December 3, 2021
Dear Interested Readers,
If There Are Four Americas, What Does That Mean For Healthcare?
We all are aware of the deep bipartisan divide that stymies attempts to improve access to healthcare and lower its cost for all consumers. The same political division threatens the reproductive rights of women and the lives of high schoolers, concertgoers, and worshipers who are vulnerable to people with guns. There are others for whom the political divide is a chasm that isolates them from the life they could enjoy like those who are staggering under a crushing burden of student debt or the mothers, fathers, and other family members who need child care or elder care so that they can return to the workforce. The list of those who suffer from our failures of self-governance goes on and on, and except for a very few very privileged members of our society almost everyone is suffering from the increasingly wide separation in our society that is most obvious in the performance of our elected officials.
I have persistently asserted that when it comes to healthcare COVID has demonstrated that our political divide will eventually cause healthcare problems to eventually touch and harm even the most elite and comfortable members of our community. If COVID represents a proximate threat, global warming is becoming an even greater threat and is quickly moving from being a lethal threat to future generations to being a problem at this moment that is increasing geometrically. We seem to be awash with “wicked problems” that would be hard to solve if we were united, and are a constant source of frustration in our divided state.
Despite the common danger and the efforts of President Biden to pursue bipartisan solutions to our chronic problems, we continue to go about our business as if all the problems are of a hypothetical and not urgent concern. I own many books going back to Crossing the Quality Chasm (2001) that describe the problem in bits and pieces. One journalist who has consistently tried to get us to face up to the mess by using the stories of real-life people to underline the growing problems which will lead to even greater messes for us all in the future is George Packer. I was first impressed with his writing when one of my sons gave me as a Christmas present Packer’s 2013 book, The Unwinding: An Inner History of the New America which received the National Book Award for Nonfiction.
When the book was first published Dwight Garner wrote a very favorable review of The Unwinding in The New York Times where he commented:
“The Unwinding” begins like a horror novel, which in some regards it is. “No one can say when the unwinding began,” Mr. Packer writes, “when the coil that held Americans together in its secure and sometimes stifling grip first gave way.” If you were born after 1960, Mr. Packer suggests, you have spent much of your life watching structures long in place collapsing — things like farms, factories, subdivisions and public schools on the one hand, and “ways and means in Washington caucus rooms, taboos on New York trading desks” and “manners and morals everywhere” on the other.
The book was a “page-turner” that read like a novel for beach reading. Some of its stories are much like Hillbilly Elegy: A Memoir of a Family and Culture in Crisis, J.D. Vance’s 2016 memoir of his rise out of a childhood in turmoil and poverty in Ohio and Kentucky. In 2013, David Brooks wrote a mostly favorable column about The Unwinding that praised the literary effort by comparing it to the 1930s novels of John Dos Passos but wished that Packer had gone beyond the stories toward a more academic analysis. Nevertheless, he said:
By “the unwinding,” Packer is really referring to three large transformations, which have each been the subject of an enormous amount of research and analysis. The first is the stagnation of middle-class wages and widening inequality. Depending on which analyst you read, this has to do with the changing nature of the information-age labor market, changing family structures, rising health care costs, the decline of unions or the failure of education levels to keep up with technology.
The second is the crushing recession that began in 2008. Depending on which analyst you read, this was caused by global capital imbalances, bad Federal Reserve policy, greed on Wall Street, faulty risk-assessment models or the insane belief that housing prices would go on rising forever.
The third transformation is the unraveling of the national fabric. Depending on which analyst you read, this is either a gigantic problem (marriage rates are collapsing; some measures of social connection are on the decline) or not a gigantic problem (crime rates are plummeting, some measures of social connection are improving).
Brooks’ analysis aside, It was clear to some three years later in November 2016 that Packer’s 2013 book was in essence a prediction of the emergence of Donald Trump or someone like him. As impressed as I was with Packer’s 2013 book, it surprises me that I let five months pass between the publication of Packer’s next book last June and the end of November when I noticed that he had written a new book, Last Best Hope: America in Crisis and Renewal. Over the last week, I have quickly consumed Packer’s latest offering and want to bring it to your attention because it expands our understanding of why the political divide exists and is getting worse, and what we can do about it.
If there is any hope of ameliorating the deficiencies and inequities in health care we must be diligent students of what divides us, and all of us must ask ourselves what part we individually and collectively play in the persistent problem. In the practice of medicine, we learn that it is hard, if not impossible to improve a disease or condition without some understanding of the problem. Packer has now done what Brooks asked for in 2013, he has searched for the origin of the stories behind the ones he has told, the stories that others like J.D. Vance and Ibrim X. Kendi have told, the stories on Going for Broke, the podcast hosted by Ray Suarez, or the events in our own lives that range from annoying to tragic, the origins of which we don’t fully understand. If an incomplete analysis was the problem with The Unwinding, then perhaps a less than convincing solution to a “wicked problem” could be considered as the deficiency in this book.
It’s a short book of 224 pages which is probably less than 50,000 words, but you don’t need to read the whole thing like I did because Packer did an 11,500-word article in The Atlantic which is a great condensation of the ideas in the book. If you don’t think you have time for The Atlantic article, let me offer Emily Basilon’s review in The New York Times or William Galston’s review in The Washington Post. Both reviews capture much of the essence of Packer’s formulation and add their thoughts and criticisms. Your final alternative is to keep reading as I continue to try to explain why those of us who care about the future of healthcare and the health of the nation in a politically and culturally divided land should consider what Packer has to say.
The core of Packer’s formulation is that the divide is not just between Democrats and Republicans. That would be too simple. He goes back in history to follow the historical evolution of both parties which over time have swapped positions and the populations to which they appeal. The evolution of the parties is not the whole story. The story is even more influenced by the increasing complexity of the world we live in and the variation in responses that we have to the complexities that confound us as individuals. Joseph Campbell made us aware of the “myths that we live by.” Packer updates the analysis of some of our national myths and demonstrates how the combination of our stories and our destructive economics work in concert to generate the current mess. I think Packer would probably agree that expanding the analysis of our polarized political environment from two groups to four is probably still an oversimplification of the root causes of the frustrations and potential disasters that we all face no matter which group we are in but it is a start. Packer includes in the title of The Atlantic article an italicized statement and a question:
People in the United States no longer agree on the nation’s purpose, values, history, or meaning. Is reconciliation possible?
The article continues:
Nations, like individuals, tell stories in order to understand what they are, where they come from, and what they want to be. National narratives, like personal ones, are prone to sentimentality, grievance, pride, shame, self-blindness. There is never just one—they compete and constantly change. The most durable narratives are not the ones that stand up best to fact-checking. They’re the ones that address our deepest needs and desires. Americans know by now that democracy depends on a baseline of shared reality—when facts become fungible, we’re lost. But just as no one can live a happy and productive life in nonstop self-criticism, nations require more than facts—they need stories that convey a moral identity. The long gaze in the mirror has to end in self-respect or it will swallow us up.
Tracing the evolution of these narratives can tell you something about a nation’s possibilities for change. Through much of the 20th century, the two political parties had clear identities and told distinct stories. The Republicans spoke for those who wanted to get ahead, and the Democrats spoke for those who wanted a fair shake. Republicans emphasized individual enterprise, and Democrats emphasized social solidarity, eventually including Black people and abandoning the party’s commitment to Jim Crow. But, unlike today, the two parties were arguing over the same recognizable country. This arrangement held until the late ’60s—still within living memory.
Packer was born in 1961, so his own living memory becomes more accurate in the 70s, but since I was born in 1945 my living memory clearly includes most of the Eisenhower years and reaches back to the comments of my parents regarding Harry Truman in the late forties. My “living memory” does not contradict the story Packer tells. It is sad for me to report that within my lifetime events, unforced national errors, an overemphasis on the benefits of capitalism without adequate control of its downside of greed that even Adam Smith was aware of in the eighteenth century, our continuing inability to recover from our original sin of slavery and its consequences, our dualistic focus on the virtues of male whiteness while excluding the concerns of women and minorities, and the justification of all of our biases through some combination of a misinterpretation of the message of Christianity and the highest virtues of individualism, have come together to further divide us and in concert are a major part of the foundation of the mess in which we find ourselves. To reapply the title of Packer’s 2013 book to the moment, how do we begin the unwinding of the mess of our “national unwinding?”
Packer begins the new unwinding by hypothesizing that we are a nation of at least four groups. I should pause here and point out that currently there is a coalition between groups one and two and between groups three and four. If you are Bernie Sanders or a strategist for the Democratic Party you spend a lot of time trying to articulate a message that would attract at least some of the members of group two to your ranks. If you are a Republican strategist you have noticed that there are many people who live in the suburbs who are frustrated by the many unforced errors and poor communication efforts of Democrats and are possible crossovers from their current status to vote for Republican candidates. This just happened in Virginia. In his book and in the article in The Atlantic, Packer suggests that each of us imperfectly fits into at least two of the groups. Galston’s article nicely summarizes the four groups. As usual his words are in italics and my comments about the subjects are in brackets:
- Free America, economic conservatives and religious traditionalists whose organizing principle is a leave-us-alone, “Don’t Tread on Me” conception of liberty. [Packer calls this group the most politically powerful of the four. They certainly control the Supreme Court and may soon control Congress. This group includes libertarians like the Tea Party. As Mitch McConnel demonstrates this group will rarely compromise.]
- Real America, an assemblage of white Christian nationalists for whom the principle of moral equality has curdled into resentment against experts and bureaucrats. [It feels to me like this group in Packer’s formulation covers many of the same people in Hillary Clinton’s “basket of deplorables.” These are the people in Red State America with gun racks in their pickups. They are a large part of the population that are victims of the diseases of despair. They often vote against their own economic interests, and that fact creates a small opportunity for Democrats who might win them over if they were treated with respect and not felt to be “less than” or as Hilary said, deplorable. As my wife and I rode through middle America last year in our RV we were moving among many of these people. We saw them at Walmart. We saw the boarded-up storefronts on their desolate main streets, the rusted and empty shells of the factories where they once earned a middle-class wage. There were Trump signs by the thousands on their lawns and at the edges of the cornfields that flanked the byways off the Interstate highways. Jonathan Metzl describes their attitudes beautifully in his 2019 book, Dying of Whiteness: How the politics of racial resentment is killing America’s heartland, which adds more depth to Arlie Russell Hochschild’s wonderfully informative 2016 portrait of Red State emotions and mentality in her book, STRANGERS IN THEIR OWN LAND: Anger and Mourning on the American Right.]
- Smart America, the winners of the new economy’s meritocratic competition for wealth and status. [This is the group where I am most closely affiliated although there is some intersectionality with the Just America group. We are a minority. We are not the “0.1%.” They may control everything by controlling the “Free America” group which for them means to be free to make huge profits from America. This group is mostly the next 9.9% down from the top of the economic ladder. If you want a profile read Matthew Stewart’s 2018 article in The Atlantic with the challenging title, THE 9.9 PERCENT IS THE NEW AMERICAN ARISTOCRACY: The class divide is already toxic, and is fast becoming unbridgeable. You’re probably part of the problem. We are so effective in our ability to pass on what we have gained to our children that the other 90% of the country is “slip slidin’ away” and probably doomed to a lifetime of regret that they did not get enough education to pursue a profession or work their way up through the meritocracy which we control from a white-collar desk job to an executive position.]
- Just America, the home of identity politics with race at its core. [Many of the children of the 9.9% have found a home here where they are passionate about trying to create a better world. If they are white, Bernie Sanders may be their hero. AOC epitomizes the youth and ideals of the group. I feel some kinship with their cause but I know that though I share their desire for a more equitable society, I am always fearful of the warning in the old saw that “the far right and the far left always meet in the back” in some form of authoritarian control.]
I have some difficulty with Packer’s nomenclature with the category “Just America.” I think what Packer is trying to describe is a group that desires “ a just America where there is equality and justice.” It could be derided as the “woke” America. It is a group whose members are “progressives” who despise the inequalities in our society. They are antiracists. They care about the rights of minorities, women, immigrants, and the LGBTQ+ community. They err by not caring as much about the rights of the other groups, and to others, they seem “self-righteous.” They are sometimes intolerant of the opinions of others, and in their fervor, they undermine their cause by suggesting that they will not tolerate opinions that don’t follow their strict canon.]
Packer more eloquently describes the danger that “Just America” has of becoming authoritarian from the left. He sums up his concerns:
Just America has dramatically changed the way Americans think, talk, and act, but not the conditions in which they live. It reflects the fracturing distrust that defines our culture: Something is deeply wrong; our society is unjust; our institutions are corrupt. If the narrative helps to create a more humane criminal justice system and bring Black Americans into the conditions of full equality, it will live up to its promise. But the grand systemic analysis usually ends in small symbolic politics. In some ways, Just America resembles Real America and has entered the same dubious conflict from the other side. The disillusionment with liberal capitalism that gave rise to identity politics has also produced a new authoritarianism among many young white men. Just and Real America share a skepticism, from opposing points of view, about the universal ideas of the founding documents and the promise of America as a multi-everything democracy.
…Just America is a narrative of the young and well educated, which is why it continually misreads or ignores the Black and Latino working classes. The fate of this generation of young professionals has been cursed by economic stagnation and technological upheaval. The jobs their parents took for granted have become much harder to get, which makes the meritocratic rat race even more crushing. Law, medicine, academia, media—the most desirable professions—have all contracted. The result is a large population of overeducated, underemployed young people living in metropolitan areas.
Packer’s reproduction of our evolution toward these four groups is a story that unfolds like looking at a picture album of a trip you took several years ago. He has snapshots of many of the moments and monuments along the way and reminds us of the villains and heroes among us, some of which seem to be trading places as time goes by. Bill Clinton, Newt Gingrich, Ronald Reagan, George McGovern, the Koch brothers, Sarah Palin, the war in Vietnam, globalization, the emergence of the “rust belt,” the woes of middle America, and the rise of the super-rich all get pictured. Running through this album are random pictures from our collective experience that give proof of our ever-present inability to overcome our racial inequities or eradicate poverty despite our collective wealth. The last pages of the album picture Donald Trump, COVID, and our loss of esteem and dominance in the world.
Packer has some compassion for all four groups. They share some common causes in their development.
…all four of the narratives I’ve described emerged from America’s failure to sustain and enlarge the middle-class democracy of the postwar years. They all respond to real problems. Each offers a value that the others need and lacks ones that the others have. Free America celebrates the energy of the unencumbered individual. Smart America respects intelligence and welcomes change. Real America commits itself to a place and has a sense of limits. Just America demands a confrontation with what the others want to avoid. They rise from a single society, and even in one as polarized as ours they continually shape, absorb, and morph into one another. But their tendency is also to divide us, pitting tribe against tribe. These divisions impoverish each narrative into a cramped and ever more extreme version of itself.
After a much richer description of the state of our divided nation than I have been able to transfer to you, Packer goes on to deliver his analysis of possibilities and treatment suggestions. I have bolded the hope he infers in the title of the book, The Last Best Hope.
I don’t think we are dying. We have no choice but to live together—we’re quarantined as fellow citizens. Knowing who we are lets us see what kinds of change are possible…Our passion for equality, the individualism it produces, the hustle for money, the love of novelty, the attachment to democracy, the distrust of authority and intellect—these won’t disappear. A way forward that tries to evade or crush them on the road to some free, smart, real, or just utopia will never arrive and instead will run into a strong reaction. But a way forward that tries to make us Equal Americans, all with the same rights and opportunities—the only basis for shared citizenship and self-government—is a road that connects our past and our future.
Meanwhile, we remain trapped in two countries. Each one is split by two narratives—Smart and Just on one side, Free and Real on the other. Neither separation nor conquest is a tenable future. The tensions within each country will persist even as the cold civil war between them rages on.
In his book, Packer admits that the resolution of the problems and attitudes he describes will be a long slow process. It probably will not occur in my lifetime, but I am reminded of a piece of Jewish wisdom that I was given by a friend a few years ago. The version of the thought which I wrote down was: “It is not incumbent upon you to complete this great work, but neither are you free not to begin it.” The actual statement that I discovered with some Internet research is even more appropriate to our time:
It is not your responsibility to finish the work of perfecting the world, but you are not free to desist from it either. — Rabbi Tarfon, Pirke Avot 2:21.
With that pronouncement, I would argue that we are all responsible for this moment and that we should continue the long and frustrating work of learning how to live together. There will never be a way for any one of the four groups to gain control without violence and common loss. Packer points out that the pursuit of mutual tolerance and equity is a very long road but it is probably the only rational way out of the woods in which we are lost. I offer my “amen” to his expression of hope.
Healthcare’s greatest challenge for the future is how will we pursue equity in all aspects of our work together. Equity seems like an afterthought for many as they chant the “six domains of quality” described in Crossing the Quality Chasm. In fact, I am coming to believe that equity is the foundation for the other five. We will not have a sustainable system of care that serves our nation well until everyone can count on their access to care that is patient-centered, safe, timely, efficient, and effective. The equity must also be extended to those who provide the care. For the last twenty years, we have structured the pursuit of the transformation of our healthcare system through innovative efforts to improve patient satisfaction, cost, and safety when all along we have stumbled with the key first step–equity. Things will not improve until equity becomes our primary intent. There is much to change if equity is our initial objective.
It’s Late Fall in New York, But Winter Has Arrived In New Hampshire.
My wife and I took the bus to New York to enjoy a wonderful Thanksgiving weekend in Brooklyn and Manhattan with our youngest son and his wife who live and work there. My daughter-in-law has recently begun her legal career as a public defender in domestic disputes, and my son continues to work at Per Scholas, a well-established nonprofit organization that lifts impoverished people into good-paying jobs as IT professionals. Per Scholas has recently been named a 2021 Nicholas Kristof Holiday Impact Prize Honoree.
We avoided the subway for fear of COVID exposure. We took Uber rides to many great restaurants between seeing an off-Broadway play entitled “Medicine,” which as a reviewer said should have been called “Therapy,” and an afternoon at MoMA. All that activity was worth the expense, but what I enjoyed most was free. We took several walks in Prospect Park, Frederick Law Olmstead’s favorite production. Our son and daughter-in-law live a couple of blocks east of the park across Flatbush Avenue in Prospect Lefferts Gardens which is a very diverse neighborhood that has large Caribbean and African American populations. The park is essentially their “backyard.” The park is where they go to relax and exercise whenever time, work, and the weather permits. The topography of the park is spectacular with little post-glacial moraines and kettle holes that gave Olmstead and his mentor, Calvert Vaux, a lot of variety to use creatively.
Today’s header is a picture of the tunnel under the Cleft Ridge Span, one of the innovations that Vaux and Olmsted used that was as beautiful as anything I saw at MoMA. As you can learn if you click on the link, the elaborate tunnel under the Cleft Ridge Span is the first structure composed of cast concrete built in America. For some reason, I refrained from reverting to preadolescent behavior and did not test its echo capacity. I wish that I had, and have promised myself that I will give it a big hoot on my next trip to Brooklyn.
When the bus returned us to Lebanon on Sunday evening we had to clear ice and snow off of our car. It was still late fall in New York, but winter has arrived in New Hampshire. The temp did not get above 32 degrees until Wednesday afternoon. As you can see in the picture below, the lake is quickly freezing over. I am beginning to dream about “ice out” which should occur between late March and mid-April. Between now and then job one for me will be to avoid falling on an icy walk. So far so good.
I hope that you will be out and about with care this weekend. The ski resorts around me will be open, but those days are behind me. I do hope the weather allows a safe walk on dry roads this weekend for all of us.
Be well,
Gene
