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.

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