While walking I often listen to podcasts from Tom Ashbrook’s weekday morning shows on NPR. The first hour on most Friday mornings is usually the “week in review.” A recent Friday broadcast provided food for thought. Tom Gjelton, veteran NPR reporter was sitting in for Ashbrook. I have transcribed what I heard at about 25 minutes into the conversation.


Tom Gjelton: Let’s go now to Justin who is on the line from Texas. Justin, I assume you have been following the discussion on the program so far, what are your thoughts?


Justin: Well I just had a couple of comments. Uh, I just a, I’m 43 years old. You know I have been through a few presidents, uh, that I can remember, and uh, I don’t think you guys any have criticized, scrutinized, or have been so biased against any one man in my memory. Obama could have run over and killed somebody and you all wouldn’t even cover it. Uh, you all have just flipped as soon as this man was elected president. I think that he’s doing a great job. He’s not perfect. He’s had some screw-ups here and there, but jeez Louise, nobody has even given him a chance. You all has just cut him off at the knees every chance you all get. It is, it’s unreal. It’s unfathomable how you’ll have just shredded him. You all didn’t give Clinton this much deal when he had his little fling in the White House. It’s just unreal.


Tom Gjelton: Ok Justin, Let me just ask you a couple of questions, just to clarify. First of all what is, what was your reaction to the news that the president had shared classified intelligence with the Russians? And second, what did you think of the news that Jim Comey, the FBI director, wrote a memo in which he said that President Trump had urged him to back off of his investigation of General Flynn?


Justin: Well, the deal with the Comey memo, uh, you know it, it’s, uh, what’s the problem with one man asking another man, hey do something? That is not obstruction, uh and uh…


Tom Gjelton: It is the President of the United States.


Justin: Correct, he can do whatever the hell he wants, just about. But you all, uh, but as far as  the sharing classified info, you all have got, you all, the press has gotten so comfortable with being, you know Obama just letting them in everywhere. And who knows what the truth is on some of you all’s reporting. Um, if he shared a little info, big deal to my knowledge, and to what McMaster said nothing was inappropriate.


Tom Gjelton: OK Justin, thanks very much. What’s the big deal?



It is unclear to whom Gjelton was speaking when he asked, “What’s the big deal?” Perhaps it was a rhetorical question to all of us. I think the big deal is our inability to talk with one another. It is our biggest barrier to getting to the Triple Aim. Gjelton is an archetypical example of the urbane, highly educated and connected individual who would immediately accept the pronouncement of Tom Ricks that:  



The fundamental driver of Western civilization is the agreement that objective reality exists, that people of goodwill can perceive it and that other people will change their views when presented with the facts of the matter.



I feel like I have met Justin. He could be one of my relatives down South, or a neighbor here in New Hampshire. I will assume that he represents many middle aged and intelligent white men from both red states and blue states who can look at the same facts and from the context of their own experience come up with a completely opposite set of “facts” while looking “objectively” at exactly the same events that generate a different set of “facts” from a guy like Tom Gjelton or me.  The sad reality is that the moment was lost. Justin had the courage to call, and Tom treated him with respect, but the conversation ended without even the agreement to disagree or consider seriously the point of view of the other man. We have a barrier to progress that we must cross that is like the rock wall at the edge of a dense forest that I passed on the road during my walk while listening to Tom and Justin.



I had hoped that during the week when the president was abroad there would be some respite from the daily bombardment of controversial decrees and Tweets, but it was not to be. As he flew off to Saudi Arabia the president’s budget recommendations were sent to Capitol Hill. The document was entitled “The New Foundation for American Greatness”. The link allows you to  review the staggering list of 66 programs that will be cut. The list includes business development, public education, healthcare training programs, housing programs, food stamps, and support for community clinics. It is important to conceptualize that just as the “repeal and replace” legislative agenda threatens individual access to care, a budget like this will undermine attempts to address the social determinants of health.


We are reassured by the fact that it is unlikely that these budget proposals will ever be passed as recommended, but many of the cuts could survive the bargaining in Congress that will be necessary to pass a budget. This budget is the financial expression of the philosophy of the administration, and an attempt to stay aligned with campaign promises. The fact that these cuts could be presented as suggestions for consideration is very discouraging as it engenders fear and undermines the confidence of many who are critically dependent on the programs that this administration’s budget recommendations would abolish. Many of those who should be concerned did vote for the president. The budget is also intellectually dishonest as noted by many economist. The proposal contains tax cuts for the rich and even double counting. The tax cuts damage healthcare but are justified as the creators of economic growth.  Economists say that the budget will not pay for its tax cuts, nor abolish deficit spending during the next decade.  


None of us were really surprised by the Congressional Budget Office’s scoring of the personal and fiscal impact on the American Health Care Act recently passed by the House. I would recommend reading the analysis published by the Commonwealth Fund. In it David Blumenthal and Sara Collins sum up their take on the sad reality:


The bill now moves to the Senate, where Republicans are reportedly drafting their own ACA repeal and replace plan. The reconciliation rules under which the bill is being moved through Congress (so that it can pass without the support of Democrats who uniformly oppose repeal) will require that the Senate bill affect federal spending no more than the House bill, which the CBO scores as saving $119 billion over 2017–2026. The House achieved this result through cuts of $1.1 trillion in spending on Americans’ health insurance and tax cuts of $992 billion that accrue disproportionately to wealthy people.

The CBO’s score demonstrates in black and white the consequence of such a trade-off: a steep price for millions of American families in coverage losses and a heavy toll on many people’s personal budgets.


I am focused on the devastation that will result from 23 million people losing their coverage, meaning that there will be more than 50 million Americans without healthcare in 2026, and the president has the gall to say that he is on track to “make America great again.”


In a creative piece in the New York Times Jeanne Lambrew, who was an advisor to President Obama for healthcare, imagines some headlines that might create trouble for the Republican majority as we work our way toward the 2018 midterm elections if Mitch McConnell is able to figure out a way to pass something that resembles the AHCA as scored by the CBO.


  • Trumpcare Premiums to Soar by 26 Percent.” The C.B.O. estimated that the new health care bill would add an average of about 20 percent to individual market premiums next year.


  • “60-Year-Olds to Pay Over 50 Percent More Under Trumpcare.” The new bill would let insurers charge older Americans five times more than they charge young adults (up from the three times more allowed under Obamacare)


  • “Insurers Fleeing Trumpcare.” Over the last three and a half years, people in all areas of the country had marketplace insurance plans to choose from. But in part because of questions about the future of the marketplaces, some insurance companies are reportedly planning to cut their offerings in 2018.


  • “Biggest Rise in Uninsured in History.” The C.B.O. projects that 14 million people will lose coverage in 2018 as a result of cuts to Medicaid, subsidies and rising premiums.


  • “Untreated Opioid Addiction Surges.” Hundreds of thousands of people who are addicted to opioids got addiction and mental health treatment through Obamacare, preventing many overdose deaths. Trumpcare would end the nationwide requirement that plans cover these services…


  • “Trumpcare Is a Windfall for Millionaires.” Warren Buffett recently said that the House bill “is a huge tax cut for guys like me.”


It may be entertaining to imagine how the attempts to repeal and replace the ACA could lead to uncomfortable moments for Republican politicians, but that does little to help us maintain the progress that has been made toward the Triple Aim through the ACA. It would be a much better use of time to try to conceptualize how to convince three Republican senators to block the effort to repeal and replace the ACA or engage all senators in a productive conversation across the aisle to find ways to produce something better.


Paul Kane offers us an analysis in the Washington Post that gives us a starting point of saving the ACA or creating a coalition that might produce a bill. He sees the Republican leadership losing votes from both moderates and conservatives. The conservatives who will argue that the bill doesn’t go far enough are Rand Paul of Kentucky, Ted Cruz of Texas, and Mike Lee of Utah. The moderates who may be predisposed to work for something better may include Senator Shelley Moore Capito (R-W.Va.), who has 180,000 constituents relying on the Medicaid expansion for insurance coverage. After the CBO’s updated estimates, those Senate Republicans, predominantly from states with large populations of people who benefited from Medicaid expansion, may dig in even further against the House bill because millions of their constituents would be left in the lurch by the GOP proposal. There are actually twenty Republican senators from states that did implement the Medicaid expansion in the ACA. Potential leaders for positive action include Lamar Alexander (Tennessee), Rob Portman (Ohio), John McCain (Ariz.) and Lisa Murkowski (Alaska), Susan Collins (Maine) and (Dr.) Bill Cassidy (Louisiana).


My advice is to dream of something better like a single payer solution, but to work hard to preserve what we have, and hang on for 2018. The thought of the possibility of losing what we have under the ACA should  mobilize us all to express ourselves to our senators and especially to the ones who seem likely to understand the pain or may have political fears of the voter response that the AHCA might create for those unfortunate souls among us who would lose their care.


An interim pathway, a “public option” where the government would offer a plan on the exchanges in competition with commercial insurers was considered and killed during the run-up to the passage of the ACA. Perhaps the road to


…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..


will pass through a public option on the way to a single payer system sometime before there is moss on all of our tombstones.