Thoughts on the Robert E. Lee Statue Removal from Duke Chapel

I became chair of the Academic Council at Duke on July 1, 2017, and was chatting with the Provost a few weeks ago and we agreed there “weren’t any hot button issues” on tap for the Fall semester. That, of course, is no longer true.

I support President Price’s decision to remove the statue of Robert E. Lee from the Duke Chapel Entrance, as well as with his commitment to preserve the statue in a way that will allows students, faculty and all of us to learn from it. The creation of a commission of faculty, students, staff, trustees and members of the broader Durham community to help guide the next steps shows that this will be an ongoing process. The removal of the statue is best understood as the beginning of a new chapter, not an ending.

Duke is a relatively young University, and I think this new chapter may provide a book end of what I often think of as the beginning of modern Duke–the Bassett Affair of 1903 (the University was then called Trinity College). Professor Bassett wrote that Booker T. Washington and Robert E. Lee were the two greatest Southerners of the previous 100 years:

….he inserted a sentence praising the life of Booker T. Washington and ranking him second in comparison to Robert E. Lee of Southerners born in a hundred years. Such a sentiment invited controversy at a time when race baiting was commonplace due to the revival of bitter partisan politics with the division of the Democratic Party, the rise of the Populist third party, and the revival of the Republican Party. State Democratic leaders in nearby Raleigh who were also represented on the Trinity College Board of Trustees demanded that Professor Bassett be fired. When parents were urged to withdraw their children from the college and churchmen were encouraged not to recommend the college to prospective students, Bassett offered his resignation.

The Trinity College Board of Trustees did not accept Bassett’s resignation, a founding chapter in Duke’s history that made clear the critical principle of freedom of speech for the University. Of course, it was non-controversial to so-praise General Lee in 1903, while today his likeness is the source of controversy.

The common denominator then and now is the life of the mind that should be the heart of the University, demonstrated first and foremost by the faculty and students engaging in scholarship, teaching and learning. This is a big moment for Duke and our country, and I believe that the University has special process and educational responsibilities not only to the members of our community, but to society at large. We have a chance to model that difficult issues can be navigated truthfully, respectfully and openly, and if done well, we can help to make our world a better place.

May we be up to the challenge.

N.C. Medicaid Managed Care Proposal

The N.C. Medicaid Managed Care proposal was put out today by the Cooper Administration NCMedicaidManagedCare. Don’t look now, but North Carolina looks to be engaging in bipartisan health care reform. You may recall that the Republican-controlled Legislature dictated that the Republican Governor develop and submit a 1115 Medicaid waiver by June 1, 2016, which he did. I submitted a comment on their plan with Aaron McKethan–some good ideas, some not so good. However, it was mostly an aspirational document and was not really detailed enough to warrant a CMS response.

Governor Roy Cooper’s Secretary of HHS Mandy Cohen (and former COO of CMS under President Obama) was confirmed last Spring and immediately set out to lead a process that is putting the meat on the bones of the Republican Medicaid reform aspirations. She fully committed to moving it ahead, demonstrating that both political parties are searching for common ground on Medicare reform.

It will take both sides to do something this big.

RCT of Palliative Care in Heart Failure

A big team from Duke lead by Joseph Rogers has a new Paper (PAL HF) reporting the results of a RCT of palliative care in late stage Congestive Heart Failure, published today in the Journal of the American College of Cardiology. Patients who got palliative care had better quality of life, higher function and reduced anxiety and depression (with no survival difference, as hypothesized). Costs were not a primary endpoint, but will be analyzed in later work.

CHF_7-11-2017 8-56-05 AM.

After the publication of a RCT of early palliative care in stage 4 lung cancer in the NEJM in August 2010 showed improved quality of life, lower costs and longer survival, there was a move to see if such findings could be replicated in other diseases. This NHLBI funded study is part of that effort.

Real world evidence is provided imperfectly, especially with respect to policy. One example from this paper. This studies’ exclusion criteria ruled out patients with anticipated heart transplant or LVAD implantation within 6 months. Arguably, these patients aren’t ready for palliative care because they are seeking such aggressive treatments, but from a policy perspective, it is arguable that they definitely need the goals of care type of discussions that are a key part of palliative care. The successful conclusion of a trial of CHF without patients on the way to heart transplant or LVAD implantation leaves an evidence hole, even as we add to the evidence base.

Should patients thinking about an LVAD or a heart transplant get palliative care? I think the answer is yes, but this trial provides no direct evidence to inform this question. So, there remains an evidence gap (as always–good studies suggest more questions than they answer). However, the health care system often doesn’t and can’t wait for such answers, and in the case of palliative care there has been a tremendous increase in its provision at Duke, and across the nation since this study was began. The process and timing of research is slow, and the answers are often muddled, while the pace of change in addressing the needs of seriously ill patients is much more rapid. When one’s interest is policy applications, even an RCT–the gold standard of research–cannot answer all of the most pressing questions.

Does Health Insurance Improve Health?

An old question has gotten some new evidence. Does health insurance coverage improve health? This is a simple (and important) question that is complicated to answer definitively due to methodological reasons, but the evidence base has grown by two important papers in peer review journals in the past few weeks:

  • Ben Sommers has a recently accepted paper in the American Journal of Health Economics that is available online as an eprint. He finds that Medicaid expansions in the early 2000s in 3 states saved lives, and he documents the costs of doing so. The point of the paper is better methods of determining if Medicaid expansions did in fact save lives and looking at the cost of coverage. His top level findings:
    • 1 life saved for every 239-316 persons newly covered by Medicaid (the range represents the uncertainty in the estimate–could be as high as 316 lives saved, or as low as 239, for each newly covered person).
    • The cost per life saved was $327,000-$867,000
    • He discusses the other things that could be done with this amount of money and notes these amounts are less than often paid per life saved for many interventions
  • Ben Sommers, Atul Gawande and Kate Baicker have a paper in the most recent NEJM that looks more comprehensively (not only mortality as an outcome, and at different types of insurance, public and private) and reviews the recent peer reviewed work on the broad topic of does health insurance improve health. This is a nuanced paper that focuses on the current health reform discussions that our nation is having and goes directly to how important losses in recent coverage expansions could be to public health. On the most basic question at hand they conclude

    There remain many unanswered questions
    about U.S. health insurance policy, including
    how to best structure coverage to maximize
    health and value and how much public spending
    we want to devote to subsidizing coverage for
    people who cannot afford it. But whether enrollees
    benefit from that coverage is not one of the
    unanswered questions. Insurance coverage increases
    access to care and improves a wide range
    of health outcomes. Arguing that health insurance
    coverage doesn’t improve health is simply
    inconsistent with the evidence.

The evidence base changes weekly. These two important papers need to make their way into the ongoing policy debates.

Time & Motion Study of Community Based Palliative Care

We have a new paper (open access) in the Journal of Palliative Medicine, providing a Time and Motion study overview of the care delivery model at the heart of our CMMI HCIA-2 innovation award with Four Seasons Hospice in Western, North Carolina (Janet Bull, who is also President of the American Academy of Hospice and Palliative Medicine and I are the co-PIs of the project).

This figure provides an overview of the palliative care model that we are providing across setting (~5,000 patients will enrolled by the end of Summer, 2017, and we just received Medicare claims records for the first 2+ years of the project, so should have preliminary cost findings in the Fall).

TimeandMotion.6.6.17jpm.2016

 

House Republicans Pass AHCA

House Republicans passed AHCA, their version of repeal and replace of Obamacare, 217-213. The Republican controlled Senate declared it dead on arrival and set about to write their own bill. Here is past blogging on earlier versions of AHCA; they did not wait for a CBO score before voting, but the prior score estimated that 24 Million people would lose coverage as compared to the ACA baseline, and the most important policy points of AHCA 1.0 and zombie AHCA remain

  • Tax cut for persons with AGI greater than $200,000
  • $890 Billion (~25% cut) in Medicaid that existed prior to ACA
  • Ending of Medicaid expansion in the ACA

The new parts of AHCA related to the individual insurance market, devolving waiver responsibility to the states related to pre-existing conditions, under funded high risk pools, etc. They are mostly incoherent as a policy whole and won’t survive the Senate.

A few thoughts on all this.

  • Its shocking that after 6 or 7 years of ‘repeal and replace’ as the unifying theme of a party that this is the best they can do, both in policy and process terms. Health Policy is just not the Republican Party’s thing–sorta like the 1980s Oklahoma football team trying to throw the ball. But they spilled so many words they had to do something.
  • The Medicaid changes are by far the most consequential part of the bill. I have written lots about changing the state-federal relationship on Medicaid and think it is a big part of an eventual (inevitable) deal on health reform. But AHCA’s Medicaid provisions are just “tag, you’re it” flexibility to the States.
  • The rage of progressives/left/supporters of the ACA shows the asymmetry of health policy for the two sides. It is our ‘main thing’ and Rs in the House were willing to pass anything, just to say they had passed something. And the clarity of the ACAs ending of pre-existing conditions and lifetime limit provisions gives way to long, complicated answers under AHCA that end with, ‘well, its complicated and really depends upon that state in which you live.’ Here are two examples addressing the question of whether rape would be a pre-existing condition under AHCA (probably not; and more of same–there is some info in the length of the analysis required to answer the question).
  • After the football spike is over, I think if Rs actually pass a health reform law, it ends exactly like the ACA did–with the Senate jamming the House. Whatever passes the Senate, if anything, will define Trumpcare if there is to be such a thing.

 

Both Sides Still Need a Deal

The Republican Party suffered a spectacular political defeat yesterday when they pulled their AHCA legislation from the House floor, after all the words they spilled the past 7 years. Speaker Ryan said the ACA is the law of the land, and President Trump said that Democrats will want a deal to improve the ACA within a year.

On December 16, 2010 I first blogged that “Both Sides Need a Deal” and laid out a set of big ideas that I claimed would emerge in a deal if the two sides negotiated in policy good faith. I even wrote a book that more fully laid out what a health reform deal would look like, and said it was the crux of a sustainable federal budget. Last Sunday, Ross Douthat, maybe sensing the outcome of yesterday, wrote that a catastrophic insurance program loosely based on Singapore would be the best way forward for Republicans. This column reminded Reihan Salam of my pitch from several years before.

reihan.bloginsert

Deal’s between Democrats and Republicans seem impossible politically, but the structure of our system of government makes them a feature, and not a bug. At some point we will have to return to that type of equilibrium. And both sides really do need a deal to achieve more of what they want. I want to re-emphasize 3 of the big ideas from my original proposal and add a fourth in the hopes of starting a conversation, perhaps only with myself.

  • Replace the individual mandate with federally-guaranteed, universal catastrophic insurance coverage and sell private “gap” insurance in state-based exchanges, with income based subsidies
  • End the Medicaid program as we know it by transitioning full responsibility for dual eligible Medicaid costs to Medicare, and moving non-elderly and disabled low income persons into subsidized private gap insurance
  • Modify the tax preference of employer paid health insurance, and replace the cadillac tax with this provision
  • Not in my original proposal, but we should provide some help in purchasing health insurance to persons in the individual market, but whose incomes are too high to qualify for tax credits under our current system; it will help the risk pool and high income persons get a subsidy via the tax treatment of Employer coverage

I am a policy guy, and the policy is crucial (I wrote in 2014 what some of the above ideas could look like for one state–North Carolina to try some of this via an ACA waiver). What I have proposed above is a bit more grand, but it seems that a big deal may paradoxically be easier to obtain than a small one, particularly around the issue of Medicaid. Precisely because there is a no “best way” to address health policy, the politics are particularly important if we are to ever develop a sustainable health care system. A quote from my 2012 book in Chapter 7 sums this up for me:

What our nation most needs is a bipartisan health reform strategy that will allow us to address the interconnected problems of the health care system: cost, coverage and quality. There is no perfect health care system and no perfect plan. However, without a deal that allows both political parties to claim some credit as well as to have some responsibility in seeking to slow health care cost inflation, we have very little chance of success.

I will do some follow up posts on the policy aspect of the imperfect ideas above. I am happy to engage in dialogue if anyone is interested.