Engaging Responsibly In the Health Care Debate

flying cadeuciiWith no apology offered, I will be venturing into a very subjective realm, namely, a characterization of today’s healthcare dialogue and what, in my opinion, might be an improvement.

I would suggest we have fallen into the trap that was partly enhanced by email and blogs, namely, that we can say outrageous things impolitely and without consequence.  With email we tend to be much blunter and impolite than we would be face to face.  On blogs, we can be positively toxic.  It’s like driving in a car with a tinted windshield that no one can see through.  You are anonymous and therefore can act less responsibly.

Another vignette.  I grew up in a very small upstate New York town where everyone knew everyone else.  You used your car horn to beep “hi” or to warn, and not in anger, ever.  When you waved at someone, it was with all five fingers.  And so on.  I think you get my point.

The healthcare debate always has stoked emotions like almost no other.  It is intensely personal, and the stakes are high.  We’re all involved and engaged.

As I’ve written in the past, I first earned my stripes as a lawyer representing my local Blue Cross plan in rate hearings.  These rate hearings always started with “public comment.”  The comment ranged from pure outrage to controlled anger to discontent coupled with suggestions.  What did we pay the most attention to?  Of course, the latter.

In healthcare, this really got rolling in 1993-94, when the Clinton Administration tried to reform healthcare.  Derek Bok has an informative description in Chapter 9 of of a larger work entitled “Public Discourse in America” (Rodin & Steinberg, 2003), where he states that “Interest groups spent large sums communicating with the public, but most of their efforts seemed designed less to inform than to arouse latent fears and anxieties and to reinforce existing views.” One of the points of the larger treatise was to point to sports, where outrageous, disrespectful behavior seemed to be accepted and rewarded.  Actually, as a survivor of the 60’s, I can recall how some of my contemporaries learned that outrageous protest got the most traction.  I think it’s called, “the squeaky wheel gets the grease.”

Before 2010, it was bad enough, but then came Obamacare.  The debate, usually divided by party lines, covered no one in glory.  Each side engaged in dreadful misrepresentations.  This escalated into what I call “cartoonization.”  My English teacher would hang me for that one (verbalizing a noun so to speak).  Our President recast the issue from health care reform to health insurance reform.  That unfortunate switch also switched the focus from the delivery of healthcare to its financing.  While financing is important of course, it’s the cost of what we’re financing that has gotten us to where we are today.

So, we had insurers portrayed as the systemic evil.  And from the other side of the aisle, such healthcare experts as Sarah Palin suggested that reasonable end of life initiatives such as living wills were “death panels.”

The idea, not dissimilar to the purpose of a good blog, is to advance intelligent debate on important issues.  That means an exchange of ideas.  Not just one voice howling at the moon.  Usually, with an exchange of ideas comes better perspective.  IF one is listening.  What seems to have happened is that a lot of people are writing vociferously, but not really considering the offered criticisms or alternative views.  THAT is unfortunate, because when that happens, no views are enhanced.

There is a fine article on line by Henry Doss titled “Healthcare Debate in US:  Can We Talk?”  He states:

“The national dialogue is about payment systems, and it should be about cost.  The national dialogue is about expense, when it should be about consumption.  And the national dialogue is about who merits what when it should be about dignity and human autonomy.”

He suggests that our national dialogue is grounded in the absence of trust, and that some degree of trust is needed to move us to the next level.  I applaud and agree with that.  Trust that the critic is coming from a good faith basis for disagreement and that he merits an informed response.  Or as we say in the mediation business, the rules of courtesy and respect will be enforced.  So…

Step One:  Perhaps to start here on this Blog.  It is appropriate to be critical of or even eviscerate a particular aspect of our current healthcare “system.”  But it is irresponsible to do so without also offering partial or complete solutions.  If you are smart enough to eviscerate something as complex as an aspect of healthcare, you also are smart enough to consider, evaluate, and propose solutions or paths to solution.  If you were my Vice President in charge of [fill in the blank] and came to me with a problem or a complaint, I would not hear you out unless you also offered its solution.  A not uncommon business practice.

If you were to do an informal sampling of blogs on healthcare, the angriest often are from physicians.  Understandable given what has been done to the profession over the past 40 years.  BUT…we all  know that physicians usually are the smartest men and women in the room.  They owe us and themselves more than bare criticism.  It IS their system.

Step Two:  People, whether elected officials, providers, insurers, consumers, or bloggers, should take strong positions on healthcare issues.  Commendable.  But there is a developing trend that when such people are criticized, they become immediately defensive and the quality of their responses (if any) suffers.  I have been guilty of just that.  But we have to move beyond that.  Our responsibilities to the “system” demand that we do.  We must take criticism as a huge opportunity to test out the validity of our position.  Welcome it.  It is your opportunity to take your theory out for a ride, albeit on a bumpy road.  Does it work?  Does it need fine tuning?  Maybe it’s good to find out whether you can (with facts and respectful dialogue) successfully respond to the criticism.  Assuming the good faith of the critic for the moment, others may well harbor the same criticism.  Thus you have to deal with it.  Either the critic was wrong, partially right, or right.  Without respectful and thorough dialogue and exchange, you’ll never really know.

This issue is causing buzz.  Huffington Post has an article titled “How to Have a Rational Debate About Healthcare Reform.”  Its suggestion:

It’s easy to demonize those who disagree. We have to stop – right now. People who disagree with me or with you don’t hate America. Nor do they hate the poor. They don’t hate insurance companies, they don’t hate sick people, and they don’t hate capitalism. It’s a myth that only one solution is available or that we can’t disagree about what to do. We should debate this; we should argue with each other passionately. That’s what Americans do.

There was a great 1980 song by Pat Benatar called “Hit Me With Your Best  Shot.”  Appropriately released on her album titled “Crimes of Passion.”  It might be our new anthem in the healthcare dialogue. A welcoming of your best shot (delivered respectfully with positive suggestions to correct) such that I may be better informed.  That I may be saved from a mistake.  That I may write a better article or make a better proposal next time.

I earnestly hope this didn’t sound overly preachy.  But too often I don’t see the constructive back and forth amongst clearly qualified commentators with the goal of reaching a better position.  Perhaps not complete agreement, but a clearer view.


18 replies »

  1. Oh, for crying out loud.

    This article started becoming difficult to read somewhere mid title.

    I am sorry but, in the context of the train wreck called the American health care system, this article is just irresponsible for being irresponsive.

    Could we all take a trip on over to truecostofhealthcare.net where we will be met by Dr. Belk who will say:

    “Hello everyone.  Once again, it’s time for another case study on how our health care industry is robbing us blind.”

    Kudos to Dr. Belk. And to Dr. George Dawson, psychiatrist, for his comment below.

  2. Anish writes: “Hopefully, my smarter, more experienced colleagues who are actually doing direct primary care can help me out.”

    Barry has artfully changed the subject from what needs to be done to blaming the physician for the problems we face. [“I think the doctors should take the lead on that.”] He believes that because the physician is the one that leads to hospital admission and testing that the physician should disavow his responsibilities to the patient and work for the government to cut costs (…and to the h-ll with the patient). That of course, is ridiculous.

    Take note that none of the three suggestions by Barry actually reduces the actual costs of healthcare rather they support a program that has increased cost and disadvantaged the majority of Americans while reducing the effectiveness of our healthcare system now and in the future.

  3. James I am enjoying your articles. In 1975, there were about 2000 companies selling true health insurance in the US…ex supplement policies like AFLACs portfolio. I know huge numbers have gone out of the business: NY Life, Mass Mutual, Metropolitan, Prudential, Mutual of Omaha, etc etc etc. They all exited the business because they couldn’t charge enough premium to cover their claims costs. Do you have any idea how many companies including HMOs are selling true “under age 65” health insurance?

    If you care to answer directly my email is temerick479@gmail.com


    Tom Emerick

  4. I want to say this as politely as possible.
    This statement is misleading:
    “Our President recast the issue from health care reform to health insurance reform.”

    That “recasting” occurred during and as part of the legislative crafting process. It happened when the public option was shouted down. And the opposition did not come from the president. It came from the insurance industry. The individual mandate was not enough. As my mother used to say, they wanted the whole hog and wouldn’t settle for the hams.

    A public option would have furnished an escape for those unable to afford private insurance. It would have been less costly (minimal advertising, no sales commissions, no executive bonuses and a thrifty administrative alternative measured against the medical loss ratio metric).

    Yes, I’m talking about a kind of Medicaid/Medicare-for-all option. But that idea, sensible as it could be, was DOA, not because the president preferred, but because the private insurance lobby made it go away. All the president did was clarify what had already been done. (I have no doubt that in this forum the notion will get little to no consideration either, but I want it noted for the record.)

  5. All excellent questions/comments. I would never deign to form health policy by myself – so I don’t have good answers for you. Hopefully, my smarter, more experienced colleagues who are actually doing direct primary care can help me out. Here’s a link – https://www.bostonglobe.com/business/2016/04/19/primarycare/KWhFenipdotfHFN0ZZZhrN/story.html.

    Certainly I don’t think there’s a one size fits all solution – and I didn’t mean to suggest direct primary care would solve every problem with the current health care system.

    I will say that the ACA was sold as a health care expansion that would cover folks, and curb costs. It would be paid for because it would bend the cost curve. While it is certainly good that people now have health insurance that didn’t before – is it wrong to point out that the cost curve has bent up as a result, and that the job of physicians has become harder as a result? Should this not send policy makers back to the drawing board?

    With regards to cost, I am on much firmer footing. While there is certainly waste, and even fraud that we must go after – it would help to have an honest conversation about costs. A tweet being passed around by cardiologists over the weekend talks about the magic of placing a transcatheter aortic valve in a 95 year old who went home 48 hours later. A patient that was non-surgical a few years ago, now goes home with a valve placed without major open heart surgery. It certainly is miraculous – but miracles in healthcare don’t come cheap. Are we ready as a society to start saying no to patients like this? Who is going to say no? II know it won’t be the politicians.

  6. Three relatively simple ideas to improve the ACA are (1) significantly tighten the rules around the special enrollment periods to cut down on gaming the system to get needed care and then drop the insurance, (2) make the income verification process much more robust, and (3) eliminate the income ceiling on eligibility for a subsidy so nobody has to spend more than 9.5% or maybe 10% of modified adjusted gross income for health insurance.

    The age rating bands could also be increased from 3 to 1 up to 6 to 1 which would more accurately reflect actuarial risk. Younger people would pay less and older folks would be protected by the 9.5% of income ceiling that must be spent for health insurance before subsidies kick in.

    I would also be fine with high risk pools if we are to return to medical underwriting. However, adequately funded high risk pools would be significantly more expensive than politicians appear willing to fund. The pools that existed in the pre-ACA days were grossly inadequate and 15 states didn’t offer them at all.

    If taxes have to be raised to finance high risk pools and / or broader income eligibility for subsidies, so be it. There’s no free lunch. All of my suggestions relate to covering the cost of health insurance. For reducing the cost of or slowing the growth in the cost of actual healthcare, I think the doctors should take the lead on that. They’re the people with the most expertise. Let’s hear from them.

  7. Anish – I would be open to any number of changes in or replacements for the ACA as long as, at the end of the day, they work for the unhealthy, the already sick and low income people who need subsidies to afford the premium. Unfortunately, from what I’ve seen so far, republicans are all about ACA repeal but their replacement ideas, to the extent they have any, don’t come close to meeting the criteria I suggested they need to meet.

    I don’t know enough about the direct primary care model to comment on it in any depth but as a patient, my questions would include the following: (1) how much is the typical monthly fee if that’s the way payment is structured, (2) does it include tests like x-rays and blood work, and (3) how high would the deductible typically be for the catastrophic care plan that it’s paired with?

    Healthy people might balk at the monthly fee and, if you need hospital based care or other care outside the scope of DPC offering, those costs have to be paid out of pocket until the (high) deductible is reached since the DPC fees don’t count toward the deductible because they are not submitted to an insurance company. Low income people, for their part, might not be able to afford the monthly DPC subscription fee or the high deductible that comes with the catastrophic insurance plan unless they are subsidized.

  8. For the sake of argument, let us say the ACA costs 1.9 trillion dollars. Let us say it is unfunded. Let us also say that it mandates value based payment and alternative payment models that don’t actually improve outcomes or reduce cost , but do threaten the independent practitioner. Let us also say that the the single reason health care cost increased in 2015 relative to the prior 4 years was due to expanded enrollment in Obamacare.
    All of those statements are unfortunately true. I voted for the ACA under the premise it would expand coverage and reduce healthcare spending via some handwaving value based reimbursement. The current folks in charge of course see no problems with the ACA..so there is little hope anything will be fixed. There are other solutions.. Ask Paul below. What about a direct primary care model + catastrophic insurance coverage (currently not allowed by the
    ACA).. This conversation unfortunately doesn’t take place among the current policy talking heads. So when folks talk about repealing the ACA I shrug my shoulders – there are certainly large parts of it we could do without. Addition by subtraction?

  9. @RogueRad – While I think I hear you, let’s look at the argument in the context of the ACA. Most people who lacked health insurance before the ACA was passed either couldn’t afford the premium even if they were healthy or were unhealthy and already sick and couldn’t pass medical underwriting.

    Now, thanks to the ACA, we have 20 million people who either have Medicaid after expansion of that program or have an ACA exchange plan with help from large subsidies to pay the premium. At the same time, we have quite a few healthy folks who can no longer buy inexpensive underwritten policies including some with very limited coverage and we have still others who previously chose to remain uninsured but now, in many cases, have to pay a penalty / fine for doing so.

    The healthy people want to repeal the ACA and either return to the old status quo or maybe go to a system that provides age-based tax credits that would pay for most of the cost of a medically underwritten plan for a healthy applicant. The fact that their alternative no longer works for the unhealthy, the already sick and many of the lower income folks isn’t their concern.

    I would suggest that any alternative to the ACA has to work for the unhealthy and already sick as well as those who can’t afford insurance with or without age-based tax credits. Adequately funded high risk pools might be one alternative but they wouldn’t come cheap. In fact, they would be pretty darn expensive. If the alternative approach doesn’t work for those who need insurance the most, it’s unacceptable in my opinion.

    I note that in Switzerland, which probably has the model that would be the closest fit to our culture, 45% of the population qualifies for a subsidy. Everyone buys insurance on a community rated basis with some leeway to choose their deductible and there is no such thing as Medicare or Medicaid so the premium for a given level of coverage in a given canton is the same for everyone over age 25 and is only slightly lower for the 19-25 age group.

    So, the ACA is not like the malaria vaccine that doesn’t work or the EHR system that doesn’t work. It does work for those who need health insurance the most and couldn’t access it before. Under those circumstances, it’s perfectly appropriate to ask those who want to repeal the ACA, what’s your alternative?

  10. The MOC “debate” provides the perfect example of why things have become “uncivil”. A request for reconsideration of onerous, expensive and arguably irrelevant certification requirements was met with extreme arrogance and dismissal. The “debate” got more heated with more traction. This was met with even more arrogance. Now you have physicians who want to basically eliminate the ABMS with extreme prejudice. That type of resentment has to be cultivated. Vitriol and embarrassment are some of the only things you can use when dealing with concentrated unaccountable power in the absence of real engagement. The ABIM had to fold because they were repeatedly framed as corrupt and self serving. That, and many physicians were going to walk away.

  11. With all due respect Mr. Purcell I don’t think you have given the corollary of your premise sufficient thought. Think about it a bit more. You don’t need an alternative to eviscerate an idea. A bad idea can be a bad idea for its own sake. Otherwise change is always good for its own sake and status quo is always bad for its own sake.

    Imagine someone proposes a vaccine for malaria. There’s only one problem with the vaccine, they say. It doesn’t work. In defense the manufacturers say “I know this vaccine doesn’t work, but what’s your alternative?” Would you buy that argument? Would you produce the vaccine en masse and distribute it en masse, just because there is no alternative?

    But we seem to buy this argument. “I know EHRs, with meaningful use requirements, didn’t achieve interoperability. But what’s your alternative?”

    Even statins have more rigorous evidence than some of the healthcare policy. It is precisely because policy ideas escape scrutiny because of the “what’s your alternative” shield which you so gallantly defend, that they fail so often and fail so miserably.

    For further exposition here’s a piece.


  12. Hmmmm…I’m trying to follow you but failing. If you have the information/knowledge to eviscerate something, you surely have the information/knowledge to then move on to constructive alternatives. I agree that bad ideas deserve resection, but then what? So, I respectfully disagree.

  13. Lack of civility is just part of the problem. Yes, it is true that people seem not to have the ability to tackle the ball, not the man. The other problem is that people take attacks on their ideas very personally. You attack their premise, in return they’ll call you an idiot for attacking their premise.

    The whole healthcare debate strikes me as hypersensitive and self righteous. For example: “How can you question the number of deaths caused by medical errors? Don’t you care about patients?” See the response to Anish Koka’s post “Very Bad Numbers” or the responses to Lisa Rosenbaum’s series in the NEJM on Conflict of Interest and Pharma.

    The problem bigger than lack of civility are the moralizers, who bring the uncertainty of the scientific debate to the level of religious absolutism.

    Ideas, Mr. Purcell, should be eviscerated. Ideas can’t hide in the cloak of nobility. Don’t you wish meaningful use was eviscerated? The EHR goals were eviscerated?

    The notion that you can only criticize something if you have an alternative is utter balderdash. Note, Mr. Purcell I’m criticizing your premise, not you, and while I trust you’re smart enough to make that distinction, others aren’t. This assumes that doing something, even badly, is better than nothing. This is a false assumption which inverts the burden of proof.

    Here is an example.

    Critique: measuring surgeon’s performance using 30-day mortality is flawed.

    Defense: what’s your alternative?

    You see the problem? The assumption is that change, any change, measurement, any rickety measurement, is always better than status quo.

    Eviscerate ideas. Let the generators of those ideas develop a tougher hide and sharper intellect to defend those ideas. I’m tired of hearing the only defense to patent nonsense being “what’s your alternative?” How about absence of that nonsensical idea?

  14. I think that you are starting out from a false premise.

    There really is no debate – the government and big business have won. Physicians have been outmaneuvered at every step of the way. It has reached such absurd proportions that our own professional organizations – the same entities that we pay rather steep dues to – echo all of the big business and big government platitudes and no longer represent front line physicians doing all of the work.

    The problem has always been that the people who “manage” health care and make all of the decisions know very little to nothing about it. That has been amplified exponentially by the proliferation of a class of managers who are as superfluous now as when they were not needed 30 years ago.

    As far as I can tell the only recent healthy innovation has been the effort to get rid of ABMS initiated maintenance of certification. That is probably a symbolic gesture against business and government and if it succeeds at a wider level – it may give physicians the confidence and rationale to successfully push back against the real problems in government and management.

  15. I’m not a physician, (although I once was a licensed clinical psychologist provider…now an organization psychology consultant)…..but in my view the entire profession of Medicine is (and has been for a long while) being massively transformed….perhaps even assaulted….in a way that deserves….maybe even requires…..passionate push back. If someone forcibly breaks down your door and enters your home civility is not the appropriate response.

  16. Appreciate this call 4civility & constructive suggestions in healthcare debate

    Like with everything else, recent calls of civility in every domain will gain traction only if practitioners seem > successful than a-holes

    via TweetBot

  17. Great, calming attitude Jim. Thank you.

    If we step way back, what we are trying to do in this health care sector is to allocate both science and art to a yearning public. They cannot wait and they deserve service for all the cash they have thrown our way. We shouldn’t even try to regulate the art part of this as it then vanishes. Eg some of the outcome indices in health care are art. We have to ignore these, other than to try gently to get prices down. Gently I said. The scientists are going to have the upper hand for a few more thousand years, I think, what with their molecular biology. Good for them and us. But, in the meantime how can we get them to lower their prices down a little? Each new scientist with an invention wants to be famous and rich. What is wrong with this? The Wrong is that it can stop cold the engine of allocation, just like glue in the gas tank. So if you are a scientist in health care and you invent a tremendous new device like an extracorporeal membrane oxygenator–an artificial lung–you are going to have to face SOME societal restrictions on some of your activity. Too bad : maybe the U.S. Patent has to be shorter or the device cannot be marketed without more proof of utility; or we have to allow the generic folks to rush in very soon; or you cannot take profit for a certain number of years until the price nears marginal production cost; … or something. This is why we need calm thought without emotions. We need answers from lots of brains. We really should use the old Delphi technique here: Everyone gets to speak and no one gets criticized… for awhile at least.

    I have picked this technology imperative as an example
    because it is less laden with emotion…but you get the point.