Evidence-Based Health Reform

President Trump campaigned on making health care better, cheaper and available to all Americans, regardless of ability to pay. Once Mr. Trump was safely in the White House, the Republican thought leaders in Congress were quick to supply him with plans to repeal and replace Obamacare. Most were written in protest to President Obama’s policies and were never meant to be implemented.

When scrutinized by the rank and file of the Republican Party, it turned out that the Ryan/Price American Health Care Act was neither repealing enough for some, nor replacing enough for others.

The Democratic Party lost no time in whipping up public frenzy against the Ryan/Price bill, and Speaker Ryan lost no time in generating a sense of false urgency to pass his bill now, now, now, because for Paul Ryan this was a once in a lifetime opportunity to begin dismantling the welfare state.

From the left, it looked like the bill will be withdrawing billions of dollars in health care benefits from the most vulnerable citizens who also happen to be Trump supporters. From the right, the bill looked like Obamacare Lite because it didn’t throw all the poor people under the bus fast enough.

These were the cards President Trump was dealt. If he signs the bill, he breaks his campaign promises and loses his base. If he comes out against the bill, he confirms the worst fears of all Conservatives and loses Republican support in Congress.
There is zero chance for this President to appeal to another set of voters anytime soon, and currently, there is zero chance that even one Democrat in Congress will support anything President Trump proposes, no matter how liberal and beneficial that proposal might be. It was a difficult hand to play, but he played it brilliantly, in my view. Or maybe it was just beginner’s luck.
Right now the Democratic Party and its echo-chamber media are celebrating the defeat of the would-be destroyers of Obamacare.

The Republicans are in disarray again. Paul Ryan has been humiliated. Trump, the closer, the grand deal maker, lost big league. Nancy Pelosi declares victory without having to fire one parliamentarian shot. The President in the meantime calls The New York Times and Washington Post reporters and doesn’t sound angry at all.

No irate tweets. No below-the-belt punches. No fighting back. No nothing. How weird is that? Think about it. Is this how a beaten Donald Trump sounds like? Nope. That’s how a winning Donald Trump sounds like – calm, collected, magnanimous and low-keyed. President Trump passed his first test.

What’s not next?

According to my Twitter list of health care policy experts, Big Bad President Trump will now “sabotage” Obamacare so it fails spectacularly, right before the mid-term elections, dragging millions of poor people down with it. Sabotage, espionage, life is good when you are kibitzing from the sidelines.

Now why would a Trump administration want to create huge hardships for millions of people right before the mid-term elections? The thought process here is that if Obamacare collapses, the people will blame the Democratic Party, because as long as Republicans do not repeal and replace anything,

Democrats continue to “own” health care. Therefore, the GOP will finally have a mandate to get rid of Obamacare any way they see fit, and will likely increase their majorities in both houses in 2018. There is only one little problem with this logic: when things go wrong, most people blame the currently governing administration, not the previous ones, and rightfully so.

Deliberately blowing up the health care system is a criminal endeavor that must be executed in the public eye, because Secretary Price cannot promulgate secret regulations. No administration can afford to do something like this, and expect to survive. Every new President in recent memory insisted that he “inherited a mess”, and every President then gives a State of the Union Address taking credit for fixing said mess.

President Trump will be no different. Obamacare may not be in a “death spiral”, as detractors love to decry, but for millions of people, including those who receive generous subsidies, Obamacare is already a monumental mess. No sabotage needed.
Here is a tiny example. Remember that poor 64 year old, making $26,500 per year who, according to the CBO, ended up paying $1,700 under Obamacare and would have had to pay $14,600 under the Ryan plan? Well, that’s only part of the story, because those dollar amounts are just for premiums. Thus a fully subsidized healthy 64 year old is indeed paying “only” $1,700 for the cheapest Silver plan currently available on the Obamacare marketplace (in my zip code). A sicker 64 year old, making $26, 500, with high medical expenses is projected to have over $7,500 in total yearly costs, which is almost 30% of his gross income. I would like to humbly suggest to the Washington DC jet-setters that for this gentleman, there is no difference whether he needs to pay $7,500 or $14,600, or $140,000 or $14,000,000. He can’t come up with any of this. He is uninsured for all practical purposes. The only difference is that under Obamacare, they may have talked him into donating $1,700 to some insurance company.

What’s next?

I know conservatives and libertarians abhor the sheer existence of Medicare and Medicaid, but a savvy Secretary of Health and Human Services (HHS) could use the girth and might of these government programs to nurture the reemergence of a relatively free market in medical services, and minor bi-partisan legislation could create a relatively less predatory market in medical products. These two efforts will do more to reduce the price (and costs) of health care than any Obamacare folly or any Obamacare repealing and replacing idiocy. Furthermore, the effects could be framed in terms of freedom, choice, access and even deficit reduction, in addition to quality and affordability for those less fortunate, pleasing people on both sides of the ideological aisle.
Here is my very modest wish list for Secretary Price. All I’m asking for is that from this point onward, we start practicing evidence-based health care reform.

Independent Evaluation – Between CMS itself, CMMI, HRSA and other agencies, HHS has billions of discretionary dollars in its budget to try new things, and even more billions to implement statutory experimentations. Traditionally, large sums of money have been spent on health system “transformation” to patient-centered, team-based, coordinated, value-based, managed care (feel free to insert your favorite buzzword if I left something out). Many, but not all, of these “demonstration programs”, pilots, innovation models, etc. include evaluation studies to assess performance and so far the results have been tepid at best, but artfully spun as inconclusive. I want independent evaluations of all CMS funded “initiatives”, and I want programs that do not deliver on promised fantasies to be wound down immediately and the money reallocated to better thought out projects.

Practice Research – For the last decade or more, it has been the unequivocal position of HHS that better health care at lower costs necessitates large integrated delivery systems. There is not one iota of bona fide research to support this assertion. And yet, the Federal government has engaged in massive direct and indirect efforts to dismantle the so called “cottage industry” of small independent physician practices. I want CMS to fund several serious comparative-effectiveness studies across various medical practice models before it’s too late and we have nothing left but monopolistic chains for medicine. And I want CMS to follow through and undertake the deconstruction of all infernal medical factories where nobody knows your name, but everybody knows your risk score.

Hospital Research – I remember reading something a couple of years ago about someone trying to study the effectiveness of hospitalist care compared to community doctors who are allowed to admit and care for their own hospitalized patients. Hospitalists are another pre-Obamacare “innovation” based solely on hospital profitability arguments. As such, it caught on like wild fire and we have very few community physicians left who follow their patients inside the hospital walls. I want to see that study performed immediately, before the last dinosaurs die off and we forget that continuity and coordination were once built into health care, by default.

That’s it. That’s all I want for Christmas. Disappointed? Don’t be. A comprehensive, well researched report on our health care delivery models (shall we call it The Price Report?) could change the trajectory of health care in America and the entire world. I did not forget about Medicaid, the ludicrous deductibles, the device taxes, the pharma bidding and all those big huge things every pundit is reciting on cable news channels. These are important things of course, but they are temporary solutions at best. Single payer, if implemented tomorrow, is going to implode just as quickly as Obamacare did, and end up rationing care worse than the British system does. The various free market solutions are even more vulnerable to the ominous crescendo of unchecked profit extraction and incompetence engulfing our health care system.

Health care cannot be sustainably fixed in broad political strokes. If we want a real and lasting solution, we will need to step away from the political theater and engage in painstakingly detailed work on fundamentals. Health care is about medicine, and medicine is about applying science to the bodies and souls of people. We know how to do it. We do have the best health care in the world. We just forgot where it is, so now we have to systematically look around until we find it again. Hopefully Dr. Price understands the historic moment he finds himself in.

Categories: Uncategorized

13 replies »

  1. The healthcare industry at large has fallen head over heals with the latest buzzwords and magic elixirs of Population Health and Value-based care. Intuitively, of course preventive services performed to capture conditions up front results in less cost later on, right? David Goldhill, in his book “Catastrophic Care” rightly predicts what is about to happen next: the health care complex of insurers and health systems will simply define ever more “need” based care that must be reimbursed. The result? Higher premiums and costs, and more services and medications for people who don’t actually need them. Goldhill sarcastically states that before we know it there will be a requirement to cover programs and medications for people with “pre pre hypertension.” Without consumers and pricing mechanisms to mind the store, of course the entrenched interests are going ot make sure they find a way to stay whole in this transition from inpatient to outpatient services. It will do absolutely nothing to stop healthcare from growing faster than the rest of the economy, much like it has for five decades.

  2. Two things, Steve:
    I actually agree with you about what the President should do next. I just hope Democrats care more about the country than they care about taking revenge on Mr. Trump. I am not sure which one it is, but if they keep at it, there will be a price to pay for them as well, particularly if he goes public with a reasonable offer for compromise and they reject it just because something, something…. Russia…. something….Putin….
    I don’t think he had a choice in this first round, and I hope Schumer/Pelosi allow him a choice, which is more aligned with his “personal core” and the people’s interest, in the next round…. I know people of a certain ideology think he is a fool, but you don’t come out of nowhere and get to be President if you are a complete idiot. So there is that….

    As to small practices, of course it depends, but my impression is that chances are much better that a small practice (in the same geographical area) will be cost-effective, particularly small practices that are not “in compliance” with the latest and greatest CMS ideas on how things should be done. There have been a couple of studies indicative of precisely that, but nobody wants to pick this hot potato up and run with it because small practices are not as easily exploitable as large groups of employed docs. I don’t know about Mr. Andy S, but I think he is just setting the table to run for office now, so there is this too… 🙂

  3. Margalit — Once again, as ever, very interesting and provocative. And sort of all over the place. It defies credulity that you would think Trump somehow won here. Wow. I don’t even know how to assess that. Remember, this was not just about repealing and replacing ACA but about reducing taxes on companies and the rich. The Rs really wanted that, and failed. But, OK, you are entitled to your opinion.

    I do like some of your ideas for research. Agree that we really need to address/assess the integrated large system care vs “cottage industry” care. Very operative with MACRA of course. My strong suspicion is that the answer won’t be one side wins and other loses, but rather a more muddled finding of “it depends.” And of course that would be a sort of victory for long-besieged small practice medicine. Andy S changed his tune on this issue during his time in office.

    In my most recent THCB post (March 27), I mostly disagree with you on the politics. I think Trump should this fall or in early 2018 pivot to seeking a collaboration with Dems on ACA fixes and addressing health care costs, bypassing the Freedom Caucus. If he’s as smart as you apparently think he is, that’s his best play and chance for success. Ryan will hate it though and may not go along….

    Late breaking today…Rs in House apparently are still looking at ways of repealing and replacing…..by modifying AHCA. Oh boy.

  4. Yeah…. that’s the right way to look at it…. fingers crossed 🙂

  5. I hope he will be good for the patients. If he is, he will be good for primary care physicians.

  6. Watching what Dr.Price does in the next few months will be fascinating…. I have to admit, that I have mixed feeling about this though. I do think he’ll be good for physicians. I just hope he’ll be extra good for primary care docs…

  7. Thanks. As you know assembling the right or even wrong people is easier said than done…. 🙁

  8. At what point can it be said that Americans will do the right thing after exhausting all other alternatives?

  9. “Big Bad President Trump will now “sabotage” Obamacare so it fails spectacularly”

    Margalit, big bad President Trump historically has had healthcare ideas closer to many Democrats than those with libertarian views. He is a populist, hated and felt to be stupid by the elite. He isn’t stupid and though sometimes a bit gruff he is a decent human being if any human being can be called decent.

    I don’t know how he felt about the Ryan plan, but he did try to help pass it while I am sure recognizing that the Senate would have a lot to say. We have to remember that many of the Republican establishment were anti-Trumpers and that included Paul Ryan.

    Trump picked Price for a reason and the Ryan plan wasn’t Price’s plan. Trump is not disarmed. The ACA contains a phrase that provides the executive branch to make all sorts of changes. The wording is “the secretary shall” “will” do all sorts of things and that is stated over a thousand times in the text of the ACA. It just so happens that that secretary today is Secretary Tom Price. We might be in for some interesting times.

  10. Margalit, hear, hear for using evidence to guide health care policy reform. I agree with Dr. Nelson below. Assemble the “right” people and get them to come up with something simple emphasizing a return to free market principles and it is so very possible. Great post!

  11. Margalit,

    Please arrange a 2 – 3 day, marathon seminar comprised of the following people:
    * Tom Price, M.D. – Secretary, Dept HHS
    * Darrell Kirch, M.D. – President/CEO, American Association of Medical Colleges
    * Henry Aaron, Ph.D. – Economist, Brookings Institute
    * Victor Dzau, M.D. – President, National Academy of Medicine
    * Mark Bertolini – CEO, Aetna Health Insurance
    * Suzie Buffett – Philanthropist, Sherwood Foundation
    * Rachel Naomi Remen, M.D. – Psychiatrist, Author (“Kitchen Table Wisdom”)
    * Rosanne Haggerty – President/CEO, Community Solutions International, Inc
    I suspect a group effort could outline a doable healthcare reform plan fairly quickly. It might need a couple of f/u sessions with their individual surrogates to finish. With you, it would 9 total….perfect.
    I would gladly come and manage their baggage. Maybe their would be some other volunteers.