September 29, 2023
Dear Interested Readers,
A Hybrid Letter
For several weeks, I have suspended most of my comments about current issues in healthcare, healthcare policy, current politics, and policies that impact our health. In lieu of those usual subjects, I have been writing about my own experiences in training and early years of practice with a focus on the individuals and events that formed my personal medical and social values. This week I want to write a “hybrid letter.” The first section will draw on a recent column by Nicholas Kristof of the New York Times entitled “How Do We Fix the Scandal That is American Health Care?” and an editorial entitled “America’s Safety Net Isn’t Working” which was written by The Bloomberg Opinion Editorial Board and then republished in my local newspaper, The Valley News, a week ago and earlier in The Washington Post. In the second section, I will write a little bit more about my early practice experiences at Harvard Community Health Plan.
Comments on Current Offerings
The Kristof article is the third segment in a series of articles entitled “How America Heals” that he has been writing. I have enjoyed Kristof’s writing about healthcare, poverty, and common sense suggestions for better gun control. You might remember that in 2022 he left his position as a columnist and tried to run for governor of Oregon where he grew up, but he lost a challenge in court about whether he was really a resident. I am glad that after that disappointment he has returned to writing because I think he offers us clear pictures of the big issues that deserve our attention. His recent article on American healthcare is a jewel.
Kristof begins his article as many other healthcare pundits, myself included, do with references to our terrible outcomes that persist despite spending so much on healthcare, but then he brings the subject into focus by shifting to a specific issue in a specific place— diabetes in Mississippi. He writes:
It’s not just that life expectancy in Mississippi (71.9) now appears to be a hair shorter than in Bangladesh (72.4). Nor that an infant is some 70 percent more likely to die in the United States than in other wealthy countries.
Nor even that for the first time in probably a century, the likelihood that an American child will live to the age of 20 has dropped.
All that is tragic and infuriating, but to me the most heart-rending symbol of America’s failure in health care is the avoidable amputations that result from poorly managed diabetes…
That noise of a saw on bone is a rebuke to an American health care system that, as Walter Cronkite reportedly observed, is neither healthy, caring nor a system…
Dr. Raymond Girnys, a surgeon who has amputated countless limbs here in the Mississippi Delta, one of the poorest and least healthy parts of America, told me that he has nightmares of “being chased by amputated legs and toes.”
The quote by Kristof from Walter Cronkite hit me with a thud that took my breath away because of the shattering reality of its continuing truth:
[avoidable amputations are]…a rebuke to an American health care system that, as Walter Cronkite reportedly observed, is neither healthy, caring nor a system…
Depending on your wealth, location, political point of view, and current health the failures of American healthcare may be hidden from you or something that you don’t care to consider for years to come. The ability to avoid thinking about how bad American healthcare is and how enormous the task of turning it around will be is not a luxury that is available to an increasing number of us. What disturbs me is how few people actually see the healthcare peril we face the way Kristof so clearly presents it.
One thing that I like about Kristof’s approach to any issue is that he both describes the problem and offers some potential, and doable solutions or improvements. He continues:
..there are fixes, and three in particular would make a huge difference: expanding access to medical care; more aggressively addressing behaviors like smoking, overeating and drug abuse; and making larger societywide steps to boost education and reduce child poverty. One reason to believe that we can do better on health care outcomes is that much of the rest of the world already does.
Sometimes Kristof makes a statement that feels like a condemnation, but his conclusions are defensible if you look in the mirror he holds up that reveals ugly things about us. He implies that maybe our problems persist because we are indifferent, or worse yet, cruel. I’ve bolded the origin of that observation.
Cost is often the argument against expanding access to health care. But it’s hard to understand how just about every other advanced country can afford universal care and the United States can’t. And consider that 94 percent of Americans with substance-use disorder do not get treatment, even though this pays for itself many times over. Our policy often seems driven less by cost considerations than by indifference, even cruelty.
I would prefer to explain our deteriorating healthcare system by adopting Walter Cronkite’s conclusion from fifty years ago that we don’t have a healthcare system. We have multiple systems: private insurance, employer-sponsored plans of many different types and quality, multiple Medicare plans, Medicaid that varies drastically by variations in state policies, a VA system, and now the ACA that was meant to establish minimum standards of care across all these systems, and yet we still have thirty million Americans with no care and more than seventy million more with inadequate coverage that leaves them with huge out of pocket costs.
I once heard Atul Gawande say that we no longer suffer from as much scientific ignorance as we once had. Now, we suffer from ineptitude. I would add that we suffer from a political system that is well constructed and fortified by rules and precedents that are not in the Constitution and function to protect us all from our best interests.
I will leave the rest of Kristof’s article for you to read and ponder and move on to the article from the Bloomberg editors. I must admit that I was hooked from the moment that I read the title, “America’s Safety Net Isn’t Working.” Over the past few years, I have struggled to understand how to help people who ask for help from the two non-profits that I work with obtain benefits that I know they should be eligible to receive but don’t. In frustration, I have said that New Hampshire has a “tattered social safety net.” My comparison was to Massachusetts which has a safety net that isn’t quite as porous or “rent.” The truth is that the “safety nets” in all of our states fail to protect a growing number of vulnerable people. Some state nets just have much bigger holes than others.
The editorial is short, less than five hundred words, but the picture it paints is a likeness of reality at the national level. Things usually get worse as we move from federal to state programs and from north to south or from “blue states” to “red states.” We read:
The U.S. has a long-acknowledged problem of poverty and inherited economic disadvantage — though not for lack of policy interventions.
Its social safety net is expansive, encompassing multiple schemes including Medicaid, the Supple-mental Nutrition Assistance Program (SNAP, or “food stamps”), Temporary Assistance to Needy Families (TANF) and numerous other subsidies to help pay for childcare, housing, energy and more. All told, such programs receive more than $1 trillion in federal spending annually.
Yet they’re much less effective than they should be. That’s partly because many individual policies are poorly designed or not fully funded by Congress. But the system’s overall complexity is also to blame.
The complexity is expensive. It creates a system where many who are eligible for help find those barriers too great to overcome, and those barriers often more than double the cost of the programs they are meant to protect. We read:
Researchers at the Urban Institute measured payments through Supplemental Security Income; SNAP; TANF; the Special Supplemental Nutrition Program for Women, Infants, and Children; Child Care and Development Fund subsidies; the Low-In-come Home Energy Assistance Program; and public and subsidized housing. They found a remarkable shortfall: If each of these programs were fully funded and 100% of eligible beneficiaries participated, payments would double, from $220 billion a year to $447 billion. That would be enough to cut the poverty rate from 14.7% to 10.1%, and child poverty from 15.2% to 8.5%.
Ideally, the whole system would be taken back to the drawing board and made simpler and internally consistent, with particular attention to the inadvertent interactions of various federal and state-run programs. For now, there’s little hope of any such overhaul…
Well, that is depressing. Add healthcare, adequate housing, improved access to higher education, and other infrastructure to improve the social determinants of health to the wish list and it is easy to see why building fences at the border, hiring more police, and continuing to be tough on crime while building bigger prisons seem to be better uses of public resources. I am reminded of the punch line from the “Bert and I” routine “Which Way To Millinocket.” As you probably know the conclusion to that routine was, “You can’t get there from here!” Or perhaps you have heard it said in a moment of frustration, “The harder we try, the behinder we get.”
Back To 1975
I don’t always learn a lesson on the first try. In last week’s letter, I described how my medical assistant bravely came to me to chastise me for my disrespectful habit of arriving late for my practice sessions. I got the message but did not extrapolate the concept to all of the activities at Harvard Community Health Plan. The physicians in the group met in the evenings once a month. In the meetings, there were discussions about how to improve our quality and care delivery. Collectively, decisions were made about new services and whom we should hire. By the time I became a member of the group, it had become a desirable place to work and many of the best graduates coming out of the local training programs wanted to join us. Our patient population had grown from less than one hundred pioneers who gave us a try in October of 1969 to about 50,000 when I joined the practice. Plans were underway for a second practice site which was scheduled to open in Cambridge in 1977.
I usually arrived late for the meetings, if at all. In retrospect, I don’t think that I had yet made a long-term commitment to the organization. I was still operating on the advice of Lee Younger to “give it two years” before deciding to move on. Although we were growing, and it was clear to me that the practice was becoming successful in its desire to be a demonstration project for innovative practice with a focus on health and prevention, most people that I would meet had little appreciation for what we were trying to do. It was very typical for me to be asked where I worked when I attended some social event in our neighborhood or went to a party put on by one of my wife’s friends from grad school at Simmons College where she was in an innovative program designed by the authors of a popular book, The Managerial Woman, to give women the tools and insights to become successful in a world of business dominated by men. When I was asked what I did and where I worked I would answer that I was a doctor at the Harvard Community Health Plan. My answer would often precipitate a look of confusion or a blank expression. Sometimes, I would hear some third-hand report about some negative experience. When we would travel South to see family in the South, where almost every doctor had a private practice, I would be pummelled by questions about when I was going to open my practice. It was hard to explain that I saw the era of private practice coming to a close, and even if it did not vanish, I had no desire to practice where I would be sending patients bills for services rendered or interacting with insurance companies several hours a day.
These experiences plus the fact that I was uncertain about my own professional or domestic future kept me on the sidelines of our group meetings, if I attended at all. I remember one meeting that I attended where the agenda was to pick one new hire from a group of three outstanding applicants who had been vetted by the more senior members of the group. I knew one of the candidates very well. I had been his resident at one point. I thought that he would be perfect for our practice. He was a very good doctor who also wanted to teach and continue to do some research in public health and care delivery research. He was a Rhodes Scholar. He had a terrific personality and a very easy sense of humor. To my surprise, he was not selected.
The person we selected was very good. The takeaway from the experience for me was that I was left wondering how I had ever been cleared by this group if they did not select someone who I thought was a better candidate than me. I guessed that they really needed a cardiologist. The fellow whom we did not select went to the Mass General where he practiced, did noteworthy research, and by mid-career had a significant position at the medical school. He eventually became a full professor at Harvard Medical School.
Another example of my early sense of uncertainty about whether I was in the right place was my involvement with what was facetiously called the Thursday Touchy Feely Lunch Group. The Robert Wood Johnson Foundation had given HCHP a small grant to fund a weekly meeting of recently hired and more senior group members at the Kenmore practice to gather for sandwiches at lunch on Thursdays to discuss their feelings about the practice. The group was a mixture of doctors and nurse practitioners. HCHP was one of the first groups to incorporate NPs as relatively independent practice partners. By the time I became CEO we employed over two thousand nurses and of that number there were hundreds of NPs and about as many PAs.
The lunch group was prototypical of “Balint Groups.” I described Balint Groups and my experience in our group in detail in a post from about three years ago. What I did not focus on was that originally I thought of the group mostly as a free sandwich, and I considered my attendance to be optional. I treated it much the same as I treated my arrival for practice before I was confronted by my medical assistant about the impact on others of my “tardiness.” When I attended I found it interesting. The group was co-led by an experienced internist and a psychiatrist. After a few months of somewhat disparaging looks from the psychiatrist when I arrived on “Gene time,” I happened to encounter the psychiatrist in the stairwell as I was hustling to avoid being late to my office one afternoon. He didn’t grab me physically, but he might as well have. He asked me to stop for a conversation. He was very blunt. He asked me if I didn’t get it. He pointed out that everyone else was committed to the work and that my non-committal attitude made me an outsider. In no uncertain terms he said that we were a group and that I needed to at least act with respect for the group as long as I was a part of it. I got the message.
As I became a regular on-time attendee and active participant, the group with its honest discussions about the stresses of practice and some of the tensions between practitioners and management, and between doctors and nurses became one of the biggest factors in my continuing evolution. In a few years, I was asked to be the leader of the discussion along with a psychiatrist partner. I saw the light. I was becoming more involved and was on the edge of long-term commitment.
Attacked By A Busy Beaver
Look closely at the picture which is the header for this letter. In the center, you see two spikes and one recently downed sapling. The spikes are all that is left of two little trees that were “volunteers” that had probably been planted by a bird. I was surprised when the first little tree went down because I had never seen a beaver on our lake. I did know that there are plenty of beavers in our area because I have seen their work in small ponds that I passed when I was able to hike in the woods before I developed a footdrop that made me vulnerable to the roots and rocks that you encounter on a trail.
Since I was not “committed” to the little tree, I noted the oddity of a beaver in our yard and mentally added beaver to the bears, deer, turkeys, foxes, bobcats, and raccoons that regularly pass through. Somehow it did not occur to me that if it happened once it could happen again. Well, it did. Earlier this week the beaver was back! Fortunately, we had a visit this week by friends from Santa Fe. The wife has been a lifelong friend of my wife since nursing school who had spent most of 1969 working and living in Hawaii with my wife. Her new husband worked all of his life as a ranger, engineer, and manager in our National Parks all over the country after being a decorated army medic in Vietnam. He told me that beavers had to chew to keep their teeth from getting dangerously long. He suggested that other small birch trees near the water that we did value were probably at risk. He then helped me protect the vulnerable trees by encircling their trunks with wire fencing. The adventures never end.
I will be enjoying the weekend on Martha’s Vineyard where we have come for a wedding. I am looking forward to seeing my grandsons who are also going to be there with their parents. I hope that you are anticipating a restorative fall weekend. The mornings have gotten chilly. It’s amazing how fast the seasons change!
Be well,
Gene
