Joe Biden has won the presidency no matter what Donald Trump says or does, but the road ahead will be difficult for him and for all who were hoping that all the damage done to dreams of healthcare as a right for all who live in America, affordable universal coverage, and the Triple Aim could be quickly repaired. I am reminded of a piece of satire that appeared in The Onion shortly after Barack Obama won the presidency by defeating John McCain in November 2008, the article was brief and entitled “Black Man Given Nation’s Worst Job.”
WASHINGTON—African-American man Barack Obama, 47, was given the least-desirable job in the entire country Tuesday when he was elected president of the United States of America. In his new high-stress, low-reward position, Obama will be charged with such tasks as completely overhauling the nation’s broken-down economy, repairing the crumbling infrastructure, and generally having to please more than 300 million Americans and cater to their every whim on a daily basis. As part of his duties, the black man will have to spend four to eight years cleaning up the messes other people left behind. The job comes with such intense scrutiny and so certain a guarantee of failure that only one other person even bothered applying for it. Said scholar and activist Mark L. Denton, “It just goes to show you that, in this country, a black man still can’t catch a break.”
The Onion joke turned out to be more than funny, it was prescient. Things were hard from the start for President Obama as he sought to pull the nation out of the Great Recession and deliver on the progressive platform which he had offered as “hope and change.” Despite the dire state of the economy he immediately encountered very effective resistance from Republicans who rejected outright his efforts at a bipartisan approach to governing. After spending most of his political good will passing the “American Recovery and Reinvestment Act of 2009” and the Affordable Care Act in March of 2010, his political capital was exhausted. Despite attempts to involve Republicans in the writing of the Recovery Act only three Republicans senators, Arlan Specter, Susan Collins, and Olympia Snow voted for it, and to do so they extracted huge costs. To get the ACA passed Obama had to eliminate many important parts of the original proposal including the demand by Joe Lieberman of Connecticut that he drop “the public option.” Republicans demanded changes that they got in committee but then voted against the ACA when it came to the floor of the Senate. All of this difficulty occurred even though in 2009 and 2010 the Democrats held commanding majorities in both the House and the Senate.
The environment of resistance was dramatically underlined by Sarah Palin’s taunt of Obama and Democrats to the delight of right leaning tea party Republicans when she said at a big rally in the run up to the 2010 midterms: “How’s that Hopey-Changey stuff workin’ out for ya?” The Democrats lost the House a few months later and almost everything that was positive that happened over the next six years was accomplished by executive orders that were quickly reversed by Donald Trump. The job that Joe Biden faces has got to be recognized as an even greater lift than the one that faced Barack Obama when many of us were filled with hope for change as he took the oath of office on a cold January day in 2009.
The good news for those who worry about the future of healthcare and desire passage of a progressive agenda that addresses inequities and limits the damage to the planet is that it is possible that the slow drip of losses and embarrassing departures from normative behavior that we have endured over the last four years of losses will stop with the likely inauguration of Joe Biden as the 46th president on January 20, 2021. That statement assumes that the Supreme Court will limit the damage to the ACA when it renders its opinion on the challenge that it heard on November 10. The bad news is that the road ahead will be much more difficult than the experience of President Obama in 2009-2010. The gains that might be accomplished through new legislation will be limited. On November 4th when it seemed likely that Joe Biden would get to 270 votes and win the election, but the early results suggested that it was likely that the Republicans would retain control of the Senate, Julie Rovener of Kaiser Health News wrote a piece entitled “A Biden Win and Republican Senate Might Lead to Gridlock on Health Issues.” She wrote:
Former Vice President Joe Biden appeared to be inching toward the 270 electoral votes needed to win the presidency Wednesday afternoon, but at the same time it was becoming clearer that Democrats would not take back the Senate majority they lost in 2014. If that bears out, it could well be a prescription for gridlock on health care.
Now about four weeks after Rovner published her piece, we all know that short of a constitutional disaster Joe Biden will be the next president. The Senate remains as the greatest uncertainty and the best that Democrats can hope to achieve is the slimmest possible margin for control of the Senate–fifty seats plus the vice presidency. To avoid certain gridlock we now must hold our breath waiting for the runoff elections for two Senate seats in Georgia.
It is a reality that there is power in the presidency, but it is also true that there is enough power in a Senate or House majority to stymie the legislative agenda of any president. It is good to remember the great joy Democrats experienced when they regained control of the House in 2018 which enabled them to block Trump’s further legislative attempts to dismantle the ACA, and to impeach him. In our form of government it is much easier to prevent things from happening than it is to make things happen. 2018 presented the Democrats with exactly the same opportunities to resist the president that the Republicans gained when the “tea party”movement in 2010 allowed Republicans to regain the House with a victory that gave them 63 new House seats. With that loss Obama’s ability to pass progressive legislation ended. After the Republicans gained control of the Senate in the 2014 elections things were even worse for Obama’s promise of hope and change. Not only was he blocked from passing effective progressive legislation, he could not even name a new Supreme Court justice and have the nominee get a Senate hearing. Both the Republicans and the Democrats have learned that the most practical path to power is not through bipartisan efforts but through resistance that frustrates the will of voters. Voters have not learned to reward attempts at bipartisanship, and do not vote against a party that does not participate. They just vote for results, and if the road is blocked and results are not forthcoming, they will vote out party that was unsuccessful in achieving a bipartisan outcome, and as Mitch McConnell has learned, vote the party that resisted cooperation and was the cause of the gridlock back into office. Go figure. Like the song says, “When will we ever learn?”
If even one of the Senate seats up for election in Georgia on January 5th goes to a Republican candidate, we will be doomed to at least two more years of “gridlock.” If my opinion is correct that many Americans hold the president and his party accountable for progress toward the promises that were made during the campaign, and vote against the party and the president when results are not forthcoming, over the next four years we are unlikely to see any significant new healthcare legislation. As Julie Rovner says deeper into her article:
Without a Democratic majority in the Senate, Biden as president could not likely advance many of his top health agenda items — including lowering the eligibility age for Medicare to 60, expanding financial assistance for health insurance under the Affordable Care Act, and creating a “public option” government health plan…
Even if Biden wins, this is not the outcome Democrats were hoping for — and, to some extent, expecting, based on preelection polling. Andy Slavitt, who ran the Centers for Medicare & Medicaid Services during the Obama administration, noted that frustration in a tweet Wednesday. “A large disappointment is that many hoped for a significant repudiation of Trump & his indifference to human life, human suffering, his corruption, and goal of getting rid of the ACA. No matter the final total it will be hard to make that claim,” Slavitt said.
The reality of how the public responds to gridlock, and the fact that they seem to reward the resistors to progress makes me doubt that a majority of American voters had a civics course in high school. I wonder if a critical number of voters remembers Dave Frishberg’s 1976 ditty on “schoolhouse rock,” about how a bill is passed. If you never saw the video or heard the song I’m Just A Bill,” click here. The video and the song describe the process, but they leave out what is perhaps the biggest threat to the opportunity for progressive change and that is the “filibuster” in the Senate. If you are one of the several million Americans who are reading or listening to former President Obama’s new book, “A Promised Land,” let me refer you to pages 241 to 243 where he succinctly describes the history of bipartisanism and the Senate filibuster. The reality of the filibuster means that the real benefit of the Democrats winning in Georgia and controlling the Senate will not be to pass progressive legislation but rather it will allow them to have a chance to ratify judicial appointments and other positions that require Senate approval because under Harry Ried when the Democrats last controlled the Senate they cancelled the filibuster for appointments. This move came back to bite them in the form of three Trump nominations to the Supreme Court that were confirmed with simple majorities, Neil Gorsuch, Brett Kavanaugh, and Amy Coney Barrett. A host of other federal judges have now been confirmed that probably would have been rejected or blocked had the filibuster for appointments persisted. If the Democrats do gain a majority in the Senate they could, if they all voted together, exercise the “nuclear option” and end the filibuster once and for all.
This is a pivotal moment. What happens on January 5th in Georgia will be like coming to a fork in the road. If both seats go to the Democrats the job and the decisions that face Biden will still be hard but the road leads to more opportunity. If the Democrats lose one seat or both, I am sure efforts at bipartisanship will continue, but gridlock with perhaps a few pieces of legislation around the edges where there is a recognized consensus and a clear public will like trying to lower the cost of drugs could still be possible, but real progress will probably not occur at the national level, which does not preclude efforts to improve access and costs at the state level, but that will mean a continued state of huge variation in access and quality of care across the country.
As I was writing this note with its mixed message of positive and negative possibilities and expectation of continuing difficulty, I asked myself what I was thinking four years ago in the aftermath of President’s Trump’s election. The post from November 29, 2016 was entitled “Why You Should Look to Lean Between Repeal and Replace” Toward the end I wrote:
What is evolving is the picture of an interim state during which elements of the ACA may persist for up to a year and a half. As the ACA fades away, the Republicans will not have the sixty votes to move something like Paul Ryan’s plan into legislation. The midterm elections of 2018 may well be the time when the debate about healthcare will get the attention it needs and did not get in 2016. Your plans for the next two years and perhaps longer should probably include the concept of legislative chaos, but I feel that the long view may be more positive than many who are so crushed emotionally by the thought of a Trump presidency may be able to envision.
There several things that the moment should underline for all of us and that will be important in determining the process and outcome:
- Care costs too much and unless the cost comes down fewer people will be covered.
- The cost can never come down unless doctors and other professionals are working in a context that allows them time to think critically and spend more time focusing on the needs of their patients.
- The cost of care can not come down when care is delivered by a growing number clinicians who are burned out and performing inadequately. Their own despair precludes collaboration, effective interaction with patients and the ability to do the critical thinking that leads to efficient, effective care that satisfies their professional expectations and delights their patients.
- Fee for service finance aggravates the problems of cost, patient satisfaction and optimal clinical performance.
- We will never have more financial resources for the population than we have now.
- Unless we can reduce the resources per person necessary to deliver quality care, we will be delivering a lower quality of care to fewer people who will be living in a declining environment of increasingly poorer health per capita.
When we realize that the opportunities to make progress over the next two years lie primarily within organizations and not through legislation, we are fortunate that over the last seventy years we have evolved a body of knowledge that if applied to healthcare can move us toward the Triple Aim.
The article goes on from there to advocate for a focus on continuous improvement efforts. In retrospect John McCain and the 2018 election saved the ACA and forced the question of whether the ACA should exist back into the courts where it is today. The other points are also still valid. Legislation does not improve care. It can create opportunities and expand the number of Americans who have access, but the experience and cost of care remains your responsibility. It remains my bias that the pandemic has revealed many deficiencies that we as a profession have allowed to persist. While Joe Biden, Kamala Harris, and their administration do the best they can do in a difficult situation it is up to you and to me to work for improvements where we are. That has always been true. It will be true in 2022 at the midterms and again in 2024 when we vote again for president. What you chose to do now and over the next two years at home will make a difference no matter what Joe is able to accomplish even if you don’t live in Georgia.
