December 27, 2024
Dear Interested Readers,
Strategy Formation Looking Forward
If you read my post from last week, written in response to Charles Handy’s death, you might remember the comment about how Handy contended that almost everyone has a construct about how we got to this moment, and I might add, an opinion about whose fault it is, while being clueless about where we are going. I wrote:
Somewhere in Handy’s writing, perhaps in his book, The Age of Paradox, I had come across his concept that everyone had an idea about the changes that had already occurred in politics, science, technology, world events, and even morality, that had come together to explain the present moment, the status quo. Handy contended that many could tell us how we got to where we are, but few people thought about or even imagined where we were going, and how change was an ongoing process that would in time overcome the inertia of the status quo. No moment lasts. Change is inevitable. Many of us see inevitable change as an impending disaster or at least the potential for a decline in the good fortune we might be enjoying at the moment. Handy was not a prophet of doom. He contended that we could shape the future. Handy was convinced that with thought and appropriate action that guided change, we could produce a better future for everyone.
Handy was an optimist and a proponent of hope. Handy’s advice to be active in shaping the future to be what we want it to be is a compelling but perhaps unrealistic way to view this moment as we watch the formation of the next administration and shake our heads in dismay. How is it that a man could be proposed as our Attorney General when a majority of members of his own party on the House Ethics Committee issued a report describing evidence that he committed multiple crimes involving drugs and the sexual abuse of an underaged woman? Other nominees for high office in the next administration may not be as obviously flawed. Still, it is hard based on their public statements and the books some of them have written to imagine them performing well in the offices to which they have been nominated.
We will be challenged over the next four years with the difficult task of working around these marginally qualified appointees to create strategies for progress that are consistent with Handy’s advice that we shape a positive future for the country. Many of the nominees seem to have been chosen for their willingness to implement the radical changes advocated in Project 2025. I suspect that the majority of Trump’s nominees will eventually be confirmed and will begin to implement policies that will hamper efforts to improve the social determinants of health or address issues of equity. Metaphorically, it feels like those of us who favor progressive ideas are planning a day at the beach when a tsunami or hurricane is predicted.
As dark and depressing as the outlook may feel, I still believe that Handy would continue to say that despite the dark uncertainty, the future still belongs to those willing to shape it. Following the shock of Trump’s election in 2016, the dominant strategy that emerged was resistance as an attitude and containment and redirection through responsible aides and advisors as a strategy. It is obvious that this time around, with the plethora of marginally qualified nominees for administrative office, Trump is not going to be contained by the likes of another John Kelly or Jim Mattis. We may be able to expect that a few remaining Senate Republicans who still have not kissed Trump’s ring might join with Democrats to resist one or maybe even two of Trump’s controversial nominees, but it is quite likely that most of Trump’s nominees will get through the confirmation process. If there is the courage to push back on at least one nominee, it is an interesting exercise to pick who that might be.
If I had a vote to block one nominee out of the pack of marginally qualified appointees, I would vote against the nomination of Robert F. Kennedy, Jr. to be the Secretary of Health and Human Services. Click on the link above to see all of Trump’s appointees that require Senate confirmation to help you make your pick. If I get only one pick to block that means Pete Hegseth will be secretary of defense, Tulsi Gabbard will be the Director of National Intelligence, Kristi Noem will head Homeland Security, Linda McMahon will head the Department of Education, and Kash Patel will lead the FBI. Those are just a few of the marginally qualified appointees most of whom will win confirmation and become a source of ongoing concern for me. Not requiring confirmation, but potentially more threatening to the future of healthcare and efforts to improve the social determinants of health, is the announcement that Elon Musk and Vivek Ramaswamy will be the leadership of the newly announced Department of Government Efficiency (DOGE). Some wonder if Musk will become a “shadow” president.
As I have reflected on Handy’s ideas and the challenges to the future at this moment in time, I realize that there is a benefit in reviewing how we got to where we are. Where we are going is an increasing source of anxiety for my crowd as it is a moment of hope and enthusiasm in MAGA world. The MAGA camp won the election with a focus on inflation and immigration. They kept it simple. They contended that the cause of both was the failure of government. In their analysis, there is a “deep state” of bureaucrats who are corrupt or inept, or perhaps both. The thesis suggests that the Biden administration, of which Kamala Harris was a major participant, supported deleterious policies in immigration, energy, education, policing, taxation, government regulations, and international affairs that resulted in a loss of American power, and prestige. Their pre-election allegations suggested that ordinary Americans were vulnerable to paying more taxes as they were vulnerable to increasing crime and displacement in jobs and housing by illegal immigrants. Theoretically, voters who pulled the lever for Trump often felt disrespected by elites and wanted a strong leader who could protect them by reversing many of the changes advocated by “progressives” that felt to them like the harbingers of more potential losses. For this group, unregulated markets and high tariffs are foundational to future success.
My side, the losing side, believes in the ability of the government to improve lives. We believe in the utility of markets and the benefits of capitalism if regulated to prevent harm to vulnerable populations and taxed to contribute to our collective future. For us, verifiable data, the scientific method, and a focus on achieving diversity, equity, and inclusion are essential as building blocks for a better future that all Americans can enjoy together.
Further on in last week’s letter, I reiterated the importance of trying to shape a better future and alluded to ineptitude, not ignorance, as a challenge to progress. Many pundits believe that the Democrats lost because they were inept in delivering their message just as they were inept when they did control Congress and the Presidency. I wrote:
In 2016, I wrote a letter entitled “Anticipating the Future.” The post began with a reference to Handy:
I have been thinking a lot about the future lately. Years ago I concocted a quote that works for me by leaving out a few unnecessary words from a passage in The Age of Unreason by the British business guru and futurist, Charles Handy.
The future we predict today is not inevitable. We can influence it if we know what we want it to be…We can and should be in charge of our own destinies in a time of change.
Our biggest problem is not our inability to imagine a better future. Atul Gawande has famously said that our problem is not our collective ignorance, but rather it is our collective ineptitude. We seem to be unable to collectively execute a strategy for the future. The biggest barrier to that exercise seems to be the self-interest that traps us in the problems of the status quo. To imagine and accomplish a better future requires that together we manage our fears, self-interests, and variations in opinion to achieve the future and the outcomes that we say we jointly embrace.
Perhaps it was political ineptitude that left the door open for a MAGA victory in 2024. I learned long ago that in any game between closely matched opponents the team that makes the fewest unforced errors usually wins. One would hope that Democrats will catalog the unforced errors of 2024 and develop new approaches for the 2026 and 2028 elections.
In the interim, I see hope in continuing to find ways to narrow the political divide that both sides bemoan, but our most significant opportunities will be through local strategies, and efforts within individual institutions to promote the attitudes that will be foundational to future advances. As a sports metaphor, we should play like a hockey team that is trying to “kill a penalty” that has left them short-handed. We should endeavor to block further losses through collaboration with willing Republican partners who are uncomfortable with their leader while looking to score a few short-handed goals by looking for opportunities to collaborate for gains where there are shared concerns with some “Trump warry” Republicans.
We should search for small gains by making a complete list of concerns and then focusing on a few achievable victories. In Lean thinking, a two by two analysis is often helpful in establishing priorities over a specific period of time. On any issue, the questions are about cost and difficulty of implementation and potential impact. An item that has a big impact but is hard to accomplish and has a high cost, is not likely to be achieved in our current environment. We should shoot for improvements that can be easily achieved and have a greater impact. We should be looking for the “low-hanging fruit.” An example of what I am saying is the cost of care. The efforts required to lower the total cost of care will be huge since it will require the “creative destruction” and rebuilding of much of our current system of care. Smaller objectives would be to lower the cost of individual drugs or advocate for efforts to reduce out-of-pocket medical expenditures. In the context of looking for what we could do without a control of Congress and the presidency, I would remind us that most of the “quality movement” developed and was implemented in individual institutions like Harvard Community Health Plan and Kaiser and nonprofit organizations like The Institute for Health Care Improvement (IHI) and NCQA. There are also options at the state and local levels. Don’t forget that “Romneycare” presaged the ACA.
There has been and will continue to be much that can be done to improve healthcare and the social determinants of health without passing new laws or obtaining federal funding. My list of issues focuses on where we can still make progress—components of the social determinants of health, professional issues, patient concerns, and public health concerns.
- Workforce issues
- DEI issues within organizations and at a state level
- State, local, and nonprofit efforts to improve transportation
- State, local, and nonprofit efforts to improve housing
- State, local, and nonprofit efforts to diminish food deserts and enhance food pantry distribution efforts
- Institutional efforts to improve quality and develop cost-saving efficiencies in care delivery
- Renewed efforts to collaborate with patients and patient advocates to make care more patient and family-friendly.
- State, local, and nonprofit efforts to improve access to mental health care
- State, local, and nonprofit efforts to improve and support access to women’s reproductive health
- State, and local efforts to establish more rational gun policies.
Having put my thoughts down on paper, I decided to ask Chat GPT for its analysis. I asked:
What are ten issues of healthcare and the social determinants of health that could be addressed through state, local, and nonprofit efforts in 2025?
ChatGPT said:
Here are ten key healthcare and social determinants of health (SDOH) issues that could be addressed through state, local, and nonprofit efforts in 2025:
Healthcare-Specific Issues
- Access to Affordable Healthcare: Many individuals lack access to affordable medical care, including preventive and specialty services. State and local governments could expand Medicaid or develop sliding-scale payment programs, while nonprofits could support free clinics and advocacy for policy changes.
- Mental Health Services: The demand for mental health care often exceeds the availability of services. Expanding community-based mental health programs, crisis intervention teams, and telehealth options could help address this gap.
- Health Workforce Shortages: Addressing shortages of healthcare workers, particularly in underserved rural and urban areas, by funding scholarships, loan repayment programs, and training initiatives for community health workers.
- Chronic Disease Prevention and Management: Focused efforts to reduce rates of diabetes, hypertension, and obesity through education, community-based health initiatives, and increased access to healthy lifestyle resources.
- Maternal and Child Health: Improve access to prenatal care, reduce maternal mortality rates, and enhance childhood immunization programs, especially in vulnerable populations.
Social Determinants of Health Issues
- Housing Stability: Lack of safe, affordable housing contributes to poor health outcomes. State and nonprofit organizations could fund housing-first initiatives and improve housing conditions in low-income neighborhoods.
- Food Insecurity: Access to nutritious food is crucial for health. Efforts like expanding food banks, increasing Supplemental Nutrition Assistance Program (SNAP) benefits, and creating community gardens could help combat this issue.
- Transportation Barriers: Lack of reliable transportation limits access to healthcare, jobs, and education. State and local governments could invest in better public transit systems, and nonprofits could provide transportation assistance programs.
- Education and Health Literacy: Enhancing access to quality education and health literacy initiatives can empower individuals to make informed decisions about their health. Community centers and schools could partner with nonprofits for programming.
- Environmental Health Inequities: Disproportionate exposure to pollutants and unsafe environments affects marginalized communities. Efforts could include advocating for stricter environmental regulations, creating green spaces, and providing resources for disaster preparedness.
Collaborative Approaches
Addressing these issues often requires partnerships between state and local governments, nonprofits, healthcare providers, and community members. Initiatives like public-private partnerships, grants, and community-based participatory research can strengthen these efforts.
You can probably think of other opportunities that ChatGPT and I have left off of our lists. We should be on the outlook for any possibility for improvement. What eventually gets presented as a policy suggestion that turns into federal law has often first been developed away from the politics of Washington. I believe Handy was right. We should always be hard at work shaping the future that we want. As we approach the New Year and the inauguration on January 20, it is not too soon to move from disappointment to contemplation and from there to strategy development, and strategy deployment. To do anything else would be to turn our backs on several decades of effort to improve the lives and health of all Americans.
Wishing You A Happy and Productive 2025
We had a very “White Christmas.” it was also a very cold Christmas with the temperature never making it out of the twenties during the day and dipping to near zero on several nights.
The picture in today’s header was lifted from a drone video taken on December 15 by my friend and neighbor Peter Bloch. To see the whole video, click here.
What you see is the west end of our lake with a sliver of “big” Lake Sunapee in the distance at the foot of Mount Sunapee where I can assure you there are plenty of skiers enjoying a holiday week on the slopes. My house is at the far left of the shoreline of Little Lake Sunapee. What the video shows and what you can also appreciate in the still shot is the amazing patterns in the ice. I sit in my easy chair and look out on skaters, cross-country skiers, and one brave soul who uses a sail for propulsion across the ice. So far this year I haven’t seen any ice fishermen, but I am sure they will be here soon.
For the past twenty years or more, we have celebrated New Year’s Eve and most of New Year’s Day with friends we met because our children went to school together in Wellesley, Massachusetts. All the children are now grown, gainfully employed, and have families of their own. For at least the last fifteen years our friends have joined us in our home in New Hampshire.
Most years, this one included, we stay in. As I understand the menu, we will be dining on lobsters. I am sure there will be fantastic deserts. After dinner, we will play “Mexican Train” until the ball drops. Once we make it to midnight, we will quickly get to bed. By staying at home, we will be out of harm’s way and will not need a designated driver. On New Year’s Day, we will probably play more “Train” and take a walk. I can push my rolling walker quite a distance these days.
I hope that you are looking forward to the New Year without dread. It will be a year of opportunity if we have the will and the energy to work for what we care about. Seeking to minimize our unforced errors and be open to creative collaborations at every level would be a resolution that could create many opportunities to move closer to the goals of the Triple Aim and a more equitable system of care.
Be well,
Gene
