7 September 2018
Dear Interested Readers,
Countering Despair, Maybe
“If something cannot go on forever, it will stop. That’s Stein’s Law. Herbert Stein was a bright man. He was a conservative economist, a fellow at the American Enterprise Institute, a columnist for the Wall Street Journal, and during the administrations of Nixon and Ford was the chairman of the Council of Economic Advisors.
Since on the surface of things, Stein’s Law seems to be corroborated by personal experience, just Like Newton’s Laws of Motion and Gravity, I have put as much faith in Stein’s Law as I have in all of Newton’s Laws. Newton taught us that a body in motion stays in motion unless acted upon by a greater force, which may also explain why there is validity in Stein’s Law. In politics and in healthcare what’s been going on can’t go on forever and it may behoove us to think about the greater forces that act to validate both Stein’s Law and Newton’s First Law of Motion, the Law of Inertia. Some thoughtful people also contend that Newton’s Laws apply as much to the trajectory of human affairs as they do to the motion of objects. I think those people are just not aware of the fact that Stein beat them to the punch. What makes Stein’s Law seem so true to me is that it is a restating of Newton’s laws about physical objects to apply to the world of human affairs, attitudes, and events.
I am not an economist, physicist, or philosopher, but I was once a physician and learned early from personal experience that Stein’s Law applies to the trajectory of health and illness. As a healthcare governance leader, and later as a manager, I quickly transferred a few key concepts that were based on Stein’s law from my medical practice to my “practice” as a manager and leader. First, the only problems over which you and I together had enough control over to make a difference were the ones where most of the problem was us. Second, proactive changes that we could initiate within our own enterprise were the best defense against the reality that external forces beyond our control would dictate that what we had been doing could not go on forever.
The most effective managerial strategy in response to Stein’s Law is also two fold. First, accept and vigorously act on the inevitability that since things must change because circumstances exist that preclude it continuing indefinitely, you have a leadership responsibility to act in advance of the collapse. Do not wait and see. Second, agree with colleagues on a solution process to the failing reality, and then get to work establishing an improved process before whatever can’t last dies in disaster. Many healthcare professionals, many practices, many hospitals, and many health systems are not embracing the devastating realities that are easy to predict. Perhaps that is too harsh. Many did make efforts to transform themselves in response to the quality movement. They were willing to give the ACA some support, especially since the ACA reduced their bad debt by expanding coverage to many of the uninsured. Some tried to be ACOs, albeit usually without a deep understanding of the real challenge of simultaneously accepting risk and improving value. If you think that ACOs are a way to enhance revenue, you are wrong. ACOs are a way to learn how to “manage by process” to improve the health of a population despite diminishing resources.
One reason that things won’t go on forever is the persistence of Republican politicians in their efforts to destroy the ACA. They have tried regulatory neglect, regulatory malfeasance, legislative attempts to undermine what they can not repeal by throwing out the ACA’s mandate in the new tax bill, and now they are mounting an increasingly obvious attack on the ACA in the courts. By the dual action of simultaneously challenging the ACA as unconstitutional since there is no longer a mandate, and naming Brett Kavanaugh to be the new fifth conservative vote on the Supreme Court, their goal of destroying the ACA is within their grasp. Examining what has happened and is in process one must assume that their goal is not to improve the health of the nation; it is to reduce entitlements to preserve the ability to continue to lower taxes on those who have more than enough.
Paul Krugman is my favorite economist. I was delighted to find an old New York Times column of his that is evidence that he and I share a preference for an alternative expression of Stein’s Law: ‘‘Things that can’t go on forever, don’t.” As usual he adds insight to the discussion.
Academic economists often cite Stein’s Law, a principle enunciated by the late Herbert Stein, chairman of the Council of Economic Advisers during the Nixon administration. The law comes with various wordings; my favorite is: ”Things that can’t go on forever, don’t.” Believe it or not, that’s a useful reminder.
For we’re now led by men who think that macho posturing makes Stein’s Law go away. On issues ranging from budgets to foreign policy, they insist that we can sustain the unsustainable. And when challenged to explain how, they engage in magical thinking.
Krugman wrote that in 2003.
I wish that what the future of healthcare in America will be up against in 2018 will only be magical thinking. What we are challenged by are platitudes that are a more cynical expression of the continuing attack on the ACA than just magical thinking. I recently reported a statement from Ron DeSantis, the Republican Congressman from Palm Beach, who is the Republican nominee for governor in Florida. What he said about healthcare is a perfect example of my point: “People should have a right to pursue the healthcare that they want.”
Statements like the one from DeSantis or whole bills introduced into Congress like the ones that failed in the spring and summer of 2017 are attempts to obfuscate the reality that tens of millions of Americans are at risk of losing access to the care they need unless we collectively accept that quality healthcare can’t persist for everyone unless there is a collective recognition that we are on an unsustainable course. We must decide together how we will alter our course before millions are harmed. What does freedom to pursue the healthcare you want mean if you are either poor or have a preexisting condition and the ACA is destroyed, as Ron DeSantis tried to do as a member of Congress? The beauty of the Triple Aim is that its objectives include a recognition that we must find something “that can go on forever” or at least for a few decades, which in politics is often the equivalent of “forever.”
In May, fifteen years after referencing Stein’s law, Krugman published a column entitled “The Plot Against Healthcare.” In the article he helps us understand where DeSantis and other Republicans are coming from by aptly describing the reality that Republican strategists know all too well.
Here’s what history tells us: Expansions of the social safety net are relatively easy to demonize before they happen — before people get to see what they actually do. Opponents declare that they’ll destroy freedom, that they’ll be wildly expensive, that they’ll be a national disaster. American politics being what it is, opponents of a stronger safety net also tap into racial resentment, convincing white voters that new programs will benefit only Those People.
Once social programs have been in effect for a while, however, and it turns out that they neither turn America into a hellscape nor break the budget — and also that they end up helping people of all races — they become part of the fabric of American life, and very hard to reverse.
He then points out why Republicans feel undermining the ACA sooner rather than later is so important:
And this gets at the heart of conservative opposition to social safety-net programs: It’s not about the belief that they will fail, but about fear that they will succeed, and in so doing become irreversible — which means that they must be stopped before they can start showing results.
More recently he published a piece with a title that I wish I had written: “Get Sick, Go Bankrupt and Die” You should read it if you have not already done so, but here are some key thoughts from the piece that I will offer to you now. He can be facetious:
Surely Republicans have spent the past year rethinking their policy ideas, trying to come up with ways to undo the A.C.A. without inflicting enormous harm on ordinary Americans, especially those with pre-existing medical conditions. Right?
See I made a joke…
He points out that Republicans don’t do social policy. They do resistance to social policy. He explains that you can’t come up with something that will work that is more conservative than the ACA. If you really don’t care if your solution achieves better health for everyone, there are many options. The ideas behind the ACA were developed at the Heritage Foundation, the premier conservative think tank, back in the eighties when there were Republicans who called themselves “compassionate conservatives.” The idea was applied by Romney in 2006 to create near universal coverage in Massachusetts before Obama adopted the idea and offered it as an attempt at bipartisan problem solving in 2009.
Krugman says it this way:
The G.O.P. can’t come up with an alternative to the Affordable Care Act because no such alternative exists. In particular, if you want to preserve protection for people with pre-existing conditions — the health issue that matters most to voters, including half of Republicans — Obamacare is the most conservative policy that can do that. The only other options are things like Medicare for all that would involve moving significantly to the left, not the right.
Health economists have explained this point many times over the years; but as always, it’s difficult to get a man to understand something when his salary depends on his not understanding it. Still, let’s try one more time.
If you want private insurers to cover people with pre-existing conditions, you have to ban discrimination based on medical history. But that in itself isn’t enough, because if policies cost the same for everyone, those who sign up will be sicker than those who don’t, creating a bad risk pool and forcing high premiums. That was the case in New York, where premiums for individual policies were very high before the A.C.A. — and promptly fell by half when Obamacare went into effect…
…they’re going to kill it (the ACA) if they hold on in two months. But covering pre-existing conditions is popular; therefore, they’re pretending that they’ll do that, while offering proposals that would, in fact, do no such thing.
…Do they imagine that voters are stupid?
Well, yes…
He goes on in that vein, adding evidence to his claim before he sets the hook.
So if you’re an American who suffers from a pre-existing medical condition, or fear that you might develop such a condition in the future, you need to be clear about the reality: Republicans are coming for your health care. If they hold the line in November, health insurance at an affordable price — maybe at any price — will be gone in a matter of months.
Sustainability is the third leg of the Triple Aim. The Triple Aim was built on systems analysis. As Krugman notes, the ACA represents the least intrusive insurance program to personal freedom that could be expected to function sustainably in an environment of private healthcare ownership jointly utilized by commercial and public payers. To reiterate an important point, Krugman and other economists and healthcare theorists tell us that the two most essential things necessary make quality care for individuals and the improved health of the community possible without economy crushing expense are a mandate with adequate penalties for “not playing” and guaranteed insurability without regard for preexisting conditions. Everyone needs to participate and everyone needs to be allowed to participate. Almost as important is the necessity of a basic or standard minimal product that provides for universal coverage and service across the country. Without a basic or standard minimal product consumers can not compare offerings and a competitive market is impossible. A car with three wheels and no brakes may be less expensive to produce and can be sold for a lower price, but comparison shopping with a real car would be confusing.
All this info underlines for me that Republicans do understand Stein’s Law. Stein earned his doctorate at the University of Chicago which was also the academic home of Milton Friedman. Friedman wrote the book on conservative economic theory. Republicans know that the dream of healthcare as an entitlement can’t go on much longer because as Krugman suggests, the idea might become a universally accepted concept, along with many other efforts to reduce economic inequality and increase social justice. I fear the forces that want to turn back time and progress are a formidable foe and in a short time their endurance and power will be further augmented by the control of the Supreme Court that will be a reality after Brett Kavanaugh is confirmed.
I fear that there is not much time left in which to counter the despair that will occur when the ACA, now minus the mandate that allowed the Supreme Court in 2012 to call it a tax, will be judged by a conservative court to be unconstitutional. After the collapse of the ACA, the damage done to healthcare as we now experience it will be devastating, and the repair will be a long process.
The first step in recovery will be electing a Congress in 2018 and 2020 that will deem quality healthcare to be an entitlement of all Americans and sound economic policy for this country. The second step will be to elect a president that will sign the bill that Congress produces. In the interim there will be pain and suffering, perhaps not for you, but the Kaiser Foundation suggests that over 50 million Americans will be thrown off insurance because of their preexisting conditions. As the Medicaid expansion is rolled back progressive states will need to go it alone as Massachusetts did in 2006. The sum total of the effects will be to increase bad debt and make more healthcare enterprises and consumers insolvent, as Krugman says, “Get Sick, Go Bankrupt and Die.”
We will be worse off and more challenged than in 2009 before the ACA was passed because of anger and disillusionment of both providers and patients. Your commitment to the mission of your calling will be tested. Even if you have no mission and see being in healthcare as a good way to make a six or seven figure salary, things will be harder. There will be anger and blame because Stein was right, if it can’t go on forever, it won’t, and I would add that because it can’t we will be blamed. If you were waiting to see what would happen before you began to consider how to prepare for the future, your wait is almost over. I pray that most of you will respond heroically to the problems that we all helped to produce.
Sunset on Summer
A few days before the Labor Day weekend my wife took the beautiful shot of the sunset that is today’s header. I was out on a late afternoon walk when our neighbors invited her for a “sunset cruise.” I like to be on the lake at sunset, but my day had been filled with some easily forgotten tasks and I was forced to choose between getting in my walk or relaxing on the boat. I think I made the wrong choice. It’s ironic that a week later I can’t really remember anything important that I did that day that would have delayed my walk from midday or mid afternoon. There should be some sort of insight associated with that observation.
Summer ended with sunset on Labor Day. I had a great Labor Day. We came back on Sunday, forfeiting Labor Day on the Cape, choosing to beat the holiday traffic after a brief, but very pleasant, two night stay in Falmouth. We had a great time riding our bikes and socializing with many good friends at an event that gathered together those who have scattered from Wellesley in retirement. The bonus was that my Falmouth friend and host gave me his old Sunfish which we hauled home on the roof of our car. On Labor Day I was eager to try out the Sunfish and rediscover the joy of “wet sailing.” I capped off the day with some household chores before heading out to catch what may be the largest smallmouth bass I have ever pulled out of the lake. He hit my fly just at sunset. A perfect finale for a very pleasant summer.
If we are lucky, we may be into “bonus time,” or what I call summer’s encore. A long warm fall ending in a Red Sox victory in the World Series would be nice. But things are never guaranteed and are always tricky in fall.
Late August and early September are often hurricane season, but this year looks pretty good so far. There was a little excitement in Florida about Hurricane Gordon but no real damage as it pretty much fizzled before turning into the Gulf Coast and then traveling up the middle of America with mostly heavy rain and a loss of prestige as only a tropical storm. The temp has been in the nineties this week in New Hampshire, as well as in North Carolina where I have been spending time with my Dad who has now entered hospice care. Uncertainty is the word of the day. We have uncertainty in the weather, uncertainty in sports, and uncertainty for the future of healthcare and our country. As previously noted, things are up in the air in Washington with the raucous Senate Judiciary hearings on Judge Kavanaugh’s appointment to the Supreme Court. We now have a new “deep throat” telling anonymous tales from the White House that confirm the obvious. We are into that uncertain part of the baseball season where a season of victories could dissolve into an agonizing end of season collapse. (Remember Bucky Dent and 1978?) And who knows what is coming next in the unraveling of Donald Trump?
I think the antidote for the uncertainty of the times is to look for more sunsets. As the afternoons get shorter I will see more sunsets on my walks than from my kayak, but no matter how you see them, sunsets like the one in the picture will keep you coming back for more despite all of the various forms of uncertainty in our crazy world.
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
