October 4, 2024
Dear Interested Readers:
Thirty-two Days to Go and Counting Down
In the Healthcare Musings letter for last week, I reviewed the relationship between the Structural Determinants of Health, the Political Determinants of Health, and the Social Determinants of Health. It is good to remember what the World Health Organization (WHO) said about the Structural Determinants of Health:
When the World Health Organization (WHO)’s Commission on the Social Determinants of Health (CSDH) published their framework for the social determinants of health (SDOH) in 2010, they intentionally included two distinct concepts in their definition, “distinguishing between the mechanisms by which social hierarchies are created, and the conditions of daily life which then result.” The WHO continues to include both “the conditions in which people are born, grow, live, and age” and “the wider set of forces and systems shaping the conditions of daily life” in their definition. Perhaps responding to prior criticism, the CSDH explicitly called out changing the distribution of power as central to addressing the forces and systems that maintain inequity and was clear that engaging in this work is a political endeavor.
Recently, Dr. Daniel Dawes has defined the Political Determinants of Health in such a way as to allow us to understand that political power can be used to mitigate the longstanding Structural Determinants of Health that can lead to the negative realities of inequality in care and outcomes that we have observed to be the outcomes of the Social Determinants of Health. Dawes has defined the Political Determinants of Health:
The Political determinants of health involve the systematic process of structuring relationships, distributing resources, and administering power, operating simultaneously in ways that mutually reinforce or influence one another to shape opportunities that either advance health equity or exacerbate health inequities. – Daniel E. Dawes (2020), The Political Determinants of Health, Johns Hopkins University Press
When political parties or candidates are debating structures for our care delivery system, control of the cost of drugs, access to reproductive health resources, improved housing policies, changes to improve educational outcomes, solutions to “food deserts,” improvements in transportation systems, or regulations to control pollution or global warming, they are having a policy debate that will ultimately impact the Social Determinants of Health. Those debates are an exercise of the Political Determinants of Health that will either improve the Structural Determinant of Health and subsequently diminish or enhance the health inequities and improve or worsen health outcomes.
Last week, as an afterward to this letter, I asked ChatGPT to discuss the relationships between the Structural, Political, and Social Determinants of Health. The conclusion ChatGPT offered was:
In summary, the Social Determinants of Health are the everyday conditions that directly impact health outcomes. The Structural Determinants shape the distribution of these social determinants by creating systems of inequality or equity. Finally, the Political Determinants are the decisions and policies that create the structural framework, making them the foundational drivers of health disparities. To achieve health equity, all three determinants must be addressed, with a particular focus on reforming the political and structural systems that perpetuate inequality.
You might have noticed over the last six months that I am very focused on the 2024 presidential election. You could even say it has become an obsession with me. My bias is that the election of Donald Trump would be a disaster for the ongoing efforts to improve the Social Determinants of Health, expand access to care, and reduce the cost of care for individuals.
I have reviewed for you the healthcare policy statements in the platforms of both parties, the healthcare philosophy presented by Project 2025, and the debates between Trump and Biden and Trump and Harris. My conclusion so far has been that if elected Kamala Harris will use her administrative powers to do anything possible by presidential action to improve the Social Determinants of Health. If Harris is elected along with a Congress that has Democratic majorities in both houses, the Democrats will enact policies that support efforts toward significant improvements in access to care, the quality of care, the reduction of the cost of care for individuals, and broad improvements to the non-medical components of the Social Determinants of Health.
Before Harris became the Democratic candidate, I was distressed by the fact that healthcare was near the bottom of the list of issues that the candidates discussed. A defining moment of the debate between between Trump and Harris, was when Trump responded to a question about healthcare and the ACA by saying that he had “concepts of a plan.” It may be true that Trump’s inability to intelligently discuss what he would do with the ACA if reelected may be remembered in time along with “Haitians in Springfield, Ohio eating their neighbor’s pets” as the most defining political missteps of the 2024 election. If nothing else, one outcome is that healthcare has now joined inflation, “the border,” and abortion as a defining issue for debate and discussion.
In a previous letter, I directed you to an opinion piece in the New York Times by Nobel Prize-winning economist Paul Krugman on the meaning of Trump’s “concept of a plan.” Krugman’s conclusion was:
…very likely, the reason Trump has never produced a health care plan that wouldn’t deny coverage to millions of Americans is that he and those around him don’t know how to do that. Indeed, if they’ve thought seriously about it at all, they might have realized that they’d probably just end up reinventing the A.C.A.
So, am I saying that Trump has probably been faking it all along, that he has really never had an idea about how to improve on Obamacare? Why, yes.
Shortly after the debate, The New Republic commented on Trump’s “concept of a plan.”
After his particularly lackluster response criticizing Obamacare but giving no alternatives, ABC moderate Linsey Davis asked Trump outright if he knew what he was talking about. “Yes or no, you still do not have a plan?” she said.
“I have concepts of a plan,” Trump replied. “I’m not president right now.”
“But if we come up with something, I would only change it if we come up with something that is better and less expensive. And there are concepts and options we have to do that. And you will be hearing about it in the not too distant future.”
Trump’s ridiculous answer about “concepts of a plan” has become the core of an ad blitz by the Harris campaign in “battleground” states. NBC News reports:
Kamala Harris is launching a seven-figure ad blitz about health care targeting Donald Trump’s calls to replace the Affordable Care Act with a mystery plan he hasn’t yet released.
The ad campaign, first reported by NBC News, is aimed at elevating the issue and capitalizing on what polling says is a weakness for Trump. The new 60-second spot features Trump saying during his face-to-face debate with Harris that he has “concepts of a plan” to remake the U.S. health care system.
“You have no plan,” Harris tells Trump in the ad while touting her calls for protecting the ACA (or “Obamacare”) and extending the Biden-Harris policies that expanded subsidies to buy coverage and capped the cost of insulin for seniors at $35 per month.
I was very interested in whether the debate on Monday night between J.D.Vance and Tim Walz would add any insight into what Trump’s “concept of a plan” might be. This week my wife and I are in California where we had come to see our grandsons and visit some friends. A nine o’clock debate on the East Coast is a six o’clock debate on the West Coast. For two people in their late seventies, there is not enough bandwidth to provide much attention to a debate when in the company of two active boys ages seven and ten.
I tried to watch the debate while ignoring the pandemonium around me, but what caused me to turn off the debate was that I could not stomach the arrogant misrepresentations of facts presented by Vance in the first few minutes of the debate. It is obvious that he shares many of Trump’s talents for misrepresentation, but does it with even more strategic effectiveness. Vance at dinner time is a sure recipe for dyspepsia. My plan was to depend upon YouTube and New York Times reruns of the debate after the boys had gone to bed and we had retreated to our Air B and B bedroom a few doors down the street from our son’s home, but I just couldn’t bring myself to spend ninety minutes listening to Vance at any hour of the day or in any environment. My lack of fortitude and commitment surprised me and suggested to me that if Vance and Trump were elected, I would probably be facing the biggest emotional challenge of my life.
Since I could not stomach the debate as it aired, and I could not listen to a recording of it, what was I going to do? I decided that I needed to see if ChatGPT could come to my rescue once again. I will assure you that my personal approach to AI stems from the only advice I have ever accepted from our fortieth president, Ronald Reagan, who is famous for saying, “Trust, but verify.” Formulating good questions to ask the Chatbot is also a key to effective use. So I asked:
Please discuss the healthcare and women’s health-related issues discussed in the October 1 Vice Presidential Debate between J.D. Vance and Tim Walz.
ChatGPT said:
Searched 3 sites
“October 1 2024 Vice Presidential debate JD Vance Tim Walz healthcare women issues” bing.com
Advocate.com — 5 key takeaways from the vice-presidential debate
[It surprised me to see that since the week before ChatGPT has begun to lead with the references it is using.]
The October 1, 2024, vice-presidential debate between J.D. Vance (Republican) and Tim Walz (Democrat) touched on key healthcare issues, particularly related to women’s health, abortion, and access to care.
- Women’s Health and Abortion:
The issue of abortion was a significant topic during the debate, with J.D. Vance defending Republican calls for stricter abortion regulations. He emphasized the need to protect “unborn life” and highlighted his support for a national abortion ban after 15 weeks, positioning it as a compromise. Tim Walz, on the other hand, stood firmly in defense of reproductive rights. He criticized the GOP’s push to limit access to abortion, arguing that such restrictions would disproportionately affect low-income women and communities of color, exacerbating existing health disparities.
Walz underscored the importance of bodily autonomy and the need for comprehensive reproductive healthcare, which includes not just abortion but access to contraception and maternal care. He linked women’s health rights to broader healthcare equity issues, arguing that GOP policies could roll back decades of progress in women’s health.
2. Healthcare Access and Affordability:
Beyond women’s health, both candidates debated broader healthcare access. Walz advocated for expanding the Affordable Care Act (ACA) and increasing federal investment in public health services to improve access to healthcare, particularly for underserved populations. He highlighted the successes of Medicaid expansion in his home state of Minnesota as a model for how other states could improve healthcare access.
Vance, in contrast, argued for more market-driven solutions to healthcare. He pushed back against further expansion of government healthcare programs, instead focusing on reducing healthcare costs through competition and deregulation. He expressed concerns that increasing federal involvement in healthcare would lead to inefficiencies and reduced quality of care.
3.Maternal Mortality and Women’s Health Disparities:
Walz also raised concerns about the U.S. maternal mortality rate, particularly among Black women, who face disproportionately high risks during pregnancy and childbirth. He framed this as a direct consequence of systemic inequities in the healthcare system that need to be addressed through expanded access to prenatal care, improved healthcare infrastructure, and targeted interventions for at-risk populations. Vance countered that improving healthcare outcomes requires addressing broader social issues, such as economic inequality, but maintained his position against expanding government-run healthcare systems.
Overall, the debate highlighted the stark differences between the two candidates on women’s health and healthcare policy, with Walz advocating for expanded access and protections, while Vance emphasized limiting federal involvement and promoting conservative values around life and health.
For more detailed fact-checking and analysis of the debate, sources like PolitiFact and Advocate have covered the major policy points (Poynter) (Advocate.com).
That seemed like a good response. When I researched the sources I discovered that The Advocate was a publication that reports on issues of interest to the LGBTQ+ community. What ChatGPT had not mentioned was the Social Determinants of Health, so I decided to be more direct and give it a command:
Please discuss any points made by either Vice Presidential candidate in their October 1 debate that revealed their likelihood of trying to improve the Social Determinants of Health.
ChatGPT said:
In the October 1, 2024, vice-presidential debate between J.D. Vance (Republican) and Tim Walz (Democrat), both candidates made points that indirectly reflected their stance on addressing Social Determinants of Health (SDOH), though in different ways.
1. Tim Walz (Democrat)
Walz’s platform and debate comments revealed a focus on improving the structural conditions that affect health. His emphasis on expanding healthcare access and addressing economic inequities pointed to a willingness to improve SDOH, particularly in marginalized communities. Specifically:
- Healthcare Access: Walz supported expanding the Affordable Care Act (ACA) and Medicaid. Access to affordable healthcare is a key social determinant of health, and Walz argued that expanding these programs would help improve health outcomes for low-income and underserved populations (Poynter)(Advocate.com).
- Maternal Mortality and Racial Disparities: Walz raised concerns about the disproportionately high maternal mortality rate among Black women, positioning this as a clear example of how structural racism in the healthcare system leads to poorer health outcomes for certain populations. His proposed solutions, such as expanding access to prenatal care, directly tie into improving the social and structural conditions that shape health inequities(Poynter).
- Economic Inequality: He also linked healthcare access to economic inequality, arguing that improving wages and economic opportunities would lead to better health outcomes. Economic stability, a critical social determinant of health, was highlighted in his comments on raising the minimum wage and expanding worker protections (Poynter).
2. J.D. Vance (Republican)
Vance’s comments reflected a more conservative approach to addressing health outcomes, with a focus on economic freedom and reducing government intervention. His policies suggest indirect attention to SDOH but through market-based solutions rather than government programs:
- Free-Market Healthcare Solutions: Vance emphasized reducing healthcare costs through deregulation and increased competition rather than expanding government programs. While not directly tied to social determinants, lowering healthcare costs could improve access for some individuals, although it remains unclear how this approach would impact low-income or marginalized communities (Advocate.com).
- Economic Growth: Vance also focused on economic policies that he believed would help individuals improve their own health outcomes through job creation and economic opportunities. This aligns with his broader vision of addressing SDOH through economic growth and self-reliance rather than social safety nets (Poynter).
Conclusion:
Overall, Tim Walz was more explicit in addressing the Social Determinants of Health, particularly in his focus on healthcare access, racial disparities, and economic inequality. J.D. Vance, while advocating for economic policies that could indirectly improve SDOH, focused more on market-driven solutions and personal responsibility rather than systemic government intervention to address health inequities.
It boils down to two different world views. If you are a Democrat you hope that through good public policy and the thoughtful application of progressive values, the lives of people can be improved. The Republican stance can be succinctly summed up by a Reagan quote with which I strongly disagree:
J.D. Vance has been more articulate than Trump about relying on the market to fix healthcare. That is a “concept of a plan” that has not worked for over a hundred years and there is no reason to believe that over the next four years the “market” will improve the health of the nation or the Social Determinants of Health. The ACA was passed in 2010 without a single Republican vote in the Senate or in the House. The ACA has been a boon directly or indirectly to the health of every American. It makes sense to me that the path to improving the health of the nation and the Social Determinants of Health lies with a partnership for improvement between the healthcare industry and the government that is built on improved public policies–an exercise in the Political Determinants of Health.
There are only thirty-two days before the election. There are no more scheduled debates, but if the past two elections, 2016 and 2020, are any guide we are likely to have some surprises between now and November 5 which could tip a tight election in either direction. The vulnerable issues for Harris—inflation and the border— aren’t likely to change much in the next month. Harris’s biggest vulnerability may be the Biden-Harris support of Israel and the potential for substantial escalation of the conflicts in the Middle East and possibly in Ukraine. I hope that the increased focus on healthcare and reproductive rights will be an effective counterbalance to the arguments that Trump and Vance continue to make that most Americans were better off when Trump was president. I don’t think that is true, but it has been said by Trump so many times that many people believe it and discount the real risks of a second Trump presidency.
There is also no doubt that Trump has changed the election rules and norms over the last nine years. Various forms of verbal inaccuracies are no longer recognized as out-and-out lies or attempts at deception. There seems to be a hierarchy of lies. There are many statements like the consumption of pets by Haitian imigrants in Springfield, Ohio that are “pants on fire” lies.
What worries me the most is the multitude of statements that really require context. An example is that “crime and murders are up ” during the Biden-Harris administration. Crime and murders are on the whole significantly deminished during the Biden years, yet there are some places like perhaps Chicago where the impression of many people is that crime and murders are increased.
It is probably true that these statements that may be partially true when taken out of context do substantially confuse uncommitted voters and provide benefit to the user. This tactic is used by both candidates now, but at the Vice Presidential debate Vance outscored Walz substantially in the categories of false, partially false, or needs context statements as scored by the host of the debate, CBS News. The destruction of truth and the introduction of “Fake News” are politically effective tactics that as practiced by Donald Trump have transformed our elections. Deliberate falsehoods and inaccuracies have been coupled with the overall destruction of political “norms.” Our democracy may never recover from the destruction of truth and the disregard for norms that Trump has introduced as political innovations that Vance has quickly mastered.
It is an understatement to assert that so far increasing voter confusion seems to be a tactic that grants an advantage to Trump. I expect that over the next month, we will see more and more confusing claims. The question is whether or not those few undecided voters in the battleground states have “wised up” to the scam or will accept claims that are meant to verify their biases. All the votes will have been cast in thirty-two days, but when there will be a definitive outcome, and what might follow that outcome, no matter who wins, remains anybody’s guess which is why I am very uncertain about the future of our attempts to improve the Social Determinants of Health and the health of the nation.
Eight Days In the “Golden State”
Last Sunday was our next to youngest grandson’s seventh birthday. His birthday was a good excuse to take a trip to California. I have made dozens and dozens of trips to California over the last sixty-six years since my first trip in 1958 when my family visited a then new Disneyland and also enjoyed a tour of the set of “Sky King.” It was a wonderful family car adventure that also took us to the Grand Canyon and to many out-of-the-way places that I had never heard of like the Salton Sea and Thermal, California where it was 110 at eleven o’clock at night. Thermal is a well-named town.
I enjoy visiting my California grandsons who live in a little “cowboy town” about nine miles up into the mountains above Santa Cruz. The San Lorenzo River flows by at the foot of the mountain slope where they live in a neighborhood with about as many magnificent coastal redwoods as people.
Where they live is somewhat precarious two years ago a huge fire came within a half mile of their home. At the foot of their street, San Lorenzo Avenue, just across a bridge that was nearly washed away by a deluge from an “atmospheric river” last year, lies the Henry Cowell Redwoods State Park. As the link implies, the park is pretty spectacular:
Henry Cowell Redwoods State Park is located in the Santa Cruz Mountains and is most famous for the 40-acre grove of towering old-growth redwood trees. Its historical significance and spectacular scenery draw travelers from around the world.
The tallest tree in the grove is almost as tall as a football field is long. The oldest trees are over two thousand years old. Every time I visit my grandsons, I take at least one walk in the park. I took the picture that is today’s header on Monday when my wife and I took the walk while the boys were in school. It was in the nineties out in the open, but much, much cooler under the cover of the redwoods. We repeated the walk late Tuesday afternoon with our grandsons. They know all the neat nooks and crannies in the trunks of the trees. There is one huge tree known as “The Hotel” that had been used as an overnight shelter in the wilder days of the distant past.
I was delighted that we did the walk twice during our busy four-day visit before we headed south to Laguna Woods in Orange County to visit old friends who recently moved there from Santa Fe, New Mexico. I am pleased to hear from my friends that Orange County is not quite as “red” as it once was even though San Clemente is just down the road.
My friend, Harry Carpenter, who was wounded and received several medals for valor as a medic in Vietnam, proudly sports a hat that say Veterans for Harris-Walz ’24.
Harry gets plenty of thumbs up as he goes about his business. If Harris and Walz can win a few votes in deeply conservative Orange County maybe my worst election fears will not be realized.
I hope you will check for the facts when you hear strange assertions from Trump and Vance. I hope that your political contributions and efforts can be added to those of others who care about the future of healthcare and the Social Determinants of Health and that our collective efforts can result in an outcome that ensures that we make continued progress toward the Triple Aim over the next four years.
Be well,
Gene
