Safety Net

Dear Senators: I Took an Oath to Do No Harm. You Should, Too.

Dear Members of the U.S. Senate,

My name is Samantha and I have been a pediatrician for exactly 360 days. I work in Southwestern Virginia, for a hospital system that also provides care to underserved parts of West Virginia and Tennessee. We mainly work with struggling families that rely on Medicaid to provide health care to their children. That means, at this exact moment, you are debating a bill that would directly impact the children that I took an oath to serve.

I could tell you countless stories of medical crises averted, serious illnesses cured, chemotherapy administered, and families counseled through the parts of parenthood that they often did not anticipate. But you are all intelligent people, and you can imagine these scenarios for yourselves. Even if you can’t, I’d hardly be the first to point these stories out.

Instead of telling you about what it means to have health care, I want to talk to you about what it means to have health insurance. I want to talk to you about what it means to a parent to worry that they can’t afford the treatment their child needs—and to know, deep down, that they might bankrupt themselves trying to keep their child safe.

First, I want to talk to you about the provisions of your bill that would chip away at coverage for people with pre-existing conditions. Last week, I had the privilege of meeting a young woman and her mother in our clinic. The mother had a heart condition that is often passed genetically from parent to child. As she and I spoke about definitive testing that would tell us if her daughter carries the gene that might cause her to develop the same condition, she started to get nervous.

She was afraid that this test, which could help us treat and protect her daughter, was a medical Catch-22. Without it, we wouldn’t know how to care for her daughter. With it, her daughter might be labeled as a person with a pre-existing condition, which could make her unable to afford the care she needs. And it was all based solely on a tiny gene that has not yet even made her sick.

Parents can no more risk the well-being of their ill children than walk on water.

Even as we told her that her daughter’s heart is currently perfectly healthy—news a mother should get to receive with untainted joy—I could see her eyes fill with tears. She told us that she had been unable to get insurance coverage until recently, because of her heart condition. Insurance companies even resisted covering her children, based on the risk that they may have inherited her heart condition, despite the fact that none of them had been diagnosed.

If you pass this bill, the children who lose their insurance will still come to my clinic. Their parents will bring them even if they aren’t sure how they’ll pay, and even if they know deep down that they can’t. Parents can no more risk the well-being of their ill children than walk on water.

The doctors, nurses, and therapists I work with will still care for these kids when they come. We’ll do it even though medicine is a difficult career. We’ll do it even though it requires sacrifice and emotional risk to care so deeply for these tiny people who need us. We’ll do it not only because it is legally required of us, but because of the little pieces of our souls that our patients have come to inhabit.

I’ll do it for days like today, when I get to see a boy I have cared for since he was a newborn take some of his earliest steps and wrestle through his check-up like it was a game. I do it for the incredible growth I have witnessed in his mom and dad: a young, at-risk couple who have become thoughtful and loving parents over this past year. I do it for the moment when the baby stops pulling on my stethoscope just long enough to give me an unprompted hug, or when I give him a high-five for doing a good job and he gives me high-fives over and over until I absolutely must move on to my next task.

I am asked to give these children the care they deserve, and to do right by them and their families. In return, I get these little gifts now and then. Small rewards for living as “men and women for others”—the core belief instilled in my medical school classmates and me at our alma mater.

I like to think that you all became representatives of the American people with a similar goal—to be “men and women for others.” I like to imagine what our nation might become if lawmakers such as yourselves did your work by the same principles that guide us as caregivers through each day.

I would hope that you choose to live by at least one of our principles, known in ethics circles as non-maleficence. You might be more familiar with its colloquial phrasing, “First, do no harm.” With this health care bill, you hold the futures of millions of Americans in your hands. Please, if you keep nothing else in your heart as you vote in the upcoming days, think of your constituents and hold close the aspiration to “first, do no harm” to those who are depending on you.

 

With my sincerest thanks,

Samantha Cerra, M.D.

 

Editor’s note: Some identifying details have been changed in order to protect patient privacy; however, the essential content and experiences represented are recounted faithfully.

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Culture

Americans Oppose School Segregation in Theory. So Why Not in Practice?

In the Upper West Side of New York City, Public School 199 stands on West 70th Street as a high-wealth, high-performing, and intensely sought-after elementary school. But this fall, the popular school will usher in a new, different class of students—and the enrollment change has drawn fear, scorn, and fierce opposition from local parents.

In the fall of 2015, the New York City Department of Education announced plans to redraw District 3’s attendance zones with the goal of making schools like P.S. 199 more economically integrated. The proposed changes would move several elementary school students from Public School 191—a neighboring, high-poverty, majority-minority school—into P.S. 199.

Parents at the wealthy school were outraged, and the city’s first attempt to integrate the two schools failed amid the backlash. After contentious debates and heated protests, the city dropped the plan, stating it would need more time to devise a new approach that “reached consensus.”

The city resurrected its proposal the next year, and although the rezoning plan is still fraught with conflict, it somehow muscled its way through the dissension to reach a final vote last fall. District 3’s Community Education Council—a locally elected parent group that votes on zoning policies—had long been in favor of new zoning lines and approved the city’s plan on a 9-to-1 vote.

But parents who are opposed to the plan have continued to fight. Some are placing political pressure, threatening to campaign against any official who supports the new zones. Others have warned of enrolling their children in private school. Some have even hinted at taking legal action. Overall, the battles roiling P.S. 199 and P.S. 191’s elementary school campuses have proved that when it comes to school integration, change is no easy task.

One would think Americans are ready for school integration, though. In a new study released by me and my colleague, Ulrich Boser, we found that most Americans—more than 60 percent—report that school segregation is an important issue for them, and nearly 70 percent of Americans agree that more should be done to integrate low- and high-poverty schools.

These findings were a bit startling at first glance. After all, if most Americans are in favor of school integration, why aren’t diverse, integrated classrooms spreading across the country?

Historically, school integration has met intense resistance. But at least in principle, the general public seems to endorse it, and our poll may have tapped into the country’s sympathy for people living in poverty.

Affluent parents may feel territorial over the high-flying success of their school.

In fact, one 2012 poll found that 52 percent of Americans believe “helping the poor and needy is a top priority.” Another poll found that reducing poverty is “very” or “extremely” important to most Americans.

National support for school integration may also be due to the country’s increased attention on income inequality. More than three-quarters of adult Americans, for instance, believe “the rich just get richer while the poor get poorer.” Nearly 90 percent of Americans also believe they are “falling backward” in their finances. And a majority believe “the next generation has it even worse.”

Seeking to disrupt trends of economic inequality, Americans could be keen on helping children with low incomes have a fair shot at entering the middle class, and they see education as the best way to get there. But if there’s anything the desegregation battles in New York City prove, it’s that integration can leave both a sweet and bitter taste in Americans’ mouth. Americans might support integration in theory, but many have different reactions when it reaches their own backyards.

Research shows that reporting favorable views of integration can demonstrate a “superficial tolerance” of integration. But sending one’s own child to an integrating school is a much greater challenge: It requires a person to acknowledge—and maybe uproot—deep-seated stereotypes about families with low incomes and education.

Poverty is also racialized in the United States, and words like “low-income” in America can trigger other words like “black” and “brown.” Children of color, as young as five, are more likely to be perceived as violent and disruptive, which can stoke fears about integrating schools on both economic and racial lines.

But it may not be student diversity, per se, that is distressing to parents as is the thought of losing certain privileges. For affluent parents, they may feel territorial over the high-flying success of their school. And property values, neighborhood identity, and a sense of safety feel as though they are at stake.

“A school belongs to the neighborhood it resides,” said one parent at PS 199.

“It’s not that I don’t want my children to go to school in a mixed school … But at the same time we want the best for our children. We want the best for our property value,” said another.

And it’s not just wealthy parents who are afraid. Through our focus group sessions with diverse parents in the Baltimore and Washington, D.C., metro areas, we found that low-income parents were wary of integration, and they drew on their own life experiences as supporting evidence.

For instance, low-income white parents spoke of being looked down upon by the “rich kids.” As one parent put it: “They don’t want us there, so why should we go there?” They pictured affluent families throwing lavish birthday parties, showering the higher-income kids with fancy cars and expensive gifts, making their own children feel insecure.

Despite whatever frustrations may be brewing among high- and low-income parents, District 3’s rezoning plan will take full effect this fall. In the Upper West Side of Manhattan, children who used to live in two separate worlds will now read, write, learn, and play together.

Fortunately, it’s not the only plan to mark a real shift in school diversity for New York City. The New York City Department of Education recently unveiled its citywide plan for integration, pledging to increase diversity across their entire public schooling system.

These changes are promising. Despite rapidly changing demographics in this country, school diversity has barely kept pace, and research shows that all students perform better academically and socially when they learn in diverse classrooms.

Many Americans do believe the time is ripe for change, but it remains to be seen whether all Americans will embrace this change when it arrives in their own communities.

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Media and Politics

No, Young People Aren’t Poor Because They’re Not Married

In his latest op-ed, Washington Post columnist George Will deplores the culture of today’s young people, blaming their disproportionate poverty on the fact that too many don’t get a high school diploma, a good job, and a spouse before they have kids.

Just a minor problem: Literally every aspect of the argument is dead wrong. Today’s young people are more educated than any previous generation, and the share of people living in poverty who have some college education has grown dramatically. Seventy-seven percent of people in poverty have the high school degree that Will claims is part of the golden ticket out of poverty.

BoteachPovertyData-webfig1
Source: Center for American Progress

Even with those increased credentials and growing productivity, young people still can’t escape poverty because there are not enough good jobs. Unemployment and underemployment have been falling for years, yet the electorate gave a primal scream this past November, imploring policymakers to understand that their communities had been left behind. Take a look at the graph below: Even with unemployment falling, the share of families struggling to make ends meet remains high. Why? If you pay people poverty wages, workers will remain in poverty. Unfortunately, President Donald Trump and congressional Republicans’ solution is that if we simply take away people’s health care to pay for more millionaire tax cuts, that will help people find jobs faster!

BoteachPovertyData-webfig2
Source: Center for American Progress

And marriage? Two poor people getting married does not make anyone less poor. As my colleague Shawn Fremstad explains in his issue brief, Partnered But Poor, “the vast majority of people in low-income families with children are in families headed by married or unmarried partners, as are most people in families with children that receive means-tested benefits.”

Today’s young people are more educated than any previous generation

Moreover, this overemphasis on marriage can actually have detrimental effects and promote extremely dangerous practices when considering violence committed against individuals—usually women—within partnered relationships. Blindly promoting marriage over programs that support independent financial security—like jobs that pay a living wage or education that’s accessible for all—places even more pressure on survivors to stay in an abusive marriage or partnership.

We all want our children to get educated, work hard, and find partners who will treat them well (if they want partners). But George Will’s column conveniently forgets two things: At the macro level, in an off-kilter economy, where the gains from economic growth are concentrating among the wealthy few, all the hard work in the world isn’t going to change this basic economic reality: There are not enough good jobs for today’s young people, and this has implications for their marriage prospects as well.

At the micro level, life happens. People lose jobs. They get sick or have an accident that leaves them with a disability. They have babies in a country without paid leave or adequate child care, leaving families struggling to afford the basics for their kids. “The poor” aren’t some stagnant group that just needs to make better life choices. Seventy percent of Americans will turn to a means-tested benefit at some point during their working years, because Medicaid, nutrition, tax credits for working families—all the things at risk under this conservative Congress and president—are there for us if we fall on hard times. And most of us will.

Will’s column isn’t just wrong; it resurfaces a dangerous myth at a moment when the basic economic security of millions of struggling Americans is on the line.

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Safety Net

How the U.S. Can Prevent a Fire Like Grenfell Tower

At least 80 people are missing and presumed dead after a devastating fire in Grenfell Tower, a high-rise apartment building in London. It’s the deadliest fire in Britain in more than a century.

This fire is, unequivocally, a tragedy—particularly because it was so preventable. Investigators say the root causes were lax regulation and an unwillingness to invest in basic safety features. Residents had repeatedly warned that their living conditions were dangerous, pointing out that the building didn’t have fire alarms, sprinklers, or a fire escape, and there was only one stairway for people to get out and one road for firefighters to get in.

The fire has been a wake-up call for British politicians about a dangerous lack of investment in safe housing. Unfortunately, Britain is not the only country that has underinvested in safe homes.

A report by the Federal Healthy Homes Work Group found that more than 30 million homes in the United States are putting their occupants at risk. Six million homes have moderate to severe infrastructure problems, such as substandard heating, plumbing, and electrical wiring. Another 23 million homes have lead-based paint hazards, and 6.8 million homes have dangerously high levels of radon exposure. This means that millions of families face increased risk of lung cancer from radon exposure, fire-related injuries, and lead poisoning.

So far, the Trump administration has stymied efforts to address these problems. The administration’s proposed $6 billion in budget cuts to the Department of Housing and Urban Development (HUD) would severely curtail efforts to provide safe and affordable housing.

At least $300 million in cuts would come from rental assistance programs such as the housing choice vouchers program, which means that 250,000 people could lose access to housing vouchers. Landlords participating in the housing choice voucher program commit to extensive property maintenance and safety standards that other private landlords serving very low-income families are often not required to meet. When families who cannot pay their rent are evicted, they often move into homes with more health and safety hazards, which is why children who are evicted are twice as likely to be in poor health.

More than 30 million homes in the United States are putting their occupants at risk

The Trump administration’s budget also calls for direct cuts to the HUD public housing Capital Fund, the program that funds repairs to public housing. The budget would slash the fund by more than half, so that 212,000 fewer units would receive the repairs they need next year. It also means that local public housing authorities—which rely on this funding to address fire hazards before they become disasters and address health risks like mold, lead, and rodent infestations—could be short on their budgets.

Even indirect cuts, such as the proposed elimination of the Legal Services Corporation (LSC), will put more people at risk. LSC funds civil legal aid organizations that help low-income households bring lawsuits against landlords who refuse to deal with potentially deadly living conditions. After similar cuts to legal aid in Britain, residents of Grenfell Tower were unable to afford legal advice when they had concerns about their building’s safety.

We’re not doomed yet. Fire deaths have been dropping across the United States due to stronger building safety codes. Most states ban the usage of flammable aluminum cladding in tall buildings, which contributed to the Grenfell Tower fire.

Still, the Trump administration has promised to dramatically cut back on important safety regulations. Trump’s recent executive order that requires eliminating two regulations every time a new one is created forces agencies to choose which life-saving regulations they should prioritize to comply with the rule. Congress is now considering the Regulatory Accountability Act, which would add so many hurdles to the regulatory process that companies that produce dangerous products could delay regulations indefinitely. The Environmental Protection Agency faced similar roadblocks when it tried to ban asbestos—a known carcinogen—more than 25 years ago. Asbestos manufacturers used hurdles in the regulatory process to their advantage and blocked the agency from removing this toxic substance from commerce. Since 1999, at least 12,000 Americans have died every year because of asbestos exposure. Under the Trump administration, long-awaited asbestos regulations and many other critical protections may never be implemented.

In a chilling letter written just months before the building caught fire, residents of Grenfell Tower warned that “only a catastrophic event will expose the ineptitude and incompetence of our landlord, the KCTMO, and bring an end to the dangerous living conditions and neglect of health and safety legislation that they inflict upon their tenants and leaseholders.” Americans shouldn’t wait for a tragedy of this magnitude. Investing in the health and safety of low-income Americans begins with the funding decisions Congress will make this year.

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Culture

The Media Narrative Around Families Is Racist and Homophobic. It Needs to Stop.

Last week, David Brooks wrote an article about “Why Fathers Leave Their Children.” In a piece that largely focuses on the perceived moral failings of low-income families, where women are “bossy” and men are “disreputable,” Brooks lays out a plan for how to get Americans to live in “the stable two-parent family…we want.” This plan includes waiting to have sex, creating a couple’s budget, and “a few economic support programs and a confident social script.”

This goal—and the plan for how to get there—are bullshit.

Let’s talk about the goal first: a stable two-parent family. Brooks is feeding the narrative that there is an ideal kind of family—one that does best, one that is how people should be. It’s a family with two married parents. It’s a family in which people have children and mostly women raise them. It’s a family in which no one dies or is infertile or is incarcerated. It’s a family in which no one decides to stay single or childless or get divorced.

It is, in short, not reality. And making policy around this idealized vision of family has very real, often terrible consequences.

First, there is the emotional toll. When there is one ideal, people are crucified for falling short. They are blamed and marginalized. Their families are vilified and demonized. We have seen this with black single moms during welfare reform, gay parents during the same sex marriage movement, and now families with disabilities as policymakers seek to cut benefits. This helps no one.

Second, policies that focus on this idealized family, which account for less than one-fifth of American households, leave out the needs of tons of other families. We saw this last fall, when the Trump campaign floated a paid leave plan that only applied to birth mothers. The plan not only left out adoptive parents and male parents, it also ignored the needs of people caring for aging or disabled loved ones, sick children, their partners, or themselves.

Third, it can waste a ton of money. Jennifer Randles’s work reveals that though the nation has spent close to a billion dollars on programs that promote marriage over the last two decades, “couples who took government-funded relationship skills classes were neither more likely to marry or stay together nor to improve their financial situations.”

Fourth, policies aimed at keeping people married can trap people in dangerous relationships—even kill them. Perhaps the starkest example is the dramatic changes in women’s well-being after the passage of no-fault divorce. Research by Betsey Stevenson and Justin Wolfers shows that in states that passed no-fault divorce laws, suicide rates among wives decreased by 8 to 16 percent and domestic violence rates fell by 30 percent.

The policies he mentions would fall short of what any kind of family needs.

Even if we set Brooks’s dubious two-parents-a-dog-and-a-white-picket-fence goal aside, the policies he mentions would fall short of what any kind of family needs. His proposals to “help” families focus on changing individual choices without mentioning the systems that override them. Brooks fails to mention how America’s incarceration system is dividing families, particularly black families. He doesn’t address the fact that our nation’s immigration policies are literally ripping families apart. He does not discuss the importance of health care, good jobs, or reproductive care—all of which have been linked to strong and stable families. A few programs and a social script are not going to cut it.

Instead of this harmful, narrow vision of family, we should be looking for ways to value and support a whole range of healthy, stable families. Some are single parents. Some are couples without children. Some are brothers taking care of sisters, grandparents caring for children, extended chosen families. All of these families deserve support and appreciation.

When you have a broader vision of family, you can make the kind of policy choices that actually support everyone. And you can also make clear to all kinds of families that they are not less than or inadequate—and they deserve to have their needs met.

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