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Prezi on the Basics of the Human Rights Based Approach

June 25, 2012

Health insurance companies profiting under the PPACA

January 13, 2012

A new report out from Bloomberg Government, Despite Predictions, Health Insurers Prosper Under Overhaul, confirms many of the predictions I have made in on this blog about the positive impact the Patient Assistance and Affordable Care Act (ACA) would have on the insurance industry. I have made these predictions not just because they were obvious if you looked at the facts, but because bogus health care reform groups like Health Care for America Now, Health Access, and Families USA, and other groups involved with health care reform like SEIU, continue to push for ACA implementation by claiming it’s a blow to health insurance companies. News articles discussing this report and these groups also continue to overstate insurance industry opposition to the ACA.

According to the Bloomberg report, the largest for-profit insurance companies saw their average operating profit margins expand to 8.24 percent in the six quarters since the overhaul became law, compared with 6.88 percent for the 18 months before it was passed. Although not focused on the (nominally) non-profit insurers like Blue Cross, the report notes that “the recent performance of the largest nonprofit … plans closely parallels that of the largest publicly traded insurers”. Their future strategic plans assume the full implementation of the ACA.

In an earlier post about the health care reform law, I showed that the number of people under 65 covered by private health insurance in the US has declined significantly since 1978. Before the ACA this continuing loss of customers represented a large threat to future revenue growth for insurance companies. When health care reform became a political possibility, all the medical care related industries went to Washington to get the biggest slice of the reform pie for themselves. In the end, the biggest winner was the pharmaceutical companies, but the insurance industry was well taken care of. In exchange for some limited regulations in the individual insurance market, regulations similar to how insurance works in the group market (companies providing insurance as an employment benefit), the insurance industry was handed a massive increase in customers. These new customers come from 3 pools (individual purchasers via the individual mandate, Medicare, and Medicaid), but in all cases the expansion is the result of public funds (taxes collected by the government) being used to subsidize or fully pay for the purchase of private insurance. In essence, instead of the government and individuals paying directly for actual health services, a greater percentage of the increasing total amount spent on health services in the US will now pass through health insurance companies before being used to purchase goods and services.

Because the individual mandate + federal subsidy portion of the ACA won’t be implemented until 2014, most of the increase in profits comes from expanding contracts under the Medicare and Medicaid programs.

…quarterly revenue from Medicare, the $525 billion federal health program for the elderly and disabled, increased by one third, to $16.39 billion, for the four insurers that reported figures, the study shows. Medicaid revenue more than doubled to $4.11 billion.

The companies run managed-care plans for Medicare that may see revenue rise by $10 billion by 2015 as more baby boomers retire, industry analysts have said. The insurers also administer benefits for Medicaid, which is being expanded under the health-care law starting in 2014 to cover more uninsured people. States have turned to private plans to manage Medicaid caseloads and help control health spending.

Health plans will be able to bid on an estimated $40 billion in state Medicaid contracts from now to 2014, the study found.

There is an important point in the report about the convergence going on in the US health care between the program for those over 65, Medicare, which used to be a public single payer system, and health care for everyone else. Medicare has been increasingly privatized so that the government often doesn’t directly pay providers, but passes the money through the Medicare Advantage program of private insurers. Medicaid, the program for the poor,  has undergone a similar privatization process. After 2014, people who purchase insurance by themselves will be assisted by state government exchanges to purchase a private plan with help from federal subsidies. The ACA essentially establishes “Medicare Advantage for All” starting in 2014.

On the face of it, this expansion (of revenues from Medicare) has little to do with the overhaul law. Medicare serves those 65 and older while the overhaul focuses overwhelmingly on health care for the under-65 population. But the health-care systems for the two groups are essentially the same. The overhaul law seeks, among other things, to recast that system and encourage care for both groups that is better managed, of higher quality and cheaper. As will be seen, executives with the large insurers recognize the link and characterize their companies’ Medicare Advantage expansions as part of a broad set of moves intended to prepare the firms to operate in a markedly different health-care sector after 2014.

Of course, that “higher quality  and cheaper” claim is corporate-speak bullshit both because health care in this country hasn’t produced good health and there is no evidence that this new system will reduce the outrageous costs of health care in the US.

The Bloomberg report also notes that a portion of the increase in profits comes from people using less health care services during the recession. These are people with insurance who put off getting care because they are tightening their belts and decide they can’t afford the co-pays or deductibles they have to pay under their particular plan. This trend will reverse when and if the economy improves and if co-pays and deductibles don’t increase.

The report, and news articles about it, along with Health Care for America Now, et al, vastly overstate insurance industry opposition to the health care reform law. Yes, they put an obscene amount of money into lobbying, but most of that was to get the best deal, not to oppose the reform outright. To support its claim that insurance companies opposed the ACA the article and the report point to a contribution of  “$86.2 million (given) to the U.S. Chamber of Commerce to oppose the law after Obama administration officials criticized the plans for enriching themselves by raising customer premiums”.

This ignores the whole context and sequence of events leading up to this donation. Early on in the process the main goal of America’s Health Insurance Plans (AHIP), the industry lobby,was to prevent the enactment of the Public Option. Once that was out of the picture, and they had gotten the individual mandate and government subsidies they wanted, much of their PR campaign was aimed toward convincing the public that health care reform was a good thing. In 2008, before the contribution to the Chamber, AHIP formed an astroturf health care reform  campaign called The Campaign for an American Solution. Unlike Pharma publicly getting in bed with the reform effort right from the start, the insurance companies took a more “inside/outside” strategy and probably ended up being the public bad guy because of it. In order to package the corporate welfare in the bill as “health care reform” the Democrats’ PR strategy made big bad insurance companies the enemy and emphasized the increased regulations mentioned above to appeal to the public. As this PR strategy ramped up in 2009 and it became clear that private market regulations were going to have to be in the bill to get any public support, that’s when the Chamber donation was made.

Finally, this report once again confirms that citizen’s voices were completely ignored in the health care reform process. The real debate wasn’t between people with different opinions about how to achieve better health care, but between corporate interests trying to get the most out of the so-called reform. This is what activists mean when we say that corporations have taken over the government. So-called progressives can ignore this fact, and continue to argue that we vote and lobby for change, but at this point it is clear that they must be either just plain stupid or they have chosen which side they are on.

I may need to add a new blog post category to use as the PPACA is implemented called “I told you so.”

Street Medics are Community Health Workers

January 8, 2012

Comprehensive primary health care (CPHC) is the health system strategy that, outside of the US at least, is considered to be the basis of a health system. The World Health Organization defined primary health care at the Alma Ata Conference in 1978 as:

Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self reliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.

CPHC is only given lip service in many countries, but in many others it is implemented as well as the country can given the limitations on its budget, personnel, etc. Although hardly mentioned in the Alma Ata Declaration, community health workers (CHW) are the principal work force in most CPHC systems. CHWs are often women with average literacy for their community who serve as both basic health care providers and health educators, as well as community organizers. The latter is key because in CPHC the health worker not only treats common illnesses but also helps community members understand the root causes of their health problems in order to work together to prevent disease. Since root causes are the relationships of power that mean one neighborhood or village is clean and gets the services it needs, while another doesn’t and is built next to a toxic factory, improving health is very political.

For many readers in the US, most of this post so far will be completely new information. The US health non-system is the pariah of health systems and has almost no instances of true primary health care. Even most community health centers take a curative/individual behavior modification approach to community health problems and use community health workers in a limited fashion, if at all. One of the only “legit” organizations I’m aware of that understands and implements the primary health care strategy using community health workers is Latino Health Access in Los Angeles.

An interesting historical fact about community health workers is that the concept and practice of community health workers was significantly developed in the context of revolutionary struggles and their aftermath. Chinese barefoot doctors, the early village health workers of Tanzania and Zimbabwe, and Gonoshasthaya Kendra in Bangladesh are principle examples. With few trained health personnel available to take care of people wounded in battle, or just the regular health needs of fighters and their social base, doctors and nurses were forced to train those around them to carry out most of the healing work. In these situations, the community is already mobilized to tackle the inequalities of power that underlie their health problems.

A similar process in the US has produced the other major type of community health worker in the US – the street medic. The Medical Committee for Human Rights is often cited as the first street medic organization:

Medical Committee for Human Rights (MCHR) was formed in June of 1964 to support Freedom Summer. More than 100 northern doctors, nurses, psychologists, and other health professionals, — Black and white — came to Mississippi. Though MCHR volunteers were not licensed to practice professionally in Mississippi, they could offer emergency first-aid anywhere and anytime to civil rights workers, community activists, and summer volunteers. Working without pay, they cared for wounded protesters and victims of police and Klan violence, assisted the ill, visited jailed demonstrators, and provided a medical presence in Black communities, some of which had never seen a doctor. They established and staffed health information and pre-natal programs in many Black communities. Appalled at the separate and unequal care provided to Blacks by Mississippi’s segregated system, they soon involved themselves in political struggles to open up and improve Mississippi’s health care system for all.

After Freedom Summer, MCHR continued working in Mississippi and expanded its operations into Alabama and Louisiana. Like battlefield medics, with their canvas medicine-bags marked with a red cross slung over their shoulder, they were easy to spot in Selma, on the March to Montgomery, and in the hellish violence of Bogalusa. They marched side by side with the protesters, set up their emergency clinics in Black churches, taught community health and pre-natal classes, and fought the white health system to end its segregationist policies. And just like the organizers in SNCC, SCLC, and CORE, the courageous sisters and brothers of the MCHR were targets for arrest and Klan violence.

Today  street medics are less likely to be doctors and nurses and more likely to be EMTs or lay health workers. They are often organized in collectives that provide training and support for members and act autonomously from the health care system. They continue to provide health support during demonstrations and other actions, and to participants in protest movements. There is a street medic wiki that presents much of the knowledge and practice standards generated by street medics and a brief history of street medics. However, street medics are unrecognized in mainstream medical and public health discourse. I have never heard them referred to in discussions of CHWs. Although I have known about street medics for a while, I have become much more familiar with street medic practice through my involvement in the medic group of Occupy Oakland.  Two OO medics were arrested just last night while attending to a person injured by police during a demonstration. Luckily they were released without charges.

Unfortunately, street medics here do not seem to be aware of the comprehensive primary health care model. As the Occupy Movement continues I hope there will be opportunities to discuss it and what CPHC might look like in the US context.

From now on when I am discussing CHWs with my international health colleagues, I will no longer just lament the absence of CHWs in the US Health system, but also proudly point to the health workers of our communities in resistance.

Don’t Google Santorum

January 5, 2012

This post is completely out of character for this blog, but here it is anyway.

Rick Santorum’s rise to top contender status among the Republican presidential candidates has added much needed hilarity to the otherwise humorless primary season, as naive Republicans Google the candidate and discover one of the best public practical jokes ever.

The Santorum resurgence has produced headlines like this one in Mother Jones: Rick Santorum’s Anal Sex Problem. The article explains:

Santorum’s problem got its start back in 2003, when the then-senator from Pennsylvania compared homosexuality to bestiality and pedophilia, saying the “definition of marriage” has never included “man on child, man on dog, or whatever the case may be.” The ensuing controversy prompted syndicated sex columnist Dan Savage, who’s gay, to start a contest, soliciting reader suggestions for slang terms to “memorialize the scandal.” The winner came up with the “frothy mixture”* idea, Savage launched a website, and a meme was born. Even though mainstream news outlets would never link to it, Savage’s site rose in the Google rankings, thanks in part to bloggers who posted Santorum-related news on the site or linked to it from their blogs. Eventually it eclipsed Santorum’s own campaign site in search results; some observers even suggested it may have contributed to Santorum’s crushing 18-point defeat in his 2006 campaign against Bob Casey.

Santorum’s statement about Google’s refusal to remove the site is also hilarious:

“I suspect if something was up there like that about Joe Biden, they’d get rid of it,” Santorum said. “If you’re a responsible business, you don’t let things like that happen in your business that have an impact on the country.”

I don’t think this joke will keep any leotard for voting for him, but I can’t stop laughing.

Just to make sure Dan Savage’s site, spreadingsantorum.com stays in the top three hits on Google, I’m going to link to it. And you should too after you read it.

* Santorum – a neologism for “the frothy mixture of lube and fecal matter that is sometimes the byproduct of anal sex.”

(I was laughing hysterically for the past hour going through this stuff, until I just found out Occupy Oakland has been raided again. 40-50 cops swooped in to arrest 7-12 people who were standing around talking in Oscar Grant / Frank Ogawa Plaza. Really not funny since there was another man killed in Oakland today while cops were wasting time and money attacking people peacefully exercising their first amendment rights.)

On Political Movements

December 29, 2011

One big reason why the Occupy movement has been so unexplainable by the media, and incomprehensible to many regular folks, is  that there hasn’t been a real mass political movement in the United States since about 1973(1). We hear about x or y movement all the time, but usually these “movements” are rapidly growing organizations or coalitions.

Having been associated with an international movement for several years now, People’ Health Movement, I have had to explain many times to people in the US how a movement is different from the kind of political activism we are used to. These distinctions also apply to Occupy and if people understand them then they will stop making those stupid suggestions that often begin with “The Occupy Movement should focus on..”

  • A movement is not an organization. A movement transcends organizations.
  • A movement happens when masses of people reach the same conclusions about the situation in the world around them at about the same time and something sparks them to come out, recognize each other, and begin to take action.
  • Participants in a movement share a core vision, values and analysis. The better those are articulated, shared, and understood by participants in the movement, the more powerful and effective the movement will be.
  • Movements are not about issues. Movements are about ideas in response to threats to human well-being.
  • Movements are made by people acting in their daily lives according to the shared vision, values, and analysis, not by professional, paid activists.

Example: The Civil Rights Movement, broadly speaking, was not about passing the Voting Rights Act or even, ultimately, about black people, although they led the way and formed the core (a pun!). It involved oppressed people of all kinds – women, chicanos, youth, etc., asserting their human dignity and claiming their rights. It was not an organization. It used a diversity of tactics, many people expressing a philosophy of non-violence, while others were willing to use violence in self defense or offensively. People took up different tactics and used them locally as they thought they applied. Lunch counter sit-ins were loosely organized with over 70,00o direct participants and spontaneous solidarity boycotts of Woolworth’s and other chain stores by northern white supporters (2). People who thought it was a good idea did it. When that tactic achieved success, people moved on to other things.

Within the civil rights movement there were people who worked against Jim Crow, on voting rights, on media representation of people of color and women, on making health care services available to everyone and responsive to the needs of the community, on housing, on community organizing, and on and on. The Civil Rights Movement didn’t have a focus. It had thousands of demands on every level. Sometimes over the years the broad movement would coalesce in support of a particular demand or campaign, but that didn’t stop the local work or other ongoing actions.

So what is the shared vision and analysis of the Occupy movement? It hasn’t been completely processed and articulated yet, but here is my interpretation.

Every system that we rely upon for our well-being in the US – education, health, justice, public safety, etc – is dysfunctional. As the economy becomes more dysfunctional and unable to provide a livelihood for people, more people see and experience the problems in the system. On top of that, there are a number of looming potentially catastrophic environmental crises that we haven’t been able to address. On top of that, our government at all levels has been become so corrupted by the same corporate interests that created many of the aforementioned problems, that we can’t go through the government to fix them. Therefore, we have no choice but stop the old system and turn to each other to begin building a new system that meets our needs in a way that enables human survival through the environmental chaos to come.

Right now I think there is a lack of shared understanding about the 4th item, the corporate takeover of government. Everyone agrees that that is the case, but some people, think it is possible to use the government to end this corruption. These are folks like George Lakoff who urges the movement to “occupy elections,” or others who propose we “occupy congress” or focus on ending corporate personhood. But by the time we get those things done we’ll be crispy or soggy critters. This realization that government can’t be reformed by using the system’s tools in time to save ourselves is why people are in the street, why the camps were set up to model the vision of the world we are building. Occupy Oakland, at least, has withdrawn its consent from the government. So have most other occupiers, even if they aren’t fully conscious of this yet.

1. An argument could be made that the Central America solidarity “movement” of the ’80s was a real movement, but it never included a significant portion of the US populace either as activists or supportive followers, and mainly consisted of organizations that received direction from their allied organizations in Central America. I would describe it as a wing of the liberation movements in Central America, but not a US movement in itself. I say this as an active participant in that movement who ended up actually working in Central  America.
2. Clayborne Carson, David J. Garrow, Gerald Gill, Vincent Harding, and Darlene Clark Hine, eds., The Eyes on the Prize Civil Rights Reader (New York: Penguin Books, 1997)

Elementary politics

December 21, 2011

Occupying over the last few months has gotten me thinking about how I learned what I know about political struggle. Some things I feel like I always knew or I learned as a kid. For university-level training however, I had to get out of the USA. A friend “interviewed” me by email recently for an article he is writing for a Venezuelan journal and his questions prompted this memory.

My 3rd grade class was the site of my first political action. It was 1971 and there were many semi-mocking news stories about the women’s liberation movement on TV.  The news stories didn’t fool me though. I knew that women and black people and anti-war protestors were right. I had heard people in my own family say racist things. The war was incomprehensible to me, but the Vietnamese were really poor and so the US fighting them didn’t seem fair. In my own school the teachers treated the boys differently from the girls – tolerating boisterous and aggressive behavior from boys but not girls, and talking about boys becoming doctors and girls becoming nurses. The boys themselves often treated us derisively, using femininity as an insult, and limiting our play because we were girls. I started pointing this out to my girlfriends and they seemed to share my anger.

One day we hit upon the idea that we should form our own women’s lib group, as we called it. We decided that whenever we saw anything discriminatory, we would say something. After that, if a teacher suggested that one thing was for boys and something else for girls, several hands would shoot up and we would point out that we were the women’s lib group and girls could do anything boys could do.  The idea spread throughout the 3rd grade classrooms. Girls were standing up to boys and teachers, and the teachers, all young women, started to get annoyed. After a week or so, the teachers called a big meeting of all the classrooms with a women’s lib group. Our teacher said, “This women’s lib thing has got to stop. You are disrupting the classrooms.”

I felt excited. If they were telling us to stop, we had to be having an effect! I met with my comrades at recess, looking forward to defying the teachers’ order and the escalation of the struggle, but the other girls were already resigned to the end of our organization. When I explained that we didn’t have to stop, we weren’t doing anything wrong, the other girls looked at me like I was crazy. For them it had only been a game. Of the whole situation, what I remember most intensely is this moment when my joy turned to shame under the screwed up faces of my friends.  After that, my life changed. I had a hard time making and keeping friends and was socially excluded until high school. Around my peers I kept my political opinions mostly to myself.

Fortunately, I was able to get out of my hometown, experience different places, and gradually find people whose political ideas engaged and challenged me. I began to think about health as a political issue when I worked at a feminist women’s health center. I learned about international struggles and the role of the US government in the repression of people around the world and joined groups working to change US foreign policy in Central America. After the signing of the peace accords in El Salvador in 1992, I went there as a lay health worker to support the social base of the FMLN and the demobilizing compas. That is where I learned most of what I know now about war, power, and political struggle.

Shameless plug: That story will be told in a chapter in Comrades in Health: US Health Internationalists Abroad and at Home, coming out sometime early next year from Rutgers University Press.

Press Release from Occupy Oakland Medics on False Health and Safety Concerns

November 1, 2011

FOR IMMEDIATE RELEASE: November 1, 2011

Oakland City Used False Health Concerns Against Protest, Medics Say

Occupy Oakland medical professionals and health workers condemn use of unfounded claims about health and safety as an excuse to violently dislodge protesters.

Our group of street medics, nurses, physician assistants and doctors have staffed a first aid station 24 hours a day on most days at in Oscar Grant/Frank Ogawa Plaza, the site of the Occupy Oakland (OO) encampment. We attest that health and safety problems in the camp were not as severe as stated by the city of Oakland, and did not justify the violence used and city funds spent to dislodge the protest movement.

In statements regarding the eviction of the protest camp, City officials cited “threats to public health and safety,”  “increasing frequency of violence, assaults,” and “denial of access to emergency personnel.” These concerns were overblown or untrue, as we describe below.

Emergency access. The OO medic team dealt with injuries in the camp where possible, and called emergency medical service (EMS) on several occasions. We never witnessed campers blocking the EMS. In these cases:

  • Once a mildly sick person refused to go the hospital and the ambulance was cancelled
  • Twice EMS was called and transported the sick or injured person from the plaza.
  • Twice EMS was called but did not arrive and other means were found to transport or treat the person.
  • Once EMS didn’t arrive in the camp when called to pick up a man who had been knocked unconscious. After several minutes he came to and walked away from the encampment where the ambulance found him several blocks away. That man was treated and released by Highland Hospital. It is unclear why the ambulance did not arrive. No one from the camp blocked its entrance.

We also believe the plaza was at times declared unsafe by Oakland Police Department and/or Oakland Fire Department, preventing EMS from coming to the camp despite our calls for needed emergency assistance. We urge the media to request dispatch records from American Medical Response for all medical calls in or around the plaza from October 11 through October 24, which would show whether this was the case.

Violence and assaults. Chief of Police Howard Jordan has cited two incidents that we have been unable to confirm and believe to be false. He stated that a woman fell out of a tree and that campers blocked EMS personnel from entering the plaza to transport her. As far as all of us know, this never happened. There was a man who fell out of a temporary structure in the plaza; he was picked up by EMS and transported with a possible broken ankle.

Police Chief Jordan also alleged that a sexual assault took place. We can find no one with knowledge of this occurring, and no police report has been shown by Chief Jordan or cited in the media. That does not mean that it did not occur, but unsubstantiated allegations of sexual assault in Occupy encampments have been made in many cities. The camp has made it clear in repeated meetings that sexual harassment and non-consensual touching are improper and will not be tolerated.

OO participants have worked to make the camp as safe and healthy as possible, but the camp exists in a city with many problems: people without housing; people affected by time in prison; people in need of services and support for mental and physical health problems; and rats. While it is true that in the first few days of OO, there were a few altercations in the camp that resulted in violence, we do not believe the camp has been more dangerous or unhealthy than other places in the city where people informally congregate and cook food.  In addition, as the organization and community structures of OO took shape after the first week, camp conditions have continued to improve.

Threats to public health and safety. Overall, conditions in the camp are much better than those experienced by the people who slept in the plaza or on the streets before the occupation. In the camp there are tents, a supportive community tolerant of people often excluded from society, and access to healthy food and basic health care.

Besides calling EMS where necessary, we had begun to bring in outside health services to support the needs of the encampment beyond first aid, such as HIV testing, and Alameda County Health Care for the Homeless. However, the City of Oakland refused to permit Alameda County Health Care for the Homeless to park its clinic van in the downtown area until the eve of the eviction.

Summary: The alleged health and safety problems of the camp did not justify the millions of dollars and the overwhelming police force from17 jurisdictions used to evict the campers and suppress the peaceful demonstration of October 25th. Our medic teams assisted protesters injured by tear gas and projectiles shot by police. Images of injuries observed by street medics are available here, here, here.

It is also worth noting that when a police projectile felled veteran Scott Olsen, police on the scene did nothing to help him. It was volunteer OO medics (with other protesters) who carried him from the scene, provided first aid, and took him to Highland Hospital. Eviction of the encampment was certainly not worth the extremely serious neurological and potentially fatal injury of this young veteran.

PRESS CONTACTS

Seth M. Holmes, MD, PhD; Assistant Professor of Public Health, UC Berkeley (for identification only); sethmholmes@berkeley.edu

Laura Turiano, MS, PA-C; Physician Assistant; phm@turiano.org