Here's an excellent follow-up to my paper on "Healthcare, Culture, & The American Economy" from the NY Times.
“Instead of being able to focus on my health, I focused on insurance to cover the tests and treatments.”
Tuesday, December 23, 2008
Monday, December 22, 2008
The Organic Green Revolution
Christopher Bedford from the Center for Economic Security has given one of the best descriptions of our current state of affairs that I've seen in recent times. The Rodale Institute's "Organic Green Revolution" document, seems like a great resource. Here's his message:
Comfoodies and HENs,
What do next? Hank suggests that the change we seek has to rise up from thousands of local food system (let 10,000 flowers bloom) developments that inform, push, demand action from elected officials. I agree with that prescription for change with these substantive additions.
Those of you who have heard me speak know that I am enamored with the Bill McDonough lines, “If you want to go to Canada, but are driving towards Mexico at 100 miles an hour. Slowing down to 30 won’t help. You are still going the wrong direction.”
Many of the suggestions made in these last commentary strings around the appointment of Tom Vilsack as Secretary of Agriculture are the good intentioned equivalent of “slowing down to 30”.
Sure, it is important to have Obama appoint Under Secretaries of several federal departments who understand our concerns, who share parts or all of our agenda. But absent real change in corporate dominated agriculture and food power relationships in Washington politics, these “friendly appointments” may help us secure some grants for our institutions or some other helpful, marginal actions…but little more. (Not marginal if it is your institution, I know)
The change we are facing is real, profound, and potentially overwhelming because of…
…climate change and its impact on food production,
…the emerging ecological and economic limitations of the global industrial paradigm in agriculture and food production, (want a little melamine with that milk?)
…the growing health crisis produced by poor nutritional policies, (let them eat cheap food so we continue to increase the cost of health care)
…the economic and food security consequences of the rapid decline in petroleum availability for the US food system, (Peak Oil)
…a growing planet population with unequal access to food, energy, capital and information resources, (why would someone become a terrorist, anyway?)
…our continued reliance on new technological practices like GMOs and cloning to solve problems caused our lack of harmony with nature’s systems, (if brute force isn’t working, you aren’t using enough of it!)
…the relentless logic of greed by many in power when faced with future defined by new ecological limitations and scarcity, (the corporate patenting of genes, seeds and, indeed, now whole animals like pigs.)
…the growing use of corporate funded disinformation campaigns to slow the coalescence of voters and consumers around the need for fundamental change in our food and farming systems, (the Corn Processors’ HFCS campaign is just the latest example of a strategy that was first developed by the tobacco industry to slow the regulation of cigarettes.)
…the use of governmental actions and regulations to slow and stop the development of “local food systems and regenerative agriculture in every food shed in the United States” that kind Hank referred to in his earlier emails. (The Monsanto seed laws)
Does anyone on these lists seriously think I have exaggerated the scope and depth of the challenges that I have listed above? If, not, then we have to ask ourselves the question
”what do we really need to do to affect the change we seek?”
If you answer, “lobby Tom Vilsack”, then you should stop reading here. Tom Vilsack is a decent person. His wife, a more aware person, understands the importance of good food to our future. But Tom Vilsack won’t and can’t save us.
We must actually imagine what it means for us to “turn around and go in a new direction.”
Hank suggests that the “ten thousand flowers” of the local food revolution will create this change. I totally agree with him as far as he goes. Urgency is the question on my mind.
We don’t have time to fight a guerrilla war against the global industrial food system. Nature’s and history’s clock is ticking. Although, the local food revolution ultimately will be successful in replacing the global corporate industrial systems now in place, it could be a Pyrrhic victory if we have passed one or more of Nature’s tipping points (when decline is unstoppable) in the process.
I believe we need to demand fundamental change – the change presented in the Rodale Institute document “The Organic Green Revolution”. www.rodaleinstitute.org/files/GreenRevUP.pdf
In this new organic Green Revolution, industrial, petroleum based agriculture will become the niche (like arsenic sniffers of the 19th Century, a doomed and dying niche) and ecologically intelligent food and farming systems based on organic and permaculture growing principles will be the way we farm.
Now, anyone who speaks regularly to conventional farmers knows that such a suggestion is tantamount to treason. If you want to really make conventional farmers really angry just raise the issues surrounding “organic farming”.
But why such anger? If organic food production is just a niche, why does it arouse such powerful emotions?
The answer is, most farmers know deep in their hearts, that industrial agriculture is dying as an operational, viable paradigm. “Anger” is just one of the five Kubler-Ross stages in acceptance of this death. It is followed by “bargaining” (perhaps IPM and GMOs can be seen in this light) and “depression” (something working farmers are all too familiar with).
The final stage is acceptance, in this case, of a new way to farm, one that has the power to regenerate not just the health of the earth, but farmers’ economic, physical, and emotional health as well.
We must help conventional farmers through this transition and not let their “grieving” dictate the food policy for an entire nation.
Luckily, we have an example, a role model, for what we need to do. The WE Campaign, a project of the Alliance for Climate Protection, seeks “repower America with 100% of its electricity from clean energy sources within 10 years.”
That means no more carbon-based energy to produce electricity within a decade. A remarkable goal. A fundamental change of the same scale we seek.
The WE Campaign makes effective use of media to allow us to visualize this change. Their latest TV commercial depicts a working class guy recharging his pickup truck’s batteries from a wind-powered plug-in station. This is a brilliant commercial at many political levels.
The French anthropologist, Clause Levi-Strauss, says, in most cultures men must dream their children before they can conceive them. I believe this is true of the local food revolution as well.
Michael Pollan’s NY Times “Letter to the Farmer-in-Chief” is an example of creating a clear frame for our dream of regenerative, healthy food future. Every time a local TV station does a story about a chef using local food or a farm operating a CSA, our collective dream, necessary to imagine this change, is enriched.
But I believe we need to do more. We need to use the arguments and principles presented in “The Organic Green Revolution” to develop an effective national media effort to promote the ecologically intelligent values and community-based processes of the local food revolution that Hank wrote about.
In effect, we need our own “We” campaign to change the debate in the public square. In doing so, we will empower those ten thousand flowers of transformation, regeneration, and hope.
Does anyone want to join together to make this happen?
Peace and good food and Merry Christmas,
Chris Bedford
Comfoodies and HENs,
What do next? Hank suggests that the change we seek has to rise up from thousands of local food system (let 10,000 flowers bloom) developments that inform, push, demand action from elected officials. I agree with that prescription for change with these substantive additions.
Those of you who have heard me speak know that I am enamored with the Bill McDonough lines, “If you want to go to Canada, but are driving towards Mexico at 100 miles an hour. Slowing down to 30 won’t help. You are still going the wrong direction.”
Many of the suggestions made in these last commentary strings around the appointment of Tom Vilsack as Secretary of Agriculture are the good intentioned equivalent of “slowing down to 30”.
Sure, it is important to have Obama appoint Under Secretaries of several federal departments who understand our concerns, who share parts or all of our agenda. But absent real change in corporate dominated agriculture and food power relationships in Washington politics, these “friendly appointments” may help us secure some grants for our institutions or some other helpful, marginal actions…but little more. (Not marginal if it is your institution, I know)
The change we are facing is real, profound, and potentially overwhelming because of…
…climate change and its impact on food production,
…the emerging ecological and economic limitations of the global industrial paradigm in agriculture and food production, (want a little melamine with that milk?)
…the growing health crisis produced by poor nutritional policies, (let them eat cheap food so we continue to increase the cost of health care)
…the economic and food security consequences of the rapid decline in petroleum availability for the US food system, (Peak Oil)
…a growing planet population with unequal access to food, energy, capital and information resources, (why would someone become a terrorist, anyway?)
…our continued reliance on new technological practices like GMOs and cloning to solve problems caused our lack of harmony with nature’s systems, (if brute force isn’t working, you aren’t using enough of it!)
…the relentless logic of greed by many in power when faced with future defined by new ecological limitations and scarcity, (the corporate patenting of genes, seeds and, indeed, now whole animals like pigs.)
…the growing use of corporate funded disinformation campaigns to slow the coalescence of voters and consumers around the need for fundamental change in our food and farming systems, (the Corn Processors’ HFCS campaign is just the latest example of a strategy that was first developed by the tobacco industry to slow the regulation of cigarettes.)
…the use of governmental actions and regulations to slow and stop the development of “local food systems and regenerative agriculture in every food shed in the United States” that kind Hank referred to in his earlier emails. (The Monsanto seed laws)
Does anyone on these lists seriously think I have exaggerated the scope and depth of the challenges that I have listed above? If, not, then we have to ask ourselves the question
”what do we really need to do to affect the change we seek?”
If you answer, “lobby Tom Vilsack”, then you should stop reading here. Tom Vilsack is a decent person. His wife, a more aware person, understands the importance of good food to our future. But Tom Vilsack won’t and can’t save us.
We must actually imagine what it means for us to “turn around and go in a new direction.”
Hank suggests that the “ten thousand flowers” of the local food revolution will create this change. I totally agree with him as far as he goes. Urgency is the question on my mind.
We don’t have time to fight a guerrilla war against the global industrial food system. Nature’s and history’s clock is ticking. Although, the local food revolution ultimately will be successful in replacing the global corporate industrial systems now in place, it could be a Pyrrhic victory if we have passed one or more of Nature’s tipping points (when decline is unstoppable) in the process.
I believe we need to demand fundamental change – the change presented in the Rodale Institute document “The Organic Green Revolution”. www.rodaleinstitute.org/files/GreenRevUP.pdf
In this new organic Green Revolution, industrial, petroleum based agriculture will become the niche (like arsenic sniffers of the 19th Century, a doomed and dying niche) and ecologically intelligent food and farming systems based on organic and permaculture growing principles will be the way we farm.
Now, anyone who speaks regularly to conventional farmers knows that such a suggestion is tantamount to treason. If you want to really make conventional farmers really angry just raise the issues surrounding “organic farming”.
But why such anger? If organic food production is just a niche, why does it arouse such powerful emotions?
The answer is, most farmers know deep in their hearts, that industrial agriculture is dying as an operational, viable paradigm. “Anger” is just one of the five Kubler-Ross stages in acceptance of this death. It is followed by “bargaining” (perhaps IPM and GMOs can be seen in this light) and “depression” (something working farmers are all too familiar with).
The final stage is acceptance, in this case, of a new way to farm, one that has the power to regenerate not just the health of the earth, but farmers’ economic, physical, and emotional health as well.
We must help conventional farmers through this transition and not let their “grieving” dictate the food policy for an entire nation.
Luckily, we have an example, a role model, for what we need to do. The WE Campaign, a project of the Alliance for Climate Protection, seeks “repower America with 100% of its electricity from clean energy sources within 10 years.”
That means no more carbon-based energy to produce electricity within a decade. A remarkable goal. A fundamental change of the same scale we seek.
The WE Campaign makes effective use of media to allow us to visualize this change. Their latest TV commercial depicts a working class guy recharging his pickup truck’s batteries from a wind-powered plug-in station. This is a brilliant commercial at many political levels.
The French anthropologist, Clause Levi-Strauss, says, in most cultures men must dream their children before they can conceive them. I believe this is true of the local food revolution as well.
Michael Pollan’s NY Times “Letter to the Farmer-in-Chief” is an example of creating a clear frame for our dream of regenerative, healthy food future. Every time a local TV station does a story about a chef using local food or a farm operating a CSA, our collective dream, necessary to imagine this change, is enriched.
But I believe we need to do more. We need to use the arguments and principles presented in “The Organic Green Revolution” to develop an effective national media effort to promote the ecologically intelligent values and community-based processes of the local food revolution that Hank wrote about.
In effect, we need our own “We” campaign to change the debate in the public square. In doing so, we will empower those ten thousand flowers of transformation, regeneration, and hope.
Does anyone want to join together to make this happen?
Peace and good food and Merry Christmas,
Chris Bedford
Sunday, December 21, 2008
Op-Ed: Vision of a Grassroots, Grass-Fed Revolution
Here's an article I wrote for the NYU Steinhardt Public Health Student Group Fall 2008 Newsletter:
Op-Ed: Vision of a Grassroots, Grass-Fed Revolution
by Kelly Moltzen
Growing up, we were taught by the USDA that “all foods can fit,” that everything in moderation is good for us. We were taught that we needed dairy products in our diet in order to get calcium, otherwise we would develop osteoporosis. We were taught that we needed to get our protein from meat. But what if this were not the whole picture? Would the USDA actually hide information from us?
Unfortunately, yes. It seems as though Congress is more concerned about taking food industry lobbyists’ money than about giving the public scientifically sound advice, as Marion Nestle tells us in her book Food Politics. However disturbing this may sound, we cannot allow the food industry to dominate us, not when 63% of Americans are overweight or obese and children born in the year 2000 or after may be the first generation to die before their parents; not when animals are subjected to living on claustrophobic, unsanitary Concentrated Animal Feeding Operations (CAFO), force-fed corn and artificial substances that make them sick, necessitating the use of administering antibiotics before we buy and eat the omega-6 laden meat which makes us sick. Not when 25% of the foods we buy in the grocery store has some form of corn in them, and the ammonium nitrate left over from the production of explosives during World War II is used to fertilize crops – facts Michael Pollan shares with us in The Omnivore’s Dilemma.
This country needs a complete change of mindset, where we raise humanely treated omega-3 rich grass-fed animals and stop using additives and pesticides on our food. We need to craft a world that is not dominated by the need of the food industry to keep money in its wallet, but one that is driven by the need to keep real food on the table. A world where our children don’t need to learn how to read labels, but instead learn how to grow vegetables. A world where we get energy from the sun and wind, not coal and oil, and where we eat our food, not burn it as biofuel.
Fortunately there is a revolution starting, as people have banned together for such programs as the Real Food Challenge and Slow Food Nation. Californians had an initiative on their ballot this November called “Proposition 2,” which was a huge breakthrough for humane farm animal treatment. It prohibits cruel and inhumane ways of confining animals in their cages. The USDA recently passed more rigorous regulations for organic food, prohibiting the existence of organic CAFOs. The list of 2010 Dietary Guidelines Advisory Committee appointees looks promising as well. Yet we need to continue supporting CSA communities, creating farm to school programs, and weakening the connection between food industry lobbyists and Washington, D.C. If we don’t do it, then who will?
Op-Ed: Vision of a Grassroots, Grass-Fed Revolution
by Kelly Moltzen
Growing up, we were taught by the USDA that “all foods can fit,” that everything in moderation is good for us. We were taught that we needed dairy products in our diet in order to get calcium, otherwise we would develop osteoporosis. We were taught that we needed to get our protein from meat. But what if this were not the whole picture? Would the USDA actually hide information from us?
Unfortunately, yes. It seems as though Congress is more concerned about taking food industry lobbyists’ money than about giving the public scientifically sound advice, as Marion Nestle tells us in her book Food Politics. However disturbing this may sound, we cannot allow the food industry to dominate us, not when 63% of Americans are overweight or obese and children born in the year 2000 or after may be the first generation to die before their parents; not when animals are subjected to living on claustrophobic, unsanitary Concentrated Animal Feeding Operations (CAFO), force-fed corn and artificial substances that make them sick, necessitating the use of administering antibiotics before we buy and eat the omega-6 laden meat which makes us sick. Not when 25% of the foods we buy in the grocery store has some form of corn in them, and the ammonium nitrate left over from the production of explosives during World War II is used to fertilize crops – facts Michael Pollan shares with us in The Omnivore’s Dilemma.
This country needs a complete change of mindset, where we raise humanely treated omega-3 rich grass-fed animals and stop using additives and pesticides on our food. We need to craft a world that is not dominated by the need of the food industry to keep money in its wallet, but one that is driven by the need to keep real food on the table. A world where our children don’t need to learn how to read labels, but instead learn how to grow vegetables. A world where we get energy from the sun and wind, not coal and oil, and where we eat our food, not burn it as biofuel.
Fortunately there is a revolution starting, as people have banned together for such programs as the Real Food Challenge and Slow Food Nation. Californians had an initiative on their ballot this November called “Proposition 2,” which was a huge breakthrough for humane farm animal treatment. It prohibits cruel and inhumane ways of confining animals in their cages. The USDA recently passed more rigorous regulations for organic food, prohibiting the existence of organic CAFOs. The list of 2010 Dietary Guidelines Advisory Committee appointees looks promising as well. Yet we need to continue supporting CSA communities, creating farm to school programs, and weakening the connection between food industry lobbyists and Washington, D.C. If we don’t do it, then who will?
FYI. When I don't have enough time to do a full blog post, I sometimes post things on Twitter instead because it's easier. So go there sometimes :)
http://twitter.com/kellymoltzen
http://twitter.com/kellymoltzen
Saturday, December 20, 2008
Healthcare, Culture, and the American Economy
And here's another paper. Only God knows how I managed to write all these in the past 2 weeks...
Kelly Moltzen
Community Health & Medical Care P.11.1830.002
Professor Soffel
December 18, 2008
Healthcare, Culture, and the American Economy
The United States spends 16% of its Gross Domestic Product on healthcare – more than any other developed country in the world – yet ranks poorly in comparison to other developed countries in terms of life expectancy. There are many contributors to this paradox, most of which have to do with the fundamental structure and culture of the US healthcare system. Money funneled into the healthcare system currently overemphasizes spending on long-term care for the elderly while inadequately funding public health programs and failing to account for behavioral determinants of health. It should be noted that “virtually no one in Canada or Western Europe views the U.S. health care system as a model to emulate” (Rodwin).
The first inefficiency of the US healthcare system is that it overemphasizes spending on long-term care for the elderly. Medicare and Medicaid together account for 19% of total US government spending, but the majority of this money goes towards a small number of beneficiaries. With the number of Americans over age 65 growing due to the aging of the baby boomer generation, the United States cannot afford to continue spending excessively on this population. In 2006, ten percent of Medicare beneficiaries accounted for more than two thirds of Medicare’s $374 billion budget, while 52% of beneficiaries accounted for only two percent of expenditures (Medicare: A Primer, 2007). And while the elderly and disabled comprise 25% of total Medicaid enrollees, they account for 70% of Medicaid’s $316 billion in expenditures, leaving only 30% of the funds for the other 75% – children, parents, and pregnant women (Medicaid: A Primer, 2007).
The majority of spending on healthcare for the elderly is on nursing home care, with 44% of Medicaid spending going towards nursing homes (Medicaid: A Primer, 2007). Yet nursing homes are not the most efficient way for the elderly to be cared for, as nursing homes are a very expensive business. In addition, they are generally understaffed, do not provide optimal care, and “many elders say they would rather die than live permanently in a nursing home” (Feldman, Nadash, & Gursen). Elderly people deserve to be treated with respect, and taking away their autonomy by forcing them to live in institutionalized settings denies their “right to take risks in order to lead a preferred lifestyle” (Feldman, Nadash, & Gursen). This “medicalization of everyday life” is not only draining the US budget, but is unfair to the elderly who normally prefer to live on their own as much as they can. Therefore, less costly ways to care for the elderly should be considered, such as in continuing care retirement communities and other residential alternatives (Feldman, Nadash, & Gursen). Consumers – no matter what their age – should have a say in what type of services they will receive through personally directed care. Many elders would prefer informal care while living at home or with family members, although this can be exhaustive and financially draining to their caregivers. By providing elders a specific allotment of funds for personally directed care, they could choose to hire who they saw fit. In any case, a primary goal should be ensuring that people die with dignity (Nuland, 1995).
A more humane future for America’s elderly can be expected to encounter various barriers, principally high costs of care, no matter what options are considered. The services Medicaid purchases for the elderly (i.e. nursing homes) are primarily provided by the private sector (Medicaid: A Primer, 2007), but if money were spent instead on purchasing care in public, non-for-profit institutions, or home-based care, it might cost less. However, many people may be concerned about quality assessment in home health care and assisted living facility settings (Feldman, Nadash, & Gursen). There needs to be a shift in the mindset of Americans and the culture of the healthcare system which currently seems to be more concerned with keeping people alive than ensuring the elderly can enjoy their life and maintain social relationships, which not surprisingly seem to have beneficial effects on health (House, Landis & Umberson, 1988). Yet getting Americans to change the way they conceptualize caring for the elderly will continue to be very challenging.
Another reason for the inordinate costs of healthcare in the United States is an inadequate funding of public health programs, with less than four percent of healthcare funds going towards public health (Hunt & Knickman). Although improvements in health have historically come from public health – not medical – interventions (Conrad & Schneider, 1992), the US healthcare system has become very focused on downstream interventions, which do not get to the root of the problem (McKinlay, 1974). These are extremely cost ineffective, and there are a “large number of unnecessary procedures” with “unexplained variations in practice patterns” and “unclear answers to rudimentary questions about which treatments [are] most cost-effective” (Light). Insurance providers and Medicare will pay for expensive end-stage medical procedures such as kidney transplants, dialysis, and amputations for diabetes patients, but will not pay for primary, population-based interventions that can prevent health problems, such as health education, public service announcements, and accessible healthy food. As McKinlay observes, “we long ago surrendered control of food…to private corporations…[which] have shaped the kinds of food we eat for their greater profits,” so much that “most people now eat more processed and synthetic foods than the real thing” (McKinlay, 1974).
The government needs to be much more stringent in enforcing restrictions on the advertising of unhealthy food products, as the food industry has a very influential voice in Congress due to the revolving door between Congressmen and lobbyists (Nestle, 2007). While a substantial amount of money has supposedly been set aside for public health interventions in the 2008 Farm Bill (Rush, 2008), the government needs to be sure this money goes towards interventions for those with the highest risk of disease (Leviton, Rhodes & Chang). More consideration should be given to efforts such as those that took place in post-war East Germany, where decentralization and prevention were emphasized, medical stations were put in places of work, and an extensive health education program was started in public schools (Light).
While it has historically been an American tradition to rely on non-profit organizations for public health interventions (Leviton, Rhodes & Chang), they can no longer support the country’s needs by themselves. The private sector’s contribution to health expenditures has unfortunately been declining since the 1960’s (Hunt & Knickman). Overall, the private sector needs to contribute more of its resources to public health interventions – particularly the food industry and the tobacco industry, as their products cause the most harm to human health.
Public health does not get the attention it deserves because it is largely invisible, avoiding problems rather than fixing them (Knickman & Kovner). Unfortunately, American culture and Western medicine in particular tend to err towards the side of wanting to see “something being done,” even if that “something” is inefficient and unproductive. In addition, the general public often may not understand what public health comprises, “often supposing it refers to programs for the poor” (Leviton, Rhodes & Chang). It is difficult to change the mindset of the American population, to whom health advertisements appear “boring” and “largely misdirected” (McKinlay, 1974). Very often people follow “quasi-health” fads that they believe are meant to improve their health, and “to request people to change or alter these behaviors is more or less to request abandonment of dominant culture” (McKinlay, 1974). Another challenge is trying to convince education officials of the value of investing time in teaching children more health and nutrition information during the school day, as school curricula already face difficult time constraints.
A third failure of the US healthcare system is the inadequate attention that has been paid to the behavioral determinants of health. While a growing number of Americans do not have health insurance, even those who are insured still experience barriers to accessing healthcare (Billings & Cantor). Families that are eligible for services such as Medicaid may not even know what they are eligible for or how to go about using the services. This could be because of language barriers, cultural barriers, a failure of health professionals to properly explain to them the necessary procedures and paperwork, or a combination of these factors. Many immigrants may be unfamiliar and skeptical of Western medicine and may not seek it out, even when ill. Immigrants may also have fears about immigration status. Individuals who have Medicaid may not use it because of a stigma attached to it or having to wait long periods of time.
Further, research shows that ethnic minority groups use healthcare services more, but the service they are provided is of lower quality (Gabe). This is particularly true for investor-owned hospitals that evidence shows spend less of their resources on uninsured patients than do voluntary hospitals (Relman, 1991). Individuals without private health insurance – such as the uninsured or those with Medicaid – may receive sub-par treatment from physicians who do not benefit from low reimbursement rates, or may even be outright rejected by some physicians and hospitals that avoid certain types of patients in order to maximize revenues (Relman, 1991; Billings & Cantor). The uninsured may be more likely to seek care in an emergency room, either because they waited until a late stage of disease progression, or thought they would eventually be noticed there. And even once they receive attention, limitations to functional health literacy may impede proper use of prescribed medication (Billings & Cantor).
Solutions to improving access to healthcare necessitate culturally sensitive interventions. By modeling Great Britain’s National Health System, walk-in clinics that are “accessible, convenient, and customer-focused” and address social issues of underprivileged populations could be put in place, such as a nurse-led phone help line and walk-in centers with accommodating evening and weekend hours (Gabe). Special outreach by non-profits and local governments may also be needed “to take preventive and therapeutic measures out of the hospitals, clinics, and emergency rooms and deliver them to the population at highest risk” (McCord & Freeman, 1990).
Other solutions may include setting up commonwealth funds for easier access to insurance, requiring employers to contribute to their employees’ insurance, subsidizing insurance through increased taxes on health-damaging products such as tobacco and junk food, and starting programs that teach people how to manage chronic diseases effectively (Billings & Cantor). Maine, Massachusetts, and Vermont – three states where these interventions were successful – started out with comparatively low rates of uninsured individuals. Barriers exist for other states, where employer mandates and taxes may work “against states’ economic development efforts to recruit and retain jobs within their boundaries” (Billings & Cantor). Mandating employer-sponsored insurance would likely meet fierce resistance from the business community. Capitated payments and publicly funded managed care can also be considered, although Medicaid managed care could create yet more barriers for low-income patients, as the enrollment process may be too confusing, the new site may be too far away, and continuity of care may be disrupted (Billings & Cantor).
Clearly, on many levels, today’s US healthcare system developed together with American culture, bringing the capitalistic mindset along with it. Resources are limited, however, and the United States must make much wiser choices with regard to how it utilizes those resources. At the same time, bringing some humanity into the information-dominant, depersonalized domain of medicine could go a long way in improving the health of all patients. It is possible for the US to simultaneously solve its health crisis and its economic crisis, but it may be that the underlying problem is American culture: “values shape financing. They have to change before financing can change” (Light).
References
Billings, J and Cantor, JC. “Access to Care.” In A. Kovner & J. Knickman (Eds.). (2008). Health Care Delivery in the United States (pp. 444-476). New York: Springer Publishing.
Conrad, P and Schneider, JW. (1992). “Professionalization, Monopoly, and the Structure of Medical Practice.” In: P. Conrad, (Ed.). (2005). The Sociology of Health and Illness: Critical Perspectives (pp. 170-176). New York: Worth Publishers.
Feldman, PH, Nadash, P, and Gursen, MD. “Long-Term Care.” In A. Kovner & J. Knickman (Eds.). (2008). Health Care Delivery in the United States (pp. 238-265). New York: Springer Publishing.
Gabe, J. “The British National Health Service: Continuity and Change.” In P. Conrad, (Ed.). (2005). The Sociology of Health and Illness: Critical Perspectives (pp. 522-539). New York: Worth Publishers.
House, JS, Landis, KR, and Umberson, D. (1988). “Social Relationships and Health.” In P. Conrad, (Ed.). (2005). The Sociology of Health and Illness: Critical Perspectives (pp. 74-82). New York: Worth Publishers.
Hunt, KA and Knickman, JR. “Financing Health Care.” In A. Kovner & J. Knickman (Eds.). (2008). Health Care Delivery in the United States (pp. 56-83). New York: Springer Publishing.
Knickman, JR and Kovner, AR. “Overview: The State of Health Care Delivery in the United States.” In A. Kovner & J. Knickman (Eds.). (2008). Health Care Delivery in the United States (pp. 2-11). New York: Springer Publishing.
Leviton, LC, Rhodes, SD, and Chang, CS. “Public Health: Policy, Practice and Perceptions.” In A. Kovner & J. Knickman (Eds.). (2008). Health Care Delivery in the United States (pp. 84-124). New York: Springer Publishing.
Light, DW. “Comparative Models of “Health Care” Systems.” In P. Conrad, (Ed.). (2005). The Sociology of Health and Illness: Critical Perspectives (pp. 500-515). New York: Worth Publishers.
McCord, C and Freeman, HP. (1990). “Excess Mortality in Harlem.” In P. Conrad, (Ed.). (2005). The Sociology of Health and Illness: Critical Perspectives (pp. 30-37). New York: Worth Publishers.
McKinlay, JB. (1974). “A Case for Refocusing Upstream: The Political Economy of Illness.” In P. Conrad, (Ed.). (2005). The Sociology of Health and Illness: Critical Perspectives (pp. 551-564). New York: Worth Publishers.
Medicaid: A Primer. (2007). Kaiser Family Foundation.
Medicare: A Primer. (2007). Kaiser Family Foundation.
Nestle, M. (2007). Food Politics. Berkeley, CA: University of California Press.
Nuland, SB. (1995). How We Die. New York: Random House, Inc.
Relman, AS. (1991). “The Health Care Industry: Where is it Taking Us?” In P. Conrad, (Ed.). (2005). The Sociology of Health and Illness: Critical Perspectives (pp. 268-274). New York: Worth Publishers.
Rodwin, VG. “Comparative Analysis of Health Systems Among Wealthy Nations.” In A. Kovner & J. Knickman (Eds.). (2008). Health Care Delivery in the United States (pp. 152-187). New York: Springer Publishing.
Rush, B. (2008). “Turning Urban Deserts into Urban Oases.” Retrieved October 10, 2008, from TheHill.com. Web site: http://thehill.com/op-eds/turning-urban-deserts-into-urban-oases-2008-06-10.html
Kelly Moltzen
Community Health & Medical Care P.11.1830.002
Professor Soffel
December 18, 2008
Healthcare, Culture, and the American Economy
The United States spends 16% of its Gross Domestic Product on healthcare – more than any other developed country in the world – yet ranks poorly in comparison to other developed countries in terms of life expectancy. There are many contributors to this paradox, most of which have to do with the fundamental structure and culture of the US healthcare system. Money funneled into the healthcare system currently overemphasizes spending on long-term care for the elderly while inadequately funding public health programs and failing to account for behavioral determinants of health. It should be noted that “virtually no one in Canada or Western Europe views the U.S. health care system as a model to emulate” (Rodwin).
The first inefficiency of the US healthcare system is that it overemphasizes spending on long-term care for the elderly. Medicare and Medicaid together account for 19% of total US government spending, but the majority of this money goes towards a small number of beneficiaries. With the number of Americans over age 65 growing due to the aging of the baby boomer generation, the United States cannot afford to continue spending excessively on this population. In 2006, ten percent of Medicare beneficiaries accounted for more than two thirds of Medicare’s $374 billion budget, while 52% of beneficiaries accounted for only two percent of expenditures (Medicare: A Primer, 2007). And while the elderly and disabled comprise 25% of total Medicaid enrollees, they account for 70% of Medicaid’s $316 billion in expenditures, leaving only 30% of the funds for the other 75% – children, parents, and pregnant women (Medicaid: A Primer, 2007).
The majority of spending on healthcare for the elderly is on nursing home care, with 44% of Medicaid spending going towards nursing homes (Medicaid: A Primer, 2007). Yet nursing homes are not the most efficient way for the elderly to be cared for, as nursing homes are a very expensive business. In addition, they are generally understaffed, do not provide optimal care, and “many elders say they would rather die than live permanently in a nursing home” (Feldman, Nadash, & Gursen). Elderly people deserve to be treated with respect, and taking away their autonomy by forcing them to live in institutionalized settings denies their “right to take risks in order to lead a preferred lifestyle” (Feldman, Nadash, & Gursen). This “medicalization of everyday life” is not only draining the US budget, but is unfair to the elderly who normally prefer to live on their own as much as they can. Therefore, less costly ways to care for the elderly should be considered, such as in continuing care retirement communities and other residential alternatives (Feldman, Nadash, & Gursen). Consumers – no matter what their age – should have a say in what type of services they will receive through personally directed care. Many elders would prefer informal care while living at home or with family members, although this can be exhaustive and financially draining to their caregivers. By providing elders a specific allotment of funds for personally directed care, they could choose to hire who they saw fit. In any case, a primary goal should be ensuring that people die with dignity (Nuland, 1995).
A more humane future for America’s elderly can be expected to encounter various barriers, principally high costs of care, no matter what options are considered. The services Medicaid purchases for the elderly (i.e. nursing homes) are primarily provided by the private sector (Medicaid: A Primer, 2007), but if money were spent instead on purchasing care in public, non-for-profit institutions, or home-based care, it might cost less. However, many people may be concerned about quality assessment in home health care and assisted living facility settings (Feldman, Nadash, & Gursen). There needs to be a shift in the mindset of Americans and the culture of the healthcare system which currently seems to be more concerned with keeping people alive than ensuring the elderly can enjoy their life and maintain social relationships, which not surprisingly seem to have beneficial effects on health (House, Landis & Umberson, 1988). Yet getting Americans to change the way they conceptualize caring for the elderly will continue to be very challenging.
Another reason for the inordinate costs of healthcare in the United States is an inadequate funding of public health programs, with less than four percent of healthcare funds going towards public health (Hunt & Knickman). Although improvements in health have historically come from public health – not medical – interventions (Conrad & Schneider, 1992), the US healthcare system has become very focused on downstream interventions, which do not get to the root of the problem (McKinlay, 1974). These are extremely cost ineffective, and there are a “large number of unnecessary procedures” with “unexplained variations in practice patterns” and “unclear answers to rudimentary questions about which treatments [are] most cost-effective” (Light). Insurance providers and Medicare will pay for expensive end-stage medical procedures such as kidney transplants, dialysis, and amputations for diabetes patients, but will not pay for primary, population-based interventions that can prevent health problems, such as health education, public service announcements, and accessible healthy food. As McKinlay observes, “we long ago surrendered control of food…to private corporations…[which] have shaped the kinds of food we eat for their greater profits,” so much that “most people now eat more processed and synthetic foods than the real thing” (McKinlay, 1974).
The government needs to be much more stringent in enforcing restrictions on the advertising of unhealthy food products, as the food industry has a very influential voice in Congress due to the revolving door between Congressmen and lobbyists (Nestle, 2007). While a substantial amount of money has supposedly been set aside for public health interventions in the 2008 Farm Bill (Rush, 2008), the government needs to be sure this money goes towards interventions for those with the highest risk of disease (Leviton, Rhodes & Chang). More consideration should be given to efforts such as those that took place in post-war East Germany, where decentralization and prevention were emphasized, medical stations were put in places of work, and an extensive health education program was started in public schools (Light).
While it has historically been an American tradition to rely on non-profit organizations for public health interventions (Leviton, Rhodes & Chang), they can no longer support the country’s needs by themselves. The private sector’s contribution to health expenditures has unfortunately been declining since the 1960’s (Hunt & Knickman). Overall, the private sector needs to contribute more of its resources to public health interventions – particularly the food industry and the tobacco industry, as their products cause the most harm to human health.
Public health does not get the attention it deserves because it is largely invisible, avoiding problems rather than fixing them (Knickman & Kovner). Unfortunately, American culture and Western medicine in particular tend to err towards the side of wanting to see “something being done,” even if that “something” is inefficient and unproductive. In addition, the general public often may not understand what public health comprises, “often supposing it refers to programs for the poor” (Leviton, Rhodes & Chang). It is difficult to change the mindset of the American population, to whom health advertisements appear “boring” and “largely misdirected” (McKinlay, 1974). Very often people follow “quasi-health” fads that they believe are meant to improve their health, and “to request people to change or alter these behaviors is more or less to request abandonment of dominant culture” (McKinlay, 1974). Another challenge is trying to convince education officials of the value of investing time in teaching children more health and nutrition information during the school day, as school curricula already face difficult time constraints.
A third failure of the US healthcare system is the inadequate attention that has been paid to the behavioral determinants of health. While a growing number of Americans do not have health insurance, even those who are insured still experience barriers to accessing healthcare (Billings & Cantor). Families that are eligible for services such as Medicaid may not even know what they are eligible for or how to go about using the services. This could be because of language barriers, cultural barriers, a failure of health professionals to properly explain to them the necessary procedures and paperwork, or a combination of these factors. Many immigrants may be unfamiliar and skeptical of Western medicine and may not seek it out, even when ill. Immigrants may also have fears about immigration status. Individuals who have Medicaid may not use it because of a stigma attached to it or having to wait long periods of time.
Further, research shows that ethnic minority groups use healthcare services more, but the service they are provided is of lower quality (Gabe). This is particularly true for investor-owned hospitals that evidence shows spend less of their resources on uninsured patients than do voluntary hospitals (Relman, 1991). Individuals without private health insurance – such as the uninsured or those with Medicaid – may receive sub-par treatment from physicians who do not benefit from low reimbursement rates, or may even be outright rejected by some physicians and hospitals that avoid certain types of patients in order to maximize revenues (Relman, 1991; Billings & Cantor). The uninsured may be more likely to seek care in an emergency room, either because they waited until a late stage of disease progression, or thought they would eventually be noticed there. And even once they receive attention, limitations to functional health literacy may impede proper use of prescribed medication (Billings & Cantor).
Solutions to improving access to healthcare necessitate culturally sensitive interventions. By modeling Great Britain’s National Health System, walk-in clinics that are “accessible, convenient, and customer-focused” and address social issues of underprivileged populations could be put in place, such as a nurse-led phone help line and walk-in centers with accommodating evening and weekend hours (Gabe). Special outreach by non-profits and local governments may also be needed “to take preventive and therapeutic measures out of the hospitals, clinics, and emergency rooms and deliver them to the population at highest risk” (McCord & Freeman, 1990).
Other solutions may include setting up commonwealth funds for easier access to insurance, requiring employers to contribute to their employees’ insurance, subsidizing insurance through increased taxes on health-damaging products such as tobacco and junk food, and starting programs that teach people how to manage chronic diseases effectively (Billings & Cantor). Maine, Massachusetts, and Vermont – three states where these interventions were successful – started out with comparatively low rates of uninsured individuals. Barriers exist for other states, where employer mandates and taxes may work “against states’ economic development efforts to recruit and retain jobs within their boundaries” (Billings & Cantor). Mandating employer-sponsored insurance would likely meet fierce resistance from the business community. Capitated payments and publicly funded managed care can also be considered, although Medicaid managed care could create yet more barriers for low-income patients, as the enrollment process may be too confusing, the new site may be too far away, and continuity of care may be disrupted (Billings & Cantor).
Clearly, on many levels, today’s US healthcare system developed together with American culture, bringing the capitalistic mindset along with it. Resources are limited, however, and the United States must make much wiser choices with regard to how it utilizes those resources. At the same time, bringing some humanity into the information-dominant, depersonalized domain of medicine could go a long way in improving the health of all patients. It is possible for the US to simultaneously solve its health crisis and its economic crisis, but it may be that the underlying problem is American culture: “values shape financing. They have to change before financing can change” (Light).
References
Billings, J and Cantor, JC. “Access to Care.” In A. Kovner & J. Knickman (Eds.). (2008). Health Care Delivery in the United States (pp. 444-476). New York: Springer Publishing.
Conrad, P and Schneider, JW. (1992). “Professionalization, Monopoly, and the Structure of Medical Practice.” In: P. Conrad, (Ed.). (2005). The Sociology of Health and Illness: Critical Perspectives (pp. 170-176). New York: Worth Publishers.
Feldman, PH, Nadash, P, and Gursen, MD. “Long-Term Care.” In A. Kovner & J. Knickman (Eds.). (2008). Health Care Delivery in the United States (pp. 238-265). New York: Springer Publishing.
Gabe, J. “The British National Health Service: Continuity and Change.” In P. Conrad, (Ed.). (2005). The Sociology of Health and Illness: Critical Perspectives (pp. 522-539). New York: Worth Publishers.
House, JS, Landis, KR, and Umberson, D. (1988). “Social Relationships and Health.” In P. Conrad, (Ed.). (2005). The Sociology of Health and Illness: Critical Perspectives (pp. 74-82). New York: Worth Publishers.
Hunt, KA and Knickman, JR. “Financing Health Care.” In A. Kovner & J. Knickman (Eds.). (2008). Health Care Delivery in the United States (pp. 56-83). New York: Springer Publishing.
Knickman, JR and Kovner, AR. “Overview: The State of Health Care Delivery in the United States.” In A. Kovner & J. Knickman (Eds.). (2008). Health Care Delivery in the United States (pp. 2-11). New York: Springer Publishing.
Leviton, LC, Rhodes, SD, and Chang, CS. “Public Health: Policy, Practice and Perceptions.” In A. Kovner & J. Knickman (Eds.). (2008). Health Care Delivery in the United States (pp. 84-124). New York: Springer Publishing.
Light, DW. “Comparative Models of “Health Care” Systems.” In P. Conrad, (Ed.). (2005). The Sociology of Health and Illness: Critical Perspectives (pp. 500-515). New York: Worth Publishers.
McCord, C and Freeman, HP. (1990). “Excess Mortality in Harlem.” In P. Conrad, (Ed.). (2005). The Sociology of Health and Illness: Critical Perspectives (pp. 30-37). New York: Worth Publishers.
McKinlay, JB. (1974). “A Case for Refocusing Upstream: The Political Economy of Illness.” In P. Conrad, (Ed.). (2005). The Sociology of Health and Illness: Critical Perspectives (pp. 551-564). New York: Worth Publishers.
Medicaid: A Primer. (2007). Kaiser Family Foundation.
Medicare: A Primer. (2007). Kaiser Family Foundation.
Nestle, M. (2007). Food Politics. Berkeley, CA: University of California Press.
Nuland, SB. (1995). How We Die. New York: Random House, Inc.
Relman, AS. (1991). “The Health Care Industry: Where is it Taking Us?” In P. Conrad, (Ed.). (2005). The Sociology of Health and Illness: Critical Perspectives (pp. 268-274). New York: Worth Publishers.
Rodwin, VG. “Comparative Analysis of Health Systems Among Wealthy Nations.” In A. Kovner & J. Knickman (Eds.). (2008). Health Care Delivery in the United States (pp. 152-187). New York: Springer Publishing.
Rush, B. (2008). “Turning Urban Deserts into Urban Oases.” Retrieved October 10, 2008, from TheHill.com. Web site: http://thehill.com/op-eds/turning-urban-deserts-into-urban-oases-2008-06-10.html
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