Jen’s Half Cents: On Prognostication and Pragmatism
Much has been made over the 2024 election results and the expected two, if not four, years that we’ve already begun to enter.
On the day this blog publishes, those results will be certified by the 119th Congress. Despite expected heavy snow fall, by law, there is no discretion on the day and time in which certification of the electoral college must occur.
And, I suppose, this is an apt metaphor for how much of the American public might be feeling about our upcoming political experience. If Scott Gottlieb’s recent Washington Post column about the bird flu threat is any indication, this feeling is certainly the air hanging heavy over the heads of public health and healthcare policy experts and advocates nationwide, regardless of their subject matter focus or political alignment. To say the least, much prognostication has occurred in the last two months.
For a brief but pointed background, the 118th Congress had the opportunity to close out the session with broadly popular ideas via a continuing funding resolution (often referred to as a “CR”). Included was a prohibition on managed care organization spread pricing and 340B Program abuses in Medicaid, significant PBM reform, several child cancer bills, and more. Not all provisions were wildly popular - the “third rail” of American politics, a Congress pay raise, was also included. Importantly, of the “good” pieces of the now-dead CR, several were items the incoming President had championed less than 48 hours prior to his most noted advisors taking to their social media platform of choice and riling a ready public. A good but imperfect bill, which would have returned more than $5 billion to the American public and government, died in a spectacle that even just two years prior would have been unimaginable.
Many and notable elected Representatives have referenced Voltaire’s infamous “Le mieux est l’ennemi du bien” (“The best is the enemy of good” or “Can’t let perfect be the enemy of good”) in negotiating critical legislation during a tightly divided government. There is a pragmatism to this wisdom that conflicts with ideological opposition to “compromise”. The logic goes “if you start from a place of compromise, you’re always going to lose",” or “Compromise means you’re giving up on meeting your ideals” and both of those things are absolutely true in terms of short-term investments. They are necessary truths in a country of an estimated 334.9 million souls, all with deeply held, even if sometimes morally repugnant, ideals. That does not change the necessity of pragmatism to achieve functionality. “Burn it all down” - the Purge, if you will - will only ever serve those already with the means to survive and thrive; it’s us peasant left to fight for our lives, after all.
That does not mean we should not strive to achieve our Promise as a country. Rather, it means that every step we take will also always be someone else’s “increment”, not matter how big or small and that the nature of “progress” is taking steps.
Shortly before the year turned, Jimmy Carter died. An unquestionably Good Man whose legacy as a President was, at best, challenging. Carter was not necessarily known as a “favorite” among his Presidential peers. Anchored to his ethics, the Peanut Farmer shattered some of the secrecy of the Presidency and championed ethical progress above all else, while building a stronger, more collaborative executive branch. Less a cornerstone of his legacy in terms of “pop” culture, Carter’s mark on how Americans experience healthcare and public health access can only be accounted as indelible. The 39th President of the United States is rightly credited for shaping the debates we have in healthcare today - for the better. From wanting broad access in a private-public program for every resident of this country to recognizing a need to ensure that access did not amount to a blank check for hospitals to readily recognizing that access meant rural and mental providers via community health centers, Carter did not blink at the necessity of pragmatic reforms. Indeed, beyond renaming the Department of Health, education, and Welfare to the agency we know today as Health and Human Services, Carter established one of the most essential regulatory and bodies in healthcare - the Health Care Financing Administration or, as it’s known today, the Centers for Medicare and Medicaid Services (CMS).
He was…thoughtful.
And so, rather than prognosticating about what bills we will and will not, or how often they’ll get yanked because of a whim as strong and reliable as a limp noodle, I would like to open 2025 encouraging our readers, friends, and colleagues to consider what “pragmatism” might look like as we work to defend access to care, HIV programs, health and human rights, and our neighbors more deeply affected by prejudices and inequity than ourselves.
