The Child Sexual Abuse Conspiracy

BY DAVID INTROCASO

(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!

By JEFF GOLDSMITH

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 …”

By NIRAN AL-AGBA, MD

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?

By MICHAEL L. MILLENSON

“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

By KIP SULLIVAN

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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They’re Taking Selfies in the Streets …

BY JOHN IRVINE

Filed under: Worth 10,000 words.

Taken as word of the Trump administration’s decision to pull the AHCA broke Friday afternoon, a selfie by Sean Patrick Maloney (D-Cold Spring) @RepSeanMaloney quickly went viral on Twitter.

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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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Evidence-Based Health Reform

By MARGALIT GUR-ARIE

President Trump campaigned on making health care better, cheaper and available to all Americans, regardless of ability to pay. Once Mr. Trump was safely in the White House, the Republican thought leaders in Congress were quick to supply him with plans to repeal and replace Obamacare. Most were written in protest to President Obama’s policies and were never meant to be implemented.

When scrutinized by the rank and file of the Republican Party, it turned out that the Ryan/Price American Health Care Act was neither repealing enough for some, nor replacing enough for others.

The Democratic Party lost no time in whipping up public frenzy against the Ryan/Price bill, and Speaker Ryan lost no time in generating a sense of false urgency to pass his bill now, now, now, because for Paul Ryan this was a once in a lifetime opportunity to begin dismantling the welfare state.

From the left, it looked like the bill will be withdrawing billions of dollars in health care benefits from the most vulnerable citizens who also happen to be Trump supporters. From the right, the bill looked like Obamacare Lite because it didn’t throw all the poor people under the bus fast enough.

These were the cards President Trump was dealt. If he signs the bill, he breaks his campaign promises and loses his base. If he comes out against the bill, he confirms the worst fears of all Conservatives and loses Republican support in Congress.
There is zero chance for this President to appeal to another set of voters anytime soon, and currently, there is zero chance that even one Democrat in Congress will support anything President Trump proposes, no matter how liberal and beneficial that proposal might be. It was a difficult hand to play, but he played it brilliantly, in my view. Or maybe it was just beginner’s luck.
Right now the Democratic Party and its echo-chamber media are celebrating the defeat of the would-be destroyers of Obamacare.

The Republicans are in disarray again. Paul Ryan has been humiliated. Trump, the closer, the grand deal maker, lost big league. Nancy Pelosi declares victory without having to fire one parliamentarian shot. The President in the meantime calls The New York Times and Washington Post reporters and doesn’t sound angry at all.

No irate tweets. No below-the-belt punches. No fighting back. No nothing. How weird is that? Think about it. Is this how a beaten Donald Trump sounds like? Nope. That’s how a winning Donald Trump sounds like – calm, collected, magnanimous and low-keyed. President Trump passed his first test.

What’s not next?

According to my Twitter list of health care policy experts, Big Bad President Trump will now “sabotage” Obamacare so it fails spectacularly, right before the mid-term elections, dragging millions of poor people down with it. Sabotage, espionage, life is good when you are kibitzing from the sidelines.

Now why would a Trump administration want to create huge hardships for millions of people right before the mid-term elections? The thought process here is that if Obamacare collapses, the people will blame the Democratic Party, because as long as Republicans do not repeal and replace anything,

Democrats continue to “own” health care. Therefore, the GOP will finally have a mandate to get rid of Obamacare any way they see fit, and will likely increase their majorities in both houses in 2018. There is only one little problem with this logic: when things go wrong, most people blame the currently governing administration, not the previous ones, and rightfully so.

Deliberately blowing up the health care system is a criminal endeavor that must be executed in the public eye, because Secretary Price cannot promulgate secret regulations. No administration can afford to do something like this, and expect to survive. Every new President in recent memory insisted that he “inherited a mess”, and every President then gives a State of the Union Address taking credit for fixing said mess.

President Trump will be no different. Obamacare may not be in a “death spiral”, as detractors love to decry, but for millions of people, including those who receive generous subsidies, Obamacare is already a monumental mess. No sabotage needed.
Here is a tiny example. Remember that poor 64 year old, making $26,500 per year who, according to the CBO, ended up paying $1,700 under Obamacare and would have had to pay $14,600 under the Ryan plan? Well, that’s only part of the story, because those dollar amounts are just for premiums. Thus a fully subsidized healthy 64 year old is indeed paying “only” $1,700 for the cheapest Silver plan currently available on the Obamacare marketplace (in my zip code). A sicker 64 year old, making $26, 500, with high medical expenses is projected to have over $7,500 in total yearly costs, which is almost 30% of his gross income. I would like to humbly suggest to the Washington DC jet-setters that for this gentleman, there is no difference whether he needs to pay $7,500 or $14,600, or $140,000 or $14,000,000. He can’t come up with any of this. He is uninsured for all practical purposes. The only difference is that under Obamacare, they may have talked him into donating $1,700 to some insurance company.

What’s next?

I know conservatives and libertarians abhor the sheer existence of Medicare and Medicaid, but a savvy Secretary of Health and Human Services (HHS) could use the girth and might of these government programs to nurture the reemergence of a relatively free market in medical services, and minor bi-partisan legislation could create a relatively less predatory market in medical products. These two efforts will do more to reduce the price (and costs) of health care than any Obamacare folly or any Obamacare repealing and replacing idiocy. Furthermore, the effects could be framed in terms of freedom, choice, access and even deficit reduction, in addition to quality and affordability for those less fortunate, pleasing people on both sides of the ideological aisle.
Here is my very modest wish list for Secretary Price. All I’m asking for is that from this point onward, we start practicing evidence-based health care reform.

Independent Evaluation – Between CMS itself, CMMI, HRSA and other agencies, HHS has billions of discretionary dollars in its budget to try new things, and even more billions to implement statutory experimentations. Traditionally, large sums of money have been spent on health system “transformation” to patient-centered, team-based, coordinated, value-based, managed care (feel free to insert your favorite buzzword if I left something out). Many, but not all, of these “demonstration programs”, pilots, innovation models, etc. include evaluation studies to assess performance and so far the results have been tepid at best, but artfully spun as inconclusive. I want independent evaluations of all CMS funded “initiatives”, and I want programs that do not deliver on promised fantasies to be wound down immediately and the money reallocated to better thought out projects.

Practice Research – For the last decade or more, it has been the unequivocal position of HHS that better health care at lower costs necessitates large integrated delivery systems. There is not one iota of bona fide research to support this assertion. And yet, the Federal government has engaged in massive direct and indirect efforts to dismantle the so called “cottage industry” of small independent physician practices. I want CMS to fund several serious comparative-effectiveness studies across various medical practice models before it’s too late and we have nothing left but monopolistic chains for medicine. And I want CMS to follow through and undertake the deconstruction of all infernal medical factories where nobody knows your name, but everybody knows your risk score.

Hospital Research – I remember reading something a couple of years ago about someone trying to study the effectiveness of hospitalist care compared to community doctors who are allowed to admit and care for their own hospitalized patients. Hospitalists are another pre-Obamacare “innovation” based solely on hospital profitability arguments. As such, it caught on like wild fire and we have very few community physicians left who follow their patients inside the hospital walls. I want to see that study performed immediately, before the last dinosaurs die off and we forget that continuity and coordination were once built into health care, by default.

That’s it. That’s all I want for Christmas. Disappointed? Don’t be. A comprehensive, well researched report on our health care delivery models (shall we call it The Price Report?) could change the trajectory of health care in America and the entire world. I did not forget about Medicaid, the ludicrous deductibles, the device taxes, the pharma bidding and all those big huge things every pundit is reciting on cable news channels. These are important things of course, but they are temporary solutions at best. Single payer, if implemented tomorrow, is going to implode just as quickly as Obamacare did, and end up rationing care worse than the British system does. The various free market solutions are even more vulnerable to the ominous crescendo of unchecked profit extraction and incompetence engulfing our health care system.

Health care cannot be sustainably fixed in broad political strokes. If we want a real and lasting solution, we will need to step away from the political theater and engage in painstakingly detailed work on fundamentals. Health care is about medicine, and medicine is about applying science to the bodies and souls of people. We know how to do it. We do have the best health care in the world. We just forgot where it is, so now we have to systematically look around until we find it again. Hopefully Dr. Price understands the historic moment he finds himself in.

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After the American Health Care Act

BY JOHN IRVINE

I asked THCB’s editors and bloggers for their reactions to Friday’s news.

DANIEL STONE, MD

The late UCLA Professor Richard Brown, once commented that the Clinton healthcare initiative failed because the status quo was everyone’s second choice. Some of that logic applies to today’s failure to vote on the AHCA. Additionally, no one ever lost money betting against the rollback of an established entitlement program.

The Republicans opponents of the ACA have not yet faced the fact that the reason coverage is so expensive is because the care is so expensive. You can’t have cheap insurance for expensive services. So, something “better and cheaper” was a never more than a slogan. That slogan showed the AHCA to be the bait and switch that it was.

Health insurance has evolved to serve two purposes; to protect against health related financial catastrophe and to finance care. The ACA, with its high deductibles does a better job with the former than the latter. (Although opponents give short shrift to the mitigation provided by the provision of preventive services without charge.) It will be hard to satisfy the diverse collection of stakeholders with anything much different.

This is another illustration of the fact that anything approaching universal coverage is challenging for the developed world’s outlier on healthcare cost. Medicare has around 15% lower costs than commercial plans. The only practical way out of the cost vs access quandary is to harness the commercial insurance overhead/waste/profit and direct it toward coverage.

So, to paraphrase Keynes, in the long run, we’re in both single payer and dead. It’s just a question of whether we’re all dead first or just some of us.

JOHNATHAN HALVORSON

My immediate reaction is that now they are going to nibble at the ACA for 4 years. I’d actually have preferred the House passed this monster of a bill, which the Senate would have rejected, and then had to answer for it in 2018.

Energy and Commerce committee is not going to rewrite the AHCA now and is instead turning to CHIP reauthorization (where they may sneak in ACA cuts) and exchange stabilization.

MICHAEL MILLENSON

I think Jonathan Chait’s piece in NY Magazine addresses a lot of the substantive issues very well, particularly noting high up the opposition of a broad array of conservative experts.

Let me comment briefly on a small political point. Trump issued an ultimatum asking for a vote, just like you’d do if you last paid attention to how Congress works during 8th-grade civics class. But, clearly, when it became clear they would lose, Trump Congressional allies who are more sophisticated explained to the White House why you didn’t want to expose GOP House members to casting a potentially toxic vote in a sure-to-lose cause, and so the president “requested” that the vote not be held; i.e., put the onus on himself, not Ryan.

Translation: Trump is learning how politics really works and is adjusting to reality. That will likely help him in the future.

BRADLEY FLANSBAUM

The central force behind the creation of the bill was reconciliation–not a formed policy nidus. Since the ACA, invoking the use of it (for any possible purpose within the rules) has taken on a radiant glow. In this case, it made for a shaky foundation on which the R’s constructed the bill. And faulty policy followed.

I am too confident I believe, but in future sessions, the use of this limited tool will be preceded with, “The INSERT PARTY HERE would be wise to learn the lessons of the of GOP 115th and take heed. Careless legislating soils undergarments.”

JOE FLOWER

A little rampant speculation here.

This moment, after the failure of Speaker Paul Ryan’s American Healthcare Act, is obviously a hinge point in Donald Trump’s Presidency and specifically in the future of healthcare in the United States.

If we are trying to imagine where this might go from here, a key question is: Can Trump learn? If he can learn, what might he be learning from this brutal experience?

Okay, okay, Trump is monumentally stubborn, hard-wired, and so on. See also: deluded. But in his career he has shown an ability to re-invent himself and adapt to realities, especially after his bankruptcies of the 1990s. When banks were no longer willing to lend to him, he found other (mostly Russian) lenders, re-shaped his business into deal-making trading on his outsize name, does the reality show thing to increase the cachet of that name, and so on. He can change, learn, adapt.

He just got whacked upside the head with a big clue stick. How he perceives the information carried by that clue stick might give us some sense of what happens next.

After consistently, literally for decades, backing universal healthcare of one kind or another (though without apparently really understanding the policy and cost implications), he campaigned for the Presidency on specific healthcare promises such as “We’ll take care of everybody, it’ll be way cheaper, you’ll love it.” For those who can’t afford it, he even promised, “the government’s gonna pay for it.” He repeated these promises even after his election. They appear to be something he actually believes in: Healthcare for everybody, inexpensive, with government help where necessary.

Then he won. This President famously does not get down in the weeds of policy and politics. He immediately delegated much of that weedy stuff to Vice President Pence, and the legislative part of it to Speaker Ryan. Starting in December he allowed them to lead him down a garden path to a bill that is the opposite of all his populist promises: Far fewer people covered, the poor much worse off, much leaner coverage, no real help for those who just can’t afford it.

Led by whom? Ryan and Pence, soon joined by his new Chief of Staff Reince Priebus and his new Health and Human Services Secretary Price. Trump agreed to back Ryan’s bill and Ryan’s process for getting it through Congress, apparently without really getting how opposite to his own instincts the bill was. According to the Washington Post, when Ryan introduced his bill on March 6, Trump asked his advisers, “Is this really a good bill?” — and continued asking the same question of them repeatedly over the coming 18 days, even as he ramped up the campaign to sell it to Congress and the American people. This shows in the nature of that campaign: He never campaigned publicly on the actual provisions of the bill, instead merely repeating his vague promises that it would all work out for the better. Even as he was trying his best to sell the hell out of it, he was realizing that it was a mistake, but by now he desperately needed the win.

In a March 15 interview, Fox News’ Tucker Carlson confronted Trump with the fact that according to analyses, the bill would be a huge tax cut to the very rich, while the people most hurt by the bill will be the very counties and populations that are his biggest fans. For once Trump did not try to misdirect or deny. He simply said rather sadly, “Oh, I know,” before going on to insist that the bill was preliminary, there was a lot of negotiation, that a lot of things would change when it got to the Senate…implying that it would change in a direction that would be less hurtful to his strongest followers

I found that amazing. This guy’s biggest goal in life is to be popular, admired, a winner. As a corollary, the highest value he sees in others is loyalty. These guys (Ryan, Pence, Priebus, Price) led him into a box canyon where he became the #BiggestLoser. And the Congressional Republicans, especially the Freedom Caucus, who repeatedly declare themselves his biggest fans, would refuse to stand with him.

His comments after the defeat were revealing in interesting ways. He of course said nice, complimentary, understanding things about everyone involved, even the Freedom Caucus. Okay, that’s boilerplate. He blamed Democrats for not supporting the bill. More nonsense boilerplate.

A couple of things stood out to me. He actually named what he learned. He said, “We all learned a lot. We learned a lot about loyalty. We learned a lot about the vote-getting process. We learned a lot about some very arcane rules…”

You hear that bit about loyalty? What I heard was seething rage at the Freedom Caucus that stood him up, and a total unwillingness to put himself in that position again, in hock to the whims of these ideologues who will not back him when he asks them to.

Second, he revealed a clear image of what happens next: Obamacare will “explode” and then they can build a better bill: “Perhaps the best thing that could happen is exactly what happened today, because we’ll end up with a truly great health care bill in the future after this mess known as Obamacare explodes.”

Third, he mentioned that this “truly great” bill would have to be bipartisan. It would have to be crafted with Democratic support. How much does he believe this? He mentioned it not once, not twice, but seven times.

So he 1) is clear that this was not a “truly great” bill, 2) believes that such a bill could be crafted, but 3) it would need, and it would get, Democratic support. This sounds like a bill much more in line with his populist “take care of everybody” rhetoric.

This sounds like he is learning something very big: He can’t depend on the Congressional Republicans to just bring him the votes. If he wants to accomplish healthcare reform, or his $1 trillion infrastructure plan, or anything else big, he needs to bring forward legislation that can get Democratic votes — because at least some of those Republicans think they have him on a string, and can make demands that he just has to meet. Can you imagine how much he hates that thought?

He is not down with the Freedom Caucus’ ideology, and he is much less tied to any ideology than he is to getting things done, being “the winner.” He also is probably very down on Ryan, he might fire Priebus, and he is likely less willing to rely on Pence to steer him.

To whom does he turn? To those who apparently were trying to steer him away from lashing himself to Ryan’s mast on healthcare, particularly Bannon and Cohn. Steve Bannon, the Prince of Darkness, who nonetheless has more populist leanings, and Gary Cohn, the guy to whom I wrote my recent open letter.

Cohn is a Democrat and a former president of Goldman Sachs. He is apparently whip smart but without a healthcare background — yet Trump had designated him the policy guy for healthcare. He has rapidly built a solid policy shop in the White House, and has been cautioning Trump against going all in on Ryan’s bill. Cohn’s briefings explain Trump’s late February comment that, “Nobody knew healthcare could be so complicated.” (Did my letter actually reach him when I sent it to the White House? Did it helped Cohn in his search for answers and different directions? Possible. No way to tell, but the timing was right.)

Put that all together, connect the dots. Trump has actual populist desires about healthcare, he wants to be the people’s savior. He gets led down a garden path in the opposite direction, then gets beaten like an Army mule. He realizes that these people are not his friends. He says that he’s going to try something different, it will be something the Democrats would get on board for, and he looks forward to crafting a “truly great” healthcare reform with them.

We could well see Trump try to put together a winning bipartisan coalition in Congress on this and other issues to bypass Ryan and break the power of the Freedom Caucus. We could well see something from Trump much more like a Medicare-for-all, or a universal Medicaid base plus Medicare buy-in for people over 50, or other “public option” solutions.

Possible.

Niran al-Agba, MD

Joe, I totally agree with your response …. it is the reason I voted for him in the first place.  He is a “deal maker” and with the clearly drawn partisan lines, true progress will require pragmatism, compromise, and patience.  While he is short on patience, I suspect it is possible for him to learn a little of it and at least we have an opportunity to bring both sides together.  Time will tell, but I am hopeful.  His promise to come back around later and craft something with moderate Democrats and Republicans on both sides is very encouraging to me.  Of course, bypassing Ryan is never a bad thing   for almost any reason.

While I am not necessarily in favor of total universal health care, I am in favor of basic universal healthcare and believe this is the ultimate direction this country must go.  As to Jim’s point regarding the large number of healthy individuals required to support those with chronic illness, the bottom line is, we must ration and will end up rationing.  My hope is we use science and common sense, QALY or something along those lines so these decisions to treat or not are made with cool heads and hearts throughout.

Unfortunately, in the future every single person wanting a transplant or outrageously new chemotherapy is not going to be able to receive it without paying for it themselves and that is reality.  Now how to get the nation on board?

HAYWARD ZWERLING

To be a successful politician, one must be able to make “deals” with your opponents. This requires that one’s opponents “believe” the President’s statement which are made to them in private. Trump’s political and business experience is littered with deception.

STEVE FINDLAY

A poorly constructed bill, with bad policy substance from the get-go, met the end it deserved. Tortured politics and an inept President aided the demise.

I agree with Jonathan H that this is far from over, but of course it’s not clear what will (or politically can) happen next. Most likely nothing for a while in Congress….but Price and Verma have some big choice to make on stabilizing/helping the marketplaces as plans prepare to make their bids. Do that, or screw it and let things fall apart—as the president implied today. CMS already took some regulatory steps—a few of which could help but others of which will hurt consumers/enrollees. More steps are needed, and urgently.

I agree with Dr. Stone’s comments….

In keeping with almost everything else he has said since inauguration on any issue, Trump was deaf to the substantive issues that helped bring AHCA down in his comments today….and he was menacing in his threat to let the ACA “explode” at which point the Ds would come running to him for help to repeal and replace. Trump deserves the harsh judgement that will certainly come….since he never stuck to any philosophical or policy principles as the process unfolded….right up to the end. Shameless, even if expected.

JIM PURCELL

Let’s all get back to the real enemy here–rampant rate of use of services driven by every increasing chronic illness.  Now THAT might be a worth focus.

The above comments are inciteful, and, as a wise old lawyer once said to me, “they have the additional benefit of being the truth.”

MICHEL ACCAD

Jim,

How is the statement that the rampant use of services is driven by increasing chronic illness substantiated?

I am genuinely asking without doubting that it is true, but there can be funny business about what constitutes chronic illnesses.

Is “high cholesterol” a chronic illness?  Osteoporosis?  Uncomplicated diabetes defined on the basis of an abnormal lab test?  Millions of people have chronic diseases that are quasi fabricated by the medical establishment.  There’s a deep seated confusion between factors of risk and actual disease.

MARGALIT GUR-ARIE

If I am not mistaken, Americans see doctors less often and are hospitalized less often and for shorter stays than most OECD countries. We take more drugs, get more MRIs and have more hip and joint replacements, all of which are obscenely overpriced by comparison to OECD, and other than some meds for over-diagnosed stuff like pre-this or pre-that or the depression “epidemic”, these things have little to do with chronic disease.
Chronic disease, however you define it, does consume most resources, but that is true in other countries as well. We can’t just say that our solution to unaffordability of medical care is to make people healthy (not that there’s anything wrong with making people healthy…).

JIM PURCELL

The data indicate the Americans are far more chronically ill than others. Chronic illness accounts for at least 75% of US medical expenditures according to CDC (their number is actually higher, and I had a hard time believing it myself). Chronic illness overwhelmingly is a result of unhealthy lifestyles which we Americans are expert at. Yes, fee levels for certain things (most of which we would not need if we lived healthier lifestyles and were not chronically ill) are obscene; and yes, 30% of care is waste and error–those would be good to address as well. I’m just saying we seem to be missing the forest for the you know what. Healthy people don’t use services. We need scads of healthy people buying health insurance to cover one chronically ill person.

If I am in any way missing something, please let me know cuz I’m writing a book on this. I’d really appreciate your insights.

And I love the respectful and collaborative tone of our interchanges; and yet if we disagree, we say so. Let’s keep this up.

HAYWARD ZWERLING

The “ridiculous” prices need to be abolished, by Federal fiat.

Clearly, capitalism does not work to control healthcare costs and all the other industrialized countries understand this. We have already tired multiple variation of “capitalism” in healthcare, over the last 4-5 decades, and every variant has failed and was then replaced by another variant which then failed.

It is time to move on to solutions which have been objectively demonstrated to work.

ANISH KOKA, MD

I think there’s enough waste in us healthcare right now – whether that be low value care, unnecessary care, or iv fluids in hospitals that cost $1000. I mean basic labs at the local AMC are 1100 dollars, and yes that all came out of the deductible.

We have to differentiate agreeing as a society to pay for these ridiculously upcharged items, paying for things such as transplant ( NNT of 1, payoff could be 5 yrs of life with lung transplant or 30+ with pediatric liver transplant) and paying for 95 year olds to get percutaneous aortic valves.

The richest country in the world can afford and should pay for miracles (transplant, curative gene therapy, or curative cancer therapy) – it just needs to prioritize and focus on some of the bad actors taking advantage of taxpayer largesse due to a rigged system (We can start with non profit teaching hospitals that long ago lost their way)

STEVEN SOUMERAI

These are hopeful and interesting remarks. Pray that they come to fruition.

I also agree with Anish that we have to eliminate the waste. But so far, we have mostly built ineffective policies that throw out the baby with the bathwater. For many decades we have failed to come up with policies that carve out the fat and leave the valuable care. I partly blame all the foolish incentive and penalty policies created by Obamacare that don’t have anything to do with the causes of the deficits– pay for performance (see our Vox/THCB/Huff Post/Boston Globe pieces on that), ACOs, non-payment for preventable infections and readmissions, discriminatory wellness penalties (the legal basis for giving employers your genome without asking first), yada, yada. There is actually science out there to refute those and a ton of other policies.

To tell the truth, the things that work take a little more thought, incl educational partnerships with physicians like face-to-face drug academic detailing (we published in NEJM in 1983!) and the Yale studies that showed that interdisciplinary teams of docs, social workers, nurses and pharmacists could prevent readmission of frail elderly through TEACHING about drug adherence and other things at discharge and at home. Less is more. They actually learned about the determinants of the problem before acting on the basis of unidimensional and useless economic theories that didn’t survive the voyage from business to health. I have voted Democratic — well except for Governor Charlie Baker (even if we clashed once when I advocated for medications as a necessary component of Mass health reform). But Obamacare is a mess. I hope one day that half of it is abolished so that the valuable things can live on (clearly this was not the anti-science Republican bill).

The way that the innovation center at CMS does its evaluations of those silly ACA penalties is to ask for proposals and pick a tiny fraction of the best delivery systems, “The All-Star Baseball Team” that they then compare to those who couldn’t or wouldn’t even write a proposal. Like Pioneer ACOs (they quit anyway), maybe now MACRA? These policy evaluations don’t meet standards of systematic reviews and are excluded from them; my doctoral students love to point out the fatal flaws and can’t believe that anyone could believe them. Yes, the evidence needs restoration. Neither administration has respected it.

We need to commit to a true rigorous learning system before we pay for billions and trillions of ineffective policies (HITECH comes to mind- that’s another sad story). Best, Steve

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How Not to Innovate (And the Stuff You Really Should Be Doing)

JOHN HALAMKA, MD

I’ve written several posts over the past two years about the need for innovation in healthcare IT – deploying self-developed apps, leveraging third party cloud hosted functions, and embracing the internet of things.

I’ve previously discussed establishing a center for innovation.   In preparation,   I’ve worked on innovative projects in industry accelerators, academic collaborations, and government sponsored hack-a-thons.

What has worked?

1. I’ve learned that it is very important to make innovation a part of the day to day work inside an organization.    Creating change externally and then trying to graft it internally results in a disconnect between research and operations.   At BIDMC, we’ve created a meritocracy in which those have competitively illustrated out of the box thinking are given reserved time each week to focus on highly speculative areas of innovation.    The project started as ExploreIT and is now being formalized as the Center for Information Technology Exploration in Health Care.

2.  It’s important to leverage commercial tools and services rather than trying to reinvent technologies that are becoming commodities.   Agile innovation is the unique combination of existing ideas and is more about creating the plumbing between components to support a workflow than doing large amounts of raw coding.

3.  Just as with venture-funded startup companies, in a cohort of 10 projects,  6 will fail, 2 will limp along and 2 will be winners.    We must create a safe environment where failure is permitted and exploration is its own reward.   We’ll move projects from pilot to production only when they are proven to be ready for prime time

4.  We’ll avoid being distracted by magical technologies at the peak of the hype curve (see below).  Instead, we’ll choose the appropriate technologies that satisfy business owner requirements based on experience in industries outside of healthcare.

5.  At times we’ll be early adopters and will be the first to test a new idea.   At other times we’ll be a laggard, allocating our limited resources for the best functionality with appropriate safety and robustness.  Also, will not deploy a technology until privacy protection is addressed with appropriate business associate agreements and security controls.

This ExploreIT powerpoint illustrates some of our projects in progress, created  by internal staff supplemented with external products and experts selected by our operational teams.

We hope to commit more than $1 million to our innovative efforts this year through a combination of in kind efforts and philanthropy.    Thus far, we seem to be achieving a perfect storm of alignment between business owners, internal developers, and technologies to leap frog existing solutions.

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