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
Came as a Journalist, Stayed as Friend
by Celeste Fremon
October 15, 2019
Celeste Fremon is an award-winning freelance journalist specializing in gangs, law enforcement, criminal justice and education policy, the founding editor of WitnessLA.com, and author of "G-Dog and the Homeboys."
In the midst of the media's drug war hysteria of the 1990's, Fremon's perspective was divergent. Her integration into a Los Angeles community allowed her to report beyond headlines.
As we focus on the press, this interview with Celeste Fremon reexamines how relationships can change the depth of a story.
This interview was conducted and condensed by frank news and originally published on June 12, 2018.
Can you introduce yourself a bit?
The fall of 1990 was the first time I took the drive that would change my life, which is to go to meet this priest I had heard about that was working with gangs in Boyle Heights, he was the pastor of Dolores Mission, which was the largest parish in Southern California. He was having a lot of luck working with street gangs, and it was at the height of the gang crisis in Los Angeles.
This little mile-square area that was then the Pico-Aliso housing projects had, according to the LAPD, the highest level of gang activity in Los Angeles County, and since Los Angeles was at that time the gang capital of the world, that mile-square area was probably the most intense area for gang activity on the planet. It seemed like a really interesting laboratory to see what this gang thing was about. I talked an editor of mine at the Los Angeles Times Magazine into letting me do a story on an alternative school that this priest, Father Greg Boyle, had started.
I realized very quickly that the story was about the kids he was working with and that the guy and the school was just a tiny part of it. I wrote the story for the Times, but I was so fascinated with the depth of the stories I was seeing with the moms and the dads and the sisters and the homeboys and homegirls and the family interaction and the community interaction and the complexity of it that I sort of never left. I developed an unlikely expertise of LA street gangs.
We were madly passing, in the state of California, legislation that was getting tougher and tougher with sentencing enhancements. What I was seeing was hurting kids. That was the beginning of how I started reporting on criminal justice and juvenile justice because, once I pulled on that thread, all kinds of other topics came down, and I think finding out what you want to do is as mysterious as falling in love.
Had you met me 30 years ago, you wouldn't have said, "As a white chick, former USC song girl, what you should probably be reporting on is Hispanic street gangs." But I felt at home and this is what I'm meant to be doing, and one topic led to the other, and I've reported a lot on law enforcement and prison policy and all kinds of juvenile issues having to do with the justice system, and most of it here in LA.
Long answer to a short question.
Who is most impacted when a member of the family disappears via incarceration?
In the incarceration mania that occurred in the 1980s and 1990s, what we failed to take into account — and what I saw up close because the more I reported in these communities and became friends with moms and sisters, are all of the collateral effects. I came a journalist, and stayed as a mom and auntie and friend.
Right now, of the 2.3 million people in prison in the United States, 52 percent of the state inmates and 63 percent of federal inmates are the parents of minor children. To put it another way, according to the Bureau of Justice, 2.3 percent of the US population under 18 have a parent or parents in prison. In addition to all of the shame and stigma that occurs with kids, it has such a profound effect when a family member is removed.
A guy who might have been low level, selling drugs — that was only part of who he was. He was also the guy who babysat for his sister who was struggling or was there for his mom or had all kinds of other functions in the community and in the family. You see all these people disappear from the community and it had a crippling effect, not just on families, but on the communities themselves, and watching that close up, anecdotally, you could just see the damage that was being done.
I remember I talked to Father Greg where I'd seen most of the people in the community where I was reporting were suffering from a high degree of what appeared to be PTSD. Now, we talk about it as early childhood trauma. People have been rigorously studying it, but at the time, all of these effects of being in a war zone and also having seen family members vanish into prison, the trauma led... There was a study done at Stanford where they went into some of the most intense Los Angeles neighborhoods and tested a bunch of the middle school kids and found that they had a high degree of PTSD — as severe or greater than service people returning at that time from Iraq and Afghanistan.
I even saw symptoms blossoming in me because I'd been in situations where I got shot at accidentally. They weren't aiming at me, but I was in the line of fire. More importantly, I saw kids I got to know be killed and went to a lot of funerals. For most of the people in these communities, it seems like everybody's been through that, and the trauma is very deep from being around a lot of violence and also having family members removed into the prison system. It's only now that we're starting to address that stuff and see the harm that's being done.
How does this adolescent trauma stay with people as they become adults? Are they being equipped with any tools to deal with it?
We're starting to see a little bit of it, but it's largely absent. A high majority of the kids that wind up in our juvenile system are suffering from a high degree of trauma. That affects their attention span. It affects their health. PTSD or early childhood trauma can mimic ADHD.
If nobody acknowledges that, it can have long-term health effects. If it starts to be acknowledged, there's stuff you can do. There's a lot of good work being done finally. We're acknowledging that these things are going on and that kids having a brush with any one of our governmental systems and our county systems, whether it's foster care or the juvenile justice system, are by definition coming in there with a high degree of trauma. If we don't admit that and address it, we're going to have problems and we're not going to be helping these kids.
Looking at LA county probation, which is the largest juvenile probation system in the country, they're trying to train staff in trauma. This is like a day-long training. That's not enough.
This is an agency where it's being talked about and the supervisors are all on board. The probation commission is all on board, and it's hysterical trying to get this done.
Thinking of you last night, I was talking to my friend about a then-young man I met, during the early-to-mid-'90s when I was reporting in Pico Aliso in Boyle Heights. He's not a young man anymore. He's been in prison for 17 years. He just got out and he called me because he remembered I'd been sort of an auntie way back when and felt I was a person he could trust and could talk to.
Turns out he spent 10 years in solitary confinement absolutely for no reason, under completely torturous circumstances. For so many years, we thought this would never change, and now in the state of California, we're starting to understand that the use of solitary really, no kidding, is torture, and that we do great damage.
At least it's actually changing. For so many years, it was very, very difficult to get public policy to change. But it's changing now.
How has gang culture shifted since the 90s in Los Angeles?
The gang culture is very different. Still a high percentage of homicides in Los Angeles according to Chief Charlie Beck. They are still gang-related, but our homicides are way down and the gang culture is very different. There are so many other ways people are looking to do rehabilitation, and it's not gang-centered. It's re-entry centered. The gang problem is still a problem, but there are a lot more problems.
So many of the communities, and the moms, and the fathers, and the men are feeling that they are the solutions to their community problems, and they're feeling, to use that horrible word, empowered to start organizations and programs to fix their own communities.
There are a lot of remarkable people who are doing work that come out of the communities themselves, rather than people coming in from the outside to be the helping entities.
The Youth Justice Coalition, they've got policymakers scared to death because you don't want to get in their way. They're relentless, thank heaven, and they're kids who have seen that they can help change policy. When I first began reporting, there were groups of mothers that had found their voices, but that's expanded many, many, many times over. That's a big cultural change.
Are you optimistic about what this next generation is facing? Do you think this generation coming up will see less incarceration and less violence?
I think that's the direction everything is turning, and oddly enough, there seemed to be a breakthrough around 2007, 2008.
I don't think that made all the difference, but the rest of the populous went, "Oh. Maybe we need to cut back on some of this nonsense."
But, yes, I'm much more optimistic because there's real reform coming out of the communities, and policymakers are listening and a lot of them are doing their own part to lead the charge. I'm much more optimistic when I watch kids like those at the Youth Justice Coalition. I was at a meeting recently, and one of the people on this board was a young woman from YJC, and she was just formidable. I don't know what her background was, but most of their kids have come out of a very at-risk situation and many of them have been locked up themselves.
They're becoming activists and organizers, and their blooming is really an inspiring thing to watch. There's still a lot of work to be done. I'm still amazed that so many people don't feel an urgency to make changes, particularly when it comes to the county's kids who wind up brushing up against these systems.
I think it's a very interesting generation.
Because I've followed the same people for such a long period of time, often since they were teenagers to people in their 40s, I see some of the people I knew and cared about get killed or get locked up for a very long time, but I've seen so many who, according to the cultural views of that time, people wanted to cross off. They were wonderful kids who were struggling with some really incredible burdens and were up to no good and were very, very at risk and very involved with gangs.
Now they're good moms and good dads and responsible working people. They were able to redirect the arc of their lives toward a very positive future with tremendous burdens affecting them while they did it. They're the best of victory stories. I don't know how I would have done with the kind of childhood and adolescence that they had, that were not of their choosing.
It's been both humbling and joy-bringing to have the privilege of knowing people over time who have really gone through the steps of trauma and have come out the other side to something really good and healthy. They're great miracle stories.
What do you feel most urgent about?
Any of the things affecting kids is really urgent. When I hear from policymakers and people in some of these big agencies that affect kids say,
That's how I feel. We have to feel that urgent. All of these kids are ours. We belong to each other. Are we willing to sacrifice a generation of kids in certain communities? Is that okay with us? If it's not, then we need to move heaven and earth to get to them. It's that urgent. It makes me nuts.
Somebody who worked for one of the supervisors a couple of years ago said, "It sounds like you're really upset about this."
I said, "Yeah." She said, "Well, yeah, but juvenile probation has always been that way. Why are you so upset?" I went, "They're children!" We can't ever be complacent. Most anybody I know, if they met the kids being adversely affected by the policies we have, if they just met personal kids and got to know them, they would be absolutely aghast.