An Intimate Perspective on Obamacare

GUEST: Dr. David Blumenthal
AIR DATE: 12/28/2013
VTR: 11/07/13

I’m Richard Heffner, your host on The Open Mind. And this is the second of two new programs on healthcare in America with Dr. David Blumenthal, President of the world renowned Commonwealth Fund, a major national philanthropy heavily engaged in independent research on health and social issues.

Now, Dr. Blumenthal first joined me here a dozen years ago when as a distinguished Harvard Medical School Professor of Medicine and Professor of Healthcare Policy he discussed with me “Medical Scientists and the Marketplace” as well as the then seemingly much needed professional injunction, “Physician…Prepare Thyself”.

Recently Dr. Blumenthal also joined me here for a most illumining conversation about his and historian James A. Morone’s quite extraordinary new book, The Heart of Power…Health and Politics In The Oval Office. For other than war and peace, few issues have commanded our recent Presidents’ attention more than healthcare…their families’, their own, most importantly, their fellow Americans’.

And today – it’s November 7th, 2013 as we record this program – even without a crystal ball to peer into, I want to talk with Dr. Blumenthal about America’s national healthcare potentials.

My guest, to be sure, was senior healthcare adviser to Barack Obama in the 2008 Presidential campaign. And in the period 2009-2011 he was the President’s National Coordinator for Health Information Technology. So that it’s not inappropriate for me to ask Dr. Blumenthal, “What in the world is happening with Obamacare, even as we speak?”

BLUMENTHAL: Well, thank you for having me, it’s great to be here. Great question … what’s happening to Obamacare? This is not the script that the President would have written, it’s not the script that anyone who cares about healthcare would have written and my view of this is that it … there are many factors at work in this troubled roll out of the new plan.

I want you to remind you and your listeners that the plan has actually been in effect for nearly three years and that an enormous amount has been done under … without, without much coverage.

So millions of young Americans have gone on their parents insurance polices and are now protected against the cost of illness because of new provisions in the plan.

Millions of Americans are covered for the cost of preventive services when they weren’t before. And millions of elderly Americans have drug coverage that they didn’t have before.

There have also been a huge number of healthcare system delivery reforms that have been part of the law, that have been quietly rolled out without great controversy and with potential great benefit.

However, it’s a … it is November of 2013 … it’s impossible to ignore the daily stories about problems with the website, for the marketplaces that are core to extending coverage to uninsured Americans and to individually insured Americans.

So what went wrong with that? I think there are several things. First of all, there has never been a social program of this size or maybe of any size that has been implemented under such adverse circumstances.

By “adverse circumstances”, I mean with such vehement, intense, persistent attacks from the opposing party … in this case, the Republican Party. What that has occasioned is a inability for the President and his Administration to do anything that would cause public anxiety or give ammunition to the opposition.

One of the things that clearly was not done adequately in the roll out of the website, and by the way I think the websites will be fixed. But one of the things that led to the complications with the website was the fact that it was never fully tested.

HEFFNER: How come, one must ask.

BLUMENTHAL: So, I don’t know the answer to that in … with full authority … I, I haven’t talked to anybody about exactly why it didn’t happen. I have … I can speculate. But I can paint a scenario for you that would cause almost anyone to be reluctant to test it in a transparent way.

So what happened just before the web … the October 1st deadline for the roll out or around the October 1st deadline. The budget … the Congress shut the government down and threatened to default on our national debt in order to overturn Obamacare.

If the failings that are now apparent had been apparent before that time, the ability of the President to hold the line on his first and most important domestic priority … the Obamacare roll … the Obamacare implementation … could have been dramatically compromised.

That’s not to say that it doesn’t forgive the problems, but it does give you some sense of the difficulty that I think the Administration had in coping with the inevitable difficulties that were going to happen as soon as the roll out began … to test it, talk about and risk having its problems be public … and by the way … any private company that rolls out a website will roll it out and gradually encounter problems, go back … redesign and go forward … we don’t’ afford public officials the luxury of failure.

That luxury which is built into any normal technology project was not available to this President for political … for political reasons.

Now I also think that there were some very, very difficult problems around the IT infrastructure itself in the Federal government.

And the massive nature of this project … 36 states … keep in mind that there are 14 or 15 states that are doing their own websites. But 36 states that … where the Federal government was going to implement a website.

Now, you might think that the same website and the same software would work for every state … but you’d be wrong.

Because all those states have their own Medicaid programs. And this software has to integrate with 36 different Medicaid software infrastructures.

Medicaid information systems are terrible. They are old. The languages in which they’re programmed are old. The, the code is old, they’re not meant to communicate outside of their states. To have 36 well functioning interfaces and to do it with some states that were absolutely opposed to letting it happen … that’s an enormous socio-technical and political challenge.

So, many adverse circumstances. Then there’s one relatively minor point that I can speak to because I recently was a Federal official in the IT space and then I went from there to being the leader in my home state of Massachusetts of a very large IT implementation.

The difference between how you procure IT services in the Federal government and how you procure them in the private sector are night and day.

In the private sector … the process of deciding which IT vendor we wanted to contract with was a many month long, very transparent and very detailed process of vetting. I visited with their programmers, they visited with us … we met the CEO and the leadership of the company. They came and presented their product to us … we did that with multiple other vendors.

What was it like for me, as the National Coordinator of Health Information Technology to let a contract in the Federal government?

I would write and RFP … it would be shipped off to the contracting office. And then some months later I would be presented with a contractor … contractee who I had to accept.

No opportunity to interview. No opportunity to examine their work. No opportunity to kick the tires. Why is that crazy system in place? To avoid conflict of interest.

So to protect the public from economic conflicts, we have set up a process of contracting which completely hamstrings effective management of IT services.

I think that’s why the President has actually begun talking about the need to fix IT procurement in the Federal government.

HEFFNER: You know, Dr. Blumenthal, listening to you two things occur to me. Number one, why in the world hasn’t this been said as articulately as you’ve just said it. That’s number one.

And number two whether the last point you made isn’t a point that those who do not want the government in many different social programs … isn’t that the point they make … “We can do it better in the private sector.”

BLUMENTHAL: Well, there are some things that the Federal government can do … that the Federal government doesn’t do and never will do as well as the private sector.

And I think one of them, actually, is managing information technology. So it was right to contract that work out. It was, however, not the case that the private sector can insure the poor and the elderly and the uninsured because if they could, they would have done so.

So, there is a dilemma which is that the Federal government or government of … at some level has to take a role in reaching the poorest and the least protected among us. Because the market will not do it.

If it was profitable to sell insurance to those people and if they could afford it … it would have been sold and they would have bought it.

We have Medicare for the elderly because prior to its passage, virtually no elderly Americans had insurance. Because there was no profit in insuring people who were destined to get sick.

So, ahh, there is an irreducible requirement for public action, collective action, as some level where we can come together collectively to take care of these most … these uninsured and underinsured Americans.

And once the government takes a role, then the government is accountable. And the taxpayers hold the government accountable. So someone in government has to be in charge.

Now they’ve made errors, no question about it. They had to overcome many barriers that were extremely high in this case.

I think they’ll get it right. I don’t think it’s an insupportable barrier. God knows the NSA seems pretty good at this stuff. And they’re a government agency.

So I think they’ll get it right. I think the A-team will now be brought in, there are a lot of people from the private sector who are going to be willing to help. Who wouldn’t have been willing to help prior to this difficulty.

The President … it’s got the President’s attention in a way that it never would have had otherwise. And I think in six months or eight months … maybe less, maybe more … we’ll have a pretty smoothly functioning website.

HEFFNER: Let me go back to my first question then. Which was why hasn’t this been articulated as clearly and as well …

BLUMENTHAL: Yeah.

HEFFNER: … as you have just done.

BLUMENTHAL: Well, I don’t know whether it has or not.

HEFFNER: It hasn’t.

BLUMENTHAL: Well, …

HEFFNER: Couldn’t we concede that?

BLUMENTHAL: I … you know … I’m not willing to concede that Secretary Sebeluis or someone else working for her hasn’t made this case to your colleagues in the media …

HEFFNER: Aha … okay …

BLUMENTHAL: … and it’s not been reported because it’s a complicated argument. And it’s …and the echo chamber of reporting about this has focused on a “trop” a common cliché about government incompetence. And it’s very hard to break through that.

So the fact that it’s really complicated to do this work and there may be things built into Federal government … in any government … that are designed to protect people, that also make it hard to do something. That story is a hard story to tell. And people don’t have patience for it.

HEFFNER: I was hoping that you would say that because … talk about the media’s role, because I’ve watched every night as a loyal PBS person, public television person … I watch the Nightly Newshour … the PBS Newshour and I wondered why they, of all people, wouldn’t say the things that you’ve said instead of repeating the charges that are made with such an obvious political ax to grind.

BLUMENTHAL: I don’t know and I’m not expert enough on the media to explain this. I, I … part of what I imagined is that someone’s been making this case, as I’ve just said …and that it seems not credible, or it seems too complicated. Or that, in the end, what they’ve concluded is that the competence wasn’t there to get the work done. And I can’t exclude the fact that there were failures of judgment, failures of management … that’s probably and almost certainly at work.

It’s just that there were many other things going on at the same time. And harder to explain in a short period of time.

HEFFNER: You know I, I have my students read a speech that Lyndon Johnson made the night after … the morning after he withdrew from the Presidential race in 1968 to the National Association of Broadcasters.

And he was saying to them, you have great power in your hands and with great power grows great responsibility. And he was making the point that the media like negative things. Peace doesn’t go so well with them. War, opposition, attacks does.

And I’ve wondered and I’m interested that you raise this point … whether it hasn’t been a matter of covering over the possible answers … not, not to lie to the public, but just not being able to deal rationally, calmly …

BLUMENTHAL: MmmHmm.

HEFFNER: … with obvious answers.

BLUMENTHAL: Well, again, not being an expert on the media … I, I have some sympathy for them, so I’m sure that whatever anybody reports … they hear from the other side. That … you know … if they … that they, they are constantly battered …

HEFFNER: Yeah.

BLUMENTHAL: … from both extremes.

HEFFNER: Well, I wish you’d go batter them.

BLUMENTHAL: (Laugh)

HEFFNER: With the sort of points that, that you’ve made. You say you think it’s going to work out. And a little bit snidely you say “If NSA has managed to …

BLUMENTHAL: HmmMmm.

HEFFNER: … figure out how to do these things …”. You think it will be in time?

BLUMENTHAL: So this is an interesting point that I also think the media has missed. During this month of October two major things happened that are relevant to the healthcare law. First websites opened and they crashed. And we’re dealing with that. Second the President went eyeball to eyeball with the Republican Party and the House and Senate … who wanted to use the nuclear option of debt default, to end Obamacare. And the opponents backed down.

Now which in the history of this law will turn out to be most important? The impact of the … of Obama’s success in backing Republican opposition off the desire to defund or delay the law meant that the President has 38 months to complete its implementation before the next President walks out onto the Capital Hill steps and raises his arm to take the oath of office. He has until that moment … 38 months … that is unchangeable … the fact and so as the law gets implemented and as more and more people get insurance under it … they will become a constituency … a positive constituency for the law.

Now the other thing that happened is … I mentioned is … the website crashed. Now we know websites can be difficult to get in place, but we also know from the California experience, the Massachusetts experience … from the Kentucky experience that websites that do this kind of thing, that form healthcare marketplaces are possible to create.

And I believe that that kind of a technical project is a matter of time and effort and elbow grease … not a matter of miraculous transformation.

So the President has time to get the website up, to start getting people enrolled and to push the implementation right through to January 2017. I think that’s a good enough time frame for him to make the law a fact of life in the United States.

HEFFNER: One thing is time, the other thing is perseverance and nerve. And I wonder … I started off by saying full disclosure … we’re talking together now end of the first week of November … we’ll be seen at the very end of December because of the intricacies of public television … I wonder what the reaction is going to be … I wonder where we’ll be at the end of December …

BLUMENTHAL: Yeah.

HEFFNER: … to help people be sympathetic to the point that you’re making. Or just the … just the opposite. Your involvement with IT has been a very positive one I gather.

BLUMENTHAL: So, I’m not a technologist, I’m not someone who programs computers … I am … I got interested in information technology in medicine because I was practicing primary care and I was forced to use an electronic health record.

And I thought that it was a great force for good in medicine. Made me a better doctor. And I got interested in why it wasn’t spreading like wildfire … given how good it is.

HEFFNER: Why?

BLUMENTHAL: It’s hard to use … some are hard to use … and it’s costly and there’s no market for it. I actually think that the fundamental reason that electronic health records haven’t spread more is that providers of care are not forced to report and optimize quality and efficiency in the US healthcare system. Because if they were, they would gravitate naturally toward electronic health records and digital solutions to making care better.

HEFFNER: Is that true of doctors … also of doctors who take Medicare patients?

BLUMENTHAL: It’s true of all doctors. I think there is not the kind of pressure in our fee for service system which mostly lacks accountability … it’s changing slowly … but mostly in the past has lacked accountability … there … we, we aren’t desperate as clinicians to prove ourselves every day the way people who sell in other markets have to meet the customers requirements on a day by day basis.

The reason why IT is universal in almost every other industry in the United States is because of competitive pressure. Not only national, but international. And that’s why Hertz and Avis and American Airlines and Apple and you name the company, they’re all IT … financing industry … its virtually an IT industry … because they are competing for the business of you and me and we are very much attuned to the … to how good the service is and how good the product is.

HEFFNER: Will Obamacare in your estimation lead to a situation where that accountability is much more the law of the land?

BLUMENTHAL: Obamacare creates more tools for creating accountability than we’ve ever had in the history of the US healthcare system. They’re not all the tools that we might need, but they’re a very good start … again, part of the law that’s not discussed very much. But it is a very, very important part of the law.

What I like to say is that for the first time our toolbox for delivery system improvement … for improving performance is full. We have a whole lot of new tools that didn’t exist five years ago and the industry … the healthcare industry is taking notice. And there are some indicators like falling re-admission rates for Medicare patients which was one of the targets of the law … there are questions about moderate … whether healthcare costs are moderating now, partly in response to some of those new provisions of the law. That’s debatable, but some people believe it might be the case. So there’s a lot of change going on on the delivery system side that’s being promoted by aspects of the law.

HEFFNER: You know I … again, in a situation where we just have a few minutes left … but I, I was thinking of, of the programs we did a dozen years ago and I wondered whether you think some of the problems we discussed then are being handled …

BLUMENTHAL: MmmHmm.

HEFFNER: … not necessarily through Obamacare, but that we’re moving.

BLUMENTHAL: Well, on the issue of relationships between physicians and hospitals and scientists and industries that have an interest in the results of the decisions that professionals make … I think we have actually moved quite a long way. So another one of the un-discussed aspects of the Affordable Care Act is a provision that was inserted by Senator Grassley the Republican from Iowa called The Sunshine Act, which requires that all American pharmaceutical and device manufacturers make public their gifts and payments to physicians. First time in history. So that the public will be aware of who’s consulting to who … and who might have a conflict of interest.

HEFFNER: It’s interesting that there is so much more to Obamacare … the initial legislation than the public is aware of. And I wonder again … in 30 seconds … is the Foundation … is the Commonwealth Fund moving in that direction of informing them?

BLUMENTHAL: Well, we, we … we are informing people to the very best of abilities about what the law is doing. It is, again … ultimately the national media that control this to some degree. Now we’re also experimenting with social media, which may be a way to by-pass some of the traditional media … we’ll see how that works.

HEFFNER: Dr. David Blumenthal, I’m grateful to you, indeed, for coming here for these programs.

BLUMENTHAL: Very glad to be here.

HEFFNER: Come back again.

BLUMENTHAL: Thank you.

HEFFNER: And thanks to you in the audience. I hope you join us again next time.

Meanwhile, as an old friend used to say, “Good night and good luck”.

And do visit the Open Mind Website at thirteen.org/openmind to reprise this program online right now or to draw upon our Archive of 1,500 or so other Open Mind and related programs. That’s thirteen.org/openmind.