Call to Action: Organizing for Patient Care

By NIRAN S. AL-AGBA, MD and MARGALIT GUR-ARIE     

On November 8th America elected a President who ran on a promise to restore government of the people, by the people, for the people (among other things). However, we cannot expect such government to be given to us on a silver platter, no matter who resides in the White House. We must build it ourselves, by definition. Government of, by, and for the people requires the people to stand up and do more than just vote every four years, do more than author clever blogs, do more than compose brilliant tweets, post cynical quips or write constructive comments on the websites of power. Self-government requires informed citizens with a vision to organize, mobilize, and take purposeful action.
For the last eight years we engaged in all of the former and none of the latter. We know many of you are in the same predicament. We are the everyday people and frontline doctors everybody in government is supposedly trying to help. We don’t entirely doubt the intent, but the end results have been so much less than we want, so much less than the American people deserve, so much less than we know is possible. We come from vastly different backgrounds. We have diametrically opposed political ideologies. We have a broad and dynamic spectrum of prescriptions for how health care in America should work. This is our strength.

You may be elated by the 2016 election outcome; you may be on the fence, indifferent, worried, depressed or positively enraged. Whether you love it or hate it, you cannot deny that something extraordinary happened on November 8th. Whether you think disaster breeds opportunity or victory itself is the opportunity, let’s “seize the present; trust tomorrow even as little as you may” and try to gain some control over our personal and professional fates.

Call to Action

We would like to propose that we organize a workgroup of physicians and people with interest in health care to create evidence and consensus based guidance and recommendations for the new administration as it undertakes major changes in health care policy, legislation and regulation. Our initial thoughts are that we create an objective position paper to address the impeding changes to current health care legislation, free of political and partisan shenanigans. Our dreams are that this grows into a perpetual grassroots advisory group which brings real-world experiences, varied points of view and wisdom from the frontlines of medicine and from everyday life into the hallowed halls of government to inform the work of public servants.

If you think the American people and their doctors should have a voice in governance, if you believe the welfare of your patients stands above politicking, if you want to amplify your voice and the voice of others, please join us. If you think you can contribute a small amount of time to such effort, we invite you to kick start this endeavor. You can remain anonymous if you so choose. You can contribute as much time as you have available. You can choose how, when and what. Let’s leave the actual details open and brainstorm together how best to move forward quickly.

Let’s Roll

Are you all in? Would you prefer to dip your toes in the water first?
Email us today: mga111026 at gmail.com
We will communicate via email to set up a conference call and take it from there. We will do the housekeeping, bottle washing and ashtray emptying to get us started. For those who already expressed enthusiasm (or guarded interest) on Twitter and elsewhere, retweet, spread the word and let’s make this happen. It’s time.

Is the Better Way Really Better?

Dear President-elect Trump,

The American people, myself proudly included, chose to send you to Washington DC to do their bidding. That’s what happened on November 8th 2016. Everything you hear now from the elite punditry is aimed at obfuscating this simple truth. Forget about dainty glass ceilings, we the people were able to break through the fortified ramparts erected by entrenched money and power and exercise our right to govern ourselves. I would caution the smug intelligentsia against underestimating the wisdom of the people once again, and I would caution you against forgetting who sent you there and why we did so. We now know we have the power, and what the people giveth, the people can taketh away.

RyanCare

The ecstatic welcome you received from Paul Ryan and Mitch McConnell the other day looks more like an act of violence than one of true reconciliation. Fair weather friends are usually there because they want something, and in this case they want to hijack the people’s agenda and replace it with their own conservative garbage. Mr. Ryan in particular has been proposing bogus alternatives to Obamacare with alarming regularity. Similar to Obamacare, Mr. Ryan’s health reform plan is based on belief in his own superior intelligence and devoid of any evidence that it can indeed work. Unlike Obamacare, the Ryan plan is also based on the assumption that helping the poor get poorer and the rich get richer is the ultimate role of government.

A few days before this historic election, I used your Old Post Office renovation project to highlight the big picture facets of health care in America in ways you can easily relate to. It will be very helpful if you read that first, believe me. From reading your latest Obamacare repeal and replace literature, I am starting to think that you are about to swallow Mr. Ryan’s fantasy hook, line and sinker. I would like to remind you that on the campaign trail you promised to replace Obamacare with “something terrific”. In keeping with tradition, the GOP Better Way may be great for GOP corporate donors, but for us, it is anything but terrific.

Have you read Mr. Ryan’s plan, Mr. President-elect? I suggest you do, and I suggest you ask your old friend Chuck Schumer to bridge an introduction to Bernie Sanders, who is perhaps the only other elected public servant not beholden to lobbyists and special interests. If I had to summarize the difference between RyanCare and Obamacare I would say that whereas Obamacare is providing people with a government defined set of health care benefits, RyanCare is proposing to make a government defined financial contribution towards purchase of health insurance. This difference extends to all insurance including Medicaid and Medicare, with RyanCare essentially dismantling Lyndon Johnson’s 1965 landmark legislation. I know you’re now in the “take the lumps out, son” phase, but some lumps were just meant to be taken as is.

Industrial Care

While Obamacare and RyanCare differ on how they finance health care services, they are unsurprisingly similar when it comes to controlling health care delivery costs, because this portion of both nightmares was dictated by corporate lobbyists and special interests. When you leave medical decisions in the hands of millions of people interacting with hundreds of thousands of doctors in unique ways, the result is utter chaos, or what we call freedom. The Obamacare lieutenants decided early on that the best way to exert control over costs is to industrialize health care.  You have to admit that this sounds pretty tempting. Industrialization has made lots of things cheaper and often better and more reliable. The conservative Ryan plan, which is by definition dismissive of workers and non-wealthy people in general, went all in with this aspect of Obamacare.

But here we are attempting to industrialize people. Not only is this impossible without enslaving humanity as a whole, but these futile attempts at industrialization are costing us a fortune. This is the fundamental round-hole-square-peg paradigm plaguing both Obamacare and RyanCare, because insurance prices are driven by the prices of goods that are being insured and you cannot have affordable insurance prices for unaffordable products. During the 2008 election season, President Obama made fun of Mrs. Clinton’s proposal to mandate that everybody buys health insurance, because it would be like trying to solve homelessness by mandating that all homeless people buy a house. A couple of years later he did precisely that. RyanCare on the other hand is turning health care into a food stamps program.

Here is the most important piece of health care information you’ll ever need: When you go to a doctor who runs his or her own small business, you pay half as much as when you go to a doctor that is employed by a large health conglomerate, and you get better care to boot.

To be fair, consolidation of health care started decades before Obamacare, but the Obama administration trifecta (the 2009 Stimulus, the 2010 Obamacare and the 2015 MACRA) made consolidation of health care providers pretty much mandatory. In a perverse and illogical way, this set of laws ensures that excessive health care prices are baked into this cake in perpetuity. In particular, the bi-partisan and fairly new MACRA legislation represents a complete regulatory capture of medicine, its transition to indentured servitude to moneyed interests, and hundreds of billions of health care dollars wasted.  Get rid of MACRA Mr. President-elect. Replace it with what Sen. Tom Cotton suggested on the floor right before the Senate voted on it. You do that and you are 90% where we need you to be.

The other day I listened to your favorite negotiator, Mr. Carl Icahn, and his description of how excessive regulations are killing our industries by discouraging capital investment in new machines, which in turn suppresses productivity growth, leaving stock buybacks the only venue for CEO enrichment. Health care is different. In health care, regulatory capture mandates the purchase and expensive operation of machinery that is designed to kill productivity, which leaves consolidation to gain market power, the only revenue enhancing alternative. MACRA is the final, and still removable, nail in this coffin. Whatever you do with Obamacare, if you leave MACRA in place and allow the passage of the 100% lobbyist crafted 21st Century Cures Act, it will all be for naught. To put it in construction terms, if your remodeled Obamacare is the building, MACRA and the Cures Act, are the termites and black mold devouring it from within.

Words that Go Bump in the Swamp

I know the President of the United States sets the tone, but cannot possibly be delving into policy details. Unfortunately, Mr. President-elect, policy details is where corruption lives. You may not be bound by allegiances to money and power, but your political appointees will be. Big league. They will come to you with executive summaries, both written and verbal, so here are three of the most common, most potent and most dishonest health care buzzwords. You should never use them, and you should never use advice from any swamp dweller that is using them, because these are code words for defrauding the public and we, the public, know that, and we are watching carefully. As simple as that.

Patient-Centered – Every calamity in health care is patient-centered. Every time you hear or read patient-centered, repeal and replace it with “circular firing squad”. The most common usage is to demand “transformation to a patient-centered model of care”. Now, you’re a smart man, think. What the hell does that mean? Try these: guest-centered resort, golfer-centered club, gambler-centered casino. See what I mean? People who pitch patient-centered ideas are known as “thought leaders” or “industry experts” and are invariably looking to fleece either doctors or taxpayers or both.

Patient-centered means big health systems using big computers to collect and analyze personal information of patients and target them for certain services that optimize payments and revenues for the system. Very much like the RNC campaign software worked to target voters for you. You think that system was voter-centered? With that answer in mind, perhaps it would be a good idea to remove that patient-centered reference from your website and fire whoever put it there. You are supposed to be the authentic one, remember?

Value-Based – This is a very simple one to understand, because as a businessman, you should know what value-based pricing means, and you should know that it is not something that has the buyer’s welfare in mind. You should also be cognizant of the fact that value-based schemes are intended to enable wealthy patrons to purchase better stuff, while the masses are kept content with generic, cheap stuff. This may work well for socks, but this is not how health care can or should operate. There is no such thing as generic versions of coronary bypass surgery, or buy-one-get-one-free dollar-store stents.

Value-based care is the key to the regulatory capture of medicine. Its sole purpose is to herd doctors and the working class into cheap, substandard systems of health care, and use the leftover money to enrich a vast array of special interests, ranging from insurance companies, think tanks, Silicon Valley vultures, and all the way to software developers in India and computer manufacturers in China. Like all fraudulent schemes to steal hundreds of billions of dollars, this is a huge and very complex subject, but for now you just need to beware people carrying value-based health care solutions. Treat them like they were carrying the plague.

Transparency – I heard you read this term from the teleprompter in a speech about health care. I know you didn’t put it there. Please, stop. President Obama promised the nation that his will be the most transparent administration in history. It ended up being the exact opposite. You said many times during your rallies that you are struck by how smart the American people really are. You were correct in that assessment. We may not look smart, or sound smart, but we are smart and you, of all people, should sympathize with our predicament. We know that a promise of transparency is only necessary if the enterprise is a secretive sham. When you promise transparency in health care prices, we know that we are about to be brutally beaten, raped and robbed. Transparently.

Bottom Line

We did not vote for you because we fell in love with the Republican Party elitist agenda. If that were the case we would have elected Mitt Romney in 2012 or Jeb! in 2016. We picked you precisely because we recognized that the conservative agenda, much like the progressive agenda, is an anti-working people agenda. We know what “defined contributions” are. We know what “vouchers” imply. We know what “skin in the game” means for us. And we know what the synonyms for “modernizing” Medicare and “block granting” Medicaid are. Thanks, but no thanks. We didn’t take much of your campaign-trail bluster literally, but we took your promise to be our voice seriously. Consider this a friendly reminder from the deplorable gallery.
Godspeed Mr. President-elect!

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 façade 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 anyone you know 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.