8 December 2017

Dear Interested Readers,


The House and Senate Tax Bills Will Hurt The Most Vulnerable Among Us

I am an avid reader of the “fake news” feeds from the New York Times and the Washington Post. I like both their factual coverage of the news as it evolves, and I like the the spectrum of analysis of the writers of their opinion pieces. Even though both papers are labeled as purveyors of “fake news” their opinion writers vary across the spectrum from responsible conservatives to less than radical liberals.

I like the concept that there is little practical difference from the far right and the far left. Speaking in generalities, both extremes don’t negotiate or make an effort to hear any voice other than their own. It seems that the far right and the far left both follow roads that end up in the same places: authoritarian rule and loss of personal liberty justified as necessary to protect the “good” that the state deems “is best.” In World War II we resisted fascism and the authoritarian rule of hyper nationalism coming from right leaning points of view. In the 72 years since WWII we have squared off against equally authoritarian forces that were real threats from the far left in the form of Russian and Chinese communism. These facts support my personal opinion that real progress occurs from the productive conversations between the proximate right and the proximate left.

My personal working definition of a liberal is someone who believes that government can pass laws and regulate businesses and services in such a way that improves the lives of all people. Liberals frequently see conservatives as personally greedy and willing to let an injustice persist especially if to correcting it would increase taxes or restrict the use of private property. Liberals like to think that they can legislate a better world.

My definition of the responsible conservative is someone who believes that government has a tendency to overreach and rarely comes up with programs that over the long run enable real improvement in the lives of real people. Most conservatives consider that many entitlements are paternalistic and undermine personal responsibility, and that the bureaucrats and regulators of social programs usurp power and focus on their continuing ability to thwart the energy of the business interests that have created the great progress that America has made in becoming the richest, most successful and diverse democracy in history.

Both sides of the middle can still come together around most natural disasters and immediate threats to national security. Where we can’t come together very often is over seeking solutions to chronic problems like environmental threats, social policy, tax policy, issues related to personal freedom like women’s rights in the workplace to respect and equal pay, reproductive rights, the definition of marriage, rights related to sexual preference, the general issues related to income inequality, immigration policy, persistent manifestations of racism, and healthcare as a right. Over the last forty years our ability to make bipartisan progress on any of these issues seems to have geometrically declined as we asymptotically approach zero.

What is remarkable is that conservative columnists like Jennifer Rubin in the Post and David Brooks in the Times join liberal columnists like Paul Krugman of the Times and E.J. Dionne of the Post in agreement on just how awful the House and Senate tax bills are. The question that exists in my mind is just how much worse the compromise bill coming out of conference between the two chambers will be. I am hoping that it will be so awful that a few Republican senators will balk at voting for it. I know that it is a long shot, but preserving the framework of the ACA was an unexpected victory. Maybe the lower middle class and the working poor will get a national gift for the holidays. Maybe those who are elderly, the children of the poor, the disabled, all of our citizens who are unable to work for some justifiable reason, or all of our citizens who are among the millions who work hard, often at several jobs, but still can’t earn a living wage will get a break.

If something like the current bills does pass, the prediction of centrist conservative and liberal columnists alike is that it won’t be long until the deficits that the tax law engenders will have Republican “deficit hawks” upset. Even though their votes created over a trillion dollars of new deficits they will demand cuts in entitlement programs, supports for education, Medicare, Medicaid, basically the whole smorgasbord of supports for the poor. As I have implied before, perhaps that was the plan all along. Whatever the plan, servicing and diminishing the needs of the underserved, and improving the possibility of a better life for all of them remains a hope without a workable plan.

It’s interesting to note that there are similarities in the opinions of two very popular young thinkers and writers about how government should approach the problems of the poor. Many of those problems are powerful influences in the “social determinants” of health. I had no problem understanding the story of J.D. Vance in his powerful memoir published in 2016, Hillbilly Elegy: A Memoir of a Family and Culture in Crisis. If you are one of what seems to be a shrinking minority that has not read the book, click on the title and read the New York Times book review that came out when it was published in 2016. Vance is a conservative who did not vote for Trump but is very critical of the social services created by liberals that failed him and protracted the misery of his family. In an address to the right leaning Heritage Foundation last July, he was even more straightforward with his criticisms of the lack of effectiveness of the welfare programs of the liberal left that failed him as a child. Despite his criticism he was not calling for programs for the poor to be discontinued. He was asking for them to be made more effective. The article summed up his main points.

His request reminded me of Dr. Ebert’s observation that the solution to the problems of healthcare were not more money, more personal, and more facilities, but rather a better operating system and finance mechanism.

I doubt that J.D. Vance or Ta-Nehisi Coates would think that they have much in common, but they do. Coates had more opportunity as a child than Vance despite his race, but he speaks for millions of black Americans who suffered just as Vance did from parents and social programs that have failed them. They speak for young people, black and white, who grew up in foster care and attended inadequate schools because of their parent’s crimes and drug dependencies. Both of them find it easy to point out the failure of programs created by liberals who meant well but did not solve the problems, and often made them worse.

In his recent book, We Were Eight Years In Power: An American Tragedy Ta-Nehisi Coates slams the idea that laziness, defects in personal morality, and intellectual inferiority explain the current plight of poor black Americans. Like Vance he hopes that things will get better in time, but is no Pollyanna and goes so far as to say there may be no hope. He talks about white supremacy as the root cause problem, but then he connects that reality to many of the same issues and deficiencies that concern Vance. One area where Vance and Coates are very similar is that what they write makes many people uncomfortable, a few feel guilty, and some very angry. Coates writes:

IN ALL OF AMERICAN LIFE, THERE IS A BIAS TOWARD THE HAPPY ending, towards the notion that human resilience and intellect will be a match for any problem. This holds especially true for the problem of white supremacy. For white people who have not quite taken on the full load of ancestral debt but can sense its weight, there is a longing for some magic that might make the burden of slavery and all that followed magically vanish. For blacks born under the burden, there is a need to believe that a better day is on the horizon, that their lives, their children’s lives, and their grandchildren‘s lives are not forever condemned to carry that weight, which white people can only but sense...

Coates goes on from there to catalog the racial inequity in all of the federal programs that were passed to ameliorate poverty, like Social Security which Roosevelt was able to pass after mollifying racist Southern Senators by excluding farm workers who in the South were predominately black. Later programs of federal housing support like FHA guaranteed loans were manipulated to undermine opportunities for blacks to obtain mortgages. These practices persisted in many places into the recent decades, despite the passage of the Fair Housing Act of 1968. The efforts of liberal reformers like sociologist and former Senator Daniel Patrick Moynihan and conservative politicians like Richard Nixon (for whom Moynihan worked) were so focused on crime prevention and the war against drugs that they created programs that fostered even more poverty, even as crime rates fell. The list of liberal politicians Coates generates that fostered policies that deepened the injury to black Americans includes such darlings of the left as Bill Clinton, Joe Biden, and Mario Cuomo, the liberal governor of New York who was so focused on incarcerating criminals, the large majority of which were black, that he diverted funds appropriated for public housing to build more prisons. These are disappointing revelations and show how deeply connected are our stereotypical images of black Americans to the reality of persistent poverty.

A black man with a high school education competes equally in the job market with a white man with a criminal record and no high school diploma. Many middle class black families still live in neighborhoods that are suffering the issues of widespread poverty because of persistent racial exclusion through subtle exercise of discrimination in more desirable real estate markets. In many communities the integration of public schools resulted in a movement of white students to private schools and then declining financial support of the public schools. This has been particularly true in the states of the old South. It is interesting to note that Rush Limbaugh criticized the ACA as a program that was another entitlement designed to favor black Americans, and that the majority of the states that have refused to allow the Medicaid expansion are states of the old Confederacy where large numbers of the working poor are black. One fact that Coates presents that I find particularly concerning is that the overwhelming majority of children who have suffered the ravages of lead poisoning are black children living in inner city black neighborhoods.

Coates effectively destroys a position that I have held for decades which is that poverty is largely an economic issue and that we can fix it with better social programs that will bypass racism and make the issue moot. This is where he comes closest to echoing or singing in harmony with Vance. His argument is that slavery plus the “second more subtle slavery" of the last one hundred and fifty plus years has left black Americans disproportionately disadvantaged compared to white Americans in poverty. Both groups have suffered from automation and the exportation of jobs, but the impact has been greater in the black community and the road to recovery is steeper. I am not sure if Vance would agree with this assertion. I am not sure if there is benefit in deciding who has suffered the most. At the time he was assassinated, Dr. Martin Luther King, Jr was trying to join the struggles of all the poor, white and black. His Poor People’s March was meant to be a visual argument of the similarities, not the differences, of poor people of all races.

I see the common reality that Dr. King saw for the poor who are dependent for stability on an impossibly difficult to mange set of politically structured programs. At best these programs provide a little respite in momentary misery and create a way out of poverty for a depressingly small number of people. Now with the looming threats of the impact of “tax reform,” the bandaids to poverty that we now offer may well be removed allowing us to see the full extent of the never healing lesion that we have allowed to persist while we make sure that all of Donald Trump’s, Paul Ryan’s, and Mitch McConnell’s donors get what they paid for.

There is perhaps no greater lie ever attempted in politics than the one so many Republican members of Congress have been telling as they argue that this is a “jobs bill.” It is a deficit creating bill that many responsible people believe will be followed by an attack on the programs that provide precious little relief to those who suffer from the lie that a “rising tide will float all boats.” I am sorry. The problems are too chronic, the status too bleak, the number who suffer too many, to take any more chances with policies built on lies, or if you wish to be more charitable, fuzzy thinking. Both sides share the blame for the current state. I do not know how we come together to envision the “happy ending” for which Coates says we all have a “bias.” I do not think politicians can deliver a workable solution any time soon because they they have forgotten how to work together. The first step is to make sure it doesn’t get worse. I am praying for the very small miracle of about three Republican senators who might have the courage to vote against this manifestly awful bill. Short of that the incompetence of this governing majority, or the midterm elections of 2018 are my “fallback” hopes.


Will You Be Prepared For The Day After Trump's Attack on the Triple Aim Ends?

What will be left when the storm is over? It’s the sort of question you might have asked yourself if you were living in Puerto Rico on September 20 when Maria hit. I ask it of myself on a regular basis when I think of Donald Trump’s attack on healthcare, the environment, the State Department, energy policy, immigration policy, and most of the social services that so many Americans depend upon as they struggle to get through each day and not lose too much ground to what have been their hopes for a little better life.

I have a great deal of sympathy for those who voted for him with a misplaced trust in his seductive promise to “Make America Great Again.” It surprises me a little that I harbor next to no ill will for those who voted for him because of his promises. I’ve spent a lot of money on products that falsely promised to make me run faster, be smarter, be more relaxed, catch more fish, have better hair, play music with more skill, speak Spanish easily, and have more fun if I would just make a purchase.

There is no doubt in my mind that the storm will pass. What is less clear is what will be left when we wake up someday to discover that despite all of the evangelical Christians willing to vote for a pedophile, or look the other way and vote for a candidate who brags that he is so popular that he could shoot people and not be arrested, and by the way can’t commit a crime as long as he is in office, it will end. Gun owners will probably still be entitled to “open carry” in an amazing number of states, but someday all the losses will end, and if we are lucky there will be a rainbow of civility.

Some years ago I noticed that efforts to improve healthcare in this country occurred in herky-jerky cycles of ten to twenty years. Between 1965 and 2010 most of the efforts failed, although there were a few minor victories like the CHIP program passed in 1997 after the Clinton health initiative in 1993-94 was killed by Harry and Louise. Medicare and Medicaid passed in 1965 about 20 years after Harry Truman’s ideas for healthcare with a single payer died shortly after world War II ended. The Hill-Burton Act was the consolation prize that Truman won. It was a creative piece of legislation that was flawed in its implementation by many states, but it built a little hospital in thousands of towns across America about the time we started building Interstate highways. Hill-Burton was a little step forward between big events that most people have forgotten. There is a good chance that you, Dear Interested Reader, were either born in a hospital built with HIll-Burton funds or had your tonsils removed in one.

My point is that it’s been a step forward or two followed by a step back for a little while for a long time, but over the last seventy years we have made some progress. I’m certain that Trump will earn a position in history some place way behind Richard Nixon and eventually Paul Ryan and Mitch McConnell will become demonstration projects for how not to legislate, or will be totally forgotten and we will return to making progress toward the Triple Aim.

Where you will begin your part of the recovery when the storm passes will be a function of what you did to weather the storm. Here are some tips. Plan to never have the financial resources after the storm that you have enjoyed up till now. Those resources were not sustainable under any administration. Do not be fooled into thinking that just because the “mandate” goes away and Trump’s executive orders will allow “association” policies that don’t conform to the ACA, that fee for service payment has a future, or that planning on a new bed tower with flat screen televisions in private rooms will guarantee an increasing volume of fee for service “hips, knees, and hearts” to protect your margin forever. Trump and company, if they stay in power, will give Medicare and Medicaid a haircut and those revenues are 60% plus or minus a few points of the total revenue in most systems. Commercial payers don’t like FFS either. It ends with or without Trump.

The competition among payers with or without a Trump defeat will be around price and eventually even Partners Healthcare will need to live with less. If you have not started to look at your costs rather than your price you will have more than a cleanup to do after the storm passes. By the way, if your plan is to lower your cost by laying off a lot of employees and ending some of your service lines, you will be walking on your knees. As much as you may hate the idea of managing by process, that is by using continuous improvement science like Lean, attempting to cut your way to success will only aggravate your best employees and disappoint the customers who might have been loyal to you. If you have not started yet, you may have a year or so to get ready.

The ACA survives because with all of its flaws it is the best idea unless we want to go to a single payer. The big problem now, and always, has been the individual market. Someday after trying all the wrong approaches we will go back to community rating and incorporate both of the arms of the individual market in the overall process of creating a competitive market. We will eventually have an adequate penalty for the mandate, or we will grant universal coverage to everyone either by a single payer program or by the development of a public option for the individual market.

It is interesting to note that some experts say that there is no example of a program of social legislation like the ACA being reversed unless you include the end of Reconstruction in the 1870s. It is true that “it has never been this late before” and things that haven’t happened can happen, but given the public support that was demonstrated for the ACA, the core principles still have a good chance to survive in a damaged state that is repairable. The principles of the ACA drive us toward the delivery of care based on concepts of population medicine. If you are still building your budget on expected surgeries and admissions and have not planned to conceptualize your future activities in terms of identifying the populations that you serve, Donald Trump is the least of your problems.

Commercial insurers keep their mouths shut, but they are not going to pay for more and more services when they can use the market and their resources to lower your prices and introduce you to risk. What do you think the sale of Aetna to CVS means, or what UnitedHealth is up to when they buy practices like DeVita’s medical groups? While you are figuring it out, they are preparing to eat your lunch. CVS has 9700 locations in 49 states, the District of Columbia and Puerto Rico. If you are a PCP, try to imagine the impact they will have on your FFS revenue from primary care and chronic disease management. By the way, CVS is on Epic. Why do you think they made that investment?

If I were still in practice I would be less worried about Donald Trump and the day after his departure than how I might develop a strategy to be more appealing to my patients than CVS will be. For starters I would be looking at their experience of scheduling an appointment and the experience they had through the entirety of an episode of care. I would be more concerned about the cost of their care to them than I was about the reimbursement that I got at their expense for things that added no value to their management.

Yes, the storm will end. When it does there will be no distractions from our responsibilities and no place for us to hide if we are not ready. The future of your practice will be a function of your preparation for what you could have seen coming for a long time before Donald Trump and Congressional Republicans became a distraction. I fear that there will be many who will be like deer in the headlights, frozen in place until the inevitable reality hits them that things that are unsustainable don’t go on forever and are followed by new organizing principles. Are you ready for the day the distractions end?


A Steep Climb In A Winter Wonderland

I call my side of New Hampshire, the quiet side. That’s because only discerning tourists and those on their way to Vermont come this way, up I-89. The largest tourist attractions are “up 93” If you are a skier that’s the way to Waterville Valley, Loon, Cannon, Wildcat, and Bretton Woods. I-93 gets you most of the way to Mount Washington and it passes right through Franconia Notch which I consider to be the closest thing the East Coast has to rival Yosemite.

On Wednesday I set out with three other old guys (ages 63 to 74) on the short but steep climb of over thousand feet from the floor of the Notch to the Appalachian Mountain Club Hut on Lonesome Lake, the beautiful puddle left by a glacier on the backside of Cannon Mountain. The trail is quite steep and is a challenge when covered with ice capped with a thin coating of snow. The trip down made you feel like you were one step away from the waiting room of an orthopedic surgeon. In winter the “Hut” offers no heat or lights after 8:30 PM and not much before. Forget a shower. You bring your own bedding, food, and entertainment. What you have, you carry in, and what is waste or leftover you carry out.

The header today is a shot of Mount Lafayette, one of the over 5,000 footers in New Hampshire taken across the frozen lake near the end of day. If the picture looks cold, it was.

What I enjoyed most was being “unplugged” for thirty six hours. Not only was my cellphone useless, but my iWatch ran out of juice and time became a matter of daylight. I am ready for the next hike. You don’t need to go to Franconia Notch to have a nice walk and lose track of time. I hope that whatever the weather, you will lose yourself on a walk this weekend.