Let’s Dance

March 29, 2017

Diversity is being invited to the party.  Inclusion is being asked to dance.

I heard this phrase at a recent half-day training in diversity, inclusion, and equity as part of my new employee orientation at Children’s Minnesota.  What a great metaphor for how we need to approach these issues!  By virtue of my status as a white, heterosexual, professional male, I rarely have to deal with exclusion on the basis of the typical “checkbox” categories.  But even the most privileged of us have all experienced occasions where we were somehow not included – where maybe we’ve been invited to the party but no one asked us to dance.  It reminded me of being a public high school graduate at a selective Ivy League university club.  The door wasn’t barred, but never having golfed or been a varsity athlete or summered on the Cape, I didn’t exactly fit in, and no one made much of an effort to make me comfortable.

I’m not sure any of those preppies worried about it, and honestly after about 10 minutes neither did I.  But the stakes were pretty low.  There were plenty other places to drink beer.  But when it comes to making decisions about healthcare for children and families from a plethora of backgrounds, or good leadership choices for a nearly billion-dollar organization, a narrow perspective can literally be deadly.  Diversity – inviting people with a full range of backgrounds, experiences, beliefs, and skills to the table – is necessary, but not sufficient.  Diversity is a start, but without true inclusiveness, it’s just window dressing.  Checking the boxes.

Which may be part of why diversity programs are at times viewed skeptically. Without a commitment to being not just diverse but inclusive, a team or organization can’t expect much to change.  This is a commitment to being not only proactive in seeking diversity of all kinds, but active in promoting inclusion of all in the decision-making process.

The fact that Children’s Minnesota chooses to devote fully one-third of its new employee orientation to this is a strong statement that we recognize how important inclusiveness is to our success, and to the health of the patients, families, and communities we serve.  It opened my eyes to the fact that as a leader, I have to invite a lot of different people to the party.  And then I need to ask them to dance.

Resegregating our Schools

March 7, 2017

Because of the historical racial patterns of church-going, it has been said that the most segregated time in America is Sunday morning.  Thanks to changes being pushed by, among others, Secretary of “Education” Betsy DeVos, that is likely to change to Monday morning, when school bells ring.

House Bill 610, in the words of its sponsor, “repeals the Elementary and Secondary Education Act of 1965.”  This 50 year old law, the backbone of American education policy through Democratic and Republican administrations, is being scrapped. The new law sharply limits the authority of the Department of Education, which is reduced to administering block grants to states.  More importantly, the law establishes a national voucher program allowing children to attend any public or private school, including home schooling, at taxpayer expense, and it requires states to allow complete school choice as a condition of receiving any public education funds. (As an aside, this seems to me to be exactly what the original Affordable Care Act tried to do to force states to accept the Medicaid expansion; it will be interesting to see if any progressive states choose to challenge this “coercion” under the Supreme Court ruling that invalidated that portion of the ACA. Turnabout is indeed fair play.). It will obliterate this nation’s long-standing commitment to public education.

As with health care, the forces behind this change are obsessed with free markets and choice as the answer to, well, everything.  They believe that competition is the only way to improve the quality of education, and that the public school monopoly is the root cause of our troubled education system.  The evidence does not support this.  I should note that finding unbiased research is challenging – for those who want to go straight to the sources, the nonpartisan National Center on School Choice has a comprehensive compendium of studies.  However, my admittedly brief review shows mixed evidence, with some studies showing choice is helpful, some showing it is neutral, and in some studies harmful. It seems fair to say that if 3 decades of research have failed to demonstrate a conclusive benefit of choice on education, it isn’t a slam dunk that choice is THE answer.  One issue is that choice can mean many things: choice among public schools, or charter schools, or vouchers to be used in non-public settings.  It’s therefore hard to draw a firm conclusion about “choice” overall.  But the evidence about vouchers specifically – the centerpiece of HB 610 – is less mixed.  It’s negative.  The largest, best designed studies have consistently shown that voucher students do worse than those who stay in traditional public schools.  The reason is unclear, but it would certainly seem to warrant caution before unleashing it on millions of American students.

If it were simply a matter of mixed evidence, this move to privatize education would be perhaps understandable as a reasonable gamble, a decision that could be refined with more and better research.  But at its heart, this privatization scheme is a radical undermining of core principles of American democracy.

Our commitment to public education goes back to the early days of the Republic.  Thomas Jefferson was a strong proponent of education as the foundation of a free society.  He was so committed to it that his founding of the University of Virginia was one of only 3 things he wanted to be remembered for in his epitaph (the Declaration of Independence and the Virginia Statute for Religious Freedom were the other two; he left out being president, much less the size of his electoral college victory).  Jefferson and others understood that a sound democracy depends on an educated and enlightened citizenry.  Education should not be available only to those of means, nor should it vary based on those means.  One important function of public schools in a democracy is as a place where diverse people from different walks of life could mingle, interact, exchange ideas, and learn a common cannon of democratic principles.  It is an important basis of a level playing field in a free society.  (Granted, the diversity of schools in Jefferson’s day was lacking, but the idea is still valid.) Jefferson believed there should be a constitutional right to education, and while there is no such right in our national constitution (as there is in the constitutions of 174 other nations), every one of the 50 states does include such a right.

Jefferson had nothing against religious instruction; indeed, he believed it to be an important supplement to public education.  But not a substitute for it.  Sectarian separation of education would undermine the development of the American people, which required schools to be inclusive.  And in fact, the various waves of private and parochial school growth, starting with the Irish Catholic schools in the mid-1800s, through the segregation academies in the South in the 1950s and 60s, have been driven in large part by a reaction to this inclusivity.  This has also been behind many other forms of “choice” including suburban white flight starting in the 1970s (my own family was part of this in New York) and the more recent push to restrict busing and promote “neighborhood schools.”  This is the ugly truth behind most school choice – it has frequently been used as a means of re-segregation.  No doubt most parents who choose to move to less diverse neighborhoods with “better schools” or elect to send their children to private schools are motivated primarily by the desire to make sure their kids are well educated.  But some simply don’t want their children going to school with “those” children, and even those among the majority of the well-intended need to be aware of the segregationist effects of their choices.

If challenged by my many friends who choose to send their children to private and parochial schools, I would try to convince them of the value, to both their own children and to society, of a shared public education experience for all, supplemented by the religious education of their choice.  In a democracy we can’t force this, only try to encourage it.  But we shouldn’t be encouraging the dismantling of public education.  And we shouldn’t be paying for private goods with public tax dollars.

The sponsors of HB 610 state it is about the repeal of the 1965 education act.  But they should really be saying it is about the undoing of Brown v. Board of Education.  I can’t wait for the bill that reinstates Plessy v. Ferguson.


March 1, 2017

We’re starting to see why those who supposedly hated Obamacare have been so reluctant to say what their replacement plan is.  It’s because it’s essentially Obamacare, minus the good things.  Their replacement is “Nobamacare.”  And it’s not likely to work.

First, let’s recall why health reform was such a big issue in the 2008 election.  15% of Americans were without health insurance at that point, the highest number since the creation of Medicare and Medicaid in the 1960s, and a figure that was increasing steadily over the prior 5 years. There are two basic approaches to trying to correct this.  One is a national health plan, where healthcare is either paid for (e.g., Canada) or provided by (e.g. Great Britain) the government.  The other is to work through the free market, using a combination of carrots and sticks to make private insurance more affordable, and incentivizing people to purchase it.  Over decades, and true to form, Democrats have tended to favor the former, while Republicans have promoted the latter.  Until, that is, Barack Obama was elected.  He essentially adopted the Republican idea of working through private insurance.  The Affordable Care Act – a.k.a. Obamacare – is almost exactly the same market-based plan as that instituted in Massachusetts by Gov. Mitt Romney (yes, the same Republican Mitt Romney who ran against Obama in 2012).  In fact, Democrats initially wanted to compromise on a hybrid where there would be a public option – that is, people would be able to choose among private plans or a public plan similar to Medicare – but that was dropped in a futile effort to get Republican legislators to support the Republican plan.

So, Obamacare was basically an effort to increase private insurance coverage (OK – there is one exception which I will get to in a minute). The reasons there were 48 million people without health insurance included that it was too expensive, that there were practices that prevented people from getting covered (e.g., companies refusing to give a policy to someone with a pre-existing condition), and that some people chose to take the risk of not having insurance. Trying to increase coverage through private insurance meant lowering costs, removing barriers, and incentivizing people who were choosing not to buy insurance.

The ACA plan to increase coverage addressed each of those.  To attack the issue of costs, Obamacare sought to create a better marketplace.  The theory was that if you could increase competition, costs would drop and most people without insurance would be able and willing to buy it.  Adam Smith wins again.  So the ACA created an insurance marketplace (sometimes called the “exchange”).  People who did not have insurance through their employer would be able to go on line, compare several insurance plans with information on what they covered, which providers were included, and how much they cost – sort of an Expedia for health care – and competition would drive down prices.  Removing barriers meant preventing insurance companies from excluding those with pre-existing conditions, or placing lifetime caps on coverage which would toss many people with expensive illnesses like prematurity or cancer off the policy part way through their treatment.  And finally, incentives included both carrots – premium and cost-sharing subsidies for lower income people, allowing young adults to stay on their parents’ plan, and requirements that preventive care be covered without cost-sharing – as well as the stick of the individual mandate, which required everyone to have insurance or pay a fine. (Here is where that private insurance exception comes in.  The architects of the plan realized that some people were too poor to buy insurance no matter how many carrots or sticks were offered.  Therefore, one element of the plan was to expand Medicaid to make sure that all those below the poverty line were covered.)

OK, with me so far?  Obamacare was a Republican plan, implemented by a Democratic president, to expand health insurance coverage through the miracle of the free market.

So what happened?  Well, as far as the primary goal of increasing the number of people with health insurance, it was a big but not complete success, with some 20 million additional people covered by 2016.  Also on the plus side, the tens of millions of people predicted by naysayers to lose their employer-based coverage – that never happened.  Of course, that still leaves a lot of uninsured – over 25 million.  Of those, half cite cost as the reason they remain uninsured.  And this is not surprising, since after an initial flattening, health insurance premium costs have started to increase more rapidly again (though at a slower rate than before the ACA).  Why?  There are several factors.  Many insurance companies, in an effort to gain market share quickly, underpriced themselves in the marketplaces.  As competitors dropped out, they jacked up their prices.  Also, fines for not buying insurance under the individual mandate were very low, so lots of healthy people continued to forego insurance, meaning companies were covering a sicker and more expensive population than they expected. Finally, despite its title, the Affordable Care Act did little to address the root causes of high health care costs including private insurance overhead.

So what do the Republicans plan to do?  Instead of expanding health insurance coverage through the miracle of the free market, it appears they plan to expand health insurance coverage through the miracle of the free market.


Yes, that’s right, the mainstay of Nobamacare is the insurance marketplace.  So what, you may ask, will be different?  That’s not entirely clear, but the main things seem to be changing the incentive system.  Rather than offering subsidies that vary based on income, Paul Ryan’s plan calls for tax credits and incentives to contribute to health savings accounts.  Both of these would be tilted toward those with higher incomes.  Moreover, the Medicaid expansion for the poorest would be reversed.  In other words, there would be fewer incentives for those most in need of incentive.  Given what we know about who is not covered – coverage increased least among the poor in states that did not accept the Medicaid expansion, and inversely proportional to income among those above the poverty line – that is simply not going to make things any better.  And like the original Obamacare, “Nobamacare” does virtually nothing to address healthcare costs.  If that were my plan, I’d be scared to release it too.

Now, I tend to agree that Obamacare has not lived up to its promise.  It has increased coverage, but less than hoped.  It has slowed healthcare spending, but less than hoped.  But the reason is not because it is insufficiently free market.  Rather, it demonstrates the limitations of the “free market” in healthcare.  Acknowledging the shortcomings in those ideas in the first place would be a start. Calling Obamacare something else because Republicans can’t abide the fact that a Democrat took credit for implementing their ideas isn’t the answer.  Maybe turnabout is fair play: today’s most prominent New York Republican, now that he realizes that healthcare turns out to be complicated, could steal the Democrats’ idea of “Medicare for all” and name it after the New York Republicans who also supported that idea in the 1970s.  He could really shake things up and introduce a single-payer Javitscare or Rockefellercare.  Now that would be interesting.  That would be progress.

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