Elisabeth Rosenthal at Politics and Prose (video)

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Elisabeth Rosenthal discusses her debut book about the American health care system


In her first book, Rosenthal, editor in chief of Kaiser Health News as well as an M.D., takes a comprehensive look at the country’s ailing health care system. By breaking down the whole into its parts, she guides readers through a complicated tangle of hospitals, doctors, insurance companies, and drug manufacturers, focusing especially on the problems that have arisen in recent years as more hospitals are run by business executives and more research charities enter into profitable relationships with drug companies. Rosenthal shows how these arrangements harm patients and suggests ways we can heal the system.

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Produced by Tom Warren

An American Sickness Book Cover (1)

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Conference Call with Elisabeth Rosenthal

Author of American Sickness

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Reader’s Forum – Frank Fear, Sr. and Frank Fear, Jr.

Rosenthal Demystifies America’s Health Care System and How to Fix It

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Frank Fear, Jr. and Frank Fear, Sr.

When beating cancer costs $17,000 a month, what do you do?read the newspaper headline. “1,495 Americans describe the financial reality of being really sick” reads another.  It’s no wonder that health care weighs heavily on the minds of America’s voters as they head to the mid-term polls.

That’s no surprise to Frank Fear, Jr., former vice president of a community hospital and current chief information officer at a regional health system. It’s no surprise to his father, Frank Fear, Sr., a cancer survivor.

Cancer had an indelible impact on Fear Sr.—and not just because of the disease. It was also because of the cost, which totaled tens of thousands of dollars. Fear’s cost-share was manageable. He had employer-sponsored health/medical insurance.

Fear, Sr. was fortunate. Many are not. That’s a problem. It’s America’s problem.

And it’s why Elisabeth Rosenthal’s An American Sickness is such an important book. A physician and journalist, Rosenthal shares her grounded perspective understandably and persuasively. “In the past quarter century,” she begins, “the American medical system has stopped focusing on health or even science. Instead, it attends more or less single-mindedly to its own profits.” (p. 1)

Profit-making isn’t a new story and it’s not even a bad story, either—at least on its face. It becomes a problem when for-the-public-good operations get out of balance, focusing too much on money and not enough on public obligations.

To make that point, Rosenthal analyzes the system’s components—insurance, hospitals, physicians, pharmaceuticals, testing services, medical devices, billing, and general management. The centerpiece of her critique is what she labels, “Economic Rules for the Dysfunctional Medical Market” (p. 8).

If you read nothing else from this book, read that material! The reason? Rosenthal pinpoints what needs to change, things like: More treatment is always better. Treatment is preferable to a cure. There’s no such thing as a ‘fixed price.’

Rosenthal doesn’t believe our current plight is caused by bad people doing bad things. Indeed, she recounts story after story of people and organizations doing good things. They share a common characteristic, though: swimming against the tide trying (as hokey as it may sound) to do the right thing.

What’s the answer? Rosenthal’s answer is clear: “return the system to affordable, evidence-based, patient-centered care” (p. 328). For that to happen, she says, “we need to…become bolder, more active and thoughtful about what we demand in health care and the people who deliver it. We must be more engaged in finding and pressing the political levers to promote the evolution of the medical care we deserve” (p. 329).

The “we” to which Rosenthal refers is us— everyday citizens. She’s right, but there’s a hitch, and a big one, too. Rosenthal’s advice applies to other areas in need of public reform (the cost of public higher education, for example), which require citizens to roll up their sleeves, be bold and knowledgeable, and get the political system to work as it should.

In all of those situations, resolution also requires ‘smarts,’ including the ability to figure out solutions that don’t generate a new set of problems. That’s especially important when change-seekers want BIG change (as they do in health care) by replacing existing systems with entirely new ones. (For Rosenthal’s critique of the single-payer model, go here).

That’s why the option we prefer involves fixing the system that exists in America today—the market-based system. That system isn’t the problem. The problem is that it’s not patient-centered.

What would it take to make that happen? First, the system needs to operate the way that other (and perfectly sensible) customer-driven systems work. And, second, the system needs to be wellness- not illness-focused.

Fixing the first problem means making costs more transparent and for health vendors/providers to be more accountable. Rosenthal gives plenty of examples of how to do both, including providing patients with upfront figures regarding the full costs of medicines, tests, and medical interventions—even enabling patients to price-compare. Doing that just makes common sense.

The second matter involves changing the mindset that drives the system, including the way that many of us think about health, doctors, and hospitals. Rosenthal gives examples of how organizations, states, and the Federal government have incentivized the health system to keep people healthy vs. paying them to treat patients when they’re sick. Examples include the Boeing Company (p. 289) and the State of Maryland (p. 298). Another example is Medicare Advantage.

What’s it all mean? The clock is ticking, just as it is with other critical issues facing America (e.g. climate change). In the meantime, too many people are being hurt as we stumble around trying to figure out how to improve the system.

At issue is figuring out what change is workable (politically and economically) and how to make change a reality. It’s with those objectives in mind that Elisabeth Rosenthal gives America a get well card—how to figure out both.

Frank Fear, Jr. is Chief Information Officer at Covenant Healthcare (Saginaw, MI), a non-profit health care system that serves twenty counties in central and northeast Michigan. Frank served previously as vice president at Memorial Healthcare (Owosso, MI), a non-profit hospital offering inpatient and outpatient services to those living in its 100,000-person service area. He received a B.A. in psychology from Albion College and graduated from Michigan State University with an M.A. in counseling psychology.

Frank A. Fear, Sr. is professor emeritus, Michigan State University, where he served as a faculty member and worked in a variety of administrative positions. He is primarily interested in how public and nonprofit institutions serve the public good. Frank currently works as Managing Editor/columnist at The Sports Column (Baltimore, MD) and writes regularly about social issues for the Los Angeles-based, LA Progressive

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Politics for the People

Conference Call

An American Sickness

With Author Elisabeth Rosenthal

Sunday, Dec. 2nd at 7 pm EST.

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Listen to Elisabeth Rosenthal on NPR’s Fresh Air

Shots - Health News shots   HEALTH NEWS FROM NPR

How U.S. Healthcare Became Big Business

“We’ve trusted a lot of our health care to for-profit businesses and it’s their job, frankly, to make profit,” Rosenthal says. “You can’t expect them to act like Mother Teresas.”

Below is the full transcript of the show, for those of you who would like to read it.

*Reminder*

Conference Call with Elisabeth Rosenthal

Author of American Sickness

Sunday, December 2nd at 7 pm EST

Call: 641-715-3605
Pass code: 767775#


TERRY GROSS, HOST: 
This is FRESH AIR. I’m Terry Gross. Have you ever looked at a hospital bill and been aghast at how expensive and incomprehensible it was, or tried to figure out which health care plan to choose and played the odds about whether you should go for the high deductible plan or not? Patients are told to be good consumers, but we’re navigating a system that isn’t exactly user friendly.

The new book “An American Sickness” explains how health care became big business and how the pricing and billing of medical services, devices and prescription drugs became so complicated even a lot of doctors don’t understand it. My guest is the author, Elisabeth Rosenthal. She’s the editor-in-chief of Kaiser Health News. Before that, she was a reporter at The New York Times. When she was covering health care for the Times, she wrote a series called “Paying Till It Hurts.” Before becoming a journalist, she was a physician.

Elisabeth Rosenthal, welcome back to FRESH AIR. Let’s start with some of your economic rules of the dysfunctional medical market. You say more competition doesn’t mean better prices. In fact, it can drive prices up. That’s a very interesting thing to say considering how much we’ve been hearing that if we repeal and replace Obamacare and make the market more competitive, it will be more favorable in terms of price for medical consumers. So why do you say that more competition can actually drive prices up?

ELISABETH ROSENTHAL: Well, what we see in health care is not like what we see in any other economic market. I mean, it’s sad. It’s amusing. It’s baffling, which is partly why I undertook this book. But basically if you look at drug prices, for example, there was a miraculous drug called Gleevec which really changed cancer patient’s lives when it came out maybe 10, 15 years ago.

Now there are many, many kind of copycat versions of Gleevec. We call them in the profession sons of Gleevec. And they’re all four or five times more expensive than Gleevec was when it came out. So if you were looking at a world where an economic market worked, you would think, wow, there are 10 of these now so the price should have come down – it hasn’t.

GROSS: Why not?

ROSENTHAL: Well, because the standard in health care has been usual and customary. So that kind of doesn’t let the market work. You may have seen that on your insurance bills, or you may have seen that when your insurer is saying this is how much we’re going to pay. It’s the usual and customary in your area. Well, what happens if everyone is charging five times as much as is reasonable? Well, then five times as much becomes usual and customary.

And it’s a very inflationary concept over time. So what you see because of usual and customary is that maybe a gallbladder operation will cost $50,000 in Nassau County on Long Island, but it might cost $10,000 five miles away in Queens. And that’s because the usual and customary in those two geozips are very different.

GROSS: So you’re saying prices rise to whatever the market will bear?

ROSENTHAL: Well, that’s the ultimate lesson of much of American health care is that prices rise to whatever the market will bear. And another concept that I think is unique to medicine is what economists call sticky pricing, which is a wonderful term. It basically means – and you see this over and over again in the drug sphere and also in the hospital chargemaster sphere – once one drug maker, one hospital, one doctor says hey, we could charge 10,000 for that procedure or that medicine. Maybe it was 5,000 two months ago, but once everyone sees that someone’s getting away with charging 10,000, the prices all go up to that sticky ceiling.

Maybe they come just a little bit below. What you see often now is when generic drugs come out, so there’s lots of competition, the price doesn’t go down to 20 percent of the branded price, it maybe goes down to 90 percent of the branded price. So we’re not getting what we should get from a really competitive market where we, the consumers, are making those choices.

GROSS: But the premise of the competitive market is that we’ll be shopping for the hospital or the doctor that does the procedure for the cheaper cost and that will bring prices down. Apparently things aren’t working that way.

ROSENTHAL: Well, this concept makes me a little nuts frankly because we’re told over and over again – and this is part of why I’m so obsessed with this – we’re told over and over again, oh, you should be a good consumer of health care. OK, right. What do you need to be a good consumer? You need to know a price. OK. I need – say my doctor tells me you need to get that wrist X-rayed after you fell. I may call 10 X-ray centers. No one’s going to tell me the price. They’re all going to say it depends on your insurance or we don’t know.

So how can I shop around? Even in that kind of elective situation, I can’t really shop because I don’t know the prices. And P.S., a lot of medicine isn’t so elective. Your doctor says hey, you need to have your hip replaced. Or your doctor says, I’m going to fill out a requisition for this blood test. Here’s the lab I’m sending it to. You don’t have a lot of choice.

Now, part of what I’m saying is you should ask for that choice. So if your doctor says, I’m going to order this blood test and here’s the lab you should go to, it’s beholden on us now to say hey, which labs are in my network? I’m going to go to one in my network because I don’t want to be hit with an out-of-pocket cost for that test.

GROSS: OK. I’m going to name another one of your economic rules of the dysfunctional medical market. And that rule is a lifetime of treatment is preferable to a cure. Preferable for who?

ROSENTHAL: Well, you know, you’ve got to look at every medical problem from two sides – what’s right for health care and what’s good for business. And you have to remember, we’ve trusted a lot of our health care to for-profit businesses. And it’s their job, frankly, to make profit. Much as that makes me uncomfortable and I might not like it, you can’t expect them to act like Mother Teresa’s – they’re not.

So if you’re a pharmaceutical manufacturer and you have a problem like diabetes, for example, if I invented a pill tomorrow that would cure diabetes, that would kill a multi-billion dollar business market. It’s far better to have treatments. And, you know, sometimes really great treatments, very effective treatments, so that’s good. But you kind of want the treatment to go on for life. That’s much better than something that will make the disease go away overnight.

Now, one expert in the book joked to me – kind of tongue-in-cheek, of course, because no one would think of this as a good outcome – that if we relied on the current medical market to deal with polio, we would never have a polio vaccine. Instead, we would have iron lungs in seven colors with iPhone apps.

GROSS: If you’re just joining us, my guest is Elisabeth Rosenthal, author of the new book “An American Sickness: How Healthcare Became Big Business And How You Can Take It Back.” One of the things I’ve been noticing is the consolidation of hospitals, where one entity will buy up a bunch of hospitals in the region. And the hospitals maintain their name, but they’re all under a larger entity. What’s that about? Why is that happening?

ROSENTHAL: Well, that’s a complicated question. It started happening because in many cases it’s not very efficient to have a huge number of hospitals scattered in every little town. You know, if you’re – if you need open-heart surgery, maybe you should go to a center that does lots of open-heart surgery. And in the beginning – and this is – so much of this book starts in the beginning because we’ve seen these things evolve over time. And in the beginning, this was a good idea.

Hospitals came together to share efficiencies. You didn’t need every hospital ordering bed sheets. You didn’t need every hospital doing every procedure. You could share records of patients. So the patient could go to the medical center that was most appropriate. Now that consolidation trend has kind of snowballed and skyrocketed so to a point now in many parts of the country, major cities only have one, maybe two hospital systems.

And what you see with that level of consolidation is, you know, it’s kind of a mini-monopoly. And what happens, of course, when you have a mini-monopoly is you have an enormous sway over price. And so what we see in research over and over again is that the cities that have the most hospital consolidation tend to have the highest prices for health care without any benefit for patient results.

GROSS: There are so many shopping plazas now that have a dialysis center and an imaging center. You’d never see that in a shopping center in the past. What’s going on there? Why are there so many kind of standalone medical centers like that – medical specialty centers?

ROSENTHAL: Yeah. Again, what we see over and over in health care is something that started maybe 20, 30 years ago as a good idea and a positive thing, has kind of morphed into something that’s far more ambiguous in its utility. I mean, the idea was in the ’80s and ’90s that a lot of things that used to be done in hospitals, could be done as outpatients.

You know, that’s far more convenient for patients. If you need dialysis, you don’t have to go into a hospital. If you need minor surgery, you don’t have to go into the hospital. So there was a movement of a lot of things to outpatient status. Also anesthesia got better. We could do much more under local. It was a good idea in the beginning. And it still is for a number of things.

But what’s happened is it became a revenue source. So a lot of these outpatient clinics became owned by doctors who were doing the surgeries. So there was a kind of mixed motivation in do you need the surgery? And I’m making money from this surgery. So when your doctor says, OK, you need a colonoscopy. We can do it on either Tuesday – I’m doing it at my surgicenter – or Thursday, where I do them in the hospital.

For patients, that can mean the difference between an outpatient procedure, which may cost you $5,000 and a hospital outpatient procedure, which will be billed perhaps at twice as much because you’re paying for hospital O.R. time. So, you know, there’s a huge price implication for patients. And often, patients aren’t told that. So you may just say, oh, I’ll have it done on Thursday. That’s my day off and – not knowing that it’s going to cost you twice as much. But…

GROSS: So the hospitals are likely to cost more than the outpatient procedure in a surgical center?

ROSENTHAL: Yeah. Yeah. It almost always will because you’re paying a hospital fee. On the other hand, I think, you know, there’s an upside and a downside. If you’re having a serious medical procedure in a surgicenter, maybe it can’t handle emergencies that a hospital could handle. So, you know, there are things that need to be done in the hospital. And there are things that can be done in surgicenters.

And that decision, I think, sadly, now is often made as the result of a trade war between those two entities, rather than really what’s best for a patient. There’s a big push to do more and more as an outpatient. And there’s a big debate in the medical community about whether we’re trying to do too much in the outpatient setting now. But more…

GROSS: Why is there a push to do more in the outpatient settings? The push coming from the people who run the outpatient centers or from the hospitals or from the health insurance companies?

ROSENTHAL: (Laughter) There’s a new twist in this. But let me – the push is partly from the health insurance companies because it’s lower cost. It’s driven largely, though, by the people who own the outpatient surgery centers, of course – the ones you see advertising on TV and in shopping malls because they want the revenue.

So the hospitals as a whole don’t like it. But in the latest twist of this ongoing consolidation of financial power, many of the hospitals have decided to end this trade war with the outpatient surgery centers and are just buying them up. So the thing in your shopping mall that looks like an outpatient surgery center that may be owned by some investors or some physicians, is now actually rebranded as being the hospital.

Even though it’s the same surgicenter in the same shopping mall, they’ll just say, oh, it’s now part of our hospital network. So now that same surgery center will charge hospital prices. So in some ways, the consumer/patient can’t win.

GROSS: If you’re just joining us, my guest is Elisabeth Rosenthal, author of the new book “An American Sickness: How Healthcare Became Big Business And How You Can Take It Back.” She’s editor-in-chief of Kaiser Health News. And before that, she was at The New York Times – there as a reporter for a long time and ended up covering health care there. We’re going to take a short break, and then we’ll be right back. This is FRESH AIR.

(SOUNDBITE OF MUSIC)

GROSS: This is FRESH AIR. And if you’re just joining us, my guest is Elisabeth Rosenthal, author of the new book “An American sickness: How Health Care Became Big Business And How You Can Take It Back.” She’s editor-in-chief of Kaiser Health News. Before that, she was a longtime correspondent at The New York Times where she ended up covering health care and wrote a series about health care called Paying Till It Hurts.

So, you know, there’s a big conflict now between people who want to save Obamacare and people who want to replace and repeal it. We know what happened the first time around. The repeal and replace attempt failed before it got to the floor. There are still a lot of proponents of single payer.

ROSENTHAL: Yeah.

GROSS: Are you one of them?

ROSENTHAL: Well, I’m still a journalist. So I can’t endorse one solution or another. Single payer has certainly worked in many other countries. But I’d like to point out if Americans really want something that’s more market-based, other countries have used market-based solutions or more market-based solutions and have gotten really good health care, too.

If you look at Switzerland, they have a largely market-based system. But – and this is a really important but – all the countries that have working marketplace-based systems have some form of control over pricing. It’s not kind of the Wild West open market. They’ll say this is the ceiling you can charge for that procedure. They’ll say this is a bandwidth in which you can charge. And you can compete all you want below that ceiling or within that band.

But you can’t just drive up prices to whatever the market will bear because – I think one of the legitimate analogies is if water or electricity was a totally free market, imagine what prices would be like.

GROSS: I want to ask you about coding. And this is, like, the letters and the numbers that are used in the doctor’s office to codify, for billing purposes, what procedure you’ve done, what diagnosis you’ve been given, what kind of examination you’ve had. And, you know, it’s usually part of your bill that you’re handed, like, when you walk out of the doctor’s office. You get this, like, big, say, pink sheet with a grid (laughter) of all the things the doctors could possibly bill for with these codes on them. And it’s, of course, indecipherable if you’re a patient. But I think it’s indecipherable for a lot of doctors, too. I mean, it’s really complicated. Why does this kind of coding – and that’s C-O-D-I-N-G – why does this kind of coding system exist?

ROSENTHAL: Well, again, it evolved from a good idea and got perverted into something that is really kind of toxic if you think of health care as a market, I think. You know, it originally – the coding systems originally evolved during the bubonic plague in order to classify diseases. And, you know, there were a lot of people dying in different countries, and you wanted to be able to track disease epidemiologically.

Now in the U.S. – and I believe only in the U.S. – these coding systems became the bedrock of medical billing. So you were billed according to what the ICD code was for your disease. And at some level, you know, you say – yeah, that makes sense. You know, rather than write out pulmonary hypertension with grade 3 blah, blah, blah, you just put 107.2 – that’s not the actual code for that. But – so yeah, at some – first pass you can say, yeah, OK. That made sense.

What happened over time once that coding performed a bedrock financial function – like all the rules on Wall Street for markets, people learned to manipulate it, and other codes developed because, hey, those codes were kind of vague. You know, they just said what disease you have. But if I’m a doctor, I do a lot of different kinds of things for different diseases that I want to bill for. So then you need a coding system for what doctors do, which is called the CPT code. And those CPT codes, by the way, are owned by the American Medical Association. So there’s a little bit of a conflict of interest there.

OK. So you have the CPT codes for doctors. Well, you know, what about when you’re in the hospital? You need a different kind of code for all the stuff that’s done there because, hey, in the U.S., we don’t bill by you have this disease, so we’re going to bill you X amount. We say – and particularly not now – everything is billed item by item in the hospital for most commercially insured patients. So it will be – and you’ve seen it if you’ve looked at these 60-page hospital bills – they’ll be oxygen, you know, per 15 minutes, $100; recovery room time per 15 minutes, $500; Tylenol – you know, every little thing that’s done to you is barcoded and charged and has a code.

GROSS: So before the doctor does anything, what questions should you ask to avoid billing problems down the line?

ROSENTHAL: Yeah, I think you should start every conversation with a doctor’s office by asking – is there a concierge fee? Are they affiliated with a hospital? Which hospital are they affiliated with? Is the office considered part of a hospital? – in which case you’re going to be facing hospital fees in addition to your doctor’s office fees. You ask your doctor always – as I do mine, I’ve really learned a lot from covering this topic – if I need a lab test, if I need an X-ray, will you send me to an in-network provider so I don’t get hit by out-of-network fees?

You know, our insurers have deals with certain laboratories and certain X-ray chains. And if you stay within that chain, you’ll be largely protected from costs. If you go out of it, you can be hit with big costs. And often, that will be a little hard for your doctor because they may have to fill out a different requisition. But it’s worth asking. And any doctor who won’t help you in that way, I think, isn’t attuned to the financial costs that we’re bearing today.

I think also when your doctor suggests – why don’t we just get this test? You can ask – well, why? How will it change my care? Because often – I’ve been a physician – doctors are ticking off boxes on a long checklist of tests, and maybe they’re not thinking, do I really need that one? Often, a bunch of them come together. And maybe these days with electronic medical records, a lot of them are automatically checked off. The doctor may have to uncheck tests. So help your doctor be more attuned to your financial needs.

GROSS: My guest is Elisabeth Rosenthal, author of the new book “An American Sickness.” After a break, she’ll explain why, if you’re in the hospital, it’s really important to know whether you are officially under observation or you’re being admitted as an inpatient. That’s after a break. I’m Terry Gross, and this is FRESH AIR.

(SOUNDBITE OF MUSIC)

GROSS: This is FRESH AIR. I’m Terry Gross, back with Elisabeth Rosenthal, author of the new book “An American Sickness.” It’s about how health care became big business, and it has plenty of advice about how to navigate your way through the health care system and what questions to ask. Rosenthal is the editor-in-chief of Kaiser Health News. Before that, she was a reporter at The New York Times and covered several beats, including health care. And before becoming a journalist, she was a physician.

You suggest that if you’re in the hospital for any reason, you need to ask whether you are officially under observation or whether you are being handled as an inpatient. So what’s the difference, and why do you need to ask that?

ROSENTHAL: Well, the difference between inpatient admission and under observation status is huge in terms of the finances. It’s not any different in terms of what you see as a patient, and that’s why you’re so at-risk because you’ll be moved to a hospital bed. You’ll see the same doctor. You’ll get the same tests. But technically, you’re not admitted to the hospital.

And that has a huge implication for what you’re expected to pay because observation status is technically, for financial purposes, outpatient care, which means the terms of your outpatient insurance applies. That means you’re responsible for co-payments that may be up to 20 percent. And two days in a hospital, 20 percent co-payment, you’re easily into the thousands if not tens of thousands of dollars. Also, if you’re a Medicare patient, Medicare will cover your nursing home care if you’re transferred out of a hospital after admission. If you’re under observation status, they’ll say, you don’t really need nursing home care. You were never really in the hospital. So you always have to ask. When my mom was admitted to a hospital in New York a couple of months ago, after – is she OK? – the next question was she’s not under observation care, is she? She’s admitted – because I know the vulnerabilities of that.

GROSS: So you should have the presence of mind to say I want to be admitted. I don’t want to be under observation.

ROSENTHAL: Well, that’s the problem, you know. If you’re a person who’s really sick, what’s on – and that’s the problem with our health system. If you’re a person who’s really sick, you’re not thinking – oh, am I going to be able to pay this in two months? You’re just thinking, I feel awful. I want to get better. Am I going to die? So it’s always helpful to have someone who can serve as an advocate for you in the hospital while you’re there. But I think it’s kind of a sad reflection of our system that that’s necessary.

GROSS: Another question you suggest that patients ask, especially if they’re in the hospital – because this will have an impact on your billing – is, who else will be involved in my treatment, and will I be getting a separate bill from another provider? So what’s behind that question?

ROSENTHAL: (Laughter) Well, there’s been a lot of talk lately about surprise medical bills. And I’m really glad that one of the articles in The New York Times series helped ignite that discussion. That article, which is one of my favorite, was about a young man who went in for neck surgery at a hospital in New York and ended up being billed $117,000 by an assistant surgeon who he’d never met, and it was out of his insurance network. I mean, he was asleep in the OR, so he had no idea this guy was in the OR. When he got the bill, he flipped out and, thankfully, called me at The New York Times then to talk about it.

So I think we are all vulnerable to surprise medical bills. You go to an emergency room; you think everything’s covered because it’s in your network. But guess what – the doctor there may not be part of your network. He might call in a dermatologist who’s not in your network ’cause he just wants the dermatologist to look at a funny rash on your shoulder, you know, little things like that. And so you have to ask – who’s going to be involved in my care that you’re not telling me about?

And you have to insist that they be in your insurance network because, otherwise, you can be on the hook for those really, really huge out-of-network charges. And to me, logically, you go to an in-network hospital, you go to an in-network emergency room, everything should be covered in-network. But that’s not how the system currently works, so you’ve got to watch your back.

GROSS: You said that when you’re in the hospital, that nice doctor who you don’t know who stops by every morning and says, how you doing? – might end up charging you, like, $700 for each time he stops by. And you don’t know about that. You don’t know why the doctor’s there. It’s not, like, your doctor. Right?

ROSENTHAL: Right.

GROSS: So you call that drive-by doctors.

ROSENTHAL: (Laughter) Yeah.

GROSS: Is that your expression? I’ve never heard that before. But what do you mean by that? How are they – why are they there?

ROSENTHAL: Well, you know, sometimes they’re there because your primary doctor asked them to be there. And so they’re doing a kind of drive-by ’cause your primary doctor said, oh, you know, she looks like she could use some advice about nutrition, you know. And your primary doctor probably isn’t thinking, that’s going to be a big bill for my patient. They’re just thinking – well, she’s in the hospital anyway. It will be useful. But a consult in the hospital is going to be really, really, really expensive. And there’s a good chance you’re going to be paying for it or your insurer’s going to be paying for it, and we’ll all pay.

So in other times, it may be the hospital who’s assigned that person to come by. You know, there are hospitals now – I would say some of this is motivated by billing, perhaps not all – who say, every patient before discharge has to have a physical therapy consult. What I hear from patients over and over again, the kind of obsessive patients I love who look at their bills, who say, wait – that physical therapy consult – that was just someone who came by and, like, walked with me down the hall. That wasn’t a consult. That was five minutes, and there’s no way that was worth 600 bucks.

But so you do have to say – who are you, who called you, and am I going to be billed for this? And it’s – again, it’s tragic that, in recovery, people have to think in this kind of keep-on-your-guard, somewhat adversarial way. But I think if we don’t push back against the system and the way it bills, we’re complicit in allowing it to continue.

GROSS: You know, but at the same time, I’m not sure patients are in the best position, even if they’re alert, to evaluate what care they need and what care they don’t. Like, maybe you really need that physical…

ROSENTHAL: Right.

GROSS: …Therapy consult before you leave the hospital, especially if you’ve become a little deconditioned from lying…

ROSENTHAL: Right.

GROSS: …In bed several days. So I’m not sure what advice you’re actually giving on that because I’m not sure how much power – like – and if you don’t need that physical therapy consult, can you send away the physical therapist and say sorry, I have unilaterally decided I don’t really need to have your consult? Thank you very much. Go away.

ROSENTHAL: Well, obviously, it depends on the situation and your condition. Right? In places where it’s just mandatory for discharge, I’ve gotten complaints from doctors – from heart surgeons who say, I know when my patient needs a physical therapy consult, and I’ll order it if they need one. I don’t want it to be the kind of automatic check box for everyone. It’s just not necessary. You know, everything is context, and health care is individual, obviously. And so you have to be a good consumer and say, if what the physical therapy consult is going to involve is walking you to the bathroom, you can say – oh, thanks, but I’ve already done that. And I’m fine.

GROSS: So something that you can’t really do when you go to the hospital say how much is this going to cost me? Because…

ROSENTHAL: Right.

GROSS: …You’ll be told I don’t know, it’s – it depends on how it goes, right? You say in Australia doctors have to obtain informed financial consent as well as medical consent from patients.

ROSENTHAL: Yeah.

GROSS: What’s entailed in that informed financial consent and what do you think America might be able to learn from that?

ROSENTHAL: Well, I think what America could learn from it is it is possible, right? It’s not like breaking a law of the universe. This is something that doctors do in other countries. It may be harder in our highly compartmentalized medical system, although more and more we’re seeing procedures bundled, meaning having a flat all-in fee for everything you might need.

Hospitals say, oh, how can we do this because every patient is different? Well, yes, but on average they know about what they have to spend, so they could give you a pretty good ballpark. I know one patient when she asked about the costs of pregnancy that she was paying out of pocket, got an estimate of between 5,000 and 45,000. Sure, those…

GROSS: That’s not really helpful is it? (Laughter).

ROSENTHAL: It’s not very helpful. If we’re supposed to be a consumer, I don’t know how you can act on that. But also, yes, there are extremes, but they know pretty much what the ballpark is. And more and more maybe we should be asking them to pay that bundled fixed fee that’s the ballpark, and it’s their problem that some go way over in some go under.

That’s what Medicare does for hospital payments, and it’s worked pretty well for Medicare. It can be done. It’s just that we have not put pressure on our hospitals, our providers and on our insurers to think that way.

GROSS: If you’re just joining us my guest is journalist Elisabeth Rosenthal. Her new book is called “An American Sickness,” and it’s about how health care became big business. We’re going to take a short break and then be back. This is FRESH AIR.

(SOUNDBITE OF MUSIC)

GROSS: This is FRESH AIR, and if you’re just joining us, my guest is Elisabeth Rosenthal author of the new book “An American Sickness.” It’s about how health care became big business. She’s also editor-in-chief of Kaiser Health News. Before that, she was a longtime reporter at The New York Times where one of her beats was covering health care. And as part of that beat, she wrote a series called Pain Till It Hurts.

So let’s talk about hospital bills. What advice can you give us about how to read a hospital bill and what to look for?

ROSENTHAL: Well, the first piece of advice I give people is it’s overwhelming, but you can figure out a lot with the right tools. First of all, don’t be alarmed by the prompt payment discount. Go back to the hospital and say I want a fully itemized bill. I want to know what I’m paying for. Some of it will be in codes, some of it will be in medical abbreviations.

I’ve discovered you can Google those codes and find out what you’re being charged for often, and most importantly you might find you’re being charged for stuff that obviously you know you didn’t have. I mean, Wanda Wickaser (ph) who was the subject of a section of the book – she discovered that in her $356,000 bill for her surgery which was inpatient. I mean, she came into the hospital unconscious and was in the intensive care unit. There was something like 70,000 billed for outpatient surgery. She was never an outpatient. So that kind of thing you can pick up pretty easily.

If your son didn’t have a circumcision, you know that. Many bills have errors, and you’ll find things that will save you money. Even more than that, if we all start asking to see those bills – I mean, I’ve seen patients who’ve got bills that just said $76,000 you pay and no explanation of what it is you’re paying for. I mean, if I went to the supermarket and shopped and nothing had prices on it and then went home and a month later I got a bill saying $2,000, I, as a consumer and every consumer, would be ballistic.

GROSS: So I want to ask you about Obamacare. There are several insurance companies that have pulled out of the ACA marketplace exchanges. What’s your understanding about why they pulled out and what that says about how the ACA has been functioning?

ROSENTHAL: Well, I think the first thing you have to start with is to say the ACA did some incredibly important things, whatever flaws you can point out, and there are flaws. It guaranteed health insurance to people with pre-existing conditions. Before the ACA, I heard from patients who had a history of mild depression or used an asthma inhaler And as a result couldn’t get insurance. It also removed lifetime caps which was really important to people with chronic diseases who might have maxed out their insurance coverage.

And it also, I think, in a very important way established health care and health insurance, I should say, as a right that we should all care about as a nation, and it insured 20 million more people. So that being said, the ACA had – and has because it’s still the law – its flaws. One of those is that the marketplaces are highly uneven in how well they function. Some have function fantastically. Some have been beset by huge premium increases. Others have been beset by insurers pulling out and saying we can’t make money doing this.

Well, I would note overall insurers are doing just fine. I think that’s one of the lessons, so it was going to take some learning. Some people that dove in were going to say, you know, this just doesn’t work for us. Others were going to say it’s working great. A lot of patients were pretty happy with it. Some patients found that their premiums went way, way up, and they weren’t happy with it. So I think to say the ACA as one thing wasn’t working is disingenuous. It’s working very well in some places and in some aspects, but not working well in some others.

Another thing to point out, I think, which I point out in the book, is that the ACA struggled to become law and is less than the Obama administration had hoped it would be. So part of the distress we’re seeing is that Congress did not come through for the ACA in the way that had been initially anticipated, meaning some of the money that had been promised to support the exchanges didn’t arrive. It never was approved.

So, you know, yes, some of the exchanges are having trouble. Some insurers are pulling out. But in essence, these marketplaces were trying to work often with kind of one hand tied behind their back.

GROSS: So one more question – you started off as a physician and became a journalist instead. Why did you leave medicine?

ROSENTHAL: Well, oddly, I feel like I’m circling back to the same place. I always loved writing, and I was always writing freelance on the side. And in 1994, I was working in an emergency room in New York City. And I saw a lot of problems with our health care system. And if we remember what was going on in ’93, ’94, Hillary Clinton was proposing a health care reform plan.

And so I initially converted to journalism at the invitation of some editors at the Times to cover the Clinton health reform. And I honestly always thought – OK, I’ll do this. I’ll cover medicine. I’ll cover health care reform, and it will be done. And then I’ll go back and be an ER doctor, and I’ll be happy. And I guess I got distracted. And of course, the Clinton health reform didn’t pass. And here we are, you know, more than 20 years later talking about the same issues, only more so. And I think that’s what drew me back to health care reporting, was I saw all the same issues but in such an exaggerated form.

And I think – you know, when I was drawn to journalism, to write about health care reform in the ’90s – at that point in time, health care was still pretty much working for the upper-middle-class people who were insured for physicians. I mean, it was OK. It wasn’t working for the people I was seeing in the emergency room, people with HIV/AIDS, people who were poor. When I came back to the U.S. after years as a foreign correspondent, my kind of aha, eureka moment was – hey, this system isn’t working for anyone now.

GROSS: Elisabeth Rosenthal, thank you so much for talking with us.

ROSENTHAL: Thank you for having me here.

GROSS: Elisabeth Rosenthal is the author of the new book “An American Sickness” and is editor-in-chief of Kaiser Health News. The new season of the “Breaking Bad” spin-off “Better Call Saul” starts tonight on AMC. Our TV critic David Bianculli has the review after this short break. This is FRESH AIR.

Copyright © 2017 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

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Next Selection–The Secrets of Mary Bowser

Secrets of Mary Bowser Bk Cover

 

Author’s Note

This novel tells the story of a real person, Mary Bowser. Born a slave in Richmond, Virginia, Mary was freed and educated in the North but returned to the South and became a Union spy during the Civil War. Like many ordinary people who choose what is right rather than what is easy, she did extraordinary things.

Few details about Mary Bowser are known today. In the nineteenth century, little effort was made to record the daily lives of most slaves, free blacks, or women of Lois L alternateany race. The scant facts about Mary Bowser that survive cannot tell us what we most want to know: What experiences in freedom would make her risk her life in a war she couldn’t be sure would bring emancipation? How did this educated African American woman feel, subjecting herself to people who regarded her as ignorant and even unhuman? How did living amid the death and destruction of America’s bloodiest war affect her?

The Secrets of Mary Bowser interweaves historical figures, factual events, even actual correspondence and newspaper clippings, with fictional scenes, imagined characters, and invented dialogue, to answer these questions. Like Ralph Waldo Emerson, who lived at the same time as Mary Bowser (and who, in the style of the period, often said man when today we would say person), I believe that the crises of an individual life can shed light on national crises. The novel tells the story of one woman’s life—but it also tells the story of a nation torn apart by slavery, and brought back together by the daily bravery of countless people like Mary Bowser.

—Lois Leveen

 

Lois will be my guest on the Politics for the People conference call on Sunday, June 3rd at 7 pm EST.  So, get your copy of The Secrets of Mary Bowser and start reading today.

Lois also wanted to invite those P4P members who would like an autographed copy of the book to purchase your book from Broadway Books, an independent bookstore in Portland, OR.  You can order your book  and when you are in the check out, there will be a comment section that says: “Use this area for special instructions or questions regarding your order.” You can request an autographed copy or if you would like a more personal message, you can make that request here as well.   

***

POLITICS for the PEOPLE

BOOK CLUB CONFERENCE CALL

With Author Lois Leveen

The Secrets of Mary Bowser

SUNDAY, June 3rd @ 7 PM EST

***

 

New Selection—A Declaration of Independents by Greg Orman

 

Book Image

I am delighted to announce our first selection of 2018.  A Declaration of Independents  by Greg Orman was released in 2016.

In 2014, Greg Orman–a successful business leader and entrepreneur–ran for U.S. Senate in Kansas as an independent.  His landmark campaign attracted national attention as he nearly beat incumbent Republican Senator Pat Roberts.  The Democrat in the race dropped out, recognizing that Greg had animated record numbers of voters and was in the best position. The race was very close until the very final days.

The book chronicles Greg’s journey to becoming an independent and his experiences in this historic campaign.

In Declaration of Independents, Greg describes the huge price we are paying as a result of the toxic partisan political culture in Washington. Greg spells out how that two-party machine works, the supporting institutions that reinforce the paradigm limiting both competition and accountability to voters. In the final section of the book, Greg lays out his vision for reinventing our political system.

In his Acknowledgements, Greg writes that he had been “…writing this book in my head for over fifteen years….” He goes on to share the impact of his campaign on the book, “What would have been missing [had the book been written before the campaign] is the perspective that comes from having run for office in Kansas and being able to talk to my fellow citizens about issues that matter to the.  Without our campaign, there would be no book. Running for the U.S. Senate was genuinely the honor of a lifetime.”

ORman announcement photo from IVN

AP Photo

In January, Greg announced his independent candidacy for Governor of Kansas.  In an interview with Tim Carpenter from the Topeka Capital -Journal, Greg shared how he thinks about being an independent:

For me being politically independent is not about ideology. It’s about 3 things:

  • it’s about putting my state and my country ahead of a political party.
  • it’s about using facts and common sense to solve problems, not just clinging to rigid ideological solutions even when they are not working.
  • and importantly, it’s about being free from obligations to party bosses and special interests.”

Later in the interview Greg shared his view of state government, “At the end of the day we’ve had a government in Topeka that has been very resistant to the involvement of its citizens. And you’ll see when we come out with our transparency plan that we plan to open up the statehouse to the citizens of Kansas. We view them as equal partners in the problem solving process and we’re going to involve them.”

IVN has been regularly covering the campaign. In his latest article about Greg’s campaign launch, Shawn Griffiths writes,

The two parties will do all they can to make this about them — a race between red and blue. They — along with their allies in the media — will tell Kansas voters that any vote outside the two-party duopoly is a wasted vote. Republicans will accuse Orman of being a closet Democrat, while Democrats will say he is really a Republican.”

Sound familiar???

As we head into the 2018 election cycle, I am eagerly diving into A Declaration of Independents, looking forward to reading it with all of you and having the opportunity to talk with Greg.

Happy Reading!

***

POLITICS for the PEOPLE BOOK CLUB

CONFERENCE CALL with GREG ORMAN

SUNDAY, APRIL 15th @ 7 PM EST

Join Tonight’s Call. $2.00 A Day: Living on Almost Nothing in America.

Reader ‘s Forum–from Nevada to the Bronx to Florida

We wrap up our Reader’s Forum this afternoon with four submissions. One from Catana Barnes, the President of Independent Voters of Nevada, two from college students at  Bronx Community College and a note from an independent activist in Florida.

I hope that you will join us this evening at 7 pm EST for our conversation with co-author of $2.00 a Day: Living on Almost Nothing in America, Kathryn Edin.

TONIGHT @ 7 pm EST

Politics for the People Conference Call

With Kathyrn Edin, co-author of

$2.00 a Day: Living on Almost Nothing in America

Join the Conversation

641-715-3605 and passcode 767775#

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CATANA BARNES

Kathryn J. Edin and H. Luke Shaffer’s $2.00 A Day Living on Almost Nothing in America is one of the most personally relatable books I have ever read. As I read through chapters 1 and 2, I felt as though I was reading through a diary of my own life. Chapter 2, Perilous

catana barnes speakingWork, affected me so much it was suggested that I not finish reading the book. I will, of course, finish reading the book with great anticipation and, unfortunately, with great sadness. This is a book that can be of comfort and support to those, like myself, who have had to survive on little to nothing and a book that can provide great insight to those who have never had to deal with this kind of struggle. I absolutely believe this book can and will change the way people, in the United State and the /world, understand and view poverty in the United States; a country that proclaims its economic prowess.
Catana Barnes is the founder and President of Independent Voters of Nevada.

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CLAUDIA ARROYO

My name is Claudia Arroyo. I am a Full Time Student from Bronx Community College and I am majoring in Psychology. I learned about your work from my Psychology professor Rafael Mendez. I am submitting my thoughts and questions about the writing $2 A Day on Extreme Poverty in America and will be attending the conference call on Sunday at 7PM.

Upon Reading $2 A Day it is interesting to know how close to home many aspects of this book touch upon. Either we have experienced many of these events ourselves or we know somebody who has lived through it or is going through it currently. There claudia arroyois so much struggle and trauma that the individuals mentioned in the story and those who encounter these challenges face everyday and must continue to live with it because it has shaped who they are. What stood out a lot to me was the story of Jennifer and her children. When living with family members it still wasn’t a positive or safe environment for her children. Little did she know the impact that this had for them, especially her son who suddenly became very aggressive and violent to the point where he harmed his sister. Even then his sister also suffered being molested by one of her own family members which forced Jennifer to flee with her kids to somewhere else she could call “home”, although it is difficult to consider a place home, when it isn’t yours and there is no stable settlement. With this we see difficulties of finding places to safely call home, especially with ones own family, they are the ones which can hurt you the most or even abandon you in your time of need. But because these events do have an influence to shape who we are, they certainly are not what officially determines the person we can be, as humans we are dynamic and constantly changing and have the ability to adapt and overcome.

My question to you is, yes it is already difficult to live in the U.S, especially in major cities like New York or Los Angeles, but how much more does the difficulty increase of sustainably living here in the U.S as a person of color, someone who is hispanic/latinx, or even outside of the U.S?

Thank you.

Sincerely, Claudia Arroyo

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MADELINE MANZUETA

    My name is Madeline Manzueta and I am a student at Bronx Community College and here is my comment on the story.
    Poverty is something that is overlooked in this country. Congress doesn’t really care about the poor and their struggles. We see this in chapter 3, as Jennifer talks about her not being able to afford such a place like the one in which her aunt was letting her stay. I can relate to Jennifer because it is very expensive to live. In the Bronx a one bedroom apartment is now going for 1,400 which is impossible for someone with a minimum wage job to afford. They now have programs offering rent controlled housing for what they call “those with low income.” In order to qualify for these apartments you must at least have an income of about 16,000. The average poor person barely even has an income of 5,000 so how do they expect for us to be able to afford these places?

***

ASHLEY BRUNO

I just started the last chapter of this book and I am only now starting to see the organized

Ashley Bruno

outlook and commentary on what needs to be done to cure the “disease” of poverty, in addition to accepting the sad symptoms. With 20 pages left, I remember when I was only 20 pages in, still then naive to the wrenching reality of modern day poverty in America and how it would be illustrated in this writing. I really believed I would be reading a how-to-guide on living on almost nothing, as if there was an underground network of people administering tips and lifestyle advice on getting it done, against all odds, without criminal and dangerous activity and/or total dependence on an ultimately unalleviating and traumatizing welfare system.  I am glad to have read this book and been given a reminder, yet again, of what the collective mind set and experience is of the people who aren’t making it, where the cycle of poverty is like a chain that seems to be unbroken, as the closest thing to direct slavery, and actually still is in many ways, especially mentally.

The last few years, since I joined this network of direct urban humanitarianism and canvassed low-income housing buildings advocating for open primaries, I have felt the need to understand better the communities that are suffering the most, and why,  eliminating the “us and them” and completely eliminating the pursuit of “success” in a capitalist driven society that aims to keep the rich-rich, and the poor and ethnic in a box to provide for cheap labor, control, and pocketed subsidies, made on people, that should be going to the programs and the people themselves. The money exists! The gap, margin, and total imbalance in our demographic economy is so extreme, the outlook has become bleak! There are so many people caught in this cycle and they keep procreating in the most terrible conditions. This isn’t yesterday’s “third-world” problem, and this is not a television show. This is today and now. These family stories are just a few of the endless situations going on and all the people suffering, fearing being out in the divided world today, yet unsafe at home, or the bare survival of one.

I am truly amazed by those who are courageous enough to get involved and try to take these issues on, for I have made no difference and was starting to feel like I just can’t. I think of the serenity prayer. “God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.” I want to focus on that last chapter. I want it to expand. I believe that together we can create the how to guide, because essentially we need to.

This book is definitely not boring, somewhere in between a dramatic yet disturbing lifetime movie and an interview with the real life person behind the door of the NYC Projects buildings the day you stop in and say, “can you sign this petition if you believe in positive change and a fair system?”, wondering how many people live in there and why it smells like that.  I will aim to make the conference call, but I should be working tomorrow. If I change that, I will hear you all on the call. Otherwise you know you will hear from me; I appreciate this listen and learn.

Ashley Bruno is a volunteer with Independent Voting and Open Primaries.

***

SAGE SEPULVEDA

What I’ve been thinking ever since I read this chapter is that while a lot of operations are trying to help families in poverty even when it’s rather difficult, there are at least a few operations that make things worse for these families. Poor people may not have hygiene because they weren’t properly taught by their families or that there wasn’t enough IMG_0286water. Families may go into poverty because the housing costs are too much for them to handle. When I read this chapter, it makes me think of a similar problem is happening in all apartments in the Bronx, especially in the South Bronx, because families will lose their apartments because of housing. I think it was an amazing decision for Kathryn J. Edin and H. Luke Shaefer to write how the family, especially Jennifer, will help Kaitlin to cope with the trauma of being sexually molested by Jose, since it shows that even or especially in dark times, some families can still support each other, since not all of them do. It kind of seems like people of poverty are victims of abuse because they’re easy targets. Why are poor people more likely to be subjected to physical, mental, and sexual abuse than people who aren’t in poverty?

Sage Sepulveda is a college student at Bronx Community College.

 

 

New Selection–Chosen by You

Thanks for voting and selecting our next book club selection.

AMAZON | BARNES & NOBLE | BOOKS-A-MILLION | INDIEBOUND | APPLE | KOBO | SONY

Written by Kathryn J. Edin and H. Luke Shaefer

 

From the $2.00 A Day: Living on Almost Nothing in America website:

“Jessica Compton’s family of four would have no income if she didn’t donate plasma twice a week at her local donation center in Tennessee. Modonna Harris and her teenage daughter Brianna, in Chicago, have gone for days with nothing to eat other than spoiled milk.

After two decades of groundbreaking research on American poverty, Kathryn Edin noticed something she hadn’t seen before — households surviving on virtually no cash income. Edin, whose deep examination of her subjects’ lives has “turned sociology upside down” (Mother Jones), teamed with Luke Shaefer, an expert on surveys of the incomes of the poor. The two made a surprising discovery: the number of American families living on $2.00 per person, per day, has skyrocketed to one and a half million American households, including about three million children.

But the fuller story remained to be told. Where do these families live? How did they get so desperately poor? What do they do to survive? In search of answers, Edin and Shaefer traveled across the country to speak with families living in this extreme poverty. Through the book’s many compelling profiles, moving and startling answers emerge: a low-wage labor market that increasingly fails to deliver a living wage, and a growing but hidden landscape of survival strategies among America’s extreme poor. Not just a powerful exposé, $2.00 a Day delivers new evidence and new ideas to our national debate on income inequality.”

You can get your copy at Amazon, your local bookseller or library.

The book is riveting and paints the disturbing picture of growing poverty in American post the “welfare reforms” that started in the Clinton era.

Join in our conversation on line…

And join us when we welcome Kathryn Edin

To our Politics for the People Conference Call       

Sunday, December 3rd at 7 pm EST

Image result for kathryn edin johns hopkins

Kathryn J. Edin

 

RATF**KED

Our new selection is RATF**KED: The True Story Behind The Secret Plan to Steal America’s Democracy, by David Daley.

The book outlines in detail the plan hatched by the Republican Party after the 2008 election of President Obama to take control of key state legislatures in 2010 in order to be able to control the redistricting process.  As the author says in the introduction to the book:

This book is not an argument for Democratic control of Congress. Nor is it an apologia for a mushy, split-the-difference centrism, nor a history of the Voting Rights Act or the various Supreme Court cases which have brought us here. Those important stories have been well told by brilliant reporters and scholars. Rather, this is the story of how one election tilted our democracy in unforeseen ways, for the unforeseeable future. It is the story of how, in Karl Rove’s words, when you draw the lines, you make the rules. It is an argument that when our democratic institutions become separated from the popular will, they cease to be effective and democratic.”

 

From the KIRKUS REVIEW:

An alarming study of the GOP’s redrawing of the American political map across the country.

According to Salon editor-in-chief Daley, while Democrats were celebrating President Barack Obama’s victory in 2008, they took their eyes off the important state legislatures, especially in key swing states. Subsequently, the defeated Republicans were already hatching nefarious plans to turn the “disaster into legislative majorities so unbreakable, so impregnable, that none of the outcomes are in doubt until after the 2020 census.” According to law, every state redraws its district lines every 10 years, after the census. Both parties use gerrymandering—named after Massachusetts governor Elbridge Gerry, who redrew a state Senate map in 1812 so skewed it looked like a salamander—to their advantage, but with wildly more sophisticated mapping abilities, gerrymandering has become a “more lethal weapon.” Republican strategists initiated the Republican State Leadership Committee in order to raise millions of dollars for the Redistricting Majority Project, REDMAP, which would indicate where the money should be spent in order to bolster Republican candidates in Democratic-controlled state legislatures from Pennsylvania to North Carolina to Michigan to Wisconsin, flip control of the chamber, lock in redistricting, and thus control Congress for the next decade. This political “dirty deed done dirt cheap” is called “ratfucking,” as designated by Edmund Wilson in the 1920s and used by Bob Woodward and Carl Bernstein during the Watergate scandal. Indeed, this is just what happened after the midterm election of 2010, as the GOP captured 63 seats in the House of Representatives and 680 new seats in the state legislatures. Daley takes on each significant state race in turn and notes that despite the country’s pulling more center-left on many issues, the far right is going to be calling the shots until 2020. The author looks at the masterminds behind the strategy and the mapmaking technology as well as the roles of restrictive voting rights laws, “dark money,” and voter turnout.

A chilling intimation of the growing entrenchment of partisan politics.

 

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You can pick up a copy of RATF**KED through Amazon, Barnes and Noble, and most local booksellers. The book is available in hard cover, paperback, and audiobook.

I think you will find the book compelling. I am looking forward to our exploration over the next several week.

Conference Call with David Daley

Author of RATF**KED

Sunday, June 4th at 7 pm EST

Call: 641-715-3605
Pass code: 767775#

 

 

 

 

 

 

A Letter to Margaret Sanger

From Juliana Francisco

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Juliana marching in the 2016 African American Day Parade, Harlem

Thank you, Mrs. Sanger.

I’m learning your story now and I need to thank you for everything you did. I wanted to let you know that your courage and determination has inspired me and that you have saved so many women that you will never know – myself included.

I also need to apologize to you. I judged you before I even learned your story. I demanded perfection from you because of my anger at society – and at myself. I went into the reading expecting to thump my nose up at this outdated woman who fought for women only like herself and ignored the plight of other less fortunate women but I was wrong. As I read on I found a sister.

Growing up I was a little woman rebel too. I was raised in a conservative Catholic household in a society which largely was not as progressive as it pretended. As hard as it must have been for you to have an openly atheist father and be teased as the devil’s children I think in a way it was a blessing. You were taught to question society early. As a little girl, I was not encouraged to question society or the church. When I look back on my earliest years, I feel intense heartache because I believed in everything I was told I should be as a girl and what they were projecting for me to be as a woman.

I had a much smaller family than you – it was just my mom, my two brothers and myself. My mom was always there for us and I praise her for all the sacrifices and hardships she endured to raise us. I no longer blame her for what she couldn’t control. In the last months of your mother’s life you tried to get her to confess her regrets. “I wanted her to say that if she’d had her choice, as the women on the hill did, if my father believed in French letters as fervently as he did in the single tax and socialism, she would not have spent her life populating the world and cleaning up after it.” [page 15] When your mother finally passed away, as you, your siblings and your father stood around mourning you compared it to vultures around carrion. This visual shook me and I openly wept on the subway. I understand now that my mother, even though she was so encouraging of me and so loving, was not taught to question her society or the church, which gave comfort and meaning to her sacrifice. She was only doing what she thought was best for me. I’ve made peace now but as a teen when I finally started questioning everything I was furious with her. Anger born out of insecurity. I was desperately lonely at that age and I wanted someone, anyone to love me – to “fix” me. But I, like you, never wanted to marry. I knew it was a trap. As much as I longed to be loved, I knew I would just end up forced to have children and abandon all my hopes and dreams and passion because of what was expected of me as a woman – something I was ardently rebelling against. I was also angry at myself for being born and preventing my mother from living the life she wanted – or at least the life I decided she must have wanted.

By this age, I was suffocating under all the pressures and expectations of “womanhood”. I didn’t want to end up like all the women I knew – imprisoned at home, caring for 2 or 3 or 5 children, married to a husband that was always cheating and never there. I wanted to travel and have adventures and create art and change the world and I knew that the women in my life must have felt the same way when they were my age only to be imprisoned by husbands and children and “womanhood”. At the same time, I had internalized so much shame and misogyny. At some level, I must have still believed in everything my upbringing taught me a woman should be. I was terribly lonely and depressed at that age. As uncomfortable as it is for me to admit now, I think a way I elevated myself over my peers, whom I still resented for their taunting and for not liking me, was that I was “pure”. I was a virgin and I wasn’t having children in high school like some of the other girls. I’m so embarrassed by this now. Sure, I had begun questioning society, the church, and gender roles but I couldn’t bring myself to reject the patriarchal myth of “virginity” and “purity” because, in a way, it made me feel some self-worth at a time when I felt completely worthless.

However, you saved me, Margaret. Planned Parenthood was the catalyst that helped me unlearn all the bullshit I was taught. I still remember it – I was around 15 and was learning about politics. Unfortunately, the men in power nowadays don’t really care about women’s rights, just like when they were indifferent when you were alive, but I digress. I was learning that Planned Parenthood was under attack but I didn’t even know what Planned Parenthood was. I went to their website and, of course, I was scandalized! Sexual health?! They’re encouraging promiscuity?? In teenagers?!?!

As I kept reading I LEARNED SO MUCH! I never had sex education in school and my mom never spoke to me about sex. Planned Parenthood taught me everything about women’s health from condoms, to birth control, to body image. This sent me on an internet rabbit hole where I learned about feminism and woman’s rights. This will sound dramatic (I was 15 after all) but I felt like Giordano Bruno pulling up the curtain of the perceived end of the universe and soaring into the limitless universe in front of him. Suddenly nothing was sacred and my possibilities were infinite and no longer confined to my gender. I didn’t have to be a wife or a mother, pure or refined, sexy or pretty, or anything I was taught. I didn’t have all the answers at the time and I still don’t but I was finally unlearning what I was taught. I have you to thank for this. All your hard work and determination paid off. It WAS worth it! How sad it is that you would never live to truly see what you left behind.

I feel a deep kinship with you while reading your story. Like you I grew up very poor. I was teased for showing up with holes in my clothes and for wearing the same clothes from last year which I had already outgrown. I remember missing meals and coming home from school to find the lights turned off and the threat of eviction was always present. I’ll never forget it and you never forgot what it was like to be poor either. You fought hard for poor women, even the ones who didn’t look like you. When the wealthy suffragettes you were trying to bring onto the cause disparaged poor women for having so many children and implied they were daft for not caring about suffrage because of the other pressing issues in their lives you stood up for poor women and you never backed down.

I admit, without doing my research I thought you were like those wealthy suffragettes who didn’t care for the poor or for women of color and for that I apologize. You did fight for all women. You opened clinics in Harlem to help poor black women and in Brownsville to help the poor Jewish women and anyone who came by asking for help. My obsession with knowing and being right and demanding perfection from myself and my predecessors in the fight for social justice led me to disparage you and I was also influenced by the propaganda machine against you. People still twist your legacy and say you wanted to exterminate African-Americans and Jewish people through birth control and without doing my research I believed this. It was easy for me to believe this because, in my opinion, middle-class white feminism still doesn’t listen to poor women or women of color. Younger intersectional feminists and womanists are frequently ignored by them and I think we vilify one another. It’s complicated but at any rate I’m glad I learned the real Margaret Sanger. You weren’t perfect, you hurt your children and Bill but you had good intentions and I at least think you did the right thing. I’m not excusing everything. I’m still upset that you left your children suddenly without even saying goodbye but as an activist I understand your single-minded drive for your cause.

Reading your story has given me so much perspective about the fight for women’s rights and what it means to be an activist who courageously goes against society and the law even if it means going to prison like you, and Ethel did. As I mentioned I am an activist. I work for structural political reform to ensure that everyone’s voice is heard. I’ve always cared deeply for social justice and women’s rights and I think fixing the political system is the best way for me to help the cause. As I’m writing this a racist, sexist president is being sworn in who’s vice president and cabinet members openly oppose women’s rights, gay rights, racial equality etc. I, however, am not despairing. I know that the work I’m doing is important because it will ensure that the people are heard and not the special interests. My activism is how I express my love for humanity and how I can help others. I don’t know what these next four years will be like but I do know that I will work hard for what I believe in and to help others. I’m reminded of you when Anita Block asked you to step in and lecture a crowd on the ballot for women and you didn’t feel you were an authority on this issue or that you knew enough to do so. Instead you spoke about women’s health and taught what every woman should know. This is so inspiring. I’m still developing my voice as an activist and will always be. It really struck me that instead of going through the motions and lecturing about something you didn’t really get you spoke from the heart and lectured about something you were so passionate about. You didn’t need to be perfect. The work you did transcended any of that.

I think my biggest takeaway from your story is to stop adhering to the illusion of perfection. I will never be perfect and I mustn’t let the fear of making mistakes stop me from my activism or from living my life. So once again, I thank you, Mrs. Sanger, for the wonderful work you did. Thank you for educating me and inspiring me. I celebrate your life and all that you accomplished. Tomorrow I will be marching with hundreds of thousands of people around the country who are swearing to uphold women’s rights in the face of adversity and you are a tremendous reason we can do this today. It’s now up to us to continue your legacy and fight for your cause and I’m proud to be there in your honor.

Juliana Francisco lives in Brooklyn and is an activist with IndependentVoting.org and the New York City Independence Clubs.  

 

Politics for the People Conference Call

With Ellen Feldman

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Sunday, January 22nd at 7 pm EST

Call In Number: 641 715-3605

Access code 767775#

New Selection–Terrible Virtue

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