December 30, 2022
Dear Interested Reader,
Looking Back, Looking Forward
Janus, the two-faced Roman god, is the god of doorways and beginnings and endings. He also presides over the beginning and end of wars, making him the god of war and peace. Given those domains, it is obvious why our first month of the new year is named January. January is a time of looking back and looking ahead.
I don’t worship Janus, but during the week after Christmas, while looking forward to the new year, I am always looking back at the year that has passed while making plans for the coming year. I thought I would invite you to remember some of the things I discussed in these notes over the last year, and then briefly look at the challenges we see on the horizon for 2023.
My first letter to you of 2022 was on January 7, 2022. I used the carol “In the Bleak Midwinter” as a metaphor for my concerns. Reading the letter again now I am impressed that we survived some of the concerns that worried me then. I concluded a year ago that looking for ways to make a difference locally would be a good strategy that would work no matter what happened at the national level. The last paragraph of the first section of the letter reads:
So, 2022 begins with a continuing threat from the ability of COVID to evolve to match many of our defenses while on the political front there is a continuing faceoff between the parties that is unlikely to serve any of us well. I have no doubt that we will survive the bleak midwinter, but I remain very concerned that a lack of progress on the issues that divide us will continue to threaten the ultimate health and aspirations of all Americans. I am not sure that our democracy can survive much more stress. My concern encompasses the haves and the have-nots. We all are on a trajectory for even greater losses. My own limitation of one vote in a small state leaves me nothing to do but express my concerns to you and continue to look for ways in 2022 that I might be of some benefit to my neighbors who might not have shared the good fortune that has come my way.
There were many startling events in 2022, but none was more concerning than Putin’s invasion of Ukraine on February 24. I was terrified and flabbergasted by the audacity of Putin’s actions when I wrote to you on February 25, 2022. At that time, the outlook for the Ukrainians was bleak. Most experts expected a Russian victory in a few days. We had no way to know then that the Ukrainian president had the inspirational skills of Winston Churchill and the courage of the defenders of the Alamo. What we knew then was that Putin’s invasion was a threat to us all that had surprised most of us. The future of the world was more uncertain than we had imagined. On February 25th I did not expect that ten months later victory would still be possible if the rest of the world could match the Ukrainian determination and willingness to sacrifice to secure freedom.
I had a pessimistic outlook and expressed my apprehensions that the majority of Americans would conclude that Ukraine’s war was not their problem. I extrapolated the concept to include healthcare. I am pleased that ten months later we have not abandoned Ukraine. I wish I was as confident that we would never find it advantageous to abandon the underserved:
This may be inappropriate to say, but I fear that Americans born since World War II conceptualize war as something that occurs at a great distance from us and to people who neither look like us nor share much of our cultural heritage. Historically we have preferred not to get involved in international conflicts. “Not our problem” and not worth American lives or treasure have been knee-jerk responses that have been magnified by long and disappointing engagements in Korea, the Middle East, and Southeast Asia. To many those places just don’t seem to have much in common with New Hampshire or South Carolina. We care, but we seem to be very careful about acting on our cares in the aftermath of Iraq, Afghanistan, Vietnam, and Korea. All of our strategies seem to begin with a consideration of what’s best for America at the moment. The problem with that approach is that what is best at the moment in foreign policy is often not what is best over the long term. Unfortunately, we often exercise the same philosophy when approaching healthcare, especially for the underserved who struggle with inequities. “Not my/our problem” is invariably fertile ground for the growth of bigger problems.
Throughout the year I was torn between writing about the war in Ukraine, our deeply divided politics, global warming, continuing gun violence, and inequality on the one hand, and what should be happening in healthcare if we were ever going to have a system of care that gave everyone something like an equal chance at a healthy life. On April 1, 2022, I wrote:
Rising healthcare costs, medical workforce issues, access issues, concerns about quality, and the deterioration of systems of care get lost within the larger discussion of inflation, supply chain failures, worker dissatisfaction, the dehumanization created by the digitalization of every aspect of life, and the surprising hostility we see on social media. Just as it is hard to know how the war in Ukraine will end and what will follow, I feel it is equally difficult to predict the future of healthcare reform and the trajectory of improvement of healthcare in America in the years to come. Like climate change and the deterioration of our infrastructure, failing systems of healthcare and what to do about them seem to get lost as we attempt to deal with the barrage of problems that seem to be more acute. Just because our attention is diverted these chronic issues don’t go away. They continue to grow.
As the year rolled along, we were educated by the House’s January 6 Investigation. Inflation seemed to guarantee that there would be a “red wave” that would give control of Congress to the Republicans. We tolerated the behavior of Lindsey Graham and other Republican members of the Senate Judiciary Committee as they tried to block the confirmation of Judge Ketanji Brown Jackson as a justice on the Supreme Court. There were many tense moments this year, but the biggest domestic shock, despite the leak of the tentative judgment in May, was the Dobbs v. Jackson decision from the Supreme Court on June 24 that repealed a woman’s right to control her reproductive life. On the day the decision was announced I tried unsuccessfully to put it into some perspective:
I wonder what Dr. King would say if he knew that the concept of “settled law” so-called stare decisis is just a neat way for a candidate for the Supreme Court to lie about their biases so that Susan Collins can justify voting for their confirmation. It is ironic that as we struggle to decide whether or not Donald Trump broke the law and should be held accountable he has scored one of the biggest victories for oppression in the history of the nation as the Supreme Court has thrown out Roe. With decisions on guns, abortion, climate, education, and voting rights, his three conservative appointees are systematically undermining decades of progress. One wonders what will be left when their work is done…
This morning we have heard that Roe is dead. American women no longer have a right to control when and if they want a child. This painful moment did not begin a few weeks ago. Evangelicals have been gathering a coalition against Roe since 1978.
They have had a very patient strategy with an eye on the prize. They have built a coalition with white supremacists, the NRA, and powerful individuals who see a minority control of government as in their best short-term interest with no concern for the long-term consequences of their actions…
I finished the letter by referencing a speech given by President Biden shortly after the decision was announced.
As President Biden stressed in his speech in the aftermath of the announcement of the Court’s decision on Roe, the mid-term elections offer us the first opportunity to prevent losses as we attempt to keep our democracy from “slip slidin’ away.” [ My “hook” for the letter had been Paul Simon’s philosophical song “Slip Slidin’ Away.”]
Click here to hear the song if you don’t know it, or love it and want to hear it again. When I wrote those words in late June there was no way to know that the campaign to defend democracy that was launched by President Biden’s speech that day would turn the “red wave” into a “pink ripple.”
Perhaps one of the biggest disappointments of the year for me, for the millions of children living in poverty, and for our effort to improve the social determinants of health was the success that Senators Joe Manchin and Kyrsten Sinema had in blocking President Biden’s Build Back Better proposed law. The original proposal was a straight-on push to enable families to rise out of poverty and to invest in the human infrastructure of our nation. We eventually got “Build Back Better Light” in the form of the Inflation Reduction Act of 2022, but when the child tax relief died at the end of 2021 with its substantial grants to families, millions of households and children slipped back into poverty. I wrote about childhood poverty as a factor in the social determinants of health several times during the year. I was inspired by “The Family Health Project,” Joe Knowles’ private experiment in universal basic income, but the letter where I most vigorously expressed my disgust with the failure to renew the child tax credit was written on September 30th. It was triggered by the publication of an article in the New York Times that showed how many children had been lifted out of poverty only to fall back into it when government programs were discontinued. I concluded the piece with an attempt to be analytical in a way that gave some oxygen to hope.
I know at least seven things that are true about the current state of poverty in America. First, no matter how much success has been recorded over the last twenty years we could have done more. Second, all of the programs that have helped could be vulnerable to sudden cancelation for political reasons as we experienced with the very effective pandemic child tax credit. Third, the combination of housing shortages, inflation, and the high cost of gas and heating fuels will push many families who have recently “escaped” poverty back into the economic stress from which they had enjoyed a brief escape. Fourth, poverty remains the most significant negative factor in our analysis of the social determinants of health. Fifth, poverty is a problem across all racial groups, but the percentage of white Americans in poverty is half of the percent of impoverished minorities while many impoverished white Americans continue to be politically aligned against their own best economic interests. Sixth, we will never see health equity as long as we tolerate economic inequities and poverty. Finally, we have the ability to eradicate poverty “as we have known it,” all we need is the will. To add an eighth thing that I hope is true, I believe that someday we will eliminate poverty, and when we do we will ask ourselves how we tolerated its presence as long as we did.
2022 was a year filled with more uncertainty than most. Uncertainty arose from turbulent politics, from Trump’s continuing lie, from the war in Ukraine, from our deep political divisions, from COVID, and from personal and shared concerns about the threat to economic security as inflation seemed to be running away. The uncertainty with the greatest long-term implication other than global warming was the uncertainty about the health of our democracy. As important as the physical health of individuals is, a healthy nation with healthcare equality seems incompatible with illiberalism or a kleptocracy and we had elements of both threatening our democracy. The election in November was a huge temporary relief, and a cause to hang on to hope. In retrospect, I believe that many many voters set aside inflation as an issue and were motivated by their concerns generated from the Dobbs decision, the findings of the January 6th House Committee, the efforts of President Trump to get MAGA sycophants elected, and the brave push back from President Biden in speeches that warned about the fragility of the democracy. There were inspiring grassroots efforts in many states to turn out enough voters to override the effect of the regressive election rules and gerrymandering by state legislatures in states where the legislature and governorships were controlled by Republicans intent on maintaining their minority control. The end result was a reprieve and a battle, not a war, won. My “homage” to the election and the commitment to democracy that it demonstrated was written on November 11. Near the end of the letter I wrote:
My hopes for an ever better and more equitable America are buoyed by the pluralistic collection of citizens who came out to show by their votes that they wanted to damp the red wave. In many places, it took a greater effort to vote than it should have thanks to decisions of conservative courts and the efforts of Republican-controlled state legislatures and governors trying to win culture wars by making it harder for their opponents to vote. It amazed me that there were more than three hundred candidates for office who were still willing to demonstrate their fealty to Trump. It is hard to believe that there are still some election losers like Doug Mastriano who are still modeling Trump’s illiberal behavior by refusing to accept that they lost. The threat to democracy has not completely passed, but we have moved from a hurricane of concern about a red wave to a doable cleanup task after the eye of the storm has passed. It is a joy to see that all we value was not washed away.
Looking back is a lot more certain than looking forward. My guess is that even if all goes well this year and next, we will see our political divisions persist in ways that make much progress on healthcare equity and the social determinants of health dependent on executive actions and the work of concerned private individuals and institutions. I was delighted to read in this week’s New England Journal a “Perspectives” article from authors at the Harvard School of Public Health and the Beth Isreal Deaconess Medical Center entitled “Hospitals and Health Equity — Translating Measurement into Action.” The article references the fact that hospital systems have done little about health equity, but that the Biden administration through its leverage associated with CMS and Medicare is introducing the requirement to measure the needs of patients served. I guess we must measure a problem before we address it. The authors write:
The U.S. health care system ranks last on measures of equity among similar high-income countries. Although policymakers and payers have increasingly looked to hospitals to help reduce inequities, there’s been less focus on their role in addressing health-related social needs (HRSNs). Such needs are related to food insecurity, housing instability, a lack of access to transportation, an inability to afford utility bills, and exposure to interpersonal violence, among other concerns. Despite the strong links between HRSNs and health outcomes, recent evidence suggests that only one-quarter of U.S. hospitals screen for these five needs.
To address this issue, the Centers for Medicare and Medicaid Services (CMS) recently announced the adoption of three health-equity measures in the Hospital Inpatient Quality Reporting program.
Progress is slow, but I hope that similar efforts will continue. I have a friend whom I saw over the holidays who is in a leadership position at HHS. He assures me that HHS and CMS will do as much as their executive powers allow over the remaining two years of the Biden administration to advance health equity. I am hopeful that what he assures me will happen does indeed come to pass.
I am sure that efforts to make progress toward health equity will continue in organizations like the Robert Wood Jonson Foundation and the Commonwealth Fund, but like the government, they must apply influence and money to a stressed system of care and progress will be slow. It is ironic that many delivery systems suggest in their mission statements that they are dedicated to improvements in healthcare, but something is lost between their mission statements and their strategic plans, and even more is lost between strategic plans and measured outcomes. I think that it will take divine intervention plus CMS to change that reality in 2023.
Much of what happens this year will be a function of four things 1) the war in Ukraine, 2) the decision the Justice Department and the Attorneys General in Georgia and New York make about prosecuting Donald Trump for his many crimes, 3) the continuing struggle to control COVID, and 4) actions taken by our Supreme Court. I am concerned about the uncertainties at our borders and how the conservative majority on the Supreme Court has once again gotten the issue wrong as identified in a recent editorial in The Washington Post. They write:
Republicans and Democrats broadly agree that the nation’s asylum and immigration systems are broken. Both are aware that Congress, paralyzed by partisanship, has failed to provide a fix. But that failure cannot be a pretext for the democracy hack that GOP elected officials from 19 states have undertaken in asking the Supreme Court to retain a Trump-era anti-covid public health measure that has been repurposed as an immigration enforcement tool along the southern border. And by siding with those officials, at least temporarily, the conservative majority on the high court has made a mockery of the law.
I am not an authority on issues of immigration, but I am moved by the footage I see of the suffering at our borders. I believe that we have both the wealth and the need for an expanded labor force to make it advantageous for us to offer many many more families and individuals a chance to be Americans. To incorporate millions more into our society will require changes to child care, housing, food security, education, and healthcare infrastructure that would be a step forward for all of us. Do I expect that we will make progress on immigration and infrastructure issues in 2023? No, but I hope I am wrong.
It is pointless for me to try to anticipate more about what lies ahead in 2023. I am making my list of resolutions for personal growth, metaphorically buckling my seat belt, putting on a crash helmet, saying a prayer, and crossing my fingers as I wish us all luck in the coming 12 months! It is still true that in an uncertain world it’s good to have a plan and direction, but it is even better when those aspirations are coupled with grace and good fortune!
Getting Into Winter
We enjoyed a quiet Christmas with very cold weather, about a foot of snow, and a very frozen lake. Today’s header was taken while walking with my youngest son and his wife in 15-degree weather in preparation for our big Christmas dinner. It shows a lot of ice, and if you look closely you can see Mount Sunapee and its ski trails on the horizon under the “ngs” of “Musings,
We started the week before Christmas with almost two feet of snow which was a good thing because we still had plenty of snow after we got several inches of warm rain (50 degrees) and heavy winds (over 40 MPH) two days before Christmas. The other thing about the rain was that it created areas on the frozen lake that had no snow and were like skating rinks. By Monday skaters were taking advantage of that clear ice as you can see below.
I keep telling myself that I need to learn to skate. If you grew up where most of the ice was in a tea glass you probably did not learn how to skate or ski. I can remember one Christmas we had in Texas when it was 95 degrees on Christmas Eve which made it a tough night for Rudolph and Santa. As an adult in New England, I have tried to ski and skate. I got off to a very slow start with skiing. I lost my right ACL at Stow on an icy beginner’s trail in 1981. Eventually, wearing a knee brace, I was able to negotiate most intermediate trails with very wide looping arcs across the fall line, but I gave that up a few years ago. Who wants to ski with a guy who uses that sort of technique? My skating attempts did not lead to anything more than a few bruises, but that was because I gave up early.
My neighbors who are obviously more comfortable on skates than I am took advantage of the natural ice rink in my “backyard.” I was envious of their grace and skill. Now I am wondering if there is still a chance for me to learn to skate. I was inspired especially by one woman who literally skated for miles as again and again, she skated around the perimeter of the clear ice that extended out several hundred yards toward the center of the lake in a gently curving path. I noticed that she had those extra-long nordic blades on her skates. I frequently pass the store where they are sold. I read that ‘Nordic skates” can be strapped onto regular boots. That sounds good because one of the things I found difficult during my attempts to skate was the way the skates pinched my feet. Maybe I should add Nordic or “tour” skating without injury to my goals for 2023.
Have a safe and happy New Year’s celebration on the way to a great 2023!
Be well,
Gene
