21 July 2017

Dear Interested Readers,


What’s Inside and a “Brief” Catch Up on a Wild Washington Week

I do not know if it was a quiet week in Lake Wobegon this week, but it was anything but quiet in the Washington, D.C. where Donald Trump keeps things well stirred with falsehoods and surprising revelations and reversals. So much has happened since Mitch McConnell’s announcement last Monday evening that his attempts to push the Senate to vote to begin debate on the Better Care and Reconciliation Act of 2017 were over. The majority leader had announced last Saturday that the vote to begin the debate would be delayed until Senator John McCain recovered from his surgery. That delay was precipitated by McConnell’s fear that without McCain’s vote the whole charade would be over. Susan Collins of Maine and Rand Paul of Kentucky had already announced, for entirely different reasons, that they would vote against the motion. That was just a warm up for Monday’s announcement of the simultaneous defections of Senators Mike Lee and Joe Moran, killing the bill for good. In this turbulent environment what happened last week often seems like ancient history.

For about twenty four hours Moran was my hero. He had been impressed by the messages that he had gotten from patients, doctors, and hospital leaders about the damage that McConnell’s bill would do to the people of Kansas. Mike Lee just thought that the bill preserved too much of the ACA. He is a self reliant man who seems not as interested in the health of others as in preserving pristine conservative values. Healthcare progressives across the country smiled and were delighted that the BCRA, the acronym for the hideous legislation, was dead even before the CBO could add real numbers to what everybody, including big insurers were saying, was one of the worst bills ever written.

We now know from the CBO that repealing the ACA without a replacement, the next suggestion from the powers that be, would be its own disaster, costing many millions their coverage in 2018 and 32 million by 2026. That is an outcome that is worse than either the House’s AHCA or the Senate’s BCRA. We now know that that nightmare will never see the light of day. Thanks to the quick response of three moderate Republican Senators, Susan Collins of Maine, Lisa Murkowski of Alaska, and Shelley Moore Capito of West Virginia, we will be spared the pain and suffering of the debate. Their quotes are worth bringing to your attention because they do create a small point of light that may lead to something better through a bipartisan process, like the one Senator Murkowski called for in her announcement. Senators Collins and Capito agreed with that sentiment but chose either to talk about the pain in their own states, as Capito did, or about the need for the usual committee process as expressed by Collins. I bolded what spoke most directly to me in each statement.

Senator Murkowski’s Statement on Senate Healthcare Process

“I have recommended to Chairman Alexander that the Senate Health Committee begin to hold hearings to examine ways to fix the many flaws in the ACA so that it will work better for all Americans.”

Senator Capito’s STATEMENT ON HEALTH CARE, VOTE TO REPEAL OBAMACARE

WASHINGTON, D.C. – U.S. Senator Shelley Moore Capito (R-W.Va.) issued the following statement about the Senate health care bill and a planned vote to repeal Obamacare:

“As I have said before, I did not come to Washington to hurt people. For months, I have expressed reservations about the direction of the bill to repeal and replace Obamacare. I have serious concerns about how we continue to provide affordable care to those who have benefited from West Virginia’s decision to expand Medicaid, especially in light of the growing opioid crisis. All of the Senate health care discussion drafts have failed to address these concerns adequately.

“My position on this issue is driven by its impact on West Virginians. With that in mind, I cannot vote to repeal Obamacare without a replacement plan that addresses my concerns and the needs of West Virginians.”

It has been a strange journey to where we have arrived. The president never effectively supported the current bill or provided any input, despite his campaign promises that his genius would produce a beautiful and wonderful healthcare law that would cover everybody so much better and for much less money than the flawed ACA. After McConnell waved his white flag for a second time, the president began talking about just letting Obamacare die. It is a threat he has used before. What he doesn’t say as openly is that he is currently trying to kill it and there is more that he could do. Writing in the New York Times Haeyoun Park and Margot Sanger-Katz describe three things he is already doing and more that he could do to fulfill his death threats for the ACA. As a businessman Trump was famous for a combination of persistence, prevarication, and bullying that often got him what he wanted.

After threatening the Democrats on Tuesday, he called all of the Republican Senators to lunch at the White House on Wednesday and demanded that they pass a bill to repeal and replace the ACA before leaving town. He said he was waiting for something to sign. Read the story or watch the video. He bullied and cajoled them all but directed both praise and threats at Senators like Heller of Nevada and Capito of West Virginia who were sitting next to him. The event should remind us of Yogi’s wisdom, “It ain’t over till it’s over…” That brings us back to the hope that what we will see before it is over is a bipartisan process that builds on the ACA while correcting some of its demonstrated liabilities. What remains as a cloud on the horizon is the president’s ability to further damage the ACA through the administrative options that are available to him. The main topic of this week’s letter includes a brief consideration of the president’s ability to do harm and blame it on the existing law as a bully’s approach to getting what he wants versus the more positive consideration of reciprocal altruism as a foundation of a bipartisan process.

The president sold himself to a majority of angry white blue collar voters in states like Pennsylvania, Michigan, Ohio, and Wisconsin, all states that Obama won, who were frightened about an uncertain future and had a cultivated distrust of Hillary Clinton, the liberal press, and progressive ideas that embraced inclusive policies as the most efficient and effective way to pursue America’s greatness. He ran on slogans that were not supported by rational economics or plausible policy suggestions.

His biggest con was to pass himself off as an effective negotiator. That was quite a stretch for a man who demonstrates no facility for interest based negotiations or an understanding of the nonzero concepts of win-win outcomes. Bullies sometime win a round or two but game theory and the history of progress by our species suggest that not considering the welfare of others is the fast track to your own disappointment. That is the lesson that they’re teaching in my grandson’s preschool. Somehow our president did not learn what he should have learned before the first grade. His misunderstandings about how to achieve results through a process of reciprocal benefit based on trust and effort have persisted into adulthood as a problem for himself and others. Managing people in high places who did not learn the lessons of preschool sometimes calls for great coordination, bravery, and a willingness to be vulnerable to the bully.

This week three strong women passed “the stand up and do the right thing test.” I hope that they will become the core of a coalition that does understand how to negotiate something better for everyone. All far reaching social legislation needs to be developed across the aisle or risk being the subject of the persistent attacks that have been the experience of the ACA. The road to the Triple Aim was always going to be a long and difficult journey with many surprises, many setbacks, and pauses to get our energy back for the next push that will produce a small victory that will eventually coalesce with other positive events to get us somewhere. The process nicely fits the lyrics of the Grateful Dead's song “Truckin’”

Lately it occurs to me what a long, strange trip it's been.

Truckin', I'm a goin' home. Whoa whoa baby, back where I belong,
Back home, sit down and patch my bones, and get back truckin' on.

I hope that the women Senators that McConnell excluded from the disaster of a bill that he and 12 other old white guys came up with will now continue their advocacy for a bipartisan process that helps us “keep on truckin’” toward

...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..

Last week’s letter discussed the realities of the impact on attitude of cultures that stressed individualism or collectivism. I tried to present Lean process and philosophy as a way to overcome some of the differences in outlook that these tendencies introduce when we must solve big problems. Senators Collins, Murkowski and Capito have moved us a little closer toward the possibility of a bipartisan process. If we ever get there, it will probably create a lot of distress for the president because he does not understand effective principles of interest based negotiation or reciprocal altruism. He will probably feel excluded and will certainly feel diminished because it will not be all about him. He has manifestly demonstrated that participating in conceptualizing effective paths toward universal coverage requires more focus and learning than he is willing to invest. He certainly understands how he can destroy the ACA, but seems unable to offer solutions to improve it, nor does he have an interest in asking his advisors to do so, despite his campaign promises.

I hope that you are getting an email notice each Tuesday that connects you to the latest output of Strategy Healthcare. You can easily forward the notice to a friend or “share it.” There is a signup box on the site that will allow your friends and colleagues to also become interested readers. Many of the readers of the the Healthcare Musings letter are not medical professionals! It will be impossible to develop a demand for the Triple Aim if we limit the conversation about the future of healthcare to the people who provide or support the delivery of good care.

Better Healthcare Requires A Bipartisan Expression of Reciprocal Altruism

A major event that changed the way I see the world occurred in 1995 when I read Robert Wright’s The Moral Animal: Why We Are The Way We Are: the New Science of Evolutionary Psychology. The book was so good that I immediately gobbled up Nonzero: The Logic of Human Destiny when it was published in 2000 and then The Evolution of God when it was published in 2009. In the midst of the span between Nonzero and The Evolution of God I found a copy of his first book from 1988 which was out of print, Three Scientists and Their Gods: Looking For Meaning in an Age of Information. Robert Wright is not a traditionally religious man which raises the question of why he is interested in why we are moral animals looking for our God or Gods and inventing them if necessary to fill a need. Wright calls himself an atheist, or if it seems more acceptable, a secular humanist. I was delighted when I learned that like me and the famous sociobiologist E.O. Wilson who was one of the three scientists in his first book, he was raised by parents who were Southern Baptists. It was through my reading of Wright that I developed an interest in how these powerful forces that drive our individual behavior affect how we live together. More practically I began to wonder and think about how these realities of behavior either contributed to or compromised my ability to be a physician who could work in a complex organization with other professionals in the pursuit of a mission.

Wright begins “Chapter 9: Friends” of The Moral Animal with a quote from Charles Darwin’s The Expression of the Emotions in Man and Animals (1872).

[I]t is not a little remarkable that sympathy with the distress of others should excite tears more frequently than our own distress; and this certainly is the case. Many a man, from whose eyes no suffering of his own could wring a tear, has shed tears at the suffering of a beloved friend.

We saw a perfect example of this reality this week when Senator Lindsey Graham responded to the plight of his dear friend and colleague John McCain, and it was not that long ago that McCain expressed the same remorse for the suffering that Ted Kennedy was enduring with dignity. We all know that shared grief and empathy is easy with kin or close friends, but most of us are capable of the same feelings for people we have never known and could easily avoid without any sense of guilt and with no ill feelings about our disinterest from anyone we know. I have a friend in New London who after she had been successful in business decided on her sixtieth birthday that she was going to find a village in Africa that she could help. Over the next decade she made 26 trips to Ghana where she found a community she thought she could help and began the work with a program of “micro investments” giving the people chances to build businesses and improve their own lot. She did not have the resources of a Bill Gates or an Oprah Winfrey, but she did use what she had to build a non profit that has transformed the lives of many in a place far away. How do you explain such behavior?

It almost seems wrong to try to analyze and understand the origins of these urges to “do good” for people that we do not know, but I believe that reminding ourselves of the reality and learning more about it so that the forces can be used to find common ground and make progress on the problems that challenge us in a small world and a divided country. Perhaps a deeper understanding of what determines what we do could help us make a difference in a variety of areas. Strategies to improve healthcare, income inequality and climate change begin to look somewhat similar when you search for reasons why to care enough to try to do something.

I was deeply moved by the words and actions of Shelley Moore Capito, Lisa Murkowski, and Susan Collins this week. All three dared to disappoint their colleagues and leaders because to be silent and to go with the majority meant that many people would suffer. Capito said it best, “...I did not come to Washington to hurt people.” All three are hoping that their actions will lead to a better outcome. I believe that their unwillingness to vote for the BCRA or for “repeal without replace” was an expression of complex feelings that are a starting point on the road to a bipartisan creation of a widely acceptable set of compromises and joint experiments that in time could lead to a workable mechanism to fund universal coverage.

At the core of the opportunity is the reality that true achievements and improvements in the complex collective problems of society are made through the exercise of what people like Wright, Wilson, Robert Trivers, and Robert Sapolsky call reciprocal altruism. You may understand the concept but there is benefit to looking more closely at it in the context of the current healthcare debate. It is more complex than just “I help you and then you help me and together we have a win-win.” Social scientist have given the issue a lot of thought and from game theory, using mathematical analysis of “games” like the “prisoner’s dilemma” and concepts of “tit for tat” a useful set of ideas have been described. All of these ideas require trust and a willingness to resist those who are self serving. Our president’s assertion that he and his agents, principally Tom Price, Secretary of HHS, and Seema Verma, the Administrator of CMS do have the ability to kill the ACA or as the president euphemistically says, “Let it die.” That would be a strategic error that would surely undermine any chance of bipartisan cooperation and would drive the wedge that divides us deeper than even Mitch McConnell’s promise to defeat or overturn anything that President Obama would do.

Some authorities trace reciprocal altruism to our days as “hunters and gathers.“ I think we can see it in our own history when Farmer Brown helps Farmer Jones raise his barn and realizes that the next time his crop fails he can be sure that Jones will be willing to help him and his family make it through the winter. My neighbor who does not have lakefront property uses my dock to park his ski boat and then reciprocates by taking my granddaughter out to wakesurf when she visits. I am sure you have your own examples of the process. How does this relate to a bipartisan effort to “repair and improve” what we have learned with the ACA?

To try to answer that question let’s look at a schema that describes the rules of reciprocal altruism. There is a nice summary of the work of Stephens in the Wikipedia discussion that serves our purpose nicely which I have modified just a little.

Christopher Stephens from the University of British Columbia published a set of necessary and jointly sufficient conditions in 1996 for reciprocal altruism:

1. the behaviour must reduce a donor's fitness relative to a selfish alternative;
   
2. the fitness of the recipient must be elevated relative to non-recipients;
   
3. the performance of the behaviour must not depend on the receipt of an immediate benefit;
   
4. conditions 1, 2, and 3 must apply to both individuals engaging in reciprocal helping.
   
5. There are two additional conditions necessary for reciprocal altruism to evolve. There must be a mechanism to detect cheaters, and there must be many many times that the process is used.
   

OK, that may be a little abstract but let’s take them one at a time. Condition 1 describes a “donor.” In the ACA I would say that is a combination of taxpayers, individuals forced by mandate to buy insurance, and employers. In the moment their generosity or participation “reduces their resources” or costs them money relative to the alternative of not participating. Condition 2 is easy. The beneficiaries of the ACA are better off than they were, and better off than those unlucky enough to live in “red states” that did not expand Medicaid. Condition 3 is also easy. How often do we hear about people who feel cheated by the fact that they see no personal benefit in the tax dollars they lose today to pay for some deadbeat’s healthcare. Condition 4 says that we are all in the same process and if fortunes change we can expect to be recipients of what we are making possible for everyone. Condition 5, no cheaters and a lot of activity are also reflected in the ACA. The more people who are involved in a process that is considered to be beneficial and is basically fair and equitable, but monitored for cheaters, the more secure it becomes as an important part of our lives together. Social Security might be a good example of both of these concepts.

When trying to promote a bipartisan process these principles that we all accept in our culture need to be identified along with empathy for those who in the moment need help. We must realize that just a diagnosis and a few unforeseen pieces of bad luck separates “recipients” from “donors.” One of my senior residents once pointed out to me that we all look pretty much the same in a hospital johnnie. That is just the sort of observation that holds a truth that we often try to avoid.

Bipartisanship will also require that we understand what is important to everyone so that we can find common objectives. Working together to lower the expense of care and mutually developing strategies to reduce waste are areas where initial common ground is possible. A willingness of progressives to look at the rapid growth of the expense of entitlement programs is also a consideration. I think there is reason to hope for a renewed effort from our Senators. There are at least three who have shown the courage to act in the defense of what has been accomplished. They deserve our support and our encouragement. Perhaps through their example a bipartisan majority may evolve that sees the wisdom of exercising the principles of reciprocal altruism to guarantee that we will all get the care we need.

Early Morning Mist

The picture in header on this letter was taken by my wife. It captures the ethereal feel that accompanies the glassy water and low hanging blanket of fog riding just above the lake that is present on so many summer mornings before the world is fully awake. It is a very quiet time that doesn’t last long as the rising sun quickly burns off the fog. I miss the scene most days because I stay up late and then sleep late. I do enjoy the inverse experience of the sunsets over the lake. The sky and clouds turn red, orange, pink and purple at sundown and almost every evening the chop on the water quiets to a glass like finish. It is the best time to fish, and a good time to peddle around the lake in my kayak as I try to come up with a fresh perspective on chronic problems over which I have no control.

I hope that you will have the opportunity to quietly enjoy an early morning moment or a beautiful sundown this weekend. They are the best part of the great days of summer and a good time to see something wonderful.

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