The Child Sexual Abuse Conspiracy

(After this essay was submitted to THCB the Senate Judiciary Committee held a hearing on March 28th titled, “Protecting Young Athletes From Sexual Abuse.” USA Gymnastics refused to appear and provide testimony likely, in part, because USA Gymnastics’ President, Steve Penny, was forced to resign on March 16th. The issue was framed by Committee Chairman Chuck Grassley as a “heinous crime,” no health care or public health expert testified and the hearing and was reported in sports pages of the The New York Times and The Washington Post.)

If you do not read the sports page you may have missed the news that this past November, December and February Dr. Larry Nassar, a former USA Gymnastics and Michigan State physician, was charged with numerous counts of criminal sexual misconduct and for possessing 37,000 child pornography images and videos of him sexually molesting girls. Beyond these charges, there are at present another 80 and counting related police complaints and several related civil lawsuits filed against Nassar. 1 Before he retired in September 2015, Nassar served on the USA Gymnastics National Team’s medical staff for 29 years and before he was fired last October, he also worked as a physician at Michigan State where for two decades he treated, among others, members of the university’s women’s basketball, crew, field hockey, figure skating, gymnastics, soccer, softball, swimming and track and field teams. Dr. Nassar was also associated with a Lansing-area girls’ gymnastic club and a high school.

In one significant respect Nassar’s case is strikingly similar to: Former US House Speaker Denis Hastert’s 2016 conviction for violating federal banking laws stemming from molesting high school boys dating back to the 1960s (see my THCB June 4, 2016 essay concerning Hastert); strikingly similar to USA Swimming Coach Rick Curl’s 2013 conviction for molesting a teenage girl dating back to the 1980s; similar to Jerry Sandusky’s 2012 conviction on 45 counts of sexual abuse dating back to 1994; similar to abuses committed by the BBC’s Stuart Hall and Jerry Sevile also dating back to the 1960s; to the numerous New York City Horace Mann School and abuse cases at over 65 private New England schools dating back to the 1970s; and, similar to the countless Catholic priest pedophilia cases dating back at least 70 years. What all these cases have in common is that fact that during the hundreds of years thousands of children were being molested, with rare exception no one that was aware bothered to report the perpetrator or make them known publicly.

It appears complaints against Nassar were first reported to Michigan State officials without consequence as far back as 1994. In courtroom testimony this past February, a victim stated that in 1998, or when the woman was six, Dr. Nassar began seven years of escalating sexual abuse. Not coincidentally, three days before this testimony, Kathie Klagas, the Michigan State head gymnastic coach, retired immediately after a woman came forward to accuse her of having ignored her complaints about Nassar. USA Gymnastics (an Indianapolis headquartered organization that, much like, for example, USA Swimming, was created by the 1978 Ted Stevens Olympic and Amateur Sports Act) alleges the organization first became aware of complaints against Nassar in June 2015. Despite the fact that all states require all allegations of child sexual abuse be reported immediately (for example, the Indiana Supreme Court ruled a high school principal violated the state’s “immediate” reporting rule by waiting four hours to report an alleged student rape), USA Gymnastics waited five weeks before contacting the FBI because USA Gymnastics chose first to investigate the matter itself. After learning of the allegations against Nassar, the FBI, in turn, waited nine months before it began its’ investigation.

USA Gymnastics has an established history of child sexual abuse. As The Washington Post recently reported, as early as 1999 USA Gymnastics CEO, Bob Colarossi, was sufficiently concerned to write to the US Olympic Committee (USOC) urging the USOC to adopt child sexual abuse prevention measures. His efforts were unsuccessful. As The Indianapolis Star reported last August, USA Gymnastics repeatedly failed to respond to sexual abuse allegations. As USA Gymnastics’ President Steven Penny believed there was no duty to report if you are a third party. The organization chose instead to keep files on more than 50 coaches suspected of sexually abusing children. The IndyStar reported, for example, as early as 2011 USA Gymnastics was made aware of 2010 national Women’s Coach of the Year Marvin Sharp’s practice of taking nude portraits of girl gymnasts as young as five at his photo study 15 miles from USA Gymnastics headquarters. Shortly before being charged, Sharp killed himself in 2015. USA Gymnastics was aware of James Bell’s behavior for five years before he was arrested for molestation. The organization knew for eight years of complaints concerning William McCabe, including one by a gym owner who stated McCabe “should be locked up” “before someone is raped,” before he pled guilty in 2006. It appears the organization learned of allegations against Nassar after a coach overheard a US national team member discuss with another gymnast abuses by Nassar while at Bela and Marti Karolyi’s gymnastic training facility, or ranch, in Texas. The Karolyi’s, along with USA Gymnastics and related others, are named in at least one civil suit filed last September where the plaintiff, a former gymnast (named Jane Doe in the complaint), alleges among other things, the Karolyi’s and other defendants actively concealed Nassar’s sexual abuse for years. 2

All this is all too familiar. This past November, after a five-year investigation the US Department of Education, acting under the 1990 Cleary Act, fined Penn State $2.4 million for failing to report campus crimes and to take measures to adequately protect its students. 3 For example, the Department found Penn State’s police department concealed a 1998 report concerning Sandusky molesting an 11-year-old boy in the team shower by failing to record the matter in the police department’s crime log. (Mike McQuery who witnessed Sandusky raping a 10-year-old boy in a locker room shower in 2001 that he made known to Joe Paterno, the Athletic Director and the university’s vice president, testified this past fall in a defamation and retaliation case in which he was rewarded over $12 million, that Penn State coaches Greg Schiano and Tom Bradley were aware for years that Sandusky was raping boys.) 4

In the Rick Curl, USA Swimming case, after Curl was hired by the University of Maryland as a swimming and diving coach in the mid-1980s, the university became aware he had, before becoming an employee, admitted in writing to molesting a teenage female swimmer. Though the university forced Curl to resign in 1988, the university concluded the school had no duty to report Curl to the police. Curl went on to coach for another 25 years at a prominent Maryland swim club. There have been numerous other similar instances of long-delayed revelations of sexual abuse by USA Swimming coaches. So many instances that Tim Joyce, who has done extensive research and reporting on sexual abuse within USA Swimming, was forced to conclude in 2014 that the problem was so endemic it was analogous to, he said, the “global problem of sexual predators in the Catholic Church.” 5

As for the Catholic Church, in protest over Pope Francis’s Pontifical Commission for the Protection of Minors (created in 2014) inaction, Marie Collins, a survivor (molested at age 13 by a priest) resigned in early March from the Commission. The one other survivor serving on the Commission, Peter Saunders, also criticized the Commission for the same reason and left last year. To date no bishop, including Bernard Law who served as Archbishop of Boston for 18 years and made infamous in the film “Spotlight,” has been punished for their complicity. For his sins in 2004 Law was appointed Archpriest of the Basilica di Santa Maria Maggiore in Rome where he served until he retired in 2011. 6

In the Stuart Hall and Jerry Savile cases, Hall, at age 86, was jailed in 2013 for admitting to assaulting 13 girls as young as 10 and Savile was posthumously charged in 2013 with 214 acts of sexual misconduct against boys, girls and women including boys under hospice care. Among other conclusions in Dame Janet Smith’s 2016 “independent review into the BBC’s culture and practices,” she stated flatly, “children were not protected as they should have been.” In response to Smith’s and Dame Linda Dobbs’ companion report, BBC Trust Chairwoman Rona Fairhead stated, “no one reading the reports can be in any doubt that the BBC failed them [the victims].” “It turned a blind eye, where it should have shown a light.” 7

As in the Denis Hastert case, once again Nassar’s alleged sexual abuse is neither the concern of medical or public health professional associations nor the health care media despite the fact, as I noted in my Hastert essay, child sexual abuse is highly prevalent, the CDC estimates one in four girls are sexually abused before reaching age 18, and the health consequences of sexual abuse are frequently extreme. In 2010, after 16-year-old Sarah Burt told her parents she was sexually abused by a USA Swimming coach, she drove to a busy intersection in Illinois, parked, promptly walked into traffic and was fatally struck by a semi. As in the Hastert case, if you search the Health Affairs Blog, Inside Health Policy, Kaiser Health News, The Morning Consult, Politico Pulse or RealClear Health you’ll find no mention of Larry Nassar. If you search the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), the American College of Physicians (ACP), the American Public Health Association (APHA), the American Medical Association (AMA) or the American Psychological Association (APA) websites you’ll again find no mention. You will learn that Denis Hastert is still, incredibly, named as the 2006 recipient of the AMA’s Nathan Davis award recognizing his contribution to “the betterment of public health.” 8

Once again, neither the White House nor the Congress has bothered to express concern – with one trivial exception. California Senator Diane Feinstein, ranking member of the Judiciary Committee, appeared in a February “60 Minutes” segment where she promised to introduce legislation that would address the problem. On March 6 Senator Feinstein along with 15 other senators introduced an anemic bill – far shorter than this essay – titled, “Protecting Young Victims of Sexual Abuse Act of 2017.” 9 The legislation would require USA Gymnastics and other like governing bodies to immediately report sexual abuse allegations and improve oversight of prevention policies and sexual abuse prevention training. The bill includes no enforcement mechanisms. As noted above “immediate” reporting is already required by law in all 50 states. The bill’s oversight and training provisions are already being addressed by the US Olympic’s SafeSport program initiated in 2012. However, the organization’s effectiveness has been called to task by among others ABC News and ESPN. After examining the program’s effectiveness, one journalist termed SafeSport “PR bullshit.” 10 (The Congress is of course presently attempting to pass health care legislation that would cut $880 billion over the next ten years from the Medicaid program that would leave even fewer therapeutic and social service resources available to victims of child abuse who, not surprisingly, tend to be financially less fortunate.) Legislation aside, as in the scandal involving Penn State Congressional members are still unwilling to hold a single hearing investigating child abuse under organizations the Congress-is-responsible-for-creating, or ask the FBI to conduct an actual investigation. When Representative George Miller now retired, pleaded in 2013 for a hearing and wrote an 11-page request to the FBI to investigate USA Swimming, as noted in my Hastert essay he received a half-page response by the FBI stating the agency had met with USA Swimming officials. The Washington Post’s recent February 20th retelling of the Miller effort, the paper aptly tiled, “Government Probe of Sex Abuse Prevention in Olympic Sports Went Nowhere.” 11

Some argue sexual abuse and witness indifference can be explained or explained away by arguing rape culture. However cynical the explanation, again, one in four girls are sexually abused by age 18 and one in three women experiencing sexual violence at some point in their lives. Examples of adult victims of abuse abound: Bill Cosby; Donald Trump; the Baylor football team; and, the practice and known consequences of convincing co-eds to play “hostess” to “entertain” college athletic recruits. Under this lens widespread child sexual is ordinary, it’s commonplace. Even Dame Smith cited cultural factors in explaining the BBC’s bureaucratic myopia. Girls raped by Hall and Savile were not put in moral danger, they were instead viewed by the BBC, Smith stated, “as something of a nuisance.” Survey findings published in JAMA Pediatrics in 2013 found half of young adult perpetrators felt the victim was “completely” responsible. 12 There’s no reason, no believed social responsibility for witnesses to report perpetrators of child sexual abuse or to make them publicly known. Jonathan Frazen captured this reality in his 2010 novel, Freedom. When Patty, a high school athlete, is raped by Ethan, a New Hampshire prep schooler, Patty’s mother argues Ethan should simply apologize. Patty’s lawyer father tells her to “forget about it,” “shake it off.”

Far worse than the USOC’s failure to fulfill the purpose of the Olympic idea, i.e., to place sport in service to mankind’s development, is the fact we’ve reached a point where moral agency has disappeared. The French philosopher Simone Weil wrote in 1933, “never react to an evil in such a way as to augment it.” The willful indifference by the White House, the Congress and any number of medical and public health professional associations along with a blind health policy media has done just that. It’s this kind of callousness where evil becomes banal. We’ve become are our own misfortune.

Final Note: It appears one of Larry Nassar’s favorite molestation techniques was to place his unsanitary, ungloved, non-lubricated hand in a girl’s vagina under the guise of performing an “intravaginal adjustment.” He did this without the consent of the victim, their parent and typically without the parent or another adult being present. In a civil complaint filed by Tiffany Lopez this past December, Ms. Lopez alleged beginning in 1998, while still a minor, Nassar began sexually abusing her, abuse that included performing “intravaginal adjustments.” When Ms. Lopez complained to the Michigan State athletic department she was told Nassar was a “renowned doctor,” to continue to see him and not to the discuss her treatment. In 2001 Ms. Lopez refused treatment from Nassar and left Michigan State. 13

Endnotes
1. The Nassar case has been mostly widely reported by The Indianapolis Star. The newspaper has published approximately a dozen related articles over at least the past seven months. The Washington Post’s reporting has been done largely by Will Hobson.
2. The complaint is at: http://ift.tt/2cUHU1f.
3. See: http://ift.tt/2fIAQ9E.
4. Among other articles see: http://ift.tt/2fIAQ9E.
5. See: http://ift.tt/2opB5ay.
6. See: for example, http://ift.tt/2ohBVZM.
7. The Dame Smith report is at: http://ift.tt/1LHlHum. Fairhead’s statement is at: http://ift.tt/1TAwU6x.
8. Denis Hastert is listed as a Nathan Davis winner at: http://ift.tt/2opDRwo.
9. The Feinstein bill is at: http://ift.tt/2opDRwo.
10. See: http://ift.tt/2ohzo1O.
11. See: http://ift.tt/2opEFS5.
12. See: http://ift.tt/2opEFS5.
13. The compliant is at: http://ift.tt/2ohFTBy.

from THCB http://ift.tt/2ojvtC0

Trump’s Obamacare Debacle: Vanquished by a Ghost!

Judging by the dazed expression on President Trump’s face at his Friday afternoon press conference, it is clear that he never saw his first major political defeat coming. It was as if he had stepped off the curb looking the other direction into the path of an uncoming bus.

The key to any political victory is situational awareness- clarity about your goals and mastery of the details. There were warning signs of a potentially fatal disengagement, for example, in Trump’s periodic references to “the healthcare” when discussing the issue.

It doesn’t make Trump’s political pain any more bearable to know that he was mugged by a ghost, by a potent political symbol nourished by the Obama administration. The stunningly rapid political failure of the American Health Care Act more resembled a botched exorcism than a serious exercise in health policy.

From his successful campaign, Trump knew that repealing and replacing ObamaCare was the most reliable thunderous applause line in his stump speech. This visceral connection moved the issue to the top of his political agenda. To Trump’s political base, repealing ObamaCare was striking a blow against a paternalistic all-knowing federal government, against interference in citizens’ private lives, against confiscation and redistribution of peoples’ wealth, to a new “entitlement” program, but most of all, against a President they reviled.

What his base really wanted to do was banish the Obama legacy symbolized by this legislation. Abolishing the reality of Obamacare, which needed to be addressed by detailed legislation, was very different, messier and more complex than erasing the symbol. The real Obamacare was a bewilderingly complex and sprawling mish mash of liberal good works intended principally to reduce the number of the nation’s uninsured.

Unraveling Obamacare the Law without leaving a politically damaging, gaping hole in the healthcare system was a daunting and complex technical challenge which easily evaded an inexperienced new Republican majority in Congress. The political challenge was made even more complex by Trump’s running far to the left of his Congressional base in wanting to preserve coverage gains for the formerly uninsured.

The core of Obamacare was a partial federalization of one of the twin pillars of the Great Society, the Medicaid program (scaled back by the Supreme Court in 2012), as well as a partial federalization of the nation’s private health insurance market. But that was only 10% of the 900 plus page law. There was also the removal of the hated “doughnut” hole in the 2003 Medicare drug benefit, a charter for experiments with new Medicare provider payment models, new health manpower provisions, a reform of the US Indian Health Service, public health funding enhancements, a new federal agency to evaluate the effectiveness of medical technology, a raft of new taxes to fund its provisions and literally dozens of other things, all enswathed in gigantic heaps of almost unreadable legislative prose.

The circle of people substantively aware of ACA’s actual scope and complexity included at most a couple thousand Democratic health policy wonks, legislators and their staffs, and reporters- none of whom were at Trump’s side when he began his doomed crusade. Some members of Trump’s majority, notably Senator Lamar Alexander, could be heard at the late January Republican retreat pleading with his colleagues to narrow their focus to the troubled health insurance reforms in ACA and not attempt “full repeal”. These voices of reason were brushed aside in a bloody rush to uproot as much of the law as humanly possible in a short period of time.

The origins of Trump’s political embarrassment are buried not only in his White House’s lack of substantive knowledge of the law, but also deep public ignorance of what ACA actually did. By the summer of 2009, anger at the Obama Administration’s perceived failure to address the nation’s economic crisis (despite a stimulus bill and auto industry bail-outs), was boiling over in angry town hall meetings and the rise of the Tea Party.

Concerned about rapidly deteriorating political polls, Obama’s political advisors urged him to change the conversation after signing the ACA on March 23, 2010. The President’s political advisors viewed health reform as a quixotic “legacy” Democratic political project and had misgivings about leading with it in the first place. Given the dire economic circumstances, further focus on the ACA was digging a deepening political hole deeper.

So the administration basically walked away from ACA, and invested virtually no energy or resources in explaining to people how the law actually benefited them. Obama’s advisors were right about the rising anger part. Less than eight months later, in the 2010 mid term elections, voters stripped Democrats of control over the House of Representatives in the most stinging electoral repudiation of any political party in 72 years!

But by moving on, and failing to educate the public of ACA’s benefits, the President left the law’s growing rank of opponents free to define what it was. Because the ACA was intimidatingly opaque, even to experienced policy analysts, it was far from obvious what it did or whether it was going to work.

Failing to explain in plain English how the law benefited Americans was a fundamental political failure. The law became, by default, a gigantic Rorschach blot onto which the public could project their emotions about government. For progressives, ACA was an extension of the New Deal and Great Society, a merciful government keeping its promise to provide security to Americans. For the Tea Party, and the emerging alt-right movement, the ACA was an assault on liberty, an onrushing phalanx of black helicopters, a government take over of the health system, etc. But most important, for the right, “ObamaCare”, as its enemies called it, was about Obama, and his vision of the country.

By failing to explain to people what was done in their name, Obama effectively orphaned the law. And the result: ACA achieved 50% approval ratings in Kaiser Family Foundation’s tracking poll for exactly one month in the ensuing seven years. http://ift.tt/2lyLam3 Even as Congress debated killing it, it only reached 48% approval in February, 2017. The Kaiser poll also repeatedly confirmed vast ignorance of the law’s contents (e.g. the presence of “death panels”, covering “illegal aliens”, who was actually eligible for coverage, and the like). The law’s opponents largely succeeded, by default, in the battle to define ACA politically.

Obama added color (bright red!) to the law’s image by embracing the label “Obamacare”, co-opting the Republican slur on the ACA. The logic was, “Well, since it is really going to help people, why not put our name on it?” In retrospect, embracing the radioactive partisan label Obamacare was the equivalent of a tacky end zone celebration, a form of political taunting. This made the law more vulnerable, because it closely tied the ACA to a particular person.

Social Security was a political lift for the New Deal, a lift that would have been much heavier had it been labeled “RooseveltCare”. Was it merciful political restraint or mere prudence that prevented Lyndon Johnson’s White House from rebranding Medicare and Medicaid as “JohnsonCare”? These measures were controversial in their day, but evolved over decades into part of our social infrastructure.

Embracing the “Obamacare” label for the Affordable Care Act made it all the more tempting a political target, and by the sheer rage it evoked on the alt-right, might actually have helped intensify the political energy behind “repeal and replace”. What overwhelmed the Republican Party last week was almost like the political equivalent of an auto-immune reaction to a bee sting.

The law’s image was also damaged by the catastrophic roll out of Healthcare.gov in October, 2014, the “if you like your health plan, you can keep your health plan” fiasco when ACA’s grandfathering provisions went into effect and the surge of individual and small group insurance rates as the Exchanges opened for business. This infuriated many innocent bystanders (including this author’s wife, who received a 62% renewal quote for the small group insurance for her florist business in the fall of 2014).

That these problems could have overshadowed the ACA’s headline success story- covering over 20 million formerly uninsured people and doing so without igniting a new round of health cost inflation- should tell you something about our present political moment.

In retrospect, things could have gone worse on the Trump Administration’s maiden voyage into health policy. They could have failed slowly, and dragged the divisive debate over the future of ACA into next year’s off year election cycle. OR they could actually have passed the American Health Care Act and been swamped by the damage done to their base of working class voters, millions of whom would have found themselves without health coverage http://ift.tt/2m2OjbL “Failing fast” may actually have been the least worst political outcome for a Trump Administration. By failing to understand the complexities of the actual law, and being seduced by the taunting symbol of the previous administration, the Trump Administration fell into a political trap.

from THCB http://ift.tt/2nzyYRm

“Let Obamacare Explode …”

Last week, the AHCA was pulled from the House floor after not enough votes could be secured in favor of its passage.  A Washington Post article reported President Trump’s thoughts on the matter.  “We couldn’t get one Democrat vote, not one. They [Democrats] own Obamacare.  So when it explodes…we make one beautiful deal for the people.”

Journalist Robert Costa asserted “there was little evidence that either Trump or House Republicans made a serious effort to reach out to Democrats.”

Well Robert, I sure did. And I did not get very far.

In the interest of full disclosure, over the past 20+ years, I have been a Democrat, Republican, and just about everything in between.  I recently reached out to lawmakers on both sides of the aisle, yet the responses were lopsided.  A recent entry myself into the political physician realm, I gave a presentation last week on lowering Medicare drug costs to the National Physicians’ Council for Healthcare Policy (NPCHP), in the Energy and Commerce Committee Hearing Room in Washington DC.  This phenomenal group of physicians was assembled by Congressman Pete Sessions (R) from Texas; and they are innovative, engaged, and working to improve the lives of their patients and fellow physicians.

Six weeks prior to my Washington DC visit, I reached out to three local lawmakers in the interest of discussing healthcare:  Congresswoman Cathy McMorris-Rodgers (R), Congresswoman Jaime Hererra-Beutler (R), and my own local Congressman (D), who I am not naming because of the story below.  Both Congresswomen responded and met with me briefly; they were gracious, honest, and forthright about their support or lack thereof for the AHCA.   Despite three attempts to set up a meeting with my own Representative, I have yet to receive a response.

In my opinion, not engaging with practicing physicians on the subject of health care reform is a lost opportunity.  There was very little chance my Democratic Representative would vote in support of the AHCA (which is perfectly acceptable), but why is it not worth his time to exchange ideas with a local practicing physician?

Eighteen months ago, my Representative and I were both in attendance with our respective extended family members at a local theatre production watching our children perform.  During the event, I responded as a Good Samaritan for a relative of my Congressman.  Without a second thought, I jumped up quickly to respond.  To qualify for Good Samaritan protection, you must meet three qualifications:  there must be an emergency, aid must be rendered outside a hospital or a place with medical equipment, and care provided must be voluntary.   In the interest of privacy, suffice it to say, this particular situation met all three criteria and I rendered all necessary and appropriate treatment.

Partisanship has no place in the rendering of health care services and should play no role in the work of advancing health care reform.  Regardless of party affiliation, lawmakers should solicit recommendations from local practicing physicians whenever they are able.  Both Representatives McMorris-Rodgers and Herrera-Beutler set aside time to speak with a concerned physician from their home state about impending healthcare legislation.  They are both strongly committed to ensuring the populations of Washington State have timely access to healthcare.  I realize their time is precious.  So is mine.

Practicing physicians are partially to blame for not insisting our voices be heard by lawmakers.  As a group, we willingly lend our expertise assisting others in our offices, our communities, and our country, yet we accept the status quo as second class citizens when it comes to having a place at the proverbial healthcare policymaking table.  This MUST change.  Lawmakers who passed the foundering ACA and burdensome MACRA legislation consulted very few practicing physicians on the front lines, and their legislative plundering is destroying our once noble profession.

The last independent pediatric group in my local Congressmans’ hometown was recently purchased by a hospital conglomerate as a direct result of the ACA legislation he supported. Everyone seeking pediatric care in that county will see their costs rise significantly as a result of the mandatory “facility fee” imposed by the hospital for primary care services. This is a loss of affordable access for his community.

After pulling the AHCA bill last Friday, Trump said, “As you know, I’ve been saying for years that the best thing is to let Obamacare explode and then go make a deal with the Democrats and have one unified deal. “  I agree with him.  It will ultimately result in a better healthcare plan for us all.  First and foremost, however, lawmakers responsible for ACA and MACRA legislation must be held accountable for the unanticipated consequences resulting from “coverage with no access to care;” the folly of which is unfolding before our very eyes.

Physicians care deeply about our patients and our communities. Physicians must ensure they have input on the next healthcare go-around.  Meaningful healthcare reform will require pragmatism, diligence, compromise, and patience.  Working across the aisle is vital to developing better health care legislation for the American people.

It is time lawmakers consider front-line doctors as the ‘industry experts’ best positioned to contribute to the development of effective and enduring health care reform rather than relying on the renderings of lobbyists who are padding their own pockets as well as those of legislators.  In response to Robert Costa at the Washington Post, I believe President Trump when he said they could not obtain one single Democratic vote.  My own Democratic Representative would not spend five minutes discussing healthcare legislation with me, a practicing physician from the district he represents in Congress.  It is time to roll up our sleeves, shake hands, and get to work.

from THCB http://ift.tt/2nhqfS9

Did Medical Darwinism Doom the GOP health plan?

“We are now contemplating, Heaven save the mark, a bill that would tax the well for the benefit of the ill.”

Although that quote reads like it could be part of the Republican repeal-and-replace assault against the Affordable Care Act (ACA), it’s actually from a 1949 editorial in The New York State Journal of Medicine denouncing health insurance itself.

Indeed, the attacks on the ACA seem to have revived a survival-of-the-fittest attitude most of us thought had vanished in America long ago. Yet, again and again, there it was in plain sight, as when House Speaker Paul Ryan (R-WI) declared: “The idea of Obamacare is that the people who are healthy pay for the people who are sick.” Contemporary language, but the same thinking that sank President Harry Truman’s health care planalmost seven decades ago.

Ryan’s indignation highlighted a fundamental divergence in attitudes that repeatedly turned the health care debate into a clash over the philosophy behind Obamacare-style health insurance. To some, the communal pooling of financial risk of medical expenses seems too often an unacceptable risk to personal responsibility.

As a researcher who has documented this approach to health care, I’ve been startled to see the debate over the AHCA reignite a political philosophy and policy approach that seemed to be have been discredited – and be in sharp decline.

When Truman launched the first comprehensive effort to cover all Americans, most of the population had no health insurance.

Last year, thanks to the ACA, nearly 90 percent did, according to a Gallup-Healthways poll. Yet then and now, many conservatives have downplayed the impact on physical health and focused, instead, on fiscal temptation.

If You Can’t Afford to be Sick, Then Don’t Be

Take, for instance, Rep. Jason Chaffetz (R-UT) warning low-income Americans on March 7, 2017 that they had “to make a choice” about their spending: “So rather than getting that new iPhone that they just love and want to go spend hundreds of dollars on that, maybe they should invest in their own health care.” (He later walked back his statement.)

In reality, of course, the premiums from the GOP’s late and abandoned American Health Care Act would dwarf any savings from iPhone abstinence. For a 64-year-old making US$26,500 a year, the cost of health insurance would have shot up from $1,700 to $14,600, according to the Congressional Budget Office (CBO), or more than half that individual’s pre-tax income.

Chaffetz and others seem to sincerely believe that “what keeps the great majority of people well is the fact that they can’t afford to be ill” – although those words come from the 1949 editorialist again, not a Trump administration tweet. The editorial continued:

That is a harsh, stern dictum and we readily admit that under it a certain number of cases of early tuberculosis and cancer, for example, may go undetected. Is it not better that a few such should perish rather than that the majority of the population should be encouraged on every occasion to run sniveling to the doctor? That in order to get their money’s worth they should be sick at every available opportunity? They will find out in time that the services they think they get for nothing – but which the whole people of the United States would pay for – are also worth nothing.

As it happens, the effect predicted in 1949 on the detection of cancer – less of it – is precisely what has happened with the spread of high-deductible health plans praised by conservatives for encouraging more careful “shopping” by “consumers.” A study in Medical Care showed that screening rates for colorectal cancer declined under high-deductible plans until, under Obamacare, the federal government forced those plans to include first-dollar coverage of preventive services. The screening rates for colorectal cancer promptly rose. A recent study in Cancer found the same results for mammography.

Separately, surveys and research on high-deductible plans have found that 20 to 25 percent of people have avoided needed care of all kinds because they can’t afford it.

Nonetheless, the GOP’s conservative wing denounced ACA-mandated “essential health benefits,” echoing the idea that it is a threat to American freedom. Or as that same New York medical journal put it:

It is time that someone – everyone – should hoist Mr. Charles Darwin from his grave and blow life into his ashes so that they could proclaim again to the world his tough but practical doctrine of survival of the fittest…The Declaration of Independence said that man was entitled to the “pursuit of happiness.” Any man who wishes to pursue happiness had better be able to stand on his own feet. He will not be successful if he feels that he can afford to be ill.

The Quality of Mercy is Not Strained

For most physicians, that compassionless condescension lies in the faraway past; for example, the AHCA was overwhelmingly opposed by medical professional groups, including the American Medical Association.

Yet an implacable medical Darwinism retains a firm grip on many conservatives, even on physicians. Then-Oklahoma Sen. Tom Coburn, an obstetrician/gynecologist and prominent Republican, told a sobbing woman at a 2009 public meeting on the ACA that “government is not the answer” when she said she couldn’t afford care for her brain-injured husband.

Similarly, in 2011, after the ACA passed, then-Rep. Ron Paul (R-TX), also an obstetrician/gynecologist, was asked what should be done about an uninsured, 30-year-old man in a coma. “What he should do is whatever he wants to do and assume responsibility for himself,” Paul responded, adding, “That’s what freedom is all about, taking your own risk.”

Or as conservative scholar Michael Strain put it in a 2015 Washington Post editorial: “In a world of scarce resources, a slightly higher mortality rate is an acceptable price to pay for certain goals – including…less government coercion and more individual liberty.”

Strain is right, of course, that resources are limited. Moreover, it’s long been known that overgenerous health insurance can lead to overuse of medical care services.

However, most Americans, including some prominent conservative intellectuals, don’t see stripping away health insurance from 24 million countrymen – the CBO’s estimate of the AHCA’s 10-year impact – as striking a blow for liberty. In a Quinnipiac University poll released just before the scheduled AHCA vote, only 17 percent of respondents approved of the Republican plan and 46 percent said they’d be less likely to vote for someone who supported it.

One day later, GOP leaders withdrew the legislation, sparing Republican representatives a vote “on the record.” Although Vice President Mike Pence has called evolution an unproven theory, it turns out Republicans really do believe in “survival of the fittest” (at least in a political sense), after all.

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Repealed and Misplaced

Like Joe, Michael and others, I find myself wondering what, if anything, Trump learned from the demise of the AHCA last Friday. But I’m also wondering what Democrats and other Republicans are thinking. The question I would like to ask all Republicans is: Is it clear to you now that merely saying no to any Democratic proposal to lower the uninsured rate is bad for your party? The question I would like to ask all Democrats who supported the Affordable Care Act is: Is it clear to you now that that the managed care nostrums in the ACA cannot lower costs, and that attempting to lower the uninsured rate without cutting costs is bad for your party?

Here’s my short answer to these questions: Trump didn’t learn anything about health policy but he did learn not to trust the Freedom Caucus; Republicans did learn that saying “hell no” is bad for their party; and I haven’t the faintest idea whether elected Democrats (as opposed to the Democrats’ base) are finally ready to look outside the Book of Managed Care for solutions to high US health care costs.

Let me start with Trump. I doubt he learned a darn thing other than “health care is complicated” and the Freedom Caucus cares more about their anti-government religion than they do about Trump or the GOP.

I might have entertained the possibility that Trump is capable of learning if he had made statements Friday night aimed at reassuring nervous insurance companies that he and Tom Price will work overtime to stabilize the individual markets. But Trump didn’t do that. Instead he used his TV time to state over and over that Obamacare will “explode.” A man with any brains would have realized that Obamacare is still the law of the land and is now his responsibility, and if he deliberately sabotages the exchanges the public will assign much, perhaps all, of the blame to him and the GOP.

Trump’s inflammatory statements come at a time when the exchanges are extremely vulnerable. Trump had already weakened the exchanges by instructing the IRS not to reject tax returns that fail to tell the IRS whether the filer has insurance, and by leaving the insurance industry in the dark about how he intends to resolve House v. Price(formerly House v. Burwell, the case in which a federal district court held that Congress never authorized funding for the subsidies for out-of-pocket costs for people under 250 percent of the poverty level). His gratuitous fear-mongering Friday night will only further weaken the exchanges.

The next most important question for Republicans is whether the non-suicidal wing of the Republican party learned anything. Surely all sane Republicans now know that obstructionism is no longer a surefire way to build the Republican party. Unadulterated obstructionism has been the GOP’s position on health policy affecting the non-elderly since 1993 when William Kristol and then Representative Newt Gingrich began their campaign to persuade congressional Republicans to refuse even to negotiate with Democrats on the Clintons’ Health Security Act (HSA).

In December 1993, William Kristol, then with the Project for the Republican Future, privately circulated a memo http://ift.tt/180dgsc telling Republicans that “simple criticism is insufficient” and that Republicans must demand “surrender” and should “erase” and “kill” the HSA. Kristol did not present an alternative to the HSA. His argument was purely ideological (the Clintons were going to “destroy” the health care system) and Machiavellian (“[The HSA] will …. strike a punishing blow against Republican claims to defend the middle class by restraining government.”) Gingrich promoted the same message — just say no, and don’t offer an alternative. His Contract with America had nothing to say about health care other than, “We don’t need a government-run health care system.”

By 1994 Republicans were not only willing to be public about their Hell No strategy, they bragged about it. It paid off. The HSA went down in flames in September 1994, and Republicans took control of both houses of Congress two months later. The November 1994 election was one of the worst mid-term setbacks to a sitting president in US history.

The advantage of the Hell No strategy was that Republicans never had to declare whether they supported universal health insurance, or even cared enough about the uninsured to go beyond occasional handwringing about the problem. But Republicans gradually gave up that advantage after the enactment of the ACA in 2010. They weakened that advantage first by adopting the “repeal and replace” mantra; now they were at least officially in favor of “replace,” something they had never promoted before. The unveiling of the AHCA, the release of the CBO report on the AHCA, the near universal opposition to the bill by provider organizations, and the demise of the AHCA last Friday obliterated what was left of the Hell No advantage. Now the entire world could see that Republicans cared so little about reducing the uninsured rate, never mind achieving universal coverage, that they never bothered to develop an alterative to Obamacare, much less one that was better than Obamacare.

The ACA, for all its defects, did one thing good for this country: It forced Republicans to come out of their Hell No bunker and put up or shut up. And when Ryan and Trump put up, the vast majority of Americans and a significant number of congressional Republicans wrinkled their noses and said that wasn’t good enough.

I agree with those who suggest Trump might eventually ask Democrats to help him figure out how to improve the ACA. If he does, Democrats will feel compelled to at least appear to be negotiating. But even if negotiations come to pass, what could Democrats propose to Trump that Trump might be interested in beyond tiny tweaks to the ACA? All Hillary could propose was more bailouts for the insurance industry and more money for “navigators.” I think the best we can look forward to is bipartisan tweaks — letting insurance companies charge older people more, for example.

I wish I could say with some confidence Democrats will soon start thinking seriously about abandoning their ancient obsession with overuse and the managed care “solutions” the overuse diagnosis naturally leads to, and start focusing instead on high prices and the administrative waste and galloping consolidation(encouraged by managed care solutions) that drive prices up. (Note to Jim Purcell: Jim, please read my comment on the overuse obsession here http://ift.tt/2d5LuER. You are welcome to use anything you see there in your book.) I also wish I could say the awful price Democrats have paid for the defects in the ACA and the demise of the AHCA has emboldened Democrats to start thinking seriously about how we extend the traditional Medicare program (not the Medicare Advantage program) to the non-elderly (in stages if necessary).

But at the moment I can’t say the Democratic leadership is ready to abandon the overuse diagnosis and all the managed care fads that were endorsed by the ACA. A large portion of the Democratic base wants a debate about Bernie’s and and Rep. John Conyers’ Medicare-for-all legislation. But what does the leadership of the party think? Who knows?

Over the last four years, elected Democrats at all levels, and ACA supporters generally, have responded to the constant bad news about Obamacare like deer staring at headlights on a Mac truck. They knew they were about to become roadkill, but they didn’t know what to do about it, so they froze in the crouch position as the lights bore down on them. And now that they have survived being run over, what are they thinking? They know the Affordable Care Act was a significant factor in their losses in 2010, 2014 and 2016, but are they now ready to concede that their high hopes for the managed care cost-containment nostrums in the ACA were based on faith, not evidence, and that that faith severely damaged their party? Who knows? To continue the deer-in-the-lights analogy, they appear to be coming out of their crouch and thanking the gods they didn’t get killed, but they’re still in the middle of the road and too confused to know what to do next.

The Democrats have suffered the political equivalent of a near-death experience. Near-death experiences can cause people to develop fresh thinking about old problems. But they can also cause PTSD and make people fearful of change. I predict that that over the next two to four years the PTSD effect will rule Democratic strategy even as a large portion of the Democrats’ base demands fresh thinking. I predict, therefore, that even if Trump decides to approach Democrats for help fixing the ACA during this session of Congress, Democrats won’t coalesce around Medicare-for-all but will instead cooperate with some tinkering with the ACA and some tinkering with a few other health-related programs, possibly including MACRA.

Here’s one wild card I suggest we all watch out for: Revival of Paul Ryan’s proposal to complete the privatization of Medicare with a voucher program. Trump has shown repeatedly he is willing to lie and break promises. He just broke possibly the biggest promise of his campaign — the one about repealing and replacing the ACA. (If he didn’t break it, why didn’t he promise to return to this issue soon?) Might he not also break his promise to leave Medicare alone? I can see him doing it to free up some money for his tax cuts for the rich, his infrastructure proposal, and his military build-up.

If Trump and Ryan decide to push Ryan’s voucher program, Democrats will face a problem. They told the public that a voucher program was good for the non-elderly (the Obamacare premium subsidies are the equivalent of vouchers), so how do they now take the position that vouchers for the elderly are bad? Will they resolve this contradiction in favor of abandoning support for the ACA and supporting Medicare-for-all? One can hope.

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Now What, Mr. President? Here’s What.

By STEVEN FINDLAY

In the wake of the AHCA’s demise, most lawmakers and policy experts agree that Congress will put repeal and replace aside for the rest of 2017.

As House Speaker Paul Ryan acknowledged on Friday that means the ACA/Obamacare remains the law for the “foreseeable future.”

Thus, as was widely reported over the weekend, that begs the question: how will the Trump administration administer the law and when might be the right time to return to the issue of fixing and improving it (however you want to label that.)

This is unknowable at the moment. The President, although inconsistent in his remarks, threatened to let the ACA “explode” this year and in 2018, thus forcing Democrats, in his mind, to beg him to fix it. At the same time, he said maybe the legislation’s demise was the “best thing” that could have happened since it would allow him to work with Democrats to craft an ACA replace or fix bill that would win their votes, bypassing the hard-right Freedom Caucus block in the House.

There are very tricky political waters here. For example, if Trump follows through on the work-with-Democrats strategy anytime soon and thereby alienates the 40-member strong Freedom Caucus, he could lose their votes on other priorities. There’s also no guarantee that, emboldened by AHCA’s defeat, Democrats would go along with him on anything but the fixes they to Obamacare they want.

Bear in mind that the mid-term elections are on Nov. 6, 2018. All 435 seats in the House and 34 of the 100 seats in the Senate will be contested. (That election is, of course, one reason Ryan told Trump they had to pull AHCA given that they didn’t have the votes in the House and Senate passage was in serious doubt.)

Will ACA repeal and replace, by Nov. 2018, be an issue Republicans want as a campaign issue, or not? Would it inure to their benefit to return to it in 2018 and do a smaller bore fix, with Democrats, they could then call a win? Or would it be better for them politically to continue to bash Obamacare, especially if premium hikes and insurer pull-outs continue?

Democrats almost certainly will be looking to batter Republicans with their repeal and replace failure, and on the merits of what they proposed in AHCA. So, again, they may have no motivation to do anything.

All that said and acknowledging the many uncertainties, I think Trump’s smartest play is to pivot back to the philosophical approach he campaigned on—access to coverage for all; lower premiums, deductibles, and copays; lower costs overall (drugs and other high-cost care); and improved care.

When the time is right—possibly this fall or early 2018—he should take this step, explicitly denouncing the AHCA framework including any major pull-back on Medicaid.

This approach would lay the foundation for working with Democrats—again, when the political timing is right—to make ACA repairs. At the same time, he should up the ante on health care prices and costs, proposing specific legislative steps to address unnecessary, wasteful care through payment and delivery system reform. (He might consider reading a couple of health care books over the next 6 months.)

In the meantime, Trump should take steps to stabilize and improve the exchange marketplaces while at the same time extending flexibility on health care to the states. Combined, this approach would curry favor with Democrats and mollify most Republicans. Specifically, he should:

(1) Direct White House lawyers to continue the Obama Administration’s legal fight to preserve the subsidies that help low-income exchange enrollees pay their deductibles and co-payments. House Republicans filed suit in 2014 alleging that these subsidies were not authorized in the ACA. The case is in the courts. Without the subsidies, used by some 70 percent of enrollees, insurers stand to lose money and, of course, millions of consumers will be financially stressed.

The Republicans won a preliminary victory on the issue in May 2016 when a federal judge agreed that the ACA had failed to properly set up funding for the program. The Obama Administration filed an appeal. Then in December, after Trump’s victory, the Republicans asked the 3-judge appeals court panel to hold off on the case, pending repeal and replace legislation. The panel agreed.

In January, the panel denied a request by two exchange enrollees to rule on the subsidies before the Trump administration weighed in. Trump’s lawyers now must decide what to do. If he declines to fight to preserve the subsidies, he will piss the Democrats off big time, not to mention millions of people.

(2) Direct HHS Sec. Tom Price and CMS administrator Seema Verma to reconsider several of the exchange market rules for 2018 that the administration proposed on Feb. 15, based on comments received. The deadline for comments was March 7.

Most notably, a proposed rule that imposes barriers to “special enrollment” (outside the annual fall open enrollment period) due to changes in life status such as divorce would very likely do more harm than good as drafted. Some restrictions are needed, but they need to be more targeted.
Other proposed rule changes threaten to reduce the value of the premium tax credits. Trump should ask CMS to weigh the comments carefully.

A proposed rule that allows insurers to collect premiums for prior unpaid coverage, before an enrollee can enroll in the next year’s plan with the same issuer, is likely to be finalized unchanged. The rule fairly incentivizes consumers to avoid coverage lapses.

(3) Direct Price and Verma to contact (a) insurers operating in the exchanges and major insurer groups, (b) leading physician and hospital interest groups, and (c) leading consumer groups to solicit their advice on further steps that could/should be taken in 2017 and 2018 to enhance enrollment of young, healthy people.

Related, direct Price, Verma and OMB director Mick Mulvaney to appeal to insurers to stay in the exchanges in 2018 while the administration promulgates new rules and sorts through its options. (Tell Steve Bannon to avoid all contact with any health care group.)

(4) Direct Price and Verma to evaluate current payment and delivery system reform initiatives being conducted at the CMS’s Center for Medicare and Medicaid Innovation (created by the ACA), with an eye towards terminating those programs that are not bearing fruit and enhancing those that are.

The ACA requires CMS to give priority to 20 models, including medical homes, all-payer payment reform, and initiatives that transition payment from fee-for-service reimbursement to global fees and salary-based payment. But the ACA permits CMS pretty broad leeway in gauging program priorities without the need for Congressional approval. That’s a change from the past that the Trump folks should embrace if they want to get their hands dirty in on-the-ground health reform.

(5) Direct Price and Verma to immediately assess their approach to section 1332 of the ACA. Section 1332 permits states to apply for “State Innovation Waivers to pursue innovative strategies for providing….affordable health insurance while retaining the basic protections of the ACA.”

Any programs under the waiver, per the law, have to meet certain specs, however. They must “provide access to quality health care that is at least as comprehensive and affordable as would be provided absent the waiver, provides coverage to a comparable number of residents of the state as would be provided coverage absent a waiver, and does not increase the federal deficit.”

The 1332 waiver program became operative on January 1, 2017. The Obama administration in 2016 signaled strict interpretation of 1332, which discouraged most states from applying. Many decided to wait for the election, too.

But 1332 permits flexibility and experimentation. Most notably, 1332 does not require major, large-scope proposals. They can be narrow bore. Alaska, California and Hawaii sought 1332 waivers in the months before the 2016 election. With the collapse of Republican repeal and replace, 1332 could become a much more important vehicle for reform in both red and blue states.

Related, Verma is widely expected to expand the long-existing waiver program that allows states to experiment with their Medicaid programs.

See this May 2016 Health Affairs post on the 1332 waiver program. http://ift.tt/1TDgKMc And this one from Nov 2016. http://ift.tt/2eecvmD

One of the most consistent findings of public opinion polls over the past five years is that a substantial majority of the American people want: (a) the two parties to work together more on the nation’s major problems and be less overtly partisan and (b) something done about soaring health care prices and costs. It would seem a propitious time to honor that opinion.

Steven Findlay is an independent journalist, policy analyst, researcher and consumer advocate.

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