12 January 2018

Dear Interested Readers,

This coming Monday is one of those rare times when we celebrate the birthday of Reverend Dr. Martin Luther King, Jr. on his real birthday rather than just the third Monday of January. He was born on January 15, 1929. He would have been 89 if he had not been brutally assassinated almost fifty years ago during the tumultuous Spring of 1968. President Reagan signed the law that created the holiday in 1983. It was first officially celebrated in most states three years after the signing. Some states resisted creating the tribute to him, and to my amazement New Hampshire, my adopted home state for retirement, was the last state to officially celebrate the holiday as Martin Luther King, Jr. Day in 2000. The state began to celebrate “Civil Rights Day” a few years earlier but apparently many in the legislature felt the holiday was inappropriate because there were so few African Americans in New Hampshire. Some say that the resistance was an expression of the residual anger felt by some “patriots” over Dr. King’s objection to the war in Vietnam. I wonder just how influential the businesses that benefit from another big ski weekend were in the final acceptance of the holiday. 

I was miffed when I realized that I have a meeting scheduled for Monday afternoon. I sit on a local board that dispenses emergency funds to the poor of the region. It meets on the third Monday of each month. I have rationalized the fact that we are meeting on Dr. King’s birthday by thinking about how focused Dr. King was on alleviating poverty and inequity of all forms, and for people of all races. The face of poverty varies by race and region. There are very few black New Hampshirites, but there are many, many poor people here, and most of them are working hard at multiple seasonal jobs.

Dr. King was a powerful speaker. He was a preacher who used his pulpit and many podiums around the country to move the world to a little better place. His sermons, speeches, writings, and comments have been mined for the wisdom they contain. I love his quotes and have repeated his statement about healthcare many times. It has become a mantra for me:

There are many, many recorded quotations that he made about poverty and injustice that I will think about as I attend the meeting on Monday. Here are a few for your consideration:

“As long as there is poverty in this world, no man can be totally rich even if he has a billion dollars.”
“The American Dream” speech, 1961.

“Injustice anywhere is a threat to justice everywhere.”
“Letter from Birmingham City Jail”, 1963

“There is nothing new about poverty. What is new, however, is that we have the resources to get rid of it.”
Nobel Peace Prize address, 1964


“The time has come for us to civilize ourselves by the total, direct and immediate abolition of poverty”
“Where do we go from Here: Chaos or Community”, 1967


I wish that Dr. King’s message could remain active in our minds throughout the year. I recently caught sight of Dr. King’s statue in the rotunda of the Capital while watching Paul Ryan, or some other politician, talking on the evening news about what a wonderful boost the tax bill was going to be for the economy. I thought it ironic that Dr. King was looking over his shoulder as he was spouting his misinformation.

This week’s letter continues the process of looking back and looking forward that has been at the core of my conversation with you over the last few letters. Long time readers will remember my love of the term VUCA, an acronym derived from the description of our times as volatile, uncertain, complex, and ambiguous. Often when I explain the term to someone who has never heard it they respond by saying, “Oh my! That’s my life!” I can think of no time in my own life when the term has seemed more appropriate. Sadly, VUCA may now be an inadequate description of what we see around us. Perhaps VUCAT is better: volatile, uncertain, complex, ambiguous, and terrifying, or if you prefer, traumatizing.

VUCA times test our fundamental principles and concepts. Personal and collective strength must be combined with clarity about what are our most important shared responsibilities. I believe that survival in stressful times requires extraordinary leadership, individual commitment, and strong relationships with those who share similar principles and dreams. At a minimum, I hope this week’s letter will keep you thinking about how you fit into the larger picture in healthcare that will continue to evolve in 2018. I believe that how we have responded to the challenges to healthcare in 2017 has set the tone for how we should respond to wider threats to our collective well being this year. It goes without saying that there will be many new challenges in 2018, but despite those predictable challenges that will be heightened by midterm elections, I also believe that this could be a year of progress.

I have the expanded hope that this year will be a year of personal growth and transformation for you. I hope that in 2018 you will move beyond thinking about how you will survive the future toward a consideration of the larger question of how you will contribute to the healing of the deep rifts that exist in our society, and how you might lead others toward the resolution of inequities. We must improve our internal relationships if we are ever to make true progress toward something as utopian as the Triple Aim. I doubt we will complete the journey in 2018, but I do believe we can make progress. For progress to happen in 2018 more people must choose to be a voice for transformation in the healthcare organizations where they work or get their care, and be active in the wider process of resolving the social and economic inequalities in their communities.

Progress will require more heads, more hands, and more hearts aligned with the core principles of fairness and equality of opportunity if we are ever to have a realistic dream of universal coverage and improved quality and safety in our healthcare. Ultimately, healthcare improvement will also require acceptance of continuous improvement as core to our operating systems and further evolution toward sustainable finance. Using tools like Lean to reduce waste where you work is the best place to start being a contributor. In the letter I try to further make the case that although we will still not have universal coverage in 2018, we can chose to make progress this year in our journey toward the vision of the Triple Aim.

Under the title “housekeeping,” I should say that this week I received a letter from an Interested Reader whose access to these letters was recently disrupted because his email was changed by his employer. I know that this happens frequently. Changing emails as well as the filters that some employers introduce to their email servers are reasons for some Interested Readers to lose their contact with these Friday letters and the midweek posting on the Strategy Healthcare website. The disruption in receiving your copy of the these Musings can be avoided by scrolling down to the bottom of any of these letters and putting in your new email. At the very bottom, at the end of the letter, you will find in very small font the notice that “you can unsubscribe or change your contact details at anytime” by clicking on the link. I hope that you do not “unsubscribe,” but do hope that you will change your contact details if your email has changed. I think the best address to use is your personal email which frees you from any of the restrictions or filters that your employer may choose to introduce, and will also not change if you move to a new organization. Some people have written and asked me to change their address for them. I would be happy to do it, but I can’t because of ICANN rules. I hope that you will make sure that these letters can get to you at the very best address.

In last week’s letter I tried to describe how I planned to contribute to the journey toward equity and the Triple Aim in 2018. I asked others for their plans. Patty Gabow, an Interest Reader, friend, and the retired CEO of Denver Health wrote back:

I know that Patty will do much more than she is saying. She participates on multiple boards and advisory groups where she is a consistent voice for equity and continuous improvement. Throughout her long career she has been fearless and persistent in her commitment to improving access to care for the underserved. If more of us followed her example, the Triple Aim would be a slam dunk. Statements like Dr. Gabow’s add to the hope that I have that during 2018 we will see real progress in our efforts to give everyone in this country the access to the care they deserve.

I once heard that Life magazine was written for those who could not read. The joke continued by adding that Time magazine was written for those who can’t think. I was an avid consumer of both. I am sad to say that for some reason, perhaps all the pictures on the Internet, Life with all of its great photo layouts is gone. Time may be on its last legs. US News and World Report printed its last copies at the end of December 2010, and Newsweek died at the end of 2012, but Time marches on, or at least hobbles forward. I was surprised to see when I got my copy of this week’s edition, that there was a guest editor, Bill Gates. The whole issue is about “optimism.” I prefer hope to optimism, but I was inspired by reading several of the articles, especially the introductory essay by Bill Gates entitled “The Good News.”

Bill tried to make the case that despite the disturbing and frequently bad news reporting natural disasters and the crazy things that our leaders do, we are not going to hell in a handcart. In fact, he uses facts to support his argument that for most of us, and more of us, things have never been better. Better yet the trends are looking better everyday. Here are some of the facts upon which he rests his case.

• In 1990 more than a third of the world lived in poverty; now only a tenth of the world lives in poverty.
  
• Since 1990 the number of children in the world who die before their fifth birthday has been cut in half. That’s 122 million children saved over the last 25 years.
  
• A century ago it was legal to be gay in about 20 countries. Now it’s legal in over 100 countries.
  
• Women now make up 20% of national parliaments around the world.
  
• The world is finally listening to women’s complaints about sexual assault.
  
• More than 90% of children in the world attend school.
  

All those facts are good news, but each of them still presents plenty of room for continued improvement, and in a few rare situations, like life expectancy in America, our progress has plateaued, or we are losing ground. Bill asks why, if things are getting better, do we feel like the world is in decline? One answer he offers is that improvements are not keeping pace with expectations. He points out that we are wired to need anger as a motivation for making things better. I would point out that angry people don’t always make the best decisions. It is also true that if you live in a land of plenty, and feel as if you don’t have any of whatever it is that you need, it feels really bad. But, it seems that we are doing a better job of looking for “reasons for action.”

As an example of our continuing need for improvement, An awful event was recorded as a video this week by a concerned citizen with a cell phone. He saw a woman sitting in freezing weather in a hospital johnny at a bus stop just outside the University of Maryland Hospital in Baltimore. The video has gone viral and the story has been on many news broadcasts. Donald Trump promised us that people would not be dying in the street, but we do still have work to do because there are still people in America being put into the street for lack of the coverage or support they need.

My desire is to focus on the positives, so I will report that my hope for 2018 was further expanded this week in the most surprising of ways. While reading my local newspaper, The Valley News last Saturday I was surprised to see an editorial entitled “ACA Not Dead Yet.” I agreed with every line of the piece. Neither the New York Times or the Washington Post could have put out a better written editorial. I am sure that no one at The Valley Times reads these Friday letters but the coincidence between their points and ones written here filled me with a sense of affiliation. The editorial began with the same information that was celebrated as a reason for hope in the letter of December 29:

It just feels great to read the acknowledgement of this remarkable achievement in my local paper. From there it got only better and once again underlined a previous point made in these notes:

The editorial continued to sing a song that warmed my heart as they attacked the Republican tax bill that included the repeal of the mandate. They reiterated that the “mandate” was a policy that had originated from the insights of the Heritage Foundation, a conservative Republican “think tank” that had proposed that one of the merits of a mandate was to “encourage personal responsibility.” That was an indirect and more delicate way of say that it was “designed to end freeloading by people who didn’t carry insurance and whose health care costs ended up being paid for through higher premiums borne by people who did.”

The editorial ended by celebrating that the ACA lives despite its abuse:

Perhaps their view is a little too optimistic. I wish that we could rest on the laurels of 2017. It feels good to say that the ACA remains largely intact and has a growing popularity with a majority of Americans, but I fear that The Valley News claims victory prematurely. It is becoming clearer with each passing day that in 2018 the battle for the Triple Aim moves from defending “Obamacare” to sustaining the social safety net of entitlements that is so important to the social determinants of health. One fact lost on many is that all of the countries that provide better care than we do for their citizens, do so in part because they invest heavily in the future and welfare of their people with a more effective set of social supports. 

I was feeling pretty hopeful for 2018 until I opened my computer yesterday and found that in a letter dated January 11, 2018, Seema Verma, the Administrator of CMS, granted states the ability to pursue 1115a requests to modify their Medicaid programs to include the requirement that recipients work, be in school, do community service, or be a caregiver to be eligible for Medicaid. Ten states have made a request to add work, or some equivalent of work, to eligibility requirements. The Obama administration had routinely turned down such requests from states, since the ACA had expanded Medicaid to everyone who made less than 138% of the poverty level in the states that accepted the Medicaid expansion. Since Medicaid’s inception in 1965, work has never been a requirement. As an effort to insulate the concept of a work requirement from the court challenges that are sure to occur, Ms. Verma wrote in her letter to the state Medicaid directors that the proposal is presented as something that supports mental and emotional health. The Kaiser News service quoted from her ten page letter:

The cynic in me says that Republican job one for 2018 is to cut entitlement spending to reduce the huge budget deficits that the tax cut that was a Christmas present for the wealthy will surely create. What is a reality is that 40% of Medicaid recipients are already working full time, and that the majority of the other 60% are either in school, providing care to someone else, or are just too sick to work. The impact of the waivers will be to allow states like Kentucky, one of the ones that wants the work option, to introduce more onerous sign up requirements making it harder for new enrollees to get coverage. If you would like a picture of life and the dependency on entitlements in the most impoverished “white” county in America,” let me offer you a picture of Booneville in Owsley County Kentucky, where government entitlements like food stamps and Medicaid are the only barrier to starvation and disease for a huge percentage of the population.

So where do we stand? It’s a very mixed picture. Some of our gains with the ACA are still in place for the moment. The public is getting wiser, and I am hopeful that the energy that preserved some of the ACA will preserve some, or all of the CHIP program. On the downside you can expect to see in 2018 challenges across the entire spectrum of programs for the poor. Our social safety net has been thrown into a dangerous position by the passage of the tax reform bill. Social Security may survive but Medicaid will change for many. I would expect that short of a resounding midterm victory our efforts for universal coverage may slip a bit this year, but the big vulnerability will be to programs that address the social determinants of health. On the up side, we have a growing awareness that we could do better, and as Bill Gates and The Valley News report, progress is being made. Like last week, I am wondering what you are planning to do to cut the losses the poor can expect as you enjoy watching your 401K account grow, not that those two movements are connected.

There was no other song that came closer to being number one for me when I was a little boy than Cole Porter’s “Don’t Fence Me In.” I did not know then who he was or that he wrote the music as part of a 1934 Broadway musical “Adios, Argentina” to go with words of a poem written by a Montana highway engineer named Bob Fletcher who sold the rights to his poem to Porter for $250. I don’t remember whether I was playing the Bing Crosby version or the Roy Rogers version on my little record player. I would have sung along to any rendition. These days I like Willie Nelson’s version. Perhaps it was the defiance and the freedom expressed in the spirit of the song that grabbed me. In case you don’t remember the words:

It’s hard to imagine a line that is better than Oh give me land lots of land under starry skies above, until you hear Gaze at the moon until I lose my senses. There is no more basic human plea for freedom than Don't fence me in. The entire song is a celebration of being outside and free. I was not “outside” nearly enough between ages 22 and 69 so I have a lot of catching up to do.

Being outside most of this last week required seriously bundling up against the elements which made it all that more exciting. I took the picture in today’s header on the town green in Newport, New Hampshire early this week as it was warming up a little. I volunteer once a week in an after school program for children in the fourth, fifth and sixth grades that is co sponsored by the Episcopal Church and 4H through the University of New Hampshire. There is a monument to soldiers at the far end of the green that can’t be seen in the picture. Despite the high level of poverty in the community, the green is surrounded by large homes from another era that are in various stages of repair. The town floods one end of the green each winter to make a skating rink, and trucks in a warming house full of skates of all sizes for free use. It was still below freezing, but this week when the temp got above 25 it was time for the kids to go skating.

I laced on a pair of hockey skates that had seen better days, but when I got on to the ice, I remembered that I had grown up where the only ice was in a glass of tea. The few times I have tried to skate have been exercises in frustration, and the last time was at least ten years ago. After standing on the ice in my skates for about five minutes, I reminded myself that I did not enjoy spending time being “fenced in” in an emergency room or in the office of an orthopedic surgeon. It was good enough just to be outside in my boots. I hope that if you can skate or ski with skills I do not possess, you might enjoy those activities this weekend. If, like me, you would find either activity to be imprudent, just get out and enjoy the fresh air.