healthcare reform

Podcast • February 20, 2014

Cuba’s Healthcare Revolution

Cuba’s revolutionary vanguard: US medical students Keasha Guerrier, Kereese Gayle and Akua Brown Three winters ago our Open Source trip to Cuba turned around on an astonishing moment of serendipity. At a bus stop in Havana ...

Cuba’s revolutionary vanguard: US medical students Keasha Guerrier, Kereese Gayle and Akua Brown

Three winters ago our Open Source trip to Cuba turned around on an astonishing moment of serendipity. At a bus stop in Havana my colleague Paul McCarthy heard a laugh he recognized from high school in California. “Only Akua Brown laughs like that,” he blurted. And Akua Brown it was, the friend he hadn’t seen for a decade, now finishing her fourth year at the Latin American Medical School in Havana.

Over the next few days, Akua Brown and her friends poured out their four-year immersion in Cuban life and language, Cuban magic and slang, the Cuban versions of sexism and racism, Cuban boyfriends and families, drums and faith, bureaucracy and student volleyball, and by the way, this strange Cuban thing about toilet seats and toilet paper: the revolution doesn’t seem to believe in either.

But the core of our long conversations is medicine, the Cuban way. This is aggressive, free, hands-on health care that makes house calls, and lingers for the feel of emotions and homelife. Doctors’ training like doctors’ care is free: the payback required of the students here from all over the hemisphere is only that they return to underserved areas of their home countries.

Michael Moore and our friend the Nobel Prize cardiologist Bernard Lown knew the results in Cuba all along. “I have been to Cuba 6 times,” Dr. Lown emailed me, “and learned much about doctoring in Cuba. Their thinking on social determinants of health, on the primacy of public health and the vital role of prevention strategies are unmatched in the world. With spending of less than $200 per person per year for health care, they have achieved health outcomes no different than in the USA where expenditures now exceed $7000 per person annually!”

Keasha Guerrier, a science major from the New York Institute of Technology, knew about Cuban medicine because “my father’s from Haiti, my mom is from Guyana.” But her brother teases her about “blackouts” in Cuba, and she has other relatives and friends who don’t know why she’s there, or ask her to “pick up a box of cigars on the way out.”

Keasha Guerrier

Am I just a pawn in a game the Cuban government is playing? I push back hard against that idea. There are a lot of things that the Cuban government has done that some people might not agree with. But medicine with a community base in training and practice — that is one the things they got right on the nose. They hit the nail on the head. The people who instituted this program saw how it works in Cuba… and they compared Cuba’s situation to countries in Central and South America or third world countries, Africa, Haiti. And they saw how they can make a difference. Here, you do a lot with a little bit… What they are trying to teach us is that you don’t have to be confined to working for a paycheck. But using all the things that you know, you can help a broad base of people. In that respect, I think that the intentions are pure.

Keasha Guerrier in conversation with Chris Lydon over roast chicken with rice and beans at the restaurant El Ajibe in Havana, December 19, 2008

Kereese Gayle grew up in Lousiana and Florida. She was a Spanish major at Georgetown who could see herself coming out of medical school in the US with crushing debts. “My family is Jamaican,” she says, “so we knew about the quality of the Cuban medical system. To this day I know I’m where Im supposed to be.”

Kereese Gayle

We’re here at a very important time in the history of the world. We’re getting the type of education that I think people are looking for. More and more people are thinking very seriously about the idea of universal health care, about the idea of rights for everyone to basic access to health care. I think we’re going to be a huge part of that…

We learn how to diagnose our patients with our hands, our ears, our eyes more so than with technology–X-Rays, CT scans– because you don’t end up doing those kind of really costly labs as often here. So we definitely have that as an advantage… We learn how to interview our patients thoroughly, and how to do a really thorough physical exam and do it well, and be comfortable with that… Doctors here not only do house visits but they go into homes: they have a form that you fill out to check off what risk factors the person has [in their home]. Is their water contained properly? Do they smoke? We get that kind of first hand view. In the United States, you can ask someone if they smoke or if they have a pet and they easily can lie to you. But here, as someone’s primary physician, you can see not only the physical medical aspects but the psychological medical aspects as well. Do you feel tension the minute you walk into the room? Are people in a mentally healthy environment, or do we need to get [them] to a psychologist. There are so many advantages to the system that we can take back and apply to the communities where we live.

Kereese Gayle in conversation with Chris Lydon sipping lemonade at El Ajibe in Havana, December 19, 2008

Akua Brown minored in Spanish at San Francisco State University, and spent most of her first two years in Havana learning the Cuban vernacular and testing her Bay Area ideal of the Revolution.

Akua Brown

The education system here is excellent; there is very little homelessness. Everyone has a right to free health care… up to the most specialized needs. Neurosurgery, open heart surgery, cost nothing to the people. And the fact that a government with so little financial resources is able to do this says that the United States can do so much more… And without the debt that most medical students graduate with, we won’t be afraid to start our own projects and programs without necessarily needing the money to pay back the loans and the things hanging over our heads. Living here for six years, I think we have learned to live a simpler life with bare necessities. I ride the bus, I hitchhike, I buy from the community market. I’m not complaining–home is comfortable, but this is livable.

Akua Brown in conversation with Chris Lydon savoring the coffee at El Ajibe in Havana, December 19, 2008

The practical visions of these blessedly gifted women brought to mind Ralph Waldo Emerson‘s indomitable “world spirit.” Entering the second half-century of both the black freedom movement in the US and the Socialist revolution in Cuba, each with its ups and downs, these very American young women would remind you that grand ideals, the best we have, can prevail. “Things seem to tend downward, to justify despondency, to promote rogues, to defeat the just,” as Emerson wrote at the end of his essay on Montaigne; or the Skeptic. “Although knaves win in every political struggle, although society seems to be delivered over from the hands of one set of criminals into the hands of another set of criminals, as fast as the government is changed, and the march of civilization is a train of felonies,- yet, general ends are somehow answered. We see, now, events forced on which seem to retard or retrograde the civility of ages. But the world-spirit is a good swimmer, and storms and waves cannot drown him…”

Podcast • March 23, 2010

Healthcare: in the post-game booth with James Morone

Click to listen to Chris’s conversation with James Morone. (42 minutes, 26 mb mp3) “Show him a poltical near-death experience, and this guy rallies!” James Morone has been telling us all along that healthcare politics ...

Click to listen to Chris’s conversation with James Morone. (42 minutes, 26 mb mp3)

“Show him a poltical near-death experience, and this guy rallies!”

James Morone has been telling us all along that healthcare politics was peculiarly personal — this business of medicine and presidents and policy, starting with Franklin Roosevelt’s polio and Dwight Eisenhower’s heart crises and JFK’s many brushes with death. Each of their adventures in healthcare legislation reflected their medical records, and shaped the narrative of their terms in office. And now the dazzling Obama bounce marks a second chance, a sort of second inauguration, a fresh start of the age still struggling to be born.

Jim Morone’s exuberant post-game commentary makes a variety of uncommon points, among them:

(1) The healthcare victory should be framed as the end of the 30-year Age of Reagan. It is a moment for Barack Obama to reintroduce himself as the child of a refugee from the British Empire in Kenya, and the visionary of an old American dream of both opportunity and community.

(2) It may be time to do something about Congress. “We can’t have a legislature that’s this broken,” Morone says. “I think the world has had a year-long seminar on why America doesn’t have health insurance. Why? The one word answer is: Congress.” After Harry Truman’s election in 1948, on a health insurance pledge, “if we’d been playing by English or Canadian or Australian or German parliamentary rules, we’d have had national health insurance in 1949 — two or three years after the Brits, eleven or twelve years before the Canadians. We didn’t get it because Congress laughed at Truman… It’s not that the public wouldn’t vote for it, or that Americans hate Socialism. It’s because we have a legislative process designed by the founders to break the democratic will and one that has multiplied its checks and balances until now, I think, it’s the broken branch of government.”

3. It might be time to try real representative democracy in America. Let the Left sit down with the Right and agree: “Here’s the deal. When we’re in power, we get to do what we promised the people. When you’re in power, you get to do what you promised the people… Put aside all those checks and balances that make elections kind of wild dumb puppet shows about all kinds of extraneous issues, and really make it about the kind of legislation we’re going to pass. It’s called democracy, and we might try it one year.”

4. We all — starting with the news commentariat — need a political scorecard tuned more to the perspectives of history, less to short-term electoral swings. The great monuments of Lyndon Johnson’s domestic record, in retrospect, were the Civil Rights Act of 1964, the Voting Rights Act and Medicare, too, in 1965. Democrats paid heavily for those victories in huge losses in the mid-term Congressional elections of 1966, and then in Hubert Humphrey’s crushing defeat by the combination of Richard Nixon and George Wallace in 1968. But the election returns were not the measure of LBJ’s achievement. And neither will the 2010 House and Senate races — up or down — be the best judgment on Barack Obama’s young, still developing presidency.

Podcast • September 28, 2009

James Morone: What healthcare politics lays bare

From FDR to Barack Obama, James Morone’s revelatory history of presidents and healthcare policy lays out some basic rules — the conditions, in short, that Lyndon Johnson met to pass Medicare in 1965, but that ...

From FDR to Barack Obama, James Morone’s revelatory history of presidents and healthcare policy lays out some basic rules — the conditions, in short, that Lyndon Johnson met to pass Medicare in 1965, but that asked too much of Jimmy Carter and Bill Clinton in the losing campaigns of 1977 and 1994 for universal insurance.

The bare essentials: Passion, personal and sustained. Speed in the legislative drive. Keep-it-simple engagement of the public. Suppression of economists, wonks and budget numbers. An opportunistic mix of muscle and deference with kingpins in Congress, who must inevitably write the final law. And the foresight, in case of defeat, to leave the issue in good shape for the next try, as Harry Truman did for Johnson, and Bill Clinton entirely failed to do for Barack Obama.

Obama hasn’t flunked any of the core tests so far, in Jim Morone’s judgment. But then, he’s a long way from a victory that would have been automatic in a parliamentary system and may actually be impossible in the American labyrinth of a special-interest Congress.

We will repair early and often to Jim Marone, a born color commentator on politics and chairman of the political science department at Brown, for reviews of the Obamacare scorecare. Meantime, Morone the story-teller is letting us in on some of the striking original themes of his new book, with David Blumenthal of the Harvard Medical School, The Heart of Power: Health and Politics in the Oval Office.

Health policy, Marone argues persuasively, lays bare the soul as well as the working temperament of presidents as almost nothing else does. Our presidents tend to be “sick men,” he writes, with complex medical histories and poorer health than American males in general. But in fact they all have two health stories: first of their own submerged afflictions (FDR’s polio, Eisenhower’s grave heart problems, Kennedy’s wrecked adrenal system and drug dependency) and then: the family memories of health and medicine (Ike’s agitation about his mother-in-law’s ruinous bills for years of round-the-clock nursing care, or JFK’s devastation by his father’s major stroke in 1962). Surprise: it’s not their own medical charts but rather the imprinted stories of near-and-dear exposure to medicine that drives our presidents on healthcare. It may not matter much that, on and off the basketball court, Barack Obama looks like the healthiest president we’ve ever had. The well of his passion is the tearful memory of his grandmother’s battles with insurance companies before she died of cancer just as he got elected.

“Every president changes the conversation about health care in America,” Morone and Blumenthal write in The Heart of Power. It’s a point that leaves me less impressed than Jim Morone is with the Obama drive so far. Obama’s opposition has made it a conversation about socialism and death panels. The media coverage has made it a conversation about Obama: will he bend, or be broken by, the lobbies? Can he dominate the Congress as Lyndon Johnson did? Can he win the big one? Even people who love Obama as I do have doubts that he has addressed the exclusions from care, the fee-for-service racket or the ruinous rise of costs to the whole economy. So we root more for him than for his plan, which is not the way it’s supposed to be.

This is the start of a continuing conversation with Jim Marone, about a battle just well begun:

If you talked to the Obama people ahead of time, they would have said “Oh, we’re girded, we’re ready, whatever they throw at us, we know it’s going to be ugly” — but not this ugly. Why is it so deep? That’s the interesting question here, really. What does this touch? I’ve got two answers…

One, this is the thing that Franklin Roosevelt never fought for in the New Deal. He gets unemployment compensation, he gets welfare, he gets Social Security, he gets the whole list of good welfare-state stuff, but he pulls back on healthcare. So for Democrats this is the lost reform that the New Deal never won. And for the Republicans, this is what distinguishes the United States from all those other welfare states, like Denmark, like Canada, like France. So that this is in the DNA, in the genetic code of each party. Ask a Democrat, and they’ll say, shamefully, “we are the only industrialized country without national health insurance.” Republicans: “We’re the only country without national health insurance!!” So this is a battle about America.

That’s one level. That’s bad enough. Add to that, this is the battle for the high ground in Washington. If Obama wins something significant — if he wins, if it’s significant, two very big ifs — he has done something that Truman, that Carter, that Kennedy, that Clinton couldn’t get done. He emerges from this a star. If the Republicans manage either to make this a very weak bill, or to defeat it, Obama becomes Carter. He’s defeated. This is Waterloo. James DeMint, Senator from South Carolina is absolutely right. But remember, Waterloo had both Wellington and Napoleon: there’s a winner that comes out of this, and the winner is dominating the Washington conversation for the next year. So we are met on the great battlefield. Of course it’s ugly. Of course it’s bloody. Control of our politics is at stake.