Monthly Archives: June 2018

Health Policy Post! My Actual Day Job!

I work at a state Medicaid agency that’s planning to cut payments to doctors who can get that dough back by improving their patient outcomes. It’s generally called “paying for value.” Its opposite, “paying for volume,” pays docs for the number of services they provide, rather than their patients’ improved ability to bike to the river.

Clearly we need to pay for health care quality instead of for however many brains one can stuff into an MRI machine.

But we also know that social factors–jobs, education, immigration status, housing and food security–determine up to 80% of a person’s health. Not their doctor. Not their genes. Not their kale smoothies or meditation apps.

So paying doctors for outcomes may not make much sense for doctors who primarily serve people with low wage jobs in polluted neighborhoods and generally live without the kind of accumulated advantages that allow me, for example, to hit the bookstore for something to read on the airplane, which I’m flying tomorrow to a small town with a fantastic pastry shop and a famous theater.

Dhruv Khullar points out that scoring doctors who take public insurance against doctors who don’t, and paying them less when their patients inevitably can’t manage their chronic conditions as well, will probably result in lower-income people getting worse care.

And we haven’t yet figured out how to use the health care system to address people’s actual health needs: food, safe and secure housing, child care, decent wages.

I’ve been saying this around the office for a while, that value-based payments may punish doctors for poverty the same way that teacher evaluation systems punish teachers for poverty.

But Dr. Khullar is a doctor published in the New York Times, and I’m a pee-yoo-rocrat blogging for about 3 readers (hi guys!).

So not that I can do much about it, but I’ll spend my Fourth of July thinking about how to leverage health care funding streams to mitigate social inequity. Also cake. Happy Fourth.

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On Dehumanization

I want to write about Legion (it’s all about an abusive dad, guys!!) and Ursula Le Guin (she hates technology, guys!!) But there is nothing to say, really, while babies, toddlers, kids, and their parents are victims of this spectacle of political cruelty.

  1. These families are seeking asylum, which is legal
  2. They seek asylum because they are already traumatized by violent conditions in their homes
  3. They enter a country expecting kindness–or at least a stable fucking legal process–and instead face horror perhaps equal to what they tried to escape.

I used to think that racist and misogynist cruelty depended on the abuser having already dehumanized their* victim. This conception of abuse was the only way I could make sense of my own trauma: my abuser must not have seen me as human, because what human could hurt another human so much, so often, so deeply, so intentionally, if they were fully immersed in that person’s humanity?

Then this article, which has haunted me since November, has transformed how I think about cruelty.

A victim’s humanity is the point. If an abuser did not engage with the rich, beautiful humanness of their victim, their cruelty would be less there’s-really-no-other-way-to-put-this meaningful. From the article outlining this transformative model of cruelty:

Timothy Snyder offers a haunting description in “Black Earth: The Holocaust as History and Warning”:

The next morning the “scrubbing parties” began. Members of the Austrian SA, working from lists, from personal knowledge, and from the knowledge of passersby, identified Jews and forced them to kneel and clean the streets with brushes. This was a ritual humiliation. Jews, often doctors and lawyers or other professionals, were suddenly on their knees performing menial labor in front of jeering crowds. Ernest P. remembered the spectacle of the “scrubbing parties” as “amusement for the Austrian population.” A journalist described “the fluffy Viennese blondes, fighting one another to get closer to the elevating spectacle of the ashen-faced Jewish surgeon on hands and knees before a half-dozen young hooligans with Swastika armlets and dog-whips.” Meanwhile, Jewish girls were sexually abused, and older Jewish men were forced to perform public physical exercise.

The Jews who were forced to scrub the streets—not to mention those subjected to far worse degradations—were not thought of as lacking human emotions. Indeed, if the Jews had been thought to be indifferent to their treatment, there would have been nothing to watch here; the crowd had gathered because it wanted to see them suffer. 

I read and click out and re-open and skim and shut down so many reports of the cruelty imposed on these children and families. I don’t need to rehearse any of that here. Nonetheless, every time I think about those kids, which is often, I return to this image of the Jewish surgeons crawling on the ground in their suits. I think of white people bringing picnics to lynchings.

And I return to what we knew from the first day of this administration: cruelty is its foundation. Mocking, defiling, fracturing the humanity of others (people with disabilities, black people engaging in free speech, women, immigrants from the Global South, people with expertise, etc etc etc) is the base upon which they construct every action.

We can shout at them all the ways this policy will destroy lives. We can list out the long long list of what we know about attachment, trauma, the deep need children have for a loving, attentive caregiver. We can throw the entire fucking UCLA med school curriculum at his head. That would only encourage him and his goons.

Our facts, our passion, our desperation about the lives these policies destroy are like cans of hairspray thrown onto the bonfire. Destroying lives is the point. Enflaming liberal ire is the point. Spreading hate is the point.

Sure, the US has destroyed families for white supremacist political expediency since its founding–Black families, native families, immigrant families. Even Obama wasn’t cool about migrant family reunification.

We now have an opportunity now to repudiate all of that disgusting history.

Let’s each one of us do a little more than we think we can to stop this horror.

 

*Post script/announcement, speaking of the ennobled humanity of our beautiful allies: Thinker for Hire now embraces the gender-agnostic singular them. It took me too long. Thanks.

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TfH’s 1-line reviews

Solo: I’d rather have watched a whole movie about Chewie freeing his enslaved wookie comrades, gently touching foreheads with them, joking freed wookie jokes with them, dancing freed wookie dances at freed wookie parties eating freed wookie electric blue antennaed hor’s oeuvres.

Tully: Our country’s so crap about families that when a whipfirecrackingbadasssssss lady has a surprise third baby, she is in such desperate need of care that her personality cleaves, like a car floor string cheese divided and knotted over onto itself in something like a salty, half-melty, lint-riddled hug.

The Americans series finale: Marriage is hard, but nationalist violence is harder.

The Mars Room: WHY ARE THERE SO MANY STORIES OUT ABOUT PARENTS LOSING THEIR KIDS ABOLISH ICE AND WAREHOUSE THEM ALL WITHOUT RIGHTS OR DIGNITY IN A MAX SEC PRISON IN THE CALIFORNIA DESERT PLEASE THANKS

Ursula Le Guin’s Hainish novels and stories (which include The Left Hand of Darkness and The Dispossessed): The strand of US ideology encapsulated loosely now as “Trumpism” is terrible, which we’ve known since always but especially since the Vietnam War, and which advancing technology may only reinforce if we don’t put the anthropologists and artists in charge.

 

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