Tag Archives: health care

The American Dental Refugees of Mexico’s ‘Molar City’

A mouthful of healthy teeth has become a luxury in America, and the divide between rich teeth and poor teeth has become a stark symbol of inequality. Poor dental care can be both humiliating and life-threatening, and those who wait in lines for hours at free clinics in tents or local stadiums are often given the chance to fix one thing, and little else.

Los Algodones, Mexico — tucked into the sharp corner where California and Arizona meet at the border near Yuma — has 600 dentists among its 6,000 residents, giving it the nickname “Molar City.” As Republican senators cobble together a plan to repeal Obamacare behind closed doors, little has been done to address the dental crisis currently unfolding in the United States, where 114 million Americans don’t have dental insurance.

Dental insurance has only been commonplace for about thirty years in America. As a 34 year old, I remember trips to the dentist in the mid-1980s as intense and frequent. Fluoride was a cure-all at the time; I was given extra-fluoridated chewables on top of our already-fluoridated town water supply, which left my teeth strong but streaked with white stains. When I lost my four adult front teeth in a playground accident at ten, I didn’t get porcelain veneers until I was 18. They cost $1000 each, so we had to save.

In Los Algodones, porcelain metal crowns that can cost $1500 in the states are just $180 each — one patient got fourteen in a single go. “We’re helping the United States take care of the people they are not able to,” the mayor of Los Algodones told Buzzfeed in their recent profile of the city.  And many of those people the US is unable to take care of just put the new president in office.

Jennifer Ure smiles sheepishly through the numbing agent as we stand on the sidewalk outside her dentist’s office. She’s just had her first round of surgery to replace three crowns on the right side of her mouth and is speaking with a lisp. The crown would have cost $600 back home in Ashland, Oregon; here, it’s $190. Her sister, Dana Gross, is here, too. Both are retired, both lack dental insurance, and both have been coming to Molar City for years.

“I’m on Medicare, and I can’t afford dental insurance,” Ure says as she starts to choke up. “I just can’t afford to pay.”

Both sisters warn that to get quality care in Molar City, you have to get recommendations from people you know and trust.

“You really need to do your research,” Ure, 61, tells me. “You can get some who don’t know what they’re doing, which happened to me.” Her first procedure here seven years ago didn’t go well — the implants a dentist put in fell apart soon after Ure returned to the US.

Ure, like most of the Americans I spoke with in Molar City, voted for Trump. The president’s dark warnings of Mexican rapists and gangsters coming into the US haven’t deterred his supporters from coming to Mexico for dental care.

Of course, that’s not to say the Mexicans providing care don’t see the irony.

David Gil, the manager of TLC Dental, says he’s become Facebook friends with many of the patients, and “everything is Trump, Trump, Trump.” But so far, he hasn’t seen a drop-off in customers who support the president — and he hasn’t had any problems with visiting Americans. “I think when it comes to racism, people hide it … [but] why else would you vote for him?”

“I think it’s a little bit odd, but we can’t judge them on how they voted, so we just try to respect them,” says Margo Carilla, who works as a translator for a dentist in town.

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What Are the Secret Moves Being Made on the Senate Health Care Bill?

As most Americans are riveted by former FBI Director James Comey’s hearing on his firing, Senate Republicans are rushing behind-the-scenes to put together a bill to repeal and replace the Affordable Care Act. Amanda Michelle Gomez, health care reporter at ThinkProgress, reported that while eyes are on the Comey hearing, “Senate Republicans leaders and the health care working group will still be meeting for a working luncheon to continue negotiations.”

Senate Majority Leader Mitch McConnell has implemented Rule 14, allowing the Senate to skip a committee debate and vote and putting the bill on the Senate’s calendar. Gomez reported that McConnell wants a vote by July 4, before Congress leaves for their August recess. Gomez noted that Sen. Claire McCaskill asked Sen. Orrin Hatch if there will be a public hearing, and Hatch said he didn’t know. Andy Slavitt, who ran Medicare, Medicaid and the ACA under President Barack Obama said on Twitter that he’s been informed over seven conversations that McConnell wants the public to only have two days to read the bill, with a day to debate it, and a vote on June 28.

Several reports indicate the GOP is resigned to the goal of getting support from 50 of the 52 Senate Republicans, with the expectation that Vice President Mike Pence would be the tie-breaker. Slavitt said they already have 43 votes.

Republicans are attempting to use “reconciliation,” which Gomez notes is “a 1974 act that expedites the senate’s consideration of bills that pertain to the budget” and which prevents Democrats from filibustering. But the Senate’s process still has more complications than the House’s did:

“Unlike the House, the Senate cannot vote on a bill until the Congressional Budget Office scores it. CBO needs to score the bill to see if it meets budgetary standards of reconciliation. The Senate health bill needs to save $2 billion, which the House bill successfully did. But the Senate bill is also bound by the Byrd Rule, which has its own host of additional surgical rules, like that the bill cannot change Social Security spending or dedicated revenue.”

But what does the Senate bill entail? It’s hard to know, as it’s all being brokered behind closed doors.

Several reporters have indicated disputes within the Senate’s GOP ranks over the House bill allowing insurers to deny coverage to Americans with pre-existing conditions. From Gomez:

“The House bill would also allow states to opt out of some Obamacare regulations by requesting waivers. However, the Senate is looking to preserve one Obamacare protection that prevents insurers from denying care to people with pre-existing conditions. Even so, Senate Republicans are allowing states to opt out of providing essential health benefits to individuals and small group markets. Meaning even though insurers may not be able to deny people with pre-existing conditions, insurance plans may not cover care this community needs.”

Politico also reported that Senate Republicans “appear poised to preserve the Obamacare pre-existing condition protections,” and that McConnell and his team are aiming to submit a “preliminary framework” to the CBO by the end of the week and bring the bill to a floor vote by the end of this month:

“Senate Republicans expect their bill to be more generous than the House-passed measure in almost every way: A longer runway for ending the Medicaid expansion, more money for insurance market stabilization to lower premiums and beefed up tax credits for Americans of lower income, senators said. But no decisions have been made on some key policy questions, including on handling Medicaid.”

Slavitt tweeted that the GOP wants the CBO to review the bill “in pieces.”

Caitlin Owens at Axios has details on McConnell’s proposal for Medicaid, and reported that it’s likely the Senate bill will have waivers allowing states to opt-out from several regulations, but not the ones protecting people with pre-existing conditions — though conservatives are unhappy with that, wanting more of the regulations to be waived.

According to Politico, “there is general GOP consensus around boosting the tax subsidies in the House bill and a general framework of how to reduce premiums. An agreement on Medicaid is unlikely this week, Republicans said, but progress on premiums is more doable.”

The CBO estimated that the House bill would result in 23 million Americans losing health coverage, and a Georgetown University report found rural areas will be hit the hardest by Medicaid cuts. The House bill would cut Medicaid funding by more than $800 billion over 10 years; Medicaid covered 45 percent of children and 16 percent of adults in small towns and rural areas in 2015, according to the Georgetown report. A Kaiser Family Foundation brief estimates that 27.4 million non-elderly adults who have pre-existing conditions might be affected.

The major differences between the Senate and House bills so far seem to be a longer “slope” on ending Medicaid expansion, adjustments to the pre-existing conditions coverage, and more money for tax credits. Like the House bill, the Senate bill seems likely to have Medicaid caps, an end on expansion, and increased premiums. The ultimate goal is to save money to put toward tax cuts.

Further Reading:

“To Be Sick Without Obamacare” (Olga Khazan, July 2017) 

“A complete list of all the reasons Senate Republicans can’t repeal Obamacare yet” (Dylan Scott, May 2017)

A Tale of Two Americas Through the Lens of Health Care

Two articles published by the Washington Post and the New York Times this weekend focused on extremely different versions of the U.S. healthcare system: The Post feature— part of a series on “Disabled America,” which focuses on rural populations receiving federal disability checks — bears the dateline of Pemiscot County, Missouri, a place where the dwindling population has an unemployment rate of eight percent. The Times’ feature is part of the series “The Velvet Rope Economy,” which focuses on “how growing disparities in wealth are leading to privileged treatment of the rich.” Nelson Schwartz reports from San Francisco, currently the second-most densely populated major city after New York, with the third-highest median household income. Known for being plagued by homelessness, the poverty rate is 12 percent, lower than the national average, and the unemployment rate is 2.6 percent.

In the Post, Terence McCoy reports on a multi-generational family on disability that struggles to make ends meet in “a county of endless farmland, where the poverty rate is more than twice the national figure, life expectancy is seven years shorter than the national average and the disability rate is nearly three times what it is nationally.”

McCoy offers up a host of statistics gleaned from his own analyses of federal data and interviews both with rural residents and with professionals like social workers, lawyers, school officials and academics. An average of 9.1 percent of working-age people are on disability in rural areas, nearly twice the urban rate and 40 percent higher than the national average. The rate spikes in areas from Appalachia to the Deep South and into Missouri, dubbed “disability belts” by economists, and is highest in 102 counties within those belts, where McCoy estimates a minimum of one in six working-age residents are on disability.

“Multigenerational disability, the Post found, is far more common in poor families,” writes McCoy, gesturing at the difficulty American families face in attempting to climb out of poverty. When the family he follows loses the disabled status of their youngest members, they must convince the government to reinstate it in order to “climb from crushing poverty into manageable poverty.”

Meanwhile, in San Francisco, reporter Nelson Schwarz goes behind the scenes of boutique medical services with “concierge doctors” who target Silicon Valley’s millionaires and billionaires with five-figure annual fees that afford “a chance to cut the line and receive the best treatment.” (As one doctor says, “this is cheaper than the annual gardener’s bill at your mansion.”) 

Both patients and doctors express some misgivings: One patient professes “guilt over what he admits is very special treatment” and physicians are “quick to admit they struggle with the ethical issues of providing elite treatment for a wealthy few, even as tens of millions of American struggle to afford basic care.”

Several of the doctors who joined these boutique enterprises say they wish they could have afforded patients at their old practices “the time and energy” they have for their new, ultra-wealthy patients, but none explain why they couldn’t. The insinuation is either pressure from insurance companies or a need to squeeze in as many patients as possible, or a combination of both, but it’s never made explicit.

Catering to the wealthy isn’t just for individual doctors — hospitals are also on board with putting up a velvet rope. Stanford recently committed to a $2 billion wing designed by “star architect” Rafael Viñoly, which features a rooftop garden and a glass-paneled atrium topped with a 65-foot dome. (Until then, red blankets are given to benefactors when they check in for treatment, so anyone who stops by their room knows their status.)

One doctor balked at the notion that healthcare should not be a polarized system. “Whenever I bump into a bleeding-heart liberal, which I am, I mention that schools, housing and food are all tiered systems,” he said. “But healthcare is an island of socialism in a system of tiered capitalism? Tell me how that works.”

“In my old waiting room in Seattle, the C.E.O. of a company might be sitting next to a custodian from that company,” he recalled. “While I admired that egalitarian aspect of medicine, it started to appear somewhat odd. Why would people who have all their other affairs in order — legal, financial, even groundskeepers — settle for a 15-minute slot?”

The Times rejoins, “It’s a fair question.”

But is it? Or is healthcare — like food and housing — a basic human right that should be afforded to everyone, whether they are a CEO or a custodian? A hospital executive argues that courting the ultra-wealthy allows them to provide care to the less wealthy “as reimbursements from private insurers and the federal government shrink.”

In the Washington Post story, the family matriarch has taken to diagnosing illnesses based on her own research, convinced her hyperactive twin grandsons have a slew of disorders. Her daughter lives a life in which “for as long as she could remember, what she couldn’t do had defined her far more than what she could,” and the only medical professional who appears in their life is a therapist “who drives all over the county counseling distressed families.” It doesn’t seem like any substantive care is getting to the people who need it most.

The Greatest Trick the Government Ever Pulled Was Convincing Us We Aren’t Already on Welfare

Paul Ryan

With the prospect of 24 million Americans losing health care if the Affordable Care Act is repealed, the question of the year is shaping up to be: “Why did so many Trump supporters vote against their own self-interest?”

At Forbes,  self-described former Republican Chris Ladd comes up with a credible answer — and at the center of it lies race, class, and a flawed perception of who gets or deserves “government assistance.” For generations, white middle-class Americans were taught to believe they “earned” everything given to them — and that by having a job, they were entitled to it. Meanwhile behind the scenes, the government used tax credits at the individual and employer level to hand over billions in subsidies for their health care, their housing, their public education, and their infrastructure:

My family’s generous health insurance costs about $20,000 a year, of which we pay only $4,000 in premiums. The rest is subsidized by taxpayers. You read that right. Like virtually everyone else on my block who isn’t old enough for Medicare or employed by the government, my family is covered by private health insurance subsidized by taxpayers at a stupendous public cost. Well over 90% of white households earning over the white median income (about $75,000) carried health insurance even before the Affordable Care Act. White socialism is nice if you can get it.

Companies can deduct the cost of their employees’ health insurance while employees are not required to report that benefit as income. That results in roughly a $400 billion annual transfer of funds from state and federal treasuries to insurers to provide coverage for the Americans least in need of assistance. This is one of the defining features of white socialism, the most generous benefits go to those who are best suited to provide for themselves. Those benefits are not limited to health care.

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Weighing the Impact of Nationalized Medicine

When the ACA was passed in 2010, Ana Maria Garza Cortez could hardly believe it. She’d spent decades trying to help poor people in San Antonio get health care. She knew the barriers they faced because she’d faced them too. She’d grown up in West Side housing projects, and her family never had health insurance. She and her seven siblings didn’t go to the doctor when they were sick. “That was a luxury,” Cortez says. “My mom loved us, but we were poor. She would wait to see if whatever we had would go away.” If it didn’t, she would take them to the neighborhood clinic or, more often, the emergency room. Since Cortez graduated from Our Lady of the Lake University, in 1990, she has worked with nonprofits, usually in health care. She serves as the vice president of development and marketing at CentroMed, one of the city’s sliding-scale, safety net clinics, with 23 locations in the area, many in the city’s poorer neighborhoods. She became one of the leaders of EnrollSA, along with Guajardo and Joe Ibarra, the deputy state director and operations manager at Enroll America. Among the city’s health care advocates, Cortez is admired for her energy and passion. “We call her ‘Santa Maria,’ ” Guajardo says. “She lives for the community. It’s in her bones.”

Now that President Obama had pushed through a law making health insurance available, at least in theory, to everyone, Cortez was elated. She knew Texas needed help—the state had five million uninsured residents, more than any other—and her hometown especially so. Officials figured there were 300,000 or so uninsured in the city and surrounding Bexar County. Latinos make up 60 percent of the San Antonio population, but 75 percent of the city’s uninsured. On the South Side, which has a significant Latino population, rates of diabetes, hypertension, and obesity were higher than average. For generations, says Santos Hernandez, who grew up in the Rio Grande Valley and now works as an application counselor at CentroMed, many in the poor Latino population, rural and urban, have had a three-step system for dealing with illness. “First you go to church, light a candle, and pray. Second, you see a curandero. Finally, you borrow money and take your kid to the doctor.”

In Texas Monthly, Michael Hall surveys the Texans whose health has dramatically improved after receiving medical coverage through President Obama’s Affordable Care Act, and discusses the group who labored to get them enrolled. The question that lingers now is: what will happen if the ACA gets repealed?

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A Birth Story

Meaghan O’Connell | Longreads | Nov. 6, 2014 | 57 minutes (14,248 words)

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It was Monday, June 2nd, and I was wide awake at 6 a.m. Maybe to some of you this hour doesn’t sound remarkable, but for me it was. It was the first day in a lifetime of six in the mornings, and I made the three-hour leap all in one go.

By this point, it was 10 days past my due date, and I had a very specific and recurring fantasy of being moved around town in a hammock flown by a helicopter. I wanted to be airlifted between boroughs.

When I told my fiancé, Dustin, this wish, he was quiet for a second. He had learned to reply to me with caution, but I imagine in this case he just couldn’t help himself.

“Like a whale?” he asked.

I laughed, standing on the curb somewhere. Actually yes, come to think of it: Like a whale.

On the morning of June 2nd I had been waking up “still pregnant” for quite some time—41 weeks and two days to be exact; 289 days. My mom was in town already, at an Airbnb rental a block away. Dustin was done with work. I was chugging raspberry red leaf tea, bouncing on a purple exercise ball whenever I could, shoving evening primrose oil pills up my vagina, paying $40 a pop at community acupuncture sessions I didn’t believe in, and doing something called “The Labor Dance.” The Dance (preferred shorthand) involves rubbing your belly in a clockwise direction—vigorously—and then getting as close to twerking as one can at 41 weeks pregnant.

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We No Longer Drop Dead as Frequently as We Used to

Jacob M. Appel practices medicine at Mount Sinai Hospital in New York City, and his writing has appeared in numerous literary journals. In the Kenyon Review, Appel’s “Sudden Death: A Eulogy” examines living in a world where we no longer suddenly drop dead as frequently as we used to:

The exact rate at which we are not dropping dead is difficult to calculate: while the government keeps meticulous records on the causes of our deaths, and the ages at which we perish, it makes no effort to estimate the speed of our grand finales. Nonetheless, as a physician, my anecdotal sense is that we’re not dying nearly as suddenly as we once did. “When I started as an intern,” an elderly colleague recently observed at a staff meeting, “most patients only stayed in the hospital for a day or two. Either you got better or you didn’t. Lingering wasn’t part of the protocol.” Today, in contrast, lingering is the norm. Insurance companies force you out of the hospital, not rigor mortis. Where a generation ago, the expectation was for men to retire at sixty-five and keel over at sixty-seven—the basis for the pension plans now bankrupting municipal governments—a massive myocardial infarction in one’s fifth or sixth decade is no longer inevitable. Stress tests and statins and improved resuscitation methods mean we are more likely to survive to our second heart attack, live beyond our third stroke. Life ends with a whimper, not a bang.

That is not to say that the Grim Reaper never arrives on a bolt of lightning: I’ve lost a medical school mentor to a plane crash, a neighbor to suicide, a childhood friend to a brain aneurysm. Thousands of Americans, smoking less but eating more, still do succumb to heart attacks in their fifties and sixties. But we greet these swift departures not only with grief, as we have always done, but also with a sense of indignation simmering toward outrage. In an age of prenatal genetic testing and full-body PET scans and rampant agnosticism, all varieties of death strike many of us as anathema. Death without fair warning becomes truly obscene.

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Photo: Pargon

How Japan Prepared to Care for Its Rapidly Aging Population

As far back as the early 1960s, the government became aware of the imminent ageing problem and began to establish nursing homes and home helpers. In the 1970s, benefits for retirees were more than doubled and a system of virtually free healthcare for older people was established. In 1990, Japan introduced the “Gold Plan”, expanding long-term care services. Ten years later, it started to worry about how to pay for it, and imposed mandatory insurance for long-term care. All those over 40 are obliged to contribute. The scheme’s finances are augmented with a 50 per cent contribution from taxes and recipients are charged a co-payment on a means-tested basis. Even then, there have been financing problems and the government has had to scale back the level of services provided. Still, Campbell calls it “one of the broadest and most generous schemes in the world.”

As a result of these and other adaptations, he argues, Japan has struck a reasonable balance between providing care and controlling costs. Other countries, including Britain, have studied Japan closely for possible lessons. Of course, 15 years of deflation have left Japan’s overall finances in lousy shape, with a public debt-to-output ratio of 240 per cent, the highest in the world. Spending on healthcare per capita, however, is among the lowest of advanced nations, though outcomes are among the best. That is partly down to lifestyle. Most Japanese eat a healthy, fish-based diet and consume less processed food and sugary drinks than westerners. Obesity is far less common. So are violence and drug abuse. But even taking into account such factors, Japan gets a big bang for its healthcare buck. Every two years, the government renegotiates reimbursement fees with doctors, hospitals and pharmaceutical companies, routinely imposing restraints or reductions. Primary care is given priority over specialist treatment: the Japanese visit the doctor far more often than Americans but receive far fewer surgical interventions.

In the Financial Times, David Pilling looks at Japan’s aging population and what the country has done to take care of their elders. More stories about Japan.


Photo: George Alexander

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The Mother of the 'Distressed Baby' Speaks Out After AOL's CEO Blames Them for Reduced Benefits

Some commentators have questioned the implausibility of “million-dollar babies.” I have no expertise in health care costs, but I have a 3-inch thick folder of hospital bills that range from a few dollars and cents to the high six figures (before insurance adjustments). So even though it’s unlikely that AOL directly paid out those sums, I don’t take issue with Tim Armstrong’s number.

I take issue with how he reduced my daughter to a “distressed baby” who cost the company too much money. How he blamed the saving of her life for his decision to scale back employee benefits. How he exposed the most searing experience of our lives, one that my husband and I still struggle to discuss with anyone but each other, for no other purpose than an absurd justification for corporate cost-cutting.

Author Deanna Fei, in Slate, on the fight to save the life of her daughter, who was born just five months into her pregnancy, at 1 lb., 9 oz.—and what happened when AOL CEO Tim Armstrong pointed to their situation as a reason the company had to cut benefits. Read more on health care.


Photo: Flickr

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Why Good Health Care Depends on Nurses

What personal care hospitalized patients now get is mostly from nurses. In the MGH ICU the nursing care was superb; at Spaulding it was inconsistent. I had never before understood how much good nursing care contributes to patients’ safety and comfort, especially when they are very sick or disabled. This is a lesson all physicians and hospital administrators should learn. When nursing is not optimal, patient care is never good.

Even in the best of hospitals, with the best of medical and nursing care, the ICU can be a devastating psychological experience for patients—as it was for me. Totally helpless, deprived of cohttps://blog.longreads.com/2014/02/04/why-good-health-care-depends-on-nurses/ntrol over one’s body, ICU patients desperately need the comforting presence of family and loved ones. I was fortunate to have that support, but some others in the MGH ICU were not. I can only hope they received extra attention from their nurses.

Arnold Relman, a physician with more than six decades of experience, broke his neck and discovered what it’s like to be critically ill and cared for under today’s health care system. He wrote about the experience for The New York Review of Books.

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Photo: Army Medicine