Comments to Brattleboro Hospital Convocation on October 4, 2023

Photo of Brattleboro Hospital courtesy of

We’re here to talk today about how best to design and implement a healthcare and social system that secures our shared goal of population health for an aging demographic.

My main point today is that ensuring the wellbeing of our aging community goes well beyond healthcare. It’s more dependent on our commitment to “the common good” in our communities than we care to understand. In trying to solve our societal challenges, we tend to focus on the typical silos of housing, food systems, environmental degradation, poverty, public education nut fail to understand them as all intrinsic to healthy aging.

Today, I would like to substantially broaden our understanding of wellbeing in an aging demographic.

The number of Vermonters ages 65 to 79 increased significantly, up more than 40,000, as many baby boomers moved into their retirement years. The share of Vermonters ages 65 to 79 from 2011- 2019 rose from 10.5 percent to 16.4 percent. This puts us at No. 2 nationally for the percentage of people 50 and older. Only Maine has a higher ratio of seniors, and Vermont is tied for No. 2 with New Hampshire for the highest median age.

A recent Washington Post study indicates we’re going in the wrong direction while our peers in other countries are making progress. The United States is failing at a fundamental mission — keeping people alive. After decades of progress, life expectancy — long regarded as a singular benchmark of a nation’s success — peaked in 2014 at 78.9 years, then drifted downward even before the coronavirus pandemic. Among wealthy nations, the United States in recent decades went from the middle of the pack to being an outlier. And it continues to fall further and further behind. This does not bode well for our current understanding and approach to extending quality of life into old age.

On a lighter note, I’ve tried everything to cure aging. It seems, for  me, there’s no cure other than gratitude for being alive.

But let’s start at the beginning.

Population health is understood as a system that ensures quality, access, and affordability. Many of our hospitals generally succeed on the quality component   ̶   remembering that medicine is both an art and a science and, as such, is subject to human error. We also agree that we’re largely failing on access and failing everywhere on affordability.

We can do something about this and that is part of what we’re here today to explore.

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As to our discussion today, I’d like to look at healthcare for an aging population somewhat differently. Rather than putting people on the defensive discussing what’s broken, why, and who’s responsible, I’d rather jump to endgame and imagine together an ideal healthcare and social system for an aging demographic.

If we had to design the optimum system, what would it look like? That is our task today  ̶  reverse engineering such a system.

So first, let’s review our tool sets?

As to people: we have a spectrum of healthcare providers from volunteers to nurses, nurse- practitioners, physician assistants, hospitalists, primary care docs, specialists, and surgeons.

As to healthcare infrastructure: we have sole practitioners, small group practices, clinics, free clinics, federally-qualified health centers (FQHCs), critical-access hospitals, secondary-and tertiary-care hospitals like UVMMC, Dartmouth, and Albany.

Our goal must be to deploy all available tools in the most cost-efficient and accessible manner consistent with our goal of population health for all, especially seniors.

Too many Vermonters give up on healthcare, fearing they can’t afford it, or struggling to book an appointment and giving up, or they may not have the transportation they need to travel to an emergency room far away.

One strategic change that will make possible our goal: we must move our investments in population health upstream to locally accessible primary and chronic care, education, prevention, and trauma-informed counseling.

(You’re all familiar with T.I.C.? –  do I need to explain?)

This calls for locally accessible primary-care options, except for emergency trauma. There’s no more affordable way to deliver primary care than at the local level. Likewise, there is no more expensive way for both patient and provider than to deliver primary care in a remote emergency room.

There’s no more expensive or hard-to-access facility than a distant tertiary care hospital emergency room. Large hospitals should always be the first stop for true emergencies and trauma but the last stop in a well-designed upward referral system based on patient acuity.

This must be our vision for appropriate healthcare infrastructure for our aging population as well as for many of the other complex problems we face.

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But let’s not make the shortsighted mistake commonly made by policymakers, legislative consultants, and study committees who sadly often confine their thinking to silos. Housing, food systems, healthcare, education, transportation, the environment, criminal justice are all part of the social fabric of our being. They have substantial interactions and, as such, each contributes materially to population health at any age.

Time to tear down the silos!

The child who arrives at school hungry or abused is not ready to learn.

The unsheltered widower worried about winter does not focus on his chronic diabetes.

The un- or under-insured person with a medical concern is not going to go to the emergency room for fear of the billing. Two of my own children have told me they will not go to the hospital unless taken there unconscious in an ambulance.

(Digression on “noncompliant” female patient not following her diabetes regimen.)

The social milieu in which we live is a major driver of good or bad health. You are all familiar with Dr. Don Berwick’s social determinants of health (DH). Let’s remind ourselves of them.

These are the non-medical factors that influence health outcomes   ̶   the conditions in which people are born, grow up, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life, such as social, economic, and political policies and systems, social norms, and even birth zip codes. It is a known fact supported statistically that a person’s zip code affects their life expectancy more than their genetic code. With a profound influence on health, levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health.

The social determinants can also be more important than healthcare or lifestyle choices in influencing health. Numerous studies conclude that they account for between 30-55% of health outcomes. Finally, estimates show that the contribution of sectors outside healthcare affecting population health outcomes exceeds the contribution from the health sector.

By way of example, in May, U.S. Surgeon General Vivek H. Murthy issued a sobering advisory on loneliness in American society. He was clear about the serious public health consequences of an increasingly solitary population.  Research supports that the risk of premature death posed by “being socially disconnected is similar to that caused by smoking up to 15 cigarettes a day, and even greater than that associated with obesity and physical inactivity.” I want the entire country to understand how profound a public health threat loneliness and isolation pose,” he added.

Here are some of the social policies that affect population health:

  • Income and social protection
  • Education
  • Unemployment and job insecurity
  • Working life conditions
  • Food insecurity
  • Housing, basic amenities and the environment
  • Early childhood development
  • Social inclusion and non-discrimination
  • Structural conflict
  • Access to affordable health services of decent quality.

This tells us that in our efforts to envision an ideal system of population health for our aging community we must focus not only on healthcare quality, access and affordability, but also on the social fabric in which we age together. Do we have these in place to ensure personal connections, civic engagement, group and solo activity?

I suspect we all agree that physiological, mental, and spiritual health are all key to wellbeing. This opens us to exploring the social and economic tools outside of healthcare infrastructure that are critical to promoting wellness in an aging population:

  • Community meeting and exercise places in nature such as parks and biking/walking paths.
  • Diverse centers of worship, ritual, and celebration.
  • Accessible, affordable public transport.
  • Lifelong-learning opportunities for all ages with opportunities to explore and learn about artistic expression, crafts, and hobbies: painting, dance, choral singing, pottery etc.
  • Cohousing opportunities for those who seek or need it.
  • Strong local news organizations.
  • Communities in which citizens are not segregated by age but can interact socially with young people ̶  opportunities for mentoring, volunteering in daycare, schools, sports etc.

I suspect that many of you here today never imagined that population health strategy was so comprehensive. But if I have any message today this it.

Wellbeing in our aging state goes well beyond healthcare infrastructure. The health and wellbeing of each community is the largest factor in the health of its citizens.

Thank you for all you do to keep people well. My comments will be accessible online.

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