| 13 January 2017 Dear Interested Readers, Inside This Week’s Letter and Remembering MLK on His DayMichelle Obama is famous for saying, “ When they go low, we go high.” When I think of Dr. Martin Luther King, Jr., I am thinking of an individual who was always going high, always turning the other cheek, and always willing to speak truth to power as he found the way to be true to our purest ideals while contending with a status quo that was uninterested in living out those ideals. It is hard to imagine what America would be like today without his influence and the example of his leadership in a world that does not want to change. The continued presence of his example and the wisdom that he gave us serves us well now forty nine years after we lost him. Perhaps you learned this week, as I did, that we came within a few centimeters of losing him long before he delivered his “ I Have a Dream Speech”, or had been able to use his immense wisdom and his strategic skills to enable the passage of the Civil Rights Act of 1964 and the Voters Rights Act of 1965. I sometimes wonder what would have happened if Lincoln, the Kennedy brothers and Martin Luther King had survived the assassin's bullet. Surely you were once moved by the pain and longing in Dick Holler’s lament following the deaths of Martin Luther King and Robert Kennedy, Abraham, Martin and John. I hate to think about the change in the course of history had Dr. King not survived one attempted assassination at age twenty nine to remain among us and bless us with his wisdom and courage for another ten years before he was taken from us by an assassin's bullet nine months before his fortieth birthday. When I think about all that he accomplished it is hard to believe that he was with us for such a short time. I love reading Dr. King’s quotes. I visit his monument on the Mall on almost every time I am in Washington. It is like going to church. Yet it was a real disappointment when I first visited his memorial and discovered that among the many quotes that had been chosen to be carved into stone, my favorite quote was omitted. The quote that I love comes from a press conference held in Chicago on March 25, 1966, in connection with the annual meeting of Medical Committee for Human Rights. Of all the forms of inequality, injustice in health care is the most shocking and inhumane.You can find the quote in many places including a wonderful compendium of 122 other quotes containing his wisdom entitled “ Keep Inspiring Me.” These quotes deliver a message of service, love, transformation, exhortation, and abiding wisdom. They are not empty slogans with “wink-wink” meanings that appeal to an angry and frightened world. They are affirmation of the redemption that is possible, if we can only exercise the love and solidarity that he gave his life to demonstrate. Buried within the quotes is a challenge to the hearer or the reader to take stock of their own complicity in the dysfunction of the status quo and resolve to contribute to change. Here are a few more favorites to ponder that should be good guidance for us in these times. Every man must decide whether he will walk in the light of creative altruism or in the darkness of destructive selfishness.
We may have all come on different ships, but we’re in the same boat now.
An individual has not started living until he can rise above the narrow confines of his individualistic concerns to the broader concerns of all humanity.
Love is the only force capable of transforming an enemy into friend.
There comes a time when one must take a position that is neither safe nor politic nor popular, but he must take it because his conscience tells him it is right.I hope that these few will encourage you to read more of them and ponder their wisdom as you reflect on the life of Dr. King and the relevance of his wisdom to the challenges that we face in a time of “repeal and replace” and so many other threats to our meager accomplishments so far. The main discussion in this letter could only be about the importance of maintaining the benefits of the ACA, even as it seems so certain that it will be repealed, and even as we are promised that it will be immediately replaced by something that will make all of us very, very proud. I apologize if you are tired of this discussion, but it is hard to think of much else at this time. I hope that the repetition of points that I have made in the past will not cause you to put it down. I use recent speeches by the President, Michelle Obama and Meryl Streep to try to suggest an attitude that may help us as we struggle through these very volatile and ambiguous times. I try to use personal experience to reinforce one of my main points which is that as an industry we are complicent in the persistence of the problem. The letter concludes with reflections on the January thaw, football and the potential joys of a long weekend. Did you take advantage of the opportunity to read “Thinking Again About ACOs for the First Time”, the latest installment of strategyhealthcare.com? The concept of an ACO existed before the ACA. The ACA has certainly fostered the development and evolution of the ACO movement, but ACOs cannot be discarded by the actions of a reactionary Congress. If nothing else, I hope that by reading the article your appreciation for the thinking about accountability that fostered the idea of the ACO will be increased. We must appreciate things if we are to have the will to protect them. VUCA and the Angst of “The Loyal Opposition” While Thinking About “Replace”Regular readers of this weekly letter are familiar with my use of the term VUCA, an acronym that is derived from the realization that we live in a world that is volatile, uncertain, complex and ambiguous. I have asserted before that our current state of uncertainty about the future of our healthcare system in the era of repeal and replace certainly complies with the spirit of VUCA. VUCA is a strategic concept. It implies that the world is not evolving along easily predictable lines of progression. Since the term was first introduced to strategic thinkers in the mid nineties substantial literature has evolved to move the concept from a convenient excuse for failure to a set of principles that can help us figure out how to proceed in difficult times. This last week I have been asking myself about my personal strategy for survival as well as whether there are any guiding principles that we all should follow. If you clicked on the last link you discovered a two by two analysis that gave me an even deeper insight into VUCA. The authors suggest that strategy deployment is possible in a VUCA world if you analyze the moment in the context of how well you can predict the results of your actions against the question of how much you know about the situation, as demonstrated in the illustration below which I have copied from their paper. The chart was clearly developed for a business situation but is applicable to the political realities of this moment. |
| | If you have an interest in learning more, let me offer you a five minute video to view which you may find instructive.
As I apply the two by two analysis to the impending Trump administration’s plans for healthcare, it is clear that I have little ability to predict the results of my actions such as writing to you about my concerns. On the x axis I have a little more confidence. I know that I do know something about what is planned in the repeal and replace process. Unfortunately some of the things I know add more ambiguity to the moment. For instance I am pretty sure that neither the President Elect nor his candidate for Secretary of HHS, Rep. Dr. Tom Price, has a viable alternative plan ready at this time that will allow him to lead a process where repeal and replace will occur on the same day and certainly not on the same hour as he suggested that he could do in his raucous press conference on this past Wednesday. I also know for sure that the repeal process has begun and that Mitch McConnell, the Senate majority leader, is trying to imply that the work is as urgent as a Code Blue in the emergency room of your local hospital.
The sum total of what you or I can do in the moment is not much, and it would be easy just to accept defeat. The President Elect will be inaugurated next week and I sense that Paul Ryan and Mitch McConnell are working hard to have something for him to sign almost the moment he takes his hand off of the Bible. That knowledge is more than enough to severely depress me and leads me to conclude, after looking at the analysis, that the best strategy for me to follow is to continue to gather information, and to be vocal as I try to adopt the stance of a member of the “loyal opposition”. I hope that the claim Mr. Trump made at his press conference on Wednesday is either another example of empty bragging, or the healthcare equivalent of cold fusion, an impossible to explain miracle.
I watched the events of this week with great apprehension fueled by a totally unexpected one degree of separation encounter across thirty years with the President elect. Let me tell you a story.
Recently on Monday afternoons I have volunteered in an after school program for fourth, fifth and sixth graders in Newport, New Hampshire. Newport is a town with enormous social and economic challenges. It was once a vibrant mill town and agricultural center with jobs in manufacturing driven off of the use of hydropower from the Sugar River that dates back to the nineteenth century. Those jobs are gone now, and there are many empty storefronts and rundown properties as the people of Newport search for a new basis for their economy. Newport is a town that Donald Trump won easily, taking over 57% of the vote. Most of the children in our afternoon program experience the ramifications of families under economic stress.
Being present in the program has been a meaningful experience for me. I am fascinated by the children. They are bright, eager and engaged. It is fun to be with them and the time flies. I am also enjoying getting to know some of the other volunteers in the program. I was surprised to learn in casual conversation that one of the couples had “met” Donald Trump. What follows is a story that my new friend told me and gave me permission to tell to you.
My friends attended the US Open Tennis matches in Flushing Meadows on a very hot August day in the late 80s. They were lucky to get tickets, even though they were sitting in the “nose bleed” seats. Between matches they headed down under the stands for some refreshment. My new woman friend decided to get a strawberry ice cream cone and was standing with her husband busily licking it, trying to stay ahead of its melt in the heat, when she noticed a man approaching. He was very well dressed and was coming out of the exclusive court side seating area, surrounded by an entourage. To her surprise she suddenly recognized him as the celebrity real estate developer, Donald Trump. He stopped right in front of her and lifted her strawberry ice cream cone from her hand. Without speaking he took a big lick right off the top of the cone. He then handed the cone back to her, gave her a big wink, and walked on to wherever he was headed with his entourage in tow. My friend was speechless. In a way that is easy to understand, she felt this man had rudely crossed a boundary.
The story is just a way of underlining what we saw in the contentious news conference on Monday. Surprising things that add to the uncertainty happen when Donald Trump is on the scene. I hope that he will be able to produce a fabulous, wonderful, tremendous plan that makes us all proud the same hour that the ACA is repealed, but I doubt it. My guess is that there will be a wink, and he will hand us back an ice cream cone that we will not want to finish. Perhaps nothing will be said, or we will be given an explanation for why things won’t happen for a while like the one that we heard about “the fence”, I mean “the wall” that we will be paying for until the Mexicans pay, which of course they will do, sooner or later, gladly.
My thoughts on how I would position my emotions and my hopes were stimulated by two outstanding performances that were available for all of us to watch this week. I was surprised and inspired by the example given to us by Meryl Streep at the Golden Globe Awards. Her speech was impressive. She was specific without using names. She described a performance that showcased objectionable behavior that was inconsistent with high stations of responsibility without naming the actor. Any child could have gotten her message and understood just why such behavior should be shunned. Her presentation was well constructed and delivered with the skill of an Oscar winning actress whose career is unparalleled by any living actor of either gender. The President Elect immediately responded in the social media with the sort of aggressive response that we have come to expect whenever anyone with any level of celebrity points out a flaw or questions his qualifications for the office that he has won.
After hearing Meryl Streep appeal to common decency on Sunday night and then observe her being trashed by the President Elect on Twitter a few hours later, I was eager to hear the President’s farewell address to the nation on Tuesday night. I was not disappointed. Our exiting President left the stage with a demonstration of wisdom, presence and grace that we have every reason to expect in the holder of our most significant elected position. His graceful and inspiring comments added more depth to my concept of becoming an announced member of a “loyal opposition.”
Here are a few of my favorite lines from the 52 minute speech with bolding of the points that lifted me added for emphasis:
It’s the conviction that we are all created equal, endowed by our creator with certain unalienable rights, among them life, liberty, and the pursuit of happiness. It’s the insistence that these rights, while self-evident, have never been self-executing; that we, the people, through the instrument of our democracy, can form a more perfect union. This is the great gift our Founders gave us. The freedom to chase our individual dreams through our sweat, toil, and imagination – and the imperative to strive together as well, to achieve a greater good...
So that’s what we mean when we say America is exceptional. Not that our nation has been flawless from the start, but that we have shown the capacity to change, and make life better for those who follow....
In 10 days, the world will witness a hallmark of our democracy: the peaceful transfer of power from one freely elected president to the next. I committed to President-elect Trump that my administration would ensure the smoothest possible transition, just as President Bush did for me. Because it’s up to all of us to make sure our government can help us meet the many challenges we still face…
Understand, democracy does not require uniformity. Our founders quarreled and compromised, and expected us to do the same. But they knew that democracy does require a basic sense of solidarity – the idea that for all our outward differences, we are all in this together; that we rise or fall as one…
Our democracy won’t work without a sense that everyone has economic opportunity.
Healthcare costs are rising at the slowest rate in 50 years. And if anyone can put together a plan that is demonstrably better than the improvements we’ve made to our healthcare system – that covers as many people at less cost – I will publicly support it…
There’s a second threat to our democracy – one as old as our nation itself...race remains a potent and often divisive force in our society...we’re not where we need to be.
So regardless of the station we occupy; we have to try harder; to start with the premise that each of our fellow citizens loves this country just as much as we do; that they value hard work and family like we do; that their children are just as curious and hopeful and worthy of love as our own.
Politics is a battle of ideas; in the course of a healthy debate, we’ll prioritize different goals, and the different means of reaching them. But without some common baseline of facts; without a willingness to admit new information, and concede that your opponent is making a fair point, and that science and reason matter, we’ll keep talking past each other, making common ground and compromise impossible.
Democracy can buckle when we give in to fear. So just as we, as citizens, must remain vigilant against external aggression, we must guard against a weakening of the values that make us who we are…
...our democracy is threatened whenever we take it for granted. All of us, regardless of party, should throw ourselves into the task of rebuilding our democratic institutions.
...George Washington wrote that self-government is the underpinning of our safety, prosperity, and liberty, but “from different causes and from different quarters much pains will be taken…to weaken in your minds the conviction of this truth;” that we should preserve it with “jealous anxiety;” that we should reject “the first dawning of every attempt to alienate any portion of our country from the rest or to enfeeble the sacred ties” that make us one.
It falls to each of us to be those anxious, jealous guardians of our democracy; to embrace the joyous task we’ve been given to continually try to improve this great nation of ours. Because for all our outward differences, we all share the same proud title: Citizen.
There was more to the speech but those were the high points for me. As I thought about his speech, I felt that he was giving advice to each of us about the stance that we should assume whether we are delighted with the new government that President Elect Trump is creating or whether we are frightened as we feel we live in a VUCA world where we are threatened by an uncertain future where the progress of many years may be reversed and our dreams of a more perfect union jeopardized. The following points occurred to me as I contemplated the way in which I will think as a member of the loyal opposition:
- Despite all the concerns about Russian intervention in the election, we must go forward with the outcome that we have. New ideas will be introduced and they should be discussed and processed within the context of existing rules. Anything else would discard the accomplishments of the last 240 years.
- We must all exercise more respect for one another and constantly remind ourselves of the mutual benefit of living under the protection of a nation of laws. There should be great comfort for all of us to know that we live in a nation built on law. There should be a unanimous agreement that within our arguments we have the right to express feelings and contest the status quo.
- None of us should give up imagining an even better Amercia where ideals like equal opportunity, the pursuit of economic justice, and equity in access to healthcare are to be pursued as foundational principles. As the President suggests, the debate should be about how we way we achieve the goals and pursue the dreams that have carried us for 240 years, and not about who is in and who is out.
- Those of us who disagree with the pronouncements of new or different policies should adopt the mindset of a “loyal opposition”. That concept is enabling of progress when those in power and those out of power recognize that within the principles of decency and the protections of minorities within the law, it is not treasonous to exercise freedom of speech and disagree with the sitting powers. Indeed all is lost and we are not a democracy if there is not a freedom to object and attempt to hold the party in power and its leadership accountable for the actions that are taken.
- In healthcare we should expect that the replace process will be an opportunity to inject reality. Just as Mexico is not going to pay for a fence, I seriously doubt that insurers and providers will absorb losses that enable universal coverage to excellent care at an expense that will be incurred without a mandate. It is even possible that several Republican Senators who do not reject sound economics or science will decide to break from the control of Mitch McConnell and seek to form a responsible coalition. It would not take many. Rand Paul voted “no” on Wednesday night. We could hope that Susan Collins, John McCain, Lindsey Graham and a few others might decide that risking the care of twenty million people is not the American Way.
I am a dreamer, but no matter what happens there is a responsibility for all of healthcare to renew it efforts to make care more affordable so that it can be available for all. As strong as we have been in our ability to survive poor leaders in the past and even overcome the attempt at throwing it all away over which we fought a Civil War, I am concerned that without everyone’s conscious commitment to be part of the solution, the principles that have made it safe to be a member of a loyal opposition are in as much danger now as ever before. The cacophony of President Elect Trump’s first press conference since the election was upsetting to me. I am a “news junkie” and over the years going back to Eisenhower’s last term, I have viewed many press conferences of Presidents, President Elects, and Presidential candidates. Even as I think back to President Johnson under pressure from the critics of his policies in Vietnam, President Nixon as he defended his criminal Watergate acts, President Clinton struggling with impeachment precipitated by his personal behavior, or President Bush defending the lack of evidence for weapons of mass destruction and the ill advised war that he sought; I can not remember seeing such a disturbing display of combativeness directed toward legitimate questions from the press or a more arrogantly defiant posture emanating from the man who will lead us toward a more perfect union. I can not understand how pettiness can create “greatness”. The next four years will be hard for many of us, but I think that Michelle Obama’s strategy is the right one, “When they go low, we go high.”
I doubt there is a better way “to go high” than to commit yourself to the challenge of working to insure
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
While remembering that:
Of all the forms of inequality, injustice in health care is the most shocking and inhumane.
Oh What A Difference A Few Days Can Make
I have done a pretty good job of avoiding college football this year, but I could not turn my eyes away from the National Championship Game on Monday night. I had many reasons to cheer for Clemson. I have roots in South Carolina. I once had a chance to play football for Clemson and did play against them more than fifty years ago when small slow boys still had a chance to participate, even if only to fill out the roster. I had also played a few downs against Alabama in 1965, and despite the fact of family connections to Alabama I have never felt at home there. My antipathy for Alabama, coupled with the fact that I love underdogs, made me want to see Alabama lose more than I cared who beat them. It was a great game. I think watching one game a year is a minor compromise of principles. Now all I need to do is to come up with a rationalization for watching the NFL playoffs.
What I do not need to do is rationalize a reason for a walk in the woods. On Tuesday my buddy and I started out from the Cardigan Mountain AMC Hut, down the trail along Clark Brook headed for Wilton Falls. The frozen falls and its pools were beautiful and spectacular but did not photograph so well with my iPhone. But, the header gives you a nice sense of the beauty of the day as we followed the trail past the falls.
Every joy has its challenge. The January thaw is my challenge now. Since Tuesday, rain and warm weather has wiped out much of the beauty to be seen on the road and in the woods nearby. In exercise, as in life, sometimes you just need to struggle through the down days that join the better days together.
I hope that this weekend you will ponder the lessons and the answers that Martin Luther King,Jr. offered us as you think about how you will engage in the debate of repeal and replace. A walk in any weather would be a good time and place to think those thoughts or discuss the issues with a friend.
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| 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
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