December 12, 2025
Dear Interested Readers,
I Am Trying to Develop a Little Hope
Now and then, I get an unexpected email response to one of these letters. This week, I got one of those surprises in an email from a longtime reader. He wrote:
Have just read your recent blog post, which is spot on, raises and addresses all the key “macro” issues in healthcare. Thank you — very well done.
My first reaction was that I could not remember exactly what I had written just a few days before that might have elicited such a positive response. To reorient myself, I looked back at the post and reread it. After rereading the letter, I realized that almost everything that I said in the post I had said in previous posts. What was different was that I expressed my concern that it will take a long time, if ever, to recreate the key components of our healthcare system that are being abused or even destroyed at an increasing pace by the policies of the Trump administration.
I implied that much of the progress made toward patient-centered, safe, equitable, efficient, effective, and timely care during my years in practice was at risk or had been lost. Even worse, it felt to me that our recovery could not begin before we had fundamental changes in the operations and financial infrastructure of our care delivery system, which would not easily occur in our deeply divided current culture and political environment. I also postulated that if our “recovery” ever happened, it was unlikely to start before our next president was inaugurated in 2029. I don’t know if it was that “downer” message or my attempts to describe all the issues currently facing us, without any current plausible solutions, that must have resonated with the reader who reached out to me. The paragraph that best expressed what I was feeling was:
We never established that access to adequate healthcare should be an entitlement or a reasonable expectation of every American. The passage of the “One Big Beautiful Bill” and the withdrawal of financial support for the ACA marketplace did not create our problem, but they will accelerate our further decline and diminish the hope of beginning our recovery any time before 2029. I fear that it will be many years before we can start the repair of our current reality, a system of care that often poorly serves even those who can pay the high cost for attention and access. Worse than “slow care” for those with access, which will be delivered in crowded and understaffed environments for problems that could have been avoided with adequate access to preventive care, will be those who end up getting no care until any care will be futile.
Perhaps to prove that we once were on a more positive trajectory that recognized that medicine did need to move from a “guild-like” profession to an “enterprise,” let me suggest that you click on the “reference” section of this website and scroll down to “Dr. Gene Lindsey: The Oration, Mass. Medical Society, November 28, 2012.” The history of the “Oration” is explained on the Mass Medical Society’s website.
The MMS Annual Oration dates back more than 200 years, when in 1804, Dr. Isaac Rand addressed the topic of “On Phthisis Pulmonalis, and the Use of the Warm Bath.” The historic purpose of the oration is to inform physicians of issues such as “the histories of epidemics, tables of births and deaths, diaries of the weather, etc.”
While the original theme has expanded considerably through the years, the essence of the oration remains to inform Massachusetts physicians of issues pertinent to current medical practice.
The following is a list of orators and their dissertations from 1804 to the present.
If you scroll down the list of titles from that introduction of the “Oration,” you will find:
2012
Eugene Lindsey
Working Together: From Guild to Enterprise
If you click on the title, you can actually see and hear the speech. If you do, let me warn you that my delivery was terrible. The room was dark, my eyesight was beginning to fail from cataracts, and I could not easily read my manuscript. Most of the speeches I gave during my leadership years were extemporaneous discussions of a slide deck that illustrated our efforts to improve care at Atrius Health. This speech was a low point in my professional experience. It reads well, but my delivery was painful for me and the audience. The honor of being asked to deliver the annual oration should have been a peak career experience. In retrospect, it was the beginning of a year of gradual recognition that it was time for me to retire. I present the story to prove that back in 2012, our organization was focused on the hard work of blending the best traditional professional objectives of personalized care with the necessary efficiencies of a “corporate” enterprise, done right to preserve the basic principles of traditional patient care. As I said in the speech:
Medicine is rapidly morphing from being a guild-like activity to an activity embedded in an enterprise. The enterprise is necessary to handle the complexity and the capital needs of today’s medicine. Yet many of us have our hearts trapped in the model of the craftsman. We daily express our desire to be free and independent of onerous regulation and administrators who lack personal understanding of the difficulty of working under the scrutiny of the rules of politicians and the threat of the plaintiff’s bar. Our independence is threatened on the one side by hospitals that want to control us to serve their objectives and on the other side by investors and agents of other business interests who see healthcare as a great opportunity if they can control the flow of patients by controlling the doctors. In other words, one could say that we are a guild under siege.
I posit that we can be true to our best intentions and exercise the best of our guild values while our craft becomes part of an enterprise that is beginning to be known as an Accountable Care Organization. I want to share with you my observations and reflections about what strategies have worked for Atrius Health in a time of change and what we have learned from what did not work so well for us.
Let me start by introducing you to Atrius Health…
At that time, I was invested in the idea that the “ACO” movement could represent the 2.0 version of capitation that had been misdirected when the HMO movement of the seventies and eighties lost its way in a flourish of profit-oriented IPAs and was rightly accused of often denying necessary care. The “quality movement,” coupled with the ability to use the growing electronic capabilities of monitoring patient satisfaction and outcomes, seemed to offer us the opportunity to move away from fee-for-service finance and toward value-based reimbursement and a more efficient operating system that took advantage of our growing technology and our increasing skills in “team-based” practice. I still hold that belief, although time has moved it from an aspiration to a hope.
What I wrote last week and what I am trying to say this week is an extrapolation of my experiences during my years of practice, as well as my mid and late career responsibilities in governance and management of a large healthcare provider that was trying to participate in the reinvention of practice by incorporating the progressive principles that were well described in 2001 in the landmark publication, Crossing the Quality Chasm: A New Health System for the 21st Century. That important book was a compilation of the best ideas from our most innovative minds in medicine. It was published by the Institute of Medicine (IOM) in 2001. The IOM was renamed the National Academy of Medicine in 2015.
Back in those heady days of hope for the future of healthcare after the passage of the ACA, I was encouraged by the efforts of visionary physician leaders from across the country. I earned many frequent-flyer miles and developed meaningful relationships with like-minded physicians and administrators as I attended national conferences and visited innovative systems of care across the country. I was particularly inspired by the efforts of several dynamic leaders to bring the benefits of Lean process management to healthcare.
I traveled to Seattle to see the work at Group Health of Puget Sound (now a part of Kaiser) under the leadership of Dr. Michael Soman. In Seattle, I also visited Virginia Mason, where Dr. Gary Kaplan even took his executive team to Japan to learn the skills of Lean by working on the assembly line at Toyota. I traveled twice to Appleton, Wisconsin, to see the wonders Lean had achieved under its dynamic CEO, Dr. John Toussant, at ThedaCare. In South Carolina, I observed an excellent small-town and rural health care system, McLeod Health, that had been transformed by a process of continuous improvement and Lean led by Rob Colones, one of the finest healthcare executives I ever had the privilege of meeting. Perhaps the most extensive and impressive innovations in the care delivery systems of small-town and rural areas I visited were at Geisinger Health in central Pennsylvania, where an old HCHP colleague, Glenn Steele, served as the CEO. Finally, I developed a deeper understanding of leadership from Dr. Patty Gabow, the remarkable woman who revitalized and transformed Denver Health using Lean. Alas, all of these leaders, and many others I met through the Group Practice Innovation Network (GPIN), have, like me, retired. I traveled a lot as I tried to observe what the best systems in the country were doing to improve care.
Last to mention, but perhaps first in contribution to the list of those who labored to give our country the healthcare it deserves through his role in the creation and leadership of the Institute of Healthcare Improvement (IHI) and also among the number of those whose voice is no longer as frequently heard, I would add Don Berwick, who was a driving force behind Crossing the Quality Chasm and the Triple Aim. I sometimes wonder if the enthusiasm for transforming healthcare along the lines of Crossing the Quality Chasm and the Triple Aim of these healthcare stars of the early years of this century has been successfully passed on to the next generation of medical leadership, which must have organizational survival rather than improvement as its primary task. I don’t know.
What I do know is that healthcare and the patients it serves are in a world of hurt, with little evidence of hope on the horizon. Whatever my appreciative reader saw in the letter that moved him to send me his compliment, my grave concerns about the future of our system of care were the partially hidden thought behind last week’s letter to you. I am sure you know by now that yesterday, the Republican majority in the Senate probably killed any last chance to renew the extended market supports for the ACA. As my friend and coparticipant in Kearsarge Neighborhood Partners and a member of our local hospital’s board, Steve Allenby, said to me just yesterday when we were discussing the rising cost of care, when I recommended to him that he should read “$27,000 a Year for Health Insurance. How Can We Afford That?” in Wednesday’s New York Times, “It may need to get much worse before it can get better!”
Zack Cooper, an associate professor of public health and economics at Yale, wrote the Times article that I recommended to Steve. Click on Professor Cooper’s name to see other scholarly articles he has written about the mess we are in and some of his ideas about the path out of our morass. Below, I will lift a few of his insights to share with you. I will bold the ideas that I don’t want you to miss. He begins by suggesting that the debate behind the shutdown was wrong.
The debate over whether to extend the expanded Affordable Care Act subsidies has consumed lawmakers over the past two months, precipitated a government shutdown and sparked Republican infighting. Unfortunately, it’s the wrong debate.
While I believe we should extend the subsidies, which expire at the end of the month, to help families pay their insurance premiums, doing so wouldn’t fix the underlying problem: surging health care spending. That’s the reason we need the subsidies in the first place, and it’s bankrupting families and shredding jobs for low- and middle-income workers across the economy.
What follows feels like what you might hear from your doctor who is telling you that the little ache that brought you in is the harbinger of much more grief and suffering ahead.
Just how bad is it? The best evidence we have shows that rising health spending in the United States since 1975 can explain roughly the same share of the growth in income inequality as increased trade, outsourcing or automation. It has pushed down wages, fueled inequality and left families drowning in unaffordable medical bills. Rising health care spending is killing the American dream.
Despite devastating out-of-pocket costs, Americans are generally insulated from the true cost of health care premiums. However, the expiring subsidies on the Affordable Care Act marketplaces, where more than 20 million Americans get their insurance, show just how exorbitant premiums have become. Consider a 60-year-old couple earning $85,000 a year. Without subsidies, their health insurance premiums next year will approach $32,000 (akin to buying a new Toyota Camry).
That is not good news, but like the silent progression of a potentially fatal problem, we haven’t fully appreciated the hurt to come because the problems ahead have been hidden until cure without a radical intervention is unlikely.
Those of us who get health care insurance from our employers — some 160 million Americans — may be breathing a sigh of relief. But our health care premiums are also staggering (an average of $27,000 a year for a family of four), and the fact that our employers pay part of the tab isn’t much of a reprieve.
That’s because decades’ worth of research shows that, even though employers pay most of workers’ premiums, those costs are passed on to workers in the form of lower wages and fewer jobs. That’s why the rise in health spending above the rate of inflation over the past decade has depressed wages by nearly 10 percent, according to my calculations. And because premiums are a bigger share of total pay for lower-income workers, the job cuts triggered by rising health care spending fall disproportionally on low- and middle-income workers and fuel income inequality.
As a confirming aside, I can report that last Sunday, as moderator of my church, I led the annual congregational business meeting that affirms our church budget for FY 2026. The most significant year-over-year increase in cost was the more than 10% increase in our purchase of healthcare for the church employees. I stepped aside from the podium and, perhaps inappropriately, asked the congregation to pray that we might find a way to control these rising costs, because the increasing cost of care, as access to care becomes more difficult, is a threat to the more disadvantaged members of our community now and would eventually be harmful for everyone. Perhaps my words were inappropriate in a house of worship, but I did not blame a political party; instead, I expressed the current problem as the outcome of our collective actions and inactions over several decades.
Back to Professor Cooper, after elaborating on this bad news about the world of hurt created by the rising cost of care, Professor Cooper continues to describe the complex ramifications of our collective pain that make the search for a solution so difficult. These problems would not have gone away even if Republicans had agreed to the Democrats’ demand to extend the ACA’s financial support. He deftly describes how difficult it will be for us to get to a better place and for my prayers to be answered. We need a miracle.
I wish there were a simple way to lower U.S. health spending. It’s easy to come up with ideas for what a better health system would look like if we could start from scratch. Unfortunately, the sheer scale of our system (if the U.S. health system were a country, in dollar terms, it would be the third-largest economy in the world) means there are no silver bullet solutions. Reform involves trade-offs. One person’s health care spending is another person’s health care income — profits, jobs and paychecks for the tens of millions of people who work in the health care sector. And some higher spending does lead to better care. As long as they’re in competitive markets, higher-priced hospitals deliver higher quality care. Slowing health spending would create winners and losers, which makes the politics of reform tricky.
Just as your doctor might lay out a treatment plan that onerously includes extensive surgery followed by months of chemotherapy, radiation, and hopefully eventually PT with no guarantee of success, our collective path forward if we want to get better will be complex, complicated, and personally and politically painful. He says that there are three imperatives to be performed in parallel.
First, we should fix existing policies that are plainly inefficient. For example, as a result of Medicare payment rules created in the 1980s, the government program pays more (sometimes double) for care delivered in a hospital or hospital-owned doctor’s practice versus in an independent doctor-owned practice, even if the care is identical…
Second, there are numerous meaningful reforms that don’t involve wholesale change and could be introduced now. I run a project called the 1% Steps for Health Reform that identifies discrete interventions that could lower the cost of health care without adversely affecting quality…
His second step sounds to me like the quality management search for practical innovations to improve quality and costs that were the focus of Lean. Those of us who were committed to Lean or other industrial improvement techniques believed Don Berwick when he said that 30-40% of healthcare costs were pure waste. We believed we could use process management techniques to eliminate waste, improve patient experience, and increase the safety of care while lowering costs. We were eager to learn and borrow from manufacturers and other industries that had learned how to control costs while improving the quality of their products.
The third and last step is the most difficult. I have always viewed the ACA as a transitional step toward something like Medicare for All, but without fee-for-service hindrances.
Finally, policymakers should explore the design and feasibility of larger structural reforms to the U.S. health system that could be introduced over a decade. These ideas include decoupling health insurance from employment, broadly regulating the prices hospitals and other providers negotiate with insurers, creating a very basic, but universal insurance coverage program and, yes, even Medicare for all. It is not enough, however, to describe what an idealized U.S. health system would look like. Serious exploration requires tangible solutions that are politically feasible and won’t tank the economy.
In these notes, I have previously suggested that healthcare is so crucial to the nation’s fate that our path forward should not depend on the casual expertise of lawmakers. Like our Federal Reserve System and other agencies, which the president is trying to dismantle systematically, our system of care should be a central responsibility free from the seesaw ride it currently takes, depending on which party is in power. Dr. Cooper has had a somewhat, but not as extensive and permanent, idea. I doubt that either his idea or mine has much of a chance until the situation gets much worse.
During the government shutdown, one idea that briefly surfaced was a bipartisan commission to study ways to lower health care spending. That commission shouldn’t be a footnote; it’s essential. At the same time, the real pain families are feeling requires extending the expanded Affordable Care Act subsidies, at least temporarily. Americans have high premiums because elected officials have ducked the tough choices needed to rein in spending. Lower- and middle-income people shouldn’t be stuck paying for that failure. But subsidies alone aren’t a solution; they simply buy us time. The point is to use that time to build a system in which coverage is affordable because care is affordable. That would take political courage and an American public willing to reward leaders who choose to compromise and work together.
My cynicism toward all of Professor Cooper’s ideas suggests that my response to Dr. Cooper should be, “Yes, just after pigs begin to fly.” Progress in healthcare is mired in the quicksand of vested interests of the status quo. As I said many paragraphs earlier, my friend Steve imagines that it won’t get better until it gets worse. I hope Steve is wrong, but my gut tells me the momentum points to darker days ahead. I fear that the 2026 midterms and the 2028 presidential election can’t come soon enough to save us from further deterioration of the compromised position we are in now. We will need to be creative in the interim if we hope to limit the damage the loss of their healthcare will cause for many Americans.
We Are Still In the Freezer
You might recognize that the picture that is today’s header shows the same Japanese maple that I enjoy so much every fall. I used a picture of it in its full glory as the header for the October 31 letter. Now it stands, in deep snow with bare limbs, and with more snow falling. My tree reminds me of Shakespeare’s Sonnet 73, which compares the bare limbs of a tree in winter to the fading realities of age. We don’t know why Shakespeare died on his birthday at age 52, but he was prescient, expressing sensibilities at that young age that I now relate to at 80. My favorite lines are:
That time of year thou mayst in me behold
When yellow leaves, or none, or few, do hang
Upon those boughs which shake against the cold,
Bare ruin’d choirs, where late the sweet birds sang.
In me thou see’st the twilight of such day
In Sonnet 97, he used winter as a metaphor for time away from a loved one. The first four lines of his lilting iambic pentameter are:
How like a winter hath my absence been
From thee, the pleasure of the fleeting year!
What freezings have I felt, what dark days seen!
What old December’s bareness everywhere!
Those lines from the Bard come alive for me as I struggle to walk in the cold. We are off to an unusually cold start this winter. On Wednesday, we had our second storm that produced “plowable” snow, so we are virtually assured of a White Christmas. I have Raynaud’s and can usually cope with temps into the high 20s using double or triple gloves. To better equip myself to deal with what looks like colder weather than we have had over the past few years, I recently bought a pair of heated gloves on Amazon. The gloves were total junk and provided no relief. I plan to return them. Yesterday, I tried chemical hand-warming packets from a local outdoor gear store. The packets helped, except my thumbs still got numb. The temp during yesterday’s walk with the warmers was a balmy 18, but a brisk wind, according to my iWatch app, made it feel like minus 1. Suggestions would be welcome. I look forward to the end of next week because the long-range forecast suggests some warmer weather after some more snow.
I hope that wherever you are, you can get out for a walk at least once this weekend. I find that a daily walk is good for my physical health and my soul in troubling times like these. If you are going for a long walk, I suggest you put in your earbuds and listen to an amazing one-hour-and-forty-five-minute conversation between Ezra Klein and Gavin Newsom. It is all political rhetoric examining the changes in attitude necessary to preserve our democracy. Without a functioning democracy, the outlook for progress toward improving the health of our nation and the performance of our healthcare system seems unlikely.
Be well,
Gene
