17 November 2017

Dear Interested Readers,


Introduction and a Request for Understanding

Some of you may remember my letters and posts of a few weeks ago that were triggered by Patty Gabow’s question “Can the American Healthcare System Deliver Health?” Her data and discussion launched me on a journey of personal discovery. I have long hidden the fact that issues of race still confuse me. There is a phrase that describes my turmoil, “Fake it till you make it.”

I first began to worry about race as a small child. My family was progressive on issues of race in comparison to other families in the South between the late forties and mid sixties, but like most white Southerners we usually held our own council and did not say anything at all. We had many warm relationships with people of other races, but we were silent on the big issues. I was present when my university was integrated, but I looked the other way. I felt uncomfortable when injustice was obvious. I minded my own business. I smiled when appropriate. I never called out injustice, and I got out of town as soon as I could. Coming North to Boston, I discovered that I was in the midst of just as much discrimination, and almost as much injustice as I had seen at home. Again, I minded my own business. I went to work on my studies. I shed my Southern accent, and adopted the posture of a “liberal.”

Years ago I learned that quality was a systems function. Don Berwick taught us that poor quality was not an individual failing but a systems issue. I reasoned that perhaps the same was true of poverty, and that the issues of race were issues of economics to be decided at a much higher pay grade than mine. Patty Gabow’ analysis of health and the social determinants of health do line up with systems issues. I say this with the hope that no one will feel that I am criticizing them personally in this letter. If there is any individual that I have enough evidence to call flawed it is me. What I am calling for is a collective effort to resist the reversal of the very small gains we have made with our poverty programs, feeble attempts that they are, at promoting equality of benefits and opportunity across all Americans. Perhaps we need a national “truth and reconciliation” process. We too had a form of apartheid that injured us all. My personal scars and pains are minimal, and I can’t imagine what my life might have been like but for an accident of birth. I believe that now that none of us can be really whole or healthy until we do a lot more work to make everyone whole and healthy.

I have revised this letter several times. It still needs work, but I must let it go.


Inequality, Justice and Health

My 97 year old father has been ill lately and was hospitalized. He was the beneficiary of fabulous care. His progress is attributable to the good medical management that he received at his local hospital that is affiliated with the Carolinas HealthCare system, and the inpatient rehab care provided at the lovely new facility on the campus like grounds of Abernethy Laurels in Newton, North Carolina where he and his wife live.

There is something wrong with the wonderful picture that I am describing. The problem is the lack of equity that my father’s care demonstrates. Not every person in North Carolina has access to the kind of care my Dad is enjoying. Over a lifetime he worked hard, saved diligently, and invested wisely so he has the resources that make his care possible.

Dad grew up during the Great Depression in a mill village on the outskirts of Greenville, South Carolina. His father was a millworker with a third grade education. Dad’s greatest advantages were his family and that he came from a community where everything evolved around the church. Because he wanted to be a minister he was provided support that helped him go to college. His parents had deep religious convictions, impeccable personal values, and an intense work ethic coupled with frugality. My Dad has conservative values, and has voted as a Republican in almost every election since Roosevelt. Nevertheless he has acknowledged that social programs initiated by the Democrats, especially FDR, have greatly benefited our family. He once joked with me and said that he loves to calculate how much more money in 35 years of collecting Social Security he has taken out of the program than he ever put into it.

The benefits that my family has enjoyed are multigenerational. All of my grandparent’s children on both sides of my family tree have gone to college and many have graduate degrees, as has everyone of their numerous grandchildren and great grandchildren. Federal funds made my medical education virtually free. It’s hard to deny that the last 80 years since my Dad went off to college have been very good for us all. Not everyone born in 1920 has enjoyed the good fortune my Dad and his progeny have experienced. I am sure that we feel like “we earned” the benefits we enjoy.

It is easy to overlook the advantages that came our way. Sometimes we say we have been “blessed,” but I really do not have a theology that explains the differential blessings that I see across America. It is unfortunate that many other people living within the shadow of the institutions that have provided my father great care do not have his advantages, or the advantages that have been passed on to our family. I feel a little guilty as I realize that what disgraced former North Carolina Senator John Edwards said when he ran for president remains true. There are “two Americas.” It is ironic that Edwards grew up near where my dad lives in an environment and community much like my father’s boyhood neighborhood.

In 2013 there were 1.5 million (16%) North Carolinians without access to healthcare. North Carolina is one of the 18 states that has not accepted the Medicaid expansion and some of its congressional representatives, like Congressman Mark Meadows of the eleventh district, are some of the most anti-ACA members of Congress. Nevertheless, because of the ACA, there are now only a little over a million (about 10%) North Carolinians who lack coverage. The gains of the last four years are at risk if Congressman Meadows and his Republican colleagues succeed with their agenda. It is estimated that as many as a million North Carolinians will lose their care if Congressman Meadows eventually gets his way.

I know many doctors, nurses, and healthcare administrators who work in North Carolina. I have met some amazing humanitarians at the North Carolina Hospital Association who are fighting for the Triple Aim and the healthcare equity that it will require. Lean has been enthusiastically embraced by many hospitals in North Carolina. Their efficiencies have enabled them to do great work when many of their patients have no coverage. My concern in this letter is that the great work they do for people like my father, and many North Carolinians without the blessings he has, is compromised by the continuing efforts in Washington to cut the resources required to improve care and the social determinants of health.

Despite the great care that so many dedicated healthcare professionals provide in North Carolina, the state is representative of some problems we face across our country. There are two North Carolinas. Just like there are two New Yorks, two Californias, and two Alabamas. All are all blessed with modern cities, fabulous academic institutions, beautiful seashores, wonderful recreational opportunities, and spectacular mountain vistas. Each state has some unique social problems, but the states of the old South are especially challenged by remnants of the Jim Crow infrastructure that followed the failure of Reconstruction and existed for more than one hundred years. It’s legacy lives on in palpable ways, and is relatively easy to discern if you allow yourself to look. It is easy to see under the covers of healthcare, education, employment opportunity, housing policy, and in the criminal justice system. What discourages so many is the fact that it lives on despite marginal improvements that make us want to assert that it is dead.

I know, and I would bet that you know, from your own continuing experience that there are still more than remnants of a culture where for years good people rationalized why the advantages they enjoyed could be justifiably denied to others. Those of us who were not the target of those discriminatory laws were, and still are, hugely advantaged. Those laws and the customs and culture they perpetuated were built on lies of racial superiority and the twisted concept that natural and divine forces supported the wisdom of the races living in parallel communities with little intersection.

Traveling the 15 miles between my brother’s home in Lincolnton to the lovely 130 acre assisted living community where my Dad lives, I am always struck by the beauty of the farmland, the occasional glimpse of the Blue Ridge Mountains to the west, and the persistence of the symbols of the Confederacy along the way. North Carolina celebrates its dual heritage as one of the original 13 colonies, and its participation in the “Confederacy.” I understand the value of remembering the stories of valor and honor. North Carolina has sacrificed many of its sons in every one of our wars. The North Carolina 26th Infantry sustained more casualties than any other regiment of the South or North in the War Between States, as it is preferably called by many in the South. Given the histories of personal valor and a willingness to die for the values of one’s community, perhaps I should be defending the statuary that honors those ancestors who died in an ill conceived cause. I can’t.

I accept the theory that those monuments had another more strategic function other than honoring the fallen heros. They were symbols that supported and perpetuated the cultural divide that I can still see today. Martin Luther King, Jr. gave his “I Have a Dream Speech” more than 50 years ago. Before you tell me that things have changed tremendously since then and I agree in part, let’s look at his description of a post racial world, and then we will see how much farther we have to travel to get to the dream:

I have a dream that one day this nation will rise up and live out the true meaning of its creed: "We hold these truths to be self-evident: that all men are created equal."

I have a dream that my four little children will one day live in a nation where they will not be judged by the color of their skin but by the content of their character.

These words should continue to be a painful reminder that slavery may be over, but we are still far from the dream. Race still makes a huge difference in every metric of health status, employment, incarceration, access to capital, and income in America. Race is still a source of difference and friction in almost every interaction in our society. If Jim Crow is dead, his ghost still haunts us, and there is no better place to sense that ghost than in healthcare and health.

I have relatives who fought, and some who died, at Gettysburg and in other battles of the “War of Northern Aggression.” Some of my ancestors were slave owners. Those are facts I can’t control. I feel that I do have an obligation to acknowledge that all of us born when those laws existed have enjoyed advantages that continue to this day. I contend that part of that legacy are the continuing realities of economic inequality and healthcare inequality.

I would agree that race is not the only factor that is out of balance in our society. My family enjoys benefits and a security in their healthcare that many of our neighbors, white and black, North and South are still denied. Part of the explanation is cultural, part socioeconomic, part racial. There are fundamental inequalities of opportunity that impact all poor, of all races, in all of our states. But, I am biased that the sum of all the history and circumstances that create inequality in this country has had a greater impact on black Americans. I say that knowing that everyone’s lot is better than it was 65 years ago when I first began to recognize that race was a powerful reality in my world. Better, but still different, is not good enough.

The statues and ubiquitous Confederate battle flags are evidence that the last one hundred and fifty plus years have been a pretty effective defense of many of the elements of white advantage. It leaves one wondering who won the war. The South seems to have won most of the battles after Appomattox. Those “victories”for the South were continuing losses that still matter in the lives of millions of people who deserve a basic equality of opportunity that they have never enjoyed. Ironically, in such an environment you can also find controlling leaders in business and politics who can still rationalize the benefits and “rightness” of ignoring the plight of the poor of all races. The plight of the poor is always explainable in terms of personal defects rather than a function of their systematic exclusion from real opportunities.

In last week’s letter I advised you listen to the podcasted conversation between Ezra Klein of Vox and Bryan Stevenson, a founder of the Equal Justice Initiative. I also told you that I was going to read Stevenson’s book, Just Mercy: A Story of Justice and Redemption. I have gobbled up this book. It is a page turner! The 2014 review from the New York Times is very laudatory but is an undercall of the power of the story. In the introduction Stevenson summarizes what his life work has taught him. As I read it, I was reminded of the quote from Hubert Humphrey carved into the walls of the Washington office building that bears his name and is home to Health and Human Services:

The moral test of government is how it treats those who are in the dawn of life, the children; those who are in the twilight of life, the aged; and those in the shadows of life, the sick, the needy and the handicapped.

I think you will see the similarity between Humphrey’s quote and Stevenson’s insight if you include “health” with “justice” in the quote I have lifted from Just Mercy. Don’t forget that according to Reverend Dr. Martin Luther King, Jr.: Of all the forms of inequality, injustice in health care is the most shocking and inhumane.

Here is Stevenson’s insight, he was writing well before 2016:

My work with the poor and incarcerated has persuaded me that the opposite of poverty is not wealth; the opposite of poverty is justice. Finally, I've come to believe that the true measure of our commitment to justice, the character of our society, our commitment to the rule of law, fairness, and equality cannot be measured by how we treat the rich, powerful, the privileged, and respected among us. The true measure of our character is how we treat the poor, the disfavored, the accused, incarcerated, and condemned.

We are all implicated when we allow other people to be mistreated. An absence of compassion can corrupt the decency of a community, a state, a nation. Fear and anger can make us vindictive and abusive, unjust and unfair, until we all suffer from the absence of mercy and we condemn ourselves as much as we victimize others. The closer we get to mass incarceration and extreme levels of punishment, the more I believe it is necessary to recognize that we all need mercy, we all need justice, and-perhaps-we all need some measure of unmerited grace.

Bryan Stevenson, Just Mercy: A Story of Justice and Redemption

What is really remarkable in both quotes is the idea that we are all diminished by the difficult experiences that befall any of us.

It may seem mundane, but the reality that we all are diminished when anyone is treated unfairly brings me to the current tax reform attempts. I wanted to quote a Paul Krugman column in last week’s letter about the implication of the Republican tax reform process on the health of the poor. That was my subject in this Tuesday’s Strategy Healthcare post. The problem was Krugman did not write what I wanted him to say about “tax reform” until this week:

...Meanwhile, funding for the Children’s Health Insurance Program, which covers more than eight million children, expired a month and a half ago — and so far, Republicans have made no serious effort to restore it. This is surely the shape of things to come: If tax cuts pass, and the deficit explodes, the G.O.P. will suddenly decide that deficits matter again and will demand cuts in social programs, many of which benefit lower-income children.

So this isn’t just ordinary class warfare; it’s class warfare aimed at perpetuating inequality into the next generation. Taken together, the elements of both the House and the Senate bills amount to a more or less systematic attempt to lavish benefits on the children of the ultra-wealthy while making it harder for less fortunate young people to achieve upward social mobility.

Or to put it differently, the tax legislation Republicans are trying to ram through Congress with indecent haste, without hearings or time for any kind of serious study, looks an awful lot like an attempt not simply to reinforce plutocracy, but to entrench a hereditary plutocracy.

Last week’s rant about the tax reform efforts of Republicans had as it core point my opinion that the tax discussion was way off target. Everyone was talking about how corporations and the rich were being unfairly advantaged to the neglect of the middle class. My point was that we were missing the real issue that had some moral impact. No one was talking about how the tax bill would undermine programmatic efforts to address the causes of poverty and the social determinants of health. I seriously doubt that the quality of life of a child whose parents earn a million a year will change much when they get the $59,000 tax break that they are expecting. Even after all the social programs are gutted I doubt that the children of middle and upper middle class parents who earn $150-200,000 a year will notice much difference either. I have no doubt that the children of the poor and their poor elderly grandparents will immediately notice the gutting of the programs that will fund the tax reductions for the rich and for corporations. Those dollars will be lost without much societal or personal benefit to the “marginal propensity to consume” of wealthier families.

I experienced a muted catharsis from expressing myself last week. My plan for this week was to tone it down, reclaim my composure, and talk about a favorite subject, leadership. I abandoned that plan when I realized that faster than either I or Paul Krugman had anticipated, the Republicans were discovering that to fund their tax plans they needed to immediately ramp up their war on “entitlements” and benefits to the underserved and disadvantaged.

I have always contended that a major error to avoid is underestimating the strength or intellect that a focused adversary will apply to win their objective. As the Senate Republicans try to fit the square peg of their tax gift to the wealthy into the round hole of passage using the “reconciliation process” they have realized that by eliminating the hated “mandate” in the tax reform bill they kill several birds with one stone. They could not repeal or replace the ACA, but they can cause it further damage by repealing the mandate because many “low risk” enrollees will go without insurance. The subsidies going to those people will be “saved” and reduce the federal deficit! On Tuesday the New York Times explained it:

The move to tuck the repeal of the so-called individual mandate into the tax overhaul is an attempt by Republicans to solve two problems: math and politics. Repealing the mandate, a longstanding Republican goal, would save hundreds of billions of dollars over the next decade. That would free up money that could be used to expand middle-class tax cuts or help pay for the overall cost of the bill, which can add no more than $1.5 trillion to the deficit over 10 years. It could also help secure the votes of the most conservative senators, enabling lawmakers to pass the bill along party lines.

If it becomes law, the repeal would save more than $300 billion over a decade but result in 13 million fewer Americans being covered by health insurance by the end of that period, according to the Congressional Budget Office. Republicans said on Tuesday that they would use the savings — which stem from reduced government spending to subsidize health coverage — to pay for an expansion of the middle-class tax cuts that lawmakers had proposed.

Paul Krugman and I agree that eliminating the mandate to free up 300 billion to help pass the tax law that differentially favors the rich who have enough, is a rip off for the middle class, and is severely damaging to the disadvantaged.

Eliminating the mandate will not be the end of things. By Wednesday things were getting worse as my concern from last week was beginning to look like a possibility. What worried me last week, was the possibility of Republicans turning the mission of tax reform into an attack on entitlements. Where will it end? I am beginning to wonder, in my paranoia, whether tax reform, which was presented as a strategy to improve the economy, was really just a tactic in the more important Republican strategy of gutting entitlements. The president assured us during and his campaign and in his early months in office that he would not change Social Security and Medicare. We are beginning to understand what his assurances are worth. Medicaid was the preferred target in all the failed attempts at “repeal and replace.” The CHIP program has already died. It is interesting to look at the ethnicities of the children covered by CHIP. It is clear that CHIP is a major protector of minority children. The CHIP phase out seems well under way and those who fear a more equitable society must be happy. They seem happy to harvest the benefits of standing behind a madman who is a genius at tapping into fear and prejudice to achieve their objectives.

There are plenty of targets that have long enticed tea party libertarians and bottom line oriented business conservatives from both the North and the South. For years I have heard rants against women who are “welfare queens” and men who abandon their responsibilities and are lazy drug using welfare recipients coming from the mouths of friends and neighbors in the most unlikely venues of churches and social gatherings of the moderately affluent. Ending welfare as we have known it was supposed to have been a Clinton achievement. My guess is that others might have preferred, “End welfare, period.” The intermediate strategy has been to suggest that the social safety net should be decided at the state level. In that transitional plan the federal government makes grants to states and then slowly exits stage left. It’s all an exercise in “states rights” which many Southerners contend was the reason their ancestors seceded from the Union. It looks like we are getting closer to chalking up another post War of Northern Aggression win for the gray side.

If you clicked on the last link you would have read an article which supports my contention that inequality is likely to be enhanced as we work through the complexities of tax reform and its impact on the poor and on health in America:

University of Minnesota sociologist Joe Soss spent a decade studying how those reforms [Clinton’s welfare reform] shook out in the real world. With Richard C. Fording and Sanford F. Schram, he co-wrote the book, Disciplining the Poor: Neoliberal Paternalism and the Persistent Power of Race, explaining how race became a determining factor in how states created their own welfare programs — and how that ultimately led to a system that’s rife with racial bias.

We all know Will Roger’s joke that he is not a member of an organized political party--he’s a Democrat. I fear that continues to be true and the election victories in Virginia and New Jersey as well as the attempts to discredit Roy Moore from becoming a Senator do not really give me much hope. Racism, confusion about entitlements, wealthy seeking to maintain advantage, and attention to one’s individual concerns in ways that trump [pun intended] the issues of the underserved and disenfranchised are associated with both parties. Democrats frequently achieve with their political incompetence, and what my brother calls the “bigotry of the progressives,” as much damage for the poor with programs that do not work as Republicans, conservatives, and libertarians do with much more effective planning and execution to underfund or kill programs. When it comes to fixing poverty and improving inequality through legislation both parties demonstrate staggering incompetence.

The “gated community” is the symbol for me of the ultimate destination of the road we seem to be on. The acquisition of “more” does not diminish fear or ultimately offer much protection from the harsher realities of this world that we fantasize can be eliminated by better walls, guns, and self serving legislation. Stevenson nailed it when he said that the opposite of poverty is not wealth, it is justice. He pointed out that understanding that the law of humankind leads to the realization that:

We are all implicated when we allow other people to be mistreated. An absence of compassion can corrupt the decency of a community, a state, a nation. Fear and anger can make us vindictive and abusive, unjust and unfair, until we all suffer from the absence of mercy and we condemn ourselves as much as we victimize others.


First Snowfall

There is nothing like a little snow to give you a fleeting sense of the possibility that all our worries and sins can be covered up, and we can get a fresh start. The first early morning sight of fresh snow that has fallen overnight always fills me with joy. This week I got that same sense of renewal and possibility in the middle of a dreary dark day.

Monday was cold and dark in New Hampshire. There was virtually no wind. The lake was like glass. Early in the afternoon I realized that any walk that I might take would be in the face of the worse kind of “wet cold” that can exacerbate my Raynaud’s so I elected to get my exercise at the indoor athletic center of Colby Sawyer College. It is a great facility with an indoor track and I reasoned that I could resume my swimming in the college pool. When I emerged from the facility a few hours later, I was startled to see that the trees had been draped in snow and almost all of the grass was covered with the first snow of the year.

I took a lot of pictures with the idea of showing one of them to you, but when I got home I discovered that my wife had done a better job of capturing the feeling. Her picture is not a black and white picture, although it was such a gray day that there is no color. The fir trees along the shore have retained a little of that first snowfall and the lake is a mirror that reflects it all. I thought it looked a little bit like a picture Ansel Adams may have snapped if he had ever come to New Hampshire.