by John Geyman, M.D.

Having just finished reading Bob Herbert’s excellent book, Losing Our Way: An Intimate Portrait of a Troubled America, I am struck by the parallels between trends in public education and in health care. Herbert, opinion columnist for the New York Times for 18 years and now a Distinguished Senior Fellow at Demos, a public policy think tank in New York City, describes trends in recent years in public schools in this country.

Here are some of his findings of these pervasive trends, accelerated since the passage of George W. Bush’s No Child Left Behind law in 200l and continued after Obama’s Race to the Top initiative:

•  Deep budget cuts to traditional public schools; nationwide, more than a quarter million staffers and administrators, including 150,000 teachers were cut between 2010 and 2012 (1)
•  Increased emphasis on privatization, including charter and online schools
•  Dedication to required testing to evaluate student achievement as well as the performance of principals and teachers
•  Increasing numbers of principals and teachers being fired for not meeting testing goals,  especially in schools and school districts in lower socio-economic areas
•  Teaching to the test has become the norm, with widespread cheating involving teachers and administrators.
•  Increasing division along social-economic and racial lines between predominantly white charter schools and mostly black/minority public schools
•  Transfer of resources from public schools to for-profit charter and online schools
•  Almost two-thirds of the nation’s school districts were providing fewer dollars per student in 2012 than they had in 2008.
•  More than 100 school districts, many in rural areas, cut the school week to four days, with almost one-half of school districts in California cutting back on art, drama, and music programs.
•  Continued attacks from the right on teachers, their unions, and the problems of public education while promoting private alternatives
•  Despite the policies of No Child Left Behind and the Race to the top, the U.S continues to fall behind in international student rankings.(2)

I am nearing completion of my next book, How Obamacare Is Unsustainable: Why We Need a Single-Payer Solution for All Americans, due out in January 2015. It will be a five-year evidence-based assessment of the Affordable Care Act (ACA). To be fair, the ACA does bring about some improvements, such as providing for children to stay on their parents’ health insurance until age 26, prohibiting exclusions based on pre-existing conditions, establishing government-sponsored exchanges to allow the uninsured to shop for coverage, and expanding Medicaid (at least in those states that agree to expansion). Almost 8 million people have gained coverage on the exchanges (though only 57 percent of them were previously uninsured) and about 7 million people have new Medicaid coverage. Despite these gains, however, there is a long list of problems that won’t be solved by further implementation of the ACA, including these:

•  Access to care is still very limited for many millions of Americans, even if “insured”, and at best, there will still be 31 million uninsured in 2019.
•  Costs of care continue to soar, especially as hospital systems expand and consolidate, thereby gaining increased market shares in their areas.
• There are no price controls throughout a largely private, for-profit delivery system.
•  Private insurers are still in charge, gaming the system in new ways, such as establishing narrow networks of physicians and hospitals and marketing plans of low actuarial value.
•  Many insurance policies now have annual deductibles more than $5,000 for individuals and $10,000 for families, forcing many people to forego necessary care because of cost.
•  New pay-for-performance (P4P) initiatives have not improved quality of care, and there is widespread gaming of the reimbursement system to increase payments to physicians and hospitals.
•  Cross-national studies of access, efficacy, quality and equity of care in the U.S. continue to be near the bottom by most measures in comparison with 10 other industrialized countries.(3)
•  Patients have decreased choice of health care provider and hospital, as well as less continuity of care.
•  Morale among physicians and other health care professionals is declining under the burden of increased administrative bureaucracy.
•  Tiering of health care is increasing by ability to pay, not by medical need.(4)

These big changes in public education and health care in the U.S. over recent years have much in common. These are some of the parallels that raise serious concerns about where to go in the future:

•  We are seeing erosion of access and quality in public education and health care, that will place many middle class and lower income Americans at a disadvantage, especially as income gaps continue to widen in our society. Legislation has been driven by corporate and private interests, leading to increasing privatization in both of these fields.
•  The power of money in politics, bolstered by the Citizens United decision of the U.S. Supreme Court and the lack of campaign financing reform, has led to these predictable outcomes.
•   Federal and state policies in public education and health care have both been driven by unproven or even discredited premises, such as—in education that “private must be better” and that “public school teachers are the problem,” and in health care that “private is more efficient,” and that “patients are the cause of increasing costs through overutilization” (moral hazard).

As a result of these policies in recent years, new norms have become established that do not work in the public interest. In public education, teaching to the test has become the rule, with firings of teachers and principals who do not meet arbitrary performance goals, ignoring the fact that socio-economic factors, such as poverty, play a big role in test results. The same holds true in health care, with physicians serving lower socio-economic groups having worse patient outcomes than those practicing in more affluent communities. Quality of teaching, as with quality of health care, worsen in such areas, despite the best efforts of dedicated teachers and health professionals. Instead of being rewarded for such service, they are punished  by misguided approaches intended to gain “efficiency,”  “cost containment,” and “improved quality,” but instead bring new profits to private interests at the expense of the public good.

Bob Herbert brings us this helpful insight about where we now find ourselves:

America’s increasingly stratified education, civic, and social
hierarchies will have to be modified. The great imperative of our time
is to imagine what that newer, fairer version of America would be
like and then to begin the very difficult work of creating it.”(5)

1,166 words

1. U.S. Bureau of Labor Statistics, Occupational Employment Statistics Surveys, 2010-2012.
2. Herbert, B. Losing Our Way: An Intimate Portrait of a Troubled America. New York. Doubleday, 2014, pp. 124-145.
3. Davis, K, Stremikis, K, Squires, D et al. Mirror, Mirror on the Wall: 2014 Update: How the U.S. Health Care System Compares Internationally. The Commonwealth Fund, June 16, 2014.
4. Geyman, JP. How Obamacare Is Unsustainable: Why We Need a Single-Payer Solution for All Americans.Friday Harbor, WA. Copernicus Healthcare, 2015.
5. Ibid # 2, p. 248.