interviews
Insurance Coverage Design
by Naomi Zewde
September 24, 2020
This interview with Naomi Zewde, an Assistant Professor in the Graduate School of Public Health & Health Policy at the City University of New York, and a research fellow at the Roosevelt Institute, was conducted and condensed by franknews.
Naomi | I focus on health insurance coverage and the economic and financial implications of insurance coverage design. I look at how these things affect household financial wellbeing.
franknews | We know that medical debt is rising. What is happening in the healthcare system that explains the increase?
The issue of consumer debt in general in America is almost like a slow fire.
If people don't have the resources to meet their basic needs healthcare, education, housing — these fundamental things end up being sources of debt.
In healthcare, people’s deductibles are growing at incredibly fast rates; deductibles are growing much faster than premiums, and certainly much faster than wages over the past decade. People are left exposed to a greater share of their medical expenses, and exposed to huge medical bills — typically more than what most people have in their savings. That creates a lot of stress and fear, and often the threat of that financial burden deters people from seeking care.
What drives the prices of care up?
We don’t know.
The United States spends more on healthcare, both in dollars and in percent of GDP, than any other OECD country, but it is not clear exactly what we are spending that on.
We have a lower life expectancy. We have fewer physician visits per capita. We have a higher rate of chronic conditions. Those who provide healthcare - physicians, nurses - are not necessarily reaping the benefits either. We know that the utilization rate of the healthcare system is not unique to the United States. So why are the prices so high? That is up for debate.
We do know a few things. One, we know that a lot of this money goes towards the vast administrative bureaucracy — something that is unique to the United States. We also know that the government in other countries set prices: they either operate as the sole purchaser and thus dictate prices or they dictate prices through legislation. In the United States, Medicaid has price controls, but private insurers can charge whatever they want. There is no real way for anyone to fight back. There's no designated person to say no, you're charging too much.
Based on your research, what effect does this have on households’ finances?
I have done work around housing evictions and medical debt. We found that Medicaid expansion reduces the rate of home eviction. Going into the research it was not necessarily clear what relationship the two would have, if any. It sounded plausible — people with chronic conditions, for example, end up having to choose between rent and care. But it is astounding to think about the fact that the design of our healthcare system can have these ramifications.
I also found, in a paper that came out last month, that for 25 percent of people who were uninsured before ACA, it's cheaper to file for bankruptcy than to reach a deductible of the subsidized ACA private insurance policy.
Wow.
It’s surprising right! But it makes sense and might explain why there is such low participation in ACA private insurance policies. The congressional budget office projected that 10 million more people would enroll in these plans than actually did; only 8 million people got these. They were way off. The paper investigates why.
And what did you find?
I suspected from the beginning that it was because the deductibles are so high. The median deductible for the silver tier coverage is $4,000. There is a sweet spot in terms of the subsidies that substantially lower your deductible and premium. If you make between $12,000 and $18,000 a year, subsidies will bring down the deductible to around $200. But once you make $24,000 a year as a single adult, you're facing between a deductible between $3,000 and $4,000. So in designing the policy, it was kind of like, we will give extra subsidies to lower-income households, but not in a way that reflects what it is actually it's like to live with these medical bills. It feels divorced from reality.
Our findings don’t necessarily mean the people have to declare bankruptcy. Bankruptcy sucks and hospitals also know that when you file for bankruptcy, they typically do not get anything out of it. So, they look to work with you. Neil Mahoney has a paper, Bankruptcy as Implicit Insurance, that essentially shows that hospitals tend to settle with consumers at their cost of filing for bankruptcy. Hospitals essentially say, whatever you were going to lose if you were to file for bankruptcy, just give that money to us instead.
That reminds me of what Deborah Thorne said in our interview with her: "As Americans, we often rely on credit cards to be our social safety net. And when that falls apart, we are left with bankruptcy.” What is your understanding of how we got to this place?
It's tied up with a social-political larger trend. I have been watching this show called the Black Journal from 1968 to 1977 with a bunch of progressive Black scholars.
I watched one that was right after Nixon got elected, and everyone was saying, "America is taking a turn towards facism. All of American’s white guilt money is gone.” I think that really well foretold this mass acculturation that happened under Nixon.
The United States is not unique in this march away from social egalitarianism over the last half of the 20th century, but we are living through the consequences.
How do we return protections?
There is this famous paper - It’s the Prices, Stupid. I think there needs to be some kind of direct effect on price.
You mentioned the government can do so by either acting as the sole buyer of care or passing legislation. What do you think is the best way to achieve fair prices?
Right. One way of doing so is through a single-payer system. I am actually working on a study now that is going to be published to the Roosevelt Institute that compares single-payer with a public option.
There are two things to know about single-payer that are useful in this context.
One, it would get rid of most of the bureaucracy involved in negotiating prices — the different insurance companies, the different kinds of billing, and different plans. Right now, every doctor's office has multiple people whose full-time job is to understand how to interact with every single different plan of every different insurance company. There are many people employed on the side of the insurance company as well. Under a single-payer system, that would be gone. There wouldn't be multiple different rules to understand, and that reduces the aggregate resource use that is allocated towards healthcare.
Two, a single-payer system is tax-financed. That is important in terms of equity. You get to decide what percentage of household income should be allocated towards healthcare. Basically, the way our healthcare system is designed now means that the more money you make, the smaller percentage of it you have to put towards healthcare.
It is regressive, and no one has a choice but to participate in it.
If we structure it as a tax-financed healthcare system, the way we fund most of our infrastructure, you just get to decide what percentage of household income you are going to take from each household along the income distribution.
interviews
In Conversation with Dalila Rodriguez of Children's Institute, Inc.
by Dalila Rodriguez
June 25, 2018
This interview with Dalila Rodriguez, the educational manager at CII, was conducted and condensed by frank news.
Would you start by introducing yourself?
I'm the education manager at CII. Once upon a time, I was a home visitor and then moved my way into a site supervisor position and was there for a couple of years. Now I'm the education manager. I have moved away from being the administrator over programs and getting that one-on-one face-to-face with families like I did back then. My role is to support staff development and to improve the quality of the services that we provide in all aspects, so curriculum and teaching instruction.
What are the services you provide and who are you serving?
We provide early childhood services educational programs for children and families, birth to five. We have a multitude of programs. One of them, for example, is our home-based program. Our home visitors go into the homes for families, we call that Early Head Start. We start with mothers that are pregnant and then up until three years old. So about 2.6, they transition into a center-based program.
Then we have our center-based programs, which we have from birth to five years of age. Those are called Early Head Start and Head Start center-based programs. We have also programs that are solely funded by the state of California. Those are pre-K programs. We serve about 2,000 children in the community approximately.
Within our Head Start framework, it's a comprehensive program. It's not just educational-based services, but rather it looks at the entire family unit. We know that at that early age, in early intervention programs we want to make sure that we're addressing the entire family. There's someone whose sole role is to work with the families to find out what their goals are as a family.
Then it's the family community partnership team's role and responsibility to build partnerships in the community where we can get resources that are going to support that family. We actually have parents that have finished school, finished their degrees, and work for our agency now, which is amazing to know that, wow, this parent started coming in and asking for help for their child but ended up getting support for themselves, too. We also have a health department. We have a registered nurse on staff as well as a consultant.
We also have our mental health managers. We have a mental health component and we have specialists that go out to the sites. The teacher identifies that there may be a concern with the child experiencing some type of stress or trauma, atypical behavior. They'll write out a referral, they'll send it out to the team. The team goes out and observes the child and then identifies if they qualify for early intervention or if it is a disability ... usually it's both. We all work together: education, disabilities, and mental health. We call it the dream team. All of them have a role in observing on different days and times to see the child's behavior and to make sure that from the education lens, the teacher doing everything they're supposed to be doing to make sure that this child has the environment and the experiences that they need to be successful in the classroom.
Wow. That's a lot. Let's take a step back, can you specific "community" and who you serve?
The Los Angeles population. We concentrate our services to the highest need communities, so for example, our highest concentration of Head Start programs from three to five are in the South Los Angeles area. Our main office is right on Figueroa and Florence. All of the schools, we have about 20+ schools that are within a five mile radius of that center. We have schools in our housing developments over at Nickerson Gardens, Imperial, Avalon.
Are you in Jordan Downs as well?
We're in Jordan Downs, Imperial Courts, Nickerson, Avalon. Yes, we're in all of them. We're also in the South Vermont Green Meadows area, so on the other side of the 110 Freeway. We go as far as Western. That's about as far as we go. The best way I could gauge it is about a five mile radius. We have services out in Compton as well.
What percentage of the kids you're working with are dealing with a parent who's incarcerated?
Percentage-wise, I wouldn't be able to tell you. I could ask our family community partnership specialist because during enrollment, those are some of the things that they may or may not disclose.
It's not something we really quantify where we're like, "Oh, this many children have this many parents incarcerated." It's not something we track to a certain extent.
How do you engage with children who are dealing with trauma?
It's very case-by-case. Basically the way it goes is if the teacher identifies or the home visitor identifies there's something happening here that's not typical, they'll reach out to their mental health specialist. The mental health specialist observes and then from there, we have to have consent. A lot of the barriers we find is obtaining consent.
That's one of the areas we're working on currently. Our mental health manager and FCP manager just got a grant to do some work with families around that. We just started that journey recently. Let's say they do sign the consent and we do get that acknowledgement from the parents, the mental health specialist and the education team that is working with that child go in to provide some early intervention support for the teacher in the classroom first. Step one will be to set up some classroom strategies that are going to help support that child. Right now what we're working on is in implementing a new social emotional curriculum. It's called Conscious Discipline, which is an adult first approach. Something we've noticed too is that teachers are not equipped.
When I went to school, no one told me this is something that you could potentially experience and here are the strategies for you to use in the situation. It's very much the education component and not as much like these are children that ... these are some of the common things you'll see when you see a child that is experiencing stress or trauma. You really learn as you go.
Part of the adult first model is really helping them cope first. Practicing relaxation exercises, how to breathe, how to channel some of your positive energy into that child, and then be able to understand also what is happening in that child's physiological state.
We've been learning a lot about brain development and what trauma causes to the brain. We call it QTIP, Quit Taking it Personal. It's not about you, it's about what's happening to this child. We're supporting teachers and learning how to first cope with that. Then what you transpire or what you're feeling, you're going to emanate. You're going to transfer that to the child. Our goal is to calm them, so how do we calm ourselves first and then approach?
We work on setting a plan with the family. The teacher, the family, the administration, the specialist all get together and have a multidisciplinary team meeting. We acknowledge the parent for whatever things that are happening in the home. Sometimes the home and the school can be very different. It could be that they're great at school and then at home, the parent is really not able to know how to work with the child, or vice versa.
There are times when we refer to our overall CII mental health program, which are more intensive therapies like Parent Child Interactive Therapy. PCIT. The Parent Child Interactive Therapy program is one of the ones that we refer to the most. Again, it's parent-centered, so it's focusing on the parent's role and how they interact with the child.
How does CII decide where there needs to be a physical presence?
The CII's overall mission has always been to work with children and families that have been impacted by some sort of trauma, violence, things that are happening in the community. We acquired the grants over in the Watts/South Los Angeles area about four years ago.
Head Start has very rigorous requirements that we have to follow. Sometimes agencies do not keep up to par with what the Office of Head Start requires.
What is the Office of Head Start?
The Office of Head Start is the grant that we acquire from the federal government. This is how we get the money to offer the services that we provide.
Is everything is government funded here?
Not everything, but mostly. Most of it comes from the Office of Head Start, which is a federally funded government program. That's a nationwide program. We also have state funding, which is the California Department of Ed. For example, this school is a state funded school. They're solely state funded.
Are the national and state guidelines different or at all contradictory?
They're not necessarily contradictory. They're different in the sense that they don't have the comprehensive component. Early Head Start and Head Start that come from the federal government require the comprehensive model.
And the state does not require that.
The state funded programs are more modeled towards families who are experiencing poverty, but are working and/or are going to school, so they qualify for these services. They're still families experiencing poverty. With Head Start, what we find, is that it's more intergenerational poverty where they are not coming out of that cycle. With State funded, we see that they're more young parents that are wanting to go to school but cannot afford childcare. There are immigrant families that have come here and are having trouble finding work, or they may work but they're not making very much. They're making minimum wage.
Are there guidelines where you are dealing with immigrant families?
No. At this point, we don't ask for immigration status. In terms of second language learners, for example, this population here Mid-Wilshire and Otis Booth, this location is highly Korean. They are also coming in with ESL, second language needs. They're also experiencing the same types of immigration issues and poverty issues that all of our Hispanic families are. It's just that we have to modify in terms of language and making sure that we have translation and things like that available for them.
One of the things that I know our family community partnership team has been working on is doing workshops and informationals at parent meetings regarding immigration.
We know our families are experiencing things that are beyond even our comprehension. When you hear the things that happen, it's just like, "Okay. Wow. Where do we start?" I know that's going to be one of the things we're going to see. I know from experience with knowing families that your automatic instinct is don't call the police. Don't go to certain events. Don't go to these things because then you just don't know. Now, with the whole separation of families, who knows what ... That's just an added layer of fear. Fortunately, I feel like we've built a good rapport with the community that we've been working with to support them in still coming to us. It seems like they're still bringing their children to school.
Part of the work that we're doing is trying to really let families know how much more we have to offer because of the type of funding that we have. That we're not just focused on the child's education, we're focused on the whole family's success as a family unit and getting them out of poverty and trying to support the steps that they need to do that. If they've experienced trauma, then getting them the tools and the resources that they need to be able to not only help their child but to help themselves to overcome.
What do you feel is CII's most urgent work?
One of the overall common trends amongst families is wanting the best for their child and wanting to learn how to support their child through the educational system or understanding development and milestones. For us, we have this window of opportunity to get the families in and build trust with them so that they know that we have their child's best interest in mind. While we will get to the educational pieces, we know coming in as an agency that understands trauma, that we're not going to get to the educational pieces now.
Part of the early childhood services side is really helping parents understand development and understand how the environment in the family impacts their child. We can't get them to write their name until we can help them self-regulate and sit in a chair. If your child is still running rampant in the classroom, they're not really ready to learn how to do one plus one, or know their shapes, or know their colors because there's something happening.
Educating the family is our highest priority in terms of really supporting them as educators and advocating for them to say, "Okay, I understand what is good for my child. I understand that learning in terms of academia will come when I have the foundational pieces in place."
Do you feel like CII is on the right path in the way you're working with these families?
Taking a look at our data is very important to us and really analyzing it and understanding what it's telling us so that we know whether or not we're on the right track and what different things we can do to approach it. We can make assumptions all we want, but at the end of the day, what type of data do we have to support that? As of now, it seems like we're on the right track.
Some work we're doing this year is really getting teachers more trauma informed-style trainings that are going to help them understand the process of trauma. What to look for and how to understand it and then build some empathy around it so that they can cope. Then they can do their best to support that child and their family. It's all around understanding the brain. They call it the survival state, the emotional state, and the executive state. They're all pieces of the brain and how they work and how they work when under stress, when under trauma. Then how do we get to the executive functioning? It's really interesting work. I love the adult first approach to it.