October 9, 2020
Dear Interested Readers,
Thoughts About Healthcare Now and in the Future While Awaiting the Election
Years ago, when I was a Boy Scout, I garnered all the merit badges associated with the waterfront at camp: swimming, canoeing, and life saving. One fundamental requirement that we had to complete to pass the life-saving test was to demonstrate that we could “tread water.” It is important to be able to keep your head above water for a long time even if you are not making any progress. Now over sixty years later, I can still tread water for an extended period of time.
Treading water has been a term that has always had a double meaning for me. I use it as a metaphorical expression of how we “hang on” until things improve, help arrives, or a danger passes. At the literal level, as I bragged above, I can still tread water, keeping my head above water, but making no progress toward the shore, for hours. At the metaphorical level in terms of healthcare policy and practice, we have been treading water for almost four years. In retrospect it feels like those of us who want to see the expansion of healthcare access to everyone while maintaining a sustainable healthcare expense, and improving the health of the nation, have been treading water since Donald Trump was elected in 2016.
Now we are coming to the place where progress is either going to be made, or perhaps we will be hit by another wave that will put us under water, not to rise again for a long time, if ever. It is just three and a half weeks until the election that will define the near future of healthcare, and may set the stage for the coming of the Triple Aim and universal access to care, or if the president and his supporters prevail, we could be sunk by a rejection of the idea that it is in the best interest of the nation, and our collective responsibility to end the inequities that we know exit in healthcare.
It is a “binary” moment. Vice President Biden is offering a next step toward universal coverage through the addition of a public option to the existing ACA. His plan is a strategy that will allow us to make great progress toward universal coverage for care while still giving choice to those who prefer private insurance. Donald Trump has offered no plan and no details as he continues to act in any way he can to undermine the ACA. His administration supports the challenge in the Supreme Court that would abolish the ACA and send us back to where we were in 2010. He has essentially said, and Mike Pence confirmed through his vague statements in the VP debate this week: “Trust me. I have a plan. I will continue to provide access to care despite pre existing conditions and I will lower drug costs.” It’s hard to believe that he has anything in mind other than a future of continued healthcare inequities and unnecessary human suffering as he leads the nation in retreat from the idea that access to affordable healthcare is a human right that should be available to every person living within the boundaries of the United States.
As I have been “treading water” this week, I did watch the debate between Kamala Harris and MIke Pence. Pence was offensive in his disregard for the rules that both parties had agreed to respect. His answers usually went on for much longer than his allotted time as he talked over the request of the moderator, that he respect the rules. In time, Harris must have decided that if Pence was going to be speaking 70% of the time rather than his fair share of 50% of the time, she should occasionally follow suit as a defense. It is sad to say, but the most interesting thing in the evening was the house fly that seemed stuck to the front of Pence’s coif for over two minutes. I guess his “Ken” look requires a lot of sticky “product” that can turn his hair into the equivalent of fly paper. During the time the fly was on his brow, he was so intent on making his point that Senator Harris did not respect the police, that he never noticed the fly. In time, the fly was able to move on, and all that Pence had to offer was empty rhetoric that was parroted from the president’s worn out lines and lies.
As I have treaded water this week, I have not paid much attention to the president’s pronouncements that seem to be coming more and more erratic and nonsensical. This week’s presidential tweets have risen to new levels of absurdity as he has berated his personal Attorney General, William Barr for not indicting Joe Biden and Barack Obama. I have believed for a long time that if the president’s lips are moving, he is lying. Now, I wonder if it is fair to call what he is saying a lie if in fact it represents the delusions of a man having a side effect from a powerful drug. Some say that his antics and inconsistencies are the “steroids talking.” If so, his steroid speech has left us wondering, and concerned about the misery that will occur for millions of individuals and the long term impact on the whole economy if no bill is passed to provide economic relief to the unemployed millions, and relief to the budgets of local and state governments that have been devastated by their struggle to survive the impact of the pandemic.
Time may reveal that the president was having meetings and traveling to fund raising events after he was symptomatic and shedding virus. If this is so, it should be considered an act of criminal negligence. At a minimum, most of us would have self quarantined if we had known that a close associate, like Hope HIcks, had tested positive. Peter Baker and Maggie Haberman have documented most of his recent derangement in a New York Times article entitled “Trump Lashes Out at His Cabinet With Calls to Indict Political Rivals: The pressure on his top administration officials to take action came as President Trump bristled at the restraints of his illness.” Please click on the link and scroll down to the two and a half minute video that the president released via Twitter. Baker and Haberman describe the video if you don’t have the time.
Mr. Trump later released a video addressed specifically to senior citizens, who were once his political base but have increasingly soured on him as they have been disproportionately affected by the pandemic, according to polls.
“To my favorite people in the world, the seniors,” he said in the video. “I’m a senior. I know you don’t know that. Nobody knows that. Maybe you don’t have to tell them. But I’m a senior.”
Acknowledging that he had been “very sick,” he praised the experimental treatments he was given for the virus and vowed to provide them to seniors. “I want you to get the same care that I got,” he said. “You’re going to get the same medicine. You’re going to get it free, no charge, and we’re going to get it to you soon.”
Nobody knows that he is a senior? Seniors are going to get the same care when they get the “China virus” that he got for free? Baker and Haberman report that this strange reassurance in the video is an echo of his call to Fox News:
“I felt pretty lousy,” Mr. Trump said. But, he added, “I’m back because I’m a perfect physical specimen and I’m extremely young.” He once again played down the severity of the disease. “Now what happens is you get better,” he said. “That’s what happens, you get better.”
As we continue to tread water the president is planning, with the blessing of his White House physician, and to the amazement of other less conflicted medical experts, to resume his campaign with events in Florida and Pennsylvania this weekend. The October 15 debate appears to be off because the debate commission wanted to make it a virtual event for the safety of all, and the president refused. That is fine with me given how difficult it was to listen to the first debate. I would rather tread water for an hour and a half than listen to his misinformation and self serving claims that would be all one might expect from any future debate.
If Trump is describing himself as a perfect physical specimen who is extremely young, I think it is time to invoke the 25th amendment. When I hear the president talking I become sullen with the thought of all he has destroyed and all that he might yet damage. The president’s promise to seniors that he will give to all seniors the care that he got brings me to an article by Susan Kliff in the New York Times on Tuesday entitled “How Much Would Trump’s Coronavirus Treatment Cost Most Americans?: Even for those with insurance, surprise bills for things not covered can add up fast.” The answer to “how much” is “a lot,” if you could get the same drugs since much of what the president got was still experimental. The reality is that the treatment availability to the president is not just an issue of cost, it is also an issue of supply chains, production, and effective distribution. If he is sincere in his desire that all seniors get what he got then he is demonstrating a severe lack of understanding about the issues of how we produce and distribute effective therapies. The experience that we suffered through with inadequate PPE appears not to have taught him anything.
Susan Kliff is a medical journalist who has had a busy week. She was a guest on “Fresh Air” yesterday with Dave Davies who was sitting in for Terry Gross. There is a transcript of the interview entitled “Will The Affordable Care Act Survive The Next Supreme Court Challenge?”
The conversation between Davies and Kliff is an excellent status report on the attempt of multiple Republican state AGs, with the support of the Trump administration, to have the Supreme Court rule that the ACA is unconstitutional, another process where we are treading water while we hope to be rescued.
In the interview Kliff gets into the legal weeds and offers welcome insights that give me hope that despite a conservative majority the Court may rule to preserve the ACA. To my surprise it all may depend upon judicial consistency from Justice Brett Kavanaugh.
Dave Davies began the conversation with an introduction of the subject and Sarah Kliff:
This is FRESH AIR. I’m Dave Davies, in today for Terry Gross. One week after the presidential election, the U.S. Supreme Court will hear oral arguments in the latest challenge to the Affordable Care Act. Republicans have sought to put an end to Obamacare through litigation and legislation for most of the 10 years it’s been in effect.
The current legal challenge could be decided by a court with a six-vote conservative majority if President Trump’s nominee, Judge Amy Coney Barrett, is confirmed and sworn in by then. All this happens as candidates this fall debate the issue of preserving health insurance for people with preexisting conditions, and President Trump’s handling of the COVID-19 pandemic and his own infection are issues in the campaign.
For insight today, we turn to Sarah Kliff, an investigative reporter for The New York Times who focuses on national health policy. Kliff has been covering the beat for more than 10 years for several media outlets, including Politico, Newsweek, The Washington Post, Vox and now The New York Times. She spoke to me from her home in Washington, D.C.
The interview begins with a review of the moment. She offers comments about the proposed confirmation of Judge Amy Coney Barratt, and the loyalty of Trump’s base. Next, there is a review of the effectiveness and durability of the ACA, despite its many challenges as it has treaded water over the last four years. Kliff points out that everyone had imagined the ACA to be like a three legged stool. The mandate, which is the issue that has precipitated the Supreme Court challenge, was one of the legs.
Yeah, this was something that surprised health economists is they constantly talked about Obamacare as – they’d use this analogy of a three-legged stool. And one leg is, you know, getting rid of preexisting conditions – you let everyone in. The other leg is subsidies – you make it affordable. And the third leg is the mandate – you make everyone buy coverage, even people who don’t think they need it. And health economists spent, you know, the better part of a decade saying you cut off any leg, and the stool just tumbles over.
And Republicans did cut off one of the legs, and it hasn’t really tumbled. You know, we just got the health insurance numbers from the census for 2019, which is the first year without the mandate, and there wasn’t really any noticeable change. A lot of economists have gone back and kind of no longer think the mandate was quite as important as they initially did when they were drafting the Affordable Care Act. I kind of loved – what one economist told me was that, you know, maybe it’s not a three-legged stool. Maybe it’s kind of like the wobbly table at a restaurant that isn’t perfect, but, like, it works, and it does the job you need to do to eat your dinner.
The mandate, it turns out, was a kind of weak penalty. The size of it wasn’t very big compared to the size of purchasing health insurance. And one of the things I think economists have realized that the subsidies, the things that make insurance affordable on the Obamacare marketplace, that’s really what got people enrolled, not the mandate to enroll, but the money to make it affordable.
The continued success of the ACA despite the fact that the mandate has been gone since 2017 suggests that for a majority of Americans the ACA has gained the sort of acceptance that Social Security has gained over the years. The issue that may save the ACA in the court is not whether or not the mandate was ever constitutional but whether the whole law is unconstitutional if one part of it is not. The issue is called “severability.” Kliff continues:
Having the mandate struck down as unconstitutional really wouldn’t change Obamacare much one way or another. The real question of this case sits on this question of severability, of if the court decides that they are not going to sever the mandate from the rest of the law, I mean, that’s – that would be a huge, huge deal to pull the Affordable Care Act out of the health care system after it spent a decade kind of integrating into all of our lives.
At this point in the conversation Davies asks:
And to just get a little technical for a moment, I mean, this idea that one part of a law – the invalidation of one part of a law invalidates all of a law. Surely that issue comes up in many, many different kinds of legislation at every level. This is a new issue?
Kliff delivers a surprising and reassuring response that will allow me to tread water for a few more weeks:
No, no, it’s definitely not a new issue. And it’s come up recently in the Supreme Court. And it’s actually given defenders of the Affordable Care Act some hope that the Affordable Care Act will survive, given how conservative justices have written on it. There’s an opinion that came out earlier this year written by Justice Kavanaugh that deals with this issue of severability and it feels quite pertinent to the Affordable Care Act case, where Justice Kavanaugh, you know, really advocates for a narrow interpretation of severability, saying, you know, that they should not be trying to strike down entire laws based on tiny portions. So that Kavanaugh opinion from earlier this year, it kind of gives us some insight into how he thinks about the severability issue, which, like you mentioned, is not new. It’s just going to get a lot more attention with this Affordable Care Act case.
There is much much more in this interview. I think that I will listen to it several times as I attempt to calm myself over the next few weeks as we endure the confirmation hearing of Judge Barrett and watch the increasingly frenetic antics that are likely to come from the president as we hopefully will hear that he is sinking lower and lower in the polls in the “battleground” states.
We do live in strange times. I ask myself on a regular basis, “Will reason, empathy, science, and common sense prevail over the narrow distorted views of a controlling self interested minority? What will happen between now and November 3rd? Will there be much to be thankful for by the time we have our first COVID, probably virtual, family gatherings for Thanksgiving in just seven weeks?
Birthdays of Note, and Notes From the Road
The 9th of October has been an important day for me for 50 years. My second son, Bruce Lindsey, was born on the 9th of October 1970. I was a fourth year medical student and had just completed my OB-Gyn rotation at the venerable Boston Lying In Hospital, or the Lying In division of the Boston Hospital for Women, as it was known then. During my rotation at the Lying In, I had enjoyed some contact with my wife’s OB, Dr. Ted Barton who was an attending on the teaching service. He graciously invited me into the delivery room to witness the birth of my son, which is common these days for fathers, but was not so common 50 years ago. It was a thrilling experience that I will never forget.
Fifty years later, Bruce is an LICSW who works for the Albuquerque Public Schools where his wife is an assistant principal at one of the local high schools, and he cares for some of the most disadvantaged students in the country at another high school. He also has a practice where he sees a variety of patients, but with special expertise for those of all ages who are on the autism spectrum. I am very proud of him, his work, and his commitment to the delivery of quality care to a difficult population.
This 9th of October would have also been the 80th birthday of John Lennon. Of all his songs “Imagine” has spoken most directly to me. This is not the first time in the last twelve years that I have quoted it in these notes. It is a piece that expresses to me a philosophy of hope and continuous improvement. As a person of faith, I am not offended by the lines that suggest that we imagine a world without a heaven, hell, or religion. I don’t have a clear concept of the afterlife. I am willing to live in expectation that it will be better than my small mind can comprehend. I have always felt that the deeper meaning of imagining a world without the divisiveness of religion, the punishment and rewards, of heaven and hell, and all the wars and suffering that religion has spawned is a good thing to ponder. The broader vision Lennon is presenting is a utopia that we may never attain, but reaching for it through collective efforts to do the best we can to reach defined goals like the Triple Aim and universal access to healthcare would make this world a better place. I know that many clinicians and healthcare professionals like my son do go to work everyday and make sacrifices that they hope will, in some small way, make the world a better place. If you need to hear the song to remember its message and understand what I mean, or could just use a small break from a stressful day, click here. You can follow the words below:
Imagine
John Lennon
Imagine there’s no heaven
It’s easy if you try
No hell below us
Above us only sky
Imagine all the people
Living for today… Aha-ah…
Imagine there’s no countries
It isn’t hard to do
Nothing to kill or die for
And no religion, too
Imagine all the people
Living life in peace… You…
You may say I’m a dreamer
But I’m not the only one
I hope someday you’ll join us
And the world will be as one
Imagine no possessions
I wonder if you can
No need for greed or hunger
A brotherhood of man
Imagine all the people
Sharing all the world… You…
You may say I’m a dreamer
But I’m not the only one
I hope someday you’ll join us
And the world will live as one
Moving on, after thirteen days and 3,796.3 miles my wife and I have arrived at Felton, California. Felton is a little western town of 6500 that lies in the coastal redwoods six miles of twisting mountain curves on Route 9 north of Santa Cruz. We could have made it in ten days at our pace of about 350 miles a day, but we took a wonderful three day, two night side trip to Yellowstone. We parked the RV in West Yellowstone, Montana and used a rental car to log an additional 200 miles driving around the Yellowstone National Park. Despite hazy skies from the fires in Oregon and California, we got great views of the Grand Tetons going into Yellowstone and leaving. Neither my wife nor I had ever been to Yellowstone. If you have never been, it must be on your bucket list. I know that without the apprehensions of coronavirus we would have never made the trip. Over the whole trip we entered only two grocery stores. Twice I needed to go into a service station because the pump would not accept credit cards. Our family in California has been limiting their outside contact for six months. They have all groceries delivered, and they are able to work from home. I am impressed by the attention to masks and social distancing that I see on the streets here compared with what we saw on our long journey across the country.
Despite all the coronavirus worries we saw all of the “must see sites” in Yellowstone without doing any of the touristy things like river rafting or visiting museums. We entered no shops, which was fine with me. Our most memorable moment occurred while we were picnicking at a roadside area in the far northeastern corner of the enormous park. We had been told that if we wanted to see wildlife, the best place to go was the Lamar River Valley. One of the tributaries of the Lamar River is Soda Butte Creek. By the time we got to Soda Butte Creek and the picnic tables a few feet from the creek, we had seen hundreds of bison and other animals. It was a little bit like our trip to South Africa in 2015.
As we were enjoying some refreshment before turning around to retrace the many miles back to West Yellowstone, we looked up to see an enormous bison amble toward us and then take a right turn to cross to the meadow on the other side of Soda Butte Creek. He was a magnificent fellow as you can see from his picture in the header. Bison are “front end heavy.” I tried to imagine just how big he would be if his back half was a good match to his front end. Yellowstone National Park has a wonderful concentration of breathtaking scenery, amazing geothermal phenomena, and gorgeous animals. I can’t believe that it took me 75 years to make the trip. I hope to get back there several times before I find out what lies in the “here after.”
Be well! Enjoy the fall. When you are out and about, wear your mask and practice social distancing as best you can. Look for opportunities to be a good neighbor. Let me hear from you. I would love to know how you are managing the uncertainties of our times,
Gene
