Medicare for all?
STAFF & WIRE REPORTS
FILE - In this Friday, Jan. 18, 2019, file photo, Speaker of the House Nancy Pelosi, D-Calif., takes questions from reporters on Capitol Hill in Washington. Pelosi is laying out her strategy on health care and first up is improvements to “Obamacare” and legislation to lower prescription drug costs. (AP Photo/J. Scott Applewhite, File)
Pelosi works her health care strategy from the ground up
By RICARDO ALONSO-ZALDIVAR
WASHINGTON (AP) — House Speaker Nancy Pelosi is laying out her strategy on health care and first up is improvements to “Obamacare” and legislation to lower prescription drug costs. “Medicare for all” will get hearings.
Pelosi and President Donald Trump have been sounding similar themes about the need to address the high drug costs. But her plans to broaden financial help for health insurance through the Affordable Care Act are unlikely to find takers among Republicans.
Either way, Democrats believe voters gave them a mandate on health care in the midterm elections that returned the House to their control.
Pushing her agenda, Pelosi is working from the ground up through major House committees. Her relationships with powerful chairmen and subcommittee chairs stretch back years. She’s “playing chess on three boards at once,” said Jim McDermott, a former Democratic congressman from Washington state, who predicts Pelosi’s most difficult challenge will be “herding new members” impatient for sweeping changes.
Responding to written questions from The Associated Press, Pelosi called the ACA “a pillar of health and financial security,” comparing it to Medicare, Medicaid and Social Security. “Democrats have the opportunity not only to reverse the years of Republicans’ health care sabotage, but to update and improve the Affordable Care Act to further lower families’ premiums and out-of-pocket costs, and expand coverage.”
Legislation from Energy and Commerce Chairman Frank Pallone, D-N.J., Ways and Means Chairman Richard Neal, D-Mass., and Workforce and Education Chairman Bobby Scott, D-Va., would broaden the number of people who can get financial assistance with their premiums under the Obama health law, and undo the “family glitch” that prevents some from qualifying for subsidies. It would also restore the HealthCare.gov advertising budget slashed by Trump and block some of his administration’s health insurance alternatives.
Those issues are separate from legal questions raised by ongoing Republican litigation to overturn the health law. The Democratic-led House has voted to intervene in the court case to defend the law.
The 2010 health law belonged as much to Pelosi as to former President Barack Obama, said McDermott. “She’s taking ‘Obamacare’ and very carefully figuring out where you have to support it,” he said.
The House ACA package has little chance as a stand-alone bill. But parts of it could become bargaining chips when Congress considers major budget legislation.
On prescription drugs, Trump and the Democrats are occupying some of the same rhetorical territory, an unusual circumstance that could bring about unexpected results.
Both say Americans shouldn’t have to keep paying more for medications than consumers in other economically advanced countries where governments regulate prices.
The Trump administration has designed an experiment to apply international pricing to Medicare “Part B” drugs administered in doctors’ offices.
Pelosi wants to expand price relief to retail pharmacy drugs that seniors purchase through Medicare’s “Part D” prescription drug benefit, a much bigger move. A bill introduced by leading Democrats would authorize Medicare to negotiate directly with drug companies using international prices as a fallback.
“President Trump said he’d ‘negotiate like crazy’ to bring down Medicare prescription drug prices, and since the midterm election he’s spoken about working with Democrats,” Pelosi wrote to AP. “We have an opportunity to enact the tough legislative negotiating authority needed to actually lower prescription drug prices for consumers.”
One of the top Senate Republicans on health care says he’s not inclined to do that. Finance Committee Chairman Chuck Grassley of Iowa says having private insurers negotiate with drug companies has worked.
“Part D is the only federal program I’ve been involved with that has come in under budget,” said Grassley. “If it’s working, don’t mess with it.”
Nonetheless, former Health and Human Services Secretary Mike Leavitt, a Republican, said Medicare is “a good example of places where the administration might surprise.”
“Prescription drug pricing is in a category where both the president and the Democrats have made a commitment,” Leavitt added. “There will be a lot of division, but in the end there is a very good chance they will find a way that they can both claim victory.”
But the biggest health care idea among Democrats is “Medicare for all,” and on that, Pelosi is cautious. To those on the left “M4A” means a government-run health care system that would cover every American. That would require major tax increases and a big expansion of government.
Pelosi has tapped two committees, Budget and Rules, to handle “Medicare for all.” Health care legislation doesn’t usually originate in either of them.
Says Pelosi: “We’re going to have hearings.”
American health care has plenty of problems, and we can learn by observing other countries’ achievements. But unfortunately, one of the more popular modes of research is also one of the most uninformative (“counter-informative,” really). That mode is asking people in various countries, “How satisfied are you with your country’s health care system?” and pretending the responses are meaningful and comparable.
With some regularity, my friends and colleagues return from overseas to tell me, as one doctor did: “People I talked to over there seemed very happy with their system.” I asked whom he talked to and, unsurprisingly, they were well-to-do urbanites vacationing at the same pricey inns where he stayed. People in slums or on remote farms, I responded, might have been less enthusiastic.
But even with demographically representative samples, cross-country comparisons of subjective responses are hopelessly entwined with cultural idiosyncrasies. America was founded by discontented, cranky people who never accepted limits on their aspirations. Our tendency to whinge and smash ceilings is what made America the world’s engine of creativity. Quiescent folk who are content with their countries’ health care systems aren’t the likeliest candidates to redesign care or find the cure for cancer.
Years ago, I interviewed for a job in British Columbia. My wife and I wondered what Canadian health care would mean for us, so we did some digging. One specific and personally familiar datum stood out. Every eight or nine years, some radiologist sees suspicious spots on my wife’s latest mammogram and tells her to get a biopsy. After one sleepless night, she has the procedure. Thankfully, the results have always been fine, but if they weren’t, she’d be in surgery or other therapy within days. In British Columbia, we found, the average wait-time for the biopsy would be one month — not one night. After a bad result, the average wait-time for treatment would be 17 weeks. Yet Canadians, surveys always show, are happier with their system than we are with ours.
In November 1984, late at night, I found myself transporting a woman in labor to a hospital in Monrovia, Liberia — a desolate 50-kilometer ride away. The hospital was a dark, crowded, hellish-looking place. In contrast, my wife gave birth at a high-quality hospital adjacent to Columbia University. If you asked the Liberian mother, “How satisfied were you with your hospital?” she might well have answered, “Very satisfied.” If you asked my wife or me the same question, we, being cranky, pampered Americans, might have rattled off our nitpicky complaints. (They forgot to bring me a cot for after she delivered!!!) Comparing the Liberian mother’s answer with ours tells you about our life experiences and attitudes, but near-zero about the comparative quality of care.
To learn from other countries, downplay subjective, culturally slanted responses to overbroad, amorphous questions. Focus, instead, on smaller, concrete points.
The U.S. Food and Drug Administration’s monopoly on medical device approvals allows the agency to run developers through needless gauntlets; in the European Union, devices are approved by private, competitive, state-sanctioned entities (“notified bodies”). By all means, compare the costs, time lags, safety and efficacy of the two systems.
Observe unmanned aerial drones transporting blood and medicines in Rwanda, Tanzania and Vanuatu and ask whether such technologies might benefit Americans (say, in rural areas) and, if so, why we don’t use them.
Ask how India’s Narayana hospitals can perform cardiac bypasses for under $2,000 (versus $100,000 in America) and still get equal or better surgical results.
Ask why vaccination rates are lower in the United States than in loads of other countries, and ask whether it’s our health care system’s fault. (Spoiler: It’s more about well-educated, but credulous, Americans buying into junk science.) Look at Singapore’s health savings accounts and Switzerland’s competitive private health insurance markets. Ask why Kobe Bryant had to go to Germany for therapy on his broken knee.
While you’re at it, explore why fve-year cancer survival rates are lower in other countries than in America.
There’s a whole world full of good ideas out there. But improving American care lies in discovering and implementing hundreds of small improvements — not in asking gooey, sweeping, pop-psych questions while hunting for an off-the-rack system to transplant here.
On the agenda is how countries can respond to and shape changes in how goods are produced, distributed and consumed. It is based on the idea that the world is entering a fourth industrial revolution, where a new wave of technological progress will launch us into a new era of globalisation. But while the world’s leaders pin their hopes for economic growth on a technological leap, the rest of us are left to wonder what the implications may be.
The first industrial revolution saw the mechanisation of production, using water and steam power. This dramatically transformed how people lived and worked. The second industrial revolution used electric power to create mass production. The third saw the automation of production using electronics and information technology.
The fourth industrial revolution is characterised by a fusion of technologies that is blurring the lines between the physical and digital. It is based not just on digitisation but on the integration of new and emerging technologies such as robotics, artificial intelligence, big data and 3D printing. These will combine into the “factories of the future”, which are wholly automated. Supply chains will be transformed with predictions that production will become more local to consumers.
There is some evidence that progress towards this vision is happening. 3D printing is quickly advancing. Digitising manufacturing technology enables production systems to be integrated and intelligent. Many governments have developed policies designed to support the factory of the future, such as Germany’s Industrie 4.0 and the UK’s industrial strategy.
A surprising choice
The logic of the World Economic Forum’s choice to focus on Globalisation 4.0 is connected to debates in industry and among policy makers about the potential transformation of production and consumption. This begins with a shift in how goods are manufactured. The Schumpeterian “creative destruction” thesis is increasingly used to justify the fourth industrial revolution idea. Schumpeter argued that capitalism is driven not by incremental efforts to cut costs and boost profits in a competitive market (as Adam Smith suggested) but by the pursuit of game-changing technological transformations.
But focusing on this at Davos is surprising, given the plethora of highly troubling issues facing the global economy. These include renewed concerns about the environment, geopolitical tensions, the rise in nationalism and migration crises.
The focus on technology may have been chosen precisely because, at first glance, it is apolitical and uncontentious. Surely everyone can benefit from technological improvement? But the Davos agenda does not appear to critique the very notion of this new globalisation enough. It assumes our inevitable progression towards this vision and fails to question whether it is even a desirable future.
Mixed fortunes
Globalisation 4.0 is based on the assumption that globalisation is a perpetual, unstoppable force. Klaus Schwab, founder of the World Economic Forum, recently said that at the core of Globalisation 4.0 is the understanding that globalisation won’t disappear. He said it will deepen, based on the connectivity of national digital and virtual systems and the related flow of ideas and services. Yet the current nationalism around technology and the increase in trade barriers suggests not.
Nor does the theme indicate that much attention is being paid to the implications of the fourth industrial revolution. Technological shifts are disruptive. The WEF suggests it has the potential to raise global income levels and improve the quality of life for populations around the world. But this is contrary to the effects we’ve seen of globalisation so far.
Unfortunately, capitalism and globalisation have benefited some but not others and there is currently little evidence that Globalisation 4.0 could be any different. As the WEF acknowledges, greater inequalities could result, particularly through the disruption of labour markets.
Increased automation will radically alter the structure of work in the global economy. What will the displaced workers do? Deindustrialisation in advanced economies has created some profound difficulties including unemployment and poverty. These have still not been adequately addressed. So it looks like we could enter the fourth industrial revolution without solving some serious problems remaining from the third.
Proponents of Globalisation 4.0 may argue that a greater number of highly skilled, highly paid jobs will be created instead. This could be partially true, but those industries charged with producing the fourth industrial revolution are repeatedly asking governments to help increase education and training in STEM subjects, especially engineering.
The Davos agenda states that “global growth must be inclusive and sutainable”. This fails to recognise the rise and importance of “degrowth” movements. Instead of a focus on GDP growth, these emphasise well-being, conviviality and open, localised economies.
Davos is stuck in 20th century understandings of the global economy, viewing “progress” as being achieved through economic growth. This year’s meeting also runs the risk of being irrelevant thanks to the notable absences of leaders like Donald Trump, Theresa May and Emmanuel Macron. Perhaps the economic thinking upon which the WEF is based needs a revolution of its own in order to meet the challenges of future technological change.
Many saw the white teenagers, who had traveled to Washington for an anti-abortion rally, appearing to mock the Native Americans. Others interpreted Phillips’ drumming and singing as a hostile act. Phillips has since explained that he was trying to intervene between the boys and a group of black street preachers who were shouting racist insults at both the Native Americans and the white kids.
Sandmann said he definitely felt threatened by the black men, who were calling them things like “incest kids” and “bigots.”
“In hindsight, I wish we’d just found another spot to wait for our buses, but at the time, being positive seemed better than letting them slander us with all of these things.”
Sandmann said he isn’t racist and for that matter, neither are his classmates.
“We’re a Catholic school and it’s not tolerated. They don’t tolerate racism, and none of my classmates are racist people.”
Both Sandmann and Phillips have since said they were trying to keep the peace in a volatile situation. Phillips has since offered to visit the school and lead a dialogue about cultural understanding. Sandmann said he’d like to speak with him as well.
“I was not disrespectful to Mr. Phillips. I respect him. I’d like to talk to him. In hindsight, I wish we could’ve walked away and avoided the whole thing, but I can’t say that I’m sorry for listening to him and standing there.”
The boys’ school reopened Wednesday under extra security measures after officials closed the campus Tuesday as a precaution.
A letter to parents sent by school officials said that if they don’t feel comfortable sending their sons back to class, they will “understand this viewpoint during this difficult time period.”
Of all the terms used to describe students who don’t perform well in traditional educational settings, few are used as frequently– or as casually – as the term “at-risk.”
The term is regularly used in federal and state education policy discussions, as well as popular news articles and specialty trade journals. It is often applied to large groups of students with little regard for the stigmatizing effect that it can have on students.
As education researcher Gloria Ladson-Billings once said of the term “at-risk,” “We cannot saddle these babies at kindergarten with this label and expect them to proudly wear it for the next 13 years, and think, ‘Well, gee, I don’t know why they aren’t doing good.’”
My most recent encounter with the term “at-risk” came when I was tapped to review and critique a draft report for the Maryland Commission on Innovation and Excellence in Education, also known as the “Kirwan Commission.”
The Kirwan Commission, chaired by William E. Kirwan, a longtime higher education leader, was created in 2016 to make recommendations for improving education in Maryland. The initial draft of the Kirwan Commission report included a working group report called, “More Resources for At-risk Students.”
Fortunately, in this instance, commission members were aware of some common objections to using “at-risk” to categorize students and publicly discussed the limitations of using the term. Some of those objections included risk of social stigma to students and lack of a uniform definition of “at-risk.”
However, when it came to finding a better way to describe students who show lower levels of academic success because of nonacademic factors, such as poverty, trauma and lack of English proficiency, commission members were not sure what term to use.
As an outside consultant for the commission, I was asked to come up with an acceptable alternative word or phrase. As I argue in my forthcoming book, “No BS (Bad Stats): Black People Need People Who Believe in Black People Enough Not to Believe Every Bad Thing They Hear about Black People,” three things are essential to good decision making in education: good data, thoughtful analysis and compassionate understanding. What I have to say about the term “at-risk” will be based on those three things.
Practical uses exist
First, let’s acknowledge that, paired with good data, “at-risk” is practically useful and generally accepted in professional and academic settings. Used effectively, identifying risk and protective factors can help mitigate harm to students.
For example, dating back to the 1960s, research about how exposure to lead placed children at risk for cognitive impairments helped educators create safer learning environments for students by removing lead from paint, toys and drinking water.
Today, in educational research and practice, educators routinely use “at-risk” to classify students who do not perform well in traditional educational settings. However, the factors that determine “at-risk” are often either unknown or beyond the control of the student, caregiver or educational provider.
As a scholar of counseling psychology – and as one who specializes in counseling persons of black African ancestry – I believe that to designate a child “at-risk” for factors such as growing up in a single-parent household, having a history of abuse or neglect, or how much money their families make or their race or ethnicity – adds more chaos and confusion to the situation. Instead, compassion and care are what are needed.
Using “at-risk” as an adjective for students is problematic. It makes “at-risk” a category like honors student, student athlete or college-bound student. “Risk” should describe a condition or situation, not a person. Therefore, “More Resources for At-risk Students” might more appropriately be “More Resources to Reduce Risk Factors for Students.”
Be specific
Assessments of risk should be based on good data and thoughtful analysis – not a catch-all phrase to describe a cluster of ill-defined conditions or characteristics. If the phrase “at-risk” must be used, it should be in a sentence such as: “‘This’ places students at risk for ‘that.’” If the “this” and “that” are not clearly defined, the “at-risk” characterization is useless at best, and harmful at worst. But when these variables are clearly defined, it better enables educators and others to come up with the solutions needed to reduce specific risk factors and improve outcomes.
Skip the alternatives
Common alternatives to “at-risk” include “historically underserved,” “disenfranchised” and “placed at-risk.” These indicators acknowledge that outside forces have either not served the individual student or population well, or have assigned the at-risk label to unwitting subjects.
These phrases move the conversation in the right direction. However, using these phrases still comes up short because they obscure the problem. For example, research suggests that child abuse, poverty and racism can place students at risk. However, different strategies can lessen each risk. When the risk factors are more clearly identified, it puts educators and others in a better position to strategically confront the issues that impede student learning. It also better enables educators and others to view the individual student separately and apart from the particular risk.
Some have suggested replacing the term “at-risk” with “at-promise.” While well-intended, the problem I see with that is it could easily be seen as a condescending euphemism for the term it was meant to replace.
The best alternative for ‘at-risk’
In my book, I describe an in-service training for staff members of a public high school, in which I asked the participants to describe the neighborhoods of their students. I heard phrases like “crime-ridden,” “broken homes” and “drug-infested.” I then asked if anyone grew up in neighborhoods that had similar characteristics. After several raised their hands, I asked, “How did you grow up in such a neighborhood and still become successful?” This question spurred a more meaningful discussion about the neighborhoods where students are from. It was a discussion that considered community assets – such as hope and resilience – against a more thoughtful examination of community challenges.
Every student has a combination of risk and protective factors among their friends, in their homes, schools and neighborhoods. These factors can help or hurt their academic potential. Students who live in poverty, or have been assigned to special education, or have a history of trauma, or who are English learners, may or may not be “at risk” depending on their respective protective factors. But when students are labeled “at-risk,” it serves to treat them as a problem because of their risk factors. Instead, students’ unique experiences and perspectives should be normalized, not marginalized. This reduces a problem known as “stereotype threat,” a phenomenon in which students perform worse academically when they are worried about living up to a negative stereotype about their group.
For all these reasons and more, I believe the best alternative to describe “at-risk students” is simply “students.” For what it’s worth, the Kirwan Commission agrees. The commission recently revised its call for “More Resources for At-risk Students” to “More Resources to Ensure All Students are Successful.”