Healthcare Musing For December 12, 2024

December 13, 2024

Dear Interested Readers,

 

Bracing For The Worst While Clinging To Hope

 

We have endured a very bizarre month since the election. The only good thing about it is that time feels like it is moving very fast. One month down and only forty-seven more months until the 2028 presidential do-over. I have been thinking about hope, and I hope that the next four years won’t be associated with as much turmoil and surprise as we have experienced in the last month. 

 

It is tough to know what to expect over the next four years because of the jaw-dropping announcements coming out of  Mar-a-Lago recently of appointments to high offices in the next Trump administration. It is clear that a few “descriptors” other than “expertise” have influenced the choices.  It is hard to imagine some of these folks ever gaining a position of authority if their primary quality was any expertise in the area of the government they will manage if confirmed by the Senate.

 

The most important qualification for a position in the next Trump administration is absolute fealty to Trump. Almost all of the appointees have been high-volume, money and noise, supporters of the MAGA movement. A necessary prerequisite for an appointment is to say that the 2020 presidential election was stolen from Donald Trump, or at a minimum give an answer to any question about the 2020 election that is so ambiguous that at least Donald Trump is confused into thinking that you drank the Kool-Aid. An appointee needs to be “photogenic” since appearance seems more important to Trump than expertise. Many of the new cast have been employed by Fox News or were regular contributors to programs. There are going to be at least eleven billionaires in high government positions. The richest man in the world is well positioned to “self-deal” to further enhance his wealth and act as a “shadow president.” In a recent article in US News and World Report, we read:

 

Throughout the campaign, President-Elect Trump declared that he had no knowledge of Project 2025 or the people associated with its development with the support of the Heritage Foundation, a conservative think tank where many Republican bureaucrats go during a Democratic administration to plan for their next turn at bat. How many of Trump’s appointees have a connection to Project 2025? According to a recently published article in New York Magazine, the correct answer is “all of them.” Most prominent in terms of guidance and editorial influence in the final document of over 900 pages, is Russell Vaught whom Trump has nominated to be the Director of the Office of Management and Budget. I doubt that many people who bothered to give Project 2025 any thought ever believed Trump when he denied knowledge of Project 2025. It is difficult to believe a man for whom the truth is for suckers and who holds a history-shattering record of 30,000 plus lies during his first four years in office. 

 

I had promised myself that I would look the other way and begin to read more poetry than politics. I had also begun to construct a survival strategy for the next four years with a focus on family and community rather than on national political concerns and international conflicts. In my plan, I would limit my political attention to monitoring Trump’s administration’s management of healthcare and healthcare policy, plus the efforts of government at all levels to improve the social determinants of health for our most challenged neighbors. So far, I feel like my grandfather must have felt when he would talk about his unsuccessful efforts to stop smoking. He would facetiously say, “It is easy to give up smoking. I’ve done it at least a thousand times.”

 

Beyond my daily head shaking over the latest Trump appointment announcements, I was really struggling with whether or not I would listen to the Trump interview last Sunday by Kristen Welker of NBC. In the end, my autonomic nervous system reinforced my resolve to pay little attention to all things Trump and rescued me from my lack of willpower. I could not resist looking, but then after watching him sit face-to-face with Ms. Welker and spew nonsense, I began to have some nausea and felt if I continued to watch I would have some sort of GI disaster. In the end, I did succumb to looking at the transcript of the interview which was easier to digest than listening and watching as his lies and misrepresentations flowed like a swollen river after the hurricane passed through.

 

I focused on the section of the interview about Trump’s healthcare agenda. As I have done in other posts, I will throw in my thoughts as Ms. Walker questions Mr. Trump. Ms. Welker begins the healthcare section of the interview by asking Trump to comment on the impression that many Republican solons have that the ACA has proven its durability and is here to stay. Once again, I have bolded what I think are the big-picture words or comments. She begins:

 

KRISTEN WELKER:

Let’s talk about health care. I’ve been talking to Republican lawmakers on Capitol Hill. They say it’s no longer feasible to repeal and replace Obamacare because it’s so entrenched in the system. Do you see it that way? Is that now off the table, repealing and replacing Obamacare?

                

PRESIDENT-ELECT DONALD TRUMP:

So, when John McCain let us down by voting, and Murkowski and Collins, and whoever it was that voted against, but they really let us down. They did us a great disservice, because we would’ve had great health — Obamacare is lousy health care. It’s very expensive health care for the people. It’s also expensive for the country, but for the people. It’s lousy health care. When John McCain gave his thumbs down after saying for ten years that he wants to repeal and replace, okay, and then he came out, he put his now famous thumbs down and he became a hero to the left, just let me just tell you, if we find something better, I would love to do it. But unless we find — but, one thing I have to say, I inherited Obamacare, or anything else you want — it’s got about 20 names. But I inherited it. And I had a decision to make with health and human services. I had a big decision to make. Do I make it as good as we can make it or do I let it rot? And a lot of political people said, “Let it rot and let it be a failure.” I said, “That’s not the right thing to do.” And I had very good people in the medical area that handled that. And I said, “What do you want to do?” I said, “We really have an obligation to make it as good as we can,” and we did. We made it as good as we can make it. Instead of, instead of making it bad, where everybody would be calling for its repeal, I made it so that it works. Now, it works —

 

If I had stayed with the telecast, I am sure that I would have lost my cookies with that answer. It is really hard for me to believe that the soon-to-be president again really believes there is anyone in America who would say that he made the ACA work. I do share with him the cherished memory of John McCain’s dramatic gesture. It was the high point for me of the first four years of Trump that we had to endure. I think it says a lot that Trump begins his healthcare comments by saying he made the ACA work because McCain defeated his sham replacement bill. Click here to see that moment once again. I highly recommend the three-minute memory because it includes comments about the moment and the character of John McCain by Elizabeth Warren, Chuck Schumer, Susan Collins, and even Mitch McConnell. There is hope in that memory. 

 

Welker is not going to fall for Trump’s misrepresentation of his feelings about the ACA. She comes back with:      

          

KRISTEN WELKER:

But you did try to overturn it, sir.

                

PRESIDENT-ELECT DONALD TRUMP:

Well, it’s lousy. No, no.

                

KRISTEN WELKER:

You did try to overturn it. You did have your Justice Department try to direct the Supreme Court to overturn it.

 

It has always galled me that Trump succeeds by his ability to distort the truth while he avoids responsibility for any of his actions that aren’t obviously successful. So, his answer to Welker’s persistent probing about this attempt to repeal the ACA should not surprise us. Remember, he has just said that he made the ACA successful implying that the popularity it currently enjoys and the benefits to millions of Americans that it has achieved are due to his efforts rather than the efforts of far more intelligent and patriotic people including John McCain whom he has openly sought to undermine as not a hero in life and after death. 

                

PRESIDENT-ELECT DONALD TRUMP:

No, we had a little bit of a surprising opinion, to be honest with you. If it would’ve been overturned, we would’ve had much better health care right now. But right now we have something that I made the best of. I could’ve made the worst of it and it would’ve fallen by the wayside. I did the right thing from a human standpoint. But, you know, I’m sort of proud of my decision. At the same time, sometimes I regret it. I told the people and I gave them the money to do it. I said, “Fix it. Make it work.” Because people would’ve suffered. But it’s too bad that they voted no. I wish John McCain, I wish — he fought for ten years on repairing, replacing Obamacare. For ten years. And then he voted against. Nobody understands it.

 

Trump is not a mathematician or historian. The ACA was passed in 2010. McCain’s thumb went down in 2017. He died of a brain tumor in 2019. When his thumb went down, he said he would have voted to repeal and replace the ACA if Trump had offered a better bill. The bill Trump’s supporters offered in 2017 and that McCain’s thumb doomed had various names when it was in the House and Senate. Under any name, it would have been a huge step backward which is why McCain said he voted against it. That Trump’s previous efforts offered us something inferior to the ACA is something we should remember if he ever pulls together his “concept of a plan.”

 

Welker decides to move on to the famous “concepts of a plan” statement which he ad-libbed in the one presidential debate that he chanced with Kamala Harris. In his answer, he moves on from saying that he made the ACA work to saying that it stinks.

 

WELKER:

Sir, you said during the campaign you had concepts of a plan. Do you have an actual plan at this point for health care?

                

PRESIDENT-ELECT DONALD TRUMP:

Yes. We have concepts of a plan that would be better. But —

                

KRISTEN WELKER:

Still just concepts? Do you have a fully developed plan?

                

PRESIDENT-ELECT DONALD TRUMP:

Let me explain. We have the biggest healthcare companies looking at it. We have doctors who are always looking. Because Obamacare stinks. It’s lousy. There are better answers. If we come up with a better answer, I would present that answer to Democrats and to everybody else and I’d do something about it. But until we have that or until they can approve it — but we’re not going to go through the big deal. I am the one that saved Obamacare, I will say. And I did the right thing. I could’ve done the more political thing and killed it. And all I had to do is starve it to death.

                

KRISTEN WELKER:

You did try to have your Justice Department effectively kill it, though, sir.

                

PRESIDENT-ELECT DONALD TRUMP:

No, no. Kill it from a legal standpoint. But from a physical standpoint, I made it work.

 

Welker gets points for getting our “smartest” president to tie himself into nonsensical knots

                

KRISTEN WELKER:

In — in your concepts of a plan, sir, will people with preexisting conditions still have coverage? And can you guarantee their prices will not go up?

                

PRESIDENT-ELECT DONALD TRUMP:

The answer is yes, they’ll have coverage. You have to have it —

                

KRISTEN WELKER:

And what about their prices —

                

PRESIDENT-ELECT DONALD TRUMP:

— because you know what, it’s —

                

Maybe what is about to happen is similar to Joe Biden’s debate meltdown. I am an authority on mental processes at the far end of a person’s seventies. I hate the fact that I am a year older than the man who will still be president at age 82. Welker reminds him that she is asking about healthcare prices. She has probably given up on getting a believable answer to her question about the preservation of insurability despite pre-existing conditions. 

 

KRISTEN WELKER:

What about their prices, sir?

 

PRESIDENT-ELECT DONALD TRUMP:

I want the prices to go down. I want to have better healthcare for less money, and there are ways of doing it, I believe. And I have the — I have the smartest people in that world. You know that’s a separate world unto itself. I have the smartest people in that world looking at it and trying. And if they come up with something, I will present it. Now, maybe you won’t be able to sell it. But if — if we get better healthcare for less money, I believe it’s very salable.

                

KRISTEN WELKER:

Just very quickly, when will we see your fully developed plan? When are you going to — 

 

PRESIDENT-ELECT DONALD TRUMP: 

Well, I don’t know — 

 

KRISTEN WELKER: 

— show the public that?

 

PRESIDENT-ELECT DONALD TRUMP:

— that you’ll see it at all. I can only say that we have some of the best healthcare people. I’ve always tinkered with it. I think — it’s a little hard to explain. Obamacare, when I took it over, was a disaster. And I made it workable.

 

And who are those healthcare experts who are working on the cost of care? Would they be Robert F. Kennedy, Jr. and Dr. Oz?

                

KRISTEN WELKER:

It has insured 20 million people.

                

PRESIDENT-ELECT DONALD TRUMP:

Yeah, because of me. Because of me. If you look at what I did, I was the one —

                

KRISTEN WELKER:

But you tried to —

                

PRESIDENT-ELECT DONALD TRUMP:

I made it good — yeah legally — 

                

KRISTEN WELKER:

You tried to repeal and replace. You tried to kill it, sir.

 

I know that if I had been able to stomach watching the interview this far without hurling, I would have been yelling at my TV. Trump rambles on with arrogance and ignorance. He has no idea of the real issues, but self-awareness of his ignorance never prevents him from rambling on with a word salad blend of audacity, arrogance, and ignorance that is surprisingly successful with the half of the population who like his style. Welker isn’t buying what he is saying either, but he continues in his fabrication or delusion with words that “alla Biden’s debate performance” don’t really make sense. What does “we would’ve had a better system because we wouldn’t have had healthcare” mean? That almost makes sense and then he loses all coherence as he shifts to what the Democrats would do.

                

PRESIDENT-ELECT DONALD TRUMP:

Because if I repealed it and replaced it, we would’ve had a better system because we wouldn’t have had healthcare. And the Democrats would’ve been forced to do something. If we wouldn’t have had it, the Democrats would’ve been forced to do something that they wouldn’t do if we have it.

 

Having demonstrated to the world that “the once again emperor” still has no clothes, Walker moves on and Trump sees an opportunity to congratulate himself for his “great wisdom.”

              

KRISTEN WELKER:

Let me ask you about another aspect of healthcare. You talked about this on the campaign trail. IVF. You promised free IVF for all who want it, either through the government or through mandates with insurance companies. I’ve been hearing from Republican senators, some of them, who say they’re not going to support that plan. How are you going to get that passed?

                

PRESIDENT-ELECT DONALD TRUMP:

Well, we’re going to see. We want them to — ideally the insurance companies to pay for it, the fertilization. I came out very early for a Republican, especially. And I think they were looking for my guidance, my great wisdom, right? They were looking for it. And I got a call from Kate Britt, who is a terrific person, senator from Alabama. And she said, “Sir, we just had a really negative ruling from a judge in Alabama, conservative judge, that all of these clinics had to be closed.” And she said — she went into great detail. And she said, “People are devastated over it.” And after literally speaking to her for five minutes, I issued a — an order, really an order, in a sense, and it was a statement from the Republican Party that we are all for IVF and fertilization. Ok. The Alabama legislature met the following day and passed it. It was a beautiful thing to see. And I consider myself to be the father of IVF, in a certain way. And the Republicans were very strong on the issue.

 

So will he ask Republicans for a bill to sign making IVF a free benefit for all women? I doubt it. He hasn’t even supported universal access to affordable care for all women. I think we can count his position on IVF as one of his early second-term lies. 

                

KRISTEN WELKER:

But, sir, I want to understand where it falls in your list of priorities. I mean, is this something we can expect to see you try to move on in — 

PRESIDENT-ELECT DONALD TRUMP: 

Well, we’re going to be —

 

A skilled journalist like Welker can make a man of “great wisdom” say some pretty nonsensical things. She presses on and he pivots to a totally unrelated subject, tax cuts:

 

KRISTEN WELKER: 

— the first 100 days?

              

PRESIDENT-ELECT DONALD TRUMP:

— we’re going to be talking about it and we’re going to be seeing. We have a lot of other things. I have tax cuts. You know, we’ll be submitting in either the first or second package to Congress the extension of the tax cuts. So that might very well be in there. Or, or it’ll come sometime after that.

 

Welker treats his response as if he had been talking to himself. It is possible that when he is not talking about himself he is talking with himself. He is certainly not talking in an informative way about the questions for which she is seeking answers. So she moves on:

                

KRISTEN WELKER:

Let’s talk about abortion, sir. You have taken responsibility for overturning Roe v. Wade. You’ve said that abortion is now a state issue. There are steps that you could take, though, as president to restrict abortion through executive action without Congress. More than half of abortions in this country are medication abortions. Will you restrict the availability of abortion pills when you’re in office?

                

PRESIDENT-ELECT DONALD TRUMP:

I’ll probably — I’ll probably stay with exactly what I’ve been saying for the last two years. And the answer is no.

                

KRISTEN WELKER:

You commit to that?

 

She is looking for a commitment from a man whose life’s accomplishments are derivative of his ability to lie and disavow previous commitments when they don’t match his immediate needs.  She has him on the ropes, and he wants to find a safe place to hide. He immediately begins to counter with a form of “whataboutism.” He does indeed have world-class “whataboutism” skills.

                

PRESIDENT-ELECT DONALD TRUMP:

Well, I commit. I mean, are — things do — things change. I think they change. I hate to go on shows like Joe Biden, “I’m not going to give my son a pardon. I will not under any circumstances give him a pardon.” I watched this and I always knew he was going to give him a pardon. And so, I don’t like putting myself in a position like that. So things do change. But I don’t think it’s going to change at all.

 

That was enough for Welker. Her next question was about his administration picks:

 

KRISTEN WELKER:

Ok. Let’s talk about some of your picks to fill out your administration. You named Kash Patel to be the next FBI director. 

 

She moved on and so will I.

,

It was a very interesting week on many fronts. I won’t comment on the tragedy of the senseless killing of United Healthcare executive, Brian Thompson, nor will I try to justify the actions of the very sad, probably mentally ill, surely misguided, young man to whom all evidence points as the killer. I just wonder what needs to change in our society for us to move to a higher level of effectively caring for everyone. Everyone deserves the help they might need to be well, and everyone needs to know that they can walk down the street in our most famous city without the fear of being victimized. I don’t expect much progress addressing these expectations when to win an election one must be a merchant of fear, hate, and division. I am certainly not proud of the odor of the feelings that the moment presses out of me. 

 

Most of the time, when we hope, we are hoping for something positive to happen. Most of my current hopes are that negative things won’t happen. I am hoping that healthcare’s progress toward the ideals of the Triple Aim will not be reversed or damaged over the next four years as described in Project 2025.  I hope that the damage Trump and others will do over the next four years will be minimal and that most of our progress in all domains of healthcare will survive. For my hope to come true acts of courage will be required from unexpected heroes. We will need a few Republican senators to model their actions on the example of John McCain’s courage which is now forever symbolized by his downturned thumb.  The agents who will bolster my hopes will once again be a few Republicans like McCain, Collins, and Murkowski in the Senate and Cheney and Kinzinger in the House who know that this man is pushing us dangerously close to places that will be difficult to return from. The next forty-seven months will be difficult, to stomach, but its too early tp give up the hope that this genius will find some way to undermine his own success. I hope so.

 

Paul, Say it Isn’t So

 

For many years, one of my favorite columnists has been Paul Krugman, the winner of the 2008 Nobel Prize for Economics. You can imagine my surprise when I opened the opinion section of The New York Times on Tuesday and read the title of his post: “My Last Column: Finding Hope in an Age of Resentment.” I gulped, winced, and then began to read.

 

This is my final column for The New York Times, where I began publishing my opinions in January 2000. I’m retiring from The Times, not the world, so I’ll still be expressing my views in other places. But this does seem like a good occasion to reflect on what has changed over these past 25 years.

 

Another hero of mine is moving on. It is way too soon. He is only 71. I suspected that maybe he was a victim of election depression. But, I read on to give him a chance to make his case to me, a dedicated “interested reader” of his work. He continues:

 

What strikes me, looking back, is how optimistic many people, both here and in much of the Western world, were back then and the extent to which that optimism has been replaced by anger and resentment. And I’m not just talking about members of the working class who feel betrayed by elites; some of the angriest, most resentful people in America right now — people who seem very likely to have a lot of influence with the incoming Trump administration — are billionaires who don’t feel sufficiently admired.

 

That is vintage Paul Krugman! We are in sync. The billionaires also baffle me. The next few paragraphs were a description of those times in contrast to these times. He is nostalgic for simpler times, but he admits that in 1999 all was not well:

 

…There were financial crises in Asia, which some of us saw as a potential harbinger of things to come; I published a 1999 book titled “The Return of Depression Economics,” arguing that similar things could happen here; I put out a revised edition a decade later, when they did.

Still, people were feeling pretty good about the future when I began writing for this paper.

Why did this optimism curdle? As I see it, we’ve had a collapse of trust in elites: The public no longer has faith that the people running things know what they’re doing, or that we can assume that they’re being honest.

 

Yes, the bolding is mine to show that he made a point with which I agree. I don’t like it, but I understand what he is saying.

 

He then reviews the disappointments that followed our invasion of Iraq and the economic downturn of 2007-8 which can rightly be blamed on decisions and actions within the circle of “elites.”

 

If you have had any stomach for reading the early explanations for the outcome of the 2024 election that go beyond the price of eggs and how many people are attempting to cross the southern border, you will read about the anger of those whom Hillary Clinton termed a “basket of deplorables” have for the “elites” in our society. Paul presses on:

 

It’s not just governments that have lost the public’s trust. It’s astonishing to look back and see how much more favorably banks were viewed before the financial crisis.

And it wasn’t that long ago that technology billionaires were widely admired across the political spectrum, some achieving folk-hero status. [Steve Jobs?] But now they and some of their products face disillusionment and worse; Australia has even banned social media use by children under 16. 

Which brings me back to my point that some of the most resentful people in America right now seem to be angry billionaires.

 

What? Angry billionaires? Paul, make some sense of this. I have imagined that the outcome of the election could be the result of a conflict between a coalition of college professors and cat ladies who were disrespecting truck drivers and Walmart greeters. 

 

We’ve seen this before. After the 2008 financial crisis, which was widely (and correctly) attributed in part to financial wheeling and dealing, you might have expected the erstwhile Masters of the Universe to show a bit of contrition, maybe even gratitude at having been bailed out. What we got instead was “Obama rage,” fury at the 44th president for even suggesting that Wall Street might have been partly to blame for the disaster.

These days there has been a lot of discussion of the hard right turn of some tech billionaires, from Elon Musk on down. I’d argue that we shouldn’t overthink it, and we especially shouldn’t try to say that this is somehow the fault of politically correct liberals. Basically it comes down to the pettiness of plutocrats who used to bask in public approval and are now discovering that all the money in the world can’t buy you love.

 

“Can’t Buy Me Love” was an early (1964) hit of the Beatles. The best lines were:

 

I’ll buy you a diamond ring my friend if it makes you feel alright

I’ll get you anything my friend if it makes you feel alright

‘Cause I don’t care too much for money

But money can’t buy me love

 

If both Krugman and the Beatles agree, there must be some truth in the fact that money doesn’t buy love. At times money breeds resentment and resentment breeds anger. It is a sign of the times that the rich are now among the angry. Ergo, we have angry billionaires who have conned a lot of people into thinking they can fix what they claim is wrong about our government. We are back to the Trump cabinet of billionaires. Paul finds hope in the moment that is derivative of the flaw that has brought all of this misery down on us. He seems to be suggesting that our society has something like an immune system that will eventually save us from a deadly infection. 

 

So is there a way out of the grim place we’re in? What I believe is that while resentment can put bad people in power, in the long run it can’t keep them there. At some point the public will realize that most politicians railing against elites actually are elites in every sense that matters and start to hold them accountable for their failure to deliver on their promises. And at that point the public may be willing to listen to people who don’t try to argue from authority, don’t make false promises, but do try to tell the truth as best they can.

We may never recover the kind of faith in our leaders — belief that people in power generally tell the truth and know what they’re doing — that we used to have. Nor should we. But if we stand up to the kakistocracy — rule by the worst — that’s emerging as we speak, we may eventually find our way back to a better world.

 

And with those strange words of hope he is done!  Once again he has educated me. I have a new word in my vocabulary–kakistocracy. I will miss his insights. He may be taking a break from The NY Times, but a man who has written 27 books and over 200 scholarly articles, plus hundreds of very readable and insightful columns for folks like me, can’t just be done and gone.

 

Weird Weather Leaves Me With Hope For Snow Covered Holidays

 

The picture in today’s header was taken on Tuesday morning when we were getting yet another dump of snow. If it looks familiar, it is because in the past I have used other pictures taken from the same place, inside the slider between my living room and my deck. There are many winter days when walking to the slider to look out onto the lake is the extent of my travels.

 

Wednesday brought lots of rain and temperatures that inched toward the mid-forties before the temps plunged again to leave deadly ice on our roads and walks. Yesterday, was precipitation-free but very cold. Today we are looking for a high in the low twenties with no precipitation. We will not top 32 degrees until Monday when it may snow again. Our weather is up and down, but we still have almost a foot of snow. 

 

If you are a skier, the weekend looks good. My crutches look a little like ski poles, and as is true for skiers, ice can be a problem for me. I guess that I will spend the weekend in front of my fireplace or helping my wife decorate the house for the Holidays. 

 

I hope that you have a great weekend. I suggest talking about the weather and avoiding political discussions if you go to a holiday party,

Be well.

Gene