February 10, 2023
Dear Interested Readers,
President Biden Had A Lot To Say, And He Said It Well.
I hate to say it, but I have got a feeling that the near-term likelihood of the improvement of the health of America is dependent upon the political future and longevity of Joe Biden. I keep reading that he is too old. There is no doubt that we have never had an eighty-year-old president, and it is a fact that if he is reelected he will be 86 at the end of his second term. With those concerns in mind, I asked the Internet what was the life expectancy of an 80-year-old caucasian male in good health. The best answer that I could find was a little out of date, but every way I phrased the question brought me back to a 1995 article in the New England Journal of Medicine that suggested that the life expectancy at 80 was about seven years. That fact alone was some relief since I admit that I hope old Joe will throw his hat in the ring for 2024. Along the way, I was pleased to discover that since I have made it to 77, I have a good shot at ten more years.
I am not much of a historian, but I tried to remember other national leaders that were still going strong after 80. First up was Moses. At the end of Deuteronomy (chapter 34, verse 7) we learn that he died at the age of 120 and “his eye was not dim, nor his natural force abated.” That sounds like good health until the end. Winston Churchill left office as the Prime Minister of the United Kingdom at the age of 81 but lived for another ten years. If you ask who were the oldest heads of state while in office, Queen Elizabeth is hands down the winner, but there are several who have served into their late 80s. So, let’s set age aside and talk about his performance this last Tuesday night as he delivered the annual “State of The Union Address” to a joint session of Congress.
The Washington Post did a great job of giving an overview of the obvious tensions, the conflicts, and the content of the evening which turned out to be quite a charged encounter between the president and far-right members of the Republican Party who seem to have forgotten all the fine points of decorum that they should have learned along the way to becoming individuals who have an enormous responsibility to the Constitution and the rest of us. In their article entitled “Biden, in State of the Union, mixes bipartisanship with defiance: Speech is marked by unusual back-and-forth between president and Republican lawmakers” Toluse Olorunnipa and Yasmeen Abutaleb write:
The speech, taking place just weeks before Biden’s expected announcement that he will seek reelection, was widely viewed as a soft launch for a campaign for a second term. Adding to the tension of the moment was a looming partisan fight over the debt limit and the approach of the one-year mark of Russia’s war against Ukraine.
Biden presented himself as an elder statesman capable of working across the aisle while also cutting the figure of a shrewd politician with strongly held beliefs. He outlined areas for potential bipartisanship including technology, health care and foreign policy, but sharply rejected Republican proposals on issues ranging from immigration to taxes to Social Security and Medicare.
He adopted “Let’s finish the job” as a mantra, a phrase that seemed designed to temper his triumphant declarations with a recognition that many Americans remain anxious and are far from feeling secure or prosperous.
I am biased toward all things “left.” So, it should be no surprise that I think that he did a remarkable job. He rolled with the punches from members of the far right like Representative Marjorie Taylor Greene who seems more interested in being a performance artist than a participant in the development of policies that might benefit her constituents.
I know her district in Georgia, the 14th. Until recently, my youngest sister lived in its largest city, Rome, Georgia, and trust me there are many many people in that district who could benefit from the policies President Biden is trying to foster that would improve the social determinants of health. According to census data, an inordinate number of people of all ages in the 14th district don’t have healthcare and there are many who live in poverty:
Healthcare Coverage In the 14th District of Georgia
Between 2019 and 2020, the percent of uninsured citizens in Congressional District 14, GA grew by 3.72% from 13.5% to 14%.
Data from the Census Bureau ACS 5-year Estimate.
I should point out that nationwide the percentage of uninsured Americans is about 9%. So, in the 14th District of Georgia, the percentage of those without healthcare coverage is significantly higher than in the rest of the country. There are about 750,000 people in the district and over 100,000 of them have no healthcare coverage. Congresswoman Taylor Greene should consider that statistic to be a source of shame and concern. If there were 100,000 uninsured people in every Congressional district there would be about 44 million people rather than 30 million who don’t have healthcare coverage. There seems to be a healthcare disadvantage to living in the 14th district of Georgia.
Poverty and Diversity in the 14th District of Georgia
13.5% of the population for whom poverty status is determined in Congressional District 14, GA (96.1k out of 709k people) live below the poverty line, a number that is higher than the national average of 12.8%. The largest demographic living in poverty are Females 25 – 34, followed by Females 35 – 44 and then Females 45 – 54.
The most common racial or ethnic group living below the poverty line in Congressional District 14, GA is White, followed by Hispanic and Black.
The Census Bureau uses a set of money income thresholds that vary by family size and composition to determine who classifies as impoverished. If a family’s total income is less than the family’s threshold then that family and every individual in it is considered to be living in poverty.
Data from the Census Bureau ACS 5-year Estimate.
Again, we see that the hills of Georgia may be beautiful; the area looks a little like southern New Hampshire, but there are many of the congresswoman’s constituents who might benefit from her supporting a more organized approach to mitigating poverty. So much for Representative Taylor Greene, she is entitled to her point of view, and if the people in the 14th district of Georgia care more about the issues that she trumpets than their own health and economic well-being, all I can say is that it is still a “free country,” except for the reproductive rights of women in many Republican-controlled states like Georgia where abortion is banned after six weeks.
Much of the president’s speech did present and call for policies that would improve the social determinants of health for everyone. As the Washington Post article implied, his battle cry or mantra for the next two years, and I hope the next six years, will be “Let’s finish the job.” The Inflation Reduction Act of 2022 did get the ball rolling to employ more Americans in good jobs that upgrade our deteriorating infrastructure and did increase the speed at which we might develop clean energy sources to combat global warming. The bill also contains some healthcare benefits, especially for recipients of Medicare, but there was a big difference between the bill the president wanted and we needed and what Joe Manchin would let him have. Now with a Republican-controlled House, those items are out of reach even if Joe Manchin and Kyrsten Sinema were to have a change of heart.
There are many items on the president’s wish list that he touts as investments with great paybacks like resuming the child tax credit, investing in child care and education, and redeveloping our production capacity in all industries. All of those measures would decrease the number of families living in poverty. He calls for the creation of more housing as a boon to low-income families that will have spillover benefits for us all as essential workers find housing closer to where they are employed. He is an advocate for better policing. He is willing to work hard to come up with a bipartisan immigration policy that is long overdue and would protect “Dreamers” by providing them with a pathway to citizenship.
The two issues that the president raised that I am sure will get the greatest pushback from Representative Taylor Greene and Speaker Kevin McCarthy, the man who is forced to give her and her crew voice so that he can be speaker, are the elimination of assault rifles and fair taxes for the ultra-rich. When President Biden began to talk about tapping the resources of those who have too much and never pay anything, the cameras swung around to Senator Elizabeth Warren who was beaming in approval. Bless her, she never gives up.
I was interested in what the president had to say about the practical issues of health care. He said more than I expected given the fact that there is little likelihood for any of it happening before he wins again in 2024, and when I hope that the control of the House returns to the Democrats. The Kaiser Family Fund did a nice job of summing up what he said about core medical issues which include gun violence. I was surprised that they did not include drug overdoses since over 90,000 Americans died of an overdose in 2020 and the number keeps rising. The president did acknowledge the problem. The KFF list is:
- Insulin. Learn what’s behind the push to expand the cap of out-of-pocket costs to $35 for everyone, not just Medicare enrollees.
- Protecting Medicare from potential budget cuts. Read our key facts about Medicare spending and financing to understand the program’s role in our health system.
- ACA & Medicaid. President Biden called on Congress to make the enhanced ACA subsidies in the Inflation Reduction Act permanent. Learn more about the subsidies and which states haven’t expanded Medicaid.
- COVID-19. The Biden Administration recently announced it will end the public health emergency on May 11. Learn what this affects and when.
- Mental health. Here’s a landscape of school-based mental health services as the president calls for greater access for youth.
- Gun violence. Firearms are the leading cause of death among children and teens in the U.S.
I must admit that Elizabeth Warren was my choice for president back on February 11, 2020, when I voted in the New Hampshire Primary which was won by Bernie Sanders. Senator Warren’s showing was disappointing (for me). She finished fourth, but she did beat President Biden who finished fifth. I say this to underline the uncertainties in presidential races. What I know for sure is that short of a miracle we will be treading water with our healthcare hopes for at least the next two years. If you want to see changes that benefit your community, you need to develop a local strategy that reduces the overuse and misuse of medical resources, develops operational efficiencies, and focuses on programmatic ways to be more patient-centered and oriented toward doing what can be done to improve the social determinants of health where you live and work, but that is not a new situation. It was the reality of the eighties, nineties, and the first decade of this century before the ACA was passed. I have long contended that clinicians and other healthcare professionals should be leaders in community discussions about better programs of childcare, affordable housing, job training, and education. Effectively innovating to Improve the social determinants of health in the communities from which their patients come should be part of the mission and vision of every healthcare practice and institution. We have known that for a long time. I refer you to Crossing the Quality Chasm.
Things have changed a lot during the past two years, and I am sure that things will change more between now and 2024. I doubt that there will be many national public policy gains in healthcare access, healthcare quality, improvement in the equity of healthcare, or any decrease in healthcare costs because change is slow and the Republican House is unlikely to take up the president’s offer of a bipartisan partnership aimed at “finishing the job.” It is good to know that the president is willing to invest what may be the bulk of the years he has left to get the job done, and I am rooting for him to find ways to continue to surprise us all.
The Winter Rolls On. Thankfully, A Little Warmer Than Usual
The header on this letter is a picture that shows three things. In the background, you can see the dwindling woodpile of Kearsarge Neighborhood Partners (KNP). In the foreground is my old truck which is loaded up and ready for a wood delivery. The man standing by the truck is my co-volunteer, Ron Clark. Ron and I frequently deliver wood together, and we also enjoy a book group together and a discussion group that meets twice a month as well as other social gatherings.
On Wednesday, Ron and I delivered a load of wood to a typical KNP client. She is a young single mother recovering from a recent difficult divorce. She has two school-aged children and works very hard cleaning houses while they are in school. The family heats primarily with wood. It was the third delivery that our organization has made for the family this winter.
Ron is a retired mental health nurse who was also a Medicaid administrator in Vermont for many years. During our deliveries, we often “talk healthcare” and contemplate the challenges that face us all going forward. I think we both may have mixed feelings of relief and sadness from knowing that our “turn at bat” is over. In the background, there may be a little regret that our personal attempts to improve our little corners of the system of care fell far short of what we had hoped to see happen “during our time.”
One of the beliefs that we share is that poverty and the inequities in our society are a challenge to any attempt to improve the social determinants of health. We also agree that the starting place for improving the social determinants of health is to address the issues of poverty, housing, and the inherent biases that so often complicate the delivery of care, and deny so many people the access they need for basic medical care and adequate attention to their mental health and substance abuse problems.
Firewood is very expensive. I recently paid $425 for a cord of wood, and I felt fortunate to get it as a “preferred customer.” At any price, wood is hard to find. I bought two cords of wood from the same man last year for $325/cord. I need not tell you that everything is more expensive even if the rate of inflation is slowing as the president claims.
SNAP benefits are a central part of the finances of the individuals and families we see as we deliver wood. Those benefits often add several hundred dollars a month to family resources. SNAP benefits were increased substantially during COVID and people have gotten accustomed to having the extra money, but in March the COVID extensions will end in thirty-five states including New Hampshire. The reduction in SNAP benefits will be a big “pay cut” for many of the recipients of our wood, not unlike what happened when the child tax credit was not extended.
The federal fuel assistance program that many of our clients benefit from will pay for heating oil, kerosene, propane, electricity, and firewood. In most winters the allotments don’t cover the entire expense of heating so we usually see requests for help paying for oil, propane, and wood pellets in February, March, and April after the allotments have been used up. This year the allotments have been enhanced by about twenty percent, but that increase is not enough to cover the inflated fuel costs we are experiencing. “Workforce issues” have also been a problem because the agency that distributes federal funds is understaffed and unable to keep up with the demand for approvals. The result is that many of our “clients” applied for assistance several months ago, but so far have not been approved for this year even if they were approved last year.
Because of the increased price of fuel and the delays in approving fuel assistance, our organization has delivered a lot of wood. We have also bought a lot of oil, propane, electricity, and pellets along with electrical heaters to use as supplemental sources of heat. We have paid electric bills to prevent service from being cut off.
It has been a blessing that we are having a relatively mild winter, but I am concerned that the next two months could be even more challenging as our wood pile dwindles down and federal resources are depleted. We are fortunate that there are three other non-profits in our community that have joined us in an effort that we call “Heat Kearsarge.” It is a community effort that has brought “compassionate conservatives” together with “left-leaning progressives” to try to fill the gap created by inadequate public programs. If we can join forces to solve a common problem, you would think that our politicians could set differences aside to address the problems that generate so much pain and suffering.
There are many things happening in the wider world that Ron, our friends, and I discuss as we do what we can to serve those in need near us. I remind myself that technically our neighborhood is affluent, but there are still so many in need among us if you know where to look. Economically, New Hampshire ranks near the top of the fifty states (#4 in the US News and World Report Rankings across economic and quality of life issues). It is sad to contemplate that if we are number four there are forty-six states where life is not as good and comfortable as it is here.
Almost any evening news broadcast reveals weather, crime, poverty, homelessness, gun violence, and public unrest in some parts of the country that far exceeds what we experience. If we are having a tough winter economically, I can’t imagine what it must be like in those less fortunate forty-six states, not to mention the rest of the world like Ukraine, Africa, Turkey, Syria, and many parts of Africa and the Middle East where wars, famine, and natural disasters turn millions of people into refugees.
I think that the president is trying to address the right problems. I am certain that he would like for the pace of improvement to be faster. I am also sure that progress will be slow because we are deeply divided in our opinions about why we have the problems we have and how, or if, they should be addressed.
There is a lot for us to think about as we settle in to watch the Super Bowl where our divisions will be less consequential than they are most days. I ventured out on an errand several years ago during the Super Bowl and discovered that no one was on the road. It was an eerie feeling that made me wonder if I had been left behind at the second coming. I hope that you enjoy the game, if you watch it, or enjoy the solitude that you might experience if you don’t join the party.
Be well,
Gene
