April 18, 2025
Dear Interested Readers,
Everything Is Connected, Uncertain, and Likely to Get Worse
The last thirty years have convinced me that healthcare, political issues, controversial social issues, and economics are connected in ways that can’t be teased apart. Early in my years of practice, I was focused internally on developing my practice skills and becoming an effective member of our practice. I did not pay much attention to the external forces that impacted patient care. Now, in retirement, the situation is reversed. I realize that healthcare is connected to every aspect of our shared lives in ways that are often not obvious, but are nevertheless critical. At almost 20% of GDP, the cost of healthcare impacts the entire federal budget and is a major aspect of every household budget. You can be assured that, whatever the outcome is of the international storm of uncertainty that the president has created with his obsession with tariffs and his disruptive foreign policies, there will be some impact on your healthcare and that of your neighbors.
When I began to practice in 1975, the nation was enjoying the benefits of the extension of access to care created by the passage of Medicare and Medicaid in 1965. Our practice consisted mostly of patients and their families who were covered by commercial insurance, but we were actively pursuing the opportunity to become an HMO, which had been created by the HMO Act of 1973, which President Nixon had signed. Despite his many other faults, Nixon cared about healthcare. At that time, government and healthcare seemed aligned and became even more aligned as Jimmy Carter became president and sought to launch a robust community mental health program.
Like many other medical students, I received substantial government support that allowed me to graduate from medical school in 1971 with very manageable debt that was never more onerous than a monthly car payment, and I did not need to begin to pay down my debt until 1981. Simultaneously, our government was creating robust research efforts at the NIH and in collaboration with universities and their medical schools. The collaboration between the research community and the government produced amazing results that brought benefits to every American and extended to the “ends of the earth.”
The first time I experienced our government as an obstruction to patient care was during the early years of Ronald Reagan’s first term. He abandoned the mental health initiatives that Carter had launched, and we were informed that there were “welfare queens” who abused social services. I frequently had patients who were disabled from their heart condition, and were eligible for financial support through their Social Security Disability benefits. During the first five years of practice, I helped several patients apply for Social Security Disability support, and everyone was approved. Not long after Reagan came into office, my patients applying for disability support for which they were entitled were denied. It was an early iteration of the strategy to avoid payments that some health insurers now use– “delay, deny, defend.” I’ve told the story before, but what I discovered was that after three denials, a patient could ask for a hearing before an administrative law judge. Those patients who could persist finally got the support for which they were entitled. It is my opinion that healthcare and politics shouldn’t be connected, and that those in need expeditiously get the help they need.
Perhaps the explanation for what I observed is that the whole country was shifting its philosophy from a community focus to a “me first, take care of yourself” orientation. There is no question now that over the last twenty years our “right v. left” politics have deeply impacted access to care, the cost of care, and the experience of care, but it was not until January 21, 2025 that our politics became divided over our support of medical research and our public health efforts at home and abroad. It is usually true that when “external” forces become a problem for institutions and even families, the stress creates internal divisiveness and disruption over how to respond.
In September 2007, about six months before I became the CEO of Harvard Vanguard Medical Associates and Atrius Health, the New England Journal of Medicine published Dr. Steven Schroeder’s Shattuck Lecture entitled We Can Do Better — Improving the Health of the American People.” This article never uses the phrase “the social determinants of health,” but it presents the stark reality that social conditions have a greater impact on longevity than disease, the system of care, or genetics. Supportive government policies are absolutely critical to the improvement of the social determinants of health. Indeed, as I wrote last September, the social determinants of health are derivative of the structural determinants of health, which are derivative of the political determinants of health. Those insights were initiated by Schroeder’s article.
If I could have only three pieces of medical literature, I would choose Schroeder’s speech as recorded in he NEJM, the Health Affairs publication of The Triple Aim by Berwick, Nolan, and Whittington, and Crossing the Quality Chasm: A New Health System for the 21st Century published by the Institute of Medicine in 2001. These three publications from 2001, 2007, and 2008 describe the platform from which the meager accomplishments of the last two decades have been launched. Within the last three months, the slow progress that we have made toward the Triple Aim has been put in jeopardy along with our medical research infrastructure, our system of public health, intellectual and academic freedom, our economy, and our leadership of the democracies of the world.
Our president has now pushed us to the brink of a Constitutional Crisis by ignoring rulings from our courts and turning the Department of Justice into a tool for political revenge. In December of 2023, long before he was re-elected, President Trump declared that he would be a dictator only on “day one.” As of today, he has been “a dictator on day one,” and for an additional eighty-seven days. From where I stand, it appears that we are the subjects of a very inconsistent, rathful, ruthless, and narcissistic sociopath, who has terrorized his own party, and threatens the economic, military, and ecological future of the whole world. Everything is in a state of confusion or dissolution, and all of the subsequent uncertainty and chaos are ultimately connected to our personal health, our collective economic health, and the health of our planet.
These days, I am desperate for any evidence of effective resistance to block the president’s campaign of chaos. There have been a few hopeful signs in the last few days. Harvard’s refusal to accept the ultimatum of the collective thuggery of the administration gives one reason to hope. Dr. Alan Garber, the president of Harvard, showed real courage. If you have not read the communication between the Trump administration and Harvard, you should. Click here to read a New York Times article from Monday that gives access to the letter from the government to Harvard and the letter back from Dr. Garber to the Trump administration.
As a Harvard Medical School graduate who has benefited greatly in life from the opportunity to attend the medical school and then maintain a relationship with the medical school and its affiliated instutions, I am quite proud of the fact that the Harvard has shown that its principle of academic freedom is not for sale, and has offered its resistance as an example of courage to other institutions and individuals. I am also very impressed by Dr. Alan Garber’s leadership in a very difficult situation.
I feel fortunate to have had some limited professional contact with Dr. Garber. If you clicked on his name above and read his personal history, you will see that he graduated from Harvard College, earned a doctorate in economics from Harvard, and then went to Stanford, where he earned his medical degree. I first encountered Dr. Garber when he was an intern at the Brigham in 1983, I did not realize at the time that, besides being a very capable house officer, he was also a healthcare economist. He finished his residency at the Brigham in 1986, and I did not have direct contact with him again until 2011 or 2012, when he was the provost of Harvard and I met with him to discuss some of our collaborative efforts. My takeaway from my brief encounters with him is that he is a very thoughtful, capable, and committed leader. He presents an example of just the sort of leader we need at this time. I hope that Dr. Garber’s willingness to stand up to the absurd and probably criminal, if not unethical, abuse and misuse of power by the president and his hoodlum underlings will give courage to other university presidents and public leaders to collectively say that the intimidation must stop.
For some time now, political pundits have been debating whether or not we will have or are having a Constitutional Crisis. I believe that the recent interactions between Trump and the law firms and universities that he is aggressively harassing are regrettable, but do not rise to the level of a Constitutional Crisis. I do believe that his disregard for the court rulings related to how he is cruelly abandoning a legal resident without a criminal history to a horrible prison in El Salvador does qualify as a Constitutional Crisis and proves that he has no intention of respecting and complying with court decisions that seek to right the injustices that he visits on those who cross him or are convenient targets that enhance his sense of power.
In his podcast yesterday, Ezra Klein expressed the opinion that the Constitutional Crisis that many fear has occurred. Klein is not a Pollyanna. He doubts that there is any possibility of checking Trump’s abuse of his office until the midterm elections of 2026. Only Congress can hold the president accountable for his crimes. Our Republican-controlled Congress, which is populated by legislators who have already shown their agreement with or fear of the president, is not going to check his abuse of his office. Klein declared:
The emergency is here. The crisis is now. It’s not six months away. It’s not another Supreme Court ruling from happening. It is happening now. Maybe not to you, not yet, but to others. To real people whose names we know, whose stories we know. The president of the United States is disappearing people to a Salvadoran prison for terrorists.
What disturbed Klein even more than Trump’s abuse of Kilmar Armando Abrego Garcia was the president’s declaration that he would also like to send some of “our homegrown” criminals to El Salvador. If you respond by stating that this is just “Trump being Trump,” I would ask you to make a list of all the things he said during the campaign that he wanted to do, and then compare that list to the surprising things that have happened over the last eighty-eight days.
The problem with predicting anything about the president’s actions is that we don’t have confidence in anything he might say. His reversals, lies, and contradictions create an environment where basic trust is impossible. Do you trust that nothing he does will compromise Medicaid? Will the financial support for programs that provide food and fuel for the poor be adequately financed? Will he not turn the US military into an internal police force to block demonstrations like the “Blck Lives Matter” demonstrations in 2020?
His tendency to shoot and then aim creates an environment of distrust that is antithetical to accepting the risks associated with operating a small business or the decision to build a new factory.
The Pulitzer Prize-winning New York Times columnist Tom Friedman reports that the recent advances in supply chain management and manufacturing in China preclude a successful outcome of our ridiculous trade war with China. Our economies and our supply chains are linked in ways that give the Chinese many options up to and including refusal to sell us at any level of tariff the materials that we don’t have and without can not do business. Friedman writes:
Trump’s constant bluster and his wild on-and-off imposition of tariffs are not a strategy — not when you are taking on China …
…The question for Beijing — and the rest of the world — is: How will China use all the surpluses it has generated?…We need to encourage China to make the right choices. But at least China has choices.
Compare that with the choices Trump is making. He is undermining our sacred rule of law, he is tossing away our allies, he is undermining the value of the dollar and he is shredding any hope of national unity…
…If Trump doesn’t stop his rogue behavior, he’s going to destroy all the things that made America strong, respected and prosperous…
I have never been more afraid for America’s future in my life.
I would add to Friedman’s list of bad outcomes in the wake of Trump’s delusional policies that might “Make America Great Again” is that as a result of what he is doing we are throwing away at least fifty years of progress in the performance and infrastructure of our healthcare and programs that support medical research. As you know, I have always thought that we could do better. I never imagined that our president would make choices that would zealously undermine the progress toward “better” that we have made with such great effort.
Progress toward improved care and improving life expectancies for all Americans is hard to imagine in the mud and dust of the upheaval in norms that characterize the first three months of our second Trump adventure. What I hope might happen is that people in positions that might have some ability to stand up to the uncertainties, like Dr. Garber did, will have the courage to do so. The rest of us need to show up for public demonstrations to register our concern, and we should be looking around in our communities and healthcare institutions to see if there are ways that we can help those who will suffer from the loss of resources that are likely to occur.
It will take several more months before we experience the full impact of all that has occurred in these first frantic days of Trump II. While there is great uncertainty about the future, there should be no uncertainty about the fact that we should continue our resolve to resist further injury to our democracy and the damage that will be done to healthcare as we have known it.
A Difficult Road Ahead
As I have mentioned before, my youngest son works in a large non-profit that provides free IT training to people who are living in poverty. If you clicked on the link, you have seen some of the work he does. He was a graphic art major in college, but his passion is his music. For the past fourteen years, he has posted a song on the Internet every Monday. Some weeks, when he is busy at work or as a father, the songs are just snippets of poetry with a few chords and a short essay with an interesting photograph. This week, for the first time in quite a while, he substituted a drawing for the usual photo. The graphic has a simple beauty that may contain a message, so I thought I would share it with you.
When I look at the picture, I see a solitary figure on a curving up and down path over rough terrain. There are steep declines and challenging rises ahead for our lonely hiker. It feels like the picture is telling a story. My only reservation that prevents me from saying that the picture is a metaphor for what we are experiencing in these difficult times is that the hiker is alone. At times when I read the announcement of some new outrageous attack on our country’s stability, I do feel alone, but then I remember that although he fooled a majority of voters last November, it is probably true that he has undermined that support and in time he may virtually stand alone in history as the worst president we have ever endured. Those of us who he has terrorized are not alone, but the path forward remains a challenge for each of us. We will all be impacted. Some will suffer more, but all of us will suffer some loss in the end. In that regard, we are not alone.
I have not forgotten that spring is coming in its own good time. Whether you celebrate Easter or not this weekend, or plan on enjoying the Boston Marathon this coming Monday, it is hard not to experience some form of hope as the days get longer, the sun gets warmer, and the vegetation comes alive in splashes of bright green. I hope that you have a great weekend.
Be well,
Gene
