Punishment Versus Compassion

Punishment Versus Compassion

An idea that Johann Hari explores in his book Chasing The Scream is that people with drug addiction need family and community support to get through their addiction, not punishment and castigation. Throughout the book Hari asks why people develop addictions, what do people do when they successfully get past an addiction, and what structures and systems work against recovery?

 

Early in the book Hari references a conversation he had with pastor and civil rights activist Eugene Callender about singer Billie Holliday. Hari writes, “Callender had built a clinic for heroin addicts in his church, and he pleaded for Billie to be allowed to go there to be nursed back to health. His reasoning was simple, he told me in 2013: addicts, he said, are human beings, just like you and me. Punishment makes them sicker; compassion can make them well.”

 

Hari argues that community is the cure for drug addiction. He sees drug addiction as a consequence of trauma, pain, depression, adverse experiences, and a loss of a sense of togetherness. When people are isolated and don’t truly feel as though they are part of a larger community where they belong and where their lives and actions matter, then people can’t take personal responsibility, they can’t work for more, and they often turn to drugs to blunt the pain and fill the empty voids. What this means, is that addiction is a consequence of everyone’s selfish actions, it is not just a moral failing of the individual. Consequently, we all have a role to play in the recovery of those in our communities dealing with addiction.

 

What Reverend Callender noticed, as highlighted in the quote above, is that people dealing with substance addictions need support and guidance to get through their struggles. People turn to drugs in times of pain when they feel something lacking in their lives. Taking more away from them, limiting their ability to interact with a community, and pushing more challenges at them only worsens the underlying psychological stress and trauma that drove them to addiction in the first place. Punishment is harmful, whereas compassion and forgiveness is what gives people a second chance and encourages them to improve their lives. If we don’t treat people facing addiction with dignity and respect, can we ever expect them to treat themselves with the dignity and respect needed to overcome addiction?
A Racist Start to the Drug War

A Racist Start to the Drug War

My last post was about Harry Anslinger’s racist views and how they influenced public policy. I wanted to focus on what we could learn from his mistakes, and how we could think about our own policy positions given the terrors we have seen in the past from biased policy positions, confirmation bias, and believing things are true simply because we want them to be true.

 

Today’s post is more specifically just an examination of race and drug policy, looking all the way back to the start of the war on drugs. During a time when protests against racial violence in policing is front and center, I think it is helpful to consider how race was specifically used in drug wars to hurt racial minorities, especially black men and women. Black lives matter, but our nation has not always believed that, and we cannot separate the disparities in racial sentencing, death rates, and wealth from the policies of our nation’s past.

 

In his book Chasing the Scream, Johan Hari writes about his shock at finding that the drug war, in its early days, was not so much about mitigating drug addiction or preventing new addiction in teenagers, as it is today, but about controlling racial minorities. He cites overtly racist headlines in newspapers and talks about Anslinger’s efforts to target minority populations, while letting white drug users off the hook and helping them find treatment to wean off drugs. A central character in the book is Billie Holiday, a black musician targeted by Anslinger for her drug use. Her story provides a window into the racialized tactics used to enforce drug laws, and create a nationwide story about the danger of black people using drugs.

 

Hari writes, “Many white Americans did not want to accept that black Americans might be rebelling because they had lives like Billie Holiday’s – locked into Pigtowns and banned from developing their talents. It was more comforting to believed that a white powder was the cause of black anger, and that getting rid of the white powder would render black Americans docile and on their knees again.”  The failure of black Americans to become successful was blamed on drugs, and ultimately on a genetic and/or cultural inferiority that justified their low social positions and justified a drug war waged against them. White American’s didn’t want to believe that they could be held responsible for the strife of African Americans, so they invented new excuses for racist policies.

 

As we look around the country today, we should keep these kinds of policies and views in mind. It was not that long ago that we were so openly racist in the development of policies that are still impacting the world today. We can no longer justify racial disparities by saying that there is some type of problem with minorities that justifies the disparities in our policies and outcomes. We need to demonstrate that black lives matter and advance policies that correct the wrongs of our past.
Racially Motivated Policy

On the Dangers of Racially Motivated Public Policy

In his book Chasing the Scream, Johann Hari writes about Harry Anslinger, the Nation’s first commissioner of the Federal Bureau of Narcotics. Anslinger was a staunch anti-drug crusader, but he also held deeply racist views which came to influence his opinions about drug use and national policy related to specific drugs. In many ways, it was Anslinger’s racist views that created a national prohibition on marijuana, and lead to years of laws prosecuting marijuana use and racially disparate arrests.

 

Early in his career, Anslinger wasn’t very interested in marijuana. He was more focused on heroin and cocaine, but Hari explains that heroin and cocaine use was not wide spread enough in the American population to justify the size of his agency. As newspapers began to report on crime related to black and brown people in the United States who had used marijuana, Anslinger seized on the opportunity to demonize the drug. Hari writes, “almost overnight, he began to argue the opposite position. Why? He believed the two most-feared groups in the United States – Mexican immigrants and African Americans – were taking the drug much more than white people.”

 

Despite evidence from researchers and physicians indicating that marijuana use generally did not lead to the atrocities that Anslinger began to claim, he pushed forward with harsh drug policies related to marijuana, policies that he knew would have a racially disparate impact. At a certain point, in the picture Hari presents, it appears that Ansligner began to believe what he wanted and see what he wanted in the world around him. After he proved how dangerous the mafia was in the United States, contrary to the view of many experts, he began to believe his own rhetoric about racial inferiority and marijuana dangers. Hari writes, “Anslinger began to believe all his hunches would turn out like this. He only had to defy the experts and keep using his instinct until, finally, he would be shown to be more right than anyone could have predicted.”

 

Anslinger was clearly wrong, and his stance and attitude are easy to denounce today. But what we should learn from his story is just how dangerous public policy can be when it is motivated by racist values and hatred. For many of us today, we believe our values are high minded, and we believe that the policies we favor can have no downside. Nevertheless, we can still learn from the example of Anslinger and the resulting racial problems his policies created in the Untied States.

 

We need to be honest with ourselves and those around us about the values that drive our policy decisions. We should be honest about the potential failure points of the policy we support, and we should acknowledge that there are potential negatives of what we do. This requires that we recognize the message we are trying to push, and avoid simply looking for examples in the world that confirm what we already want to believe. If our values are indeed high-minded, and if we can be open and honest about our motivations, then our policies should be supported by a larger audience. Failing to be honest and open can put us in a place where we defend bad policy, and push for policies that explicitly hurt others, without us acknowledging the downsides. It is also critical that we acknowledge the role that race plays (or has the potential to play) in the policies and attitudes we support. The same reflection and honesty regarding our policies must apply to the racial outcomes of the policies we favor, and we have to push back against policies with disparate negative outcomes for minority groups.
Harry Anslinger and the Fragility of Civilization

Harry Anslinger and the Fragility of Civilization

To open his book Chasing The Scream, author Johann Hari tells a story about Harry Anslinger and the fragility of civilization. Anslinger was the first commissioner of the Federal Bureau of Narcotics, and sparked the war on drugs in the United States. As a young child, Hari explains, Anslinger was at a farm house where he heard a woman screaming in agony as she possibly experienced drug withdrawals. The owner of the house sent him to the pharmacy to return with a package and drugs to ease the woman’s suffering, which Ansligner did, but the memory of the screams would haunt Ansligner forever, pushing him to spend his entire life fighting against any drugs that he believed were dangerous.

 

In World War I Anslinger became a diplomatic agent in Europe, and he saw the destruction of entire cities and the destruction of human life first hand. At  the end of the war, Anslinger learned another lesson that would stick with him for life. Hari writes, “What shook Harry most of all was the effect of the war not on the buildings but on the people. They seemed to have lost all sense of order.” Ansligner was concerned about riots, starving desperate people driven to chaos, and entire institutions crumbling, leading to strife among the people. Hari continues, “Civilization, he was beginning to conclude, was as fragile as the personality of that farmer’s wife back in Altoona. It could break.”

 

Chasing the Scream is a brutally honest look at drug policy and the war on drugs in the United States. Anslinger was key in kickstarting the war on drugs, but his message was carried on after he left office, and to this day after his death. Hari asks tough questions, trying to understand if there is a way to win a war on drugs and whether we should be more concerned about the consequences we have seen from battling drugs in every arena. At the end, Hari concludes that what we need to fight a war on drugs is not a war mentality, but an understanding of the importance of community, and a rebuilding of social solidarity, trust, and a new sense of our responsibility to each other. Anslinger was right, to conclude that civilization was fragile, but he was wrong is his prescribed treatment. A war to end vice only tears apart our social fabric, weakening the communities which build our civilization.

 

Hari believes that what we need are better ways to understand each other, and more supports for everyone in society. Many of the evils that we attribute to drug use, Hari argues, are in fact byproducts of the war we wage against drugs. In an effort to impose social order on people, with the rhetoric of war and a mindset steeped in racism, Ansligner helped to create a system that broke civilization for some of the most vulnerable among us, just as he always feared from the moments he heard the screams of the farmer’s wife in his childhood.

 

We must remember just how close our civilization can be to chaos and disorder. We need to look for leaders who can bring us together rather than leaders who seek to castigate others and toss them out. We need to think about how we build new institutions that help develop greater sense of community, and how we help those who have the least. If we fail to do so, we will increase inequality, and then blame the inequalities on those who faced the greatest adversity as a result of our inequalities. This will segregate our societies and create more chaos, making it harder for us to come together when we need to, exacerbating our drug and violence problems.
Design Matters - Healthcare Systems Edition

Design Matters – Healthcare Edition

In his book The Opioid Crisis Wake-Up Call, Dave Chase quotes Dan Munro by writing, “The [healthcare] system was never broken, it was designed this way.”

 

I’m a fan of Debbie Millman’s podcast, Design Matters. When we are making something that other people will use and engage with, it is important to think about all the various aspects of how the thing will be used and how it can meet the needs and expectations of others. Whether what we are producing is art, a branding campaign, or a national healthcare system, design matters.

 

Unfortunately, the Untied State’s healthcare system wasn’t built on a design matters philosophy. We see inefficiencies everywhere, with some people getting care they don’t need while others can’t get routine basic care that could save their lives. Dan Munro says that the system was built this way, meaning that the inefficiencies, the inequalities, and the high costs were part of the system from the beginning, intentionally built in. The dysfunction we see in the system, according to Munro, is not so much a bug but rather a feature, helping someone make a profit or get priority access to the healthcare they want.

 

I think Munro is a little wrong. I think the system is a hodgepodge of pieces smashed together over the years. It is an incoherent patchwork of tools and players that has been haphazardly assembled over the years, with some working to truly do good, and others taking advantage of design flaws for their own aims. The system, in my argument, was never designed at all.

 

Design matters and what needed to happen decades ago was a real conversation about how the country would design a healthcare system that could innovate, that could meet the needs of citizens, that could ensure basic access to medical services, that could help provide preventative care rather than just emergency interventions, and that could be sustainable. Instead, doctors went about providing medical services, insurance companies popped up to help pay for some pieces here and there, and eventually businesses got in the mix and offered health insurance to employees. Each new step in healthcare in the Untied States has happened almost randomly, without a lot of deliberate planning.

 

Now the system is so large and complex that planning feels impossible. Legislation to address the challenges of the system is thousands of pages long, and because the most comprehensive law to restructure the program adopted the namesake of the nation’s first black president, a Democrat that became a polarizing figure, half the country derided the attempt to design something better. We can try to reshape bits and pieces of the system now, but design matters, and I understand why so many want to hit a restart button and rebuild a system from scratch.
Healthcare Profit and Subsidization

Healthcare Profit and Subsidization

Medicaid simply doesn’t pay enough for many medical providers to make a profit. The reimbursement rates often cover only fixed costs, and don’t really cover the full operating costs of a service. Medicare pays slightly better, usually covering operating costs and sometimes providing just enough for a small profit. Private insurance, however, pays a lot more than the two main public funding sources for health care in the United States. It is in private insurance that profit is to be made for medical providers.

 

As Dave Chase writes in his book The Opioid Crisis Wake-Up Call, “While employer and union health plans are roughly one-half of all health care spending, they likely represent over two-thirds of health care industry profits because they often wildly overpay for health care services.”

 

Think about who is most likely to need healthcare services: elderly and disabled individuals. Our system of Medicare pays just enough for providers to make a tiny profit, most of the time, for elderly patients. Our patchwork of state Medicaid systems, which many poor, minority, and often disabled individuals rely on for health care coverage, pays below operating rates for many procedures. While we have more elderly people utilizing the healthcare system and while we have more low income individuals with disabilities relying on healthcare, services for these two groups is not where profit is generated in healthcare. Instead, profit is generated from the reasonably healthy people who work steady jobs and heave employer provided insurance. The charges to private insurance companies are so high that even though their patients use less care, they provide a much greater percentage of the providers’ profit margins.

 

The first implication of this system that I want to highlight is the inequality in terms of access that arises within the system. If you rely on Medicaid, you may have trouble finding a provider who will take you. That is because the provider knows that while they will get paid for treating you, they might not actually break even for their time. There are other patients out there who offer more profit to the provider than what your Medicaid coverage will offer.  Because of the low reimbursement rates of Medicaid, many providers cap the number of Medicaid patients they see, making it harder for people on Medicaid to receive any services at all. For Medicaid patients, care is strictly rationed.

 

The second piece that I want to highlight is a way of framing the costs in this scenario. Providers lose money on Medicaid, maybe make money on Medicare, and jack up their prices for private insurance to ensure they make a profit at the end of the day. A lot of times providers will justify this approach by describing their high rates to private insurance patients as subsidizing the meager rates they receive from seeing patients covered by public plans. In a country that hates the idea of government redistribution and direct subsidizing of healthcare for the poor through taxes to support universal healthcare, we are already subsidizing the care of those who can’t afford care.

 

Most healthcare providers generally want to help people, it is usually a big part of what pulled them into their work in the first place. And even without Medicaid, many of them would likely still treat some people with no means to pay, writing off the free care they provided and potentially charging other patients more so they could afford to take on some charity cases. In a system built on empathy and care for the health and well-being of others, there is no way to avoid subsidizing other people’s care, at least a little bit.

 

I think we should be honest with the fact that we are already subsidizing healthcare to a large extent through our private health insurance system and the charges from providers for patients with private health plans. The incredibly high charges to private health insurance means higher premiums for everyone on those plans. For some reason we hate the idea of having to pay higher taxes for free health care, but are willing to shove out unreasonable healthcare premiums for expensive health insurance.
Value in Healthcare

Value in Healthcare

A common complaint about healthcare in the United States is that it has traditionally operated on a fee for service (FFS) based model. It is a natural and easy to understand system, and generally the type of system that both patients and providers prefer. The idea is that you pay for the services you receive from a healthcare provider. So if you need a tooth extracted, you go and have the tooth extracted and pay for the extraction. If you need a skin check, you go and get a skin check and pay for it. However, this FFS model can encourage a lot of waste through unnecessary medical procedures, and the value in healthcare is sometimes lost when we wait until someone has a problem before we help them with their health.

 

A lot of government programs, employers, and insurance companies are making efforts to push against FFS in an effort to provide greater value in the healthcare services we pay for, but it is worth asking, what is value and how can healthcare systems provide it? Is value just better health? Is it services that a patient said they were happy about? Is it care that saves a life or can it just be care that makes a life somewhat more comfortable? Dave Chase helps explain one aspect of value in healthcare in his book The Opioid Crisis Wake-Up Call, “Value is defined as the ratio of quality to cost. Value increases as the quality of the care increases or the cost of care decreases.”

 

FFS encourages short appointments where doctors cram as much as they can bill for into the shortest possible time before moving on to the next patient to do the same. Value based models, on the other hand, seek to improve the quality of the care provided without adding more costs to the patient and their insurer. As opposed to simply cramming in more tests, treatments, and procedures to get more money, value based systems that increase quality focus on improving health outcomes while keeping costs stable.

 

Alternatively, value based models might seek to keep quality the same, but reduce overall costs. This can wade into territory we don’t necessarily want to support, such as cutting nurse management staff to keep overhead low, but it could also look like more comprehensive care to reduce costly re-admissions after a procedure. When we think about value and try to build systems around value, we ultimately have to think about quality and cost, and how those are related. We can cut pieces out of the system that are just meant for signaling and cut pieces out that might be unnecessary without diminishing quality. But at the same time, we really need to examine whether the pieces we want to cut really do help with the quality of the care, especially over the long run.

 

Thinking about value in healthcare isn’t entirely new, but it is receiving increased focus, which is important if we want to have a healthcare system that people actually trust and are willing to engage with when necessary.
Status Quo in Healthcare

Status Quo in Healthcare

How can we really make change to the United States healthcare system? Dave Chase, in his book The Opioid Crisis Wake-Up Call argues that changes to the system need to come from private businesses, because private businesses are responsible for the health insurance coverage for over 50% of American’s. If business don’t take action and demand changes, Chase argues, then the system will not have enough strength to push against the status quo of rising costs and stagnant productivity within healthcare.

 

A quote from Chase about changing the American healthcare system reveals something larger about public opinion and the status quo in American public policy in general. Chase writes, “This book focuses on non-legislative strategies since the politics of health care are fraught with pitfalls. As we know, the best way to perpetuate the status quo is to politicize a topic – and nothing is easier to politicize than health care.”

 

I think Chase is correct about politicization and the status quo in the United States. Our country has deeply internalized ideas of liberal and conservative and wedded those ideas to the Democratic and Republican parties. This means that if an idea is taken up by a party, if it is politicized and adopted by a party, then it instantly becomes an identity marker, and people who might not have had a strong reason to care about an issue, suddenly find it to be a maker of who they are and what groups they belong to. Politicizing an issue in this system virtually guarantees gridlock, preventing any legislative action on the issue.

 

Private businesses, however, can make changes without relying on a 50% majority vote (or 2/3rds majority vote in congress). Throughout the book Chase presents economic and moral arguments for businesses to take the nation’s opioid crisis seriously, and uses it as a wake-up call to show businesses how our healthcare system is failing individuals, and ultimately failing the companies that hire those individuals and provide for much of the healthcare that individuals receive (or fail to receive). Public action is hard, so in many arenas, private action is the best chance for making the changes we want to see in the world.
Health Care Supply

Health Care Supply

Dave Chase makes an argument in his book The Opioid Crisis Wake-Up Call that healthcare has a substantial supply side drive, not just a demand side drive. This argument doesn’t align with standard pictures of healthcare, the idea that people seek care when they are sick, and don’t use care when they are well. Its troubling, but evidence does support the idea that the healthcare market is in some very important ways a supply driven market, meaning that as supply and capacity increases, demand also increases.

 

I’m not completely sure I understand this idea, but it is important for us to acknowledge and think about, especially if we live in growing cities, gentrifying regions of the country, and areas of the United States that have real opportunities for reinvention. When looking to the future of healthcare in the United States, Chase includes many elements from Bruce Katz and Jeremy Nowak’s book The New Localism and thinks there is an important role for new models of city and local government to play in shaping local healthcare ecosystems. He is also heavily influenced by Jim Clifton’s book The Coming Jobs War and the importance that local communities invest in sectors that are likely to be highly productive in the future. Chase writes,

 

“Sooner rather than later, we can expect other developments along the same 3.0 spectrum [More info on Economic Development 3.0 here]. Cities will incorporate true health needs into mater planning and review building permit applications with a deep understanding that health care is a supply-driven market. The more supply there is, the more demand will increase, with little regard for value and community well-being. Approving more health care build-out virtually guarantees a massive burden on local citizens.”

 

It is important that we think about what it is in healthcare that actually provides value. If simply adding more healthcare capacity will lead to greater demand and utilization, then we need to take steps to ensure that an uptick in services is actually accompanied by improvements in health. When communities are redeveloping and growing, they should be focused on upstream social determinants of health rather than just hospitals and healthcare service buildings. Designing communities that will have ample green space for outdoor activity, that will control noise, and will have well lit parks and outdoor areas will help build healthy communities. Plopping a hospital in a space that doesn’t include these elements might give people a place to go when they are stressed, overweight, and injured by debris in the streets, but it will not help people actually live healthier, it will capitalize on a broken environment that fails to support health.

 

I think that is part of the idea that Chase argues for. We should maintain the healthcare capacity and services which actually improve health, and we should be weary of systems that provide healthcare but fail to demonstrate real health improvements for citizens and communities.
Fiduciary Healthcare Responsibilities

More on Fiduciary Healthcare Responsibilities

Yesterday I wrote a little bit about the fiduciary healthcare responsibilities that employers hold given that companies invest our healthcare dollars in plans and structures that can be quite costly. In his book The Opioid Crisis Wake-Up Call, Dave Chase writes, “Given the wide cost differentials, CFOs and CEOs are failing in their fiduciary responsibility if they do not move to modern health care delivery models that are proven to save money while maintaining or improving health outcomes and patient satisfaction.”

 

Chase’s book is all about current structures and systems for healthcare coverage, delivery, and access that are within the control of employers. Healthcare is a complex field, and for years, employers have not had a hands-on role in shaping and creating the models they work through to provide health insurance to their employees. Chase argues that the result has been increasing costs without pressure on providers or insurers to make sure that the quality of care matched the costs.

 

Innovative and truly caring companies have shifted the status quo and shown that quality healthcare can be affordable. They have shown that preventative medicine can be supported and promoted by thoughtful employers, saving healthcare dollars and improving employee health in the long-term. Companies that ignore these models will effectively be wasting healthcare dollars and hindering the health of their workforce. This exposes companies to liability for not fulfilling their fiduciary healthcare responsibility.

 

When we talk about health policy and improving the healthcare system in the United States, we usually talk about government policy, about hospital charges, and about minimum standards for insurance and rising insurance premiums. Chase thinks we need to spend more time talking about our employers, and about what they can do to help improve the system, without requiring laws to be passed or companies to make policies that go against their own best interest. Employers have a lot of leverage if they take their fiduciary healthcare responsibility seriously.