14 December 2014
Dear Interested Readers,
Sustainability, a Foundational Concern for Healthcare
Late Wednesday afternoon I decided to take a walk, since the hike in the woods that I took with a friend earlier in the day had been more about enjoying the experience than burning off calories. I am also trying to hit my goal of over 1500 miles on the road in 2018, and I am getting close. It was getting dark so I donned my yellow reflective sash with the blinking red light on the back and slipped a head lap over my cap. I decided to listen to NPR while walking to hear what they had to say about the recent events in the news: The Trump, Pelosi, Schumer shoutdown over a government shutdown; the sentencing of Michael Cohen; Theresa May’s Brexit dilemma despite surviving a vote of no confidence. Those were brief stories, and although I was informed, I did not learn anything new or have my imagination stimulated in any way. My take was: Trump is losing control. Michael Cohen has probably gained seven to ten years of freedom by talking to Robert Mueller. May is in trouble, and Brexit is a “wicked problem.”
The best and most enlightening report I heard was an unexpected delight that also changed my mind about what I wanted to write about in this post. It was a piece by Kirk Siegler entitled “’Rethinking The Past’ In The Aftermath Of California’s Deadly Wildfires.” The hook for my imagination was:
“Every one of the fires, Thomas, Tubbs, Carr and of course Camp, have all been leading us down the same direction — we have to rethink the past,” said Jim Broshears, emergency operations coordinator for the town of Paradise…”I hope that one of the outcomes of this is that we’ll all be at the same table,” Broshears says.
The so-called timber wars of the 1980s and 90s pitted environmentalists against the logging industry. Battles over the spotted owl and other issues led to a significant drop in timber harvests on federal public land.
So what am I talking about? What is the relationship between the aftermath of the “Camp” fire which destroyed Paradise, California and the future of healthcare? In one word “sustainability.”
Smokey the Bear was a lovable fount of well intended advise that went sideways. The “tree hugging environmentalists” were only partly right. The land use advocates who wanted the freedom to do whatever they wanted to make money off the land were not as far off base practically as they seemed to be from the environmentalist’s concept of what is socially responsible. The epiphany coming out of the Camp/ Paradise disaster and all of the tragic fires that seem to be as common now as school shootings is that nobody was one hundred percent right and that everybody has a common concern that could be the beginning of a productive conversation that might lead us to a metaphorical “way out of the woods” and a better future. What is needed most is a comprehensive agreement that takes ideas and facts from both sides and blends them into a sustainable program of forest management that reduces the risk of fires that threaten property and life. The idea was nicely presented by a woman named Arielle:
Arielle Halpern, a wildfire scientist with the Mount Shasta Bioregional Ecology Center, says there’s a realization now that all the finger pointing and the blaming of the past wasn’t constructive.
“I think there are a lot of discussions that need to happen and everybody could use some education,” she says. “I say this for myself as well.”
North of Paradise near the town of Mt. Shasta, Halpern is organizing her neighbors — from hippies to ranchers — into community groups that will conduct prescribed burns on private land.
“We do have common goals; we all like to have safe homes and families,” Halpern says. “You talk to an environmentalist on the far left and someone on the far right and I bet that they could agree with that statement.”
If the “far left” and “far right” can find common ground on forest management because they realize that the course they have been on has left all of them homeless or vulnerable to be homeless, and at risk of being burned alive, then there may be a possibility that the left and right might someday find enough common ground to work together for better healthcare. The objective of the agreements on forest management should be the protection of life and property, the use of our forests as a sustainable common resource, and the preservation of habitat for wildlife. It would seem that the conversation that might end in better forest management was made possible when both sides recognized that everyone had a shared interest in solving a problem together. Everyone seems to realize they have a lot to lose if they can not make progress through a new consensus that would effectively lower the risk of future fires. To reach the shared objectives each side needed to admit that it was not absolutely right. They needed to agree on a set of facts. They needed to search for answers together based on a shared understanding of a common objective and a common vulnerability.
The big takeaway for me from the Trump, Pelosi, Schumer meeting this week was the realization that for the next two years there will be the possibility to use the new leverage of controlling the House to promote consensus and the opportunity for compromise to improve healthcare and begin to address some other concerns like our deteriorating infrastructure. I doubt that the President had any epiphanies following the “transparent” Oval Office debate that he staged, but it was clear to most observers that unless he holds all the cards his sense that he is a great negotiator exists only in his head. With his vulnerability nicely demonstrated and his future under the cloud of continued investigation, maybe some Republicans will not be so intimidated by his bullying and will recognize that collaborating with Democrats to do the people’s business is a good strategy for them to try.
The conversations in California grow out of a sense of mutual vulnerability because the mismanagement of the forests that have become a shared liability and an obvious threat to everyone no matter what their preferred point of view has been. Is there a similar threat to the collective from the mismanagement of medical resources? I think so. Perhaps, the recent knowledge that life expectancy has been falling for the past three years will be viewed as a call for a closer examination of the future far beyond the superficial explanation that the decline is due to the opioid epidemic. For years progressives have tried to base the argument for healthcare reform on issues like cost, quality, and safety. Up to now those issues have not really been understood by most individuals as a collective concern.
The problem with basing the argument for healthcare reform on costs and quality has been that the incremental creep of the percent of GDP that we spend on healthcare and the dispersed reality of the impact of defects in quality and safety do not have the same motivating impact on the public that a forest fire has. Having healthcare move from 17% of GDP to 18% of GDP over a couple of years with the expectation that in 10 years it could be over 20% of GDP has even less built in motivation than hearing that the average temperature will rise by a degree or two over the next decade has. The ability to connect slowly changing numbers to meaningful changes in the future and potential disasters are hard tasks for most people. The inconvenient issues seem like something for someone else to worry about until the house next door is burning and the wind is blowing toward your house.
We shrug our shoulders when we we hear that signups for the exchanges are down 10% this year as a function of the Trump Administration’s policy changes and the cancellation of the mandate fine by the law that created the Trump tax breaks that primarily benefited the rich and corporations. It’s hard for the average voter or consumer of healthcare to get excited about the Trump administration’s undermining of the ACA since the large majority of us are covered by our employer or get Medicare where our big decision is whether to choose Medicare Advantage or a Medicare wrap around product to augment Medicare A and B.
It is understandable that individuals should be apprehensive about changes in how they get their healthcare and how it is financed. It is a huge leap to go from your personal concerns to realizing that your ultimate security, or insecurity, is a function of the economic sustainability of the system. Any potential change in the system could be a loss for those of us who have a good deal already. Some people may be afraid that a public option on the exchanges could adversely effect their own coverage. Others might fear that a move to Medicare for all that would benefit all Americans might reduce their own coverage and increase their taxes. These fears diminish their motivation to demand changes to the system that they know and understand, no matter how inadequate it is for a large minority, or how potentially bad it may be for all of us and our children over the next few decades. Being concerned about sustainability before the fire burns your house requires deep reflection and a real insight when there are so many other distracting issues like your own immediate economic insecurity.
I wish that the only risk we face was increasing cost. It is hard for someone to imagine how the quality of their personal care is put in jeopardy by the growing dysfunction of the system that is a possibility as workforce shortages spread from thinly populated rural areas in less culturally and recreationally desirable areas of the country to suburban and urban areas. Today, finding professionals who want to practice in rural New Mexico or in a small rust belt town in Ohio is becoming a challenge that threatens even those with “platinum” coverage. For most healthcare consumers in metropolitan areas it is hard to imagine that the evolving professional shortages will come to their neighborhood. What is the waiting time for an appointment in dermatology where you get your care?
Healthcare suffers from the distortions created by economic inequality and the growing number of people who are not ready to participate in an economy where good jobs with good benefits are available only to those who have technical skills that require training. It is hard to imagine putting together a system of care that is sustainable without also addressing other societal concerns like education, housing, infrastructure deterioration, and job creation. We talk a lot about the social determinants of health, but most of us believe that it is a conversation that does not impact us. Is it not a conversation about the care of the economically disadvantaged members of the community? We don’t realize that just as it rains on the just and the unjust, when the forest burns it burns the homes of the tree huggers as well as the homes of those who favor clear cutting. When the system of care that we all share fails financially or produces low quality care with safety defects, we are all vulnerable no matter how many benefits our special plan offers.
Ultimately the objective of the Triple Aim is sustainability. In most systems sustainability requires continuous improvement. The improvement of quality and safety and the creation of access for everyone are central to any effort at sustainability. The Triple Aim has a message and a promise for all of us.
It is important to talk about drug prices, but it is more important to talk about how we utilize our resources. Money spent on a drug that is not needed is too expensive at any price. Structuring the delivery system in a way that makes hospitals “revenue centers” rather than considering them as “cost centers” is always going to lead to unsustainable increases in hospital costs and utilization. Managing chronic disease as a series of physician interventions for avoidable complications from mistreatment or a failure of patient education and self management makes sustainability an unreachable goal. There is no way we can achieve a sustainable healthcare system when 20% of the population gets care only when their condition warrants emergency hospitalization. Those who don’t want to cover primary care access for everyone must believe in alchemy if they imagine a system without universal coverage that is financially sustainable.
The conversations that are beginning after that Camp fire are encouraging. Any conversation across the divides in this country can offer promise for other areas of contention and disagreement. I believe that the majority of Americans want to see us find a way to avoid similar forest fires in the future. I also believe, and know that statistics support, that the majority of American favor some form of gun control. A majority also wants to see effective measures taken to limit global warming. Research associated with the midterm elections suggested that healthcare was the issue that concerned most Americans. The greatest challenge of this moment when a majority of Americans want better care for themselves and their families is to convince them that they can never have the healthcare security that they want for themselves and their families without demanding that the care they want for themselves will be equally available to everyone. Whether it is forest fires or healthcare we need sustainable policies that protect us all, or no one will ever be really safe.
Winter Hiking: There Is Nothing Like It
The picture in today’s header was taken during a hike this week with my friend Steve. What you see is the Lane River as it flows through conservation land in South Sutton, New Hampshire. The picture was taken from a sturdy footbridge that arches over the river. The Lane River is hardly more than a creek, or if you prefer a brook. It is only 8.5 miles long and lies entirely within the town of Sutton. It begins as the outflow of beautiful Kezar Lake in North Sutton and flows in steps through wetlands, rapids, wetlands, and rapids before joining the Warner River at the Warner/Sutton town line. The river is part of the Contoocook River watershed. Eventually its waters join the Merrimack River which flows into the Atlantic at Newburyport, Massachusetts.
I like thinking about how things come together on the way to going some place. One of my favorite walks in my neighborhood is the three mile loop around Kezar Lake which sits in the shadow of Mount Kearsage. The lake has been a vacation area since the late nineteenth century. There are old lodges and camps scattered around the lake. In late winter there is a big event, the cutting of the ice into huge blocks. It’s been happening for more than a century. The blocks are packed in straw and put in an icehouse which makes it available through the spring, summer, and fall. There was a time when ice was a big commercial product in New Hampshire.
I never knew the name of Kezar’s outflow, the Lane River, until now. I did know that its inflow was from Lyon Brook which comes from New London. Some years ago the town of New London had to pay for a clean up of sewerage in Lyon Brook because it was damaging Lake Kezar in Sutton, the next town south from us.
Our hike began at a trailhead in the Webb-Crowell Forest about a quarter of a mile out of picturesque South Sutton. South Sutton has not changed much over the last one hundred and fifty years. As you can see from the aerial photo below of the village, the marsh, and the river that was taken in the late fall, the area is like a postcard from a simpler past. There is a village green with a monument to townsmen who died in the Civil War. Behind the monument is the town meeting hall and community church. It is a classic white structure with a tall steeple. What is amazing is that the building has no plumbing, no electricity, and no heat. At Christmas people gather for a candlelight service of carol singing and the reenactment of the Christmas story by the local children. Afterwards everyone gathers at the historical society across the green for hot cider and cookies.
The hike was an easy jaunt on an up and down trail through the woods and along the river where we had views of the picturesque village across the marsh through which the river meandered before diving over a small waterfall and roaring down the long descent that you can see in the picture. We used micro spikes and ski poles out of deference to the icy spots and the crunchy snow. The was no wind, but it was cold, 22 degrees. The trail is littered with huge erratics that were dropped by the glacier that carved the land about 10,000 years ago. My lake is another product of the same glacier. My friend Steve is over six feet tall to give you a sense of the size of the the rock (erratic) behind him.
The trail is a short loop of a mile and a half. We completed the walk in less than forty five minutes, even though we had stopped frequently to take in the scenery. Despite the cold, I had worked up a little bit of sweat and an appetite for some late morning quiche and coffee before my Pilates workout. I can hardly wait to come back to the Lane River in the spring with my fly rod since I have discovered that the little Lane River is home to brook trout and brown trout.
Just when I think that I have seen most of what there is to enjoy in my neighborhood, I am surprised to learn that there is so much more to discover and enjoy. I doubt that I will run out of surprises soon because every location is quite different in each of the four seasons. I hope that you will have an outdoor adventure this weekend. If you live in the New England you are probably not far from a really good walk in the woods. If you ever venture as far north as Mount Kearsage and Sutton you should check out the Lane River in any season.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
