This is my inaugural posting. I should introduce myself by declaring my two reasons for writing. First, I am a strong Obama supporter. Second, I am a public health researcher. I hope to convince Democratic readers to take these concerns seriously in the 2008 campaign. This first posting hits political preliminaries and notes some realities of our deteriorating urban health system pertinent to health reform. In places here, I draw upon a longer and different blog linked here.
It is easy for researchers to despise the practicalities of a presidential campaign. Healthcare is a colossal, troubled enterprise which touches every interest group in America. Its poor relative, public health, struggles to gain a hearing. The candidates must speak substantively to these issues, but they cannot possibly engage many accompanying complexities.
Citizens listen to experts argue about arcane matters. They watch each candidate and wonder: Does this accomplished and privileged person really understand my needs as a patient, a caregiver, or, in many cases, as a health care provider? Cutting through the hype, what will this candidate actually do that can help me?
I will not dissect competing Democratic health plans. Others have performed this task. Each of the major plans is superior to current practice and to what Republicans propose. Each also an opening bid within a Byzantine legislative process designed to thwart large reforms. I am heartened by the similarity across the plans. Democrats are ready to govern.
Much of the primary debate focuses on one issue: whether government should require adults to purchase coverage. I suspect that most voters share Senator Obama's reticence. Individual mandates raise intricate political and administrative tradeoffs. Policy wonks reasonably disagree. I have no dog in this fight. The impoverished people at the center of my work cannot remotely afford coverage. Mandates are largely irrelevant to them.
Our healthcare system includes countless inefficiencies and stupidities. Making due allowance for the inevitable clumsiness of a $2.1 trillion colossus, we still get surprisingly poor results by any reasonable cost-effectiveness or quality measure. Despite all we spend, we still do not treat people decently. People do not receive needed care because they cannot afford it. People lose homes, cannot buy health insurance, or cannot change jobs because they become seriously ill. In one irony among many, legions of home health aids, orderlies, and other healthcare workers are themselves uninsured. Meanwhile, glaring problems of public health go unaddressed.
Both the candidates and the public would benefit if our national conversation moved past mechanical financing matters to see the human faces on both sides of the examining room table: the patients who struggle to access needed services, and the people who struggle to provide proper care in an increasingly dysfunctional healthcare delivery and financing system.
Senator Obama sees these faces. So -- for that matter -- does Michelle Obama, a distinguished healthcare leader in her own right. Senator Obama began his political career pounding the pavement in south Chicago, in neighborhoods where public health problems are glaring, and where hundreds of thousands of people lack access to needed care.
In the state legislature, he confronted the challenge of improving health care in Illinois. In a depressingly backward policy environment, he made real accomplishments. As an important committee chair, he reached out to Republicans and moderates to assemble working majorities for progressive policies when others thought this was impossible. He inspired African-Americans and Latinos in Chicago. He also touched whites in Cairo, Illinois who might never have supported a person of color before.
Senator Clinton argues that her legislative experience makes her the most effective leader of health reform. Channeling Tip O'Neill, she argues: "You campaign with poetry, but you govern with prose." She got into some difficulty trying to claim the legacy of LBJ, but we know what she means.
Senator Edwards also claims parallels to liberal heroes of old. He adopts an angry populism and promises to openly confront the pharmaceutical industry and other vested interests. In a recent blog, Katherine Newman exemplified the populist perspective of many Edwards supporters. She believes that Edwards' life story will steel him to fight when other Democrats would go soft. She says, "[W]e want FDR or LBJ in the White House. We don't want someone who will compromise or put a finger up to see which way the wind is blowing."
Senator Obama has the better case. In the first place, his poetry is more impressive than Senator Clinton's (or Edwards') prose. Hillary Clinton is diligent and knowledgeable, but I see no record of legislative mastery comparable to LBJ's. She also brings one huge liability. She attracts unique antipathy, and would provide a focal point for Republicans to mobilize against Democratic candidates and causes. This is not fair, but it is the way things are. That's why Republicans celebrated her gritty New Hampshire victory. John Edwards, for his part, left a conspicuously light footprint in the Senate before making his presidential run.
Most important, FDR and LBJ won great liberal victories because they commanded huge congressional majorities at two anomalous moments in American history. Both men were notorious compromisers and deal-makers when they lacked such majorities. Our next president will probably command a wafer-thin majority, and will need moderate and independent allies. One might bluster about steamrolling special interests. So, though, did Hillary Clinton years ago, when her minions clumsily alienated key senators such as Daniel Patrick Moynihan, whom they desperately needed for health reform. Democrats understandably hunger for a street fighter. Yet the ability to nurture broad coalitions is more valuable than fiery rhetoric in enacting social change.
Senator Obama has these skills. The New Republic's Jonathan Cohn recently described Obama's "talent to achieve consensus on a good compromise and then push it through." Through hard bargaining with health insurers and others,
Obama was able to fight for what he and the reformers thought mattered most: bringing insurance to a great many more people. And they won, prevailing over resistant conservatives. "He could not be accused of partisan aggression... but he got his way."
I have spoken to many Iowa, South Carolina, and Nevada voters. A surprising number of Republican and Independent express interest in Obama. The other day, a Romney supporter asked me whether Senator Obama refused to pledge the flag or is secretly Muslim. Then she surprised me: "I will be seriously considering Obama in November." I don't hear that about other Democrats. Obama's eloquence and intellect, his ability to build broad coalitions for progressive causes, make me more excited about any Democrat since, well, Bill Clinton, with whom Obama shares notable similarity. That is why Republicans fear him.
That matters greatly, because our medical and public health systems are a mess, and because Democrats have good ideas about how to fix them. Healthcare won't be fixed until we nominate a Democrat who can actually win, and who can assemble a working majority to get things done.
In Chicago and many other places, the health system is being crushed under the weight of uninsured people. Our area includes a million uninsured people, and large numbers of Medicaid recipients on whom providers receive low and late payments for costly services. We have always had uninsured people: the homeless, undocumented immigrants, young people who took a foolish chance. We have always had uninsured or underinsured patients. Now, though, there are simply too many people requiring too many costly services. The old ways that government and healthcare providers covered the gaps just don't work anymore.
Major academic medical centers respond by assuming a protective stance to (in a revealing phrase) improve their payer mix. Within walking distance of my office, residents of embattled neighborhoods experience remarkable mortality rates from HIV/AIDS, diabetes, obesity, heroin overdose, and traumatic injury. Our university hospital, and many of its peers, are becoming increasingly irrelevant to these concerns. Such institutions pursue a market niche serving well-insured patients who pay a premium for high-tech services, and it seeks other patent groups who fit particular teaching and research needs. Areas such as trauma care, psychiatry and substance abuse services, infectious disease, adult emergency medicine, and primary care are central to any reasonable account of our city's public health needs. They are decidedly peripheral to the competition for lucrative private-pay patients that dominates the economics of inpatient care.
While academic medical centers erect high barriers, safety-net providers face even greater burdens. Many hemorrhage money. The resulting problems are most severe at the public and nonprofit hospitals that have traditionally served poor people. Great institutions, such as Atlanta's Grady Memorial Hospital, teeter on the edge of bankruptcy. County health systems endure punishing budget cuts and layoffs.
These trends impose the most profound human costs on low-income patients. They affect the rest of us, too. Senator Edwards has spoken eloquently of the two Americas, in health care and other realms. Like many people, I myself straddle both worlds. I am a tenured professor. Yet my wife and I care for her intellectually disabled brother, who is sweet and gentle but who has complex needs and a mischievous streak. Not long ago, he pried the childproof locks off our cabinets and downed a bottle of flavored vitamin chews. My nice job didn't spare us having to wait ten hours in a crowded emergency room.
We rarely stop to consider that we bear witness to avoidable suffering. During that interminable visit, my young daughters watched a woman five feet from us groan for several hours in visible pain before she was seen. Dozens of us looked away in embarrassment as a young woman sobbed hysterically in full public view. Not long afterwards, I dropped my daughter at dance class and stepped into a diner for a coffee. Taped to the door was a flier hawking raffle tickets to pay for someone's cancer care.
These conditions take a toll on health care providers, who work hard every day to care for people under increasingly difficult conditions. It is demoralizing to turn patients away. It is demoralizing to know that the patient in front of you may go bankrupt because she is being harassed by your own hospital over a bill. It is demoralizing to spend hours battling multiple third-party payers over basic care. It is demoralizing to discharge homeless people or drug users to the street because there are no available services. Doctors and nurses -- but also many other health care workers from the administrators and social workers to the licensed practical nurses and orderlies--take pride in their work, I have heard countless professionals say that they can't do the job they were trained to do, that they can't care for people as well as they know they should.
The deteriorating network of urban emergency departments provides one obvious casualty of our fraying safety net. My next posting will explore why ED closure and overcrowding are such problems, and why physicians, citizens, and policymakers misdiagnose the reasons for these difficulties.