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Cartoon – Celebrating Freedom
Cartoon – A Time to Stop and Reflect on Our Freedom
Saving Thomas Jefferson’s soul
In a long letter, a mariner-turned-minister worried about Jefferson’s salvation. The founding father’s response was remarkable.
One midnight in the spring of 1814, Miles King, a pious former sea captain in Mathews, Va., woke up thinking about Thomas Jefferson’s soul.
When it happened again a month later, King took it as a sign. So he put quill to parchment and wrote a letter to the former president, who had retired to Monticello, his estate in Virginia.
In the grip of what he considered divine inspiration, King let it rip. His letter is something like 8,000 words — equivalent to about 32 typed pages. But the basic message is simple: All your accomplishments mean nothing if you don’t adopt Christian zeal before you die.
Miraculously, Jefferson responded. His reply is the calm, respectful rebuttal most people only dream of writing to a critic. Jefferson also offered a sincere and moving declaration of freedom of thought. As a slave owner, he may not have lived his ideals. But almost four decades after writing the Declaration of Independence, Jefferson could set out the words of liberty in ways that few can match and that continue to inspire.
With all the correspondence that swamped Jefferson, it must have taken great patience to wade through King’s stream of consciousness, which unfolds in loops of exhortations and references to Scripture.
But buried in there is the hint of a fascinating tale. King says he was “brought up to the Sea,” commanding a trading vessel to Europe from an early age. He spent a couple of years in the Navy during the John Adams administration, then resumed being a prosperous sea captain. He “was much disposed to a luxurious life of debauch and intrigue,” he writes. “I lived a life of pleasure and gaiety, with now and then a hair Breadth escape from death, either by shipwreck or other casualty.” He hosted parties and weekly card games and generally caroused with a bunch of other rich sots.
You’d like to hear more about that guy. But after his second wife died, he married a wealthy widow who eventually prevailed on him to go to church. There, King learned the error of his ways. He renounced his old life and became a Methodist minister.
He viewed the world darkly. The new nation had wandered from God, as evidenced by the latest clash with Great Britain. “Our impiety hath provoked this war upon us,” King wrote. Judgment Day is coming soon, he warned, and the people need pious leaders to show them the path to righteousness.
“It is not sufficient that our rulers & private worthies . . . merely tolerate religion: they must themselves become religious — thier Light must shine to the Glory of God!” he wrote.
King had a high opinion of Jefferson, of course, but other people were saying some troubling things about the great man.
“I had often heard you indignantly called, deist, infidel, illuminati &c &c,” King wrote. Surely, Jefferson did not want to be lumped in with “horrid” figures such as Voltaire and other free thinkers who questioned the value of central religion? Their writings had “poisoned the minds & proved fatally ruinous to many.”
There can be no neutrality on religion, King argued — and he quoted the gospel of Matthew to say that whoever is not for it is against it. “Does this quotation,” he asked Jefferson, “not rub you pretty close Sir?”
With the earthly world soon ending, he beseeched Jefferson not to be satisfied with rational thought and simple faith in the divine — what King called “head religion.” “Never rest untill you feel it in the heart! Influencing all Your words and actions & regulating the thoughts of your heart!” Saying he had heard that Jefferson was reading the prophecy of Isaiah, he quoted another Bible verse to ask, “Understandest thou what thou readest therein?”
He closed with the wish that he would one day meet Jefferson in the “Kingdom of Everlasting Glory.”
Jefferson wrote back a little more than a month later. He thanked King for his letter “because I believe it was written with kind intentions, and a personal concern for my future happiness.”
As for whether King’s revelations were directly from God, “your reason alone is the competent judge.” Human reasoning “is the only oracle which god has given us to determine between what really comes from him, & the phantasms of a disordered or deluded imagination,” Jefferson wrote. (On social media he might have added: “Just sayin’.”)
With lawyerly guile, Jefferson said that if God wanted to give him a direct communication, he would “obey it with the same fidelity with which I would obey his known will in all cases.”
Until then, he wrote, humans may use the power of reason gifted to them by God to figure things out for themselves. Sometimes that means making a mistake, he added. But in that case, he said, “I have trust in him who made us what we are, and knows it was not his plan to make us always unerring.”
God is too far above humans to take pleasure or pain from their actions, he explained. Instead, the purpose of human morality is to guide people in their treatment of others: “by acting honestly towards all, benevolently to those who fall within our way, respecting sacredly their rights bodily and mental, and cherishing especially their freedom of conscience, as we value our own.”
Jefferson’s failure to live by those words on the crucial matter of enslavement is something that history — if not his maker — must judge him for. But his vision of personal rights and intellectual liberty remain central to the country’s founding principles. In this letter, Jefferson put those revolutionary concepts on a personal scale. It’s good advice, and just as provocative today as it must have been 200 years ago.
Religious beliefs, he told King, “are a subject of accountability to our god alone. I enquire after no man’s, and trouble none with mine.”
He argued that humans have no way to know which type of religion is “exactly the right.” In heaven, he said, there are no denominations — “not a quaker or a baptist, a presbyterian or an episcopalian, a catholic or a protestant.”
“Let us not be uneasy then,” he wrote, “about the different roads we may pursue, as believing them the shortest, to that our last abode: but, following the guidance of a good conscience, let us be happy in the hope that, by these different paths, we shall all meet in the end.”
He closed with a salute of “brotherly esteem and respect.”
King apparently didn’t write Jefferson again.
Two years later, King sent a similar — and only slightly shorter — entreaty to another of the founders, James Madison.
Madison’s reply was brief. He thanked King for his concern, but said that letters on religious subjects “have been so numerous and of characters so various, that it has been an established rule to decline all correspondence on them.”
Thank God that Jefferson had a different policy.
Cartoon – Happy 4th
HAPPY INDEPENDENCE DAY
Cartoon – Prescription for High Drug Prices
Downside risk contracts still less common for ACOs, study finds
The proportion of ACOs taking on downside risk remained relatively stable, with the majority in upside-only risk contacts.
While the number and variety of contracts held by Accountable Care Organizations have increased dramatically in recent years, the proportion of those bearing downside risk has seen only modest growth, according to a new study published in Health Affairs.
ACOs, which use financial incentives in an effort to improve patient care and reduce healthcare costs, have become one of the most commonly implemented value-based payment models by payers. In 2018, there were more than 1,000 ACOs nationally, covering an estimated 33 million lives and including more than 1,400 different payment arrangements.
Yet debates about the impact of the ACO model persist, especially pertaining to the contribution of downside risk, in which ACOs share responsibility for financial losses with payers if the former fail to meet their targets.
WHAT’S THE IMPACT
To help improve understanding of the rapid growth and evolution of ACOs, the research team analyzed ACO structure and contracts over a six-year period from 2012-2018, using data from the National Survey of Accountable Care Organizations.
They found that while the number of ACOs had grown fivefold during that time period, the proportion of ACOs taking on downside risk remained relatively stable — increasing from 28 percent in 2012 to 33 percent in 2018. Overall, the majority were upside-only risk contracts, which reward cost and quality improvements but do not financially penalize poor performance.
There’s concern among industry experts that these kinds of contracts might not provide adequate incentives to boost ACO performance.
When examining the leadership, services and size of ACOs, the researchers said those bearing downside risk were less likely to be physician-led or physician-owned, more likely to be part of larger, integrated delivery systems (that included hospitals), had more participating physicians, and were more likely to provide services such as inpatient rehabilitation, routine specialty care, and palliative or hospice care.
In addition, the authors found that ACOs with downside risk contracts were more likely to have participating providers who had experience with other forms of payment reform, such as bundled or capitated payments, and had more ACO contracts across payer types — Medicare, commercial and Medicaid.
THE LARGER TREND
The authors said increasing the number of ACO payment contracts per ACO suggests a broadening of financial incentives around value-based care, but that there’s been “stagnation in the proportion of ACOs with deeper financial incentives.” In 2018, just one-third chose contracts with downside risk.
CMS recently issued a rule mandating that ACOs take on financial risk sooner.
Cartoon – The Whole Office smells like Failure
Democrats have lurched leftward on health benefits for undocumented immigrants
President Trump could barely hide his glee when every one of his potential Democratic opponents shot up their hands at Thursday night’s debate when asked whether undocumented immigrants should be included in government health plans.
And for a clear reason. Extending public benefits to immigrants who are in the United States illegally has long been a fraught issue, even among Democrats. Nine years ago, the Democratic-led Congress banned such immigrants from the Obamacare marketplaces — even if they use their own money to buy a plan — and even the most liberal states have struggled to expand coverage to the undocumented population. Undocumented immigrants are excluded from the Medicare and Medicaid programs, with some exceptions for children and pregnant women.
It’s hardly the first time a Republican has pounced on a Democrat for appearing to support government health benefits to the undocumented. Many will recall the infamous moment in 2009 when Rep. Joe Wilson (R-S.C.) yelled, “You lie!” in the House chamber as President Obama told them health proposals wouldn’t cover undocumented immigrants.
Wilson was wrong — the eventual ACA did indeed exclude undocumented immigrants from health insurance expansions, as Obama had promised. But this is one of several issues on which the 2020 Democratic contenders are now moving quite a bit further leftward as they seek the presidential nomination. They’re certainly far from where the last Democratic presidential nominee — Hillary Clinton — stood on the issue.
In her 2016 health-care platform, Clinton would have allowed undocumented immigrants to buy marketplace plans, one step further than the ACA’s outright ban. But she would have still excluded them from getting the ACA’s income-based subsidies, increasing the likelihood undocumented immigrants still couldn’t find affordable coverage.
Rewind to two decades before that, to when Clinton as first lady was trying to get a health-care revamp passed from her perch at the White House. At the time, the first lady expressed concern that extending benefits to the undocumented could encourage more people to enter the country illegally.
“We do not think the comprehensive health-care benefits should be extended to those who are undocumented workers and illegal aliens,” Clinton told Congress in 1993. “We know now that too many people come in for medical care, as it is. We certainly don’t want them having the same benefits that American citizens are entitled to have.”
The Democrats onstage last Thursday sounded a lot different.
NBC moderator Savannah Guthrie posed this question to them after an extended discussion about the Medicare-for-all and public option plans they are proposing to offer Americans:
“A lot of you have been talking tonight about these government health care plans that you have proposed in one form or another,” Guthrie said. “Raise your hand if your government plan would provide coverage for undocumented immigrants.”
All the candidates — which included the two front-runners, former vice president Joe Biden and Sen. Bernie Sanders (I-Vt.) — raised their hands in response.
But Biden’s stance was notable, considering where mainstream Democrats used to stand on the issue. “You cannot let people who are sick, no matter where they come from, no matter what their status, go uncovered,” Biden said on the stage. “It’s just going to be taken care of, period … it’s the humane thing to do.”
Both Biden and South Bend, Ind., Mayor Pete Buttigieg noted that undocumented immigrants pay Social Security taxes if they have jobs and sales taxes when they purchase goods and services, arguing that’s another reason they should be included in public health-care programs.
“This is not about a handout,” Buttigieg said. “This is an insurance program. And we do ourselves no favors by having 11 million undocumented people in our country be unable to access health care.”
To Buttigieg’s point, there’s considerable evidence that helping people buy health insurance results in less spending in the long run. When hospital emergency departments care for uninsured patients, the hospitals end up passing along the costs to the insured patients, resulting in higher premiums for everyone.
Julian Castro, former HUD secretary under Obama, reiterated his support yesterday for giving health insurance to undocumented immigrants.
“What I’d like to Americans to know, right now, No. 1, undocumented immigrants already pay a lot of taxes,” Castro said on ABC’s “This Week with George Stephanopoulos.” “Secondly, we already pay for the health care of undocumented immigrants. It’s called the emergency room.”
That’s a reason California — home to about one-fifth of the country’s undocumented immigrants — recently passed a budget extending Medicaid to some of the undocumented. But it’s the only state to do so, and it chose the most limited, least-costly option.
Last week, Gov. Gavin Newsom (D) signed a $214.8 billion budget into law that extends California’s Medi-Cal program to undocumented adults ages 19 to 26. That measure also expands on the federal health-care law in a number of ways, reinstating its individual mandate to buy coverage — which Congress repealed a few years ago — and raising the income threshold for getting marketplace subsidies.
But the Medi-Cal expansion is only a shadow of what many state lawmakers wanted. The state’s Senate passed a bill also opening its door to undocumented immigrants over age 65, while the Assembly’s version would have opened it up to everyone. Newsom insisted on expanding coverage only to young adults, a much less expensive option estimated to cover 138,000 undocumented immigrants.
The political obstacles to such a move were evident back in 2010 when Congress was constructing the ACA and barred people in the country illegally from participating in any part of the law.
California took some steps in 2016 toward asking the federal government for permission to let undocumented immigrants buy marketplace coverage but withdrew its request over fears the young Trump administration might use the request to target immigrants for deportation. New York lawmakers have proposed similar legislation, but it hasn’t gained traction.
HENRY KOTULA 