Living in a “purple state” I often meet interesting people with whom I share some possible connection that both of us choose not to explore because a little superficial exchange quickly reveals that we see the world through the lenses of different political affiliations. Our assumptions about who we are then flow quickly from the stereotypes that are attached to those ideas. In the exchange of a few polite words we can both come to the unstated conclusion that discussing more than sports and the weather is probably ill advised.  We both politely move along, never knowing what we might have learned if we had the courage or the skill of knowing how to talk to one another about the things that we see differently.

Sometimes words are not necessary to decide that there is no use to pursue a more complex conversation. We make many decisions on the basis of visual clues. My wife bought a new car a year or so ago, and I inherited the old energy efficient 2008 Toyota Highlander with 150,000 miles on the odometer that she had been driving. It is a good car to have for trips to the dump or to take to parking lots in Boston where strange things can happen to a car. At our local dump I occasionally sense that someone is judging me because of the bumper stickers that festoon the tailgate of the car. My wife is one of those people who uses bumper stickers to advertise her point of view. A quick look at the tailgate of the old Toyota makes it immediately clear just what our political preferences are. There are Obama/Biden stickers, stickers that endorse Obamacare, Elizabeth Warren stickers, and one that just proclaims, “Not a Republican,” as if anyone who looked at the collection might still wonder what our political affiliation is. There is even more information about our political history that can be gleaned from a closer analysis of the display. One sticker says “Ready for Hillary,” then there is “Bernie in 2016”, and a slightly newer sticker that says “Bernie has my heart, but Hillary has my vote.” The most recent addition to the collection simply says “Resist.”

We label ourselves in both obvious and sometimes subtle ways. John Gallagher, my good friend and Lean guru, once informed me (long before the 2016 election) that conservatives do not drive Subarus! I was skeptical, so he challenged me to send him a photo taken with my iPhone of a Subaru with a conservative bumper sticker, if I ever saw one. It was no problem finding Subarus that were festooned somewhat like my Toyota. Finally after about two years, last August, John helped me out with the quest. He texted me a picture with the title “Black Swan event” showing a Subaru Outback in a parking lot in Virginia sporting a “Cuccinelli for Governor” bumper sticker. Ken Cuccinelli, a very conservative Attorney General for Virginia, lost the 2014 election for Governor to the Democrat, Terry McAuliffe.  Despite John’s refutation of his own theory that conservatives do not drive Subarus, I figure that I can always smile and wave to Subaru drivers with a secure sense of probable affiliation.

You probably have read, and maybe remember, my admonition to ask whenever you are concerned about a problem to drop back into a reflective posture of self examination and ask, “What part of the problem am I?” Applying that line of reasoning to the lack of civil discourse and the widening gulf that exists in our society between those that label themselves as conservative and those that like to consider themselves progressive or liberal, I find that I am playing as big a role as anyone I know in the perpetuation of the problem. I need to follow the advice of Ghandi and be part of the change I want to see in the world.

I have been in a self examining mode since hearing Patty Gabow presentation: “Can the American Healthcare System Deliver Health For Every American?” What made Dr. Gabow’s presentation unique was the rhetorical nature of it. Behind it all was the question, “Is this the way we want it to be?” If not, what are we doing that needs to change, and what are we not doing that we should begin to do?” As I wrote in a previous post she made suggestions of things to do if we want to use our healthcare system to deliver better health.

Dr. Gabow finished her presentation talking about short term and long term efforts that begin at home. She asked the rhetorical question, “Can the healthcare system be the entity that broadens our national focus from its current narrow biomedical focus to the broader determinants of health.” She thinks that it will require changes outside the healthcare system, but the healthcare system can continue improvement efforts on access, cost, and quality. Those efforts are necessary but insufficient. We must do more to reduce waste to free up resources. We need to make the public aware of the social determinants of health and the healthcare disparities that exist and advocate for addressing the problems. We must address income inequality by ensuring that all work produces a “living wage.” We must be sure that all of our healthcare programs and institutions are adequately funded.

Given our current realities she is describing a sum of actions which taken together on the up side add up to a long shot. There is the possibility that our divisiveness will lead to an outcome that  won’t be positive, and health in America may decline. Our collective health may continue to deteriorate as we argue with neighbors and political gridlock increases with the result that the social determinants of health deteriorate more while spending on non value providing care continues to rise, and access to care for many deteriorates. That mindset was reinforced when I listened to a podcast that my son in California gave me.  During our recent visit I had been talking with him about how much I had enjoyed reading Yuval Noah Harari’s 2015 book, Sapiens: A Brief History of Humankind. I have mentioned this book in a recent post. He immediately suggested that I listen to a podcast where Ezra Klein talked with Harari about his books. Following his advice I listened to the podcast as I was out for a walk earlier this week, and about forty five minutes into the conversation Harari said:

What we are talking about in the twenty first century is the possibility that for the first time that most human beings will lose their economic and political value. They will become a kind of massive useless class. Useless, not from the viewpoint of their mother or their children, but useless from the viewpoint of the economic, military and political system. And once this happens the system also loses the incentive to invest in human beings. In the twentieth century governments all over the world, even in dictatorial regimes, invested heavily in the health, education, and welfare of masses of people because the government and the elites needed them.

Yuval Harari, author of “Sapiens” on the Vox podcast “The Ezra Klein Show” February 28, 2017

What followed was Harari’s review of the history of the last one hundred years as a majority of Americans moved from working on the farm, to working in factories, to working in the warehouses of Amazon and as cashiers at Walmart and at my local grocery store. At each step along the way the efficiencies of mechanization and the emergence of globalization made fewer and fewer people necessary. It’s sort of like the game of musical chairs.

What is next? There is a hint of the future at the grocery store where now I am learning how to check myself out at the self service counter. What will the cashier do next when I finally get proficient?  As “progress continues” fewer people are needed for everything from food production, to product creation, to distribution, to defense of the country. Some cashiers won’t be “needed” and will fall onto public assistance, or find a less desirable job for less money. Many Americans have already felt discarded or felt that they were vulnerable to eventual neglect and in 2016 voted to “Make America Great Again.”

Another event occurred this week that got me thinking. My wife and I went out to dinner and to hear some live music with neighbors whom we have known since the day we bought our home in New London nine years ago. We don’t see eye to eye on everything with them politically, but we are good friends who understand each other and laugh about our different takes on the big issues. The husband is a gregarious man who loves practical jokes. The funniest part of some of his efforts at humor is the way they can backfire.

There was one tense moment a little over five years ago when he thought it would be funny to secretly add a “Romney for President” banner to the rolling political commentary on the back of my wife’s car. When his deed was discovered things were tense for a while as various forms of retaliation were considered and then rejected. The “joke” created a meaningful dialog about the “real” issues and made our friendship stronger.

The other couple that went to dinner with us were very nice and interesting people who are planning early retirement in their mid fifties. In the small talk we got into a discussion of healthcare, and brushed up against some superficial review of the current efforts on tax reform in Congress. I was treading lightly, attempting to preserve civility, not wanting the evening to fall off the high road and into the ditch of uncomfortable and impossible to resolve tensions. The most precarious moment was when he revealed that in retirement his employer would maintain his access to his doctor who was a concierge physician. It seemed like such a great way to get care that he had a hard time understanding why that was not the solution to America’s healthcare concerns. I finished the conversation without a review of all the economic and practical reasons why his idea would not work by simply saying that I was happy that he was so happy with his care, but I doubted that we had enough doctors to extend that sort of access to every man, woman and child in America. I realized that if someone is secure and happy with their health and healthcare a simple recitation of facts like Dr. Gabow has given us is never going to change their mind. Trying to explain the vulnerabilities and inequities of our healthcare system over a good but high volume cover of “My Girl” is not a viable tactic that supports the larger strategy.

I realized while listening to the music across the dinner table from my new friend that if we needed to avoid the issues of healthcare and tax policy there was no way that we could ever get to the larger subject of why we all need to talk about the ideas that did make America a brave experiment, and how so far those ideas have never applied to everyone. Harari has insightfully pointed out that there are more and more people in the world whom some treat as a “not their problem or concern” at best, and sometimes as just another form of discardable surplus. We will never be able to effectively respond to Dr. Gabow’s challenges until people like “us” can listen to people like “them.” Perhaps if we listen and ask questions of those with whom we disagree, rather than preach at them and bombard them with contempt, there will begin to be some progress toward a healthier nation. The alternative is one side eventually subduing the other. History underlines the fact that totalitarian states work for a while for some, but eventually fail for all.