13 September 2019
Dear Interested Readers,
Looking For Answers While Hoping A Leader Might Emerge From A Raucous Conversation.
I made the mistake of waiting until I had witnessed the third Democratic debate last night before writing this letter to you. I had hoped, but really did not expect, that it would be a more interesting exercise than the first two debates. My wish was not totally absurd since the number of participants had been reduced to the ten candidates who could meet significantly more selective requirements.
After all ten candidates gave their introductory comments, George Staphanopoulos devoted the next half hour to quizzing the candidates in a healthcare discussion. It was not a conversation that introduced any new ideas. I was bored listening to each candidate give homage to President Obama and the achievements of the ACA, and then try to distinguish themselves as the one with the right approach to move us toward universal coverage. There were spirited exchanges between Sanders, who favored an immediate move to a single payer “Medicare For All” system, and Joe Biden who advocates building off the accomplishments of the ACA by challenging employer financed commercial insurance to compete with a “public option,” the so called “Medicare For Those Who Want It” proposal.
I can put the discussion in terms of football strategy. The debate seems to be over whether to throw the long pass hoping to score with one big play versus the more patient strategy of working your way down the field with a sustained drive of short passes and a bruising ground game. The problem that I had was that the discussion did not advance the resolution of the question of who our quarterback should be.
I could carry this football metaphor a long way, but I will leave it after expressing the firm conviction that the real question that each candidate needs to answer is to describe what course they would pursue if the first play they called did not work. After the first debate, Kamala Harris was burned by criticism from other candidates and the press when she recognized that some sort of transition plan was necessary for migration from our current dysfunctional system toward a publicly funded system that covered everyone. Whether Medicaid For All or Medicaid For Those Who Want it should be the objective is a tactical discussion. All candidates would say that the goal is universal coverage. They would all agree that the cost of care paid by consumers should go down. It is interesting that no candidate has suggested that the ultimate objective is the Triple Aim: better care for the individual, a healthier community, reduction in the cost of care to sustainable levels. Lowering the expense of care for individuals is not the same as lowering or stabilizing the cost of care for the nation. No candidate has specifically suggested that our strategic goal is much greater and more difficult to achieve than universal coverage. Amy Klobuchar went so far as saying that doing away with commercial insurance was a bad idea. She is definitely playing for the support of middle aged, middle class, middle America.
I like the idea that is imbeded in Bernie’s Medicare For All that in the optimal system of care any person would be able to see the clinician of their choice, and that there would be no charge at the point of care. I disagree with the finance system of his plan because it preserves Fee For Service payment as the finance mechanism of that system. I know that if the finance mechanism of such a system is Fee For Service payment directly to individual clinicians the cost will be prohibitive, and it is likely that the recent gains in quality and safety would be in jeopardy because those accomplishments are primarily related to changes at the “systems” level that could be compromised by inadequate funding for vulnerable populations. Bernie Sanders is not the only candidate who is neglecting the necessity of addressing the need to move away from Fee For Service compensation. No candidate mentioned healthcare finance beyond the pointless discussion between Bernie Sanders and Joe Biden over whose plan would cost more over the next decade. The correct answer is that as presented both of their proposals would likely be so expensive that no amount of taxing billionaires would generate enough money to allow appropriate investment in education, housing, job training, universal day care, public support of higher education, and the other needed programs of infrastructure development and efforts to fight climate change. Universal access for individual care is unlikely to improve the social determinants of illness.
It’s not just Joe and Bernie that are coming up short. No candidate has integrated the cost of care with the concept of how care is delivered, and the need to improve the social determinants of health for the whoile population. Most of the candidates will say that they support the Green New Deal, which does seek to integrate healthcare with other approaches to sustainability, but they do not demonstrate that understanding in their debate. By continuing the circular conversation that has run now through the first three debates they are missing an opportunty to use the debates to educate the public. I fear that deficiency is not a function of the fact that they are concerned that it would be too “wonky” or complicated for the average voter to consider. I have the bias that they don’t discuss the relationship between the organization and delivery or care, the cost of care, and other challenges because they don’t fully understand the importance of the hard work of lowering the cost of care, or they don’t comprehend its importance.
President Obama may not have understood all the complexities of care delivery and finance. An incomplete understanding of the complexities of healthcare was perhaps the origin of his disastrous statement that the ACA would allow you to keep your health plan if you liked it. Obama did engage experts like Zeke Emanuel who did understand the need to use the power of federal funding of public programs to move away from Fee For Service finance. Those policy advisors did try to incorporate strategies to promote the transition to value based reimbursement into the design the of the ACA. The ACA was never a final solution. It was always a first step in the right direction.
I believe that a better day is coming in healthcare because of the marginal successes of the ACA. The public is gradually coming to appreciate the importance of everyone having access to better care. I say this even though we have recently learned that for the first time since the ACA was passed the number of American with healthcare has gone down. There are several attempts to explain this disappointing result that you can review on the Internet. The highest rates of uninsured are still in the states that have declined the Medicaid expansion offered in the ACA. There are still racial differences in coverage. The link above is to a Vox article that reports that 5.4 percent of white non-Hispanic people are uninsured, while 9.7 percent of African Americans, and 17.8 percent of Hispanic Americans still lack coverage. The breakdown of the numbers also suggests that some participants in the exchanges have dropped their coverage after the tax bill of 2017 disallowed the mandate. The explanation for the decline in coverage must also include consideration of the fact that the Trump administration has used almost every administrative move at their disposal to undermine coverage or complicate the process of enrollment in the exchnges of the ACA.
My belief in a better future is supported by my belief in the momentum and the power of an idea whose time has come. The accomplishments of the ACA are not limited to the number of people newly enrolled. It is likely that its greatest accomplishment is the wide acceptance of the idea that everyone is entitled to care. There is clear evidence that Millenials, born between 1981 and 1996, and their younger sibs in Generation Z who were born after 1996 are more empathetic and community oriented than the “me first individualism” of the baby boomers (1946-64) and the Gen X ers (1965-1980). There are early suggestions in data from the Pew research center that Gen Z ers and Millennials will have substantially more liberal and empathetic political profiles than earlier generations. Quoting from the Pew report:
No longer the new kids on the block, Millennials have moved firmly into their 20s and 30s, and a new generation is coming into focus. Generation Z – diverse and on track to be the most well-educated generation yet – is moving toward adulthood with a liberal set of attitudes and an openness to emerging social trends.
On a range of issues, from Donald Trump’s presidency to the role of government to racial equality and climate change, the views of Gen Z – those ages 13 to 21 in 2018 – mirror those of Millennials.1 In each of these realms, the two younger generations hold views that differ significantly from those of their older counterparts. In most cases, members of the Silent Generation are at the opposite end, and Baby Boomers and Gen Xers fall in between.2
…majorities in Gen Z and the Millennial generation say government should do more to solve problems, rather than that government is doing too many things better left to businesses and individuals…
When we look across the podium at the Democratic debaters we see candidates from all living generational categories. Biden and Sanders, both born before 1946, are from the generation that Pew calls “Silent.” I have also heard that generation, to which I also belong, called “Traditionalists.” Elizabeth Warren, Amy Klobuchar, and Kamala Harris are boomers. Cory Booker, Beto O’Rourke, Julian Castro, and Andrew Yang are Gen X ers, and Pete Buttigieg is a Millennial. Will date of birth and a sense of generational affinity be more important when the voting begins than any espoused position on an issue? Across the list of big issues, beginning with the fact that Donald Trump is a dangerous and disgraceful occupant of the White House, there is more concordance on the issues than disagreement. They all want universal coverage for healthcare, a return to efforts to reverse climate change, reduction in student debt, better efforts to reduce gun violence, and the list goes on. They all have interesting personal stories, and as they were asked to do, can describe moments in their lives when they were challenged by failure, some mistake, or some other disadvantage. I could support any of them, but have an emerging preference that I will keep to myself because things might change. It is a long time yet before I will cast my vote early next February.
My local paper, The Valley News, offered a thoughtful editorial on Thursday morning: “There is no ‘normal’ anymore: Democrats must offer a new vision for the country and identify a way to get there.” The piece was in part a report on observations from the recent state Democratic Convention in Manchester that was attended by 1200 party faithful that gave all of the candidates a chance to speak. The editorial begins in an interesting way:
With Labor Day in the rearview mirror and the 2020 Democratic presidential race headed into the critical weeks leading up to the Iowa caucuses and the New Hampshire primary, Democrats are said to be divided between progressives who want to pursue a transformative agenda and those of a more moderate outlook who simply want things to go back to the way they were in 2016 b.T. (before Trump).
The big issue is not a real issue. It is the issue of “principles” versus “electability.”
Several of the progressive favorites (Elizabeth Warren, Julian Castro and Bernie Sanders, to name three) explicitly urged those attending not to play it safe when choosing a candidate, thus implicitly seeking to erode the central argument for the candidacy of the putative front-runner, former Vice President Joe Biden: electability.
Elizabeth Warren pushed backed most effectively on the “electability” discussion which would be impossible to review in a debate:
“There is a lot at stake, and people are scared. But we can’t choose a candidate we don’t believe in because we’re scared. And we can’t ask other people to vote for someone we don’t believe in.”
The obvious counter to that is, “Do you mean that you are willing to lose to be faithful to a principle.” It is a tough question, but I have got to believe that any Democratic candidate who ran an effective campaign that turned out all of the traditional Democratic base and the disgusted independents could win, and that the “electability” choice is likely to backfire, as Warren suggests. It smells too much like the establishment advantage that gave the 2016 nomination to Hillary Clinton.
The editorial got it right I think when it wrote:
But “safety first” is not a prescription for generating a lot of grassroots enthusiasm, leading some Democrats to worry that the safe choice might actually be a risky bet.
I agree with the idea that choosing a “safe” candidate is possibly a failing strategy. If Joe Biden becomes the nominee, I hope it will be because the process has led to the judgement of the electorate that he is the best candidate to lead continued progress, and not because he is “safe.”The editorial then makes two great points that drip with wisdom and are, I believe, correct assessments of reality. I have bolded big ideas:
- First, nostalgic yearning aside, Democrats must surely recognize that there is no normal in American politics that can be returned to. The mold was cracked even before Trump smashed it, and it must be recast in a new form. There’s no going back to the time when bipartisanship prevailed at the end of the day and the nation’s business got done. So, too, have the norms of political discourse and behavior been shattered in the age of social media; it’s impossible to imagine that a return to civil discourse is just a matter of unseating Trump. No new Democratic president — whether it be Biden or one of his rivals — is going to magically bring together a bitterly divided people and forge a newly unified nation. That is not a dream; it’s an illusion. Whoever is elected will have to navigate uncharted political waters, full of dangerous shoals.
- Second, even if there were a “normal” to revert to, it must be remembered that that normal gave rise to a large number of embittered Americans who felt left behind as the rest of the country moved ahead, and who were primed to respond to the politics of grievance exploited so deftly by Trump.
After making those two points they finish with well articulated wisdom:
Returning to that normality ought not and cannot be the goal of any of the Democratic candidates. Their job is to imagine a new normal and articulate a path of how to get there; the voters’ job is to assess how well those visions mesh with the times and how realistic they are.
Biden is right that what matters most to the country next year is defeating Trump. But Sanders was right, too, when he told the crowd Saturday, “Frankly, it is not enough just to defeat Trump. We must do much, much more.”
The good news and the bad news is that there will be more, a lot more. The next round will be on October 15 and possibly 16 “somewhere in Ohio.” Two nights may be necessary since Tom Steyer has risen in the polls enough to qualify for the next round. We will have many more debates going through the fall and into the dead of winter. I love the 19th century carol, “In the Bleak Midwinter” written by Christina Rossetti. The words create a powerful image for me, and the melody enhances the sense of weariness and impending loss that frequently gets us down in winter:
In the bleak mid-winter
Frosty wind made moan;
Earth stood hard as iron,
Water like a stone;
Snow had fallen, snow on snow,
Snow on snow,
In the bleak mid-winter
Long ago.
Well, I think the primaries are set up to arrive at a conclusion about who the Democratic candidate will be sometime in the bleak midwinter, or at the latest, before the winter is over. Perhaps sometime in the bleak midwinter after we gain a little clarity about who the standard bearer will be, we will learn with greater detail how that person plans to build the case for better healthcare. Perhaps then when the issue is no longer “who” but is finally “what,” we will hear a better discussion of how to win support from the wider public for the values of the Triple Aim. Knowing who that person will be may seem like a moment that is a long time coming, but it will be here before the next baseball season starts!
Beauty Observed As The Seasons Change
Technically, we have another nine plus days of summer. The autumnal equinox will occur at 3:50 AM EDT on September 23rd. As I have said before, summer really ends at 6 PM on Labor Day. That was true for me again this year. It’s been chilly and fall like where I live since Labor Day. Some nights, the temp has dropped into the forties and although we have had one or two days with clear skies and bright sun, on most of those days there has been a chilly breeze. The majority of our days have been overcast, and it feels like we have had more rain than usual, perhaps the flame out of the northern demise of hurricane Dorian is the explanation for what I have observed.
The header for this post was taken over the Labor Day weekend, so it was one of my last pictures of the summer. My wife and I spent most of the Labor Day weekend with friends down on the proximal end of Cape Cod in Falmouth. The picture of this beautiful monarch butterfly was taken in the “pollinator garden” of the good friends that we were visiting. Their garden is just a few yards from historic Siders Pond (named for Consider Hatch, an early resident of Falmouth) that stretches from the center of town toward Vineyard Sound.
I see monarchs in my garden, but not as many as my friend has in her “pollinator garden.” Their garden is a large plot of beautiful colors. It is full of phlox, the pink flower being visited by the butterfly, and also has black-eyed Susans, moth mint, milkweed, bee balm, autumn sedum, and pink knockout roses. I wish that it was true that everyday I could pull up a comfortable lawn chair to a spot near that garden, or one like it, open a good book, and then be distracted by the sight of such a beautiful butterfly as it flutters from one flower to the next. But, that is not reality. Soon, the big deciduous trees that frame the garden and the shores of Siders Pond will begin to show their colors. The seasons are changing once again, but with luck we will have a few curtain calls from summer. I am hoping to enjoy a reprieve from the evening chill and the overcast skies this weekend. Seeing a butterfly would be a nice addition to a curtain call from summer. I hope that you will be out and about in warm sunshine, and might also see a magnificent monarch.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
