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
Anti-Colonial Science & The Ubiquity of Plastic
by Max Liboiron
January 9, 2019
This interview with Dr. Max Liboiron was conducted and condensed by frank news. It took place December 4, 2018.
I'm Dr. Max Liboiron. I often introduce myself in Michif. So, I say, Taanishi. Max Liboiron dishinihkaashoon. Lac la biche, Treaty 6, d’oshchiin. Mtis naasyoon, niiya ni. Which means my name is Max Liboiron. I'm from Northern Alberta, treaty six territory, where I'm part of Mtis Nation, and I now live and work in Newfoundland and Labrador in Northeastern Canada.
I'm an environmental scientist and we do anti-colonial, feminist science – which means we draw a lot from the insights of the social sciences and also different traditional teachings and law, to inform our scientific practices. So that they are anti-colonial. So they are feminist. So that they do deal with questions of equity, questions of justice, questions of humility, and do work in a good way, as opposed to just an efficient way or a fact-y way.
Science, and research in general, has long played a role in colonial entitlement to land, both in proving that people deserve to be dispossessed in being the reason for research – we need to research tropical diseases so we can better settle in this tropical place, not our environment. Or, how do we patent different botanies? A lot of those legacies have stayed in science and aren't usually noticed anymore.
They used to be fairly contested, especially when science was trying to move into new places or when race was being scientized. But now people seem to have forgotten about that legacy. So our task at CLEAR, my lab, is to first of all recognize how science is already colonial, and then number two, work very hard to do the practices of science in ways that do not reproduce entitlement to land or universalism, which is actually just self portraiture of Europeans usually. The idea of mastery over nature, or that nature is a resource for use.
Courtesy of: Bojan Furst.
Every moment of science has these sort of legacies. There's lots and lots and lots of room for doing anti-colonial science and feminist science. Those are different things, but they're related in that they both find that science isn't neutral. It is deeply political.
Courtesy of: Max Liboiron. Plastics wrapped around a squid beak found in a Northern Fulmar. 2015
The presentation of your research, visually, is patient, subtle, pretty – completely different from the majority of images I see related to plastics research. Can you talk about the work you’re doing right now?
I'll start with the premise of that, which is that we, I think, look at plastic very differently than a lot of the dominant discourses. Like you said, a lot of the dominant discourse about plastic is that plastic is inherently bad, and it's a bastard child of industrialization, and it needs to be eradicated, and illegalized, and banned, and exorcized.
But also plastic is our kin, it's our relation. It's from ancestors – organic ancestors from a long time ago. And if you neglect your relations to that, then you're bad kin. Even when plastic is misbehaving, which means it's being bad kin, you can still do good kinship with bad kin. And you know this. You have an asshole uncle somewhere. He might be bad kin but you still call him on his birthday, or bail him out of jail depending on what kind of bad kin he is. The same thing is true of plastics. I spend a lot of time with plastics. I do a lot of care work for plastics. I make sure that they are cleaned properly and I look at them a long time, and when I look at them, and I look at them in aggregate, I learn things about where they've been, and how they might have got there, and what their journeys might have been like, and where they might be going, because they're going to go for a long time.
We hang out together a lot, and they have a lot to teach us. Trying to ostracize them as the only sort of relation you can get, misses a lot of teachings that they have for us and also a lot of the respect. Because they are made of the earth. They've been pulverized in various ways so that they're not very earthy anymore, but you still have to respect that.
There's a tension with that in that the research that I do is mostly ingestion studies. Animals that have eaten plastics. Mostly what we focus on are animals that people, especially in Newfoundland & Labrador, use for food, depend on for food. For cultural sustenance, for nutritional sustenance, for economic sustenance. So the contamination of that food web is a form of colonialism. It's based on the idea that land is pollutable in the first place, that it is an okay place to put wastes. And magically, not magically, it's through different power structures, those tend to accumulate in rural, Indigenous, northern communities, which are never the places that benefit from plastic production. Almost never, but pretty much never.
At the moment, we’re doing some ducks, cod, seal, some geese. We get them mostly from hunters and fishers. We have a rule in the lab, all of our samples have to be eaten because what we test is food. We don't test oceans or some abstract fish, we work on food sovereignty. That means we sample food.
Are you consuming it?
Often.
Is that difficulte after seeing what's inside of it?
No. It's delicious. In the area we're researching, we do find plastic, but we also find them in smaller numbers than we find them in other places. Up in the north, we're fluent in things like the breast milk debate. In the 90's there were these big debates where scientists found really high PCBs in breast milk, and there was this huge protracted debate as to whether or not mothers could be considered abusive for feeding their kids that breast milk. A lot of stigmatization, ostracization, really screwed up relations within science. It turns out after multiple years, scientists decided, and medical practitioners decided, that actually, it's better to feed your kids contaminated breast milk than it is to feed them formula for their entire lives.
That being said, we have some of the least contaminated food in the world at this moment. Maybe not going to stay that way, but we consistently find lower ingestion rates in say, cod or ducks, than in other places. Part of that is the water that surrounds the province that I work in comes from the Arctic. There are certainly plastics in the Arctic, and that number is increasing, but it's not like the Gulf Stream which is filthy, where a lot of people get their fish.
Courtesy of: Max Liboiron
What state is the plastic in when you find it in animals?
The vast majority of what we find are microplastics, smaller than five millimeters, that are fragmented from larger things. You can't usually tell what they're from. Most people don't eat the guts of animals, so we don't usually ingest those plastics. There are some exceptions. People here eat seal intestine, and if you eat the fish called capelin or sardines, you eat the entire animal.
The concern that we have is that we know plastics absorb oily chemicals. Like when you have your tupperware that's stained orange from your chile or your curry, that's because plastics is really good at sucking in oily chemicals. If you want to wash that orange color out, which is really hard, you would put it in hot, abrasic, acidic conditions, like a stomach.
My dogs eat plastic everyday and there's no crisis of the dog species. Most dogs eat plastic.
The albatross on Midway Island, Chris Jordan's photographs, drive me crazy because those birds did not die of plastics. In fact, albatross are one of the only marine bird species in the world that is increasing in population and range. They are the healthiest bird species literally in the world. Albatross die a lot because they're what's called an R-species. They live a really long time and have a baby every year, and the vast majority of those babies die. While those babies are dying and starving, they eat a lot of things that aren't food, including plastics. When you find an albatross that's dead with plastics in its belly, the incorrect assumption is that it died because of plastics, not because it was dying and thus ate plastics.
That’s a revelation & also cause for pause about what we’re panicking about.
I think we need to be concerned, but differently than we're currently concerned.
Right.
We're really concerned about objects that are plastics, and that is a concern. But more concerning are all the chemicals that originate in plastics and get absorbed by plastics, many of whom are built by the same industry. The petrochemical industry makes plastics, makes gas, makes plasticizers, makes fragrances, makes flame retardants. Those are the same companies. Those are the same set of products. And the plastic parts are like the vehicles or the vectors, and that's not great, especially because it assumes disposability and therefore access to land, which is a form of colonialism, to dispose of. But the health concern is really these chemicals.
Are you optimistic about the future of plastics? In our ability to innovate, or participate in change?
No, because I don't believe in end of pipe solutions. At all. And that's because I fully understand the scale of plastics. It's like trying to bail out a boat, but you haven't plugged the hole that's sinking the boat.
How about if we stop top of pipe? How about if we stop the production of disposable and ubiquitous plastics? People like GAIA, or Break Free From Plastics, which are these large coalitions that not coincidentally are global coalitions with a lot of people from the global south in them, those are the groups that are like, screw your end of pipe, because they're the end of the pipe. They're where American corporations are building their incinerators. They’re where the people are shipping their recycling to. And they're like no, these solutions clearly don't work. They just defer and shuffle the problem.
What you need to do is stop the pipe. That's what I believe in. This isn't a technological problem, this is a problem rooted in colonialism that assumes you get access to other people's land for your solutions, whether it's storing your pollution or your recycling or whatever. I'm really interested in things like China's recycling ban, which ripped a hole in the world's recycling program because the entire world's recycling programs depended on the idea that things went away, and away was China.
People are looking for other ways. They're like oh, let’s ship our recycling to other places in Southeast Asia. Oh, Vietnam. And you're like, no, no. China taught us something, folks. What it taught you was you're going to run out of aways, and your aways are going to get tired of you, and folks in Malaysia right now are fighting, fighting, fighting not to be the next away. That's colonialism. That's just waste colonialism. That's just the newest frontier in waste colonialism.
If I'm going to put my optimism somewhere and my change making somewhere, it's in that. It's in people being like no, I'm not going to be your away. Go find your own god damn away. Once we run out of that, or once we take ownership of that – when I say we, I mean industrialized nations mostly. I don't believe in most narratives of “we” because they make it sound like consumers can do something. If you live in Newfoundland, even if you live in other places, there's one fucking store. There's no such thing as consumerism or consumer choice. Reuse is already to the nines because there aren't a lot of resources. So all of the...banning straws? There are no straws.
The straw thing put me over the edge!
A lot of the common discourses make zero sense in the north. It's a handy barometer when someone's like, this is a solution! And you just sort of look around and you say no, not possible. Moving on. Really helps you scale and prioritize the types of things that might work.
What is the alternative to our dependency on mass produced plastics?
The alternatives would mostly come from industry. The number one product category for plastics is packaging. It's not more than half, but it's the largest chunk. Most of that packaging has been necessary only since the 50's. That's living memory. We could circulate goods in ways we remember from living memory differently than totally packaged in plastic. Yeah. They circulate differently. They don't circulate as far. It just means you have different distribution systems. The problem is that oil has just reinvested in plastics big time. Eight months ago they invested more money than they put in the last few years into new plastic production. So that's their call, right?
Why are they re-upping their investment?
I don't know. There was no discussion of why this, like why plastics? I do know, and I have studied historically the reason that plastics and plastic packaging in particular is so attractive to industry is because it is so cheap and it is so easy to turn a profit off of. Part of that is disposability. The fact that you don't have to be responsible for the end of life of your product. Some other country, someone else's land takes care of that for you. It's a huge cost savings compared to other things that are possible.
That's deeply upsetting.
It is. That's why any conversation about plastic, if it also doesn't talk about power, it's missed the boat. If it talks about individual agency and consumers, and it talks about empowerment but not power, it's actually missed the entire structure of plastic production and pollution.
Do you think large government policy can be effective in altering our use of plastic?
Yeah. If government stops subsidizing oil. I look for these things that are not the expected things, like China saying no. Or someone being like, no more corn. No more subsidizing corn for alternative plastic stocks, which makes plastic just like plastic. These unexpected things, because plastic is so dependent on these really extensive networks. Transportation, extraction, production, disposability.
Are more people understanding the relationship and connectedness between plastic and industry?
I don't know about more people, but I do think that key people do. Some of these international global coalitions, get it. A few key scientists get it. The Story of Stuff pretty much gets it. GAIA gets it. Teen Vogue gets it! These folks who have moved away from the end of pipeline story and the recycling story and the five small steps story, and have considered or deeply know power structures. That's increasing, a lot.
I've been working on plastic pollution since before it was cool, and the story has shifted significantly. The recycling and five small things continues to proliferate on its little treadmill, but there's now a lot more variety than there ever has before, especially as people are like holy shit, car tires. Holy shit, clothes. Holy shit. Those are things where you can’t just make a little shift because of their massive infrastructural ubiquity. People are starting to understand scale. Key people are starting to understand scale. Yeah. So that's nice.
How do you work to eliminate plastics but also acknowledge those who will likely become more disenfranchised by a rising cost of plastic, primarily medical items, that are dependent on plastics?
I work with folks who are at the periphery who aren't getting benefits. People who hunt and fish and need that food for all sorts of reasons. The thing is, if you think about anyone who needs plastic medical equipment – medical waste is different than packaging waste. I don't want a pacemaker that's not plastic. First of all, it's not possible. Second of all, I want my fucking pacemaker. But the thing is, there's ways to do that that is not about mass production, that is not about releasing and patenting and circulating chemicals that haven't been tested properly.
The problem isn't plastics. There are natural plastics. There are polymers that decay.
That's the problem. This idea that you either have to ban it all or take it all, you're like no. Those are not the only two things available. And I know this because I live in the fucking north. Concepts of ubiquity don't really work here. The all or nothing doesn't work in a lot of places, and that's obvious.
What would a local plastic economy look like? Huh. No one’s ever asked that question really. If you had to own the plastics, own the extraction of those plastics, own the chemicals that go in the plastics and the extraction of those chemicals, I bet your plastics would look a lot different. I bet you wouldn't have packaging. I bet you wouldn't have BPA. I bet you'd just move to something else half the time. And I bet you'd have plastic pacemakers.