August 8, 2025
Dear Interested Readers,
We Are Struggling And It Is Likely To Get Worse Before Getting Better
This week, there are some significant anniversaries. It has been 80 years since we dropped atomic bombs on Hiroshima and Nagasaki, killing more than half a million civilians. President Truman justified the action by the estimate that as many as a million American lives might be lost with a “D-Day” like invasion of Japan.
There is another noteworthy anniversary this week. It has been sixty years this week since the Voting Rights Act was signed by Lyndon Johnson. If you clicked on the link, you will discover that the Voting Rights Act is likely to be the latest piece of history terminated by our very conservative Supreme Court. Will anyone be able to save us from a national decline when majorities in our Congress, on the Supreme Court, and President Trump now have the opportunity to Make America Great Again by bringing back one of the centerpieces of our Jim Crow past? Anything is possible when you realize that it’s been three years since the “settled law” of Roe v. Wade was overturned, initiating for many American women the loss of control over their bodies, and placing many obstetricians under great legal uncertainties in many of our states.
Fifty years from now, this week may be remembered as the beginning of another MAGA tragedy since this week, Robert Kennedy, Jr., all but killed the future of mRNA vaccine research in America. Who knows what is next? If gerrymandering efforts in Texas succeed, there may be no chance of a partial recovery by electing a Democratic majority in the House in 2026. In many ways, thoughtful people are struggling to understand the hurricane of rapid losses we are experiencing, and it is likely to get worse as the pillars of our democracy are attacked daily by those for whom Project 2025 is the grand strategic plan. Click here to see how much of Project 2025 has already been accomplished.
I feel very sorry for all current healthcare professionals. When I entered medical school in September of 1967, things were far from perfect for trainees, practitioners, support staff, and those who managed hospitals and medical practices. However, there was a sense that great opportunities lay ahead for patients and everyone involved in the complex healthcare process. Lyndon Johnson had just used his immense legislative skills to push Medicare and Medicaid through Congress in 1965. The passage of the Civil Rights Act in 1964 and the Voting Rights Act of 1965 were evidence that we could recognize and correct great injustices. In the wake of the hard-won successes of the Civil Rights movement, Dr. Martin Luther King, Jr. was expanding his efforts to speak to the shared needs of the poor of all races and ethnicities. We were making progress toward political, if not economic, equality. The Great Society that President Johnson proposed would have initiated a better day for many Americans if it had not been undermined by the misadventure of Vietnam. It was on August 7, 1964, sixty-one years ago this week, that Congress passed the Gulf of Tonkin Resolution, which in retrospect initiated the war that cost us the great social progress that those heady days of the mid-sixties promised.
Looking back at missed opportunities doesn’t fix anything in the moment, but it may help to explain our current confusion and give us some hints of how we might “cut our losses,” or begin to plan for a better day if we can survive this one.
Last week, David Brooks attempted a “long view” of the social evolution of our past forty or fifty years. It helps to know how and why things changed if you are going to try to positively impact the future. Brooks’ piece is entitled The Crucial Issue of the 21st Century. He begins:
The main political argument in the 20th century was over the size of government. On the left, people tried to use government to reduce inequality and offer an economic safety net. On the right, people tried to reduce taxes and regulations to boost growth and social dynamism.
That may sound to you like where we remain now, but Brooks sees it differently.
That era is clearly over. Donald Trump is a big-government populist who has destroyed small-government conservatism. He’s using state power to adopt a mercantilist tariff policy that redirects global trade flows. He’s using industrial policy to pick economic winners and losers. He’s using state power to micromanage key universities…
…Well, the 20th-century argument over the role of government happened at a time when people basically thought America was working. When society seems stable, the individual is seen as the primary political reality: How can we support individuals so they can rise and prosper — a tax cut here, a new social program there?
But today, most people think America is broken. According to recent surveys, public trust in institutions is near its historical low. According to a recent Ipsos survey, about two-thirds of Americans agree with the statement “Society is broken.”
When it comes to healthcare, many doctors, nurses, support staff, and administrators would say healthcare is broken. Rates of “burnout” and “moral injury” among medical professionals have never been higher. Patients, even those with insurance, Medicare, or Medicaid, complain about out-of-pocket charges, medical debt, poor access, and a sense of being lost in systems where it is hard to find the help they need. There are no proven solutions for the problems that plague professionals or patients.
There are efforts. Just this week, it was front-page news in Boston that the behemoth MassGeneral Brigham was joining with CVS Minute Clinics to improve primary care access. Click here to read about it. It is a strategic move that I am sure will benefit both CVS and MassGeneral Brigham, but is it anything but a stopgap measure to make up for the fact that the “operating system” of healthcare is failing? We made strategic errors in our development of professionals over forty years ago that we are paying for now. We have drained every possible doctor we can from other parts of the world, and we still don’t have enough. We also don’t have enough NPs and PAs to fix our access problems. “Concierge care” will benefit those few who can afford it or find it, but it won’t improve the health of the nation.
Dr. Danielle Ofri, who practices primary care at Bellevue in New York City, has written books about the current challenges of practice, and is an occasional contributor to the New York Times, published a recent opinion piece entitled “Doctors Have Lost Their Mount Olympus of Medicine.” It is a complaint about how the Trump administration is robbing her of the information and resources that she needs in practice. In reference to changes at the HHS, CDC, and FDA, she writes:
The institutions I trusted to be deliberative and evidence-based sources of knowledge that extend my medical abilities are no longer that. In the first Trump administration, despite relentless attacks from the president, the nation’s public health institutions remained largely intact, if wearied. But the plunder of the second Trump administration has disemboweled them and installed fox-guarding-the-henhouse leadership. Medical professionals can no longer fully trust federal health guidance, and our patients are the ones who will suffer the most.
For most of my colleagues and me, the C.D.C. and the N.I.H. were the medical Mount Olympus, the towering pillars of medical authority. Contrary to right-wing portrayals, these were not dictatorial authorities. These were earned authorities, comprising our best, brightest and most dedicated peers. The formidable talents of these doctors and scientists would have commanded enviable salaries had they taken jobs in industry, but they chose the public sector instead — something that we clinicians were forever grateful for.
She is already feeling the impact of changes made during the first six months of what will be a long four years.
But now that support is a shell of what it once was. I can no longer automatically rely on these institutions because their scientific North Star, even if imperfect at times, has been replaced by one that seems nakedly political. Remaining staffs are no doubt working valiantly to do their jobs, but they are hobbled by loss of colleagues, resources and reliable leadership. So when I hear that the C.D.C. has changed a vaccine recommendation, I now question whether that’s a recommendation I can trust. When the F.D.A. commissioner says he wants to change how the agency approves or rejects new treatments, I no longer feel sure that science is driving those decisions. It’s hard to convey how profoundly grieved my colleagues and I feel.
Like so many in medical research, as a practitioner, she has serious concerns about the delusions of Robert Kennedy, Jr.
… Robert F. Kennedy Jr.’s view seems to be that we doctors are shills for corporate interests and government bureaucrats, and that torching our vaunted institutions is the prescription to fix us.
Mr. Kennedy’s ire seems oddly directed. I, too, am disgusted by the role of money in health care, but I see it more as a result of the system we’ve set up, rather than the people who labor within it. And the public seems to be able to make that distinction as well. Americans may be upset with how the system works and how much care costs, but most people say they are satisfied with their medical care. Most trust their doctors, even if that has declined slightly over the years. Nursing continues to top the list for most trusted profession.
I was gratefully appreciative of her continued denunciation of Kennedy:
Notably missing from Mr. Kennedy’s Make America Healthy Again agenda is any suggestion that we provide universal health care, as most other developed countries do. There is no push to expand Medicare and Medicaid, which help some of our sickest patients. There is no focus on expanding access to early childhood education and supplemental nutrition programs, which offer steep health benefits. In line with the thrust of most of the Trump administration’s actions and the outlines of Project 2025 is a barely concealed antipathy toward the people who are the engine of these institutions — doctors, scientists, policy wonks.
These attacks feel deeply personal for so many of us in health care. And of course, we are most pained about what this means for those we take care of.
I am happy that she is writing in the Times and not the New England Journal because her thoughts need to be read by patients as well as healthcare professionals and scientists. She is speaking directly to patients and the public when she writes:
Every time you go to your doctor or get treated by a nurse, there’s a chorus of researchers, public health workers, policy experts, epidemiologists and advisory panels arrayed behind them, aided by laboratories, databases, websites, early-detection systems and clinical guidelines. Our current government seems determined to wrench this away, handicapping your health care team’s ability to care for you.
Dr. Ofri probably agrees with what Paul Krugman wrote recently in frustration over our president’s lack of appreciation of science and good policy development. Krugman wrote:
And unfortunately, again, it’s the old Stephen Colbert line, “Reality has a well-known liberal bias.” If you report what’s really happening, it sounds liberal.
Dr. Ashish Jha is the dean of Brown University’s School of Public Health. Years ago, while he was at Harvard, Dr. Jha invited me to one of his classes to discuss with his students how Atrius Health and Harvard Vanguard were seeking to lower the cost of care and improve quality and the patient’s experience of care, while improving the work lives of our professionals. In the interim, he managed President Biden’s COVID efforts. Dr. Jha is upset about Trump’s One Big Beautiful Bill, which, according to the CBO, will deny many of the care they need while adding three trillion dollars to the national debt. Dr. Jha wrote an op-ed piece in the Boston Globe this week entitled “Millions could lose health insurance after the ‘Big Beautiful Bill.’ Here are three ways states can prevent that. How bad will the damage be? A lot depends on how states respond.” It is a very long title for a relatively short article. Dr Jha begins with a lament that I share:
Over the past decade, the United States has made meaningful progress in expanding health coverage and improving care for millions of Americans. But that progress is now in jeopardy. The newly passed “One Big Beautiful Bill Act’’ will have far-reaching consequences for the health insurance of millions of Americans. The Congressional Budget Office estimates that nearly 10 million Americans could lose their health insurance by 2034 as a result of the new legislation. In Massachusetts, officials estimate 300,000 people are at risk of losing their health coverage.
As you probably know as well as either Dr. Jha or I know:
These changes will worsen health outcomes for people who lose coverage while leading to higher costs for both patients and hospitals. It will overburden nursing homes, community health centers, and emergency departments, and some facilities may be forced to reduce services, lay off staff, or close altogether.
Dr. Jha continues with a point that I have also made in recent letters to you:
How bad will the damage be? Well, a lot depends on how states respond. By streamlining enrollment systems, investing in community partnerships, and making targeted investments to protect at-risk populations, states can soften the worst effects of this bill, reduce how many eligible people lose coverage, and ultimately ensure millions of people still get the care they need.
Unfortunately, what could be done probably won’t be done in a majority of states where either Republican control of state government or other political factors like overburdened state budgets will block actions that could be taken to blunt the effects of “OBBB.” Dr. Jha’s list of actions that could be taken is worth your review. Some states, like Massachusetts and other “progressive blue states,” will probably do many of the things Dr. Jha recommends, but I fear that many won’t, and that is why, as bad as things are now, as noted by Dr. Ofri, they are likely to get worse.
There is one final reference I would like to share with you this week. Heather Cox Richardson is a professor of history at Boston College who writes a very informative letter almost daily entitled “Letters From An American.” Her letters cover a lot of ground in a few words. In the letter of July 30, she has a long laundry list of grievances against the president, but in essence, she is demonstrating that what is happening now was the plan all along. She begins with a name most Americans won’t recognize, Kevin Roberts.
Roberts was the man who organized Project 2025, the blueprint for a new kind of government dictated by a right-wing strongman. Creating that new government would require a president willing to act illegally, stripping the secular language of civil rights from public life, packing the government with loyalists, ending the social safety net, killing business regulations, and purging American institutions of all but right-wing ideologues.
Further along, she writes:
…six months into the second Trump administration, on the sixtieth anniversary of the law that symbolized the modern American state by establishing Medicare and Medicaid, it’s clear we are indeed in a revolution designed to destroy the government we have known in favor of the radical right-wing government envisioned by those who wrote Project 2025.
All the August anniversaries after Hiroshima and Nagasaki, which, on the positive side, may have saved more lives than were lost, suggest that in the past, we have had great expectations, and now many of our expectations have been undermined, derailed, or abandoned. Sadly, many younger Americans don’t have any idea that we once imagined something better. I brace myself each morning when I open the newspapers that come to me on my computer for some new bit of bad news that proclaims yet another loss, or demonstrates that our society is in decline. I believe that we must expect that it is likely to get worse, so that we can find the courage to resist losing what is left of years of remarkable efforts to promote and improve the health of everyone.
The Flowers of August
Summer is like a trip with changing scenery as you journey toward fall. I think that August is the month with the most dramatic floral display. Our gardens are in full bloom with blackeyed susans, coneflowers, phlox, Rose of Sharon, and a host of other flowering native plants that my wife has had planted around our home. On my walks, I have identified over twenty different August wild flowers along the roads near my home with my “Seek App” which can name any plant, insect, or animal that I might encounter.
Today’s header features a coneflower (echinacea) being visited by an eastern tiger swallowtail butterfly. The butterfly is a male because females of this species have blue jewel-like enhancements along the bottoms of their wings. If you look closely at this fellow, it looks like he may have encountered hard times because the posterior borders of his lovely wings are a little tattered.
We are expecting a pretty nice weekend before much warmer weather next week. I hope that your weather will be inviting, and that you will have the chance to forget our evolving misery by getting out for a couple of walks wherever you are. Time flies. Labor Day weekend is only three weeks away.
Be well,
Gene
