13 April 2018

Dear Interested Readers,


Healthcare and The Continuing Circus in Washington

What Washington story are you following most closely? Is it Robert Mueller’s slowly unfolding investigation of just what the Russian’s might have done to make what happened to make the election of 2016 the equivalent of a political assassination? So far the biggest part of the story that we can actually see is the tension between the man who says nothing and the man who says nothing happened, but nevertheless seems always one ill advised tweet away from beginning a political armageddon. I well remember how the story unfolded after Nixon fired Elliot Richardson for not firing Archibald Cox. Perhaps the president is unaware of the “Saturday Night Massacre,” or thinks it was a movie. You may have forgotten the whole story, but Nixon commanded Attorney General Elliot Richardson to fire the special prosecutor, Archibald Cox. Richardson, being an honorable man resigned. Nixon then commanded Deputy Attorney General William Ruckelshaus to do the deed and he resigned rather than soil his name. Focused on completion of his objective, and tone deaf to the whole sordid idea of firing Cox, Nixon then asked Solicitor General Robert Bork who was by then the acting AG to fire Cox and he did.

I wonder how much Bork’s participation in that Saturday night act was in the minds of those who later denied him a seat on the Supreme Court. I also wonder if any of this ever crosses the president’s mind. I do remember that it seemed like a very long time between the massacre and the day Nixon resigned in August 1974. In reality it was a little less than ten months. This remake of a classic political drama may unfold more slowly than the original, and have more plot twists but something tells me that the president protests too much for there to be nothing. If it is not a story like the Watergate, it is a story that feels a little bit like a continuing series like “Designated Survivor” or “Homeland” where a little bit of the tale comes out each week over several seasons. This week’s show was all about Michael Cohen and the president’s reaction to the FBI’s raid on his office, home, and hotel room. All the analysts that I have read contend that the fact that the raid occurred means a lot since several officials at the Department of Justice and several judges would have needed to approve the activity based on evidence before it could have ever happened.

The prurient among us, or those interested in ongoing contemporary legal questions remain enthralled with the efforts of Stephanie Clifford (Stormy Daniels) and Karen McDougal to find a way to be released from their contractual non disclosure agreements so that they can press their cases in the court of public opinion. Again we are reminded of a story from recent history where the three main characters were the 41st president, a former public employee of the state of Arkansas, and a White House intern. This plot goes back to Greek mythology and could be survivable as it was for Zeus and was for the subject of the last impeachment. The Access Hollywood indiscretions have been forgiven by a majority sufficient for election. What we have with this story is just another form of “reality TV,” an artform where the president has had great success.

I guess we should be more focused on the ups and downs of the stock market, the looming trade war with China, the fact that John Bolton is the National Security Advisor, that something will eventually happen in Syria, and oh yes, we still have concerns about North Korea and Iran. But we are stupified by “crisis overload” and have no more emotional resources that can enable our ability to consider the implication of these issues on our future. One set of outcomes we often forget as we focus inwardly on the president’s behavior is the possible consequences of our resignation as the leader of the free world in favor of maximizing stockholder return on Make America Great Again, Inc.

A year ago I would have imagined that there could be nothing more significant in any news cycle than Paul Ryan’s announcement that he was not seeking reelection to Congress and therefore will not be the speaker of the House when Congress reconvenes after the 2018 elections. Ryan and Mitch McConnell, the Republican Senate Majority Leader, have been the most persistent advocates for repealing and replacing the ACA. The president has been noise in the conversation and his appointment of Tom Price and Seema Verma to be the Secretary of Health and Human Services and the Administrator of CMS was a very strategic move that put a few dents into the fuselage of the ACA, but it was Ryan and McConnell that were the strategic field commanders for the attack.

You may have not have watched Ryan’s news conference because, unlike me, you still work for a living. I did watch it. It was a great example of “political speak.” He is going home to Wisconsin so that he will not miss out on being the father of teenages. He is grateful for the opportunity he was given to be the speaker. He spent a long time thanking the president for the opportunity that he gave Congress to improve the lives of “the American people” by passing the first real tax reform in 36 years, the greatest accomplishment of his tenure as speaker. He is also proud of increasing the military budget to protect America. The skeptic in me says that he has real fears that he will not be reelected because he has a tough challenge from two very good Democratic candidates ahead, or if elected again he would lose the speakership because the Democrats win a majority. There is even the possibility were the Republicans to retain control of the House and were he to be reelected that by next January he would be in a fight to retain his speakership. He has declared his personal victories and will now retreat to the safety of Janesville with the expectation of being a spectator and not a participant in whatever happens to the president. Many have speculated that he would like to be president himself so now he will be relatively unencumbered by having to be an apologist for the current president. More importantly he can hope that the stain he has acquired from enabling the president whom he initially resisted will fade a bit by 2020 and that Mike Pence will be covered with soot and not a viable alternative for the party. I am just speculating. As an experienced father I can empathize with his desire to be closer to his children, but he is coming in on the third act. The best shoot at being more than a spectator in their lives was earlier in their lives.

His skill as a politician was on display as he pivoted and switched the direct questions about the deficits that are predicted from his tax bill to an answer that translates as “not my fault” because the House did pass some entitlement reforms (and a repeal of the ACA) that just didn’t make it through the Senate. Anyone can see that if we had slashed spending on healthcare with his bill and put Medicaid and other entitlements back in the hards of the states with a cap on federal dollars, the deficits from tax reform would be a lot less. Now he only needs to worry about how history will treat him or possibly the voters in 2020. If our memory is short or if other realities intervene and he is lucky enough to become the candidate of the righteous right, and with even greater good fortune becomes the 46th president, who will care that he put the concerns of the wealthy way ahead of the troubles of the underserved when he was the speaker? In the main portion of the letter I will try to pass on to you some understanding of the very different “righteous minds” of the right and left.

What is becoming increasingly clear is that unlike the election of 2016 when healthcare was discussed for less than 20 minutes in the totality of all the presidential debates, it will be the single most important issue for 2018. In a column published this week (April 10) entitled “Obamacare’s Very Stable Genius” Paul Krugman once again gives a clear accounting that answers the question of just how the ACA has mostly survived the hostility of a Trump administration that has abused it, and the tax bill that has removed its mandate. The short answer is that it was built very well. He sights a poll done by the Huffington Post that finds that healthcare is the issue that concerns the largest number of voters as they look to the 2018 elections that are coming up fast. Not far behind healthcare are guns, the president’s performance, and immigration. On all these issues well meaning people feel increasingly estranged from those with whom they disagree.

There seems to be very few concerns that bridge the divide between the coalition of conservatives and libertarians on the Republican side and liberals or progressives on the Democratic side. The sum total of all these questions that divide us seems only to grow larger with each passing year and taken together they threaten the stability of our union as much as any external force. We seem no more able to develop consensus on how to address internal issues than we can agree on how to face the external issues that challenge us and the rest of the world. We have been divided before, but I do not remember a moment since 1968 when the chasm has seemed wider. Perhaps the natural history of our union is to separate and then come together in an oscillating fashion again and again. Natural disasters, huge internal tragedies, and credible external threats seem necessary to move us closer together, but each time we come together as we did after 9/11 we quickly separate again as we did over the invasion of Iraq under the pretense of “weapons of mass destruction. No one disputes our division, no one discounts the potential from our division for harm to all of us, and very few can explain it in such a way as to allow us to venture a solution, although the threat is something we all feel even as we withdraw from contact with those who disagree with us.

I know friends who have “unfriended” on Facebook lifelong friends or even family members over “posts” that reveal that they are on opposite sides of an issue like gun control or abortion. One wonders how long this can last. If we use a disease model for analysis, we must admit that we really do not understand the origin of our problem even as we experience all the pain and threat of our collective social distress.


The “Righteous Mind” and Healthcare

Someday the presidency of Donald Trump will be a subject for historians. Some future master of history will put it all into perspective just as Robert Caro has done with LBJ, despite the fact that we are still waiting for the fifth and final volume. Some future historian like Doris Kearns Goodwin may show us things we did not appreciate as she did with Lincoln and his “team of rivals” that will go far beyond the tabloid revelations of Michael Wolfe’s Fire And Fury: Inside the Trump White House. I hope that I live long enough to read what Jon Meacham might do with Trump’s story compared to his books about Andrew Jackson, Thomas Jefferson, and George H.W. Bush (the elder). Whatever historians say, I am sure that they will begin the story long before we thought of Trump’s bid for the presidency as anything more than a joke.

The story will not begin with a review of his history of being a reality TV star, or with a review of his life as a playboy real estate developer who was involved in many shady deals that damaged many others as he made what he says was “billions.” They will not begin with a review of his self described powers of negotiation, or even with his position as the most notable poster boy for narcissism. No, they will start the story someplace far back in our history. Maybe they will go back to the controversy over Vietnam. Maybe they will start with the social upheavals of free love or begin with the Beatles’ appearance on the Ed Sullivan Show. They might even go back to the riff between young and old over the pelvic gyrations of Elvis that emerged in 1954, or perhaps the startling case of Brown v. The Board of Education of Topeka that also threw the country into confusion that same year. Wherever they start they will go far upstream and write about the deep divisions in the country that existed long before Roger Stone, Ann Coulter or even Steve Bannon ever fantasized that Trump was the one. Trump is a distraction in the real story. The issue that explains Trump is the deep division in America that existed before him and will threaten the country after he is gone. What divides us is the story that produced this moment and produced the unlikely reality of Trump’s presidency and that connection is worth a historian’s interest.

A dozen years before Trump was elected (2004) Thomas Frank wrote What’s The Matter With Kansas: How Conservatives Won the Heart of America. Frank focused on how voters in Kansas had their concerns shifted from their worries about their personal economics to cultural issues like abortion and gay marriage. As their focus shifted they felt more and more estranged from “liberal elites” on the coasts. They were more than the “heartland” or “flyover America” and probably were not amused by the famous 1976 cover on The New Yorker magazine that diminished most things beyond the Hudson River.

Earlier this year I reviewed Arlie Russell Hochschild's book Strangers in Their Own Land: Anger and Mourning on the American Right. Although it was published before the 2016 election, it was a study of people in Louisiana who could be described as victims of corporate greed who nevertheless consistently, willingly, and with enthusiasm voted against their own personal health and economic best interests. She documented that core values and cultural affiliations “trumped” economics and environmental threats that produced cancer. I am sure that she was not surprised by the outcome of the election.

I wish that I had discovered Jonathan Haidt’s book The Righteous Mind: Why Good People Are Divided by Politics and Religion long before last month. It was written in 2012. I doubt anyone in Hillary Clinton’s campaign ever read it, or if they did the message never got up the ladder. There has been a resurgence of interest in the book over the last year since the election. Haidt who is now Professor of Ethical Leadership at New York University's Stern School of Business was at the University of Virginia when he wrote the book. He studies the psychology of morality and moral emotions. His research and his book are a mixture of some of my favorite subjects: evolutionary psychology, behavioral economics, sociology, anthropology, literature from all ages, and theology. His story arises from the wisdom of David Hume, Thomas Jefferson, Darwin, E.O. Wilson, Jesus, Buddha, and Plato among many others that even include Dale Carnegie with his ideas about how to win friends and influence people.

He weaves his story and makes his point that we lead with our emotions and justify what we believe with facts that support our biases. We do not search for the truth. We search for confirmation of the truth that supports our convictions. If you want to invest 20 minutes, as many people have since the 2016, you can hear a YouTube presentation of a TED talk in which Haidt explains the Righteous Mind. Ironically the TED talk is dated November 8, 2016, the day Donald Trump was elected. I would also suggest that you read an excellent review of his book written in 2012 by the political journalist, William Saletan. You might also want to check out the website YourMorals.org where he states that the objective is to understand how the moral mind works.

It is upsetting to many that Haidt gives the strategic advantage to conservatives because of the way morality has evolved as a matrixed interaction between six fundamental “foundations” and culture. Those foundations are:

• The Care/Harm Foundation
  
• The Fairness/Cheating Foundation
  
• The Loyalty/Betrayal Foundation
  
• The Authority/Subversion Foundation
  
• The Sanctity/Degradation Foundation
  
• The Liberty/Oppression Foundation
  

He spends a lot of time reviewing the cultural differences in how the individual interacts with the group. Our genes that manage the emotional responses that flow from the moral issues covered in the “Foundations” evolved in response to the tension between the individual and the group. Much of the molding of our moral mind results from the necessity of positioning our reputation within our group for the respect that is necessary to be accepted. The existence of the foundations of moral attitudes can be identified by asking people tough questions that challenge the “foundations” while doing functional MRIs and EEGs. He defines part of the problem that liberals have as the WEIRD syndrome: Western, Educated, Industrialized, Rich and Democratic. Ironically, that acronym is a disadvantage to the liberal elite within the country just as it is an issue for all Americans outside the country except in Europe which is also WEIRD.

Saletan says in his review that if you have a big dose of WEIRD :

You’re smart. You’re liberal. You’re well informed. You think conservatives are narrow-minded. You can’t understand why working-class Americans vote Republican. You figure they’re being duped. You’re wrong.

Haidt’s objective is not to undermine liberal causes, issues, or candidates but to hold up a mirror that allows us to make progress narrowing the gap between ourselves and our conservative neighbors. You do not narrow the gap by calling them “a basket of deplorables” as Hillary Clinton did, or by claiming that 47% of the population does not work as Mitt Romney did in one of the few comments ever made by a Republican candidate that estranged many with a conservative moral mind. I think that Haidt’s message is very important for those of us who seek to promote equity in healthcare and are concerned about the impact economic inequity on the social determinants of health. We all know from personal experience that we never make progress in head to head arguments with our conservative friends, colleagues, and even family members. We must understand the mind of those whom we want to influence and see the world from the point of view of their moral sentiments if we are ever going to negotiate a way forward.

I have heard many of my liberal friends describe a strategy for future political success or dominance based on winning elections and controlling both house of Congress, plus gaining a filibuster proof Senate majority and the presidency. Obama discovered that such an advantage is not a permanent fixture. Jimmy Carter was elected in the aftermath of Nixon’s crimes but Reagan brought the party back in only four years because of his ability to speak to the sense of morality of a majority. He hit hard on all the Foundations and was so effective that he attracted the moral minds of many “Democrats for Reagan.” Dominance is not an effective strategy for embedding improvements and programs in our social and political structures that run against deeply held moral opinions and feelings.

As Saletan describes in his review:

Haidt seeks to enrich liberalism, and political discourse generally, with a deeper awareness of human nature. Like other psychologists who have ventured into political coaching, such as George Lakoff and Drew Westen, Haidt argues that people are fundamentally intuitive, not rational. If you want to persuade others, you have to appeal to their sentiments. But Haidt is looking for more than victory. He’s looking for wisdom...Politics isn’t just about ­manipulating people who disagree with you. It’s about learning from them.

Saletan says it better than I can:

To the question many people ask about politics — Why doesn’t the other side listen to reason? — Haidt replies: We were never designed to listen to reason. When you ask people moral questions, time their responses and scan their brains, their answers and brain activation patterns indicate that they reach conclusions quickly and produce reasons later only to justify what they’ve decided...The problem isn’t that people don’t reason. They do reason. But their arguments aim to support their conclusions, not yours. Reason doesn’t work like a judge or teacher, impartially weighing evidence or guiding us to wisdom. It works more like a lawyer or press secretary, justifying our acts and judgments to others...If you follow Haidt through the tunnel of cynicism, you’ll find that what he’s really after is enlightenment. He wants to open your mind to the moral intuitions of other people.

Haidt points out that conservatives deeply believe in “karma.” You are due what you earn. Behave badly and life should not go well for you. They believe in the basic issues of private property and to take resources from someone who “has earned” what he has and give it to someone who “is lazy” is just wrong. Their sense of loyalty to family and tribe is expressed in their objections to globalization and immigration. Again, as Saletan says:

These moral systems aren’t ignorant or backward. Haidt argues that they’re common in history and across the globe because they fit human nature...People accept God, authority and karma because these ideas suit their moral taste buds. Haidt points to research showing that people punish cheaters, accept many hierarchies and don’t support equal distribution of benefits when contributions are unequal....Republican themes touch all six moral foundations, whereas Democrats, in Haidt’s analysis, focus almost entirely on care and fighting oppression. This is Haidt’s startling message to the left: When it comes to morality, conservatives are more broad-minded than liberals. They serve a more varied diet...Conservatism thrives because it fits how people think, and that’s what validates it. Workers who vote Republican aren’t fools. In Haidt’s words, they’re “voting for their moral interests.”

When I review my own ideas about healthcare and the issues that we call the social determinants of health and feel my blood boil when I think about Paul Ryan’s efforts to undermine entitlement programs, I see that Haidt’s been reading my mind. I see the recent tax “reform” as organized theft that is oppressive to many, lacks fundamental fairness and caring for the underserved, and is an expression of greed that I must resist. I am not offended by same sex marriage and I do not find myself willing to deny a woman’s right to control her reproductive life because her choice to have an abortion might offend my sense of the sanctity of life. I also understand that people who are diametrically opposed to my point of view on every issue may be wrong from my point of view, but they are just as comfortable with their own sense of righteousness as I am with mine.

The path toward future progress that might bring us back to more productive conversations that mends our divided country requires us to search for a larger shared view that encompases even more that we can learn to share. The alternative to trying to understand one another is to accept that we are both going to experience more loss and disappointment. It’s not about Donald Trump. He has just capitalized on our growing disrespect for one another for his personal gain and to satisfy his craving for attention.

The Triple Aim is a perfect example of a concept built on the moral foundation of caring for all people and overcoming oppression that appeals to the liberal mind. The challenge is for us who long to see the fulfilment of the Triple Aim to demonstrate to more conservative minds how our intentions strengthen the nation and contributes to their own security while not violating their moral minds. We will still disagree about many issues but we could agree to continue to search for ways to move forward together realizing our differences while preserving civility. This is much easier to say than to imagine doing, but one fact that Haidt returns to many times is our ability to modify our cultures, adapt to changes beyond our personal control, and to move forward together as social beings. That is how we made it past caves and campfires after we came down from the trees. It just takes a little time, but can be faster than you think as our moral minds continue to evolve.


Signs That the Wait May Soon Be Over

On Monday I saw my first crocus! I’ve been looking for weeks and finally found one. In the past I have seen them at the edge of snow or in the bare spots where the sun had interrupted the blanket of white that covered the yard. Have you noticed that the snow melts away from the foundations of structures like my house. I guess that is evidence of poor insulation.

I found my first crocus in a nearby town where I had gone to be one of the adults putting on an after school program. We were enjoying being outdoors working with pulleys and ropes. The sun was warm even though the air temperature was in the high thirties. It was feeling like spring and there it was. One lonely purple clump in the midst of some evergreen ground cover and a few dried leaves. It was beautiful as you can see in the header for today’s letter.

Let me invite you to go in search for blooming things this weekend. The expectation is for warmer weather. There is a place in Haidt’s book where he refers to Emerson’s observation that he experiences transcendence in nature when he goes for a walk. I would agree.