5 May 2017

Dear Interested Readers,


Groundhog Day, The Wisdom of Comedians and What’s Inside

Last week’s letter began with a reference to the 1987 movie, “Fatal Attraction.” The idea came from the sense that every time you think that the Republican desire to repeal and replace the ACA is dead the Republican leadership brings the AHCA back from its death with another ill advised attempt to present an empty bag of ideas as something that would be better for America.

Perhaps instead of “Fatal Attraction” my movie analogy last week should have been “Groundhog Day”, given the fact that Paul Ryan and company kept starting over and over again without much progress. For a while it did seem like they were caught in the same sort of warped time loop that captured Bob the weatherman, played by Bill Murray in “Groundhog Day.” Perhaps that is where the comparison breaks down because unlike Bob who got out of the time loop by becoming an empathetic involved community member and a better person, Ryan and company made deals with the Freedom Caucus and some members of the Tuesday Group of moderates that will jeopardize the health of tens of millions of people and could end up collectively costing all Americans hundreds of billions of dollars over future decades to give the super rich more tax breaks.

Nothing that has sprung from the mind of Paul Ryan or has been echoed by the self serving hyperbole of the president comes close to eclipsing the gains made by the fragile and faulty ACA that the majority of the public is beginning to cherish. Even the most superficial analysis reveals that all of the iterations of the AHCA are an attempt to give the illusion of continuing the positive benefits of the ACA while doing away with its onerous mandate and taxes on the wealthy. Throughout the debate and up to the moment of the vote Ryan and Trump have said time and time again that they are motivated by the rising cost of care. The CBO’s analysis of the original form of Ryan’s AHCA suggested that his “fix for the cost problem” would have the high cost of eventually denying 24 million people access to coverage.

The original Ryan bill was essentially dead after the CBO analysis. He did not make the same mistake twice. The deal with the devil that produced the revised bill may well make it even more onerous from the point of view of the CBO analysts so the vote was pushed before the analysis was available. That suggests that the speaker may have reasoned that since the answer from the CBO would be a message that the revision was worse than the original it would not help his cause to know the answer. More than just not caring what the answer from the CBO would be, I assume that he was afraid that the economic and social impact of the revised bill would be demonstrated to be worse than the original which meant that he should get it passed before its flaws could be fully appreciated.

It is a cruel hoax to pretend that the goal of the revised AHCA is to provide universal access to care to improve the health of the nation and lower the cost of care. The honest name of the the act should be the “American Entitlement Reduction and Tax Break For the Wealthy Act. There is no element of Triple Aim thinking in the plan. Better care is not the objective of H.R.1628-115th Congress. It is primarily about money and secondarily about fulfilling campaign promises. Care is a secondary consideration managed by a collection of contorted “faux solutions” presented to create the illusion of preserving what the public has come to like and expect since the passage of the ACA. Read its initial words. I have bolded the words that serve my point.

American Health Care Act of 2017

As time has passed since March 24 when the AHCA was originally withdrawn because it was a terrible bill that was resisted by both the right wing Freedom Caucus and the more moderate Tuesday Group of Republicans, it seemed more and more likely that the resistance to passage of a very flawed AHCA would eventual fold as it did. During this painful period of uncertainty I have sustained my hopes by watching commentary on television from late night talk show hosts, skits from “Saturday Night Live” and cable channel comedians. Watching Stephen Colbert for the humor and wisdom (sometimes diminished by crude references) has become a nightly passion. There may be a little more substance in Seth Meyer’s takedowns of Trump and the AHCA. Jimmy Fallon tries but doesn't quite have the venom or gift that he needs to score the hat trick of making you laugh, giving you a new insight, and maintaining the momentum of your anger without pushing you into a sense of hopelessness.

Even before the AHCA was withdrawn on March 24, John Oliver had presented an 18 minute tirade against it that was almost an academic denouncement of the AHCA that could have been publishable in the New England Journal of Medicine if he had cleaned up his unnecessary toilet talk and profanity. Click on this link if you missed it. The intellectual content and analysis is still worth your time. The chuckles will be for free. 

Samantha Bee along with Oliver and Colbert is a graduate of the “Jon Stewart school of political satire and comedy” as was practiced on the “Daily Show,” perhaps the original “fake news” offering, on the Comedy Channel. Is it not interesting that the “fake news” practiced by Stewart seemed to offer insights into complex issues that the talking heads on all the regular news programs who are trying to both entertain and proselytize for liberal or conservative world views can offer? Now on her own program, Bee stings uptight and less than forthcoming politicians on a regular basis. Check out this rant against the AHCA delivered back in Late March. It will be interesting to see the comeback now that the Freedom Caucus has won its negotiation and the president and Ryan have rationalized how they have fallen into line, allowing them to recover a little bit of face.

I could go on and on listing others like Conan O’Brien and Bill Maher but perhaps the most effective recent late night presentation was not meant to be be as funny as it was a concerned father’s plea for healthcare equity. This letter has to be about what is next. I begin the main section with words from another late night entertainer, Jimmy Kimmel. As you may know he has a healthcare story to tell. From Kimmel’s story we will look at what the road ahead might look like for the next two months even though Speaker Ryan and the president are talking like the outcome is a forgone conclusion.

I am back to thinking about “Fatal Attraction.” You may remember that after Glenn Closes’ character returned from her apparent death with her 10 inch butcher knife looking for a soft spot in the Michael Douglas character’s chest, his long suffering wife shows up and puts a bullet in her chest. I am hoping that the simile holds and that three Republican senators will be moved by the needs of the underserved and vote against the AHCA. I will even accept their vote if it comes for no better reason than self serving expediency.

Before the House vote on the AHCA I was having a good time this week. The letter ends with a philosophical note extracted from watching the water flow out of my lake. I think that even as we are worried about the future of the ACA we need to figure out how to maintain our perspective and sense of possibility.

A Sad State of Affairs

I have watched my favorite teams lose championship games. I remember the sinking feeling that I experienced when Richard Nixon was elected for the second time, even after it was really pretty clear that he was a crook. I suffered when Jimmy Carter, one of the most honest and earnest men ever to enter politics, lost to Ronald Reagan who was the champion of making America feel good about its defects. I read Bush One’s lips and was distressed. I lost my mind over hanging chads and shook my head when the country made the same mistake a second time after we knew that there really were no weapons of mass destruction in Iraq. I have been pinching myself in disbelief since the second Tuesday in November, hoping that it is really just a bad dream. None of those many losses has left me feeling as bad as I felt as I watched Paul Ryan, the president, and Mike Pence high fiving each other in front of some of their favorite sycophants after the House narrowly passed Ryan’s package of lies and misconceptions yesterday afternoon. Intellectually I know that there are still many potential barriers to their ultimate objective, but there was something pernicious about the moment.

My first response was to turn to that reliable source of “fake news”, The New York TImes, to check out what its pundits had to say. I felt somewhat better when I learned that the margin of the victory that our president was crowing about was really only three votes. I felt profoundly grateful for the twenty Republican members of Congress who for whatever reason refused to knuckle under to the pressure and distorted reasoning presented by Speaker Ryan and Reince Priebus over the last few weeks. If you looked at the Times you might be as surprised as I was by the linked request for readers to respond with stories about how the loss of the ACA would hurt them. In case you do not check it out I think their questions form the basis of the future defense of the ACA. Here is their request:

The House of Representatives voted Thursday to repeal and replace large portions of the Affordable Care Act. Times reporters who write about health care would like to hear from people who would be affected the most by the new bill, including:

• People who receive tax credits under the A.C.A. to help cover their premiums, or who have qualified for Medicaid under the law
  

• People who get insurance through the individual market but earn too much to qualify for tax credits under the A.C.A.
  

• Employers who are required to provide insurance to their employees under the A.C.A.
  

• People who have had to pay tax penalties for going without insurance under the A.C.A.
  

A close reading of the questions reveals the opportunity for gaining a wide range of responses from pro repeal to pro ACA. I think that this is a useful exercise because it is clear that the complexity of the issues precludes most people from doing a systematic analysis. Stories offer another route to forming opinions and making decisions. A close listening to what the president and Paul Ryan have built their case for appeal upon is the expense experienced by some people in the self insured market of the exchanges. Many of these people were unable to get insurance at any price pre ACA because of their pre existing conditions. Some who qualify because of their lower relative income get financial support. Some need to pay the whole price from their own resources. The exact size of this group is hard to know, but less than eight or nine million people are enrolled through the exchanges.

It is true, several insurance companies have withdrawn from the exchanges in some states, but the reason in part has been that Congressional Republicans have blocked some of the support that was originally guaranteed to insurers, and Congressional Republicans are currently pressing a battle in the courts to try to further deny these payments. What is difficult to understand from the lumped accusations by the president and speaker against the ACA is the real benefit going to those in the 31 states that accepted the Medicaid expansion and the benefits we have all enjoyed because of the assurance of insurability, the certainty of the quality of the coverage that we are buying, and the benefit to the institutions that provide our care from the fact that more people are actually covered.

The complexity of the angles and the numbers causes the eyes of folks who earnestly want a deeper understanding to glaze over. Their minds begin to wander when we start using terms like the “self insured market” or “community rating.” “Mandate” sounds like something that any rational individual would resist rather than an necessary component of the assurance that insurance markets will be stable and affordable. People gain understanding and respond to stories. One of the most effective stories told this year was the personal story told in Hillbilly Elegy by J. D. Vance about growing up in an impoverished and dysfunctional family in rust belt Ohio.

My greatest relief this week was not the tension relieving belly laughs that I got from the likes of Stephen Colbert, Samantha Bee or John Oliver, but rather from the story Jimmy Kimmel told about his son who was born on April 21 with Tetralogy of Fallot. Perhaps you have seen Jimmy Kimmel’s tearful and thankful testimony. It is about thirteen minutes long and if you did not see it, you must give yourself the opportunity to have a few stress relieving tears. I cried, but then old men who are grandfathers and have another one on the way are easy marks for stories about families with sick kids. If you don’t have time for the whole thing move the cursor to about 11 minutes and listen from there. A third but somewhat less effective option is to keep reading because I have transcribed below what I want you to hear. These are Kimmel’s words delivered after he knows that his son will be ok. The experience has given him a sharpened perspective and an enormous sense of community and gratitude for something that he realizes is not, but should be, enjoyed by every person if America is really to be great.

We were brought up to believe that we live in the greatest country in the world but until a few years ago millions and millions of us had no access to health insurance at all. You know, before 2014, if you were born with congenital heart disease like my son was, there was a good chance you'd never be able to get health insurance because you had a pre-existing condition. You were born with a pre-existing condition. And if your parents didn't have medical insurance, you might not live long enough to even get denied because of a pre-existing condition.

Let's stop with the nonsense, This isn't football. There are no teams. We are the team. It is the United States. Don't let their partisan squabbles divide us on something every decent person wants. We need to take care of each other. I saw a lot of families there [Children’s Hospital of Los Angeles]. No parent should ever have to decide if they can afford to save their child's life. It just shouldn’t happen. Not here…

Most people who listened to Kimmel probably felt the way I did and in the moment we’re ready to say let’s do it! It’s gotta happen! Just like we wanted assault rifles out of our communities the minute after we heard about Newtown, Aurora, or Orlando. I know that there are many people though who feel differently, and our constitution guarantees them the right to their perspective. One example of such was reported recently in the Chicago Tribune in a piece by Eric Zorn. Zorn writes:

Zorn moved from reporting the event to offering commentary.

Zorn continues describing who Walsh is and adding yet another quote from him:

Ironically it was discovered that Walsh is delinquent by over a hundred thousand dollars in child support payments, but that did not prevent him from tweeting his concepts of personal responsibility.

After reporting another in the continuing series of foolish comments by Rep. Mo Brooks, R-Ala., Zorn closed with his own analysis.

That's what Democrats are fighting for and they owe Joe Walsh thanks for so clearly illustrating what they're fighting against.

Stories will be the difference over the next several weeks as the battle moves to the Senate. Facts are important but the people who will show up at the town hall meetings will not be there hoping to see Powerpoint presentations and Excel spreadsheets. They will be there with concerns and worries for themselves, their families and their neighbors. Except for the illusion that the very very rich may have about their security, which may be right, there are very few of us who are ultimately protected from what is wrong with healthcare. All of us, no matter what our coverage status is, have much to lose by the ultimate passage of the AHCA and much to gain if we can begin a process of repair of what needs fixing and expansion and improvement of the work started by the ACA. We must continue to strive 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.

Congress will be away for the next week. Now is the time to stop, reflect on the importance of what we have achieved and then continue to conceptualize the strategies that might finally kill the AHCA or whatever the name will be for the obsession that Republicans have with the repeal of the ACA and its replacement with an illusion of care and reason. As my old coach always said, “It’s crunch time. Do not forget how bad it feels to lose!”

Sometimes Where You End Up Is Determined By Where You Start

If you have read the last 3500 words you probably think that I have given up on the idea of any sense of social solidarity with those whose political views differ from mine. I hope that is not true. I am working hard to be open to the ideas of others and trying to understand how and why they have come to where they are. I realize that everyone is on a journey. We have started in different places and at different times. We have had different traveling companions on life’s road and we have all been on different roads. Some are superhighways and others are treacherous trails over steep mountains with many parts of the trail washed out.

Today’s header shows water rapidly running out of Little Lake Sunapee downhill to Gooseneck Hole, a small pond about a half a mile away. From there water goes over a falls and down to Otter Pond which quickly gives up its flow to a small stream flowing into Lake Sunapee a few hundred yards further away. The Sugar River flows out of Sunapee and then joins the Connecticut River about twenty miles further west. The Connecticut River was a major commercial byway of Colonial America and its waters enabled mills in Brattleboro, Vermont, Springfield, Massachusetts and dozens of other New England communities before flowing through Hartford, on to New Haven and Long Island Sound and the Atlantic Ocean.

It fascinates me that water that falls northwest of Main Street which runs along the highest ridge in town and is about a mile and a half away, flows into my lake and follows the path I described. Water that falls on the southeast side of Main Street flows downhill to Pleasant Lake, the Black River, and ends up in the Merrimack which goes through Concord, Manchester, Nashua, Lowell and Haverhill. There were huge mills along its path before it empties into the Atlantic at Newburyport, Massachusetts. Two raindrops that initially fell a few inches apart on Main Street end up getting to the Atlantic at two different places almost two hundred miles from each other.

It seems that much is determined by where we start and our initial directions. I do not mean to say that we are passive sojourners, but it does seem to be true that experience has a lot to do with where we end up. We should keep that in mind as we try to work on the difficult problems that face us all. The other tidbit to extract that may seem hokey to some is that good work got done on both the Connecticut and Merrimack Rivers and ultimately their industries faced similar challenges. Is there a nugget in that observation also?

Spring comes and goes. We are expecting rain this weekend and I am moving my walks to New York City where they are also expecting rain. Wherever you are I hope that you will be walking and thinking about what lies ahead as a challenge for all, and how we eventually share a common destination, no matter where our journeys began.

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