During the presidency of Bush, his administration's agenda of "compassionate conservatism" with its emphasis on market-based, rather than government-sponsered, approaches to health care services and income support, has been rejected by Democrats innumerable times. This philosophical conflict has resulted in stalemates on many health care issues, and the administration's proposed 2009 budget, which calls for reductions of 200.9$ billion in Medicare and Medicaid spending over the next 5 years, only deepens the political divide. Bush has remained resolute, though, in fulfilling one early campaign pledge that most Democrats enthusiastically embrace: doubling the number of community health centers (CHCs) over a 5 year period so that millions more people who lack insurance or have limited access to private medical care can be treated as publicaly funded facilities. Bush's commitmement persuaded more Republicans to support CHCs, and the result has been a politically effective bipartisanship on this front.
The CHC initiative was launched by Lyndon B. Johnson duirng the administration's War on Poverty and got its inspiration from a South African movement that had offstarted the creation of facilities where poor workers could receive both public healht services and medical care. The primary goals were combining these disparate models and removing financial barriers to access. These goals, along with an emphasis on empowering the community to participate in decision making for CHCs by requiring that the majority of their board members be patients, were build into the centers' operating principles.
Reflecting this "power to the people" philosophy, the funding mechanism for CHCs consists of federal grants that bypass state governments and flow directly to these nonprofit, community-based organiztions. CHCs now number 1200 nationally and operate in some 6000 urban and rural sites in every state and territory and served an estimated 16.3 million people this year. 40% of the patients are uninsured and 35% are covered through Medicaid, with the remainder on Medicare or private insurance. Patients who are uninsured pay according to a sliding scale based on their ability to pay [like Esperanza in North Philly].
2/3 of CHC patients are memebers of racial or ethnic minority groups and many lack proficiency in English. More than 2/3 live on incomes at or below the federal poverty level and more than 92% have incomes below 200% of this threshold. Because their population is relatively young and disproportianly made up of young women and children, there is a high demand for primary care services.
Still, the mix of private and public activities that make up the health care system presents the centers with major challenges. As more people have lost their employer-sponsored or Medicaid coverage and become uninsured, greater demands have been placed on CHCs. Other challenges include recruiting and retaining physicians, nurses, and allied professionals who can provide primary care; securing specialty referrals for uninsured and Medicaid patients; and functioning in the face of budget cutbacks in Medicaid and SCHIP.
The number of doctors providing charity care has dropped significantly over the past decade, increasing the burden on CHCs and ERs. Meanwhile, it is difficult to attract physicians to staff positions at CHCs because hospital medical groups can offer them higher salaries. It is difficult to find specialists willig to treat uninsured patients who have no source of payment.
CHC,s which participate in policy activities largely through the National Association of Community Health Centers (NACHC), are striving to attract more physicians through natoinal, state, and local levels. CHCs meet the definition of a 'medical home' as developed by primary care medical organizations, but we will not be able to reach expansionary goals if we cannot attract a greater number of clinicians to these centers and more federal support from Washington. Despite good intentions on both sides, it remains uncertain whether Congress or the new administration will see the continued expansion of CHCs as a vital step toward reforming the health care system. Clearly, I think it's a vital step.
Monday, April 28, 2008
Wednesday, April 23, 2008
healthcare, community, poverty, and policy
I just spent the last three hours listening to and talking with my new hero. Dr. Robert K. Ross, the president of the CA Endowment, whose goal is to expand access to affordable, quality health care for underserved individuals and communities, and to promote fundamental imporvements in the health status of all. I was so jittery and excited and at one point almost started crying because he seriously outlined exactly what I want to do with my life and gave me tons of crazy cool new ideas, and it is so strange and yet wonderful to be affirmed in those ideas by someone much older, well-known, and generally brilliant. Here is my response to some of what he said:
Health revolution #1: The late 70s/early 80s made communicable and infectious diseases the most importand health care issue. If you want to hear about the history of AIDS watch the movie "And the Band Played On."
Health revolution #2: In 1985/86 crack cocaine became the new street drug of choice. It went from 100$ per hit to 5$. It is highly addictive, causes pain to go away, releases people from depression, and only lasts about an hour. The effects of cocaine are so much greater in a community oriented framework. Since the advent of cheap crack cocaine, life expectancy in inner cities has decreased. In 1990 in Philadelphia, the average life expectancy was 48. In 1980 it was 60. The statistics are similar for Southern California. Women get addicted and how do they get their money? Prostitution. Men get addicted and how do they get their money? Stealing and dangerous street trade. The prostitution breeds STDs and unwanted pregnancy. Cocaine induces muscle contractions, so babies are born too early. Stealing and street violence produces gangs. All of the above produces unsafe streets and home environments, and there is an entire generation of young people who grew up in houses and neighborhoods where these effects were very present. What is society doing for these youths now? What is society doing for the 1980s coke addicts now? One might ask, can we really extrapolate all of these effects from one cause: cocaine? Mostly yes, but fully no. But we shouldn't be ignoring the fact that the answer really is 'mostly yes.' LA and San Diego were hit the first and the hardest with cocaine trafficking, but it clearly has become a national problem. Economics is key here. The fact that cocaine became more abundent and cheaper effected the drug market in huge ways, which in turn effected every other systemic structure of society these cocaine addicts came into contact with, from neighborhood housing, to education, to healthcare. 1 in 3 men of minority status is destined to be a part of the criminal justice system at some point in his life as of 1990. Clearly, no part of society is left untouched by these statistics...who, after all, is paying for the incarceration of these men?
The second healthcare revolution comes to a close in the early 21st century with chronic, rather than communicable, diseases being the most talked about issue. This is largely because health care organiztions and individuals gave up on trying to deal with the problems of drug dealer and prostitutes and changed their focus to the poor. The shift in healthcare brought a focus on the chronic problems of the poor: diabetes, obesity, malnutrition, hypertension, bad eyesite, some STDs, and even cancers [not an issue of the poor as much, but definitely chronic].
Heathcare revolution #3: The closer look at chronic conditions has caused healthcare organiztions and individuals to look more closely at the healthcare system at large. Chronic conditions, after all, don't go away and require long term care, so the issue becomes a systemic one rather than a 'fix-it-once' solution. If you look up the word system in the dictionary, in no way does it describe what we have in terms of healthcare. People are starting to realize that the US spends more on health care than any other country in the world, and by no means has the best health. This third revolution is focused, therefore, around bringing health. That should be a 'duh' isn't that what heathcare is for. But if you look throughout the history of healthcare in America, it really isn't. Healthcare has been structured around reaction to problems rather than action and prevention. Reactionary care is absolutely important, but it will always be incomplete. Preventative healthcare economics is predicted to be the new and revolutionary field in the 21st century.
Take a guess: how much of your life expectancy right now is determined by the quality of healthcare you receive? Between 10 and 25% depending upon your healthcare plan. That is ridiculous!! So, what else is determining your life expectancy? Race, class, social status, gender, genes, and the way these things affect the social structures you interact with. [this is all from a legit study nationally recognized].
So when I say that the new healthcare revolution is focused on health, I really mean that it is focused on extending life expectancy. This will require tackling these other seeminly non-health related issues.
How to act: it is all about neighborhoods and community. And really, it's not just because that's what I'm passioante about. This is what all studies in the last 4 years have shown. Healthcare workers who are fed up with trying to work within the confines of the system are opting out and creating neighborhood and community organiztions [some of which have grown state-wide and nationally!]. There's a guy in Harlem who picked 20 square blocks to dedicate himself to. He has fully reformed the way the kids in that neighborhood get healthcare, education, and housing/supervision at home. On his wall he has a map of his 20 blocks of Harlem, and another map of the US with pins in the different cities where these once-street kids are now going to college. This stuff works! [and it's making me cry to think about it working :)].
What about the argument: this is too small-scale? That is a valid argument [though let's not discout the fact that the small-scale efforts are working!]. Here is where the policy makers and economists come in. So far, the benefits of small scale community health care have yet to be scaled up to fit a larger national context. There are two options: Find a way to unite and scale up the several small community focused healthcare groups, or encourage lots more of them to form in as many communities as possible. I would argue that both need to happen at the same time and that they will strengthen each other. How do we create a national healthcare structure that has all of the intimacies of neighborhood healthcare? Our problem isn't that we don't know what a good healthcare structure looks like. We do know. The last 10 years have given us success story after success story of non profits, independent hospitals, and clinics which have drastically influence the health of a community. We have the structure, now we need to find a way to fit it to a larger model.
Behold, I will bring to it health and healing, and I will heal them and reveal to them abundance of prosperity and security...And this city shall be to me a name of joy, a priase and a glory before all the nations of the earth who shall hear of all the good that I do for them. -Jer 33:6,9
Health revolution #1: The late 70s/early 80s made communicable and infectious diseases the most importand health care issue. If you want to hear about the history of AIDS watch the movie "And the Band Played On."
Health revolution #2: In 1985/86 crack cocaine became the new street drug of choice. It went from 100$ per hit to 5$. It is highly addictive, causes pain to go away, releases people from depression, and only lasts about an hour. The effects of cocaine are so much greater in a community oriented framework. Since the advent of cheap crack cocaine, life expectancy in inner cities has decreased. In 1990 in Philadelphia, the average life expectancy was 48. In 1980 it was 60. The statistics are similar for Southern California. Women get addicted and how do they get their money? Prostitution. Men get addicted and how do they get their money? Stealing and dangerous street trade. The prostitution breeds STDs and unwanted pregnancy. Cocaine induces muscle contractions, so babies are born too early. Stealing and street violence produces gangs. All of the above produces unsafe streets and home environments, and there is an entire generation of young people who grew up in houses and neighborhoods where these effects were very present. What is society doing for these youths now? What is society doing for the 1980s coke addicts now? One might ask, can we really extrapolate all of these effects from one cause: cocaine? Mostly yes, but fully no. But we shouldn't be ignoring the fact that the answer really is 'mostly yes.' LA and San Diego were hit the first and the hardest with cocaine trafficking, but it clearly has become a national problem. Economics is key here. The fact that cocaine became more abundent and cheaper effected the drug market in huge ways, which in turn effected every other systemic structure of society these cocaine addicts came into contact with, from neighborhood housing, to education, to healthcare. 1 in 3 men of minority status is destined to be a part of the criminal justice system at some point in his life as of 1990. Clearly, no part of society is left untouched by these statistics...who, after all, is paying for the incarceration of these men?
The second healthcare revolution comes to a close in the early 21st century with chronic, rather than communicable, diseases being the most talked about issue. This is largely because health care organiztions and individuals gave up on trying to deal with the problems of drug dealer and prostitutes and changed their focus to the poor. The shift in healthcare brought a focus on the chronic problems of the poor: diabetes, obesity, malnutrition, hypertension, bad eyesite, some STDs, and even cancers [not an issue of the poor as much, but definitely chronic].
Heathcare revolution #3: The closer look at chronic conditions has caused healthcare organiztions and individuals to look more closely at the healthcare system at large. Chronic conditions, after all, don't go away and require long term care, so the issue becomes a systemic one rather than a 'fix-it-once' solution. If you look up the word system in the dictionary, in no way does it describe what we have in terms of healthcare. People are starting to realize that the US spends more on health care than any other country in the world, and by no means has the best health. This third revolution is focused, therefore, around bringing health. That should be a 'duh' isn't that what heathcare is for. But if you look throughout the history of healthcare in America, it really isn't. Healthcare has been structured around reaction to problems rather than action and prevention. Reactionary care is absolutely important, but it will always be incomplete. Preventative healthcare economics is predicted to be the new and revolutionary field in the 21st century.
Take a guess: how much of your life expectancy right now is determined by the quality of healthcare you receive? Between 10 and 25% depending upon your healthcare plan. That is ridiculous!! So, what else is determining your life expectancy? Race, class, social status, gender, genes, and the way these things affect the social structures you interact with. [this is all from a legit study nationally recognized].
So when I say that the new healthcare revolution is focused on health, I really mean that it is focused on extending life expectancy. This will require tackling these other seeminly non-health related issues.
How to act: it is all about neighborhoods and community. And really, it's not just because that's what I'm passioante about. This is what all studies in the last 4 years have shown. Healthcare workers who are fed up with trying to work within the confines of the system are opting out and creating neighborhood and community organiztions [some of which have grown state-wide and nationally!]. There's a guy in Harlem who picked 20 square blocks to dedicate himself to. He has fully reformed the way the kids in that neighborhood get healthcare, education, and housing/supervision at home. On his wall he has a map of his 20 blocks of Harlem, and another map of the US with pins in the different cities where these once-street kids are now going to college. This stuff works! [and it's making me cry to think about it working :)].
What about the argument: this is too small-scale? That is a valid argument [though let's not discout the fact that the small-scale efforts are working!]. Here is where the policy makers and economists come in. So far, the benefits of small scale community health care have yet to be scaled up to fit a larger national context. There are two options: Find a way to unite and scale up the several small community focused healthcare groups, or encourage lots more of them to form in as many communities as possible. I would argue that both need to happen at the same time and that they will strengthen each other. How do we create a national healthcare structure that has all of the intimacies of neighborhood healthcare? Our problem isn't that we don't know what a good healthcare structure looks like. We do know. The last 10 years have given us success story after success story of non profits, independent hospitals, and clinics which have drastically influence the health of a community. We have the structure, now we need to find a way to fit it to a larger model.
Behold, I will bring to it health and healing, and I will heal them and reveal to them abundance of prosperity and security...And this city shall be to me a name of joy, a priase and a glory before all the nations of the earth who shall hear of all the good that I do for them. -Jer 33:6,9
Saturday, April 12, 2008
Fling, Flung, Flang...Fun?
I got a fortune cookie once that said: "you need more fun in your life." Yeah. I know. What kind of fortune is that? I thought a lot about fun this weekend. One of my med school interview questions was: "what do you do for fun?" After a little internal chuckle, I replied: "Run, be active outside, read, play piano, talk with friends, hang out with my residents.." The guy gave me a look like "are you serious, wow, you have no life." I don't know...those seem like legit fun things to me.
It's hard to be an RA in the quad during fling and not switch into "high judgment" mode. After writing up dozens of people, coordinating medical transports, calling for barf clean-ups, and watching your relatively normal and responsible residents go totally nuts, and still having it be a part of my job to "punish" these kids, it's hard to remain judgement-free. Here I am being all good and clean and responsible and what do I get for it? hallways of barf. Not exactly the easiest moment to remmeber I've got my own internal hallways of barf...I just have the priviledge of being able to keep them relatively hidden. In that sense, there is an element of freedom, or at least honesty, in outward debachaury.
But back to the theme of fun. The lines between work and fun are not as defined for me as they are for some. There isn't much that I do that I would say is wholly devoid of fun [except pchem]. But on the flip side, I also don't do much that is wholly devoid of some kind of work. [hmm, this probably requires a definition for what exactly 'work' is] For example, I am having a great time writing my final research paper on Faulkner's representations of American cycles of poverty. That's a more nerdy example of what I mean by blending work and fun. But it does make me question: do I know how to have fun? really? Do I shirk away from fully non-work and all-fun situations because maybe I don't know how to interact in them? Do I not know how to let loose and have fun? What do these fun flingers have that I don't, in that respect? Where should the balance rest between interacting with the world around me, and drawing back to do my own thing? Is the "doing my own thing" a result of judgement/pride and even resentment that other people are having fun, and even though it's not the kind of fun I want to have, they're still having fun and I'm not? or am I really content with just having my kind of fun be a little different?
I find it somewhat problematic that at the mention of Spring Fling, my initial reaction is...ok, whose house can I go hang out at to get away from it. I can name tons of reasons for why I would more readily flee from Fling than from other situations of brokenness [and yeah, i think i can say Fling has got some brokennes to it when I find couples having sex in the public trash room...]. But at their cores, what makes one broken situation different from another? Why is it so much easier for me to love the homeless guy who refuses to accept food from me but will take my money to, theoretically, buy alcohol with? than to love drunk penn kids at fling? I mean, I do have some answers to that questions, but are they legit answers? Not really. These kids are my neighbors in the most literal sense of the word, and yet this weekend I would rather think of some obscure poverty-ridden country than about some of the more tangible problems that exist on campus. And that left me somewhat in a state of apathy this fling. I saw tons of stuff I could have written up, but didn't. I just didn't feel like putting the effort in to argue with another group of drunk people to get their Penncards and write them up and internally know that nothing was actually going to happen to them. So in that respect I'm kind of diappointed in myself that I wasn't consistent with the rules. Consistency is important when it comes to inforcing protocol. I guess it's just hard for me to see students who really do have opportunities that others will never have, simply by being here or by having grown up in the family/culture environment that they did, and then not using it. But then, I guess on the tiniest scale, that's what God feels. He gives us life and we still find ways of breaking it up. And at the end of the day, that's really why I'm not allowed any judgement on the residents I write up. Without mercy and grace, God would have written me up so many times the 'house dean' definitely would have kicked me out of the 'quad.'
It's hard to be an RA in the quad during fling and not switch into "high judgment" mode. After writing up dozens of people, coordinating medical transports, calling for barf clean-ups, and watching your relatively normal and responsible residents go totally nuts, and still having it be a part of my job to "punish" these kids, it's hard to remain judgement-free. Here I am being all good and clean and responsible and what do I get for it? hallways of barf. Not exactly the easiest moment to remmeber I've got my own internal hallways of barf...I just have the priviledge of being able to keep them relatively hidden. In that sense, there is an element of freedom, or at least honesty, in outward debachaury.
But back to the theme of fun. The lines between work and fun are not as defined for me as they are for some. There isn't much that I do that I would say is wholly devoid of fun [except pchem]. But on the flip side, I also don't do much that is wholly devoid of some kind of work. [hmm, this probably requires a definition for what exactly 'work' is] For example, I am having a great time writing my final research paper on Faulkner's representations of American cycles of poverty. That's a more nerdy example of what I mean by blending work and fun. But it does make me question: do I know how to have fun? really? Do I shirk away from fully non-work and all-fun situations because maybe I don't know how to interact in them? Do I not know how to let loose and have fun? What do these fun flingers have that I don't, in that respect? Where should the balance rest between interacting with the world around me, and drawing back to do my own thing? Is the "doing my own thing" a result of judgement/pride and even resentment that other people are having fun, and even though it's not the kind of fun I want to have, they're still having fun and I'm not? or am I really content with just having my kind of fun be a little different?
I find it somewhat problematic that at the mention of Spring Fling, my initial reaction is...ok, whose house can I go hang out at to get away from it. I can name tons of reasons for why I would more readily flee from Fling than from other situations of brokenness [and yeah, i think i can say Fling has got some brokennes to it when I find couples having sex in the public trash room...]. But at their cores, what makes one broken situation different from another? Why is it so much easier for me to love the homeless guy who refuses to accept food from me but will take my money to, theoretically, buy alcohol with? than to love drunk penn kids at fling? I mean, I do have some answers to that questions, but are they legit answers? Not really. These kids are my neighbors in the most literal sense of the word, and yet this weekend I would rather think of some obscure poverty-ridden country than about some of the more tangible problems that exist on campus. And that left me somewhat in a state of apathy this fling. I saw tons of stuff I could have written up, but didn't. I just didn't feel like putting the effort in to argue with another group of drunk people to get their Penncards and write them up and internally know that nothing was actually going to happen to them. So in that respect I'm kind of diappointed in myself that I wasn't consistent with the rules. Consistency is important when it comes to inforcing protocol. I guess it's just hard for me to see students who really do have opportunities that others will never have, simply by being here or by having grown up in the family/culture environment that they did, and then not using it. But then, I guess on the tiniest scale, that's what God feels. He gives us life and we still find ways of breaking it up. And at the end of the day, that's really why I'm not allowed any judgement on the residents I write up. Without mercy and grace, God would have written me up so many times the 'house dean' definitely would have kicked me out of the 'quad.'
Wednesday, April 9, 2008
pchem = antishalom
sample test question [ok, obvioulsy this is not an actual question...but they sound like this when you're reading them during your hour of testing]
1) a) i) Prove mathematically the meaning of life and the existence of the universe using concepts from quantum mechanics, thermodynamics, and statistical mechanics. Complement your answer with a diagram, and label and explain the various significant points within it.
1) a) ii) Explain how the above proof physically relates to the color of the sky and the average atmospheric pressure on Neptune.
1) b) i) Using a SINGLE mathematical statement, state how a liter of high-speed fermions in South Dakota will influence the average daily rainfall in Argentina.
1) b) ii) BRIEFLY explain the above equation in your own words. Feel free to complement your answer with equations. And diagrams. With labels. And equations to explain those labels which themselves are complemented by diagrams. Feel free to continue your answer into another blue book.
Suggested time: 3 minutes
1) a) i) Prove mathematically the meaning of life and the existence of the universe using concepts from quantum mechanics, thermodynamics, and statistical mechanics. Complement your answer with a diagram, and label and explain the various significant points within it.
1) a) ii) Explain how the above proof physically relates to the color of the sky and the average atmospheric pressure on Neptune.
1) b) i) Using a SINGLE mathematical statement, state how a liter of high-speed fermions in South Dakota will influence the average daily rainfall in Argentina.
1) b) ii) BRIEFLY explain the above equation in your own words. Feel free to complement your answer with equations. And diagrams. With labels. And equations to explain those labels which themselves are complemented by diagrams. Feel free to continue your answer into another blue book.
Suggested time: 3 minutes
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