PROVIDENCE – For much of 14th century, there were two competing popes, one in Rome, Italy, the other in Avignon, France, in what became known as the Great Papal Schism, a divide centered more about politics and property than theology, according to historians.

At some point, as historian Barbara Tuchman recounted in her book, A Distant Mirror: The Calamitous 14th Century, each of the popes had excommunicated the other’s followers, creating an existential crisis, where everyone in Christian Europe, depending upon their allegiance to the competing popes, had been effectively damned to go to hell.

All the calamities – including the Black Death, which killed tens of millions across Europe and Asia – put the bleak European world on the shaky precipice of modernity. Fear drove the spread of the Inquisition, targeting the alleged heresy of Jews and Muslims. Greed to find new riches to plunder led to the “discovery” of the New World, and with it, colonization and slavery, which was followed by the American rebellion, a relative force of light in the world, challenging the divine right of kings.

We have perhaps reached a similar existential crisis here in the U.S. when it comes to our future health care delivery system, and with it, the fight to preserve our democratic republic, now on its own shaky precipice.

Swamping all boats
The reality is that rising medical costs in the name of health care threaten to swamp all boats, regardless of the outcome of the Congressional debate around whether or not to repeal, replace or repair Obamacare.

“In 2025, the cost of health care will reach 50 percent of the average of the average family income,” said Dr. Michael Fine, the current medical director at Blackstone Valley Community Health Center and former director of the R.I. Department of Health. “What we call health care has become economically unsustainable.”

Fine continued: “All the real wage growth in the nation is being sucked up by the medical costs of health care.”

Will the free market set you free?
If the current version of Trumpcare is enacted [and, along with it, the proposed Trump budget, with its dramatic cutbacks in public health, housing, environmental protection and scientific research infrastructure funding], it will hasten the collapse of an economically unsustainable health care delivery system, despite its free-market-will-set-you-free rhetoric, bringing with it the threat of a national if not global wave of pestilence.

It is worth recalling that the gate at the entrance to the German concentration camp, Dachau, in World War II, bore the slogan, Arbacht macht frei, or “Work will set you free.”

And, as in the 14th century, no chanting of incantations and shibboleths, or the public burning of alleged heretics at the stake [or walled cities or countries, for that matter] will halt the 21st century spread of economic upheaval, plague and death. Can you say Zika, Ebola, MERS, yellow fever and H7N9 flu in one breath?

The denial of scientific research and the cause-and-effect of climate change caused by human activity will not impede the rising oceans or the melting of the polar ice caps, with calamitous results.

Amidst the gloomy forecast, there are glimmers of hope: there is an undercurrent of people hard at work here in Rhode Island to change the equation and push the reset button on health care. They are focused on community needs: health equity zones, neighborhood health stations, healthy housing, and integrated models built around a continuum of care for population health.

There are also ongoing public conversations underway, an outgrowth of the Resist Hate efforts, to support a grassroots effort to resist the repeal of Obamacare.

In addition, there are organized platforms for ongoing conversations, such as the State Innovation Model effort, where some members have voiced to ConvergenceRI their desire to broaden the conversation.

The recognition is that if citizens want to take back control of their own health care, they will have to do it on their own, as part of community-based activism, pushing and prodding to bring their elected officials along with them.

Call it the “once-in-a-lifetime” opportunity to rekindle a lively experiment some 381 years after Roger Williams founded Providence as a haven for those “distressed of conscience.”

Ayn Rand gone wild
Republicans and President Donald Trump are asking Americans to endorse a new health care law that appears to have much more to do with politics, property and income redistribution than with improving health outcomes, reducing the costs of medical care or investing in public health prevention and protection.

After spending eight years blaspheming the Affordable Care Act, also known as Obamacare, as a terrible, miserable, horrible, no-good health care policy, using exaggerated, apocalyptic language and inaccurate facts to describe the dire economic consequences of what they viewed as rampant socialism by government, the Republicans have now offered their own version of health care delivery.

Call it Ayn Rand gone wild. It seems based upon what could be called supply-side, trickle-down economics in health care, where the poor are “undeserving” of health care: in the future, they will have to earn it. In her first policy letter, the new director of the Centers for Medicare and Medicaid Services, Seema Verma encouraged states to attach punitive work requirements to Medicaid recipients’ benefits.

And, as articulated at a recent news briefing, House Speaker Paul Ryan said: “The fatal conceit of Obamacare is that young and healthy people are going to go into the market and pay for the older, sicker people.” Huh?

Of course, that is exactly how the health insurance industry works, leaving many scratching their heads about what Ryan meant.

What Ryan may have been attempting to articulate is that Obamacare, through its expansion of Medicaid expansion and bringing some 20 million Americans into the health insurance marketplace, had increased the role of government, taxing the wealthy to pay more to take care of the poor.

More recently, Ryan spoke of the current effort to cut Medicaid spending as a once-in-a-lifetime opportunity. “We’ve been dreaming of this since you and I were drinking out of kegs,” Ryan told National Review editor Rich Lowry at an event hosted by the conservative magazine. In dreams begin responsibilities.

The goal of the new proposed law is to put the cost burden of the nation’s health care delivery system upon the backs of the poor and older Americans, and transfer wealth into the bank accounts of the wealthiest through tax breaks. There is symmetry between the cuts proposed in Medicaid and the tax breaks being given to the wealthy, both in the $800 billion range, according to some analysts.

Trumpcare, revealed
A careful reading of what the legislation seeks to do can reach no other conclusion than it will result in a massive redistribution of wealth, with the wealthy as winners and the poor and the middle-class as losers:

• Millions of Americans will lose health coverage; Standard & Poor’s puts the number that will loose coverage at about 10 million; the Brookings Institution puts it 15 million; the Congressional Budget Office puts the number at 24 million.

• Mental health benefits will not longer be required as an essential health benefit under the proposed Republican health care law, an admission revealed under persistent questioning from Rep. Joseph Kennedy. Those struggling with mental health and addiction recovery problems amidst the current epidemic of drug ODs will find it much more difficult to access treatment.

• Nearly $1 billion in funding for public health initiatives through the Centers for Disease Control and Prevention will be cut under the proposed elimination of the Prevention and Public Health Fund.

• Older Americans between the ages of 50 and 64 will seen their health insurance premiums rise dramatically under the proposed law, with rate restrictions changed on how much insurance companies can charge them.

• The proposed law will dismantle the expansion of Medicaid, now strategically timed to take place in 2019, after the midterm elections. If more conservative Republicans hold sway, that dismantling could occur next year in 2018.

Here in Rhode Island, that translates to the need for the R.I. General Assembly to spend between $25 million and $30 million in the first year that Trumpcare eliminates the expansion of Medicaid, in order to keep some 70,000 low-income adults from losing their Medicaid coverage, according to an analysis published by The Providence Journal. Those costs will escalate in the second year, projected to reach between $65 million and $70 million, according to the analysis.

• All federal reimbursements through Medicaid for women’s health care provided by Planned Parenthood will be cut, jeopardizing the only source of care that many women, particularly in rural communities, can access for reproductive health care.

When CNN’s Dana Bash asked Health and Human Secretary Tom Price what would happen to the women who rely on Planned Parenthood for health care, specifically about those who live in the 105 counties where Planned Parenthood is the only clinic that offers women the full range of contraceptive services, Price replied: “Well, I’d be interested in the list you have.”

The list was compiled by the National Coalition To Prevent Teen and Unplanned Pregnancies, which did extensive research on so-called contraceptive deserts, according to a story posted by Vox. The organization found that some 3.1 million women in the U.S. who need publicly funded contraception live in counties with zero publicly funded clinics. [See link below to view the full list of the 105 counties where Planned Parenthood is the only full-service reproductive health clinic.]

The war of the words
What is most remarkable about the effort to the repeal and replace Obamacare is the manner in which Republicans have appropriated the rhetoric of health care reform.

“Today’s markup [of the legislation] is a critical step to providing all Americans with affordable, patient-centered health care that is tailored to their needs,” said Rep. Kevin Brady, the Republican Chair of the U.S. House Ways and Means Committee. Patient-centered?

The language employed by Brady, in turn, appears to come directly from the Heritage Foundation, a conservative, right wing think tank run by former Sen. Jim DeMint.

“Health care reform should be a patient-centered, market-based alternative that empowers individuals to control the dollars and decisions regarding their health care,” the Heritage Foundation website declared.

The phrase, patiented-centered, is also associated with a basic component of health care reform innovation, with the goal of creating an all-payer [including both commercial and government health insurers], patient-centered medical home for primary care, with the goal of increasing access to care and, in the long run, reducing costs through prevention.

In Rhode Island, a pilot program known as the R.I. Chronic Care Sustainability Initiative, launched in 2009 by former R.I. Health Insurance Commissioner Christopher Koller, now known as the Care Transformation Collaborative, currently has some 73 primary care practice sites as members, providing more than 320,000 Rhode Islanders with access to a “patient-centered medical home.”

That’s one-third of the state’s population, and the goal is to add practices over the next few years to provide access to primary care through such “patient-centered medical homes” to 500,000 Rhode Islanders, one-half of the state’s population.

The Collaborative has also expanded to include PCMH-Kids, for pediatric coverage. [See link to ConvergenceRI story below.]

Changing the vision
The unsustainable numbers tell the story, according to Fine. Nationally, for every community of 10,000 people, roughly $100 million a year is spent on medical care. In Rhode Island, Fine continued, some $12 billion was spent last year on health care. The average increase in health care costs is between 6-12 percent a year. “That’s about $500 million a year in added costs of health care inflation,” Fine said.

Fine is hopeful that what will emerge following what he called “the Sturm und Drang [storm and stress] over what’s going to happen with the Affordable Care Act” will pivot to a focus by more and more communities to start work on developing their own solutions, including neighborhood health stations.

Fine has championed the concept of neighborhood health stations in Rhode Island, with two now operating – one in Central Falls, the other in Scituate – with the focus on responding to the health needs of the community, not the needs of providers.

Nationally, the Lown Institute, which seeks to catalyze grassroots movements for transforming health care system to improve the health of communities, is working to develop local chapters to encourage spending on health care that benefits patients and communities, according to Fine.

The answer, Fine said, is for folks to begin to shape their own health care systems in their own communities.

Is there a reset button to push?
In Rhode Island, the health care delivery system has already entered a crisis mode. The two biggest health systems, Lifespan and Care New England, are losing money.

The next phase of “musical chairs” in the consolidation of hospitals appears imminent, with Care New England seeking to align with a new partner and to sell off Memorial Hospital as soon as possible, which is hemorrhaging red ink.

The largest commercial health insurer, Blue Cross & Blue Shield, has also reported losing money. And Neighborhood Health Plan of Rhode Island may take a shave in the proposed FY 2018 state budget, losing some $12 million in administrative fees for lack of outcomes in its management of Rhody Health Options.

Much of the work to develop accountable care organizations under Medicare and accountable entities under the state Medicaid office, focused on global payments that reward value-based spending over volume, could be jeopardized by the enactment of Trumpcare.

There is no action plan in place – if there is, no such plan has been shared publicly – by Gov. Gina Raimondo’s team to respond to dramatic cuts in funding for Medicare and Medicaid promised under Trumpcare.

The rat’s nest that resulted in the botched rollout of the $346 million United Health Infrastructure Project will not be fixed anytime soon; it could take as long as a year, according to interim director of the R.I. Department of Human Services, Eric Beane.

In turn, Raimondo and R.I. House Speaker Nicholas Mattiello have become embroiled in major disagreement over spending priorities that has nothing to do with the looming health crisis: Mattiello is pushing an agenda for repeal of the car tax, and Raimondo is pushing her program of free college tuition two years of college for Rhode Island high-school graduates.

How will Rhode Island respond moving forward? It’s unclear. How much money is the state willing to invest in preserving the current level of Medicaid services? Probably very little, if any, given the focus on reducing spending at the State House.

What’s at stake?
Last week, news broke that Ventas, Inc., a Chicago-based real estate investment trust, had purchased the South Street Landing building for $130 million and adjacent property for an additional $21 million, according to reporting by Kate Bramson in The Providence Journal.

The South Street Landing project, when completed, will serve as the home for Brown University administrative offices and the shared Nursing Education Center for the University of Rhode Island and Rhode Island College.

Ventas is affiliated with Wexford Science & Technology, which committed an undisclosed investment in 2015 to help CV Properties buy the South Street Landing property, as reported by Bramson.

CV Properties and Wexford are also preparing to build a biotech innovation center and a hotel on the former Route 195 property.

It is the kind of commercial real estate deal that CommerceRI’s Stefan Pryor excels in.

But what happens if and when the Trump budget is enacted, with its proposed massive cuts for research funding for the National Institutes of Health and the National Science Foundation?

Much of the planned innovation center is based on the research partnerships between Brown University and the University of Rhode Island with Care New England and Lifespan. What happens if both health systems are forced to curtail activities because of the double whammy of major reductions in Medicare and Medicaid funding and cuts in scientific research grants. Will the research enterprise at the universities be forced to contract in response to the loss of federal funds?

Further, the joint Nursing Education Center serving the nursing programs at URI and RIC is based in part of the assumption of the growing demands for the nurses in the workforce. What happens if that demand is curtailed because of the shrinking health systems caused by Trumpcare and the Trump budget?