December 18, 2020

Dear Interested Readers,

 

More Musing About What’s Next

 

Last night I had the unique opportunity to hear Susan Rice speak at a virtual presentation of the Boston Speakers Series. She has an impressive resume and a very interesting personal story which she has recently told in her book, “Tough Love: My Story of the Things Worth Fighting For.” She had originally been scheduled to speak last March at the usual venue of Symphony Hall, but that event had been canceled because of the pandemic. In the interim things have changed. Joe Biden is our president-elect, and he has selected Susan Rice, former UN Ambassador and former head of the National Security Council, as his coordinator of domestic policy and the executive director of the Domestic Policy Council.

 

It has been very interesting to watch Joe Biden construct his cabinet and select his White House advisors. Just as he promised that if he got the Democratic nomination for president he would select a woman for vice president, he has promised that he would make cabinet-level appointments that reflected the diversity of the nation. Beyond Susan Rice as his chief advisor for domestic policy, Biden has kept his promise with three other very interesting appointments at HHS, Interior, and HUD. The former congressman and current Attorney General of California, Xavier Beccera was a surprise choice as Secretary of Health and Human Services. He is a first-generation American whose family immigrated from Mexico who has always had a legislative and legal focus on health. Representative Deb Haaland of New Mexico, a member of Laguna Pueblo, is uniquely positioned as a native American to be Secretary of the Interior. The department of the Interior does much more than managing our natural resources like oil, forests, and public lands. Its departments include the Bureau of Indian Affairs and the Bureau of Indian Education. Finally, in a most surprising move, Biden has named Congresswoman Marcia Fudge of Ohio to head HUD.

 

One thing is clear to me and that is we will never achieve meaningful health care reform that even approaches such a lofty goal as the Triple Aim without huge changes in the broad scope of domestic policy. When Berwick, Nolan, and Whittington gave us the Triple Aim back in 2008 most of us had the incorrect notion that we could make great progress toward the objective by adopting universal access to care and reforming the delivery of care along the lines recommended in Crossing the Quality Chasm, with a focus on making care patient-centric, safe, timely, efficient, effective, and equitable. Our focus was primarily on our industry and how we performed. There was a vague awareness of the importance of public health in the aim of improving the health of the nation, but most of us did not realize that the greatest barriers and challenges to the lofty goals of the Triple Aim were the inequities in our society that deny fairness in opportunity, employment, nutrition, housing, education, and complicate all the “activities of daily living” to so many of our minorities, and rural Americans–the bundle of issues that we lump together as the social determinants of health. 

 

If the nuts and bolts of diet, work, housing, education, and medical care were not complicated enough to improve, we now realize that there are underlying inequities in the impact of global, climate change, pollution, plagues, and problems such as the COVID-19 pandemic, substance abuse, gun violence, lead poisoning, air pollution, and the impact of violent weather. Minorities in our cities and the rural poor of all ethnicities suffer more injury and misery from these problems than those of us who enjoy the privileges of wealth and education. The root causes of these problems and the health issues that flow from them can’t be adequately managed from a medical office or a hospital where the best we can do is offer some relief and repair from injuries. 

 

Joe Biden realizes that we need domestic policies built in part on lived experience or an empathy derived from personal proximity to the problems. Biden’s appointments so far match that reality. Those were some of my thoughts as I settled down to listen to why a talented woman with an undergrad degree from Stanford and a doctorate in foreign affairs from Oxford who had spent her professional career making policy on the international stage was the right person to direct the development of the crucial domestic policies that would guide the agencies that should coordinate their efforts to improve the social determinants of health. 

 

The format of the evening was different than the usual Speakers Series presentation. Rather than a speech followed by “Q and A” with the audience, questions to Ambassador Rice had been submitted before the presentation, and the moderator read the questions for her to answer.  It worked quite well and was probably much better than her trying to give a speech to an empty room. I had never had the privilege of hearing her speak much more than a snippet on the news or be a participant on one of the regular Sunday morning “talking heads” reviews of a current controversy like the “Benghazi  disaster.” She had me hooked with her answer to the first question which was also the question that was foremost in my mind. She was asked why Biden was asking her to lead the development of domestic policy when she had spent her career in government under Clinton and Obama developing and implementing foreign policy? It was an easy answer. There is not that much difference in policy development and strategy deployment from one field to the next. Her early career as a researcher and staff member to various congressional offices had been focused on domestic policy and civil rights. Her father was a well-known economist and her mother was a leader in higher education and worked for The College Boards. It was not until after I heard her speak and did a little hunting on the Internet that I found an opinion piece that related to domestic policy that she had published in the New York Times last spring (April 28) entitled, “It’s Not Enough to ‘Get Back to Normal’: We can rebuild better. Here’s how.”

 

I liked her introduction to the piece. It set high expectations. 

 

A hallmark of America’s strength and resilience has been our ability to seize opportunity amid our greatest crises.

After the Civil War, we adopted constitutional amendments to end slavery and enshrine the concept of equal protection under the law. In the Great Depression, we established the Works Progress Administration and Civilian Conservation Corps. After World War II, we had the G.I. Bill and founded NATO and the United Nations. During the Vietnam War and civil rights era, Congress abolished segregation, secured the right to vote for all Americans, and reinforced our social safety net through the Great Society.

As we struggle through the Covid-19 crisis — the greatest challenge to global health, national security, and our economy since World War II — we must ask again how we can emerge a more just, equitable, and cohesive nation.

 

Those words tell me she has been thinking about where we go from here with our domestic policies. She outlines how President Trump has failed to protect us and is unlikely to be prepared to do better in the future and then she says:

 

The coronavirus has laid bare our domestic divisions, unequal economy, and glaring racial and socio-economic disparities as well as the fragility of our democracy. To recover from this crisis, it will not suffice to contain the carnage, reopen our economy, and “get back to normal.” “Normal” is too costly and deadly for all Americans.

Now is the time to rebuild better — our economy, our health care, and education systems, our democratic institutions — so that we cure the root causes of our collective disease. While one can hope we soon will be blessed with new leadership committed to national unity, human dignity, and respect for democracy, we cannot afford to wish and wait.

 

I wonder if Biden lifted his “Build Back Better” campaign slogan from Rice’s ideas in this article. She suggests two steps of preparation for recovery:

 

• The first is to preserve and protect our democracy by ensuring free and fair elections in November. 

 

• Second, the United States has a rare opportunity to accelerate our recovery from the coronavirus while starting to restore an ethos of service to American culture. To reopen our states and towns safely, we need to hugely scale-up testing and our capacity to trace the contacts of those infected to enable them to be isolated and cared for.

 

She was right on both points. We did exactly what she went on to describe as an effective way to have a fair election with wide participation despite the pandemic. It is not her fault that the majority of Republicans still maintain that Donald Trump won.  It is also not her fault that the president failed to follow similar recommendations from Dr. Fauci and other experts and we are now experiencing more cases, more hospitalizations, and more deaths than ever before. 

 

As I listened to Ambassador Rice’s thoughtful answers to the questions that were submitted to her, when I read her New York Times piece later, and then got a little more flavor of who she has been as revealed in the personal information I could glean from the Internet and a good review from the Washington Post of her recent autobiographical book, I nodded to myself and said, “Joe is not sleepy!” He is pretty smart. Rice has been appointed to a position that does not require Senate confirmation. She has many Republican enemies. She has the breadth of governmental experience and the managerial skill to coordinate the efforts of the various housing, health, labor, education, and immigration programs that will come out of the various cabinet based domestic agencies that she will supervise for the president-elect. In her answer to one of the questions last night she pointed out that without the need for Senate confirmation she can start working the moment President Biden takes his oath, and will not need to wait until she is confirmed by a slow-moving Senate that may still be controlled by Mitch McConnell. His dedication seems to be to whatever it takes to have power rather than what it takes to solve crushing problems. 

 

It is great to dream about bipartisanship and the flexibility that might be gained by winning the control of the Senate by winning both of the Senate seats that are being decided now in Georgia, but even if those seats are won, Biden’s plans will get enormous push back. I hope to write more soon about what strategies Biden and Rice may employ to improve access to care and the social determinants of health even if the Democrats don’t control the Senate. You can get a preview of some of those ideas by reading an excellent article that came out in the New York Times last week written by Sarah Kliff entitled “This Is the Health System That Biden Inherits From Trump: With medical spending down for the first time in decades, gains in care for the poor and vulnerable are under threat.” 

 

Listening to Ambassador Rice talk lifted my spirits. The pandemic has depressed me greatly in many ways, but none more than by its demonstration of how deeply our social problems run, and how unfair the impact is on our most vulnerable citizens. My prayers at this season of Advent and expectation will include her and our country. I will pray for her skills and determination. As I thought about the importance of the policy formation she will lead I was reminded of the words of another great American, Hubert Humphrey, that are carved on the wall of the lobby of the offices of HHS. I mentioned the quote four years ago while I was reviewing Trump’s leadership selections for HHS and CMS:

 

“The moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped.”

 

The work will be difficult but we can not measure up to Humphrey’s expectation without deploying effective strategies to improve the social determinants of health. I think that with the help of Susan Rice, Joe Biden will make progress that we can see and feel. Choosing her shows his intent.

 

It Was A Huge Dump–of Fluffy Snow

 

The weather people on television started talking about the big that was coming last weekend. I was caught by surprise when one of the forecasters offhandedly commented that the storm they were talking about had not yet formed. “How could that be?” I thought before she continued by saying that with their computers they could anticipate that a storm would form in the mid-south and begin moving in a northeast direction dumping large quantities of snow in Virginia, Pennsylvania, New Jersey, New York, Connecticut, and Massachusetts, before a slight right turn at Cape Cod. The predictions became more certain on Tuesday. Central and Eastern Massachusetts and Southern and Southwestern New Hampshire were projected to get up to eighteen inches of “light fluffy” snow. The light fuffy reality was due to the extremely cold temps and low humidity that were already established as the storm arrived. 

 

The best and the brightest forecasters at the Boston and Manchester TV stations originally said that the Lakes Region of Central New Hampshire, where I live, might get a “dusting” to two inches of snow. I was disappointed to hear that news. As you might remember from last week’s letter, I am a lover of winter. Once the lake was frozen I wanted it buried under at least six inches of fresh snow. These “experts” were telling me that this storm was going to be a disappointment. I was hoping that they were wrong, but they are experts. I got a little bit of hope from the Manchester weatherman on the 6 o’clock local news who said that the storm was tracking a little more northward along the shore and we might get four to eight inches. I thought, “Excellent just the right amount.” It will be pretty and we won’t be inconvenienced. 

 

Wednesday evening was the first night out of quarantine for my youngest son and his wife who had come up from Brooklyn to put in their time in isolation in our garage apartment before enjoying Christmas and the New Year with us. Before the good news that they were coming for the holidays, we had resigned ourselves to an extension of lonely holiday meals with Zoom for dessert that had been our Thanksgiving experience. When we heard they were coming we ran out and bought a Christmas tree. Since the toilet paper shortage last spring, we buy what we need early. The tree had been sitting on the deck since late November and we planned to decorate the tree before a Zoom birthday party for my oldest son that was scheduled for ten to accommodate my granddaughter’s sports schedule and the fact that we have family on Mountain Time and Pacific Time. I looked out the window after the tree was decorated, after the Zoom party, and even after Steven Colbert. I was preparing to be disappointed. I expected to wake up and see that reality was a dusting to two inches.

 

I woke up shortly after first light. When I looked out the window to confirm my disappointment, I blinked twice, The cedar gliders on the patio were almost completely buried. My birdfeeders were not hanging from poles, they were sitting on a white shelf. There was virtually no visibility because as I was to learn shortly from the radio, snow was falling at a rate of over five inches an hour. It continued until two. The result was over 36 inches of snow. That was the “official” measurement for our town. I think it was probably more at my house. See for your self. Today’s header is a picture of my house taken by my son from the balcony of our apartment which is up the hill from the house, as the snow was clearing. You can see the lake behind the house. If you look at the roofline, you will see that there is at least a yard of snow on the roof, and I am sure some of what was there has blown away. Claremont, New Hampshire which is 25 miles west near the Connecticut River got 43 inches. The little town of Croyden that lies at the foot of Croyden Peak, about twenty miles to the northwest, got 44 inches!. Many surrounding communities measured 40 inches. Boston got about 12 inches. Can you imagine what would have happened there if 40 inches had fallen on them? I can. I well remember the blizzard of ‘78. Why the inversion from the prediction? The weather people said the storm turned and then stalled for several hours right over us. 

 

Our roads are cleared very quickly. I got in my afternoon walk wearing microspikes to help me dodge the snowplows without falling. Wherever you are, I hope this week in the run-up to the holidays, or if it falls in the middle of your holidays, is a good week for you that has some pleasant surprises. 

 

Be well, be out and about at every chance to get some exercise, but wear your mask unless you are walking down a country road. Keep six feet between yourself and every other person at the grocery store if you must shop for essentials. If you are a brave soul who is an essential provider, demand, and effectively uses the PPE. I hope that this will be the week you get vaccinated. Remember, snow eventually melts, and every pandemic has eventually ended.

 

Happy holidays!

Gene