December 29, 2023
Dear Interested Readers,
It’s Been A Tough Year
I am not sorry that we have only two more days in 2023. I always see a little hope in new beginnings. 2024 has the potential to be an outstanding year, but there is an almost equal possibility that it could be a monumental disaster. One thing seems clear to me, we probably will not see an improvement in our healthcare concerns in the coming year.
Access to care will remain a challenge even for hundreds of millions who are theoretically covered as well as the over thirty million, almost ten percent of Americans, who have no insurance. We are almost fourteen years past President Obama’s signing of the ACA in March 2010, and ten years after it was fully implemented in 2014. When the ACA was passed I viewed it as a compromise, but the best deal that could be negotiated in the moment. I was sorry that Joe Lieberman had blocked a public option, and I hoped that there would be the equivalent of ACA 2.0, 3.0, 4.0, and onward in a process of continuous improvement as each step proved that we were on the right path, and there was more universal benefit to be gained by making appropriate changes as experience with what worked well and what needed to be improved was accumulated along the way.
What has happened is the reverse of what I had hoped would be our experience. Much of the potential benefit of the ACA has been lost through court decisions and the reluctance or delay of many conservative states to accept the Medicaid expansion. Many of the offerings on the marketplace established by the ACA have had increasing copays and deductibles that are a barrier to routine care and early interventions to limit the impact of serious problems. The ACA is better than nothing, but it has not entirely solved the access problem to healthcare. We do not have the universal coverage that most other developed nations provide for all their citizens and even visitors and aliens who become ill while within their borders.
The situation with the ACA reminds me of how the Civil Rights movement lost ground and momentum after the passage of the Civil Rights Act of 1964 and the Voting Rights Act of 1965. The last couple of years of Dr. King’s life were frustrating for him. He complained that the coalition of liberal Republicans and Democrats that had made progress possible considered the work to be done after the Voting Rights Act passed in 1965. Dr. King felt that the majority of liberals who had made success possible were tired of the process and wanted to declare victory. They were not interested in robust social equity and economic opportunity for everyone. They seemed satisfied with the work done and saw no need for further political action. Reparations for past injuries were not politically possible and programs and policies for improvement in economic equity going forward became increasingly difficult to discuss much less create.
The Poor People’s March in 1968 was the result of Dr. King’s sense of loss of the concern of liberals in addressing the struggles of the poor of all races. Dr. King tried to overcome the growing resistance to his concepts of equity for Black Americans by expanding the focus of his campaigns to the problems of all poor people. Dr. King’s assassination and the war in Vietnam signaled the end of rapid progress in the fight for his “dream” and the beginning of the slow erosion of the gains made through the fifties and sixties that continues today as the Supreme Court and state legislatures continue to diminish the benefits of the Voting Rights Act. I see a similar loss of enthusiasm from the coalition that developed around the Triple Aim and the passage of the ACA. Perhaps for some, the advances of the ACA are enough, but any scrutiny of our health outcomes, especially the experience of underserved and poor populations would suggest that there is much more work that needs to be done.
When in 2008, I became the CEO of Harvard Vanguard Medical Associates and the coalition of medical groups that formed Atrius Health there was more enthusiasm for the pursuit of the Triple Aim. There were problems with costs, access, and inequitable outcomes that affected the health of the nation, and we felt that we had a direct responsibility to participate in the resolution of these problems in the pursuit of the “Triple Aim.” I was inspired by attending the annual IHI conferences where there would always be thousands of healthcare professionals talking about the importance of making healthcare better for everyone.
I wonder what happened to that enthusiasm I experienced in 2008? Did we figure that we had solved all the problems of healthcare with the passage of the ACA? Did we just get tired of the work? Did financial pressures derail our good intentions?
As the Kaiser Family Foundation reports regularly, more than a decade into the ACA, cost remains a huge barrier to care for many among us. KFF found that 25% of covered Americans are afraid to use the health insurance they have for fear of the cost they will pay. We have more than 340 million Americans and 92% of the population is “covered,” which means that over 75 Million people had cost concerns that made them reluctant to use their “covered” access to care. Adding those 75 million people with inadequate cost protection to the 30 million Americans who have no coverage at all means there are over 100 million Americans with no coverage or functionally inadequate coverage. Those numbers don’t include all of those living among us who are not “citizens.” The tens of millions of people without access to care in America in 2023 should be a high-priority problem that politicians will be addressing in the campaigns of 2024.
So far I have heard only one candidate for president, ironically Donald Trump, say much about healthcare. Trump has revealed that he will replace “Obamacare” with a “better plan.” He provides no details, but we have seen this movie before. His statement reveals his ignorance even if you believe a man who made more than 30,000 false or misleading claims while in office. Even if he has a plan, he is ignoring or is unaware of the fact that the cost problem extends far beyond the ACA since the ACA covers only 40 million people, and at least 100 million, if not 150 million people have a problem with healthcare costs. The fact is that we all have a problem with the cost of care because of the money we waste on overpriced care and the misuse of medical resources impacts the whole economy and prevents us from financing other things like better housing and education. Candidate Trump is right to call attention to healthcare. He knows, as the KFF reports, that healthcare is a big problem for many Americans, and he knows that other politicians aren’t saying much about it.
Back in 2008, we were only beginning to worry about the potential workforce issues. It did not take me long after I became a CEO to understand that we needed to do something about future staffing when I realized that the large majority of our clinicians were over fifty-five. That worked to our advantage when we needed to downsize as our patient population shrank in the aftermath of Harvard Pilgrim going into receivership because many were willing to accept a severance package which we borrowed money to fund. Now, for Atrius and the country as a whole, workforce shortages are an evolving disaster that has added billions to the cost of care while making it even harder to solve our access problems.
Workforce issues are particularly problematic for rural hospitals and chronic care facilities. An article this week in my local paper revealed that care for the elderly on Medicaid/Medicare in nursing facilities in Vermont is collapsing because of workforce issues and inadequate Medicaid funding. Across the country, there has been a tsunami of institutional closings because of an inability to find staff and pay them. Why isn’t that a political issue?
As I think over the last few years since the pandemic began, I am beginning to think that access issues, cost issues, workforce issues which are also cost and care issues, and other issues of inequality in healthcare outcomes have become such complicated interconnected problems that no politician can offer a solution. Could it be that politicians who are unwilling to lie don’t say anything about healthcare since there is no way our complicated system of care which is built on the fallacy that markets can solve human problems can ever be adequately reformed in an environment of deep bipartisan distrust? We need something very different than we have and it probably should not be built on a chassis of fee-for-service finance. Politicians know that the vested interests in healthcare will fight that level of change to the death. I fear that what should be a huge issue in the 2024 elections will be pushed aside, by other easier-to-consider concerns.
I asked myself about the issues of 2023 that are pushing healthcare aside in the 2024 elections. It was a helpful exercise for me to make a list. My list is just an attempt to identify concerns and not an effort to rank them, but please rank them for yourself. After constructing the list, I realized that in some way every issue on the list is connected directly or indirectly to the future of healthcare through the social determinants of health or as a public health concern.
- The economy/inflation: There is no question that many of the problems precipitated by the pandemic are improving especially for people like me who have assets. I love that the market is up, but a couple of hundred million Americans are more interested in the cost of groceries, gas, and rent, and they aren’t happy yet. The cure for inflation has not been a recession, but it has been higher interest rates which aren’t popular. Few Americans care that inflation is a global problem and that compared to other nations we are doing very well in our recovery.
- Immigration/ illegal immigrants: The problems at our borders will not be solved by better fencing, more agents, and faster deportation processes. Ironically we need more labor. If you drink milk, eat ice cream, enjoy fresh fruit and vegetables, or like pork and beef, it is highly likely that the product you enjoy was probably touched by an illegal immigrant at some point in its production or delivery to you. Ironically, I fear that if we solved the immigration problem by successfully turning everyone away, the outcome might be huge labor problems and another round of price increases for most goods and services. It is also true that we are a country of immigrants and that those who have the energy and determination to make the journey have often made huge contributions to us all. Inferring that many of the people who seek to come here are criminals or rapists is one of the worst examples of contemporary demagoguery. Biased talk that demonizes those seeking to come here is easy and politically expedient for those who want to stir up some political outrage. It can be the political equivalent of tossing a Molotov Cocktail to say that we have failed in our efforts to control the masses seeking freedom and a better opportunity for themselves and their families in America. Perhaps there is political opportunity in complaining about a complex problem without participating in its solution. The history of attempts at immigration reform since 1986 is the story of failure followed by failure followed by more failure. Republican politicians like John McCain and the second President Bush made genuine efforts that failed. Every administration and Congress for the last thirty-plus years shares responsibility for the current mess.
- Drugs/ Fentanyl: Why is there a market for drugs? Again, the issues are complex, and solutions will elude anyone who just wants to focus on those who bring them into the country. This is a social problem that crosses all income levels. I have to believe that we need to focus on managing the social and mental health problems that lead people to self-medication and addiction. We have identified that we have an epidemic of disease of despair. We have consistently undermined our mental health system of care since Reagan canceled Carter’s focus on mental health in the community.
- Housing/ Those without adequate housing: Our workforce issues are exacerbated by our lack of adequate workforce housing. A great shame is the fact that some must sleep in their car or under a bridge even if they have a job. In my little town, there is competition between agencies trying to use the scarce motel rooms available for those who can’t afford a place to live, and the hospital’s need to provide temporary lodging for “the traveling nurses” we need to deliver hospital care. The total cost of traveling nurses which includes their pay, agency fees, and local housing can exceed $300 per hour. There is a perfect storm of inadequate housing stock, rising rental costs, inadequate housing policies, and “not in my backyard (NIMBYism)” attitudes which frustrate attempts to build more housing. Individual interests easily “trump” collective benefit in my little town and across the country.
- Gun violence: The biggest learning from the mass shooting earlier this year in Lewiston, Maine is that the focus on mental health restrictions to acquiring guns is the equivalent of using apricot pits to treat cancer. A focus on mental health helps, but our systems of using mental health records to restrict access to guns are imperfect. No one needs high-capacity guns and military assault rifles to be a sportsman or to defend their home from an intruder. We don’t need more guns than people. Gun deaths for 2023 have already exceeded 40,000. We have had 39,000 or more gun deaths every year since 2014. About half are suicides which may connect them to several other issues on this list. No issue is a “stand-alone” problem. I fear that “there will be moss on my tombstone” before our problem with guns is solved.
- Weather/ Climate/ Global Warming: A phrase my father loved was “The harder I try the behinder I get.” This seems to be the reality with this issue which should be more of a concern for each of us than it appears to be. There is a lot of rhetoric followed by insufficient action. I recommend that you read Kim Stanley Robinson’s sci-fi novel, “New York 2140,” which describes life in a partially submerged New York City where the taxis are boats. Efforts to control global warming increased after most of the polar ice caps had melted and billions had died. The good news is that there was adaptation/ recovery. The bad news was that predatory financial markets and crime survived.
- Reproductive rights: For me, this issue feels more like, “Do we become a theocracy?” Is Christain Nationalism a threat to reproductive rights? Without Trump’s unholy alliance with evangelical Christians, he would just be someone who was indicted for outrageous felonies. Let me be clear. I consider the right to be able to decide whether to have a baby or not belongs solely to each woman. If an individual woman chooses to carry a baby based on her religious convictions, that is her right. If another woman chooses not to have a pregnancy for whatever personal reason, that is her right. Having a state legislature, attorney general, governor, or judge do the work of a doctor when there is a possible threat to the mother’s health is a societal crime. Ironically, I think we do a terrible job of providing help to women and their partners who want children but can’t afford the out-of-pocket costs of treatment for issues of infertility. Even worse is the neglect that we give to the growth and development of many children born into poverty or dysfunctional families.
- Infrastructure inadequacies: Bridges collapse, planes almost collide, electrical grids fail, and water systems are polluted by ancient lead pipes. There is work to be done after decades of neglect as the ultra-rich and multi-billion dollar corporations used political power to avoid paying their fair share of taxes.
- Wars and rumors of wars: Enough said. Ukraine/ Russia, Gaza (Palestine)/ Israel), China/ potentially us, generate the fantasy in some that an isolationist “What me worry” attitude is our best foreign policy. I do believe that we have been in conflicts we should have avoided, but I don’t think it is in the best interest of the world to leave the Ukrainians to an “Alamo” fate or for us to fail to help find the narrow path between the security Israel desires and deserves, and the human rights of the majority of Palestinians who lack many of the rights we say are the birthright of all humans. In both the Ukraine and Gaza conflicts, there is a narrow strategic path between desired objectives and a wider conflict. We should worry about potential conflict with China if for no other reason than our reliance on them for inexpensive consumer products and many critical components in the supply chains of things that we think we manufacture. If we are going to enjoy the benefits of a global economy, we need to be part of the coalition that enforces international law and rejects invasions and war crimes.
- Democracy versus illiberalism: This one confounds me. Those on the far right surely want individual liberty. Anyone who wants to bypass the rule of law in favor of an illiberal order because at the moment the potential “strongman” favors their worldview or is offering/ promising a protection that they desire is a fool. Things change and the only protection an authoritarian has is to suppress the freedoms that become a risk to his/her power when things change. In that moment many who were once protected by their fealty to the ruler may become the next victim of the regime. As messy as our deeply partisan democracy is, I prefer it to what I see in Russia, China, Hungary, Turkey, India, Iran, or the Philippines, all of which are illiberal or beginning to lean that way.
My list does not cover all the issues. Part of the problem is that it is hard for most voters to focus effectively on more than one or two big ones. Examples of the issues that I have left out are the concerns about the cost and effectiveness of higher education, the crippling effects of student debt, and the presumed increase (false) in violent crime in our cities,
The political events of the coming year deserve your attention for these issues and more. The election won’t be just about who becomes president. The experience of this last crazy year in the House of Representatives proves that when control of government is divided no one wins and at best we must struggle to minimize the loss of past progress. If we ever hope to evolve policies that address the social determinants of health that compromise minority and disadvantaged populations, or if we are ever going to develop a system of care that equitably provides care for all individuals at a sustainable cost, we need to realize that issues of age are a decoy thrown in the mix by those who have little positive upon which to campaign. I could argue that an 81-year-old who has practiced good health habits all of his life may be healthier in 2028 than an impulsive, angry, out-of-control 77-year-old who has a weight problem and delivers rambling stream-of-consciousness speeches.
The executive branch in our democracy is usually not just one person. Government is a team effort. I prefer a team that is concerned about the well-being of our democracy and the needs of the underserved than a team selected for their desire to dismantle the machinery of good government for the benefit of those who don’t like paying taxes or regulations that may reduce profit margins or protect the environment. The challenge in 2024 will be to elect a team that can responsibly struggle with all of the issues above and more.
The Story Continues
Next week.
No Snow. No problem.
There was nothing that I could do to make it snow so that we could have a “White Christmas.”. My grandsons arrived from California with their new boots, mittens, and snowsuits, but with no possibility of using them in the snow. The last time the boys were here for the holidays they had great fun in the snow. This year there was no sledding, no building of snow forts, and no throwing snowballs. On their last winter trip to see me they even tried some ice fishing. This year the lake has frozen and then thawed three times. As it became clear that it would be warm and that there would be no snow, I was certain that they would be disappointed.
Children are resilient. Their new snow boots were great for jumping in puddles. They found small clumps of residual snow on trails in the woods and in some shaded places in my yard and tossed a few snowballs. The ice on the lake wasn’t thick enough for walking, skating, or fishing, but they had great fun throwing rocks out onto the ice with the hope that a big one might break through the thin sheet.
What I did not realize as I was grieving the fact that we had no snow was that our weather would be perfect for hiking. We have had a great time enjoying the many trails maintained by the New London Conservation Commission. Our town has made a huge investment in providing well-maintained trails through the many interesting open spaces in our town. In the middle of town, we have a town forest and nature trail with geocaching. My oldest grandson is an enthusiastic geocacher and found two caches.
Within a very compact area, we have a lot of hiking variety. There are trails along rocky mountain streams with beautiful waterfalls within two miles of my home. A mile away is a real bog with incredibly colorful vegetation which you can see in today’s header. Much of the red color in the picture is from thousands, perhaps millions, of carnivorous “pitcher plants.”
Not far up I 89 into Vermont, there is more adventure. We enjoyed an afternoon at the Vermont Institute of Natural Science (VINS) where the boys learned about birds of prey and explored the tree-top canopy on suspended walkways. Mick Jagger and his Stones bandmates had it right when they sang:
You can’t always get what you want
But if you try sometime you’ll find
You get what you need
I hope that you are getting what you need during the Holidays. 2024 will be full of election news and ads. I feel lucky that we get a break in New Hampshire because our primary craziness will be over on January 23. It will be a relief to say goodbye to Nikki Haley, Ron DeSantis, Vivek Ramaswamy, Chris Christy, and Donald Trump and their continual political ads. Sometimes there are two or three ads from the same candidate delivered back to back when I would rather be hearing the evening news report.
Enjoy the New Year Holiday weekend. My hope for 2024 is that it will be a rewardingly positive year for all of us, especially for those trying to improve healthcare and others who are struggling to protect democracy and our fragile environment. I have done my best to enjoy a global-warming winter holiday, but I don’t want it to be an annual event.
Be well,
Gene
