24 February 2017

Dear Interested Readers,

What’s Inside This Letter

This week’s letter had its origin in last week’s research. In my reading I learned that Paul Ryan had scheduled a meeting of the Republican members of Congress to prepare them for the town meetings that were scheduled back in their home districts during the Presidents’ Day holiday week when Congress was recessed. Until now, the best document that we have had to help us understand the Speaker’s thinking was the paper that he released last June which he called “A Better Way.”

For the meeting last Thursday Ryan published “talking points” and a written summary of the justification and objectives for “repeal and replace.” I am assuming that his objective when he posted the talking points on the Internet was more than to enable the Republican legislators for their town meetings. Making the talking points available to the press and anyone who was interested was an invitation for discussion which I am more than willing to accept. My objective in this letter is to take advantage of the opportunity that he has offered. I hope that you will find the discussion beneficial.

As I was gathering my thoughts for the discussion I received an email from Alan Gaynor, a friend, retired Boston University professor and “interested reader” with whom I have had many in depth discussions about a wide variety of subjects since 1975! Over more than forty years Alan has consistently pointed me toward sources that add to my understanding of the world. Alan was writing to thank me for the last few Friday letters and to express his continuing worries about the direction taken by the President. I responded to his email:

Alan,

It is always great to hear from you. We see the world in much the same way. I am still trying to figure out how not to be annoyed by the thought of Trump during my waking hours. So far he has not invaded my dreams.

It is startling to realize that because of our age and social position he is not a threat to either of us, but he is a huge threat to what I have always cared about. The only thing that seems positive about his presence is that he is a reminder of how much we should care about our system of laws and our sense of social responsibility to those not as fortunate as we are. He will hurt many many people and leave damage that will take decades to repair, if ever.

Stay in touch!


Alan responded, as always in bold type, and with some helpful information:


Yes, Gene. It’s frightening. You might want to look at two articles in The March issue of The Atlantic: one by David Frum, “How to Build an Autocracy,” the other by Jonathan Rauch, “Containing Trump.”

Take care.

A.

I was delighted to find both articles online for free! Above, I have created links to the articles in Alan’s note to me. After reading them and listening to audio and watching Frum on video, I realized that the two articles put Ryan’s presentation and the whole process of “repeal and replace” in a useful context. What is also very helpful as preparation for Ryan and the “repeal and replace” conversation is to review the YouTube reproduction of the CNN debate of healthcare between Bernie Sanders and Ted Cruz which was aired on February 7.

This is a long letter. It is longer than usual because the whole story requires reviewing and quoting from three articles. I hope that if you read it all you will find that you have made a good investment of your time. I also hope that you will invest the time to at least read the article in the Atlantic by David Frum. The link above is not only to the article, but also to an audio version of the article which is very well read. It would make a nice companion on a walk! The first section of the letter is my summary of the major points of both Atlantic articles plus some reference to the Sanders-Cruz debate. The second section of the letter, once the stage is set, is a discussion of Ryan’s “Policy Brief and Resources.” I would urge you to download Ryan’s handout and print it for your own reference as the “repeal and replace” debate progresses over the next few months.

The last two letters that Alan liked so much are now available minus all their folksy banter on the strategyhealthcare.com website as “It’s Still the Truth, Ten Years Later” and “Applying Lean Thinking to the Future of the ACA.” I hope that you will check them out and that you will pass them along to your colleagues because you found them useful to you.

The Potential For a New Form of Autocracy

Jonathan Rauch begins his recent Atlantic article, “Containing Trump” by reminding us of our experience with Richard Nixon. He then tries to imagine who we will discover our 45th president to be as we watch the interplay of personality, intent, and events. He see three possibilities. First there is the possibility that Trump will mature and develop in office. That would be good. There is also the possibility that we are just beginning on a course that will show us an “infantile” Trump or a “strongman” Trump. The article is an examination of possibilities and responses that will help preserve what we have if we are stuck with the infant or the strongman.

He quotes a warning from Timothy Naftali, a New York University historian who was the founding director of the Nixon presidential library.

“Don’t be complacent,..Don’t assume the system is so strong that a bad president will be sent packing. We have someone now saying things that imply unconstitutional impulses. If he acts on those impulses, we’re going to be in the political struggle of our lifetimes.”

Rauch posits that meeting the challenge of an infantile or strongman version of Trump will depend on “whether civil society can mobilize to contain or channel” him. He believes that with the public responses of the first few weeks “that’s happening already.”

Ever cautious, Rauch introduces us to Yascha Mounk, the co-founder of “After Trump.” Mounk, a fellow at the New America Foundation and a lecturer on government at Harvard, is concerned.

“Most people are thinking about Trump as a policy problem: how he will lead to the deportation of undocumented immigrants or lead the U.S. to pull out of the Paris climate agreement. But I think Trump is also potentially an authoritarian threat to the survival of liberal democracy.”

Mounk, a naturalized American citizen who is originally from Germany, studies and writes about the decline of democracy in the West. He believes, and offers evidence that democracy is much less stable in America and in Europe than most people think. Rauch goes on to explain more of Mounk’s thinking

...many students of political development have supposed that in prosperous and democratic parts of the world, liberal democracy has consolidated its standing. Unfortunately, that reassuring theory now appears to be wobbly. Democracy can start to unwind if popular support for it declines, if the public becomes open to undemocratic alternatives, and if undemocratic politicians emerge who can exploit that opening. All of those factors are visible in a multitude of places. “Democracy is no longer the only game in town,” ...

The explanation for the perilous state of democracy lies in three realities that are frequently offered as explanations for Trump’s election:

• Economic anxiety: the decline in the standard of living for the next generation
  

• Ethnic and racial anxiety: historically dominant groups are losing majority standing and control of the culture 
  

• Growing economic inequality between urban and rural populations 
  

It seems obvious that changes induced by globalization enhance all three factors. The combination of all of these factors, Mounk believes, “seem to create political opportunities for illiberal democracy and tough-guy populists.
”

Rauch sums up Mounk position:

So Trump might be a black swan. But he also might be a transformative figure in a global antidemocratic backlash.

Much of the article describes the reassuring ways in which we have restrained other Presidents from Jackson through Obama when they began to drift into potentially dangerous behaviors. Rauch calls for “crowdsourcing” by which he implies “organizing the mob”, a VUCA strategy. Working with the crowd that cares means having everyone, alone and through numerous organizations, being constantly vigilant and reacting to every act of “illiberal democracy” and tough-guy populism. Social media, as demonstrated by the Women’s March and the spontaneous demonstrations at airports as a reaction to the President’s immigration order, has already been demonstrated to make this possible.

If you think that is enough, you are wrong. I’ll quote Rauch:

But there’s a tougher problem we’ll have to confront: behavior by either the administration or its allies that is... “lawful but awful.” As Benjamin Wittes, a Brookings Institution expert on legal affairs, told me, “The first thing you’re going to blow through is not the laws, it’s the norms.” By “norms,” he means such political and social customs as respecting the law, accepting the legitimacy of your political opponents, tolerating speech you disagree with, performing civic duties like voting and staying informed, treating public office with dignity, and not lying....Speaking for many, Senator Lindsey Graham said Trump had “crossed a line.” Actually, Trump had erased the line, and then erased many others. A president has much greater power than a candidate to erase accepted standards of conduct, because millions of partisan supporters will rally to him. Trump and people around him seem aware of this power and willing to use it.

Mounk has a reassuring response:

“We need a positive vision of what politics can be after Trump...We need to build a new vision of how liberalism can improve people’s lives while pulling them together.” [Better healthcare and education, concern for climate change, and efforts to ameliorate income inequality can be part of this vision and amount to a more than the catchy but subversive, “Make America Great Again.”]

Rauch points out that we are likely in for a long struggle both at home and around the world. We already have evidence that if democracy declines abroad it puts pressure on democracy in America:

It’s likely to require revising the liberal-democratic social contract to meet the challenges of societies struggling with growing inequality, disappointing economic mobility, weakened institutions, and an angry, jaded public. It’s going to require a collective effort of activists and citizens and elites on several continents. Years will pass before we know whether liberal democracy can muster a new case for itself.

I was inspired by Rauch’s concluding paragraph:

To help the body politic resist de-norming, you need to make an argument for the kind of government and society that the norms support. You have to explain why lying, bullying, and coarsening are the enemies of the kinds of lives people aspire to. Instead of pointing to Trump with shock and disgust—tactics that seem to help more than hurt him—you need to offer something better. In other words, you need to emulate what the Founders did so many years ago, when they offered, and then built, a more perfect union.

I hope for a society and government where the norms support a “more perfect union” that includes:

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.

The second Atlantic article “How to Build an Autocracy” was written by Donald Frum, now a senior editor at the Atlantic who was a speechwriter from 2001-2002 for President George W. Bush. Frum’s article began with a fanciful view backwards from Inauguration Day 2021. The story is written as a reporter’s analysis in 2021 of just how the President consolidated his power resulting in a huge second term victory. The fantasy frightened me more than anything that I have read since the election, and it is very important to consider the points he makes as we engage in the “repeal and replace” conversation. It is possible to see in the emerging relationship between the President and Congress, between the President and the media, and between the President and those who have much to gain in either wealth, influence, or the imposition of their minority agenda on all of America, just how the nightmare could get worse.

Frum echos one of Rauch’s points as he describes how new norms that accept new behaviors once considered unacceptable now [in the story in 2021] exist. The President in 2021 is surrounded by an increasingly self serving governing elite that is prospering from graft. The President and his family continue to inappropriately enrich themselves. The new norms are accepted by the majority of the populace, the press and business because they have either been rendered impotent or have become dependent upon their improved economic status. Congress is controlled by a Republican majority that has gone along with the shift in behavior against the cries for investigations or impeachment because the new order has allowed them to enact some legislation and changes in the courts that they as a governing minority have desired for decades.

In the story Trump now has his electoral majority. It is composed of enough people who are happy with what they have gotten from the President’s style and new “norms” that they have sustained the Republican control of Congress. Surprisingly the resistance can still say what they want if they can tolerate the response from cyber bullies and the administrative hassles that might suddenly become a problem for them. Everyone is technically free to vote if they have not lost their franchise through new voters registration rules. But voices and votes don’t make as much difference as they did before the change in “norms.”

Frum imagines a pretty frightening progression of events and attitudes over the next four years:

Nobody’s repealed the First Amendment, of course, and Americans remain as free to speak their minds as ever...Rather than deal with digital thugs, young people increasingly drift to less political media like Snapchat and Instagram.

Trump-critical media do continue to find elite audiences. Their investigations still win Pulitzer Prizes; their reporters accept invitations to anxious conferences about corruption, digital-journalism standards, the end of nato, and the rise of populist authoritarianism. Yet somehow all of this earnest effort feels less and less relevant to American politics. President Trump communicates with the people directly via his Twitter account, ushering his supporters toward favorable information at Fox News or Breitbart.

Despite the hand-wringing, the country has in many ways changed much less than some feared or hoped four years ago. Ambitious Republican plans notwithstanding, the American social-welfare system, as most people encounter it, has remained largely intact during Trump’s first term. The predicted wave of mass deportations of illegal immigrants never materialized. A large illegal workforce remains in the country, with the tacit understanding that so long as these immigrants avoid politics, keeping their heads down and their mouths shut, nobody will look very hard for them.

What attitude has allowed all this to happen?

Still, with all the hacks and leaks happening these days—particularly to the politically outspoken—it’s just common sense to be careful what you say in an email or on the phone. When has politics not been a dirty business? When have the rich and powerful not mostly gotten their way? The smart thing to do is tune out the political yammer, mind your own business, enjoy a relatively prosperous time, and leave the questions to the troublemakers.

Frum shakes us from the chilling story with a solution:

Everything imagined above—and everything described below—is possible only if many people other than Donald Trump agree to permit it. It can all be stopped, if individual citizens and public officials make the right choices. The story told here, like that told by Charles Dickens’s Ghost of Christmas Yet to Come, is a story not of things that will be, but of things that may be. Other paths remain open. It is up to Americans to decide which one the country will follow.

The point that Frum seeks to make is that the autocracy of the future will not look like Hitler’s Germany, Mussolini's Italy, or Stalin’s Russia. He envisions a kleptocracy, a nation controlled by thieves.

“The benefit of controlling a modern state is less the power to persecute the innocent, more the power to protect the guilty.”

Are we like the proverbial frog that is gradually boiled as the temperature is increased? There are a few thought provoking assertions that suggest “maybe”. [The last link on kleptocracy is from the Washington Post and suggests that America is already a kleptocracy. Trump as much said so when he claimed that he would “drain the swamp.”]

If this were happening in Honduras, we’d know what to call it. It’s happening here instead, and so we are baffled.

It is one thing to tell a scary story. It is more important that the storyteller offer some explanations along with creating fear.

As politics has become polarized, Congress has increasingly become a check only on presidents of the opposite party. Recent presidents enjoying a same-party majority in Congress—Barack Obama in 2009 and 2010, George W. Bush from 2003 through 2006—usually got their way. And congressional oversight might well be performed even less diligently during the Trump administration.

The first reason to fear weak diligence is the oddly inverse relationship between President Trump and the congressional Republicans. In the ordinary course of events, it’s the incoming president who burns with eager policy ideas. Consequently, it’s the president who must adapt to—and often overlook—the petty human weaknesses and vices of members of Congress in order to advance his agenda. This time, it will be Paul Ryan, the speaker of the House, doing the advancing—and consequently the overlooking. [This is perhaps the most important enlightenment in Frum’s article. Seen in this context Trump is likely to “go along to get along” with Congress. Many Republican members of Congress seem to have suddenly realized that as despicable as Trump’s violation of “norms” have been, having him willing to sign their laws is not a bad trade for looking the other way.]

Trump has scant interest in congressional Republicans’ ideas, does not share their ideology, and cares little for their fate. He can—and would—break faith with them in an instant to further his own interests. Yet here they are, on the verge of achieving everything they have hoped to achieve for years, if not decades. They owe this chance solely to Trump’s ability to deliver a crucial margin of votes in a handful of states—Wisconsin, Michigan, and Pennsylvania—which has provided a party that cannot win the national popular vote a fleeting opportunity to act as a decisive national majority. The greatest risk to all their projects and plans is the very same X factor that gave them their opportunity: Donald Trump, and his famously erratic personality. What excites Trump is his approval rating, his wealth, his power. The day could come when those ends would be better served by jettisoning the institutional Republican Party in favor of an ad hoc populist coalition, joining nationalism to generous social spending—a mix that’s worked well for authoritarians in places like Poland. Who doubts Trump would do it? Not Paul Ryan. Not Mitch McConnell, the Senate majority leader. For the first time since the administration of John Tyler in the 1840s, a majority in Congress must worry about their president defecting from them rather than the other way around.

Frum makes a frightening assertion about why the Congress may be reluctant to restrain the President:

A scandal involving the president could likewise wreck everything that Republican congressional leaders have waited years to accomplish. However deftly they manage everything else, they cannot prevent such a scandal. But there is one thing they can do: their utmost not to find out about it.

Ambition will counteract ambition only until ambition discovers that conformity serves its goals better. At that time, Congress, the body expected to check presidential power, may become the president’s most potent enabler.

Frum speaks to a question that I have asked myself many times. What is the real motivation or purpose that explains why Donald Trump ran for president? I know that he says that he ran because only he can “Make America Great Again.” Frum thinks he ran to enrich himself and his family. I am not sure it is that simple, but being wealthy is important for President Trump and many others around him; with the parade of billionaires in his administration the kleptocratic tendencies that our country seems to be developing are becoming more obvious. Making many other people richer is a way for a leader to consolidate power.

It is essential to recognize that Trump will use his position not only to enrich himself; he will enrich plenty of other people too, both the powerful and—sometimes, for public consumption—the relatively powerless.

Hitler used public outrage against manufactured enemies as a path to power. Frum is concerned that Trump is already focused on violence as a justification for his policies both at home and abroad. He even manufactures reports of violence as in Bowling Green, Atlanta, and Sweden as well as lamenting the “carnage” on our streets!

Civil unrest will not be a problem for the Trump presidency. It will be a resource. Trump will likely want not to repress it, but to publicize it—and the conservative entertainment-outrage complex will eagerly assist him…

Calculated outrage is an old political trick, but nobody in the history of American politics has deployed it as aggressively, as repeatedly, or with such success as Donald Trump. If there is harsh law enforcement by the Trump administration, it will benefit the president not to the extent that it quashes unrest, but to the extent that it enflames more of it, ratifying the apocalyptic vision that haunted his speech at the convention.

Frum’s article is worth your time. His points are well made and his warning is to look out for a new and more deceptive form of authoritarian evolution that has new dimensions. The success of our democracy is not a foregone conclusion. Some of our reliance on the separation of powers, our courts, and freedom of the press can be undermined by changes in the attitudes of the public and the evolution of Twitter, “fake news” and concepts of alternative facts. What may be coming is new and the process is of undermining the norms upon which we place a great deal of confidence is well under way. If we wish to preserve our democracy we must be thoughtful, strategic and involved.

By all early indications, the Trump presidency will corrode public integrity and the rule of law—and also do untold damage to American global leadership, the Western alliance, and democratic norms around the world. The damage has already begun, and it will not be soon or easily undone. Yet exactly how much damage is allowed to be done is an open question—the most important near-term question in American politics. It is also an intensely personal one, for its answer will be determined by the answer to another question: What will you do? And you? And you?

Now armed with an expanded view of the relationship between a Congress (or at least a Speaker of the House, Senate Majority Leader and Tea Party Republicans) that has an agenda and a President who needs to maintain a relationship with a Congress that will allow him to continue to set aside “norms”, if not laws, let’s look at what Speaker Ryan and Secretary of Health and Human Services, Dr. Price who until his appointment was a lieutenant of Speaker Ryan, have given us to read.

Finally, Something To Examine

If you Google “Paul Ryan's presentation of Obamacare Repeal and Replace: Policy Brief and Resources 2/16/2017”, you will get multiple reports of the meeting that Paul Ryan had with the rank and file Republican members of the House last Thursday. The report of the meeting from the New York Times (frequently number one on President Trump’s list of purveyors of “false news”) is my choice.

In the article Robert Pear and Thomas Kaplan reported that the meeting was preparing Republican lawmakers for a weeklong Presidents’ Day recess when House members would be holding meetings with their constituents. There was a fear that the meetings would be dominated by angry or anxious questions from constituents about what would happen to the ACA. Speaker Ryan, flanked by two House committee chairmen, and the new Secretary of Health and Human services, former Representative Tom Price of Georgia, presented the plan in the form of talking points and a policy brief. Pear and Kaplan point out that the “plan”...

• Was heavily weighted toward tax credits.
  
• Would reduce payments to the 31 states that expanded Medicaid eligibility. 
  
• Did not say how the legislation would be financed.
  
• Laid out the benefits without the more controversial costs and collateral damage to the economy.
  
• Included no estimates of the number of people who would gain or lose insurance under the plan.
  
• Did not include comparisons with the Affordable Care Act, which has extended coverage to 20 million people.
  

In a companion article in the Times Margot Sanger-Katz reported on the immediate concerns that the plan elicited from the states that have expanded Medicaid through the ACA. The key thing to notice here is that the discussion began with the the concept of repealing and replacing the ACA, but it has become a much bigger discussion of Medicaid. “Welfare spending” is the largest item in the federal budget and Medicaid is one of the largest federal welfare programs. If your agenda is to reduce federal spending, Medicaid is a richer target than the ACA. This week the Commonwealth Fund has published an excellent tool that is a map that allows you to click on a state to see its total Medicaid population, the Medicaid growth since 2013 under the ACA, and an analysis of how many jobs would be lost if the ACA were repealed.

I clicked on Pennsylvania and New York, since I am on the board of Guthrie Health which has hospitals and ambulatory sites in both states, as well as my home state of New Hampshire. Pennsylvania has added almost 500,000 Medicaid patients since 2013 and would lose about 91,000 jobs by 2019 if the ACA were repealed. In New York there are 750,000 new recipients and potential job losses are estimated to be about 89,000. New Hampshire is a small state, but we still added more than 62,000 lives to Medicaid and our economy could lose as many as 8,000 jobs if the ACA were repealed. Check out California! You should explore the map. It is interesting.

The ACA looks like it was built on the concepts of the Triple Aim. It is a piece of legislation that is imperfectly aligned with the ideal that we are searching for:

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.

But, as imperfect as the ACA is, it has moved us toward the ideals of the Triple Aim. It was a giant, though incomplete, step toward universal coverage. There is much data to support that the ACA has improved the quality of care. The ACA is most maligned because of the sense of federal control and regulation that it added to the lives of individuals and employers through its mandates, and because the cost of care for many individuals who did not qualify for assistance has risen even as the rate of the annual increase in the total cost of care has diminished.

None of the accomplishments of the ACA are referenced in Speaker Ryan's presentation. His focus on finance is legitimate and was shared by President Obama. His other criticisms are primarily distortions of the experience of the majority who have realized real improvements in their care. My fear is that the gains we have made so far over many years will be thrown away while offering replacements that will damage lives and the economy. I believe that Ryan’s faux solutions will ultimately increase the cost of care, lower the number of people who have access to care, and diminish the quality of the care still available to those able to pay more.

When thinking about replacing the ACA after repealing it, fundamental questions are: where do we start and what objectives are we pursuing? Chapter 58 in Massachusetts (Romneycare) made universal coverage the highest priority. Ryan does not mention universal coverage. His paper speaks in terms of the grievances of those individuals who had care before the ACA. I am cynical and suspect his core objective is not universal coverage but rather a reduction in federal spending or some other cloaked political objective. The ACA was designed with moving toward universal coverage as its initial objective as the leading edge of the movement toward the Triple Aim. The ACA did close the gap between the number of lives covered and true universal coverage. It is likely that true universal coverage is only possible with an “entitlement” realized through a single payer option similar to the plan that Bernie Sanders advocated.

It is my opinion that the real result of the election will be at least a ten, if not a twenty year, delay in the dream of universal coverage through a mandate or an entitlement. The only hedge would be President Trump’s promise to give everyone terrific care. To do so would require a federal investment that would give Ryan, Price, Pence and associates a huge problem with their aligned supporters. This is where David Frum’s analysis in the Atlantic fits into the picture. President Trump may see, when faced with giving his populist base what they want while trying to enriching his family and his inner circle, that his best way forward is to sign off on the agenda of the members of the most demanding wing of the Republican party who want to see huge reductions in the federal budget that will undermine current support for healthcare, education and the other programs championed by liberals. We will see.

It is interesting to note that on February 7, CNN televised a healthcare debate between the two senators who were the “runners up” in the two Presidential primary marathons. You can watch the debate or read the transcript. If you listen closely to Senator Cruz, what you will hear is perfectly aligned with the position of Speaker Ryan. In response to one of the questions he talks about the “reason for action” behind “repeal and replace.” It is not universal coverage. It is about fulfilling campaign promises to the base.

Senator Cruz:...Now, nobody thinks we're done once Obamacare is repealed. Once Obamacare is repealed, we need commonsense reform that increases competition, that empowers patients, that gives you more choices, that puts you in charge of your health care, rather than empowering government bureaucrats to get in the way. And these have been commonsense ideas, I would note, that for six years Republicans have been proposing, and for six years Democrats have been fighting, saying no changes at all to Obamacare, even as people were hurting and losing their coverage. This election is about honoring the promises we made to the people who elected us.

Did he say “this election”? I think that was a slip that revealed a truth that Bernie did not catch. Ted and Paul are not thinking about universal coverage and the Triple Aim. Cruz and perhaps Ryan are already thinking about trying to get elected president in 2020 or is Cruz already focusing on his reelection campaign for 2018? It is hard to know intent but the words suggest that Cruz and other Republicans are focused on reducing the federal budget and satisfying promises to the contributors who helped elect them. With Senator Cruz’s statement and Mr. Frum’s warnings about the relationship between Congress and the President in mind, let’s take a closer look at the document that Speaker Ryan presented to his colleagues. It’s not that long. Page one has several big points. One could call them a “reason for action.”

• The law is only getting worse 
  
• Repeal is relief 
  
• A stable transition is the goal
  
• We have a better way
  

Each item has more verbiage that may interest you. I find many of the assertions inaccurate. The discussion continues with “Key Obamacare Facts.” It is my opinion that many of the “facts” like the statement, “Obamacare is hurting more people than it is helping, forcing Americans to buy insurance they don’t like, don’t need, and cannot afford” are at a minimum debatable, if not just outright distortions of the truth. What is definitely true is the assertion that there are three different ways to undermine the ACA. In Speaker Ryan’s words:

• Repeal and replace the Legislation: House Republicans will advance legislation in the weeks ahead to provide relief from Obamacare’s taxes and mandates--including eliminating the individual and employer mandate penalties--and move forward with patient-centered reforms.
  

• Action from the Trump Administration: President Trump and HHS Secretary Price have an important role to play in providing relief from Obamacare’s burdensome regulations. Most recently, the administration issued a proposed rule to help protect taxpayers and stabilize the collapsing marketplaces.
  

• Delivering Solutions through Regular Order: Both Energy & Commerce and Ways & Means have already begun to hold hearings examining reforms that will: a) Decrease costs and increase choices by promoting competition and innovation in the insurance market. b) Increase flexibility for employers to offer affordable, quality health care options to their employees. c) Allow individuals and families to purchase insurance across state lines.
  

Ryan’s policy statement is crafted to sound feasible while ignoring the underserved and the objective of universal coverage. My greatest concerns are on page 7.

• Modernize Medicaid 
  
• Utilize State Innovation Grants 
  
• Enhance Health Savings Accounts 
  
• Provide Portable, Monthly Tax Credits
  

Each of those objectives will undermine the resources for the underserved and take us further away from universal coverage and the objectives of the Triple Aim. Each of those objectives do speak to objectives that are espoused by many members of the middle class who feel threatened. They all translate into real benefits for people who already have coverage and think that they pay too much in taxes.

The remaining eight pages plus references are labeled “Policy.” I would label them as old ideas that are certain to translate into the cost of millions of people losing their coverage. Many of us believe that if millions lose their care with whatever replaces the ACA there will be a voter backlash in 2018. I hope that is true. For there to be accountability in 2018 there will need to be a continuing struggle against misinformation and self interest.

Misinformation and self interest have been well managed by President Trump to get this far and the Republican Congressional Leadership has figured out that if they go along they have a very good chance to advance things that have been on their agenda since the era of Newt Gingrich’s “Contract With America” over twenty years ago. Some hope exists, if a few Republican senators crossover and vote against the repeal. That possibility is enhanced if people study the issues now and speak out in ways that are effective. I can think of no better focus for action around which to bring voices together than the Triple Aim. Defending better care for everyone is the only durable way to be sure that you and your family will always have the care you need. The most practical thing that caregivers and other healthcare professionals can do to defend their patients in these days is to work hard to reduce the total cost of care within the framework of an improved ACA.

And The Winner Is....

My wife says that the Oscars are her Super Bowl. I like them, too. Like a lot of people, we try to see a few of the movies ahead of the show. I was depressed by the realism of “Manchester By The Sea.” I was elevated by the music and energy of “La-La Land”, although I would have preferred a fairy tale ending. “Lion” was a terrific tale of the human spirit, and I loved the small performance of Nicole Kidman. She deserves her nomination for best supporting actress. I was most disappointed by not being able to see “Moonlight”. One would think that it would be easy to find a showing of a movie that has received so much acclaim, but not so. Maybe it came and went when I wasn’t looking. Everywhere I try to find Moonlight, I find movies like “Lego Batman Movie”, “Fist Fight”, or “Fifty Shades Darker.” None of those flicks are nominated for anything, and I doubt that they are even worth my senior discounted ticket price.

With the temperature in the high forties most days in my part of New Hampshire this week I have had some great walks. Last Sunday’s walk with a couple of friends took me across town to Pleasant Lake. In the 1800s the area at the outflow end of the lake was known as Scytheville because they made scythes and other blades there using the water power flowing out of the lake. At peak production in the early 1880s they employed over a hundred men in good jobs making hundreds of thousands of blades that they shipped all over North America and Europe. By the 1890s they were out of business and the jobs were gone. Was this a preview of what was to come with good manufacturing jobs in America, or was it true then as now that progress always has winners and losers?

The area is now called Elkins. It is a “borough” of New London. Many of the homes around the lake sell for millions. The factories are gone but the spillway which you can see in today’s header is still present as evidence that once there was real manufacturing happening where now there are just big blocks of granite, millponds, and remnants of waterways that once carried the hydropower of falling water from the lake into a gathering of industry.

Stone walls that once surrounded productive fields and abandoned spillways that once turned lathes and powered presses that molded steel are around every turn on most all of the walks I take. These fading reminders of things past are reassuring that the stresses of these days will also be survived and other ways of making the world work will emerge. Time flows on, carrying us to new challenges and adventures. What was once essential becomes a quaint curiosity and subtle reassurance that if we do not give up we can go forward toward an interesting future.