Repeal + Replace

Not Normal Chaos

The short version of Vox’s Sarah Skiff on “Why Republican disarray on health care doesn’t doom repeal efforts” would read something like: “It always looks this way in the throes of preparing major legislation. Remember how wild and confusing it was when the Democrats were trying to put together healthcare reform in 2009? Joe Lieberman was insisting on a public option, ‘pro-life’ Democrats were insisting that anti-abortion language be written in? Just because it’s chaotic doesn’t mean it won’t get anywhere.”

She’s right, of course — and she’s wrong in a significant way: In 2009 Congress was debating different policy approaches and the tradeoffs involved. There was never a question whether what they were attempting was possible, just whether it was possible to find a political compromise that could garner enough votes to pass. This meant that it was reasonably predictable that they would come up with something they could call “healthcare reform.” 

Congressional Republicans are up a different creek right now: What they are attempting is mathematically impossible. The things they and President Trump have promised do not add up. Literally. Their problem is arithmetic. Getting more people covered, with better coverage, with lower deductibles and out-of-pocket costs — all that will cost more money, lots of it. Getting rid of the tax penalties for not having insurance (the “individual mandate” that is the most-hated part of Obamacare) and the taxes built into Obamacare on wealthy people and on segments of the healthcare industry — all these will cost the government revenue, the very revenue it would need to pay for the better coverage of more people. All this while they aim to cut taxes and lower the deficit. And of course they have on every Holy Book within reach that they will repeal Obamacare, so they can’t just leave it in place. This means it is highly unpredictable what they will come up with, or that they will come up with anything at all.

They are indeed in a place of chaos. But it’s not, as Skiff would have it, the usual chaos of constructing complex legislation. This is unusual, special chaos. In a class all it’s own. Really amazing chaos, chaos like you wouldn’t believe. 

This is the era of smoke, sand and fog. If there were a more “high variance” time in healthcare in these last 37 years that I’ve been covering it, I don’t know what it would be. I suspect we will continue in a state of confusion and chaos for some time now, maybe several years, with two caveats: 

  • The bounds of possibility will narrow as we move forward. Right now they seem to include everything from a full single payer system to complete abandonment of the ACA with no replacement at all, considering the wide gap between Trump’s expansive but vague promises; the Congressional Republicans’ conservative principles of smaller government, lower taxes, and lower deficits; and the rather hard, cold problem of arithmetic. As Congress begins to try to actually shape legislation, we will begin to get a better picture. I suspect, though, that between the difficulty of the problem (both politically and economically) and the fact that the new President’s negotiating style relies on lobbing grenades to continually shake things up, taking abrupt turns, and wrong-footing one’s counterparties to get the best deal, I suspect that the process of getting to final legislation will be considerably more protracted and chaotic than anyone hopes for. 
  • Importantly, the underlying trends of healthcare in demographics, economics, and technology will still hold. The push on the industry to provide more value for less is not rooted only in Medicare and Medicaid and other government-mediated healthcare. In fact, the strongest movers have been the self-funded employers, pension plans, and unions willing to get radical in searching for real value for their employees and their bottom lines.

Republican legislative initiatives and executive actions may bring us more chaos or less, faster or slower, but they are unlikely to stop the massive evolution of healthcare forward as its customers demand more value and the industry grudgingly re-arranges itself to provide it.

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Joe FlowerBobbyGvegasbobsmithWilliam Palmer MD Recent comment authors
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BobbyGvegas
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Unhappily, Peter Frase’s “Quadrant IV” may be drawing nigh.

bobsmith
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bobsmith

@William Palmer. Good observations. Everyone, including docs, talks about the need to control spiraling healthcare costs. The elephant in the room no one seems to talk about is that a big part of the solution is probably fewer or lower paid providers. Another culture problem is that decades of “invisible” employer-sponsored insurance has created the entitlement feeling that everything should be covered – routine as well as unplanned events (what insurance is really about, by definition). Regarding this article, when someone mentions all the unicorn promises made by the current president-elect and Congress, someone across the table says “Yeah, and… Read more »

Joe Flower
Member

> someone across the table says….

This is an example of what I saw someone label “whataboutism” — the rampant tendency to deflect all rational discourse by pointing to something someone else did or said that didn’t work out. It’s just a way of making sure that you never have to address the actual question.

bobsmith
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bobsmith

@Joe – I agree with both of your responses. While it is true that there will be an increase in demand for certain roles, it will still be pretty darn disruptive for the current generation (or two) of specialists already out there.

On your second point, I was marking the folly of listing unreasonable promises by politicians. They do it all the time, from both sides, and pointing it out will do little to convince an opponent of anything. Actions are what matter, and we will see.

Joe Flower
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> a big part of the solution is probably fewer or lower paid providers

Yes and no. In aggregate, obviously, healthcare that costs half as much will not be employing as many providers or paying them as much. At a granular level, no. An ideal lower-cost system would likely employ more people in certain areas, such as primary care, gerontology, early child wellness, and population health management, while employing fewer high-end specialists, especially those whose business model consist of doing expensive procedures of questionable value.

William Palmer MD
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William Palmer MD

There is a doc at UCSF who gives occasional lectures on the comparative world health care systems (mostly OECD). She keeps saying that we are all doing about the same thing medically and that all these alleged mortality and morbidity faults with the US are hooey. Anyway, what she concludes is that the US providers do make more money than their peers in other countries–both docs and hospitals– and that there are many more administrators here. Assume what she says is true. Then, what we have in the US is a sort of cultural problem in the way we view… Read more »

Joe Flower
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I would guess is that what she means is that the outcomes of our medical procedures are about the same, which means that the large differences in mortality and morbidity mostly come from things outside medical care, from social inputs, from lack of access to medical care, and so on. I’m not sure what you mean by “fiddling with … value.” Perhaps you mean that epicycles that have been added onto the fee-for-service model that gently encourage the system to give greater value. If we move to a true value-based system, an array of non-fee-for-service methods of payment that pay… Read more »