In the world of fine wine, it is well known that some types of wine grapes grow only in very specific climates and ecologies. The concept borrowed from the French is “terroir” (ter-WAHR). Terroir explains why the finest champagne grapes grow only in a small district in northeastern France, characterized by rolling hills and a chalky limestone subsoil that provides a steady level of moisture and imparts a mineral note to the wine’s flavor.
Health policy advocates have sought for generations to propagate promising forms of health care organization across the country. Yet one finds repeatedly that some forms of organization that prosper in one part of the country fail to thrive in others. Is it possible that the concept of terroir also applies in health care?
The Case Of Kaiser Permanente
Kaiser Permanente’s health plans would be a great example. Kaiser has been a darling of health policy advocates such as Alain Enthoven, Paul Ellwood, and others because of its integrated structure, global risk, and salaried employment model of physician practice. Yet, despite repeated federal interventions, beginning with the Health Maintenance Organization Act of 1973, Kaiser only recently exceeded 10 million in enrollment for the first time in its 71 year history. Moreover, 82 percent of that enrollment is in two states—Oregon and California—where Kaiser originated. The percentage of Kaiser’s enrollment that derives from its origin states is basically unchanged in a decade.
It is selfish of a leader of a nation to drop dead during office. Jawaharlal Nehru, India’s first prime minister, died suddenly at 74, apparently from a ruptured aneurysm. His aneurysm, allegedly, had something to do with Edwina Mountbatten – the wife of Lord Mountbatten, the last Viceroy of India. Shortly after Nehru’s death, Pakistan attacked India. Nehru’s replacement, Lal Bahadur Shastri, died mysteriously in Tashkent two years after Nehru’s death, and was succeeded by Indira, Nehru’s daughter. India’s future was forever changed by a burst aneurysm or, if rumors are to be believed, by a flagellating spirochaete which left the Raj in bliss.
Clearly, the death of a leader creates turmoil for a republic. So it is understandable that a nation obsessed with health is obsessed with the health of its presidential runners. Mr. Trump’s doctor declared he’s the healthiest presidential candidate ever. Mr. Trump has drawn attention to his super health by pointing to the size of his hands – by Mr. Trump’s standards a rather decorous allusion. It matters not what has hypertrophied Mr. Trump’s hands, what matters is that Mr. Trump’s large hands signal vigor and imagination. The American Psychiatric Association, to their credit, in ruling out a new diagnostic code for Mr. Trump’s colorful soundbites in the next edition of their Diagnostic and Statistical Manual, ended all hopes of banning Mr. Trump from the presidential race on health grounds.
In an open letter to President Obama that I posted here on August 24, I stated that his expectation that the Affordable Care Act would have a deflationary effect was naive. I said he was badly misled by the managed care movement, and that he should never have accepted the movement’s diagnosis (overuse) and solutions (shifting insurance risk to doctors and micromanaging them). To help him understand that, I said I would post criticism of three prominent managed care proponents who influenced him: Elliott Fisher and his colleagues at the Dartmouth Institute, Atul Gawande, and Peter Orszag.
I will start with Elliott Fisher and his colleagues at the Dartmouth Institute for Health Policy and Clinical Research because they have been so influential with the entire health policy elite, not just Obama. I will devote this post and the next to them. I devote this post to demonstrating how influential they have been; I devote the next post to demonstrating how misleading they have been.
The Dartmouth Institute deserves credit for assembling data that shows substantial variation in the rate at which medical services are provided, both within small areas and between regions of the country. This data is very useful for generating hypotheses in need of further research. But the group deserves severe criticism for promoting the conclusion that variation can be explained primarily by overuse and virtually none of it can be explained by underuse, and for promoting “accountable care organizations” and other forms of “integrated care” as the solution that will address their erroneous overuse diagnosis.
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.
As unusual as the 2016 presidential election has been, one obvious aspect has gone largely unnoticed: By the time the next president of the United States is inaugurated on Jan. 20, 2017, he or she will have reached or come close to reaching 70 years old.
That all the remaining major candidates are among the “young old” at this stage of the election process is unprecedented. Yet, in spite of the stakes for the American people, there is no independent source that can provide an adequate accounting of the medical condition of the next president.
Historians have examined the ways that previous administrations have been affected by the medical problems of presidents including Abraham Lincoln, William Henry Harrison, Woodrow Wilson, Franklin Roosevelt, John Kennedy, Lyndon Johnson and Ronald Reagan. The news has not always been positive.
Donald Trump recently released a healthcare reform plan. If only he had spent as much time crafting it as he does his hair.
The GOP frontrunner is right that Obamacare has failed to fix what ails America’s healthcare system. As Trump put it, the Affordable Care Act has “tragically but predictably resulted in runaway costs, websites that don’t work, greater rationing of care, higher premiums, less competition and fewer choices.” He famously said that he wants to “repeal and replace with something terrific.”
But “terrific” his plan is not.
Take, for instance, his proposal to legalize the importation of “safe and dependable [prescription] drugs from overseas.”
Importing cheaper drugs from other countries may seem like a great way to reduce the cost of medicine for Americans. But there are important reasons why it’s currently prohibited.
Last Wednesday marked the sixth anniversary of the passage of the Patient Protection and Affordable Care Act. As of this week, the five Presidential aspirants have each articulated key changes they’d propose, though polls show interest in the law is largely among Democrats who consider healthcare a major issue along with national security and the economy.
GOP candidates Trump, Cruz and Kasich say they will repeal the law; Democratic frontrunner Clinton says she will repair it, and her challenger, Bernie Sanders, promises to replace it with universal coverage. Some speculate that candidate Clinton’s plan will ultimately mirror her Health Security Act of 1993 that parallels the Affordable Care Act in many respects. But the law gets scant attention on the campaign trails other than their intent about its destiny if elected.
I have read the ACA at least 30 times, each time musing over its complexity, intended results, unintended consequences and hanging chads. At the risk of over-simplification, the law purposed to achieve two aims: to increase access to insurance for those unable to qualify or afford coverage, and to bend the cost curve downward from its 30 year climb. It passed both houses of Congress in the midst of our nation’s second deepest downturn since the Great Depression. Unemployment was above 10%, the GDP was flat, and companies were cutting costs and offshoring to adapt.
The “Patient Protection and Affordable Care Act” soon after became known as the “Affordable Care Act”, and then, in the 2010 Congressional Campaign season that followed its passage, “Obamacare”. It was then and now a divisive law: Kaiser tracking polls show the nation has been evenly divided for and against: those opposed see it as “the government takeover of healthcare” that will dismantle an arguably expensive system that works for most, while those supportive see it as a necessary to securing insurance coverage for those lacking.
It is possible that in a few months from now, only Nate Silver’s prediction models will stand between Donald Trump and the White House. I will leave it to future anthropologists to write about the significance of that moment. For now, the question “What will President Trump be doing when he is not building a wall?” has assumed salience.
This is relatively easy to answer when it comes to health policy. Just ask what people want. Seniors don’t want Medicare rescinded. Even the free market fundamentalist group, the Tea Party, wants Medicare benefits as they stand. At one of their demonstrations against Obamacare a protester warned, without leaving a trace of irony, “Government, hands off my Medicare.”
Rest assured, Trump will protect Medicare. Even raising the eligibility age for Medicare may be off the cards as far as he is concerned. He has promised that no one will be left dying on the streets. That people no longer die on the streets, but in hospitals, because emergency rooms must treat patients regardless of their ability to pay, is irrelevant. The point is that Mr. Trump knows that the public values their healthcare. Trumpcare will show that Trump cares.
The pandemic started quietly.In the spring of 2017 A few hundred dead chickens appeared in markets in Hong Kong and a few other cities in China. Public health officials in China were slow to respond.They did not want to panic the public about an avian flu outbreak.Nor were they eager to take the steps necessary to contain such an outbreak—the killing hundreds of thousands of chickens and poultry with devastating economic consequences.While the delay went on a few cases began to occur on Canadian and American poultry farms.Department of Agriculture experts traced the outbreak to waterfowl migrating from Northern flyways, probably from Asia. Inquiries were made about avian flu outbreaks in Asian nations.Then the unthinkable happened. Humans in Hong Kong began to get sick.Very sick.Some died.Those who died were in their twenties.
The avian flu virus had mutated.H7N9m had transformed into an agent that not only could infect humans but did so with a transmissibility and lethality that had not been seen since the Spanish flu outbreak of 1918.
Then the first American died.A young man back from a business trip to Hong Kong.The media, already primed for hysterical coverage following the severe Zika outbreak in the Southern United States in the summer and fall of 2016, went into full panic-dispensing mode.‘Experts’ began to appear on the cable channels who suggested that the outbreak was the result of irresponsible genetic research in China.Still others suggested that it was the bioterror work of North Korean scientists.One or two pointed toward ISIS arguing that they had grown desperate in the face of the massive air war that the new administration had launched.Still others saw the hand of right or left wing domestic terrorists.And an accident at an American lab was put into the boiling cauldron of speculation and conspiracy.
“Elephant in the living room” is an English metaphorical idiom for an obvious untruth going unaddressed. In most political platforms about healthcare and its coverage, there is a most resolutely immovable elephant in our living room. It is there with every single candidate. But with Bernie….
You’ve just got to love Bernie Sanders. It makes me feel like I’m 22 years old in the 1960’s and dumb as all get out about how you pay for things. But let us consider Mr. Sanders’ healthcare proposal. From his own website:
“Bernie’s plan would create a federally administered single-payer health care program. Universal single-payer health care means comprehensive coverage for all Americans. Bernie’s plan will cover the entire continuum of health care, from inpatient to outpatient care; preventive to emergency care; primary care to specialty care, including long-term and palliative care; vision, hearing and oral health care; mental health and substance abuse services; as well as prescription medications, medical equipment, supplies, diagnostics and treatments. Patients will be able to choose a health care provider without worrying about whether that provider is in-network and will be able to get the care they need without having to read any fine print or trying to figure out how they can afford the out-of-pocket costs…[etc.].”
Bernie sure didn’t go half way on this one. All care, whenever, wherever, however. A fundamental right with no filter. OK. So he jumped in with both feet. You’ve got to admire his elan. But what might this mean and how can he ignore what happened in his own home state?