What Winning Could Look Like: Two Great Tastes That Taste Great Together

Feeling a bit bleak about our side’s chances? The Nation’s got two stories that together paint a picture of what winning might look like.

Jane McAlevey has an interesting piece on NYC’s Make the Road, a 12,000 person immigrant workers organization that

is a unique amalgam of worker center, legal clinic, citizenship school, mutual aid society, policy shop, protest factory and church. Its four offices in Brooklyn, Queens, Staten Island and Long Island are an egalitarian oasis for members, who gather there for conversation and classes. According to Javier Valdés, one of three co–executive directors, “We have created a physical space where people feel dignified and at home—because outside the four walls of our offices, the world can feel really crappy. When people walk through our doors, we want everyone to feel respected and comfortable. In our experience, organizing from anger alone is not enough; part of why people stay involved and active at Make the Road is because we have built a community based on love alongside our highly agitational campaigns.”

Make the Road isn’t just fusing culture with organizing; it is fusing workplace and community issues that are of equal concern to its members. This multi-issue approach stands in contrast to that of traditional worker centers, unions and community-based organizations… as it weaves together issues like stop-and-frisk racial profiling, affordable housing, environmental and civil rights, and workplace justice. Perhaps most surprising, given its base among Catholic Latino immigrants, is its campaign for tolerance and against the discrimination directed at lesbian, gay, bisexual, transgendered and queer people.

Over time it’s also begun running union organizing campaigns, starting with carwash workers, and impressively
in less than one year, workers at six different carwashes have voted yes to forming a union in National Labor Relations Board elections.
What unites all of their efforts is
a commitment to building a high-participation organization. What it calls its “high touch” model, with dozens of weekly meetings, creates points of entry and opportunities for leadership development for Make the Road’s thousands of members. At committee meetings, where the dinner is often cooked by members at the office and served by teams carrying army-size pots of beans and rice, members discuss recent actions and plan for new ones. In addition, the group makes many of its services—from legal help with bad landlords or bad bosses, to ESL classes, citizenship classes and more—conditional on members’ participating in at least two activities per month, creating a sustained participation level where activism constitutes a kind of dues.
Meanwhile, in Oregon third term governor John Kitzhaber has been pushing forward an ambitious coordinated campaign to improve both the health and education of poor and middle class families even during a time of austerity — part of what Kitzhaber jokingly refers to as his Unified Theory of Everything.
The pathway to the American Dream,” he argues, in an e-mail he sends me shortly after we meet, “revolves around a job for which the individual is paid a living wage—enough to meet their basic needs—and an opportunity for upward income mobility. To create that pathway our public institutions (government) and our economy must be aligned around the same goal: to ensure an equal opportunity for all Americans to achieve their shared aspirations.” For Kitzhaber, poverty and ill health are too often the result of inadequate education; fixing these problems is what he calls the “left side” of his unified theory. On the right side, he talks about the need to invest in clean technologies and renewables, to open routes to prosperity that neither denude the environment nor leave millions unemployed.
In education, his goal is to create a “0-20″ system that starts with
prenatal counseling, and involves better nutrition programs, parenting classes and medical clinics in school settings. He wants to prepare all kids for kindergarten, have them reading at grade level by third grade, and get middle school kids ready for high school. He wants high school kids taking community college and university classes. Kitzhaber’s integrated model continues all the way through graduate school.
Unlike most education reform, this one isn’t designed as mostly stick.
Schools that meet those standards are labeled “model” schools, and are essentially given the funds and space to pursue their specialized projects. Those with poor success rates are categorized as “focus” or “priority” schools; the state assigns them “coaches”—retired administrators and other education specialists—who work with the principal and teachers to improve administration and classroom methods.
Part of what makes this approach unique is a series of integrated centers that are embedded in the public schools. Take the
Gladstone Center for Children and Families (GCCF), half an hour’s drive south of Portland, [where] the early-childhood pieces of the puzzle, on which all these other hopes rest, are already falling into place. There, in a converted 1960s Thriftway supermarket bought by the school district at a hefty discount back in 2005, more than 180 kids are concentrated in a stand-alone, full-day kindergarten, whose capacious windows look out onto fields and evergreen groves. Eighty local preschoolers also show up for Head Start sessions. And local families regularly attend afternoon and evening story times. Young adults attend parenting classes, and Clackamas Community College runs GED classes for Spanish speakers.

The classrooms, ranged along a central hallway, are spacious, with kids seated around six-sided wooden tables, their art lining the walls. Outside is a playground centered around a large red, yellow and blue climbing structure. Off to its side is a garden, which kindergartners plant in the spring, leaving the harvest to next fall’s incoming class. At the far end of the campus, a medical clinic offers pediatric services, adult medical checkups, shots and mental health referrals. There are two dental clinics in the area, to which campus doctors refer patients. And in a nearby building, WIC vouchers are provided as a part of the hub of onsite services offered through the GCCF.

How does he hope to pay for all of this? In part from a new approach to healthcare that is
moving more than 90 percent of the state’s Medicaid patients—about 600,000 people—into Coordinated Care Organizations, where primary care, wellness clinics, mental health centers, opticians and other services are either concentrated in one place or coordinated among the practitioners, allowing greater convenience for patients….

One goal is that clinicians will catch problems before they escalate into expensive crises. CCOs are paid not by the number of tests they do or the number of hospital admissions they preside over, but by the number of patients they have and their health outcomes….

The governor talks of how a coordinated-care model would identify congestive heart failure patients at risk of catastrophic illness during heat waves and install air-conditioning units in their homes rather than wait, as the current system does, for them to get so sick they have to be admitted to a hospital ICU, at enormous cost. “The best hospital bed,” explains [health director]Goldberg, “should be an empty bed. That should be the goal of our healthcare system. Ultimately, our goal should be to keep people out of the hospital—fewer hospital beds and a healthier population.”

Imagine if progressives took both of these approaches to building new institutions — a “high-touch,” multi-pronged democratic approach to building low-wage worker power and a blended health care/ education approach — and did them together. Then imagine we were fighting these fights in several states at the same time. It wouldn’t solve all our problems, but it’d let us help a lot of folks build a slightly better life and start building the movement power we’d need to take it to the next level. All we’d have to do is stop focusing mostly on DC and start focusing on states and cities.

Exhibits 1-10 Why Public Healthcare Controls Costs Better Than Private Healthcare

This week you’ll be hearing a lot from the Republican Convention about how public healthcare can’t compete with private healthcare. Via Paul Krugman, the Incidental Economist’s “overwhelming evidence that public programs exert greater control over health care spending than private insurers.”

• If the Medicare age is raised to 67, it will save the government $5.7 billion in 2014 butcost others twice that amount.
• Government payments to private, comprehensive Medicare plans (Medicare Advantage) have been well above the cost of the program’s public option (traditional Medicare) for years.
• The rate of growth in per person spending by private health care plans has exceeded that of Medicare for 40 years.
• Private, per person growth in physician spending has exceeded that of Medicare in the last decade, if not longer.
• The CBO has scored a public option as cheaper relative to a private-only exchange system.
• The CBO and other organizations have scored single payer proposals as cost savings (system wide) relative to the status quo.
• The VA (and Medicaid) purchase drugs far more cheaply than Medicare’s private drug plans.
• Our wealthy, peer nations have a greater proportion of their health spending funded publicly and spend dramatically less on health care than we do, even as a proportion of their economies.…
• There are arguments in favor of private insurance, but they are not based on lower spending or spending growth.
• FEHBP program spending has grown at about the same rate as Medicare’s. However, FEHBP has gotten more generous.

Are Ron/Rand Paul Socialists When It Comes to Doctors?

Recently I’ve been getting into more arguments with libertarians. One of the things that’s been striking about these arguments is that is for all their talk about how Obama is socializing healthcare, libertarians rarely bring up one of the biggest, most coercive government interventions into the market: requiring that doctors be licensed and banning other medical practitioners from performing their work. So the last time I tangled with a libertarian who was a big fan of Ron Paul I asked them, what does the good doctor say about the government violence-backed monopoly that physicians have? He didn’t know, so I decided to take a look online.

On Dr. Ron Paul’s 2012 campaign website, his message on health care is simple:

FREEDOM NOT FORCE
The answer to our nation’s health care crisis lies in freedom – not force.

As President, Ron Paul will fight to put you back in control of your health care decisions, save you money on medical expenses, and institute reforms that will once again make America’s health care system the standard for other nations to follow.

OK, I thought. That sure sounds like a call to end the government monopoly of requiring everyone who’s a doctor to be licensed by the state – and of prohibiting nurses, PA’s, etc. from doing the work that doctors do.

Ron Paul M.D. has a very long laundry list of ways to put you back in control and save you money. For example:

* Allow purchase of health insurance across state lines…

* Ensure that those harmed during medical treatment receive fair compensation while reducing the burden of costly malpractice litigation on the health care system by providing a tax credit for “negative outcomes” insurance purchased before medical treatment.…

* Stop the Food and Drug Administration (FDA) and the Federal Trade Commission (FTC) from interfering with Americans’ knowledge of and access to dietary supplements and alternative treatments.

* Prevent federal bureaucrats from tracking every citizen’s medical history from cradle to grave by prohibiting the use of taxpayer funds for a national database of personal health information.

But getting rid of doctors’ government-imposed, violence-backed monopoly? Not a word.

How about his son, Dr. Rand Paul? Continue reading

The Sorry State of Economists, the Healthcare Edition

At this weeks’s annual gathering of professional economists, there was a panel on “the political economy of the US debt and deficits.” Aside from Alan Blinder, the panelists – all prominent economists – nattered on about how deficits were destroying the country, we need to cut Social Security and Medicare, etc. At the end of the panel presentations, Mark Weisbrot jumped in.

I called attention to Blinder’s presentation of the long-term budget problem as almost completely a problem of the rising price of healthcare. I pointed out that you could take any country with a life expectancy greater than ours – including the other high-income countries – and put their per capita healthcare costs into our budget, and the long-term budget deficit would turn into a surplus.

My question was simple: are Americans so inherently different from other nationalities that we can’t have similar healthcare costs? And if not, then why are we talking about long-term budget problems – instead of how to fix our healthcare system?

Damn good question. Their replies were what you would expect:

None of the panelists offered a serious answer to this question. Auerbach, the moderator, said that other countries have rising healthcare costs, too. And some of the others said or implied that healthcare costs were rising at an unsustainable pace worldwide.

But this is nonsense. The United States pays about twice as much per person for healthcare as other high-income countries – and still leaves 50 million people uninsured. This is a result of a dysfunctional healthcare system that has had healthcare prices rising much faster than those of other high-income countries for decades.

As Mark explains, what they were really saying is that we have to stomp grandma instead of reining in insurance companies and big Pharma.

What the budget hawks are basically telling us is that we must assume that insurance and pharmaceutical companies will have a veto over the provisions of healthcare reform for decades to come. And that, therefore, we must find other ways to make up for these excessive costs, including cutting social security and other government spending, and pushing us into higher rates of poverty and inequality than we already have.

Yay for economists!

Michael Pollan: Stopping Subsidies for Less Healthy Food Isn't Enough

One of the reasons why most folks in the US eat lots of dairy, meat, and junk food instead of organic, locally grown fruits and vegetables is because it’s a lot cheaper – the government subsidizes the cost of meat, dairy, and junk food. What if we flipped those subsidies around? Michael Pollan says it might not make as much of a difference as you’d think.

Though crop subsidies certainly helped to make corn (and its boon companion, soy) the mainstay of our food system, eliminating those subsidies might not by itself be enough to topple king corn. Decades of crop breeding, advances in farm machinery and the building of a rural infrastructure all devoted to these crops means a Midwestern farmer can produce a bumper crop of corn with just a couple months of work while at the same time holding down another job. Growing anything else would mean a lot more time and work in the fields, and at this point that farmer probably depends on the other source of income.

As for subsidizing vegetables, that, too, is trickier than it seems. Subsidies tend to result in surpluses, which in the case of grain is fine: you can store surplus corn or soy in a silo for years. Try doing that with broccoli. In the case of “specialty crops” — the U.S.D.A.’s term for crops you can actually eat — we would be better off subsidizing demand rather than supply: giving vouchers to the poor to buy fresh produce, say, or incentives to retailers to lower prices in the produce section.

So then what do we do if we want to make organic, locally grown fruits & vegetables affordable?

This is the $64,000 question. There are certainly steps the government can take to make healthful food somewhat less expensive: underwrite farmers’ transition to organic and other kinds of sustainable agriculture; support the renaissance in local meat production by making it easier to build and run small slaughterhouses; use crop subsidies to reward farmers for diversifying their fields and growing real food rather than “commodity crops” like corn and soy; enforce federal antitrust laws to break up the big meatpackers and seed companies.

But these measures will never make high-quality food as cheap as industrial food, some of which will only get more expensive if we take the steps needed to civilize feedlots, clean up water and protect farmworkers from exploitation. Faux populists in the food industry battle such measures on the grounds they want to keep food prices low for the poor. But the institution of slavery kept crop prices low, too — at a cost we ultimately decided was too great for a democratic society to pay. (Come to think of it, slavery still exists in parts of the food system, according to reports out of Florida.) Cheap food has become a pillar of our low-wage economy, one reason Americans have managed to stay afloat as their wages have declined since the 1970s. In the end, if we want healthful and conscientiously produced food for everyone, we’re simply going to have to pay people enough so that they can afford to buy it.

I don’t know enough about the economics of food to know if he’s right. But even if he is, I think we could do better than “we’re simply going to have to pay people enough.” I bet a smart Agro economist could figure out a way to subsidize vegetables that didn’t result in massive surpluses. And there’s an awful lot we could do on the demand side on a large scale if we wanted to.

For example, when I used to work in downtown DC, due to government subsidies my employer automatically added $50 a month to my Metro card, which basically made going to & from work by mass transit free. What if we are to create something similar for organic, locally grown fruits & vegetables? We already have Health Savings Accounts that subsidize you by not taxing money you put into the account. Why not Food Health Savings Accounts where the government would put in a certain amount every month into your account? If it’s set up like a debit card, the way my HSA is, it shouldn’t be rocket science to make it work well for consumers, grocery stores, and farmers (assuming we also tackled the “food desert” problem in poor neighborhoods).

But Michael Pollan is right about one thing: figuring out how to Stack the Odds in favor of healthier diets will definitely take some work.

UK Conservatives: American-Style Health Care? Fuggedaboutit!

You’ve probably already seen this one, but just in case: from the LA Times via Krugman:

Ask a Briton to describe “American-style” healthcare, and you’ll hear a catalog of horrors that include grossly expensive and unnecessary medical procedures and a privatized system that favors the rich. For a people accustomed to free healthcare for all, regardless of income, the fact that millions of their cousins across the Atlantic have no insurance and can’t afford decent treatment is a farce as well as a tragedy.

But critics here warn that a similarly bleak future may await Britain if a government plan to put more power in the hands of doctors and introduce more competition into the NHS succeeds — privatization by stealth, they say.

So frightening is the Yankee example that any British politician who values his job has to explicitly disavow it as a possible outcome. Twice.

“We will not be selling off the NHS, we will not be moving towards an insurance scheme, we will not introduce an American-style private system,” Prime Minister David Cameron emphatically told a group of healthcare workers in a nationally televised address last week.

In case they didn’t hear it the first time, Cameron repeated the dreaded “A”-word in a list of five guarantees he offered the British people at the end of his speech.

More juicy quotes from the article:

[Conservative PM Cameron:] “If you’re worried that we’re going to sell off the NHS or create some American-style private system, we will not do that,” he said. “In this country we have the most wonderful, precious institution and also precious idea that whenever you’re ill … you can walk into a hospital or a surgery and get treated for free, no questions asked, no cash asked. It is the idea at the heart of the NHS, and it will stay. I will never put that at risk.”…

Governments of all stripes have taken office pledging to reform the system, to streamline it and make it more efficient, but none has fully succeeded, knowing that they tinker with the NHS at their peril. The current Conservative Party-led coalition, which has embarked on the most radical public spending cuts in a generation, has promised not to take a penny from the health service.

To each other, Britons love to complain about the NHS, retailing gruesome tales of substandard care, of long waiting lists for simple operations like hip replacements, of snotty surgeons and naughty nurses. But when Americans began citing the NHS as the epitome of socialized medicine gone wrong, people here bristled.

O Canada, the Healthcare Addition

Aaron Carroll has a nice, graph-happy post that debunks all of the myths about how rotten Canadian healthcare is. The most interesting debunking: American physicians aren’t all that happy with the US healthcare system.

Given the rhetoric of how much physicians hate reform, you would think doctors were very happy before reform passed. You’d be wrong. With the exception of Austria and Germany, fewer doctors were satisfied with practicing medicine [in the US] than any other surveyed country.

His most entertaining takedown:

When people want to demonize single payer systems, they always wind up going after rationing, and more often than you’d think with hip replacements…

It’s not true. They don’t deny hip replacements to the elderly. But there’s more.

Do you know who gets most of the hip replacements in the United States? The elderly.

Do you know who pays for care for the elderly in the United States? Medicare.

Do you know what Medicare is? A single-payer system.

Definitely worth checking out.

Drug Companies: Perfecting the Information Virus

The Guardian’s Elliott Ross has been mucking around in Big Pharma’s never-ending quest to make sure that research is slanted their way. It isn’t pretty.

When doctors are deciding which drug to prescribe a patient, the idea behind evidence-based medicine is that they inform their thinking by consulting scientific literature. To a great extent, this means relying on medical journals.

The trouble is that pharmaceutical companies, who stand to win or lose large amounts of money depending on the content of journal articles, have taken a firm grip on what gets written about their drugs. That grip was strong way back in 2004, when The Lancet’s chief editor Richard Horton lamented that “journals have devolved into information laundering operations for the pharmaceutical industry.” It may be even tighter now.

Drug companies exert this hold on knowledge through publication planning agencies, an obscure subsection of the pharmaceutical industry that has ballooned in size in recent years, and is now a key lever in the commercial machinery that gets drugs sold.

The planning companies are paid to implement high-impact publication strategies for specific drugs. They target the most influential academics to act as authors, draft the articles, and ensure that these include clearly-defined branding messages and appear in the most prestigious journals.

Big Pharma has been using the strategy for a while, and they’re getting increasingly brazen. Take the case of Merck, one of the biggest pharmaceutical companies in the world:

In a flow-chart drawn up by Eric Crown, publications manager at Merck (the company that sold the controversial painkiller Vioxx), the determination of authorship appears as the fourth stage of the article preparation procedure. That is, only after company employees have presented clinical study data, discussed the findings, finalised “tactical plans” and identified where the article should be published.

Perhaps surprisingly to the casual observer, under guidelines tightened up in recent years by the International Committee of Journal Editors (ICMJE), Crown’s approach, typical among pharmaceutical companies, does not constitute ghostwriting….

“We’ve never done ghostwriting, per se, as I’d define it”, says John Romankiewicz, president of Scientific Therapeutics Information, the New Jersey firm that helped Merck promote Vioxx with a series of positive articles in medical journals. “We may have written a paper, but the people we work with have to have some input and approve it.”

So the next time some college kid gets caught plagiarizing, maybe instead of kicking them out of college they ought to get him an internship in Big Pharma.

Computerizing Medical Records: Still No Shangri-La

Last year, I wrote about how everybody’s favorite idea for painlessly cutting healthcare costs – computerizing medical records – wasn’t really going anywhere. As part of the stimulus package, Obama tried to give those efforts a boost. How’d it go? Not so well, according to Computerworld:

Only 12% of U.S. hospitals had adopted electronic health records (EHR) as of last year, a modest increase over an adoption rate of 9% in 2008, according to researchers at the Harvard School of Public Health.

And of the 12% that have gone electronic, plenty are still struggling:

* A study by University College London found that many EHR projects fail, and “the larger the project, the more likely it is to fail.” Researchers say the systems can improve auditing and billing but may make primary clinical care less efficient.

* Experts from the Institute of Medicine who visited healthcare facilities last year found that “care providers had to flip among many screens and often among many systems to access data; in some cases, care providers found it easier to manage patient information printed or written on paper.”

One big reason why healthcare IT is still going so slowly: the joys of a market economy.

Often, the cost savings from the use of technology don’t go to the owner of the technology but to another player in the healthcare system, like the insurers.…A CIO at a for-profit company would have a hard time getting approval for an IT investment that saves money for the industry but not for the company.

“The incentives [in healthcare] are not aligned at all. In fact, there are perverse incentives there,” Stettheimer points out. “That’s very simplified, but it’s a problem we need to overcome.”