And We are Still Working on Obamacare-Susan Collins Moves The Goalposts On An Obamacare Bailout, and More

29197151_1482598261869828_1397170286071119872_nWith the 2018 midterm elections looming on the horizon, one wonders how will the GOP and the Democrats spin the issues and especially the healthcare issue.

Have we made any progress and which party is winning in the fight to get their health care system program the sustainable/stable system for “We the People?

It seems that there are a number of backroom political plans being discussed. Consider the discussions between Senator McConnell and Senator Susan Collins. The White House and McConnell should never have made an agreement on an Obamacare ‘stability’ bill with Collins in the first place.

Christopher Jacobs, an author for the Federalist, wrote that the 19th-century showman P.T. Barnum famously claimed that, “There’s a sucker born every minute.” Apparently, Republican Sens. Susan Collins and Lamar Alexander think that Barnum’s dictum applies to their Senate colleagues. Both have undertaken a “bait-and-switch” game, constantly upping the ante on their request for an Obamacare “stability” bill — and raising questions about their credibility and integrity as legislators in the process.

Flashback to last December, when Congress considered provisions repealing the individual mandate as part of the tax reform bill. At that time, Collins engaged in a colloquy with Senate Majority Leader Mitch McConnell, who said he would support legislation funding Obamacare’s cost-sharing reductions, as well as Collins’ own reinsurance proposal.

Collins described her bill in their exchange:

I thank the majority leader for his response. Second, it is critical that we provide States with the support they need to create State-based high-risk pools for their individual health insurance markets. In September, I introduced the bipartisan Lower Premiums Through Reinsurance Act of 2017, a bill that would allow States to protect people with preexisting conditions while lowering premiums through the use of these high-risk pools….

I believe that passage of legislation to create and provide $5 billion in funding for high-risk pools annually over 2 years, together with the Bipartisan Health Care Stabilization Act, is critical for helping to offset the impact on individual market premiums in 2019 and 2020 due to the repeal of the individual mandate. [Emphasis mine.]

Collins viewed McConnell’s commitment as so iron-clad that she put a transcript of the colloquy up on her website. Unfortunately, however, Collins didn’t find her side of the bargain as an iron-clad commitment.

One week after that exchange on the Senate floor, Alexander wrote an op-ed on a potential “stability” package. That op-ed claimed that Collins’ reinsurance bill included “$10 billion for invisible high-risk pools or reinsurance funds.” However, the text of the Collins bill itself would appropriate “$2,250,000,000 for each of fiscal years 2018 and 2019” — that is, $4.5 billion and not $10 billion. I noted that discrepancy at the time, writing that, “Alexander seems to be engaged in a bidding war with himself about the greatest amount of taxpayers’ money he can shovel insurers’ way.”

It turns out I was (slightly) mistaken. Alexander wasn’t in a bidding war with himself over giving the greatest amount of taxpayer funds to insurers — he is in a bidding war with Collins. Just this week, both Collins and Alexander issued press releases touting a (flawed and overhyped) premium study by Oliver Wyman. The press releases claimed that “Oliver Wyman released an analysis today showing that the passage of a proposal based on … the Collins-Nelson Lower Premiums through Reinsurance Act will lower premiums … by more than 40 percent.” [Emphasis mine.]

But the release went on to note that, “Oliver Wyman based its analysis on a proposal that would fund [cost-sharing reductions] … and provide $10 billion annually for invisible risk pool/reinsurance funding in 2019, 2020, and 2021.” Not $2.25 billion for fiscal years 2018 and 2019, as the actual Collins-Nelson bill would provide — but more than four times as much annually, for a 50 percent longer duration.

Not even Common Core math can explain the gaping chasm between the funding amounts in the two bills. Does Alexander really want to make a straight-faced claim that an estimate assuming $30 billion in funding is “based on” a bill providing only $5 billion in funding? And if so, then why should a Senator who fails a math test even a first-grader could comprehend chair the committee with jurisdiction over federal educational policy?

Collins and Alexander went to all this trouble because they want to have their cake and eat it too. Collins expects McConnell to abide by his commitment from December — she reportedly cursed out a senior White House aide when the “stability” package failed to pass late last year. But she has no place criticizing McConnell or others for not keeping their word when she has proved unable to keep hers, by upping the ante on her asks for a “stability” bill — and putting out misleading press releases to hide the fact that she ever asked for “only” $5 billion in taxpayer funds.

Collins has no place attacking the White House, or anyone else, for “reneging on the deal.” She reneged on the deal herself — by not sticking to her original commitments, and then putting out misleading press releases to cover her tracks. The White House and McConnell should never have made an agreement on a “stability” bill with Collins in the first place. But if they did, the unscrupulous way in which she has handled herself since then should have nullified it.

You wonder what they are drinking or smoking down there in D.C. when you read that the “House Democrats are Hopeful that ACA Fix Can be Passed”

It’s hard to believe, but Congress can come together. Really???

Our friend Joyce Frieden the News Editor of MedPage noted that at least one Democratic lawmaker is optimistic that Congress can pass legislation to help shore up the Affordable Care Act (ACA).

“It’s hard to believe, but Congress can come together,” Rep. Kyrsten Sinema (D-Ariz.) said here Monday at the annual policy meeting of the Federation of American Hospitals, a trade group for for-profit hospitals. “I’m part of a group [in the House] called the Problem Solvers … and all we do is work together to find lasting solutions to country’s challenges. One area we’ve been working on diligently for the last year is the stabilization of the [ACA’s insurance] market.”

The bill that the caucus is developing would fund the cost-sharing reduction (CSR) payments that the federal government sends to insurers on the ACA’s healthcare marketplace to help low-income enrollees pay their out-of-pocket costs. The Obama administration had been making the payments, but the Trump administration cut them off.

In addition to funding the CSR payments, the bill “creates patient and state stability funds that can be used for reinsurance,” Sinema said. “It [also] leaves the current Medicaid system in place, which has been hugely important to Arizonans’ ability to have access to care.”

The caucus is hoping that the bill will be included in the omnibus budget legislation expected to be introduced on March 23rd, “so, fingers crossed,” she added.

Audience members also heard from Sen. Tim Kaine (D-Va.), who said he was part of a group of senators discussing a similar bill which “involves [first] making sure the federal government makes good on its cost-sharing promise and second, making sure states have the ability to tailor programs in a way that most fits their population,” he said. “And third, reinstating the reinsurance provision that was part of the ACA for the first several years. Reinsurance really works to provide stability and bring down premiums for average folks. That’s why we use reinsurance in crop insurance — it’s a time-tested strategy that brings costs down.”

Kaine, like Sinema, said that CSRs and reinsurance “are very much [talked about] as part of the omnibus bill.” He also decried the current debate in Congress about repealing the ACA — a debate that he pointed out has been going on for 7 or 8 years — and said that Congress instead needs to “talk about the next steps forward … I want to be in a position… where we’re not afraid to talk about big ideas.”

Kaine listed three big ideas he thought Congress should be discussing:

Block granting: This is the idea that instead of states receiving a “match” from the federal government for every dollar they spend on federally approved Medicaid expenses, the government would give each state a lump sum of Medicaid money, regardless of how much the state itself spent, and free up the state to run the program as it wished. “Is there a block grant strategy that would work?” Kaine said. “As a [former] governor [and] mayor, I love the flexibility, but I’m really concerned about what block grant proposal would do — but I am not afraid to have that discussion.”

Single-payer: This idea, championed most vocally by Sen. Bernie Sanders (I-Vt.) would replace the current public/private health insurance system with an entirely government-financed one. Because more than 100 million Americans get their health insurance through their employer “and 80% of them are generally happy with their plan, I don’t think they’re going to believe [it]” when supporters say a single-payer plan will be just as good, but it’s still worth discussing, Kaine said.

Public option: This concept — initially discussed before the ACA was passed but left out of the final bill — would give people buying insurance on the ACA’s health insurance exchange the option of a publicly run healthcare plan. A bill that Kaine introduced along with Sen. Michael Bennet (D-Colo.) “would direct [the Centers for Medicare & Medicaid Services] to develop an insurance policy that they would sell to working families on the exchange,” Kaine explained. The policy, which Kaine called “Medicare X,” would cover all the “essential health benefits” defined under the ACA, and would be sold at a competitive rate. Kaine emphasized that no government funding would be involved because the policy would be financed entirely by enrollee premiums. “We think … it would give people additional options and bring costs down,” he said.

“What I hope we will do is get out of the mode where it’s just about ACA repeal and put on the table all the ideas — block grant, single payer, Medicare X and I’m sure there are other ideas as well … and we’ll hear from all the stakeholders,” Kaine said, including doctors, hospitals, and patients. “I don’t think [we can] limp along playing defense and fighting off rear-guard repeal actions and do justice to the healthcare needs of our country.”

I had mentioned a few weeks ago about how a number of wealthy and successful CEO’s were going to design their healthcare solutions/systems, but I ran across an article that cautions them about their journey.

To Amazon and Partners: Thoughts from a Healthcare Entrepreneur

Alex Heinosz, a co-founder of CipherHealth, has led the company through significant growth since inception. He directs the company’s commercial side, working to bring CipherHealth’s integrated patient engagement and care coordination solutions to healthcare systems around the country. He noted that how we spend our days is how we spend our lives, then I am dedicating my life to transforming how healthcare is delivered, experienced, and perceived. In 2009, Randy Cheung, Zach Silverzweig, and I started CipherHealth to help hospitals reduce avoidable readmissions using big data. Today, we’ve built a team driven by our shared vision of revolutionizing the patient and provider experience with one unified platform for all patient communication and coordination. I’ve chosen healthcare because health, or lack thereof, touches all of us: our loved ones and we all are, or at some point, will become patients. Because healthcare is measured in lives, the joint venture between Amazon, Berkshire Hathaway, and JPMorgan Chase is very much welcomed. We need all hands on deck – not only to address the “hungry tapeworm” of ballooning healthcare costs but to secure the future of healthcare delivery for generations to come.

As giants of their respective industries, Amazon, Berkshire Hathaway, and JPMorgan Chase are already well positioned to create healthcare’s “tipping point”. Although any new venture presents some degree of risk, the sheer size of these partners affords many resources that are unavailable to most other players within the healthcare industry. As publicly traded companies that are held financially accountable by shareholders and investors, these partners are confident that their joint venture will be successful. After all, with the combined revenue of these three behemoths totaling $501 billion, Amazon and partners have a deep well of financial, technical, and human resources from which to draw upon. By focusing initially on high-quality healthcare for their U.S. employees at a lower cost, these partners designed the most receptive audience to test their first healthcare venture. With nearly 1.2 million employees working across all three companies, they have the critical mass necessary to develop a continuous feedback loop for improvement.

As a healthcare entrepreneur and consumer, I am optimistic that this partnership will accelerate innovation for the healthcare industry. To help Amazon and partners as they embark upon their journey, I’d like to share important lessons that I’ve learned.

  1. The Inexperience Advantage: The optimism that comes with a lack of experience is an asset. If you don’t know what you’re getting yourself into, you’re more likely to jump into it. Venturing into uncharted territory requires the specific sort of optimism and courage to take risks that often diminishes with experience.
  2. Patience, Patience, Patience: The healthcare industry moves at a slower pace than that of other industries. Since change happens very slowly, progress can only be measured by the sustained improvement. In their early days, Amazon experienced success by taking a slow, deliberate approach to new markets. Since then, they have become a fast-moving company that anticipates consumer preferences. As the company that pioneered two-day shipping, the slow pace of healthcare may initially feel like a regression to the old days. When evaluating their impact on cost savings and patient outcomes, Amazon and partners need to take the long view in addition to looking at short-term “wins.”
  3. Solving Bigger Problems: Rather than focusing on cutting costs, how can we deliver more value in healthcare? By joining forces, these partners have the tremendous opportunity to increase the scope of the problem that they are trying to solve. Over time, this group can widen their gaze to address some of the fundamental challenges of the healthcare industry. At CipherHealth, one of the problems that we want to solve is closing the gap between the robust body of medical literature and everyday patient care. To do this, we are integrating evidence-based health information into clinically validated care plans to reveal insights into care gaps and population-specific outcomes.
  4. Achieving the Quadruple Aim: Healthcare delivery is often framed through the lens of enhancing the patient experience, improving population health, and reducing costs. Caring for the healthcare provider is a prerequisite to achieving the Triple Aim. Thus, to truly optimize and scale high-quality healthcare delivery, it is important to integrate staff satisfaction as the fourth success metric. By delegating repetitive processes to healthcare technology, staff can dedicate their specialized expertise and time to high-value patient care activities. Technology can reduce staff burnout by automating activities that are limited in their potential impact. To drive systemic, long-term improvements in healthcare, Amazon and partners need to address clinician engagement in addition to “checking the rise in health costs while enhancing patient satisfaction and outcomes”.

The joint venture between Amazon, Berkshire Hathaway, and JPMorgan Chase can only serve as a catalyst for innovation in the healthcare industry. If successful, this partnership could inject a healthy dose of competition into the American healthcare delivery system – ultimately, driving better patient care. As a company committed to improving the lives of patients and providers, we are rooting for the success of our fellow innovators.
Jo Ann Jenkins the CEO of AARP recently wrote that as I reflect on the current health care debate, I am reminded of a quote about the definition of politics by the late Groucho Marx. “Politics,” he said, “is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies.”

Even though the measures proposed in the Senate failed, that doesn’t mean the health care debate is over. It is clear the “remedies” that were proposed by both the House and Senate bills would have resulted in higher costs and less care, especially for older Americans, and huge windfalls to pharmaceutical companies and health insurance companies.

That’s why AARP conducted an all-out effort to urge senators and representatives in Congress to vote “no” on these bills. We ran an extensive campaign urging our members to contact their lawmakers and held tele-town halls across the country. AARP volunteers and staff in every state made more than 400 visits to their congressional representatives, expressing opposition to the bills. AARP members continue to make their voices heard.

Don’t get me wrong — the Affordable Care Act is not perfect. Aspects of the law need to be fixed in order to lower costs and maintain vital protections and coverage that millions of Americans rely on. But instead of overcharging older Americans and threatening access to affordable coverage, Congress should focus on bipartisan solutions that will increase coverage, lower costs and improve care. There are many ways to reduce health care costs that would not harm ordinary people. For example, AARP has long advocated for Medicare to be allowed to negotiate lower drug prices with pharmaceutical companies.

We urge Congress to follow the advice of John F. Kennedy, who as a senator in 1958 said, “Let us not seek the Republican answer or the Democratic answer, but the right answer. Let us not seek to fix the blame for the past — let us accept our own responsibility for the future.” Our responsibility for the future is to create a world-class health care system that is affordable and gives all Americans access to the care that they need.

Politics has also been described as the art of the possible. We believe it is possible to craft a health care bill that provides all Americans quality, affordable care. But that requires getting the best ideas from all stakeholders and having a full and open debate.

We and I agree, urge Congress to turn the page on fighting over “Obamacare” and “Trumpcare” and open a new chapter working together on commonsense solutions to increase coverage, lower costs and improve health care for all Americans. Not only is that the right answer, but it would also prove Groucho wrong.

So, back to our discussion regarding the Single Payer health care system and hopefully the idea of a bipartisan solution to the healthcare crisis.

And as I pointed out last week, yeah, we have finally published our book “The Search for Excellence in Clinical Practice- A Handbook on Clinical Process Improvement for Providers”, published by Sentia Publishers.

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