Personal Journey: Where I Am Coming From
October 9th, 2019
Little did I realize when I decided to forgo going to synagogue on Yom Kippur 11 years ago I would embark on a wonderful journey through our “dysfunctional political system.” Sitting in our backyard on that day, I listened to a recording of prayers. The prayer, Unetanneh Tokef, asks who will die by fire who by water….who will be impoverished and who will be enriched. It resonated for me. (Leonard Cohen version) As a practicing psychiatrist for nearly 20 years I have had an insider’s view of the US Healthcare system. It struck me there will be many who die as a result of preventable medical errors or lack of access to medical care. Medical bills will bankrupt many. So began my journey, with the passion to help create the best healthcare system for all Americans and chart a roadmap that will achieve healthy communities for Americans to live in and have access to excellent, safe, quality affordable healthcare services by November 2020.
The journey has taken me from reading position papers and countless articles and reader’s comments, to an addiction to C-SPAN, to participating in numerous forums and town meetings. I’ve discovered ideas and thinkers that expanded and changed my mind. I’ve attended conferences about things I never knew existed and experienced unexpected emotional reactions. I even spent a Saturday at the Peoples’ Plaza, Independence Hall National park engaging with my fellow citizens in conversation about the Health of the Nation. On the fourth anniversary of the passage of Obamacare, I paused to reflect on the road traveled and to chart the course for moving forward.
Prior to the 2008 election of Barack Obama, armed with a rudimentary understanding of the complexity of the US Healthcare System, but perhaps hindered by naivety about the dysfunctional political system, I set out to be part of the solution. I have long believed that the attainment of the highest possible level of health and well-being is a fundamental human right and that Universal Healthcare was the right solution for what ailed the healthcare system. Building on the UN Universal Declaration of Human Rights, I “created” a “Healthcare Bill of Rights and Responsibilities” to promote dialogue. I outlined a prescription (Rx4Reform) for treatment that leveraged my experience as a physician. The Case of the US Healthcare System described the “sick” system and followed the structure of a medical case presentation to define the problems, provide the relevant data, facilitate a meaningful discussion, and draft an action plan to achieve the best outcome. Few wanted to hear about universal healthcare, let alone actively engage in efforts to bring it about. But that all changed as a result of the election of Barack Obama and his focus on healthcare reform as a top agenda item for his presidency.
It was exhilarating when the Obama transition team outlined their healthcare plans. Former senator Tom Daschle was nominated to be Secretary of the Department of Health and Human Services and to lead the White House office of health reform. I invited friends and neighbors to one of the more than 4000 “house meetings” in which citizens were asked to discuss the challenges of healthcare and provide solutions. Than political reality set in. Soon after President Obama took office, Daschle’s nomination was withdrawn as accusation of failing to pay taxes surfaced. Where candidate Obama railed about the influence of special interests on Washington politics, President Obama brought them to the table. It appeared they had an important role in writing the legislation that came to be known as “Obamacare.” At that time I became a passive observer of the political drama. I was virtually addicted to CSPAN, watching committee hearings and subcommittee hearings and tuning in to “Washington Journal,” the call-in show on the weekends. Through commentary in liberal and conservative news outlets, events at the Constitution Center, and many other venues I learned of the extensive political, economics and legal issues, as they relate to the role of government and the Constitution. Health care s complicated, who knew?
On August 2nd, 2009 I had a transformative experience, a (civic) religious experience of sorts that continues to energize me a decade later. On that hot Sunday, responding to a flyer randomly picked up while enjoying breakfast at a local deli, I decided to participate at a town hall meeting about the healthcare legislation that was to become ACA AKA “Obamacare”. I had come to hear than Secretary of HHS Kathleen Sebelius and the late Senator Arlen Specter conduct a conversation with “the people” about the legislation. Little did I expect what was to follow. At the town hall, against the background of Independence Hall in Philadelphia, I experienced the passion of citizens enraged by a government that they believed will limit their liberties and freedoms, to take what is rightly theirs and give it to “others”. At the town hall, against the background of Independence Hall, I experienced the passion of citizens enraged by the fear the government will limit their freedoms or enslave them in socialist chains. The anger and passion were striking. The rage at the speakers that afternoon spread across the country that summer and in the past decade has generalized, with rage, hatred and hyperpolarization becoming the political currency of choice for many political actors. Passion and rage of citizens are not unique to our time. The current poisoned political environment, highlights the shortcomings of the political system’s architecture constructed by the founding fathers and ratified by “the people” in 1789. The DNA for our body politics that was established to contain the dangers that passions pause for republican government. Or so I thought at the time
While I didn’t agree with their conclusions, the anger and passion were striking. That rage continues to energize American political life. The rejection of redistribution and concern about having less benefits was a major driver. For others the focus on expanding insurance at a time when few were held accountable for the 2008 disastrous financial crisis was unacceptable. But as President Obama said to than House Speaker Eric Cantor, “Elections have consequences”
When The Patient Protection and Affordable Care Act (PPACA) AKA “Obamacare” was signed into law by President Obama on March 23, 2010, I was cautiously optimistic. The law appeared to hold promise to diminish the chance of financial ruin by expanding insurance. In addition, "Obamacare" included many important provisions that had the potential to improve the quality of healthcare, such as public reporting and transparency of outcomes and cost. However, it was far from what I had hoped. The implementation over the next four years highlighted the shortcomings of the law and the challenges for government. The dysfunctional healthcare system persists; Americans are dying needlessly due to preventable medical conditions, lack of access and poor quality care continue and costs continue to escalate. Once again special interests succeeded in benefiting from the law. Ideological and special interests polarize and divide Americans with fear mongering and seeding distrust. The media amplifies the winner and loser mentality marginalizes us as citizens. More citizens have become distrustful of our government. Americans are more divided and the government more dysfunctional than I can ever recall.
It was clear that in order to have a meaningful voice; we would have to engage politically as an active citizenry. But how? I created Citizens4Health. We are a small group, but inspired by Margaret Meade’s quote,
“Never doubt that a small group of thoughtful committed citizens can change the world, it is the only thing that ever has.”
I discovered James Madison and converted to "republican constitutionalism" as my civic religion. For the next few years, I watched as the nation became more polarized. With each legal challenge of the legislation, milestone in the implementation, and federal election, the passions driving a segment of the population infused our body politic with divisiveness and our governing institutions with increasing pathology and dysfunction. Concurrently, digital technology evolved with social media platforms assuming greater importance in “wiring” the body politic. Following the ACA legislation, and the battle around its passage and implementation, has provided me an opportunity to test and magnify my Madison inspired citizen evolution/transformation.
I clearly remember my initial response upon reading Federalist 10. In this paper, considered one on the most important in political history, James Madison seeks to convince the skeptics, why the constitution as constructed in Philadelphia should be ratified by the citizens of the states. James Madison, was not a physician however he was using medical metaphor to provide a diagnosis of the governments that had existed at the time and to provide a treatment plan to address the pathology. His use of the disease metaphor: that included a description of the pathology and symptoms of post revolutionary war Confederacy, were instrumental in the creation of the constitutional architecture of the American republic as a treatment plan. Additionally, as a physician and a psychiatrist two aspect of Federalist 10 resonated with me.
For the past 6 years I explored Madison’s political philosophy, his analytic skills and personal qualities as he confronted the political dysfunction of his time. I have contemplated how his efforts can guide us through our own political challenges. I have grown to appreciate Madison’s dedication and contribution to the ideals of the Enlightenment, as well as the skills he employed to construct the architectonic document containing the DNA of our nation’s political institutions. James Madison was not a physician, but he adeptly used a medical framework to shed light on the pathology of republican governments by providing both diagnosis and treatment plans to address the “mortal danger” of their ills.
James Madison’s contribution to our evolving nation was unparalleled for creating the structure that allowed the US to persist for over 230 years. As a physician I found Madison’s use the disease metaphor particularly intriguing. In particular what inspired me was Madison’s ability to communicate through the Federalist papers his reasoning for the constitution. Similar to the activity of a physician treating a person suffering with a disease, Madison used aspects of the Medical Case Presentation to achieve his goal for “individual freedoms”. He described the “symptoms” (vices) of the political system of his time; study the history of political institutions, offer an assessment of the problem and provide differential diagnosis, engages in compromise, created a treatment plan, and than monitored and adjust the treatment plan to changing data and environment.
“By a faction” he writes, “I understand a number of citizens, whether amounting to a majority or a minority of the whole, who are united and actuated by some common impulse of passion, or of interest, adverse to the rights of other citizens, or to the permanent and aggregate interests of the community.”
He identifies the symptoms of the government defined by the Articles of Confederation:
“Complaints are everywhere heard from our most considerate and virtuous citizens, equally the friends of public and private faith, and of public and personal liberty, that our governments are too unstable, that the public good is disregarded in the conflicts of rival parties, and that measures are too often decided, not according to the rules of justice and the rights of the minor party, but by the superior force of an interested and overbearing majority. “
The causes for the dysfunction, Madison diagnosed,
“must be chiefly, if not wholly, [the] effects of the unsteadiness and injustice with which a factious spirit has tainted our public administrations.”
For this malady, he identified two treatment options:
“There are two methods of curing the mischiefs of faction: the one, by removing its causes; the other, by controlling its effects”.
Madison then set forth two ways to remove the causes of faction -- rejecting both, for one meant destroying liberty and the other changing human nature -- and two ways to control the effects. His political schema involved the latter, extending the size of the territory and refining, enlarging the public views through the republican principle of representation and active participation .
Madison’s psychological insights and use of the disease metaphor, likely a consequence of his experience with disease, resonated with me. It is clear to me that what is missing from our current politics is a structure for meaningful “debate”.
Madison’s writing in Federalist 10 and 51, considered one of the greatest political articles, offered a framework. In what has been considered one of the most important works of political philosophy, Federalist 10, Madison demonstrates how the proposed constitutional framework can combat the mortal disease of faction with a republican cure.
At this political moment, when it appears that citizens all over the country are filled with rage and division and the feeling their government and other political institutions aren’t serving them anymore, when many are questioning the benefits of the democratic form of government, when congress appears to be hopelessly mired in partisan gridlock, I feel optimistic. The exploration of the process and becoming familiar with James Madison, “the father of the Constitution”, has provided a framework to become a more engaged citizen. Mr. Madison has guided me helped me regain my quest to be an informed and actively engaged citizen. His writing, activities and dedication to improve the lives of his fellow citizens have inspired me to embrace Supreme Court justice Louis Brandeis’s assertion that the
“The most important political office is that of the private citizen.”
The processed exposed me to Madison’s views about Public Opinion’s importance in a representative republican democracy. Most importantly, my quest to become “an informed” citizen has been great “treatment” for the frustration I experience as a citizen with our current political environment and its detrimental impact on most Americans.
Had Madison been familiar with current understanding of human physiology, anatomy and pathology would he have been able to make our constitutional representative democracy more resilient? would he utilize a more systemic approach to address problems facing the body politic? Would he have greater trust for citizens as the interact in the political ecosystem?
I am proceeding with a conceptual framework and an action plan to provide a citizen orients action plan to health the pathology of our body politic.
Citizenism is the recognition and the exploration of the role of the citizen within the political ecosystem. Citizenism aims to enhance our democracy, to reclaim the citizen as a central stakeholder in the political ecosystem and strive for deliberative dialogue as understood by the founding fathers, where the people are the ultimate sovereigns. It builds on the founder’s view of the active citizen continuously participating in their government, locally and nationally. It studies the nature of the citizen rights, responsibilities and the influences that make the modern citizen. Citizenism borrows from other fields and disciplines, including human behavior, medical science, social science, political science and is Informed by network science, complexity and translational democracy. Citizenism is positioned to respond to a troubling array of problems facing our nation’s political system.
Citizenism is not limited to a theoretical realm but rather it, offers a citizen user’s manual of sorts, a tool box, for reclaiming the the centrality of the citizen from subjects, consumer, taxpayer, voter, elector and related roles that have defined Americans. To operationalize citizenism, we provide a structure and tools. A citizen’s owners manual to collaboratively address challenges in our political system. Using principles of adult education, we utilize case presentations to explore and highlight constitutional principles and their impact for our body politic. Our first case, addresses the Opioid Epidemic.
The election of Donald Trump and the concerns of the path forward for American Democracy have made my desire to build on my observations and efforts to impact our democracy. To better understand and appreciate the DNA of our government and the fragility of the body politic it established. And most importantly to find ways, building on my exploration to contribute to the healing of our diseased body politic and to facilitate bringing factions together and get us back on course as a representative democracy that lives up to the ideals of the Declaration of Independence.
“Our Constitution is a remarkable, beautiful gift. But it's really just a piece of parchment. It has no power on its own. We, the people, give it power. We, the people, give it meaning. With our participation, and with the choices that we make, and the alliances that we forge. Whether or not we stand up for our freedoms. Whether or not we respect and enforce the rule of law. That's up to us. America is no fragile thing. But the gains of our long journey to freedom are not assured.”
Barack Obama Farewell, January 2017
As it turns out a decade later I plan to reconnected with the mission of making the US Health care the best it can be, that I set for myself prior to the election of president Obama,
Internet and transparency activist Aaron Swartz provided the path forward. I had become aware of his tragic death through my interest in Personal Democracy Forum, an organization that explores the role of technology in politics. I found myself consumed with his story, his commitment to using his technological skills to make the world a better place rather than to enrich himself. His understanding of and willingness to engage in the political process were impressive, as were the wide range of people that he touched in his short life. In particular I found the discussion When Is Transparency Useful? on target and a framework for citizen engagement.
“Transparency”, he wrote, “is a slippery word; the kind of word that, like reform, sounds good and so ends up getting attached to any random political thing that someone wants to promote. But just as it’s silly to talk about whether “reform” is useful (it depends on the reform), talking about transparency in general won’t get us very far.”
Swartz asked us to imagine groups of people coming together to tackle an issue they care about. Rather than each using data on their own, they use their skills to make needed change.
In my work as a psychiatrist I have found that reframing a “problem” can lead to significant insights that achieve remarkable results in addressing seemingly intractable challenges. Furthermore, having a vision serves as an important motivation and framework for action. What if we reframed the discussions associated with our healthcare system from
“What can I get?”
“What can citizens as a group do to achieve a healthcare system that is affordable and provides access to quality care for all of us?”
The change in thinking of the “we” instead of the “me” is much more likely to result in a healthcare system that works for all of us. But how?
As the healthcare debate and legislative process continued, it had impact on some of the patients I was seeing in my office. Some were developing healthcare-associated anxiety and fear that their healthcare benefits would be taken away. Others were fearful for their grandchildren as they were sure the US was going bankrupt.
The path forward:
Moving forward, on this early part of our journey, we embrace the public reporting and transparency requirements of the “Obamacare” legislation, and provide a framework for citizens to address local problems in their healthcare institutions. Borrowing from Swartz’s article, we imagine teams of people coming together to tackle the healthcare issue they care about— perhaps the quality of care at their local hospital. Technologists and public health experts could review hospital safety records reported as part of Medicare Compare, other citizens could engage their hospital boards of directors, monitoring the work done by regulatory agencies, providing meaningful education to fellow citizens requiring hospital services, and bloggers and writers could help spread the word.
On the tenth anniversary of Obamacare, we invite Americans to consider that we the people can make a difference in our healthcare system. We started with one issue, the challenging problem of healthcare associated infections (preventable infections that occur as a result of receiving care in healthcare institutions). Although great efforts has been made to lower the number these occurrences, according to recent reports they contribute to tens of thousands of unnecessary deaths and billions of dollars of added cost for our system. We asked How Safe is Your Hospital?...and plan to provide publically available information to educate the user about their hospital's performance. Additionally, we initiate the Pain Opioid Project to provide a test case for a Madisonian approach to addressing problems in the body politic. As the 2020 election approaches and the polarization and anger within the body politic will be intensified, we will make public The Case Presentation of the US Healthcare System.
We will utilize citizen engagement tools and encourage individuals to work with healthcare stakeholders, medical personnel, hospital trustees, politicians and regulators to make meaningful information available for all. Because healthcare is personal and local, each and every one of us can contribute to the reform our healthcare system so desperately needs. Our road map includes providing user friendly data public reporting about hospital performance, examples of best practice in patient safety, suggestions for engagement with hospitals and regulatory agencies that have a fiduciary responsibility to their communities. Perhaps in future years all hospitals will be top hospitals and death by preventable medical error will not threaten users of healthcare services. We believe that the citizen engagement foundations we are building will contribute to achieving our goal for excellent, safe, quality affordable healthcare services for all Americans by November 2022.
Shimon Waldfogel, MD is a psychiatrist in the Philadelphia area. He is interested in the role of James Madison’s thinking in shaping modern day political institutions and public opinion. He is currently working on a book project, Cancer and the US Political System. He blogs at Shrink the Government, offering psychological insights about the body politic.