Friday, November 4, 2016

Our Deplorable Health Care

Even the most ardent Obamacare supporters are now forced to admit that the law has hit a rough patch this year. The opposition to Obamacare is positively gloating with self-congratulatory “I told you so” assessments of the supposedly dire situation. Defenders of the cause are counteracting with the customary deluge of charts and graphs to prove unequivocally that Obamacare is actually turning out better than they expected. Integrity and honesty being in short supply on both sides of this quandary, chances are excellent that no matter what happens next, the American people will lose big league, unless….

If Mrs. Clinton becomes the next President of the United States, Obamacare will survive largely unharmed with a few minor tweaks to address a few minor initial oversights, best summed up by Sara Rosenbaum, a professor of health law and policy at George Washington University: “The subsidies were not generous enough. The penalties for not getting insurance were not stiff enough. And we don’t have enough young healthy people in the exchanges.”  To complete the solution, Mrs. Clinton may very well throw in an option to buy into a Medicaid managed care plan for rural hillbillies (similar to the Arkansas “innovation”), and call it “the public option” to make the lefty wing of her party happy.

If Mr. Trump becomes the next President of the United States, Obamacare will come under vicious attacks. Mr. Trump, who is running as a Republican, adopted the GOP “repeal and replace” Obamacare battle cry pretty much verbatim.  On Tuesday, one week before the election, at Valley Forge of all places, the Trump team unveiled its alternative to Obamacare. There was not much under that veil: selling insurance across state lines, health savings accounts, price transparency and Medicaid block grants to states, along with a commitment to retain the preexisting conditions clause and to have a transition period so nobody gets hurt. Team Trump didn’t even try to come up with a serious solution and I’m glad they didn’t, because it would have been incredibly dumb if they did, and because this gives me an opportunity to make my case.

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Dear (perchance) President Trump,

I know you don’t know much about health care, and that’s okay, why should you? You probably know that health care isn’t working well in America. Very few things seem to be working as well as they should or as well as they used to work. This, after all, is why you say you ran for President. There is unanimous agreement that health care needs to be made great again. The disagreement is on how to go about it. On the campaign trail, you had to come up with something to throw against Obamacare, which is fine, but now you have to actually fix it and those are two very different things, as all Presidents before you discovered to their chagrin, so here are a few Obamacare points to keep in mind.
  • Obamacare cannot be repealed and replaced in one stroke. It’s a lovely catchy phrase, but Obamacare is massive legislation that begot more legislations, such as MACRA (look it up), and thousands of regulations, many already fully implemented, others in various phases of implementation. Money has been spent, mergers and acquisitions have occurred, companies have been funded, contracts have been awarded, people have been hired, and this sea of change is engulfing private and public sectors inside and outside health care to the tune of $3 trillion dollars annually. You cannot change 20% of the economy the first day in office. Not even if you know precisely how you want to change it. And you don’t. My advice here is to settle down for the long haul.
  • Obamacare doesn’t need to be repealed at all. It just needs to be gradually replaced. It’s like renovating the Old Post Office with the tenants living in the building through the entire project. It’s very tricky because the end results are paramount, but the process itself is as important. The tenants, you see, are the American people, and you work for us now, and I assume you don’t want to get fired mid project. We expect you to come in under budget and ahead of schedule, of course, but we also expect no dust or debris in the lobby, no beams crashing on our heads, no interruption in utilities, and very little noise, and you promised not to disappoint us. It’s going to be wicked hard, but we know you can do it, hence our vote.
  • Obamacare is not health care. Obamacare is the two bit fa├žade they slapped on our health care. Fixing health care is precisely like renovating a building. Sure, you have to rip off the cheap paint and plaster, but you don’t start demolishing things like a bat out of hell, do you? First you get engineers to assess the building, its structural integrity, its surroundings and its potential or lack thereof. You get architects to look at blueprints, floor plans, shafts, beams, columns, electric, gas, water, HVAC, etc. You do some market research to see what people want and can afford. Then and only then, you make new plans, you make schedules, you price and choose materials, you bargain and fight, you hire workers, and the fun begins. I’m pretty sure you know what happens if, at any point, you skimp on prep work.
  • Obamacare was put together by political hacks who serve special interests and their lobbyists, and by ideologues who think the American people are too stupid to care for themselves. Obamacare in its totality is a corrupt entitlement system for large health care corporations and for Silicon Valley. If you assemble the conservative version of the Obamacare team of scavengers, your will fail. If you accept the perfidious, back-stabbing, premises of the Ryan plan to gut health care for the people who voted for you, you will fail. If you want to fulfill your promise to the American people, you’ll have to bypass the punditry swamp, put on a hardhat and go down to where health care happens and get your information first hand and free of charge.
Obamacare is irrelevant. Obamacare is at a minimum a distraction and at a maximum an impediment to affordable, high quality health care, because Obamacare misses the point entirely. I am sure you know from personal experience that in America one can get the best health care in the whole world, if one belongs to the privileged elite. What needs to be fixed is the distribution of health care across the nation. Not to disparage your “policy” speech at Valley Forge, but perhaps you should consider that the health care Inferno is nine circles deep, and what you see at first blush is just a hint of the horrors that lay beneath.
  • Health care is too expensive in America because America has become too poor. Health care is too expensive because American workers didn’t get a meaningful pay raise in decades. Health care is too expensive because poor people tend to be sicker and so are their children.  Health care is too expensive because there are too many middlemen and regulators between doctors and patients taking profits for busywork that adds no value. And most of all, health care is too expensive because politicians must pay back for their last campaign, and raise money for the next.
  • Health care is not a “consumer” product or service, and as Bill Clinton said, health insurance is not like auto insurance or home insurance. People don’t want to “shop” for medical care like they shop for hotels or shoes. It is frightening and humiliating to shop for your life or the life of your child. Imagine if you had to do that in a dire situation and understand that all people feel the same way (even the deplorable ones). Price transparency is just a load of crap. It’s one of those empty phrases politicians use to hoodwink voters. You are not a politician, so don’t do it. Just say no.
  • Free market for health care will work as well as free trade is working for the economy as whole. There is no such thing as free trade or free markets. There never has been and never will be. Trade and markets are manipulated and defined by the shrewdest and strongest participants. Sick people of limited means are no match for global corporations that managed to bring our entire government to its knees. Free market health care will leave most Americans with no doctors, no medicine and no care, just like free trade left us with no factories, no jobs and no income. You offered to be our voice, to fight for us and drain that swamp. There is no bigger swamp than health care in America.
  • Just take a look at the disgrace called Medicaid. No, seriously, look at it. Tossing block grants over the wall to states that are even more corrupt than the federal government, and washing your hands of the whole mess, will just make things worse. Remember that the vast majority of people on Medicaid are employed. They are employed in those new and improved crappy jobs that replaced manufacturing. Medicaid is now a penny-vacuuming machine that treats both doctors and patients like trash (with all due respect to your VP). Here is a litmus test for health care plans: would your less wealthy buddies be okay with getting care through Medicaid? Are any doctors you know okay with working for Medicaid? No? Neither is anybody else. You can’t fix health care without fixing Medicaid.
I don’t know how to fix health care. No matter how loudly they scream, how certain they are that theirs is the absolute truth, and how vigorously they waive their illustrious credentials, nobody knows how to fix health care. Nobody. My suspicion is that we are trying too hard. Health care is overmedicated with solutions that have toxic side effects, for which we apply other solutions with even higher toxicity, and before you know it a mild case of the flu starts to look like metastatic cancer. So what should you do on your first day in office? Anything you want, anything at all, anything but health care.

Take your time. Find the real health care still flickering underneath the suffocating layers of Obamacare and its bloated legislative and regulatory progeny. Find real doctors who still care for the health of real patients as they did before health care became a national trough for consultants, lobbyists and other fancy thieves. Beware the experts carrying charts and graphs and big data. Ask Peter Thiel about “big data” and “machine learning” and do trust him on this one. The daunting complexity of health care is largely due to greed, fraud and treachery. If you want to make health care great again, work hard to make health care simple again.

4 comments:

  1. There is no flicker of real care in Obamacare. The missing ingredient in the entire discussion is the patient and the value to the patient of the service. There is insufficient value to the patient in all of healthcare.

    Value is only determined by the buyer. Unfortunately the patient is no longer the buyer. Until the patient controls the money, he will continue to consume unnecessary services simply because there is no consequence to wasting the resources. They are not his or her resources.

    The discussion is still lost in the delusion that healthcare keeps people well.

    It does not.

    Furthermore, the worry over one's health is a life of misery rather than a life of personal fulfillment as determined by the individual.

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  2. "Obamacare is massive legislation that begot more legislations, such as MACRA."

    Let's look back a bit further here. Notably the HMO ACT in 1973 and Medicare Part C in 1997. And general explosion of Medicaid Managed Care in the 90s. MACRA appears to be all about cost and that approach far predates the ACA! It seems what has changed most dramatically is the degree of economic burden placed on providers. And the patients who have been carrying that burden for ages aren't showing up in your numerator!

    "Obamacare in its totality is a corrupt entitlement system for large health care corporations and for Silicon Valley."

    ONC: established 2004. HITECH: 2009 bipartisan effort. The ACA includes the phrase "health information technology" 28 times over nearly 2000 pages. Your ludditism is showing! Yet moments later you praise Peter Thiel (not so coincidentally named to the Trump transition team today), who isn't exactly going to stymie notions of tech saving the industry.

    I'm not impressed with the ACA (or HITECH for that matter) but healthcare was complex and corrupt way before Obama came into office. Even the use of the term Obamacare is yoking him to the "greed, fraud and treachery" as though the industry suddenly "became a national trough for consultants, lobbyists and other fancy thieves" on his watch. I find that disingenuous.

    Alas, at time of reading "(perchance)" is no longer necessary and President Trump gets his turn to stop the trend. I am skeptical he offers any hope for a serious solution that distributes care more equitably and puts patients and providers first. I fear the business of healthcare in America has yet to hit rock bottom.

    "If you want to make health care great again, work hard to make health care simple again."

    I'm curious - how does Medicare-for-All rate on your "simple" scale?

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    1. Let me start from the bottom up :-)

      Medicare-for-All is my preferred solution, the only solution that is actually a solution. Everything else we toy with is a tragic waste of time, money and most likely lives.

      I think HITECH, Obamacare, and I using the term because the President said he likes it and because ACA doesn't mean much to most people, and MACRA are doing something more sinister than increasing costs on providers (which by the way, is in turn increasing prices for patients).

      I am not a Luddite :-) but the technology forced on health care is not supportive of health care (both patients and doctors). It seems to have two other purposes: 1) funnel health care dollars into tech companies coffers, and 2) collect and aggregate mountains of liquid patient information.
      Personal data is gold. It is gold for health care corporations because they can use it under the guise of value-based care and all that malarkey to optimize payments and revenues. It is also gold for many other "stakeholders" inside and outside health care.

      When health IT produces something usable and truly helpful to health and care, there will be no need for financial coercion to buy it. I still think that day will come, but what they are doing now is just slowing things down tremendously.

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    2. Thanks for the response! Always enjoy reading your posts.

      And on the whole I agree- things are so far beyond broken. I like to tease but recognize the issue isn't fear of technology; it's about enforcing tools of unproven value that disrupt the provider/patient relationship. They are producing all that liquid gold data in tandem yet see none of the spoils.

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