Wednesday, February 21, 2018

Tales from the DOG Patch: Numero Deux

A tip of the hat to Dr. Roy Poses, who did a nice job summarizing the first blast from the DOG Patch. (For those who missed it, it's a distillate of all the dander we've mustered in recent health policy debates as they veer more and more toward the utterly surreal.) Dander omnium gatherum, hurled willy-nilly at the gentle readers of HCRenewal. Ready or not, another dispatch from the DOG Patch.

Dr. Shulkin at the VA. We commented on the recent posting, also from Dr. Poses, dealing with VA Secretary David Shulkin's "apparently scandalous travel" to Europe way back in July. We've known Shulkin for a long time. He cares about good government but you'd never know that from his own OIG's hatchet job charging "serious derelictions." A lot of this is in the above linked post, as well as related articles in most newspapers. Today however we learn from John Kelly that the secretary's "job is safe." Unless, that is, "other stuff comes out." One of the better Trump appointees, Shulkin now gets to walk the tightrope while political hacks lower down in the VA try to undermine him. His crime: Seemingly dragging his heels on doing himself out of a job. Lots of folks (viz. White House insider and Wisconsin brewmaster Jake Leinenkugel) looking to privatize VA health care. Shulkin understands the great value--despite the many depredations and flaws still enormously popular with its patients--of the institution that began with the Philadelphia Naval Home around the War of 1812. These guys circling the wagons inside the White House represent the swampiest of Washington swamps. Let Shulkin be Shulkin.

Mr. Azar goes to Washington. And tips his hand. In our first DOGpatch dispatch we wondered aloud which way the new HHS Secretary would head after being sworn in. First indications are now in. He wants, in the interest of "affordable" premiums, to issue junk insurance. It sure fits into the grand scheme of things, White House-style. If you can't do in Obamacare in one swell foop, grind it down underfoot one feature at a time. So ideological. So unfair. Individual mandate already on its way out. Now comes waivers allowing cheap policies, policies that're not ACA-compliant, to go to cherry-pickers without regard to pre-existing conditions. Extending short term cruddy policies from three months to a year might benefit a few healthy young workers--maybe the ones states like Wisconsin and Indiana (wrongly) believe, via their ideological GOP governors, they'll lure back to their states. But the cost could easily become lots of the sicker folks whose premiums will become unaffordable. We see the hand of Mike Pence's Indiana favorite, Seema Verma, in all of this. Hey, if they're sick throw 'em under the bus. Your corporate donors want their cheap labor pool back. And, then, what's Azar's long game? To ingratiate himself solidly with executive branch insiders in order to do something that Trump says he wants--most temptingly, new ways to jawbone drug prices down--for his vaunted base? That's something Azar could probably pull off. Will he even try?

Putting the Attack on Expertise in Perspective. A book from about a year ago, Tom Nichols's The Death of Expertise, is summarized nicely in the latest number of Harvard's alumni magazine. I mean, of course that's where you'd find it. Most of our "thought leaders," elite consultants, and favored members of the punditocracy come from elite west- and east-coast institutions. Of course the loudest plaints will come from their ranks. But Nichols is a little different. He has government experience and teaches in a variety of institutions while trying to reach the public. The book is a little repetitive but its gist can be found here, apparently unencumbered by paywall. We'll have to wade into this short book and see who and what and where Nichols points the finger. But we know all the isms already. Narcissism. Post-modernism. Managerialism. Consumerism. All rampant in clinical medicine, academic medicine and health policy. Nichols is rightly worried about the casualness and fecklessness with which people now in power approach everything from nuclear war risk to cyber-threats to the role of professionals in managing health. He's pessimistic.

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