Inkwell: Authors and Artists

    
Thanks, Joe. That makes a lot of sense.

What do you think determines whether we'll make this transition
successfully?
  

    
> What do you think determines whether we'll make this transition
successfully?

Tough question, but the answer lies mainly in the systemic economics
of healthcare, not in the political froth about it — and those
economics are more encouraging even that today's Court decision. Every
part of healthcare is desperately looking for a path forward that works
for them. If you look across healthcare and can begin to find ways
that not-for-profit institutions, the for-profit companies serving
them, and employers, cities, and unions can thrive and move forward by
helping people be healthier and get better healthcare at lower cost,
then this movement becomes a landslide.

I actually that we are at this tipping point now. Today's decision has
loosened the pins under the resistance to it. It will not be
immediately obvious, but looking back from the future, we will likely
say, this was the day, this was the tipping point.
  

    
and how happy are you about it? very? extremely? not so much?
  

    
I want to push just a bit more on my earlier question. Sometimes, it
sounds like you're describing forces that will *inevitably* push
healthcare toward being both cheaper and better. At other times, it
sounds like you're advocating for a revolution that might or might not
occur. Can you help clarify that?
  

    
> how happy are you about it? very? extremely? not so much?

To be precise, I am giddy with excitement. The PPACA is not the change
we need to see in healthcare, but it is a catalyst, a start. Having it
struck down would have been so much worse.
  

    
> inevitable forces ... or advocating a revolution?

Tough job, being a futurist. I would never say something is
inevitable. I do say that it is already happening, and the pace of
change is quickening every day. The forces pushing it are very much
there, and are gaining strength. 

Is it possible to stop it? To slow it in its tracks? It might be, and
some economic forces in healthcare will do their damnedest. But I don't
think it will ever be possible to return to the status quo ante, to an
environment that is entirely old-style fee-for-service. The economic
forces are too great.

Nor, to be clear, am I picturing a complete victory of the methods
that I call out in the book. I anticipate a far messier system than we
have today, with different business models serving different purposes,
but with everyone covered, and various institutions and businesses
trying different ways to make money be meeting their needs for less.
That is, a lot more like a normal industry. 

This will not be a triumph of the private sector. It will be a triumph
of the public need getting the private sector and the not-for-profit
sector better lined up to serve it the way it should be.
  

    
So I guess it's all a matter of degree. It's going to be messy,
regardless, with a hodge-podge of different systems. So the question
is, how many of the systems that we have will work well, and how many
will be old-school? 

Does it seem strongly likely to you that there will be enough of the
former that we'll get a significant virtuous cycle? I'm thinking about
your earlier comments about Kaiser -- they're doing the right things,
it's helping, but it can only go so far because the other pieces aren't
in place yet. Do you think things might go in such a way that we have
more Kaisers but still don't get that virtuous cycle started in a
strong way?
  

    

(Loving this discussion.)
  

    
Yes, great to read this.
  

    
One more question. This ties back to some questions Elisabeth asked
earlier on, and I must confess I didn't have time to read that exchange
with full attention, so my apologies if this ends up being repetitive.
One of the major points of your book is that in many situations,
cheaper = better. The way to prevent spending vast sums on repeated
emergency room visits from a homeless person is to provide him with
free, aggressive primary care, for example. But obviously that's not
true for everyone.Some people, when ignored, simply go away -- and
while there are costs to society of their untreated illnesses,those
costs don't show up in the healthcare system. I'm thinking here of
myself, with chronic fatigue syndrome. The execrable state of the
research on CFS means that there are no effective treatments, and as a
result, despite having been quite ill, I've used very little
healthcare. For other folks, like people with MS, it's not obvious
whether treating them effectively will be more or less expensive.

So, what is your sense of what's likely to happen to such people as
healthcare evolves? Will things get better, worse, stay the same?
  

    
Joe, wondering if you could talk a little about participatory
medicine, the idea of the empowered patient who's actively involved in
treatment, and how (or whether) this emerging movement will be a factor
in the future of healthcare?
  

    
> Does it seem strongly likely to you ... that we'll get a significant
virtuous cycle?

Interesting question. Above in this discussion, we talked about
economic game theory and the Nash equilibrium. Healthcare, as a complex
dynamic system, has been disturbed, knocked out of its previous
logjam, and is looking to re-form, not just reform. In this situation,
you look not just for actors who are doing the right thing, but for
actors with the greatest energy, incentive, and freedom of movement.
What we find is that certain groups pop up when we ask that question,
either because they have more full control of their funding, and are
already not in a completely fee-for-service situation (such as Kaiser,
the VA, and the Alaska Natives Health Service), or have great freedom
and incentive to try new things, such as employers.

As these new possibilities gain currency, you can see these groups
jump at them in increasingly vivid ways. As employers become more aware
that there are ways around the old system to better health for less
money, they will move, they will demand to work the new way, they will
push providers to work with them under different rules and contracts,
and if necessary they will bring new providers to come into their area
to work with them. We will see them being aggressive in ways we have
never seen before.

It used to be that I saw each such experiment in isolation. Now I am
seeing them pop up all over the place, more every day. That's the key
difference between a few years ago and now. So, yes, I do believe we
are headed toward a virtuous spiral.
  

    
> What happens to people for whom there are no effective treatments,
or for whom it is not clear that effective treatment is cheaper.

That's one reason why it is important to cover everyone. There is what
I believe is a strong logical argument in the book for why we should
consider healthcare a "right." Part of that argument is that it costs
money to deliver rights, so nothing can be considered a "right" that
costs infinite money. If it just gets better the more you have of it,
that can't be a right. There is some optimum amount to spend on, say,
justice. Spend 10 times that amount on, say, courts and police, and you
end up with less justice, not more. In aggregate, the amount needed to
secure optimum healthcare is not infinite. In fact, we apparently have
overshot. Because in aggregate, better healthcare costs less than what
we are spending now.

Individual cases may violate that pattern. But part of recognizing
that healthcare is a right is recognizing that there is no bright line
we could draw between those who deserve it and those who do not. We
need to take care of everyone as best we can, in order to know that the
system will there for us personally should we need it.

It's important to not that systems that adjust to this new way of
thinking (doing healthcare better, earlier, saves money, and therefore
can be a way to make money) have trouble doing it for some patients and
not others. To shift some huge, complex health system to the new way
of thinking, you have to make big system changes. This means that you
treat everybody systemically, the same way. As long as you were picking
and choosing treatments in a fee-for-service system, you can trat
patients differently. But if you are establishing patient registries
and going after patients with early, smart, preventive care, you do
that for everyone, and do whatever you can to be more effective with
them.

So actually, I think this is good news for the outliers.
  

    
> participatory medicine... the empowered patient who's actively
involved in treatment

This has to be a major part of the Next Healthcare, because the real
gold mine here is untreated chronic disease — and that patient has to
be involved, they can't be passive. The core of the whole shift is a
strong, active partnership between the primary provider in a medical
home, and the empowered, active patient.
  

    
I've just read this discussion in one big gulp, and feel much
enlightened. Thanks, everybody. And like Joe, I'm giddy with delight
about the SCOTUS upholding ACA, for the same reasons he is--here come
all sorts of interesting experiments that will lead to better health
for us all.
  

    
So, now that ACA has passed, I either have to buy health insurance
(which I can't afford) or pay a huge tax (which I can't afford)?

I can't afford the medical care I do use, and I don't go to the doctor
unless I have a broken bone or bleeding that won't stop.

So, the way I see this - I'm being forced to pay for something I avoid
using anyway?

Last time I had insurance, had full coverage with a $20 co-pay.  Went
in for a physical, paid my $20, and left.  Got results, overweight, but
otherwise okay.

6 months later they tried to get another $150 out of me.  4 months of
"You need to get that from the insurance company, not me" and they
finally left me alone.

So, the way I see it, the millions of us who are just scraping by, now
have to either get health insurance or pay a tax...so we are screwed
either way.
  

    

You should read the provisions of the law. There's a means test for the
must buy provision along with serious financial support if you can't
afford the coverage.
  

    
and no means by which to collect the tax.
  

    

Now that the mandate has been confirmed, is there a way--among the 
idiotic and contentious--to mandate ways to collect the tax? I do not want 
to see scofflaws revered for not paying up. Can the IRS fix rules to do so?
  

    

 Now that the mandate has been confirmed, is there a way to mandate 
 collection of the tax? I do not want to see scofflaws chortling for not 
 paying up. Can the IRS fix rules to do so? Or, is that the job of 
 Congress?
  

    
I feel so lucky having this informed conversation to read today!

(tony, the "huge tax" is only $97...  real money, to be sure, but for
someone who pays more than three times that every month for my own (no
employee coverage) health insurance, it seems not so huge. (I don't
want to minimize that's a lot of money for anyone who is barely getting
by, I hope is clear.) as I heard said on the news before this decision
came down, the penalty so much less than the cost of buying insurance
that some number of people might choose to pay the penalty rather than
sign in. but if with subsidies from the federal government, you could
have real, and affordable, insurance that will cover the costs if you
cab is hit by a truck, wouldn't you prefer that? that's the goal here,
even if this actual current circumstance will take some time to get us
there...)
  

    

The tail end of David Brooks' column in the NYTimes today mentions some of 
the changes Joe advocates that are already in process. "Hospitals are 
changing rapidly. Federal policy will change rapidly, too. The policy 
changes over the next decade will overshadow Obamacare."
  

    
Yes, Tony, this is one of the most-common misconceptions about the
ACA. I hear all the time that "I can't afford it." People seem commonly
unaware that there are financial supports built into the law for low
and middle-income people, I believe on a graduated basis for households
with incomes up to $88,000. I think the law actually will be a real
help for you to get coverage — which you really should have, if nothing
else as a hedge against the possibility that one serious illness puts
in bankruptcy and permanent poverty. 
  

    
Yes, the penalties are small compared to the cost of insurance, which
may drive down the number of people who take advantage of the new
possibilities.

As to whether it is enforceable? One hears on the Internet that there
is a section of the law that invalidates the penalties. What that
section (mischievously inserted by those opposed to the mandate) is the
Secretary of HHS may not spend any funds on an enforcement mechanism.
But if the penalty is actually a tax, that means its collection is a
matter for the IRS, not the HHS, and would presumably be done through
your normal income taxes. There would be a line where you put the
company and policy number of your healthcare policy. If not, add X
amount on this next line. And there may be a way in which health plans
report the identities of all covered people to the IRS, just as
companies now issue W2s and 1099s for everyone. I don't see what is
unenforceable about it.
  

    

I just read Brooks' column. Joe, I think he needs a copy of your
book!

http://www.nytimes.com/2012/06/29/opinion/modesty-and-audacity.html

He's both right and I think wrong. The most salient pieces of his column
for me are:

  Crucially, we haven’t addressed the structural perversities that are
  driving the health care system to bankruptcy. Obamacare or no Obamacare,
  American health care is still distorted by the fee-for-service system
  that rewards quantity over quality and creates a gigantic incentive
  for inefficiency and waste. Obamacare or no Obamacare, the system is
  still distorted by the tax exclusion for employer-provided plans that
  prevents transparency, hides the relationship between cost and value
  and encourages overspending.
  ...
  But the truth is neither I nor anybody else really knows what
  works. We’re going to have to go through a process of discovery. We’re
  going to have to ride the period of rapid innovation that is now
  under way.

  Hospitals are changing rapidly. Federal policy will change rapidly,
  too. The policy changes over the next decade will overshadow Obamacare.