Trump

Trump

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.

I Dub Thee “Three Pronged” Care

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There are approximately 18 million Americans who purchase health insurance on the so called individual market, on and off the Obamacare exchanges. There are another 14 million or so who could be buying insurance on the individual market, but choose not to buy anything. This puts the total individual market at about 10% of Americans. Half of those are, or are eligible to be, heavily subsided through Obamacare (including those huge deductibles). The other 5% are facing the full brunt of health insurance price increases under Obamacare. Of those, 3% are paying for Obamacare health insurance and getting garbage in return for their money, while the remaining 2% are uninsured.

This is the magnitude of the primary problem we are supposedly trying to solve. The 17% of Americans on Medicare are not upset at Obamacare. The approximately 23% of Americans on, or eligible to be on, Medicaid are not angry at Obamacare either (although the 1% eligible for the Medicaid expansion in states that chose not to expand it, might be angry with their Governors). Some of the 50% or so, who are getting health insurance through their employer, and used to get rather flimsy insurance in the past, may be somewhat disgruntled because the Obamacare imposition of “essential benefits” caused their share of premiums and deductibles to rise, and their ability to choose their doctors to plummet.

This is the secondary problem we are supposedly trying to solve. The American Health Care Act (AHCA) addresses neither problem and exacerbates both.

Democrats Paid a Steep Price For Ignoring the CBO. Republicans Will Too.

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Eight years ago it was Democrats who were criticizing the Congressional Budget Office. Now it’s Republicans who are bashing the CBO for estimating that 14 million Americans will lose their health insurance next year if the House Republicans’ “repeal and replace” bill becomes law.

The media and the blogosphere have done a reasonably good job of debunking the Republicans’ criticisms of the CBO. Any citizen paying attention can discover that although fewer people enrolled in the Obamacare exchanges in 2014 than the CBO predicted in 2010, the CBO correctly forecast that the uninsured rate would fall by about half and that employers would not stop offering health insurance. The attentive citizen can also discover that the CBO’s predictions were more accurate than those of many other experts.

The media has also reported that Democrats leveled their own unfair criticisms against the CBO back in 2009 and 2010. Obama, Nancy Pelosi, and Max Baucus, to name just a few prominent Democrats, criticized the CBO for not giving the alleged cost-containment provisions in the Affordable Care Act more credit.

I want to make three points here that I have not seen made elsewhere:

(1) The criticism that both Democrats and Republicans make of the CBO consists almost exclusively of raw opinion, usually delivered in a huff, and almost never cites or discusses research;

(2) The CBO may have been off in predicting how many people would enroll in Obamacare and Medicaid, but it was accurate in predicting the failure of the managed care fads written into the ACA to cut costs; and

(3) Today, more than ever, America needs the CBO because the CBO adheres to the quaint principle that evidence should trump ideology.

Join Health 2.0’s Free Webinar To Hear the Potential Impact on Health Tech from Repeal & Replace

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Register for Live Webinar To Hear Experts Discuss The Future of Health Tech

In the last week, the Republican Congress introduced the AHCA. What does this mean for the health tech industry, and how will this impact the growth rate of health technology?

Join Health 2.0’s Indu Subaiya and Matthew Holt as they tackle these questions and more with policy expert Josh Seidman from Avalere Health during the Repeal and Replace: Impact on Health Tech Webinar on March 23, 2017 at 10 AM PST.

Get the latest perspective on what the repeal/replace will mean for startups/entrepreneurs, whether companies will benefit from these changes, and if Medicaid is cut, what does it mean for hospital spending?

Space is limited so register today to secure your spot for the free webinar.

Deepa Mistry is the Operations & Marketing Manager of Health 2.0.

Dinosaur-Driven Health Reform

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I grew up during the last great age of Jurassic parenting.

We called our Dad “T-Rex” because he was the ultimate alpha predator with a big mouth, sharp teeth, limited peripheral vision and small arms that prevented him from doing any housework. His home was his castle.

Our dining room table was his bully pulpit, and fact-checking was an act of sedition, prohibited when he was on a roll. On occasion, a courageous teen would put his college education to work to question my father’s draconian position on the war in Vietnam (“Bomb the NVA back into the Stone Age”) or social protest (“America, love it or leave it”). My father would listen incredulously and then ruthlessly suffocate the nascent rebellion like a banana republic dictator.

My father is no Archie Bunker. At 86, he’s lost a step and repeats himself, but he still understands Keynesian economics. He’s a tried-and-true carnivore capitalist who borders on being libertarian. He has an IQ of 170, and in his heyday he was the regional CEO of a large ad agency. But he has major blind spots and a black-and-white view of the world. His reptilian brain is in fear mode thanks to Fox News and a world that has been reduced to a dozen meds and 3,000 square feet. Before the election, he was angry—always interpreting any action by Obama as a sign of a decline in the values and ethic that made America great. His contradictions would come fast and furious:

“No, I don’t want immigrants. Oh, yes, I do love my immigrant caregivers.”

“I hate socialized medicine, but I love Medicare and don’t want to pay more for it.”

“Bush Jr. was an idiot, but Obama is worse.”

When I listen to Donald Trump, I hear my father.

And the Democrats Wonder Why They Lost the Election?

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Now I have insurance. But I can’t use it. What am I supposed to do? I know this one is long but it’s worth a read if you want to understand issues pertinent to the Affordable Care Act. My personal story illustrates many of the problems with the ACA.

I started taking notes on the Health and Human Services Secretary hearing, and I will share more as I scrutinize the hearing in more detail but let’s start with the breakdowns below and my experience with Obamacare.  Here goes:

These are the breakdowns of who gets what coverage in the United States:

Medicare 18% – 52m

Employer 61% – 178m

Medicaid 22% – 62m

Individual 6% – 18m (exchanges cover 4% of the 6%–these are the people who have been forced onto the Obamacare plans)

Note: this writer is in the BOTTOM of the barrel here (Individual). Most of the individuals in the “Individual” category are either the upper contingent of the working poor, those who work for small businesses like restaurants or family owned grocery stores and the like that don’t provide health insurance benefits (more and more common these days), and/or sole proprietors like myself. Many health care providers are self employed hence we have been forced into the Obamacare exchanges if we are not high earners. High earners won’t buy on the marketplace and will purchase individual plans outside of the marketplace.

Whether They Like It Or Not, The GOP Must Repair Obamacare

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It’s very possible that the pejorative “Obamacare” could become the even more pejorative “Trumpcare” in a very short period of time. That is because Trump’s and the GOP’s promise to repeal Obamacare — the Affordable Care Act (ACA) — has already hit a snag called reality.

Reports are now circulating that the much-promised repeal of the health care law (60 plus House and Senate votes since 2010) won’t take effect until at least 2019, after the mid-term elections. The excuse is that it’ll take that long to figure out an alternative and get it into place. But congressional calendars and political expedience have nothing to do with the health care market. And without action early in 2017, the health insurance exchanges could collapse in 2018 or sooner — leaving millions without insurance, millions more without protections from pre-existing conditions, and possibly millions more cursing Trumpcare. The only constructive solution is to repair the ACA before, ironically, repealing it and then replacing it with a brand new, untested experiment in 2019.

Unpacking the 21st Century Cures Act

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President Obama signed the 21st Century Cures Act into law this week.  It’s the largest piece of health legislation since the Affordable Care Act.   No doubt you’ve heard or read that—and it’s true. 

But while the legislation was three years in the making and much hyped, it became the best recent example of that old saying that passing federal laws is akin to sausage making:  You don’t really want to watch what goes into it.

(An aside:  I made venison and bacon sausages from scratch for the first time this year and can attest to the “visceral” nature of that exercise.) 

There’s something for almost everybody in this new law.   That’s one reason it was the most lobbied health bill since the ACA.  In particular, the pharmaceutical and medical device industries were big winners.  Fifty-eight drug companies, 24 device companies and 26 biotech companies lobbied the bill, spending close to $200 million altogether, according to a Kaiser Health News analysis of lobbying data compiled by the Center for Responsive Politics.

What they got:  a big nudge to the FDA to find ways to approve drugs and devices faster.

For example, one change in the law allows FDA to accept as proof of safety and effectiveness less rigorous clinical trials, as well as other types of studies and data—both for the initial approval of drugs and to authorize new uses for drugs already on the market. 

Letter from Washington:
Don’t Jump … Yet

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Washington, D.C. hardly seems like a town on suicide watch.

As November turned to December, from the venerable Old Ebbitt Grill near the White House, to Charlie Palmer Steak at 101 Constitution and over to The Capital Grille at 601 Pennsylvania, revelers abounded, in both food and drink.

At the Capitol Hyatt on New Jersey Avenue though, some contrasts were evident. While contestants from the Miss World 2016 pageant moved in and out of the upper lobby to awaiting buses, in the lower-level meeting rooms, also from November 30 to December 2, the mood was hopeful optimism meets whistling past the graveyard.

There the Jefferson College of Population Health summit brought forth Andy Slavitt, Michael Leavitt, Farzad Mostashari, NCQA President Peggy O’Kane, former advisors from the George W. Bush and Obama administrations, officials from Johns Hopkins, the Henry Ford Health System, Brookings, Deloitte, AMA, AHA and the American College of Physicians and many more to dissect MACRA and ponder “population health strategy under the new administration.”

The consensus on where value-based care (VBC) is heading?

Wait and see.

Keeping Medicare’s Promise

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screen-shot-2016-10-14-at-8-43-48-amSo, you decided to come to Washington to see what was new and how things might be changing… I am sure we did not disappoint.

I am honored to have been invited to address this summit, which I’m sure will be your first of many. It’s a certainty that making our delivery system work better for patients and spend money more wisely will always be in season no matter which party is in charge. And, while many new approaches and changes may come to bear, ultimately health is not a partisan issue.

However, I do hope you all think of a better name– the MACRA MIPS/APM summit sounds like the world’s hardest word scramble. We’ve tried to make MACRA more accessible by naming it the Quality Payment Program… something to think about.

Looking at your speakers today, you have gathered some of the most experienced people across the country focused on the most difficult health care problems we as a nation face. Simply put, how to complete the changes we have begun to make the system more patient centered and accountable. So today, I come here to add my perspective to this discussion and continue to ask for your valuable help.