December 8, 2023
Dear Interested Readers,
Random Thoughts In Response To Our Collective Angst
Things could get much worse, but the question in my mind is whether or not they will get better. Before launching into my complaints and concerns, I should own up to the fact that I am a solid resident of the “better than five percent” demographic. I am fortunate that I don’t need to worry about personal economics or my access to health care. I am free of concerns for myself, but I do have short-term concerns for many disadvantaged Americans, and I have long-term concerns for everyone.
According to Forbes Magazine, my wife and I don’t make the 1% club. Maybe, we are only in the top 2% or 5%. I don’t care what our demographic is because my wife and I have all that we need. If we had more, we would probably just increase our charitable donations, give more to our children, and contribute to a few more politicians who support policies that will improve the social determinants of health.
Having been raised by a father who grew up in relative poverty in a mill community during the Depression, I do cheer when I see the cost of gasoline and propane go down. I was taught to hate to throw away food, and I put iron-on patches on pants and shirts to avoid buying new ones. Like many other people, I am frugal in some areas and wasteful in others.
I am not in the top 1% economically, but I am in the 0.1% in many domains. Few people are happier than I am. Few people have a better marriage. Few people have more family blessings than my wife and I enjoy. We are well-fed, loved, warm, and dry. Short of nuclear war or a pandemic worse than COVID-19, we are looking pretty good compared to other couples in their late 70s.
We do know that the “inevitable” is getting closer every day, but that is not our worry since whatever the answer is to “what comes next” there is not much we can do about it. It is not the “what’s to come” to me or my immediate family in the proximate future that worries me. We are troubled by the multiple disasters that threaten both the rich and the poor, the haves and the have-nots along the road we are all traveling here and abroad. I shudder to contemplate what life might be like if those who favor an authoritarian world ever achieved their dreams.
Uncertainty rules. I don’t know what the outcome is going to be in the latest chapter of the continual conflict between Israel and Hamas, but I am pretty certain that there will be continued tension between Israelis and Palestinians for decades to come. Likely, my grandchildren will still be hearing the arguments over “one or two-state solutions” long after I am gone.
China is a perennial economic and military threat that is also probably going to be a permanent problem. The Ukrainians slog on in a conflict against the evil of Putin that tests our collective attention spans and threatens the security of democracies in Europe and around the world. We probably should be focusing on how to live with global warming rather than preventing it since each year the temperature continues to rise, and we have much more talk than progress in our efforts to move away from fossil fuels.
Politics has devolved into a difficult conversation between parties that no longer share a common understanding of how a government should function. We are at risk of again electing a president who has no respect for democracy or the norms of behavior that support a diverse community with opportunity for everyone. Generally accepted norms of appropriate political behavior no longer exist.
Our parties no longer share any overlap in their sense of their domestic responsibilities. In our history, there has rarely been a time when there has been less concordance about our responsibility to the rest of the world or future generations here or anywhere on the planet. It feels like a few centuries since we elected a president who ran on a platform of hope and change.
I was very disturbed this week as I listened to speculation about what candidate Trump meant when he talked about “vermin,” suggested weaponizing the Justice Department, and was evasive when asked by Sean Hannity if he could promise not to try to be an autocrat. Those comments have been widely reported along with his suggestion that he would try to do away with the Affordable Care Act.
No single individual can solve any of the big problems that face us, but I do believe that slow progress can be made if we try to preserve, protect, or revitalize our threatened democracy. President Biden’s most effective election strategy is probably to continue to present himself as the defender of democracy. In a recent podcast from The New Yorker, I heard one commentator present E.B. White’s definition of democracy as presented in the “Notes and Comments” section of The New Yorker on July 3, 1943. It’s not a long piece, and I wanted to share the core of it with you because it spoke to me.
…Democracy is the recurrent suspicion that more than half of the people are right more than half of the time. It is the feeling of privacy in the voting booths, the feeling of communion in the libraries, the feeling of vitality everywhere. Democracy is a letter to the editor. Democracy is the score at the beginning of the ninth. It is an idea that hasn’t been disproved yet, a song the words of which have not gone bad. It’s the mustard on the hot dog and the cream in the rationed coffee…
I fear that we have already lost much of what White was describing and live every day with indications that there could be even more to lose soon. As the conversation continued, the talking heads defined democracy as a system where candidates were willing to lose and commit to trying again next time. I would add that in a perfect democracy each side would commit to working with each other for the benefit of all between elections, not against each other for the benefit of no one but themselves, until the next election
Over the last several months, I have been avoiding discussions of this moment in healthcare or the dismal prospects for the future of care in the spirit of the Triple Aim. It has been painful for me to see how the progress that had been made in the improvement of the efficiency, quality, and access to care between the eighties and the passage of the ACA has been eroded over the last ten years. I have feared, and still do fear, that along with the threats to our democracy, the chance for better care is at risk. The threat is especially acute for those who are disadvantaged by the realities of the social determinants of health. I became tired of sharing my concerns with you in these notes when I knew that there was not much general interest in policies for improvement. that would be a challenge to the powers that maintain the status quo to their advantage in our dysfunctional system of care. I guess I needed a little time off from trying to put my worries into more words.
Some of my reluctance to write about current healthcare issues was washed away this week when a very close friend and “lay” reader of these notes sent me a current New York Times note by David Leonhardt entitled “Big Profits in Caring for the Elderly In the U.S., companies seek high profits in the long-term care industry.” It sounds like an article about a “niche” problem, but it is a focus on an important aspect of our very dysfunctional system of care which over the last few decades has become one of the favorite playgrounds of venture capitalists. In his piece, Leonhardt directs our attention to a collaborative effort of The New York Times and The Kaiser News Service entitled “Dying Broke.” Perhaps the power of the article is in two graphs.
Those are numbers from two years ago, and they are worse now. Early in the article, after the two graphs which compare our health care expense per person and life expectancy to other advanced countries, Leonhardt writes:
The main reason that U.S. health spending is so high is not that Americans are sicker than people elsewhere or are heavier users of medical care (although both those factors play a role). The main reason is that almost every form of care in the U.S. costs more: doctor’s visits, hospital stays, drug prescriptions, surgeries and more. The American health care system maximizes the profits of health care companies at the expense of families’ budgets.
I am delighted that a little light is returning to the deficiencies in our system of care to which I had felt we had become numb. I have commented before about how the issue of better healthcare seems to have dropped off the list of problems that concerned politicians, journalists, and voters. That same sentiment was expressed in the most recent and very last issue of Dylan Scott’s newsletter from Vox which has been entitled “VoxCare.” In the announcement of the end of his newsletter, Scott makes an interesting observation:
In the six years (!) I’ve been writing this newsletter, a lot has changed. VoxCare started when the Obamacare repeal debate was the top politics and policy story, and it found a renewed purpose during the Covid-19 pandemic. But these days, the world of health policy is much more diffuse…
To send us out, I wanted to think big, so I asked some of my most trusted health policy experts a forward-looking question: What do you think is the next big target for health care reform?
So what did he find out? He begins with what we all know:
US health care is, to put it generously, a work in progress. So as we size up its many shortcomings, you might find yourself wondering: Okay, we’ve got a long to-do list here. Which problem will we tackle first?
Over the past week, I endeavored to find out how some of the sharpest minds in health policy would answer that question. I asked a dozen health care experts what they thought the next big target for health care reform — something that felt genuinely achievable in the next five to 10 years — would be.
We should always remain humble when predicting the future, but it still seems safe to assume a major health care overhaul is not in the cards. (My bolding)
Scott has affirmed my concerns, but here is the list of possibilities that he gleaned from his experts, all of which I have mentioned in previous letters. I have included Scott’s first couple of paragraphs of explanation following each item:
Hospital reimbursements
About one out of every three dollars that the US spends on health care goes to hospitals. That alone makes them an obvious target for reform, as US medical spending continues to dramatically outpace its peers.
But hospitals are also a politically potent force. There is a saying around Washington, DC, that every congressional district has a hospital, and that hospital is often one of the largest employers in its community. Threatening its bottom line is inviting the kind of political backlash lawmakers generally try to avoid.
Health insurance expansion
The US has edged closer to universal health care since the Affordable Care Act passed: More than 90 percent of Americans now have some kind of health coverage.
But two problems remain: One, there are nearly 30 million people who are still uninsured. Two, many of the people who do technically have health insurance still struggle to afford their out-of-pocket obligations under their insurance plan. That made the continued expansion of insurance benefits another commonly cited subject for near-term reforms.
Some kind of grand bargain on Medicare
One recurring answer surprised me more than most: the possibility of some kind of grand bargain on Medicare.
But there is a good reason the nation’s largest (by spending) insurance program kept coming up in these conversations. Actually, there are two. First, the program’s hospital insurance trust fund is projected to run out within the next 10 years, putting pressure on lawmakers to find ways to make it more financially sustainable in the long run. Second, as more and more people flock to privately administered Medicare Advantage plans instead of the traditional government program, lawmakers might want to try to better balance the two.
I guess that things are moving so slowly in the world of healthcare policy that Scott is going to move to a new focus. He says that he will still be writing about healthcare, but his parting lines suggest that there may be moss on my tombstone before we see anything as dramatic as the process that led to the ACA. He ends:
In US health policy, the best bet is that the status quo will prevail. But if you’re wondering what might happen next, these policies are a good place to start.
Back To My Story
Having Charlie Baker assume the role of CEO at Harvard Pilgrim came too late to avert disaster. Harvard Pilgrim’s financial problems quickly became a near-death experience for Harvard Vanguard when Harvard Pilgrim went into receivership because most of our 400,000 patients came to us through Harvard Pilgrim. When the word got out that Harvard Pilgrim was in trouble many employers decided that another insurer would be better for their employees. Even if employers retained Harvard Pilgrim along with other insurers as an option, individual employees would frequently decide to switch to Blue Cross, Tufts, or some other insurer.
I am getting ahead of my story because there were several months between when we lost Charlie and when Harvard Pilgrim was taken over by the Massachusetts Attorney General, Tom Reilly in early January 2000.
Immediately after the Vanguard board decided that I should remain as board chair we called Carol Emmott and asked her to find us a new CEO. As interim CEO we chose our chief of surgery, Dr. Gordon Vineyard. Gordon was one of our most respected clinicians and had been with our practice since the early days. Gordon was a great choice and had made it clear that he would be retiring soon. With no expectations for a long-term job, he was delighted to fill the role as an interim.
Carol presented us with a very interesting list of candidates from around the country. We winnowed down the list and interviewed several, but the one she kept bringing back to us was Ken Paulus, who was a rising star in the Partners Healthcare ambulatory practice. Ken was a midwesterner with a degree in healthcare management from the University of Minnesota. He was in his thirties and had come to Partners from a successful experience at the Scripps Clinic in San Diego. You can read Ken’s bio in a press announcement from Prime Therapeutics where he became CEO in 2019.
I am no dummy. I decided that as part of my mea culpa, I should not be very assertive in the choice of our next CEO. I was still trying to repair my relationship with the board. We had a search committee, and I let them take the lead.
On the day that Ken was to have his first interview with the whole board, I was late to the meeting. Our administrative offices were in the same commercial office building in Brookline Village that housed the leadership of Harvard Pilgrim. We still were quite close physically and philosophically. I ran late with my clinical session at our Kenmore offices a mile away and was rushing to the meeting.
When I got to the office building, people who were working in the building were returning from lunch. There were a lot of people in the lobby trying to crowd onto the elevator. I dashed into the lobby as the elevator doors were closing. The person who could have saved me by holding the door was a tall guy in a very smart business suit carrying a leather briefcase. Our eyes met for just an instant and his body language seemed to say, “Sorry buddy, can’t wait for you!” I stood in front of the closed doors with steam coming out of my ears and wondering, “Who is that jerk?”
When I finally got to the board room, things were underway, and to my surprise, the candidate being interviewed was the “elevator man.” I could understand that he too was late and didn’t want to wait for me at the elevator. That elevator incident was the only time Ken ever let me down. Ken is a salesman and has the knack of quickly becoming everybody’s buddy. He immediately gains the confidence of anyone he meets. He is also a hard worker and a very creative executive. I doubt Harvard Vanguard would have survived without him.
In contrast, Charlie is also a great CEO, but in 1999 he did not have much healthcare experience. Early on, his best work had been his ability to make everyone feel confident in the future, but he had little knowledge of the ambulatory practice of medicine although he and his family had been members of Harvard Community Health Plan for years. He was better suited for the Harvard Pilgrim job because of his connections to the business community and the state regulators. In retrospect, Charlie was the right man for Harvard Pilgrim and Ken was the right man for Vanguard.
Toward the end of 1999, it was clear that despite Charlie’s heroic efforts, Harvard Pilgrim was going under. Ken’s first day was to be Monday, January 3, 2000. Between Christmas and New Year’s Day, I called Ken. I told him that given the impending receivership of Harvard Pilgrim, we would understand it if he decided that he did not want to take the job. In less than two seconds, he laughed and said that he was looking forward to the challenge.
On January 6, 2000, Harvard Pilgrim was taken over by Tom Reilly, the attorney general. He left Charlie Baker in charge as the CEO. We began to lose patients. I think that over the next few months, we lost over 100,000 capitated patients. Early in 2000, I met with our auditors who announced to me that we were “not a going concern,” and it looked like soon we might not be able to pay our employees.
We started cutting. I like to say that we burned the furniture to make it through the winter. Ken must have worked eighteen hours a day. He mostly worked out of his car. He was everywhere negotiating survival contracts, signing us up with new insurers, and putting in all the machinery we needed to do fee-for-service business. Some years later I was called by Allina Healthcare in Minnesota to ask me about Ken. Ken left us in 2005 to go back to the Midwest by taking the job as COO of Allina. He was told then that if things went well he would eventually be their CEO. I assumed that it was a proforma call before he got the job. When I was asked for an assessment of Ken’s skills, I told the interviewer that I was pretty sure that if Ken had not been our leader I would not have been here to take their call. We would have been history. Ken had prevented the end of Dr. Ebert’s bold idea.
Winter Is Here At Least Until Sunday
Toward the end of last week, we had a “heat wave.” The lake which had frozen thawed except for a little rim of ice near the shore. I usually think that it needs to be below freezing for snow to stick, but not so. About noon on Sunday with the temp around 33-34, big fluffy flakes of snow began to fall. The snow came in little bursts. It never got colder, but by Monday morning we had about five inches of heavy, wet snow.
The header for today’s letter was taken from my deck on Monday morning. Once we had the snow, the temp dropped like an anchor tossed overboard, and it hasn’t cleared 32 all week. Most of the week it has been in the mid-twenties. The temp has been as low as 13. The lake is frozen again, but now the weatherman is saying that we will have rain and temps in the mid-fifties over the weekend and into next week. I fear that the lake will thaw again.
I do not like yo-yo weather! I need for it to be consistently cold and I am hoping for a lot more snow, not rain. My grandsons are coming for Christmas for the first time since well before the pandemic, and they are looking for fun in the snow. They want to go ice fishing, build snowmen, do some sledding, and maybe even take skiing lessons. That won’t happen if this yo-yo winter weather continues.
The long-range forecast doesn’t look favorable for snow through next week, and I am getting a little nervous. I am dreaming of a White Christmas. I hope that whatever weather you want for the Holidays will be coming your way.
Be well,
Gene
