There is a lot of wisdom and a call for strategic thinking behind the wisdom of the old Maine aphorism, “You can’t get there from here.” The phrase has been around a lot longer than the Marshall Dodge and Bob Bryan, “Bert and I” comedy routines. The phrase is the punchline to the short vignette “Which Way to Millinocket?” The phrase aptly describes the road to the Triple Aim. Given the current political climate I am left wondering just how we get from this moment to the goal of better health for every individual and healthier communities for a sustainable expense.
I recently referenced an online article written by Don Berwick and colleagues in JAMA about the challenges facing third world countries as they struggled to “cross the quality chasm.” In the first three sentences of the last paragraph of that note I wrote:
Just two years ago I had reason to be hopeful that we were finally making progress toward the Triple Aim. Since the election of 2016 we have been fighting valiantly not to lose ground. Not losing ground is an important objective given the current realities, but it is not the same as making progress.
As the rhetoric about the upcoming election continues In the aftermath of the confirmation of Justice Kavanaugh, I keep thinking about the wisdom of “You can’t get there from here.” It is hard to imagine a consensus on any issue, especially healthcare, given the current level of division within our society. Nothing has underlined the schism within our society like the recent debate over Justice Kavanaugh’s appointment. The president is touring the country energizing his base for the midterm elections as demonstrated by his speech in Kansas earlier this week. CNN reported on that event as follows:
President Donald Trump touted “a historic night” during a rally in Kansas Saturday that came hours after the Senate confirmed Trump’s second Supreme Court appointment, Brett Kavanaugh.
“I stand before you today on the heels of a tremendous victory for our nation, our people and our beloved Constitution,” Trump told thousands of supporters in Topeka.
One month from November’s midterm elections, Trump told his supporters that after the Kavanaugh confirmation fight, “we have been energized.” He warned of the “profound stakes” of elections in which Democrats hope to ride a wave of anti-Trump fervor to congressional majorities.
“You don’t hand matches to an arsonist, and you don’t give power to an angry left-wing mob, and that’s what they’ve become,” he said.
Using his typical attacks over immigration, Trump cast Democrats as “the party of crime.”
“Just imagine the devastation they would cause if they ever obtain the power they so desperately want and crave,” Trump said.
He took indirect aim at the women who have accused Kavanaugh of sexual assault, praising the “incredible Republican senators for refusing to back down in the face of the Democrats’ shameless campaign of political and personal destruction.”
“Since right from the moment we announced, radical Democrats launched a disgraceful campaign to resist, obstruct, delay, demolish and destroy, right from the beginning,” Trump said. “Brett Kavanaugh is a man of great character and intellect.”
The president has scheduled a series of rallies in many states with crucial congressional contests between now and the midterm elections. He will give the speech that he gave in Kansas or other variations like it at those rallies. His words suggest that his strategy is to induce fear. Bob Woodward was quoting the president when he titled his recently published book on the Trump presidency, Fear. Trump has said that fear is the source of real power. He used fear of immigrants, fear of treaties adverse to the best interest of American business, fear of crime in the cities, and fear of the loss of white privilege to get elected. Creating fear of what radical Democrats might do is just an extension of that winning philosophy. Democrats on the other hand are like the player who is penalized for throwing a punch that the ref sees after first getting punched out of the ref’s view.
No matter how the election plays out it is clear that the immediate outcome will not be one that is likely to bring financial relief to healthcare, advance the agenda of universal healthcare, or get us any closer to the Triple Aim. There could be legislation that further damages or completely destroys what is left of the ACA if the president’s efforts to preserve a majority in the House and Senate are successful. That would be extremely discouraging. If the Democrats take control of the House or even gain control of both chambers, then the efforts to curtail the ACA will continue to be through court actions where Justice Kavanaugh will be a big asset for those who would like to continue to chip away at its benefits. If the Republicans and the president are successful in their efforts to use fear to retain control of Congress they will be positioned to succeed in delivering the ACA to its moment of complete destruction.
If your response to my analysis is to accuse me of trying to use fear of further destruction of what has been accomplished to improve healthcare to motivate like minded voters to get to the polls in November and vote for politicians who believe in equity in healthcare and who are committed to creating a platform of legislation that makes healthcare an entitlement, then you are right. That is the problem we face. We are deeply divided. Perhaps we are more interested in being in control than we are in improving everyone’s access to good healthcare.
The stakes for this election are high and as is true in any closely contested athletic event, momentum makes a difference and resentment persists and fuels the next round of competition. After an election like the one we have before us, it will be hard to imagine how our lawmakers will come together to make any progress on an issue as complex as improving the health of the nation. No matter the outcome of the election the answer to the the question of how do we get to the Triple Aim is likely to be, “You can’t get there from here.”
If you listened to the presentation of Marshal Dodge and Bob Bryan in “Which Way to Millinocket?” you know that the fellow offering directions tried to answer the question. He suggested the turnpike first, but then things got complicated. Next, he considered staying on the same road even though it turned to a dirt road and you had to stay close to the river. Finally, he offered the scenic route that the tourists follow, but then when you get to Bucksport things get confusing again. In each situation the route got complicated and staying the course eventually became difficult. As the uncertainty mounted and each possible option was rejected because the route description got complicated, the opt out became, “You can’t get there from here!”
The obvious answer to the conundrum of “You can’t get there from here!” is to go to some place from which you can get there. If we can’t get to the Triple Aim anytime soon because of the political polarization that exist and is likely to persist where should we go to start our trip? I think that we must seek to repair what divides us. The solution is not an easy prescription to follow. Like the children of Israel who wandered in the wilderness waiting until the generation that had known captivity was replaced by time, we may need to evolve a whole new generation of liberals and conservatives who reject the divisiveness of their elders. I have a little time related perspective. I have a different world view than my parents had. My children and their friends are more progressive in their thinking than was my generation. As Martin Luther King, Jr said when he was passing along the wisdom of Theodore Parker, “The arc of the moral universe is long, but it bends toward justice.”
Between now and the time we have a bipartisan consensus that believes it is in the best interest of the country for every American to have access to the sort of care that is envisioned in Crossing the Quality Chasm, those of us who care must continue on despite the political and cultural divides that add to the burden of the work. The real burden is borne by those whose years will be shortened or who will continue on with burdens of illness that could be addressed if only they had the access that people who live in other developed nations have. Moments like the election in November of 2016 and the confirmation of Justice Kavanaugh are painful but the arc is long and the road goes on. We must stay the course and live and work in expectation of a better day when the politics of possibility and respect replace the politics of fear and intimidation.
