Brexit has been hailed as a turning point in the history of Western Democracy by a collection of liberal and conservative elites that decry the vote of a disenchanted and ignorant populace. The greatest threat to democracy in the modern age turn out to be the very same people that make up the democracy. We are told these are the same forces that propel Donald Trump forward. It is a convenient narrative that extinguishes any real debate on policy. If you support Brexit or Donald Trump you are an uninformed, xenophobic bigot. Yet here I am – an Indian immigrant, a physician, and a lifelong democrat to boot, who sees no other choice than Trump this election cycle.
I must confess that I have no emotional connection with Mr. Trump – his public demeanor, braggadocio, and above all, the coarseness of his manner when he engages opponents are not what are familiar or soothing to eye or ear. Yet, as a physician who has struggled through the last eight years of policies and regulations that have made my ability to take care of patients more and more difficult, Mr. Trump has taken on the form of an orange-tinged life preserver.
I’ll preface this by saying that I am a liberal who voted for the beautiful dreams of of the rhetorically gifted Barack Obama. There were too many people who did not have insurance, and health care costs were absurdly out of control. The silver tongued promise of health insurance for all that would also be cheaper for all was the pipe dream I fell for. And boy did I fall hard. It took me years to realize, in somewhat nauseating fashion, that the policy makers never had a clue. Much is made of a Trump presidency being akin to giving a teenager who doesn’t know how to drive keys to a Maserati. That’s funny, because in retrospect, that is exactly what happened eight years ago.
The signature achievement of President Obama – Obamacare – has had a massive impact on patients and physicians. For patients, more people than ever have health insurance coverage. Yet the quality of that coverage – by design – has meant an ever greater share of health care costs is now borne by patients. Since 2010, deductibles in employer sponsored plans have risenseven times as fast as wages.
The lowest tier obamacare plan for a 40 year old costs ~$300/month along with a $6,000 deductible. Since the penalty for not signing up for health insurance is considerably less than this, is it any surprise that those enrolling in Obamacare are sicker and pricier than expected? As more insurers exit the marketplace, and since the real causes of high health care costs were never addressed, even steeper increases in Obamacare premiums are promised in the years to come.
From a physician standpoint, the early hopes of being the change you believe in have been dashed time and time again. The first clue that the current administration was long on intent but hopelessly incompetent in implementation was the stimulus package known as the electronic health record (ehr). While it may have been a success as a stimulus package, it is a good example of a well intentioned policy run amuck. Almost $30 billion in incentives were appropriated in 2009 to incentivize physicians and hospitals to use an electronic health record (ehr) ‘meaningfully’. This seemed like a good idea, but it became quickly apparent that the meaningful use criteria were anything but meaningful to physicians or patients, and many small practices were simply unable to comply. Now after spending billions of federal and private dollars to implement the ehr, practices and hospitals are stuck with clunky, poorly designed systems that are meant to bill and comply with regulations rather than help physicians take care of patients. John Halamka, Chief Information Officer at Beth Israel Deaconess notes of current EHR vendors:
“They are devoting their resources to creating software which adheres to the thousands of pages of regulations introduced over the past few years. One major vendor noted that their programming staff is already booked for the next 32 months just to ensure compliance with existing regulations. The small amount of free bandwidth that incumbent vendors had reserved for innovation has been co-opted by regulation.”
Unbelievable, the lessons of this abject failure are lost on the current leadership which continues to think the problem with Health IT is not enough mandates.
Sticking with the theme of well intentioned policies that don’t work, 2010 saw the administration push through the Affordable Care Act (ACA), or Obamacare. The major thrust to lower health care costs was to unleash an alphabet soup of bundled payment programs – Accountable Care Organizations (ACOs), Patient Centered Medical Homes (PCMH), Comprehensive primary care (CPC). While some pioneer providers have participated in these programs and received generous payments from the government for delivering ‘value’, there is little to suggest that any of these programs will fulfill the original promise to bend the cost curve. Indeed, after flattening of the health care cost curve relative to GDP growth from 2009-2013, CMS economists noted health care costs rising again in 2014 driven mostly by enrollment in the ACA. Apparently subsidizing most of the new enrollees in the ACA costs money. The response from the current administration to these failed programs has been to double down and – I’m not making this up – combine acronyms. So now we have the CPC + ACO model being sold as the next magical construct by former regulators turned entrepreneur’s.
It is in this climate that Medicare’s new payment system, the Medicare Access and CHIP Reauthorization Act (MACRA) was dropped on physicians. Perhaps the reason the national media did not pay much attention to what was actually in the document, was because the document is almost unreadable. Don’t take my word for it. Again, John Halamka, the current CIO at Beth Israel Deaconess, notes:
“the 962 pages of MACRA are so overwhelmingly complex that no human will be able to understand them”.
The attempt made here was to unify the myriad of prior payment schemes that exist, and lay out a timetable for transitioning from volume to value based payment. Recognize that the primary purpose of MACRA is to cut costs – there must be losers for there to be cost savings. In this case 90% of solo practitioners are estimated to be penalized (Table 1). Practices with less than 10 physicians are estimated to shoulder 70% of the total penalties. If I believed that 90% of solo practice physicians were delivering substandard care, I would be somewhat mollified, but in this case penalties accrue based on a physicians access to a performance improvement department, NOT based on quality.
The Obama administration, perhaps emboldened by well funded physician advocacy sitting on the sidelines have shown no willingness to fundamentally change course, but instead charge forward with giddy pronouncements.
Comment on the proposed rule they say, but the underlying message is clear. The fundamental pillars of the current system will stay, though they may throw some crumbs at patients in the form of tax credits to make the unaffordable care affordable, and at physicians in the form of fewer checkboxes to check off. It certainly is to be expected that those who designed the current system (with the insurance, hospital, and pharmaceutical lobby at the table) would double down at this stage. To do anything else would be to admit failure, and these are ideologues, less concerned with the best solution to problem, but rather their solution to the problem. This is unfortunately not a problem solved by commenting. If fundamental change is what one wants, this can only happen by firing the current group that guides policy. Ergo Trump.
While I certainly have misgivings about the bonafides of a real estate magnate turned reality star who has health care bullets rather than a health care plan, I take some measure of hope in Mr. Trump’s willingness to take positions in the health care space that suggest he is not an idealogue. He has taken heretofore liberal positions when it comes to taking on the pharmaceutical industry with regards to drug pricing, as well as maintaining support for universal health care. I realize much of what Mr. Trump says may turn out to be magical thinking but as one retired steel worker, (who was a life long democrat) puts it – “If he accomplishes 10 percent of what he says he’s going to do, then that’s 10 percent more than anybody else is gonna do.”
Much is made of the coming fascist state under a President Trump. I find most of this to be hyperbole on the scale of Glen Beck warning his followers of the muslim-stalinist state Barack Obama was going to usher in. Last I checked, over the last 8 years, folks are still able to buy AK-47’s to their heart’s content, and political opponents have not been herded into internment camps. I have great difficulty believing that the recent Democrat turned Republican who invited Caitlyn Jenner to Trump towers to use whatever restroom she may like will endanger the republic.
So come November, do the responsible thing – Vote Trump.
Anish Koka is a cardiologist in Philadelphia. Follow him on twitter @anish_koka