Starting With Curious

                I recently spent 40+ hours over 4 months getting my wife enrolled in Medicare. The craziness of how challenging this was for someone with, arguably, a lot more specialized knowledge of the healthcare system than the average person (and even I needed to invoke the help of my Congressperson’s staff to get across the finish line) could itself be the topic for a column. There are many reasons for this situation, but one I want to explore is the role of the market. Although Medicare is ostensibly a government program, much of it is privatized. Consumerism has been proposed as the answer to the American healthcare woes of high costs with lagging results in terms of actual health outcomes. Give people more choices, with transparency about costs and quality, and the invisible hand of the market will make it all better. I have long been suspicious that this can actually work with healthcare (it certainly hasn’t so far). But now I find myself wondering whether even if it could deliver better value, is it the right thing to do?

                To someone like me who went into healthcare out of a sense of mission and calling, consumerism has always felt a little icky, though I couldn’t well articulate why. I recently read Michael Sandel’s 2012 book What Money Can’t Buy: The Moral Limits of Markets. In it Sandel, a Harvard political philosopher who has also written on justice and “meritocracy,” talks about the enormous expansion in recent decades, particularly in the US, of the role of markets in society. He describes the shift from a market economy, which is a tool for efficiently organizing productive activity, to a market society where market values dictate nearly every aspect of human activity, not just economic transactions but social relations. As the title of the book suggests, he believes that some things should not be left to the market, not for practical reasons but for moral ones. He raises two overall causes for concern: equity and corruption. While the book is not primarily about healthcare, I couldn’t help but conclude that it is one of the things where more marketization should raise alarm bells. I’ll tackle the latter concern, corruption, in the next installment of this blog. For now, let’s consider how marketizing healthcare threatens equity.

                The basic principle behind market transactions is that people, acting in their self-interest, pursue those goods they most want. Prices are determined by the balance of supply and demand, and goods are then allocated to the people who most value them based on their willingness to pay. If tickets to the Vikings and a dinner at the Four Seasons each cost $300, then the person who prefers football to fine dining will get the tickets because they are willing to pay for them, leaving the dinner reservation to the gourmand who really wants them. Each one, pursuing their own interest, gets what they want. Everyone is happy.

                This assumes that those individuals have the means to purchase one of these goods. I might really want those Vikings tickets, and be willing to pay $300 for them, but if I don’t have that $300 I can’t have them. Markets are based on allocation according to willingness to pay. But willingness to pay is not the same as ability to pay. Money is unevenly distributed in society – increasingly so in the US – so the ability of the market to allocate goods to those who most value them is restricted. (Indeed, when someone is constrained enough, choices may be not only limited, but coercive. I may not want to sell my plasma, but if I’m desperate enough I will.)

                With greatly uneven distribution of economic resources – of ability to pay – some people will be unable to obtain something they value a great deal. “I’d give anything for…” is a common sentiment, but very few people are in a position to literally give anything.  At the same time others with excess resources may obtain things they don’t have a great desire (or need) for simply because they can. This may not matter for stereo equipment or luxury cars, but can lead to troubling inequities if we are talking about the distribution of medicines and healthcare services.

                Fair markets also assume equal access to information about the transaction. In reality, not only is money distributed unevenly, so is information. As my Medicare enrollment experience illustrated, modern healthcare is incredibly complex. And transparency is at best a tiny step toward equalizing information. There are so many variables, with so many degrees of uncertainty, from so many different sources, it is unrealistic to think that the ability to process it can be equal. (Even if there weren’t active disinformation going on, including from our own government.) If people have different levels of knowledge about the benefits and drawbacks of a good, different abilities to know what they are getting for their money, then the transaction cannot be truly equitable.

                If a healthcare market is prone to inequity by allocating the goods and services based on willingness (or more accurately ability) to pay, is there a more equitable alternative? In many systems, willingness to pay is replaced by willingness to wait, or queuing. This is a criticism often raised by market advocates about single-payer, non-market-based systems, that they lead to waits for care. This is often true. But it can be argued that time is distributed more evenly in society than money is, though not completely so, and therefore willingness to wait is a fairer system. And to be clear, we also have waits, though in our system, it’s a bimodal distribution: some people don’t wait very long, while others wait literally forever.

                And there are ways to make a market-based healthcare system more equitable. Health insurance does that by spreading risk across the population, and income-based subsidies for insurance can reduce disparities in access. Standardizing benefits and information, like the ACA marketplace or the letter system for supplemental Medicare (“Medigap”) plans, can reduce information disparities, though trust me, it remains complex.

                But inequity isn’t the only concern about markets in healthcare. Markets are about allocating value, but are agnostic about values. It is the corrupting effect of markets that is even more troubling. We’ll look at that next time.

This is written testimony I submitted to the Minnesota House Public Safety Committee regarding legislation to ban certain weapons of war.

I am a board-certified pediatrician and pediatric emergency physician. For 25 years working in pediatric emergency departments, I treated children and teens who were victims of gun violence. I saw what happens when a bullet rips through a small, fragile body. I saw what happens when a teen in despair turns a gun on herself. I heard the fear and the anguish these children experience when a bullet rips through their psyche. These are not images I or my colleagues ever forget. They are heartbreaking. And they are all the more heartbreaking because every one of them did not have to happen. These injuries and deaths are preventable.

There are many things we can and should do to reduce the harm from gun injury. None is going to eliminate the problem on its own. There is no single solution. Gun injury is a public health problem, and it requires a public health approach which is by nature multi-faceted. Some approaches to reducing gun injury cost money, and some will involve important debates around freedom and rights, all of which can create controversy. But one action that should be non-controversial is banning the deadliest firearms: assault weapons.

Many people choose to own guns, for a variety of legitimate reasons – hunting, recreation, protection. Assault weapons were not designed for any of those things. They were designed for war. They were designed to kill people, and to make it easy to kill people. Our second amendment establishes a right to bear arms, but courts – even the current Supreme Court –  have established that this is a qualified right. No one has reasonably suggested that it extends to civilians possessing bombs, hand grenades, or antitank weapons. These are rightly recognized as weapons of war. So are assault rifles and high capacity magazines.

The mechanics of this are very simple – more bullets fired with more force cause more injury. And the epidemiology is also pretty simple. We know from research, including from when we had a federal assault weapons ban in this country, that bans on those weapons of war save lives. It really is that simple.

Since 2020, gun injury has been the leading cause of death for children in the US.  Each and every day, an average of a dozen children die of an injury caused by a bullet fired from a gun. While banning weapons of war will not prevent all of these deaths, it will help prevent mass shootings like the one that occurred last year at Annunciation Church in my neighborhood of Minneapolis. I encourage you to pass HF3433 and HF3402 as a way to help ensure my soon to be born grandchild can grow up in a world where preventable gun injury is not the biggest threat to their life.

One of the oldest documented cases of fraud is reported in Genesis chapter 29. Jacob worked for his prospective father-in-law, Laban, in exchange for marrying Laban’s daughter Rachel. However, on the wedding night, Laban tricked Jacob by substituting his other daughter, Leah, and Jacob was forced to work another seven years for the right to marry Rachel. (Not only fraud, but bigamy to boot.) Fraud is as old as humanity. And stereotypes aside, it appears to be universal among human societies.

But if you listen to the Trump administration and other Republicans, you would think it was something unique to Democratic-led states and people of color. “U.S. Treasury Secretary Scott Bessent Takes Decisive Action Against Somali Fraud in Minneapolis,” read a government press release. Conservative commentators can’t stop writing about “Minnesota’s Somali Fraud.”  This is nothing more than political retribution and racism that, in addition to being vile in and of itself, threatens to divert resources from tackling much bigger problems, and distracting from the actual root causes of fraud in public services.

Now I do not want to suggest fraud is not real. A study from George Washington University estimates that fraud in healthcare alone accounts for 3-10% of total spending. This would equal between $150 billion and $530 billion of the $5.3 trillion the US spent on healthcare in 2024. And there is another $2 trillion in other social service spending at federal, state, and local levels, also subject to fraud. The GW study suggests that eliminating fraud would yield more than enough to cover all uninsured Americans. So yes, fraud is a huge problem.

But the current obsession with “Minnesota Somali fraud” is misleading and dangerous. First, it unfairly demonizes one community for racially tinged political gain. Take Feeding Our Future, the non-profit that stole hundreds of millions of dollars in pandemic relief funds. While the vast majority of those implicated are Somali American, the convicted mastermind and ringleader is a White woman. The state officials who appeared to be ignoring warnings about the fraud at Feeding Our Future are also not Somali American. And some of the largest fraud cases in the past few years include: $73 million in fraudulent claims by Gary Martin of Texas;  $1.3 billion in fraudulent claims and kickbacks by Floridian Philip Esformes; and ongoing investigations into massive Medicare fraud at United Health Group. Minnesota has one of the largest Somali populations in the world, second only to Mogadishu (capital of Somalia). It would be surprising if Somalis were not represented among those committing fraud, just as they are represented among those providing healthcare, those in public service, those in the arts, etc.

This not only barely disguised racism, it also gets in the way of actually preventing fraud. According to US Sentencing Commission statistics, the top jurisdictions for government benefits fraud in 2024 were:

• Southern District of Florida (69);
• Eastern District of North Carolina (35);
• District of Puerto Rico (33);
• District of South Carolina (29);
• Eastern District of Virginia (26, tie);
• Southern District of New York (26, tie);
• Southern District of Texas (26, tie).

And 93.3% of those convicted of fraud were US citizens. By focusing on places like Minnesota, the Trump administration is missing out on the opportunity to follow the Willie Sutton principle of going where the money is (including large, Republican controlled states).

Asserting that some communities are uniquely prone to fraud also masks the real root cause, which is not the moral failings of liberals or immigrants, but the accelerating privatization of public benefits. In a democracy – even one that is under assault like ours – it’s very difficult to steal money directly from government coffers. The outsourcing of social services, promoted as being more efficient, actually creates layers of complexity that make it much easier to commit fraud. And increasingly, the task of detecting fraud is also outsourced to private companies, with predictable consequences. In addition to identifying and punishing those who have taken advantage of the system, we need to think about reining in the mass privatization that allows those abuses to occur.

To be clear, there are signs that due diligence was overly lax here in Minnesota in the past few years, a gap the state is now taking steps to correct. The governor and attorney general appear to have every incentive to want to find and punish the fraud. Unfortunately, the federal authorities, and many Minnesota Republicans, appear more interested in bashing immigrants and sheltering their corporate sponsors than in protecting the public good.

“The ultimate measure of a man is not where he stands in moments of convenience and comfort, but where he stands at times of challenge and controversy.” – The Rev. Dr. Martin Luther King, Jr.

Trigger warning: For those who think it’s facile and overwrought to make comparisons between 2020s America and 1930s Germany, you may want to skip this essay. Also, I urge you to read William Shirer’s The Rise and Fall of the Third Reich. Maybe it will become clearer to you.

For the second time in five years, Minneapolis – and America – is in crisis. For the second time, an unarmed civilian was murdered in broad daylight by uniformed officers of the state, an act that was captured on video and circulated around the world. For the second time, the people of the city are responding to state-sanctioned violence with resistance, with vigilance, and with mutual aid. But this time, the response of so-called leaders could not be more different.

In 2020, just a few days after George Floyd was choked to death by a Minneapolis police officer, the CEOs of nearly every major company in the state issued a statement condemning his killing and the systemic racism it so vividly demonstrated. They also committed to taking actions to address racial inequities and social justice. Now, I know from my own experience then that within the companies we led, and the communities we served, there were widely divergent opinions about Mr. Floyd’s killing, policing, and the issues of equity and inclusion. So this wasn’t necessarily an easy step for these CEOs to take in that moment. It was an act of courage, an expression of principle over expedience.

Contrast that to now. There has been near silence from business leaders about the murder of Renee Good by an ICE agent, and about the mass deployment of para-military forces engaged in widespread acts of harassment, intimidation, and violence in Minneapolis and many other communities in our state. And let’s be clear: this has little to do with immigration. It is about intimidation.  Citizens and non-citizens alike are being indiscriminately kidnapped and assaulted. For goodness sake, four of those detained are members of the Oglala Sioux Nation! (Oh, and despite the rhetoric about going after criminals, DHS’ own data shows that fewer than half of those captured have any criminal record at all, and only about 5% for violent crimes. Less than at a reunion of January 6^th rioters.)

Where are our leaders, as our community is under assault? As our nation is engaging in neo-colonial undertakings around the world and alienating our friends and allies? As the rule of law is being dismantled in front of our eyes? Where the hell are our leaders?

Many would argue that the main responsibility of a CEO is to maintain the value of their company, to act in the best interests of its owners, the shareholders. Others would expand that to include other stakeholders such as customers and workforce. But the leader’s duty is to their company, first and foremost.

Even taking that view of a business leader’s obligations, it’s hard to argue that the ICE surges, and more broadly the Trump Administrations upending of legal processes, is good for business. It can’t be good for business if employees and customers alike are afraid to leave their homes. It can’t be good for business if trust in institutions is further undermined. It can’t be good for business if contracts can be arbitrarily canceled, if economic policy is conducted by the whim of a president who is at least narcissistic and at worst unstable, if society is becoming further and further fragmented.

My first thought was that the silence is due to fear. This would be understandable, given the demonstrated tendency of Trump to use the full force of the federal government to punish anyone who disagrees with him. Indeed, unlike the business community, elected officials in Minnesota have been strong in their condemnations of the administration’s actions and they are paying for their courage. (Well, at least some of them, including Minneapolis Mayor Jacob Frey and Gov. Tim Walz. Not sure what’s happening on the other side of the aisle.)

Then, I discovered the writings of Ernst Fraenkel, a Jewish lawyer who fled Nazi Germany in 1938 for the US. In his book The Dual State, he noted that the fascist regime built its totalitarian power gradually. Prof. Aziz Huq writes in The Atlantic, “As Fraenkel explained it, a lawless dictatorship does not arise simply by snuffing out the ordinary legal system of rules, procedures, and precedents. To the contrary, that system – which he called the “normative state” – remains in place while dictatorial power spreads across society. What happens, Fraenkel explained, is insidious. Rather than completely eliminating the normative state, the Nazi regime slowly created a parallel zone in which ‘unlimited arbitrariness and violence unchecked by any legal guarantees’ reigned freely. In this domain, which Fraenkel called the “prerogative state,” ordinary law didn’t apply.” Like the proverbial frog in the pot of heating water, we don’t recognize when we have slipped over completely to rule by executive prerogative until it is too late. This is especially likely when the loss of legal guarantees applies only to marginalized groups: Jews and Communists in 1930s Germany, people of color in 2020s America. It is easy for those in positions of privilege and power to be in denial.

We do still have much of our normative state. Large companies are allowed to engage in mega-mergers, individuals are still allowed to challenge government actions in court, people file their taxes and get passports and vote. But make no mistake: what we are seeing in Minneapolis today is an example of the prerogative state. When George Floyd was killed, the legal system followed normal procedure and justice was done. When Renee Good was killed, the Department of Justice simply decided it was justified, they would not investigate, and they would not help the state of Minnesota do so either. Our companies may be able to conduct business more or less normally for now. But for how long?

I’m not suggesting we are on the verge of a full-fledged fascist dictatorship (though it is a possibility that is distressingly more realistic than I would have ever imagined). I am suggesting that unless something is done, further erosion of the rule of law is almost certain. And as we have seen throughout history, that can be successfully resisted.

Whether out of fear or denial, our business leaders have been silent. We need them to speak up. We need them to resist. Perhaps it is starting. Last week the Minneapolis Chamber of Commerce, not exactly a hotbed of radicalism, released a statement that, while measured, was clear in calling out the current harassment being conducted by ICE and the need for redress when government acts unconstitutionally. There’s still a lot of crickets, but I hope more voices will follow. Because as Dr. King also said, “In the end, we will remember not the words of our enemies, but the silence of our friends.”

Well, it’s been a minute…It’s hard to believe my last post here was over 3 years ago. Not that I’ve been idle. I’ve had an “official” blog at Children’s Minnesota, and I’ve written a book, Saving Our Kids, that lays out a public health approach to the gun violence crisis that I talked about in my last Starting With Curious post. But to be honest, I felt that despite the disclaimers about the views here being my own, it was difficult to keep it completely separate from my role as a CEO. I thought having this blog on hiatus was best for my organization.

But as of this past summer, I am retired! I can more freely write about things affecting the health and wellbeing of kids. And man, is there a lot to write about.

I’m back!

Recent studies in Pediatrics and the New England Journal of Medicine show that thanks to a sharp decline in deaths from motor vehicle crashes, and an increase in gun deaths (especially suicide), in 2019 guns became the leading cause of death for all US youth age 0-19.  More than childhood cancer, drowning or poisoning – combined.  This has generated some media attention, which I have mixed feelings about; after all firearm injury has been the leading cause of death for Black youth since 2001.  Also, while I’d love to think this might jolt policy-makers into action, it is unlikely, despite the inevitable hand wringing, that we will see any of the common sense measures to reduce this epidemic such as those proposed by the study authors, the same types of regulatory measures that have dramatically improved motor vehicle safety while still allowing free access to automobiles.  Perhaps it’s time to follow the advice of singer-songwriter Cheryl Wheeler.

Dear Dr. Watson:

As Dean of the medical school, you have a responsibility to train the next generation of health care providers.  I believe the time has come for some significant changes in our curriculum.

First, we should prohibit physicians from asking questions about illness and health.  We are taught, “first, do no harm.”  But talking about their symptoms might make some people uncomfortable.  They might feel guilty about the fact that they still smoke, or experience mental anguish when confronted with the need to reduce their salt intake.

Similarly, we should not be prescribing treatments that have any side effects, even if it is a minor discomfort.  It is not right to make someone uncomfortable solely because they have an illness.

You could argue that if we don’t ask questions about health or provide treatments, patients would not get healthy.  But honestly, I think we are making too big a deal about health.   These days, it seems everyone is trying to make everything about health. You can’t turn on the TV or the radio, or look at social media, without someone raising the issue of health. Health might have been an issue a long time ago, but now that we have antibiotics, illness isn’t a problem anymore.  People need to just get over it.

Now that we have finally stopped making people uncomfortable by talking and teaching about race, thanks to legislators in Tennessee, Texas, Wisconsin, and other places, it’s time to stop making people uncomfortable about their health status.

Today is a day set aside to remember the Rev. Dr. Martin Luther King, Jr., and to reflect on his legacy.  It’s also important to call out when that legacy is being misrepresented, as has been happening by those who want to limit the teaching and discussion of the subject of race in schools.

Over the past couple of years, and particularly following George Floyd’s murder in 2020, the notion of systemic and institutional racism became a topic of national conversation.  Recently there has been a backlash, as school boards and state legislatures have passed a number of bills intended to restrict what is taught about race and how.  Tennessee House Bill SB 0623, for example, prohibits teaching that could lead a student to “feel discomfort, guilt, anguish or another form of psychological distress solely because of the individual’s race or sex.”  In Texas, House Bill 3979 forbids teaching that “slavery and racism are anything other than deviations from, betrayals of, or failures to live up to, the authentic founding principles of the United States.”  It also specifically bans requiring assigning the 1619 Project, based on a series of articles in The New York Times Magazine, as a resource.

How American history and the topic of race are taught is a legitimate and important area of discussion.  But what is disturbing is that proponents of these laws are citing none other than Dr. King to support their stance.  Here is a representative quote: “Martin Luther King once said that he had a dream that his grandkids would be judged not by the color of their skin but by the content of their character. But what you have going on … they’re trying to make everything about skin color.”  And another: “Critical race theory goes against everything Martin Luther King has ever told us, don’t judge us by the color of our skin, and now they’re embracing it.”

As is true of most things in life, context is everything. Yes, Dr. King spoke hopefully and eloquently of a day when color will not be relevant.  But he had no illusions that such was the case today.  Consider the opening of that same speech:

“Five score years ago a great American in whose symbolic shadow we stand today signed the Emancipation Proclamation. This momentous decree was a great beacon light of hope to millions of Negro slaves who had been seared in the flames of withering injustice. It came as a joyous daybreak to end the long night of their captivity. But 100 years later the Negro still is not free. One hundred years later the life of the Negro is still badly crippled by the manacles of segregation and the chains of discrimination. One hundred years later the Negro lives on a lonely island of poverty in the midst of a vast ocean of material prosperity. One hundred years later the Negro is still languished in the corners of American society and finds himself in exile in his own land. So we’ve come here today to dramatize a shameful condition.”

He went on to call the Declaration of Independence and Constitution a “promissory note,” pledging the blessings of life, liberty, and the pursuit of happiness to all people.  But, King said, “It is obvious today that America has defaulted on this promissory note insofar as her citizens of color are concerned. Instead of honoring this sacred obligation, America has given the Negro people a bad check which has come back marked ‘insufficient funds.’” It was only after he laid out what he saw as the reality of persistent racism in the present that he went on to share his beautiful, hopeful dream of a better future.

If we look at some of Dr. King’s other speeches and writings, the context becomes even clearer.  In his 1967 speech “The Other America,” for example, he notes “we will never solve the problem of racism until there is a recognition of the fact that racism still stands at the center of so much of our nation, and we must see racism for what it is.”  However, in “Where Do We Go From Here,” written that same year, he laments that not everyone sees the same reality. “Whites, it must frankly be said, are not putting in a similar mass effort to reeducate themselves out of their racial ignorance. It is an aspect of their sense of superiority that the white people of America believe they have so little to learn.”

Yet learn we must, adults and children, White and Black. We must understand our American history and our American present if we hope to create a better American future of the type Dr. King dreamed of. How we do that – what we teach and how – is a complex subject, and a debate we should have. But that debate needs to be honest.  Dr. King may have had a wonderful dream, but he was not subject to illusions.  We should not misuse his words to defend a position he would not support. Today is a day to honor Dr. King’s legacy. Let’s make sure we get it right.