Since the political conventions ended in early August I have been obsessed with the election. Things have changed so fast this week that I have had to revise this post since writing most of it last Friday. Friday was the day that the Washington Post released the vulgar video and audio of Donald Trump describing to Billy Bush, an entertainment reporter, how his celebrity status enabled his behavior as a sexual predator. Over the weekend many Republicans withdrew their support from Trump, but on the morning after the debate the Washington Post released a poll that showed only a third of undecided voters were repulsed by his comments.
There was much that made the second presidential debate remarkable. Healthcare finally was discussed for a short time after Mr. Trump spoke to the issue of his inappropriate comments. He explained that his comments were just “locker room talk”, but he did apologize to family and those who were offended. Mr. Trump then finished his explanation of the comments on the tape with the suggestion that his offenses paled in comparison to the failures of Bill Clinton. He moved from apologizing to attacking when he lodged the threat that Hillary should go to jail for her activities. How Trump managed the debate makes a difference only in how it will either give cover to those who want to stay with him for all the reasons they have always supported him, or in how it either attracts or repulses undecided voters.
Before the Presidential debate in St. Louis this post facetiously began with my comment that I had devoted much time and great energy to an effort not to think about the election. I confessed to investing more energy in trying not to think about the election than I had in considering how the election affected healthcare. I confessed that my mind was filled with a troubling chain of continuous “what ifs” that sent me into downward spirals of negative thoughts and anxiety. I confessed to breaking my funky election blues with walks, fishing or some other temporary distraction. I complained that my effort to get the election out of my mind were often interrupted by some message about the election on my cell phone, a request for a contribution that popped up on my computer, a negative political ad on television or by an earnest comment by someone in my company that started my anxieties up all over again.
Before the Vice Presidential debates I had expressed a hope that candidates Pence and Kaine might move beyond a discussion of emails, Benghazi, failed businesses, the description and comparison of body parts, and the ethics of avoiding taxes. Given their experience in politics I had hoped that they would discuss and debate more substantive subjects like healthcare which so far was virtually undiscussed. To my surprise healthcare came back, not as a substantive discussion of the issues, but as a reference to an ill advised comment by Bill Clinton about the “craziness of the ACA” that was ripe to be lifted out of context and thrown back into the conversation during the Vice Presidential debate by Mike Pence. Pence continued the opportunity to score more points with the regrettable Clinton comment while talking with Fox television commentators the morning after the debate. He used Clinton’s comment as evidence that the ACA is a total disaster that should be discarded on January 20, 2017. If you listen to all that Clinton said, he was right and the comment was lifted from his discussion of why a “public option”, as advocated by Hillary Clinton, would be a great benefit to those who are working hard and are just beyond the limit of public assistance. Bill Clinton did a pretty good job of explaining why the ACA needs to be changed despite the error of introducing “craziness” into his explanation. He was trying to explain Hillary’s solution to a vexing problem that is a flaw in the design of the ACA that is traceable to the compromises necessary to gain its passage.
The shortcomings of the ACA are worth analysis and discussion, but to understand either point Bill was trying to make, requires the focused and open minded attention of an electorate that is engaged in the search for thoughtful leadership. Bill’s mistake was to try to explain the nuts and bolts of the insurance market during an election that rarely goes beyond sound bites. Bernie Sanders and Hillary Clinton had discussed the same issue during the primary process. His comments were consistent with the published opinion of President Obama in an article he wrote for JAMA back in August.
Social change through court decisions or legislation is always difficult. One needs only to review the long and continuing attempts at equity in civil rights beginning with Brown v. The Board of Education of Topeka, Kansas. Brown v. Topeka was just the start of a long journey and was followed by weak civil right laws in the late fifties before the demonstrations and civil disobedience led by Martin Luther King, Jr and the political courage of Lyndon Johnson and others resulted in a meaningful Civil Rights acts in 1964 and the Voters’ Rights Act in 1965. Now fifty years later we are still struggling with civil rights as the discussion of “Black Lives Matter” demonstrates. Change is slow.
Another example that may be closer to our struggle for the advancement of the goals of the Triple Aim through legislation is the frustration associated with poverty and the economy. An important explanation for the emotion in this election is the fear of economic loss and insecurity that threatens many white men without higher education who can no longer count on keeping their families above the poverty level with good paying jobs that match their expertise. The problems of poor white America are not new. Michael Harrington’s description of the problem in his 1961 book The Other America was written 55 years ago. The “War on Poverty” announced by Lyndon Johnson during the 1964 “State of the Union Address”, shortly after the assassination of President Kennedy was inspired by this book. The easy parts of any social change, put in Lean language, are the description of the current problem and the improved state. The hard parts are negotiating a strategy for solution and then implementing that strategy.
Those of us who believe that court decrees and legislation can accomplish big improvements in the life’s experience of every person should recognize that many of our conservative neighbors are not so sure, and at best, the history of the last sixty years argues that the problem lies in negotiating the “how” and not in the “why and what”. Applying the same analysis to healthcare reform we can see that the discussion of the “why” has been largely settled. Most people now accept that there are problems with healthcare that include unacceptable expense, uncertainty of quality and service, and continuing concerns about access. Though most voters probably have not heard the phrase
Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time.
I would expect that most voters would agree that it is a desirable objective. The rub once again lies with the “how”. The ACA was an initial offering as a “how”. Despite its flaws, it has accomplished a lot for everyone in terms of portability and a guarantee of insurability, even with preexisting conditions. 20 million people have gained healthcare coverage through its provisions.
The sad and frustrating fact, that was at the root of Bill Clinton’s unfortunate use of the word “crazy”, is that 29 million American still do not have coverage. 29 million is about 10% of the population, but the percentage is disproportionately higher, up to 25%, in those “red states” that have not taken advantage of the expansion of Medicaid. Some of those who do not have coverage or who are burdened by the continuing high cost of care are the owners of very small businesses and workers who make just enough to fall through the crack between their ability to pay and the limits of subsidy.
Bill Clinton’s “crazy” was an expression of frustration that problems do exist with the ACA and can’t be resolved in the climate of our current political gridlock. Hillary’s proposed solutions are worth consideration, but for them to succeed we must elect more than just a new president. We must also advocate for the election of a Congress that can understand how far we have come and can learn from the mistakes that we have made. We need ACA 2.0 to fix the flaws. Healthcare is so complex that I am sure that what we learn from ACA 2.0 will lead us to ACA 3.0 as a process of continuous improvement goes forward.
The best response from an opposition candidate to Bill Clinton’s comment that the current system is “crazy” would have been a question about how to begin the necessary bipartisan conversation. A sneer and a “gotcha!” without a discussion of the the issues leaves me troubled. Presenting no alternative solutions to a vexing problem while mining the fears and concerns of the electorate is irresponsible in the face of important and complex problems.
I calm myself by making lists of those accomplishments on the road to the Triple Aim that can not be reversed by executive action. The shift from volume to value could be hastened by the addition of a properly constructed public option, but if we elect a president and congress that discards the gains so far just because the whole package is not perfect another strategy may be necessary. We may be forced to try to hang on to our limited gains through the realities of MACRA. I am reassured that it is highly unlikely that there is a political possibility of doing away with Medicare. I am worried that if the ACA were repealed there would be even greater variation in Medicaid going from state to state if the alternative idea of financing Medicaid through block grants was adopted. An administration more focused on improving the business and tax environment for the wealthy and perpetuating the myth of trickle down improvement for all is likely not to be as interested in insuring that we accomplish universal coverage.
I am encouraged by the fact that although the election has not produced much in the way of substantive discussion of the issues of healthcare, it has not been able to avoid the core issues of injustice and inequity that are experienced by everyone of color as well as the ongoing issues of unequal opportunity for women. The ongoing concerns about the inherent diversity of sexual preference and identity, the status of immigrants and those who are refugees from the violence of the Middle East, and our epidemic of gun violence continue to be discussed. Perhaps how to deal with issues of international and domestic terrorism trump the ongoing inequities in healthcare.
I worry most about the persistence of gridlock and the lack of civility after the election is over. I worry about the persistence after the election of the backlash against “political correctness”. My frustration is the continuing discussion of the personalities of both candidates in lieu of discussing the issues. In a better world and at a better time thoughtful debates and campaign discussions of policy would allow voters to judge character and capability based on the discussion of issues and ideas. Whether or not a given candidate has the skill or temperament to be President should be judged on the basis of the observations that voters make while the candidates present their ideas and not as they exchange insults. Solving long standing social problems is a slow process and requires remarkable leadership and experience. The election process should be a positive exercise that is conducted in a way that helps us find the best leader.
