Anti-Racism Reading Group #5: Seeing White

In an effort to hold myself accountable to better anti-racism theory and practice, I’ve started hosting an anti-racism reading group in the Seattle area. In this series, I’d like to share both these readings and some of the discussion. You can read summaries of previous discussions by following these links: one, twothree, four.

For the fifth anti-racism reading group, we listened to Seeing White, an excellent podcast hosted by John Biewen at the Center for Documentary Studies at Duke University. In it, Biewen and regular guest Dr. Chenjerai Kumanyika explore the history and consequences of White racial identity in a way that is both extremely accessible and intellectually rigorous.

This was a particularly ambitious project because the podcast series is fourteen episodes long, meaning there were many hours of material to discuss. For the purposes of our discussion group, we focused on the first three episodes which cover the history of Whiteness and the last two episodes on anti-racist action. However, I encouraged the group (as I encourage you) to listen to the full series, because every episode is worth your time.

Given the expanse of the source material and the conversation, I don’t have a thorough summary of the discussion, but rather three items of conversation that I found particularly interesting. Continue reading “Anti-Racism Reading Group #5: Seeing White”

Anti-Racism Reading Group #4: White Fragility

In an effort to hold myself accountable to better anti-racism theory and practice, I’ve started hosting an anti-racism reading group for health care practitioners in the Seattle area. In this series, I’d like to share both these readings and some of the discussion. You can read part one here, part two here, and part three here.

For the third reading of the anti-racism reading group we focused on White Fragility. Our reading was the article White Fragility from the International Journal of Critical Pedagogy which you can download here. Supplementary materials were Dr. DiAngelo’s White Fragility and Rules of Engagement and this comedic White Fragility Workplace Training Video.

What is White Fragility? In Dr. DiAngelo’s words:

White Fragility is a state in which even a minimum amount of racial stress be- comes intolerable, triggering a range of defensive moves. These moves include the outward display of emotions such as anger, fear, and guilt, and behaviors such as argumentation, silence, and leaving the stress-inducing situation. These behaviors, in turn, function to reinstate white racial equilibrium.

Continue reading “Anti-Racism Reading Group #4: White Fragility”

Do No Harm: A Doctor’s Case For Single Payer

In 2013, Drs. Ubel, Abernethy, and Zafar published “Full Disclosure — Out-of-Pocket Costs as Side Effects” in the New England Journal of Medicine. In this essay, the authors grapple with the ethical responsibilities of physicians when it comes to the enormous cost of modern medicine. If a surgery or a course of chemotherapy is likely to bankrupt a patient, what is our duty to warn them, to ensure that they have considered both benefits and harms? A larger question, however, was left unasked: “How do we as physicians ethically operate within a medical system that forces people on a regular basis to choose between health and financial stability”

To grasp the extent of the issue, consider that even after the passage and defense of the Affordable Care Act, 27 million American remain uninsured. An additional 41 million Americans are underinsured which is to say that their out-of-pocket expenses (such as deductibles and copays) are enough to cause financial duress, despite having health insurance. And as health insurance deductibles increases faster than wages, the proportion of Americans who are underinsured continues to grow.

The consequences of this are grave. Three out of ten American adults report forgoing needed medical care due to cost concerns. One in four were unable to pay for basic necessities like food, heat, or rent because of medical bills. One third spent down all of their savings.

When health economists have looked to explain why it is that health care is so enormously expensive in America, time and time again they have found (in the words of the late, great Uwe Reinhardt) that “it’s the prices, stupid.”

That is to say that hospitals, doctors, pharmaceutical companies, and medical device manufacturers charge Americans prices far in excess of what people are charged in other high-income countries. Joseph Dieleman and his colleagues at Harvard reassessed this question for the Journal of the American Medical Association just last year and came to the same conclusion (though with a less blunt title).

One key distinction between America and its peer nations is that other nations have centralized institutions to determine fair pricing for medical goods and services. In Germany, this is the Institute for Quality and Efficiency in Health Care (IQWiG). In the U.K., it is the National Institute for Health and Clinical Excellence (NICE). In France, it is the National Union of Health Insurance Funds (UNCAM). Each of these countries takes advantage of a strong price negotiating position through centralization.

The other crucial distinction between America and its peer nations is that these other nations recognize that some minimum level of health is a necessary precondition to social, civic, and economic participation and as such is worth the investment of public funds. In other words, by treating health care as a human right, they protect their citizens’ capacity to exercise their other rights in good health. This framework justifies  distributing the costs of health care equitably, and in turn preventing financial penalty from compounding the injury of illness.

These two features of an improved health care system – 1) centralized purchasing and 2) equitable funding – are achievable in the United States with a transition to a Single Payer system. In such a system, a single publicly funded entity (e.g. Medicare) would pay for all medical goods and services on behalf of Americans. Medical care will still be delivered by private doctors and hospitals, and medical goods will still be produced by private companies. The only difference for most people is that the money that you had been paying to a private insurance company will instead be going to a public insurance entity (e.g. Medicare).

Many proposals for different Single Payer systems are currently being considered by both national and state legislative bodies in the United States. Perhaps the most famous at this time is Bernie Sanders’ Medicare For All Act (S. 1804 with 16 co-sponsors) and its accompanying house legislation (H.R. 676 with 120 co-sponsors) introduced by Representative John Conyers. Senator Chris Murphy has been working on his own Single Payer strategy which is qualitatively similar to Representative Pete Stark’s AmeriCare Single Payer plan. There are also numerous state-level Single Payer plans including The Washington Health Security Trust (HB 1026SB 5701), The Healthy California Act (SB 562), and the New York Health Act (A. 4738 and S. 4840).

These legislative pushes take place in the context of the rising popularity of Single Payer, which has now achieved majority support in public opinion polling. As the popularity of Single Payer legislation grows, Democrats positioning themselves for 2020 presidential bids like Kamala Harris, Cory Booker, and Kirsten Gillibrand have already declared their support, recognizing that Single Payer is a necessary part of a popular Democratic platform.

This momentum should not inspire complacency, however. There is a great deal of organizing, consensus building, and legislative refinement needed in the months ahead. For my part, I plan on working with Health Care For All Washington on their push for state-level single payer and Democratic Socialists of America on their push for federal-level Medicare For All. Others are doing great work through Physicians for a National Health Program and National Nurses United.

If this has piqued your interest, I encourage you to continue read up on Single Payer and find the right level of involvement for yourself. Whether that’s calling your elected officials, talking with your friends and co-workers, writing an op-ed for your local newspaper, or knocking on doors, it’s all important work.

More articles on Single Payer:

Securing Housing For All

As a family doctor in Seattle, I take care of numerous patients experiencing homelessness. The toll this takes on their bodies is impossible to ignore. Sleep deprivation, chronic stress, physical and sexual assault, temperature extremes, and malnutrition all weather the body rapidly. As a physician sworn to preserve and prolong life, it is profoundly disturbing to come up against such profane and preventable degradation on a daily basis.

For this reason, I joined the Housing For All Coalition last night as they put forth a call to action to a packed hall at the Seattle Labor Temple. Speakers from the Transit Rider’s Union, Socialist Alternative Seattle, Nickelsville, SHARE/WHEEL, and DESC each spoke to the urgency of ending Seattle’s housing crisis. While each speaker brought a unique perspective, including the perspective of the formerly and currently homeless, they all emphasized the importance of increasing access to both affordable permanent housing and safe temporary shelter.  Continue reading “Securing Housing For All”

Anti-Racism Reading Group #3: Perinatal Mortality

In an effort to hold myself accountable to better anti-racism theory and practice, I’ve started hosting an anti-racism reading group for health care practitioners in the Seattle area. In this series, I’d like to share both these readings and some of the discussion. You can read part one here and part two here.

For the third meeting of the anti-racism reading group, we focused on increased rates of perinatal death (i.e. death around the time of birth) for black women with this excellent piece of reporting by NPR and Propublica. NPR’s Code Switch team produced an excellent podcast on this same story which you can listen to here or read the write-up here.

This is an especially timely reading given Erica Garner’s recent death at age 27 from a heart attack just three months after giving birth. Erica was the daughter of Eric Garner who was murdered by the New York City Police. Since his death, she had risen up to be a prominent and effective activist against police violence.   Continue reading “Anti-Racism Reading Group #3: Perinatal Mortality”

Innovations in Primary Care: Moving Beyond Fee-For-Service

The American medical system has long operated under a fee-for-service model in which only specific, narrowly-defined medical services qualify for reimbursement from insurance companies. This system is reasonably well-suited for procedure-oriented specialties in which services with clear indications, processes, and outcomes such as colonoscopy or knee replacement can be appropriately paid for.

In America’s fee-for-service system, reimbursement for primary care services is limited to short office visits and certain outpatient procedures (such as a joint injection). Many primary care doctors have felt that they could offer better care for their patients if the payment structure allowed for more flexibility in services offered, but opportunities to test this hypothesis have been limited.

Today, three groups in the Seattle area – Landmark, Concerto, and Iora – are independently demonstrating the value of flexibility in primary care to improve patient outcomes at overall lower cost. They’ve accomplished this by arranging for alternative payment models with local Medicare Advantage plans (private insurance plans who contract with Medicare to provide health insurance to seniors). Rather than operating under fee-for-service, these companies get a per-member, per-month payment. This payment structure provides a flexible budget with which they can offer services that don’t necessarily fit into the established fee-for-service structure.   Continue reading “Innovations in Primary Care: Moving Beyond Fee-For-Service”

Bringing Single Payer to Washington State

Yesterday I attended a meeting of Health Care for All Washington regarding single payer legislation in our state. The particular set of bills they are supporting are SB-5701 and HB-1026 which establish a trust fund (the Washington Health Security Trust or WHST) which would eventually act as a single payer for health care services in the state of Washington.

Specifically, this legislation creates the trust fund, establishes a board of trustees and guidance committees to run the Trust, and then lays out in very broad strokes what the Trust is meant to accomplish. As described in the legislation, the Trust is meant to pay for health care for Washington residents not otherwise covered by Medicaid, Medicare, or private insurance including dental and long term care (think nursing homes). Most likely the funds for the Trust would come from a combination of a payroll tax and a sliding-scale premium.   Continue reading “Bringing Single Payer to Washington State”

Anti-Racism Reading Group #2: Theft of Black Wealth

In an effort to hold myself accountable to better anti-racism theory and practice, I’ve started hosting an anti-racism reading group for health practitioners in the Seattle area. In this series, I’d like to share both these readings and some of the discussion. You can read part one here. 

For the second meeting of the anti-racism reading group, we read part one of Ta-Nehisi Coates’ The Case For Reparations. In our first meeting, we discussed big-picture theory of race, so we followed that up by focusing in on particular racial project called redlining which had been a major contributor to both racial housing segregation and wealth inequality in America today. Continue reading “Anti-Racism Reading Group #2: Theft of Black Wealth”

Anti-Racism Reading Group #1: Racial Projects

In an effort to hold myself accountable to better anti-racism theory and practice, I’ve started hosting an anti-racism reading group for health practitioners in the Seattle area. In this series, I’d like to share both these readings and some of the discussion. 

For the first meeting of the anti-racism reading group, we read a selection from Racial Formation In The United States by Michael Omi and Howard Winant. You can download a PDF of this selection here.

In this section, the authors describe race as existing in the interaction between 1) social structures which organize society by race and 2) the cultural representations and experiences of race. Racial projects is the term given to the mediators of this interaction. Continue reading “Anti-Racism Reading Group #1: Racial Projects”

Doctors Against Deportation

This week, federal immigration agents in Texas stalked a 10 year old girl with cerebral palsy to the hospital where she was receiving emergency gall bladder surgery for a life-threatening condition. Taking advantage of this moment of vulnerability, they captured this girl at the hospital and have now imprisoned her at one of their loosely regulated detention facilities. Federal guidance lists health care settings as “sensitive locations” which are supposed to be protected from immigration raids because discouraging people from seeking needed medical care out of fear of predatory immigration agents is an attack on their health and safety.

As a doctor who believes that the value of a human being’s health and safety is not contingent on their documentation status but rather on their inherent human worth, I am appalled by the work of U.S. immigration agents who seems to be eternally at odds with my work to keep my fellow human beings safe and healthy.

Because of this, I want to take a moment to outline how I think medical professionals should interact with U.S. immigration agents in healthcare settings and to highlight the work of some amazing organizations in the Seattle area who are working to uphold the dignity of all people, regardless of documentation status.

Continue reading “Doctors Against Deportation”