23 June 2017

Dear Interested Readers,


What’s To Come and a Little Bit about What’s Inside

The events of the past few days reminded me of a song my son wrote back in January 2012, “Is This The Shape of Things to Come?”. His songs are often the poetic expression of a complex philosophical idea. The song that popped into my head began by asking some of the questions that I have been asking lately.

Is this the shape of things to come?
Is this the ground we walk upon?
Is this the way we live and die and carry on?
Is this the day we hoped would come?

For over six years he has written a new song each week and posts it on the his website on Monday evening. Along with each song there is a short explanation or essay that gives some information about what has been on his mind. In the essay that accompanied “Is This The Shape of Things to Come?” he wrote:

This week’s song was written in anticipation of an unknown future. The words are a play on the old concept that the more things change, the more they stay the same. Is the shape of things to come the same as the shape of things as they are now? Do people change? Do fortunes change? Does the country change, or are we merely playing out roles in a repeating history on a loop? Can anything or anybody ever change if we are too cynical to believe that it can?...

The song is tricky because a superficial listening may suggest to you that it is hopeless to think that things will ever change for the better, but in the last three verses his statement that “If that’s what you think...things will never change” ironically suggests that change is possible if you can change the way you think. He is cryptically suggesting that the possibility of change is up to us. It is a matter of attitude and we have choices. If we can change the way we think then perhaps change can happen. In that light the shape of things to come depends on us and whether we think that change is possible.

Change what you would. What’s the use?
The unmistakable truth:
We’d do it all the same

And somebody out in America
Has found a new belief to push their heart away

If that’s what you think
Then the shape of things to come
Will just reveal the things that never change


I do not know why the song popped into my head as I was beginning to write about the changes in healthcare coverage that the Senate will try to push with their version of the American Health Care Act between now and the Fourth of July, but I thought I should check with my son to be sure if I had not over interpreted his piece. To my delight he confirmed my sense of what he was saying:

Hi Dad,

You hit the nail on the head. The song's moment of conversion comes in the word "if". We're likely to repeat the same mistakes, but perhaps we're not destined to if we can shake off some of our cynicism. I'm glad you've dug this one up. It's written for a moment just like the one we're facing.

It is amazing to me that through the use of his computer to blend multiple tracks, he plays all the instruments, and sings all the parts. If you would like to listen to the song, click here and then read on as I try to process what is happening in the Senate.


My writing schedule was distorted this week while I was waiting for the the bad news about what’s been going on behind closed doors in Mitch McConnell’s committee of thirteen old white men who were writing the Senate version of the House bill that President Trump said was “mean.” The Washington Post came to my rescue and allowed me to start writing when it published an article at 8:52 PM on Wednesday that described what was in a draft that was circulating on Wednesday afternoon ahead of the release of copies of the bill to Senate Republicans scheduled for Thursday morning. By now I am sure you know all about the bill but here is what I got as an early warning:

A discussion draft circulating Wednesday afternoon among aides and lobbyists would roll back the Affordable Care Act’s taxes, phase down its Medicaid expansion, rejigger its subsidies, give states wider latitude in opting out of its regulations and eliminate federal funding for Planned Parenthood.

The article suggested that the bill was an attempt to walk the fine line between mollifying moderates like Susan Collins of Maine while not losing the votes of hard line conservatives like Rand Paul, Mike Lee, Ron Johnson and Ted Cruz. McConnell better be one of the Great Wallendas because he is walking a tight wire between the arch conservatives and libertarians who suggest that nothing less than a full repeal of the ACA will ever get their vote and more moderate senators like Susan Collins of Maine and Lisa Murkowski of Alaska who seem to care about what might happen to the millions of people who will lose their care if this legislation is ever signed into law by President Trump. The assessment of the Post is:

It is hard to hide the fact that the goal of the bill is not to provide for the health of the nation but rather to eventually dramatically reduce the federal contributions to Medicaid, freeing up hundreds of billions in tax saving for wealthier Americans. I hope that Senator Collins and other Republican Senators might realize that throwing tens of millions of people off of Medicaid and reducing the coverage of millions more in 2025 is as egregious as doing it in 2020.

In another article in the Post, also written Wednesday evening, Matt O’Brien offers a plausible description of the motivation behind the bill even before he had seen it:

You just can't cut taxes the way Republicans want and have “insurance for everybody” like Trump promised. Heck, you can't even have cheaper insurance. On an apples-to-apples basis, the House Republican plan, at least, would probably increase premiums and deductibles, according to the center-left Brookings Institution and the nonpartisan Kaiser Family Foundation. To the extent that people would pay less, it would only be because they were getting less and people who needed more had been priced out of the market. None of this is going to change in the Senate version unless the GOP changes its commitment to cutting taxes for the rich.

By lunchtime yesterday we had the general shape of what will now be called the “Better Care and Reconciliation Act of 2017” in the form of a draft that you can peruse it if you click here. It is 142 pages of legislative gibberish that may add up to real grief for as many as 74 million Americans. If the law is passed as it appears in the draft almost everyone who is on Medicaid now will either be eventually thrown off of Medicaid or have substantial cuts to the services they receive.

My guess is that the clumsy name is an attempt to align the bill with the concept of a “budget reconciliation” process and give it some positive aura rather than to describe it as what it is, an attempt to gut the most forward looking piece of social legislation in the last fifty years so that the slim Republican majority in the Senate has a chance to avoid a filibuster by Democrats which would surely kill the bill. The next step in the process is to get the CBO scoring of the bill early next week. Senate Majority Leader Mitch McConnell is allowing no committee hearings and no more than twenty hours of debate, although there will be a possibility to offer amendments on the floor of the Senate, perhaps after McConnell has approved them in private.

The Majority Leader controls the pace and timing of things in the Senate. Currently McConnell plans to call for the vote late next week before the Senate goes home for the July 4th recess so that Senators will not have their support of the bill challenged by angry constituents. Assuming McConnell loses no more than two votes, the next stop for the bill will be the joint committee of the House and Senate that will attempt to resolve the differences between the “mean” American Health Care Act passed a few weeks ago by the House and whatever the Senate finally passes. Once the two bills are blended into one the resolution goes back to both houses for final approval before going to the president to be signed into law.

There was a concrete expression early Thursday afternoon of the work McConnell has before him this next week as he tries to get to a vote. Cruz, Paul, Robinson and Lee, the four conservative Senators mentioned above, announced that they could not support the bill in its current form. They are looking for a more complete repeal of the ACA. This bill does not hurt enough people to satisfy their rigid concept that nothing short of a complete repeal of the ACA is enough. They say that they are not going to vote for what they deem to be “Obamacare Lite”. McConnell may not be able to make the bill harsh enough for their tastes without making it too harsh to gain the support of more moderate Senators like Collins of Maine, Murkowski of Alaska and Rob Portman of Ohio.

What more is there to say now? I am sure that between now and the vote that there will be no shortage of analysis from the left about how bad this bill is and how it will hurt millions. I am equally sure that the majority of Republicans will continue to press the fact that they need to pass something before Obamacare implodes, and that their bill frees people from the mandate to buy something that they do not want. The “freedom to buy care” if you want to is not the same as having access to the care you need.

In the main section of the letter I continue to explore the deep division in the country that we all are so painfully aware exists. Last week while I was in North Carolina I was surrounded by people who did not see the world the way I do. They have just as much trouble understanding how I could ever imagine that the government has the potential to improve lives as I have difficulty understanding how they can believe that the government is always plotting to make their lives more difficult. The divisions we see in the Senate are just an expression of what exists in the deeply held beliefs of members of the community.

How can we solve problems if we can’t talk to one another? Trying to understanding our “deep stories” may be the way to resolve our differences over the questions that arise when we try to pursue the Triple Aim and give everyone access to good care at a cost that we can afford. I am not asking that we all see the world the same way. That would be impossible, but I am convinced that what we would learn from improving care together could catalyze the solution for many of the other problems that we can chose to face together or allow to continue to deepen the divide between us. The shape of things to come is up to us. It is a choice.

The letter ends with a celebration of summer. We did pass the summer solstice on Wednesday. I also give a brief tutorial on kudzu, the natural plague of much of the South, and comment on the renewal of the Red Sox and the recent rocky road of the Yankees.

My suspicion has been confirmed that many of the people that once got these letters every week are not getting them now. If someone you know asks you if you are getting the letter because they are no longer getting it, please tell them to check their “junk mail.” If you are using your corporate email address, it is probably a good idea to go to strategy healthcare and sign up again using your personal email. While there you might check out the most recent postings.

What Is Your Deep Story?

A couple of weeks ago when I gave you Dr. Patty Gabow’s letter to Senator Alexander I reported that I was reading Arlie Russell Hochschild’s recent book, Strangers In Their Own Land: Anger and Mourning on the American Right. In that book Russell seeks to be empathetic with the very religious, very conservative, angry people in Louisiana who have consistently allowed their politicians to give tax breaks and other benefits to polluting industries in exchange for jobs. It was initially hard for Hochschild to understand how conservative Louisiana voters could reelect politicians who neglected infrastructure, education and the public welfare to help polluters who dumped carcinogens into their waterways and destroyed much of their coastline and fishing industry.

She attempted to understand their mindset by spending several years visiting them frequently and getting to know them as friends. Her book is a wonderful story that creates sympathy for people who seem to be tragically trapped by culture, a difficult to understand pride, a sense of honor, and the need for good jobs. She visited them at work, in their homes, and in their churches. She attended their political rallies and gained their confidence through her questions that were presented without judgement and without attempts to change their minds. After she got to know many of them at the level of friendship that was associated with real personal concern and empathy, she attempted to articulate what she calls their deep story.

She felt that perhaps her ability to understand and articulate their world view would be a start toward healing the divisions that exist within our society. She evolved a series of metaphors that she called their “deep story. The deep story is described in a central chapter of the book, but I found that it was accurately condensed in an excellent review of Hochschild’s book by Jason DeParle who writes:

Hochschild detects other passions and assembles what she calls the “deep story” — a “feels as if” story, beyond facts or judgment, that presents her subjects’ worldview.
It goes like this:

“You are patiently standing in a long line” for something you call the American dream. You are white, Christian, of modest means, and getting along in years. You are male. There are people of color behind you, and “in principle you wish them well.” But you’ve waited long, worked hard, “and the line is barely moving.”

Then “Look! You see people cutting in line ahead of you!” Who are these interlopers? “Some are black,” others “immigrants, refugees.” They get affirmative action, sympathy and welfare — “checks for the listless and idle.” The government wants you to feel sorry for them.

And who runs the government? “The biracial son of a low-income single mother,” and he’s cheering on the line cutters. “The president and his wife are line cutters themselves.” The liberal media mocks you as racist or homophobic. Everywhere you look, “you feel betrayed.”

In the last chapter of the book in an attempt to relate to her new right-wing friends Hochschild wrote a letter to them trying to close the gap between her world view and theirs. In her letter she admits that most liberals are not satisfied with the nation's political choices any more than are those on the right. She tells them that she is aware of what they want: a vital community life, full employment, the dignity of labor, and personal freedom. She assertively points out that historically Democrats have more often supported the goals and life they want than have Republicans. She states that progressives have their own deep story. She feels that there are parallels between the liberal deep story and the deep story of the right.

As she gave her view of the liberal or progressive “deep story” I found that my deep story was similar to hers but also a little different. So what you read is a blend of her deep story and mine. In our deep story it is as if liberals are not standing in a line but are feeling misunderstood as they congregate around a large town square or park. Around the square are wonderful shared public assets like creative science museums for kids, public art and theatre programs, libraries, schools, and I would add hospitals and clinics. There is state-of-the-art public infrastructure available for use by all. They're fiercely proud of it. Some of them help build it. Outsiders or new folks in town can join those locals or insiders standing around the square because many of today’s insiders remember that they were outsiders in the past. Everyone believes that incorporation and acceptance of differences feels like an American value represented in the Statue of Liberty.

It sounds idyllic, but the liberal deep story is laced with fear. They are afraid of a warming environment and all the disasters that might occur. They also worry about marauders who want to invade the public space and recklessly dismantle it and selfishly steal way bricks and concrete chunks from the public buildings. They fear that what they enjoy together might be dismantled, degraded, or stolen. Those guarding the public square watch helplessly as those who dismantle it transfer the bricks that were once the foundations of public assets into private McMansions. That's the gist of the liberal fear of the privatization of the public space.

Hochschild moves from the metaphorical to the specific:

Given our different deep stories, left and right are focused on different conflicts and the respective ideas of unfairness linked to them. The left looks to the private sector, the 1% who are in the over class, and the 99% among whom are an emerging underclass. This is the flash point for liberals. The right looks to the public sector as a service desk for a growing class of the idle “takers.” Robert Reich has argued that a more essential point of conflict is in yet a third location between main street capitalism and global capitalism, between competitive and monopoly capitalism. “The major fault line in American politics” Reich predicts, “will shift from Democrat versus Republican to anti establishment versus establishment.” The line will divide those who “see the game as rigged and those who don't.”

Ironically both sides of the political divide are struggling to address the same new and frightening face of global capitalism. In an age of extreme automation and globalization, how can the 90 percent for whom income is stagnant or falling respond? For the Tea Party, the answer is to circle the wagons around family and church, and to get on bended knee to multinational companies to lure them to you from wherever they are.... For the liberal-left the best approach is to nurture new business through a world-class public infrastructure and excellent schools.

Hochschild’s analysis adds some light to the discussion about healthcare. The resources that might provide universal access, or at a minimum the care that we provide to the underserved and disadvantaged through Medicaid, are resources that might end up in metaphorical McMansions. I would add that if the real challenges that face us all are globalization and automation then having a healthier nation is necessary if we are to adequately respond to the external challenge that we share. That is nebulous but perhaps a better way to add things up than saying that those of us who have resources are so self interested that we would rather focus on our own needs than on the needs of the collective.

I would be more specific than Hochschild and say that except for some minority of the one percent who have enormous wealth none of us will ever be able to be more secure individually than we are collectively. I do not think that is a liberal idea. I think it is good self serving strategy.

Notwithstanding deep stories, where do we go from here? What might we expect? Strategically I always imagine how I might deal with the worst outcome, and I guess that is why I was thinking about “Is This The Shape of Things to Come?”. If the shape of things to come is the passage of Mitch McConnell’s oppressive bill to repeal and replace Obamacare or more accurately Medicaid, what will we do?

I hope what we will do in the short term is to come together in a way many of the cities and states have responded to Trump’s withdrawal from the Paris Climate Accords. In some states Medicaid may continue at levels near those obtained under the ACA but it will be a big stress on state budgets. One outcome that would be positive would be for providers to begin to realize that the cost of care is a core issue over which they have some control. In any problematic moment a good first question is to ask “What part of the problem am I (we)?”. The answer to that question may lead to actions that you can take to begin a resolution. Finally, the repeal of the ACA followed by a loss of access to care for tens of millions of people and the reduction of resources or the increase in expense for those who retain coverage in the aftermath of the bill may mobilize a political response built out of a new understanding of how important good healthcare for all is to our collective success and happiness.

I am encouraged by the conversations that the repeal and replace process has generated. I hope that whatever happens will be a “new beginning” that causes us to be more considered in how we articulate to those who see the world differently what we are willing to share of ourselves with each other to find a way to a better world. My deep story is associated with a deep belief in the sense of community that is a best expression of what it means to be American. I hope that “the shape of things to come” is that the outcome of the Senate bill will be a renewal of the idea that the strength of America is our passion to persist in our imperfect pursuit of the high ideal of equality and opportunity for everyone. We will be reminded that this noble concept arises from our belief in the intrinsic worth of every human being and that we are all entitled to a better life that we all can share together.

Summertime and The Mystery of Kudzu

When I visit North Carolina one of my favorite activities is to go walking on the trail through town that has been built over an old railroad bed. I often walk with my brother and we do our best not to discuss politics. I was delighted to learn that plans are underway to join this trail to another existing trail that goes into the countryside. If you look closely at the header for today which was taken on the trail as it nears the center of town, you will see that there is a canopy of green that overlies all of the bushes and trees. What you see is kudzu, the vine that ate the South. Introducing kudzu to North America was an environmental mistake we made in the nineteenth century. When you see it in its full glory as is depicted in the link or in the header it is as if all the trees and bushes have had a blanket thrown over them. Kudzu just “hangs around” and sucks the life out of things. One of my favorite cartoon strips was called "Kudzu". Kudzu of the comics was about a teenage boy, Kudzu Dubose, who just hung around making stupid mistakes and other characters in his sleepy Southern hamlet of Bypass, North Carolina, like the Reverend Will B. Dunn. Need I say more.

Sometimes watching the Red Sox play can be as frustrating as watching kudzu grow, but this this last week was exciting as they clawed their way into first place for one day as the Yankees lost seven games in a row. Good times never last. The Sox fell out of first place late Wednesday afternoon when their pitchers walked three batters in the bottom of the eight and then allowed the fourth batter to hit a grand slam. You can’t win them all but I am hopeful that they will still be interesting and in the running deep into September.

I hope there is a good place for you to walk this weekend. Let me suggest that a walk is a good time to think about your deep story.

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