By MIKE MAGEE

Last weekend’s New York Times headline, The Moral Crisis of America’s Doctors, spotlights that there is growing concern that the monetarization and corporatization of nursing and medical professions by hospital and insurance power houses, have seriously undermined the mental health and ethical effectiveness of health care professionals. The pandemic has only heightened the crisis.

Since focusing on the social science of Medicine in the 1990’s in Philadelphia, it has been an uphill battle to convince leaders in and out of Medicine that doctors and nurses are critical to individual and societal success. Recently, I’ve come to the conclusion that this may have more to do with a general lack of knowledge of our form of governing, democracy, than a misunderstanding of the stabilizing effect of professional doctors and nurses.

What is democracy? For an answer I turned to John J. Patrick PhD, professor emeritus in history, civics and government at the Indiana University. In his “Understanding Democracy,” he explains that democracy as we know it is a “startling new development.” The practice of rule (krater) by the people (demos), or “demokratia,” dates back 2500 years to Athens, Greece. Citizens did rule by majority vote, but only free males of Greek descent could rise to the status of “citizen.” In those days, individual freedoms took a back seat to unconditional support of the city-community.

Establishing a modern democracy in America has been a bit of a struggle.

Our concept of a “representative democracy” allowed elected representatives to act on behalf of the citizens with the goal of achieving “majority rule in tandem with protection of minority rights.” By 1920, democracy was somewhat more inclusive and slowly gaining global recognition as a form of government. At the time, there were 15 democracies worldwide. But by the end of the 20th century, there were 100 representing 2/3rds of the global population.

The ascendant nature of democracy reflected changes and adjustments of the ancient model. Dr. Patrick has highlighted a few of those changes including:

1. “Democracy in our world implies both collective and personal liberty.”
2. “Differences in opinions and interests are tolerated and even encouraged in the public and private lives of citizens.”
3. “Unlike democracy in ancient times, which directed citizens primarily to serve the community, the primary purpose of government in a modern democracies is to serve and protect all persons under its authority and especially to secure their inherent rights to liberty and safety.”
4. “In an authentic democracy, the citizens or people choose representatives in government by means of free, fair, contested, and regularly scheduled elections in which all adults have the right to vote and otherwise participate in the electoral process.”
5. “Popular sovereignty prevails; the government rules by consent of the people to whom it is accountable.”

Democracies are anchored by Constitutions which define the the responsibilities of the various counter-balancing branches of government, and jury a system of laws or rules that apply to all citizens. The Constitution defines the limits on the power of government. It is a tricky balance. The democratic government must be powerful enough to maintain law and order. Yet it must be sufficiently restrained to avoid oppressing individual liberty.

Federalist No.51, dealt with this delicate balance, stating: “If angels were to govern men, neither external nor internal controls on government would be necessary. In framing a government which is to be administered by men over men, the great difficulty lies in this: you must first enable the government to control the governed, and in the next place oblige it to control itself.”

Dr. Patrick suggests that the rapidly expanding popularity of democracy as a form of government is its promise to deliver “ordered liberty…combining liberty and order in one constitutional government…an authentic democracy.”

This requires confidence and trust that is able to reach down into the community. It requires liberal amounts of compassion, understanding and partnership. It requires real time processing of individual fears and worries. And it requires hope.

The roughly 1 million physicians and 4.2 million Registered Nurses at their best, deliver all of the above to all comers. They are neither saints nor sinners. They are human. Those of us who have spent time educating and managing this workforce, have appealed to their sense of professionalism and their oaths of duty. We’ve reinforced that living under our impossibly high expectations is, after all, what they signed up for. Historically, in most cases, they have delivered beyond our expectations.

I see health professionals as front-line educators and defenders of democracy. As Dr. Patrick notes, “If there would be ‘government of the people, by the people, and for the people’ – Abraham Lincoln’s pithy phrase about the meaning of democracy – then there must be education of the people about what it is, how to do it, why it is good, or at least better than the alternatives to it.”

But learning in democracy, as in health care, is an intimate affair. It requires that people “touch each other.” Neither AI, nor the latest mRNA technology, can cure “what ails us.” The solutions are distinctly human.

Mike Magee MD is a Medical Historian, regular THCB Contributor, and the author of CODE BLUE: Inside the Medical Industrial Complex.

In this week’s health care tidbits, you may be wondering what happened to health policy under Joe Biden. He said no to Medicare for All because instead he was going to create a public option and lower the Medicare age to 60. Yet both those two policies seem to have vanished into the night. Presumably that’s because they think they’re a hard political sell and maybe that’s right. But why? This past week a massive study of American consumers shows that Medicare recipients are much happier with their experience than people with employer-based coverage. And employer based coverage is no better than Medicaid! To wit, the study showed:

Compared with those covered by Medicare, individuals with employer-sponsored insurance were less likely to report having a personal physician and were more likely to report instability in insurance coverage, difficulty seeing a physician because of costs, not taking medication because of costs, and having medical debt. Compared with those covered by Medicare, individuals with employer-sponsored insurance were less satisfied with their care.

Compared with individuals covered by Medicaid, those with employer-sponsored insurance were more likely to report having medical debt and were less likely to report difficulty seeing a physician because of costs and not taking medications because of costs. No difference in satisfaction with care was found between individuals with employer-sponsored private health insurance and those with Medicaid coverage.

I guess the new AHIP slogan is, “we’re just as good as Medicaid!” But you have to wonder, why are the rest of us being forced to consume an inferior product?

By MATTHEW HOLT

Those of you paying attention for the past few days might have noticed on the one hand a sense of optimism and unity as Barrack H. Obama, somewhat somberly, began his presidency.

Meanwhile, over the past few weeks the fur has been flying among the electrons on THCB while some very knowledgeable and opinionated health care wonks and geeks have been battling it out about what exactly we should be doing in terms of federal health care IT spending.

Given that even among you smart THCB readers this may be all a little perplexing, I’m going to try to try to make what I hope are some elucidating comments to put this argument in context. I’m doing this partly because I’m perplexed too, but also because I think that there is some hope for a middle road.

First the basics: As sometime THCB contributor & uber-CIO John Halamka makes clear in this excellent post about The Greatest Healthcare IT Generation, some $20 billion of the soon to be passed “spend it as fast as you can” stimulus package is going to be targeted towards health care IT. Now, that’s by no means the biggest part of the $800 billion or so package, and it’s not even the biggest part of the health care spending in the bill. Nearly $87 billion or so is going to support Medicaid, although that will mostly will be replacing cuts being forced on states.

Let’s be clear, the stimulus package’s main role is to stop the patient from bleeding out and will probably need to be joined by a bank restructuring the likes of which we’ve never seen. Health care is a sideshow, but $20 billion is still $20 billion, and given that the current health IT market is only between $20 and $30 billion annually, it’s a huge potential increase for the industry.

This spending is separate from any larger health care reform proposed by Obama, even though it appears that such a reform package is fairly likely to appear in Congress as soon as Daschle, Baucus and Kennedy get their ducks in a row. And of course, most of the issues that divide THCB’s various commentators on health IT are rooted in problems that only a major reform can solve. And realistically even those most optimistic about the prospects for reform don’t believe that the Obama/Daschle/Baucus plan will get at the core problems of the U.S. health care system any time soon.

The underlying problems: American health care has two linked and intertwined problems. First, (and it is first) due to America’s unique political history, most of the pain of dealing with increasing health costs is deposited on a poor (or soon to be poor) and relatively powerless minority of the population—the sick who are uninsured and underinsured. No one is really responsible for their financial well being, nor is any entity forced to make their cost of care equal to that of the rest of society. So the health care system has reacted rationally over the years by increasing what it charges the majority, and not worrying too much about that minority even as it grows. Every other rational country instead distributes that cost evenly by putting (more or less) everyone in the same financial pool, and puts someone (usually the government) in charge of the total cost of the system to society. The US is different, as it’s the only place where for the players in the system doing more means getting more absolutely. Everywhere else, the rest of society stops the health care system arbitrarily grabbing more resources.

The process whereby the health care system grabs more and more in the US comes mainly via an incredibly strong supplier community that has political control over the large share of spending that is government funded, and economic control over the main providers of private spending—employers. Of course it may not feel that way to the suppliers in the system but the numbers (share of GDP going to health care more than doubling over 30 years) don’t lie.

This leads to the second problem: The mechanism of that provider control is a payment system that encourages piece work, acute care, fixing rather than prevention, specialization over primary care, and—not least—big hospitals over community based clinics. Now as Atul Gawande points out in the New Yorker this week, it’s not as if every other country does exactly the opposite, but the scale by which we’ve tipped over here is unprecedented. And multitudes of articles on THCB over the years prove it out, and show that it’s very hard to change that status quo.

This starts to get us back to IT. The first significant use of IT in health care in the US was in large hospitals primarily aimed at accounting (and billing) for piece work. Eventually most large and many smaller hospitals began to extend their IT capabilities to automate other aspects of their activity, but even among the most sophisticated, the role of IT supported rather than transformed the way they delivered care. The goal of the hospital is after all for the hospital to thrive and prosper, not for the community to improve the care it gets at a lower cost. This has continued as IT investment has picked up, especially since 2003, and of course it’s been reflected in the stock price and profitability of the winners in health IT, notably Cerner and Epic.

Some other countries were introducing more clinically-based IT into their health care systems over the 1990s, and they tended to place it where their systems were focused—which tended to mean in primary care. The three Ns (Norway, Netherlands, New Zealand) along with the Danes & the Brits were close to 100% EMR use in office based primary care by the early 2000s. The UK was able to use this to actually track what its primary care docs were doing, and started paying them bonuses for doing the “right thing” in terms of prevention and evidence based medicine. But note that the IT was shoe-horned into a system which was by and large doing that already. It did not change the core way care was delivered. In fact in the UK the links between primary care (GPs) and specialty care (hospitals) are still by and large absent—despite a huge budgeted (and not fully spent) investment in Healthcare IT that exceeds what’s in the current US stimulus package for a country 1/5^th the population! The astute observer will also notice that several countries that don’t have EMRs in universal use among physicians, notably France and Germany, also have pretty well regarded health care systems.

So it’s a pretty fair assumption that IT use in health care will reflect the system it’s put into, rather than transform it to something completely different.

So why all the aggro? Since the Obama win and the recession made the stimulus a certainty and health care IT’s inclusion in it a reality, THCB has been the venue for a series of articles in the form of Open Letters to the Obama Administration by David Kibbe & Brian Klepper, a defense of the proposed spending by John Halamka, an analysis of the perversion of administrative simplification under HIPAA by interested parties (clearinghouses) from Rick Peters, all culminating in a declaration that Health IT is in fact ready, just add $20 billion, by Mark Leavitt yesterday. This argument has by no means been confined to THCB, and in fact this latest discussion was started mostly in a series in Health Affairs, in which Carol Diamond and Clay Shirky accused the current health IT establishment of “magical thinking”, while somewhat surprisingly Microsoft—which sells a lot more in copies of Windows and Office to hospitals than health care tools to consumers or small practices—in the person of its health care leader Peter Neupert suggested that we should take a pause before hitting the “buy” key, and spend money on outcomes not on technology for its own sake. And enfant terrible Jonathan Bush is warning anyone who’ll listen that we’ll be locking in place outmoded technology.

Essentially the argument comes down to two things (Warning—gross generalizations ahead!). I liken this to the common truism that dogs attach themselves to people while cats attach themselves to places

Outcomes vs. technology: The Kibbe/Klepper/Peters/Neupert/Bush faction (the dogs)assumes that we need to change the incentives in the system, and then IT will naturally follow—and the current embryonic decision support systems will flourish quickly. But that current clinical systems aren’t good enough to invest in mostly because current results from EMR installations are very disappointing.

Although they discuss incentives (and most of the $20 billion will probably be aligned with some P4P measures), the cats’ (Leavitt/Halamka/Kolodner) view is closer to the thought that if you get the appropriate clinical technology (essentially in-patient and outpatient EMRs) into the hands of clinicians, then they’ll figure out what to do with it, and eventually the government can pay them according to how well they do it. (Halamka is a bit more open about this also being an IT public works scheme).

Patients vs. facilities: There’s also a more philosophical bias which harkens back to the difference between American and European health care systems, but not in the way you might think. The dog faction is in general primarily in favor of light-weight tools (and standards) that allow for innovation and service of the consumer patient by primary care teams (that’s the European part). The recent emergence of Web-based tools and patient communities that allow patients to apply self-service techniques and easy communication with teams of providers (yes, yes, that’s Health 2.0) are for them the keys to enabling better care. These tools are relatively cheap (and flexible) and mirror the SaaS trends in the rest of technology. (Think Gmail vs Outlook).

The cats’ view is closer to the opinion that the real work in American health care happens in big hospital systems, and that the key is to get everyone connected to their core clinical systems. Hence the concern with standardizing on products and private networks (RHIOs) rather than allowing a mass of anarchic applications out on the Internet which are more likely to “mash-up” together.

What about the biases? There have been plenty of accusations of bias and self-interest on these pages, and it’s worth quickly looking at it. For example, Jonathan Bush believes he’s riding a wave towards a SaaS future, whereas most of his competitors are still MUMPS-based client sever technologies—he fears the $20bn will be used to subsidize SUVs in a world where AthenaHealth is selling the Prius. Mark Leavitt, while on loan to the Chairman of CCHIT is the former CEO of MedicaLogic (now the core of GE’s Centricity EMR product) and a former HIMSS official. Most people in health care think of HIMSS as a vendor promotion association. Halamka of course is part of a very large AMC and the chair of the HITSP standards organization which tends to favor larger systems, whereas Kibbe is well know for his work promoting the lighter weight CCR standard and his involvement in the American Academy of Family Physicians—long the orphans of our specialty dominated medical culture. I also suspect that Kibbe’s recent criticisms of the EMR haven’t exactly helped his chance of receiving consulting dollars from the major HIT vendors, but he is also involved in consulting with smaller companies that stand to benefit from the emergence of new models of care. And of course Brian Klepper and I are involved in Health 2.0 (together in a consulting venture and me as co-founder of a conference).

However, I perhaps naively choose to believe that everyone involved is motivated more by their cultural takes on what’s important for health care, than their desire to put a hand-out for the $20 billion. I think that these same positions would have been taken by the same people 6 months ago when the bailout was yet a twinkle in Obama’s eye.

So in change, can we find unity? So despite the fierce words and the grave differences of opinion, can cats and dogs live together in harmony? I think that in the spirit of Obama’s first days in power we can find some unity. At the same time we need to be realistic about what comes next.

First, we need to get rid of the notion that IT is going to transform our health care system. To transform healthcare we need to get real health reform right. Obama is not doing IT any favors by imposing that pressure on its use—the dogs are correct here.

Second, we are not immediately going to move away from an acute care, large system-focused health care environment. Any change towards overall more consumer-focused health management will continue to be slower than some of us might like. So getting those acute care facilities that are not at BIDMC or InterMountain levels of technology readiness in better shape can’t hurt.

Third, despite all the harsh words, as the bill now stands, most of the $20 billion will reward actions with some form of P4P. If the folks at HHS & CMS who will be responsible for crafting the incentive structures hear a more unified voice from the assorted commentators, geeks, cats & dogs arguing over here, we’ll likely get more incentives rewarding better process and less direction on particular technologies—which will be a good thing.

Fourth, there’s an underlying concern among the dogs that in the cat view (which is more clearly the “establishment view”) the patient is lost. Yet I still see Leavitt and the others from the establishment keen to bridge the gap to patients with connectivity tools and to give them control over their data in PHRs. And I don’t believe anyone is suggesting that we halt the rapid development in the ability of patients to manage themselves, and communicate with each other and clinicians, which is at the heart of Health 2.0.

So I have hope that, while the health IT part of the bailout will not be the ultimate cure for our health care system, it will help in many ways all over the system. I also hope that while there won’t be complete consensus both cats and dogs will agree that it should fit some core basic principles so that in years to come we’ll judge that this money was wisely spent.

Of course I’ll be reserving judgment at least till the bill makes it out of committee, and probably until we see exactly how CMS wants to spend the money!

Matthew Holt is to Founder of THCB. Follow him at @boltyboy. This piece was originally published in 2009. Read it here.

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Allscripts is one of the biggest companies in Health IT. Glen Tullman built it from almost nowhere and then last year after one bad quarter and a power struggle in the boardroom (which he initially won), he left–and he stresses it was his decision. Along the way there were lots of interesting choices made, and he and Allscripts ended up with a sweep of all the negative awards at this years HISSIES (including his first time as “Industry figure in who’s face you’d most like to throw a pie”).

But despite all the abuse, what Glen did over the past 15 years is pretty remarkable given the stagnant state of the enterprise HIT market. I’ve interviewed him almost every year since THCB started and he was never shy in giving his opinions. Last month I got him for a long retrospective. THCB will be running that in parts over the next week or so, and he dishes on the Allscripts’ record, on Epic, on the future of health IT and more.

But here’s a teaser…

There’s no one that pisses off the right in this country as much as Paul Krugman, and there’s nothing that pisses off the right as much as welfare for the poor. So when Krugman wrote recently in the NY Times supporting a program that is welfare for the poor, and describing how Romney/Ryan would decimate it, well you can expect an explosion from the GRWC. Yes the topic of today’s right-eous indignation is Medicaid.

The place to go to see that explosion is the comments section of John Goodman’s blog. That’s the halcyon world where the poor are oppressed by government programs and would much rather be set free to swim in the happy waters of the free market. Goodman proves to himself that studies showing that people without health insurance on average die prematurely must be wrong because they’re not seen in any “credible, peer-reviewed social science journal” — just in biased rubbish like the American Journal of Public Health and reports from the crack-smoking wackos at the Institute of Medicine.

Having read the comments on Goodman’s article I’m very surprised that Heartland’s Peter Ferrera hasn’t gone on welfare to show how it’s now a guaranteed path to unlimited riches (as opposed to say the tough job of taking payola from a convicted felon) and that Goodman himself hasn’t rejected his health insurance and gone naked on the income of the single mom & waitress in Dallas that Uwe teased him about a few years back. After all it would give him so much buying power to impact the market!

Back in the real world, everyone on the left knows that Medicaid is a dog-meat last ditch program. But over the past seven decades the intense efforts of assorted whack-jobs, lie-factories and mean spirited Republicans–and many right wing DINOs– mean that there is no national comprehensive health plan. Medicaid is all the poor have, and all that keeps granny in the nursing home rather than living in the front room or on the street. It’s the politics of the right that prevented folding it into Medicare in 1965 and into a comprehensive plan in 1994, and made it impossible to do anything other than build on Medicaid in 2010. That’s why Daschle championed it as the least bad route to quasi-universal insurance.

To really suggest that Ryan/Romney won’t cut Medicaid means that the fools at the AP must have been very confused when they penned this article suggesting that block grants would reduce Medicaid by $800 billion. They must have meant that instead states like Texas, Florida and Mississippi would of course massively increase their Medicaid spending and cover more people because of the “flexibility” block grants would give them. Of course those states have been falling over each other to take the Federal dollars now on offer for Medicaid.

Oh and none of the right-wingers mention the facts that for the non-elderly & disabled Medicaid is already 65% run through private health plans (see p13 here)–much closer to that free market nirvana that the right aspire to than Medicare with its 25% rate.

But that’s all fine. Medicaid does relatively well with the pittance it gets, but if the right’s boy Romney wins we’re going to see just how huge the clout of the poor is when they get those Medicaid cards taken away from them and thrown off the rolls. And I’m sure Goodman and his buddies will all be lining up to explain to them how their new reality of being broke, sick and uninsured is so much better!

I’ll wait expectantly (no, not really!) for Obama et al to pick up this thread that Clinton left them at the Convention in the next week…

Matthew is the founder of THCB and is guilt-stricken about how rarely he gets to write on it!

The protest organized by Regina Holliday over a patient’s right to access their medical information is not quite the same magnitude as agitating for integration in 1950s-era Alabama. Yet there are intriguing similarities between the crusade Rosa Parks launched then and what Holliday is attempting today. Both involve a refusal to accept second-class status and a resolve to push back against entrenched institutions.

Parks’ story is well known. Her refusal to surrender her seat to a white male passenger on a Montgomery city bus in December, 1955, prompted her arrest and a sustained bus boycott by outraged black residents. That boycott’s success propelled a young Martin Luther King, Jr. to the forefront of the fight against segregation. Parks eventually came to be known as the “mother of the modern day civil rights movement.”

Holliday’s protest is seeking media attention – as this is written, it had not taken place – by targeting the American Hospital Association’s annual meeting at a Washington hotel. The rights issue involves how quickly patients are able to see their own electronic medical information after leaving the hospital. The AHA, representing an industry that grew up as “the physician’s workshop,” wants a 30-day grace period to give doctors more time to prepare and review material. Holliday demands immediate access.

What makes this a fight about freedom, and not just fodder for the Federal Register, is its profound potential to affect how each of us takes responsibility for our own health and health care in the digital information age. What is most likely to capture the general public’s interest, however, is the way that general principle finds emotional resonance in Holliday’s personal story.

A widow with two young children, Holliday recalls on her blog how her husband, Fred, died “painfully [from cancer] after suffering for weeks.” She blames inadequate pain management and uncoordinated care due to a chaotic medical record. When they sought access to his electronic medical record, the hospital responded by saying “we must wait 21 days and pay 73 cents per page to see the story of his care. Then they told us we could go home to die.

Just as Rosa Parks was not a random bus passenger – she and her husband, Raymond, were active members of the NAACP – Holliday is not a random patient protester. An artist, she responded to Fred’s death by becoming a “patients right arts advocate,” producing paintings with titles like “73 Cents,” and “Hubris Hospital” and “Give Us Our Damned Data.”

Also like Parks, Holliday is part of a larger community that shares a similar outrage over being relegated to the back seat, even if in the doctor- and hospital-dominated world of health care, the “back of the bus” is symbolic rather than literal. Her protest drew expressions of support from the National Partnership for Women & Families, the Center for Democracy and Technology and others. But the key to whether this protest is a turning point may lie in a phrase used in a letter supporting immediate access from the Society for Participatory Medicine, to which Holliday belongs. (Disclosure: I’m a Society board member and a friend of Holliday’s, but did not draft the comments.)

The Society wrote: “The overarching principle with respect to patient access to electronic health record data…should be: ‘Nothing about me, without me.’”

That phrase comes from a health care conference held in Salzburg, Austria in the late 1990s. It echoes the slogan, “Nothing about us without us” popularized by disability activists in South Africa and then adopted by activists in this country. It is a powerful statement about equality, engagement and control of one’s own destiny even when those who do not want to share control do so with the best of intentions, whether seeking to help the disabled or trying to implement electronic medical records in hospitals.

The problem, as The Silent World of Doctor and Patient defined it so insightfully more than a quarter-century ago, is that many providers genuinely believe it is their duty to act as “rational agents” on the patient’s behalf without asking the patient’s opinion. In contrast, “nothing about me without me” is the patient’s demand for freedom and, yes, the responsibility that comes with it.

That demand is not unprecedented. I’ve written how new moms were given strict baby feeding schedules by pediatricians until Dr. Benjamin Spock declared that mothers deciding when to feed their babies was “was used by the entire human race until the turn of the century.” How the first American Medical Association code of ethics required patients to obey their doctors, and how it required repeated lawsuits by patients before doctors had to tell patients in clear language the risks as well as benefits of a procedure. And how the AHA, facing the threat of legislation, adopted a Patient Bill of Rights that included such privileges as being told the names of all the doctors treating you.

What distinguishes Holliday’s effort is the power of information access in the digital age. “Give us our damned data” means possessing the raw clinical material that lets us partner with our own doctors or choose other clinicians who better meet our needs. We can go “off the grid,” perhaps “crowdsourcing” questions to others, or we can apply that digitized information to treatment recommendations and outcome prediction algorithms based on the same evidence our doctor uses.

Demanding access to our digitized information immediately, rather than when it is convenient for the doctor and hospital to give it to us, is a stark declaration that it is our health and our lives that are immediately at stake: “Nothing about me without me” from our first cry for food on the day we are born and then every day after.

This dispute may soon be forgotten as a kerfuffle over criteria for “Stage 2 meaningful use” subsidies from the Department of Health and Human Services. But if it can ignite an understanding about what takes for us to be true equals in health and health care decisions, it could be the start of a mass movement that would make Rosa Parks proud.

Michael Millenson is a Highland Park, IL-based consultant, a visiting scholar at the Kellogg School of Management and the author of “Demanding Medical Excellence: Doctors and Accountability in the Information Age.

Amy Goldstein has an important article in today’s Washington Post detailing the place Don Berwick, the Medicare and Medicaid administrator finds himself in.

It is all but certain he will have to leave his post at year’s end, when his recess appointment expires, because the Senate will not confirm him for a lack of Republican support.

Berwick is one of the most respected health care experts in the country—his career has been dedicated to improving quality first and with that the cost of care. With the new law giving his agency more opportunities to experiment with new approaches and the ability to more quickly implement the things that work, he was the ideal choice.

But with the Democrats ramming the law through without a political consensus to support it, Berwick also became the political whipping boy for opponents to pile on. That he has been willing to point to the things that work in places like Britain only gave the political opportunists plenty of red meat to throw into an already red hot ideological debate.

In my mind, the great frustration in health care is that we really aren’t so far away from being able to make the system far better than it is—in both its quality and its cost. To test and perfect the best ideas we really need to be willing to try new things—many of which won’t work but can form the basis of finding out what does work.

His proposed Accountable Care Organization (ACO) rules were a disaster and he should have known better. But there is also no reason why that failure can’t lead to a better outcome—if finding the right answer is what we are all ultimately interested in.

But, particularly in this red hot political environment made more red hot by one side always more willing to jam their ideas down the other side’s throat—whether that be a new health care law or a debt ceiling solution—people like Berwick get caught up in the bigger political fight.

My sense is that a Republican President, as much as a Democratic one, could have as easily appointed Don Berwick CMS administrator.

People say Don Berwick’s failing is that he is a “political neophyte.” It is the reality that once you get to Washington having the right answer isn’t enough—you have to be able to get it through the system. What does it say about Washington when a first class expert speaking what he sees in good faith as “truth” is seen to be naïve and can be quickly dismissed for “having a record on rationing care?”

But Don Berwick never had a chance in an environment where trying to find the right answers takes a back seat to scoring political points.

With health care costs and the nation’s debt crisis now coming to a place that must finally be changed, we can’t afford this toxic take no prisoners political environment much longer.

In fact, August 2nd might be the day it all comes home to roost.

Robert Laszewski currently serves as the president of Health Policy and Strategy Associates of Alexandria, Virginia. Before forming HPSA in 1992, Robert served as the COO, Group Markets, for the Liberty Mutual Insurance Company. You can read more of his thoughtful analysis of healthcare industry trends at The Health Policy and Marketplace Blog, where this post first appeared.

JEFF GOLDSMITH

Though thoroughly smothered under 2900 pages of well meaning but poorly focused, expert-driven “good works”, the core of the Affordable Care Act was providing 30 million people subsidized health insurance coverage. As the country continues to decide how it feels about this monumental legislation, a major ideological divide persists over whether the aggressive coverage expansion in health reform was really needed or not.

Far from “selling itself,” as a overconfident White House aide suggested it would back on March 23, 2010,  health reform remains strikingly unpopular. Only 37% of the public thinks the country will be better off as a result of health reform, and only 28% think their families will be better off, according to the May Kaiser Family Foundation tracking poll.  There is a stark partisan divide over health reform.  While 72% of Democrats have a favorable opinion of health reform, a substantial minority believes the bill could have done more (covered more people, provided a public option or path to single payer).  Alternatively, 74% of Republicans have an unfavorable opinion of health reform; the same percentage favors repeal.  Independents tend to break toward the Republican view of the bill (49% unfavorable vs. 35% favorable).  Those opposed feel more intensely about health reform than those in favor.

The Ryan House Budget for 2012 zeroes out all new spending for health reform (while keeping ACA’s Medicare cuts, devoting them to deficit reduction!).  The conservative narrative is that the problem of the uninsured was liberal mythology, not meriting major new spending.  In the blogosphere, an analysis surfaced suggesting that the real uninsured problem is only about 4 million people. This apparently originated in a Heritage Foundation blog posting from late August, 2009.  Other conservative analysts charitably suggest there may be as many as ten to twelve million uninsured worthy of federal help.   To take care of this smaller number, you do not need a major coverage expansion, but merely to apply the familiar market oriented remedies: selling insurance across state lines, high deductible health plans, malpractice reform, high risk pools, etc.

How do you get from 51 million (the 2009 Census Bureau estimate derived from the Current Population Survey) to four million (the Heritage blog actually started at 46 million, the estimated Census number of uninsured for 2007)?   Well, begin by subtracting those who are not uninsured for a full year.  According to the Heritage blog, that gets you down to 36 million.  Then subtract another 6 million children who are uninsured but eligible for Medicaid, and whose parents have not signed them up.  That gets you down to thirty million.  Then you subtract twelve million “illegal aliens” who are uninsured (down to eighteen), and the substantial number of “free riders” who come from “wealthy” households above $50 thousand in income and, voila, you’re down to four million “poor, sick uninsured for a lengthy period.”  This facile exercise in people subtraction is riddled both with errors and questionable judgments.

It is true that the 51 million uninsured estimated for 2009, which derives from the Current Population Survey of the Census Bureau, over-counts the actual number of uninsured due to significant under-reporting of Medicaid enrollment. Subtract that out and you have about 46 million people who reported that at one point in time they were uninsured during 2009.

There is great fluidity in health insurance coverage, just as there is in employment status and also in income eligibility for public programs like Medicaid.  Separate analysis using data from the Agency for Healthcare Research and Quality using the Census’ MEPS survey data suggested that in 2008 almost 41 million were uninsured for an entire year.  In a two-year analysis using the same data series, a little more than thirty million people were uninsured for two complete years (2007-2008).

Why those who have short-term coverage issues should be less worthy of help than the “hard core” long term uninsured is unexplained by the Heritage blogger.   Diabetics, or people with high blood pressure, or with depression who interrupt their medication because they cannot afford it even for a matter of months end up costing the entire society money in acute care for avoidable illness.

There is reasonable certainty that about a quarter of the uninsured are eligible for public programs (e.g. Medicaid or SCHIP) and are not enrolled.  This number, 11-12 million, is scaring Governors and Medicaid program directors all over the country.  Policy wonks ungallantly call them “the woodwork people”- that is, folks who will come out of the woodwork, like termites, in 2014 when the individual mandate requires them to have insurance coverage.  Unlike those to be newly covered by the ACA Medicaid expansion, the cost of the woodwork people will be paid for at the existing match (which averages 43% from state general funds).   States struggling with their present 53 million Medicaid enrollees will have to find a big chunk of new money.

The aforementioned MEPS survey found almost 6 million uninsured children in 2008 but not 100% of these are eligible for Medicaid or SCHIP, because many of them live in households above SCHIP’s income threshold.  Many families are daunted by the public program enrollment process, either because of mistrust of the government or deliberate bureaucratic barriers.  States in fiscal trouble have a powerful economic motive to make it complex or difficult for people to enroll.

Hospitals are actually the biggest “promoters” of public coverage both for adults and children, for the excellent reason that it reduces their bad debts.  But you have to be sick enough or patient enough to use the hospital to get their attention. To suggest that public coverage is simply “there” and that parents are dilatory in not using it does not tell the whole story, given the program’s “welfare” lineage and bureaucratic inertia.   There is clearly a problem here, but a different one than the Heritage Foundation blog analysis suggests.

A greater and less defensible leap is assuming that the entire “illegal alien” population is uninsured and since they shouldn’t be here in the first place, we shouldn’t worry about them.  According to the Pew Hispanic Center, in 2008, there were about 11.9 million people in the US illegally. Almost 40% of the illegal adults actually have some form of insurance, whether provided by employers or, via false documentation, through public programs. In 2006, the National Institute for Healthcare Management estimated that there were only about 5.6 million uninsured undocumenteds in the US in 2006. The Congressional Budget Office arrived at an identical figure for the current uninsured undocumented in a March 2011 report.

The number of undocumented folk in the US has probably fallen significantly in the past three years due to the collapse of housing construction and the shrinkage of tourism in the Sun Belt- two major employers of undocumented workers. In some states like Texas and California, the undocumented may yet constitute as many as one-third of the uninsured.  But the Heritage estimate of “12 million illegal uninsured” likely at least doubles the real number, as well as ignoring the on-the-ground reality – the public health threat posed by a large number of uncovered and highly mobile undocumented workers and their families.  Congressman Ryan’s proposed 2012 budget not only zeroes out money for the coverage expansion, but also cuts the safety net expansion provided community health centers, which serve the undocumented population without complaint.

The “high income” uninsured, who the conservative blogosphere assumes to be free riders, constitute a surprisingly large percentage of the long term uninsured.   Of the more than thirty million uninsured who were continuously without coverage for the entirety of the first two years of the recession (2007-2008), somewhat more than 45% had household incomes over 200% of poverty ($42 thousand a year for a family of four) , and more than 40% earned over 400% of poverty ($84 thousand a year for a family of four).  These are not small numbers.  But the idea that there are massive amounts of unallocated free cash sloshing around in their household budgets that is available to pay health premiums is laughable.

By the time of the 2007-8 recession, American consumers had accumulated a staggering $14 trillion in consumer debt.  When they ran out of cash, many consumers defaulted,  creating a landslide of uncollectible accounts that caused our financial crisis. According to the Federal Reserve, only about a trillion of this unsustainable consumer debt burden has been liquidated, mostly by being written off or paid off.  Thirteen trillion dollars in consumer debt remains a huge drag on the economy and a massive claim on future consumer income.  (As late as 2004, the total consumer debt was only $8 trillion).

If consumers had free cash, they’d be spending it, and we would not have 9.1% unemployment.   The idea that there are huge undiscovered cash reserves that would enable cash strapped consumers to take on a $14 thousand a year health insurance expense is delusional.  Unless we were willing to write off the remaining $13 trillion in debt and insist that people spend any resultant free cash purchasing health insurance, the idea that tens of millions of “wealthy” Americans are “voluntarily” foregoing insurance coverage does not reflect the on-the-ground reality. There may be free riders here, but not fifteen million of them.

What’s the bottom line?  While the headline number of 51 million uninsured probably overstates the magnitude of the real problem, there are presently tens of millions of Americans who cannot afford to purchase health coverage without help.  It isn’t just a problem of the “sick and poor”, either.  It’s the middle class, anxious and hurting, that is delaying seeking care because they either cannot afford health premiums or cannot afford the cost sharing their employer provided policies require.

The 4 million Heritage blogger’s number, faithfully reblogged by countless health reform critics, is a convenient rhetorical pretext for rolling back the Affordable Care Act’s coverage expansion, but not a credible estimate of the actual needs. One can legitimately quarrel with the large fraction of the expansion paid for by Medicaid, a broken program whose present covered population states cannot afford.  One can quarrel as well with the unspoken premise that health coverage is a “human right.” It might have been a more efficient use of scarce societal dollars simply to expand the safety net directly.

But simply abandoning the thirty million people promised coverage by the ACA to the vagaries of the “marketplace” (and a very expensive care system) is not only bad politics (a Tea Party gift to a struggling President Obama), but also bad social and public health policy.

Jeff Goldsmith is president of Health Futures Inc, which specializes in corporate strategic planning and forecasting future health care trends. He is also the author of “The Long Baby Boom: An Optimistic Vision for a Graying Generation.”

This week I spent quite a bit of time at the very new and very fancy Kaiser Permanente Center for Total Health in Washington DC. It’s next door to a very large medical office building  (110+ docs) in which KP is showcasing its current integrated care model, and how far its come in its mid-Atlantic region. The Center is  a pretty fascinating place–part tech and idea showcase and part meeting room. Certainly no other health care organization that I’m aware of has spent so much on a place designed to stimulate the imagination and enhance conversation–under the nose of the folks on Capitol Hill. I won’t get into here whether this is how money should be spent in health care but on balance I’m a  fan. (FD KP is a sponsor of the Health 2.0 Conference I co-run).  Instead I want to try to give you a feel for the place, and why it fits their vision and what it’s trying to demonstrate.

I took a tour with some colleague journo/blogger types led by the always expressive Robbie Pearl (CEO of the Permanente Groups in N Cal and now DC too–the airlines thank him!) and with Phil Fasano, CIO of the whole organization. Robbie is not shy in voicing his opinions (as you’ll see) and Phil occasionally trots out the voice of caution to reel in Robbie’s vision a tad. It was great fun.

What was also fun was the cocktail party at the grand opening. There I met three of my favorite DC-based ladies in health: Deven McGraw, Regina Holliday & Cindy Throop. So we’ll start with that fun video, and then there’s a whole lot more from the tour of the center after the jump. All these videos are pretty short.

After that fun and games, lets head to the tour. This is a series of videos of me and a few others testing out the displays, and listening to Pearl &  Fasano, as well as asking them a couple of pointed questions.

But I’ll take the tour in order….after a quick thanks to Holly Potter, Danielle Cass, Ravi Poorsina & center boss Julie Norris who with a ton of their colleagues worked their butts off keeping hundreds of visitors informed and entertained.

First up, Robbie Pearl on the current state of the KP.org health record and why we shouldn’t have to put up with less; what he called the 19th century state of medicine. And I can assure that is on display in my wife’s OBGYN office every time I visit.

I asked Robbie about the impact of the KP My HealthManager system on the reduction in primary care office visits. He didnt quite jibe with the data Louise Liang showed at AHIP last year, but it’s for sure a big culture change. Pearl says that it leads to more, earlier care–but that it’s more effective and cheaper.

Next up some fun and games, as I get to use the Cisco Healthpresence system with Mark Scrimshire (@ekivemark of Healthcamp fame) playing patient.

Then there’s a video history wall, mixing KP history with medical and tech history. Listen carefully for my snarky remark about The Permanente Federation…

Next Robbie Pearl shows a mock exam room. This is really how it is in much of the KP Mid-Atlantic region and much of California. With real time access to specialists over video-consult. But not at my wife’s OBGYN (You getting  a theme here?)

Back at the front of the center, there’s a huge video display wall. Currently dedicated to the “Everybody Walk” campaign.

After the fun and games–a quick conversation with Pearl & Fasano. First, why is Kaiser different to FFS medicine (you probably know the answer but Robbie’s going to tell you anyway!) and why they built the Center in DC.

And finally, what about Kaiser’s ability and likelihood to expand the model to new geographies? You’ll note that Dr Pearl and Mr Fasano have slightly different opinions on this one!

All in all, it’s a wonderful new way to show wellness initiatives and to get people to understand that medicine can be done another way. Will it change the conversation in DC? That’s another blog post for another day. But I encourage you to visit the center in DC (near Union Station) if you get the chance.