Saturday, February 8, 2014

Baltimore, A Broken Heart Love's Cradle Is

There's no denying it: Baltimore, like many other cities, has serious problems. Terrible crime. Massive unemployment. Atrocious health disparities. Devastated housing. Leaders more interested in making a name for themselves than in properly managing the city's resources. The legacy of postindustrial economic losses and institutionalized racism are still quite real to many people in Baltimore. This is felt most acutely when people see little fruit for their hard work or have to live in fear of violence.
These are not concerns limited to the white & wealthy, as sharp as the divisions between the “two Americas” that David Simon has expounded on may be. Whether you are in Patterson Park or Sandtown, most residents want to be able to work, enjoy the many great things about the city, and commune with their neighbors without worrying that their safety will be threatened, their tax dollars will be mismanaged, or their fellow citizens will go hungry & homeless. In general, however, it is the wealthier people in the city who are able to agitate more loudly for change, especially since they are usually contributing what they believe is their fair share to the public administration.
The recent post from Tracey Halvorsen threw this fear into focus, giving us a broken-hearted perspective on Baltimore’s crime problem in particular. The pieces from Lawrence Lanahan and Tim Barnett have helpfully exposed some of the difficulties wrought by the privilege inherent in Halvorsen’s remarks. I found their articles helpful though a little less practical; for example, Lanahan calls inequality the real “elephant in the room” even though various public leaders have been discussing inequality quite a bit lately while Barnett calls us to love abstractly in a manner that’s stirring but a bit hollow. Mark Brown’s relentlessly pragmatic approach dovetails with City Paper’s 10 New Year’s Resolutions well to suggest a few policies that could make a big impact. These are all a reasonable place to start; I would also briefly suggest that razing more vacant housing and investing in more urban farms would probably help provide jobs in areas that need them, as is happening in my neighborhood.
I want to add to the conversation by talking about reconciliation, which is a crucial element that has been left out. I believe very strongly in the “air war” of policy to fight poverty and its attendant ills, but I believe even more strongly that no policy will work without personal, cultural, and environmental change that accompanies it. Policy helps to shape people, cultures, and our environment from the top down; reconciliation & relationships shape them from the ground up. My experience is shaped by the fact that I’ve lived in the Sandtown-Winchester neighborhood for the past 4 years, which is by many objective standards (including infant mortality & murder rate) not the greatest place to live. I would like to share a few of the things I’ve learned here from my neighbors about reconciliation.
There’s been a lot of talk about privilege in this debate; I don’t think haranguing someone about their privilege is particularly helpful once it’s been pointed out and we all acknowledge that our instincts for self-preservation can lead us to exclude others and even harm them unnecessarily. There has also been a lot of discussion around systemic inequalities and structures perpetuated poverty, which are also very important to consider. However, I think it is easy to forget that you can fall off either side of the privilege tightrope when talking about the poor: you can be “conservatively” apathetic about people ever escaping substance abuse & crime or you can be “liberally” overindulgent in a materialistic view of society that assumes poor people only need more stuff (which is not many of them say when you ask them what they need.) If we look at the billions that have been spent fighting poverty in America, it is clear that we have not invested in the structural reforms that will reduce poverty, nor have we created institutions that the poor in any way enjoy dealing with. Indeed, when you ask poor people around the world to describe what their biggest needs are, they overwhelmingly describe broken relationships & freedom from shame as paramount, not services or cash.
Thus, if Halvorsen's article and the responses to it teach us anything, it is that no desire of our hearts is so pure that it can't be twisted to harm others. Caring for the poor is a good thing; it becomes a bad thing when we deny the agency of the poor in their own self-improvement. Cynicism about political and economic motivations is a good thing; it becomes a bad thing when it chokes our passion until we are bitterly apathetic. Understanding the structures that stratify privilege is a good thing; it becomes a bad thing when we incentivize victimhood and fritter away our energy with privilege-checking. Safety is a good thing; it becomes a bad thing when innocent people must suffer unnecessarily for us to be safe. Dr. Martin Luther King, Jr is instructive here: "You must come to see that it is possible for a man to be self-centered in his self-denial and self-righteous in his self-sacrifice. He may be generous in order to feed his ego and pious in order to feed his pride. Man has the tragic capacity to relegate a heightening virtue to a tragic vice. Without love benevolence becomes egotism, and martyrdom becomes spiritual pride."
The poor are not, as some might implicitly desire, to be confined to areas where they might only hurt each other. However, they aren't helplessly in need of more money and fewer drug arrests from above, either. They have their own resources and capabilities that allow them to survive or thrive in difficult neighborhoods like Sandtown. My neighbors are thoughtful people who support one another through crises and want to make our block a better place. My love for my neighbors and their love for me is magnified by our proximity. My current work to bring better mental health resources benefits greatly from my presence in the community as I have stronger relationships with the people that I am trying to empower and help develop. I can learn from them far more effectively by living here and see how they are already working together to address the inequalities we face.
However, I also have neighbors whose individual moral choices- shaped by policy, culture, and environment- harm others or themselves. They are aided & abetted by others who either benefit from harming others (akin to the businesses that reap greater profits when more teenagers are locked up) or are too intimidated or unaware to exercise their own agency. These neighbors are often young men whose response to their own traumas, desperation, or stubborn pride is violence & intimidation. We can peel the onion layers of environment, culture, and personal decisions for quite a long time (and debate them fierecely!), but eventually we find a person whose relationship with himself, others, and God is broken.
Thus, if policies like more beat cops, fewer marijuana arrests, and a living wage are outside-in ways of reducing external motivations to harm others, reconciliation is the inside-out work of righting those relationships. This is a long and difficult work that is not easily accomplished in a program or a policy. It does not involve targeting just the most “at-risk,” for they live in a network of relationships that help to make up that risk. The people that are a danger to themselves and others become violent moral actors both through sheer relational neglect and through relational indulgence; if we are going to change the culture of violence in this city, we must address these relationships.
I would like to suggest that many of our policy failures have come about because we fail to recognize the strengths & assets that Baltimore’s poor have, especially in regards to relationships. The knowledge that a community has about each other when someone is in need works for the vulnerable when someone is ill or struggling; it works against justice when a desire to keep the peace results in zero tolerance for “snitching.” I have watched someone crash their dirt bike in the street and seen a brave soul move the bike to a hiding place before moving the injured man out of the road; the value system inherent in that interaction is telling. The ingenuity, tenacity, and fraternity shared by my neighbors is inspiring and challenging to me as it works itself out through these complex interactions. I cannot speak for them (though I enthusiastically support things that let them speak louder for themselves), but I can say that being here in Sandtown has challenged my privilege in a way that no college class or Upworthy video ever has.
Reconciliation happens across race, class, and gender in powerful ways when people share life together and work together in ways that respect the innate gifts of every person. It is very easy for me, as a privileged white dude with a graduate degree, to simply list off a helpful smattering of suggestions or scoldings for the problems that my friends face. It is been a discipline for myself to be silent, to listen, and to coax opinions from my neighbors as we try to address the devastation that a barrage of traumas has wrought. It is these personal interactions that have shaped the policies and programs we’re creating, and it is this sort of reconciliation—where I admit my culture’s tendency to fix causes harm and they admit their culture’s tendency to protect causes harm—that we can join together in.
My intention throughout this essay is to make reconciliation intensely practical, as I think it is easy to use a word like “reconciliation” as a careless pipe dream. Again, I think good policies like vigorous audits, more beat cops, fewer drug arrests, and accountability for slumlords are really important and I’m glad people are talking about them (most of them have some very strong component of fostering better relationships and more intimate knowledge of local communities.) All of these will not be as effective if those of us who are privileged aren’t spending more time in relationships with the less privileged in order for our outlooks to be changed and for the good things that we have to be shared in a more meaningfully.
It’s not just enough to spend time, though, as we will retain every opportunity to exercise our privilege that we can. We must build relationships in contexts where our power is stripped away and we can be equally vulnerable with one another. Having (hopefully) brought “reconciliation” out of the realm of empty political cliche, I want to turn to “love” and “brokenhearted,” which are also getting tossed around.
Your heart is not broken for Baltimore if you’re content to have zero crime in Patterson Park while Sandtown keeps up the same murder rate. Being in Sandtown, though, doesn’t really give me, my wife, my daughter, and our housemate the option to just work for justice & safety for people like us. We are slowly becoming enmeshed in a network of relationships and hopefully becoming part of the change as we learn to love our neighbors and they learn to love us. We weep with them when their children die and they weep with us when ours die. I know that it can be easily to idolize this sense of identification and I do not want to pretend that we have somehow atoned for our white guilt or erased our class privilege by buying a house in this neighborhood. (It is also important to acknowledge that the way for us was paved by other incredible pioneers who have given-- and received-- much more, such as the Tibbels family.) However, we have learned, taught, and loved in ways that I think will endure because we have been broken— for proximity has brought vulnerability to brokenness, and vulnerability to brokenness has in turn brought love. As the hymn says, "a broken heart love's cradle is."
Apathy is a bitterly prescient reality in many of these discussions. Just like we can twist our desire to walk to and from our cars in peace into a malignant “just arrest more” attitude, so we can twist our disappointed idealism into a soul-killing eyeroll. This is where I think Baltimore’s poor—who are overwhelmingly and enthusiastically religious— have the most to teach us.
The battleground of faith is where my story met Sandtown’s; I started attending New Song Community Church when I was in med school and moved into the neighborhood a few years later, as they strongly encourage intentional relocation for all the reasons that I have discussed above. It is faith that pushes many people I know forward; a relentless hope like that of Dr. King whose famous quote about “the arc of the moral universe is long, but it bends towards justice” is rooted in a fierce faith in God’s sovereign plan and eventual victory. While I know that faith is not a comfortable subject for many people, what the underprivileged and faithful people of Baltimore have to teach the privilege of the the privileged and faithless is this:
"So the greatest of all virtues is love. It is here that we find the true meaning of the Christian faith. This is at bottom the meaning of the cross. The great event on Calvary signifies more than a meaningless drama that took place on the stage of history. It is a telescope through which we look out into the long vista of eternity and see the love of God breaking forth into time. It is an eternal reminder to a power drunk generation that love is most durable power in the world, and that it is at bottom the heartbeat of the moral cosmos."- from Paul’s Letter to American Christians (don't miss the last 5 minutes of the sermon, rarely recorded elsewhere, where he talks about how he grapples with his own failures to love others and takes those to the cross.)
Faith in the justice of God gives us hope that things will be made right, but it also motivates us to change things for our neighbors in need as we are drawn into reconciling relationships with them. Jesus helps us to reconcile the broken relationships we have with ourselves and with God by forgiving our sins (so incredibly important for our neighbors who have harmed others or been harmed); as that inward relationship is transformed we then have the resources to change our relationships with others.
“For he himself is our peace, who has made us both one and has broken down in his flesh the dividing wall of hostility [...] and might reconcile us both to God in one body through the cross, thereby killing the hostility. And he came and preached peace to you who were far off and peace to those who were near. For through him we both have access in one Spirit to the Father.” -Ephesians 2:14-18
Jesus was the pioneer when it comes to moving into a bad neighborhood; when he “became flesh and dwelt among us” he shared our pain and the suffering that our sins deserved in order to accomplish this great work of reconciliation. Through the liturgy of church we move together from this inward reconciliation to outward reconciliation; we work out the difficult practicalities of life together only after we have stood side-by-side to worship at the foot of the Cross, where my neighbors and I have no choice but to stand on level ground.
So many great initiatives across Baltimore—from the ones we love in Sandtown to ones that get written up in fancy journals, many important works of community development are happening in and around churches. At New Song, we have emphasized reconciliation, redistribution, and relocation for over 25 years and some marvelous things have happened by faith and through grace. There are even a few young men whose lives have been changed by relationships and pulled them out of the dark trajectory of violence towards something far more beautiful; they are now my teachers. Come and see for yourself if you like. There are many people in Baltimore who have a lot to give us if we are willing to come to church and listen.

Friday, January 31, 2014

the future of family medicine

The American Academy of Family Physicians is collecting thoughts now on the future of Family Medicine in America; I shared mine with them and figured that I would post them here:

Right now the health care cost curve is being broken across the backs of hospitals & specialists. I think that they'll come for primary care next. If we're not prepared, we'll find our reimbursements decreased and our specialty torn apart as the hospital systems that own us realize that the reimbursable services provided by MDs can often be provided by mid-level providers. Fighting against nurse practitioner independence wastes time, money, & energy-- we need to define the terms of our health care system. We're calling on our specialist colleagues to sacrifice for the good of the system-- we're going to have to sacrifice a few things, too.

I think that Family Medicine needs to recognize that most primary preventive care doesn't belong in the medical silo at all. To this end, we should support the development of community health worker programs made up of residents local to a particular area who are responsible for giving vaccinations, doing basic health education for simple chronic diseases, and following the protocols for screening that clutter our computer screens. While providing preventive care and talking to patients who don't have very many medical problems is an enjoyable part of practice, we must recognize that our medical degrees overqualify us for such tasks and we should be doing them about as often as we are teaching our patients how to give themselves insulin-- it happens and we can do it well because we understand how it works, but it shouldn't be our bread and butter.
Family Medicine doctors should then focus on mastering the knowledge and expertise that we have acquired during our medical education and residency: managing multiple complex chronic diseases, especially with psychosocial comorbidities. We should be supervising and leading teams of CHWs & mid-levels who are managing the simpler medical issues, as is often the case in many other countries around the world. We should also embrace a more active role in coordinating care across the inpatient/outpatient divide; more family doctors should seek inpatient privileges and care for their patients in the hospital. This is one of the ways that we can avoid become aloof consultants ourselves. We should learn as much as possible about diseases like sickle cell & cystic fibrosis so that we can help transition these patients from their pediatric specialists to adult ones.

Another important aspect to our role as family doctors is embracing public health and population health; we should be spending our time not just in seeing very sick patients but also addressing the structural issues pertaining to our local neighborhoods where our patients live. Capitation may be one way to help tie particular doctors to particular communities, but it is not necessary if we are living in the same places as our patients and getting to know their neighborhoods & leaders. Our residencies should emphasize leadership training as well as opportunities to engage local communities. In case somehow you missed my endless self-promotion about it when it came out, I wrote about this in my Family Medicine Educational Consortium "This We Believe" essay entitled Proximity, Vulnerability, Faith, & Love.

We are too well-trained to order colonoscopies and flu shots all day. Family doctors should find the sickest patients and care for them in a relational, longitudinal, team-based manner that demonstrates our value to payers, hospitals, and specialists and forces them to recognize our role in health care.

Tuesday, November 5, 2013

Proximity, Vulnerability, Faith & Love: This We Believe

The Family Medicine Educational Consortium (an organization that I love being a part of!) hosts an annual "This We Believe" contest modeled off of the NPR "This We Believe" project, featuring family physicians sharing their beliefs and how those beliefs affect their work (a tremendous example on the subject of dying given by one of my mentors on death can be viewed here.) I was honored to be one of three award winners (check out the others here!) this year and the following is an expanded version of what I presented in the plenary session on Sunday, November 3rd.


I believe that transformation requires proximity.
I believe that proximity requires vulnerability.
I believe that vulnerability requires faith & love.

When I talk to a patient or my wife or anyone else that I want to have a conversation with, we have to be engaged with one another, and usually this requires physical distance. If we’re on the phone or Skyping or FaceTiming, there must be no other distractions. If my attention is drawn elsewhere—by my pager, by my cell phone, by something moving in the periphery of my vision—we’ve lost that proximity. We can diagnose an illness over the phone, fill a prescription with a fax machine, or we can even blow someone up from another country. But we can’t take off a mole or remove their appendix—much less get to know a person for who they are—unless we get close to them.

           If we can’t even really exchange ideas without practically being face-to-face, we certainly can’t change people from far away. While medical technology proliferates and invades every patient encounter that we have, family physicians in particular still have that all-important trump card that is suited for every clinical scenario imaginable: the patient-physician relationship. Technology can help our relationships. It can also kill them. The people who get money and glory as technology proliferates may tell you that technology is neutral; that’s nonsense. A scalpel isn’t neutral; it’s usually dangerous unless it’s held by the right person and pointed in the right direction.

           Any technology which puts more distance between us and our patients has the potential to cause more harm; while the most obvious recent examples of this are electronic medical records I am more particularly fascinated by the automobile and the airplane as technologies that purport to bring people together but also enable them to be further apart.

           It used to be a lot harder for doctors to go from one country to another—whether it was physicians coming from countries with less developed medical systems to study in more technologically advanced countries or physicians from here going there. Now a capable and brilliant doctor from anywhere in the world can leave his already under-resourced home country for a more secure position, and the capable and brilliant doctor from an over-resourced technological Mecca can pop in anywhere in the world for a week to hand out some antibiotics and then go home. I hope you can see who is the benefactor in these situations.

           Similarly, it used to be that you just about had to live in the same place where you worked; now you can live, work, worship, play, and be entertained in different places without the ties of proximity to hold you down. There are, of course, advantages to this—but now the disadvantage, particularly for us doctors, is that we have the freedom to be disconnected from the everyday concerns of our patients and the local history & knowledge of the places where they live, work, worship, and play. We can discharge our duties as a physician and simply be a cog in the machine.

           As Wendell Berry (a farmer and writer who has done much to advance this line of thought) once said, “A community is the mental and spiritual condition of knowing that the place is shared, and that the people who share the place define and limit the possibilities of each other's lives. It is the knowledge that people have of each other, their concern for each other, their trust in each other, the freedom with which they come and go among themselves.” Every community has its own local history, its own assets, its own weaknesses. In every place, there are people who are fierce advocates for their neighbors who disadvantage themselves for the sake of others and there are people always looking for an opportunity to take advantage of someone else.

         In my own community of Sandtown in West Baltimore—where the average life expectancy is 65 years young and the infant mortality rate is triple the national average—the needs of the community can only be appreciated by people who take the time to listen. My neighbors have been assaulted by surveys— a hazard, I guess, if you live close enough to multiple academic centers. They have had a lot of people pop in to ask a few questions and then go. They have not had a lot of people come in to mentor them, to develop leaders, to suffer with them. True compassion literally means “suffer with.” As I have piloted a mental health outreach in my neighborhood and tried to find leaders within the community to deal with the severe emotional and behavioral issues that make up the day-to-day reality of inner-city Baltimore, I have had to share in the sufferings of my neighbors, especially within my church. Yet my presence nearby gives me the ability to connect with people that I would not have otherwise.

           My long-term goal is to go overseas and teach at a family medicine residency in an under-resourced country. I want to give physicians in these places the opportunity to become leaders among their own people without ever leaving and reverse the trends that suck the local resources away. While there are a lot of excellent medical education opportunities that are short-term in nature that use technology to its absolute highest benefit, anyone involved a residency can attest that if I want to really see residents flourish, I’m going to have to live there. One such residency in Afghanistan has seen a lot of turmoil, but it is through those experiences that the physicians are bonded to their community.

           If we want to see change in a community, we have to be there. Physically. And if not physically, then our hearts and minds and eyes and hands and our pain must be there. This brings up vulnerability. Proximity requires vulnerability. You have to expose yourself to the risk of being hurt—something that everyone who has ever invested in a patient-physician relationship knows.

           I think it is certainly possible to do a lot of good at a distance. I think that good boundaries are essential, as we must carefully search where vulnerability is indicated. Like the scalpel, it can destroy a patient and their community or save them. Yet when I look at—for example—the School of Public Health at a very well-recognized university in my city and the neighborhood just a block away and the hundred years of history that have transpired between them, I have to suppose that we have drawn our boundaries a little too far.
           Vulnerability requires faith & love. There is on one hand, the faith that every now and then, your suffering will be obviously worth it and your sacrifice will yield fruit; when we see patients that we stayed up late for or argued with their insurance companies on behalf of that are living healthier we can rejoice. And I do think that is an enormous benefit. Yet we also must know that such a scenario won’t always play out, indeed, we could end up more hurt than ever before.

           C.S. Lewis once said, ““There is no safe investment. To love at all is to be vulnerable. Love anything, and your heart will certainly be wrung and possibly be broken. If you want to make sure of keeping it intact, you must give your heart to no one […] The only place outside Heaven where you can be perfectly safe from all the dangers and perturbations of love is Hell.”

           I’m sure that using the word “love” regarding a patient-physician relationship may raise a few eyebrows. However, even the most detached and cautious doctor has felt love towards a patient—not love as a mere emotional sentiment, but as a guiding commitment to care for someone appropriately regardless of the cost.

           I take care of a lot of people who make bad decisions. Many of them involve the greatest proximity you can have with another person. Many times that decision makes another person. Many times I wonder to myself as I’m talking to someone, “why on earth would you give such a sacred part of yourself to this idiot who doesn’t even have the decency to hold your hand while you’re giving birth?” I am terrified by the number of people who are like this.

           I was born at the hospital that I work at. My parents were those people, broken people from broken families. They had no idea what they were doing when I was born. They were loved abundantly by others who gave and gave, which in time transformed them into parents who could love me. But that knowledge—that very, very local and proximal knowledge—always teaches me that I could very well be the second generation sitting in my office, having just brazenly impregnated a woman without any regard for her well-being. That component of vulnerability—the humility to admit that the love I have received has changed me and put me on the doctors’ stool and not on the examining table—is difficult and a fine line must be walked when cultivating relationships with patients. But it can be done.

           How? I can only tell you my answer. You’ll have to figure out your own. For me, I am inspired by meditating on the fact that “The Word became flesh and dwelt among us.” Jesus became flesh and moved into the neighborhood.  He suffered on our behalf—because of his enormous love—to transform our human community. His death & resurrection sealed the promise of victory over death and suffering. His righteous life was not just an example for us of how incarnation leads to transformation-- it was righteousness lived on our behalf that we inhabit as we trust in Him for the forgiveness of our sins. Martin Luther King Jr. said that “The arc of the moral universe is long, but it bends towards justice.” We can know that’s true because Jesus did it first.

What we do as a community is imitate that willingness to suffer on the behalf of others and receive the transforming work of the Holy Spirit that helps us learn to suffer well. When we find our vulnerabilities, weaknesses, sins, and suffering that we experience, we take them to Him. Even when we fail our patients or our patients fail us, we’re guarded from cynicism and despair because we know that we’re just on the near side of the arc of history-- and we’re still getting closer to victory. My tiny little part in that victory is helping people in my neighborhood find mental health care and teaching residents overseas.

This we believe.

Sunday, October 27, 2013

amorphous "revolutionary" pablum is boring and useless

The Russell Brand New Statesman Manifesto is enormously instructive. Why? Because it messily sums up how profane, privileged liberalism can get the problem so right and the solution so wrong. He wants a revolution-- but he doesn't want sacrifice, suffering, grace, or discipleship. He recognizes that our power & principalities are very broken, and he is very broken, but he can't seem to tie the two together. He can empathize with the poor and he's willing to give up some of his luxuries for their benefit, but the thought of living with and for the poor seems quite foreign to him (much less any sort of empowerment or leadership by the poor.) His description of what he saw in Kibera was like he's looking at zoo animals, and breathlessly reports the spectacle to us. He wants a spiritual community, but doesn't describe how he would make that community socioeconomically inclusive (hint: if you don't try, it'll be other privileged people like you.) He sees a spiritual revolution as key, but he's unwilling to wrestle with the tough doctrines that any spiritual revolutionary must discern.

He says, "What does it matter if 2,000 years ago Christ died on the cross and was resurrected if we are not constantly resurrected to the truth, anew, moment to moment? How is his transcendence relevant if we do not resurrect our consciousness from the deceased, moribund mind of our obsolete ideologies and align with our conditions?"

...but then he moves on to resurrection as transcendent metaphor, not as transcendent reality. And that's the thing: we can't have a revolution-- in ourselves, our families, our communities, our nations-- unless we're willing to really die to ourselves and be resurrected in the likeness of Christ.

In short: booorrrring.

Tuesday, September 24, 2013

How to Fix Healthcare in 10 Politically Murderous Steps

1. The basics are free and universal
Everyone gets basic preventive services, prescriptions, lab testing, maternity care, mental health services, and emergency care for free from the government. The government also funds community health workers responsible for knowing their communities and helping them develop healthy practices. Ancillary services and drug companies are thus always competing to deliver the cheapest service so they get to be the preferred government provider; if the patient wants something fancier/faster they can pay more out of pocket. There has to be a very responsive prior auth system in place for scripts not on the government formulary for this to work, obviously, but with one streamlined system and providers familiar with the formulary, it's easier than the byzantine mess of various insurance companies deciding what they will or won't pay for.

2.Capitation for the poor, concierge for the rich
Pay your doctor/dentist/physical therapist directly for services rendered. Everyone gets an HSA with a baseline subsidy; people up to 400x poverty line get Medicaid-ish chronic disease management that pays doctors per head every 3 months (base rates determined by the diagnoses patients carry.) Each doctor/practice owns a specific population of patients and they can paid more if they offer more services (eg evening hours) or they can earn more money seeing sicker Medicaid patients since their capitation fee is higher. Young and healthy people that don't want to pay to see a doctor don't have to (or they can just bank up their HSA), and the system isn't built on the healthy subsidizing the sick. People who are working and getting this Medicaid-ish capitation get to split the savings with their doctor into their HSA, building up their ability to pay their own healthcare costs should they start earning enough money to no longer qualify for Medicaid.

3. No more fee for service.
Procedures are either included in the Medicaid capitation rates or you contract directly with the doc/facility performing the procedure and pay him/her (thus the capitation fee has to be scaled appropriately and be very responsive to new diagnoses in order to include these potential costs.) Doctors get paid the same regardless of whether or not they do a procedure; if more than one doc is involved their split of the capitation fee is based on time spent with the patient.

4. Electronic health records must be interoperable and usable
We have software that lets us battle elf mages. Surely we can build an electronic medical record system that recognizes data from other systems and can automatically transfer it, show each individual user the information that he/she wants to see while filtering out the noise. And something that's easy to input. I recognize that this is a difficult design problem. But if every other industry has nifty software that does what it needs, why not healthcare? Also, your records should be available from any provider to any other provider with electronic documentation of patient consent at point of care.

5. Coordination of care between hospital and primary care
The interoperable EMR would help a lot with this, but I would add that hospitals can't get reimbursed for a stay unless they can show that follow up care was arranged and records sent to a patient's primary care doc at the very least.

6. No-fault medical mistake compensation
Establish an independent court for reimbursing patients who suffer from medical mistakes-- New Zealand does this and everybody loves it but the lawyers. It's cheaper & simpler. Get the wrong drug in the hospital? The fund gives you 10 bucks. Get the wrong leg amputated? The fund gives you $10,000 (or whatever's fair) and flags the hospital. No fighting in court.

7. Take care of the hotspotters
A small percentage of people eat up a disproportionate percentage of health care costs, and "hotspotter" programs are demonstrating some success in improving their outcomes. Thus, intensive case management/home visiting for high utilizers and Housing First-style placements for the homeless. For people with disastrous social situations contributing to their chronic disease mismanagement, there should be more residential options with wraparound services (like Alliance for severe mental health conditions in my neck of the woods!)

8. Noncompliant? Don't expect the government to pay for it.
This is where it gets ugly. Medicaid patients with specific diagnoses who are not improving get mandatory classes in nutrition or start to incur tax penalties. If you can't/won't take your insulin (or stop drinking) or whatnot, you either check yourself into one of these aforementioned rehab facilities with comprehensive service or you forfeit the right to get your emergency care paid for-- in which case you can still get care but eventually you'll rack up enough tax penalties to get thrown in jail. A doctor or care coordinator can always sign a waiver that gets you out of this if your circumstances are appropriate. People that want to ruin their bodies but not rack up huge bills doing are free to do so.

9. Unhealthy food becomes a luxury item
Raise taxes on food/drink without substantial nutritional value as well as cigarettes/alcohol and give everybody enough seeds to plant their own victory gardens. Fix our deranged agricultural policy so that we're not subsidizing gobs of corn.

10. Address other social determinants of health
While we're in fantasyland at the end of this list: Fix marriage so there's less social chaos causing unwanted pregnancy and exacerbating mental illness and fix our schools so that people graduate able to make informed decisions about their health. Honestly, if you know anything about social determinants of health you know that what takes place in the doctor's office and the hospital is such a small fraction of what makes people unhealthy or healthy.

Most of my proposals put more power and redistribute the money in the hands of larger government institutions- not because I think that large government institutions are the best places for money and power, but because our local institutions spend so much time and money trying to figure out which larger institution to squeeze for the right resource when they could be spending time getting to know patients. One could certainly argue that we ought to cut down the size of all the state and federal institutions and forget about the squeezing process altogether, but I would argue that the resources would then only get concentrated in the hands of bigger and bigger non-governmental entities (like the businesses that make their profit selling us unhealthy things.) In the age of industrial capitalism and technological advances, the larger institutions around us exist and it seems the only way to keep them in check is to make sure they're pitted against each other. While faceless bureaucracy and transnational exploitation alike have the power to erode local institutions, we will have to learn to survive in spite of them-- and not worrying about how you'll pay for your prescriptions is, I think, a part of this.

Friday, September 13, 2013

an open letter to my sister (about modesty)

[one of my sisters asked me a really good question the other day, and I responded to her briefly and then just a little more below. she has given me permission to share.]

Dear sister, Thank you for asking. I had seen the blog post that you mentioned, and it made me uneasy. I thought about contesting it on Facebook, but I try carefully to pick my online fights these days. But since you’ve asked, I’ll answer a little more comprehensively. I think that asking good questions and not being satisfied with trite answers is pretty important, so please keep doing that!

Sex is pretty important. However, it seems that, after thousands of years of human society, we are still figuring out the basics of how to talk about it in public. In particular, your experience and mine in figuring out what sex means is interesting because we grew up in the evangelical subculture within the larger culture of the post-Sexual Revolution West. There is a cacophony of voices regarding sex and modesty, and I hope to point out to you the ones that are most dangerous and most helpful.

The easiest target, quite frankly, is the broader capitalist rape culture that exploits the bodies of men and women to sell things, assigns blame to people who are sexually abused or harassed because “they were asking for it,” and cheers for something called “sexual liberation,” which is about liberating as a car without seatbelts, brakes, or a windshield. By atomizing sexual choices to the level of the individual’s pleasure plus some vague idea of consent, we make a mockery of anything vaguely sacred about sex. We also open the field for businessmen to exploit the bodies of people in order to take the money of others who either pay for the privilege of depersonalizing someone else or pay for the privilege of having their own bodily anxieties exploited. Sex and the representation of hypersexualized bodies becomes a chaotic mess of people using sex for whatever power it gives them over others. Wendell Berry takes this apart quite skillfully, and I suggest that you read what he has to say about it. My simple solution is to not buy, watch, click, or comment-- don’t let your money go to it, and when you see your friends consuming it, kindly point it out and suggest that they spend their money otherwise.

A trickier subject to examine is that of the culture that you and I were nourished in, that is, conservative evangelicalism. We have, like many traditional cultures, tried to affirm the sanctity of sex and the truth that God designed protective barriers like marriage, the family, and decent clothes to help us honor what sex is. However, like most traditional cultures, we have relied on shame and sexual double standards to get this done.

Shame is a pretty powerful human force, and it is clear from the Bible that God uses shame to turn people to repentance. Yet Scripture also clearly tells us that those us who are in Christ cannot and should not be shamed if we are truly repentant and redeemed. Public shame is a powerful force that can be used to goad people into changing course, but it should not be used lightly. When, as you say, modesty is joked about as “girls, no bikinis; guys, no speedos” and it is inferred you are “at fault” when a man looks as you lustfully, we have imported worldly standards that demean women and diminish their personhood by emphasizing the power of their sexual parts. Rachel Held Evans unpacks this quite well, as you have already observed. Again, sex and clothes become a power struggle.

Modern feminism has worked vociferously to decry these abuses of the female body, and we have much to learn from their critiques and how they have decoded many of these power plays for us. Traditional sexual morality cannot and will not endure without understanding what feminism has taught us. The current appeal to understand and affirm true consent is, for example, quite valuable. Yet, for all the good that we have to glean from these perspectives, I think that most of them ultimately fall short because they want to have the ability to publicly shame and judge bad behavior while still tenaciously affirming the aforementioned atomization of sexual behavior and judgment to a matter of individual choices. Quite frankly, this is simply class warfare because poor women have less power overall, and so they tend to be more susceptible to the relational chaos, unwanted pregnancy, and disease that goes along with the relentless destructive power of hyperindividualized sexuality. The latter two are things that can be remedied somewhat by the aggressive provision of the appropriate pills and medical interventions, but until the pharmaceutical companies can put relational stability in a pill, all bets are off. This is the personal injury that complements the cultural insult of depersonalizing sexuality that people very happily choose for themselves and others, as mentioned above.

All sex is publicly sanctioned or shamed. Every adult who goes to a wedding knows that the couple saying vows in front of them will be having sex in a short matter of time, and by attending the wedding they are in some way supporting the union of that couple, even as that couple is giving the community the power to judge their union. This is not to say that sex is the ultimate purpose of marriage, but it is the most (literally!) tangible sign that two people have united themselves. How perverse it is that we have the opposite happening right now, with various pop stars simulating sex acts in public with tongues clucking on Facebook after salaciously watching on YouTube. The appeal of money and the strength of our sinful inclination to depersonalize others’ sexuality will always trump vague appeals to respect and consent.

I think that there is a better way. We must first recognize that our goals, as Christians, are not to use sex or clothes in power plays against one another-- whether it is women gaining attention with their clothing or men stigmatizing women with their warnings about modesty. Depending on the context and the intentions of your heart, a swimsuit, a shirt and tie, or an ankle-length dress can be used to demonstrate pride and show off to others. Or they can demurely indicate respect and love for one another. A surgeon could use a suit to demonstrate that he is of a higher class than his patients, or he could use it to demonstrate that he respects his patients enough to not wear the clothes that he was wearing while he was performing a colonoscopy or playing golf.

Just as all sex is publicly sanctioned or shamed, so it is with all clothing. We must use our clothes to love one another, and here I will turn to some of your more specific questions. Of course boys can be immodest, although they often have to work harder to do it-- all they have to do is choose to wear something to draw attention to themselves and tempt others to sin. I won’t detail any sexual examples, but a nonsexual example might be a T-shirt with an unnecessarily inflammatory political message. Such a shirt does not respect others, but rather wishes to gain their attention by inciting them to anger. So it is with clothing that is designed to gain attention by inciting others to lust. Every man should strive and pray for the power to walk into a room full of scantily clad women and not lust, and certainly the Holy Spirit is powerful enough to do so. Ultimately, every person is responsible for their own sins that they commit-- this guy said it pretty well, so I’ll let him affirm that in case any men are listening in here. Yet it is a blessed relief for many of your brothers in this life-and-death fight to be surrounded by women who thoughtfully cover themselves.

Nearly all Christian men must work very hard their entire lives to fight the inclination to depersonalize women with their eyes, mind, and heart-- which is why some of them try to settle for the easy route of depersonalizing women with shame. I confess that I have done this before with the mixed motives of both fighting lust and fanning my pride. I was fortunate enough to be called on it by a woman who recognized my clumsy attempt to shame and disrespect her. The woman who wrote the “selfies” post, I think, had a similar desire to protect her sons and yet, at the same time, she played into the same schema. The problem was not that she called people out on posting sexy selfies-- which most people consider to be a bad idea and something we ought to be discouraging-- it was that she did so without any concern for the give-and-take of Christian community. As we struggle together to build each other up in Christ, we must temper our instincts with our convictions and teach one another how to dress respectfully and speak respectfully.

God made your body, and He did not make it so that it would be totally hidden nor completely exposed. If you are dressing and acting in a way that you prayerfully intend to encourage & bless others, that is enough. Let the power of the Holy Spirit that protects us from the sins of others purge your shame if a man still looks at you with lust in his heart (or catcalls you, or tries to abuse you in any other way.) In the community of the church, we give each other the freedom to hold one another accountable, and every community should work out-- with equal input from men and women and preference given to the older & wiser people-- the standards that are appropriate for all. While this system is not guaranteed to be free of abuses, I think when it is founded in Christian love and faithfulness it will bear good fruit. This whole concept-- a community of Christians loving one another and openly dialoguing about what builds each other up while trying to live holy lives-- is also how we tackle the difficulty inherent in a life of obedience in giving our money away in a greedy world, living peaceably in a violent world, acting purely in a lustful world, etc.-- not just dressing modestly.

How we get from here to there, most importantly, is remembering Jesus, who hung naked on a cross and was jeered by everyone who was watching so that our shame could be put to death on that cross. He has risen again in glory and clothed us with His righteousness, which transforms the way we look at ourselves and one another-- body and soul. Without the Gospel, sexual morality descends into a circle of shame and sexual freedom becomes an opportunity to tear other people apart from the inside out. Again, if we repent of our sins and forgive one another, His power is displayed in us and we can boldly say that we are not ashamed.

                                          Your brother,

Tuesday, June 25, 2013

on marriage

[I comment a lot over at the excellent blog Mere Orthodoxy (which I highly recommend!) and since I say a lot of things there that I might want to save for working up later blog posts, I'm probably just going to start reposting modified versions of my comments here. That sounds vain, but it's my blog.]

If our goal is to advance a political agenda, it does not matter how far we back it up upstream culturally or how good we are at creating memes.
If our goal is to help God-honoring marriages flourish-- actual marriages, between flesh-and-blood people-- I suspect the memes will come from creative Christians going about their daily work in the midst of the work to support families who are stable and help kids from families who are not. And maybe then we'll get around to building some loving relationships with some flesh-and-blood GLBT people?
I see a lot of conservative hand-wringing nowadays about what a bad job we are doing at advancing a political agenda and a lot of strategizing about shifting the locus of control from point A to point B. I don't see much discussion about policy alternatives that encourage family formation, nor much confidence in things like preaching, teaching, discipling, evangelizing, and just havin' folks over for dinner.