2 June 2017

Dear Interested Readers,

What’s Inside This Letter and a Little Housekeeping

This week’s letter builds off a letter and a slide deck that Dr. Patty Gabow sent to Senator Lamar Alexander this week and generously shared with me. I hope that it will be a stimulus for many of you to write Senator Alexander of Tennessee who is the chairman of the Senate Health, Education, Labor and Pensions Committee. His committee and the Senate Finance Committee, chaired by Orrin Hatch of Utah will be the sites of much of the creative work that Senate Republicans try to do, hopefully with the help of Democrats, as they go back to the drawing board to try to write something that is both better than the bill that was passed in the House and a step forward that could attract some bipartisan support. The members of Alexander’s committee include Susan Collins, Dr. Bill Cassidy, Elizabeth Warren and Bernie Sanders. On the Finance Committee you will find Ron Wyden, Rob Portman, Claire McCaskill and Mark Warner, to name a few. A few senators are on both committees. Click on the links to see the membership of each of these key committees.

Back in 2009 during the run up to the passage of the ACA I had the opportunity to meet with some of the members of both committees as well as with some of Nancy Pelosi’s staff in the House and most of the members of the Massachusetts delegation. These are real people who I believe take their responsibilities very seriously and earnestly want to be remembered as having served their country well. All have staff that are largely composed of very bright and energetic young people who have been to great schools but so far have limited experience in the world you know so well. I suspect that in most instances it will be these staffers that will read your letter.

I learned in 2009 that it did not take a very long conversation to reveal that many of the people with whom I was speaking had not spent much time thinking about healthcare and did not fully appreciate the complexity of the issues that they had the responsibility of resolving. Perhaps I should say I realized that they often did not see the issues the same way I did. All seemed genuinely interested in getting the perspective of a practicing physician who was the leader of a medical practice that was trying to improve care delivery as a major element of its mission. I hope that attitude persists today.

I am sure that these senators of the 115th Congress know more about healthcare this time around, but with the exception of Ron Paul and Bill Cassidy they still do not have the personal experience of dealing with the concerns and fears of patients in a clinical setting. Legislation and the public programs that their laws create are often experienced differently at the point of care than they are conceptualized in Congress. Your opinions, concerns and experiences should be heard. After you read this week’s letter, I hope that many of you will accept the challenge of writing to the chairs of both committees as well as many of the committee members. I am sure that neither Patty Gabow or I will mind your copying and pasting anything you read here into the thoughts that you want the senators to read.

As a point of housekeeping, lately I have been getting the sense that some people are suddenly realizing that they are not getting this letter. A few asked me when we have run into one another at a meeting or event if I quit writing. Some others have emailed me with the same question. The explanation may be that your computer is sending the letter to “junk.” Perhaps that is an example of artificial intelligence. Another explanation is that your email address has changed. If your email has changed or will change, go to the very end of any of these letters and find the phrase: You may unsubscribe or change your contact details at any time. Just click on “change” and you can then enter your new email address. The equally effective alternative is to go to the companion website Strategy Healthcare which has a new posting every Tuesday at 3 PM. There on the website is a field where you can sign up again for the “Healthcare Musings” Friday letter. While there you can read the salient points of the letter from the previous Friday’s output in a condensed and updated form. If you have friends who would like to get the Friday letter, tell them to go to the website and sign up. I would greatly appreciate the opportunity to have more interested readers!


Dr. Gabow Is Sending a Letter to Washington

Dr. Patty Gabow has recently shared with me a letter and a slide deck that she is sending to Senator Lamar Alexander, the chairman of the Senate’s Health, Education, Labor and Pensions Committee. I am reproducing the letter in its entirety with her permission with the hope that it may help you craft your own letter. Many of her points may seem like common knowledge to you, but do not be so sure they are well understood by either the senators or their staffers who will write the legislation. I think several of her points deserve extra emphasis and I have bolded them. I have not included her slides because they are well explained in the text, but I will be happy to share them with anyone who asks for them.


Dear Senator Alexander,


I am a physician who was the CEO of a large, integrated public safety net health care system for 20 years, so I am deeply committed to the care of all the population. Over my 40 years in healthcare I have gained a broad understanding of the strength and weaknesses of American healthcare. As you are part of the Senate’s working group to develop a health reform plan, I thought it would be worth sharing some important facts with you. I have included a series of slides that illustrate the issues we must address to achieve health for every American.


1. We spend almost twice as much as every other developed nation (slide 1). Currently we are spending over $3 trillion/year and almost 18% of GDP. Yet despite much lower expenditures, these other countries provide health care to all their residents.


2. In America health care coverage matters. Those who are uninsured are almost five times more likely than Medicaid or privately insured patients to have no usual source of care, they are more likely to postpone seeking care, go without needed care, or be unable to purchase a needed prescription (slide 2). Without a usual source of care, or going without needed care, prevention and early intervention cannot occur, and patients develop chronic diseases and/or utilize emergency departments for care. This slide also demonstrates the value of Medicaid in enabling Americans to get needed care. Cutting Medicaid will make this worse.


3. While we often think, we get high value for the healthcare dollars that we spend, Americans have the lowest life expectancy of all 17 peer countries and it is decreasing. We have the highest infant mortality of all 17 peer countries and during a person’s most productive years we rank 17th out of 17. We never get above 15th out of 17 until age 75 and only become number 1 at age 95 (Slide 3). We also spend more at the end of life than many other developed countries. Therefore, for our expenditure we achieve much less than all the other OECD countries (Slide 4).


4. One of the reasons for this higher expenditure which achieves less value is the inefficiency our system. The Bloomberg Healthcare Efficiency Index ranks us 50th out of 55 countries -near Columbia. The Institute of Medicine study estimated that 30- 40% of health care expenditures are waste, largely due to administrative and delivery inefficiencies and provision of unnecessary care. In fact, 30% of all care provided to Americans is either not valuable or even harmful. At the current rate of expenditure, this waste is over $1 trillion dollars (Slide 5). Much of this inefficiency stems from the myriad of delivery and payment models and the fee for service system we have adopted. Health reform should increase efficiency, eliminate unnecessary care, and abandon fee for service payment.


5. Moreover, where you live in America determines your health and even your life expectancy. Examining the performance on over 40 variables, there is marked geographic variability (Slide 6). This is due in part to the huge variability in Medicaid coverage. In Minnesota, the threshold for coverage for an adult is 215% of FPL are whereas in Texas and Alabama it is 20% of FPL. Block grants or per capita caps will make this geographic disparity worse. In contrast, this disparity does not exist for Medicare since the coverage is not dependent on where a person lives.


6. While health care coverage is critical in health, our over expenditure in health care and our under expenditure on the other major determinants of health, have resulted in our shorter lives and poorer health than other developed countries. The health care system determines about 15% of health while the other determinants of health, except for genetics, determine over fifty percent. Eleven other OECD countries spend more in total on social care and healthcare than we do, but no other country, spends more on health care than social care (Slides 7,8, 9).


7. Income may be the most important determinant of health. Although we are the richest country, we have the highest percentage of poverty and the greatest income inequality (Slide 10,11) and this has been worsening in recent decades. Life expectancy rises with income with greater effects at the lower end of income (Slide 12, 13).


8. Behaviors are major determinant of health. Among these tobacco, diet, physical activity, alcohol and drug use, sexual practices and injurious behaviors play an important role.
We have the highest level of obesity and disorders related to drug use compared to other countries (Slide 14,15). Importantly, Medicaid is a major source of funding for treatment for drug use. Shockingly, we have almost 20 times the incidence of years of life lost to disability and death due to gun violence of other developed countries (Slide 16).


Therefore, it should be clear that we are not providing the path to health and well-being that other developed countries are. This is robbing our citizens and negatively impacting competitiveness in our global economy. Fixing this is no simple matter:

It cannot be addressed by cutting Medicaid or turning it over to states.

It cannot be addressed by simply addressing pre-existing conditions.

It cannot be addressed by cutting social care programs.


Fixing this will require a thoughtful approach that examines what works and doesn’t work here and in other countries. It will require input from many people including those without direct financial interest. A small group of Senators, no matter how committed, cannot accomplish this enormous task. This will require time. The solution must include developing a unified health care system that reduces inefficiencies, duplication, overuse and geographic disparity. One easy first step toward reducing inefficiencies and duplicative efforts would be to put Medicare premiums and copayments on a sliding fee scale with the poorest having no payment, thereby eliminating the need for poor Medicare patients to sign up for Medicaid only to pay premiums and copayments. Reform also must address in a meaningful way the social determinants of health. In the meantime, we must maintain and expand those programs which have a demonstrated return on investment: Medicaid, CHIP, Earned Income Tax Credit, SNAP, Healthy Hunger Free Kids, Comprehensive School Physical Activity Model, Home Visitation Program, Tobacco Cessation, and Universal Pre-school (Slide 17,18).


Thank you for your service to the country and for allowing me to provide input to your process.

Respectfully yours,

Patricia Gabow, M.D., MACP


I read Patty’s letter before going to bed. That was a big mistake because her words stayed with me. I sorted through a lot of issues and anger as I tossed and turned, but I tried to continue to have a positive outlook. Lately I have been reading Arlie Russell Hochschild’s wonderful book, Strangers In Their Own Land: Anger and Mourning on the American Right. Hochschild is a professor of sociology at UC Berkeley. She spent five years in Louisiana gathering insights through many interviews as she tried to research why there was “...an increasingly hostile split in our nation between two political camps.” Patty Gabow was saying the same thing to me last year before the election when she observed that our biggest problem was our lack of “social solidarity.”


We are now all well aware of the fact that there is this a deep divide in the country. Hochschild is a left leaning intellectual who would be very comfortable in a group my wife attends called “Ladies Left of Center.” Most of us scratch our heads in confusion as we wonder just how a blue collar worker can vote against his or her best interest and against politicians and programs designed to assist them and their families. In a wonderful review of Hochschild’s book Jason DeParle writes:

...the resentments she finds are as toxic as the pollutants in the marsh and metastasizing throughout politics. What unites her subjects is the powerful feeling that others are “cutting in line” and that the federal government is supporting people on the dole — “taking money from the workers and giving it to the idle.” Income is flowing up, but the anger points down.

The people who feel this are white. The usurpers they picture are blacks and immigrants. Hochschild takes care not to call anyone racist but concludes that “race is an essential part of this story.” When she asks a small-town mayor to describe his politics, his first two issues — or is it one in his mind? — are welfare and race: “I don’t like the government paying unwed mothers to have a lot of kids, and I don’t go for affirmative action.”

DeParle lifts a very difficult to stomach analysis from Hochschild that rings as possibly true even as it makes you cringe because it is a hypothesis born of empathy that attempts to explain the misunderstanding that exists beyond the tension of race and deteriorating economics. It surely is still only a partial explanation for our deep social division, but it represents an effort to gain understanding and start a conversation.

Hochschild detects other passions and assembles what she calls the “deep story” — a “feels as if” story, beyond facts or judgment, that presents her subjects’ worldview.

And who runs the government? “The biracial son of a low-income single mother,” and he’s cheering on the line cutters. “The president and his wife are line cutters themselves.” The liberal media mocks you as racist or homophobic. Everywhere you look, “you feel betrayed.”

Whether or not you accept or reject Hochschild’s formulation or “deep story” as the explanation for Patty Gabow’s observation that there is a lack of “social solidarity,” we must move beyond whatever the “deep story” is and begin to look forward to potential solutions to our healthcare problems that get beyond resistance to the ACA and are better than the absurd bill that emerged from House as an opportunity for the senate to modify.

I believe that we should search for a shared reason to fix healthcare and expand it to everyone. We must find a “set of reasons” that contains enough common ground to allow our leaders to negotiate an outcome that serves everyone well. We can’t go forward until we have at least some overlap in our view of why we need to solve the problem or until there is a consensus that we have a problem. The same divide exists for climate change and other critical issues like income disparities. For each of these issues there is no consensus that a problem exists because if we faced the “uncomfortable truth” we would logically have to address it. At this moment I fear that many in Congress are not as interested in a real solution to any problem as they are in finding a cleavage plane that cuts through the issues in a way that creates some political solution that can fool enough people on both sides of the question to avoid losses in 2018. That is not the same as seeking real solutions to real problems.

Hochschild was baffled by the fact that many of the poor people on the right who were the logical beneficiaries of social programs were so opposed to them and were politically aligned against their own best interests with the very rich. She evolved a “deep story” which is only a hypothesis but deserves attention because it may provide some empathetic understanding of those people that Hillary Clinton was unwise enough to call a “basket of deplorables.” Hochschild’s efforts to empathetically understand working class members of the Tea Party in Louisiana who were aligned with polluters to elect politicians who would favor the polluters and Patty Gabow’s outreach to Lamar Alexander may be the sort of small steps necessary to begin to rebuild enough social solidarity to solve the problems that we share; like it or not. Both sides have tried name calling. Perhaps now we can try listening and reasoning together.

The statistics that Dr. Gabow quotes that show America to be far from great are in part as bad as they are because of the devastating impact of pollution on the people, land and water of Louisiana. Hochschild looks at the same information and shakes her head in disbelief but then tries to use inquiry as a diagnostic tool. She develops deep empathy to enable her understanding of how and why the people of “red states” provide so much support to the political philosophies that are literally killing them. She does a pretty good job of “walking a mile” in their shoes and realizes that those shoes really hurt. I believe the answer to her question of why these people vote against people and policies that appear beneficial to them will also shed light on the confusion in healthcare. Answers to deep seated issues may provide us with insight but unfortunately, understanding does not guarantee resolution. Answers are no guarantee of success but without understanding the only logical expectation is further failure and loss. Understanding born of empathy is the essential first step.

As I thought about Patty’s letter I was reminded of a thought that I had more than twenty years ago as the Clintons were failing to achieve any substantive changes to healthcare. It had occurred to me back then that we would not have

...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.

...until Republicans and the rest of the political right became convinced that it would be good for business to have a healthy nation. The thought was somewhat facetious. At that time I was thinking of the wealthy. I was not thinking of the marginalized and suffering angry white Americans who feel their existence is threatened by the changes that universal entitlement will bring. I now understand the questions to be answered to get to a better state of health to be more complicated than the answer to the question of how we achieve universal coverage. We need to find an acceptable way to get to more general agreement on how we will all benefit, not just the “welfare” recipients, from the better society that entitlement done right offers us in a crowded and polluted world.

The concept that healthcare should be an entitlement might foster the mindset and motivation to do something to correct the circumstances of the business of healthcare gone wrong that are so well described by authors like Elisabeth Rosenthal in An American Sickness: How Healthcare Became Big Business and How You Can Take It Back and Robert Pearl in Mistreated: Why We Think We're Getting Good Health Care and Why We're Usually Wrong. If a healthier work force was critical to business and improved both productivity and enabled market growth, then maybe there could be a consensus that arises for the Triple Aim that has multiple motivations. Some people will support the Triple Aim because they see healthcare as a right, and some will favor it because they see it as a better business strategy.

Everybody should be able to see that it is hard to imagine America being truly great as it becomes heavier, more hypertensive, more addicted to opiates and more damaged by diabetes and the ravages of industrial pollution. It is equally hard to imagine a great America with an underclass of hungry, homeless, and hopeless citizens who are marginalized by issues beyond their control. The social realities that are so foundational to poor health also lower the productivity of our workforce and add expenses to our cost of doing business that diminish our ability to be competitive at home and abroad. A good workforce in the age of computers and globalization needs to be educated and have good housing.

I hope that Senator Alexander reads Dr. Gabow letter closely. Perhaps one of his staffers will open it and bring it to his attention. I hope that if he and his colleagues can’t see their way to improving access to care as the right thing to do based on their concern for the human impact of 50 million American not having care in 2026, that perhaps they can understand the business imperative of having a healthier workforce and a more efficient delivery system that consumes less of the GDP so that they can fund the tax cuts they desire and have the capital to continue to pursue the dream of further privatizing the infrastructure and resources of the country. That hope may sound like veiled disrespect but it is not. It is a realistic recognition that motivation for any activity for everyone but a few saints requires answering a couple of questions positively: What’s in it for me? How will it change my world? The status quo does not usually change as a pure act of selflessness without some compelling expression of benefit to everyone.

Nixon dropped his concerns about Communism, or at least held them in check, when he decided it was good for business to open relations with China. Why can’t all of our senators come together and agree we need to help America be healthy, if we are to remain great or, if you prefer, become great again. I sometimes try to make the joke that if our conservative brethren with libertarian leanings achieved the vision of the pure libertarian ideal most of us would be living down a dirt road in a house we built with our own hands, eating what we could grow or shoot ourselves, and fending off marauders who were out to take what we have. It is ironic that that picture is not far from the one Professor Hochschild describes finding in Louisiana. Is that not the dystopian view of the future that is so popular in many Hollywood films?

In his book, The Road, Cormac McCarthy paints a pretty ugly picture of a post-apocalyptic world. We never learn what happened to get to such a world, but it also does not seem to be so far away. In my imagination it is a destination that is achieved one step at a time down a road paved with disrespect and social division. Healthcare is not our only shared problem. Universal coverage will be expensive and we need more change than having universal access to care if we are going to protect the hopes we have for our children, the country and the world, but it is an issue that faces us now, and Patty Gabow has laid out some good reasons for action. I hope that your action will be to follow her example and write somebody a letter.

It Is Hot In South Florida in June, but I Am Here to Celebrate

Tuesday night I was shivering by the fire in my living room in New Hampshire while listening to waves of heavy, cold rain pound my windows. Wednesday evening I was in Coconut Grove and the temp was in the mid 80s at 10 PM. As you can see from the header, the bougainvillea that graces the entrance to my son’s home is gorgeous. I am here to watch my granddaughter in the ceremony where she and her classmates “move up” from middle school to the high school.

Wherever you are this weekend I hope that the weather will be conducive to some sweat producing exercise. I am pretty sure that my son will see to it that I get some good workouts. Let me suggest that while you are busy maintaining your health that you give some thought to just how you want to express your concerns to Senator Alexander and his colleagues on the HELP Committee and the Finance Committee. Something will happen. I hate regrets. Let’s work for something that is not a loss but is an improvement we can all embrace.

Be well, take care of yourself, 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