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The Inaugural:

Parsing the Speech


By Mark L. Horn, MD, MPH, Chief Medical Officer, Target Health Inc.


At first blush reviewing the President’s second inaugural address seems an odd task for this commentary, but I will try and connect some dots. Often, political rhetoric seems intended to generate passionate anger rather than thoughtful action. Worse, words are often used to obfuscate and confuse rather than convince and clarify. Whatever your positions on health care and social policy generally, the country got a rare and purifying example of verbal precision from our President on Martin Luther King’s birthday. The setting was ideal and the language clear. We now have a good sense of where President Obama wants to take the country and a chance, before the detailed bargaining begins, to predict the impact on the Affordable Care Act (ACA) and health care policy overall.


Two phrases resonate: 1) “They (speaking of Medicare, Medicaid, & Social Security) do not make us a nation of takers. They free us to take the risks that make this country great“; and, 2) “we reject the belief that America must choose between caring for the generation that built this country and investing in the generation that will build its future.“


Several elements of the rhetoric above are striking. First is the inclusion of Medicaid, a means-tested program designed for the poor, with Medicare and Social Security, programs designed for all and for which eventual beneficiaries pay into. It is fair to say that these programs are generally categorized separately by the public, especially the employed “middle class“ population that politicians so often address. Lumping them, as the President has done, suggests he intends to fight strongly to preserve Medicaid from, for example, opposition Party efforts to ‘block grant’ the federal contribution to the states. His statements suggest he will likewise oppose efforts to make significant structural changes to Social Security and Medicare although these programs are at less risk as a consequence of their profound support from powerful constituencies and are therefore less dependent upon his protection.


More importantly, is his obviously intentional rejection of the implication that reliance upon these programs somehow suggests that one is a ‘taker’. This description, clearly extracted from the just finished Presidential campaign, was, I believe, an elegant way to reinforce the oft stated notion that elections matter.


If one notion transcended the campaign as an addition to the American political landscape, it is the rhetorically novel and clearly demeaning description of those among our fellow citizens reliant upon government assistance as ‘takers’. Our President has now made it undeniably clear that he rejects this notion absolutely and will govern accordingly.


We can anticipate a full court press to implement the Affordable Care Act, including its originally intended expansion of Medicaid. The impact upon Social Security and Medicare is less clear, since among the beneficiaries of these programs are many individuals who are not vulnerable and could easily tolerate diminished benefits. Were I a bettor, I’d wager that Administration efforts to cut these programs will focus on increasing payments from, or decreasing payments to, the more affluent. As with taxes, the struggles will then focus on the definition of affluent.


In any event, lingering doubts about the principals underlying Administration social policy or its approach to the societal safety net should, following this speech, be gone. We can now get down to the business of implementing the ACA, adjusting entitlements, and remaining solvent.


We shall discover whether physical, fiscal, and mental health can be concurrently preserved.


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