The Leg.Up Local, state and national news of interest to the physician community January 25, 2017 Dr. Atul Gawande on "The Heroism of Incremental Care" Click here to read "The Heroism of Incremental Care," the latest New Yorker essay by Dr. Atul Gawande - a past speaker at RAM. Gawande describes the case of a patient who has "spent almost four decades under attack from the inside of his skull" from "severe migraines that felt as if a drill were working behind his eyes, across his forehead, and down the back of his head and neck." "He saw all kinds of doctors - primary-care physicians, neurologists, psychiatrists - who told him what he already knew: he had chronic migraine headaches. And what little the doctors had to offer didn't do him much good." Gawande describes the many symptoms of migraines -- whose cause he says "remains unknown" -- and the multiple treatments the patient tried. At the John Graham Headache Center in Boston, Gawande explores a process where "success meant that the headaches became less frequent and less intense," and "that the patients grew more confident in handling them." Bottom line: "Success would be incremental." Click here to read Gawande's essay on the power of "incremental care," which often clashes with our "heroic expectations of how medicine works." Atul Gawande is a surgeon at Brigham and Women's Hospital in Boston, a professor at Harvard T.H. Chan School of Public Health and the director of Ariandne Labs. His latest book is "Being There." Trump's ACA Order Rattles System President Trump's executive order instructing federal agencies to grant relief to constituencies affected by Obamacare "has begun to reverberate throughout the nation's healthcare system, injecting further uncertainty into an already unsettled insurance landscape," reports The Washington Post. The order Trump signed several hours after he was sworn into office Friday signaled that his administration will move quickly "to unwind as many elements at it can on its own - elements that have changed how 20 million Americans get health coverage and what benefits insurers must offer some of their customers." But, the Post notes, "the practical implications of Trump's action on Friday are harder to decipher." The order instructs all federal agencies to "waive, defer, grant exemptions or delay" any part of the Affordable Care Act that imposes a financial or regulatory burden on those affected by it. "That would cover consumers, doctors, hospitals and other providers, as well as insurers and drug companies," the Post reports, adding that "the prospect of what could flow from pulling back or eliminating administrative rules - including no longer enforcing the individual mandate, which requires Americans to get coverage or pay an annual penalty, and ending health plans' 'essential benefits' - could affect how many people sign up on the [ACA] marketplaces before open enrollment ends Jan. 31 for 2017 coverage, as well as how many companies decide to participate next year." Click here to read more about what one health policy consultant called a "bomb" lobbed into the law's "already shaky" insurance market, which is expected to operate at least through 2018. After that, hold on to your laptops! And click here to read how Trump's first order has strong words on health, but it's "actual impact my be weak" for now. The $64,000 question is what happens after all of Trump's cabinet picks -- at HHS, Labor and Treasury -- get to work. "Many of the administration's options might be more difficult than they first appear," Kaiser Health News reports. Kaiser quotes Washington & Lee University emeritus professor of law Timothy Jost who said any major stripping of federal health insurance benefits would have a ripple effect across all 50 states, nearly all of which have enacted new laws to come into compliance with the ACA. Those states "might have to repeal or amend their laws if the ACA were repealed," Jost said. Then there's the no-small matter of complying with public notice provisions. Meanwhile, "Several Republican senators on Monday proposed a partial replacement for the [ACA] that would allow states to continue operating under the law if they choose, a proposal meant to appeal to critics and supporters of former President Barack Obama's signature health law," reports The New York Times. But the plan was attacked by Democrats as a step backward from the ACA and snubbed by conservative Republicans "who want to get rid of the law and its tax increases as soon as possible." The Times notes that the proposal - by Dr. Bill Cassidy, a Republican senator from Louisiana, and Sen. Susan Collins of Maine, "a moderate Republican" - may "show how difficult it will be for Republicans to enact a replacement" for the ACA. Read this column in Sunday's RTD by Dr. Michael D. Williams, a surgeon and director of UVa.'s Center for Health Policy. He advocates paying attention to "the social determinants of health," saying, "If we don't pivot our attention and resources to affecting the social factors that have much more to do with wellness than insurance, we will continue to spend too much money without improving our nation's health and remain a nation that wastes time on discussions about who's paying for it and not what we're paying for." Dr. Price Grilled by Senate Panel At a testy Senate confirmation hearing Tuesday, Dr. Tom Price - President Trump's pick as the next secretary of HHS - declined "to promise that no Americans would be worse off under [the president's] executive order to ease provisions" of the ACA - "and distanced himself from the president's claim to have an almost- finished plan to replace the law," reports The Washington Post. Price, a six-term Georgia congressman and an orthopedic surgeon, "sought to play down the influence he could have on reshaping the health-care system along conservative lines, while attempting to deflect accusations from Democrats about his ethics." Asked about Trump's recent statements that his healthcare plan would provide "insurance for everybody," with a plan ready to be released after the HHS chief is confirmed, Price would only say, "It's true that he said that, yes." No date has been set for Price's confirmation by the full Senate. Price did say that he does not support the privatization of Medicare (click here to read more) and defended his fellow Republicans' plans to create a block grant system for Medicaid. Click here to read "Everything You Need to Know About Block Grants - the Heart of GOP's Medicaid plans." Last week, Price came under fire for his extensive investment portfolio. Click here to read more. "Some exchanges were particularly sharp," as progressive Sen. Elizabeth Warren (D-Mass) "lectured Price so persistently on his stock trading that he declared himself 'offended."" Price maintained that he hadn't tried to take advantage of his public position and wasn't aware of what precise stocks he held. "Everything that I have done has been aboveboard, ethical, transparent and legal," he said, denying any conflict stemming from the stock purchases. The Wall Street Journal reported in December that since 2012, Price had traded more than $300,000 in shares about 40 health, biomedical and pharmaceutical companies while he was involved with legislation that might affect those firms' stocks." Click here to read more. Kaiser Health News noted that while Price "is taking the heat for his controversial stock holdings," federal records show several senators who will take part in his confirmation hearing have substantial health-related holdings as well." Among them: both Virginia senators, Tim Kaine and Mark Warner. Rick Mayes on TrumpCare Click here if you'd like to see a slide show of Dr. Rick Mayes' recent talk to RAM members at the January General Membership meeting. The UR political science professor and health economist began by laying out the complex political calculus facing Trump and the GOP leadership in Congress. A theme of his talk came from a slide showing Gen. Colin Powell's signature line about invading Iraq, otherwise known as "the pottery barn rule": "You break it, you own it." As he pondered the choices ahead for Team Trump, Mayes mentioned a couple of his favorite authors on healthcare reform: Dr. Atul Gawande, and "Overkill" in The New Yorker; and Avik Roy, who wrote "Transcending Obamacare: A Patient-Centered Plan for Near-Universal Coverage and Permanent Fiscal Solvency." By keying on income-based tax subsidies and giving states more leeway in how they spend Medicaid block grants, Mayes said of Roy, "If you took his plan, you could replace Obamcare today." But Roy - who's been an adviser to other Republicans such as Sen. Marco Rubio and Mitt Romney - also wrote a strongly-worded essay, "Saving Conservatism from Trump's GOP" in the November issue of The Atlantic. Click here to read that. "Trump hates this guy and he won't be getting any appointments," Mayes said. "I think it's a tragedy." House GOP Plans Push on Direct Primary Care Plan In a reprise of a bill from last year's legislature, "Republicans in the Virginia House of Delegates will be pushing legislation again this session to promote direct primary care agreements, in which patients pay a fee for unlimited primary care," reports The Washington Post. Del. Steven Landes (R-Augusta) outlined state GOP healthcare priorities last Thursday. The direct care bill was among them as he argued that such agreements would increase access to care. Gov. Terry McAuliffe vetoed the measure last year last year, saying such primary care agreements are not insurance and cannot be regulated as such.