Vox clamantis in deserto
‘In the womb of the storm’
“Gathering Storm,’’ by Albert Bierstadt (1830-1902).
Blue through the window burns the twilight;
Heavy, through trees, blows the warm south wind.
Glistening, against the chill, gray sky light,
Wet, black branches are barred and entwined.
Sodden and spongy, the scarce-green grass plot
Dents into pools where a foot has been.
Puddles lie spilt in the road a mass, not
Of water, but steel, with its cold, hard sheen.
Faint fades the fire on the hearth, its embers
Scattering wide at a stronger gust.
Above, the old weathercock groans, but remembers
Creaking, to turn, in its centuried rust.
Dying, forlorn, in dreary sorrow,
Wrapping the mists round her withering form,
Day sinks down; and in darkness to-morrow
Travails to birth in the womb of the storm.
— “March Evening,” by Amy Lowell (1874-1925), Boston poet
Landscape at its Essence
“Abstract Tuscan Landscape #5” (oil on wood panel), by Greg Gorman, in his show “Abstracting the Landscape: In Search of the Essence,’’ at AVA Gallery and Art Center, Lebanon, N.H., through April 25.
The gallery says:
“The concept of this exhibition is to explore the process of abstracting landscape, using the Tuscan countryside as a point of departure. The works presented trace progression from relatively representational interpretations of the landscape through successive stages of deconstruction and abstraction, gradually reducing each scene to its essential elements and offering a new way of seeing the familiar.’’
Philip K. Howard: How to Try to Rebuild Trust in a Troubled world
“The more I read the papers, the less I comprehend. The world with all its capers, and how it all will end.” These are Ira Gershwin’s opening lyrics to Our Love Is Here to Stay, with music by his brother George, written in 1937, the year in which George died.
(Hit this link to hear Ella Fitzgerald sing the song.)
Now as well, the world order seems to be unraveling as we sit down for morning coffee.
My fear is not that America and other free nations lack the power to contain totalitarian threats. What scares me is that America is weakened by distrust. The strength of any culture and coalition comes not just from aligned interests, but mutual trust. Take away trust, and commitment becomes tentative. To be strong, any group must be bonded by belief in each other.
The bad guys know this. They like it if the U.S. acts like a bully, because that fractures alliances and undermines our moral authority. China, Russia and others also sow division within America, hacking our culture using social media. America can’t be strong abroad, they know, if we’re weak at home.
Our focus at Common Good is to re-empower Americans to take responsibility—to modernize infrastructure, fix poor schools, and regain ownership of our values in daily interactions. The impediment is a flawed governing philosophy, introduced after the 1960s, that strains daily choices through a legal sieve. Instead of using common sense, Americans go through the day listening to a little lawyer on our shoulders.
The harm of law everywhere is not just government paralysis, but growing social distrust. A recent Pew survey found that social distrust in America is higher than in any surveyed country. In his farewell New York Times column, David Brooks explained how “four decades of hyperindividualism” have led to growing distrust, which in turn dampens ambition and hope for the future. But Brooks does not explain why selfish individualism infected the culture.
In “The Need for Judgment,” published by Law & Liberty, I argue that distrust grows when people are not accountable for selfish behavior. Today, Americans are taught to avoid being “judgmental.” We’ve been told that almost any adverse decision about someone might be a violation of their rights. You must be prepared to prove by objective evidence that, say, the teacher has lost her spark, or that a co-worker selfishly games the system. Who are you to judge?
Distrust can arise from many sources, including the inability of governing authorities to deal with endemic social problems. But there’s hardly any more corrosive cause than letting people get away with selfish behavior. Instead, in a well-meaning effort to avoid bias, modern law encourages a mindset of self-interested entitlement: Give Me My Rights!
Both the paralysis of American government and the rise of hyperindividualism are largely caused by one flaw in modern governing structure—the disempowerment of human judgment.
A spring cleaning of the red-tape state is long overdue. The proper role of law is to provide a framework for freedom and for official authority—not to micromanage choices within that framework. Reviving trust will be hard until Americans feel free to act on their best judgment.
Philip K. Howard, a New York-based lawyer, author, civic leader and photographer, is chairman of Common Good, a nonprofit legal-and-regulatory-reform group. His books include The Death of Common Sense.
In search of nonsalt ice melters
Storing road salt.
Salt corrodes exposed metal on cars, bridges, etc.
Thester11 photo
Adapted from Robert Whitcomb’s “Digital Diary,’’ in GoLocal24.com
I hope that we get lots of rain in the next few weeks to quickly wash away the snow-and-ice-melting road salt that threatens to lay waste to plants along the roads. But maybe that’s not a good idea? Much of this salt will end up in bodies of fresh and salt water, whose ecosystems it will damage. Pray for the development of new environmentally friendlier melters that cost no more than salty ones. Made from plants?
Snow, however beautiful it can be when fresh-fallen, is a powerful dirt and pollution collector.
The Rhode Island Department of the Environment warns:
“As snow melts, road salt, sand, litter, and other pollutants are transported into surface water or through the soil where they may eventually reach the groundwater. Road salt and other pollutants can contaminate water supplies and are toxic to aquatic life at certain levels. Sand washed into waterbodies can create sand bars or fill in wetlands and ponds, impacting aquatic life, causing flooding, and affecting our use of these resources.’’
People are supposed to alert the agency if they want/need to dump snow in public waterways.
Given the gargantuan snowstorm of Feb. 22-24, Spring will be particularly polluted this year hereabouts as all this stuff melts and is dumped, often with little care.
‘Crosscurrents of color, light and Imagination’
Left “Savage and Holy Light” (acrylic on canvas) and right, “Night Visitor” (acrylic on canvas) by Pamela Granbery, in her show “Radiant States,’’ at the Newport Art Museum, through May 31.
The museum says:
“Pamela Granbery (American, born 1948) paints at the crosscurrents of color, light, and imagination. Working in watercolor and mixed media, she creates luminous, atmospheric fields where color behaves like light itself, energetic, shifting, and alive. Born of both accident and intention, her process recalls the spiritual experimentation of John La Farge’s stained glass and the dreamlike surrealism of Salvador Dalí’s landscapes.’’
Llewellyn King: Loving Ireland on St. Patrick’s Day, with all its contradictions
A St. Patrick's Day procession in Downpatrick, Northern Ireland, where St. Patrick is said to be buried.
The Chicago River dyed green for S. Patrick’s Day.
— Photo by Scott M. Liebenson
WEST WARWICK, R.I.
St. Patrick’s Day is Tuessday, and I won’t let it pass without wearing something green and reaching for a glass of something that has been produced through fermentation or distillation. It is the least I can do for all the ways the Irish have enriched the world, but especially the English language, and me.
When it comes to writing, the Irish have what might be termed an ethnic advantage, from the literary game-changers in the last century — George Bernard Shaw, James Joyce, Samuel Beckett and Brendan Behan — to two of the top practitioners of novel-writing today, Sally Rooney, who is only 35, and the prolific and so-readable John Banville.
When it comes to poets, William Butler Yeats is, to my mind, seated among the immortals.
Yet, as I enjoy my St. Patrick’s Day libation, I shall reflect on the contradictions that are Ireland. These are summed up in a personal experience.
I was, for over 20 years, the American organizer of the Humbert Summer School in Ballina, Co. Mayo. One of my missions was to take Americans — often Irish Americans who had never been to their ancestral land — to Ireland and the school.
Summer schools in Ireland are akin to Renaissance weekends or Aspen Institute meetings in America. Some are literary, like the Yeats Summer School in Sligo, or political, like the Parnell Summer School in Co. Wicklow, or musical, like the Willy Clancy Summer School in Co. Clare.
Mine, alas, is defunct, but it was named after the French General Jean Joseph Humbert who landed in Killala Bay to help the United Irishmen’s rebellion against the British in 1798, which was celebrated in Thomas Flanagan’s novel “The Year of the French,” and the movie based on it.
The Humbert School was the creation of its director, John Cooney, a distinguished journalist and major historian. Its mission was to discuss Ireland’s future at home and abroad.
Before the start of one year’s summer school, I briefed my Irish American charge, Ray Connolly, on just how awfully the British, my people, had behaved in the northwest of Ireland, from colonization in 1611 to the 1798 rebellion, to the famine of 1846, when so many perished or fled in the great diaspora, to the notorious Black and Tans after World War I. They were a paramilitary force formed in 1920 to reinforce police posts, act as escorts, and conduct counter-insurgency operations. But their cruelty caused many Irish people to join the Irish Republican Army.
I spared nothing in the telling of Albion’s perfidy in Ireland.
After the weeklong summer school, on our drive to Dublin Airport and our flight back to Washington, we stopped in a pub. When the publican heard my English accent, he asked, ”How’s the weather over there?” I knew he meant in England. I had to explain that I was now an American and had been for years.
The publican threw his arms around me and declared, “God bless you. You never lost your accent.”
Our exchange confused Ray. He reminded me that I had recounted the full litany of English horror in the northwest of Ireland including, after the 1798 rebellion, how Gen. Charles Cornwallis, chagrined after his defeat in America, hanged 20 Irish rebels per day.
“That,” I said of the enthusiastic publican, “is part of the wonder of Ireland: its contradictions.”
Ireland’s relationship with Britain is a fine example of those.
Britain is a prime destination for work and for career opportunities for the Irish. They talk of London with affection, although they may still sing rebel songs with gusto, and mention the horrors of the past as though they were last week.
Under a treaty, the Common Travel Agreement (CTA), Irish citizens have the right of abode in England. For them, there is no frontier; although, I learn, that may change as people who have acquired Irish citizenship, but aren’t Irish-born, are abusing it, adding to the immigration woes in Britain.
If the CTA should end, Britain will lose much, just as America is set to lose Irish talent because of immigration restrictions.
When talking about the impact of Ireland on America – 23 presidents were of at least some Irish descent — it should be noted that America has also had an impact on Ireland.
On the downside, there is fast food. When I asked a cab driver in Dublin about where to get good fish and chips, he said he preferred Kentucky Fried Chicken.
On the upside, there is the celebration of St. Patrick’s Day, which started in America.
But before Americans went crazy for all things Irish on March 17, it was a quiet religious day in Ireland. Now it is more of a celebration there, as it is here and much of the world. Sláinte!
On X: @llewellynking2
Llewellyn King is executive producer and host of White House Chronicle, on PBS.
Gazing at the water
“A Good Pool, Saguenay River" (1895 watercolor over graphite, with scraping on cream wove paper), by Winslow Homer, in the show “Coastlines: American Prints And Drawings,’’ July 4-Sept. 27, at the Clark Art Institute, Williamstown, Mass.
The museum says:
“This exhibition presents American nineteenth- and twentieth-century watercolors, etchings, drawings, lithographs, and wood engravings from the Clark’s permanent collection that depict the culture and landscapes of the coastline. Focused on representations of the eastern seacoast of the United States, the exhibition situates the coastline as a site of contact and exchange, of economic and cultural activity, and a terrain integral to nation building. Through the Clark’s strong works on paper collection, the exhibition brings to the forefront the artist’s ‘line’ in drawing and in print, made innovative and exceptional at the intersection of land and sea.’’
Editor’s note: The Saguenay River is actually in Quebec.
Chris Powell: Conn. public Schools couldn’t meet new home-school standards
MANCHESTER, Conn.
In principle there's nothing wrong with the basics of the home-schooling legislation that got a public hearing before the General Assembly this week. The bill would require people to notify local officials in person when they withdraw their children from public school to home-school them, to bring their home-schooled children to some sort of wellness inspection once a year, and to provide evidence that the children are learning.
But the legislation should prompt howls of ironic laughter.
The legislation has arisen out of the case of an abused girl who was murdered by her family after her abuse and murder were concealed by a claim of home-schooling that fooled the state Department of Children and Families. It's fair to worry that claims of home-schooling can conceal child abuse or worse.
Unfortunately the howling has to start when one notices that child neglect and abuse in Connecticut are almost infinitely more frequent among children being public-schooled, children about whom state and municipal governments seldom do anything.
Thousands of public school students in the state -- almost 20% of them -- are chronically absent from school, but there are no longer any penalties for them or their parents, so the problem endures. In cities the chronic absenteeism rate is closer to 25%. When those children are absent it's not because they are being home-schooled but because their parents are negligent.
A few weeks ago it was reported that Hartford's schools have changed their policy and now accept young children who are not toilet-trained. School staffers were instructed to clean and re-diaper them. This change of policy indicates wholesale child neglect in the city, but no one advocating the new accountability requirements for home-schooling has taken note of it. Nor have the state Education Department and the Department of Children and Families.
Requiring parents of home-schooled kids to produce evidence of learning may be the biggest howler. For Connecticut's public schools have no such requirement for their own students. Social promotion is policy throughout the state, with advancement from grade to grade and graduation achieved without having to learn anything except how to stash your cell phone in a Yondr pouch.
Two years ago Hartford's school system was exposed for having graduated a young woman who was illiterate. She is unlikely to have been the only such graduate in Hartford or the rest of the state that year. The city's school superintendent and the state education commissioner promised investigations but no explanation was produced and no state legislator has ever demanded one.
Indeed, while the failures of public education in Connecticut practically scream for investigation, the General Assembly is deaf to the problem.
Why?
First, it's because the people who most deserve reprimanding -- neglectful parents -- are among the legislators' own constituents. There are many in nearly every legislator's district. The law should hold them to account. But standards are falling throughout society, and politics in Connecticut lacks the courage to restore them.
And second, legislators overlook the failures of public education because an examination would discomfort teachers and their unions. Teachers aren't to blame for child neglect and abuse and chronic absenteeism; they see Connecticut's social disintegration most intimately and must play the hands they are dealt. But teachers are to blame for much of public education's unaccountability -- binding arbitration of union contracts, the secrecy of teacher evaluations, the impossibility of firing inadequate teachers, and hostility to competition in education.
That hostility to competition in education may be the bigger part of the legislative campaign against home-schooling. Legislators know that if they make trouble for home-schooling parents, they will win political points, endorsements, and contributions from teachers and their unions, Connecticut's most influential special interest.
So instead legislators scapegoat the home-schoolers, who probably get far better results with their students than the public schools do. Some proficiency testing could settle the matter but Connecticut practically forbids proficiency testing in public schools, especially at graduation, presumably because the results would be terrifying. Taxpayers mustn't know the results but instead just keep throwing money.
Chris Powell has written about Connecticut government and politics for many years (CPowell@cox.net).
Jennifer B. Nuzzo/ Andrea Uhlig: Spreading Measles outbreaks Signal wider Systemic Threat
Expression of measles by skin color.
From The Conversation, except for image above.
PROVIDENCE
Jennifer B. Nuzzo is a professor of epidemiology and director of the Pandemic Center at Brown University. Andrea Uhlig is a reserearch assocciate at the Pandemic Center at Brown.
Nuzzo receives general research funding from the Gates Foundation, Wellcome, and NTI, to support general policy and practice research on infectious-disease trends, science and practice. This support is not specific to the topic covered by this piece.
Uhlig does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond her academic appointment.
In the three decades between 1993 and 2024, measles in the U.S. was relatively rare – a few hundred cases each year, at most. But suddenly, the disease has become so entrenched in American life that it sometimes fails to make headlines when a new outbreak erupts.
As of March 2026, measles has been continuously circulating around the U.S. for more than a year, starting with an outbreak in Texas that lasted from January to August 2025. Before that outbreak was declared over, an outbreak on the Utah and Arizona border began in August and is ongoing. An outbreak in South Carolina began in September, drastically increased in January 2026, and continues.
Thirty states have had measles cases this year; 47 have seen cases since the start of 2025. Health officials across the U.S. have confirmed 1,300 infections already this year as of March 6, putting the country on track to surpass 2025’s numbers, which were the highest in 35 years.
We study outbreak preparedness and response at Brown University’s Pandemic Center, and we view the return of measles in the U.S. as a grim signal of what’s to come.
Low levels of vaccination across the country mean measles outbreaks will continue to occur, needlessly hospitalizing and killing the unvaccinated. But beyond these harms, the disease’s resurgence serves as a serious warning about the country’s capacity to manage infectious-disease threats of all kinds.
eliminated disease returns
Measles’ return is no mystery: At its root is the falling vaccination rate.
Around 90% of the U.S. population has received the MMR vaccine, which protects against measles, mumps and rubella, and in some regions of the country, the rate is below 60%. Since about 2019-2020, that overall number has dropped below the 95% needed for herd immunity. It is necessary to keep that rate nationally, but maintaining herd immunity at the local level is equally important in order to prevent measles from finding pockets of unvaccinated communities.
Measles can have serious long-term health consequences.
Countries that remain free of continuous transmission for 12 months are deemed to have eliminated measles – a designation the U.S. achieved in 2000. The Pan American Health Organization was scheduled to decide in April whether the U.S. should lose that designation, but the organization postponed its meeting until November.
Current trends suggest that both the U.S. and Mexico, which has also been battling the disease, may lose this status – as Canada did in November 2025. All three countries have seen their vaccination rates fall below the 95% threshold, and their outbreaks may share epidemiological links.
long-term threat to US health
By any measure, the ongoing U.S. measles outbreaks signal that the disease has returned in a way that will have serious adverse health consequences. In 2025, three people died from measles in the U.S. That is more than in any year since the disease’s elimination 25 years ago.
Of the country’s 2,283 confirmed measles cases in 2025, 11% were sick enough to be hospitalized. In South Carolina, where most measles cases have been reported in 2026, hospitals don’t have to report when patients are admitted due to measles complications, so the actual number of hospitalizations due to measles could be much higher.
People who recover from measles can experience complications such as pneumonia, which can lead to death, or encephalitis, which can later lead to deafness or intellectual disabilities from the brain swelling. The virus can also affect the immune system, making people more susceptible to other infections over the long term, even ones they’ve had before.
In rare instances – though more likely if someone is infected as a child – measles patients can develop a progressive dementia known as subacute sclerosing panencephalitis, or SSPE, anywhere from two to 10 years after their infection. SSPE always leads to death. This past year, a school-age child in Los Angeles died of this condition years after being infected with measles as an infant, before they were old enough to be vaccinated.
Measles an economic scourge
Recurring outbreaks of measles in the U.S. will mean high economic costs. Countries have pursued measles elimination in part because of the clear economic benefits of stopping domestic transmission of the virus.
Studies have found that the cost of containing measles outbreaks is often as much as tens of thousands of dollars per case. One outbreak in Washington state in 2018-2019, which involved 72 cases – a small outbreak compared with what states are reporting now – cost US$3.2 million for the public health response, medical expenses and productivity losses. The Common Health Coalition found that a sustained 1% drop in MMR coverage would cost the U.S. billions across health care systems and the economy.
Controlling a measles epidemic, like the one in South Carolina that started in 2025, can cost millions of dollars. Sean Rayford/Stringer, Getty Images News
opening for infectious disease
As concerning as recent outbreaks of measles have been, they herald a larger systemic problem.
How a country controls measles can be viewed as a proxy for how well it would control many other diseases. That’s because the steps for stopping the spread are the same: deploying vaccines to prevent infections, detecting and isolating cases when they occur, identifying exposed contacts of infected people and making sure they stay home if they’re likely to be contagious, and treating sick people safely.
But besides measles, we’ve already seen infections that were once controlled, like whooping cough, that rose sharply in 2024 and remained high in 2025 compared with before the COVID-19 pandemic.
That’s because controlling the spread of many infectious diseases depends on the public’s trust in the basic components of public health. Declining MMR vaccine coverage reveals underlying challenges in public support for vaccines. Public confidence in the current Centers for Disease Control and Prevention is also eroding, according to polling from 2023 to early 2026 by the health policy organization KFF. Less than half of the people polled trust the government even “a fair amount” to provide reliable vaccine information.
These growing cracks in the country’s public health armor will complicate efforts to protect Americans from future disease threats – whether an outbreak, a pandemic or a biological attack.
New A.R.T. building nearing completion
Edited from a New England Council report:
Harvard University is nearing completion on the David E. and Stacey L. Goel Center for Creativity & Performance, a 70,000-square-foot facility in Boston’s Allston neighborhood that will be the new home of the American Repertory Theater (A.R.T.). The project, at 175 North Harvard St., topped off its mass-timber structure in October and is expected to open early next year.
The Goel Center will feature two flexible performance venues, a 700-seat West Stage and a 300-seat East Stage, along with rehearsal studios, teaching spaces, a public lobby, and an outdoor performance yard. The building incorporates sustainable design elements, including low-carbon mass timber, reclaimed brick, natural ventilation systems, rooftop solar panels, and a green roof. Catalyzed by a $100 million gift from David E. Goel ’93 and Stacey L. Goel, the center will anchor Harvard’s arts presence in Allston alongside the university’s Science and Engineering Complex and Business School campus.
Inspiration from loneliness
“Shoulder Season” (mixed medium), by Jennifer Goldfinger, in the group show “Polyphony,’’ at Cove Street Arts, Portland, Maine, through April 11.
She says:
“My two forms of creative expression, fine art and children’s books, share themes of isolation, contemplation, empowerment and imagination.
“In the formative years of my middle childhood, my family lived on a farm with neighbors too far apart to know — it was a lonely existence, but in a setting that tickled my imagination. My still resonating emotion from that time unavoidably creeps into my work. As I sift through vintage photographs, I am pulled in by certain expressions on certain children’s faces, and from there the process begins. In working with these characters, I find empathy for them and for my young self. While there is a degree of personal catharsis in this process, I also know there are universal truths here, and perhaps ultimately a greater catharsis as viewers connect with these forgotten souls.
“In my art, the interaction between found antique images and my own photography and encaustic collage work bring forward modern design balanced with nostalgic subject matter. The accessibility and playfulness reflect my work in children’s literature and an imagined context unfolds into a story of the viewer’s own.’’
Give us a break
A depiction of Muhammad receiving his first revelation from the angel Gabriel. From the manuscript Jami' al-tawarikh by Rashid-al-Din Hamadani, 1307, Ilkhanate period.
“Spare us all word of the weapons, their force and range,
The long numbers that rocket the mind;
Our slow, unreckoning hearts will be left behind,
Unable to fear what is too strange.’’
- From “Advice to a Prophet,’’ by Richard Wilbur (1921-2017), famed and mostly New England-based poet
Here’s the whole poem:
Karen Brown: Primary-care practices banding together in western Mass.
Florence, Mass., headquarters of Valley Medical Group
—Photo by John Phelan
Via Kaiser Family Foundation Health News and New England Public Media (not including picture above)
Western Massachusetts, a patchwork of rural communities and low-income cities, is a difficult place to find a primary-care doctor if you don’t already have one. Frustrated patients often turn to online forums, asking for leads or advice on how to find a practice that is accepting new patients.
One name repeatedly crops up in these discussions: Valley Medical Group.
With four locations in the Connecticut River Valley, the practice has been a mainstay of family medicine since the 1990s. Valley Medical’s flagship office, in Florence, can be found right on Main Street, next door to a pizza restaurant and near a Friendly’s.
Valley has 90 medical providers — including doctors, nurse practitioners, and physician assistants — and on-site labs, X-rays, and vision care. With tens of thousands of patients, it’s become one of the largest independent practices in western Massachusetts.
It forms a key part of the region’s health-care infrastructure, yet Valley Medical has rarely been under more strain than it is now. In January, the practice laid off 40 employees — 10% of its 400-person staff — mostly in support positions.
Despite patient demand — there are waiting lists to be seen — primary-care providers take on more clinical responsibilities, and for less pay, than most medical specialists, said the group’s CEO, primary care physician Paul Carlan. Rates are outlined in the group’s contracts with insurance providers.
“It has to do with the fact that our contracts don’t pay as well as we think they should,” Carlan said. “The cost of everything is going up.”
Valley Medical Group is far from alone in this predicament. Thousands of primary-care practices, a key gateway to the medical system, are fighting to remain financially viable — and independent.
In response, many are banding together to form Independent Physician Associations, or IPAs. The goal is to increase their market power, change the way they get paid, and retain control over how they treat patients.
Threats to Physician Autonomy
Primary-practices in the U.S. are in serious trouble, according to workforce surveys. The American Association of Medical Colleges estimates a deficit of up to 86,000 primary-care doctors by 2036, as more primary care doctors retire and fewer enter the field.
The number of people who can’t find a primary-care doctor has grown by 20% in the past decade, according to a recent JAMA Internal Medicine report.
Lower relative salaries and higher professional stress are disincentives when medical students consider a career in primary care. Newly minted doctors can earn more in specialties such as cardiology or surgery.
Financial stresses in U.S. health care, exacerbated by the covid pandemic, have led to the closure of many primary care practices, according to the AAMC.
The Massachusetts Health Policy Commission released a report in 2025 partly blaming the crisis on the relatively low insurance reimbursement rates for primary care. The revenue problem for primary care is projected to get worse when the Republican-backed cuts to Medicaid start to take effect later this year.
As they seek financial security, many primary care practices have merged with large hospital systems, with doctors becoming employees of those systems.
But the doctors at Valley Medical Group were determined to avoid that fate. Joining a health system takes away the autonomy doctors need to make the best clinical decisions for their patients, Carlan said. It also siphons off income into the larger hospital system.
“Our priorities get muddled up,” he said. “And I think when you’re part of a health system, you’re constantly being asked to bend for the needs of the organization. Hospitals get paid when their beds are full.”
By contrast, primary-care providers need time and money to manage or prevent illness, Carlan said, and their insurance reimbursement rates should take that into account.
In December, Valley Medical Group announced it would be joining an Independent Physician Association. Like a union, an IPA combines individual primary-care offices, giving them power in numbers when negotiating contracts with Medicaid, Medicare, and private insurance companies.
“It’s a moment of transition,” said Lisa Bielamowicz, chief clinical officer of TrustWorks Collective, an independent health-care consultancy that works with health systems and physician groups.
IPAs are gaining momentum as older doctors retire, especially following the challenging years of the covid pandemic, Bielamowicz said. “As the Baby Boomers move out and younger physicians take leadership roles, these kinds of models become more attractive.”
The American Academy of Family Physicians, a trade group, is hearing from practice owners who joined hospital systems but now want to break off and return to being a smaller practice.
“So if independent IPAs can create the infrastructure support to make independent practice viable, then that’s a good thing,” said Karen Johnson, a vice president at AAFP.
IPAs can bring more clout to the table when negotiating rates with insurance companies. Some insurers say they like working with these partnerships because they help stabilize primary-care practices, maintaining access and options for insured patients.
Otherwise, some doctors shift their business model to “direct primary care,” which bypasses insurance altogether.
“We’re looking at independent practices that aren’t buoyed by …. these large health systems and can support members in the community in the ways that they want to be supported,” said Lisa Glenn, a vice president with Blue Cross Blue Shield of Massachusetts.
A Different Payment Model
When those independent practices band together, Glenn said, Blue Cross can offer “value-based” contracts. Instead of getting a payment for each visit or procedure, the medical practice is given a budgeted amount for each patient’s care, which provides an incentive to keep them healthy so they need fewer treatments.
Medical providers “make different kinds of choices than they would if they’re paid for every procedure, every visit, every widget,” TrustWorks’ Bielamowicz said.
If there is money left at the end of the year, it’s split between the practice and the insurer.
The catch, Glenn said, is that a value-based contract works only if there’s a big enough pool of patients to spread out the risk, in case a few get really sick. Otherwise, she said, “the risk of ending up above or below the budget becomes somewhat subject to random variation rather than performance.”
Value-based contracts were supposed to be the next big thing when the Affordable Care Act passed in 2010, an innovative way to bring costs down for the health system as a whole.
But they were slow to catch on; the traditional fee-for-service payment model was too entrenched. Experts say that could still change, if enough primary care providers work together to build market power through IPAs.
“If we keep people out of the ER, keep them out of unnecessary hospitalizations, we save money for the system,” said Chris Kryder, CEO of Arches Medical IPA in Cambridge, Mass,, the IPA specializing in value-based contracts that Valley Medical joined. “And we create more income for the PCPs [primary care providers], which is dreadfully needed.”
These contracts also allow more flexibility in staffing, Kryder said, because nurses, physical therapists, and medical assistants can take on some of the less complex medical tasks, saving the practice money.
IPAs Can Help, Depending on Who’s in Charge
But IPAs are not a panacea for primary care’s problems, according to some health-care leaders.
There are hundreds of IPAs, but not all offer the independence and autonomy that many doctors crave. Some IPAs are actually owned by hospital systems, or even private equity companies, and they’re less focused on preventive care.
The American Academy of Family Physicians advises its members to seek out IPAs with “integrity,” ones that give doctors a strong role in decision-making.
“Who’s calling the shots, who’s making the decisions, and is it really focused on the best interests and long-term benefit of physicians in practice and their patients?” asked AAFP’s Johnson.
Arches Medical is owned entirely by physicians and focused specifically on primary care, Kryder said. But to be more effective, Arches needs to recruit more practices that want value-based contracts.
That can be a hard sell, said Glenn, of Blue Cross. Under that payment model, doctors might see a lag of more than a year from the time they provide care to the moment they realize savings.
“It doesn’t happen overnight, and it does take an investment,” she said.
That lag is one reason Valley Medical Group had to lay off staff after joining the Arches IPA, said CEO Carlan. But he has faith that, after some time, the practice will become more financially stable, be able to offer higher salaries, and, most important, keep the doctors in charge.
Karen Brown is a journalist with New England Public Media.
This article is from a partnership that includes New England Public Media and NPR as well as Kaiser Family Foundation Health News.
Roots as metaphors
“Deeply Rooted III (monotype with litho crayon on kitakata paper), by Carol MacDonald, in her show “Roots: Cultivating Connection,’’ at Galatea Fine Art, Boston, through March 29.
The gallery says:
Carol MacDonald says she aims to "address issues of community, life, transition and communication" through her work as a printmaker "tugging at the threads of our shared humanity." This series of monotypes "works with images of roots as a metaphor for the support systems that keep us, as people, anchored and nourished in our seemingly rootless world. Our families, friends, community and service networks combine to sustain us as our lives develop and change.’’
Glass as dialogue
Work by Neil Neil Orange Peel (!) in his show March 18-June 7, at the Cahoon Museum of American Art, Cotuit, Mass.
The museum says:
“The work of Neil Neil Orange Peel is a vibrant reflection of personal evolution, creative exchange, and the transformative power of light. As a dedicated stained glass artist and teacher, he draws inspiration not only from his own journey, but from the hundreds of students who pass through his studio each year, each bringing stories that subtly shape the work.
“Rooted in the rich tradition of stained glass, including the enduring influence of Louis Comfort Tiffany, Neil’s pieces honor historic craftsmanship while embracing a distinctly contemporary voice. Created on Cape Cod, his work is deeply informed by the region’s shifting light, coastal beauty, and vibrant artistic community. The result is stained glass that feels both timeless and personal; an ever-evolving dialogue between place, people, and practice.
Now improved by hedge funder
“Connecticut Farmhouse’’ (medium watercolor on paper), by Warren William Baumgartner (1894-1963), at the New Britain Museum of American Art.
Gerald FitzGerald: ‘Take him to the Truro line’
The original, and long-gone, home of The Provincetown Players, founded in 1915 and the origin of The Provincetown Theater.
In 1966, I won the glamorous position of assistant to Armida Gaeta, the assistant of The New York Times’s foreign-news editor. Armida Gaeta was a tiny woman with enormous spectacles and the demeanor of a ticking bomb.
I was 19 and life was glamorous working exactly one step above office boy.
I had begun working for the paper as a messenger carrying advertising copy and art between agencies and the newspaper in a time long before most computers or even fax machines. My brother proofread classified ads there while attending grad school. I had just flunked out of John Carroll University, in University Heights, Ohio -- news I wouldn't tell my parents until I had a place to stay, a job, and was enrolled in evening classes somewhere.
Helen Durrell was a notable figure in The Times’s personnel operations. She hired me on as a messenger; later I was promoted to office boy. When the newsroom job opened up, she told me that I had to type 60 words per minute even to be interviewed. When I was a kid, Mom had taught me to type by drawing the keyboard of her old Underwood on a shirt cardboard and taping it to the wall in front of me.
“Never look at the keys, just the drawing, and you'll see it forever,” she said.
I thought that I could qualify, so Helen gave me the typing test.
I blew it, finishing at 40 wpm, and then asked when I could take it again. Helen told me I could when I had practiced at home and brought myself up to speed.
“How about tomorrow morning?” I asked.
Helen seemed surprised but didn't say no. That evening, I returned to East 4th St., in Greenwich Village, with beer and cigarettes and checked my typewriter's ribbon to be sure that I wouldn’t discover that I needed a new one after the stores closed. All night long, I sat typing some version of “The quick brown fox jumps over the lazy dog” --- a pangram containing every letter of the alphabet. I hardly ever paused but to sip beer or to use the john. Good thing I could type and smoke simultaneously.
The next day I retook the test and clocked at better than 60 wpm. Aided further by a letter of reference from The Times’s chief legal counsel, James Goodale, secretly orchestrated by his two friendly secretaries, I got the job on the third floor’s huge open newsroom.
For a kid who'd dreamed of news writing since he was old enough to attend movies, I was in heaven. What I mostly did was to compose and distribute a list of the daily whereabouts of each foreign correspondent. My desk was next to those of Seymour Topping, the foreign-news editor, and reporter Harrison Salisbury, just back from duty in Moscow.
The newsroom was an equivalent to square city block, and with few interior walls. It was so big that microphones and loudspeakers were needed to page people to report to the metropolitan desk, the sports desk, the national desk, the foreign desk, obituaries or any other part of the operation. A row of wire-service (Associated Press, UPI, Reuters, Agence France-Presse, etc.) teletype machines, constantly sounding bells and keystrokes, stood one after another after another from West 43rd St. to West 44th St.
xxx
Only my then-19-year-old mind could possibly explain why I carried just $5 for a week's stay in Provincetown, Mass. But at least I already had my ticket to Eugene O'Neill's A Moon for the Misbegotten, at the famous Provincetown Theater, along the beach. The theater’s origins go back to 1915, with the establishment of the Provincetown Players.
My tall, blond buddy, Dennis Niermann, nicknamed “The Swede” and from Ohio, would hitch with me as far as Boston. He'd been visiting my fifth-floor walk-up single-bedroom apartment at 73 East 4th St., between Second Avenue and Bowery. I had taken it over from my brother and usually had two roommates to split the $85-a-month rent three ways.
Taking the long route home to Cleveland, Dennis was doing me a favor, but he wouldn't have minded the company, either. At the time he may have been reading electricity meters for a living but, just so you know, he later became a renowned anti-discrimination lawyer. We got to Boston easily and early. We probably grabbed a burger at the Paramount, a Greek place on Charles Street, but eventually walked over to Boston Common, where we rolled out our sleeping bags in the dusk atop a grassy hill just beneath the looming column of the Soldiers and Sailors Monument and slept on the ground undisturbed through the night. You could do that back then. After coffee somewhere, Dennis and I split, he hoofing over to the Mass Pike West and I to hitchhike on Route 3 South, toward Cape Cod.
I don't remember how many rides it took to reach Hyannis, the biggest town center on The Cape, but I recall that it was getting dark and starting to rain as I walked up Main Street in search of somewhere dry. I had visited Hyannis years earlier, when New York neighbor Jack McCarthy took me deep-sea fishing with his son, Johnny. Mr. McCarthy won the boat pool for most fish; Johnny won for biggest, and I won for the first fish caught.
This time I walked past the miniature golf course, where we'd played to celebrate. Just down a cross street, I found a wooden three-sided shelter with a bench and roof. It must have been provided for those waiting for a bus or train. I snuggled into one corner and began to assess my chances of spending the night there without getting rousted by an overeager patrolman. My hand brushed something I could not see in the dark shelter.
It turned out to be one of those small leather change purses. I snapped it open. Inside were two fives and two singles and some quarters, dimes and nickels. No I.D. No phone number. Not even a scrawled nickname. My personal wealth had just catapulted from maybe two bucks to almost fifteen.
I remembered a sign for a really cheap-looking lodging back along Main Street, not a far walk from the miniature golf course on the same side of the street. I found it and purportedly clean sheets for something like $3 a night. I am sure that its exterior sign used the word “Hotel,” but, make no mistake, it was a flop house. The room was the size of an elevator, and none of its walls reached the ceiling. A flop house in Hyannis seems somehow strange, but there it was, and it was dry and I took it.
The next day, I found Route 6 North and, eventually, Provincetown, and walked to the playhouse. I had no plan other than to redeem my ticket, but that would not be for a night or so.
I know that somewhere I still have the playbill from the small wooden theater that burned down about a decade later, but as I write I cannot put hands on it.
I know I have it because I never once in my life have discarded a playbill. I always kept them, and if years later I attended a show with my wife and/or my kids, they signed my playbill. I am going to have to inspect our attic closely. In my dad's Empire book case I have all the playbills from the last nearly 50 years we have lived in our present home. The earlier ones must be boxed somewhere in the attic.
My memory of the small wooden theater along Cape Cod Bay might be distorted.
I spent the week sleeping beneath an overturned dory on a tiny strip of beach that I recall as being between the playhouse and Bradford Street. But that's crazy. The beach must have been on the harbor side of the theater. There were wooden benches inside and space to seat fewer than 200. The theater was made of wooden planks and was caressed by a salty breeze. I don't think that it was insulated at all.
Carved upside down in the port side of the bow of the wooden-plank dory were these words: “The Baron's crib.” I took this to mean that a former adventurer had escaped the elements and, possibly, the nosy, while resting concealed and dry beneath the overturned boat. So that is what I immediately decided to do.
In Provincetown I enjoyed the O'Neill play, whose lead character, Jamie Tyrone, was based on the author's ne'er-do-well older brother in a kind of expansion of the playwright's Long Day's Journey Into Night. My days were spent lazing on the beach reading while eating bread and bologna or occasionally walking through town. I was warm, dry and comfortable within The Baron's crib. Until my very last night.
In the morning blackness, at about 2 or 3 a.m., glaring light burned my face closely, held like a weapon by a uniformed police officer lifting the dory while growling about impermissibly sleeping on the beach. He ordered me to accompany him to Town Hall, a few blocks away. I don't recall that he handcuffed me. We walked to the closed building and, somewhere on the side toward its left rear entered a jail. There was one cell, two at most. A man occupied the only cot in the cell, where they placed me so that if there really were two I think I would have asked for the empty other. Anyway, the man rose as I entered. He reeked of a superhuman dose of cologne. Truly fetid.
It now being surely around 3 a.m. I asked the guy when he'd been arrested. After 10 p.m., he guessed.
“So you've had five hours on the cot,” I told him. “I guess it’s my turn.”
I stretched out on the rumpled, sickly-sweet smelling sheet and was glad to have it. I've always been able to sleep pretty much anywhere, but this was genuinely difficult. My roommate meanwhile sat on the floor, his back against the bars.
I do not recall being offered anything to eat or drink in the morning, and I think we may have been cuffed to go upstairs to the large room being used for court. I was callow enough to be mostly concerned that observers might consider me to be “with” my cellmate, whose offense I never did learn.
When my name was called, I stood before the black-robed judge sitting above the rest of us. He told me that sleeping on the beach carried a $25 fine and asked me if I had anything to say?
I looked up at him and said, quietly:
“Your honor, if I had 25 bucks I wouldn't've been sleeping on the beach.”
The judge looked at me and then turned, a bit harshly, toward a uniformed cop standing off to the side of his bench.
“Take him to the Truro line!” snapped his honor. (Truro being the next town south.)
My response to the judge was the first of hundreds, if not thousands, of responses to judges following a series of news jobs and what became close to 40 years of addressing courts as a trial lawyer. Never having paid a dime in penalty for sleeping on the beach, I guess it counts as a win.
Gerald FitzGerald’s career has included being a newspaper editor, a writer, a prosecutor, a defense lawyer and a civic leader. He lives on Massachusetts’s South Coast.
But I want to drink alone
Oil painting by Keith Thomson, at Renjeau Galleries, Natick, Mass.
The gallery says:
“Keith Thomson’s vibrant artwork showcases a masterful grasp of perspective, surrealism, and humor. He playfully juxtaposes quotidian, every-day scenery with elements of wit and satire, an homage to his career as a political cartoonist in the ‘90s. Thomson’s art is rendered via digital sketch, then transferred on to canvas and layered with oil paint for shading and added dimension.’’