Believe it or not, some things are universal

A couple of articles caught my eye today. Like most of us (i.e. Boomers), I have more than a passing interest in issues related to health and longevity. Naturally, then, when I considered where to start reading this morning– Jeff Sessions confronting accusations of lying to the Senate, another accusation of sexual assault against Roy Moore, presidential pressure for judicial retribution against a former rival (yes, in the U.S.), or research showing yet more reasons that coffee is good for us– you can guess where I clicked first. Latte in hand, I began to read.

Time Magazine (time.com) reported on a presentation by the University of Colorado medical school on their innovative analysis of the data in the landmark Framingham Heart Study. The strongest correlation they discovered was the link between drinking coffee (up to at least six cups per day) and reduced risk for heart failure, stroke, and coronary heart disease. Well, that called for another espresso!

Even sweeter for yours truly was the next article, about Harvard researchers proclaiming that “eating too quickly may be bad for your health.” Slow and steady eaters are less likely to become obese or to develop metabolic syndrome, with its associated stroke, heart disease, and diabetes. This was welcome information because my own research had only confirmed that slow eating can really irritate those waiting for you to finish. Bonus benefits seem to be that slow eaters may burn more calories and that, by chewing and swallowing more slowly, they recognize that they are filling up and consequently eat less. I am less convinced about this last finding, having learned through determined training that it is possible to eat slowly and still eat a lot. Save when one’s plate is prematurely whisked away.

As much as I enjoyed reading articles that supported the wisdom of two of my habits (and don’t we all?) it also reminded me that for every research finding there is usually another bit that more or less contradicts it, sooner or later. My favorite commentary on this observation comes from the 1973 movie, Sleeper, after the protagonist awakes from a 200 year cryogenic slumber:

Dr. Melik: This morning for breakfast he requested something called “wheat germ, organic honey and tiger’s milk.”
Dr. Aragon: [chuckling] Oh, yes. Those are the charmed substances that some years ago were thought to contain life-preserving properties.
Dr. Melik: You mean there was no deep fat? No steak or cream pies or… hot fudge?
Dr. Aragon: Those were thought to be unhealthy… precisely the opposite of what we now know to be true.
Dr. Melik: Incredible.

In spite of this, most of us do our best. Many or most of our generation are determined not to go gently into that good night. Eyes and ears always open for any new idea, book, or product to bolster our anti-aging arsenal.  But what efforts are going to be effective?

I spent some time with a friend last week who for the first time in his life has recently faced a couple of negative test results. This led him to take one of those interactive surveys that give you feedback on your health habits, your projected life-expectancy, what you can do to increase it, and by how much. I’ve done the same and his observation of the results was the same as mine: unless you are a smoker, are morbidly obese, or refuse to wear seatbelts, your increased life-expectancy if you make ALL the suggested changes amount to no more than a year or two.

Actually, there is one factor that the health questionnaires don’t address that would skew the results. The ones I’ve seen don’t ask the question, “Do you have good health insurance?” Their results are geared for those who do. Ah, you see where I am going with this, don’t you?

We want to believe that if we do all the right things, we will be rewarded with a long and healthy life. Research usually asserts that our individual choices do in fact affect our chances. A 5% lower risk of this or an 8% greater chance of that. Similarly, drivers who do all the right things and make good choices have better safety statistics and smaller risk of accidents. But, they still need insurance. Are mandated to have insurance.

When Massachusetts passed RomneyCare, or whatever they call it now, Harvard researchers found a 3% drop in the state’s mortality rate in the first four years of universal coverage. This in a state that already had a higher percentage insured than most others. The same source had this:

In 2002, the Institute of Medicine estimated that the death rate of the uninsured is 25 percent higher than for otherwise similar people who have health insurance. According to the study, 18,000 excess deaths occurred each year because 40 million Americans lacked insurance.

Of course, from listening to friends and reading the opinions of others, it seems safe to say that the quality of our lives matters at least as much as their duration. We would like a long life, but we would really like it to be as healthy as possible. So, whose quality of life do you predict will be better? Whose would you choose? Someone who has chronically deferred medical care due to lack of access or fear of financial ruin? Or someone whose annual physicals, lab tests, preventive and proactive care, and necessary surgeries have been a matter of routine?

For an individual to make smart, research-based choices for a healthy life is a baffling endeavor, a maze with conflicting signposts, detours, and dead ends. And, if we do well navigating that maze, perhaps we will live a little longer and hopefully more than a little healthier. Worth the effort and something we all can do.

But, we have no control over our DNA and limited control over the unforeseen accidents and other events that can derail the healthiest among us. And, by this point in our lives, most of us understand that everyone is derailed at some point, to some degree. If you have been there already, you know that you have never felt more vulnerable, never more dependent on others, never more naked. Everything else, except for the support of loved ones, is immaterial whether you are rich or poor.

While we live in a time that has reached a nearly-miraculous state of medical understanding and technology, we live in a country that somehow still struggles with the basic question of whether everyone deserves to benefit from it. It is clearly not a matter of whether it is affordable. It is a matter of values and priorities.

In its 2016 report, Universal Health Coverage and Health Outcomes, The Organisation for Economic Co-operation and Development (OECD) ranked its 35 member nations for population coverage for core health services. 24 of these countries have achieved completely universal coverage, 22 of them totally with public funds. The United States had the smallest percentage coverage, except for Greece, falling short of economic powerhouses Poland, Mexico, Hungary, and 30 others. While we attained runner-up to the bottom with 88% coverage, 54% of our population have primarily private insurance and only 34% public. The nation closest to that mix was Chile, with 93% coverage, 19% private and 74% public.

Each of these countries has recognized that the health of its state can be no greater than the state of their people’s health.

Is it any wonder that politics of divisiveness and partisanship are rampant when we have failed to agree on this most basic of social compacts? Indeed, it has become a perverse ideological litmus test to destroy what progress has been made.

A demonstration of this is taking place right now. The Republican effort to salvage the legislative year depends upon passage of a tax bill that will embody their priorities. The most recent strategy for preserving the greatest possible reduction of corporate taxes and individual taxes for the wealthy, without obviously doing so at the expense of the middle class, is to include the repeal of the ACA’s individual mandate. This would save several hundred billion dollars and result in 13 million Americans losing their insurance. If it passes, it is more than possible that deep cuts to Medicare and Social Security are next, as deficits resulting from the tax cuts need to be offset.

So, there it is. It is a big deal. Affecting us, affecting our families. Affecting what kind of country we are choosing to be. What to do? Order that book on the new cleansing diet? Or demand that our representatives represent our priorities and work for the longterm health of us all?

 

 

Avoid Difficult End-of-Life Decisions: Make Them Now

It’s been a quiet week in Lake Trumpbegone. Scanning the news of the last week for anything related to the Donald, I just don’t seem to find anything of significance. Well, there was some FBI flap, North Korea shooting missiles toward Japan, a Kissinger sighting and threats of White House “tapes” in case the firing wasn’t Watergate-ish enough already. Oh, and unplanned or not, the big f*** you to the country in the form of Oval Office smiles and back-slapping with the Russian foreign minister and the Russian ambassador. Yes, the same ambassador that was meeting and phoning Trump campaigners during the election and transition. That was the next day after the humiliating purge of the chief investigator into Russia’s attack on our elections! Yada yada yada. Same old, same old.

So, it seemed a good opportunity for a break from the depressing topic of present day politics in America to talk about something marginally less gloomy– present day dying in America. I know. I must have a natural instinct for building readership.

This fun idea did not drop out of the blue. There was a recent article in the NY Times by Dhruv Khullar, M.D., M.P.P., a resident physician at Massachusetts General Hospital and Harvard Medical School, titled “We’re bad at death, can we talk?”  If you are a (SSA) card-carrying boomer, I strongly urge you to read this article. Preferably after finishing this one.

A Personal Perspective

Ann and I made the decision eight or nine years ago to see a family estate attorney in order to prepare documents that included wills, advance health care directives, and durable POAs (power of attorney) for health care decisions and finances/property.

What we thought would be a simple matter of signing some papers drawn from boilerplates turned into several days (our time, not billable hours) of enforced consideration. Given numerous document samples to work with, and the option to add and edit, we faced hypothetical calamities such as cancer, car crash, and Alzheimers. We also acknowledged the certainty of death. Not the someday we really don’t expect, but the one day we know will come.

If you’ve done this already, you understand what I mean when I say it was a positive experience. Assets in a will are easy. Get it done and you can check it off your list and congratulate yourself. But, considering the reality of your own death is major league stuff, as is who will speak for you if you are incapacitated and how you will know they understand what you would choose. First, you will need to know that yourself.

For us, the process I just described was a big part. The consultation with an attorney who specializes in family estate planning helped to broaden our thinking and realize the vital issues at stake. Reading, revising, and choosing what to include and what to exclude in the advance directive required that we confront some of our fundamental beliefs, values, preferences, and fears. For example, near the end, do you want to be kept alive under any circumstances with extraordinary medical intervention? Or, under certain circumstances, at a certain point, would you prefer to be kept as comfortable as possible and have as natural a death as possible? At home or in a hospital? What are those circumstances and what is that point?

Another factor in our thinking was what we observed in the gradual decline and deaths of our own parents, two with Alzheimers or dementia, along with second-hand observations of the same experiences of friends and friends’ loved ones. What we have seen has ranged from refusal to think or do anything about it to orderly and loving preparation. It goes without saying which approach has impressed us as preferable.

We ended up with a portfolio of documents, with paper and electronic copies for our children and medical providers, that are our best effort to come to terms with the later and last stages of our lives.

If you don’t have a similar set of papers already, here is why you should. Not someday, but now:

  1. It is a gift to your loved ones that cannot be overestimated. It is like the credit card commercial: attorney costs for us 8-9 years ago were about $1000, having it accomplished, priceless. (I’m only focusing on the health care directive and POA. The will and the financial/property POA were included and equally important.)
  2. If you don’t start it now, when will you? Answer: someday. That day might come too late.
  3. The choices that must be made when you are in a hospital are usually during either a crisis, when you are least able to think clearly, or you are unconscious. Thinking you will make these decisions “when the time comes” really means you are passing the buck to loved ones who cannot read your mind and who may not be able to think very clearly at that time either.
  4. You may find, like we did, that facing up to your mortality now, and all that implies, is good for the soul and instills the confidence that you will be ready to face it in fact when the time comes.

A National Perspective*

In the last 6 months of life, Americans make an average of 29 visits to the doctor. In the last 30 days, “half of Medicare patients go to an emergency department, one-third are admitted to an I.C.U., and one-fifth will have surgery.” This, in spite of surveys indicating that 80% express a preference to avoid hospitalization, especially intensive care, at the end.

We spend 6 times as much on Medicare patients in the last year of their lives than all other patients over 65 combined, and that last year accounts for 25% of all Medicare spending. That has been true for the past 30 years.

And yet:

Patients who engage in advance care planning are less likely to die in the hospital or to receive futile intensive care. Family members have fewer concerns and experience less emotional trauma if they have the opportunity to talk about their loved one’s wishes. And earlier access to palliative care has consistently been linked to fewer symptoms, less distress, better quality of life — and sometimes longer lives.     -Dhruv Khullar, M.D., NY Times

So, there is mounting evidence that most people want access to palliative (i.e. treating the symptoms, such as pain, of a condition) and hospice care and that such care produces better outcomes, a better quality of life…and death. There seem to be two main reasons it isn’t more prevalent.

The most obvious reason is that many people fail to make that preference known, either in the moment or with an advance directive. The other reason is that the hospital either fails to honor the preference or simply does not have the facility or resources to do so.

I don’t have data, but have read of the reluctance doctors and hospitals have to stop efforts to extend a patient’s life as long as there are any avenues remaining, even if the best that can be hoped for is a few more days at the expense of more suffering and more medical bills. This inclination is likely to become stronger as medical technology continues to advance. Our challenge as a society will be to weigh the benefit of the extended days against the quality of the person’s life and the right of that person to determine how it is lived and how it ends.

The individual’s choice becomes moot when living in a state or rural area where palliative and/or hospice services are restricted or unavailable. For example, nearly 90% of New England hospitals have palliative care services, whereas only about 40% of those in the South do. And, if a hospital does not have a palliative care program, it falls to individual doctors to discuss options with a terminal patient and family. Nearly 70% of doctors say they haven’t been trained in palliative or hospice care, with many uncertain of the distinction between them. And about half of doctors say they are uncomfortable discussing terminal illness.

Most of us can relate to that. It isn’t as much fun as, well, most topics. But that is not an excuse. Not for doctors. Not for boomers. We have lived our entire lives thinking the rules do not apply to us or we should at least get to set the rules ourselves. DT is a boomer, remember? Sorry, Donald. You– we– aren’t going to weasel out of this one. Or buy, bully, or bluster your way out of it.

So, why not make our final curtain a class act? Set it up now. Do it right. Make it a farewell that is an expression of your love and care.

 

*The source for information in this section is the article by Dhruv Khullar, M.D., which was cited and linked above.

Fake Win

I was working on a post for the blog when I read this column today by Maureen Dowd saying much the same thing, only better. I hope you will read it. The thing is, Trump neither knows nor much cares what is actually in the Republican health-care-for-the-young-and-healthy/tax-cut-for-the-wealthy bill. He expects to keep getting away with claiming things are great that aren’t– and selling them. He needed a health bill passed. No matter that it hurts most those who most need help. A win for him is a win, regardless of the lives trampled along the way. That is the art of his deal.

Trump: Hazardous to Our Health – The New York Times, by Maureen Dowd

President Trump sprinkling flimflam dust in the Rose Garden Thursday to deflect attention from the health care bill House Republicans had just passed. Credit Carlos Barria/Reuters

Repeal, Replace, Regurgitate

After several attempts to start this post, I need to give up on trying to be clever or intellectually rigorous, disciplined, or even organized in presentation. I’m just too disgusted and need to get it out of my system. The ongoing spectacle to repeal Obamacare and replace it with We-don’t-care is reaching it’s absurdly noxious climax this week. We are being treated to one of the most nauseating demonstrations of legislative sausage-making I can imagine. Repeal, Replace, Regurgitate.

It looks very possible that an $8 billion ruse is going to persuade enough moderate (what the hell does that mean here?) Republicans to vote for the House bill to pass it.

How did we get here?

After sixty-some safe and symbolic votes over the years to repeal the Affordable Care Act, someone threw the House Republicans a curve in November and delivered all three Houses– Representatives, Senate, White– and a mandate to do it for real. Several problems presented themselves early on.

Republicans, including Trump, had done a smashing job of convincing their base that Obamacare was evil, awful, and a disaster. So much so that a large percentage of those voters entered 2017 not realizing that the health care they had and counted on actually is Obamacare. Once that began to sink in, views on health care became a little less partisan for real people. They liked and needed what it provided.

The new President had been promising for months that he was going to replace it with something better. He had a plan and it was great. Ready any day now. No such plan existed.

Republicans had been saying or implying the same thing for years. But, sorry, no such plan existed.

It turns out that the only thing that has been uniting Congressional Republicans on health care is the political strategy of opposing Obamacare. When it comes to providing health care, their enthusiasm wanes and is scattered all over the map.

Folks like Ryan and his cohort want mostly to get government out of health care and any other entitlement program ASAP. If they could privatize completely, they gladly would but see the need to proceed cautiously. The Freedom Caucus has similar goals but has little interest in compromising or being cautious, even within the party. The so-called moderates see some value in providing actual health care, whether they are motivated politically or sincerely.

So, when the House came up with their first bill, you’ll remember that the Congressional Budget Office scored it and determined 24 million Americans would lose insurance by 2027. Premiums would be 15-20% higher for the first couple years, then about 10% lower by 2026. Medicaid reductions would account for many of the people thrown off care. Tax cuts would result for wealthier people and businesses.

That wasn’t painful enough for the Freedom Caucus, so they voted against and scuttled it.

Recently, with both Trump and the House under extreme pressure to deliver on their promise to repeal Obamacare (or something sorta kinda like a repeal that they can sell), a deal was struck with the hard right members. Several of the popular features of Obamacare– e.g. no refusal or penalty for pre-existing conditions, a list of required provisions for all plans– can now be eliminated by states with a waiver. The states would be required to have a high-risk pool for people who have pre-existing conditions. It is widely understood that these high-risk pools almost always run out of subsidies, resulting in skyrocketing premiums and loss of insurance.

A particularly sensitive and touching explanation for the removal of the guarantee of affordable coverage for families with pre-existing conditions was given by Rep. Mo Brooks (R-AL), who said these people will “contribute more to the insurance pool that helps offset all these costs, thereby reducing the costs to those people who lead good lives, they’re healthy, they’ve done the things to keep their bodies healthy. Right now, those are the people have done things the right way that are seeing their costs skyrocket.”

Contrast that remarkable statement with the one made a couple nights ago by Jimmy Kimmel. If you haven’t watched it, you should.

So, today a couple of the so-called moderates came up with an amendment to the bill that would add $8 billion over 5 years to supplement the insurance of people with pre-existing conditions. That is vastly less than the amount that will be required if, no, when many Red states choose to exempt themselves from full coverage for their people, which is inevitable perhaps for most states since the bill also calls for cutting and then limiting (block granting) money for Medicaid and for subsidies.

Conjecture is that this bandaid could be enough to assuage the consciences of a handful of legislators, enough to pass the bill on to the Senate.

What a hollow victory that would be. What a repulsive accomplishment.

A Health Care-ol, With Apologies to Charles Dickens

Donald Trump glanced at his watch as he passed through the cordoned-off press corps gathered to hurl questions at him as he hurried to Marine One.

“Mr. President! Are you serious about your threat to withhold health care subsidies as a bargaining chip with Democrats?”

“Didn’t you read my book? There’s a whole chapter about bargaining chips in Art of the Deal,” he called over his left shoulder as he picked up the pace. “It’s great. It’s incredibly, incredibly, um, great!”

“Mr. President! Aren’t you afraid you might lose again if you go back to healthcare negotiations so soon?”

Trump immediately stopped and turned away from the waiting helicopter on the lawn to glower at the reporter. “Lose? Lose?! I never lose! Losing is for losers and I am a winner! If I weren’t so amazing, people would get bored with all my winning. It was the Democrats’ fault Ryan had to pull the bill. And the more I’ve thought about it, Ryan’s a loser. So’s the Freedom Caucus. And so’s the Republican Party. I’m getting the picture, now, see? I’m going to have to take care of that mess on my own. I’ll have the Democrats doing whatever I want on health care. You really gotta read my book.”

The President held up both arms to stop the shouted questions. “That’s it. I have to get down to Mar a Lago if I’m going to make my tee time.” He took a couple steps, caught himself, and turned back. “Yeah, I’m meeting a world leader, a really really important big name leader, and we’re gonna to meet over tea and take care of some really important business. It’s gonna be great. Gotta go!”

Barry’s Ghost

When Donald Trump collapsed on his bed that night, his mind was spinning. He wasn’t thinking anything, his mind was just spinning. Suddenly, he sat bolt upright as a loud banging noise grew closer outside his door. Before he could get up to look, he realized he was not alone. A shimmering apparition hovered in the middle of the room. Trump nearly screamed when he recognized Barack Obama.

“Hello Donald,” the former President said with a transparent trademark smile.

“I heard you coming down the hall. How did you get in here, Obama?”

“Nah,” Obama chuckled. “That was just housekeeping dragging a ladder. Who were you expecting, Marley’s ghost?”

“Huh?” Trump looked puzzled.

“Never mind, Donald. I forgot. It was in a book. No, I’m no ghost. Don’t you think the FBI would have told you if I had died?” Obama saw Trump’s expression. “Hmm, you’re right. Maybe not. Anyway man, when you retire from the presidency, they give you some crazy cool gifts. The CIA gave me a prototype of this transporter they’ve been working on. Don’t need no Scotty, man, I can beam myself wherever! It will be really terrific when they get it perfected and I can get there as my regular self, instead of this weird hologram.

“Now, listen Donald,” the ex-President said, getting down to business. “I’m here to give you a heads up. I’m not the only visitor you’re getting tonight.”

Trump looked worried. “Wait a second, are going to tell me that three spirits are going to visit me tonight?”

“So you did read it,” Obama said with surprise.

“Pfff,” Trump scoffed. “I saw it on TV.”

Obama shook his head. “Yeah, well, you’ve got the idea. But, whattaya expect? You’re not only messin’ with the lives of millions of people, you’re gonna screw up my legacy. Now, before sunrise, three friends of mine are gonna show up and give you a little TLIC.”

“You mean TLC,” Trump said distractedly.

“No. TLIC,” Obama said and he started to laugh. “Time for a Little Intensive Care!” 44’s famous cackle echoed in the room for several seconds after his hologram dissolved.

The Spirit of Health Care Past

It was no hologram that materialized an hour or so later. Trump could immediately sense a supernatural presence, in that the wind blew through the closed window and a white-coated figure completed several aerial laps before screeching to a stop, suspended about three feet in front of and above the seated President, who sent off his Tweet before looking up.

“Hey, Marcus Welby M.D.?! I loved your show!” Continue reading “A Health Care-ol, With Apologies to Charles Dickens”

Post Script to my Letter to the President

On Sunday, I wrote a letter to the President, commiserating on his difficult week due to Ryancare and the recalcitrant Republicans. (I haven’t heard back yet. I should probably check my Twitter feed.) Because he was taken aback by how complicated health care policy turned out to be, I helpfully pointed out that there are only three general paths open to us:

  1. Government-funded health care for all.
  2. Repeal the Affordable Care Act (aka Obamacare for the 35-40% who did not realize they are the same) and return to the market approach pre-ACA.
  3. Keep the ACA in place.

So, I was interested this morning to read David Leonhardt’s column (below) in the not-so-failing-New York Times. He describes essentially the same three options and makes the case that the House and the Administration are unwittingly setting us on path #1.

The nearly universal rejection of the GOP bill made clear there is little interest in returning to the bad old days for those who don’t have employer-provided insurance: either pay through the nose (or whatever ailing body part applies) or just keep your fingers crossed and pray. So, scratch #2.

If my appeal to the President to support #1 somehow fails, in spite of his public promises of better health care for everyone, that will leave #3 by default. But, Leonhardt’s contention is that Tom Price has already begun taking steps to reverse and eliminate provisions of Obamacare. The thing is, though, the provisions that are most vulnerable are the more conservative aspects of the law– remember, the ACA’s gene pool has lots of GOP DNA– those governing the private insurance markets or exchanges. Those most protected from attack are the more liberal, namely those under Medicaid and its expansion.

I cited a 2016 Gallup survey indicating a majority of Americans favor some form of federally-funded universal health care. There are others. And when survey questions are purged of political rhetoric from either side, I believe the results are even more positive. I imagine a fictional phone survey illustrating this might sound something like this:

Question: Do you think we should get rid of the job-killing Obamacare?
Answer: Hell, yes!
Question: Do you think all Americans should have good quality health coverage they can afford?
Answer: Hell, yes!

So if voters like government-provided health care and Republicans are going to undermine private markets, what should Democrats do? When they are next in charge, they should expand government health care.    -David Leonhardt

Sounds good. It’s just that, as John and Paul said, it’s a long and winding road.

Letter to the President re Health Care

Dear Mr. President,

Gosh, it seems you had a tough week. No, wait, don’t look away. I didn’t write to gloat or rub it in. In fact, unlike you, I don’t see every issue or transaction as being about winning vs. losing. So, while I can understand why the demise of Repeal and Replace is being portrayed as a huge political loss, it isn’t automatically a win for opponents.

Don’t get me wrong. You could almost hear the sigh of relief around the country when Paul Ryan announced they didn’t have the votes. You have to admit that’s understandable, since only 17% of American voters approved of the bill. I guess a lot of people started paying attention to the real life implications of what was and wasn’t in it. Turns out the 8 year campaign to repeal Obamacare was very effective, not at getting rid of it, but at confusing people with distortions and misinformation. And hey, you were pretty good at that too, but more on that in a minute. Did you know that as of early this year over a third of Americans did not realize that Obamacare and the Affordable Care act were the same thing? Or that nearly a half did not realize that if Obamacare was repealed it would mean the ACA would disappear? (You might have missed it, since it might not have been mentioned on the channels you watch.)

For that bill to have even 17% support is pretty amazing. I think you need to take some credit. Throughout your campaign, at all those rallies, and in the first two months in office, you have laid out your health care policy: Obamacare is a disaster. I have a plan. It is so great. Insurance for everyone; no cuts to Medicaid; insurance companies can sell across state lines; no one will lose coverage; better coverage for less money. Believe me. No details, but trust me.

A lot of people among that 17% still, even today, believe you. I know. Go ahead and chuckle, but the country is mostly not falling for it. And believe me, the temptation to gloat is great. But, like I said, I don’t see any winners out of this yet.

Obamacare is not imploding, at least not everywhere. States that made good faith efforts to implement the exchanges, to accept and competently administer the Medicaid expansion, and to put the needs of their citizens above politics, have actually succeeded in expanding the number of insured and often at a reduced rate of health care cost growth. States that have refused to accept the ACA’s provisions and make those good faith efforts have generally undermined the Act’s intent and gotten self-fulfilling prophecy results.

My reading of the analyses is that Obamacare won’t implode or explode on its own any time soon. In fact, cooperative, beneficial legislation could save and improve it. However, the opposite will almost certainly cause its demise. You would probably consider that a win. I doubt the 24 million, or whatever the number of millions ends up being, who lose coverage will see it that way.

You seemed genuinely surprised when you announced to the country that health care policy is so complicated. (I hate to break it to you, but it’s no surprise to most of us who have needed to navigate it most of our adult lives.) I think I can simplify something for you. The details of course are incredibly complex. But, our choices of how we, as a country, approach access to medical care can be simply categorized. And there aren’t a lot of choices, which accounts for the impasse you and the House Republicans reached this past week. As laid out in a Gallup Poll last year, here are the three basic options we have:

  1.  Replace the ACA with a federally funded healthcare program that provides insurance for all Americans. (Oddly, this is the only option that fits with your promise of delivering insurance for everyone, and has arguably the best bang for our health care buck. It is also the option that polled highest!)
  2. Repeal the Affordable Care Act. (This gets us back to the market approach that has support from most of your party but not most of the country, with approaching 20% of our fellow citizens uninsured.)
  3. Keep the ACA in place. (This can continue to work in states that want it to work, continue have problems in states whose governors and/or legislatures don’t, and can probably be killed if you choose to sabotage it. And it could probably be improved with a bipartisan effort. No, I’m not trying to be funny.)

You like winning. How about trying to win at something that actually matters? Something that allows everyone to win. How about turning your rhetoric into reality regarding health care? BE a populist, don’t just act a part. Accomplish something really great. Leave a true legacy: universal health care so our children and grandchildren will live in a society where no one lives in that dread and consequence of medical and financial catastrophe.

Will you? Can you? I’m thinking about 0% chance. But, that’s the same chance most of us gave you to become President. So, surprise us again.

 

Making America Great?

[Originally posted on Facebook, Feb 20, 2017]

Well, the Republicans finally released something tangible and it looks like the rubber is about to hit the road for Trump voters on the subject of health care. When realization dawns that millions of them, along with other Americans, will either lose their insurance or pay more for less, will that finally shake their trust in their President and Congress? Will those who, for now, retain their own healthcare status quo be willing to stand up for the medical and financial health of others? Will they be fine with the erosion or privatization of Medicare? Will they recognize that when they bought Repeal and Replace, they bought repeal of a path toward a more fair health system and replacement with a version of the old one that favors the fortunate and relegates the unfortunate to poorer health, earlier death, and/or financial ruin. Doesn’t sound Great to me.