The Occasional Perspective…

The accumulation of readings percolates some thoughts on how to proceed…

The Fairness Doctrine and Medicare for All – I had the privilege this past week of attending a conference where Michael Smerconish served as a speaker.  Over the last several years, he’s one of the pundits that I’ve listened to on cable news more and more as the shrillness of the debates among the partisans have become ever more sharp.  In fact, the one thing I love the most is that there is no “speaking over one another” in discussions or debates on the Smerconish Show.  So, why do I bring this up in a health care blog?  It’s because looming on the horizon is one of the most important debates we will be considering for the next several generations – Medicare for All!  Now, full disclosure: while I’m a recently eligible Medicare recipient, I’m still with my private health plan due to the benefits provided by my wife.  Here are my issues:

• Medicare is an absolutely crucial benefit that our society decided back on July 30, 1965 to make health insurance available for the entire USA population over the age of 65.
• Before Medicare, nearly 50% of the elderly populace did not have health insurance coverage. With the advent of Medicare, universal access to health care for the elderly and disabled was provided – something we as a society should take strong pride in supporting.
• Medicare has been shown to clearly make a major difference in the availability of comprehensive (i.e. across the board), quality (i.e. with defined measures) services (i.e. access). Prior to the implementation of Medicare, the elderly frequently did not obtain services or services were delayed inappropriately. 
• Study after study has shown that Medicare is efficient from an administrative standpoint with an overall growth in costs far lower than other insurance options. This allows Medicare payment rates to be much lower than traditional insurance products.  So, the question we need to ask ourselves is whether or not the efficiencies created outweigh the reduced societal costs.  What will happen to those programs, services and institutions that rely upon the balance of traditional insurance against Medicare to maintain survival – for example, rural hospitals?  These questions have not been adequately addressed.
• In a report of the Medicare Trustees who provide oversight to the program, the Trustees have indicated that the hospital insurance coverage provided by Medicare will remain solvent only through 2026 – in other words, only 7 years away. At that point, the revenue-to-cost ratio drops to 89% and gradually declines to 78% through 2043.  The addition of another 140+ million to the rolls overnight (NOTE: the Sanders/Warren plan calls for a four year implementation schedule) is likely to tip the proverbial wagon over!
• Medicare For All – is a catchy title but the underlying approach to payment is the Achilles heel. What do I mean?  Well, the current system is based on a traditional fee-for-service (FFS) model where the incentives for providers are in “doing things” (not inappropriate things but, things nonetheless) to people rather than emphasizing a “keeping them healthy” strategy.  Without a wholesale shift toward “value-based care delivery” my concern is that we engage in a whole lot of “doing” and not enough “healthing” of the populace. THEREFORE, before shifting to a Medicare for All strategy, we need to shift the payment systems to value-based care models or, at least move them heavily in that direction. That’s essentially what Obamacare was beginning to do.  But, that movement is now on hold with the health care systems waiting and watching to see which way the proverbial winds blow. If such a change is not made, the lack of resources to support Medicare will, in fact, bankrupt the nation as the demographics move toward an elderly tsunami which is just starting to gain force across the nation. The health care system is incredibly efficient at finding the money.  So, again, I emphasize that it seems to me that we need to shift the payment model FIRST before shifting the insurance model.
• A shift toward value-based payment models is not some monolithic approach. There are currently many different approaches including shared savings, bundled payments, shared risk, pay-for-performance (P4P), global capitation, accountable care organizations (ACOs) and provider-sponsored health plans, among other evolving approaches.  BUT, to work – these systems require market readiness in the form of “care management” systems, community-based care, adoption of telehealth and telecare capabilities and a host of other changes which health care systems have been slow to adopt. 
• So, without a wholesale change in the approach we take toward payment of services we are likely to move in a direction of overwhelming the very fabric of a program that we all (or at least the vast majority of us) believe is an essential underpinning for sustaining the health of the nation.

So, what’s this got to do with The Fairness Doctrine? Smerconish got me to thinking!!  If we don’t have a reasoned debate about “Medicare For All” and other reasonable and responsible solutions for providing access to “health care as a right” – which I firmly believe in – then, we run the risk of going down pathways that are ill-conceived.  As I noted earlier, the name “Medicare For All” is a catchy title but as a health care provider, I can assure you that catchy titles at the end of the day don’t deliver quality care.  Catchy titles don’t solve the issue of an aging demographic that can potentially overwhelm the entire nation.  Catchy titles are for campaigns but the details matter. 

In fact, I would be for a Medicare For All if we had at least a decade of experience in considering, developing and deploying alternative payment models. The single biggest lesson I’ve learned from economies that adopted Medicare for All-like strategies is that the emphasis of the payment systems is on preventive care. In addition, it would be a lot easier to support a Medicare For All strategy if we fully understood and had adopted the right technologies for helping us to deliver better more efficient care.  For example, Medicare for All could be a very smart strategy if machine learning and augmented intelligence were applied to create better protocols, guidelines and diagnostic pathways for delivering more efficient, effective care. 

AND, finally, we come to the most important consideration.  Without an honest, open debate that does not entail each of the corners yelling at one another from across the room, interrupting the presentation of facts or no facts so that we can engage in a conversation about the expected outcomes of the proposals which advocates are espousing – we will not solve the problem.  So, re-instituting the Fairness Doctrine or a facsimile of it in some fashion seems like a reasonable course of action.  We need more reasoned debates.  We need fewer Tweets.  We need dialogue not interruptive displays of one loud voice over another.  We need to think about this – together. The nation depends on it.  Does that sound reasonable?  One last thought.  All of the big challenges of the last century were resolved when we came to bi-partisan consensus on how to move forward.  That may seem old fashioned but working together – in my experience – has always been a good thing!