Health Care Reform Articles - August 17, 2019

 

We Will Win Health Justice In America

by Timothy Faust - Splinternews.com - August 9, 2019

An exclusive excerpt from Health Justice Now: Single Payer and What Comes Next, the new book by Timothy Faust.
This can all feel like so much. It feels like so much to me! I sit to read or write and the waves batter me and my body feels like a towel, wet and crumpled on the floor; I fall inside myself and wish for some angelic comet to plunge into my house and gently, quietly lift us all from this national suffering. But I don’t think that’s fair of me to do. It’s not very kind to indulge in nihilism when other people have even more at stake. What do you do? How do you tilt against the grotesque squalor of the world?
My answer begins with single-payer. Single-payer won’t solve all of the problems we’ve talked about in the previous section of this book. It won’t even solve most of them: it won’t build the houses, it won’t feed the people, it won’t bring jobs or money back to rural areas. But that’s all right, in a sense— no program can, not all at once. What single-payer can do, I believe, is serve as a ladder we can climb, all together, into a better world. A properly designed single-payer program is one titanic step toward making people safe in their own homes, in their own bodies. It is a reprieve from our continual fucking-over by the structure and stricture of private insurance. And it is a method of finally demanding accountability from a state that permits (or even encourages) the sins that cause mass suffering—and the medical inequities they produce.
It’s not a hard sell. Single-payer isn’t that complicated (the real complicated shit is the various bureaucratic coping mechanisms invented to respond to the inadequacies of private insurance!) and most people like it already. More people will be drawn to it once they learn what it means and how it fits into the nooks and crannies of their lives. Most doctors and nurses like it, both because they’ve seen the devastating consequences of uninsurance among their patients and because they’d like to avoid the grating bureaucracy of trying to get paid by insurance companies.
The people who tend not to like single-payer are people who wouldn’t like anything that didn’t make them money: the insurance companies it would replace, plus the pharmaceutical, device, and hospital CEOs whose profits might be cut into by the rise of a larger, stronger, payer. Then there’s the powerful people who generally benefit from human suffering: the abusive boss who wants to make sure you can’t quit your job; the abusive husband who wants to make sure you can’t quit your relationship; the CEO who enjoys being able to cut benefits while knowing his workers can’t strike for fear of losing insurance; the lizardlike politicians who find it useful to first advance policies that let rich people plunder their districts, then blame poor people, people with disabilities, and people of color for the resulting scarcity.
These problems are not new in America. We’ve been suffering needlessly for generations. We continue this suffering because, at every conceivable opportunity, our politicians, our policy-makers, the CEOs who mine us for profit—have decided to pursue moderate, subdued, pragmatic, and useless policies. They have had every opportunity to help and have refused. They must be left behind. They’ve started coming out of the woodwork, and they’ll continue to do so for the next few years. They’ll have “responsible solutions” for “new American healthcare.” They’ll smile and go on TV and say they’re very concerned about all these problems whose structural causes they, personally, have benefited from. They will reach out to take our hands, tenderly and piously, and whisper, “This really is the best we can do right now,” as they jam them in the garbage disposal. So they’re out.
We will have to turn to each other.

What Hasn’t Worked

There’s a lot of history to learn from. The fight for single-payer (or, before any payers existed, universal healthcare) is not new—it’s been running in parallel with the development of the entire insurance industry. Beatrix Rebecca Hoffman, a historian of healthcare inequity and healthcare organizing, wrote a wonderful brief history called “Health Care Reform and Social Movements in the United States.” I recommend it; she demonstrates why our healthcare movements thus far have failed. I would prefer not to fail again.
For the past hundred years, health reform legislation has been in many cases the domain of well-meaning, well-intentioned insiders. But every time these insiders—the senators, the policy-writers, even the union or nonprofit leaders—have taken on the insurance industry, they have been beaten by a reactionary establishment (described, unflatteringly, above) that is capable of outmaneuvering, outfoxing, and outgunning health reform. The establishment has money and power, and if you come at them from within, they can swat you down. The policy insiders and think-tank presidents have learned that they can write a healthcare bill and wave it around to gin up support among the grass roots, but they have lost, over and over and over again.

They lost in the 1940s by “discourag[ing] rank-and-file initiatives” and “never consider[ing] grassroots mass mobilization.” They lost in the 1970s, when, despite working with civil rights and antipoverty groups, the universal healthcare bill was drowned out by 13 competing bills sponsored by industry and establishment organizations. They lost in the 1990s when the Clinton administration tried to assemble a huge, complicated series of public-private partnerships that would somehow try to keep everyone satisfied—except the grass roots, who either got confused by an incredibly dense policy or were ignored when they demanded more. The Patient Protection and Affordable Care Act of 2010 was lauded as a massive success by a subsection of liberal commentators in its time, but . . . if it were actually successful, I wouldn’t have to write this book.
Hoffman sees victory in healthcare reform coming from grassroots movements—she cites ACT UP as a prime example. ACT UP (AIDS Coalition to Unleash Power) is perhaps best known for their powerful, dramatic protests—throwing the ashes of their loved ones who had died from AIDS on the lawn of the White House. Here, in the relative comfort of 2019, it’s hard to remember how completely marginalized people with HIV/AIDS were in 1987. A sizable portion of the federal government actively ignored the epidemic, and explicit descriptions of it as a “plague from God” were tolerated, if not welcomed. ACT UP organized not just people with HIV/AIDS but formed coalitions with organizations of people of color, women, and people who use needle drugs (who were disproportionately likely to get HIV), and through years of collective effort forced mayors, presidents, and corporations to take action—and then, crucially, kept the pressure on after they got their initial goals.
I would additionally cite ADAPT as a powerful popular health movement in contemporary times. ADAPT is a coalition movement for rights for people with disabilities. The fights they have had to take on just to be treated like people are many, from transit access to home health to the current fight for the Disability Integration Act. You might know them as the reason Medicaid still exists as it does today. During Congress’s various ACA replacement debates, ADAPT protestors bused down to the Capitol and protested on the floor. They were arrested, their healthcare devices broken, and they were dragged screaming to police buses and hauled off to jail without care or concern for their medical needs. The next day, they came back—over and over and over again.
These grassroots movements have succeeded. While perhaps they haven’t succeeded as much as they’d like to—these are literally matters of life and death—they’ve done more than any think tank in all the East Coast. But they cannot win what they deserve—what we deserve—alone.
We have an obligation. We must not lose again. We stand on the shoulders of hundreds of thousands of nurses, of tens of thousands of doctors, in the legacy of grassroots movements like ADAPT and ACT UP—and we must build the massive popular movement that not only demands single-payer from our government, but demands health justice in our nation.
The bill we need does not yet exist. There are bills that are good, there are even good single-payer bills, and though I hope they pass, they are not and will never be sufficient in and of themselves. Any health justice movement that is satisfied by an existing bill, or that organizes around a bill, instead of around and among the people who are most immiserated, will follow its historical predecessors and fail. It has already failed.
So the answer is easy: skip the politicians and go to where the people are. Because the people need help. And we have to do it together.

What Will Work

Idaho hardly seems like the place for a health justice movement. It’s an overwhelmingly beautiful place that holds some of the dream of the American Western frontier: a place you can go to get away from everyone else and, among the mountains and the forests, have some peace of mind. It is not so much conservative as it is isolationist (though the line between the two has narrowed in the past few decades). Its one metropolitan area, Boise, accounts for a little under half the state’s population. The rest of the state sprawls northward, a composition of scenes of great beauty.
Amid this beauty there is, of course, deep and widespread suffering. Rural hospitals are particularly overwhelmed in Idaho, as a shriveling safety-net program saddles them with high costs and a mostly uninsured population. Some of them close. After the passage of the ACA the Idaho legislature refused to expand Medicaid for various reasons: a weak governor, a coalition of far-right politicians, general Democratic reluctance. Then, in November 2018, a ballot measure to expand Medicaid in the state passed. And not by a little—with a 61 percent majority. It passed in four-fifths of the counties, not just in the urban areas. There was no “blue wave” in the state—the Democratic candidate for governor lost by 22 points.
Medicaid expansion in Idaho took a form virtually unseen in contemporary America—or, at least, the America that matters to the pundit class. It was a popular movement built by constant, diligent labor: a hundred meetings, a thousand canvasses, a hundred thousand handshakes.
I spend a lot of time exploring the mass immiseration of people in America. I take a lot of steps in the shadows of the cruel and opulent machine. So I often seek a chalice to bear, and in Idaho I glimpsed a small and powerful hope.
The movement started when the northern Idaho ski town of Sandpoint refused to pass a tax to fund its schools. Idaho schools are notoriously underfunded after a decade of property tax decreases and education spending cuts. Three friends— Emily Strizich, her husband, Garrett Strizich, and Luke Mayville—had enough and decided to run a citizen campaign to pass a lien to keep their schools funded. It succeeded.
The movement grew. They called themselves Reclaim Idaho and, after driving around talking to people, they set their sights on Medicaid. Reclaim Idaho bought an RV, painted it green, and decided to keep driving—all across the state, talking to literally anyone they could. They found people who knew their communities and who would volunteer to organize them.
Then they kept driving.
From this patchwork campaign Reclaim Idaho became a bona fide DIY statewide movement. While the three core Reclaimers coordinated resources across the state and put together hundreds of events, local organizers were generally trusted to organize their areas as they saw fit. Which they did: thousands of volunteers knocked, texted, and called hundreds of thousands of people.
Events in virtually every county of the state brought elected officials, doctors, people without insurance, and other citizens together to talk about Medicaid. The proposition got on the ballot with plenty of room to spare and not much money spent. The creaky state Democratic party alternately shied away from and then glommed onto the movement, depending on whether they thought it would poll well. The Reclaim Idaho volunteers I met spoke of kindness, of fairness, and of economy. They went to their neighbors in urban areas, in rural ones, in trailer parks, in the sticks, in gas stations and grocery stores and college campuses. They spoke about how Medicaid expansion was free federal money to help people who are suffering, which would then be invested in Idaho’s medical workers. They shared stories of making too much money to qualify for Medicaid and falling in the gap, they talked about rural hospitals that couldn’t afford to treat their uninsured patients, they talked about the parts of Idaho that were ravaged by uninsurance. They talked about justice.
And then the people turned out to vote and extended the basic decency of healthcare to their neighbors.
The three Reclaim Idaho founders insist that this was not their movement alone. It was a campaign they coordinated, but it was funded and powered by normal people trying to pitch in and help, a banner carried by thousands of volunteers every single day until the last minute, a thousand torches held aloft in a great and spectacular line from the forest to the mountains. I watched a Reclaim volunteer run into a small dive bar and canvass everyone there with about 15 minutes before polls closed. He succeeded and escorted one young voter to the polling station two blocks away. “I didn’t want to leave anything on the table,” he told me.
And the whole thing was so damn wholesome. I saw grandparents, grandchildren, friends, neighbors, and kids—everyone working together to feed each other, take care of each other, nourish and support each other, as they all sought to reach out and find new people to speak with. Like many folks my age, I’ve kind of self-atomized: I’ve never been close with my family; I’m never having kids; I move from city to city like a traveling circus. I like the family I have constructed for myself. But it really does feel special, safe, and nourishing to watch an extended community-family take care of itself. It is the self-regenerating model by which a larger one can be, slowly, and with difficulty, constructed.
There were but minutes between the news that Medicaid expansion had passed and vows from Republican lawmakers that they’d find a way to gut it, or attach work requirements. This would not be permitted. Reclaim Idaho mobilized the same people who came out to pass the bill, and they defended it—calling drives, rallies, protests. Candidates who did not win in November came out to train volunteers to effectively petition their representatives. There were more potlucks, more cookouts, more movements. In January 2019, Idaho Proposition 2 was signed into law. In February, the state submitted a Medicaid expansion request to CMS.
I insist that this is the model—this is the only model—by which health justice can ever be realized in America. Lovingly, devoutly, and diligently—an organized, focused, and trusting movement building community for those who have most been harmed—borne from the specific furies of love. All your lightning waits inside you.
We must extend the basic decency of “showing up”—going to the people around us, listening, asking questions, finding common ground, and putting our shoulders to the wheel. We must identify what battles we can win, and then win them. We must provide material relief for the people around us who are suffering now.
We must fight in our homes for a continuous spectrum of demands aimed toward health justice. Unlike liberal policy-tweak incrementalism, our successes must be material and redistributive reforms. We must bring to the front our neighbors and friends who have been made to suffer most cruelly, and we must demand that the crowns of thorns thrust down upon their heads are lifted. We cannot rest until they are liberated from the suffering inflicted upon them.
We don’t have to start from scratch. People have been fighting injustice much longer than any of us have been alive. We just have to show up.
In San Francisco, a coalition won Prop F, the right to counsel for people who are evicted. In Maine, the Maine People’s Alliance won a significant minimum-wage campaign at the ballot box in 2016. They then turned out their volunteer base for the minimum-wage campaign to collect signatures to put Medicaid expansion on the ballot—which they did, very quickly, and then won again in 2017. In San Antonio, the movement for paid sick leave collected 144,000 signatures—40 percent more than the number of people who voted for mayor in the previous election, making it the largest popular movement in San Antonio in years, if not decades. A couple hours north, in Austin, where barely anybody can afford to live anymore, a coalition of grassroots activists won a $250 million affordable housing bond at the ballot—more than twice the sum of every other housing bond in city history.
There are setbacks. Each of these victories can be waylaid by a malicious politician and, in some cases, are currently under assault. But I think these victories are building blocks. If we give people something material, they will fight to keep it. If we fight with people today, they will fight with us tomorrow. We build solidarity so that we can build power. Our job is not to build one massive popular movement. It is to stitch together a popular movement—a big, messy quilt of movements for health justice at home, spanning the country from coast to coast and plains to gulf.
This is all to say that the work of health justice is not siloed. Housing work, healthcare work, anti-carceral work, disability liberation—all share health equity in their articulations of a better world. This and only this, I think, can bring about single-payer, and, beyond it, health justice. We have seen that movements for universal healthcare that are led from the top down have not succeeded.
Yet through this massive mobilization—and only through this massive mobilization—this is a fight we will win. Single-payer is already a wildly popular idea among the people it affects. This is not a radical proposition. We are simply discussing a basic principle of fairness.
After all, we all come from nothing. We are all fashioned from a formless and shapeless place. We have been thrust through the maw and born into a world that is arbitrary and unequal in its allocation of suffering. And yet instead of affording each other the basic dignities of being human, we have developed this bizarre system of American health in which one’s suffering is one’s own responsibility, in which empathy is vestigial and unnecessary. We have atomized suffering and, in turn, assigned blame for suffering to the people who suffer it.
I have seen such naked suffering inflicted in my American name. I have seen neighborhoods ripped apart by the unrepentant, unyielding bloodlust of capitalism. I have seen families torn limb from limb in the service of extracting profit. I have seen the dehumanizing machine all at once and felt despair. For me it is heinous to feel complicit, through my simple existence in my only and horrible home, in the mass immiseration and annihilation of those against whom the whole rotten weight of the world is stacked.
This is intolerable to me. I hope it is to you, too. And so I hope you join me in saying: enough.
Not in our name may this America persist. May we root ourselves not in fear but in love—love for those who suffer around us, as we, too, will one day suffer—and from that love, may we cultivate the fury by which this cruel machine can be destroyed.
My friends—single-payer is moral. Single-payer is necessary. Single-payer is achievable. Solidarity now, solidarity forever.

---

From Health Justice Now: Single Payer and What Comes Next, by Timothy Faust. Copyright © 2019 by Timothy Faust. Reprinted by permission of Melville House Publishing. Go to healthjusticenow.com for more details.
https://splinternews.com/we-will-win-health-justice-in-america-1837003733 

Medicare for all: fears and facts

by James G. Kahn and Eliot Marseille - The Hill - August 14, 2019

Each candidate has their own way to fix what ails health insurance. Everyone claimed “Medicare” at the heart of their strategy. Sen. Bernie SandersBernie SandersWarren leads Democratic field by 5 points in Wisconsin: poll Harris wins endorsement of former CBC Chair Marcia Fudge Ex-CIA chief worries campaigns falling short on cybersecurity MORE (D-Vt.) and Sen. Elizabeth WarrenElizabeth Ann WarrenWarren leads Democratic field by 5 points in Wisconsin: poll The danger of using race and politics to declare guilt or innocence Harris wins endorsement of former CBC Chair Marcia Fudge MORE (D-Mass.) urged sweeping reform, while former Vice President Joe BidenJoe BidenWarren leads Democratic field by 5 points in Wisconsin: poll O'Rourke says Trump 'terrorizing' immigrants in campaign relaunch speech Harris wins endorsement of former CBC Chair Marcia Fudge MORE and others advocated tinkering at the margins, stoking fear of big change. 

What does it all mean?

After the first Democratic debate, we wrote a Cheat Sheet to clarify key concepts, and reviewed the minimal role of private insurance under "Medicare for all." This time, we’re tackling people’s fears about reform and comparing the proposed plans. 

Let’s start with three fears raised in the debate:

Should I be afraid of losing my insurance? Yes — under the current system. Unless you’re on Medicare, your health insurance is not guaranteed. Your employer can cancel the plan you like, forcing you to find a new doctor. 

You may change jobs, or be laid off and lose your insurance. The premium may rise so much that you can no longer afford it. Coverage that’s guaranteed wherever (or whether) you work requires insurance that covers people based on U.S. residency rather than employment, like Rep. Pramila JayapalPramila JayapalHouse Democrats urge Trump to end deportations of Iraqis after diabetic man's death 'KamalaCare' fails to address big problem: That we cannot trust insurance companies The Hill's Morning Report - Trump's new target: Elijah Cummings MORE’s (D-Wash.) Medicare for All Act of 2019.

Should I worry that taxes will go up? With Medicare for all, taxes will replace rising premiums, copays and deductibles. 

These taxes will be progressive. The more you earn, the higher rate you pay. That’s fairer than charging for health insurance based on age, without regard to income, like now. The Affordable Care Act provides premium subsidies for some poorer people, but not for all and requires high deductibles and copays. For most people, the new taxes for health care will be less than what they currently pay in premiums and out-of-pocket costs. Low and middle-income families will save money. High-income families will pay more.

Should I fear losing choice of doctor? Sadly, we already have. Unless you’re on traditional Medicare, you can’t choose any doctor or hospital you like (except if you pay the costs yourself). Some presidential candidates say the choice worth making is between health insurers. Isn’t it more important to choose the doctor and hospital that provides your care, as permitted under Medicare for all? 

Now, let’s compare the candidates’ plans. There are three approaches (see side-by-side table): 

Medicare for all (single payer) provides coverage for life, regardless of health, wealth, or work status. Everyone has a comprehensive benefit package, accepted by all doctors. A public agency directly pays doctors and hospitals’ negotiated rates. Medicare for all combines superb coverage with lower costs. How? By simplifying every aspect of insurance, from enrollment to coverage to billing. 

This results in massive administrative savings ($400-500 billion per year) and lower drug prices. How we pay for health care would also change. Taxes would rise, especially on the wealthy, but premiums and out-of-pocket costs would disappear. Most importantly, health care would cost our society less — 5 to 8 percent less in most studies, while covering everyone. 

Public Option (or Medicare expansion) means we keep the current super-complex mix of private and public plans, while letting some people buy into Medicare. This protects private insurance companies, and so keeps the bad stuff — restricted doctor networks, deductibles and copays, and administrative bloat.

Medicare Advantage for all Sen. Kamala HarrisKamala Devi HarrisWarren leads Democratic field by 5 points in Wisconsin: poll The danger of using race and politics to declare guilt or innocence Ben Shapiro: It's a 'you problem' if you 'had to work more than one job' MORE (D-Calif.) recently proposed an approach based on Medicare Advantage, the HMO part of Medicare. This assures a large role for private insurers. Thus, it has most of the same drawbacks as the Medicare public option, with few savings opportunities. It would leave private insurers and all their unnecessary expenses burdening Americans for another decade.

Is Medicare for All "fairytale economics,” as former Rep. John DelaneyJohn Kevin DelaneyHealth care fight among 2020 Democrats shifts to taxes The Memo: Warren emerges as Biden's most dangerous rival Democrats pounce on Trump in bid for rural voters MORE said? It’s a system widely used in other countries — and works incredibly well. The real fairy tale is that we can still afford insurance middlemen taking a cut out of our health-care budget.

Is it too drastic? During the Great Depression, we launched America’s biggest social insurance program: Social Security. It’s a great example of how the government can protect us against economic risk and improve our lives. Medicare for all is a grand solution in a grand American tradition. This kind of health-care reform is not only possible, it’s essential.

James G. Kahn, M.D., is an emeritus professor of health policy at the University of California San Francisco. Dr. Elliot Marseille, DrPH, is CEO of Health Strategies International.

https://thehill.com/opinion/healthcare/457403-medicare-for-all-fears-and-facts 

 

A majority of Americans with employer-based health insurance don't mind if it changes to Medicare for All — as long as they can keep their current coverage

Joseph Zeballos-Roig and Walt Hickey - Business Insider - Aug. 8, 2019

Over 59% of respondents who receive health insurance through their employer said in a new INSIDER poll they would be fine if that plan changed, as long as it meant no change in coverage.
As the battle lines are drawn within the Democratic party over the proposed government insurance plan under "Medicare for All,' that's an encouraging sign for advocates.
The results highlight the fact that although a majority of Americans are fairly satisfied with their employer-based health coverage — which supports other polling on the subject — mainly people just like being covered in general, bearing little loyalty to a specific insurer.
And the respondents' attitude toward "Medicare for All" reflects a dynamic that candidates who champion it — like Sen. Bernie Sanders— are counting on: If the system provides equal or more comprehensive benefits, then broad swaths of Americans are likely to support it.
Here's how the support broke down:

• 44% of people said they were on an employer-based plan. Of them, 41% love their plan, 20% don't like their plan, and 39% would be fine if it changed as long as they kept coverage.
• 28% were on Medicare, Medicaid or military coverage. Of them, 57% love their plan, 14% don't like their plan, and 29% would be fine if it changed as long as they kept coverage.
• 12% directly purchased health insurance. 39% love their plan, 22% don't like their plan, and 39% would be fine if it changed as long as they kept coverage.
• 7% said they did not have health insurance.
• 9% didn't know or had some other type of coverage. 

  Under Medicare for All, there would be a national health insurance system that would be funded by tax revenue and cover everyone who lives in the US. It would also pay for every medically-needed service, ranging from doctor visits to mental healthcare to prescription drugs.
But the plan would also replace employer-based health insurance, which is the most important source of health coverage for non-elderly Americans. It covered about 58% of this population in 2017, according to an analysis by the Kaiser Family Foundation.
In INSIDER's poll, those who were on some sort of government plan tended to be very satisfied with their coverage, especially compared to those who have private health insurance.
The results showed that among all respondents:

• 59% said they would support switching their employer-based health insurance to a government plan under Medicare for All. This figure includes 20% of respondents who said they "didn't like" their plan, which are more likely to contain voters more persuadable to back Medicare for All.
• 57% said they "love" their government-provided insurance plans, 16 points more than the 41% who said the same about their employer-based plans.
• 22% said they didn't like their directly-purchased health insurance — the highest dissatisfaction rate among the health insurance plans, though it was only two percentage points more than those who expressed dissatisfaction with their employer-based plans.

The poll comes after the Democratic primary field brawled in the July primary debates over the future of the American healthcare system, and how "Medicare for All" could reshape it.
Among the starkest divides that played out among the 2020 presidential candidates was whether Americans would be able to keep their coverage if the healthcare system is fundamentally disrupted.
Candidates like former Vice President Joe Biden said Americans should be able to keep their plans if they like them. But he's criticized Sanders' plan since it would virtually do away with private health insurance.
INSIDER asked over 1,100 respondents their feelings about their health insurance and whether they would be open to changing it. Specifically, we asked: "Which of the following best describes how you feel about your health insurance coverage," and respondents were asked to indicate the type of plan they had — employer-sponsored, government or direct — and how they felt about it. The options given were: "I love my plan," "I'd be fine if it changed as long as I have coverage," and "I don't like the plan."
Polling released last week from the Kaiser Family Foundation found that 76% of the public rated their employer-sponsored health coverage as good or excellent. This sets up some peril for advocates of Medicare-for-All, as guaranteeing that degree of satisfaction presents a difficulty.
Still, INSIDER's polling at least indicates that even if people think their employer plan is great, that doesn't necessarily mean that they're opposed to changing it.
For Democrats, it means the final policy should carry out a clean reform of the healthcare system that doesn't disrupt it in a way that Americans can feel, lest they face a political backlash.
https://www.businessinsider.com/most-americans-employer-based-plans-healthcare-medicare-for-all-2019-8

Couple dead in apparent murder-suicide left notes saying they couldn’t afford medical care, police say

by Marisa Lati - Washington Post - August 10, 2019

A Washington state couple whom authorities believe died by murder-suicide reportedly left several notes expressing worry that they could not afford treatment for the wife’s severe medical issues.

The husband, 77, called 911 shortly before 8:30 a.m. Wednesday and told the dispatcher that he planned to shoot himself, the Whatcom County Sheriff’s Office said in a statement. The man said he had written a note for the sheriff with information and instructions.

The dispatcher tried to keep the caller on the phone, according to authorities, but the man said, “We will be in the front bedroom” and hung up.

Sheriff’s deputies arrived at the house near Ferndale about 15 minutes later and tried to contact the residents with a phone and a megaphone for about an hour, authorities said. They said deputies then used a robot-mounted camera and saw the couple, who were dead from gunshot wounds.

The couple has been identified as Brian S. Jones and Patricia A. Whitney-Jones, 76, Whatcom County Medical Examiner Gary Goldfogel told The Washington Post. Jones shot his wife once in the head, then himself three times, Goldfogel said.

Authorities said they impounded several guns from the home and brought two dogs to the Humane Society for care.

“It is very tragic that one of our senior citizens would find himself in such desperate circumstances where he felt murder and suicide were the only option,” Sheriff Bill Elfo said in a statement. “Help is always available with a call to 9-1-1.”

Health-care spending in the United States has been increasing for decades, and costs for senior citizens are higher than those for citizens as a whole, according to the National Bureau of Economic Research.

An average of $18,424 per person was spent on medical care for people ages 65 and older in 2010 — five times the spending per child and three times the spending per working-age person, a report from the Centers for Medicare and Medicaid Services says.

Roughly 65 percent of senior citizens’ medical costs are paid for through government services such as Medicare, which covers almost all seniors, and Medicaid, which covers low-income people and families. Health-care expenses more than double between ages 70 and 90.

https://www.washingtonpost.com/nation/2019/08/10/couple-dead-apparent-murder-suicide-left-notes-saying-they-couldnt-afford-medical-care-police-say/ 

The Ethical Mess of Our Health Care System

by Amy Gutmann and Jonathan D. Moreno - NYT - August  14, 2019

The recent Democratic primary debates in Detroit made at least one thing clear: The party exclusively responsible for passing the Affordable Care Act is now waging political warfare over whether to reform it or eliminate it. Senator Bernie Sanders was loud but not lonely in advocating “Medicare for all,” which would supplant the A.C.A. with a single-payer system and virtually abolish private employer-based health insurance. His predictable answer to who will fund its high price is apparently the 1 percent who need to pay their fair share.
But there is another 1 percent, and they are not the privileged ones you’re thinking of. They are the roughly 1 percent of Medicare patients who have end-stage renal disease and cost the system $34 billion every year. No matter how rich or poor, young or old, Medicare kidney patients are guaranteed treatment mostly paid for by American taxpayers.
The product of vigorous lobbying and minimal deliberation, this one-disease carve-out that Congress passed in 1972 exemplifies the highly politicized patchwork design of the American health care system and its scandalous lack of universal coverage and adequate cost controls.
Anyone with a sense of compassion can applaud saving three-quarters of a million Americans with failing kidneys from death each year. But this program is exorbitantly expensive, and preventive therapies and other effective treatments can be made available at lower costs. It enriches two for-profit companies that control about 70 percent of the dialysis market. It has created perverse incentives for health care providers to supply too many patients with dialysis while devoting scant resources to preventing end-stage kidney disease and providing more kidneys for transplants.

These problems have long been known. Yet for decades policymakers faced insurmountable obstacles in Congress to making valuable reforms, such as controlling the price of renal dialysis, incentivizing less expensive and more convenient at-home dialysis and increasing the number of kidneys available for transplant.
This one-disease benefit raises a broader ethical question: Why is renal dialysis more worthy of such generous federal funding than are other lifesaving treatments for other deadly diseases? While almost 750,000 Americans have end-stage kidney disease, over 30 million are diabetic, over two million are insulin-dependent and diabetes treatment costs less and saves many more lives. Why shouldn’t treatment for severe cases of diabetes and other life-threatening diseases like hemophilia, leukemia and other cancers also be fully funded by Medicare?
While Congress was debating the renal disease benefit, Senator Wallace Bennett, a conservative Republican from Utah, argued “A more reasonable way to handle this amendment” was to make it “part of a broader health insurance bill” — not just insurance against one disease. Yet Congress still has not made good on this basic principle. Instead the kidney disease carve out serves as the most glaring example of the country’s counterproductive patchwork of health coverage.
The Trump administration is now proposing to rein in costs for end-stage renal disease treatment in a way it says will not undermine care. Its recommendations — which include enabling more kidney donations by compensating donors for forgone wages and child care — would be both cost-saving and lifesaving.
But the administration’s plan underscores the absurdity of our current health care debate: It would revamp the program using a provision of the A.C.A. that authorizes the Center for Medicare and Medicaid Innovation to test models of care that work in the private sector and that can enhance service to patients while also reducing costs. This is, of course, the same health care law that Mr. Trump has pledged to dismantle, including by ordering the Justice Department not to defend it in a major challenge heading to the Supreme Court.

Whether or not the administration succeeds, our health care system will remain sorely lacking in basic justice and economic efficiency. It is a system that too often creates perverse incentives favoring the overtreatment of diseases. To avoid this, we must start treating sick people fairly.
Such a path exists: Rather than repeal and replace the A.C.A., we need to revise and reinforce it. With about 90 percent of Americans now covered by health insurance, the A.C.A. was highly successful in improving our irrational system by expanding coverage for effective treatments while also reining in some spending.
That does not mean the law could not be improved by, for instance, reducing the high costs of drugs, co-pays and deductibles. But instead of calling for improvements, Republicans and now even many Democrats are threatening to dismember the law. That would be a tragic mistake when there is nothing close to a consensus on how to replace it.
There are multiple ways to achieve the worthy, non-utopian goal of reducing the uneven, crazily complicated nature of health care coverage, which has contributed to Americans’ having among the lowest life expectancies and highest infant mortality rate of any affluent nation. Reinforcements to the A.C.A. should include a voluntary public option — “Medicare for more” — that would coexist with common-sense improvements to the private employer-based coverage enjoyed by roughly 160 million Americans.
There’s also an economic and an ethical imperative for employers to improve prevention. They can use their leverage with private insurers to insist on health plan performance metrics and innovations like digitally based care systems that track medical problems before they become dangerous.
By revising and reinforcing the A.C.A., we can benefit all Americans without threatening any with the loss of hard-fought, lifesaving health coverage. Surely our fellow Americans with life-threatening diseases of all sorts are also worth saving.
Amy Gutmann is the president of the University of Pennsylvania, where Jonathan D. Moreno is a professor of bioethics. They are authors of the forthcoming “Everybody Wants to Go to Heaven but Nobody Wants to Die: Bioethics and the Transformation of Health Care in America.”
https://www.nytimes.com/2019/08/14/opinion/medicare-healthcare-system-kidney.html?smid=nytcore-ios-share
  

‘This will be catastrophic’: Maine families face elder boom, worker shortage in preview of nation’s future

by Jeff Stein - Washington Post - August 14, 2019

 

DOVER-FOXCROFT, Maine — Janet Flaherty got an alarming call last October from the agency tasked with coordinating in-home care for her 82-year-old mother. It could no longer send her mom’s home caretaker. It knew of no other aides who could care for her mother, either.

Flaherty’s mother, Caroline, has for two years qualified for in-home care paid for by the state’s Medicaid program. But the agency could not find someone to hire amid a severe shortage of workers that has crippled facilities for seniors across the state.

With private help now bid up to $50 an hour, Janet and her two sisters have been forced to do what millions of families in a rapidly aging America have done: take up second, unpaid jobs caring full time for their mother.

“We do not know what to do. We do not know where to go. We are in such dire need of help,” said Flaherty, an insurance saleswoman.

Across Maine, families like the Flahertys are being hammered by two slow-moving demographic forces — the growth of the retirement population and a simultaneous decline in young workers — that have been exacerbated by a national worker shortage pushing up the cost of labor. The unemployment rate in Maine is 3.2 percent, below the national average of 3.7 percent.

The disconnect between Maine’s aging population and its need for young workers to care for that population is expected to be mirrored in states throughout the country over the coming decade, demographic experts say. And that’s especially true in states with populations with fewer immigrants, who are disproportionately represented in many occupations serving the elderly, statistics show.

[The price of living longer: You could pay $100,000 or more for nursing home care]

“We have added an entire generation since we first put the safety net in place but with no plan whatsoever for how to support them,” said Ai-jen Poo, co-
director of Caring Across Generations, which advocates for long-term care. “As the oldest state, Maine is the tip of the spear — but it foreshadows what is to come for the entire country.”

Last year, Maine crossed a crucial aging milestone: A fifth of its population is older than 65, which meets the definition of “super-aged,” according to the World Bank.

By 2026, Maine will be joined by more than 15 other states, according to Fitch Ratings, including Vermont and New Hampshire, Maine’s neighbors in the Northeast; Montana; Delaware; West Virginia; Wisconsin; and Pennsylvania. More than a dozen more will meet that criterion by 2030.

Across the country, the number of seniors will grow by more than 40 million, approximately doubling between 2015 and 2050, while the population older than 85 will come close to tripling.

Experts say the nation will have to refashion its workforce, overhaul its old-age programs and learn how to care for tens of millions of elderly people without ruining their families’ financial lives.

Beth Lagasse collects picture frames from her father's apartment to bring to his nursing home in Dover-Foxcroft, Maine. (Marlena Sloss/The Washington Post)

Lagasse, 55, checks her father’s band. (Marlena Sloss/The Washington Post)

James Lagasse, 84, watches a nursing home employee make his bed. (Marlena Sloss/The Washington Post)

The results of not doing so fast enough are already visible in Maine. At the Hibbard Nursing Home in a rural slice of the state, Beth Lagasse cried softly as her father recovered down the hallway in Room 113.

Lagasse’s mother broke her back in May and died in June. Her father suffered a stroke in July. The nursing home near her has no open beds, so she drives an hour every day to care for her ailing father after spending months caring for her mother.

Lagasse has not been able to read a book, go canoeing or take care of her 1-year-old Shetland puppy, Paddy, since her mother first got sick. Lagasse, a physical education teacher, and her three siblings cannot afford the cost of 24/7 care, although Medicare temporarily covered her father’s hospitalization.

“I love them. I love them dearly,” Lagasse, 55, says of her parents. “I just wish this weren’t so hard.”

'Just not enough people'

Over the past two years, Mark Honey’s rare form of muscular dystrophy has proved so debilitating that he has lost control of his hands, legs and arms. Living alone in the small town of Ellsworth, Maine, Honey, 63, has for about 18 months looked for a nursing home where he can receive 24-hour care.

But with nursing homes across Maine closing at an unprecedented rate, Honey has been unsuccessful. Medicaid pays for a care aide to come to his home for 70 hours a week. But the state has told Honey it cannot find enough workers to cover the hours, even though he legally qualifies for the care.

Care workers in Maine were paid about $11.37 an hour in 2017, according to an AARP report, with a 2019 minimum wage of $11 an hour. As Kristi Penny, who has cared for Honey for four years, noted over the phone: “Even Dunkin’ Donuts pays you more.”

Honey said he lives in fear of one of the caretakers getting sick and quitting or finding another job. “When you’re confined to a bed, there’s not much you can work with,” Honey said. “It only takes one or two of the girls being sick, or one of the two of them quitting, for me to not be covered. And then you’re up the creek without a paddle.”

Gail Johnson, owner of Ship to Shore Store in Harpswell, Maine, rings up a customer. Johnson reopened the store in 2009 after spending decades as a shore captain. She now balances running the store and caring for her husband, Charlie, who has moderate dementia. (Marlena Sloss/The Washington Post)

With its 65-and-older population expected to grow by 55 percent by 2026, Maine needs more nurses, more home-care workers and more physicians than ever to keep pace with demand for long-term-care services.

But the rising demand for care is occurring simultaneously with a dangerously low supply of workers.

About one-third of Maine’s physicians are older than 60. In several rural counties in the state, close to half of the registered nurses are 55 or older and expected to retire or cut back their hours within a decade.

Maine’s largest long-term-care provider, North Country Associates, has been forced to temporarily close admissions in each of its 26 nursing homes because of staffing shortages, sometimes for as long as several months, in an unprecedented change from a few years ago.

It has also permanently shut down two of its nursing homes over the past year, while about a dozen nursing homes across the state have closed their doors over the past several years. Mary Jane Richards, chief operating officer at North Country Associates, said she has already raised wages four or five times in a bid to hire or retain staff.

“There are simply just not enough people to go around,” she said. “We try to elevate our wages, but then the nearest facility brings theirs up.”

Betsy Sawyer-Manter, president of the SeniorsPlus agency responsible for placing care workers with Medicaid enrollees, said she was not surprised by Flaherty’s story of failing to find a worker for her mother, despite qualifying for care. Sawyer-Manter said that every week her agency cannot fill more than 6,000 hours of direct care that have been authorized by the state because of worker shortages.

“If there aren’t any workers in that area, there’s nothing we can do,” Sawyer-Manter said. “As people retire, we just don’t have enough workers to do all the jobs we need done.”

'One family at a time.'

From 2015 to 2050, the number of Americans 85 and older will increase by more than 200 percent, while those ages 75 to 84 will rise by more than 100 percent, according to AARP. By contrast, the number of Americans younger than 65 will increase by about 12 percent.

America’s federal programs have not kept pace with this enormous demographic shift. With a few minor exceptions, Medicare does not pay for long-term-care services. Medicaid offers limited benefits but is available only to the very poor. The private market also has not been able to fill the void, as 7 percent of costs in the long-term-care market are covered by private long-term insurers.

Charlie Johnson watches television at home in Harpswell. (Marlena Sloss/The Washington Post)

The United States is projected to have 7.8 million job openings for care workers by the middle of the next decade, making it among the fastest-growing professions in the country, with millions of new openings created by higher demand; millions of care workers retiring; and millions more finding new professions, according to the Paraprofessional Healthcare Institute, an advocacy organization. The total cost of caring for America’s elderly will double from $2.8 trillion to $5.6 trillion by 2047, a report by the consulting firm PwC found.

“The U.S. is just starting this journey, and Maine is at the leading edge,” said Jess Maurer, executive director of the Maine Council on Aging. “As we are living longer, all the systems that have always worked for us may have to be changed.”

Congress created a commission to study the long-term-care problem. In 2013, it issued dozens of recommendations, including a “national strategy” to help family caregivers, but “a fair number of these things have not been implemented. Those that have been implemented are being implemented far too slowly,” said Bruce Chernof, co-author of the commission’s report and president and chief executive of the SCAN Foundation, which advocates on long-term-care issues.

“Left unaddressed, this will be catastrophic. We as a country have not wrapped our heads around what it’s going to take to pay for long-term care,” Chernof said.

Other countries have responded to their aging populations with government-provided care, and many have beefed up the number of aides and providers. America and England are the only economically developed nations in the West that do not provide a universal long-term-care benefit, said Howard Gleckman, author of a book about long-term care and a senior fellow at the Urban Institute, a nonpartisan think tank.

“With climate change, towns get burned down, or people die in fires,” which helps focus national attention, Gleckman said. “This is one family at a time suffering in silence.”

'Far too few younger people'

Albert Rose sits on the wharf of his seafood business and fumes that he cannot find help with his daily work of moving and unloading 50 crates of lobster, each often more than 100 pounds. In Harpswell, median age 57, he lives in the oldest town of America’s oldest state.

Rose, 40, has suffered from two torn rotator cuffs and a herniated disk but continues to perform the heavy labor ­himself in part because he has for the past five years been unable to find young workers, absent sporadic help from college students during their summer vacations.

“Ten years ago, every spring you had young people wanting work on the wharf or want to work on a lobster boat,” Rose said. “I haven’t seen a single person this spring or summer looking for boatwork.”

Maine’s aging population, and its dearth of young workers, falls particularly hard on poorer businesses and parts of the state that do not have enough resources to compete amid the shortfall.

Pogie fish stick out of a purse seiner boat to be sold to Allen's Seafood. (Marlena Sloss/The Washington Post)

College student Tommy Santaguida, 19, weighs lobsters at Allen's Seafood. He was set to work there only temporarily. (Marlena Sloss/The Washington Post)

Piscataquis County, a region in the north battered by the closure of its lumber mills, will see the number of people ages 75 to 84 increase by 81 percent from 2015 to 2025, according to the Muskie School of Public Service at the University of Southern Maine.

The biggest impact likely is in health care for the elderly.

There are 34 physicians in the county, about 70 percent less than the state average per person, and fewer available nursing home beds per person, according to a Maine Health Access Foundation report. Half the physicians in the county are older than 50, as are half the nurses.

Stepping into the breach is Pine Tree Hospice, one of the few dozen volunteer hospices in the United States. The hospice’s volunteers do not provide medical services, but they go to the homes of patients in end-of-life care, cooking, cleaning or playing a game of cribbage. About one-quarter of the volunteers are themselves in their 70s. They like reciting the hospice’s motto: “We can’t add years to your life, but we can add life to your years.”

When Jane Stitham began as the executive director of the hospice about a decade ago, she urged as many elderly people as possible to call for free end-of-life care. But over the past two years, Stitham said, the hospice has shifted its focus to recruiting new volunteers, as its waiting list has grown dramatically. Every month, Stitham has to turn away one to two people whom the hospice cannot reach.

“There are far too few younger people in the mix of volunteers,” said Meg Callaway, who ran a program in the county focused on helping older people.

Cliff Singer, who runs an ­Alzheimer’s clinic in an isolated northern region of the state, said his waiting list has more than doubled to 70 people, meaning it takes 10 months for patients to see him. Singer is trying to hire nine nurses, which would allow him to cut his waiting list dramatically, but he only has three, in part because of fierce competition from other hospitals and clinicians.

“It feels awful not to be able to help more people,” Singer said. “But we really can’t.”

https://www.washingtonpost.com/business/economy/this-will-be-catastrophic-maine-families-face-elder-boom-worker-shortage-in-preview-of-nations-future/2019/08/14/7cecafc6-bec1-11e9-b873-63ace636af08_story.html 

Medicare-for-all would help pay for long-term care. Why don’t more people know that?

by Helaine Olen - Washington Post - August 14, 2019

When Sen. Bernie Sanders (I-Vt.) spoke about Medicare-for-all at the July 30 Democratic presidential debate, he talked about how it would improve coverage for people currently receiving it. “For senior citizens, it will finally include dental care, hearing aids and eyeglasses,” he said.

But Sanders forgot to mention it would also help senior citizens pay for long-term care, something Medicare doesn’t do now.

Sanders should not forget that again. Indeed, he should make long-term care the first thing he mentions when talking about how Medicare-for-all would help senior citizens. Add that it’s especially helpful for women. There’s likely no better way to counter scare talk designed to convince the elderly that adopting a significant Medicare expansion would result in less care — I’m looking at you, Joe Biden — than by pointing out how his plan would improve on the thing that seniors likely fear the most.

To anyone over the age of 40, uttering the phrase “long-term care” is like raising the subject of the Babadook. According to the most recent annual polling by the Associated Press and NORC Center for Public Affairs Research, about two-thirds of Americans over the age of 40 say they expect they’ll need to provide assistance to a close family member or friend over the next five years. Nearly half believe they cannot fund their own long-term care. More than 60 percent of this cohort expect they will need some form of long-term care in the future, only slightly below the real number of 69 percent.

The problem: Medicare doesn’t offer long-term help to people who need assistance with tasks such as showering and dressing and other tasks of daily living, whether that’s because of chronic illness, physical frailties or something like dementia. It’s a twofold issue: First, most people want to remain in their homes as they age if they can, something long-term care can make possible. Second, it also allows many to avoid more expensive institutional care — which, for the most part, is not covered by Medicare. (This is also true, of course, for private and employer-sponsored health insurance used by people under the age of 65.)

As a result, seniors are forced to rely on family and friends or to spend down their assets until they qualify for Medicaid. No surprise, the AP-NORC polling found adding long-term care to Medicare enjoys broad popular support, including with a majority of Republicans.

By the way, private long-term-care insurance is not the solution. Many insurers no longer offer the option, as payouts exceeded their estimates. Those policies that still remain are increasingly expensive — sudden rate hikes of 75 percent are not unknown — and financially out of reach for many.

Alex Lawson, the executive director of Social Security Works, told me he believes Sanders is less likely to bring up long-term health care because it wasn’t included in previous Medicare-for-all bills. It’s not as though Sanders doesn’t speak about long-term care at all. He mentioned it, for instance, at AARP’s presidential forum in Iowa last month — after dental care, hearing aids and vision coverage, things that are currently covered by many Medicare Advantage plans.

But he should talk about it more. Seniors support Medicare-for-all at slightly lower rates than most other age cohorts. It’s possible greater awareness of how it would help them with long-term care could sway some of them. It could also give Sanders a needed assist with middle-aged and older female voters. Women are more likely to need long-term care in old age, and daughters provide twice as much help to elderly parents as sons do. In fact, women are responsible for the majority of all unpaid eldercare assistance and suffer no small amount of damage to their professional prospects and earnings as a result.

This advice also goes for every candidate who supports Medicare-for-all or other plans that would offer help. Beto O’Rourke, for instance, says he supports Medicare for America, an expansion plan sponsored in the House by Reps. Rosa L. DeLauro (D-Conn.) and Jan Schakowsky (D-Ill.). That also beefs up Medicare’s long-term coverage. Speak up! One plan that wouldn’t help as much as it sounds: Biden’s $5,000 tax credit for people who provide unreimbursed eldercare. If a woman leaves the workforce to take on eldercare responsibilities, she can expect to lose more than $300,000 in lifetime earnings.

It’s not as though Sanders’s proposal on long-term care is perfect. It could be better — the companion Medicare-for-all bill in the House, sponsored by Rep. Pramila Jayapal (D-Wash.), also offers coverage for nursing home care, something Sanders’s bill lacks. But it’s still much more than the current status quo. So step up, candidates. Start talking about what you can do to help all of us with long-term care. It’s personal. This middle-aged daughter is waiting.

https://www.washingtonpost.com/opinions/2019/08/14/medicare-for-all-would-help-pay-long-term-care-why-dont-more-people-know-that/ 

Why Doesn’t America Have Universal Health Care? One Word: Race

by Janeen Interlandi - NYT - August 14, 2019

The smallpox virus hopscotched across the post-Civil War South, invading the makeshift camps where many thousands of newly freed African-Americans had taken refuge but leaving surrounding white communities comparatively unscathed. This pattern of affliction was no mystery: In the late 1860s, doctors had yet to discover viruses, but they knew that poor nutrition made people more susceptible to illness and that poor sanitation contributed to the spread of disease. They also knew that quarantine and vaccination could stop an outbreak in its tracks; they had used those very tools to prevent a smallpox outbreak from ravaging the Union Army.
Smallpox was not the only health disparity facing the newly emancipated, who at the close of the Civil War faced a considerably higher mortality rate than that of whites. Despite their urgent pleas for assistance, white leaders were deeply ambivalent about intervening. They worried about black epidemics spilling into their own communities and wanted the formerly enslaved to be healthy enough to return to plantation work. But they also feared that free and healthy African-Americans would upend the racial hierarchy, the historian Jim Downs writes in his 2012 book, “Sick From Freedom.”
Federal policy, he notes, reflected white ambivalence at every turn. Congress established the medical division of the Freedmen’s Bureau — the nation’s first federal health care program — to address the health crisis, but officials deployed just 120 or so doctors across the war-torn South, then ignored those doctors’ pleas for personnel and equipment. They erected more than 40 hospitals but prematurely shuttered most of them.
White legislators argued that free assistance of any kind would breed dependence and that when it came to black infirmity, hard labor was a better salve than white medicine. As the death toll rose, they developed a new theory: Blacks were so ill suited to freedom that the entire race was going extinct. “No charitable black scheme can wash out the color of the Negro, change his inferior nature or save him from his inevitable fate,” an Ohio congressman said.
One of the most eloquent rejoinders to the theory of black extinction came from Rebecca Lee Crumpler, the nation’s first black female doctor. Crumpler was born free and trained and practiced in Boston. At the close of the war, she joined the Freedmen’s Bureau and worked in the freed people’s communities of Virginia. In 1883, she published one of the first treatises on the burden of disease in black communities. “They seem to forget there is a cause for every ailment,” she wrote. “And that it may be in their power to remove it.”
In the decades following Reconstruction, the former slave states came to wield enormous congressional power through a voting bloc that was uniformly segregationist and overwhelmingly Democratic. That bloc preserved the nation’s racial stratification by securing local control of federal programs under a mantra of “states’ rights” and, in some cases, by adding qualifications directly to federal laws with discriminatory intent.

As the Columbia University historian Ira Katznelson and others have documented, it was largely at the behest of Southern Democrats that farm and domestic workers — more than half the nation’s black work force at the time — were excluded from New Deal policies, including the Social Security and Wagner Acts of 1935 (the Wagner Act ensured the right of workers to collective bargaining), and the Fair Labor Standards Act of 1938, which set a minimum wage and established the eight-hour workday. The same voting bloc ensured states controlled crucial programs like Aid to Dependent Children and the 1944 Servicemen’s Readjustment Act, better known as the G.I. Bill, allowing state leaders to effectively exclude black people.
[Myths about physical racial differences were used to justify slavery — and are still believed by doctors today.]
In 1945, when President Truman called on Congress to expand the nation’s hospital system as part of a larger health care plan, Southern Democrats obtained key concessions that shaped the American medical landscape for decades to come. The Hill-Burton Act provided federal grants for hospital construction to communities in need, giving funding priority to rural areas (many of them in the South). But it also ensured that states controlled the disbursement of funds and could segregate resulting facilities.
Professional societies like the American Medical Association barred black doctors; medical schools excluded black students, and most hospitals and health clinics segregated black patients. Federal health care policy was designed, both implicitly and explicitly, to exclude black Americans. As a result, they faced an array of inequities — including statistically shorter, sicker lives than their white counterparts. What’s more, access to good medical care was predicated on a system of employer-based insurance that was inherently difficult for black Americans to get. “They were denied most of the jobs that offered coverage,” says David Barton Smith, an emeritus historian of health care policy at Temple University. “And even when some of them got health insurance, as the Pullman porters did, they couldn’t make use of white facilities.”
In the shadows of this exclusion, black communities created their own health systems. Lay black women began a national community health care movement that included fund-raising for black health facilities; campaigns to educate black communities about nutrition, sanitation and disease prevention; and programs like National Negro Health Week that drew national attention to racial health disparities. Black doctors and nurses — most of them trained at one of two black medical colleges, Meharry and Howard — established their own professional organizations and began a concerted war against medical apartheid. By the 1950s, they were pushing for a federal health care system for all citizens.
[To get updates on The 1619 Project, and for more on race from The New York Times, sign up for our weekly Race/Related newsletter.]
That fight put the National Medical Association (the leading black medical society) into direct conflict with the A.M.A., which was opposed to any nationalized health plan. In the late 1930s and the 1940s, the group helped defeat two such proposals with a vitriolic campaign that informs present-day debates: They called the idea socialist and un-American and warned of government intervention in the doctor-patient relationship. The group used the same arguments in the mid-’60s, when proponents of national health insurance introduced Medicare. This time, the N.M.A. developed a countermessage: Health care was a basic human right.
Medicare and Medicaid were part of a broader plan that finally brought the legal segregation of hospitals to an end: The 1964 Civil Rights Act outlawed segregation for any entity receiving federal funds, and the new health care programs soon placed every hospital in the country in that category. But they still excluded millions of Americans. Those who did not fit into specific age, employment or income groups had little to no access to health care.
In 2010, the Affordable Care Act brought health insurance to nearly 20 million previously uninsured adults. The biggest beneficiaries of this boon were people of color, many of whom obtained coverage through the law’s Medicaid expansion. That coverage contributed to a measurable decrease in some racial health disparities, but the success was neither as enduring nor as widespread as it might have been. Several states, most of them in the former Confederacy, refused to participate in Medicaid expansion. And several are still trying to make access to the program contingent on onerous new work requirements. The results of both policies have been unequivocal. States that expanded Medicaid saw a drop in disease-related deaths, according to the National Bureau of Economic Research. But in Arkansas, the first state to implement work requirements, nearly 20,000 people were forced off the insurance plan.
One hundred and fifty years after the freed people of the South first petitioned the government for basic medical care, the United States remains the only high-income country in the world where such care is not guaranteed to every citizen. In the United States, racial health disparities have proved as foundational as democracy itself. “There has never been any period in American history where the health of blacks was equal to that of whites,” Evelynn Hammonds, a historian of science at Harvard University, says. “Disparity is built into the system.” Medicare, Medicaid and the Affordable Care Act have helped shrink those disparities. But no federal health policy yet has eradicated them.
https://www.nytimes.com/interactive/2019/08/14/magazine/universal-health-care-racism.html?smid=nytcore-ios-share