Never before have I been happier to see a year finally end. 2020 was a traumatic experience. For many years, the humorist Dave Barry has been writing a column at the end of the year that summarizes the past events of the year lest we forget them. This year’s syndicated column was published on Sunday, and in the Washington Post it was entitled “Dave Barry’s Year in Review 2020: And we thought past years were awful.” In my local paper, the title was a little more provocative: “2020: A Stinging Review: Time to recount the nonstop awfulness of this year, and to pray that the next is nothing like it.” It’s a relatively long article. In my hometown paper, it was three full pages. He begins the column in fine style:
We’re trying to think of something nice to say about 2020. OK, here goes: Nobody got killed by the murder hornets. As far as we know.
That’s pretty much it.
In the past, writing these annual reviews, we have said harsh things about previous years. We owe those years an apology. Compared with 2020, all previous years, even the disco era, were the golden age of human existence.
This was a year of nonstop awfulness, a year when we kept saying it couldn’t possibly get worse, and it always did. This was a year in which our only moments of genuine, unadulterated happiness were when we were able to buy toilet paper.
All through 2020 I have asked myself if things had to be as bad as they have turned out to be. In sports, we talk about games being won or lost because of unforced errors or a lack of preparation. With the COVID-19 pandemic, we have failed on both fronts. We were not prepared for what was coming our way in 2020, and when the virus arrived our lack of clarity about the chain of “command” resulted in many unforced errors that could have easily been avoided. Bad processes always lead to wasted resources and unnecessary expenses and losses. We will never know for sure just how much or what part of our many losses could have been avoided, but it is hard to hide from the reality that things could have been better if there had been real leadership. Dave Barry turns tragedy into humor when he suggests that the most obvious manifestation of our disorganized state was our lack of toilet paper.
Historians, economists, political scientists, epidemiologists, and public health experts will be debating what went wrong and what could have been done better for decades to come. One tragic unforced error was that the politician with the most potential power, our president, discarded science in favor of attempts to allow early returns to a “normal” economy. In many of our red states, the governors who were aligned with him followed his lead. The sycophants who were most aligned with the president’s lead were in Florida, Georgia, and Texas. Their lack of judgment had a greater impact than in states like Iowa, South Dakota, Tennessee, and Arizona only because there were fewer people in those states. Our president told us it was not a problem when in fact there was a huge problem. Then he told us it was a problem that would soon go away, but it has not gone away. The most serious error was the idea that fewer lives would be lost and the economy would rebound sooner if we treated the pandemic like it was the flu. Perhaps it was an honest mistake, but my sense is that his judgment was biased by his fear that with an economic downturn he would not be reelected. The most ridiculous moment in his series of denials came when speculated that perhaps we could defeat the virus if we injected ourselves with disinfectants. Look at the YouTube link. He was not joking.
The horrendous loss of life, the stresses on our healthcare providers, and the vulnerability they shared with other “essential employees” would have been enough to turn what began as an interesting year with the president’s impeachment and the concurrent hotly contested race for the Democratic nomination for president into a year that we would never forget, but as you well know there was much more. Economic distress has impacted more people than have been infected by the virus. Last spring the unemployment numbers ballooned into the millions as people whose jobs could not be moved into cyberspace lost their work. Three million business owners saw their work and dreams over the years and decades evaporate before June as we sequestered ourselves at home, travel was curtailed, more shopping moved online, and bars and restaurants were closed by orders from mayors and governors or could do only a fraction of their previous volumes with curbside pick-ups. Those business losses exceeded the losses of the “Great Recession” of 2007-2008.
Is it funny or sad that we have added many new words and phrases to our vocabulary this year? A new experience requires a new vocabulary. This week NPR ran an interview with Ben Zimmer, the chair of the American Dialect Society’s New Words Committee and the language columnist for The Wall Street Journal. The Dialect Society picks a “word of the year.” This year’s word was obviously COVID, but you know there was more. I am an obvious “doomscroller,” one who scans websites and newspapers for bad news and body counts. Doomscrolling is not unlike being obsessed with baseball statistics. It’s one of the things I do when I am not “zooming.” I am always careful to be sure that I am “social distancing” when in public. Never before have so many people told me that I am “muted” or suggested that I “mute myself” although I am sure that before this year there were many people who wished that I was muted. Mr. Zimmer pointed out that there were some surprises in the race for “word of the year” like “unprecedented.” He also reminded us that COVID was not the only event of the year. “Black Lives Matter” mattered more than ever because of the disproportionate impact of the COVID pandemic on minorities and the horrendous murder by a Minneapolis policeman of George Floyd. Racial tensions spawned the widespread use of BIPAC – an acronym for Black, Indigenous, and people of color.
Even if we had not had a pandemic or an impeachment followed by a bizarre presidential election, the weather alone in 2020 would have made it a remarkable year. This year as the oceans got hotter than ever we set a record, twelve, for named storms that hit us. It was the worst year ever recorded for fires in the west. The fires came close to being a tragedy for my family when the “Big Basin” Fire in the coastal redwoods of California forced my son and his family to evacuate as the fire burned to within a mile of their home before it was controlled.
It is hard to endure a year like 2020 without experiencing significant emotional stress. The variation in ability across the population of each individual to tolerate restrictions on movement, restrictions on contact with friends and loved ones, economic loss, and all of the disruptions that 2020 has brought explains much of our inability to control the spread of the virus. We can only speculate about the future impact on our children from being forced to attend school online. As silly as it may seem it was emotionally disruptive to have sporting events and artistic performances disrupted by the pandemic. The pandemic blocked us from some activities we may never resume. After missing the baseball season and having the Boston Speakers Series canceled, I have decided to let my season tickets for both to lapse. Neither activity seems as important as they once did. In retrospect, the pandemic became real for many people when “March Madness” was canceled and Tom Hanks and his wife contracted the virus last March.
Yes, it has been an overwhelming year. Even if you survived 2020, your life was changed by the events around you. Another new phrase in our lexicon that emerged in 2020 was the “new normal.” What the “new normal” in healthcare will look like is a matter of speculation. There is one thing that is certain. It is likely that “virtual visits” will be a permanent part of practice going forward. For years, both before and when I was CEO at Atrius Health and Harvard Vanguard Medical Associates, I contended that a substantial number of our medical encounters that occurred in the office could “go online.” The barrier was compensation. Even as a predominately “prepaid practice” it was hard to get acceptance from either our managers or clinicians for virtual visits even though there were huge savings to the practice in reduced overhead and huge increases in satisfaction and convenience for patients. The reluctance arose because our compensation system was linked to RVUs and RVUs were linked to revenue and virtual visits were not a revenue line in our budget. Now with changes in payment and with finance impacted by the pandemic, insurers are paying for virtual visits and they are now a growing source of revenue. It is a sad reality to admit that how we get paid often trumps what our patients need. We can talk about being patient-centered, but isn’t it true that we are really finance centered? Most of us have a bias against any change to how we get paid.
It remains to be seen how the pandemic will drive further changes in healthcare finance. Will the losses in fee for service revenue associated with the pandemic make systems of care more open to alternative payment options? Will there be a shift to concerns for populations? Will we use more of the healthcare dollar to address issues of public health? We tend to stumble forward from one moment to the next rather than have the discipline to develop and implement long term changes in policy that will address the inequities that are obvious when we consider the social determinants of health. Will we find new ways to manage our workforce issues in health care and the distribution of our medical assets? The pandemic has unveiled big problems that we had ignored not only in the distribution of Internet services for the economy and education but also in how we supply inner-city and rural America with access to healthcare resources. The pandemic has demonstrated that it is long past the moment when we should continue a system of care that is driven by money-making procedures rather than the objective of protecting and improving the health of a population.
An article in today’s New York Times by Margot Sanger-Katz, Sarah Kliff, and Quoctrung Bui entitled “Obamacare, in Its First Big Test as Safety Net, Is Holding Up So Far: Job losses and the loss of insurance have typically gone hand in hand. This year, more Americans are staying covered” does reveal that the ACA was a fortuitous partial preparation for the challenge of COVID-19.
The authors contend that data now shows that if we had not put the ACA in place and had not saved it through previous Supreme Court challenges to declare it unconstitutional or rebuffed the 2017 Republican attempt to repeal it, many more Americans would be much worse off. As people lost their jobs in the economic distress of the pandemic, the expanded Medicaid program that is available through the ACA in all but fourteen states proved to be able to absorb many of those who lost their employer-based insurance. Two of the fourteen states, Oklahoma and Missouri have voted to expand Medicaid against the will of Republican governors and state legislatures, and are awaiting implementation, twelve still firmly resist. See the map.
Subsidies on the exchanges provided to those whose income was between 138% to 400% of poverty saved healthcare for many more Americans. The insurance coverage provided to these distressed Americans who had access to Medicaid and the exchange was also beneficial to the financially challenged healthcare systems which would have experienced a more substantial increase in bad debt had the ACA not existed.
The challenge that Joe Biden and the new administration will face in 2021 is to begin and sustain the process of understanding and then addressing all that 2020 has emphasized as defects that make us vulnerable on a planet that is challenged by inequity and a deteriorating environment. This would be a daunting task even without the certain resistance that will be encounter from the loud minority of Americans who still prefer the vision of America that Donald Trump offered but could not manage.
I am not a strong advocate for immediately doing away with the Senate’s filibuster or changing the Constitution to abolish the Electoral College. I do favor changes that emerge from the tedious dual process of education and compromise, but there are many in pain that are impatient and want change to come quickly. They are tired of the liabilities made manifest this year of being vulnerable to the minority that prefers white privilege, the unrestricted freedom to trash any environment that they might own for immediate profit, and the ability to deny established facts and science. Jennifer Rubin this week in a column entitled “America isn’t ‘hopelessly divided.’ It only looks that way because of our Constitution.” presented the reality of how our Constitution has inadvertently allowed those who profit from the status quo to maintain their advantage against the will of a growing majority.
If there is anything that the awful year of 2020 has demonstrated to me it is deep changes are necessary, and that things can and will get worse unless we are committed to what will be difficult and painful changes in how we work with one another. We need to reassess how we govern ourselves. We must also change how we provide and manage healthcare. The starkest reality is that there is likely to be more bad news coming. We look at 2021 with the hope that it will be a new beginning. The challenge will be to give that hope a plan that will ensure that 2021 will not be more of the same we experienced in 2020 or worse.
Have a safe and Happy New Year celebration, and then be prepared to work to make the “Have a Happy New Year” salutation a reality for everyone. It would be nice to dream that by the time 2022 rolls around it is clear that we are headed toward better times.
Postscript: I want to give a big thanks and recognition to my son Jesse for his quick response to my request for the graphic that is the header for this post. I would suggest that you check out his essay and the song he posted yesterday. The title is “Week 528//Other Skies.” He sets any positive theme of this note to music. He bets that the “sun will return.”
Bits of paper
On the wind
Swirl around us
And within
Scraps of ideas
All the ways
Conversations
Other days
Look around you
All the change to come
I’m sure the sun will return
Other winters
Other springs
Sleeping later
What it brings
Wake to find
A different time
Constellations
Other skies
Look around you
All the change to come
I’m sure the sun will return
