May 29, 2026
Dear Interested Readers
Looking Past Policy Failures To Human Nature
My letter to you two weeks ago revealed that my wife’s PCP had retired and that the practice was unable to provide her with a new PCP. She had originally been assigned to an experienced nurse practitioner as her new PCP, but now that woman was leaving the practice as well, and no other clinician there had an open panel. I saw that very personal event involving someone close to me as a specific example of how the issues that challenge American healthcare affect even those of us who are moderately affluent and think we have reliable access to the care we need, albeit at some expense. In the last paragraph of the May 15 letter, I laid out my writing agenda for the next few weeks when I wrote:
Perhaps, and with some hope, AI may be what rescues us. Over the next few weeks, I plan to use these notes to further explore how we got to this moment, concerns that I have had since at least the mid-80s, and then review potential solutions. I welcome any ideas that you might send me directly by email at drgenelindsey@gmail.com or through the comment window of this website.
Last week’s letter was about the failed policy decisions of the seventies, eighties, and nineties, based primarily on flawed projections that created the erroneous fear of a near future with a surplus of clinicians. That miss calculation, coupled with the AMA’s desire to diminish future competition that its members might face if a glut of doctors did develop, and an increasing disdain of the government by conservatives who saw that reducing government support to healthcare, especially government support to patient access, might decrease their taxes, led to the growing shortage of professionals we have now. Obviously, no one decision or event created our current access disaster. Knowing how, by accident or intent, we created our healthcare workforce disaster may help resolve a huge problem that will only get worse if not addressed effectively. Until that happens, my wife and millions of others who, like her, had always assumed the stability of their personal care, will be at some risk.
I listened to a podcast conversation this week that indirectly expanded the reasons for our current healthcare dilemma from just politics and poor policy to a fundamental change in our national psyche. Ezra Klein has been examining the failures of progressive politics, the recent decline in the appeal of liberal thought, and the emergence over the last decade and a half, since Barack Obama’s last election, of a growing illiberal sentiment among an increasing number of Americans, as exemplified by the MAGA faithful. The shift away from liberal thought and progressive, inclusive ideas is not limited to America. Illiberalism, intolerance, a shift toward the far right, and authoritarian leadership have emerged in many places around the world. The recent elections in Hungary that ousted Viktor Orbán offer some hope that the trend may be losing momentum, but there is no doubt that the democratic ideals and the rule of law that America has fostered internationally since World War II remain at risk.
The big questions are what happened to create this moment, and what we, who see this trend as threatening, can do to reverse our country’s slide toward autocracy. We are in a time of inherent duality, with the division between who is in and who is out. The cruelties we currently observe at home and abroad are fostered when we favor power over cooperation. If these ideas resonate with you, or more importantly, frighten you, I suggest that you invest some time reading the transcript or listening to the conversation between Klein and his guest, the historian and prolific Israeli writer, Yuval Noah Harari.
Their conversation is not about healthcare per se, but I do believe it adds to our understanding of how our healthcare system got to where it is now. What caused us to move toward an emphasis on the individual experience that favors fewer citizens, and away from collective concerns that benefit us all? This shift has already hurt many and will ultimately fail us all because, by nature and reality, the success and advancement of our species have been functions of our ability to cooperate and defer some individual concerns to collective interests.
You can read on to see the parts of the Klein-Harari conversation that I think are necessary to consider, if we are ever to repair the damage that has been done to our healthcare and return to the path of progress toward universal access to care, robust systems of public health, effective spport of medical education, and continuing advancements in medical research that will contribute to our collective health, wealth, and happiness. In the introduction to the conversation, Klein says/writes:
If you look across his mega-best-selling books, like “Sapiens” and “Homo Deus,” Yuval Noah Harari really has one major topic: cooperation.
The ability to cooperate across scale and time is the fundamental engine of human progress. It’s the way we go from being creatures that absolutely cannot beat a bear or a lion in a fight to being able to create and command the societies we have now.
I think today there’s something interestingly challenging about Harari’s work.
We live in this moment of Trumpism and right-wing populism. One of the messages of these movements is that this emphasis on cooperation, on positive-sum relationships, is a lie — that humanity, that society, is driven not so much by these soft questions of cooperation as it is by hierarchy and dominance.
This is not a new concept. As I mentioned earlier, dualism defines who is “in” and who is “out.” Dualism is a defining element of illiberal thought, and its counter concept is the movement toward diversity, equality, and inclusion. There has always been a tension between “power,” the I win, you lose aspect of transactional existence, and the inclusive ideas most recently encapsulated for me in the concepts of “non-zero” strategies that are supported by the basics of the movement toward Diversity, Equality, and Inclusion (DEI), which are logically antithetical to the MAGA movement.
Donald Trump was not the inventor of this conflict. It has been a collective concern that predates our ability to write and record history. One might argue that at least four millennia of Jewish thought and two thousand years of Christianity have this conflict at their core. I have spent some time, probably more than many, trying to make sense of the wisdom in scripture. To my ear, and to the ears of many biblical scholars who are not part of Trump’s collection of evangelical sycophants, all of those ancient stories and axioms in the “wisdom books” of the Hebrew scriptures describe the conflict between an attraction to power through “Empire” and the sustaining wisdom of “Shalom,” which leads to collective peace and flourishing.
As we move into the Gospels, it is impossible to find any words ascribed to the itinerant rabbi known as Jesus that favor the human quest for “Empire.” His message is one of Diversity, Equity, and Inclusion. As John Fugelsang so humorously depicts in his recent book, Separation of Church and Hate: a sane person’s guide to taking back the bible from fundamentalists, fascists, and flock-fleecing frauds,” Jesus never condemns abortion or homosexuality, both of which existed in his day, but does teach tolerance, acceptance of the foreigner, the inclusion of women, and a general philosophy of cooperation and the search for peace.
If you want scripture that can be used for a flimsy argument for gay bashing and male dominance, you need to read past the Gospels and into the letters of Paul. Paul was inconsistent, or more precisely, site-specific, in his advice to the churches to which he wrote. By the way, when he wrote, he did not know that he was writing what would become church canon, and the Gospels had not yet been written. It is relatively easy to find quotes and create arguments that put him on both sides of almost any of our contemporary quandaries. Nevertheless, it is good to remember that he wrote in Galatians 3:28:
There is neither Jew nor Greek, there is neither bond nor free, there is neither male nor female; for ye are all one in Christ Jesus. (KJV)
At the time, there was a deep division in Galatia between Christians with different backgrounds, social stations, and genders. Paul was expressing the need for acceptance and equality between Jews and Gentiles, the free and the enslaved, and women and men. Paul’s attempt to calm the waters of this dispute suggests to me that even he felt that Christianity that is true to its origins in the wisdom of the Hebrew scriptures, and the manifestation and example of that wisdom in the life of an itinerant rabbi that opened the possibility of that wisdom to everyone, should be a philosophy that supports the pursuit of Diversity, Equity, and Inclusion across all aspects of our collective experience, including healthcare in our troubled times.
Despite the horrors of war and the concept of a vengeful God depicted at times in the Hebrew scriptures, the underlying story is a call for human cooperation and generosity. I am not aware of any story or event in the New Testament that advocates that we pursue our interests by exercising force against others at home or abroad. We are advised to love our neighbors as ourselves, to “go the extra mile,” and to turn the other cheek in the face of another blow. These commands were not conventional wisdom, then or now, but do offer a path toward mutual benefit.
Jesus delivered the parable of the “Good Samaritan” in response to the question, “Who is my neighbor?” The antipathy between Jews and Samaritans was equal to, if not greater than, the current distrust between Israelis and Palestinians. Your enemy is your neighbor on this small planet, and we are learning once again in real time that to seek harm for your neighbor can result in your own harm. In the conversation, Harari notes that in the diaspora after the Romans destroyed the Temple in Jerusalem in 70 CE, Jews turned away from attempts at defense and dominance and focused on community and intellectual development. Harari supports the need for Israel to defend itself now, but is concerned about what is being neglected or lost in the continuous conflict.
As he continues his introduction, Klein writes/says about the current position of the MAGA movement:
It’s about winning the transaction, about coming out ahead in the conflict or in the trade. The niceties of liberalism? A lie. Humanity really runs on power — and to forget that is to forget the engine of our progress.
Klein implies, and the conversation goes on to highlight, that reliance on raw power has never led to sustained progress, and the pursuit of illiberalism almost always disintegrates into failure and human misery. Klein emphasizes this point and kicks off the conversation by playing a recent quote from Steven Miller, who was interviewed by Jake Tapper, and then asks Harari what he thinks of it. Millar had said:
You can talk all you want about international niceties and everything else, but we live in a world — in the real world, Jake — that is governed by strength, that is governed by force, that is governed by power.
These are the iron laws of the world that have existed since the beginning of time.
When Klein asks Harari what he thinks of Miller’s point of view, Harari replies:
That the whole of the history of philosophy and spirituality is an argument with exactly that point of view. That the only reality is power. The only reality is force. And from the viewpoint of a historian, it’s clear that this is not the case.
If the only human reality were brute force, we would still be living in tiny hunter-gatherer bands in the African savanna. Because the whole of human history is about how you get more people to cooperate and to trust each other, and you cannot do that only with brute force.
Before you counter with the argument that both sides in our current political dilemma are focused on acquiring and using power to advance their points of view, let me quote Harari from much further into the interview. He describes how the beginnings of some international recognition of the limits of power resulted from the worldwide conflicts of the first half of the twentieth century. Until recently, one benefit of the two World Wars was that the raw use of power had become somewhat taboo. Since the mid-century, there have been more attempts at international cooperation through entities such as the UN, NATO, and the World Bank. What has existed for the last 80 years, but is now at risk, is cooperation for mutual betterment among democracies. He uses data to demonstare how remarkable the last 80 years have been:
For most of history, a lot of the budget of every kingdom, empire, republic, city state was invested or wasted on soldiers and fortresses and warships and things like that and nobody felt safe.
One of the miracles of the international systems of recent decades — and this is not about writing pacifist poetry, it’s about government budgets: You look at the budgets, and you see that on average, in the early 21st century, about 6 to 7 percent of the government budget went to defense, to the military, compared with 10 percent on average that went to health care.
It’s the first time in history that humanity spent more on health care than on defense. They felt more secure than in any previous time in history because there was this taboo on invading and conquering other countries by force.
If we now break this taboo, it will force everybody to arm themselves to the teeth at the expense of health care, education, welfare and so forth — and nobody will feel safer as a result.
The move toward more for defense and less for social welfare programs is exactly what we are seeing. Trump is moving trillions of dollars from healthcare, education, a vast array of social services, and protection of the environment to augment defense spending and gain favor through huge tax reductions and benefits delivered to the rich in his belligerent kleptocracy. He fools many by offering laughably small tokens to the rest of us, whether or not we have bought the con.
Harari offers insight into the wisdom of cooperation and a sense of universal humanity and acceptance, rather than relying on power to force one’s will.
There are some small differences in how we look and in our languages and religions and so forth, but essentially, we are the same species. We all have the same biological needs. We all have roughly the same psychological needs, at least the deep ones: to be loved, to be recognized and so forth.
We have shared interests, and if we recognize these shared characteristics and interests, in many cases, it just makes more sense to cooperate than to compete and to fight. And by cooperating, we can build a world that will be better for everybody. This was the basic liberal story.
Obviously, it is not a big leap from a statement of that reality to a healthcare foundation that continually asks how we work together for everyone’s benefit. My health is likely to improve if yours does. In a complex world where there are frequent intersections between poverty, violence, use of drugs, poor educational opportunities, poor access to nutritional sources, and compromised access to work, transportation, and housing, these negative manifestations of the social determinants of health will ultimately spill over from our most disadvantaged neighbors to impact everyone.
Klein and Harari move on to make a point about liberalism that I had not yet considered. Liberalism, unlike various forms of authoritarian control or most religions, does not envision the emergence of a perfect state. It accepts that there won’t be a moment of sustained greatness. There will always be work to do to maintain what has been gained. That makes sense even at the level of the Second Law of Thermodynamics, which states that maintaining order always requires the continued application of energy.
Because of human nature and events beyond ultimate control, the pursuit of “better” will always be a work in progress. Whereas fascism, communism, and even Christian Nationalism are all focused on achieving ultimate victory. Liberalism does not. It recognizes that there will always be controversy and focuses on mechanisms to contain it through the community’s applied energy, while upholding commonly accepted norms, constitutions, and pacts that support compromise and diplomacy, all grounded in the rule of law. Harari sums up the point:
Liberalism does not believe it [Ultimate victory]. There is no redemption, at least not on Earth. There will always be problems and tensions and conflicts, and the question is: How do we live with them?
This is also why liberalism invests a lot in building what I think is the most important thing in every large-scale human system, which is a self-correcting mechanism.
Putting off any hope of perfection until the hereafter seems to rhym with my sense of history and personal experience. Harari explains how liberalism manages the disappointment I alluded to earlier.
Liberalism starts with the assumption that it’s just human beings trying to do the best we can, and there will be mistakes, there will be errors, so we need strong self-correcting mechanisms.
The most famous mechanism is, of course, elections. Every four years or five years or whatever, the people can say: Hey, we made a mistake last time. Let’s try something else this time.
All these very complicated systems of checks and balances and independent courts and freedom of the press and all these are just a complicated way to ensure that a country has a robust self-correcting mechanism.
It’s an almost two-hour-long conversation. The discussion of the decline of liberalism and our current struggle with an illiberal force, which I have tried to present as a movement that contributes to our current loss of ground in healthcare, consumed most of the first hour. The second hour was about how some of the difficulties of our current moment have arisen from social media algorithms, and how this evolution could be accelerated as AI becomes increasingly personal and its proponents seek to do what corporations have achieved: obtain legal “personhood” for AI.
I have just finished Robert Wachter’s A Giant Leap: How AI Is Transforming Healthcare and What That Means for Our Future. Dr. Wachter gives us an excellent presentation on the history and current state of AI in healthcare, plus a generally positive outlook for the future, which he somewhat balances with concerns that can be mitigated with forethought. I had been interested in reading the book since AI has become such a hot topic and a possible path out of the morass of healthcare’s current problems.
I was impressed by The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, which Wachter had published in 2017 as the story of Health IT and the rapid introduction of electronic medical records following the billions that the Obama administration had invested in it as part of the recovery from the 2007-8 recession. As I stated at the end of my May 15th letter, the destination of the discussion that was initiated by my wife’s difficulties getting a new PCP was to eventually present AI as the possible answer, or partial answer, to many of the workforce and access issues that are so disabling to us now, but first I wanted to elaborate on how we got to where we are. I also wanted to briefly mention what my colleagues and I were doing while the current sorry state was evolving.
Looking back, it is clear to me that in the early 80s and even into the late 90s, up to the resistance that the passage of the ACA engendered, most of my practice partners and I were somewhat deaf to the loud signals of danger from the outside world. While the false idea of a future doctor glut was evolving, we were not paying much attention to why that might not be right. Even though there was plenty of literature about how our society might be changing, think of Robert Putnam’s book, Bowling Alone: The Collapse and Revival of American Community. Putnam’s book was more about what had already happened than a prediction. We frequently don’t understand the moment, much less accurately know where we are headed. It is absolutely true that, over more than two decades as the process became a possibility, we did not forecast the massive defunding of healthcare we are now experiencing.
In my practice, we were focused on gaining healthcare “nirvana” through the intelligent application of quality improvement efforts. Our efforts were often clinician- and patient-centered and at odds with a management we thought had lost its way and become overly focused on “market issues.” We favored a focus on internal “practice improvement.” Our physicians invested great effort in managing the tension between individual practice autonomy and compliance with “best practices.” We were involved in the evolution and implementation of the automated medical record with management. Management was trying to get physicians to join them in response to competitors in our local environment, and together we were evolving internal mechanisms to improve quality and safety.
Those were laudable and understandable activities, but ultimately neither physicians nor our management, and I was both, adequately recognized the full extent of the threats in our external environment. We were naively distant from many of the social and political challenges that confront us today. Many physicians considered social issues and political concerns to be the responsibility of others. Managing a practice and attempting to improve the quality and efficiency of what we were doing seemed laudable, and our efforts seemed much more meritorious than what we saw many other practices doing.
We were somewhat self-righteous, looking at the world through blinders that obscured much of what was headed our way, with the potential to cancel years of effort. It took the near-disasters of the 2007-08 recession to awaken me to the real external threats we could not control, and that required us to devise strategies to survive. Transferring that insight to tired physicians proved to be beyond my capabilities.
At the level of national politics, a more prospective vision of the future might have revealed much earlier the threat posed by the emergence of individual concerns stemming from libertarian personal “freedom” policies and biases against public welfare programs that depended on taxes. More attention could have been given to the growing gulf between “establishment” concerns and populism, which would lead to the deep political divides that currently undermine our health system.
In a weak defense of what we knew and where our concerns lay, when I retired at the end of 2013, President Obama was a little less than a year into his second term, and ideas that would become foundational to the MAGA movement were still a few years from germination into a populist movement that would signal the beginning of a decade of democratic erosion and damage to the infrastructure of our system of care, medical education, and research.
Maybe there are other issues that you might believe pushed us to where we are. For instance, we have had some tone deaf utterances from liberal leaders that were intended to wake their sleeping supporters but did more to deepen the abyss between them and those in the populist movement who have always felt like they were not respected. Some on the left have been so single-issue-oriented that they have discounted the damage they are doing to broader progressive perspectives. Progressives have always had trouble coordinating our efforts. Even FDR could not get universal acceptance from his own party for his “New DEAL.” I will remind you once again of Will Rogers’s quote about the psyche of Democrats. He said, “I am not a member of an organized political party; I am a Democrat.”
Some introspection and perhaps behavior modification on both sides of the political divide will be necessary before there is a lasting, or at least better-negotiated, agenda for better healthcare. One thing is for sure: lasting progress requires a more bipartisan approach than either side can muster and maintain through several election cycles. If your idea is that progressives will somehow take back the government through the 2026 and 2028 elections and then force changes into existence that will permanently improve healthcare, then you are not a good student of our American experience. We have lived through cycles of change forced by one side, which are then reversed when the opposition regains control of government somewhere in the near future. As Pete Seeger’s anthem “Where Have All the Flowers Gone” asks, “Oh, when will [we] ever learn?”
Looking ahead, before I launch into the question of whether AI can save healthcare, I will return next week to Paul Krugman’s three-part discussion of healthcare as an important issue in the coming elections. Part three was published this week, and I am eager to share his thoughts with you.
At Last, Into The Water, For Awhile
After a washout weekend, Memorial Day afternoon here in New Hampshire was pretty nice. By Tuesday, the daytime temperature was in the mid-to-high seventies. The header on this note shows just how pretty it was on Tuesday. If you look closely, you can see a herd of white cows at the far end of the pasture, a bit of Lake Sunapee, and Mount Sunapee in the distance. The view is from the top of Burpee Hill, about three-quarters of a mile into one of my favorite walks.
By Tuesday, the temperature of the water off my dock was in the low to mid sixties. I decided that it was time to don my wetsuit and begin my summertime swims. That lasted two days. Yesterday, a chilly breeze blew in, putting whitecaps on the lake and dampening my enthusiasm. It was a good day to limit my exercise to a vigorous walk. We are expecting a huge 24-hour downpour to begin about the time this letter goes out to you.
Looking ahead to the next few days, it seems we will be on the cold side of the jet stream. Our air will be blowing down from Canada and Hudson Bay rather than coming North from the Gulf of Mexico or the arid West. I hope that you will be on the warm side of the jet stream this weekend, but no matter what is blowing your way, I hope that you can get a little rest and exercise. In August, we will probably look back on this time and wish we had a few cool days, like the ones we enjoyed at the end of May.
Be well,
Gene
