29 November 2019
Dear Interested Readers,
Have You Heard Enough In The Democratic Debates About Healthcare?
It’s been a little more than a week since most of the Democratic contenders for the nomination for president gathered in Atlanta for their fifth debate. This was a very different debate from the first four. In the interim, since the last debate, the big news story had been the hearings before the House Intelligence Committee that is chaired by Representative Adam Schiff. Past debates had emphasized the candidates’ opinions over the pros and cons of “Medicare For All” as originally pushed by Bernie Sanders and endorsed by Elizabeth Warren.
There is a deep divide between the candidates from the progressive wing of the party and the more moderate and traditional liberals. The drama and tension from the previous two debates had been centered on Senator Warren’s refusal to state that Medicare For All would result in a tax increase for the middle class. Pete Buttigieg and Amy Klobuchar had led the attack on Senator Warren and her plan. Even Stephen Colbert could not get Warren to answer the question as to whether or not she would need to raise taxes on middle class families to pay for her program. Following those attacks, in the interim since the last debate, Senator Warren had made two strategic moves. First, she had produced a finance plan that she developed with help from respected experts. As reported by Ezra Klein in Vox.
Warren’s financing plan has two parts. The first describes her approach to estimating the costs of Medicare-for-all. The second lays out the way she pays for the plan without, in her words, “one penny” of middle-class tax increases.
As befits Warren’s wonkish, master-of-plans persona, she’s relied in both cases on top experts. Her cost estimate was conducted by Don Berwick, the former director of the Centers for Medicare and Medicaid Services; and Simon Johnson, the former chief economist at the World Bank. Her tax plan was developed by Betsey Stevenson, who served as chief economist at the Labor Department; Mark Zandi, the head economist at Moody’s Analytics; and Johnson. Helpfully, her plan is backed up by two detailed appendices laying bare, and arguing for, the assumptions Warren makes.
As one might expect, her announcement elicited immediate responses from other Democratic contenders and critics of Medicare For All. There were arguments about her cost estimates over ten years which were about one third lower than numbers other people were offering. Berwick and her other experts estimated the cost would be an additional twenty billion while Joe Bidden and others argued that it would be in excess of an extra $30 billion.
Her second move came about two weeks later In mid November. Unfortunately, she announced it just as the impeachment process was heating up, I was surprised to learn that Senator Warren had made another bold move, and wondered whether many people, other than her opponents, had noticed. She announced how she would manage healthcare in the first 100 days or her presidency, and then how the process would eventually lead to Medicare For All. In the New York Times article connected to the link above, Abby Goodnough, Thomas Kaplan, and Margot Sanger-Katz wrote:
The initial bill she would seek to pass if elected would be a step short of the broader Medicare for all plan she has championed. But it would substantially expand the reach and generosity of public health insurance, creating a government plan that would offer free coverage to all American children and people earning less than double the federal poverty rate, or about $50,000 for a family of four, and that could be purchased by other Americans who want it…
Senator Warren explained that she would seek the second phase of her plan, the movement to Medicare for all, in about the third year of her presidency, after there had been experience with the expanded Medicare that covered lower income citizens.
Goodnough, Kaplan, and Sanger-Katz quote Senator Warren:
“I believe the next president must do everything she can within one presidential term to complete the transition to Medicare for all,” Ms. Warren, of Massachusetts, wrote in her plan. “My plan will reduce the financial and political power of the insurance companies — as well as their ability to frighten the American people — by implementing reforms immediately and demonstrating at each phase that true Medicare for all coverage is better than their private options. I believe this approach gives us our best chance to succeed.”
A Washington Post report by Paige Winfield Cunningham includes the “Tweets” that Senator Warren broadcasted at the time of the announcement. The last reported “tweet” closes the loop between the plan and the outcome Warren is hoping to produce.
By the end of my third year, I’ll fight to pass legislation to complete the transition to #MedicareForAll. Once millions have experienced the full benefits of a #MedicareforAll option and compared it to the corrupt and wasteful system we have today, the people will demand it.
Cunningham offered her analysis. She used bolded letters to emphasize her point:
Warren was the lone candidate to still support the Sanders plan without any qualifications. But now she’s tacitly acknowledging Medicare-for-all’s political difficulty by proposing that people should be allowed — but not forced — to enroll in government health insurance as a first step toward universal health coverage.
Much of this drama, Senator Warren’s announcement of her finance plan plus her explicit statement about how she would attempt to navigate from where we are to the public’s embrace of Medicare For All as the best way forward, and the pushback from other candidates and pundits who disagree with her approach, was lost when the attention of the public was focused on the impeachment hearings. I had been critical of the way healthcare issues had been managed in the first four debates. I was eager to hear what the other candidates on stage at the Atlanta debate would have to say about about Senator Warren’s strategic moves.
Apparently not many people shared my curiosity about the debate. The LA Times reported that the fifth debate attracted only 6.6 million viewers. The second debate in June was watched by more than 18 million people. It’s hard to know if the audience fall off was the result of viewing fatigue from the day long impeachment hearings, or if the count was down because the public is getting tired of the monthly joust between Democratic presidential wannabes. Stephen Battaglio, the author of the article writes:
“It was a substantive debate, but it was, in every way, a sideshow to the existential presidential drama unfolding in Washington even as the candidates were arriving to debate,” said Mark Lukasiewicz, dean of the Lawrence Herbert School of Communication at Hofstra University. “I imagine there were many viewers exhausted from tracking the impeachment hearings.”
But the number also raises the question about voter enthusiasm for the Democratic field, especially one that still has a number of low-polling candidates on a crowded stage.
The fifth debate did not begin as the other debates did. The first question was not about healthcare. It was about impeachment. After impeachment, perhaps the most defining change in the period between the October and November debates was the emergence of Pete Buttigieg as the leader in the Iowa polls. The prediction of the political analysts was that Mayor Pete would spend the evening on defense as the other candidates sought to bring him down a notch.[This last link is to a terrific twenty minute podcast report on the debate with about half of it focused on Buttigieg. I think that it is worth your time.]
If you listened to the Atlanta debate, you know that healthcare did not get its usual attention. What was said about healthcare was adequately reported in an article by Shannon Firth in MedPage Today.
Healthcare came up again during the fifth Democratic primary debate on Wednesday night, with discussions of healthcare reform, abortion, and marijuana legalization…
Warren spent a good part of her time detailing her “Medicare for All” plan.
“On day one as president,” she said, she would immediately cut costs for drugs “like insulin and EpiPen. That’s going to save tens of millions, hundreds of millions of dollars for people…. And in the first 100 days I’m going to bring in 135 million people in Medicare for All at no cost to them.”
Anyone under 18 and any family of four with an income under $50,000 could access these plans, Warren said. She would also drop the age of eligibility for Medicare to 50 and add dental, vision and long-term care benefits.
“And then in the third year, when people have had a chance to feel it and taste it and live with it, we’re going to vote” on extending coverage to everyone, eliminating private insurance.
Buttigieg countered with his Medicare For All Who Want It plan that does not include the immediate or eventual termination of all employer funded commercial plans which the politicians who are more moderate than Sanders and Warren fear would drive away potential Democratic voters to the advantage of President Trump. Ms. Firth wrote:
Buttigieg said his version of healthcare reform would be available as an option “without the divisive step of ordering people onto it whether they want to or not.”
“Commanding people to accept that option, whether we wait three years as Senator Warren has proposed or whether you do it right out of the gate, is not the right approach to unify the American people.”
Bernie Sanders was not going to be left out of the conversation. Again quoting from Ms. Firth’s article:
Asked whether it was necessary to “tear down” the healthcare system to improve it, Sanders said it was not but “we do have to do what the American people want.”
Sanders noted that Americans have been talking about “healthcare for all” since the time of John F. Kennedy and Harry Truman. “You know what, I think now is the time,” he said. “And in the first week of my administration, we will introduce Medicare for All, [which] means no deductibles, no copayments, no out-of-pocket expenses.”
Senator Sanders may be the most consistent politician of the last thirty five years. He has been preaching the same progressive sermon with essentially no wobble since the early eighties. Joe Bidden has been in the conversation even longer and has been forced by the persistence and popularity of Bernie to move left from his more comfortable position in the center. His strategy is to continue to emphasize his connection to President Obama and incremental changes that would move us toward universal coverage without the disruption that would be required to implement Medicare for all. Ms. Firth reported his comments and concerns:
But Biden rejected the notion that Democrats want Medicare for All and its $30- to $40-trillion price tag.
“It couldn’t pass the United States Senate right now with Democrats. It couldn’t pass the House.”
His own strategy would be to build on Obamacare and not force people to give up their private health plans. Those who want to could buy into a “Medicare-like proposal,” he said.
But he stressed, “they get to choose.”
After those those comments, the debate turned to the specific issues of abortion rights and the legalization of marijuana. It was a very different evening than the previous four events. I think that I am OK with the idea that there should be even less discussion of Medicare For All versus Medicare For All Who Want It versus ACA 2.0 at the next debate which will be in Los Angeles on December 12. So far only Bernie, Joe, Elizabeth, Pete, Amy, and Kamala have qualified to be on the stage.
My concern for some time has been that the debates demonstrate one big effort to “jump to solution.” Democrats captured the House in 2018 and made great progress in blocking the damage being done to healthcare by the Trump administration and Republicans in Congress. Now Democrats seem convinced that in 2020 they must sell the public on the complete answer to what comes next when they should be emphasizing why we need to be continuing to move as quickly as possible in our efforts to insure that we make sustainable progress toward a better system of care for everyone. I understand that politicians are not senseis who are capable of leading us in a process of continuous improvement. They may well be right about where our programs should be heading and feel that they know enough to try to sell “if we x, then y will happen,” but voters lack a deep understanding of the issues that are barriers to the Triple Aim. In deed, for the large majority of us the issues have nothing to do with the health of our neighbors. We are concerned about our access, about how easy the system is for us to use, what our out of pocket expenses will be, why we pay more for medications than Canadians do for our meds, and what is the risk that if things change our family will lose what we now enjoy. I fear that we are more focused on how things will work for us as individuals than how our community will be impacted.
We joke about the epiphany that President Trump had in February 2017 when he said, “Nobody knew that healthcare could be so complicated.” Ironically, it was perhaps the most factual statement of his presidency. When I am in conversations with family and friends I discover that the complexity of healthcare is a real barrier to its improvement. I think that Elizabeth Rosenthal’s book An American Sickness: How Healthcare Became Big Business and How You Can Take It Back and Robert Pearl’s “Mistreated: Why We Think We’re Getting Good Healthcare (And Why We’re Usually Wrong)” are two books that reveal most of what every voter and recipient of healthcare should know, but how many people will read one of them? I could facetiously suggest that we go back to a sixties like “teach in,” but that is not going to happen.
What could happen would be the development of questions for the remaining debates that are designed to seek knowledge of the candidates’ understanding of the problems. Questions that would enable us to understand whether they were committed to the effort and had the understanding of the barriers to better care for each of us. Which one of them understands with the clarity and empathy that is necessary for solutions that will work what really hinders our efforts to have healthier communities, and diminishes efforts to move toward sustainable medical expenses for everyone of us individually, and as one nation? And if one or more of them does have deep understanding, can they explain the realities in a way that voters can understand the wisdom in their solutions? I think they are trying to do that now, but so far they are working backward from solutions that will be hard to initiate without voters having a deeper knowledge of the “whys,” and they may be losing their audience.
I was on a long walk with a friend this week who is a diligent student of public policy. I frequently get emails from him that contain links to timely articles. Both of us have reached the age where we frequently hear of a friend being given a life changing and ominous diagnosis. We think a lot along the lines of “When will it happen to me?” That is not the same question as, “Will something like that happen to me?” He asked me about how doctors use the current care system. His questions seemed to suggest that he felt that his best personal defense was “to have connections.” I understood the practical advantage of what he was implying, and confessed that I still occasionally try to help a friend by calling up an old colleague and asking for a favor, even though I no longer have anything to offer as a “quid pro quo.” He had no idea just how unsafe and rife with waste our system of care is. Finally, he gave little evidence of an appreciation of how much the cost of our care system impacted our collective ability to address other important social issues, or how we were vulnerable to future shortages of physicians and nurses.
The whole conversation with my friend was depressing because it emphasized several points that the debates are ignoring and that many voters do not appreciate:
- There is widespread misunderstanding about how our system of care actually works. The majority of Americans are well and the few personal experiences that they have with the system do not require them to think much about the complexities that exist. The minority of voters who are forced by an event to seek care lack awareness about how the individual inconveniences and complexities they encounter add cost and avoidable errors and inconvenience in their care and are multiplied across the whole system. My friend mentioned a common acquaintance who recently had a total knee replacement. There was an infection that required removal of the hardware and a lengthy period of time when he had “no knee” and was on “high powered” antibiotics. His repeat knee replacement was further delayed when he had a myocardial infarction and required bypass surgery. My friend was astonished to know that medical errors and defects in care like our friend experienced are the third leading cause of mortality and that each day there are enough deaths across the country from medical errors to fill a 747 airplane. I asked him what he thought the public’s response would be if a commercial airliner crashed everyday. As our conversation continued, I realized that he knows much more about healthcare than the average person, but what he knows is still not enough for him to render a personal opinion with certainty about who should lead us, or the optimal way forward.
- There is not much recognition that if the system doesn’t work for everyone, including the disadvantaged, it is quite possible that the day will come when it doesn’t work reliably for anyone, no matter how advantaged they might be. That day may already be here for you if you live in rural America or a disadvantaged neighborhood in one of our cities.
- The status quo, the so called medical-industrial complex, is producing huge profits. Bernie Sanders is speaking to the profits of the drug industry and insurance companies, but other supporting industries from high tech suppliers to specialty groups, and many academic medical centers, are prospering in the current environment and see little short term benefit in having their businesses disrupted by a change in finance. It is highly likely that the charges paid by government sources will not completely replace the largess of commercial payers.
- There is a continuing distrust of the government’s reliability and fear that a government payment system will add constraints to business plans and force recipients to meet standards of transparency and performance that will be onerous.
- Many providers are so stressed that they have little time and no motivation to speak up for the necessity of changes that might turn out to require more of them than they have the energy or desire to invest. Adaptive change is hard. No one is eager to submit to it.
The potential list of barriers to any change is much longer. I do not think the Democrats are wrong to be fearful of enabling the president’s reelection by their continuing disharmony, attempts at one upmanship, and lack of an inspiring centrist leader. Would it not be better to focus on the need for change and why the discussion should begin with a more analytical and informative description of “what is” and the projections from reliable sources of the chaos that will occur if we continue to focus primarily on our individual concerns without much empathy and concern for the experience of others? They will be back at it in LA in less than two weeks, it will be interesting to see if the conversation changes.
Delighted By Unexpected Beauty
You might have noticed that I enjoy sharing pictures of my corner of New Hampshire with you. I’ve been a full time resident of New London for over five years, and a part time resident of the area for nearly a quarter century. There are many things that draw me to the area, and many other things that keep me here that I never knew existed before I came. I am delighted by the cycle of the seasons from year to year. It snows and the lake freezes in the winter, but some winters we get twenty inches and other years it’s six feet. Spring follows the Red Sox opening day by variable periods of up to a month. Summer is always glorious, but the fishing varies in ways I can’t understand. Fall is always spectacular, but some exceed expectations for a week or two and then fade fast. What I enjoy most is that just when I think that I have seen it all, I am suddenly surprised to discover a new and beautiful surprise within something that I thought I completely understood.
The delight in discovery of something new within a world that we thought that we completely understood is at the heart of both art and science. Antony van Leeuwenhoek was a cloth merchant who was playing around with lenses to get a closer look at fabrics when he discovered bacteria. We continue to look deeper and deeper into the night sky looking at what we have always seen, but expecting to see something we have never seen before. The Beatles and Hank Williams worked with the same 12 note scale that Mozart, Beethoven, and Bach used. Over the last century those notes have created jazz, blues, rock, and maybe hip hop. Musicians continue to put those same twelve notes together with new rhythms in surprising ways, so it should not be a surprise to me that I might see something completely new in something that is very familiar.
Often the new discovery has been facilitated by the creation of a new tool. New tools are often the vector of new incite or an expanded experience. Mozart played the harpsichord. Duke Ellington had the advantage of a piano. Jimmy Rogers strummed an acoustic guitar. Buddy Holly and Jimi Hendrix played Fender Guitars, solid body electric devices.
The device that has revealed more new perspectives on our local beauty in the old familiar seasons and sights in my neighborhood has been my neighbor’s drone. I was first “captured” by the potential of his drone a few springs ago when he used it to reveal from above what was happening while the ice on the lake melted. He posted a clip of a sheet of ice being cut by one of the buoys on the lake that marks an area of rocks. The wind was moving the surface sheet of ice against the buoy like someone pushing a piece of lumber through the blade of a table saw. Shards of ice were being tossed to either side of the buoy like big pieces of sawdust. A drone was the only way that picture could have been taken.
Since that dramatic introduction to the beauty of my neighbor’s drone photography, I have used numerous “screen shots” from his videos as “headers” for these notes. He has a skill that I envy for capturing the beauty that we often overlook. I use his pictures in an attempt to share with you what is going on in my world. What is going on in the natural world around me now is the emergence of winter. The sun went down at 4:12 yesterday, and it will set at 4:12 today. Before Christmas, it will be dark before 4 PM, and the sun will come after 7 AM. That is a constant that we can count on every year. What varies is when we get snow, how warm or cold it is, and when the lake freezes.
Before this year I did not pay much attention to how the lake freezes. Sure, I knew that the shallow areas along the shore froze first. The coves froze sooner than the open water areas. What I had not noticed was that it is a one step forward, two steps back, and three steps forward process. Last week’s header showed the lake almost completely frozen on the surface. This week we had nights in the twenties and low thirties, and one day in the low fifties. The lake has appeared frozen in the early morning and has choppy waves in the afternoon. It’s an oscillating and dynamic process. Last year my neighbor recorded this freeze, thaw, freeze oscillation of the surface with his drone. Up till now it is a perspective that only our eagles and other birds that circle high above could enjoy. Today’s header reveals a spectacular new perspective on something I thought I understood ,but has not really seen. The drone has enabled a new perspective on something that I was taking for granted. If you would like to see the whole video from which today’s header is lifted, click here. The piece is entitled “Winter Chapter I; First Ice.”
On this Thanksgiving weekend I add the joy of continuing discovery to the long list of things that I have taken for granted which deserve greater appreciation and gratitude. I think our greatest gifts are buried in the ordinary events and experiences of life. A great gift deserving great thankfulness is the ability to be out and about in nature just looking for surprises that delight.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
