The DNC’s best strategy for stopping Trumpcare? Do nothing

From Day 1, hour 1 of Donald Trump’s presidency the tone has been set. Taking down the Affordable Care Act — also known as Obamacare — is the top priority. There has been an executive order advising all Departments to drag their feet on previously budgeted ACA functions where possible. There has been a budget resolution proposed by the GOP (and passed) defunding many portions of the ACA.

The ACA is a massive far reaching body of legislation that touches cabinet level down to clinical front lines and everything in-between. The GOP has presented a broad view of its desired changes, but lacks a clear plan of implementation or vision of care delivery models that actually address the chronic disease issues facing our population. Via Medicaid block grants and public health savings accounts, the idea seems to be to capitate all money handed down from CMS and push all risk/implementation onto state Medicaid programs, providers and patients.

Speaker Paul Ryan provides GOP leadership in Healthcare in the House of Representatives

The GOP has 2 years until the 2018 midterm elections. The speed at which they are moving to build and then pass a complete replacement plan (both legislation and budget) makes sense. They don’t have time to do the waterfall method of building their healthcare product — they’re starting with a minimum viable product and will grow it from there. The sheer size of the ACA means that much of its finer details — particularly mandates around care quality, chronic disease management, state’s discretion, and use of technology — are likely to remain in place.

This all makes sense. The shift towards capitated, value-based reimbursement has been in the works for some time now as payers consolidate and gain even more control over the healthcare financial system. The Centers for Medicaid and Medicare Services are desperately seeking sustainable business models as near term insolvency looms. Our fee-for-service health system has resulted in an overpriced product unable to prevent one of the world’s worst obesity epidemics. If anything, the GOP proposals are just a very hard shove in the same direction ACA was trying to push.

The protest of a GOP health plan from the left on the grounds of harming the poor seems disingenuous — there isn’t any real epidemiological evidence that simply improving the access to primary care was making a dent in the extremely high rate of chronic disease in the country. I’ve said it many times — the real problem behind chronic disease management lies at the provider level. What makes the US healthcare system strange is that the service provider (the doctor) doesn’t get paid by the customer (the patient), but by one or more third parties (insurance companies). These third parties reimburse based based on the specific service provided. This means that the business model for doctors and hospitals has been focused on negotiating billing rates with insurance companies. Solvency for doctors then comes from building a high volume of the medical services that fetch the highest reimbursement rates from insurance companies, rather than providing the specific services that their patients need the most.

From a financial perspective, the patient has been an afterthought for decades. In a capitated model, the focus is shifted back to the patient, since the provider is paid a fixed per capita fee for each patient seen. Now, the provider’s profit focus is shifted from high-utilizing patients to low-utilizing patients, and preventive care becomes more important.

Fee for services vs Capitated/Value-based care

If I was the DNC, I wouldn’t expend much energy in opposing the GOP strategy. The obstructionist route during the Obama years resulted in a watered down, compromised product which has many parts that we will be stuck with for some time. The implementation — as wide sweeping as the law is — became a mess because partisan opposition was in the form of sabotage rather than genuine constructive criticism and improvement. In it’s current state, the ACA is a stepping stone and not the final product. Its value is in revealing that the root cause of chronic disease isn’t simple lack of access to care, but rather a broken relationship between providers and the communities they serve.

It’s a win-win for everyone if the DNC steps aside and allows the GOP a clear path to attempting its remake of healthcare policy. Comments like those of Representative DeGette — declaring nuclear war if the GOP excludes Democrats from involvement in crafting an ACA replacement — reek of childishness. If the GOP plan ends up being reasonable, there is no reason to make it as toothless as possible out of sheer partisanship. And if it is terrible, there are no excuses that can be made blaming DNC obstructionism, and a future mandate for both Congress and the White House can be secured in 2020.

Instead of dedicating energy to desperately opposing GOP healthcare policy at the Congressional level, the DNC should go all in on harnessing the activation we have seen around the women’s march. It should develop a comprehensive vision of what Medicare/Medicaid should look like — from federal government all the way down to the clinical front lines. It should use networks of activated community members to distribute messaging strategically, and use these same networks to get feedback on what really matters in the community. And iterate rapidly. That way, if the GOP plan is a failure, they are ready with an already means-tested replacement plan along with existing channels for communicating why it will work effectively to the public.

More showed up for Womens’ Marches than the Inauguration. Activation has happened. Take advantage of it.

More importantly, the GOP’s desire to push the work of implementation onto state Medicaid programs, providers, and patients is an opportunity for the DNC. A major miscalculation by the DNC in the most recent election was turning the campaign into a referendum on Progressivism and feminist identity politics at a time when the bottom is falling out from underneath the American middle class. By focusing its political energy on community-level strategies for supporting better health outcomes, the DNC can gain a greater appreciation for the deep cultural structures it needs to resonate with in order to build successful national electoral strategies.

What the DNC should not do is spend the next 4 years engaging in the same Congressional brinksmanship that we have been bombarded by over the past 8 years. It should not turn healthcare into an ideological referendum or a nuclear battleground. It should resist the urge to fight the GOP in Congress where they are strong and resolved, but rather take the fight to where they have no evident interest — where care is actually delivered.

To learn more about health policy advocacy at the local level in the SF Bay Area, read on at