The foundational fairy tale that Michael Wolff tells us in his bestseller, Fire and Fury: Inside The Trump White House, is that the president and none of his campaign staff, except Steve Bannon, ever thought he would win and did not prepare for the possibility of victory. Whatever the truth, when the dust settled we had an administration that was ill prepared for the challenge ahead and yet it was led by a man with a personality that made him constantly promote his every act of daily living with a sixth grade list of superlative adjectives. Everyone, but especially the president, had a big learning curve ahead, and it was not possible for him to say, “I was just fooling!”
Considering where things started, it is no surprise that the White House staff is now forced to greet each day with a list of issues to deny, positions and tweeted policy decisions that must be reshaped and defended, and endless explanations. They have exhausted Roget’s Thesaurus of all of the alternative ways to describe a lie other than to call a lie a lie. Almost every member of the staff that has any public recognition has endured personal humiliation.
That said, I want to credit the president for what he has done. He has made us all much more aware of what is and is not in the Constitution. I spent years trying to explain the ACA to friends and relatives with no success. Donald Trump pulled it off in a flash with a little help from Paul Ryan and Mitch McConnell. What was the deal with CHIP? Did you ever really care much about the ins and outs of the Paris Climate Accords before Donald Trump? Immigration has always been so complicated that unless you yourself were an immigrant why would you care?
It’s been a crash course for President Trump and for all of us. It’s a little bit like childhood when we enjoyed taking things apart to see what made them work. What is childhood at its best other than a continuous cycle of challenges, frustrations, failures and ultimate mastery? Learning to walk may be one of our first successful applications of the PDSA cycle.
In the process of growing up we gain great skills, and we also learn how to accept the reality that there are some skills that we will never acquire and can only enjoy watching others perform. I was reminded of the limits of my capacity for mastery every time I turned on the Winter Olympics and saw some snowboarder doing twists and turns high in the air before coming down to earth in a perfect landing. What the president is learning is a bit like a child learning how to walk, albeit his job description requires something more like freestyle snowboarding than walking. We all have an investment in his learning process, but more importantly we have been forced to begin our own learning process. We must figure out how to deal with him as he presents us with one challenge after another as we try to preserve many of the accomplishments of past administrations.
I am empathetic because of my own inadequacies as I watch the president try to pull off an expression of condolence and hope in the aftermath of a national tragedy. I understand that he needs reminders to let others speak. President Obama’s sincerity and clarity were inspiring. He seemed to naturally understand his role and responsibilities. Watching Obama, I felt like I feel when I see those snowboarders stick their jumps. The president’s inability to enlighten or inspire us when we are distraught reminds us that we just sat back and let Obama do the work that we all should have taken more seriously.
Most of us are continuously looking around trying to compare themselves to others. We like to see where we are in the standings. We are rarely on top so we focus on how far from the bottom we are. The individual that “defines” the bottom provides us all with a very useful service. Such was the utility of the lovable town drunk. Being able to favorably compare our inadequacies to those of an American president is a fabulous gift for us all because we are reassured that although we can’t fly through the air doing flips on a snowboard, or speak with the eloquence, empathy, and wisdom of an Obama, most of us are running well ahead of the forty fifth president in personal awareness, personal honesty, fundamental integrity, respect for the rights and feeling of others, and the personal humility and generosity of spirit that allows compassion for those whose challenges are different, and who are not blessed with our gifts.
President Trump has gifted us with an easy formula to employ in our desire to make America great, and that is to watch what he is doing and decide to do exactly the opposite thing. Rarely in history has the best way forward been so clearly demonstrated by a leader who knows without knowing how to lead from behind in such a transformative way.
All of what I have said was true long before the president took his game to new lows with the performance he has demonstrated since the most recent school shooting in Florida. My words may sound factitious, but I do believe that the president has given us all a gift when his words, personal behavior, and political actions leave us no other option than to set aside petty differences, focus on the bigger issues that threaten us all, and work with renewed zeal to become a more perfect union.
Several years ago I bought a book, Why Nations Fail: The Origins of Power, Prosperity, and Poverty by Daron Acemoglu, an MIT economist, and James Robinson a Harvard political scientist. I started it with enthusiasm and was enthralled by the authors’ concepts of the economics of “extraction” and “inclusiveness.” Something displaced it from the center of my attention and it sat unread in my Kindle for five years until recently when I decided that it might fit nicely with other books that I was reading on inequality and the relative fragility of democracies initiated by a renewed interest in the social determinants of health.
Tom Friedman reviewed the book in his column in the New York Times in April 2012. In a quote from Friedman that quotes the book we read:
“Inclusive economic institutions that enforce property rights, create a level playing field, and encourage investments in new technologies and skills are more conducive to economic growth than extractive economic institutions that are structured to extract resources from the many by the few,” they write.
“Inclusive economic institutions, are in turn supported by, and support, inclusive political institutions,” which “distribute political power widely in a pluralistic manner and are able to achieve some amount of political centralization so as to establish law and order, the foundations of secure property rights, and an inclusive market economy.” Conversely, extractive political institutions that concentrate power in the hands of a few reinforce extractive economic institutions to hold power.
The book is an impressive tour of world history, economics, psychology, and political science as it demonstrates the differences between inclusive and extractive economic and political institutions. We are always flirting with the short term benefits and conveniences of absolutism and authoritarian political structures that favor a few and allow them to extract benefit from the efforts of others.
Societies have two basic components: economic institutions and political institutions. Both have the option of being extractive or inclusive. Through these institutions “critical junctures” in history or in the experience of a nation have a profound effect on future wealth and poverty. At times the social context or contingencies send a nation toward economic decline and widespread poverty. Empires want to maintain the status quo and their leaders deny the future because of the threats progress brings to their control.
Big events like the discovery of the New World have been “critical junctures” that can establish either inclusive economies like the United States and Canada or the extractive economies that historically plagued South America, Africa, Asia, and Eastern Europe. The fall of the Roman Empire, the bubonic plague, or the failed Spanish Armada can push either the economic or political system to move to be either more inclusive and expansive, or more extractive and in favor of a rigid status quo and eventual failure. Sometimes, as in the case of the Soviet Union, extractive political and economic systems can be initially very successful but “run out of gas” because they do not allow “creative destruction” or innovation and suppress individual initiative.
Inclusive governments establish property rights, the rule of law, and broad opportunity. They shun monopolies and special relationships that allow elites to extract wealth from the labor of others. Opportunity depends on the acceptance of the role of “creative destruction” associated with innovation. To quote Friedman quoting the authors again:
“Sustained economic growth requires innovation,” the authors write, “and innovation cannot be decoupled from creative destruction, which replaces the old with the new in the economic realm and also destabilizes established power relations in politics.”
The book was written long before the current administration was even a well formed bad idea. The book’s message seems applicable now since we are facing “the contingencies” and “critical junctures” that can lead to change. Our nation has always been relatively inclusive for white, male landowners. Others, all the minorities, have experienced an extractive environment. The president’s policies feel extractive even as he promises that they will improve things for everyone. History argues that if growth happens in an extractive environment it is short lived at best. What seems possible is that a fear inducing and dysfunctional reaction to globalization, automation, and a world trapped in a cycle of increasing economic inequality may be part of a developing vicious cycle moving us toward more and more extractive economic institutions supported by extractive political forces.
How does the future of healthcare and the Triple Aim fit into this larger drama? Has healthcare become extractive? Don Berwick stated that healthcare can demand what it wants and get it. There is a status quo within healthcare that resists change for fear of losing what it has. We all talk about innovation, but we do not easily accept the “creative destruction” of the status quo. Extractive systems jeopardize our hope that innovation can form a new foundation for broader access and improved health for all which is the healthcare equivalent of “prosperity.”
“Extractive” political systems deny support to programs that expand access to care like the exchanges of the ACA, Medicaid, Medicare, CHIP and federal support for Federally Qualified Health Centers. The picture of American medicine that Elisabeth Rosenthal painted in An American Sickness: How Healthcare Became Big Business and How You Can Take It Back is a description of a system that has developed its extractive capabilities. Don Berwick’s Era 3 is a vision of an inclusive system of care.
Democracy depends upon participation and a higher degree of loyalty to its preservation than to short term individual and party objectives that are extractive. The future of better healthcare and the vision of the Triple Aim are dependent upon an inclusive political environment and inclusive economic institutions. Just as the president’s attempts to undermine the ACA led more Americans to a deeper understanding of what is at risk, could it be true that extractive laws like the recently passed tax “reform bill” will wake up a critical number of voters who will vote to defend an inclusive society? In 2018 will voters reject the politicians who support extractive policies and look away from the president’s authoritarian mindset? For the Triple Aim to have a chance we need legislators and a president who embrace principles of inclusion and clearly reject extractive practices. By historical standards our “greatness” is still a very short and incomplete story.
