Healthcare Musings For April 30, 2021

 

April 30, 2021

Dear Interested Readers,

 

Joe Hit It out of the Park

 

And on the 99th day, the president returned some grace and wisdom to the office.

 

When I lived in Waco, Texas my dad and I would play a game. He was the pastor of the First Baptist Church which was a grand edifice that sat about halfway between Austin Avenue which was, in essence, our Main Street, and the Baylor University Campus. If you ever watch the TV home improvement show, “Fixer Upper,” which originates in Waco and is produced by its stars Chip and Joanna Gaines, you might know of the two huge grain elevators that they have bought and turned into the center of a Disneyland like tourist attraction that allows people to think about something other than the disaster of David Koresh and the Branch Davidians when Waco is mentioned.

 

The First Baptist Church is just around the corner from the Gaines’ enterprise. It was about two miles from the church to the parsonage where we lived. In 2017, the parsonage was one of the homes that appeared on “Fixer Upper” as a possible makeover. It did not get chosen, but the walkthrough offered me a trip down memory lane as the Gaines’ cameras toured the house.

 

On the two-mile ride home from church each Sunday my dad would ask for feedback on his sermon. Somewhere around age twelve I stole the roll of primary responder to his question from my mother. I was always eager to respond and on one Sunday, perhaps because we were passing the baseball field where the local minor league baseball team, The Waco Pirates, played its games, I blurted out, “Dad, I think you hit a homer!” He liked that but being the honest child that I was, there were times when I would say, “Dad, you hit a single.” I think that once I judged an effort that just did not make much sense to me as “on base with an error.” I can’t remember having the nerve to call any “strikeouts.”

 

His sermons were filled with stories and had some entertainment value even if you disregarded the theology.  We only had one TV station in Waco in the mid-fifties, but every Sunday at eleven our services were broadcasted, so I guess having a critic who would give him feedback was useful because every minister has critics, most of whom keep their thoughts to themselves so maybe our game was beneficial. He loved our game, but my assessment would never seem to be a surprise. He always knew when he had made his point in an effective way, and when he didn’t he was interested in knowing why. Perhaps we played the game because he knew that if he really cared about my opinion he was granting me a special status.

 

I doubt that Joe Biden has any interest in my opinion, but I thought that he hit a grand slam on Wednesday night when addressed a joint session of the House and Senate. I have heard speeches that had a smoother delivery. I have heard speeches that did not run so long. I have heard speeches that created positive responses on both sides of the aisle, but I have never heard a more important speech delivered so straightforwardly and with such an open and non-judgemental call for bipartisan acceptance at any other time when we not been just attacked. It seems easy for us to be bipartisan following an event like 9/11 or Pearl Harbor, but it is extremely difficult for us to set aside personal interest and get across the deep political divide that now exists when the issues are inequality, race, guns, the environment, social justice, immigration, or taxation to support healthcare, education, housing, and job creation. Senator Tim Scott was appointed to be the responder from the Republicans and his comments assured the fact that there is still no bridge across our political divide.

 

I was surprised. This was not the Joe Biden who made gaffs during the competition for the Democratic nomination process. The pundits in the newspapers seemed to share my surprise and delight. Lisa Lerer and Annie Karni of The New York Times wrote:

 

Mr. Biden isn’t apologizing anymore.

Now 100 days into his presidency, Mr. Biden is driving the biggest expansion of American government in decades, an effort to use $6 trillion in federal spending to address social and economic challenges at a scale not seen in a half-century. Aides say he has come into his own as a party leader in ways that his uneven political career didn’t always foretell, and that he is undeterred by matters that used to bother him, like having no Republican support for Democratic priorities.

For an establishment politician who cast his election campaign as a restoration of political norms, his record so far amounts to the kind of revolution that he said last year he would not pursue as president — but that, aides say, became necessary to respond to a crippling pandemic. In doing so, Mr. Biden is validating the desires of a party that feels fiercely emboldened to push a liberal agenda through a polarized Congress.

 

The six trillion-dollar cost of the Biden proposals is the sum of what you get when you add up the American Rescue Plan Act which has already been passed that put much needed money into pockets of those economically ravaged by the pandemic, plus the recently proposed and still to be debated American Jobs Plan, and to the over four trillion dollar tag on those program you add the American Families Plan that he announced Wednesday night.  The American Jobs Plan addresses our woefully inadequate physical infrastructure and expands the concept of infrastructure to include many services that support workers, clean up the environment, and expand technology in many new and creative ways that don’t fit a narrower definition of infrastructure from the last century that Republicans will agree to pass. The 2.3 trillion dollar proposal is definitely “progressive.”

 

In previous speeches, the president had given us advanced notice that he would soon offer a third bill, the American Families Plan. That is what he did on Wednesday night after he had reviewed the pandemic response and reiterated the need for America to resume its role as the cooperative leader of the free world and the defender of human rights even as we struggle with our own issues of race and all the forms of “otherness” that define the gap between who we are and who we have always said we wanted to be when we talk about “These Truths…” Over the years in his role as a member of the Senate Foreign Relations Committee and as Barack Obama’s Vice President, Biden has traveled the world and is determined to convince both allies and those who disagree with our espoused values that America is back. Indeed, in the speech one of the most compelling reasons the president presented for the investments he requests is to enable us to demonstrate to the world that democracy is still a more humane and effective form of government than the authoritarian alternative that China models.

 

I see the combination of these three bills as an incredibly responsible and informed attack on healthcare disparities and poverty. Taken together and effectively implemented they theoretically represent a very effective strategy that moves all Americans toward greater social equity. Specifically, the president argued that twelve years of public education was inadequate for the twenty-first century. He would add two years of public pre-K and two years of publically funded community college. He pointed out that families are required to make a choice between crippling childcare expenses and an opportunity to work. The Families Plan would ensure that no family paid more than 7% of its income for childcare. The Plan includes support for the care of the frail elderly by family members. There is a robust plan for paid family and medical leave that is available to everyone. Perhaps the most dramatic and potentially beneficial proposal in the package is to extend until at least 2025 the child support payments that were present in the Rescue Act but will expire at the end of the year. Economists predict that this investment will go a long way toward ending childhood poverty. In essence, this is a program of universal basic income for families. Finally, the plan will give more people access at a lower cost to healthcare coverage through the ACA. If you think that this program offers too much, let me assure you that most of our peers among the developed nations of the world currently meet or exceed these benefits.

 

Beyond being a presentation of an attractive bundle of creative domestic programs, the president implied in many ways and at many times that a failure to implement the program or a better one if the legislative process can produce something bipartisan would be the equivalent of accepting an unavoidable decline in expectations for a better future that improves all lives. He did not say it, but I will. To do nothing or to do just a little ensures that a substantial number of children and families would be better off elsewhere as we continue our national slide toward mediocracy as our population sorts ever more dramatically into a bimodal society where there is a small minority that has too much and the growing majority that remains in need.

 

Jennifer Rubin of the Washington Post summed things up and looked forward to the prospect of passing into law some or all of what the president has suggested:

 

 

During the speech, the president raised a point that resonated with me as he discussed how these improvements will be financed. I think that he was right when implied that the improved infrastructure, giving more people a better life, and better managing climate change is worth the cost that he will be asking the richest corporations and individuals to pay. The rich may actually be the biggest beneficiaries as their markets grow. I think that he is right to suggest that the most certain way to a more productive and secure America for our richest people is to close the gap between what they have, and the inequities that the poor bear. Some of the wealthiest and most secure individuals and corporations pay no taxes or a smaller proportion of their income than families who are struggling to enter the middle class which is still a station in life where there are financial stresses that create disease and stress.

So it comes down to this:

Joe is presenting us with a choice that we must make. Do we vigorously pursue a new way? Or do we let our divisions win the day and nothing really changes? The sin of not addressing inequity could ultimately lead to universal loss, and “that is not the ranting of a preacher talking about sinners in the hands of an angry God.” That is a description of the consequence of having a world where everyone is so focused on “I” that one forgets that they are a part of a larger “we.” Biden’s programs are our current best offering of pushback against an emerging dystopian world where even the rich are undermining their own health and prosperity. It may sound harsh to do the right thing just to avoid disasters. Donald Trump’s solution was to build a wall and hunker down behind it denying realities at the expense of others and ultimately the wellbeing of everyone. Joe is offering us an exit ramp from the road to hell that we have been on. The road at the end of Joe’s ramp may be unfamiliar, but I would say it is a good bet that it leads toward a much better destination that we can all enjoy.

 

I Am Back On The Water Again

 

It has been a tougher spring than I had hoped for. But hey, the secret of a life well-lived is not to have everything go your way but to find your way through what comes your way, and avoid as many “unforced errors” as possible. I have been very fortunate that most things in life have actually gone my way. I am thankful for good health, a wonderful family, and all the opportunities that I have been offered over the years in medicine. 

 

What has not gone my way has mostly occurred because of my own “unforced errors.” If you have never paid much attention to sports you may not understand where I am going. The definition that my computer coughs up for an unforced error is:

 

…a mistake in play that is attributed to one’s own failure rather than to the skill or effort of one’s opponent.: “she made 88 unforced errors, including a double fault on match point”.

 

The concept of unforced errors is widely applicable to all aspects of life. Most of our political scandals are nothing more than unforced errors. Perhaps an even better and more general definition might just be “the grief and trouble we make for ourselves.” My most recent unforced error of significance was my fall on the ice in late February. It’s been a long road back and I am not quite there yet because so far I am left with pain and numbness in my left foot and a foot drop from a hopefully temporarily inactive anterior tibialis muscle. I am now getting care from a great neurologist and I have high hopes for benefit from injections and rehab. The downside is that in the interim I walk slowly with a cane. The upside of my adventure is that I have a new and more open perspective on chronic disabling pain and the disadvantages of even the most minor disabilities. 

 

I had always thought that I was an empathetic physician. I think that most doctors have a similar self-image. We went into medicine to help people. There was empathy in the concept of becoming a doctor, but now in retrospect, there were many times along the way when my own agenda may have been my foremost concern. I “knew” when people were in pain and when they were suffering from physical pain or an even harder source of pain to eradicate, the loss of some cherished capability.  I thought I was empathetic, but in retrospect, I am amazed by what I did not really feel or really understand.

 

That is perhaps a little over the top, but now it’s my turn to experience pain and loss. I have had a difficult time at two levels. First, there has been real neuropathic pain. Second, there has been the loss of an activity that was so important to me that it was part of my identity. I am fortunate that there have been two doctors, a physical therapist, and a pilates instructor, and a host of support people who have tried to help me. Closer to me friends and family have been concerned and supportive. 

 

The worst part of the last two months has been the loss of my daily walks and the pleasures I gained from those jaunts. I am moving on. I still hope that in time I will be walking just like I did before, but now I am no longer as focused on what I can’t do. I am finding great joy in discovering the things that I can do! In 2010 I had to deal with the reality that I could not run. In 2021 I am forced with the possibility that I will no longer be able to take a hike or have a long conversation with a friend on a four-mile walk. Nothing lasts forever, so the question is what will be the next adjustment that will serve me well until it too becomes difficult. The answers seem to be kayaking, biking, and swimming.

 

On a beautiful day last weekend, I enjoyed a ten-mile ride on my “e-bike” and exulted in the fact that I did not use the electric assist for the majority of the ride. I will admit to submitting to the assist on a few of our monster hills, but getting past the need for the boost can be a new challenge. The other rediscovered joy is my pedal kayak. I can’t think of any “toy” I ever purchased that has provided me more satisfaction. Until now, I have used it for fishing. It moves about without me using my arms which are free to use for casting. It also has a convenient cup holder for my preferred late afternoon beverage. I now see it in a different light. It is the equivalent of a recumbent bike. Beyond those two reasons for optimism is the reality that I am about three or four weeks away from being able to swim in my wet suit. The chlorinated water in swimming pools takes my hide off, but the clear water of the lake is a joy as long as the water temp is in the high fifties. 

 

I took the picture in today’s header while I was paddling along the shore of my lake. The south shore of my end of the lake is all in a land trust. There is only one building along the shore. It is an old boathouse that is a remnant of the nineteenth century. Through the woods, across the road into town, and up a steep hill is the old mansion that belongs to the boathouse. It’s one of the old local mansions that is “up and out of sight.” I have only seen the estate on Google Earth. No one ever does anything to “improve its appearance. It is just what it is. Every summer a few people appear lounging at the boathouse. They don’t seem to speak English. Sometimes they don’t wear swimwear. They just enjoy the sun, the water, and the old boathouse as it is. If I wave as I pedal by, they do return the gesture, but don’t seem interested in a conversation. They are a mystery to me. Perhaps this will be the summer when I learn more. It’s ok if I never meet them. I enjoy my fantasies about the mystery of the building and its occasional visitors.

 

I hope that you will have a great spring weekend that contains some interesting mystery, discovery, or encounter.

Be well!

Gene