24 January 2020
Dear Interested Readers,
What Will The Long Term Outcome Be?
I have probably watched more of the Impeachment Hearings and Senate trial of Donald John Trump than most of my readers. Most of you work, and when you drag your weary bones home from the office, the hospital, the management meetings, or wherever it is that you go everyday, your day is not done. Many of you know that later in the evening when you open your computer, there will be work that you hope you might have the energy to finish so that you won’t start tomorrow with work that belonged to today. Before getting back to the unfinished work of this day, you must attend to the needs of your children, complete various domestic responsibilities, or find the time and energy for a little exercise. If you get through all of those responsibilities, the cycle of the daily grind will be waiting for you to start all over again tomorrow. I have great empathy for you. I have known your pain. So, knowing that your chance to watch and listen has probably been small, even if you are interested, I will try to present a balanced view of what I have seen and heard so far. I hope that writing from the perspective of someone who cares about the future of healthcare I will be able to take you beyond what you might read in the newspaper, see in the video of a news feed, or hear on NPR as you sit in traffic on your way home. I will try to insert what I have been surprised to learn, and reflect on what this historic process might mean to the future of healthcare.
Despite the fact that I was an alert “news hound” with the benefit of NPR in 1999 during the Clinton trial in the Senate, I have a clearer memory of Watergate and Nixon’s battles with Congress in 1974 than I do of the Clinton trial. In 1974, I was a fellow in Cardiology, and quite frankly the pace was not as intense for me as it had become by 1999 when I suffered from the same barriers to listening to a prolonged Senate trial that I expect encumber you now.
The world of practice changed enormously between the mid 70s and the late 90s, and I know that the intervening twenty one years have added even more complexity to the average day of the typical healthcare professional. In 1999 I knew that the president had been embarrassed by the charge that he had brought dishonor to his office by an act that would be considered in an even harsher light in the era of the “Me Too” movement. Now we question whether there ever was casual consensual office sex. Were not such encounters always a manifestation of misused power and privilege? At the time, I considered what the president had done was shameful, a violation of his marriage vows, and a huge disappointment for me and the many other Americans who believed that he was an honorable man who would not risk what he could do for the country for an inappropriate relationship. I have always been naive.
The articles of President Clinton’s impeachment were the charges that he lied under oath (perjury) and that he obstructed justice as the special prosecutor tried to investigate his abuse of his office. Less clear to me then, and somewhat confusing still, was whether or not his act of perjury, committed to try to hide his affair, was an impeachable offense. There is no question in my mind that at the time, despite the fact that what he had done was wrong and he was a source of great disappointment, I was hoping that he would be acquitted. With the perspective of the last twenty years I have second thoughts, and I am not so sure that he did not commit an impeachable offense if “no one is above the law.” Perhaps the ambiguity of this moment, and the behavior of future presidents would be less uncertain if we had applied a stricter penalty to President Clinton’s behavior.
An unresolved point of contention is just what is an impeachable offense. If you have been listening to these hearings you know that it is a pivotal question that is foundational to the arguments of each side when there is little doubt about the actual “facts” of the case. A call did occur. What was the intent of the call? Does the process of planning before and the continuing negotiations through agents of the president and with the knowledge of high officials in our own government yield any substantial evidence about the intent behind the “perfect call?” Was it an act of corruption, or a request to help fight corruption and solve a plausible question of great concern? How did the attitudes of officials with high positions within our government correspond with their responsibilities as they continued to negotiate with Ukrainians after the “perfect call’ in late July? Even if the intent was to gain advantage over a potential political opponent, is that a crime? If there is no law against what the president tried to accomplish, or if his intent was not necessarily self serving in terms of behaviors of previous presidents who tried to leverage a response from a foreign power, does what he did warrant removal from office? Republican defenders are asking the same questions in the defense of the president that I asked in 1999. Is not the whole process just the result of an intense dislike for the president and a disdainful rejection of the way he executes his responsibilities in his attempt to “Make America Great Again? Surely just breaking or disregarding norms in pursuit of the objective of your political base is not grounds for removal from office. Where does allegiance to a party’s political objectives cross a line and undermine the responsibility to uphold the values of the Constitution? These are the questions under consideration. Are we not always self serving when we attempt to decide what is fair in love and war? Is it not understandable that some would seek to stretch that concept by saying that all is fair in love, war, and politics?
Before this trial began on Tuesday, we were offered many comparisons to the Clinton trial. Mitch McConnell began the trial by offering “rules” that were ostensibly based on the unanimous accords that were used in 1999. This trial began with negotiated modifications of McConnell’s initial plans, followed by a fight over the rules that extended into the wee hours of Wednesday morning. The first deviation from the Clinton trial was that all of the questions in contention settled with 53 Republicans and 47 Democrats voting along party lines. From before the start of the trial, the opinion of most analysts has been that the outcome is likely to be determined by the same number, 47 to convict and 53 to exonerate. Republican Senators have been told that if they vote against the president’s interests at any time, “their heads will be on a pike.” That’s just a metaphor for the reality that if he is crossed, he will transmit his disdain for them to his base through his Twitter attacks, and his base will attack the offenders in Republican primaries leading to their political demise.
Even if the outcome is predetermined and unlikely to change no matter what evidence is presented or whether or not testimony from witnesses is ever allowed, it does not mean that what is happening is not important, both for the moment and for the future. We must continue to examine what divides us. We must continue to act as if we can find a way through the minefield of our disagreements. This exercise has more potential as a shared experience for the public than it does for Senators on both sides who have their own fears and self serving interests that they can rationalize. Consider that the performances we see from both sides are efforts to market a formulation that you will deem to be foundational to your own concept of what America is and should be. Perhaps its greatest benefit will be as a richly detailed snapshot that will enable future historians to understand what divided us at this time.
I have always been an enthusiastic student of American History, and I loved my eleventh grade course in civics. My experience with American history has been that the closer one looks and the more one reads, the less what actually happened coincides with what we were taught in high school. My experience with civics is that what was presented as the straight forward logic and benefit of the three branches of government with their checks and balances has been distorted by the accumulating powers of the executive branch that have been further enhanced by the divisive gridlock in Congress that prevents the unity necessary for Congress to be a counterbalance to the executive branch. Furthermore the eighteenth century pace of the court system diminishes the judiciary’s ability to be a real time defender of Congress’s rights in their disputes with the executive branch. Confusion reigns in the relationships between Congress, the Executive, and the role of the Courts. In deed, if things were looking bad for the president, were a witness or significant piece of evidence subpoenaed by the Senate, it is possible that the process could be stalled in the courts until well after the election next November. As I listen to the trial, and the associated commentaries, it is clear that everyone claims that they are defending the constitution and/or the ability of future presidents to govern. It seems that suddenly we can’t have it both ways.
Is the Constitution being used like Holy Scripture? We know that different theologians can read the same text and derive diametrically opposed conclusions. We have long known, and now see again, that legal analysts can use the same words of the Constitution on opposite sides of a critical question. Alan Dershowitz has demonstrated that one lawyer can use the same words of the Constitution to support an idea at one point in time, and argue for a different conclusion at another moment.
We all know that one of the most frustrating experiences that occurs for those seeking resolution of grievances through a deliberative procedure is to loose because “the cards were stacked against them” or because of some technicality. I think that it is possible that as Adam Schiff and the House managers prepared their presentation their expectations of “winning” were small. The logic and detail that they have presented has been impressive. The headline piece in today’s LA Times presents two important insights about Schiff and his Republican audience.
The authors, Sarah D. Wire and Chris Megerian, write about how surprisingly little consideration many Senators have given to the issues, and how effective Adam Schiff and the other House managers have been in presenting their case. Again, I have done the bolding
The House managers and Trump attorneys face an unusual test: laying out the evidence of a case to senators — some of whom may only have a vague idea of how it all fits together and others who may have already made up their minds.
“I know the House proceedings were heavily reported. But I think most, if not all, senators are hearing the case by the prosecution and the case by the defense for the first time,” Sen. John Kennedy (R-La.) said. “Senators, because they are busy being senators, have not heard the case.”
Still, several Republicans called the Schiff-led presentation repetitive, saying they haven’t yet learned anything new that makes them think Trump should be removed from office.
“I think I’ve heard everything they have to say six or eight times already,” Sen. Roy Blunt (R-Mo.) said. “It’s not a very deep case.”
Schiff has long been a favorite punching bag of Trump and of conservative media, particularly for his role leading the House impeachment investigation. And those attacks have continued this week on Twitter and Fox News. Trump on Wednesday said Schiff is a “corrupt politician.”
But while some Democrats once worried Schiff had become too much of a lightning rod to effectively participate in the Senate trial, his reviews from colleagues so far border on effusive.
Schiff’s final speech at the end of a lengthy Wednesday session laying out the timeline of the Ukraine scandal had Republican senators rapt, Senate Minority Leader Charles E. Schumer (D-N.Y.) said.
“Schiff had such power in his speech that he almost forced [Republicans] to listen,” Schumer said.
In another emotional closing statement Thursday night, Schiff urged the senators to find Trump guilty.
“No constitution can protect us if right doesn’t matter anymore,” he said. “And you know you can’t trust this president to do what’s right for this country. You can trust he will do what’s right for Donald Trump. He’ll do it now. He’s done it before. He’ll do it for the next several months. He’ll do it in the election, if he is allowed to.”
Sen. Kennedy told reporters earlier that Schiff had been “very eloquent” in presenting the case.
“Good job,” Sen. Lindsey Graham, another Republican and a staunch Trump ally and critic of the impeachment, told Schiff as they passed each other in the Capitol on Wednesday. “Very well-spoken.”
The president has been effective in widening the divide in American political thought by disrespecting and taunting anyone who offers a different opinion than his. Perhaps the first step in an attempt to close a divide is to be respectful of an opponent’s performance. Good athletes frequently demonstrate respect for their opponent’s efforts. Was that what Lindsey Graham did when he tipped his hat to Schiff? The presentations of Schiff, Nadler, and the other House managers frequently moved and informed me. We have another day of their analysis to hear. They will just be getting started when this letter arrives in your “inbox.”
I am not looking forward to the three days of rebuttal and analysis of the president’s defense team, but fairness demands that we listen to them with an open mind. The most important moment ahead lies after the defense presents its case. Will four Republican Senators join the forty seven Democrats to ask for the witnesses and documents that will corroborate or refute the assertions of the House managers? If that happens, will the new evidence change anything? If that doesn’t happen, how will the public react when recent polls suggest that over 70% of Americans want to hear what witnesses and participants like John Bolton and Mick Mulvaney have to say? If Bolton, Mulvaney and others are called to present their testimony, will Joe Bidden be called? No matter the outcome and resolution of these questions, what will be the impact on the elections in the fall? Will certain senators be held accountable for their votes? Will the electorate do what Senate Republicans don’t do?
I began by saying that the Senate trial will have an impact on the future of healthcare, and I do believe that to be more important than some people have considered. Perhaps we are not thinking about it because there is not much that any one person can do to change how it all evolves. We are like a leaf on a fast moving current of water. We are going to end up where the process takes us. Assuming that the president is acquitted, the next question is how will his “exoneration” plus his previous performance effect the election? Will there be any associated corruption of our electoral process that might impact the outcome of November’s election? If the president is reelected and the Congress remains divided we will see four more years of administrative abuse, no progressive legislation, and the future of healthcare determined by a conservative Supreme Court. Justice Roberts becomes the most powerful determiner of the future of healthcare with maintenance of a damaged ACA as the best expectation. President Trump has already announced his intention to revamp Medicare along conservative lines.
A worse case scenario, Republican control of Congress, the Courts, and the Presidency would lead to a laissez faire state of healthcare with many of our recent gains in access lost and freedom from concerns about pre existing conditions in jeopardy. At the other end of the spectrum, if the electorate is outraged, and the Democratic party does maintain its control of the House, wins a majority in the Senate, and regains the presidency, the challenge becomes whether or not they can adopt a stance that begins to give bipartisan solutions that might resolve many of our chronic concerns that include healthcare. History tells us that control of the government will change if the current trend does not cause a slide into something like the Chinese or Russian variations on autocracy. The fate of the ACA should teach us that lasting changes in social policy in a democracy survive a change in control of government only if a bipartisan consensus is achieved.
The best hope for this dramatic moment is that it represents the nadir of our slide into this latest round of national strife, and that when it is over we will be left with leadership, be it Democratic or Republican, that has as its primary objective progress toward unity, and as a derivative of that achievement, lasting improvements in healthcare that will move us toward the Triple Aim as a shared reality, and not just a distant objective of a fraction of the public.
Down On The Farm In The Winter
Everything looks different in the winter under a blanket of snow. One of the things that I love about living in a place that has four seasons is the pleasure I get from seeing how a familiar scene can vary as the cycle of the seasons turns from spring to summer, summer to fall, and fall to winter. Seasonal variation is not the end of the pleasure that we can enjoy from the world around us. The same scene offers a variety of pleasures as we go from early morning sunshine to moonlight and stars in the evening. The same place or object reveals new beauty and complexity when viewed from a new perspective.
Old familiar scenes can be surprisingly fresh with some rare combination of season, light, and viewing position. Living in a small town surrounded by land that has been undeveloped or has been allowed to return to its previous natural state after farming was discontinued has offered me a much greater variety of pleasures from nature than is possible in an urban environment, even when there a well maintained parks and public places. I have gained a new appreciation for Thoreau’s assertion, “I have travelled a great deal in Concord.” As the author of the post on Thoreau maintains:
Thoreau understood something that many of us modern day nomads would do well to recognize: travel is a matter of perspective, not location.
I offer today’s header as an example of the point I am trying to make. The picture reveals the “backside” of Bucklin Farm, as it appears in the late afternoon, under a light blanket of snow, through the bright light of a cloudless winter sky. I can always count on a dopamine release when I walk or drive past Bucklin Farm. From any angle, at any time of day, under any sky, and in any season it offers beautiful site with great complexity and the suggestion of a bygone era that is an opportunity to let one’s mind travel in time.
It’s not every farm in New Hampshire that has its history recorded in a document on the Internet. Bucklin Farm does. If you click on the link, you will see the farm in summer from the front. Bucklin Farm is on the market, and it could be yours if you happen to have a little share cash. Until about two years ago it was a working farm. It’s generous owner who is a retired businessman directed much of its production to the support of local food banks. When it was active, I enjoyed dropping by with my grandson to check out the chickens, pigs, cows, and goats. Its fields were producing vegetables for people to enjoy and bales of hay to get the animals through the winter. Its apple trees were pruned and managed for a fall harvest, and its stately maples were tapped in the early spring for making syrup, just like they had been since the main house was built in 1830.
I am sure it took a lot of work and investment to keep the farm functioning. Things change. Most of the farming I see around me these days is probably done as a “hobby.” An old New England farm is not a place where anyone can get rich, and it takes a lot of effort to get the land to yield even a marginal income. Some farms, like nearby Muster Field Farm, have become non profit educational projects.
Each time I walk or drive by Bucklin Farm, I feel a little bit like I once felt when I would make rounds on an elderly patient whose problems were accumulating in number and severity at a rate that our best efforts could not match, as hard as we might try. I fear that without someone with substantial resources who wants to live in an anachronistic way, Bucklin Farm, like my elderly patients, will soon be gone. As long as it is here, I will keep “making rounds” on it and hoping for a miracle. It remains as a majestic reminder of another era in what may be its final days.
I was looking forward to fresh snow this weekend. Now the weatherman is waffleing. First he predicted snow on Saturday and Sunday, then it was rain for both days, and now he is suggesting that we will get a little snow on Saturday. I’ll be out and about in the snow or in the rain, whatever comes, with expectations of a sudden jolt of dopamine from a soggy scene or the beauty of fresh snow. I am always open to a pleasant surprise, just as I am always open to political events defying expectations and taking an unexpected turn.
The chances are greater that the world might surprise you with unexpected beauty, if you are out and about enjoying the world. If you have some spare money for investment in a piece of Americana and like to milk cows and eat the eggs your own chickens laid, let me know, and I will be delighted to point you toward Bucklin Farm, and connect you with its current owner who is a very nice man who might cut you a good deal if you are willing to become its next custodian.
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
