November 4, 2022
Dear Interested Readers,
The Election Next Tuesday Will Impact The Future of Our Democracy and Our Collective Health. No Matter the Outcome, What Will Follow Is Up To Us.
Next Tuesday is the first Tuesday after the first Monday in November of an even-numbered year which makes it election day for federal offices. In years that can be evenly divided by four, we elect the president. This formula is not in the Constitution. It was established by federal law. Wikipedia gives the logic behind how the day was determined:
A November election was convenient because the harvest would have been completed but the most severe winter weather, impeding transportation, would not yet have arrived, while the new election results also would roughly conform to a new year. Tuesday was chosen as Election Day so that voters could attend church on Sunday, travel to the polling location (usually in the county seat) on Monday, and vote before Wednesday, which was usually when farmers would sell their produce at the market.
Throughout our history, we have always been concerned about the fairness of elections and who can vote because elections determine who will protect the fair and just distribution of opportunity. Fairness in opportunity must occur if we are to deliver on our promise to ourselves that we will live by the concept that we are all “created equal” and deserve “equal protection under the law.” There was very good reason for President Biden to contend in a speech on Wednesday that the future of our democracy should be the most important issue on the minds of voters this year because not everyone on the ballot seems committed to moving us closer toward equality.
President Biden was direct. If you did not listen to his speech, I urge you to read the transcript. If you don’t have time to check it out, the core of his message was:
…this intimidation, this violence against Democrats, Republicans and nonpartisan officials just doing their jobs, are the consequence of lies told for power and profit, lies of conspiracy and malice, lies repeated over and over to generate a cycle of anger, hate, vitriol and even violence.
In this moment, we have to confront those lies with the truth. The very future of our nation depends on it. My fellow Americans, we’re facing a defining moment, an inflection point. We must with one overwhelming unified voice speak as a country and say there’s no place, no place for voter intimidation or political violence in America…
He continued:
I speak today near Capitol Hill, near the U.S. Capitol, the citadel of our democracy. I know there’s a lot at stake in these midterm elections, from our economy, to the safety of our streets, to our personal freedoms, to the future of health care and Social Security, Medicare. It’s all important. But we’ll have our differences, we’ll have our difference of opinion. And that’s what it’s supposed to be.
But there’s something else at stake, democracy itself. I’m not the only one who sees it. Recent polls have shown an overwhelming majority of Americans believe our democracy is at risk, that our democracy is under threat. They too see that democracy is on the ballot this year, and they’re deeply concerned about it.
So today, I appeal to all Americans, regardless of party, to meet this moment of national and generational importance. We must vote knowing what’s at stake and not just the policy of the moment, but institutions that have held us together as we’ve sought a more perfect union are also at stake. We must vote knowing who we have been, what we’re at risk of becoming.
No one directly asks you to vote against democracy. The threat to democracy comes from those who appeal to your fear and self-interest and seem unafraid to align with more violent elements who are willing to do almost anything to promote an illiberal agenda. The president is not calling for you to vote for his party. He is calling for you not to vote for those who would sacrifice hard-won freedoms for short-term convenience and to protect the assumed privileges of a threatened majority advantage.
The alternative to heading the president’s call for you to vote for democracy and for those who are promoting the rule of law and equality is to vote for those who are driven primarily by self-interest and are appealing to the short-term self-interests of those who seem to fear that equality and adherence to our Constitution and the norms that flow from it would be a disadvantage to their cause. Self-interest is understandable. But the pursuit of self-interest without concern for equal opportunities for all carries the risk that ultimately the outcome will be a universal loss.
For democracy to survive and for us to collectively continue to try to move toward the ideal of equal opportunity, the leaders we elect must understand that the policies they promise in their effort to get elected must not compromise our collective future. Those we elect will determine the future health of our nation. Every vote for a candidate who offers solutions to a current problem that compromises the future of the planet is a vote that moves us another step toward a darker collective future.
Recently, self-interest has been coupled with a tendency to accept or condone political violence as part of the election process. I believe that if you are not outraged by anyone who fails to condemn even the possibility of political violence then even as a lone voter you are a major threat to our collective future. I totally agree with the editors of The New York Times whose editorial yesterday was entitled “America Can Have Democracy or Political Violence. Not Both.” It was not long ago that you could rest assured that a vote for a candidate for office from a major party was a vote for the rule of law. Sadly, that is no longer true. Every vote for a candidate who will not condemn violations of the oath of office or would delay the effort to improve opportunity for everyone moves us closer to a day when everyone’s freedom is at risk.
Election day is a challenge, an opportunity, and a moment of risk. We are challenged to stay true to the pursuit of equality, and we have the opportunity to elect those who will protect what we have gained and might offer ideas that will move us closer to our ideals. We are always at risk of having our fears and self-interests move us to vote for those whose policies can lead us away from the core American ideal of the universal equality of opportunity. Nothing is a greater risk to us collectively than our ability to further damage the planet by electing those who suggest we opt for current comfort and profit over efforts to protect the future. Inflation is far from the worse thing that we could experience.
When I think of November and elections, I frequently think about my own efforts to write. In a little more than a week, this letter will have its ninth anniversary of the shift in focus of my writing. Nothing is more descriptive of my shift in focus than the change in the salutation of this letter. Let me explain. Letters written before October 25, 2013, began with “Dear Atrius Health Colleagues and Other Interested Readers. Letters written after November 13, 2013, have begun with the greeting, “Dear Interested Readers.” In my letter on October 25, 2013, I announced that I would be retiring on December 31, 2013.
My “editor” at the time, Marci Sindel who wore many hats on our management team that included responsibility for publicity, communications, and governmental affairs, had suggested to me that I not write letters to our practice after announcing my retirement. At the time I did not realize that her motivation was that she planned to have the more than 250 letters that I had already written bound in leather and presented to me as an eleven-hundred-page volume entitled Be Well, Gene at our annual awards dinner in mid-November. November 1 and November 8 of 2013 were the only two Fridays since February 22, 2008, that I have not written a letter. But, I digress.
Before October 25, 2013, I was trying to lead a practice toward the achievement of its highest internal ideals. Not long after I began to write again to those outside Atrius Health on November 13, 2013, I realized that I was now writing to a very heterogeneous external audience. There were several other changes. Before October 25, 2013, I was leading an organization. I needed to respect the fact that within the organization there was a diversity of political opinions. After November 13, 2013, I was speaking for myself, and I could present a personal point of view. That is a big difference.
It took a while for me to recognize the greatest difference between October 25, 2013, and November 13, 2013, and that was that there was a “half-life” of my expertise related to practice and the management and leadership of a medical group. It was as if I had stepped off a train that was going forward to places I would never go and any advice that I could give would relate more to the external world or time-proven principles than to current practice issues. I began to realize that after November 13, 2013, I could speak with more authority about the role of healthcare in our communities and the challenge to improve the social determinants of health for everyone than how doctors should practice and how medical groups should respond in the moment to the challenges of achieving the Triple Aim.
The presidential election of 2016 changed the way I write even more than my retirement did. In truth, things began to deteriorate with the death of Ted Kennedy and the election of Republican Scott Brown to fill his seat. Prior to that event, the Democrats had a “filibuster-proof” sixty seats in the Senate. After Brown was elected further modifications to improve the ACA were impossible to negotiate, and the law had to pass through the “reconciliation” process. Things got worse that year in the midterm election as the “Tea Party” led a Republican takeover of the House, and further changes or improvements were limited to those things that could be done by “executive orders” signed by the president which can be immediately reversed by the next president. The next tick down was the 2014 midterm election when Republicans gained control of the Senate by taking nine seats from Democrats. That disaster prevented President Obama from putting Merrick Garland on the Supreme Court and six years later that failure spelled the end of Roe v. Wade because Justice Roberts probably would have been able to negotiate its survival if there had been four liberal justices to balance four conservative justices. The outcome is a cautionary tale that emphasizes that mid-term elections are very important.
When I began my tenure as CEO of Harvard Vanguard and Atrius Health in 2008, there was the political possibility of improving the health of the nation through policy initiatives that pushed medical practices toward better performance as advised in Crossing the Quality Chasm. The elections of 2010, 2014, and 2016 largely blocked policy initiatives from pushing practices toward better performance and the country toward a more equitable healthcare system and policies that can directly address the social determinants of health which are largely a function of economic inequality.
We had a little reprieve with President Biden’s election in 2020. The passage of the Inflation Reduction Act of 2022 marked the first really positive healthcare legislation in a dozen years. The changes to Medicare and the controls placed on drug costs and out-of-pocket expenses, especially for Medicaid recipients, are a welcome relief, but all of those gains could be reversed after 2024.
If the pundits are right, after January 1, 2023, Kevin McCarthy will be the Speaker of the House because a majority of Americans want to blame President Biden for inflation. Republicans offer no plausible path to an improved economy nor do they have a plan that will lower inflation, but those facts don’t matter. As Paul Krugman, the Nobel Prize-winning economist recently wrote in his New York Times column:
…Democrats shouldn’t concede that the overall economy is in bad shape, either. Some very good things have happened on their watch, above all a jobs recovery that has exceeded almost everyone’s expectations. And they have every right to point out that while Republicans may denounce inflation, Republicans have no plan whatsoever to reduce it.
Heisenberg’s “uncertainty principle” asserts that measuring something can change it. That certainly holds true for subatomic particles, and I think it is also true for public opinion. I think it is quite probable that all of the talk in the press about inflation followed by the press’s inquiries to the public measuring their opinion that inflation is the number one issue in this election, may have guaranteed a Republican takeover of the House and possibly the Senate. The only hope that Democrats seem to have to retain control of the Senate and preserve the chance of having a Supreme Court appointment is the fact that the combination of the Trump influence and the power of the “base” in primaries has produced several very poor Republican Senate candidates. That is Mitch McConnell’s opinion.
I should assert here that I agree that economic issues are important. I think economic inequality and poverty are powerful negative forces that negate many efforts to improve care, eliminate healthcare disparities, and improve the social determinants of health. Our lack of affordable housing, workforce issues, and the barriers that families with children face when they try to work are economic issues that concern me more than inflation. I anticipate that attempts to improve any of these concerns will be fruitless if Republicans control the House. In fact, the only thing I can anticipate with a divided government in the era of deep partisan divides is that the House will harass the executive branch with endless investigations. Trump has complained of “witch hunts.” With Republican control of the House, we are likely to have more “Benghazi-like” witch hunts involving the president’s family and the performance of the Department of Justice.
The only relief that I have been able to find in my spin into “election depression” was a column I read on Wednesday in the Washington Post entitled “4 reasons to be skeptical about election polling” written by Jennifer Rubin. This was the source of some relief from the prediction I had heard the day before that incumbent Democrat Chris Pappas from the first district of New Hampshire may be tailing twenty-five-year-old former Trump staffer, Karoline Leavitt, in their race for a House seat. Jennifer Rubin made me feel a little better when she wrote:
Pollsters should worry that their profession might soon be regarded as more like astrology than political science.
Reasons to take polls with a large grain of salt abound…
She had four points:
First, the nagging sense that pollsters are “missing” MAGA voters remains, as was the case during both the 2016 and 2020 elections…
A second reason for caution: Some pollsters have reacted to their previous errors by overweighting survey results in the opposite direction…
Third, as early voting becomes increasingly popular, no one knows whether this behavior will affect voting outcomes or whether the past profile of early voters (heavily Democratic) will hold up.
Finally, Republican pollsters are flooding the zone with partisan polls, which polling averages pick up. Naturally, that means mainstream media outlets are seeing these numbers and concluding that Republicans are gaining steam. But are they?
Thank you, Ms. Rubin! I will hold on to the slim hope you offer. I hope the outcome proves you to be right, but we do need a “plan B” just in case it turns out to be true that Kevin McCarthy becomes the Speaker of the House and Mitch McConnell comes back as the majority leader in the Senate. For as long as I have been writing, I have been of the opinion that the improvements in healthcare that would make a real difference would more likely evolve from the efforts of medical professionals rather than from the authors of public policy.
There is no question in my mind that public policy can be a catalyst for improved care and improvements in the social determinants of health, but I have always believed that progress toward the Triple Aim and healthcare equity will not happen without the active leadership of the medical profession. I also believed that a committed coalition of medical professionals and progressive participants in community-based efforts to improve housing, access to transportation, public education, services for families, and financial support in crisis could join forces to make an enormous difference. I apologize if that point of view sounds a little like George W. Bush’s compassionate conservatism. I would prefer to think of it as advocating for an enlightened coalition of the concerned. I am encouraged by the fact that organizations like the Robert Wood Johnson Foundation are dedicated to improving the social determinants of health.
If the 2022 elections turn out to be a disaster for Democrats, I will hope that its benefit will be a wake-up call for the party, medical professionals, and for all Americans. I hope that we will be able to use the lessons learned to better protect democracy in 2024. I hope that you will turn out on November 8 and vote for the preservation of our democracy, better healthcare, the right for women to control their reproductive lives, and the continuing effort to improve the social determinants of health. No matter what the results of the election, I hope that you will continue to search for ways that you and your colleagues can make a difference in the noble effort to make the Triple Aim a reality on the way to better health for everyone.
Indian Summer, Volleyball, and the New York Marathon.
We have had frost. So far, our lowest overnight temperature has been 29 degrees, meaning our very pleasant daytime temps in the mid-sixties that may hit seventy this weekend will allow me to say that we are enjoying an “Indian Summer.” Every day in the sixties is a gift. Come Monday, we are back in the low fifties. So, the challenge is to enjoy the moment.
On Monday, which was a real gem of a day, I was out for my walk on the road that runs along the shore of our lake. As is often the case, I decided to take a detour down an old path that runs from the road down to the lake through the woods. The land was once a summer camp for girls. I think that I was drawn by the sunlight that was shining through the taller pines. My breath was taken away by the shimmering leaves of some young birches which were growing under the taller white pines that rim the shore of the lake. You can catch a glimpse of the lake in the background of the picture.
A couple of weeks ago I wrote about the fact that the beeches don’t drop their leaves until the new ones come in the spring. I am delighted to remind you that the phenomenon is called marcescence. At the time, I directed you to the same website as much for the picture as for the information. Now I have my own picture.
I hope that the warm breezes blow this weekend where you are. There are two big events on my family’s schedule this weekend. The first is the New England Small College Athletic Conference Women’s Volleyball tournament. My granddaughter plays for the Bowdoin College Women’s Volleyball team. They play Amherst tonight in the quarterfinals. I will watch that game on the Internet broadcast. They lost to Amherst during the regular season, but are playing better now since she has cracked the starting lineup. I am a proud grandparent. Ironically, Bowdoin beat Wesleyan earlier this year in a thriller when she played really well. My granddaughter is number 10 in the picture below.
Wesleyan is the team that is hosting the tournament as the number one seed. Tufts is the second seed and Bowdoin should have beaten them last weekend but did not. There is hope that Bowdoin could win tonight, and if they do win, I am headed to Connecticut for the semifinals on Saturday afternoon, and with some more luck, I will see Bowdoin in the finals on Sunday. My guess is for Bowdoin to win the tournament they will need to beat Amherst, Tufts, and Wesleyan. It is more a hope than a certainty, but assuming they win the NESCAC tournament, next weekend will be the first round of the Division III NCAA tournament which was at MIT last year. I have high hopes for victory for both the Democrats and the Bowdoin polar bears!
The New York Marathon is also this weekend. It’s a great event, and they are predicting a sunny day with the temp in the mid-seventies. That will be great for the enthusiastic crowds that will show up but will be tough for the runners. My favorite “marathon weather” was an overcast day with intermittent drizzle, no wind, and a temp of fifty. I ran many New York Marathons. My first was in 1977 which was the first marathon I ever finished, and a comeback for me and my hero, Bill Rodgers. We had bombed in the heat of the 1977 Boston Marathon and scored a DNF (Did not finish). The surprising heat of that Patriots Day had foiled my first attempt at the distance and also forced Rodgers to quit before he finished. I continued to run New York into the nineties. I would often run with my oldest son, the father of the Bowdoin Volleyball player, during the time he was working for a Manhattan law firm or getting an advanced law degree at Columbia Law School. This weekend in New York my daughter-in-law who is also an attorney and the wife of my fourth son is running her first marathon. I will be rooting for her and tracking her progress on the Internet. My advice to her is to start slow and then slow down. It will be a great day for the crowds, and not so good for the runners.
I hope that you have special plans and good weather wherever you are this weekend. We need to gather hope and strength to face whatever happens on Tuesday.
Be well,
Gene
