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 k / o
                                       politics + culture

Sunday, March 28, 2010

Eloy Torrez, The Pope of Broadway, Los Angeles, Victor Clothing mural

-taken August, 2009, Los Angeles, click for larger view of mural (Background on Eloy Torrez from PublicAartinLA.com.)

Friday, March 12, 2010

the circle of healthcare

When I was a kid growing up in St. Paul, Minnesota in the 70s, my mom would take my sisters and me to the local playground sometimes for lunch.

There was a program at the playground where kids from my neighborhood would get a free lunch in the summer. The idea was that so many kids showed up for school during the schoolyear not having eaten breakfast, that providing a lunch at the park in the summertime made sense. It was a simple meal. A baloney or salami sandwich, some chips, some carrots or raisins and a drink. We would sit in the field house in a big circle and eat lunch together.

One day in particular, I remember two sisters and a brother showing up as we were eating only to be told that the lunches had run out. One of the little girls started to cry. She was hungry. And, while my mom made sure that we all shared our lunches with her and her siblings, that moment burned itself into my memory the way childhood memories sometimes do.

I will never forget the taste of the baloney sandwich I was eating that day or the sight of that girl crying in the doorway feeling hungry and left out...


the Circle of Healthcare

That story has been on my mind lately. I would like to use to it as an expanded analogy to help us discuss and understand the healthcare debate and the choices faced by Congress and the President.

All of us who have good health insurance in this country are like children at a playground hall sitting in a big circle eating lunch. We can call that the Circle of Healthcare, ie. the circle of those who have good coverage and don't live in fear of falling ill.

However, in the United States that circle isn't as big at it may seem, and no one sitting in that circle is safe from being summarily left out.


who's left out

Tens of millions of Americans are underinsured or lack access to basic medical care even though they have insurance.

There are 25 million Americans who are underinsured, many of them middle and upper income Americans, and there are a further 36 million Americans who, while they ostensibly have adequate coverage, have inadequate access to healthcare practitioners: "a new report by the National Association of Community Health Centers (NACHC) found that approximately 12 percent of the nations population, or one person out of every eight, are medically unserved and simply do not have access to basic care."

Given the above it is not surprising that 60% of the 1.5 million Americans who declare bankruptcy every year do so because of medical bills, and over three quarters of the approximately one million healthcare related bankruptcies per year in the United States are filed by people who already have insurance. And again, those filing bankruptcy due to medical bills were largely middle-class Americans:

Bankruptcies due to medical bills increased by nearly 50 percent in a six-year period, from 46 percent in 2001 to 62 percent in 2007, and most of those who filed for bankruptcy were middle-class, well-educated homeowners, according to a report that will be published in the August issue of The American Journal of Medicine.

In addition to this, discrimination by health insurers against those with pre-existing conditions is rampant.

A recent national survey estimated that 12.6 million non-elderly adults – 36 percent of those who tried to purchase health insurance directly from an insurance company in the individual insurance market – were in fact discriminated against because of a pre-existing condition in the previous three years.

When the above totals are added to the number of uninsured Americans the crisis in the United States healthcare system is made clear. There were 46.3 million Americans without health insurance in 2008. With the current deep recession, that number is going to get worse:

All of these figures almost certainly will look considerably worse next year, since the economy has weakened further in 2009 and unemployment has risen sharply. The number of people in poverty will likely set a 50-year high, while the number of uninsured will likely climb toward the 50 million mark.

In sum, we have a clear picture of who is left out of the Circle of Healthcare in America, and the picture is grim.

There are over 60 million people who are "in the circle" but who are underinsured or without adequate access to basic healthcare. There are over 46 million without health insurance at all and left out of the circle completely, except as patients in emergency rooms. Further, the circle of health security specifically excludes the one million Americans who declare a health-care related bankruptcy every single year. Most of those folks are middle-class, homeowning families who have insurance. Finally, 36% of those who attempt to join the Circle of Healthcare by purchasing insurance from the individual market are discriminated against...that's over 12 million Americans in the last three years. In America, it is legal to discriminate against people when they get sick, to leave those who most need healthcare on their own, and millions have gone bankrupt and live in poverty for that fact alone.

The Circle of Healthcare in the United States is small, insecure and, for that reason, very profitable. We are all just one illness away from being that little girl at the door.


but...that's not all...

There's are two more factors to add to this mix. Americans are getting less healthy every decade and the costs of healthcare are going up. To use just one metric, obesity rates are skyrocketing in the USA.

In 31 states, obesity rates exceed 25 percent, and in 49 states and Washington, D.C., the rates are above 20 percent. Overall, two-thirds of American adults are now obese or overweight, according to the report. [snip] The number of obese and overweight children has now climbed to 30 percent in 30 states, a troubling trend that could signal decades of weight-related health problems such as cancer, diabetes and heart disease as these children become adults.

On top of that, health care costs are only increasing and one of the best explanations for this increase in cost is simply a fundamental and widespread bias favoring profits over healthy outcomes pervasive to the US health care system.

In sum, Americans are less healthy than ever, and we can expect to pay more for health care expenses for years to come. The Circle of Healthcare, our society's ability to address a basic and central need of its citizens, is fundamentally broken and in desperate need of repair.


political realities for progressives

As progressives, we get the moral and practical import of the story I used to introduce this essay. It's insane that children should go hungry in a society of plenty; it's immoral and it's impractical to boot. However, there's a reason that my story was rooted in the 1970s. The presidency of Ronald Reagan was founded on the idea that programs like the one that fed baloney sandwiches to hungry children at a city park should be abolished in the name of conservative governance, even if that made no sense. Ideology trumped sanity.

The Democrats now representing us in Congress, our Representatives and Senators, get this when it comes to health care. They know that we have failed to pass comprehensive healthcare reform for decades because of precisely this kind of ideological attack that has favored profits for insurance companies over healthy outcomes and peace of mind for the public. Decades of failed policy have brought us to this crisis. And after decades of ideological attacks on progressive political solutions, 2009 represents the first opportunity in a generation to pass laws that represent meaningful reform.

So, what's stopping us from taking bold progressive action to fix healthcare? What's the problem, why haven't we passed a bill?

Those are good questions and they lead to a set of political realities that we need to address.

reality one: there is powerful pressure for Democrats to take action this year

There is tremendous pressure on Democrats to vote to pass a plan this year that expands the circle of coverage to near universal levels, ends discrimination against the sick, regulates minimum acceptable coverage and out of pocket expenses for everyone, improves health outcomes through better access and preventive care, and begins to get runaway health care costs under control.


reality two: public solutions work better than private ones

As progressives we know, however, that the best way to achieve the above goals when it comes to health care reform is to implement a public model of health care that takes the profit motive out of caring for our nation's health. Public solutions like Medicare, with meaningful regulations and programs that improve health outcomes are the best solutions. Given that, the vast majority of progressives would support a single-payer policy, or "Medicare for All." However, with that policy for better or for worse "off the table," millions of us have joined with some members of Congress and the President insisting that a robust public insurance option open to all Americans be part of the final bill that passes into law this year. (Important: the public option currently written into the bills before Congress is not, by and large, what many of us progressives currently think it is.)


reality three: the biggest impediment to the public solutions progressives favor is the insurance industry

The political space to pass that bill is defined not so much by an ideological breakdown of the members of Congress, but by the power of the insurance industry.

We need to understand that last reality and incorporate it into our fight to pass comprehensive health care reform with a robust public option. Here's my take:


who are the big insurers and why should we talk about them by name

Take a look at this finding from a report on California's big insurers prepared by the California Nurses Association:

For the first half of 2009, as the national debate over healthcare reform was escalating, the rejection rates are even more striking.

Claims denial rates by leading California insurers, first six months of 2009:

PacifiCare-- 39.6 percent
Cigna -- 32.7 percent
HealthNet -- 30 percent
Kaiser Permanente -- 28.3 percent
Blue Cross -- 27.9 percent
Aetna -- 6.4 percent

"Every claim that is denied represents a real patient enduring pain and suffering. Every denial has real, sometimes fatal consequences," said Burger.

PacifiCare, for example, denied a special procedure for treatment of bone cancer for Nick Colombo, a 17-year-old teen from Placentia, Calif. Again, after protests organized by Nick's family and friends, CNA/NNOC, and netroots activists, PacifiCare reversed its decision. But like Nataline Sarkisyan, the delay resulted in critical time lost, and Nick ultimately died. "This was his last effort and the procedure had worked before with people in Nick's situation," said his older brother Ricky.

Naming names is powerful. Trust me, the California Nurses, a labor union, knew exactly what they were doing with that study. They named names, presented compelling data and made it real with a personal story. Too often the Democratic party and we on the blogs do not do this. Our politicians tell the story, but don't call out corprations by name. We should not let them do that. And we should not do it ourselves. Read what Cigna CEO Edward Hanway had to say about public pressure in an interview he did with (big surprise) FOX News. (What Hanway doesn't tell you is that Cigna profits were up 13% to $263 million in the 4Q in 2008.)

When we challenge the insurance industry directly we expand the political space for meaningful healthcare reform including a robust public option. Don't take my word for it.


the single most effective moments in Obama's speech were his critiques of insurers

A David Binder Research focus group (pdf) prepared for the DNC showed that the most effective moments of Barack Obama's speech all involved criticism of the insurance industry. Three three most powerful topics among a cross section of Arizona voters were:

-Insurance Industry Reforms
-Insurance Industry Accountability
-Increasing Choice and Competition

In fact,

The highest sustained positive ratings in the speech, nearly 90 on the 0-100 scale, occurred as the President said, “Under this plan, it will be against the law for insurance companies to deny you coverage because of a pre-existing condition. As soon as I sign this bill, it will be against the law for insurance companies to drop your coverage when you get sick or water it down when you need it most. They will no longer be able to place some arbitrary cap on the amount of coverage you can receive in a given year or a lifetime. We will place a limit on how much you can be charged for out-of-pocket expenses, because in the United States of America, no one should go broke because they get sick."


people get it

Instead of taking as our start point in pushing for comprehensive health care reform a linear, partisan picture of our nation, we should instead take as our start point the Circle of Healthcare. In making our case for reform, we need to define a Circle of Healthcare that includes every American and takes on the insurers who've picked and chosen whom to include and whom to exclude from that circle for decades.

It doesn't matter who represents you in Congress, you probably know someone who has been denied insurance because of a pre-existing condition. Whatever the PVI of your district, you probably know someone personally who has had to declare bankruptcy due to medical bills passed on to collection agencies by a big insurer. Rural and urban citizens alike understand that insurance is meaningless if you don't have access to basic care whether the limitation is your rural address or your ability to find a translator. And all of us know that we have become less healthy as a nation, that we pay more for insurance and care, and that we have less security when it comes to our health insurance today all while big companies have made billions of dollars in profits.

People get it. Even some folks who marched on Washington DC yesterday get it and know where to place the blame. Our nation is less healthy, less secure and more vulnerable to being denied coverage or going broke today over a health problem than we were 15 years ago.

When it comes to health care we all can imagine what it might be like to be that little girl at the door.


what to do?

I think we can do three things.

1. We can rally behind the President and Congress and help them put pressure on the big insurance companies. We do this not simply by, for example, participating in the President's letter-writing campaign to members of Congress, but by helping expand the playing field and the circle of debate by taking on big insurance companies and naming them by name.

2. Those of us committed to public solutions to the healthcare crisis need to process and understand the following realities in our efforts to work the progressive block strategy:

-all Democrats need a bill
-the bill has to work, and robust public solutions are the best way to make it work
-insurance companies are the obstacle to making comprehensive reform

3. Finally, we need to understand the tremendous force that is the pressure to pass this bill. There is tremendous pressure to pass a bill. Our ability to navigate the pressure cooker of the negotiations over this bill and pass meaningful public solutions into law depends on our ability to factor this reality into our equation and mature as a movement.

We have to learn to work both/and.

If we go too far in our efforts and kill this bill, we kill our coalition. If we don't hold the line using the tools at our disposal the insurance industry will win a package of giveaways. Big corporations are used to negotiations involving bargaining hard up till the last minute. Too often the last decades, we Democrats have not proven as adept. History has shown us that the only meaningful change worth making involves fighting hard with unity and determination.

The battle over healthcare reform will go to the final hour and all of us will need to keep a united front.



When I was a boy, I lived in an America where providing a sandwich to hungry children made moral and political sense. As I grew older, I came of age in an America where Ronald Reagan defined our national priorities by cutting funding for those very programs and implying that the circle of well being for our nation was drawn so that large corporations should be free to pick and choose those who thrive and those who fall behind.

Like all of you I reject that vision of America. Millions of our brothers and sisters agree.

In a prosperous and inclusive America, there is room in the Circle of Healthcare for everyone.

We are on the brink of making great change. No one said it was going to be easy. No one said that we would go in a straight line from A to B.

This fight for healthcare reform is worth fighting for right up to and through the very end. We need to do this standing side by side. We have spoken with one voice to our fellow Americans and what we've said has resonated loud and clear.

No one should die because they cannot afford health care, and no one should go broke because they get sick.


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