Last week when I copied and pasted the conclusions in the JAMA article by President Obama I discovered that Google Drive did not know the word “hyperpartisanship.. Did Google’s ignorance of hyperparisanship suggest that we are experiencing something new? Hyperpartisanship is a succinct seventeen letter expression that adds nuance to Patty Gabow’s concept of our “lack of social solidarity.” How could we expect to have social solidarity in an environment of hyperpartisanship?

 

Was John McCain’s thumb down to the “skinny repeal” a symbol that we are beginning a movement away from hyperpartisanship? I have no doubt that anything that can be done to reverse the trend of the last 25 years toward hyperpartisanship will hasten the day when we’ll really 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…

 

Partisanship has always been a part of our political process. The founding fathers expected that vigorous debates between coalitions would be an important component of a functional democracy. I doubt they foresaw the trench warfare that we have now across the aisles of Congress. I am sure that there is adequate blame for both sides. As a Democrat I can recognize that my party has become associated with an arrogant form of political correctness and a fondness for data, studies, and rules that seem to crimp the progress of business development and the rights of ownership. It is right to point out that we should own our failures because we have ignored “grass root” politics and have forgotten how to communicate with broad segments of the population. Our  management, when in power, has made those who believe in “self reliance,” but do not share our fondness for academia and the facts of science, feel disrespected. I should leave it to Republicans and other conservatives to catalogue their contributions to the problem.

 

I make the problem worse when I date the transition from healthy partisanship to hyperpartisanship to when Newt Gingrich proposed his “Contract With America.” After that we saw the emergence of political theater as practiced on Fox News and AM talk radio. Somehow along the way, or about the same time, we saw the emergence of Tea Party Libertarians and Gordon Norquist’s campaign against taxes. More recently things got worse with the ability of the right to funnel huge amounts of money into divisive politics following the Citizens United decision of the Supreme Court . Mitch McConnell’s decision to use “no” in every conversation with Barack Obama may have been the final event that delivered us to this moment. I can make our divisions even deeper if I trace the origins of hyperpartisanship back to the political philosophies of Ronald Reagan or Barry Goldwater.

 

No matter how long it has been, or how deep the divide, we will all suffer more if hyperpartisanship is allowed to continue. Worse than its continuation would be for either side to be victorious. We must abandon it together. For the collective progress and continuous improvement of common problems that was envisioned by the writers of the Constitution we need diverse opinions. We need mutual respect and a universal willingness to follow an orderly process. We must always remember that we are united by a shared set of enduring principles that transcend our differences in the moment.

 

Did John McCain start the movement away from hyperpartisanship with his speech when he returned to the Senate from his encounter with his neurosurgeon? Below I have lifted key points from his moving speech. Click on the link if you want to read the entire speech. I have bolded a few points that resonated with me.

“I’ve known and admired men and women in the Senate who played much more than a small role in our history, true statesmen, giants of American politics. They came from both parties, and from various backgrounds. Their ambitions were frequently in conflict. They held different views on the issues of the day. And they often had very serious disagreements about how best to serve the national interest.

“But they knew that however sharp and heartfelt their disputes, however keen their ambitions, they had an obligation to work collaboratively to ensure the Senate discharged its constitutional responsibilities effectively…”

“Our deliberations today … are more partisan, more tribal more of the time than any other time I remember.  

“Both sides have let this happen. Let’s leave the history of who shot first to the historians…

Incremental progress, compromises that each side criticize but also accept, just plain muddling through to chip away at problems and keep our enemies from doing their worst isn’t glamorous or exciting…”  

“Our system doesn’t depend on our nobility. It accounts for our imperfections, and gives an order to our individual strivings that has helped make ours the most powerful and prosperous society on earth…

“Let’s trust each other. Let’s return to regular order. We’ve been spinning our wheels on too many important issues because we keep trying to find a way to win without help from across the aisle…”

“Why don’t we try the old way of legislating in the Senate, the way our rules and customs encourage us to act…

“Let the Health, Education, Labor, and Pensions Committee under Chairman Alexander… hold hearings, try to report a bill out of committee with contributions from both sides. Then bring it to the floor for amendment and debate, and see if we can pass something that will be imperfect, full of compromises, and not very pleasing to implacable partisans on either side, but that might provide workable solutions to problems Americans are struggling with today.

Will John McCain’s speech and his vote against the “skinny repeal” be effective calls for the Senate to reject partisanship and return to the productive debates that produce the compromises that enable incremental progress? Last week I quoted from President Obama’s constructive article in JAMA. He identified three things that he learned working to establish the ACA.

  • Change is hard.
  • Special interests pose a continued obstacle to change.
  • Pragmatism is important in legislation and implementation.

 

The practical outcome of Senator McCain’s and President Obama’s words should be slow progress that begins by stabilizing the exchanges. Legislation that guarantees the CSR (cost sharing reduction) payments to the insurers offering products on the exchanges should be job one. There is a huge literature that identifies the CSR guarantee as an urgent necessity. Drew Altman, the President of the Kaiser Foundation, has points out that it is the nearly seven million Americans who do not get subsidies in the individual market who are most vulnerable to the cost increases that will occur if there is a failure to guarantee the CSR. Those seven million individuals who buy their own insurance without public assistance are joined by the ten million Americans who have their rates protected by the subsidies offered to the exchanges through the ACA. Doing something to protect seventeen million vulnerable Americans seems like a good starting place in the effort to stabilize the ACA.

 

David Blumenthal and Sara Collins at the Commonwealth Fund offered their thoughts recently on where to start the next phase of healthcare reform in a blog post creatively entitled, “In the Aftermath.” Number one for them is also stabilizing the exchanges. They agree that guaranteeing the CSR payments is the most important action to take. They stress the importance of making the CSR fix permanent because the uncertainty of having to wait every year to see if the government will pay is a prime reason for insurers to hedge their potential losses by raising premiums, as many have already done for 2018. They point out that the payments are already in the budget. The Trump administration has not assured us that they will be paid.

 

The next concern addressed by Blumenthal and Collins is the issue of “bare counties.” These are the counties where no insurer will be offering a product on the exchanges in 2018. Blumenthal and Collins make two suggestions. The first would be to require the largest insurer in the state participating in the Federal Employees Health Benefit Program to offer coverage in those counties. Their second option would be to allow residents of those counties without exchanges to participate in the expanded Medicaid programs of the state.

 

The final suggestion of Blumenthal and Collins would be for the government to appropriate ten to fifteen billion dollars for a reinsurance pool to reimburse insurers for exceptionally high losses that could occur in the individual market. The idea was a Republican proposal as part of their “repeal and replace” bills to cushion the expected losses that might follow repeal of the mandate. An enforced mandate plus a reinsurance pool would be great stabilizing actions for the exchanges. If the Senate returns to the subject of healthcare after their vacation with a bipartisan approach, these suggestions deserve exploration.

 

The primary barrier to universal coverage is the cost of care. The government can only affect the cost by gross changes in finance and regulatory requirements that “nudge us” toward practicing in more efficient and effective ways. Obviously nothing is more important to lowering the cost of care than insuring that every American has basic coverage for primary care and the guarantee of lifetime coverage without interruption or fear of reaching some maximum benefit level after which they would not have care. Numerous studies show that we can lower the cost of care by ensuring that everyone is covered. According to a Pew Research poll in January 2017 at least 60% of  “Americans say the government should be responsible for ensuring health care coverage for all Americans, compared with 38% who say this should not be the government’s responsibility.” That is a majority opinion, but it is not the law.

 

Someday a bipartisan approach to healthcare will deliver universal coverage that the majority of Americans now believe is both good policy and a human right.  The ACA is an incremental move toward universal coverage.  I am encouraged because all of the bills that were rejected this spring and summer were large leaps away from universal coverage.

 

I have discovered that most of us are stuck in a world of fee for service. We ignore the fact that we have had one hugely bipartisan healthcare law, MACRA, passed in 2015 with overwhelming majorities. MACRA should be an effective start toward payment for value and away from payment for volume. What I fear is missing is widespread programmatic preparation for value based reimbursement. Bipartisan legislation can set the stage for cost reduction, but our practices must accept the reality that the cost of care is ultimately controlled by how we practice.

 

To reach the Triple Aim we will need a bipartisan recognition that we will never have a healthier population and a lower cost of care until we address the social issues that undermine good health.  We will need bipartisan determination to launch effective changes to entitlement programs in labor, housing and education. Announcing another war on drugs and paying lip service to the fact that the opioid epidemic is a national crisis as the president and attorney general have done are ineffective starts. They may necessary first moves but they are insufficient to solve deeply rooted problems.

 

Finally, to reach the Triple Aim and provide universal care at a sustainable cost to us all we must more effectively engage individuals in self management of their health and chronic diseases. This is work where government can be supportive through payments and regulations, but the primary barriers lie within the community of medical professionals. With a new emphasis on the benefits of team based care and the principles of population health we are just getting started. Change is hard. Healthcare is complex. No one has all the answers. There is no way to ever realize our hopes without working together across the partisan divides in Congress and the deeper, more subtle divides within healthcare.

 

 

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