28 June 2019
Dear Interested Readers,
The Democrats, Healthcare, and More: It’s Complicated
For the past two nights we have had our first look at the twenty highest polling contenders for the nomination of the Democratic Party for president. The 2020 election is still seventeen months into the future, and the New Hampshire Primary won’t happen until February 11, 2020 which is nine days after the next Super Bowl. Judging from the intensity of the last two nights, it felt like the first primary might be next week.
With our presidential elections we get started early and then things move slowly. Our Constitution was designed to use time and an elaborate process to avoid rash decisions. In parliamentary democracies governments sometimes change as frequently as the seasons, and change can be precipitated by a sudden loss of confidence or one mistake, but not so here. Even in the face of “treason, bribery, and other high crimes and misdemeanors” changing leadership before a four year term is over takes a lot of collective energy, and the batting average for successfully removing a president who has lost his way is well below the “Mendoza line.”
In case you do not keep a copy of The Constitution near you, here are the pertinent sections in reference to impeachment:
The House of Representatives … shall have the sole Power of Impeachment.
—Article I, Section 2, Clause 5
The Senate shall have the sole Power to try all Impeachments. When sitting for that Purpose, they shall be on Oath or Affirmation. When the President of the United States is tried, the Chief Justice shall preside: And no Person shall be convicted without the Concurrence of two thirds of the Members present. Judgment in Cases of Impeachment shall not extend further than to removal from Office, and disqualification to hold and enjoy any Office of honor, Trust or Profit under the United States; but the Party convicted shall nevertheless be liable and subject to Indictment, Trial, Judgment and Punishment, according to Law.
—Article I, Section 3, Clauses 6 and 7
[The President} … shall have power to grant reprieves and pardons for offenses against the United States, except in cases of impeachment.
The President, Vice President and all civil Officers of the United States, shall be removed from Office on Impeachment for, and Conviction of, Treason, Bribery, or other high Crimes and Misdemeanors.
Perhaps the question of impeachment is a good place to start the discussion of the debates because what to do about President Trump’s behavior in office was one of the clearest lines of separation between candidates on the first night, and strangely did not come up on night two. There seems to be two options when considering how to protect our wounded democracy from misguided efforts to make us great again. The first option is to initiate impeachment proceedings even though the likelihood of success is low because “no one is above the law,” and waiting until Trump is out of office to hold him accountable is both a violation of the principle of our equality under the law, and dangerous because of what he might do to inflict harm between now and late January 2021. This line of reasoning assumes that the president can’t be indicted or tried in a criminal or civil suit while in office. Robert Mueller referenced this untested constitutional premise in his report. The second option is to be patient, build the case with voters, and just vote him out of office, and then when he is a private citizen let him have his day in court.
Nancy Pelosi still favors the second, more strategic, option given the current likelihood of the impeachment process failing because conviction requires a two-thirds vote in the Senate which Republicans control. That analysis says it is best to use the 2020 election as the surest and best way to remove the president. It requires patience and a focus on building momentum behind an electable candidate which is facilitated by delaying the pursuit of legal action against the president until after he is voted out of office when he will be subject to a trial. What is not usually stated is that then he may be the potential recipient of a pardon like the one Gerald Ford gave Richard Nixon. On the first night of the debates Beto O’Rourke was asked whether or not, if elected, he would direct the Justice Department to bring federal charges against an out of office Trump, and he said that he would pursue prosecution to prove that it is still true in our democracy that “no man man is above the law.”
Much will be written about who the winners and losers were. I was overwhelmed by trying to follow so many self promoters in so short a time, so it helps to have a list of players to review. From the first night group the pundits seem to think that Elizabeth Warren helped herself, and Beto O’Rourke did not. Amy Klobuchar has an impressive ability to “make sense” without being shamelessly self promoting, that Bill di Blasio and Jay Inslee lack. Cory Booker is earnest and Julian Castro was a positive surprise for many on night one. By most accounts Kamala Harris was the victor on night two. She did a well executed take down of Joe Biden over his objection to federal busing laws several decades ago, and was sharp on every question she addressed, or comment she offered. Bernie was Bernie, and Joe seemed sleepy or apprehensive that he might say something that would come back to bite him. In contrast Kristen Gillibrand seemed “pushy” and desperate to insert herself into every question although she was the strongest advocate for women’s health and reproductive issues. Several candidates were annoying in their need to constantly tell us about all the laws that they had passed in Washington, or as in the cases of Hickenlooper and Inslee, what they had proven they could do back home that they were willing to do for everyone in Washington. I had a couple of surprises. I found that I Iiked Tulsi Gabbard, the congresswoman and former major from Hawaii, and was disappointed by John Delaney who combined self promotion and interruption in an annoying way. Given the reality that the debates come close to being like March Madness where half go forward and half go home, based on performance, creative ideas, momentum, and presence that could ripen into presidential presence that might restore us to the position we had in the world before January 2017, I would have Castro, Warren, Gabbard, Booker, and Klobuchar go forward from the group on night one, and Biden, Sanders, Buttigieg, Harris, and Gillibrand go forward from the second debate, but those are just one man’s take, and in a Democracy your take is as valid as mine. It will be interesting to see if anyone from the twenty does a self appraisal that leads them to the conclusion that they have had an interesting experience, but it is time to go back to their real job.
Setting aside as obvious the consensus objective that we must rid ourselves of the president we currently have while we still have a shred of democracy left, and a chance to repair the damage he has done at home and abroad, the collection of issues for the election are clear. I think it is ridiculous to debate whether healthcare is more important than climate change except in the context of how history suggests the process of governing usually works. Given that passing a major piece of social legislation costs any president a lot of political capital, and that except for FDR and LBJ, most presidents do one thing at a time, there is some point to understanding the priorities of a candidate.
Coming out of the 2018 election Healthcare was the most important issue with voters. In no particular order the other big issues are:
- Combating climate change
- Abortion and all related issues of reproductive freedom
- Immigration in all of its complexity, including what to do in the moment about “caged children,” DACA, deportation policy, section 1325 of the immigration laws, paths to citizenship, the clogged immigration courts, medical coverage for undocumented persons, and the list goes on and on.
- Human rights including race, LGBTQ descrimination, equal pay and equal rights for women in the workplace, and all of society
- Education and student debt, including the idea of free public college
- Gun control, violence
- “Dark money” in politics
- The widening inequality gap and the plight of the middle class
- Police related issues, shootings and body cams
- International relations from how to deal with China, Russia, Iran and North Korea, to how to restore America’s relationships with its allies and its position of moral leadership in the world.
It is no wonder that we feel overwhelmed with twenty candidates debating more than a dozen “key issues.”
The healthcare discussion at the debates did reveal a lack of consensus on the scope of the problem and its potential solutions. Areas of agreement do exist.
- All Democratic candidates believe that quality healthcare is a human right and universal access to care is the goal.
- All Democratic candidates agree that we pay too much for what we get, and lay much of the blame on the structure and abuses of big pharma and the insurance industry.
I was surprised to see that the majority of the candidates were reluctant to fully endorse an immediate move to Medicare for All. Pete Buttigieg was the most articulate candidate in offering a path to universal coverage with his phrase “Medicare For All Who Want It.” Several candidates brought up the reality that at least 180 million Americans have private coverage through their employer that they would be reluctant to give up. Gillibrand, who favors Medicare For All, and asserted several times that she helped Bernie Sanders write his bill, did speak to the process of how to transition from commercial insurance and the ACA to Medicare For All over a period of several years.
John Delaney’s greatest contribution was to interject that if all hospitals were immediately reduced to Medicare and Medicaid reimbursement most would be bankrupted in a very short time. His comment underlines the current reality that commercial insurance subsidizes public programs. I was surprised that no candidate spoke to the need to transform how we deliver care to make care delivery more efficient, or to reduce expense by eliminating overuse, underuse, and misuse of resources and improving the quality and safety of the care we give everyone. Elizabeth Warren was passionate in her articulation that the most important reason to move to Medicare For All is that medical bills are an enormous source of financial failure for families.
Bernie Sanders was asked about the finance of Medicare For All and gave his usual response that seems hard for many to follow, or to believe, that for the majority of Americans the increases in taxes associated with his plan would be offset by the savings from their healthcare expenses. He assures us that for most Americans their increase in taxes would be less than what they are currently paying in total from the cost of drugs, their copays and deductibles, and their current portion of the premium paid through their employer as a deduction from their paycheck. Even though it is the rare person who has total coverage of all costs for all aspects of care through their employer, you can imagine millions of pairs of eyes across the country glaze over as he tries to explain the fungibility of all money in reference to taxes and healthcare expenses. Most people don’t understand at a level they can explain that the trend over the past couple of decades has been to shift more risk and more cost to the consumer. Most Americans are like the proverbial frog in hot water. The temp is gradually increasing toward the boiling point, and they aren’t noticing the change. It is also true that they are reluctant to give up the flawed coverage they have, for something that may be better that they do not understand.
The underlying question that was never discussed is whether or not we can ever get to the nirvana of the Triple Aim through a market mechanism. It is easy to trace the ACA to conservative market thinking from the eighties and early nineties. Even President Obama has confessed that it was adapted from the core thinking about healthcare markets from the conservative Heritage Foundation, the influential conservative policy think tank that guided Regan and Bush One. In an appeal to Democrats to moderate their positions, and avoid a take over by the far left, David Brooks writes in an op ed published in the New York Times entitled, “Dems, Please Don’t Drive Me Away,”:
…When Warren and Kamala Harris raised their hands and said that they would eliminate employer-based health insurance, they made the most important gesture of the campaign so far. Over 70 percent of Americans with insurance through their employers are satisfied with their health plan. Warren, Harris and Sanders would take that away.
According to a Hill-HarrisX survey, only 13 percent of Americans say they would prefer a health insurance system with no private plans. Warren and Sanders pin themselves, and perhaps the Democratic Party, to a 13 percent policy idea. Trump is smiling.
The concerns of Brooks are further described in a Times OP ED by Peter Suderman with a very long question and answer as it’s title: “Are We Sure Eliminating Private Insurance is a Good Idea?: Arguments over health care will dominate the primary and probably the general election, too. That could help or hurt the nominee.”
Health care, in other words, may have decided the midterm, and is certain to play a pivotal role in the primary. And next year, it could play a pivotal role in the general election, too. But will it help or hurt the Democratic candidate?
In one sense, it offers Democrats an advantage. The party is far more engaged with the details of health care policy, and far more willing to promise to extend coverage to those who don’t have it. The debate over the last two nights has not been about whether to expand health coverage, but by how much, and by what policy mechanism.
From Medicare for All to a public option that builds on Obamacare, Democrats have plenty to say on the issue…And yet looked at another way, the Democratic advantage on health care is not as strong as it might look.
First, there is the issue of eliminating private coverage…surveys have found that support for single-payer drops when respondents are told that it would eliminate private coverage. When Senator Kamala Harris of California mounted a similar defense earlier in the year, she quickly moderated her position, saying that she was open to other options as well. (Though last night, she was among the candidates who responded in the affirmative to the idea that they would abolish private health insurance in favor of a government-run plan.) It’s not an accident that when President Barack Obama pitched his health care reform to the nation, he did so by repeatedly promising that those who like their plans could keep them.
Not all of the candidates argued for single payer. Joe Biden made the case for building on Obamacare, which he helped usher into law. But even Mr. Biden’s argument was a tacit admission that the health law that was the signature policy of the previous administration is, at best, insufficient and incomplete.
And that gets to the mostly unspoken reason that health care has so dominated American politics, and the reason it played such a significant role in the first Democratic debate: It is the sense, shared by Republicans and Democrats alike, that Obamacare has failed or, at minimum, that it still needs considerable work…
The danger that faces us is failure, not because there is no need to change, but failure because of a lack of consensus about how to change. Having a large discussion that includes a wide diversity of thought is attractive, but if it goes on too long it runs the risk of frustrating voters who will respond by voting for a continuation of the status quo.
My opinion is that the next step is a public option grafted onto a revitalized ACA. If Pete Buttigieg wants to call it “Medicare For All Who Want It,” that is fine with me. The ACA with a public option gives insurers one last opportunity to demonstrate that we can lower the cost of care, move closer to the Triple Aim, and further reduce the number of uninsured through a market based mechanism. From my perspective the most important area that has been inadequately discussed is finance. We are stuck on the question of how we will globally finance Medicare For All. What seems implicit in most of the proposals is that we will just take the current processes of FFS Medicare payment, which includes a slow transition to pay for performance through MACRA, and expand those numbers to cover the whole population. In my mind that is expanding an imperfect system that drives poor utilization and will be unsustainably expensive while it compromises funding for other important initiatives that will improve the social determinants of health.
We are stuck on how the government will get the money to pay hospitals and professionals and who will be taxed for the bill, and have ignored the discussion of the other side of the finance question which is more important for sustainability. How, and for what, will the government pay hospitals and medical professionals? We have not discussed how the finance system should continue to evolve to incent patient centeredness and operational efficiencies. That discussion is probably beyond the job description of most politicians, and the interest level of most voters and consumers.
If we are moving to a new world where Medicare will pay all the money that doctors and hospitals receive, then we need to be much clearer about how we will pay them, and how we will make progress in those parts of the country where there is only one source of care, or where care is inherently more expensive because of small populations and issues of distance from secondary and tertiary care. It is also true that those areas that are most vulnerable to a rapid movement to a theoretically attractive new reality that is vulnerable to surprises in a poorly managed transitions are in the same “red states” that embrace the unrealistic fantasies of the current administration about what a better America would look like. Despite MACRA, the majority of payments to hospitals and providers is still Fee For Service. If Medicare For All meant Medicare Advantage For All, we might have a more informative conversation, but even that would be problematic for that majority of voters who still would be reluctant to move away from what they enjoy now toward the promise of something better for everyone.
I hope that between now and July 30 and 31 when the next debate is scheduled to occur in Detroit a few candidates will test their progress against the dream of getting the nomination, and accept the reality that “it won’t be me this time around.” Two nights with five candidates each night would be a much better process. My second hope is that when the debates do return there will be more focus on sustainable paths of transition and finance. It would be good that the argument is not so much between themselves, and an exercise to discover who can control the conversation, as it should be a process of educating and selling a majority of the public on why a new approach to these challenging problems is not a debate about markets versus socialism, but rather a discussion about how to fulfill and ensure the promise of personal possibility and freedom, including the benefit of better health for everyone, for generations to come. The goal must be more than understanding the best way forward in healthcare with all of its internal complexities. The goal should be that plus understanding how all of the issues interact with each other to move us forward toward a more just society. Inequality, eduction, human rights of all dimensions, international policy, immigration policy, infrastructure renewal, and fair taxation all must be resolved in the context of their interconnections. The goal is not to have all the answers, but rather choose the best person to lead us toward the answers while avoiding all the pitfalls of unintended consequences. Are we up to the challenge? Is there a sunnier day for all beyond all the clouds of disagreement, disappointment, and separation that constitute our political weather now? Is there a leader among the twenty who can move the focus from “somebody done somebody wrong” to “somewhere over the rainbow?” I like Israel Kamakawiwo’ole’s version of “Somewhere Over the Rainbow,” where he strums his ukulele while he sings:
Well, I see skies of blue and I see clouds of white
And the brightness of day
I like the dark
And I think to myself what a wonderful world
The colors of the rainbow so pretty in the sky
And also on the faces of people passing by
I see friends shaking hands saying
How do you do?
They’re really saying I, I love you
I hear babies cry and I watch them grow
They’ll learn much more then we’ll know
And I think to myself what a wonderful world
World
Someday I wish upon a star
Wake up where the clouds are far behind me
Where trouble melts like lemon drops
High above the chimney top
That’s where you’ll find me
Oh, somewhere over the rainbow
Way up high
And the dreams that you dare to
Why oh, why can’t I?
Why oh, why can’t we…
Enjoying an Overcast Weekend in an Overcast Summer During Overcast Times
Thunderstorms, showers, cool temps, and generally over all cloudiness is the weather prediction for this coming weekend in the Sunapee region of central New Hampshire. The picture of Lake Sunapee under heavy gray skies in today’s header was taken by my neighbor with his drone, and is a good representation of the beauty that exists even on a “bad day.” I am hoping that the weekend will be better than my weather app is showing, but the weatherman has become more accurate than the good old Farmer’s Almanac which has always seemed to me to be more like astrology or alchemy than science. At this point the weatherman and the Almanac seem to be aligned. If you are a devotee of the Farmer’s Almanac there is no reason to be all that excited about the prospects for July. In the end, we get what we get, so I have decided that the best plan is to see beauty in a cloudy day, and plan to have a great weekend even if it is cloudy, cool, and wet from thunderstorms.
The weather won’t bother the Red Sox this weekend because they will be playing two “home games” against the Yankees at the Olympic Stadium in London where the weather prediction is for clear skies and temps as high as 89. It is hard to believe that this weekend will be a historic first. No Major League game that counts in the standings has ever been played anywhere but in Canada or the USA. Apparently, there has been a lot of modification to the Olympic Stadium to make it ready for baseball.
In the summer of 1958 my family took a trip to Southern California and we saw the recently relocated Dodgers and Giants play at the Coliseum in LA, the site of the 1932 Olympics. It was a strange field with a forty foot left field fence 250 feet down the foul line, and the right field fence more than 400 feet down that foul line. It was a very long way to deep center field at the LA Coliseum. You can click on that last link to get a picture of the LA Coliseum as it was configured for baseball. I really enjoyed the game because so many of the players on both teams were my heroes then, and are are now in the Hall of Fame. That Dodgers/Giants game was my second “major league” experience. My first game was between the White Sox and the Indians at the old Comiskey Park on the south side of Chicago on a very chilly day in early May in 1956. Early Wynn was the winning pitcher.
What is amazing, is to contemplate all the misery in the world that we must set aside and try to get out of our minds on any weekend. Perhaps that is why an overcast weekend is such a bummer because on a weekend of clouds and rain we can’t easily leave our cares behind and be out and about forgetting all that worries us. It is eeasier to worry about the weather and whether or not we will be able to get out into the natural world during the weekend than to worry about what global warming has already done, and will continue to do to our planet over the next 10 to 20 years. We are disappointed when the weather report is for cloudy skies and rain, but a good use of an overcast day may be to make it the day we resolve to get involved in the effort to reposition America for a better day for everyone. It’s important to elect a great leader. It’s dangerously naive to think that any individual, no matter how many languages they can speak or businesses they have started, can fix difficult problems alone.
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
