September 2, 2022
Dear Interested Readers.
Where Is The Quality of Healthcare On Our List Of Concerns?
It does not take long for the hot topics of the day to change. It wasn’t that long ago that Democrats were debating “Medicare for All” versus “Medicare For Those Who Want It” while Republicans were still talking about “repealing and replacing” the ACA. With the election of Joe Biden, we settled on virtually no change with employer-supplied insurance augmented by the ACA, Medicare, and Medicaid, and no one seems concerned about the fact that about ten percent of Americans still have no coverage. That number goes up to over thirteen percent if you count only working adults and leave out children (5% uncovered) and those over 65 who are covered by Medicare. It is higher still for those who are in minority groups.
If you are poor and unfortunate enough to live in Texas, the state with the highest uninsured rate, and one of a dozen states that don’t participate in the ACA, you probably have over a 20% chance of having no health insurance even if you work. You can add healthcare to a long list of reasons, including the weather, abortion restrictions, and gun legislation, to avoid living in Texas. Governor Gregg Abbott’s performance lately after Uvalde and his busing of immigrants to New York and Washington cause me to shake my head in wonder. For many years there have been Texans who consider themselves so special and important to the overall union that they threatened to secede from the union if they did not get their way. With tongue in cheek, I sometimes think it would be a good thing for Texas to go its own way, and it could be even better if many of the other “red states” joined Texans in the grand exit. Full disclosure requires me to say that there are some equally crazy people in New Hampshire who have caught the Texas disease and are also advocating for secession so that they can avoid control by “the government.”
Speaking of Texas and the ACA reminds me that along with the silence on the lack of universal access to healthcare, we no longer seem to be concerned with the cost of care and nothing much is said about how hard it is for anyone, no matter their ability to pay, to find a doctor and be seen. In my neighborhood, it is harder to find a doctor than affordable housing. I am not being facetious when I suggest that access to care is so limited that many of those who have coverage and the ability to pay can’t find a PCP or get a timely referral to a specialist. Could an unacceptable lack of access to care for the “haves” explain some of the resistance to universal access for the “have nots” as a subconscious response to the fact that access to care would be harder for those who can pay if the uncovered 10% were given a ticket to ride? Without major changes in how care is financed and delivered the situation is only going to get worse. In my mind, workforce shortages and their impact on access have already qualified as a legitimate “wicked problem” in healthcare. An article from the University of Illinois defines “wicked problems” in healthcare:
What are wicked problems in healthcare?
Simply put, a “wicked problem” is a social, cultural, or institutional problem that is difficult to solve. These problems can arise for a number of reasons. Disparate goals of stakeholders, changing standards and requirements, and complex interdependencies, for example, can give rise to wicked problems in healthcare.
I agree with all of the wicked problems that are listed in the article, but I don’t understand how they could have left access and workforce issues off their list! Maybe it is an out-of-date list. “Wicked problems” that aren’t even recognized as problems have the potential of becoming emergencies. When I was in practice, I soon learned that many “emergencies” were “the acute presentation of unrecognized or unmanaged chronic problems.” We are in trouble when difficult problems to solve are not on our list of problems that need immediate and effective attention. Forecasts of increased shortages of doctors and nurses seem to be the medical equivalent of supply chain and infrastructure concerns. Before COVID, a lack of access to care wasn’t so obvious. It is counterintuitive for me that as important as access to care is for all of us that it is not a high-priority issue. The ability to get an appointment when you need one has become an issue now for people who are solidly in the middle class. I can’t explain why we don’t hear more complaints about the inability of so many insured Americans to get timely care. Why is such a societal threat not a political issue?
Sometimes we don’t give adequate attention to problems that are not our immediate personal problems. That can be a great source of error that allows problems to fester and grow. I have secure housing so why should I be concerned about a lack of affordable “workforce housing” in my community? There are “dots to connect” to answer the question. If the people I need in my community to provide the services I need can’t live in the community that will be a problem for me sooner or later.
I have heard that one driver of healthcare workforce issues in my town is inadequate housing for the “traveling nurses” our hospital needs to hire. On Wednesday evening I had an unexpected encounter with workforce issues in general. I’ll tell you the simple story.
My wife and I have really enjoyed the new outdoor service and upgraded menu at one of our local restaurants this summer. Our neighbors have the opinion that this restaurant makes the best pizza in town even though it is not a “pizza parlor.” They also have gourmet flatbreads that I have enjoyed. On the spur of the moment Wednesday evening after using our dock to do some water skiing, our neighbors asked if we would like to go to this restaurant with them for pizza because it was their favorite place in town to get pizza. We quickly accepted the invitation and headed out to enjoy the evening. We were careful to bring jackets because it is beginning to feel like fall and we wanted to be outdoors because there is COVID in our community. After being seated and looking at the menu we were surprised to see that the pizza and flatbread section had been deleted since our most recent visit less than a week ago. Our waitress informed us that the two chefs who had created the buzz about great pizza had both quit their jobs. One went back to college. The manager of the restaurant is the son of a friend of our neighbor. It is a small town and our neighbors are gregarious types who know everyone. The young man came to our table looking very pained as he explained how hard it was to find and keep help, especially talented chefs. He can find no one to make the pizzas. I was happy that they could still deliver a good Reuben with tasty coleslaw, but I was looking forward to that pizza with caramelized onions. Housing and workforce problems are NOT what we once thought about when we thought about healthcare, but both of those issues aggravate the cost and quality of care in ways we did not consider just a few years ago. By the way, in part because of housing and cost of living issues in our town, it is also hard to find an electrician, a plumber, or get an appointment with a mechanic. Are the complexities of all of our supply problems why healthcare has sunk so low on our list of concerns?
We once liked to say that we manage what we measure, but that is not always true. Sometimes our measurements are so disastrous that we ignore them rather than attempt to manage them. The folks at the Commonwealth Fund must be frustrated because they make a lot of measurements that are largely ignored. On a regular basis, they compare our healthcare metrics to the quality and outcome metrics of the other ten countries that have similar resources to ours. The worst we can rank in any category measured in this study is eleventh, which is a relief because in other studies where more countries are considered we drop into the high twenties in many categories including life expectancy. The latest report is from August 2021. In the conclusion they write:
Four features distinguish top performing countries from the United States: 1) they provide for universal coverage and remove cost barriers; 2) they invest in primary care systems to ensure that high-value services are equitably available in all communities to all people; 3) they reduce administrative burdens that divert time, efforts, and spending from health improvement efforts; and 4) they invest in social services, especially for children and working-age adults.
How do those other countries do it? I am quick to note that although all of these countries are democracies, none of them can match our political divisions in terms of generating resistance to social change. None of them have better science than we do, but all of them distribute the benefits of their knowledge better than we do. They seem to value primary care and public health more than we do. I am sure that some may disagree, but we seem more technically and procedurally oriented, and less oriented to or convinced of the benefit of directly addressing the social determinants of health. The Commonwealth Fund gives us much to consider. Measurement yields nothing if it is ignored or does not guide practice and policy. Consensus on national priorities and policies in this country is hard to come by. Even when we develop a national program, as we did with the passage of the ACA, the continuing rights of states further complicate effective implementation. I have heard the idea that part of the reason our COVID outcomes were so bad was not entirely an outcome of CDC failures. The states could and often did reject or undermine a coordinated national response.
When I think about how the national healthcare conversation has changed, I also wonder how the internal conversations in healthcare are going. Twenty years ago, before “Romneycare” was passed in Massachusetts, I did not expect much from the national government after being disappointed by “Hillarycare” tanking in 1993. Within our practice, we became focused on what we could do internally to improve quality. Our internal efforts intensified with the publication of To Err Is Human in 2000, and Crossing the Quality Chasm in 2001. We ramped up our efforts internally when Romneycare was passed, and we went into overdrive with the passage of Obamacare and the creation of ACOs. The desire to improve care and continuously move closer to the vision of the Triple Aim caused us to turn to Lean as a tool for continuous improvement. I wonder where all of the energy has gone. Did the effort it took to live with Trump and survive COVID put the brakes on efforts at internal improvement?
Inflation and the cost of all fuels and electricity seem to have displaced access to care, workforce shortages, and the cost of care in political sound bites for the 2022 mid-term elections. The only “good” news on the cost of care is that the recent Inflation Reduction Act did extend support for the cost of the ACA for millions and lowered out-of-pocket drug costs for Medicare recipients as described in an excellent article from the Commonwealth Fund:
Millions of Americans struggle to afford their out-of-pocket health care costs and premiums. The Inflation Reduction Act (IRA)…makes notable strides toward improving the affordability and accessibility of health care by addressing two acute areas of consumer need: extending premium subsidies in the Affordable Care Act’s (ACA) marketplaces and lowering prescription drug prices and out-of-pocket costs for Medicare beneficiaries.
Every little bit helps, but I am not surprised by how little attention this small victory has gotten in the media. I think the explanation may be that it is really a very small bite out of such an enormous problem that it is more of a recognition of defeat than a celebration of a real accomplishment. I guess Republicans don’t have diabetes since the lack of Republican support prevented reasonable cost controls on insulin from clearing the 60-vote hurdle in the Senate.
I see the healthcare part of the Inflation Reduction Act as being similar in impact and significance to the passage of the recent gun law after the school shooting in Uvalde, Texas. The gun legislation that was negotiated was better than nothing, but there are still people randomly killing people on the streets and in shopping malls and grocery stores with AR-15s and other assault weapons. Schools are starting and I still fear that we are vulnerable to Columbine, Newtown, Parkland, and Uvalde-type events despite this bipartisan compromise that took so much political effort to pass. Likewise, access and the cost of care will remain inadequately addressed public health problems because the will and the way to do more are lacking in our divided Congress. Perhaps, the reason that the cost, quality, and access to care for all are so low on the list of general concerns for voters and politicians is that it is obvious that Congress has not got the will to do more since the public’s attention for the moment seems directed elsewhere and there are so many more urgent issues that crowd out the concerns about healthcare. COVID “fatigue” seems to be extended into all healthcare issues.
To include all of the potential reasons that healthcare has been “demoted” on our list of social and political concerns would probably require a book or many more weekly “musings.” The journey toward the ultimate objectives of the Triple Aim was initially the primary focus of these weekly musings. Then came Trump. If he wasn’t enough to distract us from the effort to improve the cost, quality, and availability of care, all those efforts moved further down the list of concerns as we contended with the COVID pandemic, the acceleration of global warming with the natural disasters it fosters, Putin’s war against Ukraine and the West, gun violence, the Supreme Court’s overturn of Roe and other decisions that deepen our political abyss, and economic inequities that reveal that we tolerate enormous inequities and are becoming a third world kleptocracy under a thin and fragile patina of economic and military power that is melting at a rate faster than the polar ice caps.
It seems that every day there is a new challenge. In what kind of country do you find cities of almost 200,000 that are centers of government that don’t have potable water? The floods following heavy rain in the Gulf Coast states have revealed yet another manifestation of our national proclivity to delay investments in infrastructure so that we can avoid taxing those who have more than they need while leaving a little money in the pockets of the 64% of the population that is living paycheck to paycheck even if they are making more than $100,000 a year. If you are living paycheck to paycheck you are vulnerable to unexpected expenses and a recent survey suggests that about half of Americans couldn’t cover an unexpected bill of $400. Fortunately for me and my family, we are not in that half.
Late last week I turned on my outdoor shower after taking my usual swim in the lake. I was chilly since both the air temperature and the water temperature were in the high sixties and there was a little bit of a breeze. I was expecting to be immediately warmed by the shower, but I realized after a couple of minutes that there was no hot water. Our hot water comes off the boiler of our propane furnace. We have radiant heat that makes the floor nice and toasty on cold mornings and our heating system and hot water system have the same origin. I had cold showers for several days since our usual heating contractor was out of town and there were supply chain problems with the $600 part that needed to be replaced. When our heating man returned he used some special influence with the part supplier and our hot water was restored after five days of no hot showers and no dishwasher. We now have hot water again, and I can stop boiling water so that I can wash the dishes by hand. I am sure that when we get our final bill it will be more than $1000, but that won’t be a worry for me since we have money in the bank and don’t live paycheck to paycheck.
But what if it was January and not August? I would have had more problems than an inability to enjoy a hot shower or use a dishwasher. My pipes might have frozen if we had not drained them before the temp in the house fell. We would probably have needed to stay with friends or go to a hotel. Infrastructure problems complicated by supply chain problems and workforce shortages create problems for the affluent as well as the poor, those of us with means just have, for the moment, more degrees of freedom, because of our dollars, to help us respond to the unexpected events in life.
Severe hunger, homelessness-producing, and life-shortening poverty exist right now in our country which considers itself to be the G.O.A.T. of countries. Poverty is a greater immediate challenge to life for many Americans than rusty bridges and out-of-date water systems. I know a family in our town that was evicted recently. There is no housing available unless you can qualify for a mortgage that will allow you to buy a house for $350,000 if one comes on the market, or if you are lucky enough to find a rental for a minimum of $1300 a month plus utilities. The local motels have no more availability for the town welfare officers to rent for homeless families. The husband of the family that I have been helping recently is disabled and gets a small monthly check. Those checks get hard to receive when you have no address. The family is now living in a tent on the land of a generous friend. They are trying to convince their little four-year-old son that camping is great fun while they search for a place to live before it gets cold. The wife washes dishes at a restaurant for pay that is not a “living wage.” They are not the only distressed family I know. The stories of real people suffering in our country today move me more than economic statistics. What I don’t understand is the mentality of those that can know of the distress among us and not be moved to try to begin to make a difference or at least vote in a way that enables others who when elected will develop and deploy policies that can make a difference.
What the pandemic and global warming have given more people the opportunity to understand, if they have eyes to see, is that we live in a very connected and interdependent world where even the very wealthy will eventually be vulnerable and where all but the very wealthy are impacted now. I am sure that people of means who live in or near Jackson, Mississippi are not waiting in long lines for bottled water. They have temporarily left town and have gone someplace where there is enough water to flush toilets. We saw such an exit from New Orleans in the aftermath of Katrina seventeen years ago. Universal vulnerability with increased intensity for the poor and minority groups and a long “tail” of continuing social disruption is an emerging reality as we try to assess the impact of the pandemic and as events convince more and more people that global warming is real.
Another reality that may explain why we don’t seem to have the will to overcome the tendency to ignore problems until they personally affect us is that many of us are so affluent that we can “ride with the storm” until it is too late to act. The origins of many of our “wicked problems” of today go back in time. A good example of that reality is that many of our current problems with dysfunctional social services are traceable back to the early eighties when Ronald Reagan’s administration attacked government agencies and welfare. You surely remember his dog whistle laments about “welfare queens.” In the nineties, Bill Clinton ended “welfare as we have known it.” His trade policies contributed to the decline of American manufacturing, but they were great for corporate America. His attack on crime created the need for more prisons that were filled with many people whose crimes and addictions were in part attributable to their poverty and race. We are where we are because of our policies, our inherent biases, and unforced errors of understanding and judgment from both sides of the political aisle.
On Wednesday we got more disturbing news that is evidence that we should not forget the attention that we need to give to the social determinants of health, healthcare, and poverty. The New York Times published a disturbing article about the dramatic drop in life expectancy we experience in 2020 and 2021 compared to other nations. In an article entitled “U.S. Life Expectancy Falls Again in ‘Historic’ Setback,” Roni Caryn Rabin writes:
The average life expectancy of Americans fell precipitously in 2020 and 2021, the sharpest two-year decline in nearly 100 years and a stark reminder of the toll exacted on the nation by the continuing coronavirus pandemic.
In 2021, the average American could expect to live until the age of 76, federal health researchers reported on Wednesday. The figure represents a loss of almost three years since 2019, when Americans could expect to live, on average, nearly 79 years.
It has been worse for men than women:
The longevity gap between men and women also grew by a couple of months in 2021. American women can now expect to live 79.1 years, almost six years longer than men, whose average life expectancy was 73.2 last year, according to the new data.
But, the groups that have suffered most are Native Americans and Alaska Natives. Their life expectancy has fallen to 65 which was our national average in 1944. In an interesting twist, white Americans had a larger fall in life expectancy in 2021 than black Americans. The reverse was true in 2020. The swap may represent the fact that white Americans may have been less vaccinated and did not follow public health guidelines as carefully as did black Americans.
It is disturbing to note that the fall in life expectancy is not totally explained by deaths from COVID:
While the pandemic has driven most of the decline in life expectancy, a rise in accidental deaths and drug overdoses also contributed, as did deaths from heart disease, chronic liver disease and cirrhosis, the new report found.
Did those deaths increase because of the distortion of our care system by the need to devote more resources to COVID? Surgeries were canceled and medical offices were closed. Difficult times may have made some more prone to accidents, drug use, and suicide.
I don’t think that the proper response to this disturbing data is to forget it and assume that average life expectance losses will soon correct themselves as COVID passes, if it does, and things then “return to normal” which seems unlikely in the near future. This result, like some of the recent environmental data, may suggest that we have passed some tipping point. I can’t expect that the “wicked problems” we face will solve themselves. One action we can take is to use our votes in November wisely. By wisely, I mean to use our votes for candidates who speak to policy solutions that may even include actions like taxes that could seem momentarily disadvantageous to you. With our votes, we have some possibility of healing our common problems and promoting democracy in our community, Once we assure the persistence of our democracy we can return to our efforts to achieve something like the Triple Aim. Martin Luther King, Jr. could see our current problems coming fifty years ago when he made the title of his last book a question–Where Do We Go From Here: Chaos or Community?
All of this post down to this point was written before Joe Biden’s speech in Philadelphia last night. In his speech, I think the president nailed it. In answer to the question that the title of this piece asks, “Where Is The Quality of Healthcare On Our List Of Concerns?” I think the president would respond that we can’t return to the improvement of healthcare for all Americans until we ensure the preservation of our democracy. The president referenced How Democracies Die by Steven Levitsky and Daniel Ziblatt which I have referenced in these notes in the past. In the book, the authors cite historical evidence that suggests that the death of democracy is usually a slow process, In the book, the authors reveal the steps in the process. We have already taken many of those steps. The most significant step was the election of Donald Trump. In the Commonwealth Fund review of where America stands compared to other advanced economies, I would point out that the other ten countries, all of which do better overall than we do, are democracies. Perhaps efforts to preserve our democracy should be counted as efforts to improve healthcare.
Labor Day And Butterflies
Summer is about to end. We have enjoyed fourteen “pretty good” weekends starting with the Memorial Day holiday weekend. Will this weekend, Labor Day weekend, be our fifteenth “summer weekend?” I can remember some years when the Labor Day weekend felt like the first weekend of fall.
I have said in the past that summer ends at 6 PM on Labor Day and that may be true this year. The long-range forecast for the weather this weekend in New England looks like summer through Sunday, but Monday will be the chilliest day, and there may be a little rain. We have spent most of the weekends this summer at home. As a change, this weekend we will be with friends in Falmouth on Friday and Saturday and then on Sunday travel to Boston to enjoy a late afternoon cruise on the Charles with many former colleagues who will be celebrating the seventieth birthdays of one of our mutual colleagues and his wife. It will be a “twofer.”
I am a little nervous because it has been eight years since I have seen many of the invited guests, and I am not as quick with names as I once was. I am trying to focus on the fact that it will be a nice way to end the summer, renew old friendships, and get to hear what is happening to so many people with whom I once worked every day. It’s a fact that maintaining relationships over time and distance has always been a challenge for me.
What I do experience at reunions and gatherings where I see people that I have not seen in years is that we seem to “pick up” the relationship where we were when we last saw each other. Social media seems to have altered that dynamic for many, but I don’t spend any time looking at Facebook, Instagram, Twitter, or LinkedIn although I have accounts with each one that I never monitor.
I would like to think I don’t need a presence on social media since I have no need to keep the score of the number of likes or followers that I have. Some time ago the person who helped me set up this letter for Internet distribution also established social network connections for the letter which I have never checked. That said, I do get very excited and have enormous satisfaction when one of you takes the time to drop me an email or register a comment.
I can see on my walks that despite some hot days and summertime thunderstorms on some late afternoons and evenings, we are quickly moving into fall. The mornings are chillier. The ferns along the roadsides are turning brown and the roadside ditches are full of goldenrod. Or is what I see ragweed? According to my plant ID ap, the proliferating plants along the edge of my road are 71% likely to be Canada goldenrod, Solidago canadensis. I love the bright yellow of the goldenrod and connect it with late summer when it becomes so ubiquitous, but I guess it is technically a weed. What’s the difference between a weed and a wildflower? I also like the dandelions which turn my yard into a sea of yellow in the spring.
My wife has spent a lot of time with our plantings and her garden. This is harvest time in her raised-bed garden. We have a bumper crop of tomatoes of various varieties. There are millions of cherry tomatoes, and some of the Brandywine heirlooms are almost six inches in diameter and look like melons.
In her flower gardens and among the shrubs around the house, there are late summer bloomers like Rose of Sharon and rudbeckia, better known as Black-eyed Susans. Butterflies love the late summer flowers. My wife likes taking pictures almost as much as she enjoys her garden and her flowers. Recently we have seen many Monarch butterflies and I planned to use one of her pictures for today’s header. As I looked over her pictures, I discovered that there was a second “yellow butterfly” that I did not recognize. With the help of the Internet, I have made a new butterfly acquaintance. The unknown butterfly is named “The Great Spangled Fritillary.” The plant that the butterflies love is Hummingbird Summersweet or Clethra alnifolia. There is always something new to learn in nature.
Whether you are at the beach, in the mountains, on the road, or just relaxing at home with a good book, or plan to enjoy a backyard cookout, I hope that this last weekend of summer, or if you prefer, the first weekend of fall, is a joy for you. I am beginning to think about fall foliage.
Be well,
Gene
