26 April 2019
Dear Interested Readers,
Hello Joe, I Don’t Trust Mitch, And Other Post Op Thoughts
There is nothing that gets you thinking about the future of healthcare in America and what needs to change, like a personal encounter with our healthcare system, or to hear that yet another friend or family member has cancer. This week I have had both experiences. My encounter with the healthcare system went well. I had an outpatient laparoscopic hernia repair under general anesthesia at Dartmouth Medical Center. They were very efficient, and everyone was quite professional. What did not go well was my bladder’s response to anesthesia. I needed to go the emergency room about twelve hours after I was discharged. All is well now. I have “tested” the system and it worked for me. One of the things I like about where I live is that I am only three minutes from our local Dartmouth affiliated “critical access” hospital. By this time a year from now, it will be on Dartmouth’s Epic EMR.
While I was dealing with self limited annoyances, I learned that a close friend on the West Coast has a new cancer diagnosis. Just last week I got the same news about a member of my extended family. Both men are the picture of health, but it just takes a diagnostic second to go from being “healthy” to having a“pre-existing condition” that once would have made you uninsurable.
Years from now when historians look back on the successes and failures of the Affordable Care Act, I doubt that they will conclude that it made healthcare affordable, but I am sure that they will note that it was the beginning of a complex process of improvement that was accomplished over years of divisive political discourse that gradually educated the public and eventually resulted in the general acceptance of access to quality healthcare as a civil right for every American. Â An important early step was the election of 2018 when the voters first demonstrated an understanding that access to healthcare should not be blocked by a history of illness or the possibility of a condition that is a risk for insurance. The importance of insurability for those with pre-existing conditions was such a potent political issue that many of the Republicans who continued to favor repealing and replacing the ACA were trying to give the appearance that if they were successful in canning the ACA, they would protect people with pre-existing conditions. Â In October 2018, before the election that gave the House back to Democrats, Margot Sanger-Katz wrote in the New York Times:
Republicans in Congress have recently come forward with limited legislative proposals to ensure some pre-existing conditions protections if the health law is overturned. One, a House resolution, would have no force of law, even if adopted. The other would contain a significant loophole: Insurers would have to cover those with pre-existing illnesses, but would not have to cover care for those particular illnesses…
We can now conclude that the Democrats won back the House because a majority of voters cared about healthcare, and did not trust the Republicans. After the election and when the president supported the legal case that the Attorney General of Texas brought arguing that the ACA is unconstitutional without its mandate, the president proclaimed that he would ask Republicans to produce a bill that protected those with pre-existing conditions and provided better, less expensive care than the ACA. Nobody, including Trump’s base believes him when he says anything about healthcare except that “it’s so complicated..,” and that he hates Obamacare.
Mitch McConnell quickly told the president to give up trying to come up with a new health plan and focus on knocking down Medicare For All as a too expensive and too risky a step for the nation to take. Is that a victory for the ACA? Probably not, and if Kavanaugh, Gorsuch, Alito, Thomas, and Roberts do decide the ACA is unconstitutional, we are back to 2009 when there were almost 50 million Americans, over 16% of the population, without healthcare insurance when Obama began the work that produced the ACA, and gave coverage to over 20 million people, cutting the uninsured rate to under 9%. What keeps me upset more than the continuing increase in the cost of care is that even if the ACA is upheld, there will still be almost 30 million Americans, our most vulnerable citizens, without healthcare.
The is no question in the run up to the 2020 presidential election healthcare will remain one of the top issues that will be debated, and that is what worries me. Let me explain by presenting a point of view extracted from polling data from the Kaiser Foundation published just this week. Based on the data from their survey, the Kaiser opinion was:
Most Do Not Want the Supreme Court to Overturn the ACA or its Pre-Existing Conditions Protections
However under that banner they continued by saying:
When it comes to tackling pressing health care issues, incremental actions to address personal health care costs take precedence over broader, more partisan reforms for most Americans…
There is a growing preference for Medicare For All, but it is vulnerable. What people really want are cheaper drugs, continuing protection of insurability with pre-existing conditions, and protection from “surprise medical bills.” Perhaps a small majority thinks that they want Medicare For All and only Republicans continue to want to repeal the ACA.
The analysts at Kaiser sum up the findings:
As policymakers jockey over Medicare-for-all proposals and the legal and political fate of the Affordable Care Act, the public is more likely to choose lowering prescription drug costs (68%), continuing ACA protections for people with pre-existing conditions (64%) and softening the financial blow of surprise medical bills (50%) as top priorities for Congress. The April poll finds that fewer Americans say implementing a national Medicare-for-all plan (31%) or repealing and replacing the ACA (27%) should be a top priority.
Larger shares of Democrats say continuing the ACA’s protections for people with pre-existing conditions (82%) and implementing a national Medicare-for-all plan (47%) are top priorities, while about half of Republicans (52%) say repealing and replacing the ACA is a top priority.
The Kaiser data seems to support McConnell’s view that the president’s best strategy is to focus on attacking Medicare For All. The Republican priorities are to keep healthcare as a profitable business, and curtail entitlement spending on Medicaid and Medicare.  McConnell seems to be suggesting that the president do what he does best, attack progress and induce fear. He is advised not to offer promises to a more enlightened public that Senate Republicans don’t intend to keep. It would appear that McConnell’s strategy is based on the cynical position that Americans are always vulnerable to anything that induces fear. Getting healthcare from our employers may be getting more expensive, the system may be clunky, there may be tens of millions of our neighbors without care, but McConnell probably figures more voters will want the status quo rather than pay more taxes and trust that the government will give them what they really want after putting all the commercial insurance companies out of business. McConnell seems to know that since the president can’t win if it depends on delivering something valuable, his better choice is to attack rather than propose.
The Democratic Party has been the source of progressive ideas and efforts for a better society since FDR’s New Deal in the dark days of 1933 when banks were closing and 33% of the population was unemployed. Even at the depths of the depression many of the 67% of Americans who were still employed were apprehensive about a government take over of the economy and the Supreme Court blocked many of FDR’s proposed programs. Winston Churchill was not all wrong when he implied that Americans do the right thing after they have tried all the wrong things. What we really do is spend a very long time getting up the courage to do the right thing when there is the possibility that it will result in some redistribution of income, increase in taxes, or threat to the status quo of the business environment. McConnell knows that when it come to what Americans don’t like, Medicare For All scores a hat trick.
Having twenty plus Democratic candidates debate healthcare will be interesting for policy wonks, but my prediction is that the general public will become confused, disoriented, and ultimately distracted. The field is sorting out into a wide spectrum of opinions. Earlier this month the Washington Post offered a guide to the range of healthcare proposals from the 16 candidates that were announced at the time. The recently announced candidates, like Seth Moulton and Joe Biden, have slotted into that same spectrum. There are now twenty one candidates all of whom favor some form of universal healthcare. Politico offers a less detailed discussion on healthcare, but gives an overview of where all the candidates stand on the range of big issues.
In the Washington Post piece, Medicare For All with the total abolition of commercial insurance (you know that won’t happen) is the most far reaching proposal. There is great support for hybrid offerings like programs offering Medicare For All with the persistence of commercial insurance either as “wrap arounds”, purveyors of something like Medicare Advantage, or as completely alternative private pathways. There are some who favor a “public option” on the exchanges. Joe Biden joins others who form the less dramatic and controversial end of the spectrum by being specific about favoring universal coverage and protecting those with pre-existing conditions, but accomplishing the objectives with the less radical process of further modifying the ACA.
The Democrats are in a precarious position. Each candidate wants to be creative and to separate from the pack by offering a better specific idea. There is great merit in policy debates, but twenty one people presenting and debating very specific potential solutions to complex problems may produce more confusion than change. Change in a time of deeply divided partisan positions becomes possible only after one party gains the presidency, the House, and at least sixty Senate seats. Debating the principles of universal healthcare, focusing on the complexity of the problems to be solved, and explaining the merits of the objectives of the Triple Aim would continue the education of the voters and make the eventual candidate less vulnerable to the attack strategy that McConnell suggests to the president, than is debating specific details of solutions.
Bernie Sanders’ Medicare For All concept still needs lots of work on the finance side. His lack of clarity about the potential expense of his Medicare For All concept and who will pay for it make the idea vulnerable to attacks. Being more specific also has its problems since it provides more ammunition for attacks from other Democratic candidates and the president. In a recent Vox article Sarah Kiff does a great job of framing the proposal in its latest iteration, and lays out the potential finance mechanisms that Sanders or others have proposed. Kiff writes:
The Sanders plan goes into great detail on what kind of coverage a universal plan ought to offer. But it does significantly less work explaining how this would be paid for. Instead, Sanders’s office released a paper that included this bullet-point list of possible options:
- Creating a 4 percent income-based premium paid by employees, exempting the first $29,000 in income for a family of four
- Imposing a 7.5 percent income-based premium paid by employers, exempting the first $2 million in payroll
- Eliminating health tax expenditures
- Making the federal income tax more progressive, including a marginal tax rate of up to 70 percent on those making above $10 million
- Making the estate tax more progressive, including a 77 percent top rate on an inheritance above $1 billion
- Establishing a tax on extreme wealth
- Closing a tax-loophole that allows self-employed people to avoid paying certain taxes by creating an S corporation
- Imposing a fee on large financial institution
- Repealing corporate accounting gimmicks
Biden has a long past history to defend including his conduct of Anita Hill’s appearance before the Senate Judiciary Committee almost thirty years ago (1991) during the confirmation process for Justice Clarence Thomas to the Supreme Court. More recently the former VIce President has had some complaints from women about unwanted touching and he will be challenged about his support of anti crime bills in the 90s that have resulted in the disproportionate incarceration of young black men. Biden is now the frontrunner because of his experience in both domestic and foreign affairs. He is a very likeable guy who is more open and expressive than many politicians, and if you listen to his video announcing his candidacy he makes it clear that he is running to beat Donald Trump and restore benefit to the working people of America. He is “in a battle for the soul of the nation.” He has his “eyes on the prize” of protecting America from another devastating four years of Donald Trump.
I believe history will look back on four years of this president and all he embraces as an aberrant moment in time. But if we give Donald Trump eight years in the White House, he will forever and fundamentally alter the character of this nation — who we are — and I cannot stand by and watch that happen. The core values of this nation, our standing in the world, our very democracy, everything that has made America, America, is at stake.
That’s why today I’m announcing my candidacy for President of the United States.
The New York Times offered an annotated version of the announcement. At this point in the four minute speech Alexander Burns writes:
Mr. Biden is raising the stakes for the Democratic primary and making explicit what most Democrats already believe about the implications of the 2020 race. And he is implicitly asking Democrats to consider, above all else, which candidate appears best equipped to win. Mr. Trump’s presidency, he is saying, can be a somewhat brief, regrettable experience or a turning point in American history, and making him an aberration is more important than any other issue.
Biden very effectively ends his speech with a counter to Trump’s MAGA rhetoric:
Folks, America’s an idea, an idea that’s stronger than any army, bigger than any ocean, more powerful than any dictator or tyrant. It gives hope to the most desperate people on earth, it guarantees that everyone is treated with dignity and gives hate no safe harbor. It instills in every person in this country the belief that no matter where you start in life, there’s nothing you can’t achieve if you work at it.
Burns inserts:
This is the rhetoric of restoration, a kind of anti-Trump version of “make America great again.” Mr. Biden is asking voters to see him as a way of bringing back normalcy — and a version of normalcy that draws heavily on many voters’ favorable memories about the Obama administration. What’s not here yet: a sense of Mr. Biden’s forward-looking vision for the country.
We are left to hope that he is also concerned about the nation’s health. He never mentions healthcare. On his website he says:
Making sure the peace of mind of health insurance is a right—not a privilege: That’s the reason Barack Obama and Joe Biden fought so hard for the Affordable Care Act. We should defend and build upon the Affordable Care Act to ensure every American has access to quality, affordable health care. And, we should dedicate the full force of our nation’s expertise and resources to tackle our greatest public health challenges, including cancer, opioid addiction, and mental health.
“Building upon the ACA” will no doubt get some clarification as debates and more “town hall” meetings become a central part of the process. As I reflect on my little healthcare experience earlier this week, I know that I am fortunate. I had a small problem which the system was prepared to resolve. My friend and relative with recently diagnosed cancer will both get good care. They aren’t part of the 1%, but they are comfortable members of the 91% of the country that can get good care albeit with the possibility of some expense and inconvenience, but how long is that sustainable at a cost to the country of more than three trillion dollars a year? And, what would have happened to the 30 million, almost 9% of Americans who are not as fortunate as the three of us?
It will be a tense year. Joe may add some balance to the process and bring it back a little toward a less left leaning conversation that will appeal to a majority of American voters. As Joe implies the future of America, as well as its health, will be vulnerable to the outcome. Â
It’s Been Nice, But Not Miami Nice
A few weeks ago my daughter-in-law who lives in the Coconut Grove section of Miami wrote me to say that she was tired of seeing pictures of snow in the Healthcare Musings header. Russ Morgan, the generous soul who provides the IT support for this effort, had also told me it was time to change the picture on the notice you get when a new post comes out. He was tired of seeing the picture of the chairs in my yard with a fresh eighteen inch layer of snow. I got the message. You might have noticed that last week there was a new seasonal look to the email notice, a glimpse of Little Lake Sunapee seen through the pines on a slightly overcast early spring day. I told my daughter-in-law that if she would send me a picture of one of the peacocks that hang out in Coconut Grove, I would use it for today’s header.
I go to Coconut Grove several times a year to see my granddaughter and her busy parents. Most of Miami or Dade County is too busy for me. I am not drawn to the glitz of South Beach, and I am terrified by the incredibly heavy traffic on I 95 and the other freeways. For at least seven months of the year it is too hot and humid for my comfort. I am convinced that too much air conditioning makes you stupid. But, I do like the quiet and shady cluster of neighborhoods in the Grove that lie along Tigertail Avenue as it runs north toward downtown Miami. I also love the wonderful park that hugs Biscayne Bay near the center of town. The football field at my granddaughter’s school backs up on the bay. A field goal or extra point is likely to land in the bay, and the last hurricane left sailboats leaning up against the goal posts 100 yards down field at the inland end of the field near the school gym.
Second best to seeing my granddaughter in Coconut Grove are my walks and slow jogs through its shady neighborhoods. Her house is on a little street between Tigertail Avenue and South Bayshore Drive. If I walk up to the corner and walk across Tigertail, I enter a very shady tropical environment of palms and amazing banyan trees that have huge trunks and roots that hang down from their limbs in patterns that look almost like fences or bars on a jail cell. One banyan tree can look like a forest. Up and down the narrow lanes in this neighborhood on the westside of Tigertail there are dozens and dozens of peacocks roaming the yards and streets. Some are overhead on low limbs. Others sit on the walls and gates that create a sense of great seclusion and privacy that adds to the unique character of the neighborhood. The peacocks are like well dressed turkeys and they act like they own the place. I have no idea how they got there, how they survive, or why they occupy such a small territory. I have never seen them north of 17th Avenue or south of 22nd Avenue. Part of every walk I take in Coconut Grove winds through this land of peacocks where I usually see dozens of the sort seen in today’s header which was provided by the daughter-in-law who is tired of my winter scenes. I like to remind her that her world is the flip of mine. We have long, cold and snowy winters; she has very long, hot and humid summers. I can always put on another layer if I am cold, but there is a limit to what I can take off if the temperature and the humidity are both over 95.
We are no longer living in the frozen north. Spring is here, and it is nice. My daughter-in-law would contend that it’s not Miami nice. After a year where we had six months of snow cover from mid October until past mid April, everything that was frozen or covered in snow has suddenly thawed or melted. I have been out in my kayak. The loons are back, and they fill our evenings with their mournful calls. Jonquils are coming up fast in the garden. The maple trees are all sporting red buds that will soon be leaves. Wherever you are, most likely someplace between South Florida or the Lakes Region of New Hampshire, things are changing. Your assignment for this weekend is to get in the middle of the transition, and enjoy the moment. I will be trying to catch my first fish of the new season while rooting for the Red Sox to finally wake up and get back to playing to their potential.
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
