8 November 2019
Dear Interested Readers,
Why Medicare for All Is The Best Choice, But An Unlikely Outcome No Matter Who Wins
I know that I am writing to sophisticated readers. Much of what follows may be boringly redundant or a statement of the obvious, but I am going to try to explain why if I had my “druthers,” I would replace the ACA with Medicare For All (MFA) as the next step toward universal coverage and the realization of the Triple Aim. For two reasons, which I will reveal further on, I would prefer that we avoid an intermediate step that includes a public option attached to the ACA. Having expressed my “druthers,” I should add that it will take a miracle for Medicare for All to be the law of the land during the term of the next president. At this juncture it is good to remind ourselves of Winston Churchill’s assessment of the American approach to progress. Churchill is reported to have said:
The Americans will always do the right thing… after they’ve exhausted all the alternatives.
Perhaps, what Churchill did not understand is that doing the “right thing” or effecting change is slow here because of our national ego ideals of fierce personal independence, a belief in self reliance, and a fear of government. Our inclinations to leave well enough alone when things are acceptable for us at the individual level are fortified by a Constitution that was written to require “supermajority” acceptance before most changes can occur, unless the Supreme Court steps in to create change through a controversial judicial action. The resistance to change written into the Constitution is further buttressed by the long accepted rule in the Senate that a supermajority vote, now 60% down from 67%, is required for cloture on any bill. A lot of “majority” ideas have died, or patiently waited for decades and even centuries, for the slow accumulation of a supermajority in the Senate that matched long standing preferences of even larger public majorities.
Healthcare reform has a history that is at least 75 years long, some would take it back more than 100 years to Teddy Roosevelt. Suffice it to say, whether you take it back to Teddy Roosevelt, or begin your consideration with FDR and Truman, we’ve taken a lot of “wrong directions on our lonely way back home.” I make that statement by defining “home” as that aspirational ideal of America as the one place in the world that is continuously searching for a sustainable set of relationships that allows every American to experience the full measure of the promise embodied in the grandiose statement in our Declaration of Independence:
We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.–That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, —
History has shown that the beautiful phrase left a lot of room for disagreement. It was quite possible to initially limit “all men” to just all land owning men over 21. We fought a civil war, and have had an exhausting number of Supreme Court decisions in an effort to clarify that “all men” really meant all human beings, rich, poor, and without reference to race or gender. The concept of a creator has even been a political issue, but whether that was an eighteenth century euphemism for more complex concepts not fully understood at that time, or agreed upon at this time, the real ambiguity lies with just what the list of certain unalienable Rights is. There is a partial list given, and I say partial because the phrase “among these” suggest that what Jefferson recorded was just a partial list that included the obvious, and that there were others that he did not name. Even the first attempt at a Constitution in 1789 failed to be explicit enough about “rights,” so the first Ten Amendments were added, the so called “Bill of Rights,” as an attempt at greater specificity to aid ratification.
We all know that the list has never been adequate, nor has the government’s exact role in defending the rights enjoyed unanimous agreement. It is clear that as the author of the verbiage, Jefferson’s concept was that it was through the consent of the governed, which would come to mean those participating in elections, that the role of government was to ensure the path that would “secure the rights.”
It has always been my sense that the truth in Churchill’s statement derives from the fact that we are all granted the option through elections of expressing our opinion about how fast we move toward the ideal of “these truths,” and just how we will direct the government to secure those rights for all of us. There are some fundamental characteristics that define how we direct our elected government to protect, define, and extend the rights for all “men” that flow from these truths. As I mentioned above, we have a collective ego ideal of being free and independent individuals. We prize self reliance. Our image of a positive person is one who creates wealth or, at the least, takes care of “his” own. The adage that it is more blessed to give than receive has been modified in reference to the government. It is not only far from blessed to receive anything from the government, it is an act that defines one as a failed human being whom others may consider unworthy of equal treatment. Finally, a significant number of us don’t trust the government to do anything. In fact, the most extreme among us, which may be at least a third of us, feel more comfortable if we are armed and able to resist the government were it to ask too much of us. We trust business. We don’t trust the government to do business competently. Is it any wonder that collectively our response to any issue is to take care of our own interests first, and to be hesitant to see the government assume a responsibility to take care of us, as equals?
The strength of the status quo, is enhanced by the concept of “states’ rights” that precipitated the Civil War over the issue of slavery. Now, “states’ rights” are again being used as a weapon by the antiabortion movement, and as a barrier that blocks millions from the benefits intended through the ACA. Despite the barriers to change in the Constitution and in the Senate, and realizing the apparent contradiction in the fact that about 40% of the population wants to roll back recent changes like a woman’s right to control her own reproductive health, or anyone’s right to marry the person of their choice, I still think the most remarkable occurence of this new century so far has been the rapid expansion of our concept of human rights among voters in the general population. Sadly, that trend is not seen among most establishment politicians who are supported by dark money, and the political contributions made legal by the 2010 “Citizens United” decision in the Supreme Court. Despite the resistance of those espousing traditional values, the recent improvement in the rights of the approximately five percent of Americans who self identify as LGBTQ+ has been remarkable, but that work is not over.
The struggle for the full equality of women which “officially” began with the suffragette movement in this country, created by the abolitionists Lucretia Mott and Elizabeth Cady Stanton in 1840 as an organized effort to win the vote for women, continues to be accepted by a majority of voters and has been ratified by a majority of states, but it is not the law of the land. The movement that produced the ERA can really be traced back further than Mott and Stanton to letters from prominent women in the families of the framers of the Constitution. Progress in our country has followed a pattern of slow “glacial” movement with a long period of very gradual change that stretches much further back than the Civil War. As Jill Lepore describes in her book, These Truths: A History of the United States, the struggle for human rights in the “New World” can be traced back to when Christopher Columbus first dropped his anchor and began treating indigenous people as less than human. In a tidy little follow up book she published this year, compiled largely from previously written pieces, THIS AMERICA:The Case for the Nation, she underlines how shaky our concept of a nation with a federal government really is. Her work in both books provides a foundation for understanding the American attitudes that have previously made change so hard for us. Now as glaciers are rapidly melting from global warming, the concept of glacial change in the extension of equal rights seems to be speeding up. A big problem of perspective is whether we use previous examples of painfully slow change as a model for the continuing efforts in healthcare, or do we take heart from some of the more recent examples of the “hockey stick” acceleration of change in other long standing social issues?
Whatever the “right” has been, whether it is freedom from slavery or the ability to be proud of the person you are, and marry the person you love, the process of inclusion begins with a few individuals who are willing to recognize that “what is” should not be, and what has been restricted as a privilege for some should be available for all, if “these truths” is to be anything but an empty promise. Usually, a small group of committed individuals who are the nidus of the movement persist through persecution and derision because of their enlightenment and commitment. In time, and with great efforts and personal sacrifices, their numbers begin to grow very slowly. It is not until very late in the timeline of any movement that a majority of Americans adopt the expanded attitude. Even when the majority opinion becomes one of acceptance, the work is not over. Once a majority of Americans share a point of view, experience tells us that the “new minority” which once controlled the issue and that has lost the debate with the public, can still block legislative change for decades.
The movement for equal rights and acceptance of black Americans is the best example of the tortuous process of progress in human rights. The movement for equal rights for women has been less bloody and less dramatic, but almost as long. The majority of Americians probably can’t tell you that the Equal Rights Amendment to the Constitution was passed in 1972 and still awaits ratification by one more state before it might become a part of the Constitution. There is now new hope for the end of the more than forty year struggle for the ERA because Virginia now has a Democratic majority in both houses of its legislature and a Demoratic Governor.
Through many examples of “exclusion,” our history reveals a painfully slow, methodical movement toward the realization of “these truths” that Thomas Jefferson alluded to in the Declaration of Independence. As noted above, even though progress has been slow, lately there is acceptance of a broader extension of basic human rights. Does it seem that progress is accelerating? I keep wondering whether or not Churchill might think differently if he could observe the pace of some of our recent changes.
After the election of Donald Trump, the most significant political event of the last five years has been the growth in the popularity of progressive ideas like MFA, free tuition to public universities, support for concepts that have been amalgamated as a “green new deal” and a broader understanding of the importance of a universal living wage. Bernie Sanders’ remarkable run for the Democratic presidential nomination is the best explanation for the progress and wide acceptance that these issues that have enjoyed over the last two years. Less than four years ago when Bernie first ran for president, they were defined as a “fringe” political platform without much popularity. They were ridiculed as “socialist ideas.” In a short time, perhaps as evidence of the effectiveness of Sanders’ message, at least 60% of Americans now consider healthcare to be a “human right” and the health of the nation to be the responsibility of the government. In the same Atlantic article link above, Amanda Mull points out that how a government accepts and fulfills that responsibility for the health of the nation is as important as declaring that access to healthcare is a human right.
A JAMA opinion piece entitled “To Control Costs Expand Managed Care and Managed Competition,” written by three esteemed healthcare policy experts, Alain Enthoven, PhD; Victor R. Fuchs, PhD; and Stephen M. Shortell, PhD, MPH, MBA, was published this week. In the article the authors make a point that I have been trying to make for some time now. I have bolded the statement. Contrary to what they write, probably since Elizabeth Warren gave us the broad outline of the finance proposal of her MFA plan after the article went to press, at least one candidate is addressing the cost issue. The authors write:
Health policy will be a dominant domestic issue during the pursuit of the Democratic presidential nomination and in the 2020 election. The extent and form of insurance coverage, such as Medicare for all, a single-payer health system, and other proposals, will be prominently discussed and debated. However, another important health issue, containment of costs, will probably be neglected. It has not been a focus of discussion in recent debates. Control of health care costs has major implications for the federal budget deficit; for the ability of state and local governments to fund education, infrastructure, and other essential services; and for the lives and financial security of most US families. All candidates, regardless of what health care system they support, have an obligation to address how costs can be controlled.
So why do I think that we should go directly to Medicare For All? First I do not believe in “managed competition” lowering the cost of care. I do believe that with the government as a single payer there will be ways that finance can stimulate the removal of waste, and I am certain that any form of persistent commercial insurance will never achieve the objective. My second reason for favoring MFA is that I am also skeptical of the ACA’s ability to enroll everyone, with or without a mandate, and even with all states accepting the Medicaid expansion. The ACA was a huge accomplishment that did much to promote the idea that access to healthcare is a human right, but even its designers always conceptualized a population that would fall between the cracks. I fear that as the costs continue to rise more and more people will “opt out.” Matt Breunig of the People’s Policy Project has argued that “the health insurance that consumers most consistently can’t keep” is their employer based insurance. We lose it when we change jobs. We are at the mercy of the employer who sees it as a cost that can be mitigated by shifting risk to the employee with higher deductibles, larger co-pays, confusing paperwork, and unexpected expenses at the point of care that make using it a financial risk. MFA is the most certain, and the most equitable path to lower cost and the effective coverage of every American.
As I implied at the beginning, it will take a miracle for the next president to effectively pass MFA. First the Democrats will need at least 62-67 senators given the fact that current Democratic senators from Arizona, Alabama, West Virginia, and a few other “red leaning” states are unlikely to support MFA, no matter who is president. There will be loud, well funded voices from physicians, hospitals, insurers, labor unions, and big pharma that will oppose MFA. Obama did deals with all of them to get the ACA passed. They will not do another deal to pass MFA. Scare tactics from vested interests are already eroding support in the public. Drew Altman of the Kaiser Family Foundation published data this week that suggests that as the debate and the exacerbation of fears continues, support of MFA has dropped from 58% to 51%. That is not a good trend. My voice is small, as is yours, but if you see merit in MFA, it is time to speak up. If you never thought single payer healthcare could work or was consistent with what you think is best, you have a different challenge, you need to demand Joe Biden and Mayor Pete to start talking about how they will lower the current cost of care, and suggest to them that they stop pointing to the cost ten years from now. You also need to ask them just how many people will continue to have no coverage, or will be inadequately covered, if they were to be elected. Change is a very slow and tedious process. We are still in for a long struggle.
Soaking in the Scenery in Hawaii
Last Friday as we were flying to Hawaii, heavy winds brought down power lines all over the Upper Valley. The weather that we left behind made it easy to accept the higher than usual humidity and temps into the low to mid eighties that we have been told are more common now this time of year in the age of global warming. Our week here has felt like July in New England. There have been some cloudy days with short bursts of tropical showers, like last Sunday when we ventured up the Waimea Canyon on the west, less populated, side of Kauai. I am not complaining, it’s just a little different than when I was last here.
Hawaii is a special place for my wife. She has fond memories of living on Waikiki in 1969 and working as a nurse at Queen’s Medical Center until she got island fever, and needed to return home to the traffic and winter in Boston. My only previous trip to these islands did not occur until 2007. I think that if I lived on the West Coast, I would come much more often. Once here, the long plane ride always seems worth the payback you receive from the sensory delight of the mountains, the sea, and the wide variations in the environment from sea level to the mountain tops.
There is a Hawaiian phrase,“Mauka to Makai,” which means “mountains to sea.” I am amazed by the variations that can be encountered within a radius of a few miles between the mountains and the sea. On the fourteen mile drive from the sleepy little town of Waimea up the canyon road to the spot where I took the picture in today’s header, we passed through scenes that could have come from the Gulf Coast of Florida, to the farmland of the South, to the high plains that run up to the Rockies, and on into the forests of the Northwest, before dropping down to the reds and oranges of the Grand Canyon in Arizona. The drive feels like a condensed version of some geological masterwork.
Since Monday we have been busy on Maui with our Santa Cruz family. We are here because my son has the primary responsibility for an annual conference that is produced by SACNAS, an organization that promotes STEM education for Native American, Indigenous, and Latinex students. The conference takes place in a different city each year. 5000 students attended the conference in Honolulu last week. We have gathered on Maui, to share a short family vacation now that the annual work of the conference is behind him. When you get this letter we will be on a short trip to Molokini for some snorkeling. I am not quite sure how that is going to work with a two year old and a five year old. I am open to the adventure, and I trust my daughter-in-law who has planned it all.
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
