August 13, 2021
Dear Interested Readers,
Going Deeper Into What Could Be
If you have been a regular reader of these notes for at least a year you know that from time to time I find inspiration in the writing and songs of my youngest son. When he was a little boy I asked him what he wanted to be when he grew up. His answer was “a rock star.” It’s hard to explain to a small child that success in music may often be more related to serendipity than to talent. One does not want to hang crepe on a young child’s dream. As a follow-up question, I asked him what he would like to do if he could not be a rock star. He replied that if he could not be a rock star he would be a comic book artist. I ended my interrogation and decided to wait a few decades to see what happened.
I am glad to report that after getting a master’s degree in communications at NYU he has worked for several years with Per Scholas, a large national non-profit organization that trains for free economically disadvantaged people for good jobs in IT. If you clicked on the link you have seen his work. He manages their IT interface with the world with a focus on marketing, fundraising, and recruitment. Feel free to contribute. They do very important work that makes a big difference in the lives of real people. It occurs to me that through his work he may have contributed much more to ending economic inequity and healthcare disparities than all my many words will ever accomplish. Per Scholas directly touches and changes lives by offering real opportunities for personal growth and development.
My son never became a rock star or comic book artist, but he is a very good musician and graphic artist. He is a poet and writes big thoughts in a few words. A talent that he did not inherit from me. As you may know, he posts a new song on the Internet every Monday. His post this week was an inspiration for me. As usual, he had a brief introductory note:
Sometimes a stray thought sits with me enough to spin a song around it. This song is one of my little meditations. People talk a lot about living in the moment, about being present in the now. That’s a good thing to do, but I think maybe it gets too close to vilifying thinking about the way things were, or the way things could be. I think it’s okay to reflect on the past or the future as long as you’re not stuck there. It’s good to ponder these things so you can understand yourself the way you are. That’s the whole thought — brief like this song.
It was the second verse (the bolded words) of this short song that spoke to me. Yes, this is the 560th consecutive Monday that he has posted a new song.
Week 560 // Being Part of a Greater Thought
All the ways it can go
It ain’t a waste of time
To think on the stories of your life
All the ways that it’s been
All the ways we are
There’s nothing wrong
With being part of a greater thought
Of the ways we could be
These days it feels like there is a lot that falls under the rubric “Of the ways we could be.” I like the shift of focus away from all the thoughts about what is history and where we are stuck now to the thoughts “of the ways we could be.” As I said last week, I am moving on toward writing most about what we might do to improve the social determinants of health, reduce health care disparities, and improve healthcare equity. I see climate change and the associated concerns about the environment as connected to healthcare disparities, as is our persistent problem with poverty. As I said last week, I have come to believe that just focusing on quality and safety with the goal of the Triple Aim as our North Star has been a noble effort but I am not impressed with the progress that we have made in improving healthcare and the health of many of our patients and communities by ourselves from inside of our practices and institutions. I think it is time to go upstream with the objective of recruiting assets and insights from outside of healthcare to help us focus on fundamental issues like racism, the environment, and the self-interests of healthcare that seem to perpetuate our problems and deny many Americans of the care they need.
I was quite pleased with the posted comment of Eve Shapiro whom I had mentioned in last week’s letter. In case you missed it, she said:
Dear Gene,
I am greatly honored by your high regard. We certainly are kindred spirits. I applaud everything you’ve written here and feel just as passionately about the problems you raise.
Question is, where does change begin in medicine and how is it sustained? I have a feeling the answer lies in medical schools: both in their curricula and who is selected as teachers and students.
Grades are insufficient for choosing doctors if we’re going to achieve our vision of enlightened, equitable care. We need people with cultural awareness and emotional intelligence. We need people of color as teachers, students, and leaders. But where is the push for this going to come from?
To my great disappointment but not surprise, the cascade of words denouncing recent high profile firings of two Black female physician educators at medical schools in California and Louisiana have led to more words, but no changes, to address the root cause of these medical school firings: racism.
What will it take to prompt and sustain honest soul searching and implement change to prevent actions based on racism toward teachers and students from continuing? I am generally a positive person, but I have little hope that change will occur in medical schools, which I believe is where change must start.
Thank you for all you do, my friend. Let’s hope 13 years from now your retrospective will read very differently.
With admiration always,
Eve
Not all “interested readers” post their comments for public viewing. Some are sent directly to me. A reader who prefers anonymity has agreed to let me share his thoughts with you. He wrote within an hour of when the letter came out:
Gene, I agree with your hard-won knowledge that powerful cultural and economic forces lie behind systematic racism and FFS medicine, making both difficult to change, but carrying an increasing high price for the failure to change.
I responded to his affirmation of my “downer” thesis:
I guess that one evidence of advancing age is to bend to reality. You know how hard it is for me to come to this conclusion that represents the end of an unrealistic hope…It Is time to either abandon ideals or look for an alternative approach. I am opting for the alternative approach.
I can’t look at where we are and continue to deny that medicine is unlikely to spontaneously evolve from its inequalities and self-serving business practices that explain what we see today. Another tack must be taken. I think it is time to shift the focus upstream to the larger issues that underlie the current state of affairs in healthcare. I don’t believe that I will live to see evidence of the effectiveness or failure of that change. It may be true that healthcare will never improve, but it will not stay the same.
He wrote back:
As others have said, every system is designed to produce the outcomes it produces. Our system is designed to maximize revenues derived from providing patient care, which it does very well. The result, as you well know, is under-treatment of the uninsured and under-insured, over-treatment of the insured, and, as documented recently by the Commonwealth Foundation, mediocre public health results at the highest cost, measured as a percentage of GDP, in the industrialized world. Medicare for all could change this but the Republicans have demonized the public pay option and huge vested interests in the health care and related industries use that passionate commitment (against the interests for the most part of those so committed) to protect the status quo. Despite the lip service paid to value-based care, there is no serious, large-scale effort underway to materially change FFS-based health care. The pressure for change from FFS to value-based care should be coming from non-HC businesses and their employees who are being crushed by the ever-rising costs of health care services, but this is not happening at present.
My friend and reader is one of the smartest, best-read, and practical people I know. He has worked for many years with large healthcare systems. His note mentions the report that the Commonwealth Fund released last week entitled Mirror, Mirror 2021: Reflecting Poorly: Health Care in the U.S. Compared With Other High-Income Countries. I had already read it as well as the reviews of the paper published in The Washington Post, The Guardian, and US News and World Report. I don’t feel it is necessary to give you the grim details. You can check it out for yourself. It is no different than it has been for many years. We have known for a long time that Americans get much less for almost twice as large a percentage of our GDP.
What surprised me about the paper was its lack of reference to inequity in outcomes between ethnic groups. The authors state that there was no comparative data. There was an ability to make comparisons based on income. If you are poor, the data suggests that you will do better in most of Europe, especially in Germany.
Equity: Income-Related Disparities Are Largest in the U.S., Canada, New Zealand, and Norway
Our analysis of equity focuses on income-related disparities, based on standardized data across the 11 countries, in the access to care, care process, and administrative efficiency performance domains. Similar standardized data are not available for measuring equity in performance with respect to different racial and ethnic groups (see How We Measured Performance for more detail).
Australia, Germany, and Switzerland rank highest on the equity domain, meaning these countries had the smallest income-related disparities in performance based on the included measures.
The Commonwealth Fund couldn’t compare gender and ethnic outcomes between nations, but they have written a lot about those disparities when analyzing our internal data. In 2018 the Commonwealth Fund produced a report entitled “In Focus: Reducing Racial Disparities in Health Care by Confronting Racism.” That paper told us what we all have known for some time; your outcome is a function of your race. At the beginning of that paper, they reference the 2003 report from the Institute of Medicine (now called the National Acadamy of Medicine) on healthcare disparities related to race. The report is entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. You can download the PDF. The report is 781 pages long. It’s just another big piece of information that suggests to me that our problem is not that we don’t know what is going on. It’s like gun violence and climate change. We know what is going on. We just don’t have the will to make a change. One of the main themes of Ibram Kendi is that we can’t reason or teach our way out of racism and inequity. Those outcomes and the inequities in healthcare exist because of policy decisions that are made to protect self-interest. The history of those self-interested policies are a major part of what we call critical race theory. The solution is not more education or “suasion” it is using political power to change policies. Once policy changes there will usually be a slow change in attitude as the new dynamic gains gradual acceptance. It’s a painful reality that after centuries of bad policy it may take many decades, perhaps a generation of the new policy before attitudes adjust to the new normal.
Policies and not biological differences or differences in character or virtue are the reason we have healthcare disparities. Current policies and the persistent impact of historical policies and attitudes are the explanation behind disparities. We all know that if you are White you live significantly longer than if you are Balck, Latinx, or Native American. If you want to see a nice slide deck with an up-to-date presentation of our healthcare disparities that was developed by the Kaiser Family Foundation and includes COVID data, Check out “Racial Disparities in Health and Health Care.”
If you look around, you will discover that we have mountains of literature about what should be or could be that are the product of careful economic and policy studies that have been produced over the years in universities and think tanks. Under some progressive administrations, ideas about better policies have abounded, but conservative resistance to changes has usually defeated efforts at improvement especially if the change requires a change in the tax code to finance new efforts. As an example of a diligent non-profit think tank, I offer you The Century Foundation, a progressive think tank with a long history of fighting for equity. The Century Foundation has published several documents that I offer if you have any doubt about the shameful care experienced by Black Americans and what might be done to improve health equity. Jamilla Taylor, MD, The Director of Health Care Reform and Senior Fellow at the Century Foundation tells us what we already know:
The American health care system is beset with inequalities that have a disproportionate impact on people of color and other marginalized groups. These inequalities contribute to gaps in health insurance coverage, uneven access to services, and poorer health outcomes among certain populations. African Americans bear the brunt of these health care challenges.
She recognizes that Black Americans have made some educational and economic gains since the Civil Rights Era of the 60s, but continues:
African Americans are also living longer, and the majority of them have some form of health insurance coverage. However, African Americans still experience illness and infirmity at extremely high rates and have lower life expectancy than other racial and ethnic groups. They are also one of the most economically disadvantaged demographics in this country.
The article emphasizes that it is our policies that have created outcomes that can’t be hidden, just ignored. Without naming him, she agrees with Kendi. If we can no longer tolerate the presence of inequity in our healthcare outcomes we must change the policies that create inequities. She offers some significant suggestions which I have abbreviated somewhat as indicated. Some of her suggestions which were made in 2019 have been accepted by the Biden administration. I have bolded some of her more salient points..
1) Promote health equity by adequately addressing racism, bias, discrimination, and other systemic barriers within the health care system. To do this, policymakers must acknowledge the historical foundations of racism and ensure that health care providers, personnel and staff are substantively trained to recognize and eliminate all forms of bias in the health care system…
2) Incorporate evidence-based tools to adequately address health disparities that focus on quality of care that extend beyond health insurance coverage, including the impact of racism on the health of African Americans throughout the life course. In health reform efforts, policymakers must take into account the social determinants and address how they impact health by working across sectors, including social support agencies and community-based providers with patient-centered approaches to care. Racist practices, such as those in the treatment and pain management of African Americans, should be eliminated.
3) Protect and expanding access to insurance coverage and comprehensive benefits and bolstering the ACA benefit provisions and nondiscrimination guarantees…Policymakers should also build on the essential health benefits package to include important health care services currently omitted, such as long-term care and dental care.
4) Protect the integrity of Medicaid, an important health insurance source for African Americans, by denying state efforts to impose draconian stipulations on coverage for enrollees such as work requirements. In order to close the coverage gap among African Americans, policymakers must also implement targeted strategies to incentivize and ensure Medicaid expansion in all southern states.
5) Ensure access to quality providers and addressing provider shortages and hospital closures by anticipating increases in demand and working with HRSA [Health Resources Services Administraton] to implement concrete strategies to close gaps in health care access for medically underserved areas/populations and health professional shortage areas. Strategies should include plans to not only increase the health care workforce, but also diversify it and offer technical support and training to minority-serving hospitals.
6) Support the development of a robust, diverse, and culturally competent health care workforce by encouraging and facilitating diversity throughout the health care system and care teams, and adequately training all staff to be culturally sensitive. Payment rates and coverage guidelines for health care coverage should be developed in a way that supports fair, living wages and pay equity in the health care professions and jobs. [As my friend and interested reader, Eve Shapiro, commented in her response to last week’s letter. We need to focus on developing more minority providers.]
7) Limit the cost of premiums and out-of-pocket costs, helping to make health insurance more affordable for individuals and families across the income spectrum. This should include limiting deductibles, prescription drug costs and other point-of-service charges, and completely eliminating surprise medical bills. All of these costs are major barriers to health care access, particularly for individuals and families with limited incomes.
8) Strengthen access to trusted community-based providers currently available through safety-net programs, such as Medicaid, Medicare, and the Children’s Health Insurance Program (CHIP)…
There is no question that the inequality in healthcare for poor White people and Black people of all levels of economic status explains much of the low life expectancy experienced by all Americans. A careful reading of Dr. Taylor’s list would suggest that if these steps were fully implemented all Americans would benefit. In his 2019 book Dying of Whiteness: How the Politics of Racial Resentment is Killing America’s Heartland, Dr. Jonathan M. Metzl, a professor of psychiatry and sociology at Vanderbilt, makes many of the points made by Heather McGhee in The Sum of Us. [This is a link to an excellent and short recent Time Magazine discussion of McGhee’s ideas.] Racism and political policies that create economic inequities are killers for the disadvantaged of all races. And, as we have seen with COVID, what harms some has the potential to harm all.
Poverty and racial hierarchies explain a portion of our disparities and count for part of our very poor status among our peer nations. But there is more. We know that gender and sexual preference also make a big difference. The same author who gave us suggestions for improving the care of Black Americans, Dr. Jamilla Taylor, testified before Congress this past May about the special disparities that relate to the reproductive health and childbearing of Black women and the resultant injury to Black infants and children. In my opinion, the third world country like statistics in American medicine that are produced by the lack of quality in the care of Black mothers and their children is a national disgrace. You should read her introductory statement to the Congressional committee. After introducing herself and The Century Foundation to the committee she begins:
According to the CDC, Black women are dying of pregnancy-related causes more than any other racial or ethnic group. We are also most likely to experience severe maternal morbidity. Poor maternal health outcomes among Black women cannot solely be attributed to social determinants, such as poverty or educational attainment. Rather, structural racism is the main culprit.
Racism cannot be understood as simply interpersonal bias and animus. It is a powerful social condition that has its roots in a centuries-long system of oppression and devaluing of Black people, and Black women, in particular. It not only persists today in our health care policies and practices—it has real, significant impacts on people’s health.
Intersectionality is a concept that has become a political hot button that is attacked by conservative minds as a part of Critical Race Theory. I chuckled to myself this week when I saw that intersectionality was the subject of the “Dilbert” comic strip on Monday. Click on the link to get your own chuckle. “Intersectionality” is a term that was first introduced in 1989 by a Black law professor at UCLA and Columbia, Professor Kimberlé Crenshaw. In a Vox article published in 2019, Jane Coaston defines intersectionality and discusses the controversies the idea and Professor Crenshaw have precipitated with the conservatives that want to use that very logical term as a weapon in their struggle to perpetuate their advantages through misinformation. She writes:
To many conservatives, intersectionality means “because you’re a minority, you get special standards, special treatment in the eyes of some.” It “promotes solipsism at the personal level and division at the social level.” It represents a form of feminism that “puts a label on you. It tells you how oppressed you are. It tells you what you’re allowed to say, what you’re allowed to think.” Intersectionality is thus “really dangerous” or a “conspiracy theory of victimization.”
This is a highly unusual level of disdain for a word that until several years ago was a legal term in relative obscurity outside academic circles. It was coined in 1989 by professor Kimberlé Crenshaw to describe how race, class, gender, and other individual characteristics “intersect” with one another and overlap. “Intersectionality” has, in a sense, gone viral over the past half-decade, resulting in a backlash from the right.
I guess that the appearance of “intersectionality” as a subject in “Dilbert” proves that it is a timely topic. Ibram Kendi spends a lot of words and time on the subject in his books and interviews. As the “Dilbert” strip suggests, intersectionality describes the unique descriptors of any human being, but there is special meaning when we apply the concept to the struggle for racial equity. There is no better example of the term than to combine poor, Black, pregnant, and living in a Southern state that has not expanded Medicaid. That combination describes a huge number of Americans who experience some of the worst disparities that our system of care produces.
For me, the concept of intersectionality explains so much of what is easily disregarded when we consider the barriers to good health. In his book How To Be An Antiracist Kendi uses the concept of intersectionality to advance our understanding of the social determinants of health as applied to many, many groups composed of different races that share common burdens. Dr.Martin Luther King, Jr. was killed long before Professor Crenshaw began to write legal briefs using intersectionality as a concept to reveal greater levels of discrimination. Dr. King was definitely aware of the issues of intersectionality even if the name was not yet coined. He knew that many different groups other r than Black Americans suffered discrimination, and he was concerned about any policy that created inequity. His awareness of how intersectionality is manifested is revealed by his expressed concerns for the disadvantaged and poor people of all races. around the world.
It amazes me that we have ignored the realities of intersectionality and the impact of racism on the health of the nation for so long. Kendi is somewhat cynical based on his review of history and I agree with him that we have ignored things that could be disadvantageous to our business margins and personal self-esteem. If we were to acknowledge them as problems deserving our concern we would feel obligated to address them. If we deny that racism exists, we can justify ignoring it or disregard it as “not our problem.” I may be late to the party, but I will no longer ignore the shameful reality of racist policies that create healthcare disparities. That is why my son’s brief explanation of his song spoke to me. In case you missed it he said:
I think it’s okay to reflect on the past or the future as long as you’re not stuck there. It’s good to ponder these things so you can understand yourself the way you are.
From that perspective, I can adopt the philosophy in the last three lines of the song:
There’s nothing wrong
With being part of a greater thought
Of the ways we could be
Sailing Away
I spend a lot of time thinking about what I could be doing. I have a piano and a wall of guitars that I don’t spend much time with. I have a couple of old convertibles that are begging to be driven down country roads on a summer afternoon but mostly sit in a garage. My fly rods and waders have not been in a river since I was in New Mexico last October. My wife never says it out loud, but I think that she thinks that I have too many toys. I would counter with the reality that I have had a very long time to accumulate toys. The problem may be that I am not very good at discarding what I am not using.
I have affection for these inanimate objects. I think that is a sin, but I feel bad that I don’t use many of these things as often as I once did. I think I need some help.
On Monday afternoon my neighbor who keeps his brand new expensive wakeboard/wake-surfing facilitating behemoth of a powerboat on our dock stuck his head through the screen slider between my chair and the deck and suggested that I was wasting time. He had just been out on the water in his new boat and said there was a nice breeze blowing, and we should be sailing. I looked out at the lake and saw evidence of the breeze on the water, but I also noticed a dull gray sky.
He was persistent and I caved. It was true that you did not need many fingers to count the times that I had taken out my old sailboat this summer. I like old things. Or perhaps it is that the things that I have are old because I bought them used a long time ago. Most of my “toys” have a history. The sailboat is a 1972 O’Day Javelin. It has been out of production for over forty years and just 5100 were ever built. I like it because it was built with dimensions that make it safe for not very skilled sailors like me. It has amazed me that it has stood up to my neglect and abuse so well. If my boat was a sentient being, it would likely feel neglected and depressed, but if I can find the initiative to use it I always get a lift. It never fails that the words of Christopher Cross’s hit song of the late seventies/early eighties, “Sailing” rolls through my mind as I leave the dock.
Well, it’s not far down to paradise, at least it’s not for me
And if the wind is right you can sail away and find tranquility
Oh, the canvas can do miracles, just you wait and see.
Believe me.
We had a good sail. The canvas did do miracles for me, even though we soon lost most of the wind. My wife captured the moment with her iPhone so I decided to share it with you as today’s header. Sailing on small lakes is always interesting because of the interaction of the breeze with the shoreline. I have family coming this week, and I hope that I will be able to get some of them to venture out with me, weather permitting. I have suddenly realized that the summer is slipping away quickly. It’s now or never until next year!
I hope that this weekend you will find something that you enjoy but just haven’t had the time or circumstances to do recently, and share it with a friend. If you are up my way, let’s take a sail.
Be well,
Gene
