February 5, 2021
Dear Interested Readers,
It’s Time To Start Again
I am sure that I am not alone in my current strange mix of hope and residual fear. I am feeling much better now that Joe Biden is in the Oval office, but prior traumas are hard to forget. Before election night in 2016, I was quite hopeful that the day was fast approaching when much of what was obviously failing and fell far short of acceptable in American healthcare was on a pathway that was leading to eventual improvement within my lifetime. It is very painful to remember the sense of devastation that I felt on that election night. I remember going to bed at about two in the morning when it was pretty obvious that Trump was winning. I woke at about four-thirty and turned on CNN with the hope that what had seemed devastating but real a few hours earlier had just been a bad dream. It was hard to accept that I had gone to sleep witnessing a disaster and that the disaster was reality and not a terrible dream.
The time and events between Election Day in November 2016 and Inauguration Day in January 2017 are hard for me to remember, but I do remember the incredulous looks on the faces of those who had the responsibility to be on the platform at the inauguration while Trump ranted about draining the swamp and American carnage. It is reported that when the rant was over former President Bush summed up the moment to others sitting near him that included the Clintons and Obamas by saying “That was some weird s–t!” The next day, while the president was telling his first lies about the size of his crowd, my wife and some of her local friends, put on pink hats and got on a bus to ride to the Boston version of the Women’s March on Washington. It was not long after that the sticker on her car that said “Bernie Has My Heart, Hillary Has My Vote” was replaced by a one-word sticker that said “Resist.”
It was immediately obvious to me that any progress that we had made toward the Triple Aim was going to be put on hold. The strategies for those who might care that America had the most expensive healthcare in the world but was producing the worst results of any developed country were immediately put on hold. Success over the next four years would be defined as the preservation of a portion of previous gains, not progress toward a goal. I remember John McCain’s downturned thumb as the greatest victory for healthcare during the first two Trump years and the recapturing of the House by Democrats on the back of the issue of “preexisting conditions” as the greatest relief of the last two years.
I hope that all of those hard days are behind us although we are still vulnerable to the pending third challenge to the constitutionality of the ACA. This time the argument is that the ACA minus the mandate is unconstitutional. That decision is likely to be announced in late June.
The journey toward equitable and effective healthcare for every American is a saga that has played out over more than a hundred years since the idea of universal coverage was first proposed by Teddy Roosevelt. If you think that is an exaggeration or stretch then let’s agree that it’s been on the table since Harvey Cushing whose daughter married FDR’s son, convinced him to leave healthcare out of his social security program in 1935. That would make the effort over 85 years old. If you can’t relate to that let’s set the date in the mid-forties since Harry Truman tried to pass universal coverage after World War II. That would make it a seventy-five-year journey. If you disagree with placing the struggle all the way back to Truman, can we settle on John Kennedy’s proposals in the early sixties? That would make it a sixty-year journey. It is probably true that the only efforts that have a longer history in America of struggle and partial success through baby steps than the effort to improve and expand healthcare for all Americans are the civil rights struggle from the abolitionist movement to Black Lives Matter and the parallel struggle for equal rights for women. It is hard to accept that we have had an excellent blueprint for change, Crossing the Quality Chasm: A New Health System for the 21st Century for twenty years. It was published on March 1, 2001. It’s been a long slow journey. I guess I am being unreasonable to complain about a pause of four years, but it was four years of feeling very vulnerable to an immense loss.
I have recently finished a fabulous book that I would recommend to all my readers. It is Bill Bryson’s 2019 book, The Body: A Guide For Occupants. If you think that you don’t need to read it because you went to medical school or have a nursing degree you are wrong. Bryson presents a lot of recent science but what is beautiful is how he weaves what you know with the real world in a way that adds new perspectives and potentially useful insights. If you click on the link you will read a review that fails to point out what I think are the two most remarkable things about the book. The reviewer A.J. Jacobs does mention Bryson’s warnings about the reemergence of infectious disease as a potentially catastrophic problem. Jacobs was writing in the fall of 2019. There was no way that he could appreciate in 2019 how prescient Bryson was about the threats of pandemics from zoonoses, or how ill-prepared we were to respond to a global challenge.
My favorite chapter was the next to the last chapter, number twenty-two, that was entitled “Medicine Good and Bad.” The chapter is such a good dissertation on the current state of healthcare in America that I would suggest that you consider spending $12.99 to download the Kindle version of the book just so that you can read chapter 22. I guess that a trip to your local library would be a low-cost alternative. If your library is like mine you might even be able to “check out” the e-ebook and save yourself the trip and potential exposure to COVID-19.
Bryson begins chapter 22 by discussing life expectancy. He quotes Marlene Zuk who said, “Old age is not a recent invention, but its commonness is.” From there he goes on to the debate about whether the improvement of life expectancy of about thirty-five years that has occurred around the world over the last 120 years was primarily the result of the medicines and advancements in medical treatments or related to improvements in public health and the social determinants of health. It’s an 80/20 analysis. The 20% part is attributable to better medicines and procedures. He is not putting medicine down. He is just putting it in perspective. He says:
However we decide to apportion the credit for our improved life spans, the bottom line is that nearly all of us are better able today to resist the contagions and afflictions that commonly sickened our great-grandparents while having massively better medical care to call on when we need it. In short, we have never had it so good.
He does not stop there. He then launches into the cost of care and focuses on the very high cost of the inequitable care that Americans experience compared to the rest of the world. Earlier, he had pointed out that life expectancy was not the only way to assess the value of care, but he does imply that paying much more than any other developed country for results that in most categories are worse by a lot than other developed countries is a fact that needs explaining. He makes an effort to give us a reason for the paradox between dollars spent and results obtained.
Two things can be said with confidence about life expectancy in the world today. One is that it is really helpful to be rich. If you are middle-aged, exceptionally well off, and from almost any high-income nation, the chances are excellent that you will live into your late eighties. Someone who is otherwise identical to you but poor–exercises as devotedly, sleeps as many hours, eats a similarly healthy diet, but just has less money in the bank–can expect to die ten to fifteen years sooner. That’s a lot of difference for an equivalent lifestyle, and no one is sure how to account for it.
The second thing that can be said with regard to life expectancy is that it is not a good idea to be an American. Compared with your peers in the rest of the industrialized world, even being well off doesn’t help here. A randomly selected American aged forty-five to fifty-four is more than twice as likely to die from any cause, as someone from the same age group in Sweeden… For every 400 middle-aged Americans who die each year, just 220 die in Australia, 230 in Britain, 290 in Germany, and 300 in France.
Ouch! I like to think of American exceptionalism in more positive ways. Just in case you don’t know, Bryson was born and raised in Iowa and attended Drake University for two years before dropping out. It is true that he has spent much of his adult life in Britain although he did live for many years in Hanover, New Hampshire. His son is currently a pediatric orthopedic fellow at a children’s hospital in Liverpool. It’s also a fun fact that although he left college after his sophomore year to wander around Europe, he was the chancellor of Durham University in England for several years. He now has several honorary doctorates. He is the best example that I know of the saying that the world can be divided into two groups–those who can’t be educated, and those who don’t need to be. I know what I know about Bryson’s life from hearing him speak in Boston and from reading many of his books, especially his autobiographical and incredibly funny book about his early years, The Thunderbolt Kid.
Our ex-pat continues with a description of our exceptionalism. I will give you some of his nuggets:
- One-fifth of all the money Americans earn, $10,209 a year for every citizen, 3.2 trillion–is spent on healthcare.
- …the United States comes in just thirty first in global rankings of life expectancy, behind Cyprus, Costa Rica, and Chile, and just ahead of Cuba and Albania.
- A U.S. teenager is twice as likely to be killed in a car accident as a young person in a comparable country abroad and is eighty-two times more likely to be killed by a gun.
- …the United States records a really quite spectacular 11 traffic deaths per 100,000 people every year, compared with 3.1 in the United Kingdom, 3.4 in Sweeden, and 4.3 in Japan.
- Where America really differs from other countries is in the colossal costs of health care.
I won’t bore you with his description of the cost of various procedures here versus the rest of the world. I know that you know these facts. You’ve seen the data in places like HealthAffairs and The New England Journal of Medicine. The problem I fear is that we know these numbers and facts so well that we blow them off. Like the statistics on gun violence, global warming, and economic inequality in our society, we’ve seen this data for so long that the information no longer causes us to blink, much less commit to activities that could make a difference. I will give you one last conclusion that Bryson makes that will make you cringe because it is a picture of a truth that no one wants to admit and everyone knows is an accurate representation of the world they see.
The problem of overtreatment is exacerbated in many places by fear of litigation and, it must be said, by a desire of some doctors to inflate their earnings…Or as another commentator put it more drolly, “One person’s overtreatment is another’s income stream.”
That’s enough of Bill Bryson. What does he know? I want to announce that over the next several weeks I will be offering an extended review of the excellent policy recommendations presented by the Commonwealth Fund in a task force report that they released a couple of weeks after the election. Seventeen of our most experienced healthcare leaders worked for a year and a half on the “Commonwealth Fund Task Force on Payment and Delivery System Reform: Six Policy Imperatives to Improve Quality, Advance Equity, and Increase Affordability.” I hope that you will download the report and study it with me over the coming weeks. Early in their overview, the task force describes the same problems that Bill Bryson brought to our attention. They wrap the same ideas in a verbal package that is more in the language of scholarship and reintroduces the insights that were always available for some but that the pandemic has highlighted in uncomfortable ways:
Despite its centers of academic excellence, world-renowned research, and leadership in innovation, the U.S. health care system is also known for other traits: high costs, fragmented coverage and care, uneven quality of services, and pervasive inequities. Overlay the ravages of the COVID-19 pandemic on these shortcomings, and the list grows longer: unprepared, disorganized, dysfunctional, and inefficient.
Attempting to overcome these deficiencies, health systems in the U.S. have long studied, tested, and adopted improvements in the delivery of care. For their part, payers and policymakers have sought to encourage these improvements through incentives and mandates. Yet health care delivery systems continue to demonstrate high levels of inefficiency, while longstanding disparities in care persist by race and ethnicity, income, gender, and geography.
The basic picture of our healthcare deficiencies and inequities did not change with the election of President Trump, nor will they all be miraculously reversed now that Joe Biden has been elected. What Trump did accomplish was that he was able to put our gains and the building momentum from many years of efforts to mitigate these deficiencies on hold. Thankfully, now that Trump is gone, and with the hope that his nominees to the Supreme Court won’t do what he could not do, most of the knowledge acquired over several decades about what we might do to improve care persists despite all the administrative damage Trump and his enablers inflicted. Biden has begun the turnaround with executive orders. The first focus is on the pandemic, but it is also time for you and others who work in or use our system of care to rejoin the effort to achieve better health for everyone at a sustainable cost to our society. The money that we waste in healthcare can be more productively applied to housing, education, infrastructure, and a host of other factors that will improve the social determinants of health.
I like the mission statement of the Commonwealth Fund:
The mission of the Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, and people of color.
The introduction to their task force report gets down to business quickly to describe the focus of their report:
Meaningful improvements to how health care is organized, paid for, and delivered are not only needed but possible. The Commonwealth Fund’s 18-member Task Force on Payment and Delivery System Reform harnessed their real-world experience and the best available evidence to recommend ways to improve quality, advance equity, and increase affordability of health care in the U.S.
These recommendations are directed at delivery system reform, not insurance coverage, and the federal government, rather than states, because this is where the Task Force sees optimal opportunity for bipartisan collaboration to transform health care for all.
They have divided their recommendations into six specific areas. Over the next few weeks, I hope to be able to discuss them one at a time. Below is a list of topics under which all of their recommendations fall.
- Increase delivery system preparedness for health disasters.
- Increase health system accountability for health care quality, equity, and costs.
- Strengthen primary health care.
- Support the empowerment and engagement of people, families, and communities
- Reduce administrative burden.
- Encourage a balance of regulatory and competitive approaches to promote a high-performing health system.
In each category, the task force has laid out the specifics of what they recommend. I hope that sometime during the first two years of Biden’s administration there will be a miraculous change in Congress that will produce a bipartisan bill, or a series of bills, that will accomplish the objectives in each category. The road ahead toward the objectives of the Commonwealth’s mission, which is in essence a restatement of the Triple Aim, is probably going to be a long slog. Attempts to bring all Americans the care they need and the protection from disease that is required for a stable economy in a harmonious society have never been more obviously needed. It is high time that we all accept that we can be much better than we are for much less than we currently spend if we would only extend to everyone what we want for our families and ourselves. We have a lot of information about what can work. Now is the time to begin to put what we have learned over the last century into practice for the benefit of everyone across this land.
Overlooked Beauty
As regular readers know, I enjoy the videos that Peter Bloch, my neighbor, produces. This week Peter has outdone himself with a posting he calls “Ice Creek Ballet.” If you have a spare three minutes it will refresh your spirit. In his description of the work, Peter says that the video was captured on an iPhone 12 Pro. That is remarkable as you may judge for yourself. Even more remarkable to me is his statement in the introduction: “..the entire 3-minute movie was filmed in an area that you could cover with a small blanket, yet it captivated me.”
Here is the “macro” scene of the origin of the picture of the beautiful “micro” scene in today’s header.
The idea of closely observing a very small piece of nature is not new. I first encountered the idea in a wonderful book, The Forest Unseen: A Year’s Watch in Nature, that was written by David Haskell. The book was recommended by a great friend who has sent me on many satisfying literary adventures. David Haskell is an ecologist and evolutionary biologist at Sewanee: The University of the South in Tennesse. The college owns 13,000 acres of forest. Professor Haskell went deep into the forest and marked off one square meter as a study site. For an entire year, he came to the spot almost every day and recorded what he saw. James Gorman reviewed the book in the New York Times. I totally agree with his description of Professor Haskell’s writing:
He thinks like a biologist, writes like a poet, and gives the natural world the kind of open-minded attention one expects from a Zen monk rather than a hypothesis-driven scientist. He avoids terms like “nature deficit disorder” and refuses to scold the bug-fearing masses. His pitch is more old-fashioned, grounded in aesthetics as much as science…
He did no experiments and no research at his forest circle. He sat, and watched, and listened.
What he observed with his eyes and heard with his was remarkable. As I read his book and as I watched Peter’s video I had the same thought. We are so focused on the wider world that we miss a beautiful world that is available to us at all times if we would only be still and look at what surrounds us as we attempt to be in the moment. Being still and in the moment is one of the hardest things for me to do. I get closest to being in the moment when I am moving in nature, but Peter and Professor Haskell both stop and look deeply into what exists at their feet.
Since the election, I have been living from one dramatic moment to the next. The background of the pandemic, all of the apprehensions about when and where one might get vaccinated, the suspense about the second impeachment, and even uncertainty about whether Tom Brady will win another Super Bowl leaves my head spinning. Peter’s video reminds me that there is real satisfaction, peace, and release in just stopping for a moment to watch ice forming on a small area of a fast-moving creek. Professor Haskell and Peter are giving us the same advice that much of what we really need to know can be observed in a very small space that you think that you know well but have never really seen well enough to know what it has to offer to you. I sometimes sing to myself:
You got to make the morning last
I hope that you have a great weekend with a few quiet moments when you might slow down and observe something remarkable that you’ve never noticed before. That’s what I am going to try to do.
Be well, be hopeful, be a part of the effort to rebuild and redirect the future of your community, and let me hear from you. I would love to know what is happening wherever you are.
Gene
