Modest Expectations – Arthur Phillip

This is my 88th blog. I have not missed a week – and the sequential naming of the Modest Expectations to reflect that number in some way. 1988 – the Bicentenary of this Nation was quite a year. I received funding from the Commonwealth Department of Health to write a book where I asked a number of health professionals how and why they were there in Australia in 1988, at the time of the Bicentenary. It was called “Portraits in Australian Health” – not a particularly riveting title.

However, what I wanted to see in their recounting of their lives was why at that point of Australia’s history, they were where they were. The backdrop to each of the lives of those interviewed was Australia.

This idea was expanded by the BBC in 2004 where they identified celebrities and took them through their genealogical paces with a predictable chorus of “gosh” and “unbelievable” and “who would know?” as each of the atavistic eggs was unscrambled. All beautifully orchestrated.  By and large the people chosen were performers, who could act the part of the stunned inheritors of their family helix.

I suspect that the budget for these TV shows is generous, because it showed that people are curious about other people. “Celebrity” gossip is the fare of the magazines which concentrate on a vague representation of the truth. The BBC, as did I, actually did research!

My concept was relatively simple: sit the person down and let him or her talk. Some I had known before; others only by reputation and I tried to achieve some sort of balance. A few I regret using; others were incredibly important in tracing the path of the reason for their being health professionals and providing “a tapestry” for the 200 years.

However, in retrospect there were at least two major omissions in people from certain categories. There is no dentist in the book; the person I had singled out, because of his long family association with the profession declined to be interviewed; he died not so long after of cancer. That was the only rejection that I remember.

The other omission which, if I could I would rectify, was an Aboriginal person with a health background. On reflection, I should have asked Naomi Mayers, who was the Chief Executive Officer of the Redfern Aboriginal Service. Much later I had lunch with her and a number of Aboriginal people in Redfern and even then I had no inkling of her link to the Aboriginal singing group, the Sapphires. But I didn’t identify her and I regret it.

However, as I found as I met more and more Aboriginals, there was a rich cultural heritage, much of which was hidden from whitefellas. I have always been sceptical of the historical importance of bush tucker, which has acquired a following among well-heeled whitefellas. Much of the tucker available would hardly merit a feed, so tiny are the individual berry, fruit and the other flavouring agents.

However, what I have found very interesting and have met on various occasions were ngangkeri, the medicine men. When I was often visiting Wilcannia in the early 90s, I heard about the kadaitcha men who were still around. However, that was all, and after all “the feathered foot” left no trace; so how would a whitefella find out more. It was all intriguing and the more I was accepted the less I knew.

The Aboriginal society is “many nations” – after all, look at the difference in the culture across the nation. The problem is that in the confected restoration of Aboriginal culture, the diverse nature of the culture has been increasingly homogenised. That cannot be criticised as it recognises that the Aboriginal culture is not static; and given the improvement in communication and educational opportunities it is unsurprising that the Aboriginal is becoming less and less regionally distinctive. Having said this there will always be nests of such traditional culture.

The conundrum for such communities is how to preserve culture against the predatory nature of a culture of booze, fast foods , “black milk” and all the churning of this faddish instant googled-eyed Facebook age – yet not denying progress.

It would be a challenge now to find the Aboriginal health professional who would fit easily into a portrait of Australian health. In 1988, it was only four years since the first Aboriginal doctor graduated.

Charlie Perkins

Charlie Perkins

I was thinking about the first time I met Charlie. It was obviously in 1973, and up until that time, all I had heard about him was that he participated in the Freedom Ride to confront rural NSW concerning Aboriginal rights. To the urban Australian living in comfortable suburbia, Aboriginals were invisible.

As I child I remember receiving Church Missionary Society pamphlets about all those nice little Aboriginal children running around in Roper River Mission – so happy to be one of God’s lambkins. It was all so foreign, and the first time I saw real, live Aboriginal children was years later when I went with my parents to Central Australia. Part of the tour was a visit to the then Lutheran Hermannsberg Mission. We white children eyed off the Aboriginal children, who did likewise and giggled at this awkward bunch of kids from down south.  Nobody encouraged us to mix and eventually we got back on the bus and left. There were also the blackfella children in the settlements along the old Ghan route which then wound through the floodplain country and terminated in Alice Springs.

I remember I insisted in Alice Springs that my parents buy me a black ten-gallon stockman’s hat, and even though I have a large “scone”, the hat came down over my ears. My other purchase caused all sorts of bother, and when it was brought home it had its own “cordon sanitaire” because the ochre covering this large bowl was very thick and had never been fixed, so if you touched it, the ochre always stained your hands. Eventually the bowl disappeared from the house – as did the hat.

Hermannsberg Mission

However, there were several episodes of the ABC lunchtime serial “Blue Hills”, which have remained with me. These concerned a storyline where Aboriginal Heritage would lead to “a throwback” situation which meant that apparently white parents with Aboriginal blood could be confronted with a “piccaninny” child. Then, as the serial progressed, what relief – Aboriginal heritage was diluted – absorbed – assimilated – and joy of joy – no return to the noble savage. Well, that was the gist of the serial story and reflected the attitude of Australian suburbia superficially encased by a white picket fence of normality.

There were three films that I remember in my early childhood leading into teenage years. All had a variable effect on the development of my attitudes towards Aboriginal people. After all, I grew up in a world dismissive of our landlords. The 1947 film Bush Christmas starred a 12 year old Aboriginal boy from Woorabinda in Queensland, Neza Saunders, who showed how to eat a witchetty grub. At that moment, I wanted one to eat. A gourmet meal of witchetty grubs sadly still remains on my to do list.

The film Pinky explored the plight of the light-coloured black American in a 1949 film of the same name. I remember in the context of a society which, despite the pious comments of my schoolteacher, remained at its base racist. We, as children because we grew up in a homogeneous culture, did not have the basic experience to question. However, for me, it instilled in me a sense of unease, the word “miscegenation” still unknown to me.

This unease was reinforced by Jedda, a film where the central tragedy of the Aboriginal was played out in Charles Chauvel melodrama. Jedda was such a beautiful young image for myself, a teenage boy. Years later I went to Utopia, an Alyawarre settlement on the Andover Highway. As an Alyawarre woman, she had grown up there and later had a troubled relationship with the community.  I did speak to her on the telephone but she was away when I stayed in Utopia.

It was still a long time from Jedda before I was to run across Charlie Perkins. I do not know why but we had an immediate empathy. One problem I had noted was that Aboriginal reticence meant that you had to learn to speak through the silences. As one of my Aboriginal brothers would say, the non-verbal conversations with the various vocal clicks was difficult for whitefellas so used to voice communications. The other manifestation that was clear from a growing association with Aboriginal people was if a particular government meeting was thought irrelevant, the Aboriginal representative just did not turn up, but as the Aboriginals have come in from the fringe that dynamic changed. Aboriginal people can recognise tokenism.

In 1973 in Parliament House it was demonstrated very clearly that here was a nation wrestling with the Menzies’ legacy and in particular the engagement in Vietnam. Whitlam terminated Australian involvement, and both he and the Leader of the Opposition, Bill Snedden visited China that year. Snedden was privately concerned with the lack of involvement with Aboriginal People, since even though the 1967 referendum was an overwhelming affirmation of Aboriginal rights that was not easily translated into a workable outcome for our society.

Aboriginal tent embassy

Charlie Perkins, when he was young, had this busy enthusiasm about him. Snedden suggested that I might try and talk to him. The easiest way to talk to him was around the campfire which the Aboriginals had started outside Parliament House. We got on well from the start and spent a lot of time yarning around the fire. To me it was symbolic of establishing an understanding, and Charlie was appreciative that somebody from the Opposition had bothered to brave the fireside. It did not take long for the message to come back from one of the Nats who had seen me with Charlie around the fire saying: “Who’s that Communist working for Snedden?” The other occasion that I well remember was walking with Charlie across King’s Hall one evening, when Mick Young with Eric Walsh came up and said to Charlie without acknowledging me, “You coming to dinner, Charlie?” Charlie shot back, “No, I’m going to have a meal with Jack Best.” These are in the order of things inconsequential. Both Charlie and I wanted a better world and we threw out ideas, most of which drifted off in the camp fire smoke.

So did we, drifted away from one another. Much later when I met him when he was a senior public servant, he seemed to have lost much of this zest for life, but then that happens when you become a fully-fledged bureaucrat.

However, he was also fighting renal failure.

I read Pat Turner’s Charlie Perkins Oration this year, and even though I am not sure I agree with everything she said, she was right in saying that Charlie – the Charlie I knew – never backed down. Yet he showed a willingness to engage in all sides of politics. Later I was to have quite a bit to do with Congress, the Aboriginal Health Service which grew out his early activity in Alice Springs. It is a pity Charlie died while still a relatively young man, succumbing to one of the sequelae of that most deadly infections to Aboriginal people – the streptococcal bacteria.

Conquering that scourge of Aboriginal people still remains. It is not the only one.

Charlie to my mind was the first person who taught me the etiquette of equality of the whitefella in the eyes of the Aboriginal person.  I never attained the level that we could have called each other “brother”, but he enriched my life. Aboriginals were not a cute fringe eating witchety grubs, playing in mission dirt or conforming to a stereotype imposed on them.

Thanks, Charlie for being around when you were – brief as it was. However, you opened up a new perspective for me, and in so doing enriched my life in so many ways.

John Kitzhaber Concludes – A New Model for the Nation

Dr John Kitzhaber

A financially sustainable system designed for value and health can take many forms, but it must include five core elements:

  1. Universal coverage;
  2. Defined benefits;
  3. Assumption of risk by providers and accountability for quality and outcomes;
  4. Capped total cost of care through a global budget indexed to a sustainable growth rate; and
  5. Cost prevention by addressing the social determinants of health.

Here is one example. Starting with our current public-private financing structure, modify the three large insurance pools that currently define the US healthcare system.

  • Pool 1: To achieve universal coverage (element 1), restore the ACA individual mandate but ensure that people have affordable health plans in which to enrol. Expand Medicaid eligibility to include the 28 million people who are currently uninsured or create a new, affordable, publicly subsidized option to offer them. At the same time, move Pool 1 to a CCO-like capitated model that encompasses elements 2 through 5. If coverage in the individual market is unaffordable, those below a certain income level (e.g. 450 percent of the federal poverty level) could buy into Pool 1 with income-based cost sharing, which would make universal coverage more feasible. This is particularly important today as millions of people are losing their employment-based coverage and moving to Medicaid or the individual market.
  • Pool 2: Because Original Medicare is still paid through fee-for-service, the program must be moved to a capitated model. One approach would be to create incentives to enrol in a Medicare Advantage Plan (most of which are already capitated) and change the Medicare Advantage Plans that are still fee-for-service to capitated models that meet elements 2 through 4. Because reimbursement would now be based on managing cost and improving health, Medicare Advantage Plans would better incentivize providers to view their patients as a whole through, for example, nutrition counselling or working with social services for safe housing, thereby meeting element 5.
  • Pool 3: Allow the remaining markets—employer-sponsored medium and large group and self-insured markets—to operate as they do today, negotiating prices with health plans and using their market power to insist on capitated risk contracts with provider networks. The public sector price negotiations outlined below would provide a benchmark, giving employers additional leverage in negotiating prices in the commercial market. This advantage should be amplified by forming new partnerships with Unions

Continue the transformation by using the consolidated purchasing power of Pools 1 and 2 to negotiate one set of prices for both pools. This would include not only what providers are paid per beneficiary (risk-adjusted according to each beneficiary’s expected care needs) but also prescription drugs, medical devices, laboratory services, imaging, and all the other niche business models that have been established under the fee-for-service model to maximize revenue. This kind of price negotiation is what most large private employers (making up the majority of Pool 3) do today. Public payers should follow suit by using the consolidated purchasing power of the public sector—which is footing an ever-larger part of the bill—to get the best price and value for the United States of America community. If the public sector were so inclined, it would also be possible to both negotiate limits on individuals’ out-of-pocket expenses and ensure there are no caps on annual or lifetime benefits.

The result would be a new system of universal coverage built on our current public-private financing structure. With the majority of Americans in some form of capitated risk model, this new system (1) reduces the total cost of care through price negotiations, a global budget indexed to a sustainable growth rate, and provider accountability for quality outcomes; (2) preserves consumer choice and allows current insurers to compete for Pools 1 and 2 in a restructured market; and (3) delivers more and more value and health because it requires strategic, long-term, effective investments in the social determinants of health.

This is merely one way to design a new, health-focused, financially sustainable system. There are others. My objective here is not to advocate for the example I have just outlined here, but rather to spark a new debate that will lead to a better system. Instead of being constrained by what currently exists, we need to start with our objective, agree on essential elements, and then let the contours of the new system emerge. Long-term, this will serve us better than starting with a plan that may not meet the criteria needed to achieve our goal. For example, while both Medicare for All and a public option are ways to achieve universal coverage (element 1), neither directly addresses the total cost of care (elements 3 and 4) or focuses on increasing investment in the social determinants of health (element 5). Surely, we can imagine linking the total cost of medical care to a sustainable growth rate within the next few years. Then we can work backward to create a health system that meets the objectives of Democrats by expanding coverage and improving health and meets the objectives of Republicans by reducing the rate of medical inflation through fiscal discipline and responsibility.

COVID-19 and the Urgency of Now  

As the healthcare system has become ever more dependent on public debt, its financial underpinnings have become inexorably linked to the capacity of the government to borrow. That capacity has been suddenly and dramatically diminished by COVID-19 and by the business closures and high unemployment resulting from efforts to slow the spread of the coronavirus.

To prevent a complete collapse of the economy, there has been a massive federal intervention to keep credit flowing and to provide loan guarantees and direct payments to businesses and individuals. America will have to spend at least $5 trillion this year alone to sustain our economic infrastructure and to support its unemployed. This will leave us with an unprecedented budget deficit and a national debt approaching $28 trillion—with little or no capacity to absorb the 60 percent growth in health care spending that is projected by 2028 (from $3.7 to $6.2 trillion), especially when prices for medical goods and services are projected to account for 43 percent of that growth.

The pandemic is forcing us into an era of dramatic constraints on the public resources allocated to the healthcare system. Neither the government nor private-sector employers can afford the current system anymore, given the economic losses that both employers and individuals have experienced since February and the massive amount of public debt that has been accumulated just to hold our economy together. At the same time, those parts of the healthcare system that have been hit the hardest by COVID-19 are those most dependent on fee-for-service reimbursement, which exposes the basic flaw in a business model that depends on volume, regardless of the value of the services rendered.

This economic crisis means that, for the first time, the economic interests of workers, employers, the government, and many parts of the healthcare sector are aligned. The time to transform the system is now. We have crossed the Rubicon, and there is no going back. We can either watch our current system unravel, with millions more losing coverage and ever-widening income inequality, or we can work together to design a system that helps stabilize our economy and better serves the needs of the American people.

The Role of Unions

This is the moment for more states, facing huge general fund shortfalls, to move to a CCO-like care model for Medicaid, and for Congress, facing staggering debt, to create incentives for Medicare beneficiaries to enrol in a Medicare Advantage Plan and to move that program to a fully capitated model in which providers assume risk for quality and outcomes. Health professionals should be vocal advocates for both of these changes—and that advocacy should be backed up by the strength of the union movement to bring this model to the commercial market. This will require forging new alliances at the bargaining table between Unions and payers—both public and private.

Coverage of the cost of healthcare is, of course, part of the total compensation package, which means that in collective bargaining, wages are often pitted against health benefits. For public employees, general fund appropriations for healthcare compete not only with general funds for wages but also for essentials like increasing nurse staffing ratios, reducing class sizes, and investing in housing and other social determinants of health. The traditional goal in bargaining over healthcare is to reduce, to the greatest extent possible, out-of-pocket costs for Union members (which is very important).

The problem is that focusing only on this aspect of the total compensation package—without questioning the cost structure, quality, or efficiency of the care being purchased—suppresses wage growth. Without aggressively challenging the cost structure and value of the healthcare being purchased, the dollars spent on rising premiums flow into a system that redistributes them upward, taking money from the pockets of working Americans to enrich the profits of large corporations and wealthy individuals (further exacerbating income inequality).

A CCO-like model would be better because it caps the total cost of care without sacrificing quality and it realizes savings to invest in the social determinants of health—including wages. Particularly for workers making minimum wage or close to it, income is a primary driver of health.

Employees and employers have a shared economic interest in reducing the rate of medical inflation and in focusing on value and health. Providers, for the first time, now have an economic interest in changing the payment model from fee-for-service to capitated because this is the only way they can survive in an era that no longer can sustain debt financing. From the standpoint of the Labour movement, CCO-like models could result in increased wages, better staffing ratios, and more funding for education and other services that are critical to making our society more just.

This need for greater social investment must  emphasized. Reducing the total cost of care will assist all working Americans (not just those with union representation) because it will make not only their wages go further but also relieve them of the anxiety of not knowing whether the next illness will push them into bankruptcy. And it will give us, at last, the ability to address the conditions of injustice that underlie disease.

Let’s Begin Now!

Creating a new system with the five core elements will take time. But there is much we must do quickly. Because the economic consequences of the pandemic—particularly the increase in unemployment, with its associated loss of workplace-based coverage—are driving us toward Pool 1 (Medicaid, the uninsured, and the ACA marketplace), this is the logical place to start.

The most urgent coverage problem is for those who are not offered or have lost workplace-based coverage and whose income is too high for Medicaid (above 138 percent of the federal poverty level) but too low to afford the individual market. These struggling individuals are joined by a growing number of underinsured Americans who are technically covered by employer-sponsored plans but face copayments and deductibles so high that for all practical purposes they are uninsured. People of color—particularly Black, Hispanic, and Native American people—make up disproportionate numbers of both of these groups.

The state of Oregon offers an illustration of both the problem and the opportunity. By the end of April, 266,600 Oregonians had lost their jobs (an unemployment rate of 14.2 percent). An estimated 215,800 of these people will be eligible for Medicaid, 20,500 will move to the ACA exchanges, and 30,300 will remain uninsured.20 Because Medicaid is entirely financed with public resources and the ACA exchanges are heavily subsidized with public dollars, this amounts to a dramatic increase in public sector financing of healthcare. In terms of the healthcare model proposed in this essay, Oregon’s Pool 1 is expected to increase from 34.9 percent to 41.3 percent of the state’s population over a few months.

Furthermore, if 80 percent of those who lack health coverage in Oregon made use of coverage for which they are currently eligible—Medicaid or the subsidies available through the ACA marketplace—the number of Oregonians who are uninsured would drop from almost 250,000 to 34,000 (from 6.2 percent to < 1 percent). The only obstacle is the total cost of care.

Since states are facing enormous budget deficits and the federal government is facing a looming debt crisis, it is imperative that shifts toward public financing be accompanied by effective mechanisms to reduce the total cost of care through global budgets (indexed to a sustainable growth rate, with providers at risk for quality and outcomes). At the same time, such global budgets are now more appealing to many hospitals and primary care practices because of the sharp loss of revenue among those with fee-for-service models.

Mouse Whisper

I know we were all keen on Amy Klobucher, when she seemed to be the most articulate candidate back in those days when the Democratic race was like the first at Rosehill. She dropped out, and although considered as Biden’s running mate, she missed out here also to Kamala Harris.

However, the most final reason for her not getting the nod was:

She’s from Minnesota!

In explanation, no Minnesotan has ever made President, and such a judgement tends to stick once voiced. At least Barcelona is not in Minnesota.

Modest Expectations – Derby Day in Walla Walla

State Capital West Virginia

It was late in the day some years ago and we had just driven past the capital of West Virginia, Charleston. The golden capital strikingly stood above the low-level smog which was layered over the city itself. Here we were in the Alleghenies, a 640 kms portion of the Appalachia, a rich source of coal. Here pitched battles were once fought between the miners and the mine owners – called the coal wars. The reason lay in the fact that during this period more miners were killed here in accidents than were lost by the US armed forces in World War 1.

West Virginia had been carved from Virginia in 1863 during the American Civil War, partially because the West Virginians did not follow most of Virginia which seceded at the outbreak of the American Civil War. Yet the electoral base and its Democrat traditions lay in its workers, radical by American unionism standards, reinforced by the memories of the coal wars.

I wondered, as we approached the entrance to this property with its imposing edifice, whether it was a hotel where we could stay for the night. I drove in and the colonnaded entrance suggested that perhaps I had inadvertently driven into a private estate. However, I got out of the car, in jeans and all, and entered the building in all innocence to enquire what was this place.

The Greenbrier

The man behind the reception desk looked me up and down and said, “Sir, this is The Greenbrier.”

As I learnt very quickly, The Greenbrier was the place where Presidents stayed, and I found out there were references to them as far back as Polk and Tyler. I thought the car parking space for the resident golf professional at the time, Sam Snead, said it all. This was a comfortable Republican enclave in the heart of what was a poverty-stricken mining area. I remembered once, on a flight north in Australia, there was a dishevelled guy sitting next to me. We got talking, although I had difficulty understanding him; he turned out to be a miner going up to the coal mines in Queensland. He was from West Virginia, and his mumbled English was full of archaic constructions and words that meant nothing – it was a dialect probably based on 17th or 18th century English. In the end, in the light aircraft, the noise of the plane made it impossible to talk and we lapsed into silence.

But back to The Greenbrier. The Government had built a huge bunker at the hotel during the height of the Cold War, which had the capacity to house the whole of the Congress in the event of a nuclear attack. The facility had long been decommissioned by the time we had stayed. I believe I was punished for my disrespectful comment as the room assigned was so far from the main building that it almost collided with the fence and was well behind the bunker. Still, they allowed us into the dining room.

However, before that could occur, the reception desk clerk had said, “If you wish to dine in, sir, you will need a jacket.”

“No worries.” I had a jacket – a blazer in fact.

A key was pushed towards me. The Greenbrier had welcomed us, after a fashion. Menofregismo as the Italians would say.

West Virginia has always been reliably Democrat, but now no more.  The three Congress members are all Republicans; only one of the two senators is a Democrat and over 50 per cent of the time he voted with or for Trump, even in the impeachment he was only one who crossed over from his Democrats for Trump.

From being reliably Democrat, now West Virginia is almost the most Republican State if judged by the vote for Trump here recently – all changed in a decade! Biden received less than 30 per cent.

The use of coal is rapidly dying, so it would be a useful exercise for the Biden Government to determine how to restructure the West Virginian economy to phase out coal. It is more difficult than just bribing the mine owners to provide the semblance of work by keeping uneconomic mines open. However, it probably would be just as cheap for the Government to bypass the owners and pay the miners a living wage disguised as a redundancy package or employ them to resuscitate the once pristine landscape mined over the past 150 years.

After all, the wealthy and influential were prepared to invest in an opulent playground here, including the Congress shelter bunker. Notwithstanding that it had been decommissioned well before we stayed, here was further evidence of the very essence of privilege in one of the poorest parts of the country.

The latter part of the last century and into this, first as governor and then as Senator, Jay Rockefeller, the great-grandson of John D Rockefeller, as a Democrat (unusual because the rest of the family were solidly Republican) won most of his elections by huge margins. There is little doubt that during his long association with West Virginia he and the coal industry were on very good terms – for most of the time. However, towards his retirement, he began to realise the impact of coal on climate. Two years before his retirement, in 2012, he made in the following statement:

Scare tactics are a cynical waste of time, money and worst of all coal miners’ hopes. But sadly, these coal operators have closed themselves off from any other opposing voices and few dared to speak out for change – even though it’s been staring them in the face for years.

This reminds me of the auto industry, which also resisted change for decades. Coal operators should learn from both the mistakes and recent success of the auto industry. I passionately believe coal miners deserve better than they are getting from operators and West Virginia certainly deserves better too. 

Here in Australia the problem is that fear has gripped Joel Fitzgibbon, not any constructive thought. His livelihood lounging on the plush red seats of Parliament House is threatened. Forget about climate, but then there are unions agitating for retention of coal mining, and the power of the unions depends on these miners coughing up subscriptions – but for what? As with the car industry, government subsidy for the uneconomic only ends up improving the bottom line of the big foreign-owned companies.

The slick Monsieur Perrottet wants to restore his stained escutcheon by expanding the coal industry in NSW to pay off a short-term debt and in so doing leaving an incalculable environmental debt for generations of Australians; the feathery Premier just keeps talking to see if she can break the world record for not taking a breath. There is some in government with a contrary idea of how to lessen the coal dependency, despite export prices for both coking and thermal coal are being maintained.

Yet there is fear of divesting away from coal. This has been aggravated by the electoral results in Queensland, and by the “near-death experience” of Fitzgibbon in his seat of Hunter. The other NSW coal seats did not seem to mirror the same extreme behaviour.

There is another problem, and that is the Fly-in-Fly-Out miners. This expanding cohort should not be confused in the arguments over the hearts and minds of the local coal miners.

As one local Mount Isa correspondent has written:

The issue of Fly In Fly Out did not get much of a look-in in the federal election, perhaps because it is mainly seen as a state issue.

FIFO is convenient for workers who want to live by the coast but still enjoy high-paid jobs in remote locations.

It is also convenient for companies who have better control over their staff and their movements whether it be on chartered flights, mining camps or buses.

But it is a terrible deal for places like Mount Isa and the towns of North West Queensland which get all of the downsides of a large mining operation on their doorstep but few of the benefits.

Yes I understand that airports, motels, pubs and clubs, and the like do well out of a transient workforce but other businesses not so well.

The wear and tear of mining operations on roads and other facilities is a cost borne by those communities. And only this morning did I hear a speaker at a MineX breakfast talk about the need for a local work force because without that “we have no social licence to operate”.

The Queensland government recognised the issue with the Strong and Sustainable Resource Communities Act introduced last year to ban 100% FIFO mining near towns like Mount Isa and Cloncurry.

However, companies can get around this simply by posting one staff member locally which meets the wording of the act but not the intent.”

Balmain coal miners

Great is it not; with one selfish self-centred politician intent on contaminating the narrative of moving away from coal.  A leader, if one can term Albanese that, should have called him out immediately.  Or do I do Mr Albanese a disservice. Maybe he really wants to see the Balmain coal mines re-opened in his electorate.  Fitzgibbon can’t have it all his own way. After all, my late neighbour used to tell me that, as a boy, he would go around the corner to the coal dump and bring coal home for the stove and the fire. It was said that Balmain was then quite a sooty turn to behold.

As a 40-year resident, I remember seeing the entrance to the mine.   After all, to that smooth genius, Monsieur Perrottet, reopening the mine shafts under the Harbour would bring lots of “coal hard cash” and so convenient – or not. And what a jape – reopening a coal mine in a Green electorate. Problem is that is where Perrottet and his fellow travellers want to scar Australia, the wildlife do not vote. However, in Balmain, I am assured that Monsieur would find a different form of wildlife – one that rumbles around the suburb in their Land Cruisers looking for anybody with a lump coal in their political pocket. After all, Monsieur wants to demolish the White Bay Power Station – perhaps a new location for an underground coal mine.

But I stray from my West Virginian narrative – at least I have a narrative.

While America looks away.

I was rummaging through my old magazines and I came across a copy of a Harper’s dated August 1999, in which there is an article where two journalists were assigned to report on Cyprus – flipping a coin to determine which of them travelled to the Turkish Republic of Northern Cyprus and the other to the Republic of Cyprus. As the lead-in to that article, it was stated; “Cyprus remains partitioned, a case study in how ethnic hatred perpetuates itself but perhaps also a manual on how peace can be sustained in places like Kosovo”.

It was nearly 20 years later that my friend and I walked across the Green Zone that separated the two sides of the divided Nicosia, the major city of Cyprus.

There is something strange walking across what is essentially the line where battle formally ended.  A few peacekeepers wearing blue berets are moving around inside the buildings and the only sound is a radio blaring out modern pop. There is nobody to block our crossing through the rubble strewn street, only a strange sense of abandonment, although you know eyes are watching you in the CCTV cameras slung along your pathway. Passing from one side to the other met with little interference from the Cypriot or Turkish side.

Once we were across then there was the question of transport. We did not have to wait long before a taxi pulled up and took us to Kyrenia, a seaside town on the Turkish side where we had a pleasant seafood lunch. The taxi driver said he would return, and he did, punctually. The only noticeable difference from one side to the other was the appearance of mosques; the cars still drive on the left, irrespective of which side of the green lines one drives.

Cyprus is the only place outside the British Isles and the Republic of Ireland in Europe where there is a remnant link to the previous British occupation – driving on the left hand side of the road.

In 1878 Cyprus entered the British Empire under rather unusual circumstances. The Ottoman Empire had just been at war with Russia and were very much in danger of losing control of their capital Constantinople. The British intervened in the crisis on the side of the Ottoman Turks by sending a fleet to intimidate the Russians. The Ottoman Sultan was so thankful for the British intervention that he granted the control of the island of Cyprus to Queen Victoria. This lasted until 1960 when independence was gained. Throughout the 1950s a Greek terrorist group EOKA, under a former Nazi collaborator George Grivas, exacted a price on British occupation, a killing spree of British soldiers and Turkish Cypriots in the main.

The British still retain armed forces bases there on territory that was ceded to the United Kingdom on independence. That means that slivers of Cyprus remain British soil.

While there was a myth abroad that the Turkish and Greek Cypriot relations had been harmonious before the invasion but after Independence, that was far from the truth. The Green Zone actually began a line drawn by the British in 1963 because of strife between the two.

By 1974, the treatment of the Turkish Cypriots was bad enough for Turkey to intervene, and it did not take that long for the Greek Cypriots to quickly sue for peace. This led to fragmented jurisdictions, separated by a UN peace force which have, since the ceasefire, patrolled the Green Zone that extends across the island, cutting through Nicosia as mentioned above.

There the line has remained intact despite regular exchange of obscenities, rock throwing, and the more serious “cocking and pointing”.

When the Harper’s article was written there was very limited access across the border. The two journalists met once, face to face, for coffee in Pyla, a small fishing village within the Green Zone.

There may have been calm when we visited, but there was residual bitterness. We were there at a time before Erdogan came on the scene with all his populist fury. However, he probably recognises what one Greek Cypriot soldier said when asked whether he would retaliate: “No,” he said smiling, “We are careful not to provoke them, because we are the weaker side.” 

Erdogan must know that and after the defeat of Armenia recently, he may be tempted to have a “go” at Cyprus.

Apart from the increased access across the Green Zone, since the 1999 Harper’s article was written, another phenomenon has occurred. It was first evident when I picked up the menu at the hotel in Limassol where we were staying. The menu was not only in Greek and English but also in Russian. The Russians have made a large investment in Cyprus – either with or without Putin’s collusion. Who would know the extent of each?

Now there is a cohort of Russians who have not only invested in property but also have bought Cyprus passports, a practice contrary to EU rules. Under pressure from the EU, Cyprus has now withdrawn that permission to buy into the Republic. Unlike Armenia, Cyprus is a member of the EU, but the Russian passports have not been cancelled.

However, would that matter given that America is now  distracted and if the Turkish Cypriot grievances are inflamed by Erdogan, how would the Republic respond? Seek Greek support? It was not there in 1974.   Would it be now?

The European Union?  Does the EU want to go to war with Turkey, a member of NATO? After all, it was NATO bombing of Serbian held positions and a USA-brokered peace which, in the 1990s, ended that perennial obsession of the Serbs to dominate the Balkans.

This is different political chemistry, and one without a strong America, with a lame-duck President with Russian connections still at the helm. Cyprus has inhospitable mountainous areas. Don’t we know it? We got lost in the wilds of Cyprus, and only worked our way out by pointing the car down the mountains, but at least there was a track to follow.

So military conquest of Cyprus is not just a case of rolling up to seaside resorts like Limassol and Paphos in Turkish tanks. The mountains are perfect for guerrilla warfare.

So-called Russian peacekeepers could already be there to help – and themselves – as they have done in Armenia. They might be there to welcome the invading Turks.

As for the sovereign British bases, maybe Boris would let the Russians have them. After all, he could say it is part of his Brexit plan. Hopefully no one would write, as Queen Mary did with “Calais”, that Cyprus will be written on his heart.

Nevertheless, it should not be ignored that the Russians doing the Trump

Presidency have built up a seasoned defence force, which has honed its skills in Syria and elsewhere. Why not Cyprus? Why not indeed!

John Kitzhaber continues his analysis of the US health system…

Dr John Kitzhaber

Public Resources

We need to understand the central role of public dollars in our healthcare system. Healthcare is the only economic sector that produces goods and services which none of its customers can afford. This system only works because the cost of medical care for individuals is heavily subsidized with public resources. This happens directly through public programs like Medicare and Medicaid. It also happens indirectly through the tax exclusion for employer-sponsored health insurance and through the public subsidies in the individual insurance market established through the Affordable Care Act (ACA).

As a result, about 90 percent of Americans depend on public subsidies to help them cover the cost of their care—all except the 28 million Americans who remain uninsured. These people are not eligible for a public subsidy themselves, but through their taxes they help subsidize the cost of healthcare for everyone else. This egregious situation reflects the systemic inequality that exists not only in our healthcare system but also across our whole society.

Thus, the central issue in the healthcare debate involves the allocation of public resources, which represent a kind of fiscal commons. They are shared resources raised from society as a whole—and they should be allocated in a way that benefits all of us, not just some of us.

The National Debt

We also need to recognize that our healthcare system is increasingly financed with debt. Why? Because public resources are finite and Congress is borrowing ever more money to pay for existing programs and services—including health care. This fact is reflected in the congressional budget deficit and in our national debt. The national debt is the accumulation of years of budget deficits and represents the amount of money that has been borrowed to cover the difference between congressional spending and the tax revenue available to pay for it. Since healthcare now accounts for over 28 percent of the federal budget not spent on interest—and is projected to grow to 33 percent by 2028—it has become a major driver of the national debt.

This means that as the population ages and the cost of care continues to rise, the economic viability of the healthcare system will increasingly depend on borrowing money—and on the capacity of the federal government to absorb more debt. If the capacity to borrow is constrained, the financial underpinnings of the healthcare system begin to unravel. Since COVID-19 has created exactly this constraint on borrowing, a healthcare financing crisis that was on the horizon is now at our door.

Income Inequality

Furthermore, a growing share of the money borrowed to prop up our medical system is not being used to expand coverage. Instead, it is enriching the profits of large corporations and wealthy individuals. Let me be very clear: our current healthcare system is increasing income inequality through a process called rent seeking. This occurs when powerful stakeholders manipulate public policy to increase their own wealth without the creation of new wealth (i.e. they take more of the pie without making the pie bigger). For example, when the pharmaceutical industry convinced Congress to prohibit the government from negotiating drug prices for the 60 million Americans on Medicare, it distorted the market by putting the power in the sellers’ hands to set whatever prices they wish. After many news stories about “big pharma”, more people have become aware of concerns with drug prices. What seems to be less well known is just how profitable medical insurance is: in 2019, the seven largest for-profit insurers had combined revenue of over $900 billion and profits of $35.6 billion, a 66 percent increase over 2018.The result of the rent seeking that is evident throughout the health care industry is lower disposable income for the individuals who have to pay those inflated prices, increased profits for the companies, and wider income inequality.

Health versus Health Care

Finally, we need to recognize that the goal of the healthcare system should be to keep people healthy, not just to finance medical care. In other words, it needs to address the social determinants of health—access to healthy food and clean water, safe housing, a reliable living wage, family and community stability, and more—which have a far greater impact than medical care on the health of both individuals and communities. Yet the ever-increasing cost of care compromises our ability to invest in these things.

Today, healthcare providers and the system have different goals. While most care providers are trying to enhance people’s health, they nevertheless work in a system where the incentives are to increase profits and redistribute more wealth to the wealthy.

Confronting the Total Cost of Care

Improving health requires a financially sustainable system that ensures that all Americans have timely access to effective medical care

and

that makes long-term investments in the social determinants of health. To achieve these dual goals requires five core elements:

  1. Universal coverage;
  2. A defined set of benefits;
  3. A delivery system that assumes risk and accountability for quality and outcomes;
  4. A global budget indexed to a sustainable rate of growth; and
  5. A cost prevention strategy that allocates some of the savings to addressing the social determinants of health. A system that incorporates these elements can take many forms, but without all five we cannot achieve our goal of improving health in a financially sustainable way.

There are two primary obstacles keeping us from moving toward a new system focused on value and health: the way the debate has been framed, and the cost-shifting strategies that—until the pandemic—allowed us to avoid the growing discrepancy between the cost of the system and our ability to pay for it.

How the Debate Is Framed

For decades, the national healthcare debate has been paralysed largely because neither Democrats nor Republicans have seriously challenged the underlying healthcare business model—the debate has been over what level of funding to provide. The current business model is built around fee-for-service reimbursement. The more they do, the more they get paid. Since the fees paid for medical services usually are not linked in a meaningful way to a positive health outcome for the person receiving the care, the system incentives are aligned with maximizing revenue rather than maximizing health.

The Affordable Care Act (ACA) attempted to move away from this model with incentives to participate in accountable care organizations (ACOs), which are networks of providers that shared in savings if they delivered care more efficiently (called upside risk). The problem is that the ACOs were not required to assume any significant degree of downside risk, in which they had to refund a payer if the actual costs of care exceeded a financial benchmark. Furthermore, the ACA did not take on the rent seeking (transferring wealth to the wealthy) that accounts for so much of the cost in the system. As a consequence, the cost of health care grew from $2.6 trillion in 2010 to $3.6 trillion in 2019.

In the wake of the ACA, both major political parties have continued to debate only the extent to which we should fund the system, creating a false choice between cost and access. This false choice is reflected in the Republican view that the cost of health care is unsustainable and must be constrained, and in the Democrat view that any reduction in spending will reduce access. Both sides are right, if they remain wedded to the current business model.

Republican proposals to “repeal and replace” the ACA would simply reduce the public subsidies in the current business model, increasing the number of uninsured Americans and exacerbating the inequity that already exists. Democrat efforts to expand coverage through proposals like “Medicare for All” would significantly increase public subsidies but within the same inflationary fee-for-service business model, adding to the burden of debt that future generations will have to pay. To put it another way, Republican proposals increase inequity and harm people today; Democrat proposals increase the debt and harm people tomorrow.

Cost-Shifting Strategies

Framing the debate in this way allows legislative bodies to avoid directly addressing the cost of care by simply shifting that cost somewhere else, a strategy used by other third-party payers (insurance companies and employers). As the total cost of care increases, instead of seeking to reduce it, these payers take actions that shift the cost to individuals, who cannot afford it, or to future generations. Here are the most common cost-shifting strategies:

  • Reducing eligibility, cutting benefits, and/or raising co-payments and deductibles—all of which shift costs to individuals;
  • Reducing provider reimbursement, which may result in efforts by providers to avoid caring for those who cannot pay and/or lead to increased fees by providers when they are caring for people who are insured; and
  • Increasing debt-financed public subsidies, which shifts the burden to our children and grandchildren.

Importantly, none of these cost-shifting strategies reduce the total cost of care, which is the central structural problem in our system. Before COVID-19, we were able to rely on these strategies, particularly debt-financed public subsidies, to avoid the difficult choices necessary for a solution. But given the economic crisis we face now, we must directly confront the total cost of care. Fortunately, this gives us the opportunity to pursue new strategies that both redesign the current hyperinflationary business model and invest in those things that have the greatest impact on health and well-being.

To be concluded

Mouse Whisper

Out of an abundance of caution

ex abundanti cautela

In law, describes someone taking precautions against a very remote contingency. “One might wear a belt in addition to braces ex abundanti cautela”. In banking, a loan in which the collateral is more than the loan itself. Also, the basis for the term “an abundance of caution” employed by United States President Barack Obama to explain why the Chief Justice of the US Supreme Court John Roberts had to re-administer the Presidential oath of office, and again in reference to terrorist threats.

In reference to Chief Justice Roberts, who flubbed it the first time, Obama recognised the deep conspiracy and made him do it again – correctly. Our authority is the impeccable, Il pagliacco Guiliani.

Just a quote dripping with irony, it has become the favourite phrase of the month, and it seems that is how one formally approaches the Virus, but you must be in full evening dress with all medals displayed (sic).

For we mice it is more that we’re “Out of our barn dance our Cat’s in”.

Modest Expectations – Windy Bears

Blinman is the highest settlement in South Australia at 610metres. It has a pub and one of the distinguishing features of this area is that it sells locally-made ice cream – well, not actually made in the Flinders Ranges but in a little town in this mid north area of the State – in Laura.

The Flinders Ranges were named after Matthew Flinders who, together with his cat Trim, were the first Europeans to see the Range when he anchored his boat in Spencer Gulf near present day Port Augusta, and his name was given to the Range by Governor Gawler in 1839.

Wilpena Pound is an ancient caldera in the Southern part of the Flinders Ranges. It is one of the few places which was still on my bucket list of places I hadn’t been in this vast country. The name had stuck in my mind since I read that the famous New Zealand soprano, Kiri Te Kanawa had performed here in an open-air concert – with the all kit and caboodle of an accompanying symphony orchestra.

Within the National Park now owned by the local indigenous people, the resort is surrounded by hills and the bush crowds in upon you. Ring throated green parrots are cavorting on the terrace as I am setting down my thoughts.

Six weeks earlier the area had been flooded and there is still evidence of water damaged roads. Most of the bush that had been washed along with the floodwaters had been cleared away, but the road signs still warned of flood damage and the unmade roads into the interior of the range had yet to be graded. There are plenty of hikes, which I could have done in the past, but there is still much to see.

 

The Flinders Ranges themselves are not that high, but they have a certain majesty. There is the huge Arkaroola Rock; there are the hills which are swirls of pink accentuated in the afternoon sun. A hill pokes out from the pink diorama as though it is a sand dune not rock. There is the Great Wall of China atop, in American usage, a butte. Nature had constructed what appears to be a dry-stone wall, which meanders up and across these flat-topped hills. Other peaks are jagged, saw toothed. This has been a playground for Mother Nature to experiment in form and texture. After all, to the local Aboriginal people this is the land of the Rainbow Serpent.

Throughout the ranges on the road north to Blinman, the dominant tree is the native cypress and, because of the recent rain, they are growing amid a greenery which has coalesced with the salt bush. There is also the mauve of Paterson’s Curse, which has been let loose by the rain and, as I have written before, it can look beautiful. However, as Baudelaire once wrote, at the heart of great beauty resides evil. I always think of those words when I see this imported weed coating the landscape.

Tiny Blinman has a general store, which was closed, but fortunately the pub offered the ice cream. There was once copper mining here, and the woman at the door informs us that the tour of the mine is full. She gives me some tiny pieces of malachite as compensation. I tell her my great-grandfather, when he first came to Australia, took his family south of the Flinders Range to Kapunda, where the first commercial mine in Australia had been opened in 1842. This mine also yielded copper but has long been closed. I had been there many years ago and already gathered pieces of souvenir ore from the mine tailings.

The view from Stoke’s Hill Lookout is of a red ochre expanse dotted with salt bush. Here the greenery has not penetrated and my whole vision was one that Fred Williams may have seen and painted. After all, the Flinders Ranges was inspiration for Hans Heysen also. He painted many a vibrant gum tree landscape. Although the native cypress are dominant, there are stands of several major eucalypts throughout the Ranges. There is the Southern Flinders Mallee, which grow on the rocky slopes, but along the river-beds are the imposing river red gums beloved of Heysen.

The Big Tree, Orrooroo

The largest of these eucalypts is celebrated in the small settlement of Orroroo, south of the Flinders Ranges, where the eponymously named tree is said to be over 500 years old. It has a trunk circumference of 10 metres and no fork in the trunk until six metres up.  It is a very healthy tree, but it is by no means the only tree of similar size and in the forecourt of our accommodation, there is a tree that is not much smaller. In the reception is a huge red gum counter made from a tree that had fallen over. Part of the massive trunk had been salvaged but the rest, despite protests, was cut up into firewood, the desecration often perpetuated by government-paid foresters.

Hawker is at the southern apex of the Flinders Range, a small settlement but with an enormous tyre service. This is an ominous warning of travel on the unmade roads that penetrate the Range. While we refuelled there, we were surrounded by an exhaust of leather clad motorcycle riders, most of whom were old enough to be directly inspired by Peter Fonda and Denis Hopper in Easy Rider. This is “easy riding” in the Outback, even though the sense of hair flowing the wind is now “kerbed” by a helmet.

The road to the west of the range proceeds north to Parachilna, with a pub and an official population of three. The pub is managed by a young couple who have fled there to escape the Virus, and here gained employment. This Prairie Hotel is a well-known watering spot to where once a railway ran, but no more.

The hotel is deceptive. From the outside it is a normal pub with the corrugated iron roof slung over the walls to provide protection from the sun. However, it is different from the normal desert hostelry in not being a reservoir for stubbie holders, fridge magnets, car stickers, and sexist T-shirts in a dungeon-like public bar. Inside it is tastefully decorated, light and airy.  There is a wide array of quality, mostly Aboriginal, art on display for sale. It is also the general store, sells other Aboriginal-designed artefacts, has good accommodation, the place for a good feed at breakfast and dinner; and being a pub, a wide range of grog. A bottle of my favourite Hendricks gin peeps out of a well-stocked spirits selection. Over the road from the hotel there is the budget accommodation in the form of dongas, ship containers with a portal of entry. Without air conditioning in the middle of summer, they would be like being in a microwave.

The paved road now goes a long way north and last year was extended to Marree (once the cattle railhead) to try and help those “grey nomads” dragging their caravans. Thus, Parachilna is now not a terminus but a welcome stop on the way north into the desert. For us, given how late in the day it is, this was our turning point from where we drove back, bathed in the late afternoon sun.

Adam Goodes mob – The Adnyamathanha

Terence and Josephine Coulthard, in the words of the front cover, compiled a Culture and Language Book on the Adnyamathanha people. These are local Indigenous Guardians of the Flinders Range – the long title means Rock (Adnya) People (Mathanha). The book runs to 450 pages and serves as a dictionary – the written form of the oral language – painstakingly described.

Adnyamathanha flag

These people have a flag (pictured) which combines the blue diagonal canton as representing sky and the Blue Rock people. The brown represents the land and the Red Rock people. The saucepan star formation is the men’s story line; the seven sisters the women’s story line. The circle with the radiating white lines is Ikara (Wilpena Pound) and the symbol for the whole Adnyamathanha community. Thinking about the complexity in the cultural attachments to the land we now recognise as Australia, such a flag should be looked at in a national context. It is a proud flag; this is not the flag of the downtrodden.

This strength was exemplified by us being invited to come to the launch of the book under the river red gums, where Terence sang and played the guitar, where the mob had come  and now sat under the trees and the children ran free the aboriginal kids weren’t running around, they sat with their parents. There was a lot of talk, everybody seemed to have a word to say, including the local member for Stuart with a long Dutch name.

We purchased both the book and the flag.

John Kitzhaber – His Thoughts

Below is a the first of a multipart series by Dr John Kitzhaber, former Democratic Governor of Oregon and the author of the Oregon Health Plan. I have known Dr Kitzhaber for a long time and he has agreed to his essay being reprinted in my blog. It provides an insight into the thinking of someone whom President-elect Biden may tap for ideas. Over to Governor Kitzhaber…

Dr John Kitzhaber

“I started practicing emergency medicine when I was 27 years old, and I still remember the vulnerability of the people who came to see me. They were sick or injured, frightened, and asking for help. They didn’t know me, and yet they put their trust in me. I did everything in my power to help them and yet, even then, I sometimes failed.

As an emergency doctor, being unable to save a life was devastating. The walk across the hall to the small room where family and friends waited always felt like a long hopeless journey. Yet while this poignant intersection of compassion and mortality is difficult, it is that very compassion, and the humility and caring involved, that drew many of us into healthcare in the first place.

Today, much of that compassion is being stripped away. Early in my career, in the 1970s, we had time to build the kind of personal relationships with our patients that often contributed as much to their health and well-being as the medical treatments we prescribed. Sadly, the space in which to cultivate these deeper relationships seems to be slipping away—lost to an electronic medical record that is as much about billing as about caring, and to an impersonal corporate structure that prioritizes revenue generation over a deeper understanding of the social and economic circumstances that contribute to illness.

I became a doctor to improve people’s health and well-being, not just to treat their medical conditions. I soon realized, however, that in many cases I was treating the medical complications of social problems. I was trained to treat the medical conditions, which I did to the best of my ability; but afterwards, my patients returned to the same social conditions that had brought them into the hospital in the first place. I eventually realized that our healthcare system is designed not to support wellness but rather to profit from illness. While most healthcare providers certainly don’t approach caring for people that way, the underlying business model does.

Serving in public office while still practicing medicine gave me another insight: the realization that the more money we spend on healthcare, the less is available for housing, nutrition, education, or other things that are critical to health and well-being. Since first running for the Oregon legislature in 1978, I have spent 26 years as a representative, as a senator, and as governor trying to develop a new model—one built on the recognition that health is the product of many factors, only one of which is medical care.

In 2012, in the depths of the Great Recession, Oregon established such a model: coordinated care organizations (CCOs) for our Medicaid recipients. The CCOs don’t just treat illness; they cultivate health by addressing not only physical, mental, and dental care but also related needs such as safe housing, transportation, and fresh, affordable food. CCOs have also demonstrated that it is possible to expand coverage and reduce the rate of medical inflation while improving quality and health outcomes. Now, with the deep recession triggered by the coronavirus pandemic, it is time to scale this kind of model up for the whole nation. My primary aim with this article is to offer one way in which we might achieve that goal.

From Cost and Coverage to Value and Health

For decades, the healthcare debate throughout the United States has focused almost entirely on coverage—on how to pay for access to the current system—rather than on health. What is missing is a consideration of value, which in this context means that the purpose of the system is not simply to finance and deliver medical care but rather to improve and maintain health. Indeed, the things that have the greatest impact on health across the lifespan are healthy pregnancies, decent housing, good nutrition, stable families, education, steady jobs with adequate wages, safe communities, and other “social determinants of health”; in contrast, the healthcare system itself plays a relatively minor part.

Ironically, since the cost of medical care consumes 18 per cent of our gross domestic product (GDP), our current healthcare system actually undermines our ability to invest in children, families, housing, economic opportunity, and the many other key social factors important to health and well-being. This is a primary reason why the United States does not compare favourably in terms of health statistics with nations that choose to spend far more on the social determinants and far less on the healthcare system.

If we could reduce our healthcare spending from 18 to 12 percent of GDP (which is the average spent by most other industrialized nations), we would free up over one trillion dollars a year to invest in the things that contribute more to health. Such a reduction in spending might seem impossible, but successful examples of how to bring down the total cost of care do exist, including Oregon’s CCOs. Under these care models, providers receive a global budget to provide quality care with good outcomes for a defined population; if the global budget is exceeded in any given year, the providers are at financial risk for the difference. These care models change the system’s incentives from rewarding sickness to rewarding wellness—and they work. Because they focus on improving health, they prevent illnesses and thereby reduce costs without sacrificing quality.

Effectively addressing the access, value, and cost issues in our healthcare system is one of the most important domestic challenges we face as a nation. Doing so, however, requires both a clear-eyed assessment of what this system has become and the courage to challenge that system. The global pandemic, with its profound economic and social consequences, has brought into clear focus the urgent need for a new model more aligned with caring, compassion, and the goal of improving the health of our nation. And no one is more qualified to lead that effort than the people who have dedicated their lives to the healthcare profession.

COVID-19 and Our Legacy of Inequity

In 1882, the newly formed Populist Party wrote in its platform, “The fruits of the toil of millions are boldly stolen to build up colossal fortunes for a few, unprecedented in the history of mankind.” Now, over 125 years later, these words aptly describe our current social and economic conditions and how little progress we have made in terms of social justice and equal opportunity. The novel coronavirus has exposed anew the inequities and the linked class and race divisions within our society, problems that have been with us since before our nation’s founding, almost always churning just below the surface, visible only indirectly when we examine disparities like disproportionately lagging health and education outcomes for chronically under-resourced— often racially or ethnically segregated—communities. Especially in the past few decades, these inequities have been masked by debt-financed economic growth that has prevented us from mustering the political will and societal solidarity necessary to address them.

Perhaps nothing better illustrates the depth of these disparities, or the extent to which social justice has been eroded, than the US healthcare system. It is a massive corporate enterprise that now consumes nearly one-fifth of our GDP, a huge employer that is increasingly dependent on public debt for its financial stability, and a major driver of income inequality. The pandemic has cast these inequities and contradictions into stark relief.

We see the difficulty nonmedical essential workers have had in obtaining adequate health protections, often resulting in significantly higher rates of infection. These are people in low-wage positions—often with minimal or no sick leave or insurance—working in grocery stores, warehouses, factories, and food and agricultural production sites. We also see that Black Americans are dying from Covid-19 in dramatically disproportionate numbers—deaths attributable to the structural inequities in our society that make Black people and other people of colour more likely to have diabetes, heart disease, and high blood pressure, and to live near major sources of health-endangering pollutants and far from health facilities and grocery stores. These are issues we urgently need to address.

At the same time, the pandemic has for the first time brought the economic interests of those who pay for, consume, and provide healthcare into clear alignment. This gives us a once-in-a-generation opportunity to transform the current system by demanding value as well as universal coverage and by constraining the total cost of care.”

To be continued next week.

 What a Village

After such an above sober analysis…

The votes for the US President have been counted and, as predicted, Trump is behaving as he always has, and in so doing disgracing all American democratic traditions.

Joe Biden has won. I have not thought much of him, but now that he is on the brink of Presidency, he needs his critics – of which I am not even a speck in importance of one of these – to give him a chance.

Trump is exhibiting the sure signs of dementia. People are now openly saying he is lying and the media is by and large turning him off. The pathetic lies are obvious, but is he confabulating? There are these long blanks in his mental processes which he fills with babble. This is associated with early dementia. Therefore, with his face the colour of a tomato, which even make up cannot hide suggests a visit to an independent medical panel would be wise.

Nancy Pelosi is 80; Joe Biden is on the cusp of 78; Mitch McConnell is 78 and unquestionably the most unhealthy seems to be Donald Trump, who is only is 74. He has had a dose of the Virus and refused to heed its danger.  Instead of convalescence he embarked on a frantic schedule in which he encouraged his adoring crowd to gather into a feed lot for the Virus. He demonstrated how the President’s power must be reviewed, as the Senate has done in the past, to clip presidential authority. Trump has shown how susceptible a nation can be to bullying, even when this is limited to four years.

There is an increasing adage that 70 years is the new 50, but believe me, 80 is the new 80. Something happens between 70 and 80 in many people, and that is why it is hard to detect how well they would handle the “next four years”. Retention of physical and mental health in individuals begins to become more of a lottery. Therefore, both Pelosi and McConnell should be watched for any slippage, but in politics that is an inconvenient comment.

I do not fear of being called ageist, because I am in the same age group. Biden still shows he can jog to the President-elect’s podium, but he called upon Obama to assist in maintaining a sense of mental resilience. I had made the comment earlier that Biden would give away to an Obama restoration. I made the comment that this may be stopped in its tracks by Michelle Obama. Obama’s oratory over the last few weeks helped solidify African-American voting intentions in these closing weeks.

Kamala Harris is 56 years old and Mike Pence is 61. Whether having endured years of Trump, Pence might retire in Indiana to try and cure the PTSD engendered by four years at “Don’s Party”, with any thoughts of a future Presidency probably snuffed out. However, the future of Kamala Harris will determine whether that divide in America painted red will ever accept under any circumstances a woman, especially if Biden should die or be incapacitated over the next four years.

In short, there is much that could be added without rehashing that which has already been said. What in the end were the most significant conclusions for me?

  • America elected a woman Vice-President.
  • Trump scored 72 million votes.
  • COVID-19 has affected three per cent of the population and O.8 per cent of the population have died up to this point. Does anybody out of that 72 million in the imitation of a self-obsessed narcissistic ex-President really care about such a small group of “losers”? Is America that callous?

Mouse Whisper

Not Anywhere

            Not Delaware

                          But Somewhere

                                     Wilmington South Australia

The Worshipful Company of South Australian Field Mouse Grain Handlers have asked me to invite you Sir to open the Wilmington Night Rodeo on January 23 next. I understand to perform this important role you will have re-schedule a minor ceremony in Washington to be with us. However how could you afford to miss having the finest tucker at Rusti Kate’s Feed Lot after a trip through the Puppet Museum, which I understand as a fine array of your predecessor’s marionettes.

Respectfully

Wilmington, South Australia

Modest Expectations – Nisi

Today was Melbourne Cup day. You know, the sporting event that stops a nation. Except we have just driven 800 kilometres from   Dubbo to Broken Hill. It is not the first time we have driven between the two cities, but it served as a reminder that going on a long journey with yourselves through the Outback of Australia is a reminder of our diversity. Australia prides itself on its multicultural diversity, but even to my urban eye, Australia also has great climatic diversity.

In the brochures which highlight this diversity there are always pictures of the Great Barrier Reef, tropical rain forests and beaches, Uluru and red deserts, and the Sydney Opera House. However, along a road on a hot day, diversity springs out at you if you care to look.  The subtle changes in the landscape are there. The problem of being the driver is that one drives essentially with a strip of bitumen in front of you. Traffic is increasingly sparse the further you penetrate into the country.

The thin strip of bitumen

Whenever I go on one of these trips, I say to myself that I must learn more about eucalypts. There have been multiple experts who can tell a gum tree variety just by running their eyes up and down the structure. The fragrance of Australia is breaking apart a newly picked gum leaf and smelling it. Describe the smell and you describe Australia as it has been for thousands of years.

Between Dubbo and Nyngan, there are a number of small towns. This is wheat country interspersed with natural habitat.

There is a white blanket along the sides of the road. They are tiny white everlastings that nature has gathered into posy-like clumps and then strewn through the bush.

As the soil becomes drier, everlastings give way to small clumps of salt bush dotting the landscape and foreshadowing that there is saltbush country beyond the horizon.

The scrub varies from open woodland to areas of brigalow, with the grey feathery foliage atop a black trunk, the mallees – greenery close to the ground, then clumps of native cypress, some gidgee trees. These are interspersed with the gum trees I wished I could identify.

I well remember driving from Bourke to Goodooga in the north of NSW and my companions identifying the trees as they would their relatives. The most striking of all of them was the leopard gum. Each of these trees and others reflect microclimates in each of these areas being distinct, which in turn makes the whole landscape such a diverse experience.

On our trail today, animal life is scarce – one emu, no kangaroos, a number of feral goats, no cattle and a small flock of sheep in saltbush as we neared Broken Hill.

After Nyngan it is 130 kilometres to Cobar. At Nyngan, in a unprepossessing iron shed which houses the toilets, we find that rarest of commodity, soap – and something in my wide usage of such facilities I have never seen before – paper towels, all maintained by the volunteer group that run the adjacent wool shearing shed display.

Contrast this with the stop at the MacCulloch Range wayside rest area which boasts a children’s playground, a barbecue and a long-drop toilet without toilet paper – and where the birds are conditioned to congregate around the toilet when occupied, because the outside wash basin discharges its waste water directly on the ground for the birds to drink. Here there are several plaques identifying NSW Ministers who have made the journey to unveil them – one in recognition of the completion of sealing of the road between Nyngan and the South Australian border in 1972 and the other for the creation of the children’s playground and the other facilities there! Talk about turning up for the opening of an envelope – but then the latter was Carl Scully.

However, that stopover is closer to Wilcannia than Cobar, which owes its existence to its copper mines. Then it is 260 kilometres to Wilcannia from Cobar, with no settlements in between.

Wilcannia stone

Wilcannia was once a thriving river port where boats were loaded with the wool clip and sent down the Darling River. The magnificent buildings made from the distinctive Wilcannia stone attest to a past colonial magnificence. I was once shown the quarry from which the Wilcannia stone was extracted. It was disused although stone remained under a cover of bush. The stone makes beautiful cream coloured buildings, so much in synchrony with the intense clear sunlight. Perhaps the quarry has been worked out – but the stone would still attract use for building if that is not the case.

Wilcannia is now an Aboriginal town as it has been all the 30 years since I first stayed and worked there. Here was where I learnt so much about the Barkinji people. Today in 40 degrees heat, parked in a nearly deserted main street, we watched the Melbourne Cup on a laptop.

This year travelling the route was somewhat unusual in that rain had come and turned much of the country green.  The salt bush seemed to coalesce with this greenery. The red earth still broke through, and in particular there were some areas which had not received much rain.

The last kilometres through to Broken Hill pass through a plain almost devoid of trees. While there was a rim of hills in the distance, this land was flat and green – it seemed to be a continuation of the Hay Plains to the South, which are so treeless they give an illusion of a flat earth. It is said these plains are the area which most effectively demonstrate this illusion.

At last Broken Hill nears, we turn our watches back half an hour to South Australian time. Now on all sides we see what many people describe as the engine which made Australia – the huge silver-lead-zinc deposits – after the gold rush petered out. There is no way Broken Hill can be described in one paragraph.  I’ll reserve that for another time since this one day in the Outback stands alone – yet another tincture to colour the wonderful commodity – experience.

Old Broken Hill

The Three Horsemen of Politics 

“To spend a third of life in unproductive idleness seems a dreadful waste to some people, and now and then they decide to shun the slothful practice evermore.  No one has yet succeeded. After a couple of sleepless nights they are as sleepy as anyone else, eventually become incoherent and irrational and seek the season of all natures.”

                  The last six words are stated by Lady MacBeth.

When I listened to the tirade from Minister Frydenberg demonstrating his basic ignorance of what Daniel Andrews had done, I could not believe it – coming from the mouth of someone who in all public demeanour before has shown control albeit behind a quizzical expression.

So what did this outburst signify?  Many applauded him for it. I did not. I thought the content wild and illogical. I have watched politicians over the course of 50 years. Published many years ago in the print media, but seemingly forgotten, I have been jogged to repeat what I said then.

There were three challenges for politicians that I identified.

  • Sleeplessness
  • Isolation
  • Boredom

As I wrote about sleeplessness, it seems to be a badge of honour of some politicians not to sleep. I remember that Margaret Thatcher boasted about how little sleep she needed. She ended up with dementia. When I first wrote about the deleterious effects of lack of sleep, there was not the evidence there is today about its link with Alzheimer’s and Lewy body dementia.

I have always likened sleeping as the time you put out the cerebral garbage.  This image seems to have been validated by scientific evidence. When one does not sleep, then the garbage in the form of amyloid or other toxins is left to accumulate in the brain.

I well remember the experiment of “the tipping cat”. Here the cat would just be allowed to fall asleep and then immediately be tipped up. This was repeated time and again, eventually turning the cat into feline paranoia.

The image of Frydenberg scribbling away and then launching into the tirade made me wonder about how much “good sleep” he is getting. From a forensic point of view it would be interesting to know what he actually scribbled, and the psi impact on the paper hopefully not reflected in the way Trump violates paper with his black signature.

So that is the first question I would ask of Frydenberg. What about your sleep?

Turning to isolation; the figure brooding, looking out the window – the Person Alone – is supposed to indicate strength and a thoughtfulness, the ability to sustain 40 days and nights in the wilderness. However, the reality is that most politicians hate isolation. My thought is that when they all moved to that new Mussolini era-architecturally inspired mausoleum called New Parliament House, to offset the innate isolation of the long corridors and the vast atria with offices designed for excessive space with the consequence of distancing themselves from us plebs, the politicians employed more and more staff. In the Old Parliament House, people lived close to one another, which in itself reduced isolation – apart from which, the place was so small no one could fit a large number of staff.

However, now politicians have to work in a building which structurally promotes isolation enhanced by the ever-increasing levels of security; then, when a pandemic appears, the frailty of those isolated is shown. When isolation is a negotiable commodity, then it can be brushed aside – but when isolation comes with compulsion to save the health of a nation, then it becomes very challenging because it is real, physically.

Because in a pandemic that’s exactly what they should happen -one isolates oneself.

Another problem with isolation is that it breeds ignorance and, when combined with sleeplessness, an inability to adapt. One of the ways to combat this is to listen, not as a public relations exercise, nor one looking for an anecdote to bolster your belief system, but as a genuine effort to discover alternative views. I always remembered the politician who said he went to meetings outside his comfort cocoon, because there was often times one comment or an idea would jolt him from his “cocoon of isolation” and make him think further. Isolation thus has a mental component.

The final component which has grown over the years to feed isolation has been this obsession with security. The activities in the Middle East have fuelled this, together with the increasingly inflammatory comments from politicians revelling in the inferno of populism. When I first entered the political scene, security was not the industry it is today. Even when there was the attempt to assassinate Arthur Caldwell, then the Leader of the Opposition, in 1966 there was no knee jerk response. Security has now become an industry – a commodity – to be traded- and alongside its growth are the vested interests. It is no doubt a contributor to isolation, but how much? One can only say that if one believes it is important to combat “the politician as an isolate” it needs to be factored into any considerations.

Then there is boredom. People believe that hustle and bustle is activity. This boredom was exemplified by the criticism of Mr Albanese’s office. It sounds like a playground with or without a sandpit. The problem is that there is not enough real work for these characters to do. They then just play endless games of “gotcha” in between their sycophantic acknowledgement of their various politician employers.  As I once wrote: “Boredom and its consequences have the effect of pushing away some people who could have been important contributors. It would disastrous if, at the centre of the political world, are solely those who delight in the entrails of boredom, and who actually revel in gossip, ritual and games.”

In the intervening period I have witnessed how true most of this is. There is no reason to believe that Frydenberg ever gets bored, but it is reason for him and others in high places to be aware that boredom breeds mischief – bouncing between venial and venal. Staff members need useful work to do and if that doesn’t exist, you don’t need them.

Therefore, if a government does not have an optimistic agenda demanding substantial policy discussion, hope is rationed and eventually boredom thrives from a lack of hope, because there is nothing to do but obfuscate, let forth tirades and generally be unpleasant. Because there is that ghost of the Cheshire cat and all it conceals, to goad. Then add sleeplessness and isolation and it becomes a toxic mixture!

Paul Collier – Lest we forget

I don’t know whether his name has been mentioned in the Disability Royal Commission. I very clearly remember meeting his mother though.

At the time I was on quixotic mission handing out voting cards at the Woodcroft booth in the seat of Mawson. Dr David Senior, a rural general practitioner friend of mine, was standing on a single issue of saving the Royal Adelaide Hospital, a perfectly good building on North Terrace, rather than have it replaced with an extravaganza further up the road. The new hospital has since been built; it has had huge commissioning problems but is a legacy to that man of impeccable judgement, Mike Rann, then Premier. This judgement was attested to by his chummy relationship with Lance Armstrong.

Then, as now, Mawson has an ALP member. The electorate is a predominantly outer suburban electorate, but also includes a significant slice of the state’s wine industry and now extends to include Kangaroo Island. Woodcroft, where I was handing out cards, was very suburban – wide streets, not many trees, the signature brick veneer homes but not McMansions.

This is where I met Paul Collier’s mother. Collier was a quadriplegic, highly qualified who, at the age of 21 had the accident which rendered him with this severe disability. This had not stopped his advocacy for the disabled and he had formed the Dignity Party. He was on top of the Party ticket for a place in the Upper House, but 11 days prior to the election, he died from a cerebral haemorrhage. His name had remained at the top of the ballot. His votes were passed on to the second person on the ticket, Kelly Vincent, a young woman with cerebral palsy, who was duly elected and served one term, and tellingly was not re-elected in 2018.  The conventional stated reason for this was the change to optional proportional voting. If so, this is an indictment of how the community viewed her candidature, not important enough to either vote for or preference her, disability and all.

But then in March 2010, I shall never forget that extraordinary woman, having just farewelled her son two days before, handing out how-to-vote cards for her dead son’s Party. I did not discuss her motives with her; she was still wrestling with the grief.  She had told me enough.

When I wrote this to Mike Steketee, a journalist I knew well then, I myself was not disabled, as I am now. Once I found out the complexity of being looked after, as I have, I recognise how difficult it all is. Frankly, I don’t know why you need a Disability Royal Commission over four years. What will it tell me in its recommendations about what should be done that I do not already know.

The labour intensity of keeping people alive is huge and thankless; one problem of medical science – from the marginally viable 22-23 weeks pre-term to the centenarian with dementia – is intent on keeping them alive at all cost.  An increasingly number of people recognise, as they do elsewhere, prolongation of life of an obsolete product is about cutting losses – but tell that to the religiously superstitious! It was reported this week that almost 50 per cent of those who have died in aged care in Australia from COVID-19 had dementia.

Society is conditioned to mourn the dead, often a self-conscious piety when it just boils down to how, in personal terms, the dead are just names. We fumble in how we express ourselves when we feel nothing. Going to funerals as a matter of form is not grief. Grief is a solitary situation, and when you lose your mother as a boy, it lives with you for the rest of your life.

Disability has been raked over. Let’s assume the cost is considerable; the modelling light on “how much” flashes “a lot”.  In these times with a government in deficit, if you want to care properly – you need a tax.

Confront the country with the figure for care for a moderately disabled person if treated individually at home or in an institution; then ask each taxpayer individually would they be prepared to pay that tax, given that around every health problem is a shell of fakery and profiteering associated with the privatisation of aged care. The Disability Royal Commission should be able to answer some of the questions underlying the statement in this paragraph.  If they have, then why the need for extension?

Apart from the here and now I faced the dilemma of how to confront disability almost 50 years ago when I was a young doctor responsible for an adult rehabilitation ward. One day in 1971 a 12-year old boy was admitted, paralysed down one side, a spontaneous event without apparent cause.

He was a bright boy and I had immediate empathy with him. I saw him every day. He came from the country, but nobody came to see him. His parents seemingly had disappeared at the onset of his medical condition when the boy was transferred to the city. It is very difficult to be child in a rehabilitation ward where most were elderly. For some reason, it was difficult to discharge him, because facilities for a child soon to become an adolescent with all that meant were poorly differentiated. Adolescent medical care as a specialty was in its early stages.

Thus, for respite on a couple of weekends with the agreement of the hospital, I took him home so he could experience family life.  Our sons were seven and five at the time.

We lived very close to the hospital. My then wife and I contemplated whether we could go further and seek to take over his future care and education. We consulted a range of heath professionals, before initiating anything. We never mentioned it to anyone – we were not adopting “a pet” to be discussed over morning coffee. The question was whether we could give him a better life, not him to be regarded as a trophy.

We both agreed the question was whether we could be both appropriate “foster parents” or “adopted parents”. In the end we were dissuaded; we had to cast off any incipient emotional ties. However, for a period we wondered whether we had done the wrong thing. As it turned out, we probably did the right thing – but how would you know as we did not maintain contact. We did ensure that he would be cared for in the short term and not be forgotten. No Royal Commission could have helped us then or, I suspect, now.

In hindsight, given where we both are now, it was obviously right, but then nobody will ever know what would have happened if he had become part of the family. Dwelling on such matters at an individual level gets one nowhere, except to think that Ron Sackville must have wisdom which the rest of us do not. 

Mouse Whisper

As someone who remembers the toll of the 1980s, this piece from the New York Review of Books is sobering, so much so that if a mouse could shout from the rafters and not squeak, I would say loudly:

There is a terrible fear that the toll on health care workers from COVID will have been in vain if Trump’s failure to effectively tackle the pandemic continues, if testing is not ramped up to levels that allow for identification of carriers and contact tracing, if distribution of protective equipment is not done rationally but rather through nepotism and profiteering, if experts are removed from important positions after questioning incompetent political leadership, and if reopening the economy is done haphazardly to fulfill talking points on cable TV in hopes of gaining re-election. 

Perhaps the greatest lesson we can take from the AIDS epidemic is one that came after the movie star Rock Hudson died, effectively removing the blinders that President Reagan was wearing. Reagan, a friend of Hudson, at last ceded authority to scientists like Fauci, who knew how to speak to the public about illness and create a sense of common cause, and to mobilise both the public and private sectors to triumph over a virus that had never been seen before and many believed could not be effectively combated.  AIDS arrived as a murderer; now it can be shackled. We are nowhere near that point with COVID-19.