| 11 November 2016
Dear Interested Readers,
I Was Not So Surprised: What’s Inside This Week’s Letter
You might remember that it was back at the time of the nominating conventions in late July and early August that I decided to use this weekly letter to review the election in the context of the future of healthcare. My goal was to offer a balanced perspective and analysis that would prepare us to be able to accept any outcome. I was hoping for the continuation and improvement of the work done through the ACA to bring us closer to the Triple Aim, but I was not deaf to the anger about the ACA and recognized that anger and deep divisions within both parties and between the parties on many issues had produced a very uncertain outlook for the outcome of the election.
In retrospect, the outcome should not have been a surprise. The “establishment” Republican party did not really win. The current Democratic party seems to have lost its traditional labor base. The pundits are now debating the uncertain future of both parties. A candidate that no one but the disappointed, angry, and fearful really wanted won by passionately violating most norms of interpersonal civility and by the manipulation of a press more interested in entertaining than informing its listeners and readers. An “as if” Republican who eschewed the conventional political thinking of both parties and their elites turned the world upside down functioning as an independent who understood and could manipulate anger and fear. His words defied accountability. His intuition was so accurate that he knew he could win, even if he “shot someone on the street in New York.” Yes, it has happened before in other places and at other times.
You have heard me assert before that I believe all strategic considerations should include the concept that we live in a world that is volatile, uncertain, complex and ambiguous. I still do. One of the most important competencies for a VUCA world is “dilemma flipping”. In this letter I try, but do not succeed to my own satisfaction, to flip the dilemma of the current political moment, into an awareness that we may have an unexpected opportunity to improve healthcare in America with Donald Trump. I intend to continue this focus in the weeks and months to come.
It has been my concern that good people from all parts of our complex society have allowed a wide gulf to emerge in many dimensions, but most significantly in race, gender and economic equality. Those divisions have been created by deeply held attitudes and opinions that seem irreconcilable and are exacerbated by fear. Our differences have divided us in ways that we have not learned how to productively discuss. As a result of our differences and the deepening of our anger against one another we seem not to have the sense of community and social solidarity that is necessary to resolve our complex problems. Donald Trump did not create the divisions, but he fostered them and saw the opportunity they offered. Those divisions created a space into which he has deftly stepped. Is he a genius or just a lucky opportunist? This last year and a half of hostile campaigning in both parties has greatly deepened the divisions and he has deftly acted to widen those divisions as they have created and enhanced his opportunity. Prior to the election I was concerned that the divisions would still exist and be worse post election no matter who won. There was no question in my mind that a Clinton victory would be followed by four years of hassle and resistance that would surpass all of the self induced embarrassments of the nineties and all of the unearned venom that has been heaped on Barack Obama for the last eight years. I am convinced that much of the push back against the President was because of his race and not his policies and that had Hillary Clinton been elected president many would have resisted her leadership because she is a woman. We still have a long road ahead of us in issues of equality.
When I began writing about the election my objective was not to try to influence your vote but rather to begin to prepare for a dialogue about how to go forward after the election. I was also very concerned that healthcare had been lost as a significant issue that was not getting the discussion it deserved. In over four hours of face to face debate between the two candidates healthcare got less than fifteen minutes of discussion. I was worried that no matter the outcome of the election progress toward the Triple Aim, or progress on any shared concern, would continue to be difficult because of the deep divisions in our society that would not be resolved by an election.
I respect everyone’s right to their personal view of the world and the opinions that they extract from what they believe and what they have experienced. I was certain before the election, and am more certain now, that the group that I affectionately think of as “Dear Interested Readers” includes supporters of both candidates, and that even in our shared conversation about healthcare and the Triple Aim we have not evolved a common view of the way forward within healthcare. I believe that progress in any negotiation requires identification of shared concerns. Progress can only occur if we share enough of ourselves to allow the evolution of adequate trust or acceptance of risk to explore possible solutions that could benefit everyone. More recently I have tried to suggest and describe a mindset for the work of healthcare transformation that would be beneficial no matter what happened in the election.
Some years ago I realized that I practiced medicine from the perspective of dealing with “the worst case scenario” and then working back from that position. I always felt best when I knew that my patient would survive the greatest possible challenge that we could imagine. My job was not to be lulled into ignoring the subtle signs that things might be worse than they appeared or be blinded by my hope that all was really well when it was not. I used the same approach as a CEO. My concern about the “worst case” and my responsibility to do everything that I could to prepare our practice for that worst case drove a lot of my colleagues to disagree with what I challenged them to do. Some thought I was unrealistic in my concerns. It is not much of a consolation to me that time has proven me to have been correct with most of my worries.
Perhaps it was my concern that there was a real possibility that Donald Trump might win the election and would force the repeal of much of the ACA that was at the root of my desire over the last few months to try to imagine a way forward that was not dependent on the outcome of the election. I was very uncomfortable with my uncertainties about the election. It was difficult to have conversations with family and friends who did not want to consider any outcome that did not make sense to them. I tried unsuccessfully to accept their confident assurance and reasons why I should not be so concerned. As I have told you, I spent a lot of time reading 538 looking for reassurance. Watching Stephen Colbert’s and Saturday Night Live’s humorous attacks on the President-Elect’s unusual manners helped assuage my fears for a few moments at a time, but in the back of my mind I suspected that something was wrong and that perhaps the spoofs were just fueling his success.
My well intentioned attempts to assure myself and you that we could deal with any outcome of the election and continue to make progress toward the Triple Aim have made it a little easier to write this week. I will admit that when I realized that the failure to win Pennsylvania, Wisconsin, Michigan, Ohio, North Carolina or Florida represented the fatal end of Hillary Clinton’s effort, I was consumed with dread and fear. My pre work, however, did prepare me for a truncated Kubler-Ross process. Having already processed “denial”, “anger”, and “bargaining”, I was ready to quickly move through “depression” and arrive at “acceptance”. In my post election reading on Wednesday I was surprised to discover that Michael Moore, the controversial movie producer of “Bowling for Columbine” and other documentaries, had been way ahead of me all along. He was not only emotionally preparing himself for the possibility of a Trump election, he was certain that it would occur and was trying to do something to prevent it.
I anticipated that I would be distraught with a Trump victory. As I reported to you, I was also certain that if the election did not lead to a Clinton presidency, I would feel that I had been part of the problem if I had not been engaged in working for her success. That self protective motivation was perhaps not the most laudable reason to be a campaign volunteer. You can be sure that I would have been sitting on the sidelines without any sense that I should get involved, if I had not been worried.
Being a volunteer was a great experience. I saw my community in new ways during four different sessions of going door to door. Election day was the best. After voting in the morning I spent a wonderful afternoon meeting a variety of people in my town. The objective on that last day was not “sales” but rather getting out the vote. It was a success. In my little town Clinton won 1765 to 1064. We voted for Maggie Hassan for Senate 1625 over 1283 for the incumbent, Kelly Ayotte. Those margins were a large part of the victory for both of them in New Hampshire. Sadly, contributing to a win for Clinton in New Hampshire made no difference to the outcome of the presidential election. I will admit to a sense of satisfaction from being a small part of the effort to gain one seat in the Senate.
This week’s letter represents continuing work on “acceptance.” My objective is not to defend the ACA which most likely will be repealed in part or completely, and may or may not be replaced with any legislation of value, but rather to show how the ACA may have already given us the benefit we needed and has given us valuable information about what will be better. I also hope to convince you that holding Donald Trump and the Republican leadership accountable to their promise to replace the ACA with universal coverage that is affordable does offer opportunities that working with Hillary Clinton against their continued resistance may never have produced.
Earlier this week on strategyhealthcare.com I posted a revised edition of last week’s letter about the I-Thou mindset and the foundational work that will be required to find solutions that serve the interests of everyone in our community. The piece was written before the election with the explicit hope that it would be beneficial after the election. As always I hope that you will share these letters with friends and share your feelings and comments with me.
I hope that you will not forget that today is Veterans Day. I was never a soldier, but I have always been proud that my favorite uncle was a decorated paratrooper. He parachuted into France behind Omaha Beach the night before D-Day as part of the famous 507 (saving Private Ryan outfit) and was decorated for his bravery. He was wounded at the Battle of the Bulge. He never talked about his Bronze Stars or his Purple Heart, but I saw the scars from his wounds when I was a little boy. After the war he was educated by the GI Bill. At the time of his death in 1969 from colon cancer, he was the head of the counseling services for the school system of Oneonta, New York. He was a patriot and a contributor to his community. I think of him frequently and always on Veterans Day. I hope that you will find some appropriate way today to remember our Veterans.
The Road to The Triple Aim Has Never Been a Super Highway
When President Elect Donald Trump visited Washington yesterday to meet with President Obama, Speaker Ryan and Senate Majority Leader McConnell he was asked by the press what his priorities would be. His answer was, “Immigration, healthcare and jobs.” There is every reason to believe that, as promised, he will attempt to abolish the ACA. There are questions about how it will happen. It is also very uncertain what will replace the ACA.
When thinking about the future of healthcare it is important to begin by asking what the President Elect’s healthcare opinions and priorities are. His campaign did post a healthcare white paper on his website which I have referenced before. It begins much as you might expect.
Since March of 2010, the American people have had to suffer under the incredible economic burden of the Affordable Care Act—Obamacare. This legislation, passed by totally partisan votes in the House and Senate and signed into law by the most divisive and partisan President in American history, has tragically but predictably resulted in runaway costs, websites that don’t work, greater rationing of care, higher premiums, less competition and fewer choices. Obamacare has raised the economic uncertainty of every single person residing in this country. As it appears Obamacare is certain to collapse of its own weight, the damage done by the Democrats and President Obama, and abetted by the Supreme Court, will be difficult to repair unless the next President and a Republican congress lead the effort to bring much-needed free market reforms to the healthcare industry.
But none of these positive reforms can be accomplished without Obamacare repeal. On day one of the Trump Administration, we will ask Congress to immediately deliver a full repeal of Obamacare. However, it is not enough to simply repeal this terrible legislation. We will work with Congress to make sure we have a series of reforms ready for implementation that follow free market principles and that will restore economic freedom and certainty to everyone in this country. By following free market principles and working together to create sound public policy that will broaden healthcare access, make healthcare more affordable and improve the quality of the care available to all Americans. (I did not bold the last sentence. That is the way it was written.)
I believe that these paragraphs suggest:
- On day one he will ask for repeal of the ACA
- A replacement will be drafted that is built on free market principles that will be based on Speaker Ryan’s paper entitled “A Better Way”
- He really does hope that he can give America the care it wants for a price it can pay
- He does not know what he does not know about the issues that challenge us, the structure of how healthcare works, or what we have learned during the last half century of trying to provide care to more people at an affordable cost
What follows are seven points that emphasize the rights of the individual and a belief in markets to solve most problems including complex social problems based in economic inequity. More indefensible is a belief in the ability of local government to manage entitlements to resolve long term issues of inequity in services to those dependent on public assistance:
1. Completely repeal Obamacare. Our elected representatives must eliminate the individual mandate. No person should be required to buy insurance unless he or she wants to. [The slogan our the license tags in New Hampshire is “Live Free or Die”]
2. Modify existing law that inhibits the sale of health insurance across state lines. As long as the plan purchased complies with state requirements, any vendor ought to be able to offer insurance in any state. By allowing full competition in this market, insurance costs will go down and consumer satisfaction will go up.
3. Allow individuals to fully deduct health insurance premium payments from their tax returns under the current tax system. Businesses are allowed to take these deductions so why wouldn’t Congress allow individuals the same exemptions? As we allow the free market to provide insurance coverage opportunities to companies and individuals, we must also make sure that no one slips through the cracks simply because they cannot afford insurance. We must review basic options for Medicaid and work with states to ensure that those who want healthcare coverage can have it.
4. Allow individuals to use Health Savings Accounts (HSAs). Contributions into HSAs should be tax-free and should be allowed to accumulate.
5. Require price transparency from all healthcare providers, especially doctors and healthcare organizations like clinics and hospitals. Individuals should be able to shop to find the best prices for procedures, exams or any other medical-related procedure.
6. Block-grant Medicaid to the states. Nearly every state already offers benefits beyond what is required in the current Medicaid structure. The state governments know their people best and can manage the administration of Medicaid far better without federal overhead. States will have the incentives to seek out and eliminate fraud, waste and abuse to preserve our precious resources. [I am not sure that state and local governments do a better job than the federal government with fraud and abuse in other public contracts.]
7. Remove barriers to entry into free markets for drug providers that offer safe, reliable and cheaper products. Congress will need the courage to step away from the special interests and do what is right for America. Though the pharmaceutical industry is in the private sector, drug companies provide a public service. Allowing consumers access to imported, safe and dependable drugs from overseas will bring more options to consumers.
The objectives of the Triple Aim could theoretically be met by implementing these seven points if some big “ifs” are fulfilled and serious questions resolved.
- If the mandate is abolished what mechanism will insure the integrity of the insurance pool? How will the abolition of lifetime limits and the prohibition of bans on the negative impact of preexisting conditions be financially mitigated in what will be essentially a free market system?
- The ability to sell insurance across state lines is a favorite Republican solution to high healthcare costs. Theoretically insurers will compete for business. In many places in America there is no choice between providers. It is unclear to me how competition among insurers fixes this problem. In places where there are many physicians and hospitals as well as many insurers, providers are often in every system. Healthcare is a business where traditional market forces have never worked to lower costs. I hope that I am wrong but this seems like an empty suggestion.
- Replacing subsidies in the exchanges with tax credits for everyone ties the subsidy to income. This will certainly benefit many in the middle class who get no subsidy now. Low income patients who pay little or no income tax will need a different mechanism for support to cover the cost of care if the current exchange support of the ACA is abolished.
- Giving money to the states to use as they will to cover Medicaid patients without establishing the criteria of the care that will be provided or the promise that all citizens under 138% of poverty will be covered adequately, places a lot of responsibility on states to do the right thing when at least 18 of them have not expanded Medicaid under the ACA.
- The HSA option does sound attractive as a way of helping middle class families deal with the high cost of care. It does not guarantee that coverage will be affordable.
- Transparency is a laudable goal that we have not achieved. Transparency is necessary for consumer driven care, but it does not insure better coverage and lower costs, especially for patients who have difficulty negotiating complex programs and economic algorithms.
- Buying drugs back from other countries where they are sold for a lower price seems to have many potential problems associated with it. Reversing the decision not to use the government's leverage as a purchaser of large quantities of drugs does seem like a logical move.
Last month in the NEJM Gail Wilensky wrote an excellent analysis of the Republican proposals for healthcare. What she so aptly describes are the realities of the legislative process that will make total repeal of the ACA very difficult. There is much that can be done by executive order to impair the delivery of care through the ACA, but substantial improvement will require negotiation and compromise. Almost all experts point to the reality that the transition will surely cost many of the 20 million new recipients of care the coverage that they now enjoy. Many of the people who have enjoyed having their children remain on their policy until they were twenty six or now can buy insurance even though they have a preexisting condition did vote for Donald Trump and Republican members of the House and Senate. How the politics of taking away these often overlooked or unappreciated benefits of the ACA will be managed is now a consideration that is real and requires a solution. Issues can be avoided during a campaign that become unavoidable when it is time to lead and govern.
It is my opinion that through the ACA we have learned a lot about how difficult it is to provide universal coverage and lower the cost of care. It is harder still to provide better care to everyone at a lower cost. More than a decade ago, even before the Triple Aim was a precise concept, I postulated that only Republicans could enact universal care at a sustainable cost and quality that was comparable to the care provided in other advanced economies. I predicted that they would do it when they decided it was necessary for the economy. I also predicted that they would always vigorously resist any attempt by the Democratic Party to introduce reform before they really understood it was good for business. My analysis used trade with China as an example. Nixon and Kissinger opened China when it was better for business to look at the economics than fear their communism.
Taking care of business has determined much of our Middle East policy. Under President Trump doing what is expedient for business will perhaps be a new driver in our thinking about Russia. In Steven Brill’s interesting analysis of the ACA, A Bitter Pill, he points out that the ACA does a nice job of taking care of business which is a fact that seems lost on the President Elect who has not yet convinced anyone that he has a deep understanding of any political issue beyond the deep anger and insecurity of white men. Will he quickly learn that taking care of the health of the nation is a business priority that requires durable and pragmatic solutions that have more substance than his seven points? I would like to think so.
In a strange way I am more hopeful about the future of the Triple Aim under the leadership of Donald Trump if we can stay in conversation with him and hold him accountable than I would under A Democratic President. Hillary or Bernie would have tried hard against great resistance. If Donald and Paul try at all, and we help them, we could make progress. In doing so we must demand that what gets passed has a chance to really work. The midterm elections are less than two years away and it is only 3 years and 51 weeks until the next Presidential election. Let’s see how much real progress can be made with a new ball carrier. Like President Obama I will be cheering for Donald’s success and hoping that he learns quickly. His success will be success for all of us. At the least, I know that I will have plenty to write about over the next 207 weeks, just as I have had plenty to say over the last 450+ weeks.
The low point of the President Elect’s analysis is to note that we spend a lot of money providing care to illegal immigrants:
Providing healthcare to illegal immigrants costs us some $11 billion annually. If we were to simply enforce the current immigration laws and restrict the unbridled granting of visas to this country, we could relieve healthcare cost pressures on state and local governments.
The paper posted on Mr. Trump’s website ended with then assertion that if elected he will do the job:
To reform healthcare in America, we need a President who has the leadership skills, will and courage to engage the American people and convince Congress to do what is best for the country. These straightforward reforms, along with many others I have proposed throughout my campaign, will ensure that together we will Make America Great Again.
Now, with no other choice other than acting like Mitch McConnell did with President Obama and vowing to do everything we can to insure his failure, I choose to embrace Mr. Trump’s promise albeit with some skepticism about his abilities, and pledge to do whatever I can to help him deliver the Triple Aim for all of us.
Working Hard on Depression and Acceptance
Did you stay up until the bitter end on Tuesday night? I made it until about two AM and then slept for a couple of hours before getting up to the nightmare of hearing that Hillary Clinton had conceded the election. After watching Baron Trump yawn through his father’s superlative laced victory speech, I went back to bed for a couple of hours before arising in a new era.
Monday had been a glorious day. My wife and I were on a high from having canvassed all afternoon on Sunday and then going to see and hear James Taylor and Hillary at a rally in Manchester on Sunday night. A visiting friend and I took a long walk over the hills, through woodland trails and stopping to enjoy the views from Burpee Road and Clark Point above Lake Sunapee. The picture in today’s header gives a sense of what you can see looking west at sunset from Burpee Road. Tuesday was a warm, glorious day of blue skies, big smiles and waves at people holding signs at the poll, followed by six miles of door to door visits asking people if they needed a ride to vote.
On Wednesday there was no sun. The clouds hung low and gray over the hills and lakes. Everyone I saw seemed to be in a daze. Every commentary in the newspaper, online, and over the airways was an annoyance. I discovered that thinking about family members and the holidays ahead made me feel a little more hopeful. I took a long walk by myself and tried to think what I might say in this week’s letter.
Yesterday we did a blitz trip to Brookline for dental work. Just negotiating Route 93 into the city and the bumper to bumper traffic over the Zakim Bridge to Storrow Drive made me anxious and reconsider why I had not found a dentist in New Hampshire. I do a lot of my writing while my wife drives. For some reason I looked up from my computer about the time we were approaching the state line on the trip home. The voice on the radio was talking about Donald Trump’s tour of Washington. He had seen Obama, Paul Ryan and Mitch McConnell. For some reason I looked at the car that we were about to pass. What I saw was an incredulous message. The car had a vanity plate that said, I THOU.
|
| 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
Dr. Gene Lindsey
|
| | | | | |
