The Occasional Perspective - 6/20/25

Opinions and Reflections

How Low Can We Go? – Remember the “Limbo” (a question for the older generations and a lesson for the younger ones)? The Limbo was a dance where – after a gathering or a party got warmed up with music playing in the background – someone would bring out a broomstick or similar device onto the dance floor. The music would change to the “Limbo Rock”. And, the broomstick would be held by two dancers at about 4’ above the floor. With the “Limbo Rock” playing in the background, you then had to dance under the stick with your feet first by bending backwards and not touch the stick! Then, if you made it, the broomstick was moved to 3 ½’    above the floor, then 3’, then 2 ½’ down to 2’, which in my experience was the point where no one ever made it. Everyone stood around and cheered if you made progress and laughed loudly when you didn’t. It was festive, but it was also a metaphor for our abilities! How low could we go? 

Now we have a real-life experience of how low we can go with the current state of American politics. The difference is most of us are not cheering. I’m appalled at what was done to Senator Padilla (D-CA) after he started asking questions of a senior government official out in California. I am also appalled at the lack of backbone and leadership emanating from the U.S. Senate and House of Representatives. The acquiescence is astonishing in many respects. However, it seems that the vast majority of these elected officials (both sides) are more concerned about re-election to office than dealing with issues related to separation of powers, freedom of speech and the panoply of other issues that have been thrown open in the last six months. 

None of us should stand around and cheer, laugh and/or ignore that situation. I have tried over the years (now going on nearly 8) in the Fickenscher Files to stay away from politics except where it interfered with my lifelong purpose, which was to “make health care better”. But, that approach is getting really hard for me primarily because I believe in finding solutions, not in disseminating deflections!! 

The Great Deflection – As noted above, for the better part of the last decade of preparing the Fickenscher Files, I’ve tried to stay away from polarizing politics. I have good friends on both sides of the aisle as well as friends and colleagues who are political/elected officials on both sides of the aisle at the domestic as well as the international front. Maintaining some degree of centrality has been important. For example, during the Reagan Administration, I worked very closely with my Republican colleagues to develop support for various rural health legislative pieces passed through Congress. The “Senate Rural Health Caucus” and the “House Rural Health Coalition” were bodies I worked on to bring like-minded advocates together as a bi-partisan initiative. The result was quite successful. 

Quite frankly, I’ve always tended toward “finding solutions,” which in my experience inevitably calls for some degree of compromise for moving in the direction of solving a societal problem. The compromises may “shift” over time because they are positions held at a point in time. The end result of gravitating toward the middle (“left of center” if you will) is that it “gets things done!!” – often with the attitude that it is possible to revisit solutions going forward as needed to facilitate or improve the solution with further refinements. 

So, while my focus continues to be on health care, I’ve been contemplating a shift in my mission to “make the world better” which means considering issues outside the health care realm. So, the question is: What are the areas of focus that could make the world better? The list – in my mind consists of the following seven areas: 1) health care (still #1 in my mind), 2) climate change, 3) the critical global economy, 4) the evolving digital revolution, esp. AI/ML, 5) societal collaboration, 6) the importance of appreciating cultural diversity, and – of course – 7) politics – since we cannot manage the above essentials without some focus on that front. 

So, let me digress from the usual discourse on “’almost all things” health care, and take each of these very important issues in turn… 

Health Care – First, let’s start with my repetitive call on the need for a revolution in health care finance in the USA. It has been evident in my mind for some time. The current fee-for-service system encourages activity but not necessarily results. It has been my position for some time that we need to begin experimenting with “value-based care delivery models.” Experimenting is the right approach since there is no one model that has been deemed to be THE best model. Furthermore, we need to have “quality outcomes” serving as the core measure of all the care we provide in health care and go beyond the core “medical care” component to include the “social” and “community” components of “health” care (i.e., social determinants & public health). 

Climate Change – stated simply: have we not all seen the rapid changes in the environment occurring across the planet related to climate? The ice fields are melting, the weather in the Southern USA is reaching more than 100 degrees regularly in May. Rain patterns are changing. The oceans are warming at an alarming rate. I could go on…although this is not my area of expertise. However, it’s obvious that we need to do something since the weather changes are beginning to slug us in the eye with every assortment of weather variation. To deny climate change is to promote a sticking of society’s head in the sand from my perspective. AND, there will no doubt be health implications as climate change continues to evolve… 

The Global Economy – It seems clear to many of us that we are now inextricably connected as a global community. In the entire history of earth’s existence (as far as we can tell), there has never been the same degree of connectivity among all parts of the globe as there is today!! For example, I’ve been to China many, many times. They should be our “buddies” not our enemy. The economies of the world are all tied together. China, Vietnam, France, Germany, you name your favorite place. They are as dependent upon the USA as we are dependent upon them. This is not a naïve position. It is the reality of a world that is connected across borders by media, social media, transportation, economic interconnectedness, and the like. Furthermore, diseases are no longer local events. With the right genetic profile, they become pandemics and destroy lives across all the artificial borders that get drawn on paper maps around the world. We should be “leading” on how to be a good integrated neighbor rather than supporting sides. 

The Evolving Digital Revolution – At the outset, if we think that the Industrial Revolution was transformative, it pales in comparison to the much shorter and vastly more transformative Digital Revolution. Technology has been at the core of most of the societal revolutions that have occurred over the millennia. Starting with creating fire by rubbing sticks together, then gunpowder, then the printing press, and the list goes on to include locomotives, tractors, cars, computers, the internet, social media, and onward. Technology has represented the key transformative agent. The digital revolution, however, is happening at a pace that is breathtaking at best. The present environment is replete with a pace of change that is much more distributed than with any of the prior technological revolutions. As a result, the transformative power is much starker and more dramatic as well. We need to come to grips with it. For example, wars of the future (e.g., like in the past year) are most likely to be fought using drones. The recent done strike by Ukraine inside Russia that destroyed 1/3 of their air fleet; or, the even more recent back-and-forth strikes by Israel and Iran are exemplary. So, when will strikes occur inside the USA? And, by whom? Perhaps not another nation…perhaps a group that does not like our extradition policies? Who knows… And, the digital revolution is far more than simply drones. It is the potential replacement of humans by technology that is beginning to happen at warp speed!! But, that’s a much longer discussion… 

Societal Collaboration – Perhaps I’m naïve (although I don’t think so 😊), but I believe the world would be far better off if we could learn to support formal, ongoing (i.e., not episodic) international collaboration. We have had periods of collaboration in the past, which have created remarkable economic and social benefits for all people. Remember the lessons of the world coming together to take on Hitler’s authoritarian model. We need to set this approach as the “standard” for how countries, nations, geographies – however you want to divide up the world – work together. And, doesn’t this philosophy work really well for health care? With weather change as noted above, pandemics are likely to become more common… 

Appreciating Cultural Diversity – Rather than dispensing with our differences or pushing them aside, we should embrace them and learn from them. In my personal experience, understanding our cultural differences results in better understanding and appreciation of one another. There are good people and bad people in all places. There are different ways of living, and we should accept them. Let’s embrace the good in all places, from all people, and make them even better. 

Politics – Which brings me to the final consideration on my list for a focus to “make the world better.” Our solutions across and within societies will come by working together and understanding one another, not by denigrating one faction or another because of the way they live or whom they live with. The extremes of society – on both ends – have never solved problems in the short term. We need to engage in effective dialogue where listening and understanding are held as the core standard for framing debates. Persistence with such a standard can make change happen and it requires the embrace by others across the spectrum. 

So, back to health care… This issue should be #1 on our national debate list, whether you’re in the health care field or not!! Why? Because health care in its current form represents one of the largest components of the USA’s Gross Domestic Product (GDP). In fact, the latest Congressional Budget Office (CBO) projections reveal that health care makes up about 30%+/- of the federal budget and is the fastest growing component of the federal budget. And, it is growing consistently over time as our society ages. Such a level of GDP consumption represents somewhat of a self-immolation of the federal budget by consuming ever greater proportions of our national resources and diminishing our ability to allocate resources to other pressing national problems. Furthermore, the projected growth in health care costs is estimated at 20 – 25% of all new debt growth over the next few decades. This should be a hint for all of us that such a direction is unsustainable. Therefore, as one of the most pivotal problems we face in the USA, we should be turning our attention to health care reform. And, it is why I advocate moving toward a “value-based” payment model for health care. Finally, such an effort will only succeed if we are able to engage in bi-partisan support!! 

And, a final thought – The “Great Big Beautiful” Bill – that passed by one vote in the House – does not cut it. And, based on readings that are just coming out, the Senate version does not do any favors for the health care community. Both of these bills simply reduce the federal support for nearly 10 million low-income citizens who have no other means of insuring their health care costs than Medicaid as well as decimating the social determinants support through the SNAP program. This all occurs while simultaneously creating massive tax benefits for the wealthy. What ever happened to “love your neighbor as yourself” as a basic philosophical undercurrent in the USA? Can a millionaire afford a $20,000 surcharge better than a family of four slogging away by providing basic services to others? I think so… 

Finally, these six issues plus politics as an overlay need to be addressed if we’re going to consider real solutions that solve some real problems we face as a nation. And, we should go at it not by the whim of night-time edicts that are posted on social media but through the diligent bi-partisan conversations, debates, and decisions that once-upon-a-time emanated from Congress. Debate, discussion and building consensus – in my personal experience – creates solid decision-making. We once had that in the USA and we must get it back!!