November 8, 2024

Dear Interested Readers,

 

Can You Believe It?

 

I am sorry that I can believe It. Perhaps, you share the same sense of dismay and concern for our country that has occupied much of the chatter in my mind since I turned off my TV around midnight following the election on Tuesday. I took the picture in today’s header as I hopefully, but anxiously, was heading with my wife into our local polling place to cast our votes to preserve democracy and continue progress toward a more hopeful future for the health of all Americans. By eleven o’clock on Tuesday night, it was clear that the “Blue Wall” of Pennsylvania, Michigan, and Wisconsin was going to crumble and the hope for healthcare improvements in the near future would be buried under the rubble of that wall. We went to bed unwilling to suffer through what we knew would be a very painful end to any hope for much progress toward the Triple Aim during the next four years. 

 

It was painful enough for many of us that Donald Trump recaptured the presidency, but that pain has been enhanced by the realization that Republicans have captured the Senate. Over the next few days, the pain will probably worsen while the currently undecided races in the West will be decided leaving the Republicans in control of the House. In the end, it looks like it will be a Republican “hat-trick” that will remove all but the filibuster to limit or slow Trump’s progress toward turning his agenda into law, at least until the mid-term elections in 2022.

 

One of our sons sent us the words of Robert Reich early on Wednesday morning. It helped a little bit. If you share my disappointment, I offer it to you for the little bit of help it may offer.  

 

The question that concerns me most in this note is not how a majority of Americans were duped into voting against their own best interest by a selfish, narcissistic, sex-offending, misogynistic, racist, lying convicted felon with autocratic tendencies, but what will happen to the health of the nation after it has made such a self-harming decision. I am not interested in doing an autopsy on what Kamala Harris did wrong. In retrospect, I think she did a pretty good job of presenting a better way forward for the country. The problem was that she couldn’t overcome the reality that many people can be duped by a candidate focused on enhancing their fears, or if they can’t enlarge their concerns beyond their self-interests. In all the commentary I have heard there is the 1992 refrain from James Carville, “It’s the economy, stupid!” If you read last week’s letter, you know that Carville’s abandonment of his philosophy this year gave me a little temporary relief from my pre-election apprehensions and worries.

 

The lead article of the New York Times on Wednesday, the “morning after,” was entitled “Donald Trump Returns to Power, Ushering in New Era of Uncertainty: He played on fears of immigrants and economic worries to defeat Vice President Kamala Harris. His victory signaled the advent of isolationism, sweeping tariffs, and score settling.”   The authors of the article, Shane Goldmacher and Lisa Lerer, say a lot in a few words in the first few paragraphs of their article:

 

Donald J. Trump rode a promise to smash the American status quo to win the presidency for a second time on Wednesday, surviving a criminal conviction, indictments, an assassin’s bullet, accusations of authoritarianism and an unprecedented switch of his opponent to complete a remarkable return to power.

Mr. Trump’s victory caps the astonishing political comeback of a man who was charged with plotting to overturn the last election but who tapped into frustrations and fears about the economy and illegal immigration to defeat Vice President Kamala Harris.

His defiant plans to upend the country’s political system held appeal to tens of millions of voters who feared that the American dream was drifting further from reach and who turned to Mr. Trump as a battering ram against the ruling establishment and the expert class of elites.

In a deeply divided nation, voters embraced Mr. Trump’s pledge to seal the southern border by almost any means, to revive the economy with 19th-century-style tariffs that would restore American manufacturing and to lead a retreat from international entanglements and global conflict…

 

Over the last few years, I have shifted the focus of this letter from a granular view of medical management and medical practice toward attention to the Social Determinants of Health, the Structural Determinants of Health, and the Political Determinants of Health, plus the issues of public health in the effort to expand access, lower out of pocket costs of care and medications, and increase healthcare equity which are all issues in the pursuit of the Triple Aim. I will continue to write about those concerns. I predict that the progress made in the direction of the Triple Aim will be vulnerable for at least four years into the future as we learn more about President-elect Trump’s “concepts of a plan” for healthcare. 

 

Early on Wednesday morning, I read a quickly written analysis in the KFF (Kaiser Family Foundation) Health News of the healthcare implications of Trump’s victory. The article was written by Stephanie Armour, and was entitled “Trump’s White House Return Poised To Tangle Health Care Safety Net.” Ms. Armour begins by telling us what we feared:

 

Former President Donald Trump’s election victory and looming return to the White House will likely bring changes that scale back the nation’s public health insurance programs — increasing the uninsured rate, while imposing new barriers to abortion and other reproductive care.

The reverberations will be felt far beyond Washington, D.C., and could include an erosion of the Affordable Care Act’s consumer protections, the imposition of work requirements in Medicaid and funding cuts to the safety net insurance, and challenges to federal agencies that safeguard public health. Abortion restrictions may tighten nationwide with a possible effort to restrict the mailing of abortion medications.

And with the elevation of vaccine skeptic Robert F. Kennedy Jr. to Trump’s inner circle of advisers, public health interventions with rigorous scientific backing — whether fluoridating public water supplies or inoculating children — could come under fire.

 

Ms. Armour confirms the concern that I also presented in last week’s letter that Robert F. Kennedy, Jr. would be given a position in the Trump administration that would undermine the function of HHS, the FDA, the CDC, and the NIH.with his antiscientific views on fluoridation of water and vaccines. Armour writes:

 

Trump’s victory will give a far broader platform to skeptics and critics of federal health programs and actions. Worst case, public health authorities worry, the U.S. could see increases in preventable illnesses; a weakening of public confidence in established science; and debunked notions — such as a link between vaccines and autism — adopted as policy. Trump said in an NBC News interview on Nov. 3 that he would “make a decision” about banning some vaccines, saying he would consult with Kennedy and calling him “a very talented guy.” 

 

Armour’s article tries to predict what will happen to the ACA. There is much that can be done by executive order, and some things that would require the control of both Houses of Congress. In my July 19th letter, I reviewed the healthcare implications of Project 2025 which many believe will be a strategic blueprint for Trump’s agenda over the next four years. In that letter, I wrote:

 

If you are concerned about the possibility of a second Trump term as the beginning of an autocratic government, you are not paranoid. Project 2025 is a road map to that destination written by a think tank whose vision extends far beyond the four years of a second Trump term but is consistent with the vision of Republican politicians who are even further “Right,” well-funded, more politically sophisticated, and perhaps more intelligent, though less flamboyant then Mr. Trump. J.D. Vance would definitely be the kind of guy who could animate the 900 pages of the plan. 

 

With the help of Wikipedia, I was more specific about the comments concerning healthcare in Project 2025. In the July 19th letter I copied and pasted the following analysis:

 

Healthcare and public health:

Project 2025 accuses the Biden administration of undermining the traditional nuclear family, and wants to reform the Department of Health and Human Services (DHHS) to promote this household structure.[24] According to Project 2025, the federal government should prohibit Medicare from negotiating drug prices[24] and promote the Medicare Advantage program, which consists of private insurance plans.[124]: 464–65  Federal healthcare providers should deny gender-affirming care to transgender people and eliminate insurance coverage of the morning-after pill Ella, as required by the Affordable Care Act (Obamacare).[24]

Project 2025 suggests a number of ways to cut funding for Medicaid,[25] such as caps on federal funding,[25] limits on lifetime benefits per capita,[25] and letting state governments impose stricter work requirements for beneficiaries of the program.[32] Other proposals include limiting state use of provider taxes,[25] eliminating preexisting federal beneficiary protections and requirements,[25] increasing eligibility determinations and asset test determinations to make it harder to enroll in, apply for and renew Medicaid,[25] providing an option to turn Medicaid into a voucher program,[25] and eliminating federal oversight of state medicaid programs.[25]

Project 2025 aims to dramatically reform the National Institutes of Health (NIH) by making it easier to fire employees and to remove DEI programs. Conservatives consider the NIH corrupt and politically biased.[23]

 

That verbiage may have seemed vague back in July before Trump joined forces with Robert Kennedy, Jr. or made his reference to a “concept of a plan in the September debate with Vice President Harris. Our lens in July was cloudy, but now what might happen to healthcare is becoming a little more focused and with the addition of Kennedy, a little more bizarre. Since we are still operating on conjecture, I decided to ask my favorite chatbot for its opinion. Remember that I believe that the quality of the answers we get from AI depends on the quality of the questions we ask. So I asked:

 

Now that Donald Trump has been reelected as the 47th president, what can we expect his “concept of a plan” for healthcare might entail? How will he utilize Robert F. Kennedy, Jr.?

ChatGPT answered:

Searched 2 sites

Since being reelected, Donald Trump’s healthcare plan remains somewhat ambiguous in terms of specific policies, but his alliance with Robert F. Kennedy Jr. suggests a possible shift in direction, especially around public health agencies. Trump has hinted at giving Kennedy considerable authority within health-related agencies like the CDC, NIH, and FDA. Kennedy, known for his controversial views on vaccines and public health, could reshape agency focus toward his belief in environmental factors over traditional public health interventions, and stricter vaccine regulations. This shift has raised concerns among experts who worry it could complicate public health efforts, especially in areas like vaccination and disease prevention.

Trump’s broader healthcare approach has often centered on reducing government intervention and promoting price transparency, which he previously championed through executive orders aimed at lowering prescription drug costs and encouraging competition in healthcare services. However, it’s unclear how these initiatives will evolve under his renewed administration. Given Trump’s statements, one can expect a push for deregulation and potentially cutting federal support for mandates or requirements, particularly in areas like vaccine policies, where he and Kennedy have overlapping views.

Kennedy’s influence, if given full rein, could also lead to reforms in agriculture and food safety policy, as he advocates for limiting pesticide use and altering food production practices to address chronic health conditions. Such a direction may appeal to parts of Trump’s base, especially those interested in alternative health measures, though it has also prompted criticism from public health experts who warn that these changes might weaken the country’s ability to respond effectively to health crises.

The overall implications of Trump’s healthcare plan and Kennedy’s role remain to be fully outlined, but they point toward a potentially significant departure from traditional public health approaches, focusing more on Kennedy’s personal health philosophy than on established public health practices.

Sources:

• Wired

• The Independent

 

We will see, but there are reasons to be concerned. There are many uncertainties ahead over the next 1460 days until the election in 2028. Two things of which I am very certain are first,  healthcare will be under siege, and second, I will have plenty to write about. I don’t know how truthful the president-elect will be during his second term. He set a high bar of over 30,000 lies during his first term. I promise you that as the next four years roll on, I will stick to what I know to be true or inform you whenever I am offering a conjecture or reporting the opinion of someone else or a chatbot. 

 

As a conjecture, I anticipate some very difficult days ahead for those who care about healthcare quality, healthcare inequalities, the potential for moral injury to healthcare professionals, and the Social Determinants of Health. It is my opinion that once again many people have voted against their own best economic and healthcare interests. I am apprehensive because history and clinical experience suggest that in the end, things finish badly with a narcissist. As a narcissist burns out, there are often big problems that impact those whom the narcissist touches. Our president-elect enjoys referring to himself with an abundance of superlatives. His narcissism is of historic proportions. He frequently suggests that his accomplishments are “beyond belief.” He does have many people and leaders here and abroad shaking their heads in disbelief. It is frightening to try to predict how much we will be forced to endure or how significantly he might harm the health of the nation during his second term. 

 

Good-bye and Thanks, For Now

 

The highlight for me of a very low-energy and depressing Wednesday was the concession speech of Vice President Harris. If you didn’t hear it, you can see it on YouTube. It was an inspiring and well-delivered speech by a very intelligent and accomplished woman whose talents we have discarded for the moment.

 

I was apprehensive about whether or not I could handle my own emotions and had initially planned not to listen. I reasoned that I would catch a few clips that I could emotionally handle on the evening news. At my age, one needs to avoid moments that others might deem of “pseudo-bulbar” origin. In the end, I summoned the courage to hear her entire speech in real-time. I was deeply moved, but her upbeat and positive delivery elicited only smiles and no tears. I was delighted that Time magazine has provided a full transcript of the speech. Early in the speech, she seems to be giving a “civics” lecture to election deniers while lifting up her supporters whom she knows are suffering from worry about how she may be doing. After all the applause and her words of appreciation, she quickly gets into substance:

 

A fundamental principle of American democracy is that when we lose an election, we accept the results. That principle, as much as any other, distinguishes democracy from monarchy or tyranny. And anyone who seeks the public trust must honor it. At the same time, in our nation, we owe loyalty not to a president or a party, but to the Constitution of the United States, and loyalty to our conscience and to our God. My allegiance to all three is why I am here to say, while I concede this election, I do not concede the fight that fueled this campaign—the fight: the fight for freedom, for opportunity, for fairness, and the dignity of all people. A fight for the ideals at the heart of our nation, the ideals that reflect America at our best. That is a fight I will never give up.

 

She was not finished. Further along, just a few moments later, she dedicates herself to the continuing effort that will not be defeated by the setback of a lost election.

 

And we will continue to wage this fight in the voting booth, in the courts and in the public square. And we will also wage it in quieter ways: in how we live our lives by treating one another with kindness and respect, by looking in the face of a stranger and seeing a neighbor, by always using our strength to lift people up, to fight for the dignity that all people deserve. The fight for our freedom will take hard work. But, like I always say, we like hard work. Hard work is good work. Hard work can be joyful work. And the fight for our country is always worth it. It is always worth it.  To the young people who are watching, it is okay to feel sad and disappointed. But please know it’s going to be okay. 

 

Near the end of her remarks, she delivered words that I needed to hear:

 

You have the capacity to do extraordinary good in the world. And so to everyone who is watching, do not despair. This is not a time to throw up our hands. This is a time to roll up our sleeves. This is a time to organize, to mobilize, and to stay engaged for the sake of freedom and justice and the future that we all know we can build together. Look, many of you know I started out as a prosecutor and throughout my career I saw people at some of the worst times in their lives.  People who had suffered great harm and great pain, and yet found within themselves the strength and the courage and the resolve to take the stand, to take a stand, to fight for justice, to fight for themselves, to fight for others. So let their courage be our inspiration.

 

I have no idea what the future holds for Kamala Harris, but whatever she does, I am sure that her intent will be to benefit others. I hope that we see her again, and often. She has surely learned a lot and gained valuable political experience in her compressed 107-day campaign to try to lead us to a better future. 

 

I will be taking short walks and long bike rides this weekend. The forecast is for pretty good weather with temps in the low 50s with a few clouds but no rain. The weather will be perfect for my mood. I will not be too up or too down. I hope that your weather will lift your spirits if they need any lifting.

Be well,

Gene