| 16 March 2018 Dear Interested Readers, The Week’s Events of Note and Other More Interesting IdeasI applaud the #MeToo movement for a huge step forward in the struggle for justice in the workplace and for addressing the abuses of power that often distort relationships. We have all been surprised and at times shocked by what the movement has revealed. Some people have questioned the process because it is largely extrajudicial. It has been disappointing to me that many of those who have been “outed” have otherwise been “liberals” or progressives. It has been very difficult, emotionally jarring, and depressing to lose the previously effective voices of Al Franken, Tom Ashcroft, and Garrison Keillor. What has also been disturbing to me personally is how little focused consideration I gave to the numerous complaints against former President Bill Clinton for whom there was strong evidence of the abuse of power. It is the memory of how angry I was at the time at Ken Starr, the special prosecutor of the day, that gives me some pause now as I hear about the ongoing saga of Steffanie Clifford, a.k.a. Stormy Daniels. I read an interesting article this week entitled “The Last Temptation” from the Atlantic written by MIchael Gerson, a former member of George W. Bush’s administration who is also an articulate Evangelical. I was reminded of my ability to look past and forgive the obvious flaws in Bill Clinton’s behavior in office when I read Gerson’s description of how Evangelicals are able to rationalize their support of Donald Trump. Some even believe that Trump was selected by God to lead America in these challenging times. At a more practical level is the rationalization that Kellyanne Conway offered which was that the American voters knew who Donald Trump was, knew about the Access Hollywood tapes, and still voted for him. As she says, “Voters have this wise discernment between what may offend them and what actually affects them.” She implies that although he may be offensive when he violates women, has extramarital affairs, and brags like a teenager in a locker room conversation of his ability to abuse women, as he did on the Access Hollywood Tapes, heis politically acceptable because he speaks to their interests. There are many Americans who from their own self interest can look past puerile and disreputable behavior and say, “As long as he takes care of my interests, I can put up with that.” I would be a hypocrite to call them out for that behavior because looking back at Clinton’s impeachment, that was exactly my attitude. The situation begs the question, “Is there something wrong with all of us?” David Frum has about as solid a set of conservative Republican credentials as anyone who is appalled by the president’s disregard for the “norms” of his office and his authoritarian leanings, and kleptocratic approach to governing. In the years after writing some of George W. Bush’s speeches he has written nine books and is a Senior Editor of the Atlantic where he has published several articles about the deficiencies of the president and the harm that he is doing to our collective future. I am currently finishing his most recent book “ Trumpocracy: The Corruption of the American Republic.” The review from late January in the New York Times gives a good overview of his thesis. After reading most of the book I agree with the conclusion of Adrian Wooldridge who wrote in his review that, “ The central theme in Frum’s excellent new book, “Trumpocracy,” which draws on his Atlantic articles, is what Trump’s career tells us about the deeper structural problems of America in general, and conservative America in particular.” My only variance with that opinion would be to leave out conservative and say the problem is the deep structural problems of America. Period. That is why I pointed out my own inconsistencies in the way I think about Trump’s sexual dalliances versus Bill Clinton’s. Frum points out that Trump has an instinct for the cracks in our society and exploits them for his benefit. Frum also devotes much of his book to describing Trump’s skill at profiting himself and his cronies at our collective expense while undermining our collective future and the safety of the world. He knows that most of the people who sustain him in office love the chaos in his administration and are not at all upset by his willingness to be blunt, avoid “PC” language, and outrage the international community. Up till now many of them have felt so alienated from and personally maligned by liberals who consider them “deplorable” that they will give their support to anyone who is willing to give a middle finger salute to the press and to the liberal elite. It has appeared that they would vote for him again and against what was rationally in their own best interest. I emphasize “up till now.” The big news this week is not the failure of Rex Tillerson who was never up to the job, or the titillation of being a voyeur to the adventures of Donald and Stormy, but rather the apparent narrow victory of Conor Lamb in special election of Pennsylvania's 18th congressional district. As we all know, Trump had a 20 point victory in this western Pennsylvania district in 2016. What you might have missed is that perhaps the most important question in the election was the security of healthcare. The online political news service “ The Hill” reports that healthcare was the top issue in the race. They write: For 52 percent of voters, health care was ranked as a top issue when deciding who to vote for, while 19 percent said it wasn’t at all important to them, according to Public Policy Polling, a Democratic polling firm.
Voters who said health care was the most important issue to them favored Democrat Conor Lamb over his opponent Republican Rick Saccone 64-36 percent, according to the poll.
More voters also said Lamb was “more in step” with their views on health care than Saccone, 45-38 percent.
The poll also found that 53 percent disapprove of Republican efforts to repeal ObamaCare, while 39 percent approve. Those are interest findings to say the least. I have said before that Trump did us all a great favor by his attempts to repeal and replace the ACA. Now people understand its value to them. If, as Kellyanne Conway contends, voters are discerning and care more about what affects them than offends them then future Congressman elect Lamb played it right. By all accounts he took the high road and focused on meeting the voters and selling them on his genuine interest in their concerns and spent little time or energy running a campaign against Trump’s character flaws. If you think that all the healthcare issues are behind us until after the election this fall I think that you are wrong. Congress could still pass a bill that would provide relief to the health exchanges that would save everyone money. The VA is under continuing attack with Veterans Affairs Secretary David Sulkin perhaps slated to be the next high level official to exit the Trump administration. Lest that not seem like enough to get your attention, let us not forget the ongoing attempts to use state waivers as a way to add work requirements to Medicaid and the reality that reducing spending for Medicaid by exclusion of participants and cutting of resources rather than by process improvement remains an active strategy for many on Capitol Hill. Don’t forget that we have two huge public health issues that can potentially touch the lives of even the wealthiest members of our society, opioids and gun violence. Just announcing we have an opioid problem is not a solution to perhaps the biggest public health problem since the emergence of the AIDS. Last year there were over 60,000 opioid deaths. That’s almost as many deaths as we suffered from guns and automobile accidents combined, and far more destruction than from Islamic terrorists or immigrant Mexican rapists. Perhaps the most newsworthy event of the week is that though many adults and most of Congress would just as soon not talk about the fact that we had 38,000 gun related deaths last year, our students from elementary school through universities are fed up with their elders and are making their voices heard. Sure, the president is not a good role model for the younger generation and his treatment of other human beings is always secondary to the attention he gives to his own ego driven concerns, but outing a man who needs no outing is not a winning strategy. A winning strategy is to focus on what really is important, and that is dealing with the deep divisions and structural weaknesses in our society that created the opportunity for a man of his talents and inclinations to divide us even more. The rest of this letter is about community. Don Berwick challenges us to think globally, but act locally. The truth is most of us have only the choice of doing nothing but talk and complain, or doing something small but positive near where we live and work. What we don’t know is just how much we could do together if we all decided to do what we could. The Education of an Old Man: The Difference Between Knowing and Seeing and DoingI have been reading more than usual lately. Amazon knows what to feed me. I get notice of books about politics, especially ones critiquing President Trump and the current perils to the future of our democracy. Now their computers are aware of my interests in inequality and behavioral economics. My appetite for these subjects has been whetted by two things: - I fear the ultimate losses associated with the election of Donald Trump, and the threat he poses to the improvement of health in America. Indeed it seems likely that some of the progress of the last several years has been lost, and there is no end in sight to the potential losses that might yet occur.
- I have a rekindled awareness of the importance of the social determinants of health that are coupled with a renewed acceptance of the reality that we will never improve the health of everyone in the community for a sustainable economic expense without a more focused and effective approach to the persistent issues of poverty and the structural issues that are the origin of economic inequality.
Since 2008 I have been using a slide (reproduced below) in presentations that I make about healthcare policy and the future challenges of American medicine. The slide was lifted from a 2007 Shattuck Lecture given by Steven Schroeder and published in the New England Journal of Medicine. The title of the article/lecture is “We Can Do Better — Improving the Health of the American People.” It is a classic that you should download because after ten years its truths persist and the challenge is still before us. The point of the slide is that if we want to improve health and reduce the cost of care we need to look to more than what we do in the hospital and the medical office. |
| | “The Case for Concentrating on the Less Fortunate” is an important section of Schroeder’s discussion. I have bolded important points that Schroeder makes:
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 — most recently, the Healthy People 2010 objectives — 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.
Ten years later that last statement, ...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…, is still true. If we are really on a journey toward the Triple Aim, it is likely true that we should listen to “downeast wisdom” that is attributed to Maine, “You can’t get there from here!”
Schroeder was echoing Dr. Robert Ebert’s observations about healthcare:
“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”
Compare Ebert’s wisdom to Schroeder’s assertion:
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’s the same thought. Spending money on healthcare does not assure a healthier nation. You can’t get there from here---just spending more and focusing on better practice. Schroeder and Ebert would agree. We need to pay attention to the needs of the poor. In a very important speech that Dr. Ebert gave in the fall of 1967, about six weeks after I entered his medical school, he emphasized the needs of the urban and rural poor, and the inadequacy of our medical infrastructure to address the problems of these two populations. It’s been ten years since Schroeder admonished us to pay special attention to the issues that “disproportionately affect the poor.” It’s been 50 years since Ebert said essentially the same thing. Are we listening? Perhaps we are listening but not acting. Perhaps we are listening and want to do better but are just inept. Whatever the reason for our lack of success, if we want to move closer to the Triple Aim we must continue to try to rethink our strategies to improve the social determinants of health. That is what this old man knows and believes. “Knowing” is not enough. The question is where to start and what can any of us do since it is clear from reviewing Schroeder’s article and comparing where we are now to where we were in 2007, not much has changed.
I have always been enthusiastic about “knowing.” I can sit in my easy chair in front of a warm fire and read more to advance my knowing. What is bothering me more and more is the realization that what I know doesn’t do much good for anybody. It’s not like I am advancing our collective knowledge or making a difference in anyone’s life as I advance my personal understanding from my position of comfort.
My community has offered me an opportunity to move from just knowing and expressing that I care, to seeing and doing. Last year a friend who is active in our local Episcopal congregation offered me an opportunity to join an effort that they were sponsoring in Newport, New Hampshire which is a low income, high unemployment community just ten miles from New London. It has been both fun for me to participate in the activities, and participation has given me a little bit of insight into the impact of the poverty in this community on the children who live there.
A more instructive opportunity came to me last fall. My minister at the local Baptist church asked me if I would be one of three congregants to participate in the eccumnical effort to address the acute issues of poverty in our community. I was apprehensive at first and told him that I would explore the idea. I met with the woman who was retiring as the “church nurse” and who had been involved in the effort for several years. After talking with her and a few others I decided to take the leap. The challenge was more than just joining a board. Board members rotate the responsibility of “caring the phone” for two weeks. It is like being on call. The records are not automated so the phone comes with a big file of cards that contain information about recurrent clients. We meet once a month to discuss cases, review experiences, and try to improve the system within the means that are available. If you are interested, we have a website that describes our mission and also has links that explain “how welfare works in New Hampshire.”
After attending four or five meetings, I had heard enough to be quite apprehensive about “carrying the phone,” but my buddy promised me that she would hold my hand through the process. It was just like being a frightened medical student leaning on the wisdom of an experienced intern or resident. I realized that even after four decades of medical practice I had never really been “to the gemba” of poverty and need. Some of my patients had huge needs but the focus was rarely, “What do I do now that they have cut off my electricity and the oil company won’t deliver more oil until I pay my bill, and I am out of firewood.” Pending evictions, no money for gas or food, a broken down car that prevents getting to work, dental infections without insurance or money to the pull the teeth are just a few of the problems that someone else always addressed while I was pontificating about avoiding salt and getting plenty of exercise.
I cringed this last week as I thought about all the things I didn’t understand about the real world while in practice as I talked to a man who was status post neurosurgery and a couple of strokes who is trying to live on $1100 dollars a month in a rural setting. He gets most of his food from a local food pantry, has several hundreds of dollars in unpaid pharmacy charges for his dozens of meds for his diabetes and hypertension. Although he was admitted to the hospital within the last month for an exacerbation of renal failure he has trouble staying on a low salt diet. When I talked to him it was Tuesday. He had no money. He had a couple of packages of ramen noodles and a can of Dinty Moore stew on his shelf. The “food pantry” at the local church would not be open until Thursday. He has Medicare because of his disability, and is admitted frequently with various problems. He sees a PA at least once a month at a local clinic. As I listened to his story and mobilized money to pay off his propane bill so that he would not freeze, we did have a blizzard with 18 inches of snow falling, I said to myself, “It is true, you can’t get there from here!”
I have a new appreciation for those who are in social services. While “carrying the phone” it is easy to see that success for any client is about getting a little bit of help from many different places. Working clients, and most of our clients are the working poor, are trying to juggle relationships with multiple agencies and programs. Forget efficiency. Check your privacy as you ask for a helping hand. After a week of carrying the phone, all I can say is that if anyone wants to talk to me about “welfare queens or the shiftless poor” they do so at their own risk.
I do not want to sound either self righteous or self loathing, but what is clear is that it is easy to look the other way or even look at people in need and not really see anything. Most of the people I have encountered are embarrassed about their needs and go to great lengths to avoid asking for help. KREM sees its mission as "... meeting the emergency needs of people in the Kearsarge/Sunapee region when other services are unavailable." I am sad to say that I realistically expect that there will be a need for organizations like KREM long after there is moss on my tombstone. Looking back at the history of the last eighty years since FDR began the conversation about what government might do for all of us, the progress in social service and the efforts to lift people out of poverty have been earnest at times but are almost always only band aids that are ineffective in eradicating the problem. That said, I do not believe we should abandon the effort. We should more than redouble our efforts. We need more than charitable activities. We need to address the issues head on because we can. Dr. King talked about poverty a lot. In his acceptance speech for the Nobel Prize in 1964 he said:
“There is nothing new about poverty. What is new, however, is that we have the resources to get rid of it.”
I would contend that if we can collectively waste about a trillion dollars a year of the three trillion we spend on healthcare, and if we can stimulate the economy by giving hundreds of billions of dollars of tax relief to corporations and the very richest members of our society, we have the means. Why don’t we do something? I referenced Hubert Humphrey’s wisdom last week. My experience as a novice social worker “carrying the phone” convinces me that King, Ebert, Schroeder, and Humphrey are right. If we are ever going to live in an America that is truly great we will need to act on the truth that:
It was once said that the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped.
March: Blizzards and Town Meetings
It’s been a great week for snow in my little town. It snowed all day Tuesday and Wednesday, and now things are really beautiful. It was beautiful in New Hampshire and the ski slopes all over New England are pumped for a great end to their season, but our sisters and brothers on the coast and in Massachusetts on the South Shore and Cape did not fare so well. Both of the last storms have really hit them hard.
The storm did not close the polls on Tuesday and more than 600 people showed up to vote in the town elections. In a three way vote for town clerk two candidates tied with 270 votes each. The law calls for a coin toss. The incumbent called heads and won the toss. The guy who came up tails immediately called for a recount.
Town elections are on the second Tuesday of March. The town meeting is on Wednesday evening. The header for this week shows the citizens of New London gathering in a gymnasium to participate in the 240th annual town meeting. As always, the meeting was an exercise in the purest form of democracy.
There was substantial debate of the proposal from the selectmen that we give them $500,000 to go looking for land to relocate the police station, despite not having done an adequate evaluation of whether or not the current structure, conveniently located just off the town green and refurbished at great expense only eighteen years ago when the town had a larger population, could be upgraded to meet current demands. That “warrant” went down to defeat by a two to one margin, as did a later warrant that suggested that taxes be collected twice a year rather than quarterly. Democracy in action requires listening to a lot of different opinions, and it’s time consuming, but like watching snow fall, it is a beautiful scene.
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| Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
Dr. Gene Lindsey
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| | The Healthcare Musings Archive
Previous editions of the "Healthcare Musings" newsletter, by Dr. Gene Lindsey are now archived and available to you at:
www.getresponse.com/archive/strategy_healthcare
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