Thursday, August 31, 2023

Public Options


After I was taken from the subway station where I'd fallen down a flight of steps and broken my left femur to a well-known East Side hospital a couple of weeks ago (saga herehere, and here, I stayed in the intensive care unit while they were readying me for surgery and then got moved to an ordinary unit after the surgery was done, and was dismissed a couple of days after that, in what felt like a rush job. I had to coordinate my exit myself, via text, with various family members, and negotiate the wheelchair ride to outside with nurses who had mostly disappeared, get dressed (another nurse brought me a pair of sweat pants, my leg being much too swollen to fit in the jeans my son brought from home), and nobody seemed available to answer any questions about what the rest of my life was going to be like, or even the next few days. Then, as the kids and I waited for their mother to show up, the wheelchair-wallah got antsy—it was taking too long, and he was afraid of getting in trouble for keeping the wheelchair—with me sitting in it—too long. He suggested I should get out and stand there with my new walker, or maybe if I got too tired I could sit down on one of the 18-inch round stone objects with which the pavement was dotted, which I obviously couldn't.

So I ended up surrendering, and standing to wait for my ride to show up, which was maybe not so bad (not as bad as the horror of getting into and out of the car with the kids trying to swing the leg into position). I'll never know if the guy was reprimanded for bringing the chair back late, maybe even fired, for all I know, or if his anxiety was merely irrational, as it seemed.

It's a week since then, and the whole experience is taking on a different complexion in my memory, starting from that spot and working backwards (so that the apparently harmless events of the early part are seen to foreshadow the abandonment at the end), than it had at first, in a way that's maybe relevant to some ideas that have been floating around the Tubes in the last few days. 

Everybody I interacted most with—the nurses and physical therapists—was kind, competent, and respectful, but these relationships weren't very stable; few lasted longer than a shift, day or night. The others were still more fleeting, especially in the upper orders, social workers and doctors, of whom I never met one twice, never got a name or an offer to call, never got an effort to connect (except one of the anethesiologists, they always have a sense of humor), and at the top of the hierarchy groups of four or five from which no individuals emerged at all, except a chairman charged with the job of speaking for them, a "team", and where they mostly gave me the neurological test (name, birthdate, and "where are you?" "what year is it?"). I finally lost my temper with one of them: "What are you, tourists?" That chairman took it courteously, explained that they were the "Trauma Team", monitoring my case, and that they thought I was ready to leave. I apologized and thanked him, but I feel funny about it now.

Afterwards, I found that there was a lot of stuff I didn't know that I should have been told (almost certainly was told in many of the cases, I'm sure, but by teams rather than people). What was the prognosis? How long would it take? When would I hear from my home PT? When I talked to a firm, why didn't they call back? This was coming out actually worse than Frank had warned: instead of worrying about the contractual terms I was worried about whether I'd ever see one at all, getting no convincing clues on who to call. Finally, on a visit to the hospital's occupational therapy department last Friday (two-way trip in an accessible taxi, but the finger treatment is going really well), I dropped in on a "patient advocate" who made a couple of calls and hooked me up with a social worker called "Christian" who claimed to have spoken to me and explained that I had rejected a service offered to me, which I obviously hadn't meant to do—this was from a confusion between long-term Medicaid-paid home health aide, which I didn't want, and insurance-paid physical therapy, which I do. I'm still in the dark about what happened there, but Christian acknowledged that he isn't a social worker but a marketing agent, and asked me to sign up for Medicaid, and I'm getting the impression that he doesn't have anything corresponding to what I need and doesn't want to tell me. I'm really on my own, hoping to get some help from my own PCP, but I won't be able to see them until Tuesday.

Also, I got a request to fill out a questionnaire on my visit to "Dr. John Muller", who I'd never heard of. It turned out to be the finger clinic, but I'm still pretty sure I didn't meet that doctor there (the place was being run, excellently, by people with less exalted degrees). My old lady, using her Singapore-trained hostile interrogation technique after pinning down somebody who admitted to being an orthopedist and acquainted with my case, elicited two vital things: that it was fine for me to take the bandages off my leg, which was a joy to learn; and that the hospital, having discharged me, in particular the orthopedists who worked on the leg, had no further responsibility. At all.

This is an example of something you might call "cryptoprivatization". Bellevue Hospital, the first public hospital in the United States (an outgrowth of New York's first almshouse, founded in 1736, and developed into a medical institution during the yellow fever outbreaks of the 1790s), is also among the first safety-net hospitals, or places from which a patient is never turned away on financial or other grounds, and a place of extraordinary distinction in the history of medicine—old New Yorkers remember it chiefly for the dreadful lunatic asylum of the days of Nellie Bly (though the asylum the intrepid reporter checked herself into was on what's now Roosevelt Island), but it was also the site of the first maternity ward (1799), the creation of the world's first municipal sanitary code, in 1867, and a pioneer in the treatment of diseases from tuberculosis through AIDS to ebola. It's really not a public institution any more, though it's managed by a public benefit corporation, the NYC Health + Hospitals (founded 1970), but it's a 501(c)(3) charity

  • Defined as: Organizations for any of the following purposes: religious, educational, charitable, scientific, literary, testing for public safety, fostering national or international amateur sports competition (as long as it doesn’t provide athletic facilities or equipment), or the prevention of cruelty to children or animals.

that gets less than 1% of its revenues from government entities, and 88.3% (about $52 million) from the services it sells. (And spends 3% of its income on executive salaries


if you wanted to know.) 

But what interests me is how it's been privatized in style, in revising the mission of the modern hospital from that of caring for patients to that of processing them through the limited phase they are willing to handle in the broad project of healthcare consumption, before they farm you out to the next phase, at the hands of some other institution with which they may or may not maintain friendly ties. In a way it's the patients, rather than the care, that are the product. From the depersonalization the patient undergoes through all these alienation techniques (self-control for the higher orders and depersonalized scheduling for the lower ones, as if to make sure no nurse starts thinking of you as "my patient"—you're the team's patient) to the final abdication of responsibility when you become some other institution's burden or a freelance patient looking for another institution to take you on. I'm not complaining on my own behalf, even, as much as those, especially the uninsured, who have fewer resources.

The other day we were talking, in the Substack comments, about this compelling little essay from Josh Marshall on the concept of oligarchs, international non-state or quasi-state actors working out international agendas from their strange positions, in times of relatively weak state formation, from the private condottieri armies of the Italian Renaissance to the swarm of interested parties gathering around the Trump political movement. 

I first became interested in this topic years and years ago tied to the rise of private military contractors. But the issue came to the fore again for me during the Trump years in a different way. Behind the sprawling Russia investigation and Trump’s various other scandals and sub-scandals there seemed to me to be something more general happening. Between post-Soviet oligarchs, gulf princelings, American plutocrats and Israeli technologists, there was a trade in power and secrets that seemed to operate beyond and outside the formal relations between the various countries in question.

Marshall is writing mostly about Elon Musk in the US and Yevgeny Prigozhin in Russia, and their strange and nerve-wracking ways of pursuing what they suppose (often wrongly) are their interests, but I'm also interested in this concept of state weakness, the weakness of Russia, which Putin was able to keep concealed for a long time, and the weakness of the US in the Trump administration, which was extreme in spite of Trump's personal fascist predilections, just an open sore like Istanbul in the "Sick Man of Europe" stage of the late 19th century, at which these oligarchs came to feed like a crowd of carrion birds. Which is plainly not the way the Biden administration is going, though chaos agents like Musk and Zuckerberg are still an awful problem. The difference is that the Trump patriciate was openly for oligarchy and against governmental institutions other than police—Trump and his minions are oligarchs and chaos agents themselves.

I'm struck by the sense of an analogy between our healthcare system, especially as represented in the big hospitals and the pharmaceuticals industry, and all those private armies and unaccountable oligarchs, as another kind of non-state or quasi-state force creating its own institutionality. 

And then by a note from Robert Kuttner at American Prospect bringing these things (Musk and healthcare) together with the obvious solution, that government needs to be stronger, though necessarily from a democratic strength, with more "public options", as we used to call them in 2009, exercising institutional power.

Cross-posted at The Rectification of Names.

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