Finally, and most important, after an election in which a total outsider, Donald J. Trump, was elected president because Americans don’t trust politicians, congressional leadership drafted a bill in secret, skipped hearings, minimized open debate, and made vague promises about future actions to try to whip up support, which amounted to, “Trust us, we’re in Washington.” No surprise, no one did.
The result was that President Trump and congressional Republicans lost the argument so badly that the bill was at 17 percent approval (less than one out of five Americans) the day it was pulled.
REFORM IS POSSIBLE, BUT WILL REQUIRE A DIFFERENT APPROACH
Successful health care reform can be achieved, but it will require a very different approach from the one taken with the failed American Health Care Act.
COMPREHENSIVE DOESN’T WORK IN WASHINGTON
First, Trump and congressional Republicans should abandon Washington’s obsession with comprehensive reform. Health is the largest sector of the American economy—18 percent of GDP—and the most complex. Comprehensive legislation that affects one-fifth of our economy would be so complicated no one would understand it, and gaining majority support—much less bipartisan support—would be impossible.
Instead, health reform needs a slower-paced, transparent, simultaneous, issue-by-issue legislative approach. A series of hearings must be held to gather information and develop specific reforms that will improve health and health care. These hearings should have geographic as well as topical focuses so different citizens in different regions of the country will understand how the bill will affect them personally.
Some doubt that any health care legislation can pass Congress or garner the sixty votes needed in the Senate to avoid a filibuster. But there are recent examples of major health care bills that passed with significant bipartisan support.
The 21st Century Cures Act passed the House on November 30, 2016, by a vote of 392 to 26 and the Senate on December 7 by a vote of 94 to 5. The bill dedicated funds for biomedical research and updated Food and Drug Administration processes for approving cutting-edge therapies and treatments.
The Helping Families in Mental Health Crisis Act of 2016 passed the House on July 6, 2016, by a vote of 422 to 2 and the Senate by 94 to 5 (as a part of the 21st Century Cures Act). This nearly $4 billion reform in mental health programs was the most important in a decade.
Every Republican House and Senate member, and the Trump administration, should point to these reforms to remind Americans (and especially the news media) that Republicans are committed to work on a bipartisan basis to achieve a better health future for all Americans.
Right now, there are 25 Senate Democrats (including two independents who caucus with them) up for reelection in 2018. An effective, sustained grassroots program can force a number of them either to vote with our better Republican ideas or face defeat back home. This is a key component for Republican legislative success in 2017 and 2018.
LEARNING TO COMMUNICATE EFFECTIVELY
Second, successful health reform will require a much more morally compelling, persuasive style of communication than Republicans are used to. Eight years of opposing Obama and the temptation to remain negative will be hard to unlearn, but it is essential to governing.
The most effective conservative reformers of the past forty years all understood the importance of effective communication.
Margaret Thatcher had a rule for winning campaigns: “First you win the argument, then you win the vote.”
Ronald Reagan, in his farewell address, explained how he succeeded in pushing conservative reforms through Congress: “I’ve had my share of victories in the Congress, but what few people noticed is that I never won anything you didn’t win for me. They never saw my troops, they never saw Reagan’s regiments, the American people. You won every battle with every call you made and letter you wrote demanding action.”
When we passed welfare reform in 1996, we had explained our case so thoroughly that 92 percent of Americans favored reform, including 88 percent of those on welfare.
Thatcher, Reagan, and the Contract with America Republicans successfully communicated with the people by focusing on moral, human-focused arguments to achieve legislative success. Donald Trump and congressional Republicans must follow the same model. Winning the support of the American people for health reform will require a positive, morally centered, and human-focused vision of what such reform would mean for every single American.
Trump’s instincts, I believe, are correct on this. During his winning campaign, Trump usually focused on the emotionally powerful theme of making sure people got the health care they needed. Insurance came second.
In September 2015, for instance, Trump was being interviewed by Scott Pelley of CBS and was asked about his health care plan.
“I am going to take care of everybody. I don’t care if it costs me votes or not,” he said.
Pelley asked a follow-up question, trying to turn the discussion to insurance, but Trump refocused on making sure people get treatment.
“They’re going to be taken care of. I would make a deal with existing hospitals to take care of people,” Trump responded.
In his postelection interviews as well, president-elect Trump repeatedly emphasized his plan would offer “better health care, for less money.”
Notice that Trump put better health care first, money second. People get lost in the details when politicians focus on the technical details of insurance, because it doesn’t relate directly to their lives. Painting a positive vision of how every American’s health and health care will be better is how to communicate successful reform, not getting lost in abstraction about financing models.
President Trump and the Republicans in Congress lost this moral, personal focus once they started pushing the American Health Care Act. They became drowned in the details of refundable tax credits, continuous coverage, and changing the actuarial value of plans. The predictable result was that they could not garner support for the bill. The next health care reform effort must turn the focus back to health and health care rather than insurance financing.
Another principle to winning the support of the American people is for President Trump and the Republican Congress to discuss health care as an opportunity, not as a problem that needs to be solved. In addition to improving people’s health, an American health system that is once again the most innovative and effective in the world would be a huge source of high-paying jobs and foreign exchange.
A VISION FOR AMERICAN HEALTH CARE IN THE AGE OF TRUMP
Health is a moral issue. It is about life and death first. Money comes second.
Trump and the Republicans’ vision for health care reform must be about more than repealing Obamacare. It must be about more than insurance. It must create a clear, positive path for twenty-first-century health and health care.
Fortunately, we are entering an age of medical miracles that should give Americans reason to be excited.
Advances in science and technology have brought us to the brink of a miraculous future.
With the discovery of CRISPR, we may have opportunities to edit DNA to change, activate, and shut off genes that cause disease.
With immunotherapies, we are stimulating patients’ immune systems to attack and kill cancer with biology instead of using radiation and chemotherapy that damage healthy cells.
Already, we have built bionic eyes—cameras that transmit vision directly to the retinas of the blind. And that is nothing compared with the gene therapies for blindness that are working in clinical trials today.
In labs across the country, doctors are growing new, replacement organs for patients whose bodies are failing. Even now, there are patients walking around with bladders that were grown in incubators more than a decade ago.
Breakthroughs in neuroscience could soon slow or even halt the onset of Alzheimer’s and other dementias.
Miniature sensors can already monitor our vital signs around the clock, transmitting them wire
lessly to our phones to alert us—and our doctors—of any sign of trouble. Soon, nanosensors in the bloodstream will offer continuous access to every conceivable metric of health.
These are the scientific miracles before us. This is the future that every American could have. It would be a tragedy to abandon it. And yet we are in real danger of doing just that.
TWENTY-FIRST-CENTURY HEALTH AND HEALTH CARE RIGHTS AND RESPONSIBILITIES
The imaginations of our nation’s entrepreneurs, coupled with the constant discoveries of our scientists, can lead us to this future. But our twentieth-century policies, regulations, and market approaches cannot solve our twenty-first-century challenges. We are also hindered by our big, bureaucratic government and special interests that protect the past at the expense of progress. We must urgently rethink these failing systems and outdated regulations if we are to clear the way for a revolution in health science and technology.
President Trump and congressional Republicans, therefore, must think much bigger and broader than changes in insurance financing to enact real reform that will save lives and save money. Instead, their number one priority should be to replace our current health bureaucracy with a flatter, more transparent, and more accountable health system that embraces innovation.
Every American should be able to expect certain standards, freedoms, benefits, and opportunities from a twenty-first-century health system. If they are willing to participate and be responsible, they will gain:
• improved health;
• longer lives with a much better quality of life;
• a more convenient, understandable, and personalized experience—all at lower cost;
• access to the best course of treatment for their particular illness and their unique characteristics;
• a system that fosters and encourages innovation, competition, and better outcomes for patients;
• a system that truly values the impact that medical innovation has on patients and their caregivers, as well as on society as a whole;
• a government that facilitates and accelerates extraordinary opportunities to improve health and health care;
• continuous but unobtrusive 24/7 monitoring of their general health, chronic conditions, and acute health problems;
• access to the most modern medical knowledge and breakthroughs, including the most advanced technologies, therapies, and drugs, unimpeded by government-imposed price controls or rationing;
• the chance to increase their personal knowledge by learning from a transparent system of information about their diagnosis, costs, and alternative solutions;
• a continuously improving, competitive, patient-focused medical world in which new therapies, new technologies, and new drugs are introduced as rapidly and safely as possible—and not a day later;
• greater price and market competition, innovation, and smarter health care spending;
• a system of financing that includes insurance, government, charities, and self-funding that ensures access to health and health care for every American at the lowest possible cost without allowing financing and short-term budgetary considerations to distort and weaken the delivery of care;
• genuine insurance to facilitate access to dramatically better care, rather than the current system, which is myopically focused on monthly or annual payments;
• a health system in which third parties and government bureaucrats do not impede the best course of treatment that doctors and their patients decide on; and
• a health system in which seniors, veterans, or others under government health programs receive the same quality of care as their children in private market systems.
Big reforms are required to transform today’s expensive, obsolete health bureaucracy into a system that conforms to these principles.
REFORMS TO ACHIEVE THIS VISION
President Trump’s new approach to reform will have to be much different from what has passed for health care reform in Washington for the past two decades.
Instead of arguing over how to afford our broken health care system, he must focus his administration and congressional Republicans on actually fixing it.
We discussed why focusing on insurance financing is counterproductive to the goal of effective political communication—people care about their health, not abstract funding models. However, it is also self-defeating from an effective policy perspective.
First, most dysfunctional systems are starved for money because they are dysfunctional—not vice versa. Our broken health care system is a perfect example. Some analyses have shown that nearly $1 trillion per year is lost to waste and fraud in the health care system. You read that right: $1 trillion per year.
It is impossible to adequately finance a health system that bleeds $1 trillion annually. Costs will always overwhelm our resources. And we can’t fix our health care system solely by reducing the amount of money being spent by the government or insurance companies on health care. To use a medical analogy, trying to cure our health care system of what ails it by focusing on financing is treating the symptom, not the disease.
The disease in our health care system is a toxic mix of:
power centralized in large bureaucracies instead of the individual patients and doctors;
cultural and societal patterns that lead to poor health; and
a dysfunctional health delivery system that encourages waste, maximizes defensive medicine because of a broken litigation system, and tolerates fraud.
Only by focusing on solving these three challenges can we solve the problem of escalating costs. Figuring out how to pay for coverage and health care for the poor will be much easier if it is dramatically less expensive.
This leads us to the second reason why focusing narrowly on money is self-defeating: arbitrarily decreasing or increasing funding across an ineffective system does no good. But spending money in an effective health care system can have second-order economic benefits that end up paying for itself, or at least offsetting the costs. Effective health care spending directly saves lives, which go on to years and years of productivity instead of being cut short. Therefore, it is critical that lawmakers take a smart, strategic approach when it comes to making the health care system work, rather than waste time bickering over dollars and cents.
The following are a series of strategies and reforms I have shared with President Trump and his team. They are focused on fixing the root causes of the health care systems’ dysfunction rather than trying to tweak public and private insurance rules and funding.
These reforms are not a one-size-fits-all, Washington-knows-best model. They would give every single American the power to affect the health care marketplace. This is the only way to have a system that responds to the needs of patients instead of bureaucracies, adapts quickly to new information and innovation, encourages competition, and drives down prices while delivering better results.
STRATEGY 1: MAXIMIZE INNOVATION
Maximizing innovation and the speed at which medical breakthroughs can reach patients must be the number one priority of a twenty-first-century health care system.
The explosion of new scientific and medical knowledge we are seeing worldwide will do little good for patients if it takes decades for those advances to reach them. Yet that is the situation we are in today. Numerous studies have estimated that it takes seventeen years for research evidence to reach clinical practice.
Rapidly accelerating this process will—most important—save lives, and it will save money.
The benefit of quickly getting new treatments to patients is clear.
As Thomas Peter Stossel of the American Enterprise Institute wrote in February 2016, there is significant evidence that “the introduction of new drugs and devices has been the dominant factor behind a ten-year increase in U.S. longevity, a marked reduction in mortality from cardiovascular disease and cancer, and improved quality of life due to reduced morbidity caused by afflictions such as arthritis.”
And maximizing innova
tion would save money.
Innovation creates “cost collapses”—dramatic reductions in (or virtual elimination of) the costs of treatments for expensive diseases. Allowing market factors like innovation to cut costs is much more effective than “cost control,” which usually consists of large bureaucracies arbitrarily reducing funding across the board to try to save money.
The creation of the polio vaccine offers a simple example of how cost collapses work. The US health care system spends almost zero today on iron lungs to help polio victims breathe. One study published in PubMed estimated that the $35 billion the United States has spent on polio vaccinations since their invention has prevented 1.1 million cases of paralysis, 160,000 deaths, and created a net economic benefit to the United States of $180 billion. That’s a remarkable return on investment.
There are more recent examples of new treatments producing huge cost collapses.
A study in Health Affairs estimated that the use of statins (a cholesterol-lowering drug) in 2008 translated into a 27 percent reduction in health care costs per patient due to fewer strokes and heart attacks. This produced a net savings within the health care system itself of $5 billion.
The benefit is even more pronounced if you look at the broader benefit to society. The same study also estimated that the use of statins between 1987 and 2008 generated $1.25 trillion in economic value from years of life saved for those taking the medicine. During that time, approximately $200 billion was spent on statin drugs, meaning a net benefit to society of $947 billion. That is roughly a 4:1 benefit to cost ratio.
Another study in the Journal of Managed Care showed that the $14 billion that has been spent on treatments for chronic myeloid leukemia (CML) since 2001 has created $126 billion in economic value for patients. That doesn’t even account for the full societal benefits, such as reductions in the burden on caregivers or reduction in other medical costs due to improved health.
Understanding Trump Page 21