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.
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.
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.
The central force behind the creation of the bill was reconciliation–not a formed policy nidus. Since the ACA, invoking the use of it (for any possible purpose within the rules) has taken on a radiant glow. In this case, it made for a shaky foundation on which the R’s constructed the bill. And faulty policy followed.
I am too confident I believe, but in future sessions, the use of this limited tool will be preceded with, “The INSERT PARTY HERE would be wise to learn the lessons of the of GOP 115th and take heed. Careless legislating soils undergarments.”
A little rampant speculation here.
This moment, after the failure of Speaker Paul Ryan’s American Healthcare Act, is obviously a hinge point in Donald Trump’s Presidency and specifically in the future of healthcare in the United States.
If we are trying to imagine where this might go from here, a key question is: Can Trump learn? If he can learn, what might he be learning from this brutal experience?
Okay, okay, Trump is monumentally stubborn, hard-wired, and so on. See also: deluded. But in his career he has shown an ability to re-invent himself and adapt to realities, especially after his bankruptcies of the 1990s. When banks were no longer willing to lend to him, he found other (mostly Russian) lenders, re-shaped his business into deal-making trading on his outsize name, does the reality show thing to increase the cachet of that name, and so on. He can change, learn, adapt.
He just got whacked upside the head with a big clue stick. How he perceives the information carried by that clue stick might give us some sense of what happens next.
After consistently, literally for decades, backing universal healthcare of one kind or another (though without apparently really understanding the policy and cost implications), he campaigned for the Presidency on specific healthcare promises such as “We’ll take care of everybody, it’ll be way cheaper, you’ll love it.” For those who can’t afford it, he even promised, “the government’s gonna pay for it.” He repeated these promises even after his election. They appear to be something he actually believes in: Healthcare for everybody, inexpensive, with government help where necessary.
Then he won. This President famously does not get down in the weeds of policy and politics. He immediately delegated much of that weedy stuff to Vice President Pence, and the legislative part of it to Speaker Ryan. Starting in December he allowed them to lead him down a garden path to a bill that is the opposite of all his populist promises: Far fewer people covered, the poor much worse off, much leaner coverage, no real help for those who just can’t afford it.
Led by whom? Ryan and Pence, soon joined by his new Chief of Staff Reince Priebus and his new Health and Human Services Secretary Price. Trump agreed to back Ryan’s bill and Ryan’s process for getting it through Congress, apparently without really getting how opposite to his own instincts the bill was. According to the Washington Post, when Ryan introduced his bill on March 6, Trump asked his advisers, “Is this really a good bill?” — and continued asking the same question of them repeatedly over the coming 18 days, even as he ramped up the campaign to sell it to Congress and the American people. This shows in the nature of that campaign: He never campaigned publicly on the actual provisions of the bill, instead merely repeating his vague promises that it would all work out for the better. Even as he was trying his best to sell the hell out of it, he was realizing that it was a mistake, but by now he desperately needed the win.
In a March 15 interview, Fox News’ Tucker Carlson confronted Trump with the fact that according to analyses, the bill would be a huge tax cut to the very rich, while the people most hurt by the bill will be the very counties and populations that are his biggest fans. For once Trump did not try to misdirect or deny. He simply said rather sadly, “Oh, I know,” before going on to insist that the bill was preliminary, there was a lot of negotiation, that a lot of things would change when it got to the Senate…implying that it would change in a direction that would be less hurtful to his strongest followers
I found that amazing. This guy’s biggest goal in life is to be popular, admired, a winner. As a corollary, the highest value he sees in others is loyalty. These guys (Ryan, Pence, Priebus, Price) led him into a box canyon where he became the #BiggestLoser. And the Congressional Republicans, especially the Freedom Caucus, who repeatedly declare themselves his biggest fans, would refuse to stand with him.
His comments after the defeat were revealing in interesting ways. He of course said nice, complimentary, understanding things about everyone involved, even the Freedom Caucus. Okay, that’s boilerplate. He blamed Democrats for not supporting the bill. More nonsense boilerplate.
A couple of things stood out to me. He actually named what he learned. He said, “We all learned a lot. We learned a lot about loyalty. We learned a lot about the vote-getting process. We learned a lot about some very arcane rules…”
You hear that bit about loyalty? What I heard was seething rage at the Freedom Caucus that stood him up, and a total unwillingness to put himself in that position again, in hock to the whims of these ideologues who will not back him when he asks them to.
Second, he revealed a clear image of what happens next: Obamacare will “explode” and then they can build a better bill: “Perhaps the best thing that could happen is exactly what happened today, because we’ll end up with a truly great health care bill in the future after this mess known as Obamacare explodes.”
Third, he mentioned that this “truly great” bill would have to be bipartisan. It would have to be crafted with Democratic support. How much does he believe this? He mentioned it not once, not twice, but seven times.
So he 1) is clear that this was not a “truly great” bill, 2) believes that such a bill could be crafted, but 3) it would need, and it would get, Democratic support. This sounds like a bill much more in line with his populist “take care of everybody” rhetoric.
This sounds like he is learning something very big: He can’t depend on the Congressional Republicans to just bring him the votes. If he wants to accomplish healthcare reform, or his $1 trillion infrastructure plan, or anything else big, he needs to bring forward legislation that can get Democratic votes — because at least some of those Republicans think they have him on a string, and can make demands that he just has to meet. Can you imagine how much he hates that thought?
He is not down with the Freedom Caucus’ ideology, and he is much less tied to any ideology than he is to getting things done, being “the winner.” He also is probably very down on Ryan, he might fire Priebus, and he is likely less willing to rely on Pence to steer him.
To whom does he turn? To those who apparently were trying to steer him away from lashing himself to Ryan’s mast on healthcare, particularly Bannon and Cohn. Steve Bannon, the Prince of Darkness, who nonetheless has more populist leanings, and Gary Cohn, the guy to whom I wrote my recent open letter.
Cohn is a Democrat and a former president of Goldman Sachs. He is apparently whip smart but without a healthcare background — yet Trump had designated him the policy guy for healthcare. He has rapidly built a solid policy shop in the White House, and has been cautioning Trump against going all in on Ryan’s bill. Cohn’s briefings explain Trump’s late February comment that, “Nobody knew healthcare could be so complicated.” (Did my letter actually reach him when I sent it to the White House? Did it helped Cohn in his search for answers and different directions? Possible. No way to tell, but the timing was right.)
Put that all together, connect the dots. Trump has actual populist desires about healthcare, he wants to be the people’s savior. He gets led down a garden path in the opposite direction, then gets beaten like an Army mule. He realizes that these people are not his friends. He says that he’s going to try something different, it will be something the Democrats would get on board for, and he looks forward to crafting a “truly great” healthcare reform with them.
We could well see Trump try to put together a winning bipartisan coalition in Congress on this and other issues to bypass Ryan and break the power of the Freedom Caucus. We could well see something from Trump much more like a Medicare-for-all, or a universal Medicaid base plus Medicare buy-in for people over 50, or other “public option” solutions.
Niran al-Agba, MD
Joe, I totally agree with your response …. it is the reason I voted for him in the first place. He is a “deal maker” and with the clearly drawn partisan lines, true progress will require pragmatism, compromise, and patience. While he is short on patience, I suspect it is possible for him to learn a little of it and at least we have an opportunity to bring both sides together. Time will tell, but I am hopeful. His promise to come back around later and craft something with moderate Democrats and Republicans on both sides is very encouraging to me. Of course, bypassing Ryan is never a bad thing for almost any reason.
While I am not necessarily in favor of total universal health care, I am in favor of basic universal healthcare and believe this is the ultimate direction this country must go. As to Jim’s point regarding the large number of healthy individuals required to support those with chronic illness, the bottom line is, we must ration and will end up rationing. My hope is we use science and common sense, QALY or something along those lines so these decisions to treat or not are made with cool heads and hearts throughout.
Unfortunately, in the future every single person wanting a transplant or outrageously new chemotherapy is not going to be able to receive it without paying for it themselves and that is reality. Now how to get the nation on board?
To be a successful politician, one must be able to make “deals” with your opponents. This requires that one’s opponents “believe” the President’s statement which are made to them in private. Trump’s political and business experience is littered with deception.
A poorly constructed bill, with bad policy substance from the get-go, met the end it deserved. Tortured politics and an inept President aided the demise.
I agree with Jonathan H that this is far from over, but of course it’s not clear what will (or politically can) happen next. Most likely nothing for a while in Congress….but Price and Verma have some big choice to make on stabilizing/helping the marketplaces as plans prepare to make their bids. Do that, or screw it and let things fall apart—as the president implied today. CMS already took some regulatory steps—a few of which could help but others of which will hurt consumers/enrollees. More steps are needed, and urgently.
I agree with Dr. Stone’s comments….
In keeping with almost everything else he has said since inauguration on any issue, Trump was deaf to the substantive issues that helped bring AHCA down in his comments today….and he was menacing in his threat to let the ACA “explode” at which point the Ds would come running to him for help to repeal and replace. Trump deserves the harsh judgement that will certainly come….since he never stuck to any philosophical or policy principles as the process unfolded….right up to the end. Shameless, even if expected.
Let’s all get back to the real enemy here–rampant rate of use of services driven by every increasing chronic illness. Now THAT might be a worth focus.
The above comments are inciteful, and, as a wise old lawyer once said to me, “they have the additional benefit of being the truth.”
How is the statement that the rampant use of services is driven by increasing chronic illness substantiated?
I am genuinely asking without doubting that it is true, but there can be funny business about what constitutes chronic illnesses.
Is “high cholesterol” a chronic illness? Osteoporosis? Uncomplicated diabetes defined on the basis of an abnormal lab test? Millions of people have chronic diseases that are quasi fabricated by the medical establishment. There’s a deep seated confusion between factors of risk and actual disease.
If I am not mistaken, Americans see doctors less often and are hospitalized less often and for shorter stays than most OECD countries. We take more drugs, get more MRIs and have more hip and joint replacements, all of which are obscenely overpriced by comparison to OECD, and other than some meds for over-diagnosed stuff like pre-this or pre-that or the depression “epidemic”, these things have little to do with chronic disease.
Chronic disease, however you define it, does consume most resources, but that is true in other countries as well. We can’t just say that our solution to unaffordability of medical care is to make people healthy (not that there’s anything wrong with making people healthy…).
The data indicate the Americans are far more chronically ill than others. Chronic illness accounts for at least 75% of US medical expenditures according to CDC (their number is actually higher, and I had a hard time believing it myself). Chronic illness overwhelmingly is a result of unhealthy lifestyles which we Americans are expert at. Yes, fee levels for certain things (most of which we would not need if we lived healthier lifestyles and were not chronically ill) are obscene; and yes, 30% of care is waste and error–those would be good to address as well. I’m just saying we seem to be missing the forest for the you know what. Healthy people don’t use services. We need scads of healthy people buying health insurance to cover one chronically ill person.
If I am in any way missing something, please let me know cuz I’m writing a book on this. I’d really appreciate your insights.
And I love the respectful and collaborative tone of our interchanges; and yet if we disagree, we say so. Let’s keep this up.
The “ridiculous” prices need to be abolished, by Federal fiat.
Clearly, capitalism does not work to control healthcare costs and all the other industrialized countries understand this. We have already tired multiple variation of “capitalism” in healthcare, over the last 4-5 decades, and every variant has failed and was then replaced by another variant which then failed.
It is time to move on to solutions which have been objectively demonstrated to work.
ANISH KOKA, MD
I think there’s enough waste in us healthcare right now – whether that be low value care, unnecessary care, or iv fluids in hospitals that cost $1000. I mean basic labs at the local AMC are 1100 dollars, and yes that all came out of the deductible.
We have to differentiate agreeing as a society to pay for these ridiculously upcharged items, paying for things such as transplant ( NNT of 1, payoff could be 5 yrs of life with lung transplant or 30+ with pediatric liver transplant) and paying for 95 year olds to get percutaneous aortic valves.
The richest country in the world can afford and should pay for miracles (transplant, curative gene therapy, or curative cancer therapy) – it just needs to prioritize and focus on some of the bad actors taking advantage of taxpayer largesse due to a rigged system (We can start with non profit teaching hospitals that long ago lost their way)
These are hopeful and interesting remarks. Pray that they come to fruition.
I also agree with Anish that we have to eliminate the waste. But so far, we have mostly built ineffective policies that throw out the baby with the bathwater. For many decades we have failed to come up with policies that carve out the fat and leave the valuable care. I partly blame all the foolish incentive and penalty policies created by Obamacare that don’t have anything to do with the causes of the deficits– pay for performance (see our Vox/THCB/Huff Post/Boston Globe pieces on that), ACOs, non-payment for preventable infections and readmissions, discriminatory wellness penalties (the legal basis for giving employers your genome without asking first), yada, yada. There is actually science out there to refute those and a ton of other policies.
To tell the truth, the things that work take a little more thought, incl educational partnerships with physicians like face-to-face drug academic detailing (we published in NEJM in 1983!) and the Yale studies that showed that interdisciplinary teams of docs, social workers, nurses and pharmacists could prevent readmission of frail elderly through TEACHING about drug adherence and other things at discharge and at home. Less is more. They actually learned about the determinants of the problem before acting on the basis of unidimensional and useless economic theories that didn’t survive the voyage from business to health. I have voted Democratic — well except for Governor Charlie Baker (even if we clashed once when I advocated for medications as a necessary component of Mass health reform). But Obamacare is a mess. I hope one day that half of it is abolished so that the valuable things can live on (clearly this was not the anti-science Republican bill).
The way that the innovation center at CMS does its evaluations of those silly ACA penalties is to ask for proposals and pick a tiny fraction of the best delivery systems, “The All-Star Baseball Team” that they then compare to those who couldn’t or wouldn’t even write a proposal. Like Pioneer ACOs (they quit anyway), maybe now MACRA? These policy evaluations don’t meet standards of systematic reviews and are excluded from them; my doctoral students love to point out the fatal flaws and can’t believe that anyone could believe them. Yes, the evidence needs restoration. Neither administration has respected it.
We need to commit to a true rigorous learning system before we pay for billions and trillions of ineffective policies (HITECH comes to mind- that’s another sad story). Best, Steve