October 2, 2020
Dear Interested Readers,
Thinking About the Future of Healthcare and the 2020 Election After The First Debate
[I finished writing what follows last night at about 10:30 PM Mountain Time, 12:30 AM on the East Coast. While I was writing, Chris Cuomo and other CNN analysts were speculating about the risk to the president related to his close contact with one of his top advisors, Hope Hicks, who was reported to have been infected by the COVID-19 virus. While I was formating the post around 11 PM, my time, the President tweeted that he and the first lady are positive for the coronavirus. I spent the next hour listening to the talking heads on CNN pontificate about the event and its potential significance for us all. Stock market futures were reported to be crashing. One analyst speculated about how international rivals may seek to take advantage of the moment, there was obviously much speculation about what might happen to future debates and whether Joe BIden and others who had seen the president recently might also be infected. I am sure that as events unfold over the next few weeks there will be much more said about this sad occurrence. At this time the only appropriate thing that I can say is that the event suggests that frequent testing alone does not provide protection from the virus if social distancing is not practice and masks are not worn. I hope that the president and first lady recover quickly. It is not the time yet for me to speculate on any political or policy meaning associated with this occurrence. I hope that this unfortunate event will be a wake up call for many Americans that the virus has no political affiliation and that it is important for us to use science to guide our policies and our actions.]
I well remember the Kennedy/Nixon debates from 1960. JFK was definitely the better debater, and the camera was his friend. Nixon had a five o’clock shadow that made him look ominous. JFK used the stage of the 1960 debates to get elected. After the election he communicated with us through televised press conferences.
Franklin Roosevelt used the radio very effectively after he was elected. Perhaps, President Obama was elected because his campaign effectively used social media. We now know that in 2016 social media was turned against us by the Russians. Presidential press conferences are no longer an effective way to get a glimpse of what is evolving as the administration’s policy on any substantive issue. When the president does have a press event, he usually uses it to praise himself and demonstrate his contempt for truth, science, facts, and the free press. The president uses social media as a bully’s weapon, not as a “bully pulpit.” Now we see that he will use the 2020 Presidential Debates as a way to demonstrate his contempt for his opponent, and the process of free and informed elections.
There was precious little useful information about healthcare despite Chris Wallace’s attempt to broach the subject with both candidates. Fortune magazine published an article the morning after the debate written by Sy Mukherjee and entitled “Trump’s 4 biggest lies about health care from last night’s debate.”
Early in the article Mukherjee writes:
The freewheeling and chaotic standoff was difficult to follow at times, but it was also filled with lies and distortions about health care policy, science, and the state of the coronavirus pandemic—fueled directly by President Trump.
The president’s first misrepresentation was that the coronavirus isn’t really a problem for children and young people, it’s only the sick and the elderly who are vulnerable. Mukherjee’s response was to say:
The President has claimed that the coronavirus is only a true danger to the most vulnerable people. He doubled down on that claim Tuesday. “Now we’ve found that elderly people with heart problems and diabetes and different problems are very, very vulnerable. We learned a lot. Young children aren’t, even younger people aren’t,” he said during the debate..Over the course of the pandemic, according to the most recent Centers for Disease Control (CDC) numbers, nearly 1,800 Americans ages 15 to 34 have died of COVID-19; another 3,800 between ages 35 and 44; and more than 10,000 between 45 and 54.
It would have been nice if Joe Biden could have responded that children and young people can have bad outcomes and die, but more importantly that children and young adults are known to be able to pass the virus to more vulnerable Americans. It seems that the president’s strategy was to be so disruptive that the former Vice President would be challenged to keep his head above water, and be able to respond effectively to his misinformation. Whenever Biden attempted to speak the president interrupted him before he could complete a full sentence. It was tedious and very painful to watch.
The second misconception or piece of misinformation that the president peddled during the debate was that he could use an executive order to provide coverage for people with preexisting conditions if the ACA is ruled to be unconstitutional. This part of Mukherjee’s article covers a lot of important ground so I will give you most of his analysis:
The Trump administration hasn’t been shy about expressing its disdain for the Affordable Care Act (ACA)…In fact, it’s actively trying to scuttle the entire health law at the Supreme Court while promising to replace it.
The trouble is that what the administration will replace it with has never materialized. Even when the GOP-controlled Senate nearly repealed the ACA back in 2017, the replacement plan was essentially a blank check with a set of guiding principles and the details to be hashed out [at] a later date. Obamacare’s requirement to carry health insurance or pay a fine, the so-called individual mandate, was eventually repealed [through the 2017 tax law] and has driven the administration’s efforts to invalidate the law.
But that would have far-reaching consequences. The ACA’s Medicaid expansion has helped provide coverage to millions of low-income working Americans who otherwise wouldn’t have qualified. And, critically during a pandemic, Obamacare established that health insurers can’t discriminate against patients with a pre-existing condition.
That latter point became a big subject of debate on Tuesday night. As moderator Chris Wallace told Trump, the President had signed an executive order ostensibly meant to protect people with pre-existing conditions days before the debate. But, as Wallace and health policy experts have noted, that doesn’t really have any staying power. An executive order can’t control the whims of an entire private industry.
Trump pushed back on that notion. “Let me just tell you something. There’s nothing symbolic,” he said in response to Wallace. The facts say otherwise—and insurers would likely be able to discriminate against people who have contracted the coronavirus by price gouging or refusing coverage if the ACA were to be overturned in its entirety.
Trump also denied that there are more than 100 million people in the U.S. living with pre-existing conditions, even though multiple independent analyses have confirmed that statistic.
The third piece of healthcare information that the president presented as a certainty which is certainly not true is that there will be a widely available vaccine with proven efficacy and safety very soon, perhaps before the election. This is not going to happen. Here is Mukherjee’s analysis.
The President insisted that a COVID vaccine is just around the corner for widespread availability and contradicted the statements of both CDC director Dr. Robert Redfield (who is a virologist) and Moncef Slaoui, a former vaccines chief at the drug giant GlaxoSmithKline and the current scientific head of Operation Warp Speed, the Trump administration’s program to spur the development of coronavirus vaccines.
“I disagree with him. No, I disagree with both of them,” Trump told Wallace after the moderator pointed out that both experts have cautioned that a vaccine won’t be available to the public at a large scale until next summer.
Trump responded that companies such as Pfizer, Moderna, and Johnson & Johnson have told him otherwise. “Well, I’ve spoken to the companies, and we can have it a lot sooner. It’s a very political thing because people like this would rather make it political than save lives,” he said.
That’s not what industry executives and public health experts have said. The President may have been referring to statements from companies like Pfizer that they may know whether or not their vaccine candidates are effective by late autumn—but that’s nowhere near the same thing as Trump’s implication that a vaccine will just be out and accessible in the market by November.
If a vaccine proves effective, it may receive an emergency use authorization—but that’s not the same thing as a full Food and Drug Administration (FDA) approval. And then there’s the question of how such a vaccine will be prioritized. The most likely scenario is that it will be given to the most vulnerable populations at first as manufacturing and production of the COVID vaccine scales up. You’re not going to be able to waltz into a CVS and get your coronavirus shot this year in the same way you do a flu shot.
I am not sure what percentage of the American electorate are buying the president’s misinformation, but there is emerging evidence that many Americans would be afraid to take the vaccine if it were available. I think that is understandable. They know that the president has consistently lied to them when I thought “alternative facts” fit what he wanted people to believe. Why would they believe him now?
The final piece of the president’s misinformation that Mukherjee presented was his continuing presentation of the virus as a problem from China. I had an interesting experience this week that underlines how effective this language is with the president’s base. We were at the Curt Gowdy State Park in Wyoming where the picture in today’s header was taken. The couple who were in an RV next to us were friendly. They were from Arkansas, and were on there way home from “the bison roundup” in Utah. As the conversation progressed, the woman began talking about “the Chinese” virus. we moved on as soon as it was polite to do so.
In the debate the president once again asserted that millions would have died if he had not limited travel from China at the end of January. Mukherjee’s take:
President Trump continued to lay the blame for the pandemic on China. He referred to it as “the China plague” during the debate, a tweak on his previous racist statements calling the virus the “kung flu” and the “China virus.”
The outbreak may have originated in China, but a pathogen has no ethnicity. India is now one of the pandemic’s hotspots, and, as mentioned above, the U.S. has done considerably worse than just about every other country in controlling COVID. Travel between continents has spread this highly contagious disease, and the first American cases likely originated from visitors who came from Europe.
The 2009 H1N1 flu pandemic, which killed hundreds of thousands of people worldwide—though nowhere near the number of COVID deaths—originated in the United States and then spread globally. It was not referred to as the “American virus.”
Neither Mukherjee or Biden point out the horrendous American experience with coronavirus compared with Canada, Europe, and other advanced economies since the initial wave of cases and deaths in April and May. We have over 20%of the infections and the fatalities in the world but only 4% of its population. With his bluster and refusal to participate in a reasonable debate, Trump successfully prevented an in depth discussion of his failure to effectively manage the nation’s response to the virus.
As I am writing, I hear on CNN that the president’s advisor Hope Hicks who has been in close contact with the president is now sick with the virus, and the president and first lady are going into quarantine as they await test results. Who knows what the situation will be by the time that you read this letter. What we do know is that during the debate the president mocked Joe BIden for wearing a mask and limiting the number of people at his campaign events.
Sy Mukherjee of Forbes had four healthcare points from the debate, Paige Winfield Cunningham of the Washington Post reported other healthcare issues from the debate in an article entitled “The Health 202: Health care was first up in last night’s caustic presidential debate.” She began with Trump’s mocking of Biden for wearing a mask.
“I wear masks….I don’t wear a mask like him,” Trump said. “Every time you see him, he’s got a mask. He could be speaking 200 feet away…and he shows up with the biggest mask I’ve ever seen.”
Cunningham reminded us of the exchange that followed the mask discussion:
When moderator Chris Wallace noted Biden is holding much smaller events than Trump, Trump said that’s “because nobody will show up.”
Questioned by Wallace on the large rallies he continues to hold, the president claimed “we have had no problem whatsoever.”
“We do them outside, we have tremendous crowds, as you see, and literally on 24 hours notice,” Trump said. “And Joe does the circles and has three people someplace.”
It’s a balanced article. She noted that Biden claimed that there were a hundred million Americans that have pre existing conditions. In truth, the Kaiser Foundation estimated in 2019 that 54 million Americans had a preexisting condition; so Joe did exaggerate. Joe tried hard to have a debate, but in the face of the president’s withering attacks and unwillingness to abide by the rules of a fair debate, he did sling some mud of his own in a futile attempt to get the president to back off.
Perhaps Cunningham’s most significant criticism of Biden concerned his defense of his healthcare plan. Here is her reproduction of the three way exchange between BIden, the president, and Biden.
Biden didn’t accurately describe his own health-care plan.
His signature proposal is to create a government-run, “public option” plan which would be available for any American to purchase on the individual ACA marketplaces, alongside the existing private options.
But Biden claimed the public option would be available only to low-income Americans already eligible for the Medicaid program. He was responding to a question from Wallace about whether a public option would essentially cause private plans to shutter.
“It’s only for those people who are so poor they qualify for Medicaid they can get that free in most states, except governors who want to deny people who are poor Medicaid,” Biden said. “Anyone who qualifies for Medicaid would automatically be enrolled in the public option. The vast majority of the American people would still not be in that option.”
In retrospect the most significant moments in the debate only secondarily impact healthcare. The most discussed moment from the debate came when Chris Wallace asked the president if he would condemn violence from the far right white supremacists. His response was in essence just the opposite of a condemnation. His command to “the proud boys” to “stand back and to stand by” was in fact an endorsement that has produced substantial speculation about far right interventions during the election. What might happen if the president refused to accept the results of the election? The question that the president evaded that concerned me most was whether or not he would accept the results of the election if he lost. Again, as when asked before, he refused to confirm that he would accept the results. If you have the nerve, I would suggest that you read Barton Gellman’s article in the Atlantic, “The Election That Could Break America : If the vote is close, Donald Trump could easily throw the election into chaos and subvert the result. Who will stop him?” If you don’t have the nerve to read the article, you could listen to the interview of Gellman by Dave Davies on NPR’s Fresh Air which aired yesterday. What lies ahead for all of us may be more disturbing and long lasting than the impact of the pandemic.
It is impossible to know if there will be second and third debates. If the president does not contract COVID my guess is that we will see more. In the past the second and third debates have often been different from the initial debate. I hope that will be true this time around. The debate commission is wise in its desire to make some changes, but apparently the president is not interested.
I doubt that we will ever have a substantive healthcare discussion between the candidates during the remainder of the campaign. Trump has no plan other than canceling the ACA in the Supreme Court. He will continue to claim that Biden will introduce socialized medicine. Biden will continue to demonstrate how the president has failed us in the management of the pandemic, and Trump will continue to claim remarkable achievements. Despite it all, I will continue to watch, and hope against growing fears that Trump will be victorious. I favor an efficient migration toward universal coverage through some sort of Medicare For all, but I can accept that the next incremental step in that direction might be something like a “public option.”
My fear is that somehow Trump steals the election as our democracy dies. He does not have a healthcare plan, and other Republican leaders have failed to give him one. In my nightmare, millions of disadvantaged American have no access to care. Hospitals would have mounting bad debt. We would become more fragmented coming down from what we were trying to do to realize the Triple Aim than we were in the sixties before Medicare and Medicaid became law. It’s a dystopian view of the future, but after last Tuesday’s debate that dystopian future is a plausible possibility.
Traveling West Across “Fly Over” America
The cornfields of the Midwest and the vast emptiness of Eastern and central Wyoming are behind us. I am writing to you by the banks of the Wind River. We are near the little town of Dubois that calls itself the gateway to the Grand Tetons and Yellowstone. Over the weekend we will be exploring Yellowstone and then head south through Jackson Hole toward Salt Lake City, and then on to California.
Since we are practicing an extreme form of social distancing, we have missed the opportunity to do most of the usual tourist activities. We have visited no museums, gift shops, or visitors centers. We are resigned to the reality that if we did much more than look from a distance, we might as well have gotten on an airplane
Wyoming seems to demonstrate little interest in the election. We saw only three Trump signs between Nebraska and the Wind River. We were amused and delighted to see two “homemade” Biden 2020 signs. One was in big pink letters three feet high paint on the back of a rusted out mobile home sitting near the highway. The other one was smaller. Just a homemade sign painted on a sheet and hung on a fence that I saw as the highway passed through the Shishone Indian Nation. Both signs were welcome indicators of possibility.
The scenery is spectacular. The land is vast. It should not be hard to be great with all that we have. Sometimes it is hard to understand just how we have gotten to where we are.
I have enjoyed walks in spectacular places each evening as we stop a little closer to our goal. The leaves of the cottonwood trees are turning yeIlow. There is color everywhere. What I am really looking forward to is walking in the California coastal redwoods next Tuesday or Wednesday.
Be well! Enjoy the fall. When you are out and about, wear your mask and practice social distancing as best you can. Look for opportunities to be a good neighbor. Let me hear from you. I would love to know how you are managing the uncertainties of our times,
Gene
