And You Thought Health Insurance Was Bad

I spend most of my time thinking about health care, but a recent The New York Times article – How the American Unemployment System Failed – by Eduardo Porter, caught my attention.  I mean, when the U.S. healthcare system looks fair by comparison, you know things are bad.

Credit: Sol Cotti for ProPublica

Long story short: unemployment doesn’t help as many people as it should, for as much as it should, or for as long as it should. 

It does kind of remind you of healthcare, doesn’t it?

The pandemic, and the associated recession, has unemployment in the news more than since the “Great Recession” of 2008 and perhaps since the Great Depression.  Last spring the unemployment rate skyrocketed well past Great Recession levels, before slowly starting to subside.  Still, last week almost a million people filed for unemployment benefits, reminding us that unemployment is still an issue.

Keep in mind that unemployment rates do not tell the full story, as they don’t count those only “marginally attached” to the workforce – people who would like to work but have given up – and counts part-time workers who would like to work full time as “employed.”  The “true” unemployment rate is reckoned to be much worse than the official rate.

Congress has enacted several COVID relief measures, including in late December, to extend duration, amount, and applicability of unemployment benefits, but our unemployment systems remain predominantly state designed and administered.  The shortcomings of these systems have been severely exposed over the past few months: neither the processes nor the actual technologies supporting them proved robust enough for the volume of applicants.  Last December Pew Trusts reported that “unemployment payments were weeks late in nearly every state.” 

It’s not just a timing problem.  Mr. Porter reports:

• “In 2019, only 27 percent of unemployed workers received any benefits, a share that has been declining over the last 20 years.

• The benefits have eroded as well, to less than one-third of prior wages, on average, about eight percentage points less than in the 1940s.”

The states range from 58% of unemployed workers in New Jersey who receive benefits to 9% -- 9%! -- in North Carolina.  Robert Moffitt, a Johns Hopkins economics professor, told Mr. Porter: “The program was set up to have tremendous cross-state variation.  This makes no sense. It creates tremendous inequities.”

In case you were wondering, red states tend to be on the lower side of the median.  I would be remiss if I did not note that all 12 states that have still not passed Medicaid expansion also fall below the median in percent of unemployed workers receiving benefits.   

Cheap is cheap.

An April 2020 paper by Steven Wandner of the National Academy of Social Insurance identified some key issues with unemployment insurance (UI):

• Congress has neglected the program, except in crises;
• Oversight by the DoL has weakened;
• State laws, programs, and policies have varied;
• The U.S. economy has changed significantly, both in terns of industries and mix of employment (e.g., away from manufacturing and full-time jobs);
• The workforce demographics have also changed significantly (e.g., female and older workers, dual income households).

Mr. Wandner concludes:

The UI program is and has been broken for a long time. Nationally, UI taxes have not been sufficient to provide adequate partial wage replacement to unemployed workers. There is great variation between the UI programs from state to state. A minority of states have a well-functioning UI program, but the program is not working well in most states—in large part because of resistance to paying for a more adequate UI program.

As with our healthcare system, “broken” isn’t really a good description.  Each is working the way they’ve been designed.  Unfortunately, if you’re poor or sick, and especially if you are both, they’re not designed to help you.  Not until the poor and sick start making significant campaign contributions anyway, or at least vote in larger numbers.

Andrew Stettner, a senior fellow at the Century Foundation, told Vox: “The system has been hobbling along, and now a crisis has hit.  Then people realize we actually want this thing to work, and it doesn’t work in the way people thought it would.” 

Many unemployed workers, of course, also lose their health insurance when they lose their jobs, since ours is a predominantly employer-based health insurance system.  As many as 15 million people may have lost their employment-based coverage due to the pandemic.  If they work for the right kind/size of employer, they may be eligible for COBRA coverage, but paying for it may be difficult, between loss of employer contribution, low UI benefits, and delays in receiving UI. 

At least under ACA they may have coverage options, including subsidies, through the Marketplace or Medicaid, -- unless they live in one of the states without Medicaid expansion.

Even in the states that have expanded Medicaid, the economic crisis has hit their tax revenue severely, while increasing the number of Medicaid enrollees, creating a double whammy.  The same, of course, is happening with the money to pay unemployment benefits, causing almost half the states to ask for federal loans.

In other words, when we have the worst crises – like a pandemic -- both our unemployment insurance and our health insurance systems do worst.  Those are the times we rely most on the government, but our federalism system of shared federal/state responsibilities is failing the latest crisis.

Mr. Porter sees hope:

Perhaps there is an upside to the current crisis: The glaring insufficiencies of the regular unemployment system may encourage states and the federal government to undertake comprehensive changes.

Perhaps.  If the pandemic continues long enough – as it might – it might force deep structural changes.  So far, the various relief bills have just added more patches to our patchwork quilt approach towards UI.  But if in the coming months vaccines mitigate the impact, and the economy picks up, then our typical reaction will be to commission some studies and just kick the can further down the road. 

ACA made our health insurance system less patchwork, with more uniform requirements, more subsidies, less discrimination against preexisting conditions, and broader Medicaid options.  The Biden Administration may, and should, further improve these.  Let’s hope that it takes a hard look at how it can do something similar with unemployment insurance.

What If Healthcare Was Like Wikipedia?

Last week I wrote about, well, how awful social media has become, so this week it’s nice to write about pretty much the opposite: Wikipedia turned twenty last Friday (January 15). 

In person years that’s not even old enough to buy alcohol, but in Internet years that makes it one of the grand old masters, like Google or Amazon.  Wikipedia is one of the most visited Internet destinations, with its 55+ million articles, in 300+ languages, getting some 10b+ views per month. 

It is something that, by all rights, shouldn’t exist, much less be successful.  A non-profit, volunteer written/edited, online encyclopedia?  An online resource widely trusted for its objective, generally accurate articles in a world of fake news?  As the joke goes, it’s good that it works in practice because it does not work in theory.

That’s sort of the opposite of our healthcare system: it’s good that it works in theory, because it sure doesn’t work in practice.

Wikipedia works due to its army of editors (“Wikipedians”); some 127,000 have edited the English edition alone within the past 30 days.  They work in virtual real time; when someone wins an Oscar the update happens almost immediately.  When the U.S. Capitol was stormed two weeks ago, Wikipedia had a page up before the protesters were gone. 

Katherine Maher, CEO of the Wikipedia Foundation, told The Washington Post:

It is remarkable that it exists when you think about the history of knowledge in the world and who has access to it and the very idea that people can participate in it. It is a somewhat radical act to be able to write your own history, and in many places in the world this is not a thing people take for granted.

In an Economist article, she attributed Wikipedia’s success to Cunningham’s Law, which holds that “the best way to get the right answer to a question on the internet...is to post the wrong answer.”  It works for Wikipedia, she says, because: “People love to be right, to demonstrate their competence.”

Academics and some professionals may scoff at its entries, since Wikipedia’s editors come from a variety of backgrounds, but multiple studies have validated that the accuracy of its articles is high, even in specialized areas like science or medicine.   Indeed, Wikipedia is believed to be the most used source of information on health – among not just patients but also physicians and other healthcare professionals.   

Wikipedia acknowledges that it still has diversity issues – the vast majority of its editors are white, English-speaking men – and that false entries can slip through, either unintentionally or maliciously.  But it certainly is no worse than other Internet giants on the diversity of its workforce and much better than them on eliminating incorrect information.  If it’s a choice of believing what you see on Wikipedia or on Facebook, it’s no contest. 

Like many sites established in the desktop era, it has struggled with the shift to mobile.  Ms. Maher told One Zero: “We missed the boat a little bit on mobile but we now have a fully integrated full-service mobile editing feature. Mobile is now the primary way in which people access Wikipedia.”

Wikipedia also struggles to make inroads in India and Africa, and is blocked in China, so there is still much work to be done. Ms. Maher says: “Our vision is a world where every single human being can share in all knowledge.”

As a non-profit, it survives on the kindness of strangers, collecting some $120 million annually in donations, mostly from small dollar donors.  Google, Facebook, and Twitter are all “free” to use as well, but they survive by selling our personal information to advertisers.  Steven Pruitt, a power Wikipedian (some 3.7 million edits!), told OneZero: “If it started selling ads, that alone probably would not get me to leave…But it would change people’s perception of the project. And I think that alone could be problematic.”

Ms. Maher added: “What we always say [about ads] is, “Never say never… But no.”’

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Co-founder Jimmy Wales described the impetus for Wikipedia:

I'd seen the growth of open-source software, free software, and to me it seemed obvious that you could use the same kind of techniques to build a free encyclopedia, so I was in a real kind of panic because I thought this is such an obvious idea that other people will do it.

So what might someone like Jimmy Wales think was “obvious” about a better healthcare system?  Some possible precepts:

• Quality, not credentials: sometimes personal experience, such as from patients, is a better source of health information than from “experts.”  Sometimes people with impressive credentials spew false or outdated information.  Quality of the information is more important than quality of the credentials behind it. 
• Sharing is caring: We spend a lot of money on healthcare.  Some people spend way too much; some people receive way too much.  Too many can’t afford as much care as they need.  There must be a more democratic way to get the right amount of money to the right people for the right care for the right people. 
• Guide the way: When you have a health issue, the healthcare system often seems like a maze. But somewhere in the world someone has had a similar issue.  Someone knows what the best treatment is, and from whom.  Someone knows what your healthcare journey is likely to entail.  The trick is connecting with them.
• Open data: I’ve lost count of how many “patient portals” I have.  None has all of my information.  Collectively, the information on them is a fraction of the data that healthcare institutions/professionals have about me.  I should be the central source; I should be the datakeeper; I should share as needed.

Think Wikipedia meets GoodRx meets GoFundMe meets PatientsLikeMe meets Ciitizen. 

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Ward Cunningham, a software developer who is credited with developing not just Cunningham’s Law but also the concept of “wiki,” told OneZero:

I don’t think the future of Wikipedia is guaranteed. But then hardly the future of anything’s guaranteed…But I think there’s a lot of smart people who understand that they’ve built something fabulous.

He’s right; the future is not guaranteed for most things – not even our massive, seemingly intractable healthcare system.  Wouldn’t it be great to have a healthcare system about which we could feel we’ve built something “fabulous?”

Happy birthday, Wikipedia – and many more!

The Cost of Free Speech

Well, you’d have to say that the past week has been interesting.  It’s not every week that Joe Biden “officially” won the 2021 election, again, as Congress certified the election results.  It’s not every century when the U.S. Capitol is overrun by hostile forces.  And it’d never been true before that Twitter and Facebook banned President Trump’s accounts, or that various tech companies belatedly acted on the threat that Parler poses.  Oh, and we hit new daily records for COVID-19 deaths (over 4,000) and hospitalizations (over 132,000) in case you’d forgotten there is still a pandemic going on. 

Yes, all in all, a very “interesting” week.

I’m going to skip talking about the horror that was the Capitol insurrection, in part because I fear that we’re going to find out more details that will make it clear that it was even worse than we now know.  Similarly, I’m not going to dwell on the shame that Republicans should feel about the fact that two-thirds of their House members still voted to object to certifying the election results even after they’d been forced to flee from the terrorists who sought that very goal with their violence.

Instead, let’s talk about “free speech,” and the social media platforms that helped foster the violence and are now trying to do something about that. 

President Trump had been making outrageous, often incendiary, usually false statements on social media for as long as he has used it, going back at least to his birther claims.  Twitter started attaching warning labels to many of his tweets during the 2020 campaign, but, despite pressure, Twitter had refused to ban his accounts, as a prominent public figure.  But last week it had had enough: “we have permanently suspected the account due to the risk of further incitement of violence,” the company wrote Friday. 

Facebook beat Twitter to the punch by a day, and other social media platforms followed suit, including Discord, Instagram, Reddit, Snapchat, TikTok, Twitch, YouTube, not to mention Shopify and Pinterest (!).  Stripe will no longer process payments for the Trump campaign website.  

Parler was initially thrilled with the bans, expecting millions of Trump followers to migrate.  That was starting to happen when tech companies put the hammer down on it too.  Google first removed Parler from its Play Store, while Apple gave it 24 hours to clean up its moderation policies.  When that didn’t happen, it, too, banned it from its App Store.  Amazon workers demanded that AWS stop hosting Parler, and within days Amazon did so.    

Parler is now offline while it looks for other hosting services; it is now suing Amazon for antitrust, breach of contract, and interference with the company’s relationships with users.  Good luck with that; Parler CEO John Matze told Fox News over the weekend that “every vendor from text message services to email providers to our lawyers all ditched us too.” 

Credit: The Atlantic

Conservatives are complaining about how their First Amendment right to free speech is being taken away.  For example, Rep. Devin Nunes lamented – on Fox News – “Republicans have no way to communicate.”  Donald Trump Jr. tweeted: “Free-speech no longer exists in America.” They ignore the fact that the First Amendment only refers to the rights that Congress cannot take away, or that they were somehow still able to widely broadcast these opinions. 

There is no right to Twitter, much less to Pinterest.

Still, there is plenty of disinformation, even hate speech, left on Facebook and Twitter; Google and Apple allow other suspect apps in their Play Stores; AWS hosts other dodgy companies.  The various bans may satisfy some desire for action -- any action -- in response to what we saw January 6, but no one should believe that the problem is solved.

If it hadn’t been clear enough before, it is now very evident how tech has allowed the problem to become more widespread – and what impact tech can unilaterally bring to bear on it.  Within the space of a few days, the leading tech giants all took strong actions that, if the government had told them to do, we’d consider censorship. 

In a statement, ACLU senior legislative counsel Kate Ruane warned:

We understand the desire to permanently suspend him [Trump] now, but it should concern everyone when companies like Facebook and Twitter wield the unchecked power to remove people from platforms that have become indispensable for the speech of billions – especially when political realities make those decisions easier

President Trump can turn his press team or Fox News to communicate with the public, but others – like many Black, Brown, and LGTBQ activists who have been censored by social media companies – will not have that luxury. It is our hope that these companies will apply their rules transparently to everyone.

Ben Wizner, an ACLU lawyer, told The New York Times: “I think we should recognize the importance of neutrality when we’re talking about the infrastructure of the internet.”   

Credit: Stephanie Rieger/Medium

The problem is that when we allow neutrality, people use the internet to publish child pornography, plan mass attacks, or try to overthrow the government – to name a few abuses.  When we try to put a stop to them, we raise the questions of who is deciding which to curtail, how.  Thorny issues all. 

It boils down to the fact that free speech isn’t free.  It has consequences.  We might all agree that falsely yelling “fire” in a crowded theater isn’t an appropriate use of free speech, but we don’t always agree on when there is a fire or on the best way to put one out. 

I’m glad that President Trump has fewer avenues on which to stoke divisions.  I’m glad that when I finally write about Parler, it’s about it being shut down, albeit temporarily.  But I despair at the disinformation and vitriol that remain on social media and other platforms.    

The bans aren’t a perfect solution, but they are a start.  There is a fire and we need to recognize the threat it poses.  There have to be lines about acceptable online behavior upon which we can agree on as a society.  If we can’t, we may not have a society much longer; at least, not one we’d recognize.

Health Care: Don't Be Evil

Google’s corporate motto – written in its original Code of Conduct -- was once “Don’t be evil.”  That softened over time; Alphabet changed it to “Do the right thing” in 2015, although Google itself retained the slogan until early 2018.  Some Alphabet employees think Google/Alphabet has drifted too far away from its original aims: they’ve formed a union in order to try to steer the company back to its more idealistic roots.

Parul Koul and Chewy Shaw, two Alphabet software engineers, announced the Alphabet Workers Union in a New York Times op-ed, vowing to live by the original motto, and to do what they can to ensure that Alphabet and its various companies do as well.  They assert: “We want Alphabet to be a company where workers have a meaningful say in decisions that affect us and the societies we live in.”

It’s past time that health care workers, including physicians and executives, stood up for the same thing.

Ms. Koul and Mr. Shaw cite several grievances, including payouts to executives accused of sexual harassment, the firing of a leading AI expert over her efforts to address bias in AI, and company efforts to “keep workers from speaking on sensitive and publicly important topics.”  Doing the work, even doing it well and being well paid for it, is not enough:

We care deeply about what we build and what it’s used for. We are responsible for the technology we bring into the world. And we recognize that its implications reach far beyond the walls of Alphabet.

Their goal is for Alphabet “to be a company where workers have a meaningful say in decisions that affect us and the societies we live in.”  Alphabet, they say, “has a responsibility to prioritize the public good. It has a responsibility to its thousands of workers and billions of users to make the world a better place.” 

Investors may not quite agree.

In an AWU statement, Nicki Anselmo, Program Manager, explained: “This union builds upon years of courageous organizing by Google workers…Our new union provides a sustainable structure to ensure that our shared values as Alphabet employees are respected even after the headlines fade.”

Google’s official response, released by Kara Silverstein, Google’s director of people operations, was predictably bland:

We've always worked hard to create a supportive and rewarding workplace for our workforce.  Of course our employees have protected labor rights that we support. But as we've always done, we'll continue engaging directly with all our employees.

So far, slightly over 200 Alphabet employees have signed on, out of some 120,000 employees (and roughly the same number of contractors or temps).  AWU is part of the Communication Workers of America (CWA) but has not had an employee election or ratification from the National Labor Relations Board, and so won’t have collective bargaining rights. 

Veena Dubal, law professor at the University of California, told NYT:

If it grows — which Google will do everything they can to prevent — it could have huge impacts not just for the workers but for the broader issues that we are all thinking about in terms of tech power in society,

I won’t try to predict how successful AWU will be, either in terms of building its membership or influencing Alphabet’s priorities, but I admire the goals.  But if there is an industry in which its employees need to speak up about their organizations’ need to prioritize the public good, it is health care.

Credit: Mario Tama/Getty Images

Right now, of course, we have healthcare workers putting themselves at risk fighting the pandemic, putting their own health and lives at risk.  It’s admirable, it’s heroic, and it must be commended.  But those efforts can’t mask actions that those same organizations are taking or allowing that aren’t so noble.

In no particular order:

• Even, or because, COVID-19 vaccines are scarce, we’re already seeing reports about rich or influential people “cutting in line” to get their vaccine early;
• We want people to get COVID tests, and they’re supposed to be free, but some health care organizations have found ways to include “surprise bills” for them;
• We’ve seen health care workers silenced, fired or forced to resign for speaking out about poor working conditions or lack of personal protective equipment (PPE) during the pandemic;
• Health care workers have had to walk off the job over wage and labor condition disputes during the pandemic;
• We still have hospitals suing patients for unpaid bills, even after promises not to during the pandemic;
• As bad as the racial disparities are in our health care system normally, they’re even worse with COVID-19, and may further worsen with the vaccine rollout;
• There are profound gender wage disparities among healthcare workers, and they may be getting worse;
• While pharma is getting plaudits for its rapid response to develop COVID-19 vaccines, it is also busy further raising prices;
• Already wealthy, nominally non-profit hospitals are raking in billions of disaster relief funds;
• Health insurers have done exceedingly well financially during the pandemic.

“Don’t be evil” would seem to apply.

What we need are the health care front line workers and leaders who will stand up and say, this is not good for our patients.  This is not good for our society.  This is when the needs or goals of our organization do not take precedence over the public good.

Credit:Marrian Zhou, Nikkei Asia

There are unions in healthcare already, even for physicians, but as a percent of all healthcare workers they have made about as many inroads as AWU has at Alphabet, and over a much longer period of time.  I have mixed feeling about unions generally; while they brought workers many important protections and benefits, they’ve often fallen ended up being more about workers’ insular interests than about broader social priorities.  But sometimes organizing is necessary.

Every health care organization should be, to quote Ms. Koul and Mr. Shaw about their goals for Alphabet, “a company where workers have a meaningful say in decisions that affect us and the societies we live in,” and which “has a responsibility to prioritize the public good.” 

If that is not true of your healthcare organization, if your healthcare organization isn’t committed to “don’t be evil,” then what are you prepared to do about it?