The American Medical System Is One Giant Workaround

From Obamacare to nurses stockpiling medicine, health care has become a jury-rigged mess.

The nurses were hiding drugs above a ceiling tile in the hospital — not because they were secreting away narcotics, but because the hospital pharmacy was slow, and they didn’t want patients to have to wait. I first heard about it from Karen Feinstein, the president and chief executive of the Jewish Healthcare Foundation, who reported it at a board meeting several years ago. I wasn’t surprised: Hiding common medications is a workaround, an example of circumventing onerous rules to make sure patients get even basic care.

Workarounds are legion in the American health care system, to the extent that ECRI (formerly the Emergency Care Research Institute) listed them fourth among its list of top 10 patient safety concerns for health care organizations in 2018. Workarounds, the group writes, are an adaptive response — or perhaps one should say maladaptive response — to “a real or perceived barrier or system flaw.”

Staff use workarounds because they save valuable time. According to Anita Tucker, a business professor at Boston University, system breakdowns, or what she calls “operational failures,” and the workarounds they stimulate, can “consume up to 10 percent of a nurse’s day.” Most hospital nurses are stretched to their limits during their 12-hour shifts. No nurse has 90 minutes to lose to a slow pharmacy or an inefficient hospital bureaucracy.

I saw the common sense that can underlie workarounds when my hospital floor instituted bar code scanning for medication administration. Using a hand-held scanner to register bar codes on medications and patients’ hospital bracelets sounds smart. But then some medications routinely came without bar codes, or had the wrong bar codes, and we nurses weren’t given an easy way to report those errors. Patients’ wrist bands could be difficult to scan and the process disturbed them, especially if they were asleep. The lists of medications on the computer screen were also surprisingly hard to read, which slowed everything down.

But the biggest problem was that the scanning software did not work with our electronic medical records — so all drugs had to be checked off in both systems. This is a huge problem when dealing with patients like those receiving bone-marrow transplants, who might get 20 drugs every morning — some of which are delivered through IVs and come with nonstandard doses. What was already a lengthy process suddenly took twice as long.

Some nurses responded to the arrival of the bar code system with workarounds, including refusing to use the scanner, or taping copies of patient bar codes to their med carts. I tried to adhere to the rules, but if I was especially busy or couldn’t get a medication to scan, I would chuck the whole process.

However, because bar code scanning has been shown to reduce errors in medication administration, the hospital officials wanted it to be done consistently. They produced a public list of all the nurses on the floor. Each nurse was labeled green, yellow or red, depending on the percentage of medications he or she administered using bar codes. Family members, doctors — anyone could see how a nurse was graded.

Over time the list worked, but the sting of it also endured. We were being punished for taking time for patients, even if it meant bending the rules. No one among the managerial class seemed to understand that nurses care a lot about patient safety. The unheard concern was that a green light for bar code scanning meant a patient could fall into the red zone for something else.

Workarounds in health care always involve trade-offs like this, and often they are trade-offs of values. Increasingly, the entire health care system is built on workarounds — many of which we don’t always recognize as such.

Consider the use of medical scribes, who complete doctors’ electronic paperwork in real time during patient visits. The American College of Medical Scribe Specialists reported that 20,000 scribes were working in 2014, and expects that number to climb to 100,000 in 2020.

I have heard doctors say they need a scribe to keep up with electronic medical records, the mounting demand of which is driving a burnout epidemic among physicians. Scribes allow doctors to talk with and examine patients without having a computer come between them, but at base they are a workaround for the well-known design flaws of electronic medical records.

As a nurse, when I first learned about scribes, I was outraged. On the job, nurses hear repeatedly how health care companies can’t afford to have more nurses or aides to work with patients on hospital floors — and yet, money is available to pay people to manage medical records. Doctors who use scribes tend to see their productivity and work satisfaction increase, but the trade-off is still there: Scribes demonstrate the extent to which paperwork has become more important than patients in American health care.

The Affordable Care Act, which I support because it has made health care available to millions of previously uninsured Americans, is also an enormous workaround. The act expanded Medicaid, protected patients with pre-existing conditions and offered subsidies to make private insurance more affordable. Obamacare, though, was never intended to make sure that all Americans had affordable care; it works around our failure to provide health care to all our citizens. In its own way, the Affordable Care Act is as jury-rigged as using ceiling tiles to stash medications.

The United States spends more per person on health care than any other industrialized country, yet our health outcomes, including overall life expectancy, are worse. And interventions like bar code scanning are a drop in the bucket when it comes to preventable medical mistakes, which are now the third-leading cause of death in the country. Our health care nonsystem is literally killing us.

As the workarounds accumulate, they reveal how fully dysfunctional American health care is. Scribes are workarounds for electronic medical records, and bar code scanning is a workaround for our failure to put patient safety anywhere near the top of the health care priority list. It’s a values trade-off that the nurses on my floor instinctively understood.

There Are Really Two Distinct White Working Classes

One is solidly Republican and will stay that way; the other leans Democratic. And then there are the in-betweeners.

At Nancy Pelosi’s news conference last week, a reporter asked her about Joe Biden’s comments on his congenial dealings in the senate of the 1970s with the Southern Democrats James O. Eastland and Herman Talmadge, who were both staunch opponents of Civil Rights legislation and racial integration:

There’s been a back‑and‑forth between Vice President Biden and some of the candidates. Do you think that it is helpful to the party to sort of fight that fight over who best represents the party when it comes to sensitivities about race?

“That’s not what this election is about,” Pelosi answered in a severe tone. “This election is about how we connect with the American people, addressing their kitchen table needs.”

Reporters continued to press Pelosi: “What do you think about Vice President Biden’s words, referencing his work with segregationists and talking about his idea of civility?”

She shot back: “I have answered that question, and that’s all I’m going to say.”

The intensity of the exchange shows how determined key Democratic leaders are to keep the party focused on the bread-and-butter issues of jobs, health care and financial stability and to shore up the gains the party made in 2018, especially among whites.

Pelosi’s response illustrates the deep fear among the same leaders that the agenda could shift to issues of race and immigration. These are issues that a cadre of newly elected progressive members of Congress including Alexandria Ocasio-Cortez, Ilhan Omar, Rashida Tlaib and Ayanna Pressley — as well as Democratic presidential candidates like Elizabeth Warren, Kamala Harris and Cory Booker, all with warmly enthusiastic followings — have brought to the fore. Race and immigration are just the issues Donald Trump and his Republican allies want to place front and center in 2020.

Underlying this is the recognition by many Democratic strategists of the continuing political centrality of less highly educated white voters. Marginal shifts in partisan balloting by the white working class have been a crucial determinant in the outcome of elections since 1968.

This non-college white constituency — pollster shorthand for both the white working class and the white middle class without college degrees — makes up a massive bloc of the electorate, with estimates ranging from 48 percent of the entire electorate in 2016, according to an analysis by Catalist, a liberal voter research group, to 54 percentaccording to the Cooperative Congressional Election Study.

Pete Brodnitz, founder and president of Expedition Strategies, a Democratic polling firm that has performed studies for the Democratic House Majority PAC, wrote by email that in 2018 he found that the white working class could be divided into five political categories:

  1. reliably Democratic, 33 percent;
  2. lean Democratic, 7 percent;
  3. true independents, 10 percent;
  4. lean Republican, 7 percent; and
  5. reliably Republican, 44 percent.

How each of these categories voted in 2016 shows the importance of these distinctions. In a poll of battleground House Districts, Hillary Clinton carried the reliably Democratic base by a solid 67-point margin (78-11) and the lean Democrats by 61 points (64-3). She lost the true independents by 16 percentage points (21-37). Trump won overwhelmingly among the lean Republican whites (73-12, a 61-point margin) and the solid Republicans by 84 points (88-4), according to the data collected by Expedition Strategies working with Normington/Petts, another Democratic polling firm.

In almost every way, white non-college Democrats and white non-college Republicans are nothing alike,” Michael Podhorzer, the political director of the AFL-CIO, emailed in response to my inquiry.

Polling conducted by GQR, a Democratic firm, for the AFL-CIO, found that among the Republican white working class, 79 percent identify as Christian, two thirds of whom are evangelical or born again. Among the Democratic non-college electorate, 44 percent said they were Christian, and one third of them said they were evangelical or born again.

The Democrats are much younger, according to Podhorzer: 22 percent are Gen Z or Millennial compared with 12 percent of working class white Republicans. The Democratic members of the white working class are 59 percent female and 41 percent male, compared with 51 percent female, 49 percent male among Republican non-college whites.

Perhaps most important, the white non-college Republican and Democratic constituencies differ radically on policy and political beliefs.

Take favorability ratings of

  • Obamacare,
  • Black Lives Matter and
  • Medicare for all.

Among working class white Democrats, the ratings are uniformly positive, according to AFL-CIO data: 89 percent, 80 percent and 85 percent. Among their white Republican counterparts, the ratings are uniformly dismal: 5 percent, 9 percent and 18 percent.

What this data shows is that Democrats should have little trouble retaining the support of members of the white working class who identify as Democrats, but they will struggle mightily to win over their Republican counterparts.

This divide leaves the small percentage of the white working class whose views put them in the middle ground between left and right up for grabs and likely to determine the outcome in 2020.

The AFL-CIO survey suggests that the roughly 10 percent of non-college whites who do not identify with either party may be reachable for Democratic candidates, but there are big hurdles.

For one thing, these self-described independents do not side with mainstream Democrats on the kinds of incendiary issues that President Trump loves to promote.

The AFL-CIO study examined four categories of voters: all Democrats; non-college white Democrats; independent non-college whites; and Republican non-college whites.

The survey asked, for example, whether voters agree or disagree with the statement “Social and economic problems in this country are largely due to individuals across races and origins refusing to work and expecting handouts.”

All Democrats, including white non-college Democratic respondents, took liberal stands, sharply disagreeing with the statement by 62 points (78-16) and 56 points (76-20). Independent voters in the white working class were in favor by 11 percentage points (52-41), and Republican respondents were solidly in agreement, by 72 points (84-12).

On a similar racially freighted question — “Social and economic problems in this country are largely due to certain groups failing to work hard and play by the rules” — Democrats disagreed by large margins, while independent white non-college voters showed greater conservatism, agreeing 54-36; Republican non-college whites strongly agreed, 79-12.

The accompanying graphic shows the pattern of opinion on three additional questions measuring what sociologists call “anti-black affect.”

A Partisan Chasm on Race

Less-educated white Democrats largely agree with Democrats overall, but the views of independents and Republicans are the reverse. Percentage of respondents to a 2018 survey who agreed or disagreed with these statements.

AGREE: White people in the U.S. have certain advantages because of the color of their skin.

ALL DEMOCRATS

83%

76

DEM.

WHITES WITH

NO COLLEGE

29

IND.

17

REP.

AGREE: Generations of slavery and discrimination have created conditions that make it difficult for African-Americans to work their way out of the lower class.

ALL DEMOCRATS

73

69

DEM.

WHITES WITH

NO COLLEGE

24

IND.

8

REP.

DISAGREE: Ethnic groups like the Irish, Italian, Jewish and many other minorities overcame prejudice and worked their way up. Blacks should do the same without any special favors.

ALL DEMOCRATS

57

49

DEM.

WHITES WITH

NO COLLEGE

14

IND.

4

REP.

By The New York Times | Source: Polling Consortium Election Survey conducted Oct. 24–Nov. 7

The next accompanying graphic illustrates hostility toward immigrants — or acceptance.

Democrats Stand Alone on Immigration

Percentage of respondents who disagreed with these two statements.

DISAGREE: Increase border security by building a fence along part of the U.S. border with Mexico.

ALL DEMOCRATS

80%

DEM.

82

WHITES WITH

NO COLLEGE

IND.

28

REP.

3

DISAGREE: Deport undocumented immigrants to their native countries.

ALL DEMOCRATS

56

DEM.

55

WHITES WITH

NO COLLEGE

IND.

14

REP.

1

By The New York Times | Source: Polling Consortium Election Survey conducted Oct. 24–Nov. 7

The AFL-CIO survey demonstrate why liberal Democratic leaders like Pelosi are resolved to stand clear of some of the issues that divide their party from independents. At the same time, it shows why Pelosi and others want to focus on so-called kitchen table issues.

On health care and economic matters, there is far more overlap between the views of Democrats as a whole and independent white working class voters.

Support for a tax on wealth in excess of $100 million tops 90 percent among Democrats, while white working class independents support such a proposal 59-25.

A proposal supported by Democrats of all stripes — “Having the government produce generic versions of lifesaving drugs, even if it required revoking patents held by pharmaceutical companies” — has the backing of non-college white independents, 56-25.

By two to one, white independents agreed with two liberal populist statements: that “social and economic problems in this country are largely due to a handful of wealthy and powerful people rigging the rules to their advantage” and that “social and economic problems in this country are largely due to a handful of wealthy and powerful people dividing us against each other so they can take more for themselves.”

Two proposals backed by some of the Democratic presidential candidates — Abolish ICE and Medicare for All — do not sell well among white non-college independents, who opposed the two initiatives by 71-15 and 48-31.

Podhorzer argues that in the 2020 battleground districts and states the contest will be fought over the 13 percent who are swing voters, a group he calls “partisan bystanders.” He described them as “voters who either have a very negative view of both parties or do not have strong feelings about either party. These voters favored Democrats in the 2018 midterms by 11 points after favoring Trump by 6 points in 2016.”

According to Podhorzer, almost half (46 percent) of the partisan bystanders are “white non-college, so this group, especially white non-college women, is going to be a battleground for both campaigns.”

Podhorzer makes a key point: In his view, this 13 percent is receptive to Democratic appeals because they

are looking for answers to the basic economic challenges they face. That issues like health care are much more important to them makes sense given that just about everyone who cares about issues like immigration has already picked sides and won’t be moved.”

In some respects, the AFL-CIO poll provides ammunition to the Third Way, a centrist Democratic advocacy group.

Jonathan Cowan, president and co-founder of Third Way, argued in an email that:

Going forward to 2020, there are lines that Democrats can’t cross if they want to win nationally and hold the House and gain in the Senate. Medicare for All is one of those lines. But there are others like abolishing ICE, a guaranteed federal job, and certain climate proposals that ignore the economic circumstances of the interior of the country.

Third Way survey of Democratic primary voters, conducted in May by David Binder Research, found that calls to abolish ICE in particular are problematic. In fact, Democratic presidential candidates are backing away from their earlier support of the idea, despite the horror show that is happening on the border right now.

The Third Way poll found that Democratic voters of all stripes prefer a candidate who promises to expand employment opportunity to one who would guarantee everyone a government job; and these voters prefer a candidate who would ensure “that every student who enters college can finish with a degree” to one “who supports free 4-year college for all students.”

In the case of health care, the Third Way survey of Democratic primary voters found that a plurality, 42.9 percent, preferred a candidate “who wants an annual cap that limits the costs people pay while making sure everyone has insurance coverage” while 35.2 percent prefer a candidate “who wants to pass a single-payer, Medicare for All government-run plan.”

Both Democratic and Republican strategists are putting all of these findings under a microscope because in a highly competitive election, seemingly small shifts can determine the outcome.

ADVERTISEMENT

Take the difference between Hillary Clinton’s performance in 2016 and the performance of House Democratic candidates.

In 2016, all non-college whites went 60-34 for Trump over Clinton, while voting 58-38 in favor of Republican House candidates, according to Brian Schaffner, a political scientist at Tufts and senior researcher at the Cooperative Congressional Election Study.

This may seem insignificant, but if Clinton had been able to match the margin of Democratic House candidates, not only would she have picked up 2.9 million votes nationwide, she would have won Michigan, Pennsylvania and Wisconsin by a combined total of 383,000 votes instead of losing them by a total of 79,646 votes.

One interpretation of Democratic success in taking control of the House in 2018 suggests a strategy of moderation, while using animosity to Trump to boost turnout in hard core Democratic constituencies, including among minorities, young voters and single women. If the 2018 House give hints on the type of voters who offer the best targets for 2020, it is worth recalling that more than three quarters of the newly Democratic seats are in centrist districts.

According to data provided by Third Way, the new Democratic districts are predominately upscale, with higher than average percentages of well-educated, well-off whites and lower than average percentages of less-well-off whites.

However, the demographics of these districts mask the significant gains Democrats made in 2018 among non-college, less affluent whites. This becomes clear in an analysis of the 2018 election by Yair Ghitza, chief scientist at Catalist.

“There has been a lot of attention paid to the Democratic victories in suburban areas, but we find that Democratic gains were actually largest in rural areas,” Ghitza wrote:

These gains weren’t enough to get over 50 percent and win seats in many rural districts, so they have escaped much of the mainstream election analysis to this point. These changes are nonetheless important, particularly because they were large in many of the Midwest battleground states that will no doubt be important in 2020.

Ghitza provided further support for the Democratic strategy of going after white non-college voters by noting that 2018 Democratic gains were “largely driven by voters who voted for Trump in 2016 and voted Democratic in 2018.”

ADVERTISEMENT

It is no wonder, then, that Pelosi is not the only party leader warning Democrats to be wary of the danger of focusing too much on social and cultural issues in the heat of the primaries. Such counsel also comes from African-American Democrats.

Take Representative Cedric Richmond of Louisiana, who suggested to the Washington Post last week that there should be less attention paid to Biden’s stumble on race: “African-Americans are worried about the safety of their families. They’re worried about jobs. They’re worried about health care, diabetes, cancer, and they’re worried about how to pay for kids’ college.”

Richmond was joined by Representative John Lewis, who said he didn’t think Biden’s remarks were “offensive,” before adding, “During the height of the civil rights movement we worked with people and got to know people that were members of the Klan — people who opposed us, even people who beat us, and arrested us and jailed us.”

The Rev. J.M. Flemming, president of the Greenville NAACP, told the Washington Post:

“I’m not going to let anybody sidetrack folks that I know about who are looking at Biden, when we ought to be looking at the things said by Trump. Nobody is making anybody out to be a perfect person, but what Trump is doing, for me, that’s far worse.”

The concerns of African-Americans, in this view, are substantially the same as the concerns of the millions of white working class voters who remain open to Democratic candidates — or at least they coincide in critically important ways.

The fate of the Democratic Party in 2020 hangs on this premise and on a united resistance to Trump’s malign strategy of divide and conquer.

The Difference Between a ‘Public Option’ and ‘Medicare for All’? Let’s Define Our Terms

Various proposals are floating around, each of which would change the health care system in distinct ways. Some, like one from Senator Bernie Sanders, would do away with all private health insurance. Some would make small expansions in existing public programs. Some would try to cover all Americans through a mix of different insurance types.

It can be mystifying when people call all of these ideas “Medicare for all,” as some in the debate have been doing.

.. Private plans handle Medicare drug coverage, and you can choose among options. You pay premiums each year, and you pay deductibles and co-payments when you use medical services.

Because the program’s out-of-pocket spending has no limits, most Medicare beneficiaries also buy private supplemental insurance to limit those costs. That insurance doesn’t cover medical services outside the Medicare system, but it helps pay the patient’s share of the bill when a person goes to the doctor or hospital.

.. Mr. Sanders, who prominently featured such a plan in his 2016 presidential platform and just announced he has joined the 2020 race, uses this term a lot. His plan would both expand traditional Medicare to cover all Americans, and change the structure of the program, to cover more services and eliminate most deductibles and co-payments. So the Medicare everyone would be getting would differ in crucial ways from the Medicare older people get now.