Category Archives: Public Policy and Governance

Prescriptions from the Doctor

It’s interesting that most of the public opposition to the Affordable Care Act has come from politicians–not infrequently, from politicians whose most generous donors have a vested interest in the medical status quo–and not from providers of medical care.

Perhaps we should listen to the people on the front lines–the doctors. This is from my cousin, a cardiologist whom I often quote here:

As a physician who had been in practice for many years, I remember the hardships suffered by many of my elderly patients prior to the initiation of Medicare in 1965. During that time, I was forced to sit painfully by as many unfortunate sufferers lamented that, even though they desperately needed to be hospitalized or needed expensive tests and additional services, they had only received small monthly social security payments with or without a small pension that barely sustained them at a subsistence level. In short, that situation afforded not only insufficient medical care, but threatened their financial security during those so-called “golden years.”

Then, in 1965, something abruptly and miraculously changed the landscape—the advent of Medicare. Suddenly our elderly could receive a standard level of medical care, which included, among others, diagnostic tests and hospitalizations. The financial burden was lifted from both the patients and us physicians, because we were no longer confronted with agonizing daily decisions about how we could provide decent medical care on a shoestring budget without threatening our patients’ health or survival.

He writes that two other doctors have recently weighed in via the New England Journal of Medicine (November 20, 2014). In “Civil Disobedience and Physicians—Protesting the Blockade of Medicaid,” C. van der Horst, MD, wrote that, when he anticipated passage of the Affordable Care Act, he thought he would no longer need to worry about patients’ affording necessary medications, preventive care services and hospitalizations.

But then van der Horst’s home State of North Carolina (like Indiana) blocked Medicaid expansion (even though, as it bears repeating, the federal government would pay 100% of the costs for the first 3 years and 90% thereafter). Over the protests of health care workers, teachers, union workers, immigrants, environmentalists, and people of all races and religions, North Carolina lawmakers have stubbornly refused to expand coverage.

The second article–written by Michael Stillman, MD–detailed the very different experience of Kentucky. Kentucky approved Medicaid expansion and “fundamentally altered our medical practice, allowing us to provide data-driven and thorough care without first considering our patients’ ability to pay” and giving 650,000 Kentuckians access to decent, comprehensive medical care. Most had previously lacked health insurance, had avoided routine preventive care—and worried that a medical emergency would leave them bankrupt. Medicaid expansion lightened their financial and emotional burden–and as a bonus, provided better physician education.  (Previously, doctors in training had become accustomed to offering substandard and incomplete care to indigent populations.) Now they are able to provide appropriate, evidence-based care.

As my cousin concludes:

This country will eventually—and inevitably—support decent medical care for all its constituents. Perhaps the process would be enhanced if our politicians were forced to spend time on the “front lines” of medical care in our clinics and hospitals and actually have dialog with those patients who are most vulnerable and under-served.

Listen to the doctor.

 

Predatory Municipal Finance

Every once in a while, I come across a study that “connects dots”–that makes previously disparate bits of information tell a new and different story.

I had one of these “aha” moments when I came across a Roosevelt Institute report titled “Dirty Deals: How Wall Street’s Predatory Deals Hurt Taxpayers and What We Can Do About It.”

According to the report, Wall Street and several major financial corporations have “engaged in a systemic effort to suppress taxes.” My first reaction to this was disbelief–not because I harbor any illusions about the business practices of Wall Street, but because I didn’t understand why they’d bother to lobby for generalized tax cuts. What would motivate such efforts? What’s in it for them?

Here’s the missing piece: when it is difficult for cities and states to fund even basic public services–let alone ambitious but necessary projects– out of tax revenues, banks can take advantage of that situation by offering state and local governments “creative” (albeit predatory) municipal financing “deals.”

Predatory financing deals prey upon the weaknesses of borrowers, are characterized by high costs and high risks, are typically overly complex, and are often designed to fail.

Ironically, the money that flows to Wall Street and its partners in these transactions often ends up costing taxpayers more than they’d pay by way of a responsible tax rate imposed by elected officials–and elected officials are accountable to voters in ways that Wall Street wheeler-dealers are not. (The report notes that taxpayers “do trillions of dollars of business with Wall Street every year.)

We have a perfect example of the way this works right here and now: Indianapolis’ proposed Justice Center. I’m in favor of the project, but as I’ve noted previously, I’m extremely leery of the “creative” and highly privatized way in which the city proposes to finance it. The terms “high costs,” “high risks”, and “overly complex” certainly seem apt.

The predatory practices highlighted in the Roosevelt report are made possible by voters’ stubborn belief in a free lunch. We want public services, but we don’t like paying for them.  So “creative” politicians work with Wall Street to give us “creative financing” that allows us to pretend we’re getting a bargain.

It’s easy to con people who lie to themselves.

 

Play Politics Much?

Every so often, I use this space to share the perspectives of my cousin, a scientist and cardiologist.

Like so many medical professionals, he used to be a reliable Republican; he’s now appalled by the way in which the Grand Old Party has deserted science and especially by its total capitulation to politics over sound medicine. In a recent post to his own blog, he addressed the GOP’s refusal to confirm a stellar candidate to the post of Surgeon General.

In March of this year, President Obama nominated a highly qualified candidate, Vivek Murthy, to be the nation’s next Surgeon General, but the nomination was not advanced to a confirmation vote in the Senate because conservative lawmakers and the National Rifle Association found his reasonable views on firearm regulation unacceptable. Thus a highly respected physician with impressive credentials who would have been an outstanding Surgeon General was rejected solely for political reasons. Although I, for one, believe that the regulation of firearms does indeed qualify as being a health/medical issue (see my post of May 30, 2013), it certainly should not constitute a “litmus test” for qualification for such a position.

Ya think?

Bottom line: The office of Surgeon General is vacant because a highly qualified doctor has pissed off the NRA by saying something that every sentient being understands to be true: gun violence is a public health issue.

No one in the GOP–and damn few Democrats–are willing to stand up to an organization so far out of the mainstream of public opinion that its own members think it is too extreme.

Our political system is so broken, it may be beyond repair.

What Is Wage Theft?

I will admit that until very recently, I’d never heard the term “wage theft,” but it’s a term that I’ve come across fairly frequently in the context of the current debate over raising the minimum wage, so I consulted Dr. Google.

Basically, “wage theft” applies to situations where an employer doesn’t follow applicable wage and/or hour laws–either paying an employee for less time than s/he worked, or at a rate below the legal minimum.

A landmark survey survey of thousands of low-wage workers in New York City, Los Angeles and Chicago found that 26 percent had been paid less than the minimum wage the week before they were interviewed. According to the 2009 report by the National Employment Law Project and two other groups, 76 percent of the workers who put in more than 40 hours did not get paid or were underpaid the required time-and-a-half overtime rate. About 17 percent of the workers put in unpaid time “off the clock” before or after their shifts, another violation. In the three cities alone, the study estimated, low-paid workers were losing more than $56.4 million per week to wage theft.

As one reporter noted, the central problem in enforcing wage and hour laws is that they are basically driven by the filing of a complaint, and most people earning less than minimum wage are understandably unwilling to risk their jobs by complaining, even assuming they know they have that right.

The impact of even a little “skimming” by employers can be significant.

The Economic Policy Institute calculates: “When a worker earns only a minimum wage ($290 for a 40-hour week), shaving a mere half hour a day from the paycheck means a loss of more than $1,400 a year, including overtime premiums. That could be nearly 10 percent of a minimum-wage employee’s annual earnings—the difference between paying the rent and utilities or risking eviction and the loss of gas, water, or electric service.” Overall, according to projections based on surveys of low-wage workers, “wage theft is costing workers more than $50 billion a year.”

In our downsized, privatized, anti-government environment, I guess having adequate personnel to enforce wage laws is just too much to expect.

Why is it I think that if pervasive theft was hurting employers rather than workers, the response would be different?

 

Time for a Change

There are lots of suggestions for changing the way we Americans conduct elections.

We debate nonpartisan commissions to replace partisan redistricting (gerrymandering), making election day a holiday, changing to a vote-by-mail system (Oregon votes by mail and the turnout in Oregon last Tuesday was over 69%), eliminating the Electoral College, and efforts to get big money out of politics, starting with a Constitutional amendment reversing Citizens United. All of these, and many other suggested changes, have their merits.

Here’s another suggestion, one that I heartily endorse.

In a New York Times op-ed written before the midterms, a Duke University professor and one of his students make the case for eliminating the midterms entirely, and extending Congressional terms to four years from the current two. They begin by pointing out that barely 40 percent of the electorate will bother to vote, “even though candidates, advocacy groups and shadowy “super PACs” will have spent more than $1 billion to air more than two million ads to influence the election.”

There are few offices, at any level of government, with two-year terms. Here in Durham, we elect members of the school board and the county sheriff to terms that are double that length. Moreover, Twitter, ubiquitous video cameras, 24-hour cable news and a host of other technologies provide a level of hyper-accountability the framers could not possibly have imagined. In the modern age, we do not need an election every two years to communicate voters’ desires to their elected officials.

Agreed. The op-ed authors make several other arguments, all persuasive, and the piece is worth reading in its entirety. But the bottom line is that the people who win these off-year elections will immediately begin fundraising for the next election cycle. No time to breathe, let alone time to consider issues of actual governance. Just dialing for dollars, and not-so-incidentally trying not to do anything that will piss off big money donors.

Many of the reforms being debated should be implemented. This is one of them.