Readers of these postings are familiar with my use of the term VUCA, an acronym that is derived from the realization that we live in a world that is volatile, uncertain, complex and ambiguous. I have asserted before that our state of uncertainty about the future of healthcare in the era of repeal and replace complies with the spirit of VUCA. VUCA is a strategic concept. Since the term was introduced to strategic thinkers in the mid nineties literature has evolved to move the concept from a convenient excuse for failure to a set of principles that can help us figure out how to proceed in difficult times. I have been asking myself about my personal strategy for and the guiding principles that we all should follow.


If you clicked on the last link you discovered a two by two analysis. The authors suggest that strategy deployment is enhanced in a VUCA world if you analyze the moment in the context of how well you can predict the results of your actions against the question of how much you know about the situation.  If you have an interest in learning more, let me offer you a five minute video to view which you may find instructive.


As I apply this analysis to the impending Trump administration’s plans for healthcare, it is clear that I have little ability to predict the results of my actions such as writing to you about my concerns. I do have more confidence when it comes to my knowledge of healthcare policy and the feasible options in the repeal and replace process. Unfortunately some of the things I know add more ambiguity to the moment. For instance I am pretty sure that neither the President Elect nor his candidate for Secretary of HHS, Rep. Dr. Tom Price, has a plausible and viable alternative plan ready at this time that will allow him to lead a process where repeal and replace will occur on the same day and certainly not on the same hour as he suggested that he could do in his recent raucous press conference or as he continues to promise “insurance for everybody.” I also know for sure that the repeal process has begun and that Mitch McConnell, the Senate majority leader, is trying to imply that the work is as urgent as a Code Blue in the emergency room of your local hospital.


The President Elect will soon be inaugurated and I sense that Paul Ryan and Mitch McConnell are working hard to have something for him to sign almost the moment he takes his hand off of the Bible. That knowledge is more than enough to severely depress me and leads me to conclude, after looking at the analysis, that the best strategy for me to follow is to continue to gather information, and to be vocal as I try to adopt the stance of a member of the “loyal opposition”. The claims that Mr. Trump made at his recent press conference, the first in over six months, are either another example of empty bragging, or the healthcare equivalent of cold fusion, an impossible to explain miracle.


I continue to be amazed by the behavior of our President Elect. Whether it be late night tweets denigrating news media, attacks on individuals of moral substance like Representative John Lewis or tirades against the press,  there is always a sense of surprise. I keep shaking my head as I go back and forth between wondering if this is a bad dream and asking whether or not we have seen the worst of it. My guess is that there will be more surprises as we live through the next four years. That apprehension was recently fueled by a totally unexpected one degree of separation encounter across thirty years with the President elect. Let me tell you a story.


Recently on Monday afternoons I have volunteered in an after school program for fourth, fifth and sixth graders in Newport, New Hampshire. Being present in the program has been a meaningful experience for me. I am also enjoying getting to know some of the other volunteers in the program. I was surprised to learn in casual conversation that one of the couples had “met” Donald Trump. What follows is a story that my new friends told me and gave me permission to tell to you.


My friends attended the US Open Tennis matches in Flushing Meadows on a very hot August day in the late 80s. They were lucky to get tickets, even though they were sitting in the “nose bleed” seats. Between matches they headed down under the stands for some refreshment. My new woman friend decided to get a strawberry ice cream cone and was standing with her husband busily licking it, trying to stay ahead of its melt in the heat, when she noticed a man approaching. He was very well dressed and was coming out of the exclusive court side seating area, surrounded by an entourage. To her surprise she suddenly recognized him as the celebrity real estate developer,  Donald Trump. He stopped right in front of her and lifted her strawberry ice cream cone from her hand. Without speaking he  took a big lick right off the top of the cone. He then handed the cone back to her, gave her a big wink, and walked on to wherever he was headed with his entourage in tow. My friend was speechless. In a way that is easy to understand, she felt this man had rudely crossed a boundary.


The story underlines what we saw in the President Elect’s contentious news conference. I hope that he will be able to produce a fabulous, wonderful, tremendous plan that makes us all proud the same hour that the ACA is repealed, but I doubt it. My guess is that there will be a wink, and he will hand us back an ice cream cone that we will not want to finish.


My thoughts on how I would position my emotions and my hopes were stimulated by two outstanding performances that many of us witnessed recently. I was surprised and inspired by the example given to us by Meryl Streep at the Golden Globe Awards. She described a performance that showcased objectionable behavior that was inconsistent with high stations of responsibility without naming the actor. Her presentation was well constructed and delivered with the skill of an Oscar winning actress whose career is unparalleled by any living actor of either gender. The President Elect immediately responded in the social media with the sort of aggressive response that we have come to expect whenever anyone points out a flaw in his behavior or questions his qualifications the presidency.


After hearing Meryl Streep appeal to common decency and then observe her being trashed by the President Elect on Twitter a few hours later, I was eager to hear the President’s farewell address to the nation. I was not disappointed. Our exiting President left the stage with a demonstration of wisdom, presence and grace that we have every reason to expect in the holder of our most significant elected position. His comments added more depth to my concept of becoming an announced member of a “loyal opposition.”


I enjoyed George Packer’s analysis of the speech this week in the New Yorker’s newsletter.


Obama’s farewell address from Chicago last week was one of the very best speeches of his Presidency. He had one overriding message: that American democracy is threatened—by economic inequality, by racial division, and, above all, by the erosion of democratic habits and institutions. Its urgency gave the speech an unusual rhetorical punch: “If you’re tired of arguing with strangers on the Internet, try talking with one of them in real life”; “If every economic issue is framed as a struggle between a hardworking white middle class and an undeserving minority, then workers of all shades are going to be left fighting for scraps while the wealthy withdraw further into their private enclaves”; “We sit back and blame the leaders we elect without examining our own role in electing them.” Lines like these might not prove deathless, but because of their bluntness, and because the times are desperate, they hit hard.


Here are a few of my favorite lines from the 52 minute speech with bolding of the points that lifted me added for emphasis:


So that’s what we mean when we say America is exceptional.  Not that our nation has been flawless from the start, but that we have shown the capacity to change, and make life better for those who follow….


democracy does require a basic sense of solidarity – the idea that for all our outward differences, we are all in this together; that we rise or fall as one…


Healthcare costs are rising at the slowest rate in 50 years.  And if anyone can put together a plan that is demonstrably better than the improvements we’ve made to our healthcare system – that covers as many people at less cost – I will publicly support it…   


George Washington wrote that self-government is the underpinning of our safety, prosperity, and liberty, but “from different causes and from different quarters much pains will be taken…to weaken in your minds the conviction of this truth;” that we should preserve it with “jealous anxiety;” that we should reject “the first dawning of every attempt to alienate any portion of our country from the rest or to enfeeble the sacred ties” that make us one.


It falls to each of us to be those anxious, jealous guardians of our democracy; to embrace the joyous task we’ve been given to continually try to improve this great nation of ours.  Because for all our outward differences, we all share the same proud title:  Citizen.


He was giving us advice about the stance that we should assume whether we are delighted with the new government that President Elect Trump is creating or whether we are frightened as we feel we live in a VUCA world where we are threatened by an uncertain future that threatens the progress of many years. I contemplated the way in which I will think as a member of the loyal opposition:


  • Despite concerns about a “flawed” election, we must have an orderly transition of leadership.


  • We must all exercise more respect for one another and constantly remind ourselves of the mutual benefit of living under the protection of a nation of laws.


  • None of us should give up imagining an even better America. The debate should be about how we way we achieve that goal.


  • Those of us who disagree with the pronouncements of new or different policies should adopt the mindset of a “loyal opposition”.


  • In the healthcare debate we should expect that the replace process will be an opportunity to inject reality.  We should seek to form a responsible bipartisan coalition for better care.

There is a responsibility for all of healthcare to renew its efforts to make care more affordable so that it can be available for all.


The cacophony of President Elect Trump’s first press conference since the election was upsetting to me. I can not remember seeing such a disturbing display of combativeness directed toward legitimate questions from the press or a more arrogantly defiant posture emanating from the man who will lead us toward a more perfect union. I can not understand how pettiness can create “greatness”.  The next four years will be hard for many of us, but I think that Michelle Obama’s strategy is the right one, “When they go low, we go high.”


I doubt there is a better way “to go high” than to commit yourself to the challenge of working to insure


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


While remembering what Dr. King told us:


Of all the forms of inequality, injustice in health care is the most shocking and inhumane.