27 January 2017 Dear Interested Readers, What’s Inside and Trying to Maintain Equilibrium in A Post Inauguration TailspinHave we ever had a political week like this past week? As I was writing last week I was unrealistically waiting to hear an inaugural address in the first few minutes of Donald Trump’s Presidency that would signal that his response to becoming our president would include a personal effort to become “presidential”. I was disappointed within sixty seconds when he said This American carnage stops right here and stops right now.Carnage? I can understand “carnage” if applied to Aleppo or maybe Vietnam. I understand that there has been a recent uptick in violent crime in Chicago, but applying “carnage” to our country today seems like an attempt to lay the subliminal foundation for future radical actions that would otherwise be hard to justify. My first response to the speech was that I should devote this letter to dissecting the speech in an attempt to reveal its flaws and fabrications. The New York Times and NPR have done a much better job of that than I could ever hope to achieve. If you have not yet done so, I would advise that you invest the time to follow at least one of these articles through their annotation of this inflammatory recitation. The speech was just the beginning of a wild week of “ alternative facts”, signings of executive orders to fulfill campaign promises, and public appearances where the President seemed most interested in convincing us that more people were in attendance at his inauguration than at the Obama inauguration in 2009, and that more than 3 million people had illegally voted for Hillary Clinton. Things are happening so fast that it is hard to keep up with the craziness as well as the destruction of many years of progress. The TPP was gone in a heartbeat despite the fact that many believed it offered great hope for many of the world’s poorest people and would also be good for our country. Some warned that abolishing it would have many unintended consequences in our competitive relationship with China. The action did however reinforce one of the most dramatic pronouncements from his inaugural address: We assembled here today are issuing a new decree to be heard in every city, in every foreign capital and in every hall of power. From this day forward, a new vision will govern our land. From this day forward, it's going to be only America first. America first.I was startled by those words. My first reaction was to wonder what our allies around the world were thinking when they heard this pronouncement of a policy of national narcissism. I immediately imagined that it was not good strategy against ISIS. I would not be surprised to hear that they are using the President’s pronouncement as proof absolute that the Ayatollah was right, America is the “ great satan”. The President’s words sounded more like barroom bragging than the words of an effective world leader who realizes that all progress through diplomacy is advanced by looking for solutions that are “win-win” and not “we win-you lose”. But, I can imagine that the statement felt really good to many angry men and women who were watching the inauguration of their hero who promised to turn back the clock and Make America Great Again. By the end of the speech I was wondering if “Make America Great Again” was not perceived by many as “wink-wink” code for “return historical advantage to me and my kind.” I had foolishly thought that we had learned that that mindset never produced any sustainable advantage. We all now know that the most remarkable event of last weekend was the worldwide Women’s March. My wife took a bus with neighbors down to Boston. One of my sons and his wife joined her sisters in Washington, and my grandson and his mother were among the throng in Oakland. There has been much written about this outpouring of concern and some, like David Brooks have wondered what its real meaning and lasting effect will be, but I was was deeply moved by a blog posting by a close college friend of my son and his wife. In her blog posting she reported what the march meant to her and captured the spirit of the what she had experienced and what is at risk. To have the right to marry whomever you love.
To have the right to choose.
To protect our schools for our children.
To protect our earth for our children.
To receive equal pay.
To be black and to matter.
To be indigenous and to matter.
To be trans and to matter.
To afford health insurance.
To afford housing.
To have a place and a voice in this country even if you come from another.Perhaps your list might be different as indeed there were many different reasons, some contradictory on a surface review, that brought women together in this remarkable event. What was true was that they all hoped that their collective expression of concern might in someway be a counter to the sense of jeopardy and outrage that they collectively felt. That is democracy in action. I am rethinking the direction of these letters in the months to come. It seems impossible to comment on all of the absurdities that are presented by this administration each day. The President’s outrageous comments and his jousting with the press are analyzed each day by people who know more than I do. I do want to return to a more focused discussion of the opportunities that are available and the changes that need to be considered wherever care is delivered. I think that for a while progress toward better care and the values of the Triple Aim will be difficult. I think there will be unavoidable problems that will affect everyone, no matter how they get their care. I am searching for the right balance between comments about healthcare policy and the politics of healthcare and how to live and prosper in the changing environment of healthcare. I could not pass on using the ABC interview at the White House this week with the President as the main section of this letter. The section of the interview on healthcare raises many concerns beyond the amazing demonstration of the unusual style and demeanor of the President. I had to comment on what I heard. After my thoughts about the interview, the letter concludes with comments about the joy of exercise and the quasi religious importance of sports in our culture. It is good to finish on the familiar turf of an established pattern and liturgy! An Amazing Interview and Display of NarcissismOn Wednesday night ABC aired a White House interview between the President and its anchorman, David Muir. It was remarkable TV. Click here to see the broadcast and to read the transcript. I think Muir did the best he could asking the questions that allowed the President to reveal both his focus on the trivial and his lack of understanding of the subtleties of the complex issues of our times. If nothing else he was persistent even as he was appropriately respectful of the office. If you watched the interview you might gain even more perspective on what it reveals of the President’s concern for himself. You may also be informed if you read Jenna Johnson’s analysis in the Washington Post. To make sure that no “alternative facts” fooled you let me recommend that you read another Washington Post article by Greg Sargent, “ Trump just gave a remarkable new interview. Here’s a tally of all his lies.” The most important part of the ABC interview for me was the part of the interchange about healthcare. I have lifted the entire segment for your examination. Healthcare was their last subject. I have bolded the parts that for me were most important. I have inserted some of my concerns in brackets: DAVID MUIR: Let me ask you, Mr. President, about another promise involving Obamacare to repeal it. And you told The Washington Post that your plan to replace Obamacare will include insurance for everybody. That sounds an awful lot like universal coverage.
PRESIDENT TRUMP: It's going to be -- what my plan is is that I wanna take care of everybody. I'm not gonna leave the lower 20 percent that can't afford insurance. Just so you understand people talk about Obamacare. And I told the Republicans this, the best thing we could do is nothing for two years, let it explode. And then we'll go in and we'll do a new plan and -- and the Democrats will vote for it. Believe me.
Because this year you'll have 150 percent increases. Last year in Arizona 116 percent increase, Minnesota 60 some-odd percent increase. And I told them, except for one problem, I wanna get it fixed. The best thing I could do as the leader of this country-- but as wanting to get something approved with support of the Democrats, if I didn't do anything for two years they'd be begging me to do something. But I don't wanna do that. So just so you unders-- Obamacare is a disaster.
It's too expensive. It's horrible health care. It doesn't cover what you have to cover. It's a disaster. You know it and I know it. And I said to the Republican folks-- and they're terrific folks, Mitch and Paul Ryan, I said, "Look, if you go fast -- and I'm okay in doing it because it's the right thing to do. We wanna get good coverage at much less cost." I said, "If you go fast we then own Obamacare. They're gonna put it on us. And Obamacare is a disaster waiting to explode. If you sit back and let it explode it's gonna be much easier." That's the thing to do. But the right thing to do is to get something done now.
[Everyone, including the former President, recognizes that for all that the ACA has accomplished, it has fallen far short of the Triple Aim. As Mr. Obama pointed out in his New England Journal of Medicine article published online on January 6 and in print January 26, everyone does not have high quality care at a cost that is sustainable, but the process should be one of consensus improvement and not repeal. Based on the interview it seems unlikely that President Trump has the will, the perspective, or the expertise to initiate such a process.]
DAVID MUIR: But you ...
PRESIDENT TRUMP: So I wanna make sure that nobody's dying on the streets when I'm president. Nobody's gonna be dying on the streets. We will unleash something that's gonna be terrific. And remember this, before Obamacare you had a lot of people that were very, very happy with their health care.
[In several other letters I have been fascinated by Trump’s use throughout his campaign of the phrase “Nobody's gonna be dying on the streets.” For me it elicits the same level of disgust as “Build the wall” and “Lock her up.” As I have facetiously noted in previous references, death without intervention has been made much less likely by the passage of EMTALA in 1986. What we need to do to lower the cost of care while providing quality care for everyone is perhaps beyond the President’s understanding. The ACA represented the first step in the transformation of our expensive and inadequate system of fee for service medicine into a system that has the ability to improve the health of the nation and reduce the cost of care by improving our systems of care. As former President Obama noted in the NEJM and as Don Berwick described in the article that I quoted in this week’s posting, “Information for Responsible Resistance”, on strategyhealthcare.com, the ACA is now woven into every aspect of healthcare. Many experts have warned that removing it suddenly carries the risk of far reaching unintended damage to the health security of every American. The executive order signed on his first day in office has already introduced substantial confusion.]
And now those people in many cases don't even have health care. They don't even have anything that's acceptable to them. Remember this, keep your doctor, keep your plan, 100 percent. Remember the $5 billion website? Remember the website fiasco. I mean, you do admit that I think, right? The website fiasco.
Obamacare is a disaster. We are going to come up with a new plan ideally not an amended plan because right now if you look at the pages they're this high. We're gonna come up with a new plan that's going to be better healthcare for more people at a lesser cost.
DAVID MUIR: Last question because I know you're gonna show me around the White House. Last question on this. You've seen the estimate that 18 million Americans could lose their health insurance if Obamacare is repealed and there is no replacement. Can you assure those Americans watching this right now that they will not lose their health insurance or end up with anything less?[This is the key question. It is never really answered, because it can’t be answered. My feeling is that just as we are discovering that it is highly unlikely that Mexico will pay for “the wall” even though we are initiating the process of building it, it is also highly unlikely that the President and his Republican colleagues in Congress can deliver on the claim of “something better for less.” With an executive order on “the wall” we have begun to waste money on a project that may never be completed and would lead to no benefit if it were completed. Similarly in healthcare, the President and the Republican leadership in Congress have already launched us on a disastrous and foolish journey. I am concerned that saying care will be “universally available for those who want it” is an empty offering that will be accompanied by a substantial withdrawal of public resources and the loss of what has been accomplished, rather than the development of a quality system of care that can provide
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.
I will join Barack Obama in promising that if indeed, through some miracle, a bill is produced that is a genuine improvement on the ACA, I would gladly embrace it. ]
PRESIDENT TRUMP: So nobody ever deducts all the people that have already lost their health insurance that liked it. You had millions of people that liked their health insurance and their health care and their doctor and where they went. You had millions of people that now aren't insured anymore.
DAVID MUIR: I'm just asking about the people ...
PRESIDENT TRUMP: No, no.
DAVID MUIR: ... who are nervous and watching ...
PRESIDENT TRUMP: We ...
DAVID MUIR: ... you for reassurance.
PRESIDENT TRUMP: ... here's what I can assure you, we are going to have a better plan, much better health care, much better service treatment, a plan where you can have access to the doctor that you want and the plan that you want. We're gonna have a much better health care plan at much less money.
And remember Obamacare is ready to explode. And you interviewed me a couple of years ago. I said '17 -- right now, this year, "'17 is going to be a disaster." I'm very good at this stuff. "'17 is going to be a disaster cost-wise for Obamacare. It's going to explode in '17."
[He can make his “prediction” come true. By undermining the mandate and the exchanges with his executive orders, and by appointing Tom Price and Seema Verma to head up HHS and CMS to lead reversals of programs in Medicare and Medicaid that have begun to make a difference, he has aggressively begun the process of making his prediction of the “failure” of Obamacare in 2017 a reality.]
And why not? Obama's a smart guy. So let it all come do because that's what's happening. It's all coming do in '17. We're gonna have an explosion. And to do it right, sit back, let it explode and let the Democrats come begging us to help them because it's on them. But I don't wanna do that. I wanna give great health care at a much lower cost.
DAVID MUIR: So, no one who has this health insurance through Obamacare will lose it or end up ...
PRESIDENT TRUMP: You know, when you ...
DAVID MUIR: ... with anything less?
(OVERTALK)
PRESIDENT TRUMP: ... say no one I think no one. Ideally, in the real world, you’re talking about millions of people. Will no one. And then, you know, knowing ABC, you'll have this one person on television saying how they were hurt. Okay. We want no one. We want the answer to be no one.
But I will say millions of people will be happy. Right now you have millions and millions and millions of people that are unhappy. It's too expensive and it's no good. And the governor of Minnesota who unfortunately had a very, very sad incident yesterday 'cause he's a very nice guy but -- a couple of months ago he said that the Affordable Care Act is no longer affordable.
He's a staunch Democrat. Very strong Democrat. He said it's no longer affordable. He made that statement. And Bill Clinton on the campaign trail -- and he probably had a bad night that night when he went home -- but he said, "Obamacare is crazy. It's crazy." And you know what, they were both right.
DAVID MUIR: Mr. President, thank you.
(OVERTALK)
PRESIDENT TRUMP: Thank you very much. Appreciate it.
The President’s willful presentation of his naked narcissism was breathtaking in its demonstration of a lack of self awareness. He really does not hold his cards close to his chest. As the program ended I reminded myself of what I learned a couple of years ago (2014) when I read Jeffrey Kluger’s remarkable book, The Narcissist Next Door. Kluger is an editor at Time and also the co author with Jim Lovell of “ Apollo 13” that became a Tom Hanks movie. In his book on narcissism, Kluger presented our new President, even before he was a candidate, as the archetypical narcissist. You can view him speaking about narcissism in a short YouTube clip. What I remembered from his book that gives me a chill now was his warning that things never end well in a relationship with a pathological narcissist. Jane Brody offered a similar description of narcissism and similar warnings to those engaged with narcissists in her NYT article last summer on narcissism that had the same title as Kluger’s book, “ The Narcissist Next Door.” Perhaps Mike Pence and others close to the President are following advice that she offered in her article which she based on common characteristics of extreme narcissists from the work of Dr. Joseph Burgo, a clinical psychologist who wrote, The Narcissist You Know; Defending Yourself Against Extreme Narcissists in an All-About-Me Age.
“The best defense for employees who choose to stay is to protect the bosses’ egos and avoid challenging them,” Dr. Burgo said in an interview. His general advice to those running up against extreme narcissists is to “remain sane and reasonable” rather than engaging them in “battles they’ll always win.”
The sum total of Dr. Burgo’s advice is not that reassuring for the rest of us. Near the end of her article Brody writes:
The disorder can be treated, though therapy is neither quick nor easy. It can take an insurmountable life crisis for those with the disorder to seek treatment. “They have to hit rock bottom, having ruined all their important relationships with their destructive behavior,” Dr. Burgo said. “However, this doesn’t happen very often.”
I sure don’t look forward to the moment when the President hits “rock bottom” and is ready for therapy! Where does this leave us when it appears that we are in a struggle with a man who is more than an employer, more than a narcissistic spouse, and not as easily ignored as a blowhard bully who is our narcissistic neighbor? He holds all of the power of a sitting President and has many ways to use that power to fulfill his narcissistic needs first and consider the consequences later. The question is whether or not members of his party who think that they can control him and use him to support an agenda they have had for many years, can keep him within the bounds of propriety. We are still scheduled for elections in 2018 and 2020. Assuming things do not change, our efforts must be very strategic and like David Muir did in the interview, keep asking questions, keep refuting what is untrue undeterred by the volume and the mendacity of his responses. Walking When I Can and Where I Can Waiting On the Super BowlThis week the weather has continued to bounce around in a way that forced me out of the heavy wind and off the icy roads to take a couple of my walks on the indoor track at the Hogan Athletic Complex at Colby-Sawyer College. Within the complex, the David Coffin Field House offers a walkway above three basketball courts that is ten laps to the mile. Fifty laps goes a little faster when you can watch basketball practice. Last Saturday while the weather was great in Boston for the Women's March it was overcast in the Upper Valley and Lakes Region of New Hampshire, as you can see from the picture that is today’s header. It was taken after a 1000 foot climb out of the valley on the Black Mountain trail. “Black Mountain” is the southwestern shoulder of Mount Kearsarge. My buddy and I had worked up a pretty good sweat by the time we had gotten out of the trees and had this view that was well worth the climb. I will be headed to Florida this weekend to visit friends first and then spend next weekend with my granddaughter watching the Super Bowl before Grandparent’s Day at her school. I hope to see her play some basketball next weekend since she has been promoted to the high school varsity now that the eighth grade season is over. Grandfathers do brag. Last weekend while I was climbing Black Mountain, she led her eighth grade team to the completion of a perfect 16-0 season and the tournament championship. She was the MVP of the tournament! She is off to a good start headed toward a lifetime of fitness. Her favorite pastime, after reading, is going to a vigorous “spin” workout. The week before the Super Bowl is a long one. It almost seems like a period of religious waiting. It has a liturgy. There is a press day when pictures are taken and the players are interviewed by the press for their profound thoughts before the battle. Every local TV station in New England has an army of reporters on sight ready to comment on every cough and every sore muscle that Tom Brady or any other player of note may have. Then comes the game. All across the land families and friends will gather, as I will with my granddaughter and her parents, for the solemn kick off. The action on the field will be balanced 50-50 with the advertisements which will be rated and debated as fiercely as the performance on the field. I heard this week that there is a movement to make the day after the Super Bowl a national holiday so that everyone can recover before returning to work! Well we have a whole week to mentally prepare for it all and then it will be over. I wish that the same was true for the events that will go on for four years in Washington. Wherever you are this weekend, follow my granddaughter’s example and try to work up a sweat. A good workout is therapeutic as well as fun. It is also a good way to let off steam after hearing that the President has suggested a 20% tariff on Mexican imports. I do not understand what the benefit of that tariff would be, nor do I understand how it makes them “pay for the wall” since I would be paying for the wall with the tax on the avocados that I love to eat. | 
