Hacking ‘Affordable Care’

On this Kickstarter-launch week we’re diagnosing America’s healthcare woes with the meta-journalist and heart patient, Steve Brill.

In a new book he calls the Affordable Care Act “America’s Bitter Pill“, a rationalizing redo of health insurance that ignored cost control and served everybody but the taxpayer. But it looks as if we’ll be living with so-called ‘Obamacare’ — at sky-high prices, no public option, and another Supreme Court case notwithstanding, in all its complexity and confusion. We know it didn’t solve every problem with American care, so the question is: what’s next?

We know Vermont’s experiment with a Canadian-class single-payer system washed out this winter, after the tax burden started to soar. It raised the question of whether and how that particular progressive dream can be achieved in a country where health care is big business. So we’re on the lookout for the Next Big Idea in healthcare: the one that will get costs down to earth, or lead us away from last-minute ‘sick care’ toward a healthier hands-on model.

How would you hack your healthcare back into shape? Can the patient be saved?

Guest List
Rushika Fernandopulle
primary-care physician and co-founder and CEO of Iora Health.
John Goodson
primary-care physician at MGH and advocate.
Howard Dean
former governor of Vermont, DNC chairman, and medical doctor.
Reading List
America's Bitter Pill: Money, Politics, Back-Room Deals, and the Fight to Fix Our Broken Healthcare System
Steven Brill
Brill's book is worth a look as a roller-coaster trip back through the passage of the ACA — through gossip, numbers and personal stories.
‘America’s Bitter Pill,’ by Steven Brill (review)
Zephyr Teachout, New York Times Book Review
Our friend Zephyr Teachout liked the Brill book for the most part, and its panoramic vision of a hobbling, compromised policy machine in Washington:
...Two of the book’s more powerful insights have to do with matters of industrial or bureaucratic structure. The first involves the health delivery system. Many people tend to look with alarm at consolidation in the insurance industry, and they focus on insurance company lobbying power as the essential cause of rising ­prices. One of Brill’s critical insights is how consolidation in the hospital industry has actually decreased insurer power relative to provider power: Much of the rising cost of health care comes from overcharging by hospitals, not insurers... The second insight has to do with the structure of management within the government. Brill argues that the initial website rollout failed in significant part because the “Office” in charge was demoted to a “Center,” in order to protect it from Republican funding cuts. In a wonderful passage, he recalls taking the train to Washington and reviewing his notes, noticing that when he asked different people who was in charge of establishing the federal exchange, he got seven different answers.
"Interview: Dr. Rushika Fernandopulle"
Heidi Legg, TheEditorial.com
An energizing interview with our enterprising guest about the draining work of primary care, and his efforts to make it better:
Why should the world care about what you are doing? Everyone is going to get sick and I think being able to be taken care of in a humane and effective way is really important. Our current system does it really poorly. I’ll give you an example: diabetes care. There is a new stat that people use for diabetes, it’s called perfect care. If you are diabetic and your blood-sugar is in control, your cholesterol is in control, your blood pressure is in control, you are taking an Aspirin and you don’t smoke we call that perfect care. If we can get people to do those five things, we dramatically reduce complications like blindness and kidney failure. Do you know what percentage of people in this country, even in the best medical centers, get this perfect care? It’s often under 10%. It is embarassing and we need to change that. I read that you allow patients to come in as often as they’d like. Absolutely. How will you manage a repetitive user who shows up all the time? We want people to come in to our practice. Again we are primary care. Our goal is that people come to us and not to the ER. Hospitalization costs $17,000, while a visit to us costs $60 to $80. You can do the math. Part of our model is getting it away from the doctor having to do everything. Today I think we focus too much on the doctor. If we want to have people improve their health care, we need to wrap a team around them. And the key to that team is what we call a Health Coach. A Health Coach? We are looking for people who really care to help people, people who are engaging and ideally who are from the community. Ideally they’ve had some experience with the health care system, either from a personal illness or a family illness, so they get how frustrating it is and they understand personally how they help someone go through it, and that’s it, everything else, we can train.
"In conservative media, Obamacare is a disaster. In the real world, it’s working."
Ezra Klein, Vox
Ezra Klein tries a reality check on 'Obamacare' — the same kind of thing we hear from doctors around town: it's not perfect, but it's working and it's a fine first step.
Obamacare isn't by any means a perfect law and not everything in it is going right. The law powers a different insurance market in every state (plus the District of Columbia), so it is perfectly possible for Obamacare to be a success in California even as there are troubles in Minnesota. And there continue to be operational issues: there have been troubling revelationsabout web site security, and problems verifying the incomes of some enrollees. On the whole, though, costs are lower than expected, enrollment is higher than expected, the number of insurers participating in the exchanges is increasing, and more states are joining the Medicaid expansion. Millions of people have insurance who didn't have it before. The law is working. But a lot of the people who are convinced Obamacare is a disaster will never know that, because the voices they trust will never tell them.
"The Promise of Primary Care" (video, part 1)
John Goodson, YouTube
This is the first part of a talk given by our wonderful guest, Dr. John Goodson, about the problems confronting his beloved primary care — and where it might go from here.
"The Hot Spotters"
Atul Gawande, The New Yorker (paywall)
The article that introduced the world to Dr. Rushika Fernandopulle by one of our favorite expositors of American medicine.

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  • olderworker

    I agree with all that John Goodson has said so far on this show, BUT I think the idea of coordinated care, with the Primary Care Physician doing most of the care, with specialists as advisors, was already tried, with the HMO’s of the 70’s, 80’s and 90’s. (Actually, I go to a Harvard-Vanguard Center in Boston, which is run that way as well. Every appointment I have is documented on-line, so can be reviewed by my PCP). And I do think it saves money.
    I think it’s terrible that PCP’s, or G.P.’s, or internists, are so poorly paid. They should be compensated for all the coordination of their patients’ care, as well as for the time spent in the examining room.

  • rick

    Arguing that we have a system problem ignores the psychopathic spirit of aristocratic greed that has shaped the inhuman machine we call “health care” and every other primary institution in our modern economic rat race.

  • Potter

    Thanks for pushing back, Chris, on the excuses ( as I heard it) about why we cannot have single payer universal healthcare. There are so many issues here, too many for one program. I’m left with feeling that still today, with millions more covered ( and the energy spent fighting those who wish to do away with the progress) we still have Rolls Royce medicine for those who can afford it and varied quality for those who cannot, never mind those who are left with no care. One of your street commenters held the view that everyone should have some form of health care, but not like what he has because he worked for it.

    Your guests took opposite points of view on glass half full, half empty. Well I think Edward Kennedy, may he rest in peace, would be disappointed at the slow as molasses movement towards giving everyone access to the best medical care we can give ( that we know works). I include especially doing something about the high cost of medicines such that people in need must sacrifice for R & D ( and advertising!).

    I totally agree about the need to elevate the primary care physician. We have been going to a MGH internal medicine group for many years and have been so fortunate to benefit from the continuity/built relationship even after our Dr. of 30 years retired. He (also from a family of doctors) knew that being a doctor is as much an art as a science. But you do not run into doctors like that so easily. Doctors are actually also people with flaws. As well you have to participate in your own care and wellness. The doctors in this practice at MGH are on salary because it is a teaching hospital. I don’t feel pushed through so that the Dr. can get onto the next patient and is half listening to me. How could we as a society, if we care and start to focus on the issue, not leaving it to the money-making interests, have ever expected quality care from practices that had to push so many patients through in a day? You can’t feel you are being taken care of.

    It does seem that there is a place for some regulation, incentives, and rules. The doctors on the show seemed to be throwing their hands up at the politics. Who can blame them? So they work in areas where they can make a difference.

  • Potter

    My question: Who are the uninsured and why? So here is an article on that.