Understanding Trump

by Newt Gingrich

  Reorient Our Public Nutrition Programs toward Nutrition

  In addition, supplemental nutrition programs like SNAP and WIC should be overhauled to encourage healthy eating. The operative word in these programs’ functions is “nutrition.” The idea that food stamps can be used to purchase junk food with little nutritional benefit that leads to health problems down the road (which may also need to be paid for with public funds through Medicaid and Medicare) is both financially stupid and morally irresponsible.

  To be clear, I support consumer choice and am not advocating the taxation or banning of sugary foods. However, we should draw the line at using taxpayer money that is supposed to be dedicated to nutrition to subsidize unhealthy eating habits.

  Confront the Addiction Crisis

  Over the past fifteen years, the number of drug-overdose deaths in America has doubled. With more than 52,000 deaths in 2015, overdose is now the leading cause of accidental death in America. The opioid epidemic is driving this problem, accounting for about two-thirds of the increase. Over 33,000 Americans died in 2015 from opioid overdose, and 2.4 million Americans are struggling with an opioid use disorder. Overall, more than 7 million Americans battled a drug use disorder—over 20 million if you include alcohol—in 2014.

  President Trump made it clear during the presidential campaign and during his early presidency that he was going to confront the addiction crisis facing America. Half of the challenge is preventing the flow of drugs from the southern border, which I addressed in chapter 10, and the steps he has taken there are promising. The other half is how to deal with those who are already addicted.

  In March, President Trump tapped New Jersey governor Chris Christie to head a commission on opioid addiction. To be successful, the commission will need to do more than advocate for increased funding for treatment; it will need to look at how to change underlying attitudes about addiction and mental health. Too many of our medical rules and practices surrounding addiction grow out of outdated and inaccurate dogmas that are not based on science or medicine.

  For instance, there is no scientific evidence that suggests the standard twenty-eight- or thirty-day drug and alcohol detoxification program model is the optimum length of time for ridding the body of toxins or to fight addiction. It came about because of armed forces personnel rules that did not require service members to be reassigned if they were away for less than thirty days. In fact, the evidence shows that the longer a person stays in rehabilitation, the less likely they are to relapse.

  Ultimately, confronting the addiction crisis will require confronting the false dichotomy present in the health system between mental and physical health. Modern medicine is more than two hundred years old, but scientists have had imaging equipment sensitive enough to monitor what is happening in the brain only over the past three decades. This relative gap in understanding led the medical community to treat mental health and physical health as two different things. Now we know that a person’s mental state is largely governed by physical phenomenon in the brain that can be positively affected with medicine.

  Addiction is a disease of the brain that can be treated with medicine to curb cravings. We have known for decades that medication-assisted treatment has higher success rates at getting addicts to complete their treatment and avoid relapses, yet less than 15 percent of Americans seeking treatment for addiction receive medication assistance.

  This is because addiction is still treated as a weakness or character flaw that must be confronted through willpower alone. In fact, addiction causes physical and chemical changes to the brain that make it difficult for addicts to stop taking the drug. Genetics also plays a huge role in who gets addicted, so everyone is not on equal footing.

  President Trump should work with Congress to break down the barriers in public and private insurance that create unnecessary hurdles to accessing these types of therapies. It makes zero sense that patients can easily obtain prescriptions for the opioids that cause addiction but face huge hurdles in trying to access medicine that can help them overcome their addiction.

  In addition, as part of his health deregulation agenda, President Trump should also instruct Health and Human Services Secretary Price to lift the outdated caps on the number of patients that doctors can treat with medication-assisted addiction treatments. Many of these caps were put in place to prevent diversion (the medicine being resold illegally on the black market) but there are now implantable versions of the medicine that last for several months and make the concern over diversion irrelevant.

  President Trump should also work with Congress to enact prison reform to move nonviolent individuals with mental health and addiction issues into separate programs designed to treat their conditions. The Federal Bureau of Prisons reports that roughly 64 percent of the jail population nationwide suffer from mental health conditions. Treating those offenders as patients rather than prisoners could end up saving billions of dollars at expensive state and federal correctional facilities. Many conservative governors in Republican states have enacted similar reforms and have had great success. This is an issue that could attract a large bipartisan majority.

  Rethink Disabilities

  More than ten million people receive disability payments from the federal government every month—approximately one in twenty working-age adults in America. This ratio has doubled since 1990, when one in forty received disability benefits, despite rising health outcomes and safer jobs during that period.

  Some of the increase can be explained by the aging of the baby boomers and the increased number of women in the workforce. However, an analysis by the Federal Reserve Bank of San Francisco shows that at least half of the increase is due to fraud. This is not only outrageous, it is tragic.

  Once people go on disability, they are unlikely to come off it. An analysis by the Washington Examiner showed that only 13 percent of these Americans have worked for pay since they started receiving benefits. These benefits are small—only about $13,000 per year—but it also includes Medicare. That means a person on disability likely receives more value by not working than he or she would with a minimum-wage job earning $15,000 per year.

  So, instead of helping people, our disability program is a poverty trap for millions of Americans. And it stands to get only worse—the number of children receiving disability payments has increased 700 percent in the past thirty years. They are being taught as children to live a life of dependence.

  Tackling this challenge will not only require tougher enforcement. We also need a cultural change in the way we think about disabilities in America.

  Disabilities have to be rethought into capabilities. Our wounded warriors teach us every day that focusing on what you can do leads to a dramatically fuller, better life than being supported in dependency, focusing on what you can’t do. We need to create this same spirit and expectation in our families and communities that the “pursuit of happiness” in America is not just a right, it is an expectation.

  In the 1990s we reformed welfare to include an expectation that you either worked or pursued a certificate or degree to enable you to get a job. We should expect the same of those on disability, except for those in the most extreme of circumstances.

  Breakthroughs in health also offer the possibility of people with debilitating medical conditions being able to make faster and fuller recoveries, so they can more quickly return to being happy and productive citizens.

  STRATEGY 3: GO DIGITAL—BUT INSIST ON INTEROPERABILITY

  The most effective way to improve the patient experience and eliminate waste and fraud in the health care system is to make it a seamless digital experience for patients, providers, and payers.

  The vision for a digital health system is for patients to be able to control all their own health data, and for them to enable any doctor or provider in the country access to that information at his or her discretion. This would eliminate duplicate care and time spent filling out and processing paperwork. It could be achieved through a smart card syst
em similar to ATMs.

  Fully digital systems for claims submission, insurance eligibility verification, and most other interactions between payers and providers would eliminate enormous costs and speed access to care. Hospitals could take most of the money they spend on administration and divert it to hiring doctors and nurses.

  Digital systems would also allow for the use of big data to discover other inefficiencies, quickly identify pandemics, and create a process of perpetual learning so doctors and providers can constantly migrate toward best practices.

  A provision in the 2009 stimulus set aside tens of billions of dollars to incentivize doctors and providers to adopt electronic health records and e-prescribing. Unfortunately, this potentially game-changing initiative was implemented in a way that frustrated doctors and didn’t achieve the interoperability goals required to make that vision a reality. In fact, the degree to which hospitals contracted with IT companies to deliberately create systems that could not communicate to trap doctors and patients within their hospital networks is a scandal worthy of hearings in Congress.

  Still, President Trump and Congress should resist the temptation to impose a one-size-fits-all digital solution on the health system. We want variety and competition to create better and better products. In addition, the disastrous launch of Healthcare.gov shows that the government is not particularly good at developing its own information technology.

  The federal government should, however, set clear standards for interoperability that providers and their digital contractors must meet on all their digital initiatives. In other words, the electronic medical record system of two hospitals does not need to be the same, but they do need to be able to communicate with each other so that patients’ data can be seamlessly transferred between them. Setting that clear standard is the type of regulation by results rather than by process discussed in an earlier chapter.

  Stopping Health Care Fraud

  The FBI estimates that between 3 and 10 percent of all health care spending in America is lost to fraud. That’s between $100 billion and $300 billion per year.

  This problem is particularly pronounced in public health programs. Jim Frogue, my former colleague at the Center for Health Transformation, wrote a book called Stop Paying the Crooks, identifying between $70 billion and $110 billion Medicare and Medicaid fraud annually. This represents $1 trillion in savings over ten years without touching a single honest person’s benefits. Making progress in eliminating fraud in public health programs would free up significant resources, some of which could be used to help low-income Americans access and afford the best treatment.

  The solution to stopping health care fraud is to look at what works in other industries. The fraud rate in the credit card industry is a miniscule one-tenth of one percent. That’s because it is almost completely digital, and expert systems have been designed to detect anomalies in spending patterns. The American health care system, meanwhile, is still mostly paper-based, and detecting fraud is difficult.

  President Trump should enlist Visa, MasterCard, and American Express to design a digital system for Medicare billing that allows the detection of fraud in real time, similar to the credit card industry. States should do the same for their Medicaid programs.

  STRATEGY 4: ENCOURAGE THE ADOPTION OF BEST PRACTICES

  Numerous studies have shown there is enormous variability in the quality of care that patients receive throughout the country. This variability is both dangerous for patients receiving lower-quality care and expensive for the health system at large.

  The National Committee for Quality Assurance estimates that 57,000 lives are lost per year because physicians aren’t using evidence-based care. Meanwhile, analysis of Medicare spending data shows that even after controlling for variables such as age, sex, and race, Medicare spending is almost two times greater in Miami than in Minnesota.4 The Dartmouth Atlas of Health Care also estimates that adopting the same quality of care as Intermountain Healthcare in Utah or the Mayo Clinic in Minnesota across all of America’s 5,500 hospitals, Medicare alone would save 32 percent—with better health outcomes.

  Part of the reason for this huge level of variation is the explosion of new science and knowledge. Doctors and provider associations have not yet implemented the sort of continuing education practices necessary for physicians to stay informed enough to make sure they are practicing best-in-class medicine.

  President Trump should work with Secretary Price to encourage the development of best-practice initiatives that would educate physicians about what the latest evidence shows is the best care. However, this initiative must be located in the private sector and not be used to ration care.

  Value-Based Purchasing

  While we must avoid rationing care, it is imperative that the health system move away from payment models that compensate doctors and providers based on the number of procedures they perform rather than the results of the care they deliver.

  There has been some modest progress on this front in the private insurance industry. Blue Cross Blue Shield of Massachusetts implemented Alternative Quality Contracts, which have financial rewards for providers who reach certain quality benchmarks and save money. The program produced significant savings and improvements in the quality of care by its fourth year. Blue Cross Blue Shield of Michigan created a patient-centered Medical Home program that demonstrated improvements in quality and prevention and saved an estimated $155 million over its first three years.

  Medicare has also begun to experiment with value-based purchasing through accountable care organizations that have achieved better patient outcomes with lower costs. These pilot projects are one of the few parts of Obamacare that should be kept. In fact, President Trump should expand them to the Federal Employee Health Benefits, the Department of Veterans Affairs, and Indian Health Service to test and source good ideas.

  Doctors’ offices are also embracing economic models that emphasize keeping people healthy rather than the quantity of visits and procedures. Some practices have stopped taking insurance and instead charge an annual membership fee for patients. In this model, doctors are incentivized to keep people healthy. Plus, they avoid the expensive overhead required to handle the endlessly complex billing and compliance issues associated with public and private insurance.

  Legal and regulatory changes should be explored that allow drug manufacturers, payers, and providers to tailor arrangements among them to incentivize payments for drugs based on measurable improvements in health outcomes. This will improve health outcomes and lower overall health costs.

  Medical Liability Reform

  The adoption of best practices and value-based purchasing will be much more likely to succeed if other incentives for doctors and hospitals to waste money are removed from the health care system. One of the most significant reasons providers waste money on unnecessary tests and other procedures is to avoid the threat of lawsuits. This practice, called defensive medicine, is estimated to cost $46 billion per year.

  The fear of malpractice lawsuits does not protect patients. Instead, it drives up costs and threatens patients’ care by distorting doctors’ decision making. Addressing the medical liability crisis will bring down the cost of care, and improve it as well, by returning doctors to making medical rather than legal-defense decisions.

  President Trump and Congress have several good models from which to design potential medical liability reform legislation. Several states have implemented reforms that protect doctors if they follow clinical care standards, cap noneconomic damages, and reduce junk lawsuits through “loser pay” laws. They have seen doctors flood into their states for the lower cost of insurance, and the residents are benefiting from increased access to care. States should also look at implementing medical malpractice models similar to workman’s compensation boards, which would resolve patients’ complaints faster and with far less money going to expensive lawyers.

  Making Coverage Affordable for Those in Need

  If Donald Trump and the Republica
ns enact these and other reforms to solve the cost crisis in health care, it will free up hundreds of billions of dollars a year in federal and state resources, making the challenge of helping the poor afford care and coverage much easier.

  Medicaid programs need to continue to protect those who currently rely on them while adopting long-term changes designed to give states flexibility to implement them and give much greater choice. Governors and local leaders understand the needs of their people better than bureaucrats in Washington do. A recent study of the Oregon Medicaid system showed that while the program did improve financial outcomes for those in the system, it did not actually improve health outcomes. All fifty states need to focus on quality-of-care reforms, like those outlined earlier in this chapter, to actually deliver better health for their poorest residents. Part of this effort should be rethinking how we use our eight thousand federally funded community health centers.

  Medicare should provide seniors with new choices. They should have the option to choose whether to remain in the existing program, or to transition to a more personalized system in the private sector. If they select the personalized system, beneficiaries should be able to receive a voucher equal to the average cost per enrollee in Medicare to help cover their private sector premiums.

  High-Risk Pools: An Alternative to “Guaranteed Issue”