30 August 2019
Dear Interested Readers,
Our Heads Spin From So Many Things To Consider. Are We Talking About What Really Is Important?
I am not sure what to expect in the next round of the Democratic debates. I am very happy that there will be only ten candidates on the stage in Houston on September 12th. Those candidates are:
- Former Vice President Joseph R. Biden Jr.
- Senator Cory Booker of New Jersey
- Mayor Pete Buttigieg of South Bend, Ind.
- Julián Castro, the former housing secretary
- Senator Kamala Harris of California
- Senator Amy Klobuchar of Minnesota
- Former Representative Beto O’Rourke of Texas
- Senator Bernie Sanders of Vermont
- Senator Elizabeth Warren of Massachusetts
- Andrew Yang, a tech entrepreneur
The big question for me is not who is on the stage, but rather what the conversation will reveal. I still doubt that the format will be useful in helping a conscientious voter decide who is best to lead the country. This debate will be a production of ABC and Univision and the questions will be asked by George Stephanopoulos, David Muir, Linsey Davis and Jorge Ramos. With ten people on stage vying for attention, I fear that the only difference between these debates and the last two debates will be that there will only be one night of cacophony and not two.
We all know that there have been a few candidates who have gotten the message and have dropped out. Kirsten Gillibrand is probably the most prominent candidate to understand and accept that 2020 will not be her year. It never was going to be the year for Jay Inslee, John Hickenlooper, or Seth Moulton. I was discouraged to read that Michael Bennett, Steve Bullock, Tulsi Gabbard, and Tom Steyer could conceivably be back in the debates in October. Tom Steyer is determined and has billions of his own money to spend. Living in New Hampshire, a state that could be an opportunity for him, I get about five emails a day from him because I made the mistake of going to his website to check out what he had to say about healthcare. There was nothing there but a request for my email and a donation. I compounded my mistake by entering my email and giving him $5 dollars. About fifty emails later, all I know is that he cares about the climate; that he thinks that he and other rich people should pay more taxes; that he hopes to make the October debate; and that it is his opinion that the president should leave office now and not in January 2021.
The one-night format means the leading candidates will all share the stage for the first time. It does not mean that there will be an orderly or productive conversation. The news people will ask a question of a candidate and the candidate will have one minute and 15 seconds to answer the question. I am sure the ABC and Univision executives hope that “theater” or viewer interest will primarily arise from the 45 seconds for responses and rebuttals. There will be opening statements but no closing statements. That seems strange. Opening statements are soon forgotten, but closing statements allow us to at least get some sense of the candidates composure after the ordeal.
I was never a Jerry Springer viewer but I get the sense that the drama of the arguments and insults that were red meat for the viewers of that show are the objective of the sponsoring networks that are bringing us these Democratic debates. If you aren’t familiar with Springer’s show here is the formula for the long running show (1991 to 2018) as described by Wikipedia.
A typical episode of Springer begins with a title card warning viewers that the show may contain graphic or mature content. Springer then enters the stage by sliding down a stripper pole, being greeted by a standing audience (made up of mostly college students) pumping the air with their right hand, chanting “Jer-ry!, Jer-ry!”. He then shakes hands with those in the front and, afterward, the audience settles down. Springer then welcomes viewers to the show, introduces a particular situation, or topic, and interviews several guests experiencing such situations. After finishing the interview, Springer announces the entrance of another guest whom the first guest would like to confront. The second guest enters the stage, and a confrontation between the two guests usually occurs, often breaking down into a brawl that is eventually broken up by on-set security personnel.
Once the fight has been quelled, Springer interviews the second guest about the situation faced by the first guest. In many episodes, there is a third guest involved in the situation, who is also interviewed by Springer, and often takes part in the on-stage fighting. It is also not uncommon for a fourth guest to be involved. Often guests will be given a cup of water after fighting, ostensibly to “cool off,” but inevitably, the guests toss the water at each other, thus resuming the altercation.
Yes, I am being facetious, but I was disappointed with the quality of the debates in 2015-16, and there does not seem to be any improvement so far in the format or in the quality of these exercises for this election cycle. I am not looking for something as useful as the Lincoln-Douglas debates of 1858, or the debate between Nixon and Kennedy in 1960 where even as a fifteen year old it was easy for me to see how the two candidates differed. What I am looking for is a discussion that demonstrates the quality of each candidate’s understanding of the complexity of the challenges that we face. I am not looking for final answers. To put it in terms of a Lean analysis, I want them to address the reason for action, an accurate description of the current state, and their concept of either an improved state, or if they are so bold, an ideal state. I do not need them to jump to solutions, or proposals, that the complexity of passing laws will certainly modify. Is that too much to ask? It maybe that Donald Trump’s impact on our culture and political processes began with his belittling, rude, and confrontational behavior in the 2015-2016 Republican debates. I am not humored by Democratic attempts to mimic that behavior.
I received a brief email from an Interested Reader, Joe Knowles, earlier this week. Joe wanted to know if I had seen an article in the New York Times entitled “Our Food Is Killing Too Many of Us: Improving American nutrition would make the biggest impact on our health care.” The article was written by Darish Mouzaffian, dean of the Tufts Friedman School of Nutrition Science and Policy and Dan Glickman, former Secretary of Agriculture, 1995-2001. The article is brilliant because it underlined the importance of how important it is to connect the healthcare debate to issues beyond methods of universal coverage and the cost of prescription medicines. The article reminded me of the way one could look at how the “Green New Deal” is about much more than climate change, a subject that I wrote about in early June.
The article begins:
The Democratic debate on health care has to date centered around who should be covered and who should pay the bill. That debate, which has been going on for decades, has no clear answers and cannot be easily resolved because of two fundamental realities: Health care is expensive, and Americans are sick.
Americans benefit from highly trained personnel, remarkable facilities and access to the newest drugs and technologies. Unless we eliminate some of these benefits, our health care will remain costly. We can trim around the edges — for example, with changes in drug pricing, lower administrative costs, reductions in payments to hospitals and providers, and fewer defensive and unnecessary procedures. These actions may slow the rise in health care spending, but costs will keep rising as the population ages and technology advances.
That is a terrific opening. In Lean parlance it is a good start on a “reason for action” and an analysis of the “current state.”
They go on to catalog the impact of diet on the health of the population:
More than 100 million adults — almost half the entire adult population — have pre-diabetes or diabetes. Cardiovascular disease afflicts about 122 million people and causes roughly 840,000 deaths each year, or about 2,300 deaths each day. Three in four adults are overweight or obese. More Americans are sick, in other words, than are healthy.
You may disagree with the analysis, but every time I go to a mall or take a flight I am amazed by the number of obese adults and children that I see.
Instead of debating who should pay for all this, no one is asking the far more simple and imperative question: What is making us so sick, and how can we reverse this so we need less health care? The answer is staring us in the face, on average three times a day: our food.
Poor diet is the leading cause of mortality in the United States, causing more than half a million deaths per year. Just 10 dietary factors are estimated to cause nearly 1,000 deaths every day from heart disease, stroke and diabetes alone. These conditions are dizzyingly expensive. Cardiovascular disease costs $351 billion annually in health care spending and lost productivity, while diabetes costs $327 billion annually. The total economic cost of obesity is estimated at $1.72 trillion per year, or 9.3 percent of gross domestic product.
There is a lot of data about what kills us. The authors are essentially arguing that the root cause of many of the deaths that are attributed to cardiovascular disease, stroke, and diabetes are in fact deaths that we should attribute to our diet. Not to be lost in the discussion of their argument is the continuous improvement principle that you must address the root cause of problems to create a permanent improvement in the system. In terms of heart disease and other disorders that arise from our eating habits, we must eat differently if we ever hope to have the resources to treat the population. We will never make progress on the cost and utilization realities until we address the issues of nutrition that create so many of the episodes of disease. Prevention is the best treatment from the point of cost and patient experience. The authors offer a solution to our healthcare conundrum that has not been addressed by any of the Democratic candidates for president who will be present in the next debates.
Fortunately, advances in nutrition science and policy now provide a road map for addressing this national nutrition crisis. The “Food Is Medicine” solutions are win-win, promoting better well-being, lower health care costs, greater sustainability, reduced disparities among population groups, improved economic competitiveness and greater national security.
I get a little nervous whenever nutrition is the subject. I had a subpar medical education because I went to Harvard Medical School where they made sure that I understood the Krebs Cycle, but never offered me a course in nutrition. I have no idea whether that has changed over the last fifty years. I am pretty sure that they are still teaching the Krebs Cycle and glucose metabolism, but do they teach strategies to combat the downside of eating at KFC or Burger King? The authors offer a direction we should take if we really want to improve the health of the population and lower the cost of care in a sustainable way.
Some simple, measurable improvements can be made in several health and related areas. For example, Medicare, Medicaid, private insurers and hospitals should include nutrition in any electronic health record; update medical training, licensing and continuing education guidelines to put an emphasis on nutrition; offer patient prescription programs for healthy produce; and, for the sickest patients, cover home-delivered, medically tailored meals. Just the last action, for example, can save a net $9,000 in health care costs per patient per year.
Should I say, “Yes, when pigs fly!” But wait, there is more.
Taxes on sugary beverages and junk food can be paired with subsidies on protective foods like fruits, nuts, vegetables, beans, plant oils, whole grains, yogurt and fish. Emphasizing protective foods represents an important positive message for the public and food industry that celebrates and rewards good nutrition. Levels of harmful additives like sodium, added sugar and trans fat can be lowered through voluntary industry targets or regulatory safety standards.
Nutrition standards in schools, which have improved the quality of school meals by 41 percent, should be strengthened; the national Fresh Fruit and Vegetable Program should be extended beyond elementary schools to middle and high schools; and school garden programs should be expanded. And the Supplemental Nutrition Assistance Program, which supports grocery purchases for nearly one in eight Americans, should be leveraged to help improve diet quality and health.
That is an impressive list of specific recommendations. I am reminded that Mayor Bloomberg took a lot of flack when he tried to limit the size of sugary drinks. Maybe things have changed since the mayor made his effort in 2012.
I have not heard a Democratic candidate address the need for more research on issues like cannabis use, gun violence, and a variety of other politically controversial subjects. So their next suggestion, which seems logical, may not be well received by Congress. They continue:
Coordinated federal leadership and funding for research is also essential. This could include, for example, a new National Institute of Nutrition at the National Institutes of Health. Without such an effort, it could take many decades to understand and utilize exciting new areas, including related to food processing, the gut microbiome, allergies and autoimmune disorders, cancer, brain health, treatment of battlefield injuries and effects of nonnutritive sweeteners and personalized nutrition.
Government plays a crucial role. The significant impacts of the food system on well-being, health care spending, the economy and the environment — together with mounting public and industry awareness of these issues — have created an opportunity for government leaders to champion real solutions.
In a Lean analysis we ask about the potential barriers to any proposed solution. Our thoughtful authors wisely do the same thing. I bolded what I think is a significant barrier. By the way, if you do click on the next link I would point out that Representative Tim Ryan did not make the cut for the next debate.
Yet with rare exceptions, the current presidential candidates are not being asked about these critical national issues. Every candidate should have a food platform, and every debate should explore these positions. A new emphasis on the problems and promise of nutrition to improve health and lower health care costs is long overdue for the presidential primary debates and should be prominent in the 2020 general election and the next administration.
This article resonated with me. Frankly, I was educated by their case. I assume it is obvious that the article added to my dissatisfaction with the current process of vetting our candidates for president. I would love to hear the candidates questioned more pointedly about their positions on nutrition and other aspects of what we call the social determinants of health and the behavioral issues that operate to add morbidity and reduce life expectancy while raising the cost of care for everyone regardless of their socioeconomic class . We all know that there are food deserts, but most of the fat people I see in malls and at the airport, or in the middle seat of a row on an airplane next to me suffer less from living in a food desert than from “super sizing” their last order at McDonald’s.
We cherish our freedoms, and I guess those freedoms include not only the right to own a gun, but also the right to stuff our faces with food that will hasten our demise and add costs to the collective bill as we make our untimely exits. I like the fact that many of the solutions offered seem like exercises in patient education, behavioral economics, or are encouraging more effectiveness research. Those sorts of approaches are much more likely to make a difference than just giving everyone a ticket to ride in a system that has lost its way in so many ways. I fear that we will continue to get more of the same in debates on the campaign trial and in Congress until our leaders are asked to explain to us why they think we are so fat, why we kill ourselves and others, why our schools don’t perform well, why we take so many harmful drugs, why we have so much domestic abuse, why we don’t care about the fact that a person can work a full week and not earn a living wage, why so many people have no home. There are too many “whys” and not nearly enough evidence of understanding of the complexities that weave our problems together. I get nervous as I hear candidates try to grab some attention that will raise their position in the polls by offering yet another half baked answer to a bad question from a journalist looking to generate better ratings for their network.
Something New At Strategy Healthcare (SHC)
My Friday letters began almost twelve years ago. The Tuesday posting is only about five years old. It was conceptualized as part of a proposed communication project that was part of a federal grant associated with the evolution of single payer in Vermont. The concept of Vermont becoming one big ACO stumbled on the issue of finance, and the project died. The original plan had been for an editor to trim down my Friday posts and use them as content on the website. The advantage for me in the whole process was that I met Russ Morgan who was providing IT support for the project. Russ moved my letters from a weekly email with a very long distribution list to a web based and searchable platform.
After the Vermont project failed, I continued the idea of a Tuesday posting that was a trimmed down version of the Friday letter. In 2016, I realized that there was so much going on in the politics of healthcare that posting something new twice a week might be a good idea. Going back to the start of the Vermont project, I had thought that the platform should be available to others, perhaps some of my “Interested Readers.” I am the lucky recipient of many responses. It is not a stretch of my imagination to see some of these responders writing some of the Tuesday posts. That did happen twice early on with posts by Michael Pinnolis and Melissa Cronin. Recently, I have come back to the idea that it would be interesting to make the Tuesday slot available to other writers from time to time.
Joe Knowles is the CEO of IHM, the Institute For Health Metrics, and a serial entrepreneur. I first met Joe when we served together on the board of CRICO, the malpractice captive of the Harvard affiliated healthcare organizations and hospitals. Joe is a long term “Interested Reader” and passionate advocate for the improvement of the health of the population. In the past I have highlighted some of Joe’s work in these notes, and much of today’s post comes from information that Joe has brought to my attention.
Joe and I have a favorite place to meet for lunch in Manchester, New Hampshire. We get together there three or four times a year just to catch up on ideas and shared interests. It’s about equidistant from my home in New London and his home on the North Shore. When we met for lunch earlier this week I asked Joe if he would be interested in sharing one of his ideas about how to reduce gun related deaths. He agreed, and I am happy to announce that Joe will be the author of the Tuesday post for Strategy Healthcare.
How about you? You may not think of yourself as a writer, but I know that many of you have opinions about the current state and the future of healthcare. If you look at the list of subjects at the end of any SHC post, you will see that you can write on any subject that concerns you. I am sure that your concern will connect in some way to practice, to population health, to healthcare costs, to professionalism, to the politics of healthcare, you name it. If you are interested, let me know. You need not to have written anything yet, or before.
One More From “52 With A View”
In a post earlier this summer, I mentioned that Tom Congoran, my colleague from Atrius Health who lives in nearby Hopkinton, New Hampshire, and another buddy and “Interested Reader,” Steve Allenby, who has been my mentor in community work here, had grandiose plans to climb the 48 mountains that are over 4000 feet high in New Hampshire. On any weekend, and many week days, you can go to trailheads all over the state and find the parking lots full of cars with license plates from most New England states, Quebec, and even distant states like Ohio, but then again, it must be true that nobody stays home in Ohio, I see Ohio cars everywhere I go.
Steve is a veteran of many mountain hikes and was ready to go, but prudently suggested that Tom and I try a few hikes on lesser mountains like Kearsage and Cardigan. That is when I discovered the list of New Hampshire mountains called “52 With A View” that was developed by the “Over the Hill Hikers” of Sandwich, New Hampshire. If you click on Over the Hill Hikers you will read the line:
Many of the Over the Hill Hikers (OTHH) have climbed the New Hampshire 4000 footers, some multiple times, and some even over the age of 70!
I did not know what to think about the comment “and some even over the age of 70!”
Tom and I are in our mid seventies and there was something about that line that was discouraging. We have not given up the dream and we continue in preparation for our first 4000 footer with long walks over hills around our homes and when we can get together on lesser mountains from the geriatric “52 With A View” list. Summer visitors and sumer travel have made getting the three of us together for these jaunts a logistical challenge, but we did it this week. On Tuesday we did the Welch-Dickey Loop that is in Thornton near Waterville Valley. It was a challenge for me. If you click on the link, you will discover that the trail is rated as “hard” by All Trails. I would agree. There were a few times when I asked myself, “What were you thinking?” But, the views are spectacular and when we finally got to the end of the trail and I was pulling off my boots in the parking lot at the trailhead, I was very happy with myself. Today’s header is my little trophy, it is the view of the rocky top of Welch Mountain taken from the top of its rockier and slightly taller neighbor, Dickey Mountain.
I have learned long ago that to be healthy you need three things:
- Something to do
- Something to look forward to
- Someone to love
There are many modifications of that trio that I have seen that work. The “someone to love” can has many acceptable variations that work. For example, you can love a cause, a group, or even a pet. It is always great to have something that you are joyfully anticipating pulling you forward past the drudgery or pain of the moment. When I was young it was my birthday or Christmas. Now it is more likely to be the next time I gather with family or friends. When I was in practice and was discussing the quality of life with many of my older patients, some of whom were younger than I am now, I would frequently hear complaints of nothing to do. Sometimes it was stated as, “I have no purpose in my life. I wish that I had something to do.” If a lonely person said that they had no purpose, and nothing to do, I was always worried about their future.
I am hoping that those 4000 footers or the “52 with a view” will keep giving me something to do for a while. I know that I am looking forward to our next group challenge, and our first 4000 footer, Mount Moosilauke, which we hope to do on some clear day in September when we can all get together. How do you score on the “healthy trio?”
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
