they would lose, Trump Congressional allies who are more sophisticated explained to the White House why you didn’t want to expose GOP House members to casting a potentially toxic vote in a sure-to-lose cause, and so the president “requested” that the vote not be held; i.e., put the onus on himself, not Ryan.

Translation: Trump is learning how politics really works and is adjusting to reality. That will likely help him in the future.

Repealed and Misplaced

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Like Joe, Michael and others, I find myself wondering what, if anything, Trump learned from the demise of the AHCA last Friday. But I’m also wondering what Democrats and other Republicans are thinking. The question I would like to ask all Republicans is: Is it clear to you now that merely saying no to any Democratic proposal to lower the uninsured rate is bad for your party? The question I would like to ask all Democrats who supported the Affordable Care Act is: Is it clear to you now that that the managed care nostrums in the ACA cannot lower costs, and that attempting to lower the uninsured rate without cutting costs is bad for your party?

Evidence-Based Health Reform

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President Trump campaigned on making health care better, cheaper and available to all Americans, regardless of ability to pay. Once Mr. Trump was safely in the White House, the Republican thought leaders in Congress were quick to supply him with plans to repeal and replace Obamacare. Most were written in protest to President Obama’s policies and were never meant to be implemented.

When scrutinized by the rank and file of the Republican Party, it turned out that the Ryan/Price American Health Care Act was neither repealing enough for some, nor replacing enough for others.

Now What, Mr. President? Here’s What.

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By STEVEN FINDLAY

In the wake of the AHCA’s demise, most lawmakers and policy experts agree that Congress will put repeal and replace aside for the rest of 2017.

As House Speaker Paul Ryan acknowledged on Friday that means the ACA/Obamacare remains the law for the “foreseeable future.”

Thus, as was widely reported over the weekend, that begs the question: how will the Trump administration administer the law and when might be the right time to return to the issue of fixing and improving it (however you want to label that.)

This is unknowable at the moment. The President, although inconsistent in his remarks, threatened to let the ACA “explode” this year and in 2018, thus forcing Democrats, in his mind, to beg him to fix it. At the same time, he said maybe the legislation’s demise was the “best thing” that could have happened since it would allow him to work with Democrats to craft an ACA replace or fix bill that would win their votes, bypassing the hard-right Freedom Caucus block in the House.

They’re Taking Selfies in the Streets …

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BY JOHN IRVINE

Filed under: Worth 10,000 words.

Taken as word of the Trump administration’s decision to pull the AHCA broke Friday afternoon, a selfie by Sean Patrick Maloney (D-Cold Spring) @RepSeanMaloney quickly went viral on Twitter.

How Not to Innovate (And the Stuff You Really Should Be Doing)

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I’ve written several posts over the past two years about the need for innovation in healthcare IT – deploying self-developed apps, leveraging third party cloud hosted functions, and embracing the internet of things.

I’ve previously discussed establishing a center for innovation.   In preparation,   I’ve worked on innovative projects in industry accelerators, academic collaborations, and government sponsored hack-a-thons.

What has worked?

1. I’ve learned that it is very important to make innovation a part of the day to day work inside an organization.    Creating change externally and then trying to graft it internally results in a disconnect between research and operations.   At BIDMC, we’ve created a meritocracy in which those have competitively illustrated out of the box thinking are given reserved time each week to focus on highly speculative areas of innovation.    The project started as ExploreIT and is now being formalized as the Center for Information Technology Exploration in Health Care.

Dr. Noseworthy and the AHCA

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The CEO of the Mayo Clinic, Dr. Noseworthy, was last heard recommending patients fire their physicians suffering from burnout. While he does not have truckloads of compassion or empathy for colleagues; he is, at least, honest. Dr. Noseworthy recently confessed “We’re asking…if the patient has commercial insurance, or they’re Medicaid or Medicare patients and they’re equal that we prioritize the commercial insured patients enough so… We can be financially strong at the end of the year to continue to advance our mission.” The ‘ailing’ nonprofit generated a paltry $475 million last year.

During his speech, Noseworthy noted the “tipping point” was the recent 3.7% surge in Medicaid patients as a direct result of ACA Medicaid expansion. “If we don’t grow the commercially insured patients, we won’t have income at the end of the year to pay our staff, pay the pensions, and so on,” he said. These are difficult decisions to make by rationing access to healthcare for the poor. It is a moral dilemma those of us in independent practices have been facing for some time.

Mayo will continue taking all patients, regardless of pay or source, and this policy exempts those seeking emergency care.

Watch the Recorded Repeal & Replace: Impact on Health Tech Webinar

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Repeal & Replace Webinar Image

In case you missed the Repeal & Replace webinar this morning, click here or the image above to watch Health 2.0’s Indu Subaiya and Matthew Holt tackle questions with policy expert Josh Seidman from Avalere Health.

Jill Merrigan is the Marketing Manager at Health 2.0.

In the Land of the Health Care Experts

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Arguably, the most consequential moment of the nascent Trump administration will take place later today when Congress Votes on the first iteration of the bill known as the American Health Care Act (AHCA). If the success or failure of the bill to this point is to be judged by its reception from policy thinkers on most sides of the political spectrum, it is already an unmitigated failure.

It should be worth noting, however, that healthcare in America is a massive business accounting for 3 trillion dollars in spending with powerful stakeholders. Any real attempt at reform is bound to be opposed by those who would naturally resist attempts to dam the river of dollars that flows to them. The resistance from these parties always comes in the form of entreaties to think about patients harmed by whatever change is trying to be made.

Figuring out which stakeholder actually has the patients best interests at heart is akin to playing a shell game. All the cups look the same and its entirely possible the marble is underneath none of the cups. As a physician, I am of course, another stakeholder with inherent bias but I would submit that practicing physicians, among all the players at the table, have their interests most aligned with the patients they must directly answer to every day.

A Healthcare Reform Compromise That Just Might Work (Maybe)

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Healthcare reform is stalled, so says Politifact. Fake news or the truth? Hard to know these days. President Trump and Speaker Ryan both sounded optimistic in recent public appearances. The Tweeter-in-Chief this week tweeted, “Great progress on healthcare. Improvements being made – Republicans coming together!” Maybe so, but remember that every TV news network was optimistic over Hillary Clinton’s landslide victory until about 9 PM on election night.

Is Trump’s enthusiasm part of “The Art of the Deal”? To quote from the book, “I never get too attached to one deal or one approach. For starters, I keep a lot of balls in the air, because most deals fall out, no matter how promising they seem at first.” Is the Ryan plan just but one ball floating in the Washington, DC air?

If conservative Republicans in the House and Senate revolt, Ryan’s plan ignominiously dies. What’s next? How about a compromise that just might garner support from all warring factions? There is an old saying, “Compromise is where nobody gets what they want.” But the corollary is that everyone gets something they like out of the deal.