The Great Debate: the 10 Questions about Healthcare that will Go Unanswered Tonight

The great debate is tonight. In 2012, 67 million tuned in to see how challenger Mitt Romney and would fare against the incumbent Barack Obama. Tonight, it’s the much anticipated Trump-Clinton showdown with much riding on its outcome and an expected audience of 100,000,000—an all-time high.

Pundits say there’s more on the line tonight at Hofstra than any debate in history. Polls released this past weekend underscore its significance: The New York Times poll showed 83% of registered voters say they’ll watch. The Washington Post poll showed the race a dead heat, and the Wall Street Journal’s indicated as many as one in three likely voters remains undecided. 

The Presidential contest since the primaries has become uncivil: name-calling and surrogate sniping has dominated, muting meaningful discussion about policies and issues. And looming in the background are implications for control of Congress, appointments to the Supreme Court, an economy that’s unsteady and world that’s unstable.

I wish discussion about healthcare would get its fair share of the debate tonight or in subsequent debates. After all, the U.S. spends more than $10,000 for every man, woman and child on our system’s products and services. It’s almost 18% of our total Gross Domestic Product, one third of the average stage’s budget, 30% of total federal outlays and 20% of total discretionary spending in the average household. It touches everyone and no one lacks an opinion about its performance. But it’s unlikely to get attention tonight or in forthcoming debates. As a result of the Affordable Care Act, healthcare has become a partisan battleground. Soundbites are the rule of the realm: the campaigns on both sides avoid specifics about health policies and the direction they’d go as Head of State. Rather, we hear shorthand on both sides—repeal and replace on the one and expand and repair on the other. That’s regrettable.

Healthcare is a non-partisan challenge, especially at the community level where, like education, it’s essential to stability and economic sustainability. It deserves thoughtful discussion based on objective facts, not talking heads who talk over each other.

As Lester Holt saddles into the moderator role tonight, the give and take about national security and the economy are certain to generate the majority of the commentary. That’s understandable but regrettable. If I had my druthers, I’d ask a few about healthcare: 

1-In your view, should healthcare in the United States be treated as a right or a privilege? If a fundamental right, how should it be governed so as to deter abuse? If a privilege, how should it be structured to assure access for those who lack the means to pay for it?

2-Given that 70% of avoidable health costs are the result of unhealthy lifestyles, how should individuals in our society be held accountable for living healthier lifestyles? What is the role of the government? 

3-Data shows that as much as 30% of healthcare utilization is for services—tests, procedures, medications-- that are unnecessary or lacking in scientific evidence of efficacy. What would you do to reduce these costs without compromising quality and safety?

4-The Affordable Care Act successfully increased access to health insurance coverage for 20 million through expansion of the Medicaid program and subsidies for those making under 400% of the federal poverty level to purchase private coverage. What changes to either or both of these programs would you make? And what do you consider the future of private health insurance in the U.S.?

5-More than 10,000 seniors join Medicare daily and it’s going to operate at a deficit in ten years. Per capita spending increases for Medicare enrollees has been less than 1% annually so it’s medical inflation—what we pay for drugs, hospital stays, technologies, premiums—that are driving total costs up 6% annually. What’s the answer to the solvency and liquidity of Medicare long-term? What do you see as the future for Medicare? What changes would you make?

6-The U.S. spends more on its healthcare system than any in the world but proportionately less than other countries on social programs that improve the health in lower income populations. Data show social determinants of health—clean water, safe communities, healthy foods…--contribute to better health and lower costs for care. Our system is widely regarded as an exceptional sick care system where the latest technologies and approaches are used by hospitals and physicians to treat the sick and injured. How should the system balance its efforts toward preventive health that reduces demand for the sick care system long-term?

7-The prescription drug industry has effectively produced pills and injectables that save lives and keep people out of hospitals. But costs for prescription drugs are spiraling out of control. What would you do to rein in drug costs while not thwarting their innovation?

8-The Affordable Care Act stimulated a change in provider incentives from volume to value to reduce costs without compromising quality. But recent studies indicate some of these are not achieving targeted cost savings: last month, CMS reported only one in four accountable care organizations is saving money, and last week it said preliminary analysis of its bundled payment programs had mixed results. What your view of these programs, and how would you propose to reduce costs without compromising safety and quality?

9-Other systems of the world face challenges about utilization and costs. Some get better results than we do at a lower cost. Which systems of the world have elements you think we should consider and perhaps copy? Which systems seem to deliver the highest value to their constituents? 

10-Our’s is the system that produces most of the world’s innovations in technology, treatments and cures. We get many of them first, but pay more than the rest of the world for the same innovations. How would you as President stimulate greater innovation in healthcare that’s funded by the rest of the world? 

Honestly, I don’t expect these questions to be answered tonight or anytime in the next 43 days. As noted by the pundits, this election is about style: those issues are temperament and trust. Ironically, on healthcare, per the weekend’s Washington Post poll, they’re in a dead heat: HRC holds a slight edge (47% vs 43%) but the same split holds for many other issues.

Could healthcare journalists prompt a debate where the health policy wonks from each campaign compare strategies and approaches? That would be encouraging. Or a town hall with the candidates where individual consumers probe healthcare issues? Ideal but unlikely.

The fact is we’ll stumble into the election in 6 weeks with vague impressions about what each candidate might do about healthcare, and later learn their plans for real. The reality is that within a 20-mile radius of the debate stage, there are 40 hospitals including the prestigious academics in New York City. Their teams will be watching, as will their physicians, staff and patients.

The future of the U.S. healthcare system deserves more than soundbites and surrogate sniping. A great start would be answers from the campaigns to these 10 questions.

Paul

P.S. Last week, two CEOs were on the Congressional hot seat: Mylan CEO Health Bresch testified before the House Energy and Commerce Committee, and Wells Fargo CEO John Stumpf testified before the Senate Banking Committee. The cases have much in common: both CEOs disavowed any personal wrongdoing while acknowledging issues in their business practices (EpiPen pricing by Mylan, fraudulent cross selling by 5300 service agents in Wells’ community banks who lost their jobs). Both promised to do better without expressing remorse. And both dismissed committee claims their compensation was ill-gotten gain (Bresch $18.9 million and Stumpf $6.8 million cash and bonus in 2015 plus retirement benefits nearing $200 million). Lest a teachable moment be missed in healthcare, it’s our boards, and the compensation committees therein, that bear responsibility for these events. That impacts every organization—for profit and not for profit in our industry. These executives took a bullet for their organization and shielded their boards from scrutiny. Executive compensation is on the public’s radar. Healthcare is no exception.