Healthcare Musings For March 20, 2026

March 20, 2026

Dear Interested Readers,

 

Healthcare In The Midst of the President’s Chaos and Anger

 

As a White House correspondent for the New York Times since 2008, and for 20 years before that for the Washington Post, Peter Baker has been a close observer of our presidents since Bill Clinton’s time in office. He has written books about Clinton, Bush, Obama, and Trump. On Monday, he published an article in the Times with a very long title and subtitle, “In Choosing ‘Epic Fury,’ Trump Names a War and Defines His Presidency: The branding of the U.S. military operation against Iran is a quintessentially Trumpian choice for a leader whose tenure has been marked by anger.” 

 

After a general review about how military operations get their names like Desert Storm, Baker writes:

 

 

Trump’s anger and hate seem to be the sources of much of what makes many of us shake our heads in disbelief as we watch him dismantle the respect from our allies that our nation has enjoyed since the 1945 victory in World War II against the fascism of Germany, Italy, and Japan. What he doesn’t destroy with his anger, he damages with his immense ignorance. The adventure that he has launched in Iran is Exhibit A, confirming the deficiencies in judgment that he can’t hide behind his usual scowl. Baker expands his thesis:

 

This is in a way the Anger Presidency. Anger defines Mr. Trump’s decade on the political stage. Anger at foreigners who come to this country and change its nature. Anger at allies who take advantage of America. Anger at Democrats who cross him. Anger at Republicans who cross him. Anger at appointees he deems insufficiently loyal. Anger at prosecutors, F.B.I. agents, judges, journalists, law firms, elite universities, cultural figures, corporate leaders, pollsters, central bankers and the Norwegian Nobel Committee.

 

Even if his anger somehow leads to some sort of victory in Iran, I have serious doubts that he can “Make America Great Again” with his anger-driven ideas.  Progress toward better healthcare, consistent with the Triple Aim, has been a challenge in the best of times. In these times, with this anger-driven president trying to destroy what others have accomplished, the preservation of past improvements, not further improvement, is a laudable and lofty goal. 

 

I am not even sure that all my readers can give a concise description of the Triple Aim, which was first formally articulated for healthcare in a 2008 Health Affairs article by Berwick, Nolan, and Whittington. Unless you have access to Health Affairs, it is hard to read the original paper, but it is well-documented on the IHI website and in the abstract from the National Library of Medicine, which you can access via the link above. Let me offer you something better, a 2-minute and 44-second YouTube description of the Triple Aim presented by Don Berwick.

 

Some healthcare pundits expanded the idea to a “Quadruple Aim” in 2014 by noting increasing provider burnout and adding “Improving the worklife of healthcare providers” as a fourth aim. Others have more recently added a fifth goal, “advancing health equity.” In his video, Berwick states that prior to the conceptualization of the Triple Aim, the best articulation of the “aims of healthcare” was found in the 2001 publication, Crossing the Quality Chasm. In that book, quality care was defined as patient-centered, safe, effective, efficient, timely, and equitable. Berwick goes on to explain that those “six domains of quality” are a description of an individual’s care. The book describes how the delivery of care needs to be modified to ensure quality of care for everyone. What was missing from the book were goals for the care of our entire population, in which each individual would presumably receive the high-quality care described by those six domains. 

 

The “experience of care for the individual” as described in Crossing the Quality Chasm, is the first corner of the Triple Aim. The second leg of the Triple Aim is the “Health of the Population.” The first leg is about what you can expect from the care delivery system when you need care. The second leg is an effort to diminish the risk of illness for any one individual by keeping the whole population as healthy as possible. I would add that this is where attention to the Social Determinants of Health becomes most important, because we know that social factors are even more powerful determinants of future illness and the need for care for any of us than is our genetic propensity to disease. 

 

The third component of the Triple Aim is “the cost of care.” Berwick defends this objective by arguing that the nation, corporations, and individuals all have needs beyond healthcare. He makes the dated statement that you might want to have the money to go to the movies. I can speculate that if he were doing this recording today, he might say that you might want to pay for your Netflix subscription. Industries might want to make investments, develop new products, or pay their workers more.  The government has other priorities besides healthcare that also call for its resources. At this moment, the government’s resources are being directed to an ill-conceived military adventure. Secretary Hegseth has asked for an extra $ 200 billion, and we are just approaching three weeks of conflict. When Berwick made this video, I am assuming he was referring to items in the federal budget, such as public works, defense, international aid, and so on. As the cost of care has risen to almost 20% of GDP, and as the current administration wants to lower taxes, the cost of care has become one of the most painful realities for American individuals, businesses, and institutions that buy care through premiums and out-of-pocket payments. 

 

The cost of your care to you, your employer, or the government has gone up dramatically over the last few years. If you still have care after the passage of the “One Big Beautiful Bill” and the failure of Republicans to support the extension of the individual subsidies for the ACA marketplace, you are paying more. At a personal level, my wife and I benefit from the Blue Cross Federal Employees Retirement Program. Our costs now take most of the small pension she gets from her years of service as a nurse practitioner delivering care to veterans with heart failure, working at the West Roxbury VA Hospital in Boston. Even with that high level of benefit, our out-of-pocket expenses exceed $10,000 a year (We each have a $6,000 deductible), and we dropped the dental coverage because it cost more than the value received.

 

I am the moderator of my congregation. Our church budget had a substantial year-over-year increase in healthcare costs. I asked our church’s financial secretary just how much the increase was this year for the employees we cover. Over the last few years, the annual increase has gone up steadily. This year, the year-over-year increase was 11.21%. Wednesday night, we had our annual town meeting, a New Hampshire tradition dating back to the 17th century. At the meeting, I was flabbergasted to learn that our town’s health insurance bill for this year has by increased 16.7%. We are hiring a new firefighter. The projected cost of his or her health insurance for a family of four is $36,000. I swallowed hard and voted for the resolution. Couple increases like that with the reality that with the ill-advised war in Iran, the cost of 100 gallons of heating oil is now over $500, and gasoline is selling for $3.75 or higher for regular, and you see that the cost of care impacts everyone directly or secondarily through other channels like their employment security or the ability of government to provide other needed services.

 

Our family resources put us in the upper 5% of the population. If the cost of care is a concern for us, what does it mean for the other 95% of individuals and families? The cost of care is a problem that touches all of us. You may not have given the Triple Aim much thought, but it should be in the top 5 issues that concern voters. I seriously doubt that many members of Congress or our Secretary of Health and Human Services can describe the Triple Aim and explain why it is an important national objective. Since the president can’t even give us a logical explanation for why we have gone to war, and seems to care little about the impact of his failed policies on the lives of the majority of Americans, I would be willing to bet a huge sum that he can’t describe the Triple Aim and would reject its intent if he could.  

 

One interesting observation about the wisdom of the six domains of quality from Crossing the Quality Chasm and the Triple Aim is that neither mentions the imperative of universal access to care. I can assure you that it is a major topic in the text of Crossing the Quality Chasm, which has the subtitle A New Health System for the 21st Century, and that the necessity of universal care is a foundational assumption in the pursuit of the Triple Aim. 

 

Predating both the Triple Aim and Crossing the Quality Chasm by over 35 years is Dr. Robert Ebert’s 1965 statement on the need to optimise the operations and finance of healthcare to protect the health of the nation. At the time, Dr. Ebert was the Dean of the Harvard Medical School, where I was a student. In 1969, he launched the Harvard Community Health Plan as a pilot in search of an optimal financial and operating system for healthcare. I began my career at HCHP fresh out of training in 1975 and spent my entire career in the evolution of the organizations that emerged from HCHP: Harvard Pilgrim Health Care, Harvard Vanguard Medical Associates, and Atrius Health. I believe that Dr. Ebert was an early advocate of the mindset and objectives that were more fully described in Crossing the Quality Chasm and the Triple Aim. It is no surprise that Don Berwick left HCHP to become a founder of IHI, where the Triple Aim was described. Berwick was also one of the participants in the creation of Crossing the Quality Chasm. I have quoted many times the succinct statement that I found in Dr. Ebert’s letters about what was necessary to improve the “health of the nation.” Here it is again for the “umpteenth” time:

 

The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.

 

I have bolded the last 24 words because they contain the point I want to make. We can’t achieve the health system for the 21st Century that is advocated for the health of individuals in Crossing the Quality Chasm or the collective objectives of the Triple Aim without changing the finance system of care, which drives the costs of the operating systems of practice which have become so expensive as to undermine attempts to adopt programs of universal coverage and launch or continue the social programs that will improve the Social Determinants of Health which are fundamental to improving the health of the nation for a sustainable cost. 

 

Innovations like better drugs for cancer, better imaging systems for diagnostic and screening programs, investments to train an adequate number of healthcare providers, and developing programs to understand the utility of  AI should all lead to lower healthcare cost and improvements in the health of the nation if they were managed to achieve the Triple Aim rather than profit the bottom lines of companies involved in the corporatization of healthcare that depends on the higher utilaization objectives of fee-for-service finance systems. Fee-for-service payment is for healthcare what carbon-based fuels are for energy. Both had a role in the past, are vigorously defended by a status quo that profits many in the short run, by their continuation, and will be the mechanism or pathway toward untold future harm as our environment compromises our health, and our system of care is available to a decreasing number of us because of its expense.  

 

I hold both political parties accountable for where we are. The ACA was built on a fee-for-service chassis because President Obama realized that doing otherwise would spell defeat, as it had for President Truman and Clinton, and a host of other politicians who had tried to make too much change. Obama reformed the system by making everyone potentially insurable at some cost, through some program. The ACA addressed concerns about pre-existing conditions and mandated preventive and emergency care. It contained innovative ideas designed to begin the transition from fee-for-service practice toward value-based reimbursement. It was built with the hope that, given time, innovative progress would lead to more sustainable forms of finance and operations and that, in the interim, care would be improved for the millions who had no access to care. It was a step toward the Triple Aim, but it was always doomed to leave us metaphorical miles from the destination.

 

Programs like Bernie Sanders’ “Medicare for All” or the related idea of “Medicare for those who want it,” espoused by other Democrats, are all fee-for-service systems that are unlikely to deliver the much-needed cost improvements, but have merit in providing care to larger numbers of people. I have never seen a Republican program since Mitt Romney gave Romneycare to Massachusetts in 2005 that would provide care to more people or cut the cost of care predictably without reducing access to care. All of the Republican ideas have at their core the continuation of fee-for-service practice and the failed idea that markets done right can “fix healthcare.” 

 

So, I would say that we have learned a lot about the Triple Aim and the optimal system of care that Crossing the Quality of Chasm envisions for our nation in the 21st Century, but we are further from our desired destination than we were as the century began, and we are one quarter of the way toward the 22nd Century. I expect to exit the journey long before we arrive at the destination, and perhaps before we get back on track from our recent detours. I do find some solace in the history of our nation, which suggests that we have an element of introspection and honesty that allows us, over time, to recognize and attempt to repair our failings.  There is debate over whether Winston Churchill ever said, “You can always count on Americans to do the right thing, after they have exhausted all other possibilities.” Whoever said it or whether no one said it, and it just emerged from some supernatural source, the idea gives me hope as I witness us doing a lot of the wrong things in healthcare, in our country, and in the wider world. Maybe if we have patience, continue to advocate for equity in healthcare and world affairs, and realize that self-centered brute force rarely leads to positive change, things will come right in time.

 

Spring is coming, and so are the midterm elections. Spring is usually associated with hope and an enthusiasm for another attempt to make everything beautiful again. Anticipating the midterms and working for victories to counter Trump’s anger is an excellent way to move toward the hope that someday we will indeed do the right things for the health of the nation.

 

Spring Is Here! 

 

According to the Farmer’s Almanac, spring, or the return of the Vernal Equinox, for 2026, was today at 10:46 AM EDT. You are reading this letter sometime after 3 PM EDT on March 20, 2026, so welcome to Spring!

 

I always try to make the header for this letter appropriate to what is happening. I was hoping to find a crocus I could photograph, but my local search was still dominated by dirty snow in huge piles and nothing that was in bloom. I was pretty sure that a picture of the snow that is diminishing in my front yard after the warm rain we had mid-week wouldn’t shout “Spring,” nor would a picture of the ice that still covers the lake. All the scenes I saw looked more like winter than spring. 

 

On Tuesday, I was delivering food from our local food bank to a home-bound man who gets by on a small monthly SSDI allotment and SNAP. He has had neurological injuries that would prevent him from driving, even if he could afford to own and operate a car. One bright spot in his life is that years ago, before his injury, he was in the building trades and had the ability and the good judgment to buy a little piece of land that faced the southwest side of Mount Kearsarge. He built a little house that is still unfinished, but he has no mortgage, and though the interior is not completely finished, the little house is adequate to keep him dry and warm. He also has a great view of Mount Kearsarge that changes with the seasons. I took the picture in today’s header from the end of his driveway, which is still quite icy. I made an attempt to capture Mount Kearsarge, although the camera in my phone doesn’t really do the view justice. What the picture does reveal is that all the snow on this side of the mountain is gone! Had I taken the same shot a week or so ago, the mountain would have been white. I expect it won’t be long until it’s a beautiful green. 

 

Every spring, I think about one of A.E. Houseman’s poems. Houseman, who taught at Cambridge University and wrote at the end of the nineteenth century and the early twentieth century, is my kind of poet because, like Mary Oliver, he writes about things I can understand in words that make sense to me. His poems often underscore the transient nature of our existence. I try to read the poems that the New Yorker publishes these days, but I rarely understand what the poet is trying to say. I’ve never had that problem with the few poems I know from Houseman or Oliver, or, for that matter, with Shakespeare’s sonnets. Below is my springtime Housman reflection, which I know I have shared with you before. It is my pleasure to share it again, as I celebrate the return of yet another spring. You will note that Housman obliquely references Psalm 90:10. In the King James translation of the Hebrew scripture, it reads:

 

“The days of our years are threescore and ten; and if by reason of strength they be fourscore years, yet is their strength labour and sorrow; for it is soon cut off, and we fly away.”

 

I would occasionally quote this verse to patients at an appropriate moment, saying that the manufacturer’s guarantee on our bodies was 70 years if the equipment was well-maintained. If a person can do the work of taking care of themselves and put up with the disappointments life always presents, you might make it to eighty on your own. Any time enjoyed after that is a bonus or gift before we “fly away.”

 

One of my favorite gospel songs is “I’ll Fly Away,” recorded by Willie Nelson and his sister Bobbi Nelson. If you listen, you are in for a treat. Bobbi’s piano and Willie’s guitar will reverberate through you. You may even get in the mood of looking forward to that moment when you might fly away from this world’s occasional joys, cares, and inevitable disappointments. Enjoy it! Housman made it to 77. I am now into the gift years, and am quite grateful to have the opportunity to enjoy another spring before I fly away.

 

Loveliest of Trees

E. Housman, 1859 –1936

 

Loveliest of trees, the cherry now
Is hung with bloom along the bough,
And stands about the woodland ride
Wearing white for Eastertide.

Now, of my threescore years and ten,
Twenty will not come again,
And take from seventy springs a score,
It only leaves me fifty more.

And since to look at things in bloom
Fifty springs are little room,
About the woodlands I will go
To see the cherry hung with snow.

Be well,

Gene