To a point….
“Relying on Each Other” (oil and graphite on panel), by Jeffersonville, Vt.-based artist Rose Umerlik, in her show ‘Intricacies,’’ at Atelier Newport (R.I.) through Jan. 1
The gallery says: "Rose tells her story by conveying emotion in form and movement through abstraction.’’
She says:
”These compositions are a complex language of how I relive my past, how I self-reflect in the present, and how I hope for the future. Each painting is intricately tied to my personal history."
Main Street, in the Jeffersonville, Vt., Historic District
— Photo by Mfwills
Save The Bay Exploration Center and Aquarium, in Newport
—Photo by Kenneth C. Zirkel
A Wampanoag’s suppressed speech on tribe’s sad history
Fanciful version of Wampanoag SachemMassasoit smoking a ceremonial pipe with Plymouth Plantation Gov. John Carver in 1621.
To have been delivered at Plymouth, Mass., 1970
ABOUT THE DOCUMENT: Three hundred fifty years after the Pilgrims began their invasion of the land of the Wampanoag, their "American" descendants planned an anniversary celebration. Still clinging to the white schoolbook myth of friendly relations between their forefathers and the Wampanoag, the anniversary planners thought it would be nice to have an Indian make an appreciative and complimentary speech at their state dinner. Frank James was asked to speak at the celebration. He accepted. The planners, however, asked to see his speech in advance of the occasion, and it turned out that Frank James' views — based on history rather than mythology — were not what the Pilgrims' descendants wanted to hear. Frank James refused to deliver a speech written by a public relations person. Frank James did not speak at the anniversary celebration. If he had spoken, this is what he would have said:
I speak to you as a man -- a Wampanoag Man. I am a proud man, proud of my ancestry, my accomplishments won by a strict parental direction ("You must succeed - your face is a different color in this small Cape Cod community!"). I am a product of poverty and discrimination from these two social and economic diseases. I, and my brothers and sisters, have painfully overcome, and to some extent we have earned the respect of our community. We are Indians first - but we are termed "good citizens." Sometimes we are arrogant but only because society has pressured us to be so.
It is with mixed emotion that I stand here to share my thoughts. This is a time of celebration for you - celebrating an anniversary of a beginning for the white man in America. A time of looking back, of reflection. It is with a heavy heart that I look back upon what happened to my People.
Even before the Pilgrims landed it was common practice for explorers to capture Indians, take them to Europe and sell them as slaves for 220 shillings apiece. The Pilgrims had hardly explored the shores of Cape Cod for four days before they had robbed the graves of my ancestors and stolen their corn and beans. Mourt's Relation describes a searching party of sixteen men. Mourt goes on to say that this party took as much of the Indians' winter provisions as they were able to carry.
Massasoit, the great Sachem of the Wampanoag, knew these facts, yet he and his People welcomed and befriended the settlers of the Plymouth Plantation. Perhaps he did this because his Tribe had been depleted by an epidemic. Or his knowledge of the harsh oncoming winter was the reason for his peaceful acceptance of these acts. This action by Massasoit was perhaps our biggest mistake. We, the Wampanoag, welcomed you, the white man, with open arms, little knowing that it was the beginning of the end; that before 50 years were to pass, the Wampanoag would no longer be a free people.
What happened in those short 50 years? What has happened in the last 300 years?
History gives us facts and there were atrocities; there were broken promises - and most of these centered around land ownership. Among ourselves we understood that there were boundaries, but never before had we had to deal with fences and stone walls. But the white man had a need to prove his worth by the amount of land that he owned. Only ten years later, when the Puritans came, they treated the Wampanoag with even less kindness in converting the souls of the so-called "savages." Although the Puritans were harsh to members of their own society, the Indian was pressed between stone slabs and hanged as quickly as any other "witch."
And so down through the years there is record after record of Indian lands taken and, in token, reservations set up for him upon which to live. The Indian, having been stripped of his power, could only stand by and watch while the white man took his land and used it for his personal gain. This the Indian could not understand; for to him, land was survival, to farm, to hunt, to be enjoyed. It was not to be abused. We see incident after incident, where the white man sought to tame the "savage" and convert him to the Christian ways of life. The early Pilgrim settlers led the Indian to believe that if he did not behave, they would dig up the ground and unleash the great epidemic again.
The white man used the Indian's nautical skills and abilities. They let him be only a seaman -- but never a captain. Time and time again, in the white man's society, we Indians have been termed "low man on the totem pole."
Has the Wampanoag really disappeared? There is still an aura of mystery. We know there was an epidemic that took many Indian lives - some Wampanoags moved west and joined the Cherokee and Cheyenne. They were forced to move. Some even went north to Canada! Many Wampanoag put aside their Indian heritage and accepted the white man's way for their own survival. There are some Wampanoag who do not wish it known they are Indian for social or economic reasons.
What happened to those Wampanoags who chose to remain and live among the early settlers? What kind of existence did they live as "civilized" people? True, living was not as complex as life today, but they dealt with the confusion and the change. Honesty, trust, concern, pride, and politics wove themselves in and out of their [the Wampanoags'] daily living. Hence, he was termed crafty, cunning, rapacious, and dirty.
History wants us to believe that the Indian was a savage, illiterate, uncivilized animal. A history that was written by an organized, disciplined people, to expose us as an unorganized and undisciplined entity. Two distinctly different cultures met. One thought they must control life; the other believed life was to be enjoyed, because nature decreed it. Let us remember, the Indian is and was just as human as the white man. The Indian feels pain, gets hurt, and becomes defensive, has dreams, bears tragedy and failure, suffers from loneliness, needs to cry as well as laugh. He, too, is often misunderstood.
The white man in the presence of the Indian is still mystified by his uncanny ability to make him feel uncomfortable. This may be the image the white man has created of the Indian; his "savageness" has boomeranged and isn't a mystery; it is fear; fear of the Indian's temperament!
High on a hill, overlooking the famed Plymouth Rock, stands the statue of our great Sachem, Massasoit. Massasoit has stood there many years in silence. We the descendants of this great Sachem have been a silent people. The necessity of making a living in this materialistic society of the white man caused us to be silent. Today, I and many of my people are choosing to face the truth. We ARE Indians!
Although time has drained our culture, and our language is almost extinct, we the Wampanoags still walk the lands of Massachusetts. We may be fragmented, we may be confused. Many years have passed since we have been a people together. Our lands were invaded. We fought as hard to keep our land as you the whites did to take our land away from us. We were conquered, we became the American prisoners of war in many cases, and wards of the United States Government, until only recently.
Our spirit refuses to die. Yesterday we walked the woodland paths and sandy trails. Today we must walk the macadam highways and roads. We are uniting We're standing not in our wigwams but in your concrete tent. We stand tall and proud, and before too many moons pass we'll right the wrongs we have allowed to happen to us.
We forfeited our country. Our lands have fallen into the hands of the aggressor. We have allowed the white man to keep us on our knees. What has happened cannot be changed, but today we must work towards a more humane America, a more Indian America, where men and nature once again are important; where the Indian values of honor, truth, and brotherhood prevail.
You the white man are celebrating an anniversary. We the Wampanoags will help you celebrate in the concept of a beginning. It was the beginning of a new life for the Pilgrims. Now, 350 years later it is a beginning of a new determination for the original American: the American Indian.
There are some factors concerning the Wampanoags and other Indians across this vast nation. We now have 350 years of experience living amongst the white man. We can now speak his language. We can now think as a white man thinks. We can now compete with him for the top jobs. We're being heard; we are now being listened to. The important point is that along with these necessities of everyday living, we still have the spirit, we still have the unique culture, we still have the will and, most important of all, the determination to remain as Indians. We are determined, and our presence here this evening is living testimony that this is only the beginning of the American Indian, particularly the Wampanoag, to regain the position in this country that is rightfully ours.
Wamsutta
September 10, 1970
Sam Pizzigati: UAW victory’s global significance; next stop Tesla?
On Sept. 20, 1893, Charles and Frank Duryea of Springfield, Mass., built and then road-tested, in that city, the first American gasoline-powered car. During the early years of automobiles, several independent manufacturers built cars in the state. In 1900, Springfield gained Skene American Automobile Co. (based in Springfield but with its factory in Lewiston, Maine) and Knox Automobile. In 1905, Knox produced America's first motorized fire engines, for the Springfield Fire Department. Stevens-Duryea built cars in East Springfield from 1901 to 1915, and again from 1919 to 1927.
Via OtherWords.org
BOSTON
‘Working people the world over have celebrated the first of May as “International Labor Day” since 1886, when workers in the United States struggling for an eight-hour day staged a May 1 national protest.
Thanks to the new deal America’s auto workers have signed with Detroit’s Big Three — Ford, GM and Stellantis — that day could have new global significance. Their watershed new contracts all set April 30, 2028 as their expiration date.
If May 1, 2028 arrives without signed contracts for America’s unionized auto workers, UAW president Shawn Fain has made plain, these workers don’t plan on walking out alone.
“We invite unions around the country to align your contract expirations with our own so that together we can begin to flex our collective muscles,” says Fain. “If we’re going to truly take on the billionaire class and rebuild the economy so that it starts to work for the benefit of the many and not the few, then it’s important that we not only strike but that we strike together.”
But that May 1 day is clearly inviting coordination beyond the national level.
The May Day that workers worldwide have so long honored, Fain notes, has always been “more than just a day of commemoration, it’s a call to action.” And the labor movement worldwide is showing real signs of acting more in strategic concert.
Within the global auto industry, no corporation more embodies the inequality of our corporate world than the non-union Tesla. Under CEO Elon Musk, the world’s richest individual, Tesla pays wages that run substantially below those of Detroit’s Big Three, and that gap will only widen after the new UAW contracts go into effect.
The new UAW contracts, predicts German Bender of the Swedish think-tank Arena, could well “boost union interest among Tesla workers.”
That interest already seems to be growing. On the final Friday of the UAW walkout in the United States, workers at Tesla-owned servicing shops in Sweden went out on strike — after five years of fruitless attempts to get Tesla’s Swedish subsidiary to reach a bargaining agreement. That strike has now spread to all auto shops in Sweden that do work on Tesla cars.
This Swedish walkout represents the first formal strike against Tesla anywhere in the world. And the challenge to Tesla may be spreading. Germany’s largest union, Bloomberg reports, is hoping to organize a 12,000-worker Tesla plant near Berlin.
Tesla’s over 120,000 workers worldwide will see plenty to like in the new UAW contracts in the United States. At Ford, workers who started as temps making $16.67 an hour will automatically move to permanent status and an hourly wage rate of at least $24.91. That rate will hit $40.82 by the contract’s end, and any inflation between now and then will kick that rate higher.
Workers in major American industries haven’t seen gains that stunning since the middle of the 20th century, a time when the chief executives of America’s largest corporations averaged only just over 20 times the compensation of their workers. That gap today, the Economic Policy Institute calculates, is now running nearly 350 times.
But the greatest significance of the new UAW auto industry contracts may be the impact these bargaining triumphs will have on the future. These agreements could become the single most important step to a more equal world that any of us have ever seen.
The giants of American auto manufacturing, as Fain puts it, “underestimated” their own workers’ capacity to unite and fight together.
“We have shown the companies, the American public, and the whole world that the working class is not done fighting,” he adds. “In fact, we’re just getting started.”
Sam Pizzigati, based in Boston, co-edits Inequality.org at the Institute for Policy Studies. His books include The Case for a Maximum Wage and The Rich Don’t Always Win.
Will Brookline be a housing model?
Intersection of Harvard and Beacon streets at spiffy Coolidge Corner, in Brookline.
—Photo by Ddogas
Adapted from Robert Whitcomb’s “Digital Diary,’’ in GoLocal24.com
Brookline Town Meeting members have voted by a large margin to change zoning laws to encourage construction of more apartments and multifamily housing in commercial strips near MBTA routes. The idea is to add enough to the housing stock to slow the relentless rise in local housing costs, which among other things, threaten to make Massachusetts much less economically competitive. And the zoning change would help control sprawl.
The vote was a response to the MBTA Communities Act, which some communities have fought. That law requires multifamily zoning near public transit to address the region’s housing crisis. Brookline, like many affluent communities, has tended to fight increased density. The resulting scarcity, of course, has raised prices to the unaffordable level for many low-and-middle-income people.
Will Brookline be a model for the region?
Maybe, maybe not. Consider that in affluent Newton, voters in a low-turnout election tossed out three city councilors who backed a housing plan along the lines of Brookline’s.
Frank Carini: We need bats
An Eastern Small-Footed Bat, of a species found in New England.
Hollywood and literature routinely portray bats as blood-sucking monsters. It’s entertaining, but in reality, humans are a much bigger threat to these winged mammals than they are to us. In fact, their presence is beneficial in numerous ways.
Bats play an important role in the control of mosquitoes and agricultural pests. They save the United States about $1 billion annually in pest control. Bats in the Southwest and other warm areas around the world help plants grow by pollinating flowers. When nectar-drinking bats stick their long noses into flowers, they become covered in pollen that they then bring to other flowers. Through pollination, bats help grow avocados, bananas, and mangoes. In all, some 300 species of fruit depend on bats for pollination.
Also, of the 1,400 or so bat species worldwide, only three — the Common Vampire Bat, the Hairy-Legged Vampire Bat and the White-Winged Vampire Bat — feed solely on blood, mostly that of birds. You would have to travel much further south than southern New England to find one….
The eight species of bats that can be found in Rhode Island are divided into two classes: tree bats (Eastern Red Bat, Hoary Bat, and Silver-Haired Bat) and hibernators (Little Brown Bat, Big Brown Bat, Tricolored Bat, Northern Long-Eared Bat, and Eastern Small-Footed Bat). They are all insectivores.
To read the whole article, please hit this link.
Hold tight
“Grasping Liberty,’’ by Terry Rooney, at the PEG Center for Art and Activism, Newburyport, Mass. It’s part of the “Heroes Among Us’’ show, featuring 11 artists and a traveling Art Exhibit from the Rockwell Museum, Stockbridge, Mass.
In Newburyport: Boardwalk along the Merrimack River on a winter night.
—Photo by Caitlinmcooper
Llewellyn King: Liberal democracy, capitalism, church-state separation produce prosperity
Countries autocratizing (red) or democratizng (blue) substantially and significantly (2010–2020). Countries in gray are substantially unchanged.
— J Geest - Own work, data from Democracy Report 2021
WEST WARWICK, R.I.
With the world seemingly teetering between democracy and authoritarianism, you might feel overshadowed by gloom this Thanksgiving.
With some parts of the world torn by savage war and others wracked by persistent poverty and hopelessness, giving thanks may seem like a stretch. But make no mistake: More people than ever are living on this planet, and more are living better. Give thanks.
These are the people of a bountiful epoch stretching from the end of World War II to this day. In all of human history, never have so many enjoyed so much.
I am part of that most fortunate generation that grew up after the war ended, where hope marched arm-in-arm with prosperity. We expected to do much better than our parents in every way, and we did.
We expected life to improve on all its frontiers, from mobility to health, and it has. We expected to own something of value (maybe a house, a car, some savings), and we have.
More than ever, we have lived lives free from want, larded with good things. We have had high expectations, and they have been fulfilled.
My life and hundreds of millions, if not billions, of others have been better in every way than that of my parents and their contemporaries. They survived the Great Depression, a world war, and a life that was harder in every way.
Women were drudges, often confined to the home, cleaning, cooking, child-raising and just coping. Technology and social activism freed women from domestic slavery, which had been their lot since time immemorial. Now, they expect a full and equal part in life, and they are mostly getting it.
I am mobile in ways my parents never dreamed. My mother never traveled by plane and never expected to. She died of a cancer that was just allowed to spread because there was no other option.
My father’s greatest hope for himself was that he could provide food and shelter for his family. He had little of his own and expected little. His only indulgence was smoking. It was the thing he did that was his own, a small, comforting treat in a hard life as a mechanic.
Our family could only afford to take one vacation when I was growing up. Now, vacations are a given for many people, as is the mobility to make them special. When I am in an airport, I am awed by all the people going to and from all those places. This is not just true for the United States but for the whole prosperous world.
What makes for the life that so many now enjoy?
First and foremost is a democracy. Yes, querulous, slow to act democracy.
Authoritarianism ultimately affects the individual, subtracting freedom and adding nothing over time. Authoritarian governments soon start telling their people where they can travel, what they should believe. And they use fear as a tool, ever-present.
Countries that have enjoyed the bounty that has flowed since World War II are those with liberal democratic government, capitalism and a stout separation of church and state. This trinity is essential. If one is impeded, the whole structure is deformed. Implicit in this structure is that technology will be embraced, not impeded by the state, disallowed by religion, or monopolized by a few.
Even in these times of gloom, many have reason to cherish what they have and to be thankful. Thanksgiving as an institution is American, but the concept of gratitude after the harvest is universal.
What we have cultivated in the liberal democracies is a crop beyond all expectations. There is reason to give thanks.
Enjoy your family gathering and the bounty everywhere when the structure is right.
On Twitter: @llewellynking2
Llewellyn King, based in Rhode Island and Washington, D.C., is executive producer and host of White House Chronicle, on PBS.
Newport and China
At “The Celestial City: Newport and China” show at Rosecliff mansion, Newport through Feb. 11, except Nov. 16-Dec. 3.
The Preservation Society of Newport County (whose show it is), explains that the show:
“{E} explores China’s deep influence on Newport from the 18th century through the Gilded Age, when the city emerged as America’s premier summer playground and the fall of China’s last imperial dynasty transformed the ancient nation. The extraordinary objects displayed include more than 100 works in a range of media, from paintings, ceramics, and photographs to fashion, lacquerwares, and lanterns. Contemporary artworks by Yu-Wen Wu and Jennifer Ling Datchuk illuminate Chinese contributions to Newport as well as hidden connections between the Newport mansions and the Chinese-American experience.’’
Michelle Andrews: Primary-care physicians feel underpaid
From Kaiser Family Foundation (KFF) Health News
“You have to really want to be a primary-care physician when that student will make one-third of what students going into dermatology will make.’’
— Russ Phillips, M.D., internist and director of the Harvard Medical School Center for Primary Care, in Boston
Money talks.
The United States faces a serious shortage of primary-care physicians for many reasons, but one, in particular, is inescapable: compensation.
Substantial disparities between what primary-care physicians earn relative to such specialists as orthopedists and cardiologists can weigh into medical students’ decisions about which field to choose. Plus, the system that Medicare and other health plans use to pay doctors generally places more value on doing procedures such as replacing a knee or inserting a stent than on delivering the whole-person, long-term health-care management that primary-care physicians provide.
As a result of those pay disparities, and the punishing workload typically faced by primary-care physicians, more new doctors are becoming specialists, often leaving patients with fewer choices for primary care.
“There is a public out there that is dissatisfied with the lack of access to a routine source of care,” said Christopher Koller, president of the Milbank Memorial Fund, a foundation that focuses on improving population health and health equity. “That’s not going to be addressed until we pay for it.”
Primary care is the foundation of our health-care system, the only area in which providing more services — such as childhood vaccines and regular blood pressure screenings — is linked to better population health and more equitable outcomes, according to the National Academies of Sciences, Engineering, and Medicine, in a recently published report on how to rebuild primary care. Without it, the national academies wrote, “minor health problems can spiral into chronic disease,” with poor disease management, emergency-room overuse, and unsustainable costs. Yet for decades, the United States has underinvested in primary care. It accounted for less than 5 percent of health care spending in 2020 — significantly less than the average spending by countries that are members of the Organization for Economic Cooperation and Development, according to the report.
A $26 billion piece of bipartisan legislation proposed last month by Sen. Bernie Sanders (I-Vt.), chair of the Senate Health, Education, Labor, and Pensions Committee, and Sen. Roger Marshall (R-Kan.) would bolster primary care by increasing training opportunities for doctors and nurses and expanding access to community health centers. Policy experts say the bill would provide important support, but it’s not enough. It doesn’t touch compensation.
“We need primary care to be paid differently and to be paid more, and that starts with Medicare,” Koller said.
How Medicare Drives Payment
Medicare, which covers 65 million people who are 65 and older or who have certain long-term disabilities, finances more than a fifth of all health-care spending — giving it significant muscle in the health-care market. Private health plans typically base their payment amounts on the Medicare system, so what Medicare pays is crucial.
Under the Medicare payment system, the amount the program pays for a medical service is determined by three geographically weighted components: a physician’s work, including time and intensity; the practice’s expense, such as overhead and equipment; and professional insurance. It tends to reward specialties that emphasize procedures, such as repairing a hernia or removing a tumor, more than primary care, where the focus is on talking with patients, answering questions, and educating them about managing their chronic conditions.
Medical students may not be familiar with the particulars of how the payment system works, but their clinical training exposes them to a punishing workload and burnout that is contributing to the shortage of primary care physicians, projected to reach up to 48,000 by 2034, according to estimates from the Association of American Medical Colleges.
The earnings differential between primary care and other specialists is also not lost on them. Average annual compensation for doctors who focus on primary care — family medicine, internists and pediatricians — ranges from an average of about $250,000 to $275,000, according to Medscape’s annual physician compensation report. Many specialists make more than twice as much: Plastic surgeons top the compensation list at $619,000 annually, followed by orthopedists ($573,000) and cardiologists ($507,000).
“I think the major issues in terms of the primary-care physician pipeline are the compensation and the work of primary care,” said Russ Phillips, an internist and the director of the Harvard Medical School Center for Primary Care. “You have to really want to be a primary-care physician when that student will make one-third of what students going into dermatology will make,” he said.
According to statistics from the National Resident Matching Program, which tracks the number of residency slots available for graduating medical students and the number of slots filled, 89 percent of 5,088 family medicine residency slots were filled in 2023, compared with a 93 percent residency fill rate overall. Internists had a higher fill rate, 96 percent, but a significant proportion of internal medicine residents eventually practice in a specialty area rather than in primary care.
No one would claim that doctors are poorly paid, but with the average medical student graduating with just over $200,000 in medical school debt, making a good salary matters.
Still, it’s a misperception that student debt always drives the decision whether to go into primary care, said Len Marquez, senior director of government relations and legislative advocacy at the Association of American Medical Colleges.
For Anitza Quintero, 24, a second-year medical student at the Geisinger Commonwealth School of Medicine in rural Pennsylvania, primary care is a logical extension of her interest in helping children and immigrants. Quintero’s family came to the United States on a raft from Cuba before she was born. She plans to focus on internal medicine and pediatrics.
“I want to keep going to help my family and other families,” she said. “There’s obviously something attractive about having a specialty and a high pay grade,” Quintero said. Still, she wants to work “where the whole body is involved,” she said, adding that long-term doctor-patient relationships are “also attractive.”
Quintero is part of the Abigail Geisinger Scholars Program, which aims to recruit primary-care physicians and psychiatrists to the rural health system in part with a promise of medical school loan forgiveness. Health care shortages tend to be more acute in rural areas.
These students’ education costs are covered, and they receive a $2,000 monthly stipend. They can do their residency elsewhere, but upon completing it they return to Geisinger for a primary-care job with the health care system. Every year of work there erases one year of the debt covered by their award. If they don’t take a job with the health-care system, they must repay the amount they received.
Payment Imbalances a Source of Tension
In recent years, the Centers for Medicare & Medicaid Services, which administers the Medicare program, has made changes to address some of the payment imbalances between primary care and specialist services. The agency has expanded the office visit services for which providers can bill to manage their patients, including adding non-procedural billing codes for providing transitional care, chronic care management, and advance care planning.
In next year’s final physician fee schedule, the agency plans to allow another new code to take effect, G2211. It would let physicians bill for complex patient evaluation and management services. Any physician could use the code, but it is expected that primary-care physicians would use it more frequently than specialists. Congress has delayed implementation of the code since 2021.
The new code is a tiny piece of overall payment reform, “but it is critically important, and it is our top priority on the Hill right now,” said Shari Erickson, chief advocacy officer for the American College of Physicians.
It also triggered a tussle that highlights ongoing tension in Medicare physician payment rules.
The American College of Surgeons and 18 other specialty groups published a statement describing the new code as “unnecessary.” They oppose its implementation because it would primarily benefit primary care providers who, they say, already have the flexibility to bill more for more complex visits.
But the real issue is that, under federal law, changes to Medicare physician payments must preserve budget neutrality, a zero-sum arrangement in which payment increases for primary-care providers mean payment decreases elsewhere.
“If they want to keep it, they need to pay for it,” said Christian Shalgian, director of the division of advocacy and health policy for the American College of Surgeons, noting that his organization will continue to oppose implementation otherwise.
Still, there’s general agreement that strengthening the primary-care system through payment reform won’t be accomplished by tinkering with billing codes.
The current fee-for-service system doesn’t fully accommodate the time and effort primary-care physicians put into “small-ticket” activities like emails and phone calls, reviews of lab results, and consultation reports. A better arrangement, they say, would be to pay primary care physicians a set monthly amount per patient to provide all their care, a system called capitation.
“We’re much better off paying on a per capita basis, get that monthly payment paid in advance plus some extra amount for other things,” said Paul Ginsburg, a senior fellow at the University of Southern California Schaeffer Center for Health Policy and Economics and former commissioner of the Medicare Payment Advisory Commission.
But if adding a single five-character code to Medicare’s payment rules has proved challenging, imagine the heavy lift involved in overhauling the program’s entire physician payment system. MedPAC and the national academies, both of which provide advice to Congress, have weighed in on the broad outlines of what such a transformation might look like. And there are targeted efforts in Congress: for instance, a bill that would add an annual inflation update to Medicare physician payments and a proposal to address budget neutrality. But it’s unclear whether lawmakers have strong interest in taking action.
“The fact that Medicare has been squeezing physician payment rates for two decades is making reforming their structure more difficult,” said Ginsburg. “The losers are more sensitive to reductions in the rates for the procedures they do.”
Michelle Andrews is a KFF Health News reporter.
Michelle Andrews: andrews.khn@gmail.com
The trees that remain
‘‘Outside In” (acrylic on panel), by Concord, Mass.-based artist Irene Stapleford, in her show “Sightlines,’’ at Galatea Fine Art, Boston, Nov. 30-Dec. 31.
She says:
"From my modest home of more than a decade, I've appreciated the opportunity to observe and record some of my neighborhood's sightlines in paintings. Wildlife and trees, views of the nearby pond, and quiet peacefulness have reigned — until recently.
“Tremendous upheaval in my immediate surroundings has infused my plein air painting documentation with new urgency. Amid tree clearing, land excavation and construction activity adjacent to my home, I have continued to observe and paint. Many trees I've studied remain, but some are gone, cut down in their prime to make way for large new residences.
“As I experience these changing sightlines, the trees which remain have become my focus thanks to their steady, enduring, majestic and graceful presence.’’
What works for downtowns
Boston skyline on a windy, rainy day.
— Photo by Bert Kaufmann
In downtown Providence.
— Photo by Payton Chung
Adapted from Robert Whitcomb’s “Digital Diary,’’ in GoLocal24.com
Obviously, many jobs that have required being in a company’s office five days a week won’t be coming back, as remote work (whose adoption was rapidly accelerated by COVID) and artificial intelligence (which will probably destroy many millions of jobs) keep chomping away at them. This, of course, has presented a big challenge to city downtowns – some of which continue to report scary vacancy rates. But things aren’t as bad as has been presented, and indeed some downtowns are rebounding.
And even as employers have cut back on office space, more and more are demanding that employees who have been entirely remote return to the office at least several days a week. This requires precision planning! Good companies know that many good ideas, especially for problem-solving, come from in-person collaboration.
Hit these links:
https://centercityphila.org/uploads/attachments/clnkqulms0ngyngqdkvd1ozpk-downtowns-rebound-2023-web.pdf?utm_source=ccd&utm_medium=web&utm_campaign=downtowns&utm_id=report&utm_content=oct2023
https://www.bloomberg.com/news/articles/2023-10-31/despite-remote-work-downtown-nashville-is-thriving-for-residents-and-visitors?srnd=citylab
City officials are coming to realize that thriving downtowns will depend much more on recreational visitors and new and old residents drawn to their conveniences and cultural and other nonwork-related attractions and activities, and much less on workplaces (except the work done by staff at such places as restaurants, performance venues, museums and so on).
The Providence Food Hall, scheduled to open next year in the old Union Station, is an example of the exciting attractions that will keep people coming downtown as visitors and get some to want to live there. It will build on Rhode Island’s reputation as a food center.
BUT, the success of the food hall will depend to no small degree on the city stopping the social chaos and crime, and fear of crime, that sometimes envelop Kennedy Plaza. There are some fine examples of how public spaces that had become messes have been cleaned up and restored to the civic treasures that they had been. Consider Bryant Park, in Manhattan. (Thanks for the reminder, Brian Heller.)
Hit this link for an update on the Providence Food Hall project (named Track 15):
https://www.golocalprov.com/business/providence-food-hall-announces-name-and-initial-vendors
Downtown Providence is better positioned than many places to thrive in cities’ brave new world because of its walkable compactness, its colleges, whose students and staffs patronize local business, and the fact that a middle-and-upper-class neighborhood abuts it.
In Bryant Park, next to the New York Public Library.
— Photo by Kamel15
Mainers are like Norwegians
In far Downeast Maine Lubec, West Quoddy Head Lighthouse and Quoddy Narrows, with Grand Manan Island, Canada, in background.
“Almost everyone I spoke with in Maine who’s involved with the Arctic told me that Mainers have more in common with people from Iceland and Norway than they do with people from New York or California – they all live in relatively small communities with fairly extreme weather, and mainly depend on the ocean and other natural resources.”
Tatiana Kennedy Schlossberg (born 1990), environmental journalist, daughter of Caroline Kennedy Schlossberg and granddaughter of President John F. Kennedy
The woods are ready
“Forest Floor,’’ by Dan Hoftstadter, in his show “From Life: Drawings by Dan Hofstadter, ‘‘ at Atlantic Works Gallery, Boston, through Nov. 25.
The gallery says:
This is a show of “direct, perceptual drawings, unmediated by tools. The artist always keeps his sketchbook by his side, a constant companion to his work as an abstract painter and arts writer. Shown at the gallery are freehand landscapes – responses to wherever he was living at the time - along with portraits and figure studies.’’
Red memories
Cristine Kossow, “Summer by the Pound” (soft pastel), by Cristine Kossow, at Long River Gallery, White River Junction, Vt. She lives in Vermont’s (Lake) Champlain region.
Landsat photo of the immediate Lake Champlain region—only part of the much longer drainage basin and overall valley that reaches the Atlantic Ocean north of Nova Scotia via the St. Lawrence Seaway.
Daily Paintworks says Ms. Kossow:
“{E}njoys painting everyday objects, finding what is personal in the common items we all encounter --vintage tools; teacups; our animal friends; piles of produce; piles of anything really, because she loves the rhythm of repetition.
”Cristine has her prejudices. She likes to punctuate her work with a sneaky dash of periwinkle; it's her color. And she had a bitter feud with red for decades. But one summer, at the urging of a bumper crop of tomatoes, Cristine called an emotional truce and began a cascade of red musings that, in hindsight, mystify her.’’
Judith Graham: Who will care for elderly patients?
From Kaiser Family Foundation (KFF) Health News
Thirty-five years ago, Jerry Gurwitz was among the first physicians in the United States to be credentialed as a geriatrician — a doctor who specializes in the care of older adults.
“I understood the demographic imperative and the issues facing older patients,” Gurwitz, 67 and chief of geriatric medicine at the University of Massachusetts Chan Medical School, in Worcester, told me. “I felt this field presented tremendous opportunities.”
But today, Gurwitz fears that geriatric medicine is on the decline. Despite the surging older population, there are fewer geriatricians now (just over 7,400) than in 2000 (10,270), he noted in a recent piece in JAMA. (In those two decades, the population 65 and older expanded by more than 60 percent) Research suggests each geriatrician should care for no more than 700 patients; the current ratio of providers to older patients is 1 to 10,000.
What’s more, medical schools aren’t required to teach students about geriatrics, and fewer than half mandate any geriatrics-specific skills training or clinical experience. And the pipeline of doctors who complete a one-year fellowship required for specialization in geriatrics is narrow. Of 411 geriatric fellowship positions available in 2022-23, 30 percent went unfilled.
The implications are stark: Geriatricians will be unable to meet soaring demand for their services as the aged U.S. population swells for decades to come. There are just too few of them. “Sadly, our health system and its workforce are wholly unprepared to deal with an imminent surge of multimorbidity, functional impairment, dementia and frailty,” Gurwitz warned in his JAMA piece.
This is far from a new concern. Fifteen years ago, a report from the National Academies of Sciences, Engineering, and Medicine concluded: “Unless action is taken immediately, the health care workforce will lack the capacity (in both size and ability) to meet the needs of older patients in the future.” According to the American Geriatrics Society, 30,000 geriatricians will be needed by 2030 to care for frail, medically complex seniors.
There’s no possibility that this goal will be met.
What’s hobbled progress? Gurwitz and fellow physicians cite a number of factors: low Medicare reimbursement for services, low earnings compared with other medical specialties, a lack of prestige, and the belief that older patients are unappealing, too difficult, or not worth the effort.
“There’s still tremendous ageism in the health-care system and society,” said geriatrician Gregg Warshaw, a professor at the University of North Carolina School of Medicine.
But this negative perspective isn’t the full story. In some respects, geriatrics has been remarkably successful in disseminating principles and practices meant to improve the care of older adults.
“What we’re really trying to do is broaden the tent and train a health-care workforce where everybody has some degree of geriatrics expertise,” said Michael Harper, board chair of the American Geriatrics Society and a professor of medicine at the University of California-San Francisco.
Among the principles geriatricians have championed: Older adults’ priorities should guide plans for their care. Doctors should consider how treatments will affect seniors’ functioning and independence. Regardless of age, frailty affects how older patients respond to illness and therapies. Interdisciplinary teams are best at meeting older adults’ often complex medical, social, and emotional needs.
Medications need to be reevaluated regularly, and de-prescribing is often warranted. Getting up and around after illness is important to preserve mobility. Nonmedical interventions such as paid help in the home or training for family caregivers are often as important as, or more important than, medical interventions. A holistic understanding of older adults’ physical and social circumstances is essential.
The list of innovations geriatricians have spearheaded is long. A few notable examples:
Hospital-at-home. Seniors often suffer setbacks during hospital stays as they remain in bed, lose sleep, and eat poorly. Under this model, older adults with acute but non-life-threatening illnesses get care at home, managed closely by nurses and doctors. At the end of August, 296 hospitals and 125 health systems — a fraction of the total — in 37 states were authorized to offer hospital-at-home programs.
Age-friendly health systems. Focus on four key priorities (known as the “4Ms”) is key to this wide-ranging effort: safeguarding brain health (mentation), carefully managing medications, preserving or advancing mobility, and attending to what matters most to older adults. More than 3,400 hospitals, nursing homes and urgent care clinics are part of the age-friendly health system movement.
Geriatrics-focused surgery standards. In July 2019, the American College of Surgeons created a program with 32 standards designed to improve the care of older adults. Hobbled by the covid-19 pandemic, it got a slow start, and only five hospitals have received accreditation. But as many as 20 are expected to apply next year, said Thomas Robinson, co-chair of the American Geriatrics Society’s Geriatrics for Specialists Initiative.
Geriatric emergency departments. The bright lights, noise, and harried atmosphere in hospital emergency rooms can disorient older adults. Geriatric emergency departments address this with staffers trained in caring for seniors and a calmer environment. More than 400 geriatric emergency departments have received accreditation from the American College of Emergency Physicians.
New dementia-care models. This summer, the Centers for Medicare & Medicaid Services announced plans to test a new model of care for people with dementia. It builds on programs developed over the past several decades by geriatricians at UCLA, Indiana University, Johns Hopkins University and the University of California at San Francisco.
A new frontier is artificial intelligence, with geriatricians being consulted by entrepreneurs and engineers developing a range of products to help older adults live independently at home. “For me, that is a great opportunity,” said Lisa Walke, chief of geriatric medicine at Penn Medicine, affiliated with the University of Pennsylvania.
The bottom line: After decades of geriatrics-focused research and innovation, “we now have a very good idea of what works to improve care for older adults,” said Harper, of the American Geriatrics Society. The challenge is to build on that and invest significant resources in expanding programs’ reach. Given competing priorities in medical education and practice, there’s no guarantee this will happen.
But it’s where geriatrics and the rest of the health-care system need to go.
Judith Graham is KFF Health News reporter.
Role reversal
“Upscale Your Den and Live Fully” (graphite and colored pencil on paper), by Boston-based artist Sammy Chong, in his show, opening Nov. 24, “Be Beast,’’ at 3S Artspace, Portsmouth, N.H.,
The gallery says:
“In Sammy Chong’s surreal drawings of endangered species, anthropomorphized animals are empowered as the dominant species in a hierarchical, fictional reality. Shining light on animal extinction, the work reminds viewers about the impact of our habits and choices on the world and its creatures.’’