As the “talking heads” who analyzed the President’s speech and Governor Beshear’s Democratic party response were fading into the 11 o’clock news, Verizon offered an advertisement that contained as much or more wisdom than anything that I had heard over the previous two hours.


    Why promise something that you can not deliver? (Verizon Ad)


The President seems intent on the delivery of everything that he promised during his campaign. His problem is that he finds himself in very complicated position. He has made “populist promises” to his “base.”His party’s leadership and its congressional majority are not “populist” by nature.


His base is made up of poorly educated white men and women who live in the “fly over” states, the rust belt, the “heartland”, the Bible belt, and rural America. He won with a coalition of standard issue Republicans and these less traditional Republican voters who suffer from income inequilty. They lost out to the globalization and mechanization of manufacturing and trade, and the movement away from fossil fuels.


He has a problem. His populist promises will cost a lot of money. Many of his suggestions run counter to the long established political philosophies of the stalwarts of the Republican establishment. The two areas that are most problematic for him in the tension between his promises and the views of many Republicans in Congress are healthcare and his proposed trillion dollar investment in infrastructure.


Trump’s promises are superficially reminiscent of the vision of a progressive Democrat. Despite President Trump’s words, and the fact that everyone commented on how much he “exceeded expectations”, I was left feeling as if someone was trying to sell me a bridge. Forty five minutes into his presentation of promises and accomplishments, he finally got to “repeal and replace.” In less than 48 hours he had migrated from expressing with amazement how complex healthcare was to having a brilliant solution to a problem that had flummoxed every president since FDR.


How should we interpret what he said? Here are his words interspersed with my comments.


Tonight I am also calling on this Congress to repeal and replace Obamacare —



  — with reforms that expand choice, increase access, lower costs, and at the same time, provide better     healthcare.


Wow! That sounds great. With seven years of objection to the ACA let’s hope that the Republicans in Congress are ready to work with President Trump to deliver on this promise. Most people who have benefited from the ACA are beginning to be worried that they will lose what they have come to depend upon. The applause came in like rolling thunder as the President continued.


Mandating every American to buy government-approved health insurance was never the right solution for our country.The way to make health insurance available to everyone is to lower the cost of health insurance, and that is what we are going to do.


The President and almost every politician believes that the problem is the cost of health insurance when it is really the cost of care that is elevated by waste, greed and inefficiency. Consumers complain about the cost of their insurance, and politicians recognize the self serving political benefit of inferring a causal relationship between insurance costs and the ACA. The real causes of the high cost of health insurance are a complex set of issues that predate the ACA. The requirements for preventive quality care, and the guarantee of insurability may cause small increases in cost, but the long term impact of better coverage is better health and lower overall cost. The ACA  was a start at addressing the root causes of the expense of healthcare and by extension health insurance.  


The response of most people to “Nobody knew that healthcare could be so complicated” was, “Speak for yourself Mr. President. A lot of people knew that healthcare was complicated. Not only is the President surprised by how complicated healthcare is, it is obvious that he is oblivious to the decades of effort and the resulting understanding that we have gained over the last sixty years from experience and analysis.


The President continues:


Obamacare premiums nationwide have increased by double and triple digits. As an example, Arizona went up 116% last year alone. Governor Matt Bevin of Kentucky just said Obamacare is failing in his state. The state of Kentucky, and it is unsustainable and collapsing.


The President is lifting extreme examples and expanding them as the experience of all states. New Hampshire has had a very positive experience since the passage of the ACA. We have reduced the uninsured from 11% to 5% and reduced the cost of care.


As terrific as the results of the ACA in New Hampshire, and as high as the cost of care is in other states, it would be wrong to assign a causal relationship for either outcome to the ACA alone or to expect that the cost of care will go down by repealing the ACA.


The President continues:


One third of counties have only one insurer, and they are losing them fast. They are losing them so fast, they are leaving, and many Americans have no choice at all. There is no choice left. Remember, when you were told that you could keep your doctor and keep your plan? We now know that all of those promises have been totally broken. Obamacare is collapsing, and we must act decisively to protect all Americans. Action is not a choice. It is a necessity. So I am calling on all Democrats and Republicans in Congress to work with us to save Americans from this imploding Obamacare disaster.


The President is wrong when he says that Obamacare is collapsing or imploding. Again, the cost of care is high because of the waste, poorly organized processes of care, and perhaps the business practices of institutions and suppliers including insurance companies and big pharma. The ACA has suffered as much from the continuous political attack from Republicans as from its own inherent design flaws. Much of the ACA was designed to offer pathways of improvement for the real issues. We do have a problem and the ACA needs to be improved, but he is setting us up for a “fake solution” driven by a political agenda, and not by a search for a workable solution.


He continues:

Here are the principles that should guide Congress as we move to create a better healthcare system for all Americans. First, we should ensure that Americans with pre-existing conditions have access to coverage, and that we have a stable transition for Americans currently enrolled in the health care exchanges.

That sounds terrific. He never says how it will happen or how this “assurance” will be financed. The big deception is the phrase “ensure that Americans with pre-existing conditions have access to coverage.” Having access to coverage is quite different than saying that you can not be denied coverage or charged more because of a preexisting condition. If you get into the weeds of Ryan’s proposal that is now being leaked as “the bill”, you will discover that the “guarantee of the right to  purchase” is lost if coverage is interrupted by an inability to pay.


Secondly, we should help Americans purchase their own coverage, through the use of tax credits and expanded health savings accounts, but it must be the plan they want, not the plan forced on them by our government.


The sneak preview of these tax credits or payments suggests that the amount will be woefully less than the true cost of coverage and much less than the subsidies of the ACA. The “plan they want” may be a cheaper, lower quality plan, minus the “demands” and benefits of the ACA, that they can afford with the reduced subsidy.


Thirdly, we should give our state governors the resources and flexibility they need with Medicaid to make sure no one is left out.


Republican governors are pushing back on this one. The amounts proposed are reported to be a fraction of what is needed if Medicaid is shifted to “block grants.”


Fourth, we should implement legal reforms that protect patients and doctors from unnecessary costs that drive up the price of insurance and work to bring down the artificially high price of drugs and bring them down immediately.

Tort reform has always been a debatable and diversionary tactic in the discussion of the cost of healthcare. Controlling the costs of drugs is a challenge. Neither Trump nor the Republicans have proposed programs that achieve what he says is necessary.


And finally, the time has come to give Americans the freedom to purchase health insurance across state lines. Which will create a truly competitive national marketplace that will bring cost way down and provide far better care. So important. Everything that is broken in our country can be fixed. Every problem can be solved. And every hurting family can find healing and hope. Our citizens deserve this and so much more. So why not join forces and finally get the job done and get it done right?


I know of no knowledgeable authority who believes that selling healthcare across state lines is practical or will change anything. The idea is a diversionary “faux” solution, a favorite of Republican theorists for years. It has been debunked time and again, failing on the few occasions it has been tried.


My administration wants to work with members of both parties to make child care accessible and affordable, to help ensure new parents — that they have paid family leave.


Lots of luck on that one before there is a Democratic majority in both houses of Congress!


To invest in women’s health, and to promote clean air and clean water, and to rebuild our military and our infrastructure.


The President will need to call off the harassment of Planned Parenthood by many in Congress to make good on women’s health. He has already shot in the foot any opportunity to promote clean air and clean water with a few of his Cabinet appointments.


On this and so many other things, Democrats and Republicans should get together and unite for the good of our country and for the good of the American people.


A simple five point solution for a domestic issue that affects every American’s insurability and access to preventative care despite their previous medical history and the infrastructure of care in their community is a pretty grand plan and should be examined closely with a skeptic’s eye.


In this week’s New Yorker Atul Gawande gives us an incredibly succinct snapshot of the moment in “Trumpcare vs. Obamacare.” He reviews all of the issues between Trump’s promises and the governing philosophy of the majority of Republicans in Congress. He reminds us that the central issue for Republicans is taxes. The desire to reduce entitlement spending is incompatible with universal care even though access to better care enabled by tax money could reduce the total cost of care as it improves the quality of life.


The ACA is the easily blamable “scapegoat” that allows us to overlook or hide from the real issues that increase the cost of care. The sad reality is that those who have so little to support them, and have so much to lose, will be the victims of the President’s simple five points that are no solution. Most economists believe that at least twenty million people will lose their recently gained access to care. I believe we will see fewer people covered. Those who retain coverage through their employer or through whatever is left of Medicare may be paying even more than they are paying now. If Congress passes the bill that was leaked last week and is a nice match to the President’s five points, we will have lost all that has been gained since 2010 in our effort to achieve:


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.