Even with Recent Improvements, Obamacare’s Exchanges Don’t Cut It

“Health care should be a right, not a privilege, and Americans facing illness should never have to worry about how they are going to pay for their treatment.” Thus begins the Joe Biden White House’s description of the signature health care investment in their American Families Plan (AFP).

Unfortunately, that proposed $200 billion investment in no way matches the rhetoric. The AFP makes the expanded health care subsidies in the recently passed American Rescue Plan (ARP) permanent, but these expanded subsidies serve primarily to funnel money into insurance executives’ pockets while only making health care somewhat more affordable for millions of people in need. As policymakers debate their next steps forward on health care, it is essential that Democrats take a more critical look at one of Obamacare’s worst elements.

Health policy analysts typically focus on monthly health care premiums as the primary indicator of health plan affordability. In a February column excitedly touting the ARP’s temporary subsidy improvements, for example, New York Magazine’s Jonathan Chait included the graph below from my former colleagues at the Center on Budget and Policy Priorities (CBPP). It shows that the new subsidies should be saving people making between $30,000 and $60,000 roughly $100 per month on their premium payments.

Unfortunately, these types of graphs miss what’s really happening with health care affordability. On the most basic level, by plotting monthly premium amounts against annual income, they make it seem like premiums are much more affordable than they really are. $274 per month doesn’t sound nearly as bad as $3,288 per year, which is how much a typical 45-year-old individual making only $45,000 a year will continue to be expected to hand over to their insurance company if the AFP becomes law.

More importantly, these graphs omit the significant amount of additional money it takes for low- and moderate-income people to actually access the care their premiums are supposed to cover. Deductibles in particular are incredibly high on the Obamacare exchanges. The average deductible for a benchmark (Silver) plan on the exchanges is $4,800, meaning that, if the aforementioned 45-year-old got sick and needed $4,800 worth of care, the insurance company would not chip in at all. So that individual would end up paying $4,800 for their care in addition to $3,288 in premiums to the insurance company – or 18% of their income in total. If the individual’s health care costs exceed the amount of the deductible and the individual receives care from an in-network doctor – which is hardly a guarantee – the insurance company will begin to contribute. But even then, the individual will be on the hook for additional “co-pays” or a percentage of the additional costs due to “coinsurance.” Americans facing illness should never have to worry about how they are going to pay for their treatment, but if they have a new and improved Obamacare exchange plan they’d still be crazy not to worry. And they will continue to decline needed care because they cannot afford the deductibles and/or coinsurance.

In addition to ignoring the continuing health care accessibility problems faced by many individuals, common analyses of the increased subsidy approach fail to show the massive amounts of money being funneled from taxpayers to the insurance industry. Expanded subsidies mean individuals pay less to the insurance company but the government pays more.

The graph below addresses all of these problems. It shows health care spending and revenues for a 60-year-old individual making $30,000 who requires some medical care during the year – two doctors’ visits beyond the physical Obamacare covers, two lab tests, and a routine surgery, the combined price of which can be estimated at $5,583 – under five different coverage scenarios. The first three scenarios are coverage under an average Bronze, Silver, or Gold plan that this individual would have access to today (with the enhancements in the ARP that the AFP seeks to make permanent factored in). The fourth scenario is coverage under the Medicare program, which 17 senators and 156 House Democrats recently asked Biden to improve and extend to individuals below age 60. While Biden and Democratic leadership have yet to indicate they will actually do that, the White House does claim in both their AFP Fact Sheet and budget writeup that, in the words of the budget document, Biden “supports…giving people age 60 and older the option to enroll in the Medicare program.”

The fifth and final scenario is coverage under the Medicare for All proposal that was a centerpiece of Bernie Sanders’s presidential campaign. Medicare for All legislation in both the Senate and House of Representatives has numerous cosponsors. Biden and congressional Democratic leaders remain opposed to this policy, however.

Each bar in the graph has three potential components: individual spending (yellow), or how much the 60-year-old spends on health care taxes (they would have to pay the 1.45% Medicare payroll tax under each scenario, which would come out to $435 annually), premiums, and payments to their health care providers; net government spending (blue), or how much the government spends in payments to the individual’s insurance company and health care providers plus administrative expenses minus the fee the government charges the insurance company to sell insurance on the exchanges and the health care taxes and/or premiums the individual pays to the government; and insurance company spending (gray), or how much the insurance company ends up paying to the individual’s health care providers on the individual’s behalf.

The dotted lines show overall health care spending and who receives the revenue. The horizontal line shows what the health care providers receive in every scenario: $5,583, which is the cost of the care itself. The vertical lines show net insurance company revenue, or how much the insurance company takes in from the government and individual from premiums and subsidies minus the fee the company pays the government to sell on the exchanges and what the company actually contributes towards the individual’s care.

As the graph shows, the Obamacare plans are a disaster for both this relatively healthy 60-year-old and the government. The new subsidies in the ARP actually bring the average Bronze plan premium for this person down to $0 annually, but the average Bronze plan’s deductible of $6,900 means the individual must pay for the full cost of care themselves (assuming they do not forgo the needed care because of the cost), bringing their total health care expenses (including Medicare payroll taxes) to over 20% of their income. The government, meanwhile, pays the insurance company an annual premium of $8,160 through the Obamacare subsidies – far more than what the care itself costs and netting the insurance company $7,976 after subtracting their $184 user fee – in order for the insurance company to contribute nothing at all!

Silver plans are typically considered the best value on the exchanges, in part because lower-income individuals who buy Silver plans can qualify for some cost-sharing reductions. The amount of those reductions vary, but let’s assume this individual buys a plan with a sizable reduction that takes their deductible down $2,000 from the $4,800 average. Co-pays and coinsurance also vary plan to plan, but one of the better Silver plans might cover 80% of costs above the deductible. So once the $2,800 deductible is exceeded, the insurance company in this case would pay $2,226 of the remaining $2,783 the individual owes. Yet between the individual’s $1,020 annual premium payment to the insurance company, Medicare taxes, and $3,357 payment to their health care providers (due mainly to their still-large deductible), they would still be paying close to $5,000 towards health care – which someone making $30,000 a year obviously cannot afford. The government’s subsidy payment to the insurance company would be even larger than it was for the Bronze plan – $10,176 for the year – and the insurance company would pocket $8,718, which would once again be far more than the cost of care itself.

The average Gold plan, with a deductible of “only” $1,600 and coinsurance that might be 10%, is the best plan for an individual needing care. But with an annual premium of $1,848, the $1,600 deductible, and a $398 coinsurance payment above the deductible, our example 60-year-old making $30,000 a year would still need to pay over 14% of their income towards health care costs. The insurance company would contribute $3,585 towards care in this scenario but would still net a tidy $8,169 in revenue.

With government insurance the situation is radically different. Medicare Part B requires individuals at this income level to pay premiums comparable to those under the Gold plan, or $1,782 annually, and also has 20% coinsurance. But the deductible is only $203, saving our hypothetical 60-year-old $785 relative to the Gold plan. The biggest difference is that there is no massive subsidy for the government to pay to the insurance company in this scenario; administrative expenses are negligible (only $73) and American taxpayers collectively save thousands of dollars that would otherwise be wasted on insurance company executives’ outrageously high salaries. There’s really no justification for the Obamacare subsidies approach relative to the expansion of Medicare approach unless your goal is to pad insurance company profits.

Medicare for All would result in slightly-smaller-than-for-present-day-Medicare-but-still-major taxpayer savings relative to the Obamacare approach and, most importantly, is the best deal for the individual needing care. Our 60-year-old friend’s taxes would increase somewhat (by $704) under the income-based tax proposal Sanders released as one of a variety of potential Medicare for All financing options, but that tax increase would be more than offset by eliminating premiums, deductibles, and coinsurance. This individual would pay less than 4% of their income towards health care costs regardless of what care they needed. They would not “have to worry about how they are going to pay for their treatment,” which is why Medicare for All is the clear choice for everyone who truly believes that “health care should be a right, not a privilege.”

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My Didibhai, Purnima (Lekha) Banerji (May 2, 1927 to June 28, 2021)

I have a vivid memory, from when I was around five years old, of playing Monopoly with my didibhai (grandmother) on the floor of my family’s living room. About midway through the game, Didibhai got up to go to the bathroom. While she was gone, I placed hotels on a couple of my properties. The look she gave me and the way she asked whether I had changed anything on the board that I shouldn’t have when she came back was all it took for me to recognize that what I did was wrong and resolve never to cheat in a board game again.

Didibhai had that effect on many young people, which is why she had such a successful career as a teacher. She combined kindness and patience with unwaveringly high standards for both academic performance and behavior. Her students loved her and didn’t want to disappoint her, both because of how much they respected her and because to risk doing so was just a little bit terrifying; she inspired them to be the best versions of themselves. I got to see a glimpse of that firsthand when she subbed for a few of my classes in middle school; in my entire experience attending and working in schools, including as a teacher myself, I have never known a substitute to manage a class as well or get as much work out of their students as she did.

Fondly nicknamed “Shorty” by some of her computer science students, Didibhai packed the presence and personality of a person three times her size into her diminutive 4’ 10” frame. It wasn’t just her students who were obsessed with her; growing up, I rarely went anywhere without someone telling me they loved her. She was a raging extrovert and befriended just about everyone she met at the library, in grocery stores, at restaurants – you name it. I wouldn’t be surprised if, at one point, every waiter in Haddon Township, New Jersey knew her by name. She was extremely generous and went out of her way to thank people for the smallest kindnesses they showed her or for simply doing their jobs, baking brownies or chocolate chip cookies and hand-delivering them to local retail workers, firefighters, and neighbors. If you visited Didibhai in her apartment, the odds of leaving with a chocolate bar were very much in your favor.

Food was, in general, a Didibhai specialty. Beyond baking the best chocolate chip cookies one could find – as my older sister Lela often raved, they somehow always contained fully intact, unmelted chocolate chips – she excelled at cooking American comfort foods, European delicacies, and a variety of Bengali dishes. Her macaroni and cheese, shingara (a type of samosa), luchi (a type of bread), french toast, crepes, and fried eggplant were my personal favorites.

Word games were another Didibhai specialty. We played Boggle, Scrabble, Perquackey, and Quiddler all the time while growing up. Didibhai was competitive but took great pride in her grandchildren beating her. Much to the amusement of my wife Kate, Didibhai threatened to quit a Scrabble game she was winning against us once because, due to the fact that I wasn’t in the lead, the luck of the letters we were drawing couldn’t possibly be fair. Even during the last few weeks of her life when she was dealing with dementia and bedridden in her apartment, Didibhai maintained her sense of humor. When Kate and I visited her a few weeks before she died, she determined that I was offering her water too frequently and jokingly accused me of working for the Water Department.

I was incredibly lucky to live five minutes away from Didibhai and my dadabhai (grandfather) for most of my childhood. Their fun-loving spirits, warmth, and wisdom have helped me to grow into the thinker and person I am today. Their love for each other and enthusiasm for extended family has also been a model for me in my relationships. Didibhai and Dadabhai became family not just to my dad, but also to his parents, his siblings and their spouses, and my cousins to whom Didibhai and Dadabhai weren’t actually related. I am particularly grateful for the very close relationship Didibhai and Dadabhai developed with Kate, who they loved like another granddaughter. Kate loved Didibhai and Dadabhai as if they were her own grandparents as well.

Didibhai believed in reincarnation and would tell me occasionally that she planned to be reincarnated as Kate and my daughter. Both Kate and I hope to one day have a strong, brilliant, loving, generous, and funny child who reminds us of Didibhai.

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Justice Representatives Have Power and We Need Them to Use It

On January 3, 2021, the same day the 117th Congress was sworn into office, Nancy Pelosi won reelection as Speaker of the House of Representatives. Pelosi, who has led the House Democratic Caucus since 2003, won 216 votes from her fellow representatives to Republican Kevin McCarthy’s 209. The vote broke down almost entirely along party lines, with every Republican vote going to McCarthy and all but five Democratic votes going to Pelosi (one Democrat voted for Tammy Duckworth, one voted for Hakeem Jeffries, and three voted “present”). Each of these five defections was from the corporate wing of the Democratic Party; every member of the growing group of Justice Democrats-endorsed Representatives in the House (“Justice Representatives”) cast their vote for Pelosi.

Pelosi’s reelection is a serious problem for Justice Representatives and the social justice advocates who support them. Pelosi’s rejection of progressive priorities like Medicare for All and a Green New Deal is only the tip of the iceberg. She has locked progressive congresspeople out of committees and oversight roles, blacklisted consultants who work for progressive challengers, and campaigned for anti-reproductive choice, NRA-friendly Democratic incumbents (while trying to oust one of the most progressive Democrats in the Senate). Despite her performative opposition to the Trump presidency over the past four years, Pelosi has also routinely given Trump additional military and spying power, funded Trump’s inhumane border detention system, and deliberately steered the focus of Trump’s impeachment away from his blatant corruption. In the wake of the COVID-19 pandemic, when Pelosi had considerable leverage over Republicans, she negotiated a massive corporate giveaway; even the Democratic messaging bill she advanced in May included millions upon millions of dollars for the rich.

The Justice Representatives who voted for Pelosi are well aware of the obstacle Pelosi presents. So why did they vote for her anyway?

The answer boils down to one word: power. And if social-justice-minded individuals, organizations, media, and congresspeople want to effectively advance policies that millions of people need in the coming years, we must start wielding it more effectively.

Let’s assume that the progressive vote for Pelosi was the outcome of a negotiation. Alexandria Ocasio-Cortez, the most famous Justice Representative, implied as much in a December 16 interview with Jeremy Scahill, calling the speakership vote a “specific leverage point” and saying, “when it comes to using this leverage, I do think that there are things that we can do.” What sorts of things? In response to a tweet from Justin Jackson recommending that she demand a floor vote on Medicare for All, Ocasio-Cortez replied that she would be more inclined “to push for…a $15 min wage vote in the first 100 days [and] elevating longtime progressive champions to important positions of leadership.” In her interview with Scahill, Ocasio-Cortez offered another potential demand: repeal of “an obscure House rule that is extremely influential and significant known as PAYGO…which is saying that any expenditure that a bill has must have a tax increase or spending cut essentially accounted for in the legislation.” If “full repeal” wasn’t possible, Ocasio-Cortez said, she’d want “PAYGO waivers on Medicare for All, tuition-free public colleges, and more.”

The first of Ocasio-Cortez’s suggested goals, a $15 minimum wage vote in the first 100 days, is a little hard to understand. House Democrats passed a $15 minimum wage in 2019 and Joe Biden has already said he supports it, so it shouldn’t be something for which Justice Democrats should have to fight too much. Ocasio-Cortez’s proposed timeline may be the key part of this potential demand, and Justice Representatives may have been angling for a commitment from Senate Democrats to make a $15 minimum wage a priority, but we don’t have any evidence that they got one. Especially given the Democratic Party leadership’s approach to end-of-year government funding and coronavirus relief legislation (which Ocasio-Cortez called “hostage taking”) and party leadership’s recent refusal to fight for stimulus checks, it appears that progressives did not win any clear policy commitments in exchange for their speakership votes.

It also doesn’t look like Justice Representatives succeeded in “elevating longtime progressive champions to important positions of leadership.” They did get some committee appointments, including Cori Bush on Judiciary, Jamaal Bowman on Education and Labor, and Bush, Ocasio-Cortez, and Rashida Tlaib on Oversight and Reform, but we have not yet seen any committee chair or leadership appointments that represent progressive victories. In one of the most high-profile committee fights recently, in fact, Pelosi helped Kathleen Rice – a “Blue Dog” Democrat who voted against Pelosi for Speaker in 2018 – get a seat on Energy and Commerce over Ocasio-Cortez.

The victories that Justice Representatives have been touting are in the House rules package, which contains procedural reforms to PAYGO and limits Republicans’ ability to hold up legislation with a Motion to Recommit. Yet House Democrats did not win full repeal of PAYGO and did not even secure the specific exemptions for Medicare for All and free college that Ocasio-Cortez mentioned in her interview with Scahill. The exemptions they did get, for COVID-19 and climate change, are not inconsequential. However, it is important to remember that PAYGO exemptions do not guarantee that Pelosi and other Democrats in the House will allow bold legislation related to these topics to advance; the exemptions just remove one obstacle to such legislation. And the Motion to Recommit reform appears to be much more a win over Republicans than over Pelosi, as corporate Democrats stand to gain from it as well.

It is theoretically possible that Ocasio-Cortez and her colleagues negotiated other wins that they have not revealed yet. But what we currently know – that Justice Representatives secured a couple rule changes while losing some big policy and committee battles – does not seem worth a vote for Pelosi.

This outcome is especially troubling when we consider that Justice Representatives should have had the numbers, as a bloc, to deny Pelosi the speakership. If Pelosi legitimately thought Justice Representatives might stand together and vote against her, it’s hard to imagine that social justice advocates and the working-class people they are fighting for would not have secured more significant victories.

Pelosi seemed to know the Justice Representatives were going to vote for her. As Politico described when Rice got the Energy and Commerce Committee seat over Ocasio-Cortez, Rice was “seen as a crucial vote for the speaker.” Ocasio-Cortez was not.

In fact, Ocasio-Cortez signaled during her interview with Scahill that, even though she agreed Pelosi needed to be replaced, she did not see an alternative to voting for Pelosi. If progressives were to oust Pelosi, Ocasio-Cortez said, “there are so many nefarious forces at play [that Pelosi could be replaced with someone] even worse.” Ocasio-Cortez later justified her vote as a way to show unity “in a time when the Republican Party is attempting an electoral coup and trying to overturn the results of our election,” suggesting that she believed that opposition to Pelosi would at best result in an even more corporate Democrat as Speaker and at worst result in emboldening Republicans. That might explain why Ocasio-Cortez and her colleagues did not seem to mount a challenge to Pelosi being nominated as party leader in mid-November.

If this explanation is correct, it is problematic. As Justice Democrats co-founder Kyle Kulinski noted after the vote, “there’s no excuse for the left not to have organized in the last few years to mount a challenge to Pelosi. You know she’s hostile to you and your goals and she has a 28% approval rating.” Justice Representatives already tried voting for Pelosi in 2018 and it didn’t work; they and other like-minded members of Congress should easily have been able to identify someone better from among their ranks to run against Pelosi in 2020. And while letting Kevin McCarthy win the speakership vote would have legitimately worrisome downsides, Justice Representatives could have blocked Pelosi without putting a McCarthy win on the table by voting for alternative candidates. There’s no reason to believe that strategy would have any bearing on the Republican Party’s anti-democratic behavior.

Furthermore, a potential McCarthy win due to progressive abstentions would actually have been the single greatest point of leverage over Pelosi that Justice Representatives had. Pelosi banked on fear of that outcome to ensure Justice Representatives fell into line, but Justice Representatives could have flipped this script and used fear of their abstentions to force Pelosi and the Democratic caucus to accede to more progressive demands.

This situation was a microcosm of one social justice advocates face all the time. We are presented with two bad choices – Nancy Pelosi or Kevin McCarthy, Joe Biden or Donald Trump, corporate giveaways coupled with meager relief or no help at all for people in need during a pandemic. We are reminded that one of those choices – McCarthy, Trump, no legislative help at all for people in need – is worse than the other option, and told we must therefore accept the classic “lesser of two evils.” Once we signal that we accept this constrained set of choices and will select the less-bad choice – Pelosi as Speaker, Joe Biden as President, a bad last-minute coronavirus relief bill – the corporate Democrats who manufactured this false dichotomy know they can once again grant just enough concessions to give us the feeling that we won something while rejecting the vast majority of our demands.

In each isolated instance, social justice advocates who take the “lesser of two evils” approach can rationalize it; their choice was better than the alternative on the table, after all. Something is better than nothing and less near-term harm is better than more near-term harm. But in the long run, repeated acceptance of two bad choices will continue to enable our enemies to block the real change people need.

The good news is that Justice Representatives can chart a different path during the next two years. In the 116th Congress, they weren’t organized enough. Different Justice Representatives took different stands at different times while others capitulated on issues ranging from coronavirus relief bills to immigration to the PATRIOT Act. They will have much more power in the 117th Congress, which features a slimmer Democratic majority, if they stick together and identify key points of leverage at which to credibly withhold their support in exchange for major concessions. Justice Representatives, in other words, must function more like labor unions dealing with intransigent employers, which leverage the threat to strike to force their bosses to take them seriously. As Jackson reminded Ocasio-Cortez with Frederick Douglass’s timeless words, “Power concedes nothing without a demand.”

While the speakership fight is over, opportunities to win important battles are most definitely not. The question is whether Justice Representatives will take advantage of them.

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Remembering John Lewis and Black Politics

This week on the show, Mike and David discuss the life and times of the late Rep. John Lewis. They also talk about the new wave of incoming Black politicians into Congress and the need for a new radical Black politics. Tune in below.

 

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Making Sense of the Moment We’re In

Run It Black Podcast · Making Sense of the Moment We’re in

2020 has been a year unlike any for most of us. From coronavirus to the national movement against police violence, it feels like we’re in a moment that could best be described as tectonic. This week on the show, Mike and David explore recent protests over the killing of George Floyd, Breonna Taylor, and Ahmaud Arbery. They also address criticisms of uprisings taking place all over the country and discuss the larger issue of policing. Tune in.

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Anyone but Trump? Weighing Three Approaches for Social Justice Advocates in 2020

Now that Bernie Sanders has suspended his presidential campaign, his supporters are faced with an important question: how to best move forward given bad (Joe Biden) and worse (Donald Trump) options for president. Our goal? Helping millions of people in need through implementation of the platform that Sanders continues to fight for and Biden opposes: Medicare for All, a Green New Deal, wealth taxes on the billionaire class, decarceration, peaceful foreign policy, inclusive immigration policy, and more.

Whether or not these policies become reality is dependent on much more than presidential politics. Congressional elections will have an important impact, as will state and local elections. Building the strength of the labor movement is a must. So is the growth of independent alternatives to corporate media. Social justice advocates must continue to organize, wage effective issue campaigns, re-envision Democratic institutions, and increase the membership of promising grassroots organizations that have begun to wield power, including the Democratic Socialists of America and the Sunrise Movement.

But presidential politics still matter, and while no progressive-minded person would consider voting for Trump, there are three distinct presidential election strategies social justice advocates may embrace. Those strategies, along with their pros and cons, are summarized below.

No matter how we weigh any individual strategy’s tradeoffs, it is essential to understand its rationale and stand in solidarity with social justice advocates who pursue it. Attacking each other over strategic disagreements only undermines our common agenda; there is much more that unites people who supported Sanders (or Elizabeth Warren, for that matter) in the primary than that divides us.

Vote Blue No Matter Who

This strategy, embraced by Sanders himself, centers the threat posed by a potential second term for Trump. Sanders, like many of his supporters, maintained since he entered the race that he would ultimately support any Democratic nominee – no matter who it was – because of the importance of defeating the man he believes to be “the most dangerous president in the modern history of our country.”

It’s not hard to understand the rationale for this strategy: Trump, beyond his bigoted rhetoric, disgusting personal conduct, and disregard for political norms, has pursued the standard GOP policy playbook while in office. His administration has worked to gut labor laws, oppress immigrants, roll back environmental regulations, and chip away at the Affordable Care Act. He has appointed a plethora of privilege-defending judges to the federal bench, including two on the Supreme Court. Trump has also flouted the emoluments clause of the Constitution, using his presidency to personally enrich himself and his family, and seriously bungled America’s response to the coronavirus.

Social-justice-minded proponents of this strategy acknowledge that Biden has a long history of condoning millions of people’s oppression. They don’t deny that, over the course of his career, Biden has stymied school integration, helped engineer mass incarceration, worked to deregulate the financial industry, spread racist stereotypes used to deprive poor people of cash assistance, voted against LGBTQ equality, championed the Iraq War, fought reproductive rights, enabled abuses of immigrants, and fomented deficit panic. They recognize that Biden frequently lies, has been accused of sexual assault, and vehemently opposes urgently needed policy, like Medicare for All and a Green New Deal, that would threaten the profits of his corporate donors. But while that may be true, vote-blue-no-matter-who proponents point out, Biden would surely appoint Supreme Court justices better than Brett Kavanaugh. He also surely wouldn’t use a pandemic as cover for helping employers bust unions. In the short run, social justice advocates will undoubtedly have a better chance of successfully pushing their agenda – and preventing as much of the serious harm a president can cause as possible – with Biden than with Trump in the White House.

Still, there is a clear downside to pledging unconditional support for the eventual Democratic nominee: it deprives social justice advocates of considerable long-term power. If Democratic party leaders and their allies in the media know you will support a Democrat in the end no matter who that Democrat is, what incentive do they have to cover and push the issues and candidates you care about? Isn’t it perfectly logical for party elites to ignore you and the millions of people their policies hurt and cater instead to groups whose support is conditional upon the pursuit of their interests, like corporate America and affluent White suburbanites? The Democratic Party has for decades done just that, relying on social justice advocates’ fears of Republicans instead of actively trying to court social-justice-minded voters.

Refuse to Support Corporate Democrats

The social justice voting bloc is big enough that the Democratic Party cannot beat Republicans without it. If that voting bloc were to uniformly and credibly pledge to withhold support from corporate Democrats like Biden in general elections, less social-justice-oriented Democrats who want to win general elections above all else would have no choice but to support candidates social justice advocates support – like Sanders – in primaries. This strategy is about destroying the electability argument that won Biden and Hillary Clinton the last two Democratic nominations.

To be clear, corporate Democrats’ electability arguments have lacked evidence for years. But they have nonetheless convinced Democratic primary voters, in no small part because their logic makes a certain sense. If the only swing voters are moderates, people who want to win general elections against Republicans would naturally maximize their chances to do so by nominating candidates who appeal to this narrow swing constituency. Social justice advocates who refuse to support corporate Democrats increase their leverage by becoming a swing constituency themselves.

The goal of refusing to support corporate Democrats, in the long run, is to achieve one of two outcomes: pulling the Democratic Party in a social justice direction or creating the conditions for the emergence of a viable third-party alternative to the Democratic Party. For the millions of people who are incarcerated, bombed, deported, and/or mired in poverty due to policies corporate Democrats support when they’re in power, it is crucial that one of these outcomes occurs as quickly as possible. The likelihood of that happening through the strategy of withholding support from corporate Democrats is uncertain, but what is certain is that, all else equal, it is much higher than the likelihood of achieving these long-run objectives through the vote-blue-no-matter-who strategy.

In the short run, withholding support from corporate Democrats does not have the same impact as supporting Republicans; that’s a basic mathematical fact. It does have a real short-term downside, however. Relative to supporting a Democratic nominee, it makes a Republican win – and the four years of increased damage that would come along with it – more likely.

The Wait-and-See Approach

Some Democratic voters have yet to declare whether they will support or refuse to support Biden in November. These voters do not hold as much power to influence Democratic primaries as those who vow never to support corporate Democrats, but when a corporate nominee like Biden emerges from a primary victorious, they are well-positioned to influence that nominee’s agenda.

The successful execution of the wait-and-see strategy involves outlining concessions that Biden must make to earn your support. Perhaps what you ultimately decide will hinge on Biden’s vice presidential choice; maybe it will be based on who he commits to put in his cabinet or his shortlist for potential Supreme Court nominees. Anything you care about is potentially on the table. 

There are tradeoffs involved in figuring out how to approach this negotiation. Ask for rhetorical overtures without staffing commitments and you’re essentially deciding to vote blue no matter who. Insist on Nina Turner as Vice President, Naomi Klein as Energy Secretary, and Rashida Tlaib as Secretary of State and you’re effectively refusing to vote for Biden. Demand Pedro Noguera as Education Secretary, Lori Wallach as Trade Representative, and Matthew Desmond as Secretary of Housing and Urban Development and maybe you have a shot at getting it.

Because the wait-and-see approach can apply to fundraising, voter outreach, and other forms of activity in addition to votes, it is not mutually exclusive to voting blue no matter who or refusing to support corporate Democrats. Someone who has already committed to voting for Biden may only donate or phonebank under certain conditions. Likewise, the frequency and intensity with which Biden is critiqued by people refusing to vote for him may change in response to who he selects as his vice president or promises to appoint to key positions. In addition, these strategies complement each other. People who refuse to vote for corporate Democrats stretch the Overton Window, making other social justice advocates seem less radical in comparison. The potential to bring other social justice advocates along is the carrot that vote-blue-no-matter-who proponents offer the Democratic Party in internal negotiations, while the potential to pull other social justice advocates away is the external stick wielded by those who refuse to pledge unconditional support to the party’s corporate Establishment.

Debate the Strategies, Unite Around Goals

Vigorous debate about how to weigh the pros and cons of each of the above strategies and when to engage which strategy is healthy; joining corporate Democrats in pillorying Sanders supporters who adopt different general election strategies is not. If we are to be successful in achieving the Sanders movement’s central aim – improving millions of people’s lives through the social justice policies a majority of Americans support – we must remember who our allies are. And no matter who is ultimately elected president, we must continue the down-ballot work, movement building, and on-the-ground activism essential to advancing our shared vision.

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Resident Perspective: Volunteering at a Testing Site

This is the continuation of a series of journal entries depicting what it’s like to be a part of the COVID pandemic from the medicine resident perspective.

 

With my office hours consolidated and no longer attending morning and noon teaching conferences, I find myself wanting to get back in the action. During my self-isolation I signed up for the Philadelphia Medical Reserve Corps. I signed up to be a “swabber” (obtaining samples from the back of the throat) at the South Philly screening site in the parking lot of Citizen’s Bank Park. I have Phillies tickets for a game that was supposed to take place this weekend. But instead I arrive at the stadium parking lot to see swathes of asphalt without cars. Instead they’re filled with tents, traffic cones, and people gowned from head to toe in PPE rather than tailgaters. This screening site is a joint venture between the Philly Department of Health, the Commonwealth of Pennsylvania, and the Federal Emergency Management Agency (FEMA). There is plenty of PPE to go around and I suspect this is due to FEMA’s presence because right now nobody seems to be overly concerned about limiting volunteer access to equipment.

Testing Site

I’m interested to see who comprises the volunteer corps because there is a wide variety of people in the Delaware Valley that suddenly have nothing to do. There are retired physicians, nurses, medical students (suddenly without any clinical duties), as well as people not at all involved in medicine who just want to help. Everyone is eager and energetic. You couldn’t tell there was a pandemic about to make its way to Philadelphia and the people that are most concerned they have an infection are driving to your current location.

There are multiple large white tents set up to receive cars to drive through. Each tent has the capacity to test about 100 people per day. The decision on how many tents to open each day is dictated by the number of volunteers available and the weather. On my first day it’s windy—very windy in South Philly. So windy in fact if you dropped a glove or a face shield you better start running because it would be 10 yards away before it hit the ground. Mornings start with huddles of teams where we begin the process of assigning volunteers to different stations and assign roles for the day. A woman in a vague military ensemble and standing up perfectly straight, presumably from FEMA, calls our medical director over after our huddle. There is a line of about 30 cars waiting for the entrance gate to the parking lot to be lifted to signal we’re ready to start testing. We typically start at 1pm on the dot but today things are dragging along. The Medical Director slowly walks back to the “swabbers” tent, facemask in hand, and dejectedly says that we have to close the operation today due to high winds which are anticipated to become worse as the day wears on. This is because the specimens may blow over and be scattered in the wind, putting Philly on the map as the first city to accidentally infect its own citizens with coronavirus. We have to go car by car to notify the inhabitants that if they are truly sick they should go to the nearest ED or come back at a future date. Demoralizing indeed.

Our positive rates with the nasal swab at the testing site are between 25% to 30%. If we had tested only 200 people that day, that’s still at least 50 people we would have identified as being COVID-19 positive. Who knows how many had to take off from work to come in or might not get the chance to come in tomorrow. The volunteers are pretty disappointed.

The screening site is a well-oiled machine by the time I arrive in late March. Through intake, data collection, verification, swabbing, etc. it takes about 8 to 10 volunteers to run one “lane” of cars. Ultimately the car completes its journey at our site in the swabbing tent where the specimen is collected. The more volunteers present, the more tents and lanes can be open,  which will greatly decrease wait time for the public to get screened—therefore enticing more people to receive testing. There are times when I volunteer and only two tents are open due to staffing issues. Additionally, I’m told by the Medical Director at the site that samples are now taking closer to 10 days to process, not the 5 to 7 that we had been telling the patients. Lastly, something that I find somewhat incomprehensible is that the FEMA guidelines for eligible patients to get tested do not align with those of the Philadelphia Department of Health. This leads to some people being taken out of line by FEMA representatives even though they’re eligible for testing according to the Department of Health. It never occurred to me that things like this can affect an overall city’s number of cases. Closing or decreasing screening capacity as well as delays in reporting can make numbers artificially lower.

I’m trying to find silver linings to come from the pandemic. Some are that the people being screened are overwhelmingly appreciative of our efforts. Local restaurants provide free lunch and dinner to the volunteers so it very much feels like a community coming together. I’m fortunate to observe the way people are supporting one another during these stressful times. Philadelphians are responding positively—for now. It likely won’t stay like this for the entirety of the pandemic as economic and other life-changes will exacerbate the anxiety that many people are feeling. I take comfort in knowing that there is potential for a lot to change in our society as we emerge from the pandemic.

It won’t be a surprise that our lives will be markedly different in the coming months and most likely years. For the foreseeable future,  society will no longer run as “business as usual” following the first wave of the pandemic. The way our healthcare system functions is something I’m most looking forward to seeing evolve as people realize that our employer-based model leaves millions behind is not equipped for delivering the most care to the most people. A new awareness of what we find important in life will also develop. This may entail rethinking the significance of the local community and each person’s role. We’ll be forced into introspection – things like where we get our food how we view work, and how we spend our free time will require reflection and evaluation – whether we like it or not.

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Resident Perspective: My Biggest Fear

This is the continuation of a series of journal entries depicting what it’s like to be a part of the COVID pandemic from the medicine resident perspective.

Monday, April 6th

Aside from the very real concerns over lack of personal protective equipment (PPE), ICU beds, and ventilators, I believe that the biggest cause for anxiety among healthcare professionals is not having answers. Traditionally, the public has turned to physicians during public health scares as they purportedly know how to approach all ailments. This virus is demonstrating that given all of our progress in the medical field from state-of-the-art imaging modalities to treatments utilizing personal genetic properties, we still can’t answer many basic questions about this new disease.

Philadelphia has a geographic advantage over many other regions in relation to the viral spread. We have an up-close view of the damage that the virus has wrought in New York without having nearly the number of cases or hospital burden at this time. The delay it takes for the virus to move westward globally and down I-95 not only allows us to stock up on PPE, prepare the hospitals, and practice social distancing, it also gives us the opportunity to analyze the studies that have come out of places like China and Italy. Although hospital beds in Philadelphia are now filling up with COVID-19 patients, it’s the barrage of images in the media of trashbag-wearing nurses, overflooded hallways and pleas from staff urging more supplies or more assistance that make this even more terrifying. The answers to our questions will come, but during the quarantine when each day feels like a week, data collection isn’t necessarily the issue — interpreting the data is.

As the pandemic ramps up in our region, the ever-present fear of not knowing which patients entering the hospital with upper respiratory infection symptoms are positive is anxiety-producing, not only because these patients can become sick quickly, but because it’s easy to let your guard down. When you know your patient is infected you know to be extra cautious. Also, determining whom to test prior to admission, given the tests’ continued scarcity, remains an issue, even as our own institutions’ guidelines continuously evolve.

In an ideal world we’d screen everyone and it would be an accurate test. However, right now we cannot screen everyone and we know the test has a high rate of false-negatives. Let’s say we do identify a COVID-19 patient through testing but who doesn’t require hospitalization. Our guideline for duration of self-isolation is just a recommendation as we simply don’t know if they are still infectious post-isolation. We can’t even tell patients that tested positive whether or not they are susceptible to getting re-infected, and if it will return in autumn; we can only posit given what we know about other viruses in these situations. Lastly, we don’t even have a proven treatment plan, only what experts surmise is the best approach given the information we have. Hydroxychloroquine, among many other proposed treatments, is still in the nascent stages of evaluation but the public wants answers quickly. This is not typically how the peer-review process works in academia as it often takes months to years to evaluate therapies. In this case public expectations need to be grounded to a reality in which even when expedited, implementation of new practices moves at a seemingly-glacial pace.

Residents get daily updates regarding our own institutional policies as well as new relevant findings that could be practice-changing. It’s amazing seeing the sausage being made, but it’s also terrifying because the Attendings and veteran physicians that we as trainees look to for answers are now looking to each other for answers and opening the floor to all ideas.

The good news is that while we don’t have the answers yet (and we may never have all the answers), we can take comfort in knowing that we are in the golden age of data- and knowledge-sharing. Pooling the resources of physicians, epidemiologists, researchers, and statisticians internationally has allowed us to make great strides in our understanding of COVID-19 in a relatively short time, and work toward mitigating our greatest fear – the unknown.

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Resident Perspective: Ready or not, time for telehealth

This is the continuation of a series of journal entries depicting what it’s like to be a part of the COVID pandemic from the medicine resident perspective.

Wednesday, April 1st

Medicine residents work in the hospital as well as the outpatient office. Cleared to go back to work, I’m scheduled to see some of my patients in the office. In an effort to limit the exposure to coronavirus for both the patients and the office staff, as many appointments as possible have been converted into telemedicine visits. These are essentially video-chat appointments using a HIPAA-compliant app where I can talk to a patient, ask about their symptoms and have them show me any relevant physical exam information, like using the camera on their phone to show me the back of their throat. I complete the online training modules that all providers have to pass and I think I’m as ready as I’ll ever be.

Something is off as I arrive at my clinic prior to my shift. First, it’s nearly empty, no front desk employees are there to wave to, and there are new standing hand sanitizer dispensers everywhere. Magazines from February populate the waiting room tables which may not be alarming for most businesses, but for my clinic, not having new editions of Philadelphia Magazine on display is shocking and noteworthy. No patients in the waiting room and doors to individual offices are closed, preventing natural light from gaining entry to the normally well-trafficked hallways. This place definitely feels more bunker-like than I remember. The few staff and attendings that are present are all wearing scrubs and face masks. Recognizable but unfamiliar, the pandemic has now officially warped and invaded every facet of my life and there is no sanctuary for normalcy.

Previously, only a small portion of physicians were utilizing telehealth visits. Fewer than 1% of Medicare beneficiaries used it prior to the pandemic.  Presumably because there is a learning curve on both the provider and the patient’s end, you have the opportunity to be more thorough during an in-person visit, and the big one: it wasn’t fully reimbursed by Medicare. Recently, under the Stafford Act and National Emergencies Act, Centers for Medicare & Medicaid Services (CMS) announced its beneficiaries will now be able to use telehealth to access their PCP for non-routine visits. Important to note, this is only temporary, as once the crisis is over (whatever that means), CMS will go back to its prior payment structure. Notably, other providers like social workers, psychologists, dieticians, etc. that are also integral to a person’s overall well-being will be covered.

Many of my appointments for the day involved patients interested in COVID testing. There’s an algorithm providers are to follow to determine who should be tested given the scarcity of tests. Mainly if the patient has symptoms, has other elevated risk factors such as coming into contact with a known COVID positive person, or recent travel to a coronavirus “hot spot”, they should be tested. This doesn’t cover a lot of other vulnerable people or others who should be tested, but the algorithm is designed to only catch the most likely positive cases at this point. The rapidity with things like which screening tests are performed and whom to test are just part of the equation in this constantly developing situation. Someone who is not eligible for testing one week, very well may be eligible the next.

I’d never performed a telehealth visit but the obvious problems that come to mind, like poor internet connection and not being able to get a gestalt on a patient that you can by an in-person exam, were apparent. In my first session I immediately encountered an  issue with a patient which our staff couldn’t get in touch with to see if they could convert their in-person appointment to telehealth. The patient’s partner had lost their job and couldn’t pay their cell phone bill so they were splitting the phone and the voicemail-box was full. The current economic crisis will of course exacerbate issues like this. Additionally, most commercial insurance as well as CMS will pay for audio/video calls but not necessarily only an audio (traditional telephone) call. My next patient actually was having difficulty accessing the proprietary HIPAA-compliant app on his phone, necessitating a phone call appointment which ultimately won’t be billable. Other appointments went smoothly and were unremarkable but already it’s clear there will be growing pains in moving patients to telehealth.

I’m a big believer in the future of telemedicine for many reasons but primarily because it provides a lower threshold for patients to access their providers, and this will be beneficial to delivering healthcare. These next few months will be telling if we can make it work nationally from a logistical standpoint. I’m not as convinced from a reimbursement standpoint as I’m sure there will be many kinks to work out. If my first foray into telehealth has shown me anything it’s that for my patients telehealth is a generally welcome idea in theory– many of whom did not grow up with cell phone technology– but in practice it’s a different story. Since the beginning of the quarantine, there’s been a surge in popularity of video and teleconferencing software connecting co-workers and friends alike. This current crisis will hasten the public’s comfort with interacting over the internet.  We’ll see how long it will take to successfully adopt and integrate into daily medical practice but the test has arrived regardless of whether insurance, the public, or providers are prepared.

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Resident Perspective: waiting for test results

This is the continuation of a series of journal entries depicting what it’s like to be a part of the COVID pandemic from the medicine resident perspective.

Sunday, March 29th

Although I’m a resident and I’m able to access my own medical chart through the electronic medical record, I’m not allowed, per hospital policy. I’m relegated to waiting for my results once “released” to me. While waiting for results in self-isolation, at a certain point you don’t really care whether it’s positive or negative, you just want to know something. Unfortunately, we still don’t know if being coronavirus positive prevents you from getting infected again so I’m not at the point where I would prefer to be positive just to get it over with.

Finally, five days after having the back of my throat swabbed I get an email saying my results are back: SARS CoV-2—undetected. Whew, negative. I was able to isolate for 5 days while my wife worked and took care of our baby simultaneously. Many other households aren’t that fortunate and either the other parent would have to take unpaid time off from their job (if they are able) or the person in quarantine would have to watch the kids and therefore expose the entire family to coronavirus. This is problematic for many obvious reasons.

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A picture of me and Jack at the tail-end of my quarantine. I still smiled under the mask for some reason.

The responsiveness from the government to obtaining and manufacturing tests was bungled from the very beginning. Quick turnaround time for testing is beneficial for giving patients a diagnosis promptly and is beneficial for epidemiologic prediction models that guide how much a region will be impacted and which locations that will be hit hardest next.

There are two main testing locations. In-patient testing for those that are hospitalized, where the test is performed in the hospital’s own microbiology labs (“in-house”) which have continuously improving turnaround times. Once the tests became available to hospital labs across the country, waiting times went from 48 hours down to about 4 or 5 hours (and in some hospitals turnaround is under an hour). The other main testing sites are commercial labs (LabCorp, Quest Diagnostic, etc.), where your test would be performed if your outpatient doc sent in a referral or if you went to a screening center. Unfortunately wait times are getting much longer as the public demand goes up for testing, and along with it, any part of the supply chain that is lacking—from swabs to reagents to protective gear for the providers—will back up everything.

The answer to better prediction models and better care isn’t just faster turnaround time for tests. The media has really honed in on getting quick results as a major issue in the epidemic because the news can show a long queue waiting to be swabbed or interview people frustrated by the lack of knowing their status. Arguably just as important is the accuracy of these tests. Swabs of the nose and throat are analyzed by something called polymerase chain reaction (PCR), which is designed to multiply the virus genetic material—RNA in the case of coronavirus—and detect the presence of the virus itself. A couple of problems arise from PCR as there have been reports of high rates of false negatives—meaning getting an inaccurate “undetected” reading when in fact, one is coronavirus positive. This is called low sensitivity in a test.

Because PCR looks for the virus itself from the swab, there have been studies in which essentially, if you go lower down the trachea (“wind pipe”) and obtain a sample closer to the lungs there are higher concentrations of virus located there so you will get a better sample and potentially provide more RNA material to amplify and detect with PCR. The issue with going down the trachea, in addition to being very unpleasant, can cause more of the virus to be coughed up during the procedure potentially infecting more people. So it seems not only possible, but likely that the swab going to the back of the throat either by way of mouth or nose just doesn’t pick up enough virus to be amenable to detection in many instances.

A blood test was recently approved by the FDA under Emergency Use Authorization which will test for antibodies (our own immune system response to the virus). These tests are already in use in China and other countries and can return results in under an hour. The benefit is that these tests aren’t dependent on obtaining an adequate swab and they could potentially tell us if someone’s been exposed in the past. It will also lead to more data regarding immunity to future infections with SARS CoV-2. The downside is that the test may not be accurate either and potentially detect non-COVID-causing coronavirus like CoV-1. There also arises questions like: is it better to know with 80% accuracy with one method vs 70% accuracy with another but it takes half the time to get the results back? There are no clear-cut answers because there are pros and cons to both.

The good news amongst all of this is that there is high “specificity” with these tests, meaning that if you get a positive result then you almost certainly have COVID, however comforting that may be. Keep in mind, for the time being these only apply to people that are having symptoms. I haven’t even touched upon the messed up screening guidelines and how they’ve morphed over the past few weeks. All of this is really to say we don’t know how many people are SARS CoV-2 positive currently for lots of reasons, and looking at the current positive cases on the news only tells part of the story.

At our institution there have been patients that we’ve been so sure are COVID positive that we’ve performed multiple PCR tests yet have all returned negative. Unfortunately, the answer to those that are so sure they are positive with coronavirus but have received negative testing is to assume the test is wrong. Given the rapidity with which this is all developing there just isn’t enough data regarding how accurate these tests are and how they should be employed.

I finally received a call from occupational health telling me the test results and to go back to work. Typically I’d be starting on outpatient weeks at this time, meaning I would be seeing patients in the office and go to morning and afternoon conferences with other residents. The pandemic has disfigured outpatient life for a resident, so now I start with telemedicine appointments and we’re given strict instructions to stay away from the hospital until it is our turn again—I’ll gladly oblige.

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