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Monday, February 19, 2024

Health Care Reform Atticles - February 19, 2024

 

Editor's Note -

The link below will take you to the On Point episode on NPR for February 13, 2024,  It focuses on the futility of relying on laws to increase "transparency" of prices and other data to solve the many problems, including the rapidly costs of healthcare  in our badly broken health care system.  The show is well worth listening to in its entirelty. 

- SPC 

https://www.wbur.org/onpoint/2024/02/13/the-fight-for-transparent-health-care-prices-in-america


Who owns your medical records?

Hint: It's not you. Nor do they belong to taxpayers, who paid for their collection.



by Robert Kuttner - The Ameriican Prospect - February 6, 2024


A couple of weeks ago, a good friend found herself in the emergency room at one of our world-class hospitals, the Brigham and Women’s Hospital in Boston. After emergency surgery, the medical team decided to admit her for at least another day to monitor her recovery.

What she encountered next was something out of a makeshift battlefield hospital, as rendered by Hieronymus Bosch. There were no beds available in the patient rooms, so “admitted” patients were being stashed in beds laid end to end in the emergency area. 

A bit of delay getting a bed is not unusual. But in this case, there were seriously ill admitted patients in 73 beds crammed into the emergency area. 

They had no privacy, and many were not masked. The beds wound around an overwhelmed nursing station, where a couple of nurses were mainly dealing with new patients. This makeshift field hospital was so large that it was sectioned off into subareas that had been given Boston street names (my friend was in the Exeter Street area), so that family and physicians could find them.

What the hell?

In exploring the deeper causes of the backup, you encounter a story of multiple, cascading failures of our health system. And no, it doesn’t have a lot to do with COVID overload. There are few patients hospitalized with COVID.

The immediate cause is a shortage of skilled nursing facilities, rehabs, and home care options into which still-impaired patients can be released. So patients are kept in acute care hospitals because there is no place else for them to go. 

This means that the normal process of beds opening up, as patients are discharged, backs up and bogs down. This is completely at odds with deliberate incentives in Medicare and private insurance plans to get patients released from expensive acute care hospitals as soon as medically feasible.

There are approximately 1,200 such patients currently occupying hospital beds in Massachusetts. In December, according to the Massachusetts Health & Hospital Association, 44 percent of hospitalized patients awaiting discharge to a skilled nursing facility were waiting for 30 days or more. They were basically in residence at a hospital, taking up scarce beds at the most expensive venue for care. And hospitals do not have rehab staff.

This mess is a vivid example of how reliance on commercialized health care with piecemeal regulation has failed and backfired.

Dig deeper, and there are the multiple causes of this mess:

There is a severe shortage of slots in skilled nursing facilities. Much of this is driven by a shortage of staff, mostly nurse aides, known as certified nursing assistants (CNAs). To be precise, there were an incredible 6,900 unfilled vacancies.

Why the staff shortage? The biggest single reason is that the work is hard and the pay stinks. A CNA typically earns between $18 to $21 an hour. Given Boston rents, this is not enough to live on. Many people trained as CNAs are working at other jobs. Many others working in nonclinical jobs at nursing homes could be trained as CNAs if the pay were decent.

This staffing shortage, in turn, has caused at least 20 skilled nursing facilities to close since the start of the pandemic; there are now 3,000 fewer beds in such facilities available than in 2020. Many nursing homes that are open are running at about two-thirds capacity and not accepting new patients, due to staffing shortages. Their business model calls for them to operate at capacity, so they are losing money and at risk of closing.

In addition, consolidations and mergers have cut the total number of inpatient hospital beds. These include the ongoing collapse of the Steward hospital chain, which converted a nonprofit Catholic health system to a for-profit one and then ran short of operating money after being milked by a private equity fund owner.

Another prime cause is the evil of Medicare Advantage, the privatized, for-profit system that leaches off Medicare. As the Prospect has reported, Medicare Advantage pretends to increase coverage. But because Medicare Advantage programs are so intensely “managed” to deny needed care, they are great when you are well but not when you are sick. 

While conventional Medicare provides 20 days’ coverage in a skilled nursing facility at no cost to the patient and another 80 days with a co-pay, Medicare Advantage plans often refuse to pay for post-hospital nursing care at all, according to a report by the HHS Office of Inspector General. The Mass Health & Hospital Association’s own report puts insurance denials for skilled nursing care as the top cause of the crisis.

A further problem is that health plans often don’t pay for case managers. An elderly patient facing discharge from a hospital, with multiple conditions, often complicated by dementia, is not competent to manage her own case.

When a hospitalized patient cannot safely go home, three options are a skilled nursing facility, a rehab, or home care. All are short of staff, largely because of profiteering and inadequate pay. 

Incidentally, the Republican policy blueprint for 2025 includes a suggestion to make Medicare Advantage the default option for all seniors coming into the program.

Yet another problem is the shortage of physical therapists, key staffers in rehabs. A decade ago, most licensed physical therapists had B.A. degrees. Then, their professional association, in order to raise pay, launched a successful lobbying campaign to require doctoral degrees. Result: a PT shortage.

Jessica Pastore, the director of external communications and media relations for Brigham and Women’s Hospital, responded to my questions in an extended email, pointing out that there is only so much that the hospital can do, but that they have actually cut waiting times for inpatient beds by 33 percent over the past year. Their strategies have included better coordination with nursing homes and home care options, as well as improved discharge planning.

The system is now so bad that its structural failures affect even the most privileged among us.

Where might some real system-wide progress be made? Most long-term nursing home patients are on Medicaid, which pays nursing homes at a far lower rate than Medicare. Even at capacity, nursing homes financed by Medicaid are barely in the black. During the pandemic, emergency federal and state aid financed extra help for nursing homes, provided that much of it would be passed along in higher wages. That aid is now finished. It would help if Medicaid paid at the Medicare rate, with the increased reimbursement earmarked for wages.

We also need real leadership from Gov. Maura Healey. Three weeks ago, the Mass Health & Hospital Association, working with Blue Cross and the state’s secretary of health and human services, Kate Walsh, came up with a palliative plan that will help only marginally. Blue Cross will streamline approvals for nursing homes, and nursing homes will stay open weekends to process admissions. Other insurers were not party to the deal; and in an indication of sheer cynicism, Steward Health Care was. 

Gov. Healey needs to make better, and better-targeted, state reimbursements a budgetary priority. SEIU Local 1199, representing nursing home workers, argues that the solution is both better pay, training, and reimbursement, and also incentive bonus payments for nursing homes that score well on staffing and low turnover.

This syndrome is simply not a problem in nations with universal health systems. Ours is a systemic failure in the broadest sense. Think of it as a supply chain crisis. It won’t be fixed piecemeal solely by better pay and more training for CNAs, though that would sure help. It certainly won’t be fixed by adding more refined incentives for cost containment, which has been the obsessive focus of health policy for decades.

The shortage of post-hospital facilities and the backup effect on acute care hospitals can be fixed only in the context of a universal system, which includes planning at every level. That means planning for facilities, for needed levels of health professionals, their training, and their compensation. 

This mess is a vivid example of how reliance on commercialized health care with piecemeal regulation has failed and backfired. Single-payer, long the goal of progressive reformers, is only part of it. We also need de-commercialization and comprehensive planning, which is only possible in the context of a universal and noncommercial system.

At 4 a.m., with no prospect of a room in sight, my friend gave up on the Brigham field hospital, and decided to risk her health and go home. She is a professional, married to a doctor. They figured that if anything really bad happened, they could go back to the ER. 

In sum, the system is now so bad that its structural failures affect even the most privileged among us. Some rich people get boutique medicine for their outpatient needs. But Brigham and Women’s is where Boston’s elite go for quality inpatient care. If that’s a mess because of deeper systemic problems, there is no place to buy your way out. 

My friend, as it happens, has long been a single-payer advocate. But as the systemic failure compromises the health of well-off conservatives as well as progressives, maybe that will provide some momentum for change.

Note: This piece is about Massachusetts. The problem is national. A follow-up article will look at trends nationally and federal policy.

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Robert Kuttner is co-founder and co-editor of The American Prospect, and professor at Brandeis University’s Heller School.



National advocacy group blames hospital consolidation for Maine’s high health care costs

Hospitals contend other factors – such as Maine being the oldest state – are driving up costs in the state.

by Joe Lawlor - Portland Press Herald - February 4, 2024

A national health advocacy group is blaming hospital consolidation in Maine for spurring higher prices at hospitals for patients with private insurance.

But Maine hospital officials say consolidation is not the force driving the prices, and that the explanation lies with the state’s older population and low Medicare reimbursement rates that shift the costs of health care to younger people with private insurance.

Maine’s two biggest hospital systems – MaineHealth and Northern Light Health – have both grown larger over the last 20 years, with formerly independent hospitals joining their networks.

Mid-Coast Hospital in Brunswick and the former Goodall Hospital in Sanford are among the more recent additions to the MaineHealth system, which includes Maine Medical Center in Portland. Mercy Hospital in Portland and Mayo Regional Hospital in Dover-Foxcroft are among the hospitals that in recent years joined Northern Light Health, which includes Eastern Maine Medical Center in Bangor.

While independent hospitals and other networks remain – including Central Maine Healthcare in Lewiston and MaineGeneral Medical Center in Augusta – MaineHealth and Northern Light dominate the state’s health care market.

“What causes prices to rise uncontrollably, leaving patients subject to thousands of dollars in medical bills? Look no further than consolidation, where dominant hospital systems control markets and set prices as high as they’d like,” said Darbin Wofford, health policy adviser for Third Way, a center-left think tank based in Washington, D.C. Health care reforms are among the topics that Third Way advocates for, including clean energy, reforming gun laws and abortion access, among many other issues.

Third Way is releasing a case study analysis of Maine’s hospital costs on Thursday and provided the Press Herald with an early look at the findings.

In an interview, Wofford said consolidation in states such as Maine tips the scales heavily in favor of hospital networks when negotiating contracts with insurance companies. Those contracts influence the health insurance premiums, deductibles and other costs that people pay.

“Insurance companies can’t say to hospitals, ‘No, we don’t want to take your prices,’ ” Wofford said.


According to the Health Care Cost Institute, the Portland market was the 21st “most concentrated” health care market of 183 markets measured, which means Portland has less hospital choice for patients than much of the country. The Portland market was the only market measured in Maine.

Wofford pointed to hospital prices for private insurers, which are on average 275% of the prices Medicare pays for services, or nearly three times as high. Maine’s average costs are the highest in New England, and far above the national average of 224% of Medicare, it found. Maine’s average costs rank 19th among states. South Carolina is the state with the highest hospital prices for private insurers, at 322% of Medicare prices.

But Dr. Andy Mueller, CEO of MaineHealth, said the explanation for private insurance prices at hospitals has far more to do with Maine’s demographics.

When a higher percentage of the hospital patient mix is insured by Medicare – generally patients 65 and older – that skews hospital prices. Because Medicare’s reimbursements are so low and do not cover hospitals’ actual costs, the difference has to be made up by private insurers, Mueller said.

That’s true of any hospital in the country. But, he said, “we’re the oldest state in the nation.”

OLDEST STATE IN THE NATION

According to the U.S. Census, Maine’s median age is 44.8 years, the oldest in the nation. “That puts a greater burden on those who have commercial insurance to make up the difference,” Mueller said.

Terri Canaan, chief marketing and communications officer for MaineHealth, pointed to an analysis that showed Maine’s Medicare spending per enrollee – which includes hospital and non-hospital spending – is below the national average. The national average is $11,080, while Maine’s spending is $9,159 per enrollee, according to KFF, a national health policy think tank.

Health care costs are influenced by a number of factors, such as the push and pull of health care network contract negotiations with insurers, the health and demographics of the population served, federal and state regulations, and competition among health care providers, among other things.

A Forbes Advisor analysis in 2022 combined 11 key health care cost metrics to try to determine the difference in health care costs by state. By that measurement, Maine has the seventh-highest health care costs in the nation, at $11,505 per person. South Dakota was the most costly in the nation, with $11,736 per capita, while Michigan had the lowest health care costs at $9,524. The analysis includes all health care costs, not just the costs incurred at hospitals or costs paid with private insurance.

Denise McDonough, president of Anthem Blue Cross and Blue Shield in Maine, said hospital consolidation is one of the factors driving up costs in Maine.

“We have seen significant hospital consolidation in Maine over the years, which has reduced competition, increased costs, and limited access to care – leaving Mainers with less choice,” McDonough said.

Anthem and MaineHealth became embroiled in a public contract dispute in 2022, with Maine Medical Center nearly withdrawing from Anthem’s network in 2023 before an agreement was reached in August 2022. The dispute became public with both sides providing the media with examples of hospital overcharging of patients, and of the insurance company denying needed care.

Both Anthem and MaineHealth officials have claimed that the other side has too much leverage in negotiations.

Mueller, on Wednesday, countered the argument made by Third Way that Maine’s hospitals have leverage over insurers.

“We’re still a ‘mom and pop’ industry in comparison to the consolidation that has happened on the health insurance side,” Mueller said. “These are massive companies, and we are not, relative to (insurers). We are a tiny speck on the wall compared to them.”

REFORMS PROPOSED

Third Way has proposed a number of reforms, including tougher price transparency laws, and laws that they say would help insurers when negotiating with hospital systems.

Maine is debating regulation of facility fees, which can reach hundreds of dollars for patients for just walking into a hospital for care and are often hidden in medical bills and passed onto the patients. After a Press Herald report in 2022 that featured patients complaining about facility fees, the Maine Legislature passed a bill that created a task force, which is studying possible changes to state law.

The federal government requires hospitals to disclose prices, but some say the law doesn’t go far enough and lacks an enforcement mechanism. Maine has the CompareMaine.org website, which allows for comparison pricing of some procedures, such as colonoscopies, blood tests and hip replacements.

McDonough, the Anthem president, agrees that more needs to be done, and calls Third Way’s suggestions a “good first step.”

But Mueller, the MaineHealth CEO,  said that one of the bills currently under consideration by the Maine Legislature would protect insurers’ ability to reduce costs, such as by giving financial incentives to patients to go to less expensive clinics. MaineHealth does not prevent such cost-saving efforts, he said.

But Mueller said also built into the bill – L.D. 1708 – is a provision that would prevent hospital networks from terminating contracts with insurers.

“The only leverage we have is to terminate a contract,” Mueller said. “We believe we ought to have the ability to terminate an agreement the other party is not living up to.”

McDonough said, “we hope we can continue the conversation about greater transparency and advance legislation to protect members’ access to affordable care.”

https://www.pressherald.com/2024/01/04/national-advocacy-group-blames-hospital-consolidation-for-maines-high-health-care-costs/ 

 

Mills administration and hospitals reach agreement on new MaineCare reimbursement rates

by Patty Wight - Maine Public - February 6, 2024 

Maine's Department of Health and Human Services and the Maine Hospital Association have reached an agreement to reform reimbursement rates for MaineCare, which provides insurance for 400,000 low-income individuals.

They say that hospitals would receive see the same or higher rates under the proposal, by being more aligned with Medicare rates.

If approved, the groups say it would devote an additional $90 million in federal and state funding to hospitals.

The new reimbursements will be included in the upcoming supplemental budget proposal.

https://www.mainepublic.org/health/2024-02-06/mills-administration-and-hospitals-reach-agreement-on-new-mainecare-reimbursement-rates 

 

Drug Prices Should be Controlled

Pharmaceutical companies are angry with Bernie Sanders. The Vermont senator has vowed to force pharma CEOs to publicly answer for why their drug prices are so much higher in the United States than in other nations.

Brazenly, the CEOs of Johnson & Johnson and Merck initially refused.

An attorney for Johnson & Johnson accused the senator of using Senate committee hearings to “punish the companies who have chosen to engage in constitutionally protected litigation.” The company, along with Merck and Bristol Myers Squibb, issuing the Biden administration for allowing Medicare to regulate certain prescription drug prices.

For the last two decades, it’s been a free-for-all for pharmaceutical companies in the U.S.

In 2003, then-President George W. Bush signed a Medicare reform bill into law, promising help for seniors struggling to pay for medications. But that law stripped the federal government of its power to negotiate drug prices for Medicare’s participants. And that’s driven drug prices up for everyone.

The Inflation Reduction Act (IRA), which Biden signed in 2022, tied Medicare drug prices to inflation and required companies to issue rebates if prices rose too fast. It was the first time since Bush’s 2003 law that drug manufacturers were subject to any U.S. price regulations.

Pharmaceutical companies aren’t having it. And that’s why it’s not enough for Medicare to be able to cut drug prices — there needs to be nationwide regulation on all drug prices for all Americans.

American taxpayers generously subsidize the research and development of most drugs, as a report by Sanders’ staff explained. But “the government asks for nothing in return for its investment,” giving private corporations “the unilateral power to set the price of publicly funded medicines.”

People in other nations, the report adds, pay less for drugs that American taxpayers have paid global pharmaceutical companies to develop. Symtuza, an HIV medication that the U.S. National Institutes of Health helped develop, costs U.S. patients a whopping $56,000 a year. Patients in the UK pay $10,000 a year for the same drug.

The difference is simple: countries like the UK, France, and Germany regulate drug prices. The U.S., for the most part, doesn’t.

There’s a strong public desire for price controls. According to a Kaiser Family Foundation poll in August 2023, bipartisan majorities “say there is not enough regulation over drug pricing.” A whopping 83 percent “see pharmaceutical profits as a major factor contributing to the cost of prescription drugs.”

They’re right. Economists studying the pharmaceutical industry have found that for years, companies have been so flush with cash that they’ve spent hundreds of billions of dollars on stock buybacks and exorbitant executive bonuses and pay packages.

The Center for American Progress’s October 2023 report, “Following the Money: Untangling U.S. Prescription Drug Financing,” delves deep into how prices are determined for medications and suggests interventions at every stage.

Frankly, such complex solutions wouldn’t really be necessary if all Americans could simply join Medicare — and if Medicare’s bargaining power to negotiate drug prices could be applied to all drugs. But in the absence of this commonsense approach, even complex price controls would be better than no price controls.

Instead, pharmaceutical companies launched the new year by announcing price hikes on at least 500 medications — a massive effort to gouge the public. In contrast, the IRA’s drug price controls apply to only 10 medications so far. They’ll be expanded to 15 drugs per year for the next four years, and 20 drugs per year thereafter.

Rather than removing price controls on the paltry numbers of medications the IRA can regulate, an easy fix is to apply those same regulations to most or all drugs. Best of all, pharmaceutical company CEOs wouldn’t even have to drag themselves into committee hearings to explain away their corporate greed.

 
 

 

 

 

Monday, February 5, 2024

Health Care Reform Articles - February 5, 2024

Physicians are sounding an alarm about the health care system

by Patty Hymansom - Bangor Daily News - February 4, 2024

Patty Locuratolo Hymanson, a neurologist, is a former Maine state representative. She lives in York.

Visionary leaders looking into the future of our health care system imagine complex systems changes. They identify trends that will help people be healthy, find and treat diseases, improve efficiency, and focus on wellness as well as illness. The trends include artificial intelligence integration, medicines tailored to our individual biology, convenient care through our computers, payments to keep people healthy rather than only paying when we are sick.

The trouble is, when trying to grow a system, like a tree, the roots and trunk must be healthy. Our health care system, for most people, is sick. How can complex changes be grafted onto a sick system? This is especially true when the sick system has grown by encouraging branches that make the most profit.

The Maine Medical Association has written a three-page statement on “Reform of the U.S. Health Care System.” This statement was developed after polling the membership of the association and researching alternative models of care. It is a start and worthwhile reading to understand where Maine physicians see our system failing both patients and physicians. If the problems are not laid out, they cannot be cured.

Of the many problems, one is particularly personal. As a neurologist practicing on the seacoast for 28 years, I closed my private practice to run successfully for the Maine Legislature largely because I could not give my patients the amount of time they, and I, needed to diagnose and treat them. Physicians are forced to see too many patients in too little time. Squeezing every drop from professionals and patients drives good profits but worsens care.

You will read in the medical association’s statement: “Physicians are burdened with documentation increasingly geared toward system requirements rather than patient’s care. … Put the patient first and protect the physician-patient relationship, particularly respecting the physician’s autonomy as an advocate for the patient. Provide health care that is high quality, comprehensive, reflects a physician-patient collaboration and is not profit driven. Promote patients’ freedom to select their physicians and other clinicians.”

“The secret of the care of the patient is in caring for the patient,” said Dr. Francis Peabody of Harvard Medical School in 1925. Providers of that care are burning out, suffer moral injury and need a restructured system. I cannot build that change but I can sound an alarm. Thank you to the Maine Medical Association for sounding this alarm, too.

https://www.bangordailynews.com/2024/02/04/opinion/opinion-contributor/physicians-health-care-system-failures/

Opinion: We need to shift our thinking from ‘thing-oriented’ to ‘person-oriented’

by Susan Henderson - Portland Press Herald - February 3, 2024

In 1970, a professor told his class that the computer revolution would be greater than the Industrial Revolution. He was right. The computer revolution is part of massive scientific changes accelerated by World War II. The world has changed rapidly.

It’s hard to give meaning to what is happening; we do yet grasp the full implications of what we are seeing. We struggle to orient ourselves in a chaotic swirl of changes. We attack each other over our differences about parts of a whole that we do not fully understand. Being clear about our values might help us set goals to calm the chaos.

Our Declaration of Independence declares that all people are endowed with certain inalienable rights by their creator. This revolutionary statement constitutes a core social value. However, we have not demonstrated that value in our actions. In a 1967 speech at Riverside Church in New York City, Dr. Martin Luther King said:

“We as a nation must undergo a radical revolution of values. We must rapidly begin the shift from a ‘thing-oriented’ society to a ‘person-oriented’ society. When machines and computers, profit motives and property rights are considered more important than people, the giant triplets of racism, materialism and militarism are incapable of being conquered. … A true revolution of values will soon cause us to question the fairness and justice of many of our past and present policies.”

As the economist Rashi Fein has pointed out, people live in a society, not an economy. Capitalism is an efficient and effective economic system, but today, this system is out of balance and does not adequately serve social needs.

Fair trade laws need to ensure real competition. Every corporation needs to contribute to the well-being of society. Wage equity must be improved so working people can at least minimally meet their basic needs for food, housing and health care. The science of climate change requires changes to how and what we produce and nurture. Fixing the economy requires taming the power of lobbyists and campaign contributions. Economic systems need to enable people to meet needs so basic as to be rights. Economic decisions should reflect social goals.

Access to health care is a human right. A robust public health system would promote healthy behaviors and help prevent disease. Access to mental health and substance abuse care would reduce the suffering of those who misuse substances and reduce the pain these disorders cost friends, families and communities. If every woman had easy access to prenatal care, outcomes for mothers and babies would be improved. A system for follow-up educational and supportive visits for new families has been shown to decrease child abuse.

When private insurance plans have payments and deductibles so high that people have no money left over to seek care, and when MaineCare reimburses so little that providers do not chose to see patients, that is not access to care. Society has made the choice to not have universal access to care or a strong public health system. If we calculate the full costs of this choice, we would see it has high monetary and social costs.

In this election year, we need to identify our values. Our problems have no quick fixes, but a start is to recognize that our present economic functioning is not geared to meet the goals of a person-oriented society. Value-based goals direct us through chaos to achieve economic equity and through that access to health care, housing, decreased violence, protecting our planet and ending war. By seeking policies that honor the dignity and worth of all individuals, we can have a chance of survival.

https://www.pressherald.com/2024/02/03/opinion-we-need-to-shift-our-thinking-from-thing-oriented-to-person-oriented/ 

 

Death by a Thousand Paper Cuts

by David Brooks - NYT - January 18, 2024

Sometimes in this job I have a kernel of a column idea that doesn’t pan out. But other times I begin looking into a topic and find a problem so massive that I can’t believe I’ve ever written about anything else. This latter experience happened as I looked into the growing bureaucratization of American life. It’s not only that growing bureaucracies cost a lot of money; they also enervate American society. They redistribute power from workers to rule makers, and in so doing sap initiative, discretion, creativity and drive.

Once you start poking around, the statistics are staggering. Over a third of all health care costs go to administration. As the health care expert David Himmelstein put it in 2020, “The average American is paying more than $2,000 a year for useless bureaucracy.” All of us who have been entangled in the medical system know why administrators are there: to wrangle over coverage for the treatments doctors think patients need.

The growth of bureaucracy costs America over $3 trillion in lost economic output every year, Gary Hamel and Michele Zanini estimated in 2016 in The Harvard Business Review. That was about 17 percent of G.D.P. According to their analysis, there is now one administrator or manager for every 4.7 employees, doing things like designing anti-harassment trainings, writing corporate mission statements, collecting data and managing “systems.”

This situation is especially grave in higher education. The Massachusetts Institute of Technology now has almost eight times as many nonfaculty employees as faculty employees. In the University of California system, the number of managers and senior professionals swelled by 60 percent between 2004 and 2014. The number of tenure-track faculty members grew by just 8 percent.

Conservatives complain that diversity, equity and inclusion administrators are injecting a dangerous ideology into American campuses. That’s true. But the bigger problem is that these workers are among the swelling ranks of administrators.

The general job of administrators, who are invariably good and well-meaning people, is to supervise and control, and they gain power and job security by hiring more people to work for them to create more supervision and control. In every organization I’ve interacted with, the administrators genuinely want to serve the mission of the organization, but the nature of their jobs is to enforce compliance with this or that rule.

Their power is similar to what Annie Lowrey of The Atlantic has called the “time tax.” If you’ve ever fought a health care, corporate or university bureaucracy, you quickly realize you don’t have the time for it, so you give up. I don’t know about you, but my health insurer sometimes denies my family coverage for things that seem like obvious necessities, but I let it go unless it’s a major expense. I calculate that my time is more valuable.

As Philip K. Howard has been arguing for years, good organizations give people discretion to do what is right. But the trend in public and private sector organizations has been to write rules that rob people of the power of discretion. These are two different mentalities. As Howard writes, “Studies of cognitive overload suggest that the real problem is that people who are thinking about rules actually have diminished capacity to think about solving problems.”

Not long ago, an airline accidentally canceled one of my flight reservations. I called the 800 number and the guy on the other end of the line seemed truly unable to wrap his mind around the idea of getting me on another flight, because the rule said that my reservation was nonrefundable. I had that by now familiar feeling of talking to a brick wall.

This state of affairs pervades American life. Childhood is now thoroughly administered. I’m lucky enough to have grown up at a time when parents let children roam free to invent their own games and solve their own problems. Now kids’ activities, from travel sports to recess, are supervised, and rules dominate. Parents are afraid their kids might be harmed, but as Jonathan Haidt and Greg Lukianoff have argued, by being overprotective, parents make their kids more fragile and more vulnerable to harm.

High school students design their lives to fit the metrics that college admissions officers require. And what traits are selective schools looking for? They’re looking for students who are willing to conform to the formulas the gatekeepers devise.

I’ve found the administrators’ code of safety first is now prevalent at the colleges where I’ve taught and visited. Aside from being a great school, Stanford used to be a weird school, where students set up idiosyncratic arrangements like an anarchist house or built their own islands in the middle of the lake. This was great preparation for life as a creative entrepreneur. But Stanford is apparently now tamed. I invite you to read Ginevra Davis’s essay “Stanford’s War on Social Life” in Palladium, which won a vaunted Sidney Award in 2022 and details how university administrators cracked down on student initiatives to make everything boring, supervised and safe.

Professors used to be among the most unsupervised people in America, but even they are feeling the pinch. For example, Mark Edmundson teaches literature at the University of Virginia. The annual self-evaluations he had to submit used to be one page. Now he has to fill out about 15 electronic pages of bureaucratese that include demonstrating how his work advances D.E.I., to make sure his every waking moment conforms to the reigning ideology.

In a recent essay in Liberties Journal, he illustrates how administrators control campus life by citing the rules they have devised to govern how members of the campus community should practice sadomasochistic sex: “When parties consent to BDSM 3, or other forms of kink, nonconsent may be shown by the use of a safe word, whereas actions and words that may signal nonconsent in non-kink situations, such as force or violence, may be deemed signals of consent.” Do institutions really need to govern private life this minutely?

Organizations are trying to protect themselves from lawsuits, but the whole administrative apparatus comes with an implied view of human nature. People are weak, fragile, vulnerable and kind of stupid. They need administrators to run their lives. They have to be trained never to take initiative, lest they wander off into activities that are deemed by the authorities to be out of bounds.

The result is the soft despotism that Tocqueville warned us about centuries ago, a power that “is absolute, minute, regular, provident and mild.” In his Liberties essay, Edmundson writes that this kind of powermmel is now centerless. Presidents and executives don’t run companies, universities or nations. Power is now held by everyone who issues work surveys and annual reports, the people who create H.R. trainings and collect data. He concludes: “They are using the terms of liberation to bring more and more free people closer to mental serfdom. Some day they will awaken in a cage of their own devising, so harshly confining that even they, drunk on their own virtue, will have to notice how their lives are the lives of snails tucked in their shells.”

Trumpian populism is about many things, but one of them is this: working-class people rebelling against administrators. It is about people who want to lead lives of freedom, creativity and vitality, who find themselves working at jobs, sending their kids to schools and visiting hospitals, where they confront “an immense and tutelary power” (Tocqueville’s words) that is out to diminish them.

https://www.nytimes.com/2024/01/18/opinion/american-life-bureaucracy.html 

 LTE - Portland Press Herald - February 2, 2024

On Jan. 26, the Portland Press Herald reported a state legislative proposal to establish a state board that would permit affordable housing projects (“Lawmakers considering proposal for state board to permit affordable housing”). Although this proposal seems a step in the right direction, the state has a long way to go to adequately address Maine’s housing crisis.

Maine’s minimum wage just increased to $14.15/hr. According to the National Low Income Housing Coalition, a Mainer working full-time (40 hours per week, 52 weeks per year) would need to earn $24/hr. to afford fair market rent for a two-bedroom rental home, without paying more than 30% of their income.

There are more than 400,000 poor and low-income people in Maine. Lack of affordable housing is only one of many interlocking injustices they face. Others include inadequate wages, skyrocketing health care costs and medical debt, unaffordable and often unavailable child care, and insufficient education and job training programs.

We need sound public policies to address all these issues, and that is why the Maine Poor People’s Campaign will hold a State House assembly in Augusta on March 2. There, we will present to the Legislature and the governor the policies we demand to lift hundreds of thousands of Mainers out of poverty. We invite every individual and organization that shares our goal of racial, social and economic justice for all to join us that day as we come together to say loudly and clearly: “Fight poverty, not the poor.”

David Jolly
Penobscot

https://www.pressherald.com/2024/02/02/letter-to-the-editor-fight-poverty-not-the-poor/

NYC joins a growing wave of local governments erasing residents' medical debt