January 19, 2024
Dear Interested Readers,
An Interesting Article In My Local Newspaper
Small-town newspapers are a dying public resource. A recent report from the PBS News Hour begins:
Over the past few decades, more than 2,000 newspapers across the country have closed, leaving many communities without a reliable source of local information. Researchers say this crisis in journalism, driven by changes in technology, is fueling the country’s political divisions.
I enjoy my area paper, The Valley News. I hope that it survives. The Valley News is published in West Lebanon, New Hampshire, but it covers statewide politics for Vermont and New Hampshire as well as news/events/sports/obits in towns in Vermont and New Hampshire in the “Connecticut River Valley.” I get an online copy, and weather permitting, most days I get one delivered to the box at the junction of my drive and our road. I am a man of routine, and one thing I enjoy is walking up my drive to get the paper.
I love thumbing through the pages of the paper. One of my favorite features is an extended obituary that appears about once a week. Someone from the area who has recently died is featured in a long article that usually is accompanied by interesting pictures from their life. The person is often a tradesman, small business person, teacher, or someone known for their craft work like quilting or long years of volunteer work. It’s about real people who were part of the fabric of their community. Usually, the person has been gone for more than a month so it is not the same as a typical obituary. It is a fond remembrance and recognition of a life well lived in the service of others.
I also love the daily obits. My game is to see how many were older and how many were younger than 78, my age. These days, 78 is a little above the life expectancy in America, but close to what it was in 2019 before it began to fall during the COVID pandemic. In other advanced countries life expectancy is rebounding, but not here.
I am moved when I read about a young man in his late 20s who died unexpectedly at home. The obits often say what a great person the deceased was and how they loved the outdoors and sports. Some have young families. At times I can discern the grief of a family who is reporting the death of someone who died of a disease of dispair. I respect the families that just come out and ask that contributions be made to some organization that helps people with substance abuse or mental illnesses. I am always happy to read about a “centenarian.” There are many in their mid to late 90s. The older folks encourage me. I feel greatly for those who died of cancer or a cardiac event in their forties or fifties. I wonder if they got the care they needed, or if it was too late for them to recover when they finally got care. The obits almost always leave me wondering about the effectiveness of the medical care we provide to one another.
After the obits, I hit the editorials. One thing I like is that the paper has some remarkable local columnists. Some teach at Dartmouth. One is a regular on New Hampshire Public Television. In a purple state, my paper leans toward blue. Perhaps that is because of its proximity to Dartmouth. To the output of local talent, they usually add an editorial column from The Washington Post, The Baltimore Sun, The LA Times, Bloomberg News, or some other paper from afar. After scanning the editorials and reading the ones that interest me, I move on to the sports pages and then finish with the comics that include Doonesbury, Peanuts, Beatle Bailey, and others. I can relate to Mr. Wilson in Dennis the Menace and Dagwood in Blondie.
My sense is that even my paper is vulnerable to decline as a sign of the times. That impression was reinforced at the beginning of the month when the paper moved from publishing daily except for Christmas Day to six editions a week. For some time now the Monday paper has been “skimpy” to say the least since on Monday it has no editorials. Now they have combined Saturday and Sunday into one “weekend edition” that comes out on Saturday. It makes me wonder if this is the beginning or the middle of the end.
My favorite part of the Sunday paper has always been the “Focus” section. I have occasionally passed on things I learned there to you. I am happy that “Focus” did survive in the new “weekend edition” and this weekend, as you can see in the picture below, it had a huge article, “America has a life expectancy crisis. But it’s not a political priority,” that had been previously published in The Washington Post in late December.
If you are a regular reader of this letter, you know that several times I have registered the same complaint about how the politicians are ignoring healthcare during the run-up to the 2024 election season that was officially launched last Monday with the Iowa caucuses. This week, the action moves to New Hampshire and then on to South Carolina. Many political pundits predict that everything will be settled by “Super Tuesday” in early March. After that, it will probably be up to the courts or an act of God to give us candidates for president who were not on the ballot in 2020,
When New Hampshire votes next Tuesday I will be “writing in” the name of Joe Biden. Why Joe Biden is not on the ballot is a long story. Many Democrats here will exercise the option offered by our state of temporarily switching their party affiliation to Republican or Independent so that they can vote against Trump in the Republican primary. That is not my choice. I will spare you my reasoning on that one and get back to the concern that healthcare is not on the ballot or even on the websites of most of the candidates. I have confirmed this by visiting the websites of Nikki Haley, Ron DeSantis, and Joe Biden. All of these sites are primarily asking you to donate to their campaign without telling you much about their policy positions. We have two candidates on the Democratic ballot who have addressed healthcare, Marianne Williamson who does favor a single-payer system of care, and Congressman Dean Phillips of Minnesota who may be the richest man in the House. He has said in his ads and his policy statement that he is an advocate for Medicare For All. He reports in his ads that because of privileges not available to everyone his teenaged daughter is a cancer survivor, and he wants everyone to have access to the care that saved her life. Ironically, Donald Trump does present his position on 15 issues. His last issue, issue Number 15, is entitled “Better Health Care Choices At A Lower Cost.” It reads:
President Donald J. Trump empowered American patients by greatly expanding healthcare choice, transparency, and affordability. He increased competition in the health insurance market, eliminated the Obamacare individual mandate, and signed Right to Try that gives terminally ill patients access to lifesaving cures. President Trump lowered drug prices for the first time in over 50 years and finalized the Most Favored Nation Rule to ensure that pharmaceutical companies offer the same discounts to the United States as they do to other nations. To save lives from the China virus, President Trump organized the production of the world’s largest supply of ventilators and the development of treatments and vaccines. He will stop all COVID mandates and restore medical freedom, end surprise medical billing, increase fairness through price transparency, and further reduce the cost of prescription drugs and health insurance premiums. President Trump will always protect Medicare, Social Security, and patients with pre-existing conditions.
As is true with many of our former president’s pronouncements, that statement contains some half-truths and a few inaccurate claims. As usual, there are no descriptions of policies or programs that give a thoughtful reader any confidence. His history of tens of thousands of fabrications and unfulfilled promises gives me no confidence that healthcare or life expectancy is likely to improve if Trump is elected. It’s interesting that in another Washington Post article from last November that compared the policy positions of all candidates, nothing was said about the healthcare position of any candidate.
Do concerns about abortion rights, gun violence, and the environment represent the healthcare issues for 2024? Those are important concerns and with a stretch, they are health or public health concerns. Abortion and reproductive rights do impact the health of individuals and families, but it is my concern that we are not making progress in either efforts to improve the broad concerns that we call the social determinants of health or in improving access and quality for everyone. Even covered individuals often don’t have adequate access to care without delay or difficulty. We are losing ground in the effort to achieve universal coverage. There are many Medicaid recipients losing coverage that they enjoyed during the peak of our COVID pandemic which could mean that we will have a growing number of people who have no access to care.
Inequality is a pervasive fact of life in America. It is a huge factor in life expectancy. It may surprise you that geography and politics are also factors in life expectancy. In another Washinton Post article published last fall, there is a tool that allows you to discover your own life expectancy as a function of your age, gender, and the state where you live. I invite you to try it out like I did. I entered 78, male, and New Hampshire, and discovered that my life expectancy is eight years, but if I lived in Japan I could expect ten years. If I entered 78, male, and Louisiana, Mississippi or Alabama my life expectancy dropped to six years. The best place to live in the USA if you are male and 78 is in Hawaii where you can expect nine more years. Women do better than men by about a year in most states. Interestingly, blue states do better in general than red states and the worst states for longevity are in the deep South. I would love to see the tool expanded to include economic status, education, and ethnicity.
The issue’s political dimensions are reflected in a survey of members of the Senate.
I am curious about the independents. We have three: Kyrsten Sinema of Arizona, Bernie Sanders of Vermont, and Angus King of Maine. I bet that the senator with no response or no comment is Kyrsten Sinema. I know where Bernie stands, and King has an excellent statement about his healthcare positions on his website. The author does comment on the relationship between political affiliation and concern about life expectancy.
There is a notable partisan split in how members of Congress view life expectancy and whether they say urgent action is needed. Just 11 of the Senate’s 49 Republicans told The Post they believed that declining life expectancy was a public health problem.
The lawmakers who portray the recent decline as a crisis are often Democrats from states with the highest life expectancy — such as Massachusetts (79 years in 2020, according to federal data) and Vermont (78.8 years). Meanwhile, GOP lawmakers representing some of the states with the lowest life expectancy — Mississippi (71.9 years), West Virginia (72.8 years) and Kentucky (73.5 years) — declined to comment or did not respond to repeated questions about whether the issue represents a public health problem.
One of the problems going forward is a lack of consensus about the reasons behind our declining life expectancy. There are different opinions even between concerned politicians of the same party. Bernie Sanders is quoted:
Sanders has repeatedly called for sweeping reforms, insisting in an interview that “a failed health-care system is tied into a corrupt political system dominated by enormously powerful corporate interests.”
Senators Chris Murphy of Connecticut and Sheldon Whitehouse of Rhode Island see it differently. The author, Dan Diamond writes:
Even Democrats in neighboring states offered significantly different diagnoses. In the eyes of Sen. Sheldon Whitehouse (D-R.I.), the No. 1 cause of America’s life expectancy problem is clear: broken payment incentives for doctors and hospitals. But Sen. Chris Murphy (D-Conn.) traced the life expectancy decline to loneliness. “Americans are just much less physically and spiritually healthy than they have been in a long time,” said Murphy, who has proposed a bill to create a White House office of social connection.
One thing the article establishes is that life expectancy is a “many-headed hydra of a problem.” The bias of the Post and the author corresponds with what I think is a large part of the problem. Americans do not have equality in their access to care, especially for the management of chronic diseases. Diamond writes:
Ten senators singled out the burden of chronic disease, echoing The Post’s own review, which found that among people younger than 65, chronic illness erases more than twice as many years of life as all the overdoses, homicides, suicides and car accidents combined.
I hope that as the drama of the 2024 election progresses some miracle occurs and we discover that the health of the nation is as big a problem as our Southern border or the cost of gasoline. If that miracle were to occur, I am sure I would read about it in The Valley News.
The Impact of the Quality Movement On Me
I described the Blue Cross “LEAD” initiative in last week’s notes. In retrospect, there was no activity in the first two years of my tenure as CEO that was more influential in the further refinement of my medical moral sensibilities. The projects that were done by the participating organizations, the conversations that I had with the CEOs of the other participants, the speakers that we had from leading organizations around the country, plus the business theory and expertise of the Truepoint consultants were all remarkable gifts to someone who was learning on the fly. What I learned helped me to put the pieces of what might be possible into a coherent vision that I believed was within our capacity to accomplish.
I should add that there was an influential book that I was exposed to early on that along with Crossing the Quality Chasm and To Err is Human was foundational in helping us develop our organizational objectives. The book was Charles Kenney’s historical review of the quality movement in healthcare, The Best Practice: How The New Quality Movement Is Transforming Medicine, published in 2008. Click here for a PDF summary of the book.
All of these books were written with the same theme that Dr. Ebert had articulated in the mid-sixties which was that to deliver better care we needed to fundamentally redesign the “operating system” and finance of care to deliver better outcomes and improve the health of the nation and individuals for a sustainable cost. The problems preventing better care were primarily systems issues that were complicated and compounded by our system of fee-for-service finance which generated practices that were directed more at maximizing income than improving the health of individuals and the community. Now from the perspective of another decade and a half of experience, I would add that political philosophy about what every citizen has a right to expect and long-standing biases also needed to change for anything like the Triple Aim to become a reality. I now believe that It will take the thoughtful and vigorous efforts of healthcare professionals committed to a long-term process of continuous improvement, plus a broad-based commitment to diversity, equity, and inclusion and a political majority focused on the social determinants of health to overcome the momentum of the status quo that continues to tolerate poor care at a high cost with suboptimal outcome and a declining life expectancy.
Kenney was a journalist and author of several books who had been a writer at the Boston Globe and was a consultant to Blue Cross of Massachusetts. It is not a surprise that Clive Killingsworth who was the CEO of Blue Cross in Massachusetts wrote the forward to the book that was entitled “Call to Action.” Near the end of the forward Killingsworth described the goals and desired outcomes of the effort to transform our system of medical care. He writes:
We should demand:
- A system with a goal of “zero preventable harm” for each and every patient
- All patients receive appropriate and evidence-based care, whether preventative or for acute or chronic conditions
- A system that eliminates racial and cultural disparities in access to and the delivery of, health care
- Those who deliver care are rewarded on the basis of objective performance measures related to the quality of clinical outcomes
- Patients receive what they need to make informed choices
- Health system leaders, especially trustees and board members of hospitals and health care companies, become strong and consistent advocates of quality on behalf of those they serve
- New technologies and treatments are evaluated and compared to existing alternatives prior to their adoption
- The public and health care providers are fully informed about opportunities for improving care
- Savings from a safer, more evidence-based, and cost-effective health care system are reinvested in a way that slows the spiraling cost of healthcare and improves the health of the community
The quality movement was not news to me. I was a colleague of Don Berwick when he began to issue the quality challenge in the eighties before leaving to found the IHI with others of a like mind. In the nineties, we had dabbled in the TQM movement. Both experiences and the history of resistance to HCHP had informed me of the reality that a “better idea” almost always meets resistance. Medicine has a two-thousand-year history of practitioner and institutional autonomy to overcome which makes it an uphill trudge for anyone who wants to promote transformational change. I was someone who felt that those we didn’t serve and the resources we wasted indicated that it was time for a transformational change. In the LEAD program and with the Turepoint Consultants I would have companions and teachers for the difficult journey. Every time we had a meeting I felt like I had been in communion with like-minded souls. My sense of what was “moral” in healthcare created a great sense of purpose and urgency within me.
A Week of Winter And Great Excitement In Anticipation of A New Grandson
The temperature has not risen above freezing since last Saturday. Much of the time the thermometer has read below twenty. Some nights it has been in the low teens. The lake has frozen solid and there have been a few skaters. One brave soul carries a sail and is windsurfing on his ice skates. I expect that this weekend there will be icehouses strategically located over the same spots where I know the fish are in the spring and summer.
How long will real winter last in the age of global warming? The long-range forecast is for a return of somewhat warmer weather with some more snow by midweek, but I have other things on my mind. We are expecting a new grandson very soon. His arrival is quite possible this weekend!
I am pretty sure that I will be able to tolerate the weather whether it is hot, wet, cold, or violent over whatever is left of my time on earth. What worries me and motivates me is my concern about the world that my children and grandchildren will experience. This new grandson is very likely to live well past the year 2100, and his children, my great-grandchildren will live well into the 22nd century. I wonder what they will think of the world they will inherit from us.
Be well,
Gene
