Suzanne Gordon; Author, Lecturer and Patient Advocate

I really want to support Barack Obama.  I voted for him.  I want his proposals  to succeed.  I also think  one component of his health care plan — a public option to private insurance  — may be the only way this country will ever join the rest of the industrialized world and create a tax supported national health plan that will provide quality health care — at much less cost — to all.  But I am very, very worried about some of the polices and assumptions upon which he founds his health care proposal.  His plan, for example, continues our reliance on the  employment -linked, private, voluntary, for-profit, insurance industry.  Obama tries to reassure people that if they like their current health insurance they can keep it.  The assumption here seems to be that everyone who has health insurance coverage  is just mad about it.  Mad, i.e. happy.  I think most people who have insurance in this poorly regulated, for-profit insurance market are mad all right.  As in angry,   and frustrated with their insurance company not thrilled and delighted with it.  This is particularly true for anyone who gets sick or needs expensive services.  Folks who aren’t sick and rely on their insurance   for small routine things may feel just fine.  But the moment you start needing expensive care, that’s when the industry reveals its true colors.  The fact is, insurance companies rely on people staying health, that’s how they make their profits.  Once you get sick, then all bets and promises are off.

Consider a typical case.  My husband’s.  He went to visit our daughter who was doing volunteer work in El Salvador.  Before leaving he checked in at the travel clinic at the hospital that also houses our primary care practice — Mount Auburn Hospital in Cambridge, Mass.  The doctor offered to give him one rabies shot as a precaution, a prophylactic, in case he encountered a rabid dog.  The doctor said it probably wasn’t necessary because my husband was only staying in El Salvador for a week.  So to save money, and be a responsible health care consumer my husband said no.  Well, with the health insurance industry no good deed goes unpunished.  He went on his journey and guess what, on day four, he got bitten by a dog.  He didn’t worry too much about it because it wasn’t a serious bite.  But just to make sure, when he returned home he called his primary care doctor and the doctor said, this is a no-brainer, you need to get a series of ten rabies shots and pronto.  The shots weren’t given in the PCP’s office but back in the travel clinic.  So my husband got his ten painful shots and the hospital submitted the bill for $1000 to Blue Cross Blue Shield.  We also thought this was an insurance no brainer.  Dumb us!  My husband soon gets a call from the hospital saying the the insurance company has denied payment because the shots were coded as “not medically necessary,’ as if someone would get ten rabies shots just for fun.   They’d confused the one shot, which wasn’t medically necessary, with the ten that were.  So back and forth he goes with the hospital and the insurer.  The diagnosis has to be changed. But who will change it, the PCP or the doc in the travel clinic?  Finally, it’s correctly coded, and the insurance company finds another reason to deny payment.  They will only pay for shots given in a doctor’s office or clinic but not in a hospital.     More calls to explain that my husband was not checked into the Mount Auburn Hospital -but was in the hospital –as in inside its walls — because both the travel clinic and the PCP’s offices are in the hospital.  No luck.  Finally, my husband has to call his employer’s human relations department to get them to intervene.  Meanwhile, the hospital has given the bill to not one but two bill collectors who are also dunning my husband.   After months of phone calls, letters, emails, the insurance company finally pays the bill.  But just yesterday, my husband received another bill from the bill collector.

So what’s the moral of this story.  This is what happens when your health care system is run by prviate, for-profit insurers whose focus is only on the short-term, quarterly bottom line and for whom care of the sick or vulnerable is part of what the industry terms the “medical loss ratio”, i.e you get sick, we lose.  This is one of millions of stories that could be told about our dysfunctional system, which, in the long-term, is completely irrational. Imagine, for example, how much the insurance company would have had to pay if my husband hadn’t had those rabies shots, and in a year or two developed rabies, which is invariably fatal.  Of course, from their point of view, it’s better for enrollees to pay and then die.  But his death would not have been instantaneous but prolonged and quite expensive. And imagine how much money was spent on all the letters, phone calls and time trying to deny the bill.

When I hear or relate stories like this, I’m reminded of a comedy routine that Boston comedian Jimmy Tingle often performs.  It goes like this. We want health insurance to protect us when we’re sick but the industry only wants to deal with us when we’re healthy.  It’s as if, he says, you called the police because someone was trying to break into your house and the officer on the other end of the line replied, “I’m sorry Madame but we only deal with the well-behaved.”

If you’re at all interested in what’s going on in the current economy and how to deal — or not deal with it — I suggest you check out Ariel Ducey’s new book Never Good Enough: Health Care Workers and the False Promise of Job Training.  It was recently published in the series Sioban Nelson and I edit for Cornell University Press on The Culture and Politics of Health Care Work.  Ducey, who is a sociologist, did a thorough study of 1199-SEIU’s job training activities in the state of New York.  The union, in cooperation with the health care industry, got enormous amounts of money from the state of New York to implement and manage job training programs for health care workers.  In fact, job training activities became a core focus of the union, which could not, or would not, get improvements in wages and working conditions for its members.  Instead of trying to make jobs better at every level of the health care hierarchy, the union concentrated on moving workers from one rung of the ladder to the next.  So a nurses’ aide was encouraged to become an LPN; an LPN was encouraged to become an RN; a janitor was encouraged to become a clerk and so forth.  Universities and colleges in New York City reaped millions for job training programs.  So did the union.  The problem, as Ducey defines it, is that workers were promised not only better wages but better working conditions and better work.  In order to pursue this promise, they were encouraged to fork out money and time to take course after course.  Some courses did indeed,give them usseful, new skills, but many simply focused on changing their attitudes so that they would be more productive — not necessarily more satisfied — in the workplace.  Many newly trained workers found that they were as poorly utilized in their new job as they were in their old one.  Once in that new job, they were confronted with similar problems — understaffing, work intensification, under utilization of their skills, authoritarian management, little authority over their work, little voice in workplace organization and so forth.  The solution?  According to the relentless job training model — go back to school, take yet another training course and move on to the next rung on the ladder.

Ducey’s title suggests the problem.  Workers are told that the problems they encounter in their workplace can only be solved through mobility.  And that they are never good enough wherever they land.  Above all, don’t stay where you are and fight to make it better, move West young man — or in this case, mostly  women of color.  This false solution fails to address the problem of how to improve work at the so-called lower rungs of the health care ladder.  We need more, not fewer, nursing home aides.  Desperately in fact.  But rather than improve wages, working conditions and perhaps most of all nursing home management,   under the job training model, nursing home aides,  who have potential  are encouraged to become something else — an LPN, whatever, anything but this.  So all we do is reinforce the kind of turn-over, lack of on-site education, and low morale among staff that makes nursing homes so unsafe for residents.  The same is true everywhere in health care.

As the editor of this book, I was particularly interested in its subject and analysis because of what I had long observed in nursing.  As the problems of the nursing workload and work hours increase, as nurses become more and more frustrated with their inability to give quality care in hospitals and other facilities where they deliver direct care to the sick and vulnerable, many decide not to stay and fight but to leave the bedside to become nurse practitioners or other “advanced practice nurses.”  Just the other day, I was talking to a nurse in the South who had had it with dangerously high patient- to -nurse loads and said she’d decided to go back to school and get a masters degree so she could get the Hell out of the hospital.  ”Would you have stayed at the bedside longer if your workload was more manageable?” I asked her.  ”Yes, absolutely,” she said. ” I love bedside nursing but I work on a telemetry unit and we take care of 7 to 10 patients in the daytime and 10 or more at night.  I’ve tried to change that, but no one listens.”  I’ve had it.  I’m getting out was her bottom line (she was also fighting for better staffing ratios nationally.)  Many nurses are encouraged to get out and move “up” not only by academic institutions but by hospitals or other facilities that provide, as a perk of employment, educational stipends.  The problem is, in nursing at least, few of these subsidies go to nurses who want to remain at the bedside because masters degrees in nursing simply aren’t geared to encouraging bedside RNs so stay at the bedside.

Job training as a solution to the crisis in both education and health care has been one unions and health policy experts have frequently championed.  Today, SEIU is pursuing that solution to both health care workers’ complaints and the employment crisis.  The union and other job training advocates seem to ignore the fact that as one moves up the ladder people are losing their jobs and hospitals and other facilities aren’t interested in spending money on a new crew of newly trained workers to replace them.  In fact, even though we still have a nursing shortage, hospitals that feel strapped for cash are laying off RNs or they aren’t filling jobs when someone retires.  So training LPNs or aides to become RNs is hardly a solution to either  health care workers’ dissatisfaction with their jobs, or the unemployment crisis we are now facing thanks to out of control global cowboy capitalism.

Ariel Ducey’s book is the perfect way to jump start a long over due conversation about how to deal with poor working conditions in health care or for that matter in any other industry.  Of course, I am a bit prejudiced, since I edited the book.  But I think it’s well worth your attention.  To check it out click on the Cornell University Press heading under my picture.