Hello everyone,

It's been a really very long time, hasn't it? I'm sorry, I was very sick.

I've concluded my 2018 tours around most of the US (well, except for a week in TX, IL, and WI this month) and have settled down to--finally!--write the book. I wanted to share some thoughts.
 

I. The path forward
II. Environmental injustice: the Shipyards and Babyland
III. Podcast
IV. Repro thought

A real juicy paper came out this week, about medical costs and medical spending. Coincidentally, Health Affairs’s Halloween issue also just dropped, and it’s also about costs and prices.

On one hand, this paper has some real interesting data and a couple particularly jolting anecdotes. Here’s one, on cost-sharing in employer-sponsored insurance (ESI). In short: when insurance plans force people to pay more for the cost of their own healthcare, they refrain from seeking care altogether -- even if that care is free.

So, that’s nice. It’s confirmation that cost-sharing is a great fraud perpetrated on the American patient--that skyrocketing premiums, deductibles, and co-pays are insurer abdications of responsibility which end up keeping patients from healthcare just to preserve insurer profit margins. But you don’t need to be an expert to know this… you just need to be someone who’s ever used health insurance.

This is a cyclical pattern I’ve seen. Every six months, academics re-discover that “medical costs are high because prices are high!” (I’m not exaggerating; here’s one from six months ago). They are promptly ignored by the titans of insurance industry--perhaps because insurers are incapable of doing anything about it--who proceed to act as if the problem is “overutilization” and thus increase premiums and deductibles. A few months later, academics discover once again that medical costs are high because medical prices are high, and nothing happens again.

This is similar to my big horror at academic and nonprofit analyses of work requirements: we know they don’t work, we know they harm people, and measuring how they don’t work (usually for grant money) only gives the cover of nominal “experimentation” to the people who implement them. When I’m feeling cynical, I posit this is evidence of some academic-industrial-complex, etcetera; a perpetual professorial pomposity; a compulsion to measure the size of the cracks in the levee with millimeter precision while the stormwater rushes in.

And this compulsion trickles down to health inequity. There persists this idea that if we just measure the problem the right way, we can solve it. This “solutionism” is the lie of the technocrats: that the problem is defined by what solutions are available; that the atrocity is addressable by expert analysis; that tools and incentives and mechanisms can be devised to keep our national healthcare ducks in a row. Necessarily, then, the technocrats argue that healthcare injustice in America is complicated; much too complicated for regular plebes to understand. This is the kind of thinking which results in policies like the ACA.

But I just don’t think that holds up. The answer to “what’s wrong?” is intuitive. 

One, medical costs are, and always have been, skyrocketing. These costs are driven almost entirely by high prices. That is to say, medical costs are rising because medical prices are extremely high, not because Americans are “utilizing too much” healthcare. (Though it’s worth mentioning that utilization is a thing worth thinking about: poor patients, and patients of color, tend to be provided with both worse healthcare services as well as more ‘wasteful’ healthcare services than rich patients and white patients.)

This is particularly pronounced in private insurance, in which virtually all spending increases come from higher per-person costs--twice as much so as public payers (for whom spending increases are driven by enrollments).

Two, these cost increases are driven by industrial actors dicking around with unit costs: hospitals, pharma, and equipment manufacturers. You could write a litany of these sins hundreds of pages long--a new example is unearthed every week.

Three, the response of a private payer unable to handle these cost increases is to shift them onto the consumer--this is why premiums and deductibles go up. Increases in cost sharing are effective--they prompt people to decline to seek care altogether (including, as anyone with a chronic condition and a thin wallet has known, a hesitation to seek out high-value care).

But that's all boring asked-and-answered horseshit. Here's the real meat: Healthcare is not enough.

Even if we were to pass single-payer tomorrow--and we should--access to care explains only a fifth of the disparity in health factors and outcomes. The remainder are driven by structural causes: unsafe housing, polluted water and land, lack of food, the carceral state, mental health crises.

So what's breaking health care for people? The real drivers of health disparity--of health injustice--are structural poverty and structural racism: economic and racial segregation. It is the interwoven snakes of racial and economic and patriarchal domination: the beating heart, I would argue, of capitalism and capitalist exploitation.

Do you want examples? In rural counties, an increasing number of which are hours away from hospitals, death rates for car accidents are two to three times those of metro areas; suicide rates are two-thirds higher than those of urban counties. Nationwide, black infants die twice as often as white infants. America has the highest maternal mortality rate among ‘First World’ countries. Sixty percent of those maternal mortalities are entirely clinically preventable through simple procedures… like taking the mother’s blood pressure. They’re murdering us.

You know this! You don’t need to be a bespectacled Wharton MBA jagoff to know that if your housing is unsafe, it’s going to make you sick. You don’t need to have a grant from the Mohammad bin Salman Center for Studies of Civil Excellence or whomever to discover that if the state refuses to treat you with dignity--if you are kept under the thumb of the police state, if you can’t get a job that respects you, if you can’t go to the doctor because it’s too expensive or too far away--that you are more likely to die young. We understand the structural and social forces which make people sick. And thus we understand that the response must also be structural and social. It requires massive structural interventions which work to dismantle the core of the problem. Anything else is harm mitigation. It is insufficient.

And I believe as I have always believed that the first step is single-payer--but not one designed to relieve the burdens of, God bless them, the healthy and the wealthy. This is something your Andy Slavitts, your Centers for American Progress, and your ghoulish means-testers understand: it is possible to design a policy which, at least temporarily, satisfies the mostly-healthy and the mostly-wealthy without dramatically restructuring American health finance. These are your United States of Care whitepapers, your “Medicare Extra for All” policies, your other patchwork solutions which seek to bail the water out of the boat without repairing the holes. By addressing primarily the suffering of the mostly-healthy and mostly-wealthy, these non-solutions are freed from contemplating, much less tearing down, the structures which perpetuate vast health injustice--structures which, it turns out, end up rewarding the Slavitts and the Tandens with money, prestige, and pedigree. Given the promise of moderate relief, this movement of the less-marginalized is then dissuaded from agitating toward the grand prize itself--think about for how long we were told that we had to be patient, we just needed to “let the ACA do its work;” or how everything would work out if it weren’t for the meddling Republicans. Hell, I fell for it for a while. 

So what do we do?

While doing laundry last week I took the opportunity to read this very brief history of American healthcare reform movements over the past hundred-ish years by Dr. Beatrix Hoffman (thank you Jen). The fight for single-payer is not a new one--it has a rich historical precedent. In this paper, Hoffman details why healthcare movements thus far have failed. In short, when health reform is made the domain of elite policy actors -- elected officials, well-meaning policy people, people in charge of unions or nonprofits -- they are beaten, uniformly, by a reactionary establishment that is capable of outmaneuvering, outmanning, and outgunning the health reformers.

There has been a century-long belief that well-meaning elites can write a healthcare bill and gin up support among the grassroots. It has failed, over and over and over again. (In one defeat, in 1970, the universal healthcare bill was drowned out by 13 competing bills sponsored by industry and establishment -- a reason we have to take “Medicare Extra for All” seriously and must debunk, decry, and debase it--simply but precisely).

Hoffman sees victory in healthcare reform coming from grassroots movements--she cites ACT UP! as a prime example, and I’d additionally cite ADAPT as the most powerful popular health movement in contemporary times. Popular movements have often started by demanding incremental changes to the American healthcare model, but transitioned to making more aggressive calls for universal healthcare when their incremental changes proved to be insufficiently transformative.

If we care about health equity, I think, the path forward is to build a true popular movement.

Or--let me be more specific. It is not to build a popular movement. It is to stitch together a popular movement--a big, messy quilt spanning the country from coast to coast and plains to gulf.

For the work is being done all around us. In Idaho, a woman in a van built the popular movement which will win Medicaid expansion at the ballot box this fall. In Maine, the Maine People’s Alliance won Medicaid expansion off the back of a minimum-wage-increase campaign. In San Francisco, people won right to guaranteed counsel in case of eviction at the ballot box. In Cincinnati, the DSA won a needle exchange--the first in the region. And in Texas, beautiful Texas, we have the paid sick leave campaigns. The paid sick movement in San Antonio organized San Antonio residents (instead of well-meaning liberals from California and New York) who spoke to other San Antonio residents about paid sick leave. It turned out 140,000 signatures -- 40% higher than the number of people who voted for mayor in 2017. This is the largest popular movement in San Antonio in years, if not decades. 

What do all these campaigns have in common?

One, they offer material and redistributive relief to people who are suffering now. Two, they’re all fundamentally movements toward health justice. Three, they organize with the people who most need to be heard and respected in the development of a radical single-payer program.

This is the work that excites me: the work of highlighting the specific manifestations of health disparity in our communities, working to alleviate it, and through this work building the local grassroots movement which, in coalition with hundreds of local movements nationwide, can demand, win, and enforce federal, universal single-payer--one which forces the state to bear the costs of providing care--AND the risks and costs of what happens when care is not provided.

Only by forcing the state to reckon with the financial consequences of unsafe housing, of inadequate food, of abandoning the rural population, of the carceral state, can we force it realize that housing is healthcare; that food is healthcare, etc. But the state alone is insufficient and untrustworthy: only through the mass popular movement, this big quilt organized from below, which demands health justice can we develop the mechanisms to hold it accountable.

We do not need to shy away from discussing when and how single payer is insufficient to relieve someone’s suffering. We do not need to pretend that single-payer will solve the problems of racial discrimination in healthcare, provider shortages in rural areas, underpaid health labor, or the hospital-prison pipeline all by itself. In fact, to gloss over these questions is to lie--and if you lie to someone, why the fuck would they join you in the fight? We must embrace these questions--their answers mean literal life and death to the people who ask them. Whether we hurt deeply or have been thus far spared from misery, our task is to listen to other people who suffer in ways we don’t and bring forward these questions and bear them like a chalice before us--to demand not just an adjustment to American health finance, but a transformational American health justice.

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2. Environmental Injustice

I’m sorry. I meant to put more structure in this email. I wanted to talk about the Hunter’s Point/Bayview project in my beloved San Francisco, the most important city to me-- a decades-long coverup of the toxic waste that’s been dumped and ignored in the backyards of poor families, people of color, public housing. Not that it was a secret -- the people who live there know what’s up. They know why their life expectancy is fourteen years shorter than life expectancy in like Nob Hill a few miles north. But nobody listened. And now it’s coming to light because these YIMBY dipshits and the waxy-faced wieners in City Hall want to build more condos for rich goobers. 

Do you remember Babyland? The pauper’s field for dead infants in Memphis, where infant mortality is over 9 per thousand, almost twice the national rate? 

I forgot to mention that there are two nuclear waste disposal sites in town. 

These motherfuckers are going to keep killing us and our grandparents and our children and everyone in-between unless we not only throw them from the rafters but take hold of the machines they have built to dominate us, to rule us, to mine us and frack us--until we take hold of these machines and fold, spindle, and mutilate them until they can harm no more. The American political machine will not save us unless we uproot it, like a weed, and demand of it a new democracy.

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III. Podcast
The podcast HEAVYxMEDICAL, a podcast about health policy and metal music, exists again. Me and KJ have much more time than we used to, plus a dedicated producer, and now we can record these biweeklyish like we wanted. I promised Kelly Jo that if we did enough in a row we could get a Patreon.

Our latest episode is about Title IX, Betsy DeVos's plans for it, and the role of sexual violence in population health and maintaining existing forms of power. We interview my very good friend Kate, who knows so much, has seen so much, and who just keeps on going.

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IV. Repro thought
Also, random thought. You know who’s a casualty in the war against reproductive choice? (and it is a war, for the anti-choice movement is very cheerfully complicit in the targeted murder of abortion providers and the people who support them--I mean, hell, one GOP candidate said the quiet part loud when he agreed that people who get abortions might deserve the death penalty--for this reason, “squishiness” on abortion upsets me, for the anti-choicers are extremely good at clawing their way into the “squish” to justify themselves.) 

All this time is spent fighting for the right to not reproduce that, say, health justice for people who miscarry-- an unfortunately common occurrence--doesn’t get the attention it deserves. Hell, thanks to their anti-abortion doctrines, Catholic hospitals have been known to turn away people in the middle of a miscarriage--because to assist them would be to end a pregnancy. Isn’t that fucking wild? Isn’t that some of the most insane shit you’ve ever heard in your entire life?

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That's all for now. Thank you very much.