In last Friday’s Healthcare Musings letter I spent some time reviewing a recent David Brooks’ column entitled “Winning the War on Poverty: The Canadians are doing it; we’re not. I was drawn to his analysis because I have become very involved in efforts to address poverty in my own community. Brooks’ description of the Canadian efforts were very helpful to me, and so I passed his column on to you with the hope that you would become interested in getting involved in efforts to address poverty in your own community.
I should explain why I think that postings about poverty are appropriate on a blog that is named Strategy Healthcare, and why I hope that you will be as interested in joining efforts to eliminate poverty in your community as you are in improving the health of your patients. This blog is dedicated to the pursuit of the Triple Aim because it is a goal that represents an economically sustainable approach to better health for everyone. The Triple Aim is an expression of social justice, and if there is no social justice there will be no realization of The Triple Aim. Our assumption is that when we have achieved the Triple Aim everyone will have access to healthcare that is safe, patient centered, equitable, effective, efficient, and timely. I think that there are many who do not realize that unless care is an entitlement that should be available to every American, the Triple Aim is not achievable. Even fewer realize that even tough universal access is essential, it is not sufficient to get us to the noble objective of the Triple Aim.
As we strategize about how to reach the Triple Aim, we often do not go “far enough upstream.” As I say that we do not go “far enough upstream,” I still have great enthusiasm for efforts to make our practices more efficient through continuous improvement science applications and philosophies like Lean and Six Sigma. I still believe that we must take waste out of healthcare delivery if we are ever to reach any of the components of the Triple Aim in a sustainable way. I believe that burnout has multiple origins, and that one of the greatest contributors is the fragmentation of our systems of care, and poor systems engineering within and between practices and hospitals as they have merged into larger and larger entities, but we could improve systems and focus on the professional satisfaction of every healthcare professional and give them adequate time for critical thinking, but still not adequately improve the health of the community. I am convinced that we can never come close to the Triple Aim as long as we pay for care with Fee For Service finance, but I also believe that an immediate adoption of universal value based reimbursement through a Medicare For All system of care that abolished FFS finance would still not be enough change to ensure that healthcare expenses would be sustainable. I also believe that without equity in care that can only be achieved if we view care as an entitlement of every person, we will never lower the cost of care to sustainable levels while improving the health of the community, but that would not be enough. If our practices became as efficient as Swiss watches, and if we gave everyone platinum Blue Cross coverage, and if we all practiced population health, and if we embraced value based reimbursement with religious zeal, and if we treated every patient as if they were our grandmother, we still would not achieve the Triple Aim unless we effectively address the social determinants of health. There is no way to make headway against the social determinants of health without addressing the realities of economic inequity and poverty.
It is disheartening to learn that even in the countries that have measurably better outcomes at half our costs, and also have better social safety nets, there is still a socioeconomic gradient of health. I also believe that progress toward the Triple Aim is possible, and that reaching for the Triple Aim, even if its achievement is decades away, will improve everything about life in America for all of us. Progress toward the Triple Aim is the equivalent to progress toward the goals that have pulled America forward through all of its inconsistencies and inadequacies toward its noble objectives. Trying to build an America that will last while tolerating economic inequity is as foolish as expecting to build a sand castle that will survive a hurricane. We have achieved a level of expertise and wealth from which we could chose to reach for sustainable greatness by deciding to lift everyone out of poverty.
I have been fascinated by the social ideas of the sixties. John Kennedy gave us the vision with his New Frontier. Lyndon Johnson had the legislative skill and the ambition to try to turn Kennedy’s vision into the Great Society. It is interesting to note that prior to the wrong turn into Vietnam the sixties were one of our most productive decades. Wikipedia neatly describes what you may not realize:
Unlike the old New Deal, which was a response to a severe financial and economic calamity, the Great Society initiatives came during a period of rapid economic growth. Kennedy proposed an across-the-board tax cut lowering the top marginal income tax rate in the United States by 20%, from 91% to 71%, which was enacted in February 1964, three months after Kennedy’s assassination, under Johnson. The tax cut also significantly reduced marginal rates in the lower brackets as well as for corporations. The gross national product rose 10% in the first year of the tax cut, and economic growth averaged a rate of 4.5% from 1961 to 1968.
Johnson’s tax cut measure triggered what one historian described as “the greatest prosperity of the postwar years.” GNP increased by 7% in 1964, 8% in 1965, and 9% in 1966. The unemployment rate fell below 5%, and by 1966 the number of families with incomes of $7,000 a year or more had reached 55%, compared with 22% in 1950. In 1968, when John Kenneth Galbraith published a new edition of The Affluent Society, the average income of the American family stood at $8,000, double what it had been a decade earlier.
Those numbers may seem funny to you, but I well remember buying gasoline for 28 cents a gallon in Watertown Square in the summer of 1967, and my rent for a two bedroom garden apartment with a basement on the Watertown/Belmont line was $140 a month. Hamburger was 45 cents a pound, and milk was less than 50 cents a gallon. A new Volkswagen was $1650. We were rich and about to put a man on the moon. It was not preposterous for us to think about eradicating poverty. It was a totally appropriate goal. What is sad is that since Vietnam and Watergate, we have never been able to get back to the noble objectives of 1964-65.
Over the last three years I have been fortunate to find within my community a group of people who share the feeling that America can never be great again as long as we are willing to look away from those in our community who are struggling. Perhaps our altruism is self serving. We realize that no community can be safe and prosperous if there are excluded individuals. I would prefer to think that we are motivated by some kind of love, or if not love, it is the realization that we can’t enjoy what we have knowing that there are others, especially children, who are vulnerable. Working in a medical practice it was easy to confine my concerns to the medical problems I encountered in the office and in the hospital. It was easy, and perhaps appropriate to be focused on how to make the practice more efficient, effective, and profitable, but now I realize that without also considering the economic issues that impacted our patients, we were never going to fulfill our mission.
My own learning curve on the impact of poverty near me began when I responded to the offer to get involved with delivering firewood to people who needed it to heat their homes. Next, a friend invited me to work one afternoon a week in an after school program in a nearby community that is rust belt poor. Two years ago I began volunteering in an organization that dispenses emergency funds to people who can’t repair their cars to get to work, or can’t pay their electric bill, or have no heating oil or propane. We are there for the 40% of Americans who can’t handle an unexpected expense of $400. We have two food banks in our area. This year, with a stock market that is over 25,000, and with a huge tax cut for the corporations and the wealthy, and efforts to reduce the resources for the poor like SNAP (the old food stamp program) to ostensibly fund the tax cut, the shelves of the food banks are thinly stocked as you can see in today’s header.
My friends and I have come to realize that everything that we are doing is a “bandaid.” Christmas presents for poor children and turkeys on Thanksgiving may make us feel good for a little while, but they are not a solution. We can’t do anything about national policies other than voting out those who believe there is a future in furthering the exploitation of 90% of the population, but we believe that there is much that we can do improve life for the poor who are our neighbors.
We began to talk about possible ways to go beyond “bandaids.” Don’t misunderstand me. Bandaids are critically needed today, but our goal is to get beyond bandaids if possible for as many individuals who would our want help. We are mindful of the wisdom of primum non nocere. The principle is not to do nothing, but to be sure that what you do provides benefit and not harm. In dereference to the principle we have been meeting regularly for over four months. We have gathered a group of about twenty people who are considering options and meeting with the agencies that are attempting to provide social services in our community. If you read Brooks’ description of the Canadian efforts to reduce poverty, you would realize that a year of study was the foundation of their effort.
Last week I was surprised to find that some of Lyndon Johnson’s Great Society and War on Poverty still exists in my community. 1964 and 1965 were huge years of social progress and economic growth for the country. We all remember that the Civil Rights Act was passed in 1964, and that the Voters Rights Act followed in 1965 along with the passage of Medicare and Medicaid. Not as easily remembered are the tax cut of 1964, that was mentioned above, that President Kennedy had advocated and that Lyndon Johnson pushed through in honor of the fallen president, and the Economic Opportunity Act of 1964 which was a cornerstone of the Great Society and the War on Poverty.
The board that I am on that gives money to those in need works closely with our local Community Action Program (CAP). Much of CAP’s work is to help poor individuals and families primarily by providing fuel and food assistance. I had interacted with them over the needs of several shared clients who had also come to us. As our study group was doing a resource assessment of the fragmented social services safety net, we decided to take lunch to the two women who are the core of our local CAP program. Our desire was to just get a better understanding of what they do, and begin a conversation about how we might work with them toward the goal of eradicating poverty in our community. Perhaps we could take referrals from them if they knew people who needed extra counseling and long term support with the goal of lifting them out of poverty. What we discovered was two saintly women who were working at an impossible task. The uptick in call for their services over the last two years as federal programs lose funding and poverty grows while the wealthy become even richer, has become overwhelming for them. We spent most of our time talking about how to find increased resources for a school backpack program that could be extended into the summer. The backpack program is centered in our regional school system where eligible children get free breakfast and lunch. On the weekends nutritious meals sufficient for their families are put in a backpack for them to take home. Yes, in our country we tolerate both a tax program where Amazon, GM, Coors and dozens of other huge companies and wealthy individuals pay no taxes, and at the same time school children are hungry over the weekend.
I left the meeting enlightened and depressed. Neither of these dedicated women are working at the top of their license. They are spending the time that should be devoted to clinical activity trying to do fundraisers to get the resources they need to get the poorest people in our community to step one of Maslow’s hierarchy of needs.
After the meeting I decided I needed to know more, so I went to their website. This one office serves ten communities in my area. Warner is at exits 8 and 9 on I 89. I live at exit 12. The area schools are at exit 10. My first clue that this program was a vestigial remnant of the Great Society was the fact that they have been in business since 1965. In the section labeled “history” I found a picture of LBJ signing the 1964 Economic Opportunity Act and the following history:
In 1965, President Lyndon Johnson began waging war on poverty. To combat poverty, Community Action Agencies (CAAs) were established. They are local private and public non-profit organizations that carry out the mission which was founded by the 1964 Economic Opportunity Act to fight poverty by empowering the poor in the United States. CAAs are intended to promote self-sufficiency, and they depend heavily on volunteer work, especially from the low-income community. They also depend heavily on federal funding, which now comes primarily from the Community Services Block Grant (CSBG) program.
Community Action Program, Belknap-Merrimack Counties, Inc was established in May, 1965 and is one of five (5) Community Action Agencies in NH…There are currently over 1,000 CAAs, engaged in a broad range of activities; typical activities include promoting citizen participation, providing energy assistance and home weatherization, administration of Head Start & Early Head Start and child care programs, job training, health, nutrition, housing and employment-related assistance; and to address the problems and barriers which block the achievement of self-sufficiency.
Yes, we do need to make America great again, but our president is doing more than administratively undermining the ACA, he and his administration are systematically undermining the health of the nation by pushing poor people and the people who try to provide them a modicum of relief even closer to the brink. I can’t help but think that we are falling into an abyss that it will take us decades to exit, even with great effort.
I think about all the patients I saw in emergency rooms and in hospital beds whose acute presentation was the product of a chronic process. Poverty is a chronic process from which we are withdrawing our marginal efforts for improvement of the past several decades. I will vote, and ask others to vote to turnout those who do not have a vision of an America that offers help to repair the damages done and return to our efforts to eradicate poverty. In the interim my friends and I will redouble our efforts to do what we can in our community. I hope that you and the people with whom you work are motivated to adopt the vision that for the health of the nation we should return to the noble goal of eradicating poverty.
