Wade Rathke: Chief Organizer Blog » Health Care

Community Paramedics; Good Idea, No Reimbursement

dine — Mon, 19 Sep 2011 16:36:54 +0000

New Orleans A fascinating story ran in the New York Times by Kirk Johnson about “community paramedics” being used in Colorado along with earlier experiments among homeless populations in San Diego, San Francisco, and Washington, D.C. There was nothing about the program that involved rocket science, but in cutting back on emergency 911 calls costing an average of more than $1000 for each call, these programs focused on prevention; getting out there, spreading the word, and creating a system of care before the crisis. How smart is that? Very!

Unfortunately, despite the rave reviews one could feel the double edged knife of the coming health care regime sending contradictory messages about care for at risk populations. On one hand these programs are being driven by an emerging Medicare rule that will bar reimbursement for any hospital readmission within 30 days of a discharge if it is established to have occurred from “a preventable repeat of the previous diagnosis.” On the other hand existing rules only allow reimbursement if a paramedic actually gives someone a ride to the emergency facility. The bottom line is that preventive care extends life, most importantly, and saves money, which is also very important, but all of the bean counters know that having the paramedics out there in the community is unpaid in the sense of unreimbursed.

In such a situation how many cities and counties are really going to take this very important and much needed step in preventive care? Damned few, I’ll wager, unless this cash flow is right sized.

Impacting Healthcare: Organizing Medical “Hotspots”

jstuart — Thu, 27 Jan 2011 14:28:41 +0000

Toronto Dr. Atul Gawande writing in the current issue of The New Yorker (1/24/11) interjects himself once again into the national (global?) health care debate by pointing out that hard data often reveals, as it did in Camden, New Jersey, that as much as 30% of health care costs are generated by as few as 1% of the patients. Drawing from the Comstat work in policing, where computer aided analyzed systemic data collection and pointed to crime hot spots, arguably allowing police departments to focus more energy and personnel to deal with such problems, some of the same applications Gawande reports are shifting attention to patients with significant results in Camden, Atlantic City, and other innovative hospitals and health plans.

This would seem to be an “ah ha!” moment, it seems so obvious. In union organizing and administration it has long been an understood fact in the tension between organizing model and service model unions that the same rough distribution of resources, if not more, are true in membership maintenance: 1% of the members require 30 to 50% of the contract administration and grievance handling resources. In community organizing among lower income families I was introduced to the insights about “multi-problem” families virtually from the day I hit my first doors with welfare rights in Springfield, Massachusetts. I would run into other organizers in Boston who had gone to social work schools and they would joke about it all the time in a general way before computers allowed any of us to understand what such families said about gridlocks in resource and personnel distribution. Inevitably changing such patterns caused huge conflict, because inexperienced organizers would get drawn into virtually personal service relationships with particular members or leaders, which might have seemed a good idea to them when they were trying to win trust “on the cheap,” but always caused conflict when more real organizing programs more equitably distributed staffing to goals and membership production, rather than individual leader or member service. My memory of “firing” a volunteer when I began in Arkansas, upon realizing he had become little more than the chauffeur, lender, and problem solver for one old leader, made it possible to work with everyone, but was something the “leader” never forgave me for!

The community organizing opportunity around health issues here is also obvious. Gawande tells several stories where the data led health care folks to sets of buildings where the 1% usually lived right down to the point where it was possible to identify the top couple of buildings that generated costs that could run to $60,000 per resident annually. Stepping back there are few community organizers without computers who couldn’t identify the likely medical hot spots just from shoe leather already exhausted over the years. Even union organizers who have done a lot of house visits know the areas where on every drive of lower waged workers you always have 5 to 10 visits, because of section 8 congregations, low rents, no deposit policies, and so forth in some complexes. A couple of senior high rises quickly come to mind in different cities. And, if we didn’t already know, it wouldn’t take but a couple of hours standing in front of any public hospital and talking to ambulance drivers or doctor shuttle drivers for them to tell you where they do the bulk of their business.

So why would we care? We don’t necessarily gain immediately from cost reductions in the way the hospitals or health plans might, but that’s only half of the equation. Forcing hospitals and health plans to adopt targeted programs delivers better health care and organizing the residents of the health care hot spots to demand such a program would create tangible results in terms of increased medical and related social services delivered on the spot. In one case Gawande wrote of a building where a hospital located an on-the-spot clinic for example. People might not be willing to organize to live longer and better, but we could definitely organize them to demand – and win – more and better health care services.

And, that’s not all. It turns out, if Gawande, is right about where health care may be going, our very organizing could move the needle on which hospitals survive and which die, based on their attentiveness to our demands in this area. He writes about the experience of Denmark’s health care system which has already retooled along cost and capacity terms, leading to a downsizing of institutions which might have as few as 25% surviving when the shakeout is finished for “industrial health care.” It is clear that this is the basic incentive for the hospital administrator in Atlantic City. He wants to end up as one of the survivors.

For the campaign targets that “get it,” our winning could mean their survival, and targets that move to partners will mean that effective organizing allows us to leverage more community benefits.

It would be nice if we could win simply with the argument of saving lives, but the stories of doctor pushback in the article are also instructive. There are a lot of folks who are benefiting now because they get paid well to manage a broken system. Organizing in this way around health care with a localized focus, we could not only change the system, benefit our community, create more equity, but also save lives. What a win!

This is a campaign calling out to all organizers

Gold Hidden in Dodd-Frank

jstuart — Thu, 16 Dec 2010 14:20:07 +0000

New Orleans Wow! A seasonal surprise!! It turns out that there were a couple of pieces of gold hidden in the hills and valleys of the Dodd-Frank Financial Reform Act that I had overlooked and that have international impact. Retailers are required to report annually on the origin of minerals used in products from war-torn central Africa, thereby looking to strike a blow against “conflict” resources!

According to the Wall Street Journal our buddies Wal-Mart and Target had waged a huge war of their own to try and convince the Securities and Exchange Commission (SEC) to exempt them. As we all remember Wal-Mart was somehow successful in its battle first for and then against healthcare reform to win an exemption from the provisions of that new act based on its slim pickings health plan currently in place.

The retailers association head whined that the SEC just didn’t understand the “supply chain,” which only means that they want the rule to be caveat emptor – the buyer beware rather than having to take any responsibility for how much blood might be on their hands and later wiped off not by them as the purchaser but by the consumer way down the line. For a change the SEC held strong.

In another good play the SEC is requiring big oil to disclose how much they pay foreign governments for resource rights, hoping to bring some transparency to the global casino of bribery and corruption in the name of natural resources for developed countries at the rack and ruin of developing nations. This is also very, very good news.

What’s up these days that we find out what’s going on diplomatic work seems mainly about business and we learn about it from Wikileaks and we can’t curb Wall Street or the banks, but their reform produces international victories? We must be living in an era of the head fake and the sleight of hand, but for a change score one for us, rather than another for them!

Breastfeeding, Grandfathering, and the World to Come in New Health Care Act

jstuart — Wed, 21 Jul 2010 15:07:01 +0000

Portland Talking shop with a couple of unions about the future and prospects for new organizing was interesting, but it was truly educational to listen to three of the labor lawyers (Gregory Hartman, Henry Kaplan, and Thomas Doyle) pulled together by the Association of Western Pulp and Paper Workers to update us about some of the impacts of coming health care act and what it will mean for workers and unions. Not surprisingly in a 2000 page bill that ended up being a compromise coat of many colors, there are a lot of patches still coming into focus, so I’m betting this is first blush gives evidence of a lot more to come.

Cadillac Plans: For all of the uproar from unions and big corporations no one is thinking or worrying about this at all. Since it doesn’t hit until 2018, this is another lifetime in politics and has no meaning now.
Breastfeeding: Oregon had stood out among other states by mandating that women who were breastfeeding would have regular, mandated paid breaks on the job for the purpose of pumping and storing. Thanks to an Oregon Senator, these provisions and guarantees of additional 15-minute breaks are part of national policy and protection for women in the new Affordable Care Act (ACA). I’m hoping we snuck some other “wins” into this thing!
Grandfathering: A huge bargaining issue for unions with collective agreements that had decent health coverage in the contract falls on provisions that allow grandfathering these plans during the life of the agreements if there are no substantial changes. Given the current uncertainty about the future plans, rating boards and panels, unions are beating back employer demanded concessions in many negotiations on the old argument of “the devil you know is better than the devil you don’t.”
Retiree Reinsurance: Most folks around the room thing that retiree insurance as part of union contracts is a dinosaur walking its last steps. It seems that a sweetener for the death match is a current provision requiring employers (those who are on top of their jobs) to apply now to a direct subsidy to reinsure self-insured retiree plans (like in auto etc) for a actual cost for retiree medical of 80% of the cost between $15 and $90K, reducing claims exposure. The dream stays alive a little longer for the last of these retirees.

It was clear a lot of this was tactical in the transition rather than long term strategic. The lawyers and reps were convinced that once the new ratings are done and the various plans on offer are shaped up that the initial impact will be better and cheaper plans when grandfathering fades away as a real concern and the rush of new workers being covered and the competition for the plan. That sounds exciting at bargaining tables everywhere. There will be a lot of 2014 re-openers as most of the ACA provisions come on line.

One point made over and over that might actually have some real weight, is that workers are going to see this maze with skepticism (as they should!), and are going to be looking for good unions and good representation to make sure that their interests and not just the cheapest price and the thinnest coverage prevail when all this comes on line. Worth doing a lot of homework now and making sure that workers understand the enormous stakes and the union advantage here.

Mary’s Vote for Health Care Reform

jstuart — Mon, 22 Mar 2010 13:16:33 +0000

Washington On the eve of the dramatic and historic health care vote, I got a letter from a friend, Mary Rowles, who is also a labor official in British Columbia. She had been sick all week with pneumonia and equally ill reading with consternation the mis-characterizations of what reform might mean south of the Canadian border. Perhaps everything that can be say, has been said, about the urgent need for reform, but Mary’s clear and simple story of what life might come to mean for ordinary people is worth remembering to root us all more in reality than fearful rhetoric.

It is so distressing watching the hysterical reaction of those opposed to a national health care program. I thought I would share my own experience if you ever need to pull out of your pocket an anecdote about what it is really like if you get sick in Canada.

I called my doctor on a Monday morning, after being sick for a week with a flu that didn’t seem to be getting any better. I got to see her first thing Wednesday morning. No charge. She was concerned and sent me for a chest x-ray at the clinic in the next building. After 20 minutes, I had my x-ray in hand. No charge. I also had to stop at the lab for blood work. I waited 30 minutes before I was seen. No charge. I returned with the “evidence” to the doctor who declared I actually had pneumonia and wrote out a prescription. No charge for this second consultation.

I’m supposed to see her in a couple of days to make sure the drugs are working. There will be no charge for this visit.

So how much does an individual pay for health care here in BC? We may be the only province still using premiums to finance the system , instead of a payroll tax on all employers. The rates?. The Medical Services Plan charges 57$/month for a single person; $102/month for a couple and $114 /month for a family of three or more.

There are no disqualifications for pre-existing conditions.

A large number of workers do not pay the MSP premiums-they are employer-paid workplace benefits. And at least low income workers are subsidized. If household income is less than 22,000 annually your premiums are 100% subsidized. Even at $33,000 annually you get a 20% discount.

The drugs were not free-they would have been if I was in hospital, but I’m not that sick. Fortunately for me I have an extended health plan through my employer that will pay the $71. This is one of the major flaws that advocates want fixed through establishment of a national pharmacare program. We aren’t getting anywhere with this.

There are problems with the system of course, but on balance we receive delivers good healthcare, when we need it, at no charge.

There is no way to get there without taking the step forward from where we are, and hopefully that will happen on Sunday.

Mary ended her note by saying, “Feel free to circulate to any who might need it.”

Thank you, Mary, I have. Get well soon!

Dennis and the Nuns

jstuart — Thu, 18 Mar 2010 14:11:27 +0000

Takoma Park The health care “war of the knife” continues down to the last votes. Yesterday saw Dennis Kucinich, the great progressive voice from Ohio and the stalwart proponent of single-payer, come over and a bunch of 50 nuns stand up for passage despite the recalcitrant opposition of the National Catholic Conference of Bishops. Richard Trumka of the AFL-CIO swung by the White House to cut a deal to delay the excise tax on premium health care plans for that part of his members who still have them, though that deal may or may not survive the parliamentary whoopdedoodle and tactical morass.

Dennis Kucinich from Cleveland has been the standard bearer for the left and had recently been threatening to vote against passage for a host of no doubt good reasons. President Obama parachuted in for a speech in his district, and Dennis wisely decided that it was time to hold his nose and live to fight another day, announcing predictably that it was better to have a bad bill than no bill at all. This will not silence critics on the left, nor should it, but it does give all of the votes that had committed not to vote for anything without a “public option” to abandon ship and try to get to port with anything that floats.

The nuns once again are proving that they have character, heart, and no shortage of backbone in standing up to boys in robes. Simple for them, they believed there had to be something for the millions with nothing. There call for passage was not about politics or institutions, but a straight up stand for accountability to their mission of service to the poor and working families in their flock. You have to feel better about this vote with the nuns on your side.

The total deadlock and polarization in Congress must convince the most ideological that there is no near term way to believe that a better bill is a possibility over the next 3 years at least and maybe another 20.

It’s time to count the votes and pass the bill and get to the place where it’s all over but the shouting, since we can all guarantee that the shouting on this issue will be non-stop for years to come.

Blanche Lincoln: A Vote for Health Care

jstuart — Mon, 30 Nov 2009 16:28:18 +0000

Boston Last week while in Memphis, it was natural to start thinking about Senator Blanche Lincoln, the Queen of Eastern Arkansas directly across the mighty Mississippi and a long stone’s throw from the Bluff City. I found myself speculating about a race in Democratic primary between Arkansas Lt. Governor Bill Halter and Senator Lincoln and picking up the phone and making some calls to old political hands in the Wonder State to see exactly what they were hearing and thinking.

On Halter the bottom line was easy to find. He was opportunistic and ambitious, but no one felt there was any way that he was going to take a risk of rolling snake eyes in a primary and losing to Lincoln, and the odds for him to win would be huge. He had dipped his foot into the Governor’s race when he first returned after a 20-year absence from the state, and within weeks was running for the relative safe haven of the lieutenant governor’s slot, which is a statewide post but with a light footprint. He had a lot more dues to pay and the end of Governor Beebe’s time in 2014 was likely his best shot.

Furthermore the push for Halter to run would be to the left of Lincoln at least by a little, and all of the people I visited believed that Lincoln would end up voting for health care reform at the end of the day to give a vote to try and hold African-American and working votes against likely tough challenges from the right in the Republican list. One of the most interesting points made by one of my friends was the belief that Lincoln’s elevation to the being Chair of the Senate Agriculture Committee, a huge plum that partially fell into her hands with Senator Ted Kennedy’s death and the shake out of various lions of the Senate for new jobs, would not have come so quickly in September without a clear understanding from Senate leadership, meaning Majority Leader Reid, without a direct commitment for her vote on health care reform. Simply put, as a Committee chair she’s going to need Reid, and need him a lot in the future, and in the classic expression of former Speaker Sam Rayburn, “you have to go along to get along” in Congress.

This will be as much as she gives between now and her re-election effort most observers feel, which spells tough luck for labor law reform though since Lincoln is known as the Senator from Tyson, there’s still a chance that Archie Schaffer and other Tyson hands who have been vocal advocates of more cheap, immigrant labor in Arkansas might be able to get a little something, something from her on this post-re-election.

My sources weren’t betting people, but push-come-to-shove, they felt Lincoln was a vote for the health package, even though that’s as far as she’s likely to go.

House Votes for Health Care

jstuart — Mon, 09 Nov 2009 01:50:49 +0000

Springfield First vote on the US House passage was a full court press that worked. The Republican Cao from New Orleans was the only one of that tribe to vote for passage. Who says townhalls don’t matter!

I flew on the US Air leg from DC to Hartford sitting behind Congressman Olver from the 1^st District. If it was any barometer, the civilians and business folks on this flight were pumping his hand and thanking him for his work.

A nurse who was the sound engineer on the radio station, WUMA, in Amherst where I was talking about Citizen Wealth was rattling off which votes where with Olver and where others had fallen down. People were watching and it was on their minds.

James Carville wearing a tie and Puma sneaks crawled onto the plane in New Orleans at 6AM. I saw him live on CNN as walked down the concourse in Hartford.

It may have been Indian summer this day in western Massachusetts, but change was in the air.

Getting Leveraged on Heath Care

jstuart — Tue, 29 Sep 2009 15:29:18 +0000

Washington Everywhere I go in Washington, just like the rest of the country, but more intensely, the discussion is about health care reform and whether there’s any chance of pulling through anything at this point that would really be reform. Disturbingly, it seems the White House and the Congressional leadership is getting leveraged by narrow interests and having difficulty focusing on the meat and merits of reform.

A promise to Senator Baucus around revenue has led to a taxing problem on so-called “Cadillac” benefits, but voices from Rich Trumka at the AFL-CIO and many others are point out that the tax would go to fairly thin programs including a lot of plans that are part of collective bargaining agreements.

There now seems a cadre of folks in the House and a smaller number in the Senate who are trying to hijack the bill based on stripping out abortion and taking a promise from the President as part of the license to do so. Are we now throwing women under the bus as well?

The Times reported that some states, led by Arizona, are trying to act unilaterally to say that the state could “veto” an “individual mandate” that might come with a federal package.

The tactics seem to be overwhelming the strategy. This is not a debate but a dog pile it seems. Where’s the adult supervision?

Postscript!

My “friends” on the right seem to be using me as a source for an attack at yet another new target: Patrick Gaspard, political director at the White House.

I have huge admiration for Patrick and have enjoyed my dealings with him over the years. In almost 1400 blogs I’ve done, sometimes I don’t get it right, call it a senior moment or whatever it might be, but reading the blogsphere with me as a source took me back searching for whether or not I could be causing a problem here inadvertently. Patrick was never on the staff of ACORN. I double checked with people I still know there, and it appears that I dropped a stitch there. Hopefully my misstatement won’t lead to the White House throwing him in front of the bus in this rush to neo-McCarthyism that has become so prominent. In this case, my memory tricked me. I’m glad to carry the weight and simply say I made a mistake, and damned if I’m not sorry and hope no damage is done to a good man doing a hard job.

Let me quickly add, since I read Google alerts and have noticed that there is a attack squad at all manner of friends and associates I have had over the years, that for the formal record, I have NO friends. If there’s a problem with me, then bring it on, but for the rest of you, if you see me on the street, just nod and pass on by, if you are worried about it. Until we learn to all stand together and oppose this kind of blood sport political targeting, it’s going to be like this for a while. I’m just not sure how long it will take.

Taking the Base for Granted

jstuart — Mon, 28 Sep 2009 21:20:37 +0000

Pittsburgh The G-20 was gone from Pittsburgh so it was back to normal as I passed through. Signs to beware of deer on some streets in working and lower income neighborhoods were not just reminders of the hills all around the city, but the fact that it has shrunk to 260,000 people within the limits. The new buildings along the river that replaced old steel mills have a nice sheen to them, but they moving from community to community, it was hard for me not to wonder whether or not the real citizens of the city were reaping any benefits there. Work on an arena brought together a Pittsburgh United coalition of community groups and unions and did produce real commitments. A soccer field being built with a beautiful view of the city for the University of Pittsburgh on the Hill seemed to be adding nothing.

All of this made me wonder about the comments in the papers that are putting real leverage around the healthcare debate in the hands of people like Senator Mary Landrieu from Louisiana where I vote. Reportedly, Landrieu is buckling at the public option, and just as driving around Pittsburgh again made me wonder what was happening to the base, such a position in Louisiana is also a head scratcher given how many of the state’s citizens are working, but lower income, and have no insurance.

These perplexing “individual mandates” that might make lower income workers have to come up with a couple of grand per year as a penalty for not being insured would be a slap in the face to legions of voters especially in the cities of New Orleans, Baton Rouge, Shreveport, and Lake Charles who have been the margin of victory for Landrieu for years. Senator Arlen Specter of Pennsylvania is a “new” Democrat in the sense that he has come into the party recently to hand on to his seat, but I wonder if he hasn’t traveled the same roads through the neighborhoods of Pittsburgh, because the contrast with Landrieu is stark. He’s saying he’s going to hold out for a “public option” to protect the poorest workers, and talking about reducing the mandate charges down to as low as 3% of income on the test.

Did I say this was all complicated? Absolutely! And, the more complicated, the more difficult it will be to make the deal.

But, the fine senators in every state need to take a look at their base and step up and represent finally! The negotiations in the Senate may make great drama, but I bet the accountability back home is going to be real if the base is ignored.

Baucus Bummer Bill

jstuart — Wed, 23 Sep 2009 16:34:12 +0000

New Orleans Another reason it was good to be in Canada last week, is that I heard everyone’s views on Canadian healthcare, while missing a lot about the new bill being rolled out to almost no applause by Senator Baucus of Montana.

The kindest thing people seem willing to say is that the bill doesn’t really pass as comprehensive health care reform at all, nor does it seem to pretend to be. It’s a head scratcher to try and understand why the White House seems to be pushing this sack of stuff down the legislative highway?

It seems only yesterday that President Obama was speaking to both Houses of Congress and I swear I heard him say that there needed to be a so-called “public option.” Such an option doesn’t exist in this bill by any stretch of the imagination. And, it goes without saying that immigrants are invisible in this bill as they are supposed to be in our society (though surely not in our economy!).

In fact reading some of the more thoughtful reports by health experts, they seem to nail the bill as a huge giveaway to big Pharma and a full and overflowing plate serving to the insurance companies themselves. One fellow noted that the Baucus bill would allow insurance companies to charge 5 times cost to older folks being covered! This isn’t a granny death watch, but an elderly unemployment plan since it would seem to totally encourage workplace discrimination by letting insurers soak employers who happen to have some older and wiser hands on board. Others have belittled the “trigger” to a public option being pandered in an effort to pick up a stray Republican as only ensuring that there will NEVER be a public option.

I’m having trouble wrapping my head around this.

The right and the Republicans seem intent that they do NOT want a comprehensive health care bill period, so slapping something sorry together doesn’t get any love from them, since they have already announced that they are going to oppose Christmas this year.

The progressives and good Democrats wanting to finally move the USA into the rank of modern industrial nations (like Canada, eh?) are showing no love for this Baucus concoction. Mike Lux in a well written piece in fact argues that the White House may be allowing civil war within the Demo ranks to break out over this mess.

The 47 million folks without health care now in America are not going to be happy with this, nor are any of the rest of us going to be able to paint a smile on ourselves or lipstick on this pig.

Tell me then, why are we wasting time with Baucus rather than schooling him on reality and pressing for a real healthcare bill?

Health Care Fire Storm

jstuart — Sun, 20 Sep 2009 18:29:00 +0000

Niagara Falls Waking up after a long and productive training dialogue with Judy Duncan, ACORN Canada’s head organizer, for their talented lead organizers, I was reading The Globe and Mail. The comment page included a column by David Shribman, the executive editor of the Pittsburgh Post-Gazette trying to explain the messy health care fireworks to a head scratching Canadian audience. I identified with the effort, having tried various answers to scores of questions on my ACORN Canada fundraising tour for my book, Citizen Wealth.

Shribman did a good job actually. I hope he is as clear spoken in Pittsburgh as he is in Toronto. He nailed the issue on the head as not really being about health care at all, and it is easy to forget that right-left and middle all to agree that the system is not a system and is badly broken. He zeroed in on the fact that the firecrackers and the fight are all about power. Power and pent up anger at war, bailouts, and Bush.

The conservatives are unhappy that they are losing power and are desperately fighting back.

He quotes a Professor Sandel of Harvard in this way: “This is the standard debate about the role of government in ensuring fundamental rights and equal opportunities for all citizens, but it is also a frustration with government that goes beyond the debate about markets and gets to a sense of powerlessness. People sense that the forces that govern their lives are beyond their control, and I think this sentiment – a persistent theme in American politics – is not ‘right’ or ‘left.” It was reinforced in recent times by the financial crisis and the bailout and the sense of outrage about the help given to the wealthiest institutions and the wealthiest Americans.”

Real wisdom and insight as Canada looks at the USA from a higher plane and a good safe distance.

I’m taking a deep breath as I come back to America after a week with my Canadian friends.