| 10 February 2017 Dear Interested Readers, What’s Inside, Trump Tidbits, and a Book Suggestion for YouLast week I announced that I was giving up trying to keep up with all of the interesting events and new controversies that swirl around our president. The usual four thousand words of this weekly missive would not be enough to adequately do the job. I will continue to make occasional comments, especially when the subject directly impacts the Triple Aim, as did the confirmation of Elizabeth DeVos as Secretary of Education earlier this week. It was a disappointment that she was confirmed after she demonstrated very little knowledge of educational theory or real experience in her confirmation hearings. One wonders if she fully appreciates the importance of education to the health of the nation. What is interesting was that two Republican senators voted against her.It is interesting to speculate what those two Republican votes might mean for the future. One more was needed to deny her the confirmation, but just maybe if the issue is just right, and the consequences too high, some third senator will assume the possibility of personal political backlash from Mitch McConnell for the good of the country and we will see the senate become an interesting place where true debate produces progress for us all. I will continue to follow the debate over the ACA. This morning the Senate has confirmed Tom Price as Secretary of Health and Human Services. It is very likely that it will also endorse the other nominees of the President that require Senate confirmation. What is not so clear is how the process of “repeal and replace” will proceed. It will take only three Republican senators responding to the business and political cases for “ repair and rebuild”, if not the compassionate human case, to preserve the ACA. The last link in the line above was to a Washington Post article about changing the Republican strategy for doing away with “Obamacare.” The Post provides some reason for hope. Orrin Hatch of Utah is the Chair of the Senate’s Finance Committee and Lamar Alexander of Tennessee is the Chair of the Health, Education, Labor, and Pension Committee of the Senate. These are the two most important committees in the “repeal and replace” process which now might be downgraded in its potential harm to “repair and rebuild”. There is a growing awareness among thoughtful Republicans that many of the more than 20 million people who might lose their healthcare coverage if “repeal and replace” gets too aggressive are those same white Americans who voted them into office. They are the same voters who lack high school and college degrees and have fallen out of the middle class as good paying manufacturing jobs have evaporated. Hatch and Alexander may hate the ACA, but they are also savvy politicians and that creates some hope. This week’s letter is a look back and a look forward in the discussion of what creates health. It is a return to the discussion of the interplay of healthcare, the social determinates of health, and the forces of political reality that affect education, housing, nutrition, culture, and economic opportunity. Much of the letter draws on a classic New England Journal of Medicine article, the text of the Shattuck lecture of 2007 by Steven Schroeder, entitled “ We Can Do Better — Improving the Health of the American People”. Despite much effort over the last decade to act on the wisdom of the message of this important presentation, things have not changed much. What makes this discussion very important at this time is the realization that as we hope to repair and rebuild the ACA we need to be sure that we enhance its support of strategies that really make a difference in the effort to “improve the health of the nation.” If there is a lack of understanding and acceptance about what threatens health, then it is likely that our efforts to improve it will be disappointing and resources will be wasted. If you would like more background for the consideration of how we got to where we are and how to make America healthier, I would recommend the book - The Unwinding: An Inner History of the New America by George Packer. I received the book as a Christmas gift from one of my sons who had heard the author speak. The book was published in 2013, and I wish that Hillary Clinton had read it before she made her unfortunate comment about many of President Trump’s supporters being a “ basket of deplorables.” If you read the speech in which she made the unfortunate statement, the very next paragraph suggests that maybe she had read the book because she seems to understand its message even if she could not effectively convince the voters of her sincerity. Here is that paragraph: "But the other basket -- and I know this because I see friends from all over America here -- I see friends from Florida and Georgia and South Carolina and Texas -- as well as, you know, New York and California -- but that other basket of people are people who feel that the government has let them down, the economy has let them down, nobody cares about them, nobody worries about what happens to their lives and their futures, and they're just desperate for change. It doesn't really even matter where it comes from. They don't buy everything he says, but he seems to hold out some hope that their lives will be different. They won't wake up and see their jobs disappear, lose a kid to heroin, feel like they're in a dead-end. Those are people we have to understand and empathize with as well."Packer’s book deals with these issues to which she makes reference. In the book he uses many stories to paint the portrait of an America where many people who were once secure in manufacturing, small businesses or farming have found themselves falling out of the middle class with little hope that they or their children will ever return. Packer reveals their humiliation, frustration with their own fallen state, hopelessness for their children, and their declining health. He describes their anger and frustration from the neglect and lack of effective concern of the politicians, intellectuals, bankers, “do gooders” and advocates of the politically correct words and ways. J.D. Vance hit many of the same notes in his personal testimony of adversity and triumph in his bestselling book, Hillbilly Elegy which is still number one this week on the NYT bestseller list where it has been for over six months. Packer’s book is both background and confirmation to Vance’s personal story. One conclusion that we might draw from the stories that their books present is that in America we focus on race when we should be focusing on class. In the body of the letter this week I will assert that the greatest determinant of health is class. The poor of all races live in the shadows of our society. They are suffering from poverty in a land where many have plenty. The differential between their state and the wealth of others is their source of anger and sometimes their crime. Their anger is perhaps what leads those who have more to feel that it is best to live behind walls and locked doors. For several years we have known that life expectancy is falling for uneducated white men and women. Angus Deaton, a Scottish economist who is Professor of Economics at Princeton won the Nobel Prize in 2015 for making connections between health and economic inequity: “We should not be concerned with others’ good fortune if it brings no harm to us. The mistake is to apply the principle to only one dimension of wellbeing – money – and ignore other dimensions, such as the ability to participate in a democratic society, to be well educated, to be healthy and not to be the victim of others’ search for enrichment,” …The discussion will continue below in the body of the letter. I hope that you will view it as a strategic discussion. The premise is simple: It is hard to be healthy when you live on the economic fringes of society. As much as those with more resources would like to be even more secure, what they have will always be threatened by the needs of the underserved. Last week’s discussion about what to do in uncertain times, “Good Strategy in a Fog of Uncertainty” is ready for your review on strategyhealthcare.com. I hope that you will see this week’s letter as an extension of the discussion of good strategy beyond the doors and walls of your organization that was discussed in that post. You would be surprised if I did not have comments about the Super Bowl and Belichick,Inc. It’s there at the end of the letter along with a look forward to the imminent arrival later this month of pitchers and catchers for Spring Training in Florida. It is Still the Truth Ten Years LaterIn the January 29th New England Journal of Medicine Foller, et. al. have published an interesting article, “ Population Health--A Bipartisan Agenda for the Incoming Administration from State Leaders.” I thought that the first paragraph said a lot. The common goal of health policy leaders at the level of state government in the United States is promoting the health and well-being of all populations to the greatest extent possible within fixed resource constraints. Our health is affected by our physical and social environments, our genes, our economic and educational opportunities, and to a much lesser degree, the medical care we receive. I checked the reference that corroborated their assertion, it turned out to be a “golden oldie”, a favorite article from which I learned much and have frequently quoted. The article was the publication in September 2007 of the 117th Shattuck Lecture delivered by Dr. Steven Schroeder at the Massachusetts Medical Society in May 2007. For many years I have included a slide that was lifted from the article in almost every talk that I have given. |
| | | Schroeder began his speech by asking an important question:
The United States spends more on health care than any other nation in the world, yet it ranks poorly on nearly every measure of health status. How can this be? What explains this apparent paradox?
The answer to his question is simple:
- the pathways to better health do not generally depend on better health care,
- even in those instances in which health care is important, too many Americans do not receive it, receive it too late, or receive poor-quality care.
Schroeder proposed looking at the determinants of premature death as a key measure of health status and as a way of advancing the discussion of how to improve health. His own research involved the study of the impact of smoking and how to treat the addiction. After establishing behavior as the largest determinant of health he wondered if perhaps obesity and a lack of exercise could be approached in the same way.
His next insight was:..
...acknowledging the reality that better health (lower mortality and a higher level of functioning) cannot be achieved without paying greater attention to poor Americans.
He was flabbergasted by how complacent most Americans were about the measured inferiority of our healthcare:
Among the 192 nations for which 2004 data are available, the United States ranks 46th in average life expectancy from birth and 42nd in infant mortality. It is remarkable how complacent the public and the medical profession are in their acceptance of these unfavorable comparisons, especially in light of how carefully we track health-systems measures, such as the size of the budget for the National Institutes of Health, trends in national spending on health, and the number of Americans who lack health insurance.
He then speculated on the reason for our complacency:
One reason for the complacency may be the rationalization that the United States is more ethnically heterogeneous than the nations at the top of the rankings, such as Japan, Switzerland, and Iceland. It is true that within the United States there are large disparities in health status — by geographic area, race and ethnic group, and class. But even when comparisons are limited to white Americans, our performance is dismal…
The figure that I love to use surprises most people in and out of healthcare who imagine that their own care is terrific and that we would have a healthier nation if only more people had what they enjoy. Schroeder’s figure suggests otherwise.
Health is influenced by factors in five domains — genetics, social circumstances, environmental exposures, behavioral patterns, and health care.When it comes to reducing early deaths, medical care has a relatively minor role. Even if the entire U.S. population had access to excellent medical care — which it does not — only a small fraction of these deaths could be prevented. The single greatest opportunity to improve health and reduce premature deaths lies in personal behavior.
Most of us want to make things better and believe that facts and experience enable those objectives. Schroeder’s argument based on the facts is a challenge to medical practice, as it is generally practiced:
Clinicians and policymakers may question whether behavior is susceptible to change or whether attempts to change behavior lie outside the province of traditional medical care. They may expect future successes to follow the pattern whereby immunization and antibiotics improved health in the 20th century. If the public's health is to improve, however, that improvement is more likely to come from behavioral change than from technological innovation. Experience demonstrates that it is in fact possible to change behavior, as illustrated by increased seat-belt use and decreased consumption of products high in saturated fat. The case of tobacco best demonstrates how rapidly positive behavioral change can occur.
Schroeder was aware that using public policy to influence behavior might be controversial. The fight against obesity is the best example. Several years later Michael Bloomberg’s experience as New York City’s mayor trying to regulate the size of sugary beverages in a fight against obesity proved Schroeder to be a good prophet.
Many physicians consider the social determinants of health to be the responsibility of others, like politicians, teachers, employers, or even the police. What is often not considered is that as healthcare professionals the resources that we use to provide care for that 10% of the reasons that people die “before their time” takes valuable resources away from the effort to improve the other determinants of health. I have bolded important facts in this next outtake from Schroeder’s speech. He is stressing that class, not race, is the biggest issue for the individual.
Improving population health will also require addressing the non behavioral determinants of health that we can influence: social, healthcare, and environmental factors. (To date, we lack tools to change our genes, although behavioral and environmental factors can modify the expression of genetic risks such as obesity.) With respect to social factors, people with lower socioeconomic status die earlier and have more disability than those with higher socioeconomic status, and this pattern holds true in a stepwise fashion from the lowest to the highest classes. In this context, class is a composite construct of income, total wealth, education, employment, and residential neighborhood. One reason for the class gradient in health is that people in lower classes are more likely to have unhealthy behaviors, in part because of inadequate local food choices and recreational opportunities. Yet even when behavior is held constant, people in lower classes are less healthy and die earlier than others. It is likely that the deleterious influence of class on health reflects both absolute and relative material deprivation at the lower end of the spectrum and psychosocial stress along the entire continuum. Unlike the factors of health care and behavior, class has been an “ignored determinant of the nation's health.” Disparities in health care are of concern to some policymakers and researchers, but because the United States uses race and ethnic group rather than class as the filter through which social differences are analyzed, studies often highlight disparities in the receipt of health care that are based on race and ethnic group rather than on class.
Looking back over the politics and experience of the last ten years makes Schroeder’s next insight even more remarkable. The research of Angus Deaton, the reality of lower and falling life expectancy of blue collar and impoverished populations, and perhaps even the election of Donald Trump to the presidency achieved by understanding the issues of class and those who fear falling further from their previous status in the middle class, confirms Schroeder’s insights from a decade ago. I needed to bold his answer to the best question not usually asked, “What part of the problem are we.”
There are ways to address the effects of class on health. More investment could be made in research efforts designed to improve our understanding of the connection between class and health. More fundamental, however, is the recognition that social policies involving basic aspects of life and well-being (e.g., education, taxation, transportation, and housing) have important health consequences. Just as the construction of new buildings now requires environmental-impact analyses, taxation policies could be subjected to health-impact analyses. When public policies widen the gap between rich and poor, they may also have a negative effect on population health. One reason the United States does poorly in international health comparisons may be that we value entrepreneurialism over egalitarianism. Our willingness to tolerate large gaps in income, total wealth, educational quality, and housing has unintended health consequences. Until we are willing to confront this reality, our performance on measures of health will suffer.
Schroeder is not deemphasizing the need for universal access to healthcare. He is just saying that universal access alone is an inadequate strategy to improve the health of the nation.
Although inadequate health care accounts for only 10% of premature deaths, among the five determinants of health, health care receives by far the greatest share of resources and attention...In the area of access, however, we trail nearly all the countries: 45 million U.S. citizens (plus millions of immigrants) [pre ACA and who knows by this time in two years] lack health insurance, and millions more are seriously underinsured. Lack of health insurance leads to poor health. Not surprisingly, the uninsured are disproportionately represented among the lower socioeconomic classes.
Perhaps the reason I like this article so much that I approach it with reverence is that Schroeder does sum it all up in a logical and defensible strategic recommendation. He suggests that if we want different results we must take a different approach which I have bolded. I believe that he was right ten years ago and he is right now. Buried in his statement along with the recommendation is also a criticism of the status quo and our national error which I have also bolded.
Since all the actionable determinants of health — personal behavior, social factors, health care, and the environment — disproportionately affect the poor, strategies to improve national health rankings must focus on this population. To the extent that the United States has a health strategy, its focus is on the development of new medical technologies and support for basic biomedical research. We already lead the world in the per capita use of most diagnostic and therapeutic medical technologies, and we have recently doubled the budget for the National Institutes of Health. But these popular achievements are unlikely to improve our relative performance on health. It is arguable that the status quo is an accurate expression of the national political will — a relentless search for better health among the middle and upper classes. This pursuit is also evident in how we consistently outspend all other countries in the use of alternative medicines and cosmetic surgeries and in how frequently health “cures” and “scares” are featured in the popular media. The result is that only when the middle class feels threatened by external menaces (e.g., secondhand tobacco smoke, bioterrorism, and airplane exposure to multidrug-resistant tuberculosis) will it embrace public health measures. In contrast, our investment in improving population health — whether judged on the basis of support for research, insurance coverage, or government-sponsored public health activities — is anemic. Although the Department of Health and Human Services periodically produces admirable population health goals...no government department or agency has the responsibility and authority to meet these goals, and the importance of achieving them has yet to penetrate the political process.
Schroeder believed that the status quo was a function of the fact that the disadvantaged were not well represented in our system of government. It will be interesting to see if the election of Donald Trump using the votes of many white disadvantaged voters will change the reality that he saw. He also postulated that public healthcare investments were driven by what worries the middle and upper classes, diseases and problems like breast cancer, HIV/AIDS, and autism for example, while the greatest opportunities to improve health come from the issues that population health can address. He suggested that those trapped in the environments of the lower class did not have the political voice to argue for more resources to improve health-related behaviors, reduce social disparities, increase access to health care, and reduce environmental threats.
He then made three more profound observations that must be considered if we want to achieve
Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness.
- To the extent that poverty is viewed as an issue of racial injustice, it ignores the many whites who are poor, thereby reducing the ranks of potential advocates. [It is my sense that this exists partly because of the racial separation that exists within the disadvantaged populations. Martin Luther King was trying to create a sense of shared objective between economically distressed black and white populations at the time of his assassination.]
- The relatively limited role of government in the U.S. health care system is the second explanation. [Given the politics of the moment with the blame that is heaped on the ACA, Medicare, and Medicaid, and all of the public money that ends up as the financial floor of the health system, it is still a largely privately owned and privately operated system, and is likely to remain that way for decades to come.]
- In addition, the American emphasis on the value of individual responsibility creates a reluctance to intervene in what are seen as personal behavioral choices. [There are many levels of meaning in the state slogan of New Hampshire, “Live free or die!”]
Ten years ago Schroeder contended that he was “cautiously optimistic.” He did not expect that the political dynamics would change much, and despite all of the conflict over the ACA during the last decade, his fundamental observations remain just about as valid as they were in 2007, when Don Berwick and others first told us about the Triple Aim. He placed his hope in personal efforts to improve health and in the efforts of healthcare professionals to “become champions for population health” as “one of the most productive expressions of patriotism.” He issued a warning as well as the reason for trying to change, which I have bolded:
Improvement in most of the other factors requires political action, starting with relentless measurement of and focus on actual health status and the actions that could improve it. Inaction means acceptance of America's poor health status.
Improving population health would be more than a statistical accomplishment. It could enhance the productivity of the workforce and boost the national economy, reduce healthcare expenditures, and most important, improve people's lives. But in the absence of a strong political voice from the less fortunate themselves, it is incumbent on health care professionals, especially physicians, to become champions for population health. This sense of purpose resonates with our deepest professional values and is the reason why many chose medicine as a profession. It is also one of the most productive expressions of patriotism. Americans take great pride in asserting that we are number one in terms of wealth, number of Nobel Prizes, and military strength. Why don't we try to become number one in health?
To that noble expression of professionalism I say,”Amen!”
It Ain’t Over Till It’s Over
The wisdom of Yogi Berra’s famous quote advocating persistence in pursuit of a goal even when defeat seems likely was twice confirmed for me on Sunday. By now the whole world knows that Tom Brady, James White, and Julian Edelman combined their efforts with the vigor of other teammates, the wisdom of their famous coach, and poor play calling by the Atlanta Falcons coaches to come back from a 25 point deficit to win the Super Bowl. If you are a true Patriots fan you were thrilled but not really surprised. For once the incredible catch was made by a Patriot. For the fifth time Brady made it happen. The general consensus in the newspapers and on the talk shows on Monday was that he was the greatest quarterback of all time. He had proven it by leading the Patriots to the greatest Super Bowl comeback of all time.
The two Super Bowls that the Patriots have lost during Brady’s tenure were games where he was not the problem. Both times he played well enough to win. It was the failure of other Patriots or unbelievable plays by opponents that were the difference in those two very close losses to the New York Giants. Ironically, lost in the all the hoopla is the reality that one reason that the Patriots were so far behind was that early in the game Brady had thrown an interception that was returned for a touchdown. For completeness one should add that in the last two victories the coaches of the other teams created opportunities for the Patriots. Why in Super Bowl XLIX did Pete Carroll call for a pass on the one yard line when he had a runner who was a battering ram that was virtually impossible to stop? Why did Atlanta’s Coach Quinn try to throw a pass late in the game Sunday when he had a field goal kicker that rarely misses inside the 35, and 3 points would have guaranteed a victory? Whatever the explanations for these puzzlers, most everyone in New England is delighted with what was rather than what might have been. Last Sunday night many of my friends and family in the South were sad when Coach Quinn joined Pete Carroll in the knowledge that you must be careful not to snatch defeat from the jaws of victory, especially if you are playing the Patriots.
The Patriots victory was the second confirmation for me of Yogi’s vision in the same day. Earlier on Sunday my granddaughter played exceptionally well as her volleyball team battled back from a near defeat in the quarterfinals of the Tri County Girls Volleyball Tournament in South Florida and then went on to become the tournament champs in the girls 14 and under division. I was emotionally wrung out by the end of the tournament and then faced the challenge of Super Bowl hysteria. It was good that there was enough time between the morning quarterfinals and the early afternoon semifinals for my son and me to get in a good walk in the Miami sunshine.
As today’s header implies there are plenty of things to see when walking around in Florida. I usually think of palm trees and amazing banyan trees when I am thinking about trees in Florida, but equally impressive are the live oaks. The one in this week’s picture is the one of largest ones in Florida and over 350 years old. It is in Safety Harbor, Florida where I did a little walking last week. In these days when we debate the value of immigrants, it is interesting to note that the tree has been named the Baranoff Oak in honor of an immigrant, Dr. Saleem Baranoff who established a spa in Safety Harbor in 1945 that was a major economic resource to the community.
This weekend there will be no big games, which is a good thing. I have less than three weeks to prepare for the return of the Red Sox to Florida for spring training. Between walks in the snow I should check out the Celtics. I hear they are getting better. |
| Be well, take care of yourself in these strange times. Stay in touch, and don’t let anything keep you from making the choice to do the good that you can do every day,
Gene
Dr. Gene Lindsey
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