30 June 2017 Dear Interested Readers, What’s Inside and Reflections on Being American on the 4th of July The main section of this week’s letter asserts that the “repeal and replace” process in Congress has become an attack on Medicaid. Inadvertently that attack may become a wake up call that initiates a transition from the rhetoric of “repeal and replace” to the more positive possibility of “sustaining and improving” the effort to provide more Americans with better healthcare. I really doubt that will happen, but isn’t it an inspiring dream? It’s my effort to be positive during a moment political confusion. A few weeks ago when I was apprehensive about the significance of the apparent failure in the House of Paul Ryan’s AHCA (American Health Care Act), I referenced Fatal Attraction, the Glenn Close / Michael Douglas thriller of almost thirty years ago. As we all know, Ryan did bargain his bill back to life, and now it’s over in the Senate where Mitch McConnell is trying to figure out how to pass a bill that less than 20% (some polls say 12%) of Americans want without Republicans suffering disastrous political consequences in 2018 and 2020. I must say that this second time around has left me thinking about Jaws 2. The biggest concern that this movie connection raises from memory is that before we were done with the Jaws “franchise” we had to deal with Jaws 3-D and Jaws: The Revenge, released in 1983 and 1987, respectively. I sure hope that the similarity does not further materialize, and we will not see multiple returns of this shark. I would much rather not experience “Jaws like” healthcare nightmares. I would rather dream about a future for healthcare on the road to the Triple Aim that is like a movie full of joy and good fortune as encountered by the Von Trapp family after they escaped the Nazis in The Sound of Music. Whatever comes next we are in a pause, “on hold” so to speak, as Senator McConnell and his cabal of 13 old white men and the other 39 Republican senators use the Fourth of July congressional recess to consider their options. While Mitch McConnell tries to live up to his reputation of being as shrewd a Senate Majority Leader as anyone since Lyndon Johnson, I will emphasize that the attack on Obamacare has really become an attack on Medicaid and the millions of Americans, young and old who struggle each day with not enough in a land of plenty. Speaking of the Senate’s Fourth of July recess brings me to a discussion of one of my favorite holidays and the extra long weekend that will precede it this year! Since moving to New England from the South, I have been confused about when summer starts. Back home summer begins no later than when school ends, well before Memorial Day. As I have mentioned before in these notes, I know when summer ends in New England; it ends whenever school starts its fall term if you have children, or at sundown on Labor Day for everyone else. Each year I optimistically try to get summer going on Memorial Day and at the latest by the summer solstice, but unstable weather patterns often leave me shivering one day and sweating the next until about the Fourth of July. I have come to consider June as a warm up band for the headlining act of summer that comes on stage for the Fourth. The sum total of my calculations makes summer the shortest and sweetest season by far. This year it has only ten weekends! They will all be busy with picnics, concerts, weddings, and other gatherings with family and friends. It is sort of a bummer to need to tolerate an attack on the stability of our healthcare system as the noise in the background of these few precious weeks, but I fear that if we ignore healthcare for the summer, we will be doomed to a very long winter of discontent. As I was trying to sort through all my feelings this week about McConnell and his “Better Care and Reconciliation Act of 2017” and resolve my unkind feelings toward him and his abuse of power in the Senate with the need to celebrate what it means to be an American on the Fourth of July, David Brooks, my favorite conservative, presented us with an excellent essay entitled “The G.O.P. Rejects Conservatism.” I know that most readers don’t hit links, so below are the last few paragraphs of the column. I have bolded Brooks’ reference to Alexis de Tocqueville’s generalization or observation and interpretation of the mindset of the average American he meet during his travels in our land more than 180 years ago. How much have we changed? Because Republicans have no national vision, they seem largely uninterested in the actual effects their legislation would have on the country at large. This Senate bill would be completely unworkable because anybody with half a brain would get insurance only when they got sick.
Worse, this bill takes all of the devastating trends afflicting the middle and working classes — all the instability, all the struggle and pain — and it makes them worse. As the C.B.O. indicated, the Senate plan would throw 22 million people off the insurance rolls. It would send them to private insurance plans that they could not afford to buy. Under the Senate bill, deductibles for poor families would be more than half of their annual income. The plans are so incompetently and cruelly designed that as the C.B.O. put it, “few low-income people would purchase any plan.”
This is not a conservative vision of American society. It’s a vision rendered cruel by its obliviousness. I have been trying to think about the underlying mentality that now governs the Republican political class. The best I can do is the atomistic mentality described by Alexis de Tocqueville long ago: “They owe nothing to any man, they expect nothing from any man; they acquire the habit of always considering themselves as standing alone, and they are apt to imagine that their whole destiny is in their own hands. Thus not only does democracy make every man forget his ancestors, but it hides his descendants and separates his contemporaries from him; it throws him back forever upon himself alone and threatens in the end to confine him entirely within the solitude of his own heart.” There is no doubt that much of what we celebrate on the Fourth of July is derivative of the spirit of freedom and independence that de Tocqueville recognized in our ancestors. Our individualism can be both our best and worst trait. I think that the Frenchman recognized the fact that as we celebrate and fiercely defend the rights of the individual, we have arranged our government in a way that allows individuals to come together for mutual benefit while providing protection for minority interests and the prevention of the emergence of a totalitarian or authoritarian state. Political parties are a mechanism by which individuals freely join efforts to assert their vision of the “common good.” I hear Brooks saying that when it comes to healthcare, McConnell and company have no organized concept for the common good and have carried their individualism too far. He implies that they have lost sight of the spirit of our union and the responsibility we all share to search for pathways and solutions that resolve the issues of the many in the context of universal individual freedom. When I was a child the Fourth of July was about parades, cookouts and fireworks. As an adult, in a period of great social unrest and class division, we should remind ourselves that what we celebrate is the courage of the initial decision to separate from a government whose abuses our founders catalogued and then declared to be enough to force them to assert their inalienable right to pursue a different and independent path toward life, liberty, and happiness. On the Fourth we celebrate a state of mind at the end of a beginning toward a better destination. We celebrate realizations that were precipitated by conflicts, and a declaration of the hope that on our own we could do a better job. We have never been a perfect union, but have always imagined the pursuit of a more perfect union. What Thomas Jefferson wrote for all of us was an announcement of a willingness to believe in our collective ability to continuously improve, and the moral responsibility we share to throw off a long suffered and oppressive status quo. It always gives me a thrill and a chill to read the document in its entirety. Jefferson’s words make the case for independence based on the abuses of the king and they catalogue the pains suffered measured against the will of the creator for mankind. The signers recognized the uncertainty of their future, but they accepted the challenge demanded by their analysis and signed their names with a willingness to be held accountable at the level of execution for treason if they were wrong or their cause failed. What we also celebrate on the Fourth is that the journey the signers started continues despite wrong turns and difficulties encountered along the way. As Brooks points out in his piece, our greatest challenge at the moment is how to maintain social cohesion in the face of increasing economic and social disparity. We have the problem of how to distribute wealth in a society that has a fundamental belief in the individual’s right to enrich himself, even as individual enrichment threatens the social cohesion that is foundational to a successful society free of totalitarianism and authoritarian rule. Within our celebration we must find the unification that comes from a remembrance of shared values that we can apply to the resolution of concerns that seem at the moment to disproportionately disadvantage some but will ultimately undermine the collective future if not fairly resolved. The core of last week’s letter has been modified a little but the continuing emphasis is on empathy and union coming from attempts to share “deep stories.” I renamed the article “Sharing “Deep Stories” to Use Empathy in the Quest for the Triple Aim.” If you did not have time to read last week’s letter, click on the title and you will have it to read. When I read Brooks’ piece it occurred to me that he was describing part of our shared “deep story” when he elected to use the de Tocqueville quote. As Medicaid Is Challenged, Remember Yogi’s Wisdom: “It ain’t over till it’s over.”
When I heard on Tuesday that Mitch McConnell had announced that he would not be seeking a vote in the Senate on the “Better Care and Reconciliation Act of 2017” before the July 4th recess my reaction was straight out of the wisdom of Yogi Berra, “It’s deja vu all over again.” I was actually upset because McConnell’s move seemed similar to the one Paul Ryan pulled in March that set up a narrow “victory” in early May for the House Republicans’ version of “repeal and replace.” I would have preferred a vote and a definitive loss that might have permanently settled the issue. McConnell’s move was a strategic response to the devastating analysis rendered by the CBO that advised that more than 20 million Americans would lose their healthcare coverage by 2026. It is becoming increasingly clear to me that the so called “repeal and replace” process is not so much an attack on “Obamacare” as it is an attempt to greatly reduce what we spend on Medicaid, the core of medical support for the poor, the disabled, and the elderly who are chronic nursing home residents. The New York Times notes that about 40% of all children receive care through Medicaid. Another Times article, “How Medicaid Works,and Who It Covers,” reports that Medicaid pays for the care of more than 74 million Americans including two thirds of nursing home residents, many of whom have middle class families. In 2013 before the full effect of the ACA more than half the births in America were covered by Medicaid. Beginning January 1, 2014 the ACA offered Medicaid coverage to all Americans earning less than 138% of the poverty level. Even though for most of its 52 years Medicaid has been a nearly equal partnership between the states and the federal government, the federal government promised to cover 100% of the expansion initially and will continue to cover 90% as long as the ACA is the law. The impact of the ACA would have been the coverage of even more lives, but the Supreme Court ruled in 2012 that although the mandate was constitutional, the expansion of Medicaid could be rejected by individual states. As of now 19 “red” states continue to deny some of their poorest citizens the benefit enjoyed by the poor in the 31 states that accepted the expansion. The upside of this moment is that many people who really did not understand the complexity and the components of the ACA are now appreciative students of the thinking and strategies upon which it was built. They are beginning to appreciate that its “flaws” are in part the result of the complexity of trying to create a market that blends public and private sources of revenue. Before they were forced to learn more they felt secure in their own healthcare or had given little thought to how others would be affected by a repeal of this very creative but incomplete piece of legislation. The ACA was like a 1.0 piece of software. It was a beginning. If our Congress could have approached the problem in a bipartisan way, we would probably be working on ACA 3.0 by now. President Obama published his ideas for for ACA 2.0 last year in both JAMA and the New England Journal. As Speaker McConnell would like us to discard the ACA, we are well prepared by the experience we have gained to improve it, but improvement will require more cooperation across the aisle, and more public investment. Caregivers believe that an investment in improving access to better care is an investment that surely will give a positive return. Our core problem is the total cost of care. There is a persistent belief among those who understand how complex healthcare is that the path to a lower total medical expense runs through the achievement of universal coverage. If everyone was covered there would be many ways that we could lower the total cost of care. The ACA contained the first step of many of those options. I have always thought that it was wise policy for the ACA to incorporate and expand Medicaid as part of its strategy to give everyone access to care. Considering the measured good that Medicare has given its recipients, why is there so much resistance to it and why has it become the central focus of the Republican desire to do major surgery on Medicaid as it cans the ACA? Follow the dollars. McConnell’s bill is a proposal to vastly reduce, over a few years, the money available to support Medicaid. It will provide the states with relatively fewer dollars and hands them the ability to significantly reduce enrollment in time using their own eligibility rules and decisions about what benefits will be covered. Look at the numbers: ■ Medicaid cost $553 billion in fiscal year 2016. Of that amount, $348.9 billion came from the federal government; the states paid $204.5 billion.
■ Medicaid accounts for 9 percent of federal domestic spending. For states, it is the biggest source of federal funding and the second-largest budget item, behind education. Republicans have figured out that middle class voters who like what they have gotten from the ACA do not want to lose the ability to keep their children on their policies until age 26, so that stays in their bill. They also know that the appearance of guaranteed insurability, free of the restrictions of pre-existing illness, is popular so that has stayed in their bills, sort of. The issues with the exchanges is murky. To work financially the exchanges need subsidies to recipients and also to suppliers. Follow the money again and you can understand that inadequate support, or the threat of future inadequate support, under Tom Price and Donald Trump explains why McConnell and team are talking about the impending disaster of an imploding ACA. How many times have you heard Ryan, McConnell, Price and Trump predict a “disaster” if we don’t pass their bill? Doing away with the mandate is doubly beneficial to their political ends because it fulfils an ill advised promise to their base, and it allows Ryan to say that many of the people that the CBO says are losing coverage are doing so as a matter of their choice. As David Brooks has said, “Under the Senate bill, deductibles for poor families would be more than half of their annual income.” With a product that offers fewer benefits with deductibles that are stratospheric compared to your income, it is good to be able to chose to pass on coverage, and without a mandate as a fine for not being covered, repeal of the mandate must feel like a new kind of personal freedom that makes sense to the angry, poorer voters who form much of the base that put Trump in office. Most of us who are in healthcare understand the benefits that Medicaid has brought to many of our poorest patients and to those who seek to serve them. Many hospitals and practices across the country have seen bad debt decrease and critical revenues that allow doors to stay open rise as a benefit of the expansion of Medicaid under the ACA. The Boston Globe published predictions of the impact of the Senate bill on Massachusetts citizens released this week by Governor Charlie Baker. By 2025 the bill would cost Massachusetts 8.2 billion dollars and 264,000 people would lose their coverage. Perhaps many people who see themselves as comfortably ensconced in the middle class don’t really think that Baker’s numbers will make any difference to them, but they are wrong. I would imagine that taking that much money out of the total finance of healthcare in Massachusetts will impact everyone in terms of the premiums and taxes they pay. The rise they will see in their commercial premiums will not be the only bad news. They may be even more surprised and angered when they suddenly realize that the government is no longer paying adequately, or at all, for Mom at the nursing home where she has been for the last year because she can’t take care of herself, has burned through her assets, and all her family members are working. I feel like I am watching a tragedy. While practicing medicine, I took the benefits that Medicaid offered my organization and my patients for granted. It was socially acceptable to complain about the inadequacy of Medicaid reimbursement, but I am proud to say we accepted what we were given and provided care that was identical to the care our commercial patients enjoyed. We were cost shifting. Now in retirement I participate in the governance of three organizations that serve Medicaid patients and will face substantial challenges if McConnell’s bill is passed. Medicaid dollars are critical to the work of improving our communities and the lives of our most challenged citizens. I particularly appreciate the experience that I have had at the Whittier Street Health Center. It is easy to see there that every dollar of revenue from Medicaid is critical to the work of improving the community, one life at a time, under the leadership of Frederica Williams who is one of the most visionary and dedicated medical leaders I have ever met. In late June for the last 17 years Whittier Street Health Center has had an Men’s Health Summit. The event is a unique expression of Ms. Williams realization that high on the list of the challenges to her community is improvement of the health of men. She realizes that without men being healthy, employed, and fulfilling their roles as husbands, partners, and parents, the health of the community is compromised. The tagline for the event is Healthier Men: Stronger Families and Stronger Communities. The day is a joyous event with health screening and the distribution of information intertwined with speeches, awards and tours of the opportunities for health and wellness that Whittier provides for all its patients, but especially formulated to support men. This year the keynote speaker was Paul Burton, a man who supports the community in many ways. He is the son of Ron Burton, a star on early New England Patriot teams, who after his retirement from football created an institute and camp for the support and development of young men from the inner city. Paul also played in the NFL for Seattle and along with his work with young men at the program founded by his father, he works as a television reporter and is a pastor in Boston. Paul described just how the institute stays with boys from ages 11 to 18 to give them a chance in a world where their opportunities can be very limited and their path to manhood challenged by a lack of the real opportunities available to the youth of more affluent communities. Each year several men are honored as “Men’s Health Champions.” The story of each man’s contributions to men’s health was inspiring. One story stood out for me, and I think that in a time when many question our investments in coverage and our work to reduce the barriers to better health you should hear about the life and work of Richard Derosa. Mr. Derosa’s life is a testimony to the dignity and potential we should recognize in every life. He is the director of the Father Friendly Initiative and the director of Behavioral Health of the Healthy Baby/Healthy Child Program at the Boston Public Health Commision. He serves on the National Advisory Board of the GABE Project, which is developing a computer based platform to improve the health of preconceptional young Black boys and men. His citation noted that he was born in Boston and “is a product of the Commonwealth’s foster care system”, spending his early years residing at Nazareth Child Care Center in Jamaica Plain being raised by the Sisters of Poverty. At age 14 he was placed in the home of Roger Jackson, who as his foster parent “provided the structure, support, and consistency which allowed him to begin to experience success both socially and academically.” Mr. DeRosa’s experience in foster care “had a strong influence on his commitment to the health and wellbeing of boys and men.” After completing college and a master’s degree in counseling psychology he spent the bulk of his career providing in-home therapy to families. In a career of over 25 years of service to the underserved he has been striving to ensure social and racial justice in the development and implementation of programs for families and children. Each recipient of an award gave a short speech. Mr. Derosa described his commitment to the work of giving every young person access to the support they need to be able to have a chance in a world that presents them with a disproportionate share of life challenges. In 2009 and 2010 as the ACA was being developed, professionals like Mr. Derosa had a chance to appear before congress and give testimony to what might work. An objective of the ACA was to encourage creation of programs that served people to help them to achieve their healthy potential or regain their health. Now the objective is to cut Medicaid and underfund the exchanges so that people earning over $200,000 a year can have a tax cut. ...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. can not be killed by a few old men who have lost their way as long as there are men and women in the community like Richard Derosa and Frederica Williams. We should not be asleep at the wheel or give in to empty concepts coming from Mr. McConnell and his co conspirators that will not make the work to improve the lives of the most vulnerable members of our community better.
Have a Great Fourth of July and Thoughts on America’s Greatness, Fishing and Baseball
Donald Trump ran for president on the tag line “Make America Great Again.” My response to his slogan was along the lines of “pretty is what pretty does.” It occurs to me that while the president is talking about America’s greatness it is people like Frederica Williams and Richard Derosa who continue to do the work that is the journey to greatness as they extend the opportunities of America to many of its most vulnerable citizens. I have always been extremely proud of my country because of the people like them who are so easy to find if you look. Because of them and others like them, my pride persists even as we follow Mr. Trump down the strange road of “America First.” Historically any claim on greatest has been rooted in our core values and structures of government that have given us the ability to get back on course following the many times we have lost our way. I do not think that we have fallen from greatness. We have always been imperfect but have always been evolving and moving toward greatness. America is and has always been an experiment in progress. We are a collection of diverse people united in the pursuit of an a ideal that has a paradox at its center. We all deserve the freedom and respect of an individual, but achieve our highest ambitions when we choose as individuals to work collaboratively for the good of the collective seeking to exclude no one. The journey toward the Triple Aim is one of many examples of an enormous project we have taken on together out of our collective dissatisfaction with an imperfect status quo. It is also an example of the hope that eventually together we will do better. Failure of the American dream is always a possibility and the possibility becomes a threat when some individuals or group of individuals become self interested in ways that extract opportunity or exclude and neglect many of their neighbors. Trying to make America great by focusing on self interest will eventually make America small and irrelevant to the future except as an example of what a nation should not do.
This time of year when I need to get over what I read in the newspapers I have two immediate therapies at hand. I can get into the Red Sox or head out to fish. On Monday I was quite anxious while waiting to hear what the CBO was going to say about the Better Care and Reconciliation Act of 2017 and was delighted to have the opportunity to do some fly fishing with friends on the Sugar River not far from my home. You can see the scene in today’s header. There is a great running and walking trail that crosses the river on the old railroad bridge.
Monday evening I was off with my wife to Boston, which feels like a suburb of New London, to see the Red Sox win on a pleasant “late spring” evening. The Sox have become interesting and a source of joy and frustration as they go back and forth with the Yankees from first to second place in the AL East. I just hope they are as interesting late into September.
I hope that your Fourth of July weekend is a winner!
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