Thursday, August 23, 2018

Dander Still Up, And Also Down, All Over the Place. What Gives?

A. The Present Moment.

I've started this piece a whole bunch of times. So in fairness to you, reader, you have a few paths through it. If you don't feel like starting by sharing some navel-staring about today's bizarre predicament, please skip to 'D.' Or 'B,' or 'C.' Wouldn't blame you in the least.

I've still got my dander up about what's happening in the many troubled reaches of health care in the United States. OK, truth to tell, also about what's up world-wide. Scary stuff. Readers have no doubt waited patiently for me to recover from confusion about this sudden mess, much of said predicament stemming from various delayed reactions to the 2008 disasters. (For the wildly popular, broader and verbally less restrained version of this consternation, from a compelling voice, see this newsletter.)

Or, at least, I've waited to get over this confusion. Now I'm over it: see 'C,' below.

Overall, anyone paying attention to the press—or even for that one lone DC Legislative Assistant just reading this blog for all her health policy info—you know things just ain't right. Not in academia, not in government, not in the private sector despite a record-shattering bull market run. (Leave aside for just a moment all those other issues in US foreign and economic policy, equally in the soup.) We thought matters couldn't get worse before the arrival of the latest residents of board rooms and corner (or oval) offices in each of those sectors. But, oh, wait: then, after January 2017, they did.

But what gives beneath the surface? The news waves have become a deluge. But, to get to the "so what?", where are the rip-currents beneath today's tsunami of chaotic news? Why are things seemingly better in some areas than others? (For some specific examples see my Grade Point Average—GPA—scores below, introduced in this edition of the CDR (Cetona Dander Report),  I've been off the air while scrambling for some way of understanding the why behind the what. Now I think I've gotten what're at least some part-answers to my writer's block. And mirabile dictu, my dander's gone back down a little, especially over there in the Department of Health and Human Services.

For one thing, as Margot Sanger-Katz recently pointed out in the Times, and we're seeing this in many places, the troubled crazy-quilt of American health care, especially among the federal branches, and the antics of the DIC (disloyalist-in-chief, or my preference, doofus-in-chief), all have paradoxically made the organization of health care somewhat less anechoic. ("You see how I did that double negative in there?") This anechoic effect I began talking about over a decade ago, during the perhaps slightly calmer Shrub and Obama years—corrupt and autocratic behavior operating under everyone's radar, and I don't miss those days—this effect has repeatedly been decried by those blogging here, especially your intrepid editor.

But today, like immigration, health care is back in the political ads and it's no longer quite so anechoic, now the DIC has lanced the boil with his shrill. Hell, DIC's our poster child for health care reverb. He even claims as he campaigned on the notion of lower drug prices and better care. Just not for those people.

No matter. You can't unring this bell. Everyone left with anything resembling an open mind—come November we'll get more on the 'N' of said group—they all know what far too many in his party are trying to do. Those with brains already fully devoured (burp) by QAnon are, of course, excepted.

Biggest place the GOP and DIC overlap in goals: dance with all the lobbyists and Fat Cats who want to kill the baby in the bathtub. Kill the VA. Kill the ACA. Kill kill kill.

If this all starts to sound a little schizzy, that's precisely the point. This is a big clue to what's become the inner dynamic of federal health policy (and economic and foreign policy) in the second half of 2018. There's campaigning to the base, and there's governing. I mean, I know, I must be the last person in Montana to recognize this dynamic, especially after everybody saw the latest blind-siding on the Russian affair. No offense to Montana. I'm not from there. I know great folks there.

The executive branch of our government has cleaved in two. The White House today—quite unlike any of its predecessor administrations arguably including that of Bush II—is a perpetual political campaign. I know, others have compared it more to television reality show or one variant of the same thing: WWE. Anyway, it's a perpetual political campaign, and solely that. Its purpose is not to govern but to retain power in order to reward friends.

This goes for everything it touches in health care. Campaigns depend interminably on donors and, fitfully, even voters. The problem is, there are cabinet departments, for our purposes notably the VA and HHS, where something else, something else besides perpetually rabble- and fund-raising, has to happen. Something we used to call "government." More and more a rare bird. In the White House, the bird is as extinct as the dodo. (Charlottesville was clear-cut proof of this point, when the DIC ducked his constitutional responsibility to console and unify, in order to play exclusively to his base.)

"Government" clearly can't be effective by defaulting to sheer adversarialism and destruction. But interestingly, it's still there outside the White House. If not thriving, as least surviving and fitfully accomplishing some important tasks. In matters of health, like the tiny furry mammals scurrying among the dinosaurs after the asteroid, government is actually beginning to make some hopeful moves. It's time we called those out as well, and scored the agencies on how they're doing as we get close to mid-term elections. It's a balancing act between the campaigning DIC and his few fitfully effective folks. (If they tick him off and get fired, they'll be retroactively labelled "deep state.")

It looks to me like health care policy management, whether around how care gets paid for, or around reuniting kids suffering from child-abuse-as-foreign-policy, has become an absurdist pas de deux between these two factions. Never have they been more distinct. In this corner, the White House, with its hacks, its DIC, its billionaire donors just a phone call away, and its campaign-job explant moles planted in key departments. And in this other corner, until maybe they get fired, cabinet appointees and sub-appointees, including some pretty good old time GOP types, who want to get the job done. The first either lets these second types do their jobs, or somebody--often one of the hacks--gets to them first.

(In all of this, of course, Rule Number One is always, don't piss off the DIC. Get the job done without losing your own job.)

Among the hacks closest to the ear of the DIC, and man is that an image, chief are Larry Kudlow, Mick Mulvaney, both on money matters; and John Bolton on matters involving anyone who looks, y'know, a little foreign. (Norwegians, good. The rest: maybe, y'know, drug dealers and rapists.) In 'D' below we talk about some of the other

B. Getting a Bit Less Jumpy.

Here's how to get out of the distracting, enervating, confusing obsession so many of us complain about when considering health care and pretty much else coming out of today's Washington. (Not just the White House and the 15 executive departments. But especially.) Extricate yourself, that is, without sticking head in sand. Don't just take a break from all the crazy. Take a cue from the DIC Head himself. Note how fond he is calling everybody a dog. But in fact his prey, take for instance, are not dogs at all. It's the secret joy of more right wing GOP Trump-heads: we're all acting like cats.

Laser cats.

Just let him move that pointer around and we all go batshit batting at it. Dudes love it when we do that. We don't have to do that. Just be quiet and keep paying attention. We're on to them. Don't pounce until there's more there there than just a flickering red light. Recognize what he's doing across the board. Read Health Care Renewal. Remember, every time the red light blinks and you leap into the air, somewhere a puppy dies and a spook's security clearance goes kerplooey.

Here's an example. The daily din of Russiagate. Mueller et al. We don't jump every time there's a new lie or a new "flipper." But the DIC's organization's CFO just flipped. Now that's worth a jump. Right over the moon.

C. Sidebar: Montana and Oklahoma.

Why mention Montana? Well, actually turns out a big source of impact on our health comes right from our natural environment and the failure of Big DIC to insure its stewardship. He appointed an Associate DIC (ADIC) to the Interior department. Ryan Zinke, best known for a career as football player (Whitefish HS, University of Oregon) and Navy Seal. (Navy.) Zinke believes the California wildfires are best explained by "environmental terrorists" rather than climate change. Not cool.

The Secretary has now appointed a Whitefish team-mate essentially to vet any program that might affect our health. Steve Howke has an undergraduate business degree and a life in credit unions. So clearly he's a great pick to vet any proposed money involving more than budget-dust (i.e., > 50k) on programs. This is to make sure such expenditures "align with the administration’s priorities." Pretty much kills any chance Interior will pay attention to our health. Guy's the designated goalie to assuage the boss's desire to focus on really hopeful matters such as Clean Coal.

On a slightly brighter note, when it comes to the looming underwater loss of, oh, maybe the East Coast and all of Florida, the Big DIC seems to be appointing a real expert, Kelvin Droegemeier, as his White House Science Adviser. Job's been vacant for a long time. Maybe we'll keep Florida a little longer. Guy's impressive. See for example this actual piece of science for weather prediction. Let's fly to Oklahoma and talk to this guy.

Ah, the outsized influence of Whitefish, Montana. Is there a Trump Hotel in Whitefish? I know people there. I'll find out. If there's a solid gold toilet in Whitefish, we're finished.

D. Comparing Two Departments: a Trillion Between Them. Then Let's Grade Them.

So finally, after such all this preamble, how's life been playing out in health care? With the exception of the comparatively tiny program to reunite refugee kids with their parents, which is hapless, until now such life's not been so very vivid for most citizens glancing at their screens. Average Joe probably can't comment on either of the biggest items. But the noisy numbers, for 2019 are as follows.

  • A nearly 200 billion dollar request for the VA, well over a third of which is for health care and an over 15% request over 2918.
  • Almost 800 billion dollars for Medicare, most of which is for Medicare reimbursements, and just a 3% increase from the previous year.
  • Compare this with a bit over two billion for all HHS-supervised vulnerable-populations programs, even with a whopping 29% increase over 2018.
  • Only a tenth or so of this two billion is devoted to refugee programs. Two hundred million divided by a trillion. Hmmm, too many zeros here, so you do the math. Rounding error. But with close to a 30% increase for forcibly orphaned kids and others, maybe the Secretary tried.
  • So final tally: the three above total a trillion, 80% Medicare and 20% VA.
  • Keep it all in perspective, bearint these things in mind.
    • These are budget requests. Medicare they want to gut, even beyond ACA, so in the end maybe the aforesaid 3% will drop down into negative numbers.
    • Even here, with the 800B request, the HHS Secretary's clearly trying to be realistic on Medicare, knowing the temper of his bosses at both ends of Pennsylvania Avenue.
    • Ain't it odd! VA gets a barely passing grade despite the huge increase year-over-year. But this is the reality, as we'll see below.

Back to our echo chamber and the din of the 2018 election. It's all changing now, not so anechoic any more, as Dr. Poses recently pointed out. The fact is, and you'll hear much more of this in state-by-state campaigns just now getting off the ground for the fall run-up to November 6th, it's all now as vivid as hell. We should all remember how much more vividly people feel the loss of a dollar than they feel the bestowal of a dollar. Politicians know this. The anechoic chamber fills with a joyful noise. If only because, as occurred with other earlier water-boarding-style excesses, this same political party just gave us this most recent instance of politically weaponizing cruelty.

Really, not so joyful. But likely to command attention this fall. What else will command attention? Access to health care. And something for the vets who provided proud service to their nation.

I wrote earlier about the VA versus political donors' influence, in that case a Koch brother and a hack somehow attached to said brother. For a while seemingly, until he alienated them too, Trump and his people acted as though "things go better with Koch." In my previous dander-post, I pointed out the "Concerned Veterans," who've always seemed most concerned with privately outsourcing veterans' services while sundering the agency that protected them. (I provided medical care to these brave warriors from both inside and outside the VA. They rarely had anything bad to say about the organization. Certainly a lot less bad than I did when dealing with that hoary bureaucracy. Certainly they don't want it to go away. David Shulkin felt the same way, and lost a battle with the DIC's hacks.)

But now it's much worse. So I want to go out on this here limb and give Trump's two key departments for health care, their respective mid-term GPAs. For the VA: charitably, a D-minus. But interestingly, GPA for HHS: maybe as good as a B-, albeit constantly threatening to slide into a Gentleman's C to placate the boss DIC.

Why the qualitative disparity? Well, first let's back it up a little and rack up some of the recent events upon which this GPA result is based.

First let's take the VA. The place has had major problems for years and years, many of them self-inflicted with a self-referential bureaucracy second only to the Catholic Church. (David Shulkin knew he needed to fix this and was actively trying to do so when he was fired.) But the place just can't seem to catch a break. So harsh as it is for what's hopefully a work in progress that can still be salvaged either now or after 2020, the grade for this place is D- on a good day. Here are some of the hour-exams that go into the dismal assessment.
  • The VA's own internal watchdog just recently ripped it for failing in a recent program to help veterans' caregivers. This started before and continues during the Trump administration.
  • The effort to privatize VA care continues to ramify. Chasing down all the leads on this issue feels like trying to lop off the head of Medusa.
    • A proposed law to pay for privatization is bizarrely popular with bipartisan lip service. But it may shut down the government when you get down to finding the money.
    • There's a pathetic White House VA hotline about this, which reaches some hapless third party call-center folks who're powerless and clueless.
    • Most recently, Trump has essentially abdicated VA oversight to cronies, much like our high school footballer vetting spending at Interior. Specifically the "Shadow Rulers," a threesome of alte kakers—Palm Beach concierge doctor Bruce Moskowitz, sometime Marvel Entertainment chair Ike Perlmutter, and attorney Mark Sherman—who have in common one great thing: Mar-A-Lago! You can't make this stuff up. We owe it to (see here, here, and here) for providing superb coverage of the narrative of their undue influence. Whether official or unofficial, it's abdication of authority, with weak official leadership.
  • After Shulkin left, the place was forced to thrash around leaderless. It now has a guy Richard Stone, an unimpressive managerialist, but at least an Army Veteran. Not nearly enough!
  • Stone replaced a far better suited expert, Carolyn Clancy, who was sidelined into a looking-out-the-window job under questionable circumstances. See here.
  • Worth an entire blog of its own but start here: the VA's saga of health IT is a surpassingly strange, long and sordid one. The VA was among the first to have a workable EMR. It  ultimately got scrapped for lack of support and interoperability with the far more egregious and expensive failure of DOD's EMR program. (Which Shulkin sought to fix via COTS outsourcing.) Many billions down the drain on both sides. The VA system's lack of interoperability was in no way the VA's fault. They can't catch a break.
  • One of Trump's earliest attempts to "deal" with the VA was to put Omarosa in charge! This early episode again underlines the White House's difficulty in dealing with government organizations that give off the scent of unprivatized "deep state" players. Veterans hated her—now why would that be?
  • Another Cohen, not Michael, enters the picture. Also courtesy of New York's blogger-journalists at ProPublica, we learn that hedge fund billionaire (and of course DIC crony) Steve Cohen is cashing in with the VA. Altruistically, of caws. Just wants to help out all those PTSD patients. Privately, employing something modestly called "The Cohen Network." Read this whole sordid story at ProPublica. I'm seeing double Cohens in here.
Why does the VA story seem so haplessly fragmented, with lovers and haters constantly duking it out? A recent piece in Washington Monthly, by noted authors Suzanne Gordon and Jasper Craven, offers a simple and I think largely correct answer. Its supporters, especially those in Congress, know VA medicine is popular but they keep ragging on it as though it hurts its patients more than the private sector does. Not true! These guys just don't like government-run programs when the private sector friends want in. The private sector is also beset with inefficiencies, IT disconnects, and corruption. Shulkin was on the right track but got derailed. In every case, the common denominator is how VA medicine is a single frog in a single barrel. Shoot it or slowly boil it. Either way, a far easier target for meddling than HHS. This is the answer, folks. It's not that the VA needs more help than HHS, or that publicly supported health care's inherently bad. VA and HHS certainly both need a lot of help, but the VA did many fine things over recent decades. But boy is it an easy target.

Now to HHS, a very different story. A much more elusive target, for any journalist but more importantly for any DIC-hack or -backer. And now it has a Secretary about whom we may at least point to dramatic improvement over his spendthrift predecessor. The latter was a physician at that, should have had his head on straight, but who proved to be so far right, and frankly so peculiar, that at any given time he clearly could take a bite out of his own prostate.

Salient points about HHS's performance under Trump:
  • Key people are Alex Azar, the Secretary and Seema Verma over at CMS.
    • They're both clearly being forced to walk a tight-rope between White House and DIC-backers' ideology, and getting a whole host of jobs done. And those jobs require a great deal of organic interaction with the private sector.
    • PBM companies
    • Big Pharma
    • The AMA
    • The payers
    • Patient advocates.
    • Last and probably least, advocates for vulnerable populations—for reasons stated above.
  • They both seem to be learning on the job. B.
  • Not all's well. Trimming back access to ACA benefits, hotly opposed by many, is still a campaign in the Congress and White House, but seemingly opposed at least in part by many within HHS. Jury's out on this one, as ACA is super-popular nation-wide. D-.
  • Evidence for this: tackling the ticklish issue of stabilizing the Obamacare marketplaces. Much ink-shed over this, e.g. here and here and here.  Devilishly complex but suffice it to say that some states and perhaps the Congress will go ahead (one of the above links even refers to Scott Walker and Wisconsin) and make sure reinsurance is assured. Can this be anything other than the insurance industry pushing back on the nihilists? B+.
  • Medicaid and its expansion are also fighting back from the preferred GOP method of compression and extinction. The abusive work requirements, playing to the DIC's base and its resentment of "free-loaders," are not likely to last. The WaPo in fact now reports the emergence of multiple objective health-services-research studies showing the salutary effects of expanded Medicaid, especially for chronic illness like diabetes. So risk payments may be restored. B+.
  • Drug-price negotiations are see-sawing like crazy. Trump says he believes strongly in this. Do we believe him or the PHRMA lobbyists? He touts token prize freezes. Azar seems on the fence, though he talks a good game. Congress tries to be encouraging. Jury's out. C-.
  • The corner of Medicare known as Advantage programs, emphasizing Accountable Care Organizations or ACOs, is another complicated matter. Verma seems to be looking to restrict ACOs to those with real accountability. Some view this as more draconian behavior, but I see her point. B+.
  • PBM companies—those lucrative outfits that "manage" pharmaceutical benefits—are also on the DIC's hit list. I see little progress. What I see is rural pharmacies dying out because they get caught in the PBM companies' baroque pricing schemes. D- to F.
  • A almost wholly unnoticed federal regulation from last month deserves much more attention. This voluminous document dramatically revises fee schedules for Medicare patients, emphasizing many of the services traditionally provided with little or no reimbursement by primary care physicians. New billing codes are proposed. For the first time the playing field may soon be leveled for many PCPs. This is a potential big win for those working for Verma. A solid A+.
  • The above's an excellent example of emerging claims, for example those in a worthy new Brookings piece, that real cause for optimism exists in health care reform. At least some of that stems from activities within HHS. The conservative author, Stuart Butler, deserves a careful read. He signals several "under the radar" patterns from both the states and HHS itself, flowing from increased flexibility that HHS now has. (For all its strengths, ACA was hamstrung by some fairly inflexible regulations on matters such as metrics for improving Health IT.) A+.
Average grade for HHS: B-. Why this good in an abysmal administration? As I've intimated, for every meddling White House apparatchik there's an outside interest pushing back on Azar and Verma. Lots of IT vendors. Lots of payers. Lots of innovators. (And, of course, lots of outraged citizens in the one conspicuous but miniature case of the separated children.) The very protean and risibly shuffling-buffalo scale nature of HHS may have been its greatest virtue. In an effort to satisfy the spirit of "anything but Obama," they're trying some new stuff, and some of it isn't half bad.

Thus VA and HHS are fascinating bookends juxtaposing the risks and benefits of homogeneous versus heterogeneous health planning. Right now HHS is winning, if only because of a political atmosphere in which the latter is better adapted to thrive. It could, of course, go the other way. Personally I hope the VA is restored to its former strength, perhaps in a spruced-up and more streamlined form: less bureaucratically stodgy to get away from the current predicament in which everyone from a bad manager to a bad nurse can tie the place in knots. I also hope HHS, even if Medicare For All becomes a reality, preserves opportunities for experimentation and innovation.

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