Health care wasn't initially at the center of the shocking 2016 election. But it clearly played an important role — especially for Democrats, who heard bombs bursting in air with the news of skyrocketing Obamacare insurance premiums breaking late in the campaign. Those cost increases contributed to Democrats' loss of the presidency and of any chance to regain control of either chamber of Congress.
In retrospect, it should not have come as a surprise.
Democrats twice suffered midterm election losses after the unilateral passage of President Obama's signature legislation, the Affordable Care Act. At the 2010 signing ceremony, Vice President Joe Biden crudely called the law "a big f***ing deal." It certainly was one, but not quite in the way he meant. Passage without any Republican support doomed the ACA from the outset, and two Supreme Court decisions upholding it barely kept it on life support.
We are now surprised to be asking: Can Donald Trump (and the Republican majorities in Congress and the Minnesota Legislature) fix American health care?
The last eight years demonstrated the perils of overpromising and underdelivering, and Donald Trump's knowledge of health care reform probably wouldn't fill a single tweet. But despite claims to the contrary, Republicans on the state and national levels have many good ideas. New policies will be tried. This is made clear by Trump's picks last week for two key health care posts.
For Secretary of Health and Human Services, Rep. Tom Price of Georgia is a physician who has served five terms in Congress, most recently as chair of the House Budget Committee. His conservative credentials frighten the left, but he deeply understands the financing and delivery of health care.
Seema Verma is an Indian-American woman and expert in public health educated at Johns Hopkins who led Indiana's distinctive expansion of Medicaid under the ACA. She is Trump's great pick to lead the Centers for Medicare and Medicaid Services.
The GOP's "repeal and replace" refrain was part of the political posturing rife throughout the health care debate. Though a symbolic "repeal" is likely, Trump and the GOP will actually begin work to repair Obamacare. The fear that millions will lose their coverage is unfounded. The ACA's goal to expand coverage was noble, and many of its payment and delivery system reforms have merit. They will likely remain.
President Obama's health care achievement came in his winning the argument for offering coverage to all Americans. But good intentions couldn't make up for flawed policy. Ironically, the failure of his legislation may have paved the way for more enduring reform under a new administration.
This is because on health care (as on immigration), Trump now has a "Nixon to China" opportunity. President Richard Nixon's ardent anti-communist bona fides gave him cover back in the 1970s to open relations with America's Cold War foe. Trump's bombastic campaign opposition to the health care status quo could similarly allow him to accomplish significant beneficial changes.
Reform should focus on cost, choice and competition. Legislation from the new administration should protect existing coverage and extend coverage to more people using means-tested tax credits. States should be granted wide latitude to innovate in delivering coverage to the poor with Medicaid block grants. Much private innovation will follow.
My interest in health care reform is both personal and professional. My wife and I are among the individual insurance purchasers recently whacked with 50 percent premium increases — paying much more for less coverage. I am also a late-career physician who sees the need for dramatic change.
However, my personal experiences with medical education and working in the National Health Service Corps convince me that major change in one-sixth of the U.S. economy must protect the vulnerable and underserved — as well as provide for educating the next generation of providers. Reform will not be easy, and it must be done carefully.
Obviously, government will play an essential role. Since more than half of all health care is paid for with public funds, some argue for a single, government-run payment and care delivery system. However, if Obamacare went down in flames like the Hindenburg, why would we respond by launching a Titanic health system? Instead, choice and competition should get a chance to decrease costs and improve care.
The solution requires 1) redefinition of the product, followed by 2) redesign of the system. The current health care product is a disjointed hodgepodge of expensive services. The ideal product is delivery of the highest-quality health care to satisfied customers for a reasonable price.
But what is a reasonable price?
In every other area of commerce, prices are prominently displayed. We see prices on everything from pizza to pianos — on menus, on gas pumps and online. Not so in health care, where the exasperating answer to the price question is usually: "We don't know. You'll have to wait until the bill comes."
Not only are health care prices a mystery, but the product is paid for in a maddening fee-for-service system administered by "payers."
Payers started out as true insurers. But too many have become sclerotic, politically connected bureaucratic monopolies that process payments and make impenetrable rules — designed to minimize the amount they pay. Patients and providers both hate the payers, while politicians make deals with them, then use them as convenient punching bags during elections.
The perverse fee-for-service payment system is at the core of our problem. In my 36 years of medical practice, the primary health care finance lesson I have learned is that you get what you pay for. Our fragmented fee-for-service system gets us too little of what works and too much of what doesn't.
If you paid an electrician rewiring your house according to the number of outlets he installed, you would get many more outlets than you need. Unnecessary medical care has a similar cause. The better alternative is to pay for well-defined "packages" of care. A package might be purchased as a year of comprehensive primary care, or all of the care for a specific health care episode, such as a pregnancy, a joint replacement or cancer care.
I am personally optimistic about health care reform. In 2012, midwife colleagues and I launched a maternity and newborn care practice in independent birth centers integrated with physicians and hospitals. We did so because we believe that reform should start where we all did — with pregnancy and birth.
More than 1,000 low-risk mother-and-baby pairs have received care in a model that is safe, satisfying and cost-saving. Though we were initially seen as a competitive threat, we are now working with our hospital and physician partners to provide comprehensive care for a single price. Bundling of care requires that providers take on some financial risk, because some patients will require more care than average, others less.
That providers are willing to assume risk should be a wake-up call to the payers. Those unprepared to change will likely become obsolete. As providers and payers combine, some fear that only a few large integrated organizations will survive to provide care to millions of captive patients. I doubt that.
Americans want a wide variety of choices, large and small. Because comprehensive and coordinated care is cost-effective in the long run, successful providers will also bridge the divide between health and human services and between physical and mental health care.
Where will we see innovation beyond payment system redesign? One example is how the University of Utah Health Care system solved the exorbitant cost of the EpiPen, a device for delivering a lifesaving antidote to victims of allergic shock. The university cut the price from $600 to $10 by changing to syringe injection kits of generic epinephrine. There are many such savings opportunities in the offing. But challenges remain.
Though the government spent a total of $35 billion on financial incentives to push forward the transition to electronic health records, we still have too many distracted providers glued to computer screens filling out regulation reporting checkboxes while ignoring the patients sitting right in front of them.
Besides better electronic records, additional technological innovation is needed. Personalized digital and telemedicine health care holds great promise. Even though opposition from entrenched providers and antiquated regulations are barriers, Peter Thiel, Trump's courageous Silicon Valley supporter, will be a valuable adviser in these areas to the new administration.
Prospects for significant reform are good. Progress on payment and delivery system reform was made in the 2015 bipartisan Medicare bill (known as MACRA). But, not surprisingly, this 2,000-page law, like Obamacare, came loaded with acronyms and regulations — a feast for bureaucrats, consultants and lawyers. It is time to dump the rigid rules and unleash innovation that rewards better care, drives collaboration and decreases cost. The GOP will take the lead in January.
What can we expect on the state level? Minnesota can and should be a national leader in improving the financing and delivery of care. With a new GOP Senate and a sustained GOP House majority, we should insist that legislative leaders and DFL Gov. Mark Dayton bury the hatchet as they collaborate to improve care. There is a precedent.
In 2008, initial health reform steps came from collaboration between a DFL Legislature and GOP Gov. Tim Pawlenty. If our divided state government works in 2017, Minnesota's health care market will be open for competition on all levels — with much more choice in provider and payer options.
Big decisions still loom on what will become of the more than $100 million MNsure website and whether the decades-old policy of opaque private-insurer management of the state's public health care programs will be reassessed. But as long as competition and patient choice is the focus, we'll get a higher-value, patient-centered health care system.
Finally, some free postelection advice from a physician to partisans (and we all are partisans):
Don't forget that invective is infective, so wash your hands of hyperpartisanship.
Take a long walk (or two) with someone who didn't vote for the same candidate(s) as you. I guarantee it will be good for both your hearts — and for the larger body politic.
Steve Calvin is a Minneapolis physician and medical director of the Minnesota Birth Center.
