Anecdotes from The American Healthcare Front

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Teacher at exit ramp looking for a kidney donation

I have some issues with my ears periodically, and over the past week, it felt like one was developing a minor infection. It felt full a lot and started to become painful. I knew that I was going to need to give it some medical attention. I thought about going to my primary care team at Emory, formerly Harken Health. In the Harken days, primary care appointments were included in your insurance and you could schedule to go by any time. They also managed patient load so providers would have time to develop relationships, and they partnered with health coaches that could deal with the para-medical stuff so the medical pros could focus on things requiring their specific skill set. Now that Harken’s gone, Emory still has great staff, but works like a regular doctor’s office – scheduling visits always takes a few days, visits are shorter, and the health coaches, where they exist, are swamped and can’t give the individual attention my Harken coach gave.

The ER was out of the question, that’s a minimum of $2K spend and a distraction from people who need truly urgent, serious care. (Don’t believe me? Stop by an ER and try it for yourself. A friend of mine had stress-related chest pain due to the amount he was working and how little pay he was receiving to cope with the other stressors in his life and got slapped with a $5K bill.)

Urgent care is probably the best option, but that was going to run me a bit as well. Not too much, maybe a hundred or so. But of course I already pay several hundred a month for insurance, so that’s frustrating that my insurance is really more “hit by a bus” insurance than health care.

I ended up repurposing some antibiotic ointment I had for a recent eye injury that unequivocally required a doctor’s visit (that I’m sure I’ll get a hearty bill for soon), and it worked. I’ll keep at it for a few days to make sure it’s good.

Now, I have the means to get decent health care, even if it’s not convenient and a little pricey. What are people who have no flexibility in their schedule doing? What do you do when taking a half-day off work means you may be eating ramen next week, or nothing, because you’ll be fired “at-will”? And what happens when you face a real challenge that’s out of your control, like the teacher above who needs a kidney to live? If he can find the kidney, he will probably have decent health care as a state employee, but what if he didn’t have great insurance? Who would pay for that?

Those who support interdependent community do ourselves a disservice by allowing Medicaid for all, or any of the other public options, to be portrayed as an altruistically valuable but optional program, a gift to the neediest among us. It’s not a matter of kindness and convenience, without which life would be a little less pleasant but still bearable. People are choosing between medical bills and house payments, between medical bills and food. And it doesn’t take a significant condition or a bad decision.

We in the middle class especially make the mistake of thinking that we are where we are because of good decisions. The rich are lucky, sure, accidents of birth, right place, right time, but not us. We scrimp and save. We plan. We forego instant gratification for the long term, and look at our lives as a result. If we can do it, anyone can.

The truth is, we make the same bad decisions as the poor all the time. We buy a car that’s a hundred a month more than we should be paying. We spring for that dessert, or that hotel upgrade, or that extra night out on the town. The only difference is that we are not on the line between sustainable and unsustainable, and have a bigger cushion to absorb those mistakes. If you are making just enough to live on, springing for dessert could make you miss a payment. Missing a payment causes you to hit fees that push up your effective interest rate into triple digits. And the spiral begins.

I listened to a couple on NPR a couple of years ago that ran a food truck in Wisconsin. They were struggling, as the spouse with a corporate job had lost it, and lost their benefits along with it. When asked how they would deal with the cost of health care as they aged, they shrugged (with indecision rather than indifference) and finally stated that their children would take care of it.

I don’t believe this couple was intentionally so selfish as to burden their children with such a responsibility. But the language of American self-sufficiency has backed us into a corner. We cannot conceive of a world where a public good is actually, well, good. However, we readily imagine that a giant corporation motivated by profit will take care of our needs as well as our consumer desires. We respond with a sort of Stockholm Syndrome, where anyone on the wrong side of a law that protects the right to profit without regard to human cost deserves nothing, deserves to be cast aside. We are the worthy ones, because we currently have what appears like favor, but instead is simply utility to a soulless, unfeeling set of economic machinery.

As usual, any critique of the current order by an American must be met with “but I’m not talking about socialism!” So let’s get that out of the way. Public goods controlled by elected or especially appointed authorities who are not accountable to the people is just authoritarianism. This is what we saw in every single country that we love to hold up as inevitable outcomes of socialism. So no, I’m not talking about turning America into a giant commune or turning everything over to the government, certainly not while we have an apathetic republic that won’t hold its elected officials accountable in any consistent way. I’m also not talking about eliminating inequality. Human nature is to be rewarded in a proportion to effort, and any system that doesn’t allow that will eventually be overthrown by one that does.

But why do we think that this relentless pursuit of profit is the best of all possible worlds? We generate money printing machines that consume the landscape and crush the spirits of the people, and aggregate more and more for the machine’s makers. More importantly, we have created a mythology around poverty that causes us to see it more as damnation from a god that has refused your feeble sacrifice, while wealth is a blessing and a reward from a god that respects your hard work. This mythology is why we have the IRS losing money to chase small debts while corporations that evade billions in taxes are ignored. It’s why we won’t pay for Medicaid for All and are trying to dismantle food programs, quality public education, and other portions of the safety net, even though evidence keeps coming back that these investments are cheaper than the alternative.

Where the Christians have it right is that this is a heart issue. America loved the social safety net when it primarily benefited white men in the New Deal era. When the program was expanded to benefit more Americans through the Great Society, subsequent administrations quickly set to work dismantling them. Beyond the cost savings many properly implemented programs could bring, we have to ask ourselves what intangible cost our individual lack of accountability to our community brings. Are we safer when everyone is on their own financially? Are we less stressed when everyone has to work long days in cold environments? Are we happier when our neighbor cannot be counted on to care for us if we’re in need? Are we freer when every gift we give has conditions?

Who is my neighbor? And what is my obligation to them?

Which Bible Hero Are You?

No, this isn’t a Buzzfeed quiz.

I was talking with a Christian friend at breakfast the other day and he raised the point about how his Christian friends who are having problems always are likening themselves to Bible heroes. “This is my Gideon moment.” “I feel like Jacob wrestling with the angel right now.” That sort of thing. Even for those that don’t believe, historical stories with general applications are likely to be useful ways of putting problems into context.

The problem that he, and I, have seen, is that Christians often want to identify the story before the experience is over. Following the tradition of Christian writers and speakers I respect the most, I’ll use myself as an example. When I decided to prepare to run for Congress recently, I received the instruction to do so as a specific and direct call from God in a way that I had only heard a few calls in my life. In my fear, I likened myself to the prophets. I read the call of Jeremiah and was encouraged. “I’m like Jeremiah”, I thought. “God will put the words I need in my mouth and if He wills it, I will be given authority.”

Well, as my last post pointed out, I ended up not running. I wasn’t discouraged by this at all, but while talking about the experience with the friend I had breakfast with, I realized I actually felt something like I imagine Abraham did when he found out he wouldn’t have to sacrifice his son. Abraham brought his only son to a mountaintop to sacrifice him because he believed God told him to. He was stopped at the last moment by an angel and was given a ram to sacrifice instead. Obviously, running for Congress is not exactly the same as sacrificing a child (and, to my knowledge, child sacrifice is not yet required to pass legislation). However, I can relate to the idea of being given an incredibly difficult task, preparing for it because God said to, and then being relieved of having to do that task at the last moment.

If I had become too fixated on the Jeremiah analogy, I might have decided that God was going to raise me up, miraculously put hundreds of thousands of dollars at my disposal, and magic up my speeches so that I would win the hearts of the people in the face of a race that I had no statistical reason to place higher than fourth. In my fixation, I wouldn’t have heard the still, small voice telling me, “Well done. You may go.” when it became clear that I wouldn’t win this particular race at this particular time.

In the same way, if we decide too soon who we are in the story, we restrict our ability to follow the path God has actually written for us. Sometimes the lesson is different than we think, or contains parts of multiple stories we know to form a new story. Sometimes the lesson is a simple idea (albeit a challenging implementation), such as patience, or trust. Our goal is to stay grounded and move in faith, one step at a time, knowing that at each step we will be given what we need. I emphasize the word need because what we need doesn’t always look like what we would like most, or what is most comfortable. In doing so, we let God tell us our own story.

So next time you’re searching the Bible to figure out who you are most like in this moment, ask God to help you to have patience and trust as He reveals the story He’s writing with you as the hero. The Biblical stories are a great source of wisdom and encouragement, but only time tells our story, and we cannot predict or optimize it by being more devout or well-read.

Things I Learned Preparing for a Run for Congress

I recently almost launched a candidacy for a US House seat in my district, Georgia’s Sixth. I live in Tom Price’s district and he’s about to go Trump’s cabinet to run the Department of Health and Human Services, which together with the Republican-led Congress, will eviscerate the ACA. I felt what I can only describe as a spiritual call to run this race. The call wasn’t to win, though I would do my level best. The call was to run. As frightened as I was, and as unprepared as I felt in my mind, I had to answer the call.

I talked to my wife first, and once she agreed that we could go on this journey, we began to pray. (Make no mistake, your spouse is your co-candidate from a public relations perspective, so they’d better be ready). I prayed specifically for God to take this desire from me if it were not for me. Instead, the next day, a friend told me about a great event happening in Nashville called The Arena Summit, a rapidly organized conference specifically designed to energize, mobilize, and equip millennial and late Gen-X progressive candidates to run for office. I made a boatload of fantastic connections from around the country and got some great encouragement, mentoring and training. Next, a good friend that I told stepped up to essentially become my campaign manager. He helped me organize, research policy and tighten message, and start to get media together.

I then launched a campaign on CrowdPAC, which is kind of a Kickstarter for campaigns. It lets you raise pledges that turn into real dollars if you file to run, but not if you decide to pull out as I ultimately did. Compliance with election law is probably second only to financial industry compliance for complexity, so having CrowdPAC in my corner to test without having to file all that paperwork helped me see if I had real traction. Thankfully I did, and my friends pledged about $11K toward my potential run, enough to pay filing fees, get initial media done, and get started. (Here’s my page.) It was clear that I was going to be given what I needed, both materially and otherwise.

As you can tell from the first sentence, I didn’t actually launch the candidacy. So what happened?

I was already facing what’s called a “jungle primary”, where Democrats and Republicans run on the same ballot and the top two finishers go to runoff, regardless of party. There were 3 Democrats in the race, one of whom (Sally Harrell) was to be the party’s unofficial choice. I was to be number 4, but then a guy named Jon Ossoff entered the race with 2 local Congressmen’s endorsements (one of whom was John Lewis) and $250,000 in commitments. I saw no path to victory through two establishment candidates.

None of that is super important though. Let’s talk about what I learned.

Elections Are Expensive – And It’s Not “Because Corruption”

We all know elections are expensive. We usually dismiss it and talk about the corrupting influence of money in politics, “buying a Congressman”, and so on. However, in researching this candidacy, I learned that there is a very simple reason why there’s so much money in politics. Advertising is expensive.

Imagine you just built the WonderWidget 3000. It’s something that people need, but they don’t know it yet. They complain about their SoSoSpindle 1994s but don’t ever bother to go to the store to change them out or even call in to the manufacturer to get repairs done. So now you’ve got to convince a large group (say, about 500,000 people) that they need to get up, go to the store, and pick up a WonderWidget 3000 right now. But it’s going to take 2 years for you to see if the WonderWidget will work better than the SoSoSpindle you already have. How do you do it?

A hell of a lot of advertising, that’s how. You send out mailers (even at 10 cents a piece per person, that’s $50,000 every time you mail them). You run TV ads in their market (hundreds of thousands). You send out WonderWidget reps to extol the virtues of the product. Maybe WonderWidget fans will work for free, but someone’s got to organize them, and that person has to be paid.

That’s essentially what any campaign looks like. You are the WonderWidget: beautiful and powerful, but unproven. The incumbent (or the incumbent way of thinking) is the SoSoSpindle: not that great, but running in people’s homes right now. So just like with a product, you have to convince people that they have to go out of their way to acquire a new product, stop using the old one, and use the new one long enough to see the differences, which may not be obvious because they aren’t always paying attention anyway. That takes advertising dollars, and that’s what a lot of the campaign’s spend is, not anything shadier or more nefarious than that.

Raising Money Is Time Consuming. . . 

So how do we get the money to run these ad campaigns and pay the teams? In a Federal race, individuals can only give $2,700 per candidate per election. There are loopholes, such as primaries and runoffs being counted as separate elections, but the rule generally holds. Besides, except for the very well off or very politically committed, most people won’t be able to afford giving out money in $2,700, non-tax-deductible chunks. Political Action Committees (PACs) can give a bit more, $5,000 per year total per candidate, but they can’t collect donations from corporations or unions. Super PACs can raise and spend as much as they like from whomever they like as long as they disclose their donors periodically and do not coordinate with candidate’s campaigns.

In general, if you see an ad for a candidate, it’s from the candidate’s campaign paid for out of raised dollars. If you see an ad against a candidate that doesn’t mention the favored opponent’s name or about an issue, it’s probably a SuperPAC. Parties get to spend a pretty substantial amount of money too on behalf of a candidate, but they only do that in general elections; the purpose of primaries is for candidates to demonstrate strength in internecine combat.

Given the advertising requirements above, a typical Congressional seat requires about $2,000,000 in fund raising. That’s two million dollars, raised every two years, entirely from individuals and PACs. (Senate seats are closer to ten million, but can be a lot more depending on the size of the state). If you assume your average committed person is giving out maybe $100 to their favorite candidate, that’s 20,000 donors that you’d need. In practice, there are quite a few large donors and PACs out there. Even so, it’d still take 400 PACs or 740 donors maxing out to hit the target just for a House seat.

This means a lot of time spent on the phone. In the campaign world, they call it “call time”, and your average candidate will do 30-50 hours a week of it. On the phone, calling up everyone they’ve ever met, and asking them for as much money as they can stomach giving. As I’ve learned to say, “The path to Congress runs through a windowless room.” And by the way, that doesn’t stop when they reach office. They have to find time in between all that legislating and representing to raise two million more for the next race.

. . . But Money Is Your Voice

As I alluded to earlier, most people don’t care about your WonderWidget. They don’t even really care about their SoSoSpindle. So given the fundraising realities I outlined above, what is a candidate to do? If you had a choice of calling up a bunch of rich people and asking them for money a thousand dollars at a time or calling up a bunch of middle-class people and asking them for money 20 dollars at a time, which would you choose? The unfortunate side effect of this is that you end up spending a lot of your time and energy around richer people who have different concerns and problems than the average constituent. To paraphrase Jason Kander‘s speech at the Arena Summit, “You spend a lot of time around people that America has been really, really good to.”

The influence of the rich on elections is an emergent phenomenon. It’s not a conspiracy; it’s mathematics. If every person of voting age committed to a) voting hell or high water, and b) donating $20 to their favorite candidate in each general election, you’d see ten million new dollars entering a typical House race every time, and candidates could take most of those 30-50 hours they spend dialing for dollars and go out and actually talk to people living with the results of current policy. I am not advocating for public financing of elections as a tax. I am advocating for public participation in elections as a civic duty, and that means with a few dollars out of all of our pockets as well.

Political Parties Matter

We often pick on the Democratic or Republican Parties for being sclerotic, locked in old ways of thinking, or corrupt. At the ground level though, parties do significant work, engaging motivated constituents, talking with local community organizations and alliances, building consensus. And they do this quiet, unglamorous work, over years, in large part so candidates don’t have to. The end result is that the party workers have relationships with key influencers in communities around the country, and they bring those relationships to bear for party-approved candidates. Some county and state organizations have problems too and need to be reworked, no doubt. But that’s not an indictment of the party system, that’s an identification of a specific problem that needs to be fixed.

I was going to run as an outside candidate in the Democratic Party. This meant that no county organizations would back me. No unions or community groups that worked closely with the party would say a word or lift a finger to help. No state assembly members would lend their voice to my cause. This meant that the only chance I had was to convince the people individually, which takes a lot more time, and more money.

My platform wasn’t 100% aligned with the Democrats, and there are a lot of Republicans in my district who, as one said, would see “Chick-Fil-A open on Sunday before I vote for a Democrat” (for those outside of the area, that’s a very Atlanta way of saying “when pigs fly”). So why didn’t I run as an Independent?

Third Parties Are Hard

I could run as an Independent and have a better shot of winning some moderates. However, remember all the money I talked about from above? Remember all the relationships? Even as an outside Democrat, if I showed popular appeal and fundraising ability, the party could switch to back me. However, as an Independent, I’d better have my own cash. Few traditional Democratic donors would switch to back me. The party would offer no assistance, and depending on my stances, could actively campaign against me.

And let’s say I won as an Independent. I beat the odds!  I changed the political system in America! Right?  Nope. In 2018, I’d have to run against a Democrat and a Republican, then beat the stronger one in a runoff since none of us would likely get 50% of the vote. And you’d better believe that both parties would pour national dollars into that runoff.

If you’re Bloomberg or even just ordinary rich, these kinds of things aren’t necessarily a problem; you can write your own checks until the candidate-specific momentum builds. If you’re a normal candidate, you have to raise in spite of that. Rinse and repeat until you have so much individual respect that they give up 3 or 4 terms later, if you can last that long.

So how do we build a useful third party? It’s really hard for two reasons.

First, that unglamorous work that parties do has to be done, and you can’t speed it up. You have to build the alliances with key influencers one by one. You have to run local candidates, then state assembly candidates. You can’t start at the presidency, and even federal offices are hard.

Second, the tents of the two parties are really broad. Any message that’s resonant with more than a few people will get co-opted. The Tea Party was an insurgent movement that was essentially a third party. (Don’t get caught up in the astroturf versus grassroots debate; the point is that it was a threat to both Democrats and Republicans.) Their ideas got co-opted by the Republicans and pulled the entire party closer to that way of thinking. One could argue that the Republican Party is in fact now the Tea Party by another name. But there are still just two major parties. And the same would happen if Sanders/Warren progressivism animates the left into sustained action. The Democratic Party would co-opt and adjust and become a Progressive Party by another name.

I learned a lot of more boring but important minutia about the mechanics of campaigning, but I’ll spare you that. Here’s the big takeaway:

You Are Still In Charge!

No matter how much money you raise, the election authorities don’t count dollars. They count votes. Turnout is dismal, around 50-60% for Presidential elections, and as low as 5-10% for special elections or local. This means that you’re letting a couple hundred people in some cases decide your local tax rate, or whether a new park gets built, or what your school is going to change. The decisions that impact your life are deeply local, and the only thing between you and the world you want is you taking the time to research the issues a bit and vote.

You don’t have to be a policy wonk. Just show up at your town hall meetings and ask questions. Heck, just call the office of your city councillors and ask for an appointment. Failing that, ask one of those motivated party operatives to explain a local issue to you in simpler terms. There are people that know these things inside and out, either for love or for money, and they can help you become an informed voter without you changing your life.

If I learned one thing from making a serious exploration of political candidacy, it’s that our apathy is why things are not where we want them to be. I’m more inspired than ever to be engaged, to understand the issues from multiple angles, and to be a voter that participates with both my consistent presence and dollars. And, as my friend pointed out, the more voters that are present, the fewer dollars are needed to advertise and raise awareness.

For my friends who like to talk about corruption at every level of government and “politricks”, stop it. Seriously. Your active discouragement is destroying our country. When people stop believing in the power of the vote and the power of their personal voice, that’s when those who seek personal gain at your expense win. Commit to one political event per quarter. Commit to showing up at every. single. election. And commit to getting a strong handle on one local issue a year, whether it’s your local school, the millage rate, the police department’s record, or whatever.

One last thing. Democrat or Republican, stop voting blindly with your party. Get an understanding of what your “hills to die on” are, and what doesn’t actually matter in your daily life. When candidates know they have to work with an informed electorate and no votes are promised, that’s when you see moves to sanity rather than toward what gets the few motivated voters frothing at the mouth the most.

I’m more inspired and hopeful about what America and our democratic process can still do than I could have possibly been if I had stayed on the sidelines. My journey isn’t for all of us to take. There are no shortcuts though, everyone. It’s on each of us to make the commitment. Spend just one hour a month understanding your local landscape and what can be changed. Twelve hours of your attention in the entire year would change our country permanently.

Why should Facebook have all the fun?

I have held back from starting a blog for a long time. I don’t like the pressure of feeling like I need to say something that warrants being on a permanent post. However, as I find myself writing more and more short discussion posts on Facebook, I asked myself, “why should they have all the fun?”

So here goes. I’ll be posting some old and new thoughts here. I’ll cross-post links to Facebook, which is where I “blog” the most and have conversations with people.