11 Augustus 2017

Dear Interested Readers,


What’s Inside Plus Thoughts on the Effort to Make America Great Again

Several years ago I was captivated by the writing of Thomas Cahill who had laid out an ambitious work plan to write a series of seven books that he called the “Hinges of History.” I was hooked by the catchy title of the first book in the series, How the Irish Saved Civilization. The idea expressed by the titled seemed a bit far fetched, but the story that Cahill weaved behind the title was convincing. Cahill more than justified the title as he described the serendipitous benefits for all of us that were the legacy of the monasteries that were established following St. Patrick’s conversion of Ireland to Christianity.

As Cahill tells the story, after the fall of the Roman Empire, much of the accumulated literature and wisdom of the Greeks and Romans was burned, lost, or discarded on the European continent during the long centuries of the Middle Ages. The Irish monasteries were far removed from the dark days on the continent. The Irish monks, who were known for their artistic calligraphy, faithfully copied and preserved the classics. As the Middle Ages faded, the literature that had been saved spread across the continent. Some historians have found fault with Cahill’s tale. What I “enjoyed” most about the book was the first part where he described the disintegration of Roman society as the prelude of the Middle Ages. At times I felt like I was reading a current edition of the New York Times. We have had a lot of technology evolve over the last fifteen hundred years, but people are pretty much the same. The self interest, political corruption, and decay of the fabric of society that allowed the “barbarians” to walk in and shut down the Roman Empire with little or no resistance seems frighteningly familiar to what we are experiencing today.

I found Cahill’s next book, The Gifts of the Jews: How a Tribe of Desert Nomads Changed the Way Everyone Thinks and Feels to be more than interesting. It was uplifting. In his book Cahill described how Judaism with its sense of a relationship with a God who was an engaged partner created a sense of history that was linear and represented a progression toward a better future. Prior to this concept we were caught in a circular view of the world that was made up of endless cycles of sameness driven by the agricultural calendar and the seasons. In his book, The Evolution of God, Richard Wright also discusses this evolving and interactive “continuous improvement” type relationship between humankind and the growing awareness of the concern for others or “goodness” that is reflected from an evolving concept of a loving and supportive monotheistic deity that is replacing a judging and vengeful God. Books like these make a hopeful, positive view of a better future plausible, whether or not you believe that God exists. Most importantly either concept, with or without God, makes the future our responsibility. With a linear view of history how things change is our responsibility. We are suddenly on a journey to somewhere better, a “Promised Land.”

The story of the Jews suggests, as well as the sweep of history reveals, that we will have problems on the way. The idea that we are capable of moving toward a better place, whether it comes to us through the inspiration of a loving God or from our abilities to consider our failures and to try to continuously improve, should be a beacon of hope when the events of the moment are so frustrating and demoralizing. The examples in history that things can and usually do eventually move forward, and that lessons can be learned from previous errors of poor judgement, are comforting thoughts these days.

I am not a Pollyanna. Nothing has frightened me more, challenged my confidence in the essential goodness of America more, or threatened our collective desire to be greater, than the political experiences of the last year. Perhaps the point of all the debates and discussions of this last year has been to try to discern what being great looks like. I think that when America is great it is a beacon of hope and support for both its citizens and all humanity. The planet is too small and too interconnected for us to be only, or even primarily, concerned with our own best interest.

I have been sustained through all the political cacophony by my hopes and the reassurances that can be extracted by an occasional look back in time to see how far we have traveled and how high we have climbed toward a more just world. When I make such a statement I am not forgetting that the Middle Ages lasted more than six centuries, or that Jews have been recurrently persecuted and often despised for their abilities despite their numerous contributions that have benefited all of humankind.

Whether or not Cahill was right about the Irish monks saving civilization, we have all benefited from the wisdom of the classics. We have long ago relegated the miseries of the Middle Ages in Europe to the history books, although you can argue that in other parts of the world there continue to be abuses of human rights and people living in poverty that equals or exceeds what serfs in Europe endured; but balanced against that reality, looking back in time, there has been worldwide progress. We are positioned for even more progress if we can recognize the interdependence of all of humankind, or at least our similarities including our “inalienable rights.”

Cahill was right. It is impossible to imagine a better world denied the gifts of the Jews that have flowed from their view of history. A world without the thought of Jewish philosophers, the literature of Jewish writers, or the science and medical arts of Jewish scientists, physicians, engineers, and mathematicians would be a poorer world. Our world is fairer and more prosperous with the societal and business contributions of Jewish entrepreneurs, lawyers, judges, politicians, and economists. Our world would be duller and much less inspiring minus the paintings, sculpture, music and theater of Jewish artists.

A sense of the hinges of history does give us an advantage as we face the challenges of a volatile, uncertain, complex and ambiguous world that always seems to be on the verge of destruction under the leadership of the latest collection of self serving buffoons. History argues that they do not survive. What has survived in America up to now is a persistent pull toward greatness in a better world. What needs improving is the distribution of benefits and opportunity at home and abroad.

I disagree with the feeling of doom that is the extension of the metaphor in Yeats’s poem, “The Second Coming” that gives us a pessimistic outlook because we are in the presence of an “ugly beast” that is “slouching toward its birth.”

A shape with lion body and the head of a man,
A gaze blank and pitiless as the sun,
Is moving its slow thighs, while all about it
Reel shadows of the indignant desert birds.
The darkness drops again; but now I know
That twenty centuries of stony sleep
Were vexed to nightmare by a rocking cradle,
And what rough beast, its hour come round at last,
Slouches towards Bethlehem to be born?

Yeats wrote those words in a dark moment of history between two world wars and at a time of continued conflict and struggle in Ireland. Both wars were won. The Irish did accomplish much of what they fought to achieve, and history continues forward after lessons were learned and heinous systems of oppression and destruction were rejected. There is reason to believe that once born Yeats’s beasts can be defeated.

Each time has it’s own beasts. These days we seem to have a herd of beasts. Income inequality is a bear. The reality is that many individuals and families feel vulnerable as if they are pursued by ravenous wolves in the transition from a domestic manufacturing economy to a global economy that is built on automation and information. We all feel threatened by a beast we have never seen before, nor can we completely imagine yet, even when we have the courage to recognize the threat from climate change that none of us, no matter how great our personal wealth, can avoid as inhabitants of a crowded planet.

It is easy for our politicians to offer empty promises, point fingers, and to name scapegoats. It seems much harder for them to effectively work together for solutions. I don’t think slogans offer much defense against the complexities that face us. We won’t make America great again by attending political rallies that have the intellectual content of a pre homecoming game bonfire. Slogans without policies built on facts and experience with the objective of advantaging everyone are no more likely to appease the beasts of our future than some shamen shaking a slick at the sky and chanting magic words thousands of years ago in our prehistory. Leaders who intensify our fears, tell us convenient lies, or make us feel vindicated in our anger by enhancing the pain and suffering of the disadvantaged and the displaced at home and abroad can not be leading us toward greatness. “Getting mine at any cost” was never a strategy that ultimately diminished anxiety or created health and happiness.

I will not try to argue with those who believe that America has lost its greatness. I do believe that America and the world it leads faces great challenges and that many people feel vulnerable to the beasts that they either see or imagine. I do not negate their fear, nor do I lack sympathy for their constant sense of vulnerability. I worry about what Patty Gabow calls our “lack of social solidarity.” I worry even more about how thin our bench strength of effective leadership seems to be, but I am encouraged by the small victories of resistance of the last seven months that have preserved the ACA for the moment.

If you have read this far, you have read the main section of this letter. The remainder is built on the assumption that the votes of John McCain, Lisa Murkowski, Susan Collins and 48 Democratic senators were a first tentative step toward the possibility of a thoughtful bipartisan approach to the future of healthcare in a greater America. The discussion is an assessment of possibilities. I am encouraged by the growing courage to resist bad policy that I see in Congress, in the courts, in local government, in the actions of responsible businesses, and in the leadership from some of our traditional allies.

I am also delighted that everybody in Washington seems to be on vacation for the next month! I feel that what happens off the stage in Washington and between the congressional leaders home from Washington and their constituents over the next few weeks will be important for more than the future of the ACA. I am encouraged by the recent events in the Senate and what may follow when Congress returns from vacation. My hopes are strengthened by the articles that I am seeing about what can be done quickly to stabilize the exchanges and move us toward an ACA 2.0. I hope that the discussion will get you thinking about how you can contribute to next step forward toward better care for everyone.


Back to the Drawing Board: On The Road Again, Beyond Hyperpartisanship

Last week I discovered a new word. The spell check on Google Drive did not like some of what I had copied and pasted out of the JAMA article by President Obama. The word that Google did not know that President Obama had used was “hyperpartisanship.” The word spoke to me. It was a succinct seventeen letter expression that added nuance to Patty Gabow’s concept of a “lack of social solidarity.” How could you expect to have social solidarity in an environment of hyperpartisanship?

Sometimes we respond more to signals and physical signs of leadership than we do to words. I hope that history will reveal that John McCain’s thumb down to the “skinny repeal” will turn out to be an effective beginning in the movement away from hyperpartisanship. I have no doubt that anything that can be done to reverse the trend of the last 25 years toward hyperpartisanship will shorten the time between this moment and the day when we'll really have

...Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time,…in settings that support caregiver wellness…

Hyperpartisanship is something like a drought in an arid place. It’s hard to know when the line is crossed from “low annual rainfall” to drought. Partisanship has always been a part of our political process. The founding fathers expected and counted on the vigorous debates of a functional democracy. I doubt they foresaw the trench warfare that we have now across the aisles of Congress and in the press and other media. I am sure that there is adequate blame for both sides. Democrats have become associated with an arrogant form of political correctness and a fondness for data, studies, and rules that seem to crimp the progress of business development and the rights of ownership. It is right to point out that they should own their failures because they have ignored “grass root” politics and have forgotten their ability to communicate with broad segments of the population. Their management, when in power, has made those who believe in “self reliance,” but do not share the left’s fondness for academia and the facts of science, feel disrespected.

Feeling quite comfortable in my position as a political progressive, I make the problem worse when I date the transition from “arid to drought” to when Newt Gingrich proposed his “Contract With America”, followed by the emergence of political theater as practiced on Fox News and AM talk radio. Somehow along the way the Tea Party Libertarians, Gordon Norquist’s campaign against taxes, Mitch McConnell’s decision to use “no” in every conversation with Barack Obama, and the ability of the right to funnel huge amounts of money into divisive politics following the Citizens United decision of the Supreme Court delivered us to this moment. It is a process with a history of at least twenty years, or over thirty five years, if you want to trace its origins back to the political philosophy of Ronald Reagan.

No matter how long it has been, or how deep the divide, we will all suffer more if hyperpartisanship is allowed to continue. Worse than continuation would be for either side to be victorious. For progress and continuous improvement we need diverse opinions and an orderly process for resolution of common problems. Did John McCain start the movement away from hyperpartisanship with his speech when he returned to the Senate from his encounter with his neurosurgeon? Below I have lifted key points from his moving speech. Click on the link if you want to read the entire speech. I have bolded a few points that resonated with me.

“I’ve known and admired men and women in the Senate who played much more than a small role in our history, true statesmen, giants of American politics. They came from both parties, and from various backgrounds. Their ambitions were frequently in conflict. They held different views on the issues of the day. And they often had very serious disagreements about how best to serve the national interest.

“But they knew that however sharp and heartfelt their disputes, however keen their ambitions, they had an obligation to work collaboratively to ensure the Senate discharged its constitutional responsibilities effectively…”

“Our deliberations today ... are more partisan, more tribal more of the time than any other time I remember.

“Let the Health, Education, Labor, and Pensions Committee under Chairman Alexander and Ranking Member Murray hold hearings, try to report a bill out of committee with contributions from both sides. Then bring it to the floor for amendment and debate, and see if we can pass something that will be imperfect, full of compromises, and not very pleasing to implacable partisans on either side, but that might provide workable solutions to problems Americans are struggling with today.

“What have we to lose by trying to work together to find those solutions? We’re not getting much done apart. I don’t think any of us feels very proud of our incapacity. Merely preventing your political opponents from doing what they want isn’t the most inspiring work. There’s greater satisfaction in respecting our differences, but not letting them prevent agreements that don’t require abandonment of core principles, agreements made in good faith that help improve lives and protect the American people.

Senator McCain’s speech is a resounding rejection of hyperpartisanship. Perhaps I should have printed every word of the speech. His speech and his vote against the “skinny repeal” argue for the Senate to reject partisanship and return to the productive debates that produce the compromises that enable incremental progress. Last week I quoted from President Obama’s constructive article in JAMA. There is benefit in reviewing more than his identification of hyperpartisanship. He identified three things that he learned working to establish the ACA.

• Change is hard. Especially against the resistance of hyperpartisanship.
  
• Special interests pose a continued obstacle to change. 
  
• Pragmatism is important in legislation and implementation.
  

The practical outcome of Senator McCain’s and President Obama’s suggestions should be slow progress that seeks first to stabilize the exchanges. Legislation that guarantees the CSR (cost sharing reduction) payments to the insurers offering products on the exchanges should be job one. There is a huge literature that identifies the CSR guarantee as an urgent necessity. Drew Altman, the President of the Kaiser Foundation, has recently pointed out that it is the nearly seven million Americans who do not get subsidies in the individual market who are most vulnerable to the cost increases that will occur if there is a failure to guarantee the CSR. Those seven million individuals who buy their own insurance without public assistance are joined by the ten million Americans who have their rates protected by the subsidies offered to the exchanges through the ACA. Stabilizing the exchanges helps lower the cost of insurance for all those people. Doing something to protect seventeen million vulnerable Americans seems like a good starting place in the effort to stabilize the ACA.

David Blumenthal and Sara Collins at the Commonwealth Fund offered their thoughts recently on where to start the next phase of healthcare reform in a blog post creatively entitled, “In the Aftermath.” Number one for them is also stabilizing the exchanges. They agree that guaranteeing the CSR payments is the most important action to take. They stress the importance of making the CSR fix permanent because the uncertainty of having to wait every year to see if the government will pay is a prime reason for insurers to hedge their potential losses by raising premiums, as many have already done for 2018. They point out that the payments are already in the budget. The Trump administration has not assured us that they will be paid.

The next concern addressed by Blumenthal and Collins is the issue of “bare counties.” These are the counties where no insurer will be offering a product on the exchanges in 2018. The forty or so vulnerable counties are in Indiana, Ohio, and Nevada. Blumenthal and Collins make two suggestions. The first would be to require the largest insurer in the state participating in the Federal Employees Health Benefit Program to offer coverage in those counties. Their second option would be to allow residents of those counties without exchanges to participate in the expanded Medicaid programs of the state.

The final suggestion of Blumenthal and Collins that could make a big difference fast would be for the government to appropriate ten to fifteen billion dollars for a reinsurance pool to reimburse insurers for exceptionally high losses that could occur in the individual market. The beauty of this suggestion, in a new world of bipartisan cooperation, is that it was a Republican proposal as part of their “repeal and replace” bills to cushion the expected losses that might follow repeal of the mandate. An enforced mandate plus a reinsurance pool would be great stabilizing actions for the exchanges. Alaska does have a federally approved reinsurance program. If the Senate returns to the subject of healthcare after their vacation, and if there can be a bipartisan approach, these suggestions deserve exploration since they seem to enjoy wide support among health policy experts.

No discussion of the future of healthcare is complete without discussing the cost of care. The government, with or without a bipartisan approach, can only affect the cost by gross high level changes in payment and coverage that “nudge us” toward practicing in more efficient and effective ways. Obviously nothing is more important than insuring that every American has basic coverage for primary care and the guarantee of lifetime coverage without interruption or fear of reaching some maximum benefit level after which they would not have care. Numerous studies show that we can lower the cost of care by ensuring that everyone is covered. According to a Pew Research poll in January 2017 at least 60% of “Americans say the government should be responsible for ensuring health care coverage for all Americans, compared with 38% who say this should not be the government’s responsibility.” That is a majority opinion, but it is not the law.

One can hope that someday a benefit of a bipartisan approach to healthcare will be that we will have more than a majority of public opinion that universal coverage is morally right. It would be best to have a law that allows us to join the other advanced nations of the world with healthcare as a human right. Bernie Sanders is not giving up easily. He will soon be introducing such a bill that both makes healthcare an entitlement and provides it through a single payer approach with “Medicare For All.” The ACA is an incremental move toward universal coverage, and all of the bills that were rejected this spring and summer were large leaps away from universal coverage.

I have discovered that most healthcare providers and institutions are stuck in a world of fee for service. They ignore the fact that we have had one hugely bipartisan healthcare law, MACRA, passed in 2015 with overwhelming majorities. MACRA should be seen for what it is. It is a huge shove toward payment for value and away from payment for volume. What I fear is missing is widespread programmatic preparation for value based reimbursement. Bipartisan legislation can set the stage for cost reduction, but our practices must accept the reality that the cost of care is ultimately controlled by how we practice.

My final hope for a bipartisan approach to realizing the Triple Aim would be the eventual acceptance that we will never have a healthier population and a lower cost of care until we solve two more problems. First we will require substantial changes to entitlement programs in labor, housing and education to improve the social determinants of health. Announcing another war on drugs or paying lip service to the fact that the opioid epidemic is a national crisis as the president and attorney general have done is a start but not a solution. We have seen the movie about locking more people up and it does not end well. What is very hard to do in the fight to control opioid use, and is the other thing that we must eventually accomplish for all medical problems if we are ever going to succeed, is to redefine practice from acting on people to try to improve health to working effectively to enable them to manage their own health and medical issues. We are just getting started. As President Obama and most other effective leaders of social change realize, change is hard, healthcare is complex, no one has all the answers, and there is no way to ever realize our hopes without working together across the partisan divide.


A Question Answered and Left Coast Observations

At the end of last week’s letter I asked for help identifying the ducks in the header. I got my answer, common merganser, from my son who lives in California where I spent much of this last week. He produced pictures from the Audubon Society's, Guide to North American Birds. You can see a much better picture than mine of a mother common merganser and ducklings if you click on the link.

Long before our son and his family moved to Santa Cruz, my wife and I had been drawn to this area. We have enjoyed the beauty and geographical diversity again and again on many trips over the last thirty years since discovering it while attending a cardiology conference for CMEs in the late 80s that was produced by UCSF. Years later our son got his master’s degree from the Monterey Institute. He and his wife and son now live in the mountains above Santa Cruz where they work.

I have written many times about the joy of my walks in the redwood forests around their home. I also enjoy poking around in Santa Cruz. Santa Cruz seems a little bit like Cambridge if it was merged with Coney Island and the North Coast of Oahu. Santa Cruz is the home of the wetsuit which is as necessary for surfing the cold waters of Monterey Bay as is a surfboard.

Santa Cruz is a wonderful town to live in if you can afford it. It has one of the highest costs of living in the country. A two bedroom handyman’s dream on a 5000 square foot postage stamp lot can cost you a million. Prices are high in part because Google, Apple and all the other high tech wonders of Silicon Valley are just over the hills to the East. The millionaires that those enterprises have produced like to drive their Teslas to the beach on the weekends. Some have decided to live near the beach and commute over the mountain to work.

You can be sure that I am only a spectator when it comes to riding roller coasters and waves. I took the picture that is the header for today’s letter from the pier coming out from the center of the waterfront that divides the activities. The pier has been a landmark for more than a hundred years. The roller coasters and other challenges to your inner ear are on the right side of the pier looking inland. The surfers are on the left side of the pier out of the picture in today’s header. The round trip walk to the end of the pier is more than a mile. The treat when you get to the end of the pier is watching the sailboats and the sea lions. If you want a great seat for watching the surfers, there are closer views on a good walk from the pier up to and along the “West Cliff.” You can walk for miles as you enjoy the scenery and the show.

We are ticking off the days of summer much too fast! Including the Labor Day weekend there are only four more weekends! I hope that you have great plans for this one and the three that follow. Congress is on vacation and perhaps you will be too! As retirees, my wife and I enjoy saying that everyday is Saturday, but not every day is a summer Saturday. Those are the best, especially when the Red Sox are in first place this late in the season.

Be well, take care of yourself, stay in touch, and don’t let anything keep you from making the choice to do the good that you can do every day,

Gene