There is a moment, when performing a stage play, when you, as an actor, instinctively know that everything is working as designed. It usually happens sometime in the first act (and it’s generally best that it happens within the first fifteen minutes) – there’s a change in the energy in the theatre. You can feel that the audience has absorbed the rules for the evening and it engrossed in what’s unfolding on stage. You can relax as you know that no matter what happens moving forward from now until curtain call, it’s simply going to carry you, your cast and crewmates and the audience through to the end of the evening. It’s something like a river flowing. You just surrender to the current and trust. Doesn’t mean you don’t move the tiller or change the position of the sails occasionally to take advantage of what the river offers.

Soul Food: Another Serving, my current project, hit that mark last night. I wasn’t really expecting it. Due to various issues with production, getting the show on stage in final form was something of a drama in and of itself and opening, night, while the usual theatrical magic held it together, had its shaky spots. Last night, however, the blend of comedy, drama, great performances, and an audience eager to see characters to whom they could relate on stage made everyone realize something special was going on. And I can’t wait to do it one last time tonight. (Although, as the Soul Food series of plays appears to be ongoing, my character may be back in another one sometime).

Moments like last night remind me of how important it is to have theatre for particular audiences, not just pieces designed for mass consumption. There need to be pieces that represent and speak to different segments of society, that reflect who they are and their aspirations, and how they too belong in the wider world. And audiences need to be inquisitive enough to seek out works that don’t necessarily speak to them. Go to a show aimed at Black audiences when you’re not Black. Go to a LGBTQ themed show when you’re straight. Go to a political show which attacks the status quo when you’re well off and benefit from current systems. It’s the sort of thing which makes you think, see the world in new ways, and helps you become a better person. I love traditional American musical theatre and could easily spend my time, talents and energy solely working with and promoting that artform but, as I have aged, I’ve come to the conclusion that it’s far more important for me to work with and encourage smaller companies with very different objectives. We’re only going to get through this current political moment by finding our commonalities and being willing to see other perspectives, otherwise tribalism will continue to be the order of the day and those with the biggest mouthpieces will dictate for us all.

The metaphor of the river has been popping up in various places all week. My current classic read (I’m usually reading four or five books at once in various categories, one of which is a classic I missed along the way) is George Eliot’s The Mill on the Floss. I’ve never read any Eliot before (Dickens being my Victorian novelist go to). In terms of style, Eliot is a lot less fun than Dickens and a great deal more ruminative, but she digs deeper into the psychology of her characters and their relationships with each other and, more importantly, with the strictures of their society regarding gender and economic status. I haven’t quite reached the end but all of the references to the River Floss and various floods suggest that heroine Maggie is likely to end up like Eustacia Vye in Thomas Hardy’s Return of the Native.

We’re all more or less caught up in a the river of socio-politics and current events as well. Each of us in our own little boat. I’m rowing mine solo these days, more often than not, so there’s not a lot I can do other than be carried along by the current but I am keeping alert, trying to keep myself from running aground on the shoals and trading information with the skippers of other boats so that we all navigate safely downstream. It isn’t easy. Current headlines tell me that the US is trying to force a Russian victory which will likely irrevocably damage NATO and Europe down Ukraine’s throat. The fallout from that is likely to be unpleasant, no matter what goes down. Everyone’s favorite congress critter MTG has announced her resignation. She used her special vituperative brand of rhetoric against Democrats and the Left for years without consequences. She turned it on the Right and has been deplatformed in a matter of weeks. That should tell you something.

Given my personal expertise, the grimmest development of the last week is the CDC website now trumpeting antivax propaganda at the behest of RFK Jr. The CDC has long been the gold standard of health science in this country. It has now been thoroughly politically compromised and there is no way to trust anything that appears under its imprimatur. It’s sad. It will take decades to repair that kind of damage. I won’t be part of the medical system that has to rebuild in that way. That will be up to a younger generation. I hope William Cassidy MD of Louisiana who cast the deciding vote in favor of this philosophy can look back on his legacy with pride. I’m spending the next couple years working on my medical legacy. I think it’ll be a bit more positive.

In the destruction of the Department of Education, the federal government announced this week that nurses, physical and occupational therapists, social workers are no longer ‘professionals’ in the way that physicians or even chiropractors are. In practical terms, this will limit the numbers entering those fields as they will be unable to finance their educations with federal loans. This announcement, coming six weeks before the first Boomers turn eighty is not only enraging but mystifying. The health issues of those in their 80s and 90s, being chronic in nature, require the kinds of interventions made by nurses and therapists and social workers far more than the kinds of interventions made by physicians. I can only do what I can do because I work in terms and in tandem with the professionals in those fields. We already have shortages in these fields, especially when it comes to caring for geriatric populations. Without this workforce, the aging Boomers, unless well healed and able to contract for private care, will die prematurely. I guess that’s the point. Lower the geriatric population and life expectancy so Medicare and Social Security costs go down. The decade I refer to as The Uncertain 80s are about to get a lot more uncertain for us all.

It’s been a week of almost. Various things have gotten near to succeeding in some way but nothing has quite gotten over the edge. I’m used to that in life. It’s the way most things actually turn out. You shoot for a goal and you don’t quite make it. I don’t usually get discouraged. If I did, I’d never get anything done. I just regroup, take a slightly different aim and keep on plugging away. That seems to be where things are at not just on the personal but also the political field at the moment. One feels that we’re almost at the point where there’s going to be some accountability for the various tramplings of norms and laws that have become an everyday occurence but we never quite seem to reach the tipping point. I suppose it has something to do with the monetized media culture in which we bathe. There’s more money to be made in perpetual anticipation than there is in resolution.

The first ‘almost’ involves personal health. I took my Tuesday federal holiday and headed off to the outpatient surgery center at UAB West for my second set of injections into my cervical nerve roots on the left hoping that it would quell my shoulder girdle pain that came rip roaring back at the end of September. When I had it done last year, it was relatively easy – no anaesthesia, just lie still and a little local lidocaine. This time, fully out with the propofol and midazolam. I, of course, felt wrong for the next day or so while alll of that wore off. Did the procedue succeed? I’ll have to say almost. I think things are better, but I haven’t had the significant relief I did last year. I’ll give it a couple of weeks to see if the steroids kick in more over time. If not, on to plan B which will involve almost anything short of cervical spine surgery. I’ve seen far too many disasters with that over my career. Of course, two days later, while still a bit off, I tripped on a piece of rough sidewalk descending the 20th Street hill on Southside and skinned up my hands and knees. I’ll have to answer yes to the ‘Have you fallen in the last three months?’ question at my next checkup. Peepaw gonna have to remember. Ground Hard! Fall Bad! and start taking his walking stick…

The next almost is my attempt to fully come off book for Soul Food: Another Serving before this weekend’s rehearsals. I have my lines down – mainly – but they aren’t exactly where I want them yet. I’ve got three tech dresses before opening to be sure they’re all in place. I have my various tricks for learning and remembering them and I’m employing them all for this project as the rehearsal period has been short. I hope my castmates all give me some grace and remember that I am multiple decades older than most of them. As it’s starting to come together, it looks like the end result is going to be fun. I have a couple of really good scenes which should get me some significant laughs if I play them right. Plays next Thursday through Saturday at The Carver Theatre in town – presented by Encore Theatre and Gallery and tickets available at http://encorebham.org

The next almost are my attempts to get fully caught up at work prior to the holidays so I can actually spend some of those extra days off doing plenty of nothing rather than playing catch up. The routine work load is pretty much taken care of. I’ve got two legal cases that I have to complete, each with many thousands of pages of records that I have to finish reviewing and I just haven’t been able to fully gird up my loins on those yet. I have promised myself they will be done by the end of the month. We’ll see if I can keep that particular promise.

Then there are the almosts on the national stage. The headlines remain as absolutely nutty as they have since late January when the new administration assumed power. I really should be writing some new Mrs. Norman Maine columns but I’m finding it impossible to write her at the moment. No matter how crazy an idea I dream up for her next adventure, something even wackier hits the news the next day. Same reason why I can’t really do anything with Politically Incorrect Cabaret – how can you satirize the political moment in which we find ourselves? If I’d started writing a version a few months ago in which the president took a wrecking ball to the White House, the Republican party campaigned proudly on withholding food aid and healthcare, and Margery Taylor Green became a voice of reason, people would have told me I was going too far.

Where are the current almosts taking us? We’re about to attack Venezuela over something called ‘narcoterrorism’ that doesn’t actually exist. The real reason is likely that Venezuela’s oil reserves are bigger than Saudi Arabia’s and the oil and gas industry is salivating over getting their hands on them without the bother of negotiating with a sovereign foreign power. We have a long history of such moves in this country. See Hawaii. In the meantime, ‘extrajudicial killings’ continue which is just a fancy term for murder. As we the people don’t seem to be doing much to try and stop things, we’re all complicit and that doesn’t sit well with me. We continue to abuse and degrade immigrants, independent of their legal status and who cares if American citizens get caught up in the fray. Christian clergy dare to protest in the name of the gospel message of welcoming the stranger? Tackle and tear gas them and cheers from the MAGA crowd. Various Trump associates are inserting vacuum hoses into the treasury and sucking out millions in payments for themselves and their friends in contracts and legal recompense to which they feel entitled, all while the DOJ eggs it on and chases after Trump’s perceived enemies at his behest.

Like the rest of the world, I’m still waiting for the rest of the Epstein files to drop. Given what has appeared so far, it seems like there are all sort of sordid details yet to emerge and we’ll all be satisfying our prurient interests for some months to come. I just have to keep reminding myself that the girls involved were real people and that they were girls, without fully developed brains and they were being used and manipulted by fully grown adults who felt above the rules of society. I can’t give it a pass under ‘boys will be boys’. And the elements of MAGA who are trying to do so should be fully ashamed. But then MAGA and shame don’t ever seem to travel together.

I’m a bundle of contradictory emotions this weekend. A lot of people assume I don’t get emotional as I tend to be laidback and calm on the surface and pretty unflappable, no matter what chaos is going on around me. That’s not reality, that’s a carefully constructed persona honed through decades of experience in medicine and theatre – both environments which are prone to drama. I learned very young how to suppress, and channel and compartmentalize until you had something that didn’t have too many rough edges which would set off the world. And then, as I bury my emotions deep, I chose partners with volatile emotional cores who would challenge and unlock my emotional self, at least in my private life. I don’t have that at the moment and it’s one of the reasons I figure I won’t have a third husband. Finding someone who can do that in just the right way is going to be difficult indeed.

I don’t trust emotions. They’re messy and uncontrollable and get in the way of order and reason and logic. They’re a necessary part of humanity and I get that but I always feel most comfortable when they’re locked away in what I regard as their proper place so that I can sit at the side table and observe and contemplate life as it goes on around me. But sometimes, they will out. They’re out at the moment for a couple of reasons. One is the announcement of the new endowed professorship at UAB in my honor, something I’ve known about for a long time but could not discuss until all the is were dotted and ts crossed. Another is a group of celebratory experiences to which I am peripheral – two galas last night – one for the 25th anniversary of the UAB Center for Palliative and Supportive Care and the second for the local chapter of the national Alzheimer’s Association followed by the grand opening of some friend’s new LGBTQ coffee shop and bar, Pink Lantern which has been a long time aborning.

FIrst, the endowment. What is it and where did it come from and what is its purpose? About fifteen years ago, when UAB recognized that I had some significant talents which were useful to them as an institution, the powers that be came to me and told me that the development department was interested in creating an endowment which could support me in my work. In an academic institution, an endowment is a sum of money raised through philanthropy which is set aside for the purposes of creating money through earning interest which can then be put to specific use such as salary support so that a faculty member can give time to endeavors that do not in and of themselves create money (such as teaching, working to build new programs, community outreach etc.) An endowment given to me would allow me to do more creative work than just marching in and seeing patients day after day. Endowments are common in the research world but are rare in the clinical care/education world as clinical care always creates reimbursement on some level so having one, in a position like mine, would be something of a coup.

The effort languished for years as UAB had no major donors interested in funding this endowment. Despite the fact that everyone grows older, aging and geriatrics is not what people think of when making bequests. They prefer to give to the study of a specific disease process that has impacted their lives or to cutting edge research. It made no real difference in my life or career so I set about doing my usual and helping everyone get through a pandemic. About three years ago, the Department of Internal Medicine decided to reinvigorate the idea by committing some internal funds to the endowment and the Division of Gerontology, Geriatrics, and Palliative Care followed suit. As I was busy planning my retirement, I decided that having an endowment that would financially benefit me was not the best use of the money. Rather, it should be used as a tool to recruit and retrain someone to UAB in clinical geriatrics that might help keep the programs I’ve devoted my last three decades to flourishing after I step down. I was able to secure the final part of the funding from a family source and I gave the OK for the endowment to be named after me as a way of helping secure my legacy to UAB and to Birmingham in general. It then took time for all of the University machinery to creak forward and, at long last, it became public yesterday.

There are various levels of endowment and this one is at the lowest level. Obviously, the more money in an endowment, the more money that can be spun off for faculty support so it’s my hope that there will continue to be contributions to the fund so that it will grow and thrive and allow whomever is chosen to fulfill the position will be able to do more and more good as time goes on. When I do my estate planning post retirement, I’m going to have a decent chunk head that way but that won’t happen until my death and I’m hoping that’s not for a couple of decades. If anyone is looking for a worthy cause and would like to contribute, either in my honor or just to help carry on what UAB can accomplish in care for the aging, you can contact the UAB School of Medicine Advancement Department. They’d be thrilled to talk to you. Also, if you know of a brilliant clinical geriatrician who’s midcareer and looking for a change and a chance to continue my work at UAB and the greater Birmingham area, drop me a DM.

It’s purely coincidental that the endowment was announced on the day of the celebration of the 25th anniversary of the UAB Center for Palliative and Supportive Care. I’ve been involved with Palliative Care my whole career (there’s a lot of overlap with geriatrics) and assisted in some small ways in helping the center move from psychiatry to geriatrics a few decades ago. Steve was one of the first patients they helped late in his life so being there and seeing people who had been part of the program all those years ago of course brought him and his illness to mind. I’ve buried most of the two years he was sick and I took care of him and the feelings and emotions of that time, when they surface occasionally, always feel uncomfortable and alien. I left that gala early so I could head for the Alzheimer’s Association gala. Many years ago, I was on the board of the Sacramento chapter of the Alzheimer’s Association for a while, one of my first forays into the world of service organization boards. When I came to Birmingham, I became involved mainly with Alzheimer’s of Central Alabama, a local service organization with direct services to local families and served on their board for a decade or so. Friends of mine are now on the Birmingham Alzheimer’s Association Board and had a few tables which were filled with old theatre friends. Most of us have known and worked together in the local theatre world for more than twenty years and I just kept thinking Tommy should be here and part of the group and laughing and joking and reminiscing about now decades past.

This morning was a coffee at the soft opening of Pink Lantern which is to be a coffeehouse from morning to mid afternoon and bar from late afternoon through the evening. I don’t go to gay bars often. They’re usually too loud so conversation is impossible but a gay coffeehouse I can get behind. The power couple behind it are old friends and one of my younger friends, who comes and plays Tommy’s piano routinely, has been hired as the bartender. I feel invested. I don’t always feel like I’m part of the LGBTQ community – a lot of the younger ones view me with suspicion as a cis-white male with a functional professional life as some sort of sell out – but there are times when I need the energy that only comes from being with your own. Tribalism is both one of our strongest enemies and greatest assets as humans. (I think I’ve found the subject of one of my future essays with that comment – but not this evening. Have to head out to dinner now).

This week marks the end of my 27th and the start of my 28th year here in Birmingham. It wasn’t supposed to be. I was supposed to be here in a temporary position before heading back to California in no more than five years. That’s what I had told Steve and that’s what I had promised myself back in the dreadful summer of 1998 when forces beyond either of our control systematically dismantled the life we had built for ourselves over a decade in our beloved Craftsman bungalow in midtown Sacramento. We pulled into Birmingham on Halloween night, a Saturday in our fully laden Acura Integra accompanied by a traumatized cat who was not in the least cut out for long hours in the car and settled into a Holday Inn waiting for the closing on Tuesday, the arrival of the moving van on Wednesday, unpacking over a long weekend, and my beginning work the following Monday.

Neither of us had any idea of what was to come – Steve’s impending illness and death which manifested about a year later, my discovering of untapped talents that have taken me to practically every stage in the metro area, the ups and downs of UAB and the Birmingham VA, the arrival of Tommy and his incredible talents, the personal losses, the assumption of the mantle of story teller and now, drifting towards formal retirement and venerable elderhood. Like all the rest of us, my brain finished it’s development sometime in my later 20s and I still feel like that person inside, although the mirror shows me hard evidence that he is long gone, and I have to figure out how to make peace between the youth inside and the paw-paw outside. Something that all of my generation is working hard at. Those who do not do this inner work are bound for great unhappiness as biology cares not for our wishes and age continues to take its toll no matter what plans we may have. I’ve been asked to give a talk in late January about my experiences in medicine as a gay man through all of the changes of the last forty years. This has put me in a contemplative state, to put it mildly.

I am a bit optimistic following the results of elections last night. Mind you, it’s off year elections so they won’t make a lot of major difference in terms of policy or trajectory of society in the near term, but a quick run down of what happened suggests that the American public has caught on to what the Trump administration’s policies actually do and they aren’t having it. Counties in deep red states that were solidly Republican by double digits went Democratic. Democrats won essentially all the important races on the ballot. It’s too early to call it a repudiation of Trumpism but it shows that our means of changing how this country works, by changing our elected representatives by showing up and voting, still works. There’s a year until the midterms and a lot can happen in a year but it suggests that Republicans will not have an easy time holding their majorities without dismantling the electoral process and I don’t think that’s going to be anywhere near as easy as they think. I’m waiting to see where the cracks open up in the Republican coalition as the gap between the policies Americans want and the policies offered by the Trump administration continue to widen. Maybe more and more of us will learn that politics are not a spectator sport and all politics are local and engaging with each other to find the common ground of what we all want to see for America may lead to some better ways forward.

I’ve been wondering if I had been framing our current political moment the wrong way in my mind. I’ve been seeing the current political moment, the great unravelling, as a destruction of the society put in place after the Great Depression by FDR which has held us together for the last four or five generations. But maybe it’s not a destruction. Maybe this attempt to make government work for the average citizen and the common good is not the norm but an aberration. Tommy would have argued this. He spent most of his nursing career working with the most marginalized communities. He ran homeless clinics. He provided health services to the sex workers of Birmiingham in the late 80s and 90s. He knew where all the brothels were and was on a first name basis with a number of the madams – it wasn’t information I could make much use of but it was interesting to know how that world, hidden beneath the surface, actually worked. Seeing how badly society and systems treated people on the lower end of the socio-economic scale enraged him about how politics worked and he was quietly furious with government on all levels and wanted nothing to do with it. I had a hard time getting him to vote he was so upset at government and law enforcement. He died just over a year into Trump’s first term. I have no idea what he’d make of our current political moment but I know he’d be out there rescuing one person at a time.

Tommy always felt that when government did something positive, it was transactional and watch out for the hidden teeth which would snap at your rear end. He felt that the true America was the America of destruction of indigenous populations and cultures, wealth hoarding, geopolitical interference for the profits of American capitalism, be it produce, petroleum, or high tech, crushing of labor movements, slavery and Jim Crow and separate but equal, and subjugation of the other to puritan morality. That was the story of America from the early 1600s until the 1930s. What we are seeing now is a return to those roots which had centuries to grow and take shape and imbue everything in the culture. It’s 80% of the time we’ve been shaping this continent.

Because of these deep cultural roots, moves back to this sort of society don’t feel wrong to a lot of people. They feel right on a very deep level and that’s going to be a very difficult thing to overcome. The smart people in the Trump administration (and there are a few left) know this and have been using the iconography of Americana to repackage some truly odious ideas and philosophies and make them palatable to a population which is no longer taught critical thinking. (Thank you two generations of No Child Left Behind). Can all of this be overcome? Of course it can but it requires a willingness on each of our parts to look forward, rather than back on a nostalgic past that never really existed.

Dick Cheney died this week. He, more than anyone else, created the ‘War on Terror’ and the dreadful misadventure in Iraq that continues to ripple through world geopolitics to this day. At the time, he was considered about as right wing as you could get. He died thoroughly ostracized by the current Republican party for not being nearly right wing enough as he loved and stood by his gay daughter and preached true fiscal conservatism, not supply side voodoo economics which have caused economic disaster everytime the Republicans have held power since Ronald Reagan. I despised him when he was in power. I still do on some levels. At the same time, I can’t help but think we might be better off with a few more like him in the current administration.

Cheney was 84 and had had a terrible heart for years. Most men, even those without significant disease, start hitting the wall in regards to their bodies holding on somewhere between 78 and 86. Take a look at the ages of the senior male politicians. Change is going to come.

I wrote 25 progress notes Thursday evening and another 25 yesterday evening clearing out my backlog. This means for the first time in recent history, I don’t have a whole bunch of work related paperwork hanging over my head on Saturday and Sunday. I am therefore taking the time that would usually be occupied by my propped up on my bed with my laptop wrestling with the electronic medical record with reruns of some police procedural on the TV to keep me company and using it instead to write this, my latest missive contemplating the weighty issues of the day – like whether or not I feel like a trip to the Piggly Wiggly on Clairmont for the few perishable groceries I stock.

Electronic health records are just one of many reasons why I plan to retire in roughly 18 months. They are cumbersome, filled with data points imported from elsewhere in the system that have no bearing on what you’re trying to convey, and in general take about twice as long to complete as our old system of dictation and transcription. I have a side gig as a reviewer of medical records for attorneys. It pays well (and these days I give what I make to the local theatre community). I’ve been doing it for more than thirty years now. I enjoy the detective work piece of it, sifting through mounds of data to try and piece together the story of what happened and seeing if you can support the arguments of the attorneys with fact or not. I guess I’m rather good at it. At least I keep being asked to do it. I haven’t decided if this piece of the career ends when I step down from active faculty or not.

When I first started doing this sort of work, back in the dim recesses of the ancient past called the early 1990s, I used to get these large bankers boxes delivered by UPS with thousands of pages of photocopies. Now I get a thumb drive or a Drop Box link. I learned a few things quickly. Don’t try to read anything that’s handwritten – the important stuff is dictated and typed. Construct a timeline that serves as the backbone of the narrative. Don’t write anything down you don’t want discovered. Civil law, which covers the sort of torts I’m involved with, pretty much boils down to plaintiff and defense each spinning a seperate story out of the available facts and hoping that their story is the one that will prevail. Fortunately, the majority of cases I am involved with never go to trial. Attorneys much prefer to work things out in settlement talks where thre is a modicum of control. One never knows what a jury may do.

I suppose that goes for all groups of people and not just juries. We’re certainly seeing evidence of that left, right and sideways throughout what is left of our civil society. If I haven’t misconstrued things, current headlines include disastrous conditions and multiple legal and human rights violations at the various jury rigged (see what I did there?) facilities where they are holding detainees swept up mainly for their ease of capture, and not their danger to society. The president, on the eve of an incredibly dangerous cut off of SNAP benefits, is hosting a Great Gatsby themed Halloween party and tweeting about how much marble he put into a refurbished White House bathroom. Hasn’t anyone in the MAGA movement read any history? Revolutions happen when enough mothers have difficulty feeding their children. And it doesn’t take much. The accepted figure is that if 3.5% of the citizenry become mobilized, change is inevitable. SNAP covers 12.3% of the citizenry.

The Speaker of the House has indicated he is unlikely to call the House back into session until after the holidays, effectively removing the legislative branch and its oversight functions from our constitutional checks and balances. The air traffic control system is in melt down and there have been a number of near misses. DHS is building a more efficient version of Staasi based on biometric monitoring. The vice president appears to be throwing his wife and children under the bus in order to shore up his Christofascist credentials. (I hope Usha takes Ivana Trump’s motto from ‘The First WIves Club’ to heart – ‘Don’t get mad, get everything’.) Fox news has been welcoming literal Nazis as honored guests. At least RFK Jr. has been somewhat quiet this week and is trying to walk back his idiotic comments regarding Tylenol and autism. I guess he realized that he might have some difficulties with the discovery process in the suits he filed.

The great unravelling continues and who knows where it will all end up. The problem is that it’s being egged on by a number of different constituencies, each with a very different plan for the rebuild on the other side. Theocrats, tech bros, conservative politicians, and hedge fund billionaires don’t speak the same language or have the same frames of reference. I have a feeling the battles between those factions trying to control where society heads are going to be far more viscious than anything we’ve seen to date. I’m just going to continue to live by my mantra. Get up. Get dressed. Go out. Do good. There will be plenty of opportunity for that.

The theatrical career is moving forward. I’ve had my first few rehearsals for ‘Soul Food: Another Serving’ which performs the week before Thanksgiving. It’s fun and I’ve got a couple of realy good scenes. I haven’t quite found my character yet but that will come. I’m spending some time tomorrow pounding lines. My least favorite part of the creative process. I go from that into ‘Miracle on 34th Street’, then am off Christmas week before beginning rehearsal for South Pacific. I’ll see everyone in mid January when that closes. Mid January through late March are currently available on my performance calendar should anyone need me for something. It looks like I’ve been talked into another year of Summer Shakespeare with Bell Tower Players so I guess I know what I’m doing from late June through mid August as well. My choice is The Tempest. Hopefully a little less political than Richard II.

Somewhere in all of this, I have agreed to give a talk to the UAB LGBTQ employees group. They’ve asked me to recount my life as an out gay man in academic medicine over the last four decades. I came out during my Intern year. I wasn’t out in medical school – perhaps I’ll go into some of the reasons why. Several people have said that the material in my books should be adapted into a theatrical monologue. Perhaps this is a chance to give that a trial run. One more thing to write. I feel a nap coming on. Going to end this one here.

It’s a Alabama Symphony Orchestra performance week this week so I’ve been out at rehearsals every evening. It’s Beethoven’s 9th symphony (again) so it boils doen to an hour and three quarters of sitting in the choral balcony for fifteen minutes of singing. But what a fifteen minutes. From what I can tell, the chorus is in good shape so if you’re local, and you’ve never been to a performance of Beethoven’s Choral Symphony live, it would be a good thing for you to catch this weekend. I guarantee you’ll recognize the music. This is my third go round with this one with the ASO over the last decade. The last time was as the world was just coming out of pandemic shutdowns and choral singing was just coming back. The chorus was small for that one, but everyone was so happy to be back making music together that the energy made up for it. The other time was about nine years ago. Tommy was still alive and we were both up in the choral balcony, he with the tenors and me with the basses. It was the first time I experienced what I now refer to as tempo di Carlos in the final section where you have to hang on for dear life and hope like hell you don’t fall behind.

I get Sunday off from rehearsals and pick up again on Monday when I start rehearsing the play Soul Food with Encore Theatre and Gallery. Marc Raby is writing and directing and it’s the first time someone has written a scripted role specifically for me. I’m flattered. It has me playing the building super in a condo building full of African American folk falling in and out of love with each other. I’m going to have to work on my charisma and charm for this one I think. I don’t necessarily have a whole lot of that naturally so we’ll see what I can drum up for theatrical purposes. It plays the weekend before Thanksgiving at the Carver Theatre so make your plans now. I guess this means I have to go into line learning mode. I haven’t had to do that for awhile. It gets harder every year.

I’m as appalled at the demolishing of the East Wing of the White House without proper clearances and review as most of the rest of the civilized world. I am not, however, surprised. One just needs to look at the history of Trump real estate and historic preservation. Google the Bonwit-Teller friezes and the fate of Steeplechase Park at Coney Island. I’m becoming more and more curious about this magical ballroom. I’ve seen 3D model renderings and artist sketches but has anyone seen anything remotely resembling a blueprint? How is it going to be hooked into utilities and sewer and other necessities? Where are the kitchens going to be? Storage? How is something of 90,000 square feet supposed to fit onto the triangle of land formed by Pennsylvania Avenue and the Elipse? Is, as some have speculated, a means of digging up the plot to create a much larger bunker than the World War II era one that has been under the East Wing for nearly a century? There are so many unanswered questions.

I also have unanswered questions regarding Mike Johnson’s essentially putting the house, the people’s branch of the government into what looks like semi-permanent abeyance. The attempt to brand the shut down as the fault of Democrats is getting nowhere other than in MAGA land and even MAGA is getting restive, especially as new health insurance premiums are hitting their mailboxes. As the shutdown, and other idiocies, drag on, I cannot help but wonder how the Republican legislators who are letting the executive run amok by abdicating their constitutional duties are going to explain themselves to their children and their grandchildren in a few years and why how they are going to be able to tell posterity that they did not have the courage to stand up for what they knew was right. When I was a child, I was given a small printed card by my pastor with a quotation from Proverbs 22:1 on it. ‘A good name is rather to be chosen than great riches’. I kept that card in my wallet until well into adulthood when it had finally deteriorated too much to even be read. But I have always tried to live my life with that sentiment in mind. Pity that so few of our national leaders believe in it.

I’m waiting for next week when SNAP benefits will end in about half the states (Alabama amongst them) as part of the shutdown. I have been watching what’s going on with local communities of color. They are making plans to support and feed each other as necessary. They’re laying in supplies and coming together as they have needed to for generations to deal with the storm breaking upon them through no fault of their own. The rural white communities where I do my house calls have bought into the myth of rugged individualism promulgated by the Republican party since the 1960s and brought to its apogee by Ronald Reagan. You don’t need government and community, you need to make it on your own, That’s the American way. They aren’t going to take a hit anywhere near as well as they won’t come together for mutual support. There’s an old parable about heaven and hell that I first heard in high school. A man went to hell and found it to be a great feast piled high on tables. All around were the damned whose arms were strapped to boards so they could not bend their elbows and wrists and so they could not bring any of the delicacies near their mouths to eat and so they were writhing in torment. He then went to heaven and found it to be an identical place with a great feast and again the denizens has their arms strapped to boards. Only here, they were feeding each other and all were satisfied.

Get up, get dressed, go out, do good, feed each other. We all need it.

I returned to the US this past Thursday without incident. I keep expecting one of these days to be stopped by Customs and Immigration and asked pointed questions about my loyalties due to my tendency to be critical of the current administration’s approach to governance but so far it’s always been a wave on through. Maybe it’s because I’ve reached the age at which men become ‘distinguished’ and therefore am assumed not to be a troublemaker (my inner John Lewis doesn’t like that one) or perhaps it’s because I’m under surveillance and I am disappointingly visiting museums and hanging upside down from zip lines rather than meeting with leftist political figures or carrying secret cables for George Soros.

I’ve spent the weekend catching up on what piled up in my absence at work. Something over 2000 emails, chart notifications, and other pieces of miscellany that accumulated in various inboxes, electronic and otherwise. So here, on Sunday evening, everything has been tidied up until the tsunami of the average work week strikes again starting about 8 am. 19 months… and in two weeks I’ll be able to change that to 18 months. I don’t know yet if retirement from medicine is going to be piecemeal stepping back from thing at a time or if I’m going to hang a large ‘gone fishin’ sign on my office door and walk out. Question for another day.

This weekend I have been meditating on questions of community. What is it? What is mine? How do I fit into it? I’ve decided I’m rather fortunate in that I exist in so many overlapping areas that a Venn diagram would look like something I drew with my Spirograph when I was 8. If I’m not getting what I need from one, there’s usually another closely allied at hand which can help. While having this many is in some ways a blessing, in others it’s a bit of a chore. Human organizations, no matter their purpose, have similar group dynamics no matter where you go. One of the chief rules is that roughly 5% of the membership does 95% of the work and vice versa. As I’m a somewhat results oriented type, I often end up in that minority that gets the job done. I learned this at an early age from my parents. There wasn’t an organization that I or my siblings belonged to during our childhood and adolesence that one or both of my parents didn’t join and usually run. They were organized, methodical, and knew how to delegate. By the time I hit my early 20s, I was sitting on the boards of arts and human services organizations and that has continued to the current day. Sometimes I am the mover and shaker, sometimes I sit back. Usually what I ask for are defined tasks that I know I can accomplish with the time and energy I have available.

I’ve learned a lot from all of these endeavors. How to network (once upon a time I used to sit next to Maureen Reagan’s husband Dennis at our monthly Sacramento Chapter of the Alzheimer’s Association board meetings – he liked my jokes). How to use soft power. How to gently encourage. How to build consensus. How to exercise comity and get along with those with different agendas. And I think that’s what bothers me the most about our current political moment. All of those skills, which politicians have had to learn to get where they are, have been thrown out the window in favor of news cycle/meme driven immediate gratification episodes which do no good to anyone and widen chasms rather than build bridges. The president’s little video from this morning was really a new low. You can search it out for yourself. I’m trying to imagine a Roosevelt or a Reagan pulling a similar stunt and I just can’t.

I went to the Birmingham No Kings rally yesterday morning. Somewhere around 5-7,000 people showed up at 10 am at Railroad Park. The weather was lovely. The speakers were good. It was peaceable and a lot of saying hi to acquaintances from various walks of life. While it sounds like a lot, ten times as many turn up at an Alabama home football game. There’s been a lot of criticism about the No Kings movement in that it’s performative and isn’t really accomplishing anything. I would disagree. It’s true that yesterday is unlikely to change much of anything in this political moment but it does so a few things. First, millions of people turned out all over the country with a message that they are not happy with the current administration. There were fewer than 20 arrests nationwide, nearly all of MAGA counterprotesters who went too far. This dispels the administration narrative that those who disagree with their policies are violent marxist criminimals or whatever other derogatory words they’re using this week. Second, it reminds people that they are not alone in their feelings and that community surrounds them if they’ll only reach out for it. Third, they were celebratory in nature and there’s an innate human need for celebration and who doesn’t like a good street party?

95% of the people who turned up will go back to their ordinary lives, maybe slightly more energized but the 5% who do the work will be reminded of why what they are doing matters and will push on. My best metaphor for what we are doing and why comes from theologian Howard Thurman who wrote a brief statement in 2009 regarding the work that follows the celebration of Christmas and I find that it applies here.

The Work of Christmas

When the song of the angels is stilled,

When the star in the sky is gone,

When the kings and princes are home,

When the shepherds are back with their flock,

The work of Christmas begins:

To find the lost,

To heal the broken,

To feed the hungry,

To release the prisoner,

To rebuild the nations,

To bring peace among others,

To make music in the heart.

So I am asking myself this evening what I am doing to do this work. I’m not a politician and never will be one. (Far too many skeletons in the closet for that). But, I can support those of that calling who are moving to improve the human condition and human dignity. I can help my communities of artists, LGBTQ, healthcare providers, Unitarian Universalists and all the rest who advocate for policies that improve the human condition and uplift the human spirit. I’m about to do two plays with the local African American theater and I will continue to do what I can to bridge the gaps between White Birmingham and Black Birmingham.

Last night, I went to the theater to see a production of the musical The Spitfire Grill. I can’t say it’s a particularly good piece of material. While the book is sound, the music isn’t particularly distinguished and the lyrics are hardly Sondheim – they’re not even Charles Hart and Richard Stilgoe. But the production at Terrific New Theatre was spot on. The small cast of six singers (and a seventh key role which is silent), all of whom I’ve had a chance to work with on other projects, were sensational. They’ve all either had national careers or could easily have national careers if life choices and responsibilities did not keep them in Birmingham. I am constantly amazed at the wealth of talent we have here and even more amazed that I am occasionally invited to play in the sandbox with them.

The story of The Spitfire Grill, based on a 90s indie movie that I saw somewhere along the way and have minimal memory of, is that of a young woman, paroled from prison, who comes to a small town in Wisconsin and gets a job as a waitress at the titular diner. Her arrival is the catalyst which changes the town for the better. We never know where life will take us, what form redemption will take. I’m rolling into this next week (dominated by Alabama Symphony Orchestra and Beethoven’s 9th Symphony repeating my mantra in my head. Get up. Get dressed. Go out. Do good. I occasionally want to skip that second step but UAB gets miffed when I show up to work naked.

Dateline – Playa Conchal, Costa Rica

All good things must come to an end and this vacation does tomorrow. I’m up in the morning beginning the twelve hour process of returning to Birmingham by way of the Liberia airport. As far as I know, there are no hitches but with the government shutdown affecting air traffic control, all bets are off once I hit the United States. I suppose if I get stuck in Atlanta, I can rent a car or something.

I didn’t write last night as I really didn’t have anything to say. (A pre-dinner cocktail and two glasses of wine with dinner probably didn’t help). Yesterday and today both followed the established pattern. Sleep in (which usually means up about 7:30 local time). Leisurely breakfast. Beach and pool time (with sunburn to prove it) until midafternoon with something for lunch in the middle. Clouds and rains arrive around 3 PM so repair to the room for reading, writing, and nap. Venture forth around 7 for dinner and another glass of wine. Back around 8 for more reading, writing and Netflix and eventually drop off for some uninterrupted sleep.

I have been thinking about partisan politics and healthcare policy for the last week or so after reading some rather ridiculous claims from both sides of the aisle regarding the shut down and the role health care is playing in the whole thing. For those of you solely interested in travelogue, you can stop reading now. For those of you interested in my historical analysis of health care policy, hang on. It’s a long one. It might take you more than one sitting. It certainly took me more than one to write it.

The current imbroglio in DC which has led to a governmental shut down has, at its heart, a dispute over health care. The party which currently holds power, the Republicans keeps attempting to frame it as if the Democrats are entirely to blame and that what the Democrats are trying to do is guarantee free health care to undocumented residents. This is a gross misreading of the situation (as anyone with even a modicum of intelligence and inquisitiveness soon discovers). Therefore, the Republicans are using every tool in their box to try and force this narrative through to public consciousness. This requires multiple violations of what is known as The Hatch Act (federal employees using their jobs for partisan purpose). This law has been on the books since the 1930s and has been adhered to for nearly a century by both parties until recent days. The problem is that enforcement is dependent on the White House Office of Special Counsel and that office is under a management that has no interest in stopping the promotion of Republican alternative facts.

Therefore, I thought it might be interesting to look back at the last century or so of national legislation that has impacted our health care system and look and see what roles our two governing parties have played, either for or against. It’s not as clear cut as one might think and these issues have been used over and over in political gamesmanship, usually to the detriment of the health of Americans. While most of the world has left the design and construction of their health care systems to clinicians, public health experts, and systems analysts, here in the US we have generally relied upon politicians, industrialists, and bankers. That’s why our system costs so much more and delivers so much less than any other comparable first world country.

The first movements towards health insurance and a federal role in handling the costs of health care emerged shortly after the turn of the 20th century during the progressive era. It was one of many ideas considered by Teddy Roosevelt (R) but it wasn’t considered as important as other concerns, so nothing happened on a governmental level. The burgeoning labor movement picked it up in the years leading up to World War I with the American Association of Labor Legislation drafting a model bill in 1915 and beginning to lobby at the federal level with the Woodrow Wilson (D) administration. The American Medical Association joined in and there was some traction until 1917 when political conditions changed. First, life insurance companies lobbied against the bill, feeling that the availability of health insurance might eat into their profits. Second, more conservative state medical societies challenged the national leadership over issues of federal control over health care decisions. And lastly, and most importantly, the US entered World War I. Germany, the enemy, had a robust social insurance system that included health care. The idea of the US government providing health benefits became entangled with the World War I era Red Scare with the Prussian Menace of socialist programs being inconsistent with American values. Le plus ca change le plus de meme chose.

During the roaring 20s, health care was not an important part of the American economy. The average American family spent more on cosmetics per year than on health. Most health care happened in the home with mom or granny providing the nursing care. Physicians were generally engaged in primary care and lived and worked in a community of people whom they came to know well. Hospitals existed, but for certain specialized services and were, in general, owned by not-for-profit groups with specific charitable mission. Hospitals were places most people avoided but could provide surgical services, quarantine services (mental health, tuberculosis), care for those without intact family structures, and training for the next generation of providers.

In 1929, with the economy careening towards The Great Depression, health costs were starting to rise. Justin Ford Kimball, the then vice-president for health facilities at Baylor University in Dallas Texas, came up with a novel idea. His institution had just built a new hospital and was having difficulties filling the beds. The middle-class workers of the area were becoming concerned with rising costs and being able to afford health care. Kimball struck a deal with the Dallas teachers union. If union members would pay 50 cents a month to Baylor, they would become entitled for up to 21 days of free care at Baylor’s hospital should they need it and the first American health insurance plan was born. Ten years later, in 1939, after a number of other such arrangements began to spring up, an association of plans felt to be providing value and service were given status by the American Hospital Association and given the symbol of Blue Cross plans. At roughly the same time, the loggers and miners of the Pacific Northwest, who had high rates of occupational injuries and illnesses, had employers who recognized the need for keeping a healthy workforce and began contracting with local providers. These plans adopted the name Blue Shield. The two groups formally merged in 1982.

At the same time as the emergence of the Blues, the federal government was starting to get interested again in health care and its costs. When Franklin Roosevelt (D) proposed the Social Security Act in 1935, one of the benefits that he wanted to see included was a national health insurance plan. However, as the AMA had by this point taken the position that any government intervention in medical practice was ‘socialized medicine’ and to be opposed at all costs, it was decided to leave this particular piece of the legislation out as its inclusion might endanger the passage of the bill as a whole. There was another attempt at a national health insurance bill in 1939 which would have given federal block grants to the states to set up their own programs, but FDR never really got behind it, and it withered on the vine.

In the early 1940s, a new bill, known as the Wagner- Murray-Dingell bill, which would have established compulsory national health insurance was drafted and named after the three Democratic senators who pushed it. It was reintroduced every year from 1944-1957 under presidents Roosevelt (D), Truman (D) and Eisenhower (R). Roosevelt was preoccupied with World War II. After the war, the cause of national health insurance was championed by Harry Truman through both of his terms. He had to contend with a Republican led legislature who refused to consider the bill. In addition, the anti-communist sentiment of the McCarthy era burst forth and the AMA, in particular, was happy to taint national health insurance with the ‘socialist’ or ‘communist’ label making it impossible to move forward.

At this same time, a historical accident was changing the playing field. During World War II, when many of the able-bodied men were out of the country fighting, the heavy industrialists charged with making war materials hired women to build the aircraft and ships and munitions necessary for the war effort. It didn’t take long for the titans of industry to figure out that women had domestic duties outside of the assembly line. If they or their children became ill, they would miss shifts and slow production. Henry J. Kaiser, of Kaiser steel, pioneered the idea of corporate responsibility for the health of its workers in order to maximize production providing company subsidized health care to employees and their families. A few years later, when the men returned from overseas and went back to work, heavy industry found itself with a dilemma. Wage and price control legislation, left over from The Great Depression, was still in effect. Higher wages could not be used as an incentive for hiring so, instead, benefits were placed on the table including health insurance, leading to the development of our employment-based health care system which took root nowhere else. The government encouraged this by making these benefits tax exempt on both the employer and employee side via various tax reforms introduced between 1943 and 1954.

In the 1950s, a combination of factors collided leading to a more urgent need for the federal government to take a hand in health insurance. The explosion of medical technology and understanding fueled by the war effort, the widespread introduction of antibiotics, and the growing reverence of American culture for physicians and other providers were leading to a switch in the centering of health away from the home to the hospital and driving the idea of American exceptionalism in medicine. (A reputation deserved at that time). This in turn, was leading to a significant increase in the cost of health care for families, especially those who were excluded from the employer-based model of health insurance due to age or disability. As hospitals were still, for the most part, owned and operated by not-for-profit entities of charitable mission, they were starting to feel a financial squeeze from unreimbursed care from people demanding the new treatments American medicine could provide but having no real means to pay the bill and trusting in the charitable mission of the hospital to assist with that.

It was President Eisenhower ( R) who recognized the significant issues regarding aging and employer-based health insurance and he led the first White House Conference on Aging at the end of his term in 1961. After the assassination of his successor, President Kennedy (D), Lyndon Johnson (D) was able to get various health and welfare programs through congress in late 1964 and early 1965 as part of his Great Society plans which aimed to eliminate poverty. Medicare was signed into law as an amendment to the Social Security Act in July of 1965. An additional amendment to the Social Security Act established Medicaid, health insurance for the impoverished. While Medicare is a true national health insurance program, Medicaid is an optional program for which the federal government provides funds to states to set up their own systems and it varies in each state. In fact, it took nearly twenty years for all states to sign on. Arizona was the last state to do so in 1982.

The creation of Medicare and Medicaid allowed for more and more money to enter the health care system and, by the 1970s, several things began to happen. First, with new treatments and technologies plus the need to build new facilities for these and to train providers in their appropriate use, medical costs began to increase and rise at a rapid pace. Second, the titans of finance began to notice the amount of money entering the health care sector of the economy and began to form corporate entities to harness and take advantage of these dollars. Health care was pretty much a not-for-profit enterprise until 1973 when Richard Nixon ( R) signed the federal HMO act, championed by senator Teddy Kennedy ( D) as a way to curb medical inflation. It allowed for private enterprise to set up health maintenance organizations (which could be for profit) and cleared away bureaucratic red tape in order for them to compete with the traditional health insurance offered by the Blues. These new HMOs began to buy up pieces of the health system and organize them into networks of care and began a process of acquisition and conglomeration that continues. Their first attempts to control costs were to reduce access through gatekeeper mechanisms which were resoundingly hated by most of the population. Their next attempts, by creating networks and reducing choice in that way, as they were more stealth, worked better.

Throughout the 1980s, the competition between access, quality, and cost dominated health issues. Medicare had a major reform in 1983 with the implementation of diagnosis-related groups and batch payments to hospitals signed into law by President Reagan ( R). But there were bright spots. At the time, hospitals, becoming more and more concerned about the bottom line due to corporate influence, were becoming more and more involved in a practice known as patient dumping. Refusing to treat or actively transferring patients with emergency conditions from private to public hospitals with many cases reported of horrific outcomes due to delays in care. Congress, with a Republican controlled senate and Democratic controlled house passed the Emergency Medical Treatment and Active Labor Act and it was signed by President Reagan ( R). This law states that no hospital which receives federal funds may refuse to treat a patient presenting with an active emergency condition until that patient has stabilized. It does not allow for any discrimination based on any status including citizenship or documentation. (This is the free medical care to illegal aliens that the Republicans are currently ranting about – notice who signed it into law).

Reagan waded into health care one more time at the end of his political career. There is some speculation that he was somewhat chagrined by his mishandling of the HIV epidemic in its early years and was trying to make amends through EMTALA and, in 1988, the Medicare Catastrophic Care Act. The intent of this piece of legislation was to protect seniors on Medicare from medical bankruptcy. It had become relatively common knowledge, by this time, that seniors were spending a greater portion of their incomes and assets on health care than they had prior to the introduction of Medicare in 1965. The reason for this was that elders were now recovering from acute illness and living longer and developing chronic illnesses requiring supportive care that was not part of the purview of Medicare such as assistance with basic activities of living at home. The legislation was designed to make Medicare into a stop loss program. All Medicare beneficiaries would have a deductible but once that was met, if their health costs went beyond that, Medicare would step in and keep them from having to pay more. In order to raise the additional dollars for Medicare to cover these expenses for the few who would need them each year, congress raised taxes, but solely on the Medicare beneficiaries who would benefit from the program. The elder lobby went ballistic and flexed its muscles with significant strength for the first time. Their bone of contention was that this should not be a cost placed solely on the shoulders of elders but should be borne by all of society. The backlash was so severe that congress repealed the measure before it went into effect.

The battles over health care have continued pretty much unabated in more recent decades. In 1993, newly sworn in President Clinton (D) was determined to tackle the increasingly dysfunctional American health care system.. He had campaigned heavily on health care reform and was determined to make sure that all Americans could access quality health care at a reasonable price. He appointed his wife, Hillary, to lead a task force to create legislation which would accomplish these goals. She gathered all of the best minds she could in closed door meetings in DC and prepared a more than thousand-page bill. The lack of transparency and the time it took for her to put her plan together helped seal its doom. The health insurance industry, which would have no longer needed to exist had the plan gone forward, sponsored a very effective television ad campaign known as the Harry and Louise ads to turn public sentiment against the plan. The Heritage Foundation and Bill Kristol rallied the conservative movement against the plan and, perhaps more importantly, against the first lady. When Clinton gave his major address to congress on health care in September of 1993 urging the passage of his bill, it was already too late. Key congress folk, who had been kept out of the closed-door meetings were lukewarm in their support. The bill never got a hearing in its original form. Some watered-down compromises were floated but got no traction. The American public, leery of Democrat controlled big government fueled by this battle, voted in the modern movement conservatives led by Newt Gingrich in the midterms of 1994 and that was that.

The close fought election of 2000, eventually decided by the supreme court, ushered in a new Republican administration under President Bush ( R). His first term was dominated by the tragedy of 9/11 and his misguided invasion of Iraq in response. Later, after the 2002 midterms, when the Republicans held the presidency and both houses of congress for the first time in nearly fifty years, attention turned to domestic matters, especially as congress had been getting an earful regarding medical inflation, especially drug prices from their constituents. Seniors, in particular, were being hard hit as Medicare had no drug benefit. This was not due to neglect but rather to the philosophy and design of the program.

When Medicare was enacted in 1965, the chief issue was that elderly were excluded from hospital and other care for illnesses for which modern medicine was developing effective treatments. Medicare was created to allow elders access to the health care system for treatment of acute illness so that they could be improved and go back to productive lives. Medicare was relatively unconcerned with chronic illness. A much smaller percentage of the elder population at that time was disabled by chronic illness. Acute illness carried them off before they could settle into years of debility. Daily medication is not, in general, necessary with acute illness. That requires short courses or medications administered in health care facilities – items covered by Medicare. Taking pills daily for years on end at home was not something that anyone was concerned about in 1965. This prompted congress to pass the Medicare Modernization act in 2003, signed into law by President Bush ( R) in December of that year. The MMA has two chief sections: Medicare C which formalized HMO plans offered by private insurance companies as Medicare Advantage which seniors could elect to replace their traditional Medicare. These plans offer all Standard Medicare benefits and often a little lagniappe like a gym membership but are profit driven. They make their profits by restricting benefits through restricting participants to certain networks of providers (not necessary in traditional Medicare), prior authorization procedures, and strict scrutiny looking for reasons to deny benefits. These plans have been a goldmine for private health insurance but not such a bargain for the tax payer as the cost is roughly 27% more per capita than traditional Medicare. The other is Medicare D which is a drug benefit plan. It is best known for its infamous donut hole – it stops paying benefits once a certain amount is paid and then picks up again on the other side for ‘catastrophic’ cases and resets every year. There were other clauses inserted to benefit the insurance and pharmaceutical industries such as one preventing the government from negotiating price reductions with drug companies and buying in bulk for Medicare purposes. Ultimately the law, still in effect, became a very convenient mechanism to transfer wealth from the government to the corporate side of the health care industry and helped accelerate the costs of the system.

When the Democrats regained control of the White House again with the election of Barack Obama in 2008, there was significant pressure on the administration to do something to improve access to the health care system due to the high number of uninsured priced out of the system and the continued skyrocketing costs within the system. The Obama team knew all too well about the failures of previous years such as the debacle of the Medicare Catastrophic Care act, the collapse of the Clinton health plan, and the dubious financial issues embedded in the Medicare Modernization Act. The Obama team, knowing that they did not have the votes for true single payer or national health insurance, instead looked at proposals made by Republicans in their attempts to head off such major changes. The Heritage Foundation, a right wing think tank, started drafting what they called market-based health care reforms built around insurance exchanges and an individual mandate that all must have insurance but that there should be various means of obtaining it. These ideas were put into practice in the state of Massachusetts under Governor Mitt Romney ( R) in 2006 and proved fairly successful.

Obama, with a Democratic majority in congress, signed the Affordable Care Act into law in 2010, although most of its provisions did not come into play for a few more years. Even though the legislation was built on Republican philosophy and models, the Republican party did not want to give Obama a legislative win and swung into action to denigrate the law from its inception. Several Supreme court cases knocked out some of its underpinnings such as the individual mandate and the requirement that states participate through Medicaid but what remained worked relatively well. The Republicans continue to threaten to throw the whole thing out in order to tarnish Obama’s legacy, but they have nothing with which to replace it.

For the insurance exchanges to work and for premiums to remain affordable, there must be federal subsidies in place to help regulate the marketplace. Those subsidies were set to expire after a set period of time, based on the assumptions of universal participation which never happened thanks to the supreme court rulings on the Republican lawsuits. They end at the end of this calendar year. If those subsidies are not extended, people who get their insurance through the exchanges will see their premiums skyrocket to unaffordable levels. This is what the Democrats are holding out for currently. They want the Republicans to agree to continue those subsidies and aren’t interested in coming back to the table as long as they refuse. President Trump ( R) and his administration and Mike Johnson and the Republican house caucus are refusing and mischaracterizing the whole fight as being about Democrats wanting to give free healthcare to the undocumented. This is simply not true. The only care undocumented people are entitled to is emergency care under EMTALA as we as a country, forty years ago, thought it was a bad thing for desperately ill people to be turned away when life saving care was available.

Now you know far more about partisan politics and American health care policy than you ever wanted to. What have I learned after cogitating on all of this and spending a few hours writing it down? 1. None of what’s going on is new. Our great grandparents were having the same arguments and our great grandchildren are likely to do the same. 2. The incremental and accidental ways in which we change our health system don’t work very well. Perhaps it’s time to try something more drastic. 3. If Ronald Reagan were still around, he’d be drummed out of the modern Republican party as a RINO.

Dateline – Playa Conchal, Costa Rica

I’ve looked at the various off site excursiont that are offered and most of them strike me as being rehashes of things I did this past week (often in the same places) so rather than go trekking off, I think my best use of the next couple of days is a combination of thinking and drinking, writing and citing, and snoozing and choosing. I don’t get a lot of times to completely unwind in life and there are worse places to do it then a resort on the Pacific Ocean in the tropics in company with the birds and the strange rodents, and the iguanas. One very large and venerable iguana is, I swear, trying to make friends as he appears out of a tree and saunters my direction every time I’m in the pool area. He’s probably looking for something to eat but I am mindful of the multitude of ‘Don’t Feed the Animals’ signs posted everywhere.

The weather pattern is holding stable. The sun was out and it was a glorious and clear morning so I got up, had some breakfast with a mimosa, and headed to the beach, plunging into the Pacific. The surf was a bit stronger than I expected so I didn’t venture out too far. There was also a major drop off about ten yards out from shore. I am a reasonable swimmer (all Seattle raised children learn to swim early as self preservation – most social gatherings in the summer revolve around water activities) but am out of practice and not as young as I was so I pay fairly close attention to waves and tides and currents. (Having a father who is a physical oceanographer also gave me a very healthy respect for the power of water). After a few hours, I switched back to the pool and my iguana friend, had lunch, another drink (or two) and relaxed in general for the afternoon. The clouds rolled in around two in the afternoon but, for once, the rains held off until about dinner time so it was possible to remain in the pool area until it was time for a mocha and eventually dinner.

As I don’t have much else to report in regards to travel, I’m going to fill out this entry with something I’ve been working on for a while and which I think I’ve finally got nearly right. Feedback is welcome. I therefore present: Dr. D’s Ten Commandments of Aging Successfully.

Dr. D’s Ten Commandments of Successful Aging

1. Thou Shalt Choose Thy Parents Carefully

You’re never going to be any better than the physiognomy and physiology allotted to you by your genetic makeup. We are all given gifts by our parents. Some of them are positive, some are negative. The trick is to figure out which combination you inherited and play to its strengths.

2. Thou Shalt Heed the Lessons of Thy Mother

Most of us were raised with a maternal figure who attempted to teach us the basics of healthy living. Eat a balanced diet. Get some sleep. Go outside and play. Get some exercise. Turn off the TV. Read a book. Those truisms, passed down by mothers since time immemorial exist for good reason. They are the building blocks of successful adulthood and aging. Think back on them and incorporate them into your living patterns.

3. Thou Shalt Not Fall

There is nothing that will change the life and function of an aging adult for the worse faster than a bad fall and injury. We lose our ability to balance on two feet as we age for a whole host of reasons and our vanity often keeps us from taking the steps necessary to do the simple things necessary for fall prevention. As I say to my patients repeatedly: Floor hard! Fall bad! Use stick!

4. Thou Shalt Treat Medications with Proper Respect

Our culture assigns a great deal of the magic of the healing process to the physical object of the pill and therefore we believe that if one is good, five is somehow better. Practitioners are seduced by this thinking as well and are very good at adding medication but not good at stopping medication that may no longer be appropriate or useful. The best way to think about medicines is that they are controlled doses of poisons – substances which when taken into the body cause a physiologic alteration.

5. Thou Shalt Live with Moderation

We live in a culture of excess. Super size it! All you can eat! Get the biggest house you can afford! As we age, those trends can trap us in patterns which make the compromises necessary for successful aging harder to implement. Also, life’s little pleasures are usually fine in small to moderate doses but when we go full steam ahead, we can get ourselves in trouble.

6. Thou Shalt Treat Healthcare Professionals as Partners

Doctors and other practitioners aren’t there to tell you what to do. They are there to share their expert knowledge gained from education and experience and proffer advice. They don’t go home with you and they can’t make you change behavior in any way. Only you can do that. At the same time, while they can’t tell you what to do, don’t try to tell them what to do. You don’t have the knowledge base they have no matter how much Googling you’ve done. Work together.

7. Thou Shalt Prepare for Change and Accept It

We are all aware that a 5-year-old, a 15-year-old, and a 25-year-old are all very different from each other in function and physical being. The differences between a 65-year-old, a 75-year-old, and an 85-year-old are nearly as great but we don’t culturally understand that in the same way. If you try to create a static life in which nothing changes, the mismatch between your body and function and that life will get exponentially greater as the decades advance and will create innumerable issues for you and your family. Understand that life is change and go with it.

8. Thou Shalt Hold a Sense of Wonder and Optimism

When social scientists have looked at populations that have aged successfully into the 10th decade and beyond, they have tried to find the common factors that allow one to achieve the century mark. Almost everything falls out with statistical analysis with the exception of one thing. A sense of looking forward to the future rather than dwelling in the past. Always focus on what you can do rather than what you can no longer do due to the inevitable changes of aging.

9. Thou Shalt Make Health Decisions For You, Not Others

You are a unique individual. You understand better than anyone else what is right for you; whether that’s living patterns, medical treatment options, or what sort of symptom burden is tolerable. When faced with choices, and often in aging there are no good choices, just choices, make them based on what it right for you. Don’t try to second guess what would be better for a spouse or for children and grandchildren. As a corollary to this, begin conversations regarding personal wishes long before such conversations are necessary. There’s a campaign called ‘Let’s Talk Turkey for Thanksgiving’ which encourages older adults to initiate conversations regarding morbidity and mortality when the whole family is present and Thanksgiving is often one of those rare times.

10. Thou Shalt Trust in Luck

What will happen to each and every one of us as we age is going to be a combination of genetics, life choices, and sheer dumb luck. Always trust that luck will be on your side. Expect the best, prepare for the worst, and take what comes.

Dateline – Playa Conchal, Costa Rica

Today was another low key travel day. The bowlers must have been partying hard last night as the breakfast room was not too crowded this morning. I’ve been doing a bit of a hybrid in terms of breakfast food – some Costa Rican, some American. As long as I get my fresh pineapple I’m happy with whatever else is on the menu. I’m not overly fond of tico gallo (black beans and rice) which is the local breakfast staple but I’ve certainly seen stranger things on breakfast buffets, especially in Thailand.

The weather remained somewhat gray and rainy this morning but, as it is Sunday, the traffic wasn’t too horrific and the transfer to the airport was a breeze. I was booked on a local Costa Rican airline from San Jose to Liberia, about 100 miles northwest near to the border with Nicaragua. The country is so small that there aren’t a lot of domestic flights and the domestic terminal at the airport consists of two gates. The planes are all about 12 passenger capacity with minimal room to move about. I am not a fan of small planes. I’ve been up in a few and, in general, I’ve learned to close my eyes and wait for it to be over. I think I was scarred the first time I was up in a small plane. I was 19 and had gotten a job working on the U of W research vessel for the summer running water sampling equipment while it cruised the Gulf of Alaska and the Bering Sea. In order to meet the boat, I had to fly to Anchorage, spend the night, and then catch a small plane to Dutch Harbor in the Aleutian Islands. I did fine with the flight and got a great aerial view of Southwest Alaska on the way and then we hit the landing. Apparentlly the airport at Dutch Harbor requires you to fly straight at a mountain wall before banking into the runway. I was sure we were going to smash into that cliff face and I’m pretty certain my issues with small planes stem from that moment.

Fortunately, the flight from San Jose to Liberia, even in a small prop plane, was only about 40 minutes long and, as it was overcast, was mostly accomplished in fog. I landed, found my ground transportation, and began an hour and a half drive from the airport to the Westin Playa Conchal resort and spa on the coast some thirty or forty miles away. The drive was through the lowlands, so mainly flat. It was misty and grey so I didn’t pay a lot of attention to scenery along the way as we appeared to be driving through mainly agricultural land.

I arrived at the resort in time for a late lunch, checked in and got the lay of the land. It’s been a while since I’ve stayed in a Latin American all inclusive beach resort (Steve and I did a bunch of that. Not so much with Tommy as he was against the beach due to his tendency to sunburn within about fifteen minutes of going outside). They don’t seem to have changed a lot. This one consists of a lot of eight unit bungalows scattered through manicured tropical landscaping. It ends in a very nice beach. The restaurant consists of a number of buffet stations of various types – Latin American, meats, Italian and Asian. The drinks are included. The pool is large and relatively warm with a swim up bar. I realized I had accidentally left my bathing suit in Manuel Antonio so I bought myself a new one with three toed sloths on it at the boutique. The whole thing gives White Lotus vibes. No incest, gunplay, or drug use as of yet but it’s still early. I was texting earlier with a friend who said I needed to be a White Lotus character. Mike White needs to write a gay man of a certain age travelling alone to add to his mix. I’ll be happy to chat with him about it if anyone knows him. I’m casually acquainted with his father through LGBTQ circles but I’ve never met him.

I haven’t figured out what I’m going to do with my time here yet. I’ll check out the excursions to see if there’s anything of interest that doesn’t overlap what I’ve already done. I may just read on the beach. I may sort out my writing projects and put together a schedule so that I actually start to get things finished. I was just emailed and informed that I have been cast not in one, but in two plays at Encore Theatre between now and Christmas so maybe I’ll begin working on lines. That is if I get sent scripts. I’ve also got a couple of legal cases that I have to finish up. I don’t see boredom setting in. As there may not be that much happening, I might not do a daily travelogue as is my usual habit the next few days. We shall see.