14 July 2017
Dear Interested Readers,
What This Letter is AboutThe central presentation of this week’s letter is an attempt to gain some understanding of our difficulty in coming to consensus about the role of our government in healthcare. It does not take long to realize that there are really two conversations in process. The conversation of interest for most Republicans seems to be the one about how to reduce government expenditures that create the need for subsequent increases in taxes on wealthy Americans to cover the expense of care for poorer Americans. Senators Cruz, Lee, Johnson and Paul seem to be in their own discussion about strict conservative ideology. Most Republicans, but not all, seem to see the issue as a crisis of increasing government expense. Democrats, as a generalization, believe in the ability of government to improve the lives of all people. With the ACA they put cost second to access. I would be the first to admit that my construct is too simple to explain all that we have seen in this debate since 2009, but my objective will be to keep the discussion simple and short while still providing some increase in understanding about why the solution is so hard to find.
The attack on the ACA has educated an increasing percentage of the public to the benefits of universal access and more and more people are suddenly concerned about any legislation that would deny coverage to anyone who wants it, and especially those with preexisting conditions. The public is beginning to accept that there is a role for the government in the attempt to provide coverage for everyone. The public is also beginning to understand that we could fund access for many more people if we could lower the cost of effective care. I have not seen the new expression of the Triple Aim in a
New York Times editorial yet but any day now I am expecting to read that the
Times thinks that whatever is passed should support the idea that the correct objective is:
...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. They did go in that direction this week with an editorial entitled, “
Obamacare Is Not Collapsing, Imploding or Exploding.” Even before Mr. McConnell released his new and improved version of the
Better Care and Reconciliation Act of 2017 they wrote for the benefit of all who respect their opinion that:
Mr. McConnell’s bill would make things much worse. It would greatly reduce subsidies available to help people buy insurance. The new version might include a terrible proposal by Senator Ted Cruz of Texas to allow insurers to sell skimpy policies that are cheaper but do not meet the requirements of the A.C.A., if they also offer ones that do. That means comprehensive plans would be bought mainly by people with expensive medical needs, like pregnant women and cancer patients, and push premiums up. That would lead to fewer people buying policies, the industry group America’s Health Insurance Plans said Wednesday.
The A.C.A. is not perfect, but its problems are fixable. In fact, 71 percent of Americans want Republicans to work with Democrats to improve the law; just 23 percent want lawmakers to repeal and replace it, according to a Kaiser poll. Democrats have said they would be willing to work with Republicans to strengthen the law. But Mr. McConnell and his party have become so blinded by their rage against Obamacare that they are losing sight of what ought to be their goal: safeguarding the health of their constituents.Well, we all know that late Thursday afternoon the Senate Majority Leader did release his modified bill. His plan is to call for a vote to open debate of the bill next week. Everything seems to happen on Thursday in Congress because they have a three day work week. Hopefully their long weekends are spent listening to their constituents who are terrified of losing the benefits provided by the ACA that they have been enjoying for the last few years. If the vote, probably to be taken next Thursday, does not pass the current bill will be considered dead. McConnell says that if the vote fails, he will turn to the Democrats and begin the long process of discussing a bipartisan law. The president’s tweets seem to suggest that if the current effort fails, he favors repeal of the ACA, and then presumably a subsequent negotiation for a replacement. What he most surely knows is that either method would require a Senate majority that the Republicans do not have.
Given the fact that so far Democrats and Republicans have been trying to solve different problems, we have been reduced to a situation where one party must have the presidency, a sixty vote commanding majority in the Senate, and a secure majority in the House for their to be the unilateral passage of significant legislation. That formula was barely met during the first two years of the Obama presidency and held together just long enough for Democrats to pass a suboptimal ACA through some fancy legislative footwork after the death of Ted Kennedy, followed by the election of Republican Scott Brown to replace him. McConnell may recognize that something does need to happen and Republicans will be held accountable for their failure after years of attacking the ACA and promising something better. He also can easily predict that neither party is likely in the next few years to have the full control of Congress plus the presidency that would be necessary to “have it their own way.” McConnell is intensely partisan, as his famous commitment to destroying the presidency of Barack Obama testifies. I fear that any attempt at a bipartisan solution that he would accept will be in proportion to his fear of Republicans losing the control of Congress in 2018. An offer to search for a bipartisan solution would suggest that the Republicans are finally hearing the voice of the majority. A bipartisan discussion sounds great and even starting one would be a huge victory for the Triple Aim. The chance for a successful bipartisan healthcare bill will require getting everyone to agree on that foundational question of all group problem solving activities which is:
“What problem are we solving?” I am trying hard to restrain my optimism for a bipartisan process. Optimism is often the precursor state for disappointment and depression. The correct posture is a hopeful stance. Hope is long suffering and usually recognizes that possibility is not the same as probability, but it is better than despair. Hope means that you are still in the game, even though you may appear to be hopelessly behind by the judgement of others. The best sports metaphor available now and for the foreseeable future for long shot hope was the comeback of the Patriots in the last Super Bowl. I hope that the discussion in this letter will be useful as a foundational consideration for that bipartisan moment that I ask for in my prayers and would be happy to have happen even if it occurs less because it is the right thing to do for the country than it is the calculated acceptance of a shrewd politician.
Overcoming Individualism and Collectivism: Different Mindsets That Make Healthcare Policy Feel ImpossibleI read the
New York Times, Washington Post, Boston Globe, and the
Kaiser Health News Service and follow their various links that take me to a variety of different sources. I tune in to NPR and watch breaking news on CNN. I follow links all over the Internet trying to sift reliable sources of information from the Commonwealth Fund and the Brookings Institute from less reliable sources from the alt right and the alt left. It’s a full time job.
I make the effort because I care about the future of healthcare and not because of my own individual worries about my specific situation. As recipients of federal employees’ health benefits through my wife’s former employment as a nurse practitioner in a VA hospital, we are all set with pretty good healthcare. I am surprised by the relatively high deductibles and other out of pocket payments we do make, but put into the perspective of our overall income and the plight of others, we have no legitimate complaint. With relatively good healthcare coverage and the security of a steady retirement income from a reasonable pattern of savings over many years now managed by a trustworthy investment adviser, you could say that considered as individuals we should be all set and able to ignore the current cacophony of strident voices in Congress and the administration. I am a protected individual unless our whole society fails or there is some universal calamity of the sort that doomed the dinosaurs. So why don’t I just use whatever time I have left to take up painting, learn a new language, practice piano and guitar more so that I can move from beginner to intermediate status, or just spend more time fishing?
To borrow language from Robert Sapolsky’s book,
Behave:
The Biology of Humans at Our Best and Worst, that I have been reading, some combination of my genetic make-up, my environment, my prior experience, the culture into which I was born or the different one I have been exposed to as an adult, and other influences, perhaps beyond my control or at least buried somewhere in the circuitry of my prefrontal lobes and limbic system, I have a
collectivist world view. That should be a surprise if you consider where I come from and the professional training of medicine with its focus on clinical autonomy. Family, religion, my region of origin, and my professional training considered, the data might predict that the mix of my “nature and nurture” influences, would have given me an
individualist world view.
Terms like collectivist and individualist are perhaps useful when academics are doing gross characterizations of groups or societies, but are inadequate to give a complete understanding at the individual level. Like you, I am a mix of both individualist and collectivist feelings and responses. In moments of decision where what I should do is uncertain, when the subject is healthcare I sense my own internal conflict between the poles of individualism and collectivism. A full understanding of the context of the issue is required to predict what I will say or do. Long ago my outlook on healthcare was framed in such a way as to make me principally a collectivist.
Framing and context do matter in both the presentation of an idea and the process of decision making, strategy development and strategy deployment. Most of the time when we talk about how we frame a subject we are talking about what we are including in the subject. I learned from my son, the song writer who has a masters degree in communications, that “framing” can be used to exclude rather than include important factors.
Roland Barthes, the French literary critic, author, and philosopher used the word
decoupage that is usually associated with the art of decorating by framing or cutting away distractions
“to describe the way a picture frame cuts away that which is outside of it. In that way, every act of attention (think of how an individual looks at healthcare) is a simultaneous and inverse act of inattention.”Following the idea of “what we individually cut away” when we frame the healthcare questions that plague us may be beneficial as the Senate continues what is and has been a very divisive process where conservative and liberal mindsets talk past one another as they attempt to sell their point of view to enough votes in the middle to win the day. I was involved in an email exchange this past week with a few healthcare leaders and was startled by a comment from one of the participants. The comment below registered with me because I was already thinking about writing this essay about how conflicts between individualist and collectivist world views are an explanation for much of what prevents a consensus solution to the nation’s healthcare problems. My colleague wrote:
The fundamental issue for many of the Republicans is that they don’t care if everyone is covered adequately or if they are actually reducing the cost of care – they just don’t want to spend that much and view this as an entitlement program for the lazy, hence the directive to work if you can in order to earn Medicaid. It is a big stretch to go from there to how to organize the healthcare system which does not seem to be their goal at all. Any scrutiny of the
Better Care and Reconciliation Act of 2017, the amendments that were announced by Senator McConnell, the House version of repeal and replacement that was passed in early May, or the comments made by the president and members of his administration like Vice President Pence or Secretary Tom Price of HHS adds credence to the view that Republican concerns about the ACA are mostly related to the high spending on entitlements that it represents. I am not sure if I totally agree that they do not care about the total cost of care, but I do know that when one looks at the impact of their bill on healthcare what you see fulfills Barthes’ concept of decoupage. Their bills and their comments betray that they are “inattentive” to the real needs of people and more attentive to how to cut payments to the states for Medicaid. Their bill is not written from a collectivist world view. It is certainly American because it celebrates the rights of the individual to reject the mandate that is applied to everyone as a shared burden that produces a better outcome for the community or collective.
It is easy for me to celebrate the collectivist worldview and philosophy of the ACA and the people who wrote it, but they also operated with elements of decoupage. The part of the picture that they frame best is the access and patient care part. They have elected to be less attentive to the total cost of care.
If we are lucky enough to have an opportunity to seek a bipartisan solution to the healthcare needs of the nation we will need to begin with some attempt at drawing a picture that both sides believe represents the problem. If you have ever had an exposure to Lean, you probably know this exercise. Lean thinking is built upon the wisdom that the first step in solving problems and coming up with effective solutions is a collaboration where everyone understands the issues in the same way. There must be consensus about the “reason for action.” That is “Box 1” of the problem solving process that we call the A3. A great way to facilitate consensus on the reason for action and promote a shared understanding of the problem is for those involved to really draw a picture on a big piece of paper of the problem and what a good outcome would look like.
When or if the bipartisan discussions do begin we will need to combine the Republican and Democratic views of “current state” because it is clear that the majority view of Republicans is that the ACA is a huge failure that needs to be repealed, and the Democratic view is that the ACA has achieved much despite Republican opposition and could be improved to do more. If the bipartisan idea ever gets past the issue of agreeing on what the current state of healthcare really is and what it is important to do, then we face the very positive task of envisioning together what might be better. I hope that the Senators will take the time to hear a lot of testimony at this juncture. It is possible that they can consider both short and long term goals. Perhaps they can agree to better fund the exchanges while they work on something better.
The biggest challenge in any Lean process is the “Box 4” analysis of the barriers to be overcome to achieve the vision. Those barriers are discerned from the analysis of the difference between the “current state” and the shared concept of what would be better as described in the picture of the “target or ideal state.” A Box 4 discussion of healthcare in a Senate committee would be a beautiful thing to see. Oh wait, we did see something like that back in 2009. It was just that after participating in the process and contributing to the Box 5 development of solutions, Republicans refused to vote for what they had helped develop.
The process leading up to the ACA did share many similarities to a Lean process. We now know the outcome of many of its experiments. We have learned some valuable lessons and have evidence that some of the plausible solutions that it offered are not so easy to execute in a partisan world. What draws me to Lean is that it is a philosophy that seeks to make great progress through cycles of incremental change accomplished through collaborative processes. Japanese culture is a very collectivist culture. Perhaps that is why
Deming had to take his ideas about continuous improvement to Japan to have them really develop.
I believe that the most important part of the cycle of improvement fostered by Lean is the “deep reflection” on what has been learned from the last cycle before the next cycle begins. Perhaps deep reflection together between Republicans and Democrats is where any future efforts at discovering bipartisan solutions to the complex problems should begin. If the minds and interests of Democrats and Republicans do honestly differ, and I believe that they do, there is no hope without a bilateral process of finding ways to understand and respect one another. After respecting and making some attempt to understand the point of view on the other side of the aisle, we will be challenged to relearn how to trust each other. Bipartisanship is easy to envision but will be hard to achieve. It is best developed in a context of hope that extends to everyone. It is a dream, but it is not foolish to believe in the eventual possibility of
...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. Beautiful Days Woven Between Dreary Moments in Nice Places I do not know why I expected the weird gyration between cold rainy days and days with a bright sun and clear blue skies would end just because we had passed the Fourth of July. Outside my window rain has been falling off and on most of the day from a darkly overcast sky. The evening air is cold and raw. The thermometer in my window reads in the forties. The sum of all that data has suggested to me that I need to do something unconventional. Despite the calender reading July 13, I am writing to you while I sit in front of a warm fire.
Earlier in the week the weather was beautiful. On Monday’s walk I was delighted to find my old friend Lightening prancing around in high grass and flowers as you can see in today’s header. What he would not tell me was what Thunder, his brother and pasture companion was doing. Thunder was nowhere to be seen.
We are looking for a break in the weather sometime this weekend. I wish that we could so easily predict a break in the messy environment in Washington. One consolation is that I like walking in dreary weather or almost any weather, and long swims in the lake are still comfortable. The air temperature is fickle and changes from day to day. The water temperature changes slowly and on a cool day the water remains warmer than the air and is fine for swimming!
