Friday, September 22, 2017

More Dumb Things Leaders Say About Health Policy

These days, legislative efforts to change US health care, especially to "reform and replace" the Affordable Care Act [ACA or "Obamacare"] seem to inspire displays of jaw dropping ignorance by political and sometimes business leaders on behalf of "reforming" health care.  We last posted examples on July 7, 2017.  Now there is a new game afoot to reform and replace, and it is generating new - not to put too fine a point on it - foolishness.

So herein is a roundup of a two more examples from July after our last post, plus two more revently "ripped from the headlines," actually ripped from relatively obscure media articles, because the anechoic effect persists, and the media still does not cover these sort of things much.  In chronological order:

Vice President Pence Makes "False" Statement About Ohio Medicaid Problems, Per Ohio's (Republican) Governor

Reported by the Hill on July 15, 2017...

Ohio Gov. John Kasich's (R) office has flatly rejected Vice President Pence's claim that nearly 60,000 disabled Ohioans are on waiting lists for Medicaid’s home and community-based services.

Kasich spokesman Jon Keeling told The Washington Post that such an assertion is 'not accurate' and that suggesting Medicaid expansion hurt the developmentally disabled system 'is false, as it is just the opposite of what actually happened.'

At that time, while the previous push to "repeal and replace" was still going on, and Vice President Pence was apparently trying to make a point about how bad "Obamacare" is:

'I know Gov. Kasich isn’t with us, but I suspect that he’s very troubled to know that in Ohio alone, nearly 60,000 disabled citizens are stuck on waiting lists, leaving them without the care they need for months or even years,' Pence said in a speech Friday at the National Governors Association summer meeting in Providence, R.I.


According to the Post, waiting lists for such Medicaid services are common and are typically longer in states that did not take ObamaCare's Medicaid expansion than in those that did.

Ohio was among a number of Republican-controlled states that took the ACA's Medicaid expansion, which dramatically expanded the number of people who qualify for the program.

President Trump Makes Multiple Misleading Claims About His Efforts to Reform the Veterans Administration

We know that interesting things often happened at Mr Trump's campaign events, and at his later "campaign style" events as President.  Stat reported on July 28, 2017:

President Trump paints a rosy picture of an improved Department of Veterans Affairs under his watch, where accessing electronic medical records is 'so easy and so good' and health care is freely available without any delays.

The problem: It’s not true.

At a campaign-style event in Ohio this week, Trump’s claims of progress were so overstated that even his own VA secretary, David Shulkin — who stood right next to him — would have to disagree.

The article went on to list a number of specific claims which were false or misleading, including:

- Claims of huge improvements in VA information technology.  Unfortunately, a multiyear effort to improve health care IT "has barely even begun."

- Claims that the VA had doubled the number of veterans given approval to see  a "doctor of their choice" outside of the system.  In fact, the troubled VA Choice program increased the number by only "26 percent", and the program was facing new budget problems at the time Mr Trump made the claim.

- Claims that the administration had published wait times for all VA sites.  This actually started more than a year previously, under the Obama administration.

- Claims that the VA now offers same-day mental health services.  "This may be the case, but it happened before Trump took office."

In the "good old days," vice presidents and presidents who spoke publicly about issues like health care, about which one could not expect them to be expert, might have sought detailed briefings and/ or deferred some issues to their own experts.

White House Economic Advisor Misstates Basic Concept of Health Insurance

Reported by RawStory on September 19, 2017:

Donald Trump’s top economic advisor Stephen Moore on Tuesday demonstrated an apparent lack-of-knowledge of just how insurance works, telling CNBC’s John Harwood 'people want insurance for their own families, not other peoples.' Moore was explaining why it’s unfair to have an insurance system where healthy people subsidize sick people.

Trump adviser Moore on unfairness of the healthy subsidizing the sick: 'people want insurance for their own families, not other peoples' — John Harwood (@JohnJHarwood) September 19, 2017
Moore's implication seemed to be that people should not pay for insurance programs which might pay for health care for other people.  Yet the simple minded notion of insurance is that it is a tool to pool the resources of the many to pay for costs that only some will incur during a given time period.

The article went on to describe the withering responses on Twitter.  But for those who do not follow Twitter, I could only find a clear explanation of the problem with Mr Moore's statement in a column by Jodine Mayberry in the Delaware County (PA) Daily Times:

U.S. Sen. Ted Cruz, R-Texas, believes that people should be able to buy only the insurance that suits their needs. But there is no way anyone can ever know exactly what their needs will be, tomorrow, six months from now or six years from now.

You may not have diabetes or heart disease today, but a year from now, who knows?

A Trump economic adviser, Stephen Moore, said earlier this week, 'People want insurance for their own families, not other people’s families.'

He knows he is distorting how insurance works.

Our insurance premiums go to cover other people’s disasters as well as insure against our own.

That’s known as spreading the risk – the more people you can have in a pool of insureds, the more likely you’ll have affordable coverage for your own family.

I had a bad house fire in 1987 that cost about $50,000 to repair.

I certainly had not paid anywhere near $50,000 in homeowners’ insurance premiums up to that point (or ever).

Other people paid for my fire and I have helped pay for other people’s over the years.

We must have home and auto insurance, unless we don’t live in a house or drive.

We are all born and we all get sick and we all die, without exception, which is all the more reason for all of us to have affordable health insurance.
 So here we had the example of a top executive branch adviser who apparently provides input about health insurance, yet who does not seem to understand what health insurance is.

Aetna CEO Wrongly States Canada Has a De Facto National Health Service in Which the Government Owns and Runs Hospitals and Physicians' Practices

This example is of a top corporate health care executive, not a politician or government adviser.  As reported by Lee Fang writing in the Intercept on September 20, 2017:

[Aetna CEO Mark Bertolini] asked the room of investors and analysts to 'name a country that has single payer.'

When several participants named Canada, Bertolini disputed the answer and claimed that Canada has a 'government-run health care system. They’re not single payer, they’re single everything.'


The suggestion, however, that Canada has a completely government-run health care system under which all medical professionals 'work for the government' is false. In Canada, medical claims for virtually all non-dental health care are paid by the government, but doctors and hospitals work in the private sector.

'Doctors in Canada are not employed by the government. They are self-employed, they are independent business people,' said Karen Palmer, an adjunct professor at Simon Fraser University. 'The system is publicly funded but privately delivered.'

Bertolini appeared to be confusing single payer with a single-provider system, such as the National Health Service in the United Kingdom, under which doctors and providers work directly for a government entity.

Bertolini is the CEO of a huge for-profit health care insurance company, so one would think we might know the difference between national health insurance and a national health system.  The example of Canada is a one often used by those who promote "single-payer" health insurance in the US, an idea which Mr Bertolini opposes.  So one would think we would be familiar with the Canadian example. 


It would be too much to expect that health care policy debates would be rigorously evidence-based.  However, lately they seem to include loudly expressed views devoid of facts or rationality.  We have proposed that this is the result of "managerialism."  We have discussed this doctrine, promoted in business schools that people trained in management should lead every type of human organization and endeavor.  Management by people from the disciplines most relevant to the mission and nature of particular organizations should be eschewed.  So managers, not physicians or other health care professionals, should lead health care organizations.  Following that theme, managers, or those like them, rather than health care professionals and health policy experts should lead health policy. 

However, managers who run health care organizations, or make policy, have an unfortunate tendency to be ill-informed (as well as unsympathetic if not hostile to health care professionals' value and the health care mission, and subject to perverse incentives that often put short-term revenue ahead of the health of patients and the population.)  And in the latest health care reform debate, some of the politicians and political appointees who are the de facto managers of health policy have disdained the advice of health care professionals and health policy experts.  (And above we presented an example of a true managerialist corporate health care executive who also - to put it bluntly - did not seem to know what he was talking about in a discussion of various country's health insurance systems.)

Ignorance and falsehood in the health care debate could also be part of a broader trend toward anti-intelletualism or what has recently been termed "The Death of Expertise" (see this New York Times review of a book with that title.)  Managerialism could be part of that trend.  And the extreme relativism of post-modernism, which we also discussed in the context of the current debate on health care reform, could be another.  

Facts, however, are stubborn things.  Evidence is evidence, no matter what politicians or corporate executives it might offend.  Basing legislation on the sorts of alternative thinking displayed in the cases above could lead to real life, or life and death consequences for the sick, injured and vulnerable.  True health care reform requires clear thinking and the input of people who actually know something about health care.

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