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
Rote Memorization Won't Do
by DeNora Getachew
April 15, 2019
This interview with DeNora Getachew was originally published November 7, 2018 in our Civics issue.
DeNora Getachew is the New York City Executive Director of Generation Citizen, the flagship local site of a nine year old national nonprofit dedicated to bringing civics education back into the classroom through a new, engaging pedagogy: Action Civics. DeNora, an attorney by training, was a democracy nerd before it was in vogue. She had her civic engagement moment as a young pregnant teen advocating for her ability to remain at her high school instead of transferring to an alternative high school for pregnant teens. But it was not until after she graduated from law school and began working to eliminate the structural barriers to participation that she realized the power of her experience as a young pregnant teen.
This interview was conducted and condensed by frank news editors.
DeNora: Thanks for being with me today and giving me the opportunity to talk about Generation Citizen. I'm DeNora Getachew the New York City Executive Director of Generation Citizen. We are a 9 year old national non-profit focused on educating and empowering young people to be civically engaged. Our solution is simple and it's common sense, and it's necessary. We partner with schools to implement Action Civics in the classroom in order to give them the knowledge and skills they need for lifelong civic participation in our 21st century democracy.
Why does this not already exist in public schools?
Civics education does exist. It doesn't exist in the way that it once did. If we look back in our nation's history, back in the 1960s, students took as many as three courses before graduating high school relating to civics and democratic participation. And now, we're lucky if students take one class. But it's not about whether or not there's a class in schools, it's about the quality and caliber of that class.
The reality is, School House Rock might've been great for our grandparents, but if you can like and tweet and activate yourself online using social media, memorizing government facts isn't going make you feel like you can make a difference in your community. So it's about having Action Civics, having experiential learning as a way to educate and empower young people. Civics exists, and the majority of states have some class that pertains to civics, so it's about, is it experiential learning, project-based learning, is it student-led work – Action Civics.
When structuring courses for Generation Citizen, aimed at Gen Z, do you take into account their online lives?
It's a delicate balance because we want to both meet the millennials and Generation Z'ers where they are without also tipping the scale.
I want to be clear, both as a leader, but also when we talk to our educational partners, that you have to engage students to be digitally engaged civic learners, but you also have to teach them that systemic change includes the other tools in the toolbox that require us to meet elected officials in person, call them, write letters, engage in petitioning, etc. and that isn't only going happen online. You still need the actual face-to-face engagement in order to fuel long-term systemic change.
What do you think about organizations that focus on civic engagement through celebrity?
I honestly think that participating in democracy is a full-contact sport, so when you're engaged in a full-contact sport you're going need all the tools in the toolbox. I don't want us to over-celebritize civic engagement, so I am glad that everybody from the Taylor Swift's of the world to President Donald Trump are using social media and celebrity to get people to be engaged in a way that we've never experienced, or we haven't experienced, in a long time in our democracy. We still need every day Americans to know that their voice matters and that they too can push for systemic change, and that's the work we're doing. Both in our urban centers like New York, Boston and the Bay Area, but also in rural communities in Texas and Oklahoma.
Why do you think civics has been largely taken out of the classroom?
I say this with all due respect for the STEM/STEAM movement, we can date it back to the 60s, but when we look at the history it was this moment when America was having its Sputnik moment and thinking about how it stayed globally competitive in the STEM sector, and really how do we race to get to the forefront of that. That forced us to de-emphasize, probably not even intentionally, experiential civics learning in the classroom.
Our founders founded this democracy with the goal of having an electorate, a populace, that understood how democracy works and that they were gonna engage in it. And again, I say that to go back to this fundamental notion that I believe that it takes all of us to participate actively in democracy, and that isn't all day, every day, but we all have to engage with it, and not just on election day.
Once we started thinking more about what it meant to be active Americans from a capitalist's perspective, and not as much from a citizenship perspective and a democracy perspective, we lost sight of the priority, both of our public education system but also of democracy at large and its responsibility to make sure that all Americans can participate in democracy.
What tools are most effective to get people to learn this?
We have to meet people where they are, and I think that's the power of Generation Citizen and our work, and our Action Civics curriculum. We are nine years old and we've been doing this work in six states by-and-large over the last nine. We're in Rhode Island, where we were founded on Brown University's campus at a pivotal moment for our American democracy. It was 2008, if we harken back to that moment, America was having a historic election, potentially to elect the first African-American president of the United States.
And our co-founder and CEO, Scott Warren realized at that time when he was a student at Brown University that Americans are standing in line for hours and participating at record levels at the Federal level, and in national elections. Almost very similar to this one where we are now, where we're seeing early voting turnout in Georgia, three times above what it normally is, but that people don't turn out in local elections, that people don't wait in line to vote for their city council member or their mayor or their public advocate, because they don't view it as a critical responsibility or it doesn't impact their lives in the same way.
He had this idea of, how do we get to the root cause of fixing civic participation at the local level. By reinvigorating civics education in the classrooms. He had this idea of piloting this Action Civics approach in the Providence school district, expanded to Massachusetts, down the Northeast corridor here in New York where I have the pleasure of being our New York City Executive Director. We went to the Bay Area where there's also this big urban center, and a big education system that we thought we could influence there.
Then took a pause in our organizational growth, and launched our two new sites in Oklahoma and Texas, and realized in this moment, what is missing, is we are not teaching young people experiential learning as much as we are in the classrooms anymore. With all due respect to the education system, it is by and large driven towards metrics based outcomes – how well do you perform on a standardized test. But not all learners perform well on standardized tests. In fact many young people who drop out of high school, one of the largest reasons they drop out of high school is because of the fact that they don't perform well on standardized tests, and in fact experiential learning resonates better with them.
When we think about the work that we are doing, to reinvigorate civics education and making sure that it's student led, it's project based, it is action oriented, is making sure that we could make it the most exciting subject that's taught in the classrooms again as opposed to the most boring.
By getting young people to build consensus about an issue that is personal and local to them, and getting them to understand that they can be in the drivers seat for how they can affect change in their community, we are activating them to use all the tools in their toolbox to be change-agents, be that now in the short-term in the confines of a classroom, or, and more importantly, in their lives largely.
I want to say unequivocally that we do this work in a nonpartisan way and we do it with the goal of activating young people to be civically engaged long-term. It isn't just about what happens in the classroom, it's about how does that civic knowledge, understanding the branches of government, the School House Rock component if you will, and those civic skills, so if I have a problem in my community, who are the decision makers, what am I asking them to do? Is it legislative, is it policy-making, is it budgetary in nature, is it increasing youth voice in decision making, the skills are what's going help them understand how to use that knowledge and apply it and be motivated and have that sense of agency or disposition long-term.
What are the biggest challenges you face in achieving that goal?
That that's the exact opposite of what's happening in a public school classroom. When you ask teachers, when you talk to them about the importance about civics in the classroom and experiential learning, they're excited about it, they're hungry for it, but no one's educating them, no one's equipping them to teach that in the classroom. In fact, the incentives structure and how we compensate teachers is driven towards that metrics-based, outcome-driven success for students, so if their students are performing better on standardized tests, then they achieve tenure, or they get bonuses, or they get raises. When instead we're not preparing teachers to prepare students to be citizens. Often times the barriers that we face are that educators themselves don't have that sense of civic knowledge or civic skills. And so they're like, how do I teach someone else how to participate in democracy when no one's taught me? The number one question we often get at Generation Citizen is, do you have this for adults? And the reality is, many of us need this.
It's a problem for our democracy. We don't actually understand how it works, understand why it relates to us, then how are we going engage in that full contact sport? The biggest question and the biggest obstacle we face, is educators who don't want to reveal that they themselves don't have that core set of knowledge and skills. We want to equip them to do it, so that they can equip the next generation to do it.
What's been the most surprising thing about working at Generation Citizen?
I don't know if it's surprising as much as it is inspiring, that young people, we don't give them the benefit of the doubt. So part of it is as a society, there are certain things you cannot do until you reach the age of majority. To be that 18 or 21, depending on what it is you're trying to accomplish. But that young people have this insatiable appetite for change and for thinking outside of the box that we don't always give them credit for.
What's powerful to me about this work, is that when you go into a classroom, you have these young people who started the semester skeptical, and they'll be honest. Because they're also so pure, the cynicism hasn't set in yet, they don't understand what they can or cannot achieve. They look at us and they're like how did you get here, who invited Generation Citizen to the classroom? And so they're skeptical and they're like what is this Action Civics thing, why do I care, how is this different from anything else I'm doing?
You're going let me, during class time, call an elected official, or write a piece of legislation, or advocate for something that I need in my community, be it something as simple as a traffic signal at a dangerous intersection, to legislation to allow for updating the school curriculum around how addictive opiates are? You're going to let me do that, in this classroom?
Once you see that spark get lit up for them, to me that's what's inspiring. It's both an obstacle and a source of inspiration for why I do this work. Then you see the power of young people to lead change, and if you look at it from a history-nerd's perspective, that young people are always at the forefront of change, we just don't always give them credit for it because the adults always have the bigger microphone, the bigger voice, the better kind of sophisticated language to talk about what it is. I'm always proud of that, of just seeing that if we let young people lead, if we give them the chance and the opportunity and the tools to do so, they rise to the occasion again and again.
What's one key take-away that you want people to know about civics education that they don't already?
That despite it feeling in vogue now, my phone rings more often, I get more emails inquiring about our work and how to engage with it than I ever did, two years ago when I started here, having left the structural barriers to the participation side of the house, as I fashion myself a democracy nerd for life, civics education was always this luxury item that was gonna be at the bottom of the list. If we fixed all the structural barriers, we'll make elections more accessible by having reforms like early voting, and automatic voter registration and online voter registration, you name it. And if we can have a better campaign finance system so that every day Americans can run for office, then we could re-institute civics.
I got here two years ago, and I'm like, but no we need to re-institute civics now, and forever, because if we don't, if we get rid of all the structural barriers of participation it'll be for naught because no one will understand why it matters. For me, that's the power of Action Civics and that's why we need it now and forever. I don't want to get caught up in this cliché of like, "it's the most important thing we need," or "this is the right moment." We've always needed it, the founders believed that over 240 years ago, I'm sitting here very humbly saying we need it today, and I want all of us to understand why.