Key Takeaways for Healthcare from Iowa and New Hampshire

The Iowa caucuses and New Hampshire primary did more than narrow the playing field for the Presidential aspirants: it set the stage for a vigorous debate about healthcare at a pivotal time in its reform. Here’s the context:

The mood of the country is dour. By two in three, most think the country is heading in the wrong direction, though we divide over the root causes and whose responsible save almost universal contempt for Congress with a 76% disapproval rating versus 13% favorable (Real Clear Politics).

The economy is struggling again: after a giddy recovery through 2014, the stock market plunged thanks to China and plummeting oil prices and the majority of households saw their discretionary incomes shrink even after benefiting from low gas prices.

Our institutions are taking a beating: big banks are suspected of double dealing, drug companies are defending double-digit price increases and even the NFL couldn’t dodge the Concussion-Gate cloud in the glow of Super Bowl 50.

And our political process seems to bring out our worst: 7/24 coverage of verbal fisticuffs and battling soundbites stoke our cynicism. Respectful disagreement in the tradition of Scalia-Ginsburg, Hatch-Kennedy, Reagan-O’Neil et al has given way to boorish behavior and personal attacks deemed acceptable in many settings, especially political campaigns.

Against this backdrop, in Iowa and New Hampshire, the foundation for a vigorous debate about the future of our healthcare system was laid. Here’s what we can deduce after these two contests:

1-Healthcare will be pivotal issue in Campaign 2016 for both sides. In New Hampshire, it was a top 3 issue for the Dem’s pitting Medicare for all (Sanders) vs. ACA Fix and Improve (Clinton). The GOP challengers are promising to repeal Obamacare but its replacement is not yet their focus. As the Presidential contest unfolds, each GOP candidate will be forced to address their vision of the U.S. health system that’s newer and better. Secretary Clinton will have to specify which repairs are necessary to the Affordable Care Act she supports, and Sen. Sanders will have to define how his Medicare for All plan would work, why doctors and hospitals should support it if rates they’re paid are Medicare or below, and how the federal government could handle the price tag. And candidates on both sides will face tough questioning about their definitions for accessibility, quality, safety, fairness and affordability and how they’ll square off against the powerful special interests that seek to protect the status quo.

2-Milllennials will be a force in healthcare. They’re one fourth of the population, and they’re becoming activists on every issue including healthcare. They care about the environment in which they live.  They’ve watched their parents and grandparents struggle to understand what to do and how to afford it. They think healthcare policymakers should pay attention to their voices, not just seniors. They think constraints that limit one from owning their own medical record and lack of price transparency are lame excuses for protecting vested interests. They imagine a system of health in which their care is personalized by a holistic care team inclusive of physical and behavioral health, dentistry, nutrition, optometry, pharmacists and alternative care providers. For Millennials, it’s as much about clicks as bricks, seamlessly woven into the fiber of their schools, homes and workplaces. They believe many in the system profit excessively from its incentives and think the government should step in. And they want a system that’s easy to understand and affordable: they disavow the notion that healthcare is a privilege reserved for those with private insurance. Rather, they think it a right accessible to all. The Sanders phenomenon has tapped into these aspirations—no doubt, all candidates will need a response.

3-Outsiders are attractive. At this stage in the Presidential sweepstakes, the Campaign’s success is dependent on the Candidate’s style-points. Outsiders—Sanders and Trump-- seem to have the edge challenging the status quo with big ideas and straight talk. Ultimately, voters will choose based on their trust in the integrity of their candidate of choice. And the trust and integrity of the healthcare industry’s business practices and the ethicality of our leaders will be on full display. It’s a new day in healthcare: the integrity of our missions and the balance between our companies’ profit and purpose are of keen interest to voters in Campaign 2016.

No one knows how much more the field might narrow after primaries in South Carolina and Nevada this month and in the 14 state March 1 sweepstakes. What we know for sure is that healthcare, national defense and the economy will be the issues that determine who wins. All hit close to home and all matter, but none hits as closely and personally as healthcare.

Paul

Five Fast Facts for your Week:

1-Hospital workforce: Hospitals spend 56% of their costs on their employee overhead. Healthcare added 38,600 in January including hospitals (+23,700), doctor’s offices (+6.000), and home health agencies (+ 6300) with declines in labs, nursing homes, dentistry. For 2015, hospitals added 172,000 bringing total hospital employment to 5,000,000 or a third of the total U.S. healthcare workforce. In the past decade, hospital employment increased 14%, inpatient days & surgeries decreased 10%, and annual workforce productivity slipped to +.5% annually vs +2.2% in 90s and +2.6% in 80s. The patients are sicker and the hospital workforce is aging. U.S. Bureau of Labor Statistics, January 2016

2-Employee Health Costs: 20 big employers including American Express Coke, HCA, Verizon and others who collectively spend $14B on health benefits for their 4,000,000 employees announced the creation of a coalition to accelerate achievement of the Triple Aim: better health, better care and lower costs. The Health Care Transformation Task Force, whose members include 6 of the nation’s top 15 health systems and 4 of the top 25 health insurers, challenged other providers and payers to match its commitment to put 75% of their business into value-based arrangements by 2020. www.httf.org

3-Exchange enrollment: As of February 1, 12,600,000 had enrolled through Healthcare/gov including 28% between the ages of 18-24 and 42% new to the exchange. 10,000,000 of these are expected to pay their premiums HHS, CBO February 2016

4-Malpractice: 1% of doctors is responsible for 32% of all claims Public Citizen

5-Retail clinics: Retail clinics increased 900% to 2150 in 2015. Millennials prefer them 34% vs Boomers (17%) and 15% for seniors. “Millennials want it quick and affordable” USA Today 2/8 p1—One Nation Healthcare Series, RWJF

 Studies for your review:

The good news from the Centers for Disease Control and Prevention’s (CDC’s) National Center for Health Statistics (NCHS) is that the 2014 infant mortality rate of 582 deaths per 100 000 live births23 215 infant deathsis a 2.3% decrease from the 2013 rate and the lowest recorded US infant mortality rate on record. The bad news: the US lags most other developed countries i.e. Finland and Switzerland at 180/100,000. “US Infant Mortality Rate Declines but Still Exceeds Other Developed Countries” Julie A. Jacob, MA, JAMA. 2016;315(5):451-452. doi:10.1001/jama.2015.18886.

Parting Thought:

“If I could, I would reinvent myself today as a “confidentiality.” Someone who has the time to really get to know a patient. Someone available to be confided in. An advocate, not just for the moment, but across time. An explainer about what’s wrong; an educator about what will help and what will not. Someone who has the knowledge and confident wisdom to stand down the legions of specialists with their scalpels, catheters and scopes; the backbone to stand up to bottom-line-toeing administrators and self-serving insurance executives and policy wonks. Once I was a primary-care attending physician. It was the closest I came.”Jerald Winakur “In America, the Art of Doctoring is Dying” Washington Post February 12, 2016