At Maimonides Medical Center in Brooklyn, N.Y., some 67 different languages are spoken. A private institution, it’s among the largest 5 percent of the nation’s hospitals, treating (in 2003) 38,667 inpatients as well as 127,319 more people in its outpatient clinics. Each year it trains nearly 500 new doctors from all over the world. Maimonides’ E.R. is a scene of orchestrated chaos, especially at 2 p.m., which for some reason is the crush time for emergency rooms. Because the hospital stands in a neighborhood full of new immigrants — as well as being rooted in an established community of Orthodox Jews — many of the people who enter the E.R. are undocumented and/or uninsured, and have waited until the last minute to seek treatment. “Our patients never have one problem,” says the residency program director. “They almost always have a heart attack compounded by a urinary infection compounded by muscle breakdown … There’s never one clear explanation for the pathological phenomenon we see in a lot of our patients.”
In 2005, Julie Salamon — an author and journalist best known for “The Devil’s Candy,” her account of the disastrous filming of “Bonfire of the Vanities” in 1990 — spent a year deep in the teeming organism that is Maimonides Medical Center. She negotiated unfettered access to staff ranging from the cleaning crew to the chairman of the board (although some spoke more freely than others). The resulting book, “Hospital: Man, Woman, Birth, Death, Infinity, Plus Bad Behavior, Money, God and Diversity on Steroids,” will surely be catnip to that peculiar breed of person who’s fascinated by anything having to do with hospitals and doctors, but as Salamon observes in her prologue, she also viewed Maimonides as an “epicenter” of something larger, a forum for the social forces buffeting the city and nation, “a petri dish of the post-9/11 world.”
Despite being related to two nurses, I’ve never had much interest in hospitals (or been able to sit through an episode of “ER”), but as Salamon expertly sucked me into the saga of Maimonides, I realized that this was about more than white coats, scalpels and beeping consoles. This place was 21st century America in a microcosm.
Of course, “Hospital” does deliver hefty servings of the staple ingredients of medical drama: arrogant doctors, controversial administrators, fed-up nurses, shell-shocked residents and plenty of patients whose stories alternately warm and break your heart. (The one missing element, thank God, is an overwrought love story.) There’s the 24-year-old single mother, an uninsured, undocumented immigrant cashier, who has to be told that, due to the cancer that has metastasized throughout her body, she won’t live long enough to see her two kids go to school. And there’s “Mr. Zen,” another uninsured cancer patient — hospitals are required to treat people who walk into the emergency room until they are able to walk out the door — a stoic and considerate man in spite of the “excruciating” pain he suffered. He became a staff favorite, and in his final hours, his attending physician sat by his bed reading a Buddhist text called the Heart Sutra. “I’m not sure exactly what he knew at that point,” said the doctor, but “it was the least I could do for him.”
And — of course! — there are the arrogant, preening surgeons: the fading cardiac “star” with his cowboy boots and a photo of Hemingway hung in his office; the medical director so competitive that, when Salamon tells him she accompanied one doctor as he saw a dozen patients the night before, boasts, “You should follow me around. I see about thirty in the day. I’m like a ballerina.” The hospital is riven by two major, long-standing physician feuds, each between a pair of former medical partners, and each one, by various accounts “absolutely about money,” or, conversely, entirely “personal … We felt we were treated like chattel.” The eccentric president of the hospital, Pam Brier — a tiny woman given to bizarre pronouncements like, “I want you to know I’m considered one of the great constipation experts in the borough of Brooklyn” — alternately snubs and mothers her employees, flying an ill staff member’s daughter into town (first class), then scheduling the opening ceremonies for a new cancer center so that the director of the center has to rush back from a conference in order to be there.
Along with Brier, Salamon pays particular attention to an idealistic oncologist — among the first physicians to treat AIDS as it emerged in the mid-1980s, and formerly with St. Vincent’s Hospital in Greenwich Village — as he comes to Maimonides to work at a new cancer center. Alan Astrow is a searcher, known for organizing lecture series on the spiritual aspects of healthcare and a perennial poser of questions in a profession that promises answers: “Why do we do what we do? What keeps us going? Not just that we ought to care, but why? Faced with a suffering or demanding patient whom we might prefer to avoid, where do we find the strength to enter the patient’s room? What is the conception of the human person and the role of physician and nurse that medical practice relies on?”
Although at least one of Astrow’s oncology fellows speculates that all this philosophizing makes him “too soft” for the rigors of administration, those questions are at the heart not only of the work of this hospital, but of American work life itself. Maimonides’ staff wrangles with dilemmas peculiar to healthcare: the stinginess of HMOs, the ever-growing numbers of uninsured patients, diminishing respect for doctors in society in general and the insidious incursions of pharmaceutical companies. In an age when medical advances are trumpeted almost every day (and sometimes retracted a little later, though much further back in the newspaper), expectations run high, people start to feel almost immortal; then disappointments and the inevitability of death become even more devastating.
Nevertheless, the resemblance between the travails of Maimonides and those of the world beyond its walls can be startling. Take, for example, the computerized “bed management” system, designed to help E.R. managers track and locate places to put incoming patients, a chronic problem. The director of emergency medicine complained to Salamon that 40 percent of his hospital’s beds are “controlled by all these fiefdoms: anything from patient relations [who reserve them for "VIPs"] to a cardiothoracic surgery nurse,” so figuring out which ones are currently empty and available to the “medicine” department is essential. The hospital spent $400,000 on a computerized system to track this information, but the whole thing depended on overworked and underpaid “information specialists” taking time to stop and punch numbers into a telephone on top of all their other duties. These people were paid only $23,000 per year. It’s a classic example of too much faith placed in technology and too little account taken of labor.
Respect — or rather, the lack of it — may be the single most persistent theme in “Hospital.” It’s hard to say that respect matters more to the people at Maimonides than money, because in this market economy, money is increasingly the only way we measure worth. A former chair of orthopedics says that he fell out with Brier because he wanted to give priority in the waiting rooms to patients who paid out of pocket or who had full insurance: “People who pay for health care don’t want to sit in a room with fifty people. They want to be seen in a timely manner. I think that’s very reasonable.”
Nurses and aides complain that doctors yell at them, and doctors complain that the support staff don’t take their jobs seriously enough. But, as one executive director argues, aides “don’t have the same drive the surgeon has. It’s not the same drive even a nurse may have. I say this to doctors all the time when they tell me the nursing attendants aren’t working hard enough or fast enough. I tell them, ‘They’re not going to work like you work. They’re not going to stay for 12 hours for the good of the cause or the good of the patient or because “This is why I came to health care.”‘ How do you motivate someone who makes $12 an hour? By saying, ‘Your next raise you’re getting another 12 cents’? I think what beats them down is the hierarchy, the respect they are given or not given. Everyone beats down on the one below.”
Doctors themselves are subject to similar slights; as Salamon observes, the exaltation of specialists has led to the devaluation of the family doctor, “the generalist who saw not just a patient but recognized a person with a history, a place in the community, a functional part of a larger system.” To boost referrals, admissions and the bottom line, administrators feel obliged to lure hot-shot specialists to their hospitals (as Brier was attempting to do when Salamon finished her stint at Maimonides) by offering exorbitant salaries and perks. Competition among physicians for “star” status grows fierce and bitter; the better, more sensitive doctor doesn’t always win. When the Maimonides V.P. in charge of perioperative services vowed to enforce a “Code of Mutual Respect,” he was greeted with skepticism by many nurses, who scoffed at the idea that a doctor who had to be wined, dined and wooed into joining staff would ever be disciplined for insulting a nurse.
Then there’s the community. Maimonides was founded in 1919 by a successful Jewish businessman who thought a hospital in Borough Park, Brooklyn, was needed to serve the Jewish immigrant community there. The hospital’s own mission statement describes itself as “uniquely committed” to the healthcare needs of the Orthodox Jews who currently make up 20 percent of its patients. Those needs include a kosher kitchen and an elevator that stops on every floor on Saturdays, so that Orthodox proscriptions against “working” on the sabbath won’t be violated at the push of a button.
Still, Salamon writes, “the hospital could never do enough to please” this particular constituency. Cleaning staff complained that the family members of Orthodox patients routinely crowded into rooms, making cleaning difficult and often bearing gifts of messy food, then turned around and griped about the dirtiness of the facilities. One of the oncology fellows told Salamon, “They become so demanding and are actually so derogatory when they speak to you that you think, ‘Remind me again why should I help you?’”
Hatzolah, a network of emergency medical service volunteers, specializes in helping Jewish patients, which means not just getting them to the hospital, but agitating for better care once their charges are admitted. Hatzolah have clout; they bring a lot of paying customers to the hospital. When the chair of the emergency department displeased a Hatzolah leader by hiring a nursing director the leader didn’t like, he let himself in for a major headache. “Hatzolah didn’t work for him, he worked for Hatzolah,” is how Salamon characterized the lesson he learned from that particular contretemps. Even the hospital’s diplomatically gifted V.P. in charge of patient relations — the “favor bank,” as Salamon describes him, and Orthodox himself — says, mournfully, “The Gentiles come in, they love us … The Jews complain. Someone gets stuck on a highway, they’ll stop the car. But to get a pat on the back? Never!”
Yet all the Hatzolah are doing is insisting on respect for their charges in the only way they know how: by kvetching. Brier herself, a survivor (with her husband) of a horrific car accident, speaks of every patient’s crucial need for an advocate: “You have to have someone with you to take notes, to ask questions, to hear. Even if you take notes, it’s hard to focus. I hear so many patients say, ‘What did he say?’ when the doctor walks out of the room. That’s why hospitals are scary. For all the care organized around you, when you are in the hospital bed, I won’t say you’re dead meat, but you’re really in a vulnerable position.”
Newer minority communities, like the Chinese and Pakistani immigrants that have streamed into Brooklyn in the last few decades, haven’t fared as well in adapting to the American medical establishment. Maimonides, like many contemporary American institutions, aspires to “multiculturalism,” by which is meant a prevailing ethos that treats all patients’ cultures and languages respectfully (whether or not they happen to be good at wringing what they need out of the system) and that strives to accommodate the demands particular to each one. As described by a “labor-management developer” Salamon interviews, this still-unrealized dream is one in which everyone tries to “hold multiple realities so we can accomplish our goal while we are listening to each other and understanding how we are different from each other.”
Not everyone at the hospital is sanguine about this goal. On the subject of multiculturalism, the cancer center’s oncology fellows may have been unusually outspoken with Salamon because their tenure at Maimonides was inherently limited — or they might just represent a younger, more international perspective on the virtues of assimilation. A young, much-traveled Malaysian doctor, exasperated by patients who he feels have made an insufficient effort to integrate into American society, tells Salamon, “I had to assimilate to this country. I had to assimilate to Switzerland. I had to assimilate to France. Wherever I went. This disrespect for our country is what I hate. And this is my country now. We cater to this disrespect. Our health care system completely embraces this kind of stuff. We can’t expect these people to change because we do nothing to change them. When I was in France, they didn’t bend in any way. You either learned French or else … Here you get translators.” (Later on, the same man is singled out by one of the social workers as an exceptionally compassionate doctor, so go figure.)
To read “Hospital” is to despair (if you haven’t already) of the ultimate viability of the multicultural ideal. A Chinese-born doctor (who learned Spanish for the sake of his half-Jewish Puerto Rican wife) is one of the few residents able to appreciate the protective drive of the Hatzolah, but even he expresses exasperation at the notion that the hospital can successfully accommodate the mores of every immigrant group without a diminishment in the quality of care. “A lot of cultures don’t have the concept of preventive care,” he tells Salamon. “They don’t go to the doctor unless they’re deathly ill. That’s the way the Chinese community is. We throw all this money at it — and that’s a good thing, to have people who speak the language and understand the culture. But it’s only half the equation. If the patient has the mindset ‘I’m only going to come to the doctor when I’m on my deathbed,’ then they are going to die. I can’t see that patient reps or having doctors that speak Chinese or making inroads in the community will change the mindset of these people. The only thing that will change the mindset is themselves. … Whether the something that is preventing them from coming is our point of view or their point of view, it is reality.”
Unruly, politically incorrect, riven by factionalism and petty quarrels, exhausted by the effort to sustain their humanity amid the turning gears of a vast, ever more relentlessly capitalistic industry, the people of Maimonides nevertheless have some of the more serious, meaningful jobs in today’s America. Their work is often a matter of life or death, and almost always a battle against grievous suffering. At the end of her year at the hospital, Salamon leaves with the apparent belief that they can still find meaning in it, despite the infighting and the external pressures. For all the sturm und drang and unfinished business in “Hospital,” that makes for a heartening conclusion. Because if these people couldn’t do it, what hope would the rest of us have?
Sen. Roy Blunt, R-Mo., gave a strong defense yesterday of a portion of the Affordable Care Act that allows children up to 26 years old to remain on their parents’ health insurance plans, breaking a bit from the GOP’s hard-line opposition to Obamacare.
Blunt endorsed Mitt Romney early on and led the campaign’s efforts to recruit Republican lawmakers during the GOP primary. But his comments in an interview on KTRS radio in St. Louis may give Boston some heartburn as it tries to convince conservative voters that Romney, who enacted the predecessor of Obamacare in Massachusetts, will actually repeal the healthcare law.
“It’s one of the things that I think should continue to be the case,” Blunt said of the “dependent coverage” provision, explaining that “it’s a way to get a significant number of the uninsured into an insurance group without much cost,” because young people are generally healthy.
Blunt noted that he even introduced a bill when he was in the House that would do exactly what the provision of the Affordable Care Act does now, saying, “I was for it then, and I’d be for it now.” “You’re breaking some news,” host McGraw Milhaven quipped.
While Blunt said he still favors repealing most of the health law, he would want to preserve a few sections, including the dependent coverage provision and the creation of high-risk pools for patients with preexisting conditions.
Romney has repeatedly vowed to fully repeal the Affordable Care Act, though he hasn’t spoken out specifically on the dependent coverage provision and he enacted a similar provision as governor. The provision is hugely popular, even though the overall law is not. And while Republican leaders supported the extension of coverage to 26-year-olds as recently as 2009, when it was included in the GOP’s healthcare alternative proposal, the GOP’s message today is that they’re for a complete repeal of the law, including the minimum coverage provision.
This got Sen. Scott Brown, R-Mass., in trouble after it was revealed that he takes advantage of Obamacare to make sure his daughter has insurance.
When it comes to sex and reproduction, even the most mind-numbingly intuitive conclusions can be politicized or disbelieved. So they bear repeating and resubstantiation. Take this recent Guttmacher study on contraceptive knowledge. Surveying 1,800 men and women ages 18–29, the authors “found that the lower the level of contraceptive knowledge among young women, the greater the likelihood that they expected to have unprotected sex in the next three months, behavior that puts them at risk for an unplanned pregnancy.” In other words, access to factual information helps prevent risky behavior.
I’m holding myself back from saying “duh” here, but this still has to be reiterated at a time when abstinence-only education that doesn’t provide detailed information about contraceptive use, except occasionally to emphasize its limits, not only persists but recently got a federal stamp of approval. As an Advocates for Youth report on the impact of abstinence-only education noted, “Proponents of abstinence-only programs believe that providing information about the health benefits of condoms or contraception contradicts their message of abstinence-only and undermines its impact. As such, abstinence-only programs provide no information about contraception beyond failure rates.” That’s how you get terrifying statistics like this one from the Guttmacher report: In the survey, “60 percent underestimated the effectiveness of oral contraceptives and 40 percent held the fatalistic view that using birth control does not matter.” Overall, “more than half of young men and a quarter of young women received low scores on contraceptive knowledge.” It’s also how you get figures like the one from the CDC that found that 31.4 percent of pregnant teens didn’t use contraception because they “thought they could not get pregnant at the time.”
There are two reasons to be optimistic that some dent can be made in these depressing figures, and they both have to do with provisions of the Affordable Care Act. Much has been made of the mandate that insurance policies cover all FDA-approved contraceptive methods, but there’s another aspect that’s been relatively overlooked: the fact that the same provision includes free education and counseling about sex and contraception, at least for the insured. The second reason for optimism is that the mandate will make it far easier for women to get longer-acting and more effective forms of contraception like the IUD — which are also more expensive and which studies have shown women would be interested in if they could afford them. Incidentally, the recent Guttmacher study found that women who were using long-acting or regular hormonal contraception tended to score higher on overall knowledge.
It will be awhile before we know if these changes will move the needle on the nation’s unparalleled rate of unintended pregnancy. The women’s health provisions only go into effect for new plans in August 2012, and older plans will be initially grandfathered and eventually phased out. And of course, there’s another big fat if – whether the Supreme Court overturns all or part of the Affordable Care Act. The Obama campaign and its allies are keen to point out how such a move — or, perhaps, a legislative repeal down the line — will hurt women above all. The Center for American Progress recently released a report on “Women and Obamacare” (the campaign having officially embraced the derisively intended term). It declares Obamacare “the greatest legislative advancement for women’s health in a generation,” which may be true for reasons more depressing than inspiring: There have been very few advancements partly because there has been so much political defense played.
In addition to the reproductive health benefits, the report points to preventive care recommendations for which cost-sharing has already been cut: mammograms, pap smears, prenatal care and so on. According to the report, “close to 9 million women will gain coverage for maternity care in the individual market starting in 2014,” currently not covered in 78 percent of plans sold on the individual market. It notes that women are more frequent users of healthcare services than men, that they’re likelier to make the household decisions on healthcare and that they’re more vulnerable to losing coverage because they’re likelier to be listed as dependents on a partner’s plan. The Affordable Care Act also makes it illegal to engage in “gender rating” – charging women $1 billion more than men on the individual market – and bans states from discriminating on the basis of gender identity in their insurance exchanges.
The report does acknowledge two ways in which Obamacare falls short for women who were “left out of the law — undocumented and recent immigrant women and women who need abortion services.” It claims that “political compromises on abortion coverage were necessary to ensure passage of the Affordable Care Act” – still a bitter loss to reproductive rights groups, who memorably described women as having been “thrown under the bus” by Democrats – “but the work to obtain abortion coverage for all women continues.” The last part is particularly debatable, at least when it comes to any momentum on the funding issue from national Democrats, while Republicans in the states and federally have spent considerable energy trying to limit abortion coverage on even private insurance plans.
Still, if the Affordable Care Act is allowed to stand, the magnitude of having an actual, proactive reproductive health access policy shouldn’t be underplayed. Maybe we’ll get closer to a saner republic where hearing “birth control doesn’t matter” from people who don’t want to get pregnant is a quaint memory.
This article was adapted from the new book,
"Insourced", available May 8 from Dartmouth College Press.
Approximately 15 percent of all healthcare workers and 25 percent of all physicians in the United States were born and educated elsewhere. This means that 1.5 million healthcare jobs are “insourced,” occupied by foreign-born, foreign-trained workers brought into the United States on special visas earmarked for healthcare jobs. This number is 50 percent greater than the total number of jobs in the U.S. auto-manufacturing industry. It’s amazing to consider that in 2008 and 2009, the auto industry, which makes up just 3.6 percent of the U.S. economy, received a $97 billion bailout. If we estimate that each of these 1.5 million insourced healthcare jobs has an average wage of $60,000, that’s $90 billion a year in wages going to people brought into the United States to work rather than training Americans to do the same jobs.
The healthcare industry makes up 16 percent of our economy. Yet even in these days of close to 10 percent unemployment, we do not invest enough money in our young people to train them for jobs in healthcare — an already understaffed industry that will have to serve an additional 32 million people once the provisions of the 2010 health-reform law take full effect. Instead, when faced with pressure from hospitals and nursing homes for more healthcare workers, the federal government grants visas to import nurses, physicians, pharmacists, physical therapists, and many other types of healthcare workers from countries that can ill afford to lose them.
In some U.S. industries, the outcome of globalization is positive or neutral. Take the sugar industry. Due to lower labor and land costs and better weather conditions, it’s far cheaper to grow sugar cane in the Caribbean than sugar beets in North Dakota. As import taxes fall, global transportation improves, and the number of sugar beet farms in the United States declines, more Americans are sweetening their cereal with sugar from Jamaican sugar cane. Americans save money buying cheaper sugar; the economy of the poorer sugar-growing countries improves, lifting thousands of people out of poverty; and the few displaced American sugar beet farmers generally find other work. But sugar is not a strategic commodity. If CARICOM, the Caribbean Community, were to halt sugar exports to the United States, we would experience no crisis. Sugar is not essential to our diet or life, and we have plenty of substitutes, from honey and corn syrup to NutraSweet. If necessary, within a year we could again be producing sugar in the United States.
The U.S. healthcare industry is 200 times larger than the U.S. tire-manufacturing industry, yet President Obama risked a trade war with China, our biggest trade partner, over tires. He was understandably trying to protect well-paying manufacturing jobs for American workers. Yet each year, we bring thousands of nurses from China to work in even better-paying jobs rather than train young people in this country to become nurses. The irony is that the economic costs of “insourcing” healthcare workers, including the loss of jobs no longer available to Americans, are far greater than the costs when we import Chinese tires. In 2003 the Commission on Graduates of Foreign Nursing Schools (CGFNS), a U.S.-based nongovernmental organization that administers the U.S. nursing licensing exam for foreign-trained nurses, opened a testing center in Beijing. The opening of this center initiated a “mushrooming” of new nursing schools in China and led to credible predictions that China will soon surpass the Philippines as the number one source of foreign-trained nurses imported to the United States.
Given the publicity and furor over the loss of manufacturing jobs, the lack of protest over healthcare-worker insourcing is surprising. Congress passed legislation and President George W. Bush signed a law in 2007 to protect the American sock industry from the rival Honduran sock industry. Yes, that’s right: socks. Protecting a few hundred $15-an-hour sock-manufacturing jobs based solely in the small town of Fort Payne, Ala., was worth acting on. Yet insourcing hundreds of thousands of $60-an-hour healthcare jobs has prompted no such similarly high-level response from our leaders.
Instead, on a regular basis, Congress approves and presidents from both political parties sign legislation to enable the legal entry of an ever-increasing number of foreign healthcare workers. Each year, about 20,000 new healthcare-specific visas are issued for these workers.
The United States has traditionally not allowed strategic industries to be outsourced. That’s why the U.S. steel industry and the U.S. car industry have received bailout after bailout. Access to enough steel and automobiles is essential to our economy; without a sufficient supply of each, our economy would be severely damaged. It’s time we acknowledged that the health of the population is just as important as steel and autos in keeping our economy strong. Healthcare is too important to risk continuing to insource it.
It’s not just a matter of protecting and expanding jobs for American workers. Every year, thousands of Americans die, and the health of thousands more is compromised, because of the shortage of healthcare workers in every one of the healthcare professions.
On the surface, insourcing may appear to be a harmless or even win-win solution to the country’s healthcare-worker shortage. The hospital receives a much-needed worker, and the worker escapes life in a struggling country for a better life here. But we should be training more people in this country to work in those professions, especially people from poor and minority communities. Rather than investing in our own people and communities, however, the U.S. government has decided to take the best and brightest workers from struggling countries.
Many foreign-trained healthcare workers, no matter how smart, are not adequately prepared for practice in the fast-paced, high-tech world of U.S. medicine. Whether in operating rooms, hospital wards, or nursing homes, inadequately qualified and poorly oriented foreign healthcare workers endanger the lives of their patients, as well as the lives and careers of their American-trained colleagues.
But the main reason for this country’s rise in unnecessary deaths and delayed care is understaffing — a result of the failure to train and place enough healthcare workers, especially in rural and underserved communities. Americans who live in rural areas make fewer visits to healthcare providers and are less likely to receive preventive care. The infant-mortality rate for African-Americans is twice that for the average American; Latinos are twice as likely as white Americans to die from diabetes. These health disparities are due in large part to a lack of healthcare workers, especially primary-care workers, in their communities. The quick fix has been importing foreign healthcare workers for these unfilled positions. Unfortunately, once these workers fulfill their initial contracts, most move to communities without healthcare-worker shortages; in fact, foreign-trained healthcare workers are more likely to practice in the well-served, major metropolitan areas than their American-trained counterparts.
Even if good foreign-trained healthcare workers were here in numbers adequate to meet our needs, the U.S. healthcare system is about encounter a tidal wave of demand as 78 million baby boomers approach their 60s. Older people make, on average, six visits to a healthcare provider a year, compared with two visits per year for people under 60. The healthcare workforce is aging, too: More than 50 percent of practicing healthcare workers are eligible to retire during the next 10 years, which will leave us with fewer workers to treat more and sicker patients.
In the eyes of employers, of course, insourcing healthcare workers appears to offer many benefits. Most doctors and nurses in developing countries earn a fraction of what American doctors and nurses earn: A Caribbean nurse makes around $1,000 a month; an Ethiopian physician, about $100 a month. Not only are many foreign-trained healthcare workers accustomed to lower salaries and quality of life, but they also carry little or no education debt, while their American-trained colleagues typically graduate with five- and six-figure debt burdens. With average student debt burdens of $155,00011 for newly graduated physicians and $30,375 for nurses, American-trained health workers require a higher salary just to help pay for their education. Trained in a much more hierarchical environment, foreign workers are much less likely to unionize, or even express dissatisfaction with their work. As the percentage of imported healthcare workers increases, their attitudes toward salary and terms of employment undermine the bargaining power of U.S. workers, and even affect the important feedback loop between employees and management.
Polls indicate that 70 to 80 percent of Americans want to reduce the rate of immigration into the United States. Yet the American public is not aware of our policy of using healthcare-worker-specific visas to solve the healthcare-worker shortage.
Some legislators who publicly support stabilizing immigration consistently vote to increase the number of healthcare-worker-specific visas granted each year. It’s not that American citizens don’t want to become healthcare workers and fill these jobs. This distinction is critical, because every industry that has brought in foreign workers has argued that American workers won’t do the work for the prevailing wage, or won’t do the work no matter how high the pay is. In the healthcare industry, this argument does not apply. U.S. citizens want the jobs. They just can’t access the training. The United States does not have enough positions in health-professional schools to meet industry demands.
The tens of thousands of qualified nursing school and medical school applicants who are denied entry to school each year permanently lose out on their chosen careers, work that is consistently ranked in the top tier of salaries, with excellent benefits and almost guaranteed job security. This loss of career opportunity is even greater for rural and minority young people, who are grossly underrepresented in the higher-level health professions, such as physicians and nurses, and overrepresented in the lower-level professions, such as technicians and home health assistants. Something is wrong when so many young Americans are forced to pursue other, lower-paying careers at a time when we desperately need more healthcare providers. In exchange we get foreign healthcare workers who are less well trained (they consistently score lower on licensing exams than U.S.-trained healthcare workers) and far less culturally competent than native-born Americans.
The most tragic and most preventable effect of our hiring so many healthcare workers from other countries is the unnecessary deaths of hundreds of thousands of men, women and children in developing countries. The World Health Organization (WHO) estimates that each year more than 10 million people die needlessly, from easily treatable maladies such as diarrhea, pneumonia, malaria, tuberculosis, vaccine-preventable diseases, and complications of childbirth. The WHO Global Health Workforce Alliance estimates that there are a billion people alive today who will never see a health worker in their lives. In Ethiopia, one in 10 Ethiopian children will die before his or her fifth birthday — yet there are more Ethiopian physicians in the Chicago area than in all of Ethiopia, which, with 80 million people, is the second most populous country in Africa. As their most skilled nurses emigrate to work in U.S. nursing homes, middle-income countries such as Jamaica and Trinidad have nurse-vacancy rates of 60 percent or higher.
Throughout the developing world, nurses, pharmacists, physical therapists, and many other types of healthcare workers are being approached and offered 10 times their salaries to practice in modern U.S. healthcare facilities with state-of-the-art technologies. Even the most dedicated, socially conscious worker would be tempted by such an offer. A colleague of mine relayed a conversation he’d had with the head of the Nursing Council of Kenya, who told him about the damage the exodus of senior nurses was doing to her country’s healthcare system. In the next breath, she confessed that the next time he visited Kenya, she might not be there. She was thinking about emigrating herself.
Our unofficial policy of relying on the world’s poorest countries to pay for the training of workers whom we then entice and bring to this country is devastating healthcare systems around the world. The loss to a developing country when a single physician, representing what may be a significant portion of their total number of physicians, emigrates is far greater than our gain. Our failure to provide education for our own citizens and to better plan for healthcare staffing and distribution does not justify poaching nurses and physicians from the countries that can least afford to lose them. How many additional deaths, how much more needless disability and suffering, will we allow this misguided policy to cause?
And consider American competitiveness. Certain industries are vital to U.S. global leadership. Recognizing their importance, we protect those industries. We don’t allow them to move overseas and make the United States vulnerable to the actions of other countries. Poor farmers in the developing world can certainly grow food staples more cheaply than American farmers do. But because of the strategic importance of the U.S. food supply, we subsidize some basic food crops, such as corn and soybeans.
And yet we are overreliant on foreign healthcare workers to meet our most basic health needs. This is particularly dangerous because many countries, almost completely drained of healthcare workers and tired of subsidizing the U.S. healthcare system, are trying to slam the door shut for emigrating healthcare workers. Meantime, of the world’s wealthiest nations, the United States has the worst health outcomes, with lower life expectancies and higher rates of deaths from preventable causes. In infant mortality, for instance, we rank 27th, behind Poland and Hungary. Our disability levels are higher than in most former Soviet countries.
If the United States is to remain competitive in the global economy, we need a healthy workforce. In order to achieve that, we need a healthcare workforce made up of adequate numbers of properly trained physicians, nurses, pharmacists, community-health workers, and other healthcare providers.
Ruth Marcus is unsettled. Maybe even queasy. There is probably some light nausea. What has her worried for the future of the nation, today? President Obama’s shameful, horrific, vicious attacks on those nice people in the Supreme Court.
Obama said that the court overturning Congress’ healthcare reform law would be a textbook example of “judicial activism” as “conservative commentators” define it: “that an unelected group of people would somehow overturn a duly constituted and passed law.” And hey, that seems like an eminently defensible and not particularly unsettling point! Conservatives made “judicial activism” into a talking point and rallying cry and defined it vaguely enough to encompass judges striking down basically any law or statute.
Marcus, though, is stopped cold.
And yet, Obama’s assault on “an unelected group of people” stopped me cold. Because, as the former constitutional law professor certainly understands, it is the essence of our governmental system to vest in the court the ultimate power to decide the meaning of the constitution. Even if, as the president said, it means overturning “a duly constituted and passed law.”
Judicial review, as a former constitutional law professor certainly understands, is not in the Constitution — an unelected activist judge made it up! — and the founders themselves disagreed on the wisdom of the principle. (They tended, in fact, to decide whether or not they liked judicial review based on whether or not the judges ruled in a way that they approved of.) The history of the Supreme Court is replete with nakedly political and mostly conservative rulings until very recently, when we had a brief period of liberal-leaning rulings from a marginally more diverse group followed by a return to status quo conservatism.
As long as the Supreme Court has been making awful and indefensible rulings based on ideology or racism, presidents and politicians have been criticizing the court. Abraham Lincoln attacked the Supreme Court in his first inaugural address, in a passage that conservatives love to quote when they’re attacking “activist judges.”
At the same time the candid citizen must confess that if the policy of the government, upon vital questions, affecting the whole people, is to be irrevocably fixed by decisions of the Supreme Court, the instant they are made, in ordinary litigation between parties, in personal actions, the people will have ceased, to be their own rulers, having, to that extent, practically resigned their government, into the hands of that eminent tribunal.
I am stopped cold and unsettled!
Marcus, hilariously enough, supports the healthcare law and the mandate — she is the world’s most sensitive milquetoast moderate liberal newspaper columnist, after all — which theoretically means she thinks it’s constitutional, which would mean that declaring it unconstitutional should maybe upset her more than criticizing the court for being political, but on the other hand those judges seem very smart and our entire system of government could collapse if we aren’t all super polite to one another and constantly deferential to authority.
I would lament a ruling striking down the individual mandate, but I would not denounce it as conservative justices run amok. Listening to the arguments and reading the transcript, the justices struck me as a group wrestling with a legitimate, even difficult, constitutional question. For the president to imply that the only explanation for a constitutional conclusion contrary to his own would be out-of-control conservative justices does the court a disservice.
Yes, I could tell they were very seriously wrestling with a difficult constitutional question when Scalia began joking around about broccoli mandates and the legendary “Cornhusker Kickback.”
I’m not sure what more the Supreme Court could do before moderates like Ruth Marcus finally acknowledged that it’s a partisan body with a right-wing majority. If Bush v. Gore didn’t do it, maybe nothing could. But as a partisan body it is open to partisan attacks, and our fragile democracy will not descend into anarchy if people think as poorly of the Court as they currently do of Congress.
Of course, the Republican talking point is that the president is attempting to bully the Court into ruling the way he wants. (Because if they strike down the law, he’ll … yell at them during the State of the Union again? No one seriously predicts an arrest warrant for Chief Justice Roberts here.) Mitch McConnell: “This president’s attempt to intimidate the Supreme Court falls well beyond distasteful politics; it demonstrates a fundamental lack of respect for our system of checks and balances.” Lamar Smith: “What is unprecedented is for the president of the United States trying to intimidate the Supreme Court.” Mike Johanns: “”What President Obama is doing here isn’t right. It is threatening, it is intimidating.” (Did you notice how everyone used the word “intimidate”? That’s because they got their language from a memo.)
The only time, besides Lincoln’s suspension of habeas corpus, that any president has seriously threatened the independence of the Supreme Court was when Franklin Roosevelt tried to amend the law to give the president the power to appoint more justices. And Roosevelt, frankly, was right on the merits of his proposal. The court is completely unaccountable and ridiculously powerful, it always has been, and pointing that out does not a constitutional crisis provoke.
This originally appeared on Janine Urbaniak's
Open Salon blog. It was written in a response to
a call for essays about people's personal experiences with the Affordable Care Act. Have an Obamacare story of your own? Blog about it on
Open Salon. Mason is my 14-year-old son, who is adorable and funny, and happens to have a very stubborn and large brain tumor. We discovered the tumor four years ago, and we have been monitoring and treating it with the help of some of the finest doctors around. Mason has lived a somewhat “normal” life, despite frequent MRIs and even chemotherapy. He did his homework and hung out with friends until the fall of 2010 when his headaches became debilitating. Scans revealed that Mason’s tumor had grown for the first time since we had discovered it. Then days before we were scheduled to meet with the neurosurgeon to discuss a surgery we had tried to avoid, Mason had a massive cerebral hemorrhage.
My boy spent 65 days in the pediatric intensive care unit (PICU) at one of Northern California’s best hospitals; during that time he underwent two brain surgeries, along with operations to insert a tracheostomy and a feeding tube. We stayed with him 24 hours a day, my husband, Alan, and I, his grandparents, and his 16-year-old brother, watching his oxygen levels on a screen, tracking his heart rate in beats per minute. The doctors kept him sedated, but every morning they turned down the propofol (Michael Jackson’s drug of choice) when the neurosurgeons came to do their examination. Three to five doctors circled Mason’s bed, one of them yelled his name into his ear. When he didn’t wake up right away, they apologetically pinched him and yelled louder.
When I was alone with Mason I put a white earbud into his ear and tuned my iPod to a song I knew he liked, “Airplanes” by B.O.B. I said it was time to wake up. “You need to come back, now,” I told him in my firm mommy voice.
During our first three weeks of hospitalization Mason racked up $1.1 million in medical bills. I worried about butting up against the $5 million lifetime limit on Mason’s health insurance policy. We had a good policy with a good company. We always paid our premiums on time and in full. But Mason wasn’t getting out of the hospital at any time soon, and there were months of rehab ahead. My then 13-year-old son would have reached his lifetime limit of health insurance had such limits not been eliminated by Obamacare on April 1, 2011. That date felt like a birthday or anniversary, something to be celebrated, when it finally arrived and we weren’t yet dropped by our health insurance company.
After two months in the PICU, we moved to a sunny room on one of the hospital’s regular floors. Our boy had just regained consciousness, though he still couldn’t talk or move his arms and legs. When the neurosurgeons came for their daily exam, we cheered when Mason managed a half-mast thumbs up. It was a huge victory.
As we celebrated our first day out of the pediatric ICU, Polly, the hospital discharge planner, introduced herself. Her job was to get the necessary approvals from our insurance company and make sure every moment of our stay was covered. This meant that she needed us to be ready to leave at any time. We needed a plan. She talked about Mason’s options for rehabilitation facilities. I soon realized that it would be challenging finding a place for a 6 foot tall 13year-old with a neurological injury. I scoured the Internet on my laptop for options.
A few days later, Polly stopped by to let me know that our insurance company representative had told her that Mason no longer needed hospitalization. Someone (she wasn’t naming names but they were clearly not a part of our medical team) suggested that we send our boy to an “interim” facility in a rundown city 40 miles away from our hospital and about 60 miles away from our home. I looked at Mason, who was enjoying his lunch through a feeding tube in his abdomen and breathing through another tube attached to a ventilator. I reminded her that Mason needed to be where he had access to neurosurgeons for emergencies. She smiled blankly and repeated something about medical necessity and pre-authorization. It was out of her hands.
Mason bought us a reprieve with a high temperature and a series of seizures. It started when his eyes fluttered from left to right, then his body stiffened. I rang the emergency button and the nurse ran for the appropriate drug. I held Mason’s hand and told him we were riding a big wave. It was pulling us under but we would always emerge. It would pass. I kept my voice low and even.
When my husband arrived later that day, I told him that at least they were not going to kick us out of the hospital now. I was aware my thinking had taken on a new and undesirable twist.
I avoided Polly. If I saw her at the nurse’s station, I ducked back into Mason’s room and locked myself in the bathroom. If she called, I let her leave a message. I spent all of my time caring for my child. Did the nurse wash her hands when she came into the room? Had Mason received his 3 p.m. meds? It’s not that I wanted to spend any extra time in the hospital, it was just that Mason was still so fragile and we had nowhere to go yet.
The insurance company appointed one of their staff nurses to support us through our medical crisis. I believe she was a compassionate and concerned human being, but I never trusted her. I imagined that her notes would go into Mason’s file for the utilization department to examine and find reasons why they should cut back on his care, or lose him from their roles entirely. Any time she called, I heard the voice of Sgt. Joe Friday from Dragnet reminding me, “Anything you say can and will be used against you.”
Several people mentioned that TIRR in Houston was one of the best neuro-rehabilitation facilities in the U.S. Footage of wounded Rep. Gabrielle Giffords arriving at TIRR was airing on every news channel. I don’t believe in coincidences, especially when thousands of people were praying for us. I called to see if TIRR was a part of our health insurance network. It was. It turned out that TIRR had expertise working with teenagers and there was excellent neurosurgical care available less than a mile away at Texas Children’s Hospital. It seemed like this was meant to be until Polly burst into our hospital room and told us that we couldn’t go. Though the insurance company approved the rehabilitation, they refused to pay for the air ambulance. We dipped into our savings, grateful that we could, and chartered our first airplane; this one came with a crew of paramedics.
The rehab doctors weaned Mason off of pain medication and fitted him for a wheelchair. He was out of bed every morning and dressed in sweat pants and a T-shirt. He began occupational, physical and speech therapy, though in the early days he often nodded off halfway through a session. A neuropsychologist said Mason’s prognosis was good. The healthy brain tissue had not been harmed by the hemorrhage. It was just a matter of getting the wiring back online in Mason’s brain, retraining his muscles and building his strength.
The insurance company rationed out Mason’s rehab approvals two weeks at a time. To meet their standards, Mason had to strike the balance between needing ongoing therapy and showing continued progress. If he stopped getting better, the insurance company would stop paying for his therapy, which presents a problem because brain injury patients typically hit plateaus in their recovery. I prayed daily for the faceless insurance company doctors who parsed out Mason’s approvals, wishing them insight and compassion.
A rehab hospital is not the place to visit if you want to pretend that awful things can’t happen to blameless people. In addition to stroke victims of all ages, there was a 30-year-old woman who was rear-ended at high speed on an interstate highway. Her mother brought her 2-month-old baby to visit whenever she could, though the young woman stared ahead her eyes not seeming to focus. There was a naval officer who suffered oxygen deprivation due to an illness he suffered on a ship somewhere in the Pacific. His mother brought me strawberries when she came to visit one Saturday. Then there were two other teenage boys, like Mason, with different varieties of brain tumors. One didn’t survive his stay, though I’m not sure what happened. The other walked out of the rehab to the cheers of his therapists and all the rest of us.
We never saw congresswoman Giffords, though I found the presence of the Secret Service reassuring. Nancy Pelosi toured the gym one afternoon when Mason was having physical therapy. I introduced myself. She smiled and complimented my beautiful boy who was walking in a harness mechanism. I meant to thank her for the healthcare bill, but it was too disorienting speaking to someone I usually watch on CNN. John Boehner didn’t stop by, maybe it was too much, seeing all these folks flaunting their preexisting conditions, exceeding their lifetime insurance limits with such brazen determination to pull themselves upright again.
P.S. Mason is back in school, finishing 8th grade. He is walking, talking and working out at the gym three times a week. He received an A- on his paper on “Of Mice and Men.”
(Credit: Reuters/ Jonathan Ernst) 
(Credit: restyler via Shutterstock) 
(Credit: gualtiero boffi via Shutterstock/Salon) 
(Credit: AP) 
Supporters of healthcare reform rally in front of the Supreme Court on the final day of arguments regarding the healthcare law signed by President Obama on March 28, 2012. (Credit: AP Photo/Charles Dharapak) 
