Primary Physicians React to Affordable Care Act Repeal

Just two weeks ago, I posted a story on this blog about public rallies against repeal of the Affordable Care Act, aka Obamacare, including one I attended and observed here in Chicago that day. That article discussed patients’ reactions to the prospect of ACA repeal under the Trump administration, noting that just 26 percent of Americans currently favor wholesale repeal—far from a majority—while substantial majorities favored almost all the major provisions of the current law. But what about the primary care physicians who treat those patients and serve on the front lines of medical care? How do they feel?

Well, the New England Journal of Medicine apparently decided to find out. It turns out that an even smaller minority, just 15 percent favor wholesale repeal, including just 38 percent of those who voted for Donald Trump. The journal notes that the adjusted response rate to its survey was 45.1 percent, and that the views of primary physicians are not necessarily the same as other physicians. It also notes that about three-quarters favor making changes to the law, but that option is not at all inconsistent with favoring its continued operation. Many such laws are amended over time as a result of experience with their strengths and weaknesses. One potential change favored by those surveyed is that of providing a public option, such as Medicare, in competition with private coverage. Creating such an option for consumers runs counter to current Republican dogma on the issue.

That said, 95.1 percent favored the prohibition on denying coverage based on pre-existing conditions, and majority support for other key provisions of the current law, with the exception of the tax penalty for noncompliance, although even that support was higher than for the general public, at 49.5 percent, almost half. However, the prohibition on denying coverage depends on the mandate for individual coverage. One makes the other possible.

Jim Schwab

Petition the White House on Climate Change

I was made aware yesterday of a new petition on the White House website concerning climate change. The White House website has long contained a mechanism by which citizens can initiate an online petition on an issue of concern and then seek support from others to bring that issue to the concern of the President and his staff. To get a formal response from the White House, the petition must attract at least 100,000 signatures in 30 days. The clock is already ticking. Because petitions have a word limit, the statement is brief and to the point:

  1. Reinstate the President’s Climate Action Plan and double down on your commitment to ensuring the U.S. is the leader in combating climate change.
  2. Allow the EPA to do their job and protect the waters, air, and people of the United States. This includes allowing them to regulate greenhouse gas emissions.
  3. Use climate change as a lens when making decisions for our country. Don’t pit economic development against environmental protection – that is a false dichotomy.

I have discussed numerous times on this blog why climate change is a serious issue facing this nation’s future, how it affects our vulnerability and undermines our resilience to natural hazards, and the scientific basis for understanding that climate change is a real phenomenon significantly influenced by human activities. While President Trump seems to deny this reality, what he has not offered so far is any scientific evidence to support his assertions. I would go so far as to say he has offered little more than tweets and campaign slogans. It is time to get serious; far, far too much is at stake for the future of both the U.S. and the world to continue in this vein.

If you wish to sign on to the petition, just go to https://petitions.whitehouse.gov/petition/make-us-worlds-leader-combating-climate-change, and enter your name and a valid, current e-mail address. We may not get the response we desire, but we can at least make our voices heard.

Jim Schwab

The Fine Art of Stepping Down

“The cemeteries are full of indispensable people,” or variations thereof, is a quotation that has been attributed to many, including the late French President Charles de Gaulle, but according to Quote Investigator, actually belongs to an American writer Elbert Hubbard in 1907, using the phrase, “people the world cannot do without” and the word “graveyards.” But QI notes numerous sources over the years, many of which may well have borrowed from or built upon the other. The point is clear: None of us lives forever, and the world finds a way to move on without us. We can make an impact, but so can others. And we can come to terms with those facts long before we arrive at the cemetery.

Although it was not made public until January 9, I decided a few months ago that it was time to leave my post at the American Planning Association as manager of the Hazards Planning Center. There are two other such centers at APA—Green Communities, and Planning and Community Health—each of which has had at least three different managers since the National Centers for Planning were established in 2008 as a means of making clear APA’s commitment to certain leading-edge topics in planning. I have so far been the only manager for Hazards.  More importantly, I built that center’s portfolio atop an existing legacy of work in the field of planning for hazards dating back to 1993, when I agreed to manage a project funded by the Federal Emergency Management Agency (FEMA) that led to publication of the landmark report, Planning for Post-Disaster Recovery and Reconstruction. I did not at first foresee the ways in which that effort would forever alter the arc of my career in urban planning. Looking back, there was nothing inevitable about it. While I was http://www.statenislandusa.com/heavily involved until then in environmental planning, almost none of it involved disasters. Once I sank my teeth deeply into the subject matter, however, there was no letting go. The Blues Brothers would have said that I was on a mission from God. Increasingly, I became aware of the high stakes for our society in properly planning our communities to cope with natural hazards.

One of the special pleasures of my position was the opportunity every summer to attend the Natural Hazards Conference in Colorado. Here, along with my wife, Jean, and daughter, Anna, in 2007, are some visitors from Taiwan whom I had met during a conference there the year before.

One of the special pleasures of my position was the opportunity every summer to attend the Natural Hazards Conference in Colorado. Here, along with my wife, Jean, and daughter, Anna, in 2007, are some visitors from Taiwan whom I had met during a conference there the year before.

That quarter-century tenure in the driver’s seat of APA’s initiatives regarding disaster policy and practice made me, in some people’s minds at least, almost inseparable from the position I now hold. Perhaps in part because I was comfortable in working with the news media, I became the public face of APA in the realm of hazards planning. That may have been amplified to some extent by the fact that, until last year, the only APA employees working directly under me on a regular basis were interns, most of whom were graduate planning students. It’s not that I was a one-man show. I enlisted staff within the research department for specific projects with assigned hours. Given the expertise needed in this area, and my own willingness to listen to and learn from the best, most experienced people available, it was generally productive to contract with those people on a consulting basis or through partnerships with other organizations. Because APA is a professional organization with a membership of almost 40,000, those resources were readily available. I could marshal expertise far greater than any we could have hired for most of those years. Last year, however, we came to terms with growth and added research associate Joseph DeAngelis, who joined us after leaving the New York City Planning Department, where he had worked on Hurricane Sandy recovery on Staten Island. He has become a great asset to the organization.

His ability to span the transition to a new manager was one of several preconditions I had in mind over the last two or three years in contemplating my retirement from APA. More important, but a factor in adding him to our staff, was that I wanted to leave my successor with a center that was in good shape. This meant having projects underway, and funded by agreements with sponsors beyond the immediate few months after my departure. By late last year, we had won project grants from FEMA and the National Oceanic and Atmospheric Administration (NOAA) that will all end between July and December in 2018. That gives my successor, whoever he or she may be, more than adequate opportunity to complete those ongoing projects, maintain APA’s credibility in the realm of hazards, and explore new options and opportunities that will sustain the legacy that is already in place. I understand that people like me sometimes move quickly to another organization, firm, or government agency because a huge opportunity opens on short notice. With retirement, however, there is no need for such haste. We can take time to plan well.

That leads to another precondition in which I can say that I am greatly aided by the management philosophy of APA’s current executive director, James Drinan. He believes that, when possible, we should seek a managerial replacement who can join APA in the last two or three weeks of the tenure of their predecessor. This allows the opportunity for the outgoing person to share how things are done or even answer questions about how they might be done better or differently. I recognize, for one thing, that my own package of skills is unique and unlikely to be replicated. That is fine because someone new may well be much stronger in some other areas than I ever was. And if so, I am happy for them. It is a fool’s errand to seek replacement by a clone. Ultimately, the hiring choice will belong to APA’s research director, David Rouse, but my input on what credentials and experience are most useful is likely to have an impact. We hope to see resumes from some high-quality candidates in coming weeks.

So what is next for me as of June 1? I look forward to an opportunity to explore some new options that simply have not been feasible until now. Elsewhere on this website, I describe my intended work on some future book projects, most immediately focusing on the 1993 and 2008 Midwest floods, but there are other ideas waiting in the wings. APA would like to use my consulting services as needed to aid the transition beyond my retirement, and I have agreed, but there are and may be some other offers. I will certainly continue teaching at the University of Iowa School of Urban and Regional Planning, at least as long as they wish to continue that relationship, which has been very fruitful. And it should surprise no one if people find me on the speaking circuit from time to time. In fact, I may be much freer to accept such invitations if I am not managing a research program for APA. Finally, I shall have considerably greater free time to devote to this blog. In less than four years, its following has grown from virtually nothing to more than 14,000 subscribers as of this week. It has been a great pleasure to share what I learn through that forum.

The opportunity to spend part of an afternoon just reading a book on a 606 Trail bench beckons.

The opportunity to spend part of an afternoon just reading a book on a 606 Trail bench beckons.

But those are all activities that somehow involve work. I may well involve myself in some volunteer activities with APA divisions and its Illinois chapter, the Society of Midland Authors, and other outlets that I may discover. That too sometimes sounds like work, so let me try harder. I have written about the wonderful 606 Trail near my home; I expect to walk and bicycle there and in nearby Humboldt Park. I may well take a great novel to one of the trail’s benches (or to my front patio) and read in the middle of the day. My wife and I may travel, both as we choose and as we are invited. Anyone reading this blog must already know that I love to get around. Despite all its flaws, the world remains a fascinating place, and I want to explore it while I can. I may never get a gig (or want one) like that of Anthony Bourdain, but I will see enough. And, yes, like him, I love to explore different cuisines—in part so that, as an amateur gourmet chef with new time on his hands, I can try them out for guests at home or elsewhere. Like I said, the world is a fascinating place. Explore it while you can.

Jim Schwab

Making Natural Infrastructure Solutions Happen

From time to time, I contribute to the APA Blog, which consists of a variety of news and perspectives the American Planning Association provides to its members on its own website. Recently, I composed an article about an effort APA undertook in concert with several organizational partners to explore issues related to permitting of wetlands restoration projects and some of the obstacles such projects may face. For those interested, just follow the link: https://www.planning.org/blog/blogpost/9118459/.

Jim Schwab

“For God’s Sake, Don’t Repeal It”

Overflow crowd attends health rally at SEIU-HCII hall.

Overflow crowd attends health rally at SEIU hall.

“Six weeks ago,” said Sen. Dick Durbin, the Illinois Democrat who is assistant minority leader in the U.S. Senate, “I got a call from Burlington, Vermont.” It was Sen. Bernie Sanders, who told him “we need to rally in cities across the U.S.” to preserve health care for Americans. Sanders, though falling short of the Democratic nomination last year against Hillary Clinton, showed a noteworthy capacity as a prescient organizer. He clearly anticipated the assault that the new administration and congressional Republicans have now launched against the Patient Protection and Affordable Care Act (ACA), popularly known as Obamacare. And so today, five days before Donald Trump will be inaugurated the 45th President of the United States, rallies to preserve the ACA took place. Durbin spoke in Chicago at the overflowing hall of the Service Employees International Union (SEIU), Health Care Indiana-Illinois (HCII) unit.

Line forms at the back of the building. It got much longer.

Line forms at the back of the building. It got much longer.

My wife and I arrived about 15 minutes before noon, parked our car in the lot behind the building, and joined a long and rapidly growing line of people seeking to attend the 1:00 p.m. rally. Limited by fire code, the SEIU staff had to cut off the number of people entering, directing the rest of the crowd to a Jumbotron behind the building. We were lucky, among the last 25 people allowed inside, and the line behind us stretched around the corner. Clearly, the Republican attack on health care had stirred a hornet’s nest, at least here in Chicago.
Durbin was the leadoff speaker following an opening by Greg Kelley, executive vice-president of SEIU-HCII. With

U.S. Rep. Jan Schakowsky posing with followers.

U.S. Rep. Jan Schakowsky posing with followers.

him were several Chicago area Congressmen—Reps. Mike Quigley, Jan Schakowsky, Brad Schneider, and Raja Krishnamoorthi, all Democrats, along with Cook County board president Toni Preckwinkle. Durbin cited the statistics that reveal the origin of the angst driving the overflow crowd. He noted that some 1.2 million people in Illinois stood to lose their health insurance coverage if the ACA is repealed, roughly 10 percent of the population. The ACA saves seniors in Illinois an average of $1,000 per year on prescription drugs. People stood to lose the ACA’s protection against lifetime limits on coverage, which in the past often led to bankruptcy for people with catastrophic illnesses like cancer.

“The Affordable Care Act was the most important vote I have ever cast as a member of Congress,” Durbin concluded. “If the Republicans can’t replace it with something as good or better, for God’s sake, don’t repeal it.”

A true citizen uprising needs more than politicians at the podium, and union leaders, such as SEIU president Mary Kay Henry, health care consumers, representatives of Planned Parenthood and a small business alliance, and others, including the Rev. Jesse Jackson, kept the standing-room-only crowd revved up. Tracy Savado, introduced as a health care consumer with a story to tell about lifetime coverage caps, shared that her husband had been diagnosed with an acute form of leukemia. Fearful of lacking enough insurance, she inquired of her insurance company representative about this point, and, she said, was told that President Obama’s health care law had done away with such limits. Prior to the ACA, she noted, about half of all insurance policies had lifetime caps on coverage. She added that she had recently attended a farewell for outgoing Health and Human Services Secretary Sylvia Burwell. Asked what might happen in the new administration, Savado said, Burwell paused and noted that the biggest obstacle to the GOP plan for repeal is “people sharing their stories” about the benefits they have enjoyed from the new law. “When people understand what’s at stake, they aren’t going to want repeal,” she concluded.

Many of the other speakers essentially made many of the same points in different ways for almost an hour and a half, until William McNary, co-director of Citizen Action Illinois, ended the rally on a boisterous note with a rousing speech in which he declared that “the only pre-existing condition the Republicans want you to have is amnesia.”

His comment is a powerful point that is worth remembering in considering how matters came to this pass. More than a few Americans who voted for Trump in the recent election are also benefiting from Obamacare. While people clearly can and do vote on issues other than health care, it remains undeniable that this constitutes some form of contradiction that requires explanation. Even amid the 2010 debate that ended with the passage of the ACA, Tea Party rallies often featured protesters with signs that read, “Keep your government hands off my Medicare.” What sort of stunning ignorance is required to fail to understand that Medicare was and is a creation of the federal government by a vote of Congress in the 1960s and that, absent the “government hands,” it would never have come to be in the first place?

Recent polls have shown overwhelmingly that voters favor virtually all the key features of the Affordable Care Act even as many nonetheless oppose whatever they perceive as “Obamacare.” A post-election Kaiser Health Tracking Poll found public support at 80 percent oDSCF3283r above for ACA provisions allowing young adults to stay on their parents’ insurance plans, eliminating most out-of-pocket costs for preventive services, subsidies for low-income insurance purchasers, and state  options for expanding Medicaid, as well as 69 percent for prohibition of denial of insurance because of pre-existing conditions. Only 26 percent want the law repealed. What we have faced since 2010, and must confront now, is not a real plan to replace Obamacare with something better, but an incredibly slick campaign of propaganda to associate the word Obamacare with something evil.

People who come to terms with the origins of such contradictions may find themselves in a better position to understand the remarkable political gall required for the Republican majority in the U.S. House of Representatives to pass repeal in recent days without offering a clue as to what will replace Obamacare. “Repeal and replace” was Trump’s campaign mantra, yet even he has offered no details of consequence about what that will mean even as he insists Congress will somehow do both within the next few weeks. Anyone who believes that can be done by a party that has failed to define an alternative for the last six years is truly prepared to believe in political miracles.

It would be more realistic to look closely at Trump’s nominee for Secretary of Health and Human Services, Rep. Tom Price of Georgia, a man who advocates replacing much of current Medicare coverage with a voucher system and is devoted to dismantling Obamacare. Read his intentions closely, get angry, and organize.

Jim Schwab

The Voice of Identity

For many Americans, including numerous prominent Republicans, one of the more troubling phenomena in the 2016 presidential election was the rise of certain groups who seem to attach their own identity to resentment and rejection of those who do not fit traditional images in our culture. The frequently demonstrated reluctance of Donald Trump to distance himself from advocates of white nationalism or supremacy served only to reinforce a sense of unease about the direction our nation was taking. The situation raised some disturbing questions about who we are as a nation at the same time that it also revealed a very real sense of the loss of possibility among those who embraced the Trump messages. Before we hasten to condemn this trend, it is important to keep in mind that many of the people who launched Trump into the White House have felt a very real unease of their own, a feeling of losing their footing in what they experience as a stagnating economy. The feeling transcended party boundaries and went a long way toward explaining the surprising popularity of the Bernie Sanders candidacy in the Democratic primaries. This great stirring is far from over just because Trump won.

I do not raise this issue to reach any partisan conclusions or even to address it in any specifically political terms. But I was moved to think about it in part after observing some of the more blatant instances of racist prejudice in post-election interviews with the likes of Richard Spencer and his National Policy Institute. Spencer grabbed some attention with a speech that included the phrase “Hail Trump,” a barely veiled echo of “Heil Hitler,” and, according to a recent article in The Atlantic, made clear his dream is “a new society, an ethno-state that would be a gathering point for all Europeans,” and has called for “peaceful ethnic cleansing.” It is hard to imagine how ethnic cleansing can possibly be peaceful, so I think one can hardly be blamed for suspecting deceitful propaganda. No matter how many disclaimers the alt-right may use in trying to reframe its identity, the old stench of the Ku Klux Klan and neo-Nazi movements refuses to go away.

But I want to make a larger point and then delve into the very question of how we frame identity, and how it frames us. Our sense of identity can be both liberating and oppressive, both loving and resentful, thoughtful and downright stupid. Spencer, in a recent television interview, effectively expressed the notion of simply claiming his white identity in the same way that blacks take pride in theirs. Many on the alt-right take pains to note how much white people have contributed to our society as a means of expressing dominance. This is rather simplistic for the obvious reason that our society long was of predominantly European origin, so it stands to reason that most of our heritage bears that mark. But it is not nearly so simple as all that. The whole notion bears some dissection.

What has come to be identified as the African-American experience, for starters, resulted from a forced common experience of bondage in which most slaves lost any or most of their specific African heritages under circumstances that were not only unquestionably racist but involved violent subjugation as well. It is no accident that black slaves often readily identified with the biblical story of the Israelite release from slavery. Liberation movements throughout world history have played a role in forging new identities through struggle. The fact that the struggle has continued to this day in the form of civil rights battles has served only to strengthen those ties.

And yet—one needs only to observe the assimilation into American society of African and Caribbean black immigrants to realize that there are subtleties and variations in the African identity. President Barack Obama himself, the son of a white woman from Kansas and a Kenyan student at the University of Hawaii, struggled in his youth to establish his own sense of identity, which did not come from claiming slave ancestors in the Deep South. In current American society, one can see expressions of Ghanaian culture, as well as of Ethiopians, Nigerians, and Somalis, all arriving long after the most bitter civil rights and liberation struggles have been fought, seeking to establish their own ethnic identities in a very diverse America. The tapestry is ornate and continues to enrich American society with everything from new cuisines and artistic expression to new ways of understanding what attracts people to the American dream.

These variations and nuances extend to the frame of “white American” experience. Because what became the United States of America began with English colonies, the experience of early Americans was very English in nature—but not entirely. Early on, the British empire absorbed Dutch and French settlers into its universe, as well as a modest number of American Indians who intermarried. (It should also be noted that perhaps one-fourth of African-Americans have some American Indian ancestry, in no small part because of slaves escaping to Indian communities and integrating and intermarrying over time. See Black Indians for just one interesting exposition of this fascinating history.) Over two or three centuries, “white” America gradually absorbed more non-English elements, beginning with the Irish and Germans, and eventually including all sorts of largely non-Protestant immigrants from southern and eastern Europe as well as Lebanese, Turks, and others.

All these people brought with them unique cultural attachments. For example, Greeks brought not only their Orthodox church, but numerous specific perspectives on the world based on their own historic and philosophical outlooks, all tempered over time by new experiences in the New World. In many cases, those initial experiences included some discrimination and challenges in becoming American. Any serious student of American history is aware of such phenomena as the Know-Nothing movement of the 1840s and 1850s, a period when factory doors often sported signs indicating that “Irish need not apply.” Tensions boiled over at times, including one notable instance in Chicago in 1855 known as the Great Lager Beer Riot. Know-Nothing Mayor Levi Boone sought closure on Sundays of the pubs and bierstuben that the Irish and German workingmen patronized, and a confrontation erupted. Boone became a one-term mayor, and his initiative came to naught.

The targets of white-on-white discrimination shifted over time into the early and even mid-20th century, as assimilation proceeded and various nationalities won grudging acceptance. American literature is replete with very personal interpretations of these experiences from Norwegians, Lebanese, Greeks, Russians, and others trying to find their place in American society. One astute student of the subtleties of this evolution, Mel Brooks, generated the biting and wickedly comic satires Blazing Saddles. I have long felt that movie, which I have watched several times, offers far more insight than meets the unlearned eye into the sometimes explosive mixture of influences that shaped the American West. My own discerning eye for the subtleties of this movie came after living in Iowa for more than six years and researching a book on the farm credit crisis, as well as marrying a Nebraskan, all of which made me very aware of the diverse ethnic communities that comprise much of the West. Rural America is not nearly as monochrome as many urban Americans imagine it to be.

Let me return briefly to the phony vision of the alt-right. What I have just described should make abundantly clear that the notion of “white identity” can have only one purpose. That purpose is white supremacy and the oppression of minorities because the overall “white” experience in America is itself so diverse and has evolved so far from its English colonial roots that the only possible meaning one can attach to this “white identity” is that of suppression of any other form of identification with the meaning of “American.” I also do not think a blog article like this can do more than scratch the surface of this subject. Whole books have been devoted to the formation of personal and collective identity in the American melting pot without successfully exploring all the nooks and crannies of the issues involved. Nonetheless, I strongly believe we must keep this subject open for further exploration. We have little choice if we want to understand both ourselves and what is happening around us.

I also want to make clear that I do not believe that Donald Trump is endorsing white supremacy. What troubles me is his willingness to exploit this sentiment to advance his political ambitions. Many of the obvious splits within the Republican party had as much to do with the discomfort of Mitt Romney, John Kasich, John McCain, and the Bush family, among others, with this exploitation of prejudice as with any other stance that Trump took. These past Republican leaders simply found themselves unable to stomach such intolerance. Trade and foreign policy issues are fair game in a presidential contest, but for reasons related to his own view of the imperative of winning at any cost, there is little question that Trump took the low road in making his arguments. That choice will leave him mending fences for the next four years if he truly wants to be president of “all the people.”

Ultimately, our collective national identity is a composite of the many individual identities we construct for ourselves. Some of us construct these identities carefully and deliberately over many years, and others simply accept inherited attitudes, privileges, or resentments. But one of the central claims of the conservative right has been that America has traditionally been a Christian nation. That is a position that, in some respects, also ignores the freedom of religion that is enshrined in the First Amendment, which includes the right of people to observe other faiths or no faith at all. But I would prefer to confront white identity on Christian grounds both because I am willing to claim Christian identity and because real Christian faith flatly excludes white identity: “For in Christ there is no longer Greek nor Jew, slave nor free, male or female.” (Galatians 3:28) Saint Paul did not need to add “black nor white” to make his point perfectly clear. The only thing that is remarkable is how often this simple point is missed or ignored.

Another piece of Christian wisdom is well known and comes directly from Jesus (Luke 12:48), that from those to whom much has been given, much also is demanded. I can think of few things more appalling than to waste one’s life and talents disseminating hatred and bigotry in a world badly in need of greater love and understanding. An honest search for our collective or personal identity demands both an open mind and respect for our fellow citizens. I can think of nothing that would ever alter my perspective on that final observation.

Jim Schwab