2 February 2018

Dear Interested Readers,


What’s Inside and a Few Comments About The Real State of Our Union

I serve on a few healthcare boards and advisory councils. For a long time I have had the sense that although my participation is appreciated, and the opinions that I offer are politely heard, not much changes between meetings. It is hard to get busy people to listen to bad news, and preemptively make a change from what has been working for decades even as revenues flatten or begin to fall, and many indicators of internal performance seem to have plateaued.

The great business guru, Peter Drucker, noted that businesses will spend great amounts of capital to try to revive and prop up a once successful product that is failing rather than make a change to a new product, or adopt a new approach to their business. Clay Christensen was pointing our attention to yet another aspect of the same phenomena when he described how markets are disrupted by innovators. We can all now make long lists of companies and industries that declined and ceased to exist after failing to notice or respond to how the world or their industry/market was changing. Failure is likely when we delay in our response to what is coming, and fail to appropriately modify our work and our products.

As a metaphor, we know from physics that it takes a lot of energy, 540 Kcal/ mole, to make a phase change with water going from liquid to steam. Likewise it takes a lot of energy to move from what has been working, but soon won’t, to something new that has potential, even when that change offers an opportunity to avoid something extremely unpleasant. [I did not want to be an alarmist, so I chose the phrase “something extremely unpleasant” over “disaster.”] The centerpiece of this week’s letter is about the distractions, pitfalls, and potential for a permanent state of unpleasantness, or failure, that faces us if we fail to look ahead in the work of improving health as we try to “cross the quality chasm” on the way to the Triple Aim.

Just as we have potential unintended and unpleasant consequences ahead of us in healthcare that can be avoided by effective strategies, we also have concerns at the higher level of our democracy that were underlined for me this week as I listened to our president deliver the State of the Union address. I mentioned last week that I was reading How Democracies Die which has been recently published by two Harvard political scientists, Steven Levitsky and Daniel Ziblatt. Last week I offered a link to a “Fresh Air” interview with the authors. I have finished the book now. It is a chilling analysis of how our democracy has come to the brink of a descent into authoritarianism. It has taken us a while to get here.

The authors contend that Trump did not cause the problem. His election was a manifestation of a larger, multifaceted problem, or set of defects that we have tolerated for a long time, but like the erosion of health with a chronic disease, is gaining momentum toward an unpleasant clinical presentation. In other words, Trumpism may be viewed as the acute manifestation of some issues and defects with which we have coped with diminishing success for a long time. Impeaching the president, or even voting him out of office, will not solve our problems.

We are in a very interesting place. Said one way, we are on a road that is headed somewhere we may not want to arrive. Said in a more positive way, there are a few exit ramps ahead that offer us the chance, if we so chose, to alter our path and head toward a restoration of the democratic norms of mutual respect and forbearance that allow democracy to work. Such an alternative road would would allow us to continue to strive to establish a more perfect union in an age of racial equality and unprecedented ethnic diversity. If we do not recognize and take advantage of the choices we still have to pursue that vision, we are likely to continue the current battle as increasingly divided partisans that will ultimately abolish many of our democratic traditions. We will arrive at a place where we will discover that we have replaced a vision of an ever greater America with some yet to be imagined dystopian authoritarian state. Many people love to read novels about dystopian futures and the heroes and heroines who are trying to regain freedoms that have been lost. Those cautionary tales seem to me to be horror stories that wise people would work to avoid. I hope that many of you might read the book. On my Kindle App it is only about 230 pages, although there are an additional 70 pages of endnotes! What do you expect? The book was written by two professors. If you do not have the time to read the book, let me suggest as an alternative that you listen to a podcast that is an interactive interview between Ezra Klein of Vox and the authors.

In case you don’t have time to either read the book or listen to the podcast, let me remind you that In last week’s letter I commented on what is perhaps the major point of the book which is that up to now America has avoided authoritarian rule by voluntary adherence by both parties to some norms of behavior that are not written into the Constitution. Perhaps the most striking two norms that seem counterintuitive on first pass are “mutual toleration,” or a willingness to accept the patriotism and legitimacy of the other party, and what the authors call “forbearance.” Forbearance is the self restraint of the legal exercise of power. It is the wisdom of politicians not to exercise the option of doing everything that is within their legal or Constitutional rights.

There are many examples that might come to your mind of violations of the acceptance of the legitimacy of the other party to govern that are easy to recognize in the rhetoric of both parties over the last twenty five years. Democrats speak to the character flaws of many Republican leaders, and at times question their ability to govern because of self interest and veiled racism. Republicans have also exercised disrespect, and have suggested in their own way that Democrats are not trustworthy stewards of the government. During the last presidential campaign they loved to chant “lock her up” in reference to Hillary Clinton. Many Republicans before and during the presidency of Barack Obama were convinced, or tried to convince others, that he was either a Muslim, or was not born in America, and therefore not a legitimate president.

President Obama violated forbearance when he relied on executive orders to go around Congress to establish policy by executive order. Mitch McConnell failed to exercise forbearance when he broke with the established norm and refused to give President Obama’s nominee for the Supreme Court, Merrick Garland, even a hearing before the Senate Judiciary Committee. The lists of violations of mutual legitimacy and forbearance by both parties fill many pages of the book.

The authors trace the recent divide in the road back to the reaction to the passage of the Civil Rights Act of 1964 and the Voters Rights Act of 1965. Obviously, we could go back much further because of the lack of freedom and franchise of black Americans at the birth of the nation that is a dysfunctional shared legacy that even a Civil War could not resolve. Risking a gross oversimplification, since the mid sixties the Republican Party has statistically become demographically a party of white religious Americans while the Democratic Party has become a party of minorities and liberal intellectuals. Adding to the tension is the fact that caucasians of any religious orientation or economic status will be a minority in America by 2040-2045, as projected by many sources, including the U. S. Census Bureau. If the latest process of the deterioration of norms began in the mid sixties, it was enhanced by the controversies over Vietnam, and it was supercharged by militant rhetoric introduced by Newt Gingrich, and then fostered by the Tea Party movement. Levitsky and Ziblatt try to lay the blame for the deterioration of norms at the feet of the leadership of both parties. They present data from our country’s history, and other countries, that the greatest defense against the emergence of an authoritarian government, is the willingness of parties to reject potential authoritarians even when there is a current advantage for alliance. To reject candidates with authoritarian tendencies we must know how to recognize them. They offer a four part recognition test:


1. Rejection of (or weak commitment to) democratic rules of the game:

Do they reject the Constitution or express a willingness to violate it? Do they suggest a need for antidemocratic measures, such as canceling elections, violating or suspending the Constitution, banning certain organizations, or restricting basic civil or political rights? Do they seek to use (or endorse the use of) extraconstitutional means to change the government, such as military coups, violent insurrections, or mass protests aimed at forcing a change in the government? Do they attempt to undermine the legitimacy of elections, for example, by refusing to accept credible electoral results?


2. Denial of the legitimacy of political opponents:

Do they describe their rivals as subversive, or opposed to the existing constitutional order? Do they claim that their rivals constitute an existential threat, either to national security or to the prevailing way of life? Do they baselessly describe their partisan rivals as criminals, whose supposed violation of the law (or potential to do so) disqualifies them from full participation in the political arena? Do they baselessly suggest that their rivals are foreign agents, in that they are secretly working in alliance with (or the employ of) a foreign government—usually an enemy one?


3. Toleration or encouragement of violence:

Do they have any ties to armed gangs, paramilitary forces, militias, guerrillas, or other organizations that engage in illicit violence? Have they or their partisan allies sponsored or encouraged mob attacks on opponents? Have they tacitly endorsed violence by their supporters by refusing to unambiguously condemn it and punish it? Have they praised (or refused to condemn) other significant acts of political violence, either in the past or elsewhere in the world?


4. Readiness to curtail civil liberties of opponents, including media:

Have they supported laws or policies that restrict civil liberties, such as expanded libel or defamation laws or laws restricting protest, criticism of the government, or certain civic or political organizations? Have they threatened to take legal or other punitive action against critics in rival parties, civil society, or the media? Have they praised repressive measures taken by other governments, either in the past or elsewhere in the world?

Against that background, I applaud the attempt at a new direction that the president took in his State of The Union Address. I had to continuously fight my inherent distrust as he attempted to swear allegiance to a new American unity. Just as I do not think that he is the historical cause, but rather a beneficiary from, and contributor to the concerns of the moment, I also think that just announcing that he wants unity will not create it. If he is genuine in his desire, there is much repair to be done. There needs to be a demonstration that he is truthful. You can easily find documentation on the Internet by The New York Times, The Washington Post, and NPR of his continuing use of exaggerations, misrepresentations, and outright lack of truthfulness in many of his statements in the speech. He needs to consider the impact of his continuing references to danger from immigrants. He needs to better and more believably articulate a willingness to engage productively in the resolution of the difficult problems of illegal immigration, global warming, international trade, and foreign policy development and execution through mechanisms other than a zero sum negotiations, or threatening the use of force while taunting the other side.

The most frightening moment in the speech for me after reading How Democracies Die was his reference to the fact that change is hard to effect without an emergency. Ziblatt and Levitsky point out that many authoritarian regimes have begun when civil liberties, a free press, and the checks and balances between the executive, judiciary and legislative functions of the government were abolished in response to some “threat” or national emergency that was often manufactured, and not real. Our president has already referred on several occasions to the fact that he is frustrated by the efforts of Democrats in Congress to resist his policies. He has left no doubt that he would like to curtail the press, limit the powers of the judiciary, and interfere with the work of the Department of Justice and the Intelligence Agencies when he perceives their efforts to be attempts to limit his will. Will some future threat emerge that will enable a sudden shift and elimination of current restraints?

Since healthcare is my major area of interest, I was disappointed with the way the entire subject, as well as discussions of how to improve the social determinants of health, were short changed or treated with the same lack of believability that he treated the very important subject of investing in the nation’s infrastructure. We do know that he is aware of the opioid crisis. We do not have any substantive idea of how his administration will address it. We know that he thinks that drug prices are a problem. He is asking Alex Azar, his new Secretary of Health and Human Services, the recent CEO of a large pharmaceutical company, to fix it. Perhaps Secretary Azar has an insider’s insight that will prove useful. The other healthcare mentions that left things hanging were the troubles he has fixed at the VA, and how he killed Obamacare with immediate abolition of the mandate. The mandate is still in effect until 2019. I am ready to try to begin to build trust. I just need some evidence of trustworthiness, truthfulness, and mutual respect. He could exercise forbearance by not releasing the memo that the new FBI head and Senator Thune have advised should remain confidential.

I keep having this image of Lucy trying to convince Charlie Brown that he can trust her to hold the football while he kicks it. He takes the bait, and ends up on his back.