Dan Burns, is a former colleague who served on the Harvard Vanguard and Atrius boards with me, my dermatologist, and the person who became CEO of Harvard Vanguard after I retired three years ago. I most recently saw Dan, and we had a brief conversation during a visit I made to the Wellesley practice of Atrius Health. I was there for advice from orthopedics regarding a recent shoulder injury. (I injured my shoulder in a fall while going door to door for Hillary.) A few days later I was surprised to see a text from Dan asking if I had time for a call.


We had a great conversation. Dan made his concern known immediately when he said that he was quite worried that all that had been accomplished since the beginning of the Quality Movement was now in jeopardy with the uncertainties that were introduced by the election of Donald Trump to the presidency. His concerns had mounted as Mitch McConnell had reiterated the goal of initiating the repeal of the ACA on day one of the new administration. I quickly told Dan that I understood and shared his concerns. I found the conversation to be helpful for me and asked Dan if I could transmit his concerns to you. I told him that many of you had shared the same concerns with me.


In the course of the conversation we considered several strategies. It occurred to me that up till now most of us have been in a state of shock. The outcome of the election itself was a huge and unexpected surprise for many. The President Elect even seemed a little surprised that he had won an election which he had said was fixed.


Following the collective “this can’t be”, there have been moments of hope as the realities of the loss sink into our disbelieving minds,  but as January 20 gets closer and as the President Elect has populated his cabinet and other high level administrative positions with a set of surprising and controversial leaders it is becoming clear that very dramatic changes and some possible total reversals of policy lie ahead.


I had really felt better when a few days after the election President Elect Trump visited President Obama. Trump seemed sincere when he said after that visit that there is much in the ACA that is worthwhile and should be protected. Then in the background over the next few weeks both Paul Ryan and Mitch McConnell have reiterated that the ACA will be completely repealed, and then replaced with something better. It is unclear what they mean, especially when recently the Republican leadership said that their goal is to give every American an opportunity to chose to have healthcare. The cynic in me says, “Watch out. Read the fine print.”


“Our goal here is to make sure that everybody can buy coverage or find coverage if they choose to,” a House leadership aide told journalists on the condition of anonymity at a health care briefing organized by Republican leaders.


Republicans have an “ironclad commitment” to repeal the law, the aide said, as lawmakers moved to discredit predictions that many people would lose coverage.

What does “if they choose to” mean?


My junior high school football coach taught me that to make a tackle in the open field you must always watch the runner’s belt buckle and not his eyes or upper body. The runner always goes where his center of gravity is headed. The eyes, arms and upper body can trick you. With his cabinet appointments, which must be an indication of where his momentum is headed, this President Elect has already taken enough steps to suggest that his center of gravity is headed in a way that will be problematic for the journey toward true universal coverage. I am sorry but I do not trust that “everybody can buy or find coverage if they choose to” means universal coverage. I see Mr. Trump’s center of gravity expressed in his choice of Representative Dr. Tom Price to be the Secretary of Health and Human Services and Dr. Seema Verma to be the administrator of CMS. The choice of Rick Perry as Energy Secretary is another startling revelation of Mr. Trump’s amazingly consistent approach to dismantling the progressive agenda.  


There are many who want to move beyond rallies where the disappointed gather together to chant that Trump is not their President. Many share Dan’s sense that some sort of action is appropriate. I have discovered on the Internet that a group of congressional aides have produced a document entitled Indivisible: A Practical Guide For Resisting the Trump Agenda” to provide guidance for those who want to positively fill the role of “the loyal opposition” that is so critical in a democracy. The document is detailed but John Cassidy writing for The New Yorker has produced a very similar article with nine points for action.


Neither of these documents were available to Dan and me as we discussed our options but we came up with some similar ideas. I was in total agreement with Dan. A “wait and see” approach, coupled with prayers that the President Elect will suddenly see the light, seems like a strategy for continuing disappointment and loss. We began to consider a few peripheral questions.


Massachusetts had virtual universal coverage before the ACA. Would the state expend the resources to maintain what had been accomplished if the ACA was repealed or if its replacement resulted in huge reductions in federal aid? How secure was the recent 52 billion dollar Medicaid waiver that was granted to Massachusetts to put all Medicaid patients into an ACO? Would Massachusetts taxpayers who were already spending $0.42 of every tax dollar on healthcare be willing to make up what Donald Trump’s administration might try to rescind? Interesting questions.


Dan and I found a little bit of consolation in MACRA (Medicare Access and Reauthorization Act of 2015)and the fact that the passage of MACRA suggested a strong bipartisan support for shifting Medicare reimbursement toward payment for value. I still believe that the most important fact arising from MACRA is that it is providing encouragement to commercial insurance to follow CMS’s lead into alternative payment models. Is that enough to form a foundation for a strategy? Perhaps the alternative question would be, could MACRA be undermined and its implementation delayed by an administration that wanted to play to providers who saw only stress in further transitions that moved them away from Fee For Service payment?


Before the conversation had gone very far, Dan and I had concluded that the greatest hope for the preservation of what has been accomplished and for further progress toward the Quadruple Aim,

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…,


would be an offensive strategy. It is preposterous perhaps to imagine, but those who see value in what has been accomplished need to come together in an all out coordinated effort to preserve and improve, not repeal and replace, the ACA.


History demonstrates the path for success for unlikely processes of change can sometimes lead to surprising successes. John Kotter teaches that foundational to effective change is the formation of a guiding coalition. Actually, the first step is to have a cause, but the first action is to form a large volunteer army from up, down and across the organization (or the nation) to serve as the change engine.


Here are the eight steps in Kotter’s accelerated change process. Can the steps be followed as a framework for a strategy to preserve the work of a quarter of a century, the investment of billions of tax dollars and the commitment of huge sums of investment capital? More importantly how hard should we fight for things as important as the health of all and the preservation of the climate that we share with the rest of the world?



  • Craft and use a significant opportunity as a means for exciting people to sign up to change their organization.
  • Assemble a group with the power and energy to lead and support a collaborative change effort.
  • Shape a vision to help steer the change effort and develop strategic initiatives to achieve that vision.
  • Raise a large force of people who are ready, willing and urgent to drive change.
  • Remove obstacles to change, change systems or structures that pose threats to the achievement of the vision.
  • Consistently produce, track, evaluate and celebrate volumes of small and large accomplishments – and correlate them to results.
  • Use increasing credibility to change systems, structures and policies that don’t align with the vision; hire, promote and develop employees who can implement the vision; reinvigorate the process with new projects, themes and volunteers.
  • Articulate the connections between the new behaviors and organizational success, and develop the means to ensure leadership development and succession.


Dan and I focused on items #2, #3, and #4. Our conversation included developing a combined list of people from around Massachusetts and around the country who we believed shared the worries and concerns that we feel.


Objective #5 makes me think that the proximate battle ground for the defense of what has been accomplished so far will be in the Senate. If one reviews who populates the slim majority that Mitch McConnell controls, it is possible to construct a  list of Republican senators that might disagree with radical appointments and proposals. The list includes some interesting names. On my list John McCain and Lindsey Graham are on top. How might Susan Collins of Maine vote? Are there any who remember the fate of Kelly Ayotte? Is there leverage in the 2018 mid term elections?


Dan and I ended our conversation with the idea that doing something effective would be difficult, perhaps impossible, but we also agreed that not to try to see if there were others who shared our concerns would be irresponsible. Is it possible for healthcare professionals to appeal to the concern of those who have the constitutional responsibility to provide advice, and when appropriate, consent?


There is a very confusing statement that I have heard from Buddhism. It is essentially, if you meet the Buddha in the road, kill him. This is one statement that is not meant to be taken literally. If you type it into Google you will get several different reflections on its meaning. Over the years I have come to my own interpretation. The Buddha represents all knowledge. No human being is so smart and so all knowing that their opinion should be accepted without consideration, and therefore anyone who claims all knowledge should be rejected or avoided.


Thoughtful people know the folly of following a con, and avoid people who claim they are all knowing and all powerful. In the metaphor rejection is expressed as “kill him”. We call these “Buddhas” “know it alls” and we usually avoid them. There is a reality that sometimes in groups we can collective be led to do things that most of us would have the wisdom not to do individually. I think that happened this year.


What do you consider your options to be? Will you be rising to the challenge of defending what has been accomplished? Will you search for opportunities to flip our current disappointment into a future advancement of the search for


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…,