Category Archives: health care

Memorial Day thoughts about public health

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I grew up with books. From the time I was eight or nine years old I had a library card. It seems strange to me now, but from the time I got that library card I was allowed to walk from my grandparents’ house on Merchant Street to the old Abilene Public Library building on the edge of downtown. That building has long since been replaced, and my second home town now boasts branch libraries in addition. Present plans call for moving the main library to the building that once housed my old high school. Talk about deja-vu all over again.

Thinking of that place as it was in former times conjures up memories of sitting on dusty, hardwood floors between the stacks as cicadas shrilled outdoors and an occasional blue-jay shrieked, of studying for school projects and debate cases with friends around the old oak tables there, of chatting with Mrs. Hutto, my favorite librarian, at the circulation desk on the main floor. This photo hardly does justice to my memories, but it is what I could find. I share love of that remembered place with my friend, the late A. C. Greene, as I share the fact that the librarians allowed me to check books out of the adult stacks from the time I was twelve or so. In those days, our library in Abilene was housed in this airy, two-story structure, built of native sandstone; and it was a Carnegie Library, having been built during the years when grants of $10,000 could be got for the purpose from the Carnegie foundation.

But it’s the books on our shelves at home that I chiefly remember. I recall reading “the Barrel Organ” and “The Highwayman” in one of a couple of English poetry anthologies my mother had left from her college days, and falling in love with Edna St. Vincent Millay, whose “Recuerdo” I can still quote from memory, of being frightened by the anti-war poems of Wilfred Owen and comforted by Yeats’ “Lake Isle of Innisfree.” I remember some books of my father’s as well. Mother had sold the equipment and books from my father’s Albuquerque medical office after his death was confirmed in 1945 (he was originally listed as missing in action) but had kept his books on the shelves at home mixed in with hers.

I vividly remember reading two of my father’s books. One was entitled Devils, Drugs, and Doctors, by Howard Wilcox Haggard, the other An American Doctor’s Odyssey: Adventures in Forty-Five Countries. The woodcuts reproduced in Devils, Drugs, and Doctors rivetted my thirteen year old attention and drew me into the stories as much as Haggard’s vivid story telling. Afterwards I binged on books about the history of medicine and surgery for a while.

Both books are now out of print but still available, and if you browse through the Amazon buying options and reviews you will perhaps see why. Both are still relevant to the study of Public Health. The first is a history of childbed fever; the second a memoir that describes “conditions on ships and trains, in cities and country sides around the world,” as told by one Amazon reviewer. The author is Victor George Heiser, who served as chief health officer at the American colony in the Philippines and later as public health adviser to the international public health team of the Rockefeller Foundation. It occurs to me that my father may have run across him during the 1930s when he held a series of Rockefeller Fellowships to study at the Johns Hopkins School of Public Health and earned a master’s degree there in 1939. In one of his letters home, my father writes favorably from the Philippines of public health initiatives about which he had studied at Hopkins.

All of which perhaps explains why the idea of public health, that is the idea that society as a whole has an interest in the health of individuals, seems normal to me and why I have been troubled to discover the disarray and disestablishment into which our American system of public health (if we can even call it that any more) has fallen over the decades since we began dismantling it in favor of the present fee for service medical system we see struggling on every hand to combat the pandemic we now face. My father served in the United States Public Health Service during the 1930s, then made the choice the rest of the country would ultimately make. He resigned from the Service in 1939 and entered the private practice of medicine. Unfortunately for us all, his National Guard unit was called up in late 1940, a circumstance that would be for him a death sentence. I have written about him many times, Here is an essay that will connect you with some of them, if you’d like to read.

But it is the idea of public health that many Americans have now determined to be excessively burdensome in this era of late capitalism. I’ll not list the ways Americans have found to protest current public health initiatives; they are all too familiar and there is nothing new in them. We have always endured anti-vaxxers and others who have protested, refused, and otherwise attempted to stymie public health initiatives. Many Americans still smoke. The Catholic church staunchly maintains its opposition to artificial birth control. Once in the not too distant past, during the 1918/1919 influenza pandemic, we have even experienced a bad government in this country which, like our present government, attempted to suppress public knowledge of the spread of the deadly disease for political reasons. And there is a dark side to the history of the public health idea. We recall the Nazi determination to eradicate everything from Jewry to epilepsy in a series of racialized public health initiatives. Some of us recall with horror our American experiments with eugenics and the notorious Tuskegee syphilis study.

Much recent public behavior might recall those past examples of radical indifference to cruelty and suffering. We are all familiar with a photo depicting an armed protester wearing no mask as he screams obscenities in the faces of masked guards stationed outside the Michigan state capital building. We are now familiar with a politics that urges sacrificing the elderly and vulnerable in order to ‘reopen’ our consumption driven economy. Even more insidious is a species of argumentation that recommends against social distancing measures on the grounds that pandemics are a ‘natural’ part of our planet’s ecology, a means to control population. etc. This argumentation moves quickly (and incoherently) from claiming that social distancing doesn’t work to questioning the numbers of deaths being reported in the media and asserting that some balance needs to be struck in public policy between concern for the suffering and death caused directly by the pandemic and other so called “deaths of despair” presumed to be occasioned by social distancing. A recent good piece in the Arizona Mirror reviews these arguments.

What to do with this when one is an asthmatic octogenarian with COPD and heart failure and a stroke survivor as well. I am among the most vulnerable segment of my country’s population when viewed from this perspective. But from another perspective, I am comfortably retired, own my own home, and can stay more or less out of harm’s way as long as my spouse and my son, who must make periodic trips out to purchase provisions, do not contract the virus. My experience over the past many months has taught me to live with risk, though I must say I became convinced many years ago that my life hangs by a thread. The pandemic adds a further level of risk to my life, but it has not made me fearful. I should be fearful if I were homeless, or in want, or in jail, or forced to work in a meat-packing plant, or live in a nursing home. Perhaps I am not fearful because I am conscious of being blessed, or in a condition that resembles being blessed.

But this memorial day I am thinking again about my father and about this very fine polemic by Marilynne Robinson in the June 11 issue of The New York Review of Books. I cannot know what my father would have made of our present crisis in America, but I like to think he would have recalled his own years in the United States Public Health Service in some meaningful way, for public health as an idea, as a dream, points steadfastly at the same truths Robinson asserts in this essay. Our notion that a system of authentic human flourishing could be based on a competition for wealth could never have been sustained. Such a competition inevitably leads to the vast inequalities we now see as the system collapses around us leaving some of us well off and others destitute, or near destitute. It is at this juncture, when deaths by virus and deaths by despair may be seen to converge. For public health cannot be sustained by a winner-take-all casino economy such as ours. A public subjected to the tyranny of the marketplace is by definition unhealthy. Any public will be sustained in health either by a generalized good will or not at all. And that good will in turn must be sustained by an economy that puts no one in want. Our problem as Americans is that we have subscribed to a zero sum economic ideology that requires poverty in order to generate wealth. We are presently living with a public health system that is characterized by manufactured scarcity, and in that environment “for [many] ordinary people there is no success, no benefit” no means to a healthy life to be had from the common cost benefit analyses to which we are traditionally accustomed. This present might lead us to a common perception of human fragility not unlike my own. Robinson hopes it will, to a revaluation of human nature that might enable us to see again both how fragile we are and how wonderful. As the psalmist knew, we are both ‘fearfully and wonderfully made.’ But there is a sequel to this essay, that I’ll not write today. It might begin (or may) with Robinson’s perception that given our present chaos, and “allowing for regional variations, to the degree that democratic habits persist, the country will get by.”

As I write these thoughts in advance of tomorrow’s Memorial Day I think of headlines in this evening’s Washington Post to the effect that Covid-19 is now surging in rural American areas where there are no longer hospitals to care for the sick. Nevertheless, crowds have thronged nearby Lake of the Ozarks in defiance of the conventions of social distancing. This is the chaos of present day American life. It takes my breath away and makes my heart heavy. Still, for every image of chaos in our media there are other images of philanthropy, from Bill Gates (whom I mention because he is the subject of a particularly distasteful conspiracy theory) to my friends who are risking their lives daily to deliver meals to the homeless on our downtown Saint Louis streets. If only we made nobody homeless. If only we made nobody poor. That’s not Karl Marx, by the way; it’s William Blake. My wish for my fellow citizens this memorial day is that we collectively desire the health, safety, and security of others as we desire our own.

It’s just business

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When I hear somebody use the expression I’ve taken for a title, I think one of two things. Either some monstrous evil is about to be justified by appeal to the sacredness of profit, or it’s time to hold on to your wallet. I should likely leave this topic alone, since I’ve been trying not to write about political firecrackers. But there are so many things wrong with the SCOTUS Hobby Lobby decision that one hesitates to try to list them. Still, among the concatenation of fact, falsehood, and argument swirling around the decision’s aftermath a few things seem to me to be of particular importance.

It’s been known for some time that Hobby Lobby’s owners are connected with right-wing organizations whose goal is to push “a Christian agenda into American law,” as Eli Clifton has reported in Salon. Time has reported this week that the Green Family (Owners of Hobby Lobby) were recruited to act as poster children for this particular lawsuit against a portion of the Affordable Care Act. They had a family prayer meeting about the matter before they decided to act, but in the final analysis they signed their company up to front for a political action that originated with The Becket Fund for Religious Liberty.

The Becket Fund is a right-wing Washington law firm that specializes in “religious freedom” cases. To be fair, Becket has defended persons and organizations of a variety of faiths. On the other hand, the Fund has made significant recent contributions to the current trend that interprets religious freedom as a Christian license to discriminate against individuals and has been allied with others, including Hosanna-Tabor Evangelical Lutheran Church and School v. EEOC, about which I’ve written earlier, the recently enacted Arizona SB 1062 that would have provided religious exceptions to protections in federal public accommodations law and specifically permitted discrimination on the basis of sexual orientation, vetoed by Governor Jan Brewer, and now in Burwell v. Hobby Lobby.

It appears as well that the Green family’s participation in this present case was not the sincere religious matter it has been portrayed to be by media and by the Supreme Court. The Greens are heavily invested through their pension fund in pharmaceutical companies that manufacture IUDs and the specific birth control medications to which the Greens affected to object as well as drugs used to induce abortions. The story was first reported by Molly Redden in Mother Jones and has been confirmed by Rick Ungar in a piece published today in Forbes, and elsewhere.

The Greens have a perfect right to invest pension funds in whatever way they choose, as long as their investments meet their fiduciary obligations. But they do not have a right, it seems to me, to support the manufacture of the very devices and medications to which they claim a religious objection that qualifies them for an exemption from the Affordable Care Act’s employer mandate. Conservatives have rushed to defend the Greens, claiming among other things that they were not responsible for these investments, didn’t know about them, and didn’t profit from them. Ungar pretty much demolishes those arguments and sums up as follows:

You simply can’t say that you will give your all in defense of your closely held beliefs when it suits you while seeking to make money in violation of those beliefs. You also cannot pretend you were simply negligent in learning what investments you hold if you are going to hold yourself out as an example of righteousness.

These observations underscore the extent to which this lawsuit is a move in the political chess game that is being played out over the Affordable Care Act. Justice Alito admitted in his majority opinion that the SCOTUS doctrine that corporatiions are people is a fiction, but claimed it is a useful fiction designed to protect the people who own corporations from harm.

[T]he purpose of extending rights to corporations is to protect the rights of people associated with the corporation, including shareholders, officers, and employees. Protecting the free-exercise rights of closely held corporations thus protects the religious liberty of the humans who own and control them.

Whether Justice Alito was aware that he had contradicted himself here in including employees in one sentence among those protected by the “familiar legal fiction” of corporation=person and excluding them in the next I cannot judge. But the contradiction makes clear the perversity of the fiction.

There is a second perverse fiction involved in Burwell v. Hobby Lobby, and that is the fiction of sincerely held religious beliefs. The Greens’ beliefs as described in Burwell v. Hobby Lobby are at the very least problematic scientifically, but now it turns out that their sincerity is open to question as well. Women, it is claimed, may not use certain contraceptives with the Greens’ support, but it is perfectly all right for the Greens to profit from the manufacture of these same contraceptives.

To be sure, the court more or less invited the President and Congress to extend the arrangement devised for non-profits who claim a religious exception to for-profit corporations such as Hobby Lobby. I suspect that this will be done, and that the cost of covering Hobby Lobby employees for the contraceptives to which Hobby Lobby objects will ultimately be passed on to you and me. And perhaps this means can be extended to the many other corporations now in queue for the religious exception. I will be glad to pay it, but this eventuality merely invites the religious right to espouse another putatively righteous cause.

It’s tempting to dismiss this entire matter as just another example of the contemporary practice of religion as identity politics, though I have no dog in that hunt. But now that this deplorable Supreme Court decision has entered the realm of precedent it is being interpreted with some justice, as in Justice Ginsburg’s dissent but also on the right, as opening the door to all sorts of new exceptions to established law on the basis of religious scruple, which need not have a grounding in fact and may, perhaps, even be feigned. As Justice Ginsburg has wisely pointed out, the court has “ventured into a minefield,” exposing itself to the necessity of deciding perhaps thousands of supposed “religious freedom” cases ad hoc.

caveat emptor all over again

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It’s getting harder and harder to defend the Affordable Care Act.

That difficulty underscores the fact that health care in our society is not a right but a commodity. Recent observers have noted that President Obama has backed away from moral arguments for health care reform in favor of transactional ones. That seems to me to spell defeat for the very idea of the ACA as reform in the humanitarian sense we still hoped for six years ago.

I recently wrote that I think the intention and potential of the ACA were and would be to improve our present system of private insurance, to increase coverage and ensure greater fairness. But yesterday’s Washington Post reported that

Thousands of primary-care doctors and specialists across the country have been terminated from privately run Medicare Advantage plans, sparking a battle between doctors who say patient care is being threatened and insurers that insist they have to reduce costs and streamline their operations.

After the Supreme Court decision that allowed states to opt out of Medicaid expansion, many states, though not a majority, did so—and led by the American Legislative Exchange Council have now enacted and/or proposed a host of repressive state laws designed to deny health care to as many citizens as possible. Then with the rollout of the new health care exchanges, insurance carriers began to cancel plans that didn’t meet new federal guidelines for minimum coverage and blamed their bad faith on the government, spawning a spate of horror stories that made perfect raw material for the Republican hate-Obama industry. Then some large low-wage employers ceased to provide health insurance for their workers, dumping them into the new health care exchanges and plans that require government subsidies to be “affordable.” Not to mention those large employers who for one reason or other have sought “religious” exemptions from the parts of the ACA affecting women’s health. And now this: thousands of doctors terminated from perfectly good Medicare Advantage plans providing medical care for the frail and the elderly, cutting them off from access to their doctors, interrupting years old doctor-patient relationships.

It’s unconscionable, but to Jack Larson, United Healthcare chief executive for Medicare and retirement, the Medicare Advantage provider making the largest cuts in its physician network, these changes are business as usual.

I’m not diminishing at all the short-term disruption when someone loses access to their physician. That’s a hard thing. . . . But we do believe that to have a quality health-care system we need to seek those physicians who have exceptional quality related to cost.

For years Medicare Advantage programs were a cash cow for insurance providers bacause the government paid these plans more per patient than it spent on regular medicare patients. But the ACA cuts payments to Medicare Advantage by $156 billion over the next decade and uses the savings to pay for other parts of the new system. Physicians are protesting individually and through the AMA and other medical organizations. Patients’ groups will likely organize as well. I’m joining the first one that comes to my door.

Thus far I’ve received no notice of any changes in my Medicare Advantage plan. However, I have received several letters from my provider offering me the opportunity to participate in an “entirely voluntary” program of home visits by doctors working for a subcontractor. I’ve not responded and don’t intend to respond. I’ve done some research on the subcontractor and it appears that it is a company that employs problematic physicians (hacks at worst) and that the intent is to get my insurance provider in between me and my own physician. I’m already bombarded by questionnaires after every doctor’s visit, checking up on my experience. I always respond to these because I don’t want any failure of mine to compromise my doctor. I think all this is worse than insidious, but it is likely the best face of present-day managed care. For various reasons my Advantage plan is a very good one.

Returning to the health-care arguments that animated the Clinton/Obama debates prior to the election of 2008 is a bit like returning (assuming that one could do such a thing) to Prague Spring after its brutal suppression. And the ACA? What began as a noble effort to provide access to health care for all Americans became in the working out of it a Rube Goldberg contraption full of unexamined assumptions and naïve expectations about how the strengths of the American capitalist establishment could be marshaled in a good cause requiring action through the state. There may have been a time when such a thing could have worked in America to promote the general welfare, but not now. What has been created in fact is a new complex of opportunities for gaming the system in the interest of predatory capital; with of course the usual losers, in this case physicians as well as patients.

The reasons why the ACA didn’t include a public option get clearer and clearer. They are the same as the reasons why a single-payer system is impossible in this country and why Medicare was designed and is administered for inadequacy—and of course that inadequacy has created the presently large market for supplements and PPOs. In a recent press conference the President was heard to say that we adopted the ACA as the least disruptive of alternatives for health care reform. So far “least disruptive” looks pretty disruptive, and it’s clear that the intent was not to disrupt the patrons of the system: clients (physicians and patients) pretty much be damned.

So how do we measure the success of this program? Sure, you can’t now be turned down for coverage for preexisting conditions, and parents can keep their children on parental policies for a longer time. But the cancellations of recent weeks and months are just as arbitrary as rescissions (now supposedly illegal) were in the former dispensation, and it’s now reasonable to ask, I think, whether in the final analysis the ACA will have been worth its human cost when it will end up leaving 31m people still uninsured.

I think the ACA will survive, and in some as yet to be foreseen future perhaps it can be made better. A popular left wing source seems to indicate that public approval is growing. On balance these are probably good things; but given the ACA’s flaws, with ALEC and the Republican party attempting to sabotage it on every hand and large insurers gaming it in order to continue their present obscene profit growth, it’s hard to imagine that it has the slightest chance to become the universal health care system we once imagined.