The Administration proposal that would enable small employers to band together to purchase health insurance by forming Association Health Plans has several good features. Large companies do pay about 15% less, apples-to-apples, for health insurance than small businesses because they negotiate lower administrative fees, get larger discounts on health care prices and avoid premium taxes and risk charges by self-insuring. Allowing small business to replicate what boils down to volume discounts also appeals politically to many as a market-based alternative to government intervention. Reliance on Association Health Plans could result in substantial volume discounts, but, in the end, would be like paying $10 for a tube of toothpaste that retails for $100, a big discount and a rip-off price.
Even though the largest companies get very deep discounts, there is substantial research showing that their net costs are much higher than everywhere else because we in the United States pay higher prices for health care goods and services. One need to look no further than the benchmark large corporate purchasers who continue to pay about 40% or 50% more than Medicare for the same health care to see how excessive health care prices for private payers are. And this disparity is likely to get worse. While hospitals gobble up other hospitals and doctors’ practices and gain near monopoly market power to raise prices, employers of all sizes remain highly fragmented and, as a result, impotent price negotiators.
A better approach to health care cost containment than Association Health Plans hides in full view. Continue reading…
According to the WHO definition of health, which is “a state of complete physical, mental, and social well-being, and not merely the absence of disease and infirmity,” several million Americans became unhealthy on Tuesday November 8th, 2016 as Florida folded to Trump. As Hillary’s prospects became bleaker many more millions, particularly those on Twitter, lost their health. The WHO sets a high bar for health. It is easier for a camel to pass through the eye of a needle than for a person on social media to be in “complete mental and social well-being.”
Whilst WHO has set a high bar for health, modern medicine casts a wide net for disease, and the duo have led to mass over medicalization, overdiagnosis and overtreatment. Yet despite the wide net, Trump has thus far managed to evade the psychiatrists, medicine’s version of the FBI, who have tried imposing upon him a range of psychiatric disorders including “extreme present hedonism”, which sounds like “hyperbolic discounting,” which basically means someone who doesn’t give a rat’s tail about the future. Base jumpers suffer from this condition. I once suffered a milder version – and then I became a father and grew up.
Trump doesn’t look like a base jumper. And you’re going to need more than hyperbolic discounting to nail him on the 25th Amendment. Some tried diagnosing Trump with “mild cognitive impairment” (MCI) – a condition which heralds the more persuasive cognitive decline of dementia. MCI reminds me of an old medical school friend who went around administering the mini mental test to elderly patients on medical wards. One of the questions was: what are the dates of the 2nd World War (WW2)? No patient got that question right because my friend thought WW2 started in 1940. It started in 1939.
The resurgent debate about President Trump’s mental health prompts me to update a piece I wrote for THCB last June. That piece drew lively comments and debate.
It’s also the one-year mark of the Trump presidency.
As The New York Times editorial page recently asked, bluntly, on Jan. 11: “Is Mr. Trump Nuts?”
Since last summer, that question has gained more traction and spurred more earnest debate. The results from Trump’s medical and “cognitive” exam on Jan 12 are unlikely to quell concern. (More about those results below.)
Nearly every major newspaper and magazine has run stories. Print media columnists and TV commentators dwell on it constantly. It’s catnip for late night comedians. It’s been a trending topic on social media for months. And, of course, it’s a topic of discussion and banter almost everywhere you go.
Lawmakers have finally joined in, too, after reluctance for the better part of 2017. Some even render an opinion publicly.
And then there’s the book, which sparked Dr. Pouncey’s piece as well other articles and reviews since it came out last fall. I’m not talking about Fire and Fury: Inside the Trump White House by Michael Wolff—although that book is certainly relevant in this context.
Rather, I’m talking about The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President, edited by Dr. Bandy X. Lee, a specialist in law and psychiatry at the Yale School of Medicine.
The White House has announced that President Trump has scheduled an annual physical exam for Jan. 12. The President will go to Walter Reed National Military Medical Center in Bethesda, Md., the largest military hospital in the nation. White House press secretary Sarah Huckabee Sanders says Dr. Ronny Jackson, a rear admiral in the U.S. Navy who has served as physician to the President since 2013, “will give a readout of the exam after it’s completed.”
Some may have greeted this announcement with relief. Finally, concerns about the President’s slurred speech, overall mental health, crummy diet and obesity will be publicly addressed. Don’t get your hopes up.
A physical tends to be just that—an assessment of the physical not the mental. The evaluation of mental health in a standard physical is, to be polite, very cursory.
And while it is good that Trump at 71 will get a physical, he is under no obligation to reveal anything concerning that the exam turns up. When you are Commander-in-Chief and an Admiral reports on your exam, it is very clear that the Admiral had better be prudent about what gets said about the boss. Same goes for those on active duty at Walter Reed who perform the exam. Moreover, Trump has the same right to privacy that you or I do when we choose to get a physical or undergo any other medical procedure. It is up to him what he reveals to the rest of us.
The White House is well aware that they control what we will learn about the President’s health. And control the results they will.
A recent headline suggested that people who drink coffee live longer. Sounds great to me. I drink a lot of coffee, so maybe I will be immortal. But, wait, another report links coffee to cancer. Dang.
Estrogens were once touted as a life saving elixir for women of elegant ages, until these hormone supplements were linked to increased cancer risk. Wine will either add to your life expectancy or increase chances of breast cancer. If you are married and have cancer, your outcome is better; you live longer (and can drink more wine). Eggs either kill you (dropping the value of egg futures) or do not hurt you at all, (prompting a financial rebound in chicken-by-product).
Each study and report alluded to above is erroneous.
Indeed, these claims are what I call “fake” medical news. My definition: if a medical report is either wrong or not provable, it is fake.
There is an old Vulcan proverb saying that only Nixon could go to China. Only a man who used to work for Joseph McCarthy could set America on a path to better relations with a virulently Communist country. A few years after Nixon went to China, Menachem Begin, the Israeli Prime Minister who represented people believing that the state of Israel should start at the Nile and end at the Euphrates, gave Egypt back all the lands conquered in a recent war and made a lasting peace with Israel’s largest enemy. They said back then that only Begin could make peace with the Arabs.
Today, I want to submit to you that only Trump can make single-payer health care happen in this country. Only a billionaire, surrounded by a cabinet of billionaires, representing a party partial to billionaires, can make that hazardous 180 degrees political turn and better the lives of the American people, and perhaps the entire world as a result. Oh, I know it’s too soon to make this observation, but note that both Mr. Nixon and Mr. Begin were deeply resented (to put it mildly) in their times, by the same type of people who find Mr. Trump distasteful today. The liberal intelligentsia back then did not have the bona fides required to cross the political chasm between one nation and its ideological enemies, or as real as death immediate foes. The liberal intelligentsia today lost all credibility in this country when it comes to providing a universal solution to our health care woes.
Free health care (and free college) are not solutions. These are rabble rousing slogans to gin up the vote, slogans that end up in overflowing trashcans left in ballrooms littered with red white and blue balloons after everybody goes home to get some sleep before the next round of calls to solicit funds from wealthy donors for the next campaign. Providing proper medical care to the American people is a monumental enterprise that engages tens of millions of workers from all walks of life, every second of every day, in every square mile of habitable land, littered with the hopes and fears of hundreds of millions of invisible men, women and children who call this great country their home. This is not something that can be made free. Nothing is free in our times, not even sunshine and fresh air.
Though the process may not be “over” as of this writing, this has been the most catastrophically mismanaged federal health policy cycle we’ve seen in our lifetimes. In this post, I turn to Blumenthal and Morone’s 2009 analysis, The Heart of Power: Health and Politics in the Oval Office” for help in deconstructing the Trump Presidency’s politically costly health policy adventure.
Blumenthal and Morone distilled eight key lessons about how to manage the health care issue from the records of the post-Roosevelt Presidents’ health policy efforts. Attached to each lesson is a letter grade for Trump’s performance.
To succeed in health reform, President must “care deeply” about the issue.
Candidate Trump did not pretend to be a health policy expert, but the most potent applause line in his campaign speeches was his promise to the Republican base to “repeal and replace” ObamaCare. Trump complicated his task, perhaps without fully realizing it, by running way to the left of his base in promising not to cut Medicare and Medicaid and to give people better coverage for less money.Continue reading…
The following exchange occurred during an interview of President Trump with journalists of the NYT:
HABERMAN: That’s been the thing for four years. When you win an entitlement, you can’t take it back.
TRUMP: But what it does, Maggie, it means it gets tougher and tougher. As they get something, it gets tougher. Because politically, you can’t give it away. So pre-existing conditions are a tough deal. Because you are basically saying from the moment the insurance, you’re 21 years old, you start working and you’re paying $12 a year for insurance, and by the time you’re 70, you get a nice plan. Here’s something where you walk up and say, “I want my insurance.” It’s a very tough deal, but it is something that we’re doing a good job of.
It’s hard to know what “Trumpcare” is, but whether it’s “repeal” or “repeal and replace with something terrific,” it was and is going to fail. It was either going to fail to be enacted by Congress, or if it was enacted, it was going to set off such a bipartisan backlash it would be repealed, either by a chastened Republican Congress or a new Democratic Congress and president.
The reason Trumpcare was doomed was that health care is not like global warming or police shootings or use of military force in foreign countries: It is an issue a large majority of Americans agree on, and it is an issue voters can assess with their own eyes in their own kitchens.
Republican voters are almost identical to Democratic voters in what they want in a health care system. They want comprehensive coverage, low out-of- pocket costs and affordable premiums, freedom to choose their own doctors (they could care less about freedom to choose between Aetna and Humana), and freedom from interference by bureaucrats (be they public or private). Obamacare became a liability for Democrats because the public clearly perceived that the ACA could not meet those requirement for millions of Americans. The public now clearly perceives Republicans want to enact legislation that would be even worse than the ACA.
Senators Mike Lee and Jerry Moran said yesterday that they would not vote for the Better Care Reconciliation Act, effectively killing the legislation. As anybody who has been following this story would have predicted, President Trump reacted publicly on Twitter on Tuesday morning, vowing to let the ACA marketplace collapse and then rewrite the plan later.
Senate Majority leader Mitch McConnell attempted a quick punt this morning, calling for an immediate Senate vote on the House bill, a trick card that if it worked, would give Republicans two years to work things out.
The White House sees the failure as saying more about the political establishment in Washington than itself, which shouldn’t be all that surprising. Caught up in the drama of the Watergate-Russia emails-Trump family narrative, major media outlets like the Washington Post and the New York Times see a historic defeat rather than a temporary setback. That may or may not turn out to be true. Predictably, conservative commentators and the alt-right believe the defeat says more about the mainstream media and the Deep State than it does about the Trump Presidency. For their part, Democrats clearly think they have found their issue and can be expected to continue to exploit it using legislative Viet Cong tactics (attack on social media, melt into the jungle, lob snarky public Molotov cocktails) to punish Republicans and keep the story on the front page.
One thing is clear. Instead of repealing and replacing Obamacare, the GOP now has to rewrite and replace its own plan. Doing that would be difficult under the best of circumstances, but in the current climate in Washington it is difficult to see how it would be possible without a major shift in the political landscape.
All of this is bad news for hospitals and health plans and a frightening development for consumers, although not the really bad news some had feared. The President’s threat to let the insurance marketplace die and then “figure it out” sounds good as a rallying cry to the troops on social media, but is not the kind of thing that investors and CEOs like to hear. Realistically though, at this point everybody knew that the uncertainty would likely continue through the year (best case) or a year or longer (worst case) as the gridlock in Washington plays out. As depressing and frustrating as it is that the uncertainty will continue, by this point the industry is used to it. Insiders will continue to look for ways to minimize risk and for business opportunities to capitalize on the uncertainty.
Trump’s plan to allow the insurance exchanges to collapse is the kind of confrontational talk Trump and his advisors relish. In theory, the idea could work. There are in fact signs that it already is, as major insurers leave the marketplace and consumers hesitate before committing to expensive insurance policies. In reality, however, the collapsing exchanges will create a political crisis that is even worse than the current one for the administration, with news cycle after news cycle dominated by stories of terminally ill cancer patients and parents with children with horrible diseases and no insurance coverage. At this point, it will be difficult for the party doing the collapsing to point at the other side and say “It was them. They did it!”