March 25, 2022
Dear Interested Readers,
To Live in Challenging Times
My goal for this week’s letter was to shift back to writing more directly about healthcare. Despite my plans, I found it hard to completely ignore the Senate hearings on the nomination of Judge Ketanji Brown Jackson to the Supreme Court. It was even harder to ignore the fact that thousands have died in Ukraine where lovely cities that were the home of freedom-loving people have been reduced to rubble with unburied bodies lying in the streets, and more than ten million people have become refugees or are displaced within their country. And for what achievable objective in the mind of an evil, maniacal autocrat?
My plan was to write about the current challenges in healthcare as we move into a post-pandemic and possibly post Trump world that is in the midst of rampant inflation, global warming, and fears of Putin’s use of tactical nuclear weapons or chemical weapons pushing us into a World War III that no one can win. Healthcare policy and progress toward the Triple Aim is difficult to consider without substantial concessions to other events and circumstances in a world where rational thought is challenged by a constant state of confusion, anxiety, endless debate, and disagreement about many foundational values.
Pure, undiluted healthcare commentary was my objective, but the bombs kept falling on Kyiv and Mariupol. My goal was further undermined as we were exposed to uncomfortable days of histrionic harangues by obnoxious Republican senators who were desperately trying to use a show of unrealistic concerns about child pornography and the coddling of terrorists as disguises to advance their own political careers by using their dog-whistle racism as demagoguery to add intense partisanship to the hearings to determine the worthiness for appointment to the Supreme Court of an accomplished jurist who was also a black woman.
At first, I tied to ignore the Senate confirmation hearings, but my wife was constantly switching back and forth from the broadcast on NPR to the televised presentation on C-Span. I think that the goal for some of the Republican senators who kept repeating the same false charges was to impress voters who are “the base” of the far-right with their willingness to throw all decorum aside with the hope of being the new darling of the right in case Trump falters or is rightfully indicted for one of the many crimes he has committed. I assume that if their demonstration was not just for their own political advantage they hoped that their show of belligerence would improve the chances that their party might win the control of Congress later this year. The only bleaker future that I can imagine than a return of Trump would be to have Lindsey Graham, Ted Cruz, Tom Cotton, or Josh Hawley as our president. Some of the other Republican senators on the committee, specifically John Kennedy, Mike Lee, and Tom Tillis did “me too performances” as Senator Marsha Blackburn tried to demonstrate that she could be just as objectionable as Marjorie Taylor Greene. The ranking member, Chuck Grassley, was a little less bombastic in his inquiries and I should say that Ben Sasse of Nebraska did demonstrate some restraint and asked many reasonable questions, but I doubt that he will vote for Judge Jackson’s confirmation. I kept asking myself just how stupid did they believe the majority of American voters to be. I am reminded of just how undemocratic our Constitution is based on the compromises that were made over 200 years ago just to get it passed. Vox recently published a piece that shows just how close we were to having a Republican House, Senate, and president despite the fact that the Democrats won a large majority of the vote.
When Senators-elect Raphael Warnock (D-GA) and Jon Ossoff (D-GA) are sworn in, each party will control 50 seats in the Senate. But the Democratic half will represent 41,549,808 more people than the Republican half. In November, moreover, Ossoff barely held his Republican opponent, former Sen. David Perdue, under the threshold that forced Perdue into a runoff election that he lost. If a few thousand more voters had turned out for Perdue, Republicans would control the Senate.
Solid majorities of the nation, in other words, voted for a Democratic White House, a Democratic House, and a Democratic Senate. And yet Republicans nearly walked away with control of all three.
I am not calling for a rewrite of the Constitution, but I do believe that the same realities that make us vulnerable to a minority government also make it difficult to pass the legislation that would create a more humane and more effective system of health care, lead to low costs for medications, and better prepare us for the public health challenges that surely lie in our future. Healthcare inequities are at least in part traceable to the same compromises that make us vulnerable to a minority control of the government. As it is, the Constitution protects “geography” or the interests of those who control small states more than the millions that populate states like New York, California, or even Texas and Florida.
The benefits and the liabilities associated with our culture and society are derivative of our blend of Democracy and capitalism. We have come to believe that we are the best as a function of our status quo, but any close look at Europe reveals that it is very possible to have robust manifestations of freedom, the benefits of capitalism, and also a more dependable and humane social services safety net and fewer inequities in the distribution of healthcare.
When I was in practice and when I was trying to lead a transformation of a large medical group along the pathways suggested by the vision suggested in the Triple Aim and outlined in the domains of quality described in Crossing the Quality Chasm, I totally believed in our ability to have a higher quality, safer, less expensive, more responsive, more appealing system of care while maintaining our focus on basic science and technical expertise. I thought that we could have it all. Indeed, it was our science, the emergence of better data analytics, and the technical expertise of our clinicians that made the vision of less expensive better care for everyone plausible. Wasn’t that the promise of capitalism?
Incorporated in every consideration of the future of healthcare is the question about what system of finance is most advantageous to optimize the outputs of the system. Crossing the Quality Chasm, the thinking upon which the ACA was created, and the most successful pilots structured to explore paths toward the Triple Aim demonstrate the superiority of value-based reimbursement based on the care of populations rather than a fee-for-service payment system. The shift from fee-for-service payment to a budget for the care of populations opens the door to more robust systems of care that can quickly adapt to challenges like COVID. Medicine could walk through that door without any change in legislation or direction from the government, but the culture of medicine is resistant to such change. Medicine needs the catalytic prodding of government to make any change that disrupts the status quo.
The sagas of Medicare and Medicaid and the ACA demonstrate that structural change in the practice of medicine requires government direction and a significant Democratic majority. As long as we have a deeply divided country it is unlikely that there will be leadership coming from Congress even if the executive branch understands the need and has the political will to try to make improvements. The same conservative voices that harassed Judge Jackson will surely lead the charge against any new effort. During the run-up to the vote on the ACA, Chuck Grassley, the ranking member of the judiciary committee who also sits on the Senate Finance committee wrangled huge compromises in the ACA under the guise that those changes would allow him to suppoIt the bill. Then he voted against the bill and the changes he had forced. It is a miracle that even with all of its compromises the ACA passed, and its mandate did not survive the conservative Supreme Court.
I recently asked a board member of my local hospital how the hospital was doing financially as we emerged from the pandemic. His response was that finances were looking up. The local orthopedic surgeon was doing more and more hips and they were attracting business away from the invading orthopedic group from Concord which lies 33 miles down Interstate 89. I congratulated him on the hospital’s improving finances but asked him if he thought the success was sustainable.
Our conversation continued and moved toward a discussion of access to care in our community. I knew from recent inquiries for a family that needed primary care that currently the IM and pediatric practices affiliated with the hospital were not accepting new patients. The only care currently available for a patient who doesn’t currently have a PCP is a walk-in urgent care office or the emergency room. He countered with the fact that the board was aware of the problem and that their goals included improving care at the community level. He did admit that the objective was not coupled with much of a budget.
I am not critical of him, the hospital board, the very talented new CEO the board has recently hired, or of Dartmouth Hitchcock which is the referral center that supports the hospital. To buck the system is practically impossible for any single system. They perform within parameters that are set far away from their doors. The attention of those legislators who would be open to new healthcare legislation is divided between how to maintain control of the government despite the challenges of the 2022 election while dealing with horrific problems in the wider world that include the disaster in Ukraine, the impending problems with climate, and the complaints of an electorate who currently consider inflation and the cost of gasoline to be their greatest concern. Joe Biden knows that come the November elections the price of gasoline may well trump amazing foreign policy successes, and even though healthcare concerns are important they won’t change many votes in a situation that is always stacked against Democrats.
I don’t expect any improvements in the cost of care or in access to care in the next three to five years, and maybe never. It seems likely that quality, as described by Crossing the Quality Chasm, will deteriorate in the domains of safety, patient satisfaction, timeliness of care, efficiency (cost), access, and equity. The pandemic underlined the sad reality that healthcare’s lack of equity translates into higher death rates among minority groups. Fortunately, the pandemic also showed that our science is robust even if we have a problem with the distribution of the benefits we can create.
When I was in practice I dealt with problems in the hospital and office. When I was a board member of executive I dealt with systems issues, finance, affiliations, insurance companies, and governmental agencies. In retirement, I have a different perspective. I am a consumer of a suboptimal product, and through my work with local non profits I try to help people who fall through the gaps in the system. Let me tell you a couple of stories. As Joe Friday was famous for saying on Dragnet, “…the story you are about to hear is true. Only the names have been changed to protect the innocent.”
George is a man in his mid-sixties who was admitted to the hospital in late December with respiratory distress. He has only one lung and is also an insulin-dependent diabetic. He lives alone but has children and siblings living nearby, but all of them have substantial financial challenges. George was always “self-employed,” as a result of not paying much into Social Security during his working years, his Social Security income after payment for Medicare is less than $400 a month. His diabetic meds take much of what is left. He gets food from the local food bank. George lives alone “off the grid” in a little house he built on some rural land given to him more than thirty years ago by a relative. Before he was admitted to the hospital, when his solar panels failed to give him the electricity that he needed, he would take batteries to his sister’s home nearby and “borrow” electricity. George is now oxygen-dependent and was discharged to his daughter’s home with an oxygen extractor that requires more electricity than his antiquated “off the grid” solar system can provide.
The local electric company will provide a free line to any home that is less than 300 feet from the road. George’s home is more than 500 feet from the road and an extra pole will be required for him to get service. The cost will be $7,600.64. The community outreach worker at the hospital enrolled George in Medicaid as a dually eligible patient and found a state-financed program for the poor elderly that raised his income to about $800 a month, but the electrical problem persists and things are stressed at his daughter’s home. The proposed solution is that two local nonprofit charitable organizations will each contribute $1500. The town welfare officer will ask the town’s selectmen to approve the balance that the family can’t pay which will probably be about $4000. That may sound trivial but the town has a population of only 2,250. It is possible that sometime later this Spring George might return home, George’s future depends on whether the selectmen will approve spending $4000. There are many people like George in America who depend on the “kindness of others” rather than equitable service from a durable social services safety net that might exist in a more “progressive” state or some European “social democracy.” George lives in a state where the motto is “live free or die” which may be appropriate as a battle cry, but it has come to mean “live free, paying very little taxes, and if someone dies because of some lack of relief from an inadequate system of care, it was their own fault.” The attitude is antithetical to any form of compassion from George Bush’s “compassionate conservatism” to the left-leaning compassion of secular humanism.
Mike has a simpler story. He is a single 60-year-old hypertensive diabetic with some renal impairment who spent over a month in the ICU at Dartmouth several years ago after he suffered a ruptured cerebral aneurysm. He recovered, but he has had some cognitive difficulties since his event. He sees his PCP at our local hospital regularly and buys his medications weekly because he can’t afford to pay for them all at once. His dual eligibility was revoked for unclear reasons a few years ago and since then his meds consume much of his disability check. He lives on a Social Security disability income of about $1200 a month.
His medications cost several hundred dollars a month. He pays no rent because he owns his small home, but he does pay $250 a month in property taxes. After his meds and property taxes, he has less than $700 a month to pay for his electricity, phone, propane, food, gasoline, and car insurance (you can’t live in rural New Hampshire without a car). Two local non-profits gave him a car last fall after he had been carless for a couple of years since his old car was totaled by a neighbor who lost control on an icy road and hit his car in his driveway. He gets some food from the local food bank.
He was doing fairly well on his tight budget until recently when he lost control of his car on a dirt road in a sudden whiteout of snow. He hit a mailbox which took out his right front headlight. He is broke and it is two weeks until his next check. He has no money for car repairs (the estimate is about $1200), no money for next week’s medications, no money for food even if he could get to the grocery store, and not much expectation that things will improve. He tells me that he has “no future.” Our plan is to try to find local funds for his car repair and work with social services to see if he can get back on Medicaid which would lower his drug expense. A long shot possibility is seeking a reverse mortgage, but he tried that a few years ago and was rejected. His house is not much more than the unfinished shell of a small cabin, but the land has some value. Before his aneurysm, he was a hard-working fellow who supported his parents who have since passed away.
My point in these presentations is to present examples of how poverty and healthcare interact in ways that can only lead to difficult situations or increased medical expenses within our current inadequate system of care. There are social factors that do lead to both poor health and increased healthcare costs. Our current deep partisan divide precludes the development of workable solutions that do impact us all even if we imagine that our own financial stability protects us. Many of us resist any solution that we imagine would cost us more money in the form of higher taxes even if that is not true. One of our greatest national proclivities is the ability to vote against our own best interests.
A few years ago we learned that almost 40% of Americans would have difficulty finding the resources to pay an unexpected bill of $400. The number varies from year to year but remains an index to the fragile financial state of millions of Americans. Over 25 million Americans, around 10% of the population, don’t have any healthcare coverage. The percentages are much higher for minority populations. These problems have been with us for so long that I feel that we are numb to them.
Short of the sort of catch as catch can local charitable solutions like the ones the two people in the stories above might be fortunate enough to get, solving the problems that complicate the access to care and the outcomes of care in an equitable fashion for everyone will require the involvement of the federal government in ways that will require a supermajority control of the Senate, a majority in the House, a progressive majority on the Supreme Court, and a president who sees the benefit of a system of care that is equitable for all Americans. It seems highly unlikely, although one can hope, that all those pieces of control that will allow the development, passage, and protection of adequate social legislation seem to be a long way off. What is happening in Ukraine is a tragedy. It will also make a difference politically in ways that could improve the likelihood or decrease the likelihood of effective healthcare legislation. It may take years and a couple of more retirements from the court, but the confirmation of Judge Jackson is also a step in the direction toward the protection, if ever passed, of legislation that improves the health of all Americans.
Global Warming and Mud Season
What has evolved as an activity that I really enjoy is using the last section of this weekly letter as an opportunity to share my world with you. It occurred to me this week as I looked out my living room window at a blanket of early morning fog rising from the lake before me as the ice was melting that it is water in its three forms that define so much of my environment. The picture in this week’s header is not the perfect picture for my point. It was taken midday last Tuesday and shows the transition of ice to water. If I had taken the picture earlier in the day before the fog burned off, I would have had the perfect image of water in all three physical states: solid, liquid, and gas. It also occurs to me that in the recent past I could not have taken this picture until mid-April.
All physicians and most other people know that too little water in our systems is not good. When dehydrated, we feel weak, light-headed, thirsty, and our brains, kidneys, and muscles begin to fail. Too much water and we become edematous and short of breath. The other physical factor that impacts how our bodies and our external environments manage water is the temperature. The physical state of water in our environment is a function of temperature. If you are wondering where this is going, the answer is that with each new change of season I am made more anxious by the earlier changes in the seasonal environment that have been observable in my lifetime and the impact of water on our lives is changing as the planet gets warmer.
I am disturbed by the flimsy arguments I hear against the concerns that many thoughtful people have about global warming. It is global warming that has changed the timetable of the transitions of water from solid to liquid to gas that defines the weather we experience. Based on my personal observations there is no question that real and negative change has occurred in our weather over the last decade. Winter is shorter. Spring comes sooner. Summer is hotter. The weather is absolutely unpredictable in the Fall when many leaves get blown off the trees before they can show their colors. The transitions from season to season are different and frequently more violent with more hurricanes, more tornadoes, more blizzards, more torrential downpours, and more persistent droughts.
Most of us, but not all of us, agree with the scientists who have been telling us for several decades that the explanation for what we are collectively experiencing as climate change is our excessive use of carbon-based fossil fuels. Against that background, I recognize the complexity of how we manage our move from our dependence on oil, gas, and coal for energy and transportation to a new world where we move to sources of energy that don’t warm the planet. It is hard to let go of what we have known and to reach out with confidence toward new ways of existing.
I was startled this week when I heard a Senator from a western oil-producing state rale against the president and say that our attempts to reduce our carbon footprint are misguided and now we face the potential global disaster in Ukraine because we weren’t producing enough oil. He went on to imply that $5.00 a gallon gas was a problem created by progressive Democrats. While he was pontificating I was thinking that if never using any oil from Russia would have denied Putin the ability to put together his war machine, or if paying $10.00 a gallon for gas would help the Ukrainians win, I would gladly pay the price and be delighted that the decline in creature comfort would have the added bonus of mitigating just a tiny bit the damage being done to our environment.
When I was younger and going through the many years of education and training required to become a doctor, I would often give myself pep talks that extolled the long-term benefits of “delayed gratification.” These days the sum total of our collective immediate gratification is a threatened planet and an unstable world order. In a complex crowded world, the universal pursuit of “I want what I want now!” is a lot of disappointment and to my surprise more mud.
That’s right. I said mud. Mud season is coming earlier and earlier to New England. My big learning experience this month has been more than I ever wanted to know about mud season. NPR had a great explanation for this interesting fifth season in rural New England. The short answer is “It’s all about global warming.” Their longer explanation is:
Mud season came quickly and violently this year, stranding people in their homes. And it is not just an anomaly — New Englanders may be in for a longer mud season as the climate warms said Alix Contosta, a research assistant professor of environmental science at the University of New Hampshire.
Mud season takes hold in early spring because frozen ground melts from the surface down. Ice in the soil turns to water, but it cannot move past the still-frozen ground below it. A thick layer of mud pools, and it lingers until the water can percolate down into the groundwater or flow into rivers.
It may seem counter-intuitive, but frost penetrates more deeply in a warmer winter. When more precipitation falls as rain than as snow, snow melts faster and snow cover is scant, Contosta explained. While a thick blanket of snow insulates soil from cold air, exposed soil is vulnerable to the icy temperatures that still punctuate even a warm winter in New England.
This year, snowfall was well below average across the state, and the frost gained a deep hold in the soil, she said.
“This tends to result in a worse mud season in the spring because the deep frost is going to take a long time to thaw out,” she said.
So we have a complex problem. The more fuel we burn traveling around, the warmer it gets. The warmer it gets we have less snow to prevent a deeper layer of ice. The more ice we have deep in the soil the more mud we get in the Spring and the more we spin our tires going nowhere when we are in mud over our hubcaps. To make it more confusing, the solution to mud season is in part warmer rain that can penetrate the mud and melt the frozen layer that is deeper than ever before.
Perhaps the upside to our dilemma with Putin is that as the price of gas soars as Putin threatens the stability of the world, we will be forced to do what we have resisted. We will learn how to live with less dependence on the fossil fuels that make us vulnerable to both autocrats and global warming. Does that make sense?
Whether or not there is any sense to the moment, I am resigned to an early ice-out on the lake, muddy roads, a warmer and sweatier summer, and black flies the size of sparrows. When we want to blame someone for the cost of gasoline we should look in the mirror. We have known for several decades that we were headed somewhere we did not want to go. I don’t know if there is an off-ramp on the road to warmer more violent weather and more mud. While we wait to see what will happen in Ukraine, I will try to enjoy an early ice-out. I hope that there is more asphalt and less mud in your world!
Be well,
Gene
