4 August 2017

Dear Interested Readers,


What’s Inside and My Head Is Spinning As Time Flies and Lies are Flying

A year ago I was appalled by how little attention healthcare was getting in the campaign for the presidency. I remember writing after the three ninety minute presidential debates that the total time spent discussing healthcare was less than twenty minutes. Less than 8% of the time in head to head debate between the candidates was spent discussing what would be one of the most significant domestic issues either candidate would face as president.

It seems like the nominating conventions were about five years ago. I decided that I would look back on what the candidates said about healthcare with their acceptance speeches. On July 21, 2016 President Trump gave an acceptance speech for the nomination of the Republican Party that lasted over an hour. Here is what he said about healthcare:

My opponent would rather protect bureaucrats than serve American children. And that's what she's doing. And that's what's she's done. We will repeal and replace disastrous Obamacare.

You will be able to choose your own doctor again.

I am not sure that Hillary Clinton did any better. A week later in her acceptance speech that was a few minutes short of an hour, one of the longest acceptance speeches in the history of Democratic nominating conventions, Hillary did not say much about healthcare, unless you give her credit for slipping in the fact that under President Obama 20 million people had healthcare that did not have it before the ACA. Her comments were limited to a side thought while endorsing the work of the Obama-Biden administration’s efforts to affect economic recovery following the 2008 recession:

But none of us can be satisfied with the status quo. Not by a long shot.

That was it. I remember being a little disappointed. I guess both candidates either were caught up in attacking one another and were too busy arguing and asserting that they were the only one who could do the job, to actually build their own case for better healthcare for all Americans. In retrospect, the contrast between what was said, or rather what was not said, and the realities of the last six months now amazes me.

After examining what was said at the conventions and in the debates, I searched President Trump’s inauguration speech. You may remember that he talked about the “carnage” in America and promised: “We will reinforce old alliances and form new ones. And unite the civilized world against radical Islamic terrorism, which we will eradicate completely from the face of the earth.” He also promised incredible expansion of the economy by his focus on America and Americans:

We will bring back our jobs. We will bring back our borders. We will bring back our wealth, and we will bring back our dreams. We will build new roads and highways and bridges and airports and tunnels and railways all across our wonderful nation. We will get our people off of welfare and back to work rebuilding our country with American hands and American labor. We will follow two simple rules -- buy American and hire American.

But he said nothing about healthcare. One would presume a healthy workforce should be foundational to a healthy economy. The president was silent on healthcare at the inauguration but he did famously talk a lot about it in an interview that he gave the Washington Post a few days before he was sworn in as our new president. They reported the following:

Trump declined to reveal specifics in the telephone interview late Saturday with The Washington Post, but any proposals from the incoming president would almost certainly dominate the Republican effort to overhaul federal health policy as he prepares to work with his party’s congressional majorities…

In the same article they also reported that he was resolved to push his agenda through Congress quickly:

Trump warned Republicans that if the party splinters or slows his agenda, he is ready to use the power of the presidency — and Twitter — to usher his legislation to passage.

“It’s very much formulated down to the final strokes. We haven’t put it in quite yet but we’re going to be doing it soon,” Trump said. He noted that he is waiting for his nominee for secretary of health and human services, Rep. Tom Price (R-Ga.), to be confirmed. That decision rests with the Senate Finance Committee, which hasn’t scheduled a hearing.

In this week’s letter, I begin by reviewing what we have learned and experienced since the inauguration. It has been an amazing journey and a real education for all of us that few people anticipated. Trump had it backwards when he said, “The Congress can’t get cold feet because the people will not let that happen,...” I think it is amusing that it was “the people” who made it clear to Congress that the plans that Trump, Ryan, McConnell, and Price finally did produce did not measure up and that the final offering so far, the “Skinny Repeal” was an awful piece of legislation that that would not even be an adequate bridge to something short of a disaster that might ever be negotiated with the House.

If we consider what the president said about healthcare in January and what he has said about the various pieces of legislation that have been offered since January, we would say that a thoughtful person would reason that the president has a limited understanding of the issues and is mostly interested in just having any bill to sign. I hope that his threats about doing damage to the ACA will be as ineffective as his attempts to repeal and replace it. The unknown in it all is enhanced by the fact that a reasonable person has long given up trust in assessing the truth of what comes out of the president’s mouth or from his thumbs on his Twitter account. The New York Times keeps a running tally of the president’s prevarications (latest update was 7/21/17). This last week there were a couple of new whoppers discovered. Through his lawyers and his administration he had claimed not to be involved with the drafting of his son’s statements about his meetings with the Russians, and we now know that he was. On July 25th the president told The Wall Street Journal, “I got a call from the head of the Boy Scouts saying it was the greatest speech that was ever made to them.” The Boy Scouts say that their head made no such call and actually apologized to their supporters for the president’s speech. Ouch!

Keeping up with what is real and what is smoke and mirrors is a full time job that exhausts us all. One must keep many things in mind. President Reagan famously said of the Soviet Union, “Trust but verify.” That is unsound advice when dealing with President Trump. I would suggest that the best strategy recommendation would be to begin by questioning any statement. If it sounds strange or too good to be true, then it is highly likely that it is not what it appears to be on the surface. Every utterance needs to be explored. We should consider the motivation behind the statement. Is it to truly inform? Is it to frighten someone? Is it to deceive us directly or to divert our attention from something that makes him uncomfortable? Is it a diversion while he is doing something that he does not want us to notice?

Yesterday (Thursday) Terry Gross interviewed Bill Moyers about his work with Lyndon Johnson to pass Medicare fifty two years ago. In the course of the interview he also spoke about his occasional contact with Ronald Reagan. Both presidents had unique communication styles and both were driven by political agendas and objectives that were central to their core beliefs. We have not yet seen a consistent political philosophy in this president. Conservatives doubt that he is a true conservative. He once talked like a liberal. No one would mistake him for one now. He throws out populist ideas as promises to his base that he quickly forgets or moves to another subject with no evidence that the idea will ever come around again.

Often the president’s tweets announce what might happen, like the ban of transgendered individuals from the military that he had discussed with “his generals,” but had not. Sometimes, especially in his never ending campaign events in front of his base, he introduces confusion by presenting an obvious lie by saying “Someone is saying.” Sometimes, as he has done with Jeff Sessions, he attacks someone close to him either to bully them as preparation for getting rid of them, or to distract us all from something that is more important, like the work of Robert Mueller who must be getting close to something because he has impaneled a grand jury. It is exhausting work keeping up with the moving targets that are his substitution for a political philosophy or achievable political agenda.

When I look back over the last six months it is not the president’s lies that impress me. I am impressed by the huge learning process that has occurred among a diverse electorate that was not asked to think much about healthcare, but as the ACA was threatened many of them were forced to learn a lot about what they were vulnerable to loose. After a review of where we are now in the healthcare discussion. I reference the JAMA and NEJM articles published in 2016 and 2017 by Barack Obama as resources. Everything that follows is conjecture. It is hard enough to imagine the future when we are lead by people who have a personal compass. It is pretty much impossible if the elected leader is making up stories that seem to be primarily motivated by an intense need to be the constant focus of attention.

I wish that I could look the other way and say that we should proceed on the journey toward the Triple Aim, giving the president no attention. That is impossible. Having gotten through yesterday and today with an erratic and unpredictable leader is no guarantee that we will get through tomorrow. I once found comfort in the idea that the first step forward was to recognize that we live in VUCA world. There are guides to managing a world that is volatile, uncertain, complex and ambiguous. Those strategies are built on the analysis of information. What do we do when our information is riddled with lies from an important source of leadership?

What Is Next?

I spent most of last Friday in a daze. I watched the video of John McCain walking into the Senate chamber again and again. Perhaps I thought that it had not happened. It was the same every time. As I wrote in Tuesday’s Strategy Healthcare posting,

John McCain resolutely walked to the front of the Senate chamber and raised his right arm to signal that he wanted to cast his vote. Then without a word he abruptly turned the thumb on his outstretched right hand down and then walked to his seat as some in the chamber gasped and others gave a muted expression of their positive surprise.

To my delight it is the same every time. Just like the replay of the end of the Super Bowl never changes. No matter how many times you play it the Patriots ruin the evening for the Falcons. What surprises me is how long ago it seems now although it was just a week ago. The obvious question is what’s next? Before trying to imagine where the road goes from here it is important to ask why the ACA still lives after a vigorous seven year effort to kill it. The House, the Senate and the Presidency are controlled by a party that has promised the public that they would repeal the ACA as job one. I was amazed that during the 2016 presidential election season, after Bernie Sanders was sidelined, healthcare was barely mentioned and when it was it was a disaster as when Bill Clinton said that the ACA was “the craziest thing.” I thought I knew what he meant, but it was clear that his words could be used easily by any candidate that was running against the ACA. Perhaps Hillary Clinton decided not to rock the boat and did not give healthcare much airtime. Candidate Trump was getting more traction saying “lock her up” and “The Mexicans will pay for the wall.”

It was not until Trump was elected that the threat of repeal, and especially the plan to repeal the ACA with a delayed effective date and just a promise to replace it in the future, that things began to get scary. President Obama wrote a “Perspective” piece in the New England Journal that appeared on January 26, 2017. I have referenced President Obama’s paper before but his concerns deserve your review. Here is a nugget for you to think about:

What the past 8 years have taught us is that health care reform requires an evidence-based, careful approach, driven by what is best for the American people...Rather than jeopardize financial security and access to care for tens of millions of Americans, policymakers should develop a plan to build on what works before they unravel what is in place.

What amazes me was that the public finally began to understand that the law had given a lift to everyone. With the ACA we all share the guarantee that we can buy coverage. We can not be denied coverage because of a preexisting condition. I still do not think that a majority of people understand that any policy that they buy, even one with a huge copay, will cover them for the services they need for preventative care and that there are limits to what they can be charged even for the most complex care that they might need. We all understand that our children have access to our policies until age 26. What really became clear to everyone was that imagining 20 million people losing care was painful to the majority and they made their feelings known by attending “town meetings,” writing letters to politicians, making phone calls, and showing up for protests and rallies.

I doubt that before the discussions of the last six months many voters understood the role and the extent of Medicaid services. For most people it was a welfare program that they never imagined might be something they or someone in their family might need. People began to notice the reciprocal relationship between Medicaid and tax breaks for the most wealthy members of society. With epiphanies like that a few minds were changed and some people began to have a new appreciation for the benefits of the ACA.

Comedians, late night television hosts, and the “fake news” press like the New York Times, the Washington Post, and the New Yorker pulled out the stops and bombarded their readers with analyses and editorial comments that attracted new viewers and readers. By the end of March the “failing” New York Times had added 279,000 new readers and the trend continues. I would wager that more people now know what the CBO does. More people understand the reconciliation process that serves as a foil against filibusters and allows a limited law to pass the Senate with a simple majority. In a perverse way it has been a good process. Political scientist have always known that once an entitlement become a law it is very hard to take it away. We have seen that demonstrated once again. What we have also seen is that when threatened with a loss for themselves or others, many Americans will study, discuss, and develop an opinion about facts and policies.

Since last Friday we have heard several announcements from the powers that be. Senator McConnell seemed ready to absorb his loss and move on to other things. Senator McCain suggested that the Senate go back to work and follow normal process that would benefit all Americans. Ironically, that was exactly what President Obama suggested in an amazing article that he published in JAMA in August of 2016. He also offered an analysis of what worked and what did not work and needed to change. President Trump festered for a few minutes and then began threatening to use all of his administrative options to kill the ACA. The Times cataloged and explained three things he is already doing.

I do not think that most people realize that when Republicans talk about the failure of the ACA and insurers leaving the market or the need for the mandate, we are mostly talking about the “individual market” or in terms of the ACA, the exchanges. As of February the exchanges covered about nine million people. That is a lot of people, but is still a single digit percentage of all of us who benefit from some component of the ACA. There are numerous articles documenting the benefits that the ACA has given the country as a whole over a very short time. Even the struggle against the rising cost of care has been aided and progress made through the ACA. Do thoughtful Republicans really want it killed?

As I write I know that there are a host of healthcare policy wonks and thoughtful journalists who could go to a Senate Committee like the one Lamar Alexander chairs (the Senate HELP Committee) and give testimony to the many possible ways to do what Obama advocates, and fix what isn’t working about the ACA. One thing that needs continued work is the shift of the payment for care from “volume to value.” CMS had jump started that process with shifts in Medicare payment plans associated with the bipartisan passage of MACRA, by a large majority, in 2015. Years from now historians may debate what had the greater impact, the ACA or MACRA.

I am a hopeful person when it comes to imagining a day when we have universal healthcare coupled with healthcare finance mechanisms that lower the cost of care to sustainable levels, allowing us to invest in improving the social determinants of health. If my hopes come to be true it will be because more people actually understand what President Trump was surprised to discover when he said “who knew healthcare was so complicated.” That was one of his most truthful pronouncements of the last six months. The foundation of my hope is based on the experience of more people becoming educated to the complexity of healthcare over the last six months. It is no longer quite the longshot it once was that someday we might have:

...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…

Hope is not the same as optimism. Optimism is what the Falcons had in the early part of the fourth quarter of the Super Bowl. Hope is what grew and grew for the Patriots as one amazing thing after another happened in the waning moments of the game. Optimism is what the Republicans had in January. Hope is what those of us who care about better care had when John McCain’s thumb went down. President Obama wrote the Audacity of Hope before he became president. It is a book that is about core values that evolve into a political philosophy. In contrast, Trump’s The Art of the Deal, is a book that seems to mostly to be about getting what you want from other people. Trump’s ghost writer has suggested that a better title would have been,The Sociopath.

As Obama’s presidency was ending and before we knew that he would be followed by Donald Trump, he summed up what he had learned from his struggle to move toward universal coverage with the ACA. Reading these words is a good way to start the next leg of the journey ahead of us. I bolded some of the most important points. You can be sure that I will continue to focus my own thinking about what is to come around these points even though he did say that he was “optimistic.”

Obama’s wisdom from the ACA Struggle as Noted in JAMA

While historians will draw their own conclusions about the broader implications of the ACA, I have my own. These lessons learned are not just for posterity: I have put them into practice in both health care policy and other areas of public policy throughout my presidency.

While the lessons enumerated above may seem daunting, the ACA experience nevertheless makes me optimistic about this country’s capacity to make meaningful progress on even the biggest public policy challenges. Many moments serve as reminders that a broken status quo is not the nation’s destiny. I often think of a letter I received from Brent Brown of Wisconsin. He did not vote for me and he opposed “ObamaCare,” but Brent changed his mind when he became ill, needed care, and got it thanks to the law.67 Or take Governor John Kasich’s explanation for expanding Medicaid: “For those that live in the shadows of life, those who are the least among us, I will not accept the fact that the most vulnerable in our state should be ignored. We can help them.”68 Or look at the actions of countless health care providers who have made our health system more coordinated, quality-oriented, and patient-centered. I will repeat what I said 4 years ago when the Supreme Court upheld the ACA: I am as confident as ever that looking back 20 years from now, the nation will be better off because of having the courage to pass this law and persevere. As this progress with health care reform in the United States demonstrates, faith in responsibility, belief in opportunity, and ability to unite around common values are what makes this nation great.

There is Always Something Amazing to See

I spend a lot of time outdoors in any season, but I think that I see more happening outside in the summer. Without any baby loons on the lake this summer we have become a summer camp for unattached juveniles. I have seen up to seven at a time. The summer intern at the Loon Preservation Center over on Lake Winnipesaukee thinks that our loons abandoned their eggs on the nest because lady loon got attracted to a new beau. It was a shock for me. I preferred to think that they abandoned their eggs because their artificial island where they built their nest lost one of its stabilizing cables and was rocking on the waves kicked up by a storm.

I was really captivated by the concept that loons were monogamous. I have learned that loon monogamy is just a myth. They are monogamous to place, not individual. If a young dude comes by and kicks the old guy out, there can be a lot of squawking. In retrospect I do remember a remarkably noisy night in early June with a lot of mournful loon calls plus some vocalizations that I had never heard before. The whole sad story reminds me of the Paul Simon song about Cecilia. He was very insecure in his relationship just like Mr Loon. Do you remember verse in the lyrics where Simon complains that Cecilia is casual in her relationships?

“I got up to wash my face...When I come back to bed someone’s taking my place…”

I have transferred my affections to ducks. We have typical mallards. He is good looking. She is drab. We also have a rusty red headed duck with a pointy prominence on the back of its head. The body is a beige grey. There are two families on the lake. I have seen them once or twice before this year, but not nearly as frequently as this summer. One mother duck has six ducklings and you can see her with her brood in today’s header. The other family has nine young ones. Both mothers move their offspring around in close order drill. When spooked the whole family literally runs across the surface of the lake to the safety of a far shore. They can create quite a wake. In my ignorance I called them wood ducks, but they don’t match the pictures on the Internet. They also don’t look like the pictures of the “red headed duck”, the “canvasback duck” or mergansers. Do you know what they are?

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