March 6, 2020
Dear Interested Reader,
What’s Next ?
February was a terrible month. Not only were we dazed and confused by the explosion of the coronavirus, or if prefer, Covid-19, followed by the collapse of the stock market, but the Red Sox traded Mookie Betts to LA and let Brock Holt get away to Milwaukee after Alex Cora had to resign over the sign stealing scandal. To top off all that misery, we are living on pins and needles waiting for the expected news that Tom Brady is leaving town. One is left wondering, “What’s next?”
Not long ago Bernie Sanders was riding high and it seemed like we had a baker’s dozen or more Democratic wannabes for president. Less than two weeks ago there were seven candidates in the Democratic debate in Charleston a few days before the South Carolina primary. Biden got a huge lift from the endorsement of Congressman James Clyburn and that fact seemed to propel him to a gigantic victory. In rapid fire succession Buttigieg and Klobuchar dropped out and then joined Beto O’Rourke in supporting Biden. Super Tuesday vaulted Biden into the lead and led Steyer, Bloomberg and Warren to announce that they could see no likely path to the nomination. My wife and I keep asking each other, “What’s up with Tulsi Gabbard?”
In the Supreme Court, a 5 to 4 conservative majority that seems to have little respect for previous decisions, “settled law,” or if you prefer stare decisis, has been warming up to repeal the ACA by hearing the case about Louisiana’s ridiculous law requiring abortion providers to have hospital admitting privileges. Whether President Trump wins or not in November, it is possible that by Inauguration Day in January 2021 Roe v. Wade will be history and the court will have declared the ACA unconstitutional. We will have turned the clock back on healthcare reform to some place in the early seventies, or at least reset it to January 2009 when the legislative work that gave us the ACA began.
Our president continues to fight facts with lies, or as he now calls them his “hunches.” He appeared on our “state controlled” media outlet this week to chit chat with his buddy Sean Hannity and to reassure his frighted base with a real “whopper” of a distortion when he contradicted the estimates of the fatality rate from Covid-19 infection put forth by the UN’s WHO, the World Health Organization. To his fauning base he pronounced that Covid-19 was a mild disease, “some people with it might even go to work,” with a mortality rate that is substantially under 1%. I found that latest self serving performance to be one of his most disgusting moves to date. It appears to have been a desperate attempt to mitigate the effect of Covid-19 on the falling financial markets that threaten to wipe out his ability to brag about how his genius has propelled the stock market to unimagined heights.
Ky Ryssdal of NPR’s “MarketPlace” put the impact of Covid-19 on the economy into a very understandable picture when he interviewed the Executive Director Gene Seroka of the Port of Los Angeles on Thursday. Mr. Seroka stated that activity in our largest port was down 15% before the Covid-19 outbreak in China because of the disastrous effects of Trump’s trade policies. Now port activity is down more than 25%. Mr. Seroka described the chain of injury to the economy that has already occurred because of the trade policy and described how the fall in goods coming from China has started an inevitable decline in imports which will affect jobs here, and reduce consumer spending, one of the main sources of growth in our economy.
I feel that the discussion about the future of healthcare in America now seems buried underneath all of the rapid evolution of the Democratic presidential nominating process, the Supreme Court’s relentless efforts to undermine the ACA and Roe v. Wade, the challenges that Covid-19 creates for the health of the nation and the providers of care, concerns about another evolving recession, the confusion in Afghanistan about negotiating with the Taliban, continuing episodes of gun violence with another mass shooting at a Milwaukee brewery, and the continuing bad news from the Red Sox as Chris Sale seems to be far from ready for the season. 2020 is definitely off to a very turbulent start.
As Kipling said in his poem “If,” the challenge is to keep your head when all about you are losing theirs. Underneath all that has happened there may be an opportunity for us to begin to turn things around in what has been a very unproductive discussion in the Democratic debates of the options we have for improving healthcare and moving closer to the Triple Aim because now we will have just two politicians offering their visions for how to move forward in our attempt to improve the experience of care for all Americans. There are real differences that should be considered. Now that it is just Joe and Bernie, we may begin to clarify some realities that have been lost in the cacophony of multiple voices on the debate stage. Who knows? One of them may have the chance to do something once it becomes obvious to a majority of voters in a majority of states that our current administration runs on distortions, threats, and self serving hunches and manipulations of reality that come from an incompetent leader who has no regard for norms or the law.
Let me begin by summarizing Biden’s healthcare plan. Better yet, you can listen to him do it in one minute and seventeen seconds. Bidden wants to build on Obamacare. He is proud of his participation in its passage and the fact that it gave healthcare to twenty million Americans who did not have it, and as he emphasizes in his video, that it freed Americans from the liability of “pre existing conditions.” The former vice president believes that a “public option” is the next logical step in the journey toward universal coverage. “Medicare For All Who Want It” was “Mayor Pete’s” description of the public option. Furthermore, as Biden emphasizes, Obamacare preserves individual choice, and does not abolish the insurance industry.
Ironically, Obamacare was constructed on Republican ideas that dates back to Eisenhower and came into full flower with the passage of “Romneycare” in Massachusetts. In their book, The Heart of Power, Blumenthal and Marone describe the Republican concept offered by Eisenhower as an alternative to a government run health system like the NHS in the UK that was favored by Truman. “Ike” described a “public/private partnership” that blended private purchase of healthcare with government subsidies for the poor and operated through markets. They quote him:
“In health as elsewhere in American life, our summons to greatness calls for a lively partnership of individual effort with action by voluntary agencies and private enterprise, and, where necessary Government action at appropriate levels.”
That is what the ACA is, private effort augmented by Government support for those who need it. The ACA allows those who are able to get it from their employer to do so. Those who are self employed, or do not have employer provided insurance coverage can buy it privately on the “exchange.” Those who are poor with an income that puts them below 138% of the poverty level are allowed to get Medicaid. In the original law, states were supposed to get more federal support for the expanded Medicaid program. Those individuals and families with incomes between 138% and 400% of poverty get subsidies on the exchanges to keep the cost of their purchase at levels they can sustain. Those over 400% of poverty who do not have insurance through an employer can hope that the market as supported by the exchanges will keep healthcare to a cost they can afford.
The original plan was clearly a “market based” plan and it did include a “public option” where the government offered a product side by side with private commercial plans. Joe Lieberman, the independent senator from Connecticut, where many insurance companies have their headquarters, opposed the public option out of the fear that competing with the “public option” would force private insurance companies to drastically cut their prices since the government could offer a very low cost option. The public option seemed like a potential “Trojan Horse” that would defeat private plans through “the market.” The mandate, like the concept of a public/private partnership was originally a Republican idea, and most experts believed it was imperative as a way of supporting risk pools that were large enough to work.
Even if the ACA had included a public option as was originally planned, it was never expected to cover everyone. The original finance analysis included projected income to support its expense from penalties generated by the mandate. There was an expectation that millions of people would choose not to pay for coverage. From the perspective of the Triple Aim, the ACA was progress, but not an achieved objective. Healthcare has always defied the principles of “the market,” so costs have continued to rise. Out of pocket expenses for a family of four can be greater than $10,000, and the cost per family not eligible for subsidies and without employer coverage is over $25,000. Because of the expense and the fact that 14 states have not expanded Medicaid, any millions have not been covered. More people have not been covered than expected when the ACA was passed because many lost the possibility for coverage because their states did not accept the Medicaid expansion after it was ruled to be optional by the Supreme Court. If Biden wants to shore up the ACA, there is a lot of work to do, and he is not being very explicit about that work, or how he will do it.
In his speech, Biden warns that we should not throw away the achievements of the ACA. That is a misleading statement since there is no question that the ACA has been a very positive step forward that has changed attitudes that will persist in any new legislation that focuses on universal coverage and the principles of quality. It has established new norms like the freedom from concerns about preexisting conditions that will be “rolled over” into any new system of care. What works, and what we have learned from the ACA, will surely be included in what comes after the ACA.
On his website Sanders presents the high points of his plan which we all know as Medicare For All. His plan immediately solves the cost problem for individuals, if not for the country. It is resisted by those who either see their practice or hospital forced to live on payments determined by the government, or by insurance companies that would quickly need to transition to providing other services like data management. What is not stressed is that suppliers of devices and drugs would be negotiating with the government like the suppliers to the Defense Department do now. Those industries prosper, and I have no doubt that the medical industrial complex would find a way to remain profitable. The plan makes the government the payer, not the provider of healthcare services. Bernie’s points are directed at the consumer of healthcare. The most important point he makes is that healthcare is a right. Sanders goes further and contends that we need more covered services, and that in a just society everyone is entitled to equity.
Key Points
- Create a Medicare for All, single-payer, national health insurance program to provide everyone in America with comprehensive health care coverage, free at the point of service.
- No networks, no premiums, no deductibles, no copays, no surprise bills.
- Medicare coverage will be expanded and improved to include: include dental, hearing, vision, and home- and community-based long-term care, in-patient and out-patient services, mental health and substance abuse treatment, reproductive and maternity care, prescription drugs, and more.
- Stop the pharmaceutical industry from ripping off the American people by making sure that no one in America pays over $200 a year for the medicine they need by capping what Americans pay for prescription drugs under Medicare for All.
Those are his high points, but there is much more to read. And every assertion is up for debate. The most consistent arguments against the Medicare For All Plans of Sanders and Warren have been that they will raise taxes, kill the private insurance industry, and could never be passed because Medicare For All would unite all of the members of the status quo who have something to lose. Those are scare tactics propagated by a status quo that has a lot to lose.
Progressives believe that the cost of care for the individual can never be adequately lowered by just tweaking the ACA. In essence, they contend that our current system of finance is flawed beyond repair and drives the operations of a dysfunctional system that ignores the needs of tens of millions of people. I believe that most of the people who are attracted to “Medicare For All” have given up the hope that commercial coverage can ever work for them. Sanders frequently reminds us that fewer people get less for more in our system compared to the rest of the developed world. Sanders offers a finance concept that few accept. Basically, he says that all money is fungible. Sanders admits that under his plan taxes will go up for middle class families, but contends that their healthcare expenses will go down more than their taxes will go up, and in the balance they will be better off. Do people not understand, or do they understand and not believe his assertion to be true? He adds that not only will people have more money in their pockets, but the range of provided services will be greater. Overlooked by many is that long term care will also be provided.
Bernie has a point about getting a better product for less. As out of pocket costs rise, more and more people are not getting the care that they are “covered to get.” An emerging problem in healthcare that may be larger than 30 million people having no coverage is that 80 million or more people can’t afford to use the coverage that they have. Sanders’ Medicare for all fixes this problem. I have not heard Biden explain how he would address the fear of expense preventing covered people from getting care in his less expensive and revamped ACA.
Is our choice between a plan that delivers results that are not quite what we really want and one that is unlikely to be passed? Maybe at the next debate on March 11 in Phoenix, Biden and Sanders will debate the finer points of their various plans. Our challenge is to integrate what is best for the health of the nation with a strategy that removes the ongoing threat to healthcare from the current administration. Is the focus on providing the best healthcare tantamount to assuring Trump’s reelection? Like the potential of the coronavirus pandemic on the economy, the disasters of Trump’s four years in office on the future of healthcare and the fight to improve the social determinants of health will be with us for a long time as his impact persists in the court system where opponents of progress will surely continue to try to protect their current advantages and self serving world views. Perhaps as we go forward, we should make it simple as Elizabeth Warren suggested in her last speech earlier this week in Detroit:
Cast a vote that will make you proud. Cast a vote from your heart. And vote for the person that you think will make the best president of the United States of America.
That was easy for me to do in the now distant past of the New Hampshire primary. Who knows what lies ahead for us all?
Discovering Overlooked Beauty Near Me As The Seasons Change
The world is in transition. It’s been an unusual winter, but despite the occasional rain and a few unseasonably warm days we have had a blanket of snow all winter. I admit that compared to many previous winters our blanket of snow this winter has been more like a bedspread than a thick down comforter. This week things have thinned further to a light sheet with many holes. My guess is that even though it drops below freezing at night, almost all of our snow will be gone by this time next week. Over at Mount Sunapee they are moving into “spring skiing.”
My neighbor who loves to take beautiful drone videos of our area from above has put out a late winter masterpiece, which he has named “1Clip Wonder – Clark Creek.” Since it’s only about four minutes long, I hope that you will click on the link and ride it like a magic carpet into a few minutes of relaxation. I grabbed the best scene and turned it into today’s header.
Our little town lies between the east end of Lake Sunapee which is about ten miles long with Mount Sunapee on the west end, and Mount Kearsarge to the South. Within the town there are two smaller, but gorgeous, lakes that are like bookends on the north and south sides of town. I live on Little Lake Sunapee, the lake that is on the north end of town. Pleasant Lake lies between the town and Mount Kearsarge to the south. Throughout our region there are many brooks, creeks, and small rivers. Main Street runs down a high ridge. Water falling on my side of Main Street drains into my lake, and then flows on to Lake Sunapee and the Connecticut River which is thirty miles to the west. Water falling on the other side of Main Street flows into Pleasant Lake and other ponds that eventually flow to the Merrimack River that runs through Concord and Manchester.
The town is really a series of ridges and valleys and in the low spots are its wetlands with brooks, creeks, ponds, and lakes. There are two small ponds, Messer Pond and Clark Pond, near me that flow toward the Merrimack. They are named for families that date back to the founding of the town in the 1770s. By 1779 there were sixteen families living here, and that year they held their first town meeting. The town meeting tradition continues with the 2020 version occurring next Wednesday.
Messer Pond is a beautiful shallow pond that is full of bass and surrounded by comfortable homes. There is a little brook that drains out of Meeser Pond and runs for less than half a mile into the smaller Clark Pond. The land between the two ponds is in conservation and there are several beautiful trails between the ponds. The drone video follows the brook between the ponds. As you look down the length of the pond you see Mount Kearsarge to the south. The scene suggests the transition between winter and early spring. The snow over the dried grass from last summer is getting thin. The creek is running smoothly into the pond which is still frozen.
I am trying to hang onto winter, so I hope to hike the trails between Messer Pond and Clark Pond this week before all the snow is gone. The area is a new discovery for me even though I’ve been within two miles of it for more than ten years. I am sure that I will go back in the spring, summer, and fall just to see its beauty in every season. Is there any unfamiliar beauty near you?
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
