Don’t Deny It

June 30, 2021

United Healthcare became the most recent insurer to announce a policy of denying payment for what is deemed “unnecessary” emergency department visits.  Within days of its announcement, it said it was delaying the policy change in response to an outcry from healthcare providers and patient advocates. (Anthem put forward a similar policy in 2018, which it subsequently modified substantially under pressure.) While the goal of having the right care in the right place at the right time and at the right cost is reasonable and necessary, the punitive approach being pursued by payers is ill-conceived, unfair, and likely to be counterproductive.

First, let’s be clear about the problem.  I’ve seen no data to suggest that any significant proportion of ED visits are unnecessary in the sense that the patient didn’t actually need medical attention.  Rather, a substantial fraction of visits to the ED (estimates range from around 20% to over 60%) are for problems that could be managed in a different setting (e.g., primary care, urgent care). Because charges for ED visits are typically far higher than for those other settings (I say charges because there is some disagreement about whether the cost of such visits is actually higher, but that’s a blog for another time…), having that care provided in a different setting when appropriate could decrease health care spending while maintaining the effectiveness of the care and perhaps improving the experience.

So why do people go the ED when they could go someplace else?  Policies based on a financial disincentive seem to be predicated on the idea that people are intentionally misusing the system: I know I could go someplace else but my insurance is paying for it so what the heck.  But research has shown that ED visits for non-urgent problems are correlated largely with lack of accessible, quality alternatives; lower levels of health literacy; or a true belief that something is or at least might be an emergency. (Chest pain is an emergency whether it ends up being a heart attack or indigestion.)  In all my years of practicing emergency medicine, I encountered far more people being gamed by the system than those trying to game it.

Which is why such policies are ill-conceived – they don’t address the root cause which is lack of real access to lower-priced options.  They are also unfair.  Unfair to providers because emergency departments are legally and morally obligated to treat all who come to them.  Threatening not to pay them for the services they provide puts them at risk.  Unfair to patients because non-payment may prevent those without alternatives from getting care they need.  And barriers to accessing other sites of care are more prevalent among those with public insurance and those in higher poverty neighborhoods and those with more people of color. Denial of payment becomes one more source of inequity.

What’s worse, such policies are unlikely to achieve their goal of reducing spending, and may even increase it.  To start with, the vast majority of denied claims end up getting paid.  For example, in 2020 when Aetna was sued for inappropriate denial of emergency claims in California, the court found that 93% of the denied claims should have been allowed according to Aetna’s criteria.  However, the process requires the provider to appeal, generating a ton of paperwork and additional expense.  Second, the process for validating the “appropriateness” of the claim is likely to drive unnecessary utilization.  Approval of the claim is based in part on “the intensity of diagnostic services performed” and treatments provided (for example, visits in which IV medications or fluids are given are automatically approved).  We know that a good deal of diagnostic testing is unnecessary; this policy would incentivize additional testing as a way to justify the visit.  It would also incentivize therapeutic escalation – for instance, IV fluids instead of the equally effective oral rehydration.  All of this would actually add to the cost of care.

Excessive spending for care in emergency departments that could reasonably and safely be provided elsewhere is a problem.  Better and more equitable access to less expensive alternatives (effective triage lines, expanded primary care and urgent care hours, virtual care) would be a better approach than punishing patients and providers by denying payment.


Equity – It’s Not a Dirty Word

June 2, 2021

Last week marked the one-year anniversary of the murder of George Floyd.  After the initial shock of his brutal killing, captured on video, and the subsequent global protests against police brutality in particular and widespread racism in general, there seemed to be a change in the air.  White people, including business and political leaders, were openly using phrases such as “white supremacy” and “systemic racism” for the first time I can recall.  They went beyond the usual offering of thoughts and prayers, making commitments to real change.  Granted, actions matter more than words, but at least the words finally seemed to acknowledge the depth and extent of oppression of Blacks and other people of color.  Equity became the watchword of the day.

That in itself, in a way, represented an advance in how we talked about things.  Earlier generations fighting for civil rights tended to talk about equality.  Just treat everyone the same.  But in the wake of centuries of the accumulated effects of unequal treatment, it makes more sense to think about equity.  If equality is treating everyone the same, equity is treating everyone in a way that is based on their need.  Many of us have seen the cartoon depiction:

And here we are, just one year later, and hope is fading fast.  The New York Times, for example, recently documented the sharp decline in support for the Black Lives Matter movement among whites, to levels significantly lower than before Floyd’s murder.  Voter suppression laws likely to disproportionately affect BIPOC voters are spreading faster than kudzu across the South.  And even as Derek Chauvin was being tried in Minneapolis for the murder of George Floyd, an officer in nearby Brooklyn Center was being charged in the killing of Daunte Wright.

It isn’t just that the talk hasn’t translated into action.  In many quarters, the very concept of equity is being portrayed as itself discriminatory and somehow un-American.  Here is an example from the libertarian magazine Reason, commenting on Vice President Kamala Harris drawing a distinction between equality and equity:

“For decades, these two divergent philosophical and public policy concepts were represented by a battle over adjectival phrases. Should we strive for equality of opportunity, or equality of outcome? Though intellectual and political enthusiasm for the outcomes-based approach did have some high-water moments in the 1970s, the long twilight struggle against 20th century totalitarianism produced a rough if sometimes reluctant governing consensus that states powerful enough to promise economic and racial parity were far more likely to produce mass immiseration. Striving for equality under the law—removing legal discrimination by government—was less ambitious, but more doable.”

The author makes two claims: first, that proponents of equity are actually striving to achieve equality of outcomes for all (which he portrays as vaguely foreign and socialist), when the real goal should be equality of opportunity; and second, that equality under the law is sufficient to guarantee it.  Both of these are incorrect.

Let me start with the second.  Unequal treatment of Blacks, other people of color, LGBTQ individuals, and others does not depend on a government stamp of approval.  Segregation in the South, enshrined in law, was equaled by or even surpassed by that achieved in the North despite the lack of “legal discrimination by government” there.  Discriminatory lending by banks, discriminatory hiring practices by companies and unions, and discriminatory treatment by teachers, retailers, and police have produced as much social and economic misery for Blacks as Jim Crow laws. Simply removing officially sanctioned racism has not and will not produce equal opportunity.

Equity refers to true equality of opportunity.  It means identifying not only legal but other barriers that BIPOC individuals face as the result of centuries of racist laws and other practices, and addressing those barriers.  I’ll use the example of the COVID vaccine.  There are no legal barriers that impede access to the vaccine based on race.  However, there are numerous other barriers, including location of health facilities, availability of transportation, and access to information about the vaccine. Equitable vaccine access would mean targeted outreach and resources to overcome these barriers.  It’s the equivalent of providing a second box to be able to see over the fence.

Even true equality of opportunity – equitable opportunity – does not guarantee equality of outcomes for each individual.  I’m not sure that would even be desirable – after all, we are all individuals and wouldn’t want to be exactly the same.  Moreover, there is a need to account for individual effort, desire, etc.  To go back to the cartoon, the person getting the two boxes might not be interested in the game.  She may choose to use the wood from the boxes to build a lemonade stand.  She may even sell the boxes to someone else and use the money to by a ticket to get into the ballpark!  The point isn’t that every single person is ultimately going to watch the game from behind the fence.  It’s that anyone who has the desire and is willing to put in an equal effort to do so will not be prevented from doing it due to factors outside their control.

So while equity does not mean every individual has exactly the same outcome, it should, if done right, lead to equality of outcomes across groups.  Differences in effort and desire should even out, and the results should be roughly similar when examined over populations.  To use the vaccine equity example, equitable vaccine access does not mean that every person is vaccinated.  It means that when we look at groups in the population, the rates of vaccination should be the same.

And that is why when we see disparities in high school graduation rates, or home ownership, or vaccinations, we conclude there is inequity.  But that is not because of some nefarious totalitarian goal of imposing uniformity on everyone.  If we could quantify the accumulated effects of systemic and structural racism, we could perhaps precisely define and measure opportunity and determine if we have achieved equity in those opportunities.  I’m not entirely sure how one would do that.  How much vaccine outreach is enough?  Given the inability to measure the desired goal – equitable opportunity – we use disparity in outcomes across groups as a proxy measure for whether there was equitable opportunity to achieve those outcomes.

Equity is not a dirty word.  It is not un-American.  I would argue it was part of the basis of our founding.  The Declaration of Independence states “We hold these truths to be self-evident, that all men [sic] are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”  We don’t all have the right to be happy, but we all have the same right to pursue that happiness.  That’s equity.  We haven’t lived up to that ideal in the centuries since that document was written, but we shouldn’t give up on trying.


Hiring the Best and the Brightest (and the Most Diverse)

May 24, 2021

In early 2018, I signed onto what was then called the CEO Action Pledge on Diversity and Inclusion, joining about 120 other CEOs around the country (the number is now approaching 2000) in committing to promoting equity and inclusion at Children’s Minnesota.  Two years later, after the murder of George Floyd and the accompanying nationwide protests, many companies – including major employers in Minnesota – have gone beyond that to make specific pledges around increasing the diversity of their workforces and especially their leadership teams.  Perhaps not surprisingly, there has been some pushback.  Ever since the term affirmative action was first introduced in the early 1960s, there has been criticism of it, with arguments generally falling into two categories: that it is unfair to the majority group and amounts to reverse discrimination, and that hiring decisions should be based entirely on merit.

While I don’t agree with the unfairness argument, I understand it.  I have personally been in the situation where someone might have very similar qualifications to mine for a particular role, and I was not selected because the “tiebreaker” was race or sex.  In situations like that, I know I will lose out every time.  I can intellectualize the fact that for the vast majority of my life I have been the beneficiary of those tiebreaker considerations, and that the qualifications I have are in part the result of the accumulated effects of generations of that advantage in opportunities that my ancestors have had.  But if I am honest, I have to admit that while in the end I am convinced that is correct, it doesn’t feel great when it happens.

As to the second argument, I couldn’t agree more that hiring decisions should be based entirely on finding the best person for the job.  And that is completely consistent with efforts to advance diversity and inclusion in our leadership teams and our workforce as a whole.  To assume otherwise – that increasing diversity is somehow antithetical to hiring based on merit – is in itself racist.  When our executive leadership team was all white, white people weren’t asking if any of them got their position based on their color.

The first step in hiring the most qualified people is finding the most qualified applicant pool.  Traditional hiring and recruitment practices tend to limit the number of people identified, yielding a homogenous group of candidates and risking missing out on a good deal of potential talent.  The university I attended was, until 1969, all male, and nearly all white.  How could they claim to have the best and the brightest minds in the country when they only considered applications from at most one-third of the potential students out there?  (Michelle Obama, a fellow alum, is a great example of the kind of talented individual that would never have been on the radar screen in the earlier era.)  Casting a wide net, using a recruitment strategy that intentionally looks beyond the “usual suspects,” results in a candidate pool that is both more diverse and more likely to include those most qualified for the job.  For a large employer like us, that includes recruiting at schools serving a broader range of students (such as historically black colleges and universities, or HBCUs), or job fairs or Web sites geared toward more diverse job-seekers, such as People of Color Careers.  While this takes more work than traditional approaches, a hiring manager should not be satisfied unless the candidate pool is sufficiently diverse.

As an aside, is anyone else bothered by how we misuse the term “diverse”?  The word is often used to refer to someone who is from an underrepresented group, as in “Dr. X is a diverse candidate.”  An individual cannot be diverse! By definition, diverse refers to a group. My suspicion is that people (mostly white) who are still uncomfortable talking frankly about bias have adopted “diverse” as a euphemism.  It’s OK to say “Dr. X is LGBTQ” or “Dr. X is Native American.”

OK, anyway, so after identifying a diverse group of candidates, the next step in hiring the best person for the job means carefully considering what it takes to be the best for the job.  One must think of any hire both as an individual and as part of a team.  When evaluating an individual, for the sake of ease and efficiency, we often rely on easy-to-measure indicators like grades, test scores, or specific prior positions held.  But how meaningful are they?  The research on how well IQ tests or grades predict job performance is complex, but to the extent there is a correlation, that correlation diminishes substantially when accounting for other factors.  More importantly, we need to be thoughtful about what is required to do a job successfully.  For decades, medical students were selected primarily for their ability to memorize large amounts of information and do well on tests.  In an Internet era when anyone with two thumbs can find the differential diagnosis of any imaginable symptom on their phone, the ability to sift information critically, and communicate effectively and with empathy and compassion are probably better predictors of a good physician than organic chemistry grades.  To be clear, this is not about lowering standards.  It is about ensuring we use the most appropriate standards to identify who is most likely to succeed at a particular job.  It is about questioning the “usual” standards that may not only be poor markers of job success, but may have the unintended consequence of excluding individuals who may be as or even more likely to succeed.

In addition to a candidate’s individual qualifications, in most instances we are hiring someone to be part of team.  This raises the question of who is going to best contribute to making that team successful.  A growing body of research has shown that more diverse teams have higher performance.  Teams with more diverse members – including diversity of background, experience, perspective, and style, as well as specifically racial, ethnic, and gender diversity – are more likely to focus on facts, process those facts more carefully, and be more innovative.  In healthcare specifically, diverse patient populations are better served by more diverse care teams.  Selecting the best candidate for the job, then, involves not only establishing the appropriate standards for individual success, but accounting for the current make-up of a team and seeking to increase the diversity of that team to promote group success.

After casting a wide net and defining the desired characteristics, the final step is creating an equitable selection process.  Everyone has inherent biases; the selection process must ensure that these are minimized.  For years, symphony orchestras in the US were nearly exclusively male.  After adopting blind auditions (with musicians performing behind a screen) starting in the 1970s, the proportion of female musicians rose dramatically.  (While the evidence supporting the effect of blinding has been criticized, there is no disagreement that gender diversity in classical music has increased, with no sacrifice of quality.) Blinded evaluations are not always feasible – at Children’s Minnesota, our approach to addressing bias includes ensuring that the interview panel for leaders is itself diverse.

These strategies work. Since signing on to the CEO Action Pledge, we have made progress in diversifying our leadership.  Both the top Executive Leadership Team and the larger Strategic Leadership Team are 60% women and 30% BIPOC.  (I acknowledge there are other dimensions of diversity.  These are simply the dimensions we have focused on primarily so far, and for which we have the best data.)  And, I can say that they are the most effective and talented leadership teams I have ever worked with. I have and always will pick the best person for the job; no one on my team has ever been hired because of their color.  But without those intentional efforts in recruitment and hiring, some of these amazing people might never have made their way here, and Children’s Minnesota would be the worse for it.


Journey to Zero

April 19, 2021

What is the acceptable number of people to be harmed by healthcare?

When I started my pediatric training in the mid-1980s, my answer would have been “what are you talking about?” No one was talking about patient safety.  To the extent we acknowledged medical error, it was that there were some “bad apples” who committed malpractice, but not a huge issue.  And of course, people did sometime make mistakes – humans aren’t perfect after all – but that wasn’t really a problem, just an unfortunate fact we had to accept as the price of advanced medical care.

Then, in 1999, the Institute of Medicine published a landmark report, “To Err Is Human,” that showed that medical error is in fact rampant and preventable.  Tens of thousands of Americans were dying each year at the hands of those who intended to help them.  Not because those were bad people, but they were operating in imperfect systems.  Healthcare is complex, and like any complex system, failures can occur.  Yes, to err is human.  But the answer isn’t to accept error as a necessary evil.  It is to design systems that prevent error from occurring despite human failings.  The answer to the question I posed at the top is “zero.”  It’s never acceptable.  Which is why our patient safety effort at Children’s Minnesota is called Journey to Zero.  Our goal is that no one is ever harmed by the care we provide.  We aren’t there yet, and maybe we’ll never get all the way to zero.  But at least theoretically we can improve our systems to the point of no harm, and we won’t stop trying until we do.

The idea is to design the system to make it as hard as possible to make a mistake, and as easy as possible to do the right thing.  Consider such incredibly complex, high-risk, and high-stakes industries as nuclear power and aviation.  “Routine” airplane crashes and nuclear plant explosions would not be acceptable, and they don’t happen.  These industries are not perfect, but they are getting awfully close to it. They have developed a set of principles and practices that have been borrowed by healthcare to make our systems better and avoid preventable harm.  Tens of thousands of people area alive today who might not be if healthcare hadn’t followed their lead.

OK, let’s switch to a different topic.  What is the acceptable number of Black people to be harmed by law enforcement?

Police killings of Black people are really not that different from plane crashes or medical errors.  The law enforcement system isn’t trying to kill people.  It doesn’t want to kill people.  It doesn’t have to kill people.  And yet it is killing people.

And the problem isn’t “a few bad apples.”  The problem isn’t “mistakes are made.”  The problem is the system.  It is a system whose harm is disproportionately affecting Black people, the definition of systemic racism.  But it’s a system in denial about the nature of its problem.  Like healthcare in the 1980s, it relies on an adversarial approach to identify individuals to blame for bad outcomes.  Not only does this not solve the problem (as I said in regard to healthcare, even skilled and well-intentioned individuals can and do cause harm in an imperfect system), but it creates an environment in which calling out the problem is seen as a personal attack and it elicits a defensive response.

Our law enforcement system needs to start a Journey to Zero.  It needs to acknowledge that police killing of Black and other people of color is a systemic failing, and embrace systemic change.  As in healthcare, law enforcement needs to create a culture of safety, elements of which include:

  • shifting away from assigning blame to an individual, to identifying root system causes for harm.  Some root causes here might include officers who are not part of the community they serve; emphasis on the use of force as an early, even preferred, means of addressing conflict; and failure to address ingrained attitudes and biases that portray Black people, especially Black men, as an inherent threat
  • empowering and incentivizing all to speak out, regardless of position in the hierarchy, and report problems rather than ignoring or covering them up
  • transparency about progress or lack thereof, with accountability at all levels

When we post the number of CLABSIs on each nursing unit, it’s not meant to shame the clinical staff.  When a staff member enters a safety learning report about a near-miss medication error, they get a thank you note, not a reprimand.  Similarly, if we talk about the need for reform of law enforcement, I hope that is seen as a criticism of policing, not of individual police. Over the last 4 years, an average of 227 Black people have been killed by police annually.  This is equivalent to a Boeing 757 crashing each year, every year.  It’s time to start that Journey to Zero.


Actions and Words

January 18, 2021

What is the first thing that comes to mind when you think of the Rev. Dr. Martin Luther King, Jr.?

I’d be willing to bet a nickel that you were thinking something like “I Have A Dream,” or “speech at the Washington Monument.”  If so, you are not alone.  According to Brittanica on-line, “Martin Luther King, Jr., is known for his contributions to the American civil rights movement in the 1960s. His most famous work is his “I Have a Dream” speech, delivered in 1963, in which he spoke of his dream of a United States that is void of segregation and racism.”

Now don’t get me wrong, that speech is one of the greatest orations in American history.  (I recently learned that the “I Have A Dream” section was not part of his prepared script and was actually delivered extemporaneously, making it all the more impressive.)  But it isn’t the reason Dr. King is important or even famous.  He was already famous by the time of the 1963 March on Washington, which he helped organize.  That speech perhaps solidified his reputation as a speaker.  But he was already known as, and made his greatest impact as, a doer.  I believe Dr. King is wrongly remembered primarily as a man of great words.  More importantly, he was a man of action.

Martin Luther King, Jr., was an organizer, leading people not just in speaking out against injustice but doing something about it.  He led the 1953 Montgomery bus boycott that eventually forced that city’s transit system to desegregate.  He participated in sit-ins at lunch counters in Atlanta and Birmingham, for which he was arrested.  He led the march at Selma to demand voting rights.  And at the time of his assassination, he was in Memphis to march with striking sanitation workers.

Dr. King’s focus on deeds over words was influenced by his mentor at Morehouse College, Benjamin Mays.  Black people couldn’t end oppression by talking about it and waiting for someone else to make it happen; they needed to actively confront it and oppose it themselves.  Dr. King’s brilliance came in how he defined that confrontation.  Motivated by Gandhi’s successes in India, Dr. King recognized that physical power and brute strength were the tools of oppression, and produced transient results. Moral strength and economic power, applied in non-violent resistance, were the best way to counter racism.  But non-violence is not the same as passivity.  He rejected both violence and inaction.

I have re-read “I Have a Dream” many times. The hope expressed there is a beautiful inspiration and aspiration.  But Dr. King was not a dreamer, and he knew that hope is not a plan.  As we honor his legacy today, let’s remember that he called on us to dream, but more importantly to act.  If we want to see change, we must do more than talk about it, we must do the right things.  And as Dr. King famously said, “The time is always right to do the right thing.”


My Brother Bradley

October 5, 2020

As a White person, I do not know what it is like to be Black.  As someone raised Jewish in a largely Christian culture, as a male in a heavily female profession, as a humanist in a profoundly religious society, I have experienced a sense of being different, of alienation, even some degree of oppression.  But it is not the same.  And claiming that because one has experienced alienation or oppression, one knows exactly what someone else’s alienation or oppression is like is inaccurate and even offensive.  Imagine a man telling woman who has just given birth that he knows exactly how she feels because he broke his arm once.  Not going to go over well.

At its worst, focusing on the common elements of our experience can set us up for minimization, for downplaying the unique elements of the experience of those different from us by equating it to our own.  Such minimization gets in the way of true understanding, and can come across as dismissive. This is what can happen when White people, responding to the idea of structural racism, point out their own hardships, which may be enormous, as evidence that all people have obstacles they face.  Yes, we all have obstacles to conquer.  But they are different.  One can call out the unique challenges facing Black people as a result of systemic racism without diminishing the challenges faced by many White people.  It’s not a competition to see whose suffering is worse; there’s plenty to go around.

At its best, however, acknowledging the common human experience of suffering can allow us to achieve sympathy – a sense of caring and concern for another – or even better empathy, the ability to truly recognize and share the feelings of another.  But to do this we have to go beyond “I feel your pain.  I’ve also had pain,” to “I know pain is real, but I don’t know yours.  I want to hear about your pain.”  White people who want to address structural racism can’t just rely on any of their own experiences of difficulty or alienation or oppression.  They have to be willing to listen – really listen – to the experiences of Black people.

So finally to Bradley.  Bradley entered my life about four years ago, via my wife, Lynn. Bradley, a Black man who is incarcerated in Wisconsin, contacted our minister after hearing her speak about Black Lives Matter on local TV.  (I recognize this mention of a minister may be jarring after my reference to Judaism and humanism above – just trust me on this.)  What about my Black life, he asked?  What about my son’s black life?  Do they matter?  What are you doing about those?  That led to the start of a correspondence between Bradley and Lynn, and eventually a deep relationship of which I am privileged to be a part.

Getting to know Bradley has enriched my life, and given me an understanding of racism that I could never get from any number of books or workshops.  Recently, Bradley gave a sermon via telephone from his cell that is the best, or at least the most personal, exposition of the real meaning of Black Lives Matter I have yet encountered.  I urge you to listen here – the sermon starts at around minute 31, with remarks from Lynn following Bradley’s.

Thank you, brother Bradley, for opening my eyes by opening your heart.


Equity Learning Reports

July 31, 2020

I’m going to go out on a limb and surmise that John Lewis would say that we should approach racial justice and equity the same way we approach catheter-associated bloodstream infections.

The connection may seem tenuous, but hear me out.  Traditionally, safety in healthcare was seen as an issue of “medical error.” The focus was on “mistakes” by individuals as the root of the problem, and disciplinary action as the solution.  In that kind of culture, people who had concerns about safety issues in the hospital either kept quiet for fear of being labeled a troublemaker, or they filed an “incident report,” which was used most often to punish someone for making an “error.”

Today, safety is seen as a system issue.  People with concerns are encouraged to file “safety learning reports,” with an effort to identify the system factors that allow harm events to occur, rather than finding bad actors to blame.  Speaking up is no longer frowned upon; reporting is not labeled as troublemaking.  And preventing harm is not a divisive effort to affix blame, but a collective effort to fix the system.

Similarly, racism is being seen not as a personal failing by some individuals, but as a set of customs, practices, and laws that have had the effect of advantaging some groups over others.  Justice then is not an effort to call out and punish guilty individuals, but a collective effort by all to create a system that works for all.

Unfortunately, too often we continue to view racial justice solely through the lens of individual action and accountability.  As a result, calling out examples of inequity is seen as troublemaking and divisive.  Protest is viewed as the equivalent of filing an incident report, rather than an opportunity to learn and improve.

John Lewis, who recently died, was a long-term congressman from Georgia and civil rights icon.  He was also an apostle for non-violence.  Trained and ordained as a Baptist minister, he was a co-founder of the Student Non-Violent Coordinating Committee, one of the original Freedom Riders, and a student of both Gandhi and King.  He was both an advocate for and a practitioner of peaceful protest.

I’ve often wondered about the inherent tension in the phrase “peaceful protest.”  Protest, after all, implies discontent with a state of affairs, opposition to something.  Opposition in turn implies conflict, which seems to be the opposite of peace.  But discontent is the impetus for improvement, for change.  As long as things are less than perfect, there will be discontent – appropriately so.  We know that racial inequity is an important factor affecting the health of the children we serve.  We should be discontent.  And as long as we are discontent with the current state, as long as we seek to improve it, we will have conflict.

The error is in thinking that conflict is the opposite of peace.  As C.T. Butler, founder of Food Not Bombs, says, “peace is not the absence of conflict, but rather, the ability to resolve conflict without violence.”  If discontent is the impetus for change, conflict is the path to achieving that change.  Without conflict, there is no progress.  The trick is in engaging in conflict productively to produce that change.   Any collection of more than one person – a family, an organization, a community – will have conflict, as it seeks to improve and maximize the happiness and well-being of all.  Welcoming the airing of differences and having ways of resolving those differences amicably makes for stronger and healthier families, organizations, and communities.

It has been said you can’t improve what you can’t measure.  It’s at least as true that you can’t improve what you’re not even aware of.  If my spouse doesn’t tell me that something I am doing is annoying or hurtful, I can’t change it. If a nurse doesn’t report a mislabeled medication or a near-miss wrong-site procedure, we can’t design the system better to prevent such events.  If a marginalized group doesn’t make the dominant group aware of the ways the system works against them, we can’t make the system more just and equitable.  Protest is the equivalent of “if you see something, say something.”  It’s the safety learning report for society.

My hope is that we will stop viewing protest as an effort to divide, but rather as an effort to unite us in the journey toward equity and justice.  One of the ways I think the current moment is different is the increased willingness to see such peaceful protest as a necessary constructive step toward equity.  We are starting to listen, really listen, to the concerns of many in our community.  We must then join together to take action.

I don’t know if John Lewis would know a CLABSI from a PIVIE.  But he certainly understood the idea of peaceful protest and loving engagement as a way to help bend that arc of the moral universe a little closer toward justice:

“We must never ever give up, or give in or throw in the towel. We must continue to press on! And be prepared to do what we can to help educate people, to motivate people, to inspire people to stay engaged, to stay involved and to not lose their sense of hope. We must continue to say we’re one people. We’re one family. We all live in the same house. Not just an American house but the world house. As Dr. King said over and over again, ‘We must learn to live together as brothers and sisters. If not, we will perish as fools.’”

 


Health Care After COVID

May 26, 2020

Just 3 months ago (!), there was a debate raging about the future of the US healthcare “system.”  Should we overturn Obamacare (the position of the Trump administration), improve Obamacare (the position of most of the Democratic presidential candidates), or replace Obamacare with a truly universal single payer plan (Medicare for All).  Very few were arguing for no change at all; despite increases in coverage and some slowing of the rate of growth in healthcare spending following the Affordable Care Act, the US continues to spend more for less results than other industrialized countries.

The global COVID-19 pandemic has led to a temporary pause in this debate.  All attention in healthcare is focused on controlling the spread of the virus, finding a vaccine and effective therapies, and repairing the massive financial damage to the industry.  But we will eventually have to come back to the discussion about what to do with health care in the US, and the pandemic has dramatically shifted the terms of that discussion.  In a few short weeks, a submicroscopic bit of protein-coated RNA has ripped the cover off the US healthcare system and dramatically revealed two of its underlying weaknesses.

The first is the extent to which US healthcare is a massive shell game that is completely supported by cost shifting.  Healthcare providers can accept below-cost reimbursement from government payers (Medicaid, and to a lesser extent Medicare) because they can shift those costs onto private payers.  This particular shift has been under pressure from employers and private insurers for some time; now, in the face of a massive increase in unemployment and an accompanying increase in people who will rely on Medicaid or be uninsured, this scheme will be tested as never before.  Moreover, healthcare providers can accept below-cost reimbursement for many vital services, such as preventive care and mental health care, because they can rely on way-above-cost reimbursement for procedural care.  But now that many of those procedures that may be elective or at least less time-sensitive have been delayed due to a severe shortage of supplies such as personal protective equipment (PPE), hospitals and physician practices are losing massive amounts of money.  And if there is a persistent change in demand for such lucrative procedures, this second cost-shifting wheel that keeps the bicycle of US healthcare going will also go flat.  We’ve never before had this kind of one-two punch before, taking out both means of cross-subsidization that keep the system upright.

The second structural weakness in US healthcare is the shameful lack of investment in public health.  This includes not only the traditional public health infrastructure for epidemiology, but everything from preventive care to well-integrated health records to funding on social determinants of health to a national stockpile of supplies and medications that is actually, well, stocked (that is part of the word, after all).

So when we get back to figuring out how to make the US health care system better and more sustainable, we should ask those proposing any of these – or any other – solutions, how their plan will address these fundamental flaws in our current state.


Lynching in the 21st Century

May 8, 2020

A couple of years ago my wife met someone here in Minneapolis, who mentioned that his father was lynched in Mississippi in the 1950s.  It was hard to believe that we could know someone who was personally touched by that.  After all, much of what we read about lynching, and the accompanying black and white photos, suggest this is something from a distant past.  It is true that lynchings of African Americans in the US peaked in the late 1890s.  But if you go to the Mississippi Civil Rights Museum in Jackson (which I can highly recommend), there are 5 tall columns with the names and dates of the 600 or so people lynched in that state alone; the most recent is in the mid-1960s.  And this only includes those that are known.  Our acquaintance’s father’s cause of death was officially listed as “suicide,” so he is not included among those memorialized at the museum.

So the heyday of lynching actually extended into my childhood, but still I considered it a thing of the past.  Until the other day, when I learned that the most recent lynching was on February 23, 2020.  Ahmaud Arbery, a 25-year old black man, a former high school football athlete in Gwynn County, Georgia, was gunned down by several people as he was jogging.  Jogging.

I realize lynching is a controversial word.  It is fraught with history and emotion.  Some of you will not want to read any more of this because you think I’m being sensationalist and overacting, or being political.  Others may be upset by a white man co-opting a word that is almost synonymous with race hatred against blacks.  My only defense is I don’t mean to offend; I do mean to provoke.

According to Wikipedia, the lynching is “a premeditated extrajudicial killing by a group. It is most often used to characterize informal public executions by a mob in order to punish an alleged transgressor, punish a convicted transgressor, or intimidate a group.”  In this case, two men claimed that Arbery resembled a suspect in a rash of recent burglaries, so it fits the definition.  The alleged crime need not actually have happened (it is unclear whether there were actually any burglaries in the neighborhood in this case).  Since this definition includes killing by a group, the murder of Trayvon Martin would not count as a lynching; he was shot by an individual.  And since lynching is “extrajudicial” killing, deaths at the hands of authorities would also not count.  Matthew Shepard was not accused of a crime, so it’s unclear whether his torture and killing would technically count as a lynching.  Yet it seems his killers intended to “intimidate a group,” and no matter what you call it, it’s a tragedy.  Moreover, while in the US blacks have been the primary victims of lynchings, lynching has historically also targeted Italians, Asians, Jews, and others.

The point is, lynching – targeted killing of people because they belong to some group – is not a relic of history, it is very much alive.  And of course, lynching is merely one type of hate crime.  Physical and verbal attacks on people and property, motivated by hate, have been increasing sharply in recent years.  Since 2016 there have been increased reports of crimes in the US against Latino/a, Muslims, Jews, and most recently Asians.  And this is not only an American phenomenon. Worldwide, one of the leading causes of death appears to be being different.

I don’t know all the reasons for this, and there are many hypotheses.  My aim is not to blame; it is to mourn.  I didn’t know Ahmaud Arbery, but many people did know him and love him.  Every one of these tragic lynching deaths leaves a hole in a family, in a community.  Taken together, they leave a bigger hole, a giant rip in the fabric of society.  I grieve for Ahmaud’s family, and Trayvon’s, and Jamar’s, and Matthew’s.  I grieve for all of us.  Lynching may have made it intact into the 21st century, but my sincere hope is that it ends here.


Equity in the Time of Coronavirus – Part 2

April 16, 2020

A tiny bit of RNA, enclosed in a protein coat.  The entire package is small enough that 8 billion of them would fit in a grain of sand.  The novel coronavirus doesn’t seem nearly large or sentient enough to be a vehicle for racism.  And yet….

While statistics are spotty, it appears that at least in the US, the COVID-19 pandemic is disproportionately affecting people of color, and especially African Americans.  In most places reporting data by race, the toll of this disease is far higher among blacks than others.  In Louisiana, for example, blacks make up 32% of the population but 70% of the COVID-19-related deaths.  Of course, the disease is not evenly distributed within states, but even at the county and city level, the disparities are stark.  In Milwaukee County, blacks are 26% of the population but account for 73% of deaths.  And it isn’t just deaths: blacks get the disease at a higher rate than others.  The disease rate per 1000 population is 3.5-4 times higher in black majority counties than white or Latino majority counties, and the death rate is 6-10 times higher.

Why is this?  Surely it’s not malign intent on the part of the tiny virus.  No, the virus is not racist.  But these disparities are simply the latest manifestation of the kind of structural racism that has affected the health and well-being of blacks for decades if not centuries.  Here are a few of the leading hypotheses for the disparities in COVID-19:

  1. Blacks are more likely to suffer from other conditions, especially obesity and hypertension, that put them at higher risk of severe disease or death if they develop COVID-19. While some have been tempted to blame the victim for these disparities, these are the result largely of socioeconomic and health care system factors that have systematically disadvantaged blacks.
  2. Blacks and those who are poor are less likely to have jobs that enable them to work from home. They are overrepresented in the kinds of service industries that require closer in-person contact that spreads diseases.  As a report from the Economic Policy Institute pointed out, only 9.2 percent of workers in the lowest quartile of the wage distribution can telework, compared with 61.5 percent of workers in the highest quartile.
  3. Blacks and the poor have a harder time complying with social distancing It’s great that child care is considered an essential service, but what if you cannot afford child care and you rely on a network of family members to care for your children while you go to work?  In many places, including Minnesota, blacks are more likely to have no or limited Internet access, further limiting the ability to work or conduct other necessary activities remotely.  And the idea of wearing a mask in public sounds wonderful – if you’re white.  Some black men have expressed a reluctance to do so for fear of racial profiling, and episodes of harassment show this fear is not unfounded.

And here is the human face of this inequity: I grew up in New York, my colleague grew up in Detroit.  These are both disease hot spots.  But my colleague, who is black, knows a heck of a lot more victims than I do.  The point is, these are not statistics.  They are people.

The COVID-19 pandemic has upended almost every aspect of our world.  It has brought out the best in many of us as individuals.  But it has also placed in stark relief some of the less pleasant truths about our society, and about our healthcare system.  I only hope that this virus, when it is done wreaking its havoc on us, by making plain the inequities in front of our eyes, can compel us to begin to correct them.


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