Wednesday, December 21, 2011

Look at all the stars

Last week I was in Philadephia speaking to a conference sponsored by city's department of behavioral health and intellectual disabilities which has developed an interfaith collaboration across all sorts of lines which are supposed to be impossible to cross. A number of those involved in the conference would be thought of as 
"consumers" in other places, a term that implies several steps down from "citizen" or "human." But in this city of brotherly and sisterly affection, the generative swirl sweeps up and transforms everyone.

I wore my Van Gogh tie for the occassion, commenting that he would have been at the conference himself, if he had lived in Philadephia in 2011. The tie include a pretty significant piece of his painting "starry night" which is on the bright and garrish side for a side. But those stars to pop out to be visible even from the back row. The outrageous size and almost pulsating energy of Van Gogh's stars was part of what got him classified as deranged back then. But the fact is that Van Gogh's stars look WAY more like what we now understand stars to be like today. Anyone who thinks that stars are teeny weeny little bitty dots of pale light is danerously detatched from reality. They are all--including our little sun-- impossibly vast, distant, wild pools of energy throwing light and energy beyond our capacity to measure all across the universe. 

The universe itself is sort of like that, too. Stable, contained, predictable and cold are qualities only appropriate for minds and spirits untuned to the reality of the jumping universe. Anyone who has really paid attention to a neighborhood, much less a city, much less a region, or country knows that is true, too. But little minds like to think of all those things as stable, contained, predictable and cold, too. They are, well, crazy. How much they miss of what is possible!
Bill Mallonee and Muriah Rose (above ) opened our Innovation Studio last Winter with brilliant lyrics and deeply felt voice. They just released a set of songs for the season called Wonderland ( ). This is from their WPA series which are more like a live performance than polished studio work. There is a painfully smart song "the king will see you now." This the only christmas song I've ever heard from Herod's cynical point of view, which helps retrieves the holiday from religious smaltz. But the song you need to get you through the next couple weeks is, "look at all the stars," which Bill wrote thinking of his dad, (but I think of Van Gogh).

My father often brought me here; 
I loved to see him smile 
it was hard to tell which one of us 
was the little child 
he would stretch his arms out wide; 
he would hold me to his heart 
he’d say, “Hey, look at all the stars!” 
he’d say, “Hey, look at all the stars!” 

Life is n’er a path that’s straight; 
there’s so much gets in the way 
from here to Kingdom Come 
there’s so much to make you numb 
still I always had that light 
forever etched inside my heart 
I would tell myself at night 
as I stood out in the yard 
“Hey, look at all the stars!” 
I’d say, “Hey, look at all the stars!” 

This has everything to do with what moved the men called wise across the desert to the garage where Mary rested. And everything to do with with the man who did not listen to his friends and renounce her. His friends surely thought he was, well, crazy. 

For the next few days at least, don't pay attention to anyone who tells you to act like a stable, predictable, contained and cold adult. The world is made for surprise and hope. Don't miss it.

Sunday, December 18, 2011


A couple weeks ago I was in Washington DC and had a few hours before my plane, so I walked the Arlington Cemetery and then to the airport along the Potomac. I had walked that cemetery nearly forty years ago one Winter and remember reflecting deeply on the thousands that gave their lives for others in some brutal, violent and painful way, mostly dying far younger than I am today. From the hill through a gap in the trees you can see the Capitol in the distance. I don't get the impression that many people who work over there make it up the hill to where are the young men are buried. They may vote for the monuments and puff and rant as if they themselves would sacrifice, but its been a while since they actually did anything selfless, much less sacrificial.

But for the last 18 months we--the citizens of this nation--have actually been able to watch a civil servant at work, Dr. Don Berkick. The mean and dumb politics under the Dome ground succeeded in preventing him from holding office as head of the Center of Medicare and Medicaid Services more than that short time, but he has used every minute. And, judging from these excerpts of the speech he gave to the Institute for Healthcare Improvement right after leaving town, they did not manage to take away his spirit for the majesty of the work of government. I urge you to read the whole speech (  ). But a taste is attached here:

"Inscribed on the wall of the great hall at the entrance to the Hubert Humphrey Building, the HHS Headquarters in Washington where my office was, is a quotation from Senator Humphrey at the building’s dedication ceremony on November 4, 1977.  It says: 'The moral test of government is how it treats those who are in the dawn of life, the children; those who are in the twilight of life, the aged; and those in the shadows of life, the sick, the needy and the handicapped.'"I believe that.  Indeed, I think that Senator Humphrey described the moral test, not just of government, but of a nation.  This is a time of great strain in America; uncertainty abounds.  With uncertainty comes fear, and with fear comes withdrawal.  We can climb into our bunkers, each separately, and bar the door.  But, remember, millions of Americans don’t have a bunker to climb into – they have no place to hide.  For many of them, indeed, the crisis of economic security that we all dread now is no crisis at all – it is their status quo.  The Great Recession is just their normal life."The rate of poverty in this country is rising. Over 100 million Americans – nearly one in every three of us – is in poverty or near-poverty today – 17 million of them children. I will tell you – state by state, community-by-community, and in the halls of Washington, itself – the security of the poor – their ability to find the health care they need, and the food, and the housing, and the jobs, and the schools – all of it, hangs by a thread.  The politics of poverty have never been power politics in America, for the simple reason that the poor don’t vote and the children don’t vote and the sickest among us don’t vote.  And, if those who do vote  do not assert firmly that Senator Humphrey was right, and if we do not insist on a government that passes the moral test – the thread will break, and shame on us if it does.
"The choice is stark: chop or improve.  If we permit chopping, I assure you that the chopping block will get very full – first with cuts to the most voiceless and poorest us, but, soon after, to more and more of us.  Fewer health insurance benefits, declining access, more out-of-pocket burdens, and growing delays.   If we don’t improve, the cynics win.

"On my last night in Washington, I visited the Lincoln Memorial again – standing at the same spot that I had stood at as a twelve-year-old boy 53 years ago.  The majesty was still there – the visage of Lincoln, the reach of the Washington Monument, the glow of the Capitol Dome.  It was still unbearably beautiful.  Still majestic.  
"But, there was one change. Chiseled in the very stone where I was standing is now the name of Dr. Martin Luther King and the date – August 28, 1963, when he gave his immortal 'I have a dream…' speech.  
"When I first stood at that spot, the Montgomery Bus Boycott was only three years in the past, and Dr. King’s speech lay five years in the future.  Rachel Carson’s book, 'Silent Spring,' was four years in the future.  And it would be six years before the phrase, 'Women’s Liberation,' would first be used in America.
"I thought, standing there, of something I once heard Dr. Joseph Juran say:  'The pace of change is majestic.'  And I mused about that majesty, and its nature.

"It occurred to me that the true majesty lay not just in the words – not just in the call – but also in the long and innumerable connections between the ideas that stir us – the dreams – and the millions and millions of tiny, local actions that are the change, at last.  A dream of civil rights becomes real only when one black child and one white child take one cooling drink from the same water  fountain or use the same bathroom or dine together before the movie they enjoy together.  An environmental movement becomes real only when one family places one recycle bin under one sink or turns off one unneeded light out of respect for an unborn generation.  Women’s rights are not real until one woman’s pay check stub reads the same as one man’s, and until my daughter really can be anything she wants to be.  The majesty is in the words, but the angel is in the details.
"And that is where you come in. Here is the lesson I bring you from 16 months in Washington, DC.  Your time has come.  You are on the cusp of history – you, not Washington, are the bridge between the dream and the reality – or else there will be no bridge.  Our quest – for health care that is just, safe, infinitely humane, and that takes only its fair share of our wealth – our quest may not be as magnificent as the quest for human rights or for a sustainable earth, but it is immensely worthy.  You stand, though you did not choose it, at the crossroads of momentous change – at the threshold of majesty.  And – frightened, fortunate, or both – you now have a chance to make what is possible real."

Thank you, Dr. Berwick. May  it be so.

Sunday, December 11, 2011

Triple Eligibles

In health policy circles it is common talk about the "dual eligibles", meaning people who are both poor and old and thus eligible for programs that are meant for both types of health coverage. Normal 21st century societies where healthcare is regarded as a basic right do not have to go to such mental twists, but in the United States we do because the programs intended for the old (Medicare) are more like insurance which is deducted from one's wages. But it is not exactly like insurance because it doesn't normally actually cover anything until one is over 65. Other health programs are restricted to the poor, meaning, in reality, poor women or poor children. Real people come in more than two types--old and poor-- so there are roughly ten zillion wrinkles to who gets paid how much for providing exactly what kind of services when to whom, driving anyone who provides or receives care totally crazy every single day of the year.

All this gets especially complicated when one is both old and poor since programs intended for the poor are designed to be just a smidgen demeaning (signaled by lower payments to providers who are expected to be the demeaners). Programs designed for the old are intended to be at least a smidgen respectful (signaled by payments at least within shouting range of truly honorable private insurance). This all reflects the fundamental idea that there are people who deserve help and those that do not and that it is critical to the moral fabric of  society to ever under any circumstance mix the two. Except for these darned "dual eligibles."

It might simplify things to add a complication: triple eligibles, those who simply can't be denied decent care no matter what. It is surprising to some policy dweebs that religious organizations and every single hospital is obligated by both higher and lower law to provide some level of care to every single human being on the planet whether you can tell if they deserve anything or not. Every hospital is required to give at least a cursory examination to anyone who makes it off the sidewalk and through the doors, and enough treatment to stabilize them to the point they can either make it back to the sidewalk under their own power or get shipped to another facility. Most hospitals do more than the minimum out of fear of God, government inspectors or lawyers who keep a sharp eye on those sidewalks.

People eligible for Medicare or Medicaid are covered not just for hospital care, but also a wide range of primary care, prevention and even home care. It covers a lot less than you might think, so the concept of "triple eligible" is still very important. Our Congregational Health Network is really built for these people knowing that many of the most important kinds of care and tending will never be reimbursed by anyone. It is provided by knitting together the mercies of family, members, neighbors and, yes, strangers. And trustworthy advice on where and when to go ask for help is almost never reimbursed, only available for free.

The people only qualifying for this last kind of decency are mostly men (because they are assumed to never deserve respectful help). And it includes the travelers and "aliens," which have always been afforded special status in most religions precisely because they are especially vulnerable. Mary, Joseph and their baby were in this category, as were the whole Jewish people for hundreds of years. You and I and everyone is eligible for human decency no matter what, always, in every circumstance everywhere. Thank God.

I  mentioned this to a very high level Yale PhD in the Center for Medicare Services a month or so back and she confessed that administering the finances of dual eligibles made their head hurt and they just could not begin to think about those living outside those lines.

In reality, the most vulnerable people tend to live in neighborhoods that are triple eligible because they are triple vulnerable. Mitch Graves is the CEO of our home care company, a $100 million enterprise that is almost invisible because all of its activities are beyond the walls of our healing castles, the hospitals. We were going over the data concerning the people receiving "charity care"-- qualifying only for compassion. In just one zip code of less than two square miles in just one year there were hundreds of people mostly cared for in (and back out) of our emergency rooms. There were more than a few chalking up tens of thousands of dollars in care (one for $526k), but most everyone else was in the $1,800 range. Mitch's long experience told him quickly this meant that nearly everyone got some expensive imaging which probably was the quickest way for the ER physician to rule out a life-threatening condition so the person could be back on the sidewalk fast. Sounds a bit hard, but you and I would probably do the same.

When we restrict "eligibility" to the domain of immediate treatment services it makes everyone involved dumb and mean. Dumb because a quick look at the roster of "compassionate care" patients (isn't that better already?) shows that they often come back three or four times a year and they tend to come from the same streets and even buildings. It is dumb to not notice that and dumber to not act on it. Why not not figure out what compassion and decency might be able to see that the CT-Scan missed and can never see? This is dramatically dumb for those receiving treatment for free, but not any smarter for the other categories of eligibility which are also mostly, if not entirely, unprofitable. It is dumb to not widen the bandwidth of curiosity to see if a bit of social service might break the cycle.

And all this is surely mean. It demeans the humans who receive all this inappropriate and ineffective care. And It demeans the whole complicated and expensive apparatus of government programs and healing institutions that fall so short of their intended purposes. Intended for mercy and maybe even a taste of justice, these institutions fail to exercise the intelligence of compassion. Dumb compassion is way better than nothing. But intelligent compassion is way smarter because it opens our eyes to the complex reality of those in need. We see more and can then do more. Doing more is more likely to mean doing less over time since we are more likely to do the right thing--the complete and healing thing--first, rather than as a last resort.

 This works whether you are eligible for one, two or three types of care; once, twice or triple eligible. May God save us all, together.