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Frank LaMere: A good man’s work is never done
Frank LaMere: A good man’s work is never done
©by Leo Adam Biga
Originally appeared in The Reader (www.thereader.com)
Frank LaMere, self-described as “one of the architects of the effort to shutdown Whiteclay,” does not gloat over recent rulings to deny beer sellers licenses in that forlorn Nebraska hamlet.
A handful of store owners, along with producers and suppliers, have profited millions at the expense of Oglala-Lakota from South Dakota’s nearby Pine Ridge Reservation, where alcohol is banned but alcoholism runs rampant. A disproportionate number of children suffer from Fetal Alcohol Syndrome (FAS). Public drunkenness, panhandling, brawls and accidents, along with illicit services in exchange for alcohol, have been documented in and around Whiteclay. Since first seeing for himself in 1997 “the devastation” there, LaMere’s led the epic fight to end alcohol sales in the unincorporated Sheridan County border town.
“This is a man who, more than anyone else, is the face of Whiteclay,” said Lincoln-based journalist-author-educator Joe Starita, who’s student-led reporting project — http://www.woundsofwhiteclay.com — recently won the Robert F. Kennedy Human Rights Journalism grand prize besting projects from New Yorker, National Geographic and HBO. “There is nobody who has fought longer and fought harder and appeared at more rallies and given more speeches and wept more tears in public over Whiteclay than Frank LaMere, period.”
LaMere, a native Winnebago, lifelong activist and veteran Nebraska Democratic Party official, knows the battle, decided for now pending appeal, continues. The case is expected to eventually land in the Nebraska Supreme Court. Being the political animal and spiritual man he is, he sees the Whiteclay morass from a long view perspective. As a frontline warrior, he also has the advantage of intimately knowing what adversaries and obstacles may appear.
His actions have gotten much press. He’s a key figure in two documentaries about Whiteclay, But his social justice work extends far beyond this specific matter.
“I’ve been involved in many issues in my life,” he said.
Indeed, he’s stood with farmers, immigrants, persons with disabilities, police misconduct victims, child welfare recipients. He’s opposed the Keystone XL Pipeline.
“I must have marched a hundred times in my life and not always on Native interests. If somebody’s being mistreated and I have time and they come ask me, I don’t care who it is, I’m going to go there. That’s what it’s all about. That’s what drives me in my work.”
LaMere’s fought the good fight over Whiteclay, where he sees a clear and present danger of public health and humanitarian crisis. As a Native person, it’s personal because Whiteclay exists to exploit alcohol intolerance among the Pine Ridge populace. He’s cautiously optimistic things will get better for residents, assuming the courts ultimately uphold the denial of the liquor licenses.
“We’ll see where things go from there,” he said, “but rest assured, things will never be the same at Whiteclay. The only thing I know is that the devastation will never be like it was. I truly believe that.”
Just don’t expect him to do a victory lap.
“There are no wins and losses at Whiteclay. Nobody won, nobody lost, but all of us decided maybe we should begin to respect one another and find a better way. I think we will after the dust settles.”
The state Liquor Control Commission, a district judge and the Nebraska attorney general oppose beer sales happening there again but LaMere knows powerful opposing forces are at work.
“I think Nebraskans have good sense. We know what’s right. But there’s money involved. Whoever controls alcohol at Pine Ridge-Whiteclay controls money, controls county government and until very recently even controls state government. I am unequivocal on that. I understand what’s going on here. You’re talking about tens of millions of dollars and we’re threatening that, and when you threaten that, you know, you get a reaction.”
He said he’s received threats. He and fellow Whiteclay advocate, Craig Brewer, went there the day after the sellers lost their licenses.
“There was a foreboding I had all that day I’ve never had in my life,” LaMere said. “It was strange to me. I’ve been dealing with things my whole life and never been afraid. But this time I was looking at different scenarios having to do with the volatility there and if things didn’t work right what could happen to me. Maybe it’s aging. Maybe it was the newness of the situation. I don’t know.
“We got up there very apprehensive about what we were going to encounter, maybe from the beer sellers or from those who support the sellers or maybe from their hired associates. We didn’t know what to expect, but we went up there because that’s what we do – and everything worked out. The right thing happened.”
The sellers did not open for business.
“I told a reporter we went up to look the devil in the eye and the devil wasn’t there, and I don’t think the devil’s coming back.”
He said attorney David Domina, who represents the interests opposed to alcohol, appeared the same day there in the event something amiss happened.
“It was no coincidence,” LaMere said. “We were to be there that day. A lot of prayers went with us.”
LaMere will maintain a wary watch. “I will continue there to be careful, to be apprehensive, but I’m still not afraid.”
He knows some contentious situations he steps into pose certain dangers.
“I’m a realist, I know how things are.”
He and his wife Cynthia made an unwritten pact years ago not to be at rallies or protests together to ensure they won’t both be in harm’s way.
“I do a lot of things in a lot of places and Cynthia grounds me. She critiques whatever approach I’m taking, always asking, ‘Do you have to do it?’ I’ve learned she’s protective of me. But I also hear from her on many of these issues, ‘Well, why didn’t you say that?’ because she knows Frank, what he’s committed to, and she never questions that.
“I can do something I feel good about and I’ll come home and she’ll tell me the downside that maybe I don’t always want to hear. She’ll give me a perspective I need to hear that sometimes other people won’t give me. She’ll tell me the brutal honest truth. Cynthia’s tough, engaged, committed.”
His admirers marvel at his own doggedness.
“He’s an indefatigable worker and once he latches onto an issue that he sees as a moral challenge, he does not let go, and Whiteclay is a case in point. He’s the most principled man I know,” said Nebraskans for Peace coordinator Tim Rinne.
Joe Starita said LaMere is “hard working for his causes to the point of physical and mental exhaustion.”
“He’s a man who shows up for allies when nobody else is looking,” Nebraska Democratic Party chairman Jane Kleeb said.
Setbacks and losses he’s endured have not deterred him, including a serious stroke that required extensive speech therapy, and the death of his daughter, Lexie Wakan, who was a Creighton University student.
“He’s a man who’s had hardship, yet still continues to get up and stand up,” Kleeb said. “For me, that’s what Frank’s all about – he always shows up.”
For LaMere, it’s a way of life.
“Every day’s a fight, and if you keep fighting you win because others watch that. The impact of Whiteclay will manifest itself hopefully with a win in the Supreme Court and perhaps in some young leader who cares about these things. I’ve been in a hundred struggles in my life, lost almost all of ’em, but I was never afraid, and that’s what I want people to understand.
“If you’re not afraid, people see that as a victory because you cause others to take heart, to persevere, to take action.”
He’s glad his resilience to keep agitating, even in the face of intransigence and tragedy, inspires others.
“I’ll accept that because that’s what it is – you just keep working.”
He likes to say Whiteclay’s implications are “bigger than we can ever fathom.”
“Years from now, we will understand it is way bigger than us. I got to be a bit player. The creator of all things, said, Frank, I’m going to have you see what you can do, and along the way I’m going to cause you to struggle. I’m going to knock you down, and I’m even going to take something from you, and if you keep going, maybe I’ll let you change something.
“That’s the greatest work we can do.”
Reflecting on Whiteclay, he said, “This was an emotional roller coaster for all Nebraskans.” He chalks up the recent breakthrough to divine intervention.
“There’s things happening that are so strange,” he said.
He recalled a hearing in Lincoln on LB 407 introduced by Neb. State Sen. Patty Pansing Brooks to create the Whiteclay Public Health Emergency Task Force. LaMere testified. His son, Manape LaMear, sang a sun dance song. After finishing his sacred song, Manape asked if someone from Sheridan County was there to speak.
“A big guy got up and testified,” said LaMere. “He was asked, ‘Do you have enough law enforcement to take care of Whiteclay?’ and he answered, ‘Absolutely not.’”
“This man said some things absolutely nobody expected him, maybe not himself. to say. If you’re with those (monied) interests of Whiteclay, you’re not supposed to say that, you’re going to be ostracized. But for whatever reason, he told the truth. I attribute that to the powerful prayers said that day.
“You’re watching at Whiteclay a very spiritual journey. There’s something much bigger than us that has brought us to this point – that we would make such a great change for the Oglala Lakota people. I think it’s God’s work. From that I hope things will be better.”
He’s convinced “the greatest impact will not be felt for generations,” but added, “I’ve seen immediate impact right now.”
“I believe there’s a child whose mother and father were together at home and did not drink. I believe children are feeling very good Whiteclay is not open. I believe there’s been prayers by children that their parents be sober. I believe their prayers are very powerful. I think what we’re seeing may have to do with these children and their suffering and their prayers.”
LaMere has disdain for arguments that banning alcohol at Whiteclay will only move the problem elsewhere, thus increasing the danger of drunk drivers.
“Worrying about someone driving down Highway 87 who might get hurt by a drunk driver can’t be our greatest concern. Our greatest concern has to be the health and well-being of hundreds of children crippled in the womb by fetal alcohol syndrome (FAS). I’ve called out many on this. Where are pro-life people? Where’s the church? Children are crippled in the womb tonight and nothing’s said about it because there’s money involved. That’s troubling to me.
“We’ve crippled hundreds of kids in the womb on Pine Ridge – all so somebody can get rich, wrap themselves in a flag, and talk about this model of free enterprise. We cherish that more than we cherish life. It’s ugly to hear that but that’s what we’ve done. But we’ve always been afraid to accept that.”
Attorney John Maisch, whose documentary Sober Indian, Dangerous Indian includes LaMere, said, “I would say Frank’s empathy is what drives him. Frank is in a perpetual state of mourning. Frank has lost many family members and friends to addiction. I think that is partially what drove him to tackle Whiteclay. Frank lost his daughter, Lexie, and I think that is why he’s particularly drawn to fighting for those children, whether Native children lost in our foster care system or suffering from FAS as a result of their mothers drinking on the streets of Whiteclay. He’s drawn to suffering of others because he has also suffered great loss.”
LaMere acknowledged he’s “redoubled” his efforts since losing his daughter.
“And it’s not in any way substitution,” he said. “I don’t see it that way. I look at it very simply that now I stand on the shoulders of my daughter. In all of the things I’m doing right now perhaps I’m as bold as ever, and there’s a reason for that, for that is what she would have me do. If I hedge, she’ll say, ‘Why are you doing that? That is not who you are.’ I even heard her say in her young life: ‘This is my father, this is who he is, and this is what he does, and he does this for the people.’
“All I do for the rest of my life will be done in remembrance of my daughter because she was so committed at a very young age to the things I’m still committed to.”
LaMere’s glad Nebraska may finally own up to its sins.
“At long last Nebraskans have said perhaps it’s time for us to look at this. For once I’m pleased Nebraskans are not going to merely beg the question, they’re going to look at the impact of Whiteclay and maybe we’re going to act and make some of it a little bit better.”
As LaMere sees it, the whole state’s culpable.
“We as Nebraskans are unwittingly, unknowingly responsible for it. We need to act and to mitigate some of those things we’ve helped to cause at Pine Ridge. Even after all this, I say Nebraskans are fair – fair to a fault. Sometimes it takes us so damn long to act.”
The real culprits, he said, are “those in Sheridan County” who’ve turned a blind eye.
“The beer sellers and the rest are going to have hell to pay, not from Frank LaMere, but from the Supreme Court, the Liquor Control Commission, the attorney general, all these other interests, because when they take a good, long hard look at what’s happened, there there’s no way you can reconcile that as being anything close to normal or acceptable.”
As watchdog and conscience, LaMere said he lives out a covenant he made with his creator to serve others.
“I’ve traveled a million miles, spent everything I have, taken time from my family, taken time from myself. At some point, there’s a moral authority you feel. Nobody can give it to you or bestow it on you. Once you acquire it, it means nothing unless there’s a moral imperative that goes with that. I’ve tried to achieve some moral authority and the moral imperative that goes with it.
“I hear every day in my work with different agencies the words ‘by the authority invested in me.’ Means absolutely nothing to me. Doesn’t impress me at all. I don’t care how much authority you have – if you do not use it and if there’s no moral imperative to make things better, it’s meaningless. I meet with those people all the time. They have the authority, but they don’t use it. I’m not being cynical. I have the truth on my side.”
Whiteclay offered duly elected and appointed officials decades of opportunities to act, but they didn’t. LaMere never left the issue or let authorities forget it.
“Sometimes I can go into a room with a hundred people and I have the least amount of authority-power-title, but they have to listen to Frank because he’s put time and energy into it and he’s acquired that moral authority and he uses it. He scares them. They wish he would go away. People have to listen to Frank because he never goes away and there’s nothing in it for him.
“That’s why we made some changes at Whiteclay and that’s how we’re going to make change in our society – gain that moral authority and act.”
LaMere said his greatest asset is the truth.
“Any issues of change, even Whiteclay, you stand with the truth. I’ve learned that over many years. Because once the press conferences, the conventions, the rallies are done, the arrests are made, the petition drives are over, the legislative efforts go by the wayside, the only thing that’s left is the truth. It’s very important you stand with the truth and be recognized having stood with it.
“That’s the only thing that keeps me going. I’m firm, forthright and respectful and always telling the truth. Of late, it has worked in some respects for me.”
If Whiteclay confirmed anything, he said, it’s that “nothing changes unless someone’s made to feel uncomfortable and you have to make yourself uncomfortable.” In dealing with Whiteclay, he said, he expressed his “healthy disrespect for authority.”
“Maybe it’s a character flaw,” he said, “but you can put me in a room with a hundred people and if there’s a bully, before the night’s over I’ll probably butt heads with him.”
As a young man he was active “on the periphery” of the American Indian Movement. Later in life he got close to AIM legends Russell Means and Vernon Bellacourt. The men became allies in many fights.
“I saw Native people and non-Native people be bullied simply because somebody felt they had a position of power over them and whenever I see that I naturally react to that. I don’t care what the issue is, I’ll ask, ‘Who do you think you are? Why are you doing that? Why are you treating him or her that way?’ I’ve said that. I’ve always grown up with that feeling that if somebody is being mistreated, I will always speak up for them.”
Whiteclay offered a microcosm of predatory behavior.
“When I first went to Whiteclay 20 years ago, I took one look and you could see the Natives who went there did not have a voice and were not held in high regard. The owners and residents paid little attention to them. The other thing I saw there was the lawlessness and the mistreatment of vulnerable people being taken advantage of. I saw it and so could everybody else. Then I saw how nobody acted, so I thought perhaps I should give some voice to them.”
The still unsolved murders there of Little John Means, Ronald Hard Heart and Wilson Black Elk weighed on him. The alcohol-related illness and death of others haunted him.
“The alcohol coming out of Whiteclay has killed scores of Lakotas and we’re still waiting for that one white man or white woman, God forbid, who dies on the road between Rushville and Whiteclay.’
The documentary The Battle for Whiteclay shows LaMere at a hearing railing against “the double standard” that overlooks Native deaths.
“It means we feel there’s two classes of citizens here in this state. Would we allow the things in Whiteclay in western Omaha or southeast Lincoln? I don’t think so. Scores of our people … victimized, orphaned, many of our people murdered. God forbid that one young white woman, one white man, die at Whiteclay tonight. We’d shut the damn thing down in the morning, and the pathetic thing about that is we all know that’s the truth.”
LaMere feels that double-standard still exists.
“We want everything at Whiteclay to be just right, but we cannot even take care of the clear and simple. There’s one thing you know you can do under the law – you can shut them down, and they’ve done that, and they’re having problems keeping them shut.”
He refuses to be patronized because he’s learned from experience that playing the game doesn’t get results.
“You’ll pat me on the head and say, Frank, you’re a great guy, I appreciate what you’re bringing to us, but I know in the back of your mind you don’t want to change anything. You’ll even give me a permit to march or picket. But I bet you won’t do that for 20 years. You can handle a year and then say – this damn guy never goes away, perhaps we should sit and listen to him.”
LaMere regrets the one time he took things for granted.
“I made a mistake many years ago. I raised the issue of Whiteclay. We got a lot initiated with then-Gov. (Ben) Nelson. He put together groups of officials from Sheridan County, Pine Ridge, state agencies, and we talked about the lawlessness issues up there. So we got something in the works a long time ago and I appreciated that process. I made the mistake though of thinking it’s a no-brainer. I thought all I have to do is bring this back to Lincoln and Nebraskans will change it.
“I was too hopeful. Many Nebraskans would change it but those in power did not. Where there’s money involved, nothing is a no-brainer. People are going to weigh the money and the impact. Those with influence and monied interests are probably going to win out. That’s what I watched. Whiteclay is perhaps the poster child for greed, not in Neb. but maybe in the whole nation. It ranks up there with Flint (Mich.).”
For too long, he said, the attitude about Whiteclay was, “We know what we’re doing but it’s going to cost us money, it’s going to cost me to do my job in the public trust. Just leave it the way it is.” Because the problem was allowed to persist, he said, “Whiteclay will go down in our history as something we tolerated and that we will forever be ashamed of, and we’re only going to understand that when the Supreme Court makes that final decision to shut ’em down. Then we’re going to take a look at what we’ve truly done.”
Meanwhile, LaMere won’t rest easy. When well-meaning people offer condolences about Lexie and lament her unfulfilled promise, he said he accepts their sympathy but corrects them, saying, “There’s no unfulfilled promise – it’s more for you to do, it’s more for me to do.
“That’s how it is. That keeps me going. That’s the way I’ll be until I’m not here anymore.”
Read more of Leo Adam Biga’s work at leoadambiga.com.
Who’s Going to Pay? Before and After the Affordable Care Act
There’s nothing like getting current, though it’s hard to do when you write for a monthly. Still, in this cover story I wrote for the March 2017 issue of The Reader (http://www.thereader.com) I think I mostly managed to stay relevant to the topic of health care coverage in America, the forces pushing and pulling for and against the Affordable Care Act and what the ACA has meant in terms of gains and what its repeal and replacement would mean in losses. For the piece I spoke to local professionals on the provider and insurer sides of the equation for their take on how we got here and where we might be heading. The story went to press with us knowing Congress was working to repeal and replace Obamacare, though no one knew what that entailed, and then just about the time our story got published that plan was unveiled. As you know by now, the proposed new plan was met with disdain from all quarters, especially consumer rights groups and elected officials, even conservative Republicans, who heard loud and clear from constituents that they they oppose the called for cuts that would cause many people to lose insurance. As the push back continues, town halls and debates ensue, and presumably negotiations, revisions and compromises will get made. Meanwhile, America still can’t get its health care system to work equitably and efficiently.
Who’s Going to Pay? Before & After the Affordable Care Act
©by Leo Adam Biga
Appeared in the March 2017 issue of The Reader ((http://www.thereader.com)
Families stood to lose almost everything in medical bankruptcies when health insurance companies rejected those with pre-existing conditions and capped their policies with lifetime limits.
Uncovered costs helped health care expenditures soar, more than tripling in the last 20 years according to the federal National Health Spending Report. In 2015, the federal government was the largest payer of health care, covering 37% of the total cost through its two programs Medicaid and Medicare.
The curve was starting to bend.
According to the Kaiser Family Foundation, health insurance costs increased 63% from 2001 to 2006 and 31% from 2006 to 2011. That number dropped to 20% from 2011 to 2016.
Part of the reason was the Affordable Care Act and a landmark shift in how health care was being offered. Through a series of tax increases targeting high-income earners, the ACA was able to fund experiments in in- novation while subsidizing the cost of bringing almost 30 million Americans into the health insurance system.
With the end of Obamacare at the top of the national conversation, The Reader talked to the major stakeholders about life before and potentially after the Affordable Care Act.
It’s not just the $2 billion in federal revenues Nebraska passed up for health insurance, or the 275,000 Nebraskans with pre-existing conditions that could be denied health insurance, according to the Kaiser Family Foundation. It’s not even the estimated 165,000 Nebraskans that would lose health insurance, an increase of 111% of the uninsured, according to the Economic Policy Institute, leading to almost 3,000 jobs lost and $400 million in federal health care dollars gone that we subsidize.
It’s also about the way we take care of each other.
America treating healthcare as a commodity helps explain its high delivery and coverage expense. Characterized by historic lack of incentives to drive prices down, providers and insurers dictate terms to consumers. Subsidies to assist low income patients who can’t pay out of pocket get passed along to other consumers. But affording care and its coverage is a burden even for the middle classes.
Amid runaway costs and coverage gaps, America’s clunkily moving from a volume to a value-based system as part of long overdue healthcare reform. The Affordable Care Act was passed in 2010 after contentious bipartisan debate. The statute’s full roll-out began in 2014.
Nebraska Medicine CEO Daniel DeBehnke said, “The tipping point that brought the ACA forward is really the unsustainable growth in our country’s healthcare costs.”
The calculus of people not being able to afford care translates into real life implications. Untreated chronic diseases worsen without treatment. Early diagnoses are missed absent annual physicals or wellness checks.
Championed by President Barack Obama, who promised reform in his campaign, the ACA’s enacted consumer protections and mea- sures holding providers account- able for delivering value.
Nebraska Methodist Health System CFO Jeff Francis said organizations like his have “con- tracts and monies at risk for hit- ting certain quality items, not just with Medicare, but with some of our commercial insurers as well, Five or ten years from now,” he added, “we’ll probably have more at risk financially from a quality and outcome standpoint. Recent federal legislation changed the way physicians get paid by CMS (Centers for Medicare and Medicaid Services). Starting in 2019 they’re having potential penalties depending on whether they’re hitting certain quality metrics or not.”
He said the stick of such punitive measures works.
A new Standard in American Health Care
Aspects of Obamacare, such as the individual mandate and public health exchanges, have detractors. Federal lawsuits challenging it have failed. But its intact survival is in jeopardy today. A chief critic is President Donald Trump, who with the Republican controlled Congress vowed to repeal and replace, though that’s proving more daunting in reality than rhetoric. On February 16, GOP leaders shared a replacement plan with tax credits for buy- ing insurance and incentives for opening healthcare savings accounts, but no details for funding the plan or its projected impact on the insured and uninsured.
Debehnke said, “I don’t think there’s any question, regardless of where you land politically, there are components of the current ACA that require tweaking. Even Democrats will tell you it wasn’t exactly perfect – nobody said it was going to be perfect. It was understood there were going to need to be changes as things move along.”
There’s widespread consensus about the benefits accruing from the ACA. New subsidies allowed millions more people nationwide and tens of thousands more in Nebraska to be insured, in some cases getting care they deferred or delayed. Insurers cannot deny coverage for pre- existing conditions or cancel coverage when someone gets sick. Plans must cover essential care and wellness visits. Adult children can remain on their parents’ insurance until age 26.
Francis said, “A lot of good things have come out of this. We’re focusing on well- ness, we have fewer uninsured, we’re having better outcomes for patients. I think there’s satisfaction with the improvements. I just think there’s disagreement with how it’s occurring or being done.”
“You can’t believe the difference it’s made by setting minimum standards for health insurance,” said One World Community Health Chief Medical Officer Kristine McVea, “so that things like child immunizations and mammograms are covered.”
Since the ACA’s adoption, uninsured 18-to 24-year-olds in Nebraska dropped from 25.5 percent in 2009 to 12.4 percent in 2015, according to the Kids Count in Nebraska Report.
McVea said, “At One World people get assistance in enrolling for health insurance. Counselors guide them through the market- place. People are really becoming more savvy shoppers. Improved health literacy has been a result of this process, you can really compare for the very first time apples to apples in terms of different plans. That has been a tremendous boon to clients.”
Not everyone included – Nebraska drops the Kick- back
Healthcare disparities still exist though. In Omaha 24% of adults living below the poverty line
lack health coverage while 3% of adults with medium to high in- come are uninsured. Some 36% of Hispanic adults, 15% of black adults and 5% of white adults are uninsured in the metro, ac- cording to numbers reported by The landscape, a project of the Omaha Community Foundation.
McVea said, “The poorest of the poor are not eligible for the marketplace at all because that part of the Affordable Care Act carved them out thinking states would cover them with Medicaid. Well, Nebraska’s elected not to expand Medicaid, so there’s this whole gap of people not insured. Then there’s prob- ably another tier who do get assistance through the marketplace, but considering the economic pressures they’re under, even with the assistance, it still falls outside their reach to get good healthcare.”
The Kids Count Report found 64 percent of uninsured Nebraska children are low-in- come — likely eligible for but not enrolled in Medicaid or Children’s Health Insurance program (CHIP).
Past Nebraska Medical Association president Rowen Zettermen said, “In Nebraska we have somewhere in the neighborhood of 60,000 to 90,000 uninsured people that would have otherwise been eligible for Medicaid expansion. you find the highest percentage uninsured rates in rural counties. We still have 20 some million uninsured in this country. A number may have insurance but they’re underinsured for their various conditions. Ideally, everybody should be able to establish a healthcare proposition with their physician, nurse practitioner or physician’s assistant to access care whenever they need it.”
Then there are federal DSH monies to fund Medicaid expansion the state foregoes because the legislature’s voted against expansion. Gov. Pete Ricketts opposes it
as well. Disproportionate Share Hospital payments are subsidies paid by the federal government to hospitals serving a high percentage of uninsured patients. Nebraska hospitals write off uncompensated care cost while getting no money back for it.
Zetterman said, “We could expand Medic- aid and take advantage of the roughly $2 to $2.5 billion that’s failed to come into the state. It would have paid salaries for more people in physicians offices and a variety of things that would be taxed and bring in more revenue.”
DeBehnke of Nebraska Medicine said, “Being a large hospital health system that takes all comers, we have a Medicaid percentage of our business. We would be better off in a Medicaid expanded state. We would like to see more coverage for the working poor. That’s what Medicaid expansion is – providing coverage to the working poor. Those who don’t currently qualify for it would under an expansion.”
Proposed federal community block grants could expand coverage. DeBehnke cautioned, “We just have to be sure there’s good control around how those dollars are used and they actually go for healthcare coverage. Expanding coverage to all people is really the key.”
Nebraska State Senator Adam Morfield is the sponsor of lB 441, which would expand Medicaid in Nebraska. The bill is scheduled for a March 8 Health and Human Services Committee hearing.
The care-coverage-income gap may be more widespread than thought. Kids Count Report findings estimate 18.5 percent of Nebraskans are one emergency away from financial crisis.
Preventative Care is Long-Term Savings
Having coverage when you need it is a relief. Insurance also motivates people to get check-ups that can catch things before they turn crisis.
“A woman having symptoms for some time didn’t have any insurance and she waited
before she sought care,” McVea said. “By the time she came to us for diagnosis she already had a fairly advanced stage of colon cancer. She’s undergone chemo- therapy and surgery and is now living with a colostomy. That didn’t have to happen. We see things like that every day – people who’ve let their diabetes and other things go to where they have coronary artery dis- ease, and that’s not reversible. We’re trying to get them back to the path of health with treatments, but they’ve lost that opportunity to maintain a high quality of health.”
Zetterman said, “There’s good data to show patients with cancer who don’t have insurance tend to arrive with more advanced disease at the time of initial discovery because they come late to seek care.”
That pent-up need is expressed more often, McVea said, as “people have insurance for the first time or for the first time in a long time.”
“We’ve seen a lot of people come in as new patients saying, ‘I know I should have come in a long time ago, and I’ve just been putting it off.’ Many are middle-aged. They’ve been putting off chronic health conditions or screening tests or other things for years. We see people come in with diabetes or high blood pressure that’s out of control and within three months we get them to a point where everything’s in control, they’re feeling better, they have more energy, they’re feeling good about their health. We’ve maybe given them advice about diet and exercise and ways they can keep themselves healthy.”
More positive outcomes are prevalent across the healthcare spectrum.
“I would say overall the average patient is having a better experience and outcome now than they were five years ago,” Nebraska Methodist’s Jeff Francis said.
One World’s CEO, Andrea Skolkin, said, “We’ve been able to reach more people living on limited income so our services have been able to expand both in terms
of numbers of patients we care for as well as types of services and locations.” One World opened two new satellite clinics with help from ACA generated monies. “As we’ve opened new clinics we’ve seen a number of people that had never been seen or delayed being seen with very complex
medical and sometimes mental health issues – and it’s more costly. We grew from about nine or ten percent of patients with insurance to close to 15 per- cent. For newly insured patients it’s meant some peace of mind.”
Fewer insured people, Higher Costs
She and her community health center peers favor more afford- able coverage to increase the numbers of those insured.
Zetterman said high premiums and co-pays present obstacles that would be lessened if everybody got covered. “The financial burden on the individual patient and family for health- care right now is too high.”
DeBehnke said, “A lot of the
burdens of those premiums in terms of high deductibles and other things have been shifted to families. There has to be some degree of subsidization if we’re going to make this all work. Regardless of where we land with this, the financial burden on the individual patient and family for health- care right now is too high.”
For the poor, the last resort for care continues to be the ER.
“If you’re uninsured the one place you can go in this country is to the emergency room of a hospital because the laws say you cannot turn anyone away from there,” said Zetterman. “As a consequence the uninsured make use of the ER because it guarantees they’ll get cared for – at least at that moment. The ER is the most expensive place to go for things that could otherwise be handled in a healthcare office.”
Zetterman said America’s handling of its social contract and safety net means “we cost shift in the healthcare environment to pay for things.” “In Nebraska, where we didn’t expand Medicaid,” he said, “we cost shift from private insurance and healthcare providers to people who have private insurance. They help pay for the uninsured-underinsured. We’ve estimated that to be well over a billion dollars. We can’t control costs reliably until everybody is in the system with some kind of a paid healthcare benefit. That can include all the current federal and state programs as well as commercial insurance that’s out there.
“Once we no longer cost shift to pay for healthcare we can begin to address the questions where are we spending our money and why are we spending it in those areas. Then we have a chance to control the growth of healthcare costs.”
Skolkin said, “A lot of hands in the pot helps add to the cost. There’s a lot of system inefficiencies, particularly in billing and credentialing, that could be made a lot of easier. That would save resources.”
DeBhenke said, “As the healthcare industry, we have not been engaged to the degree we need to be to actually decrease overall cost of care because frankly from a pure financial standpoint it’s not been in our best interest. The health systems, providers and other organizations have to really get be- hind this whole idea of providing value, of decreasing overall total cost of care while improving outcomes for patients. That’s got to work in parallel with legislative and subsidization levels at the federal level.”
He said until there’s more buy-in from “young invincibles” – 20-somethings in good health – to broaden or balance the risk pool and thus reduce payouts, costs will be a problem.
“Certainly the pricing needs to be attractive to those individuals to broaden the pool. And frankly the benefits associated with products on the exchange need to be attractive so those individuals feel comfort- able and actually want to have coverage. Those least likely to go to the marketplace and buy individual health insurance plans are exactly the people we want to do that to broaden the pool. Healthy individuals that don’t utilize healthcare much soften the financial blow.”
Repeal Without replace is A mess, Why not repair?
The ACA’s meant adjustments from all healthcare stakeholders. Opponents have resisted it from the start and that fight continues. In early January the Republican-led Senate began reviewing ACA to try and garner enough votes to repeal it through the budgetary reconciliation legislative process.
“Unfortunately President Trump has focused on what he’s going to take away without have a plan in place,” said Kristine McVea, “I think that’s been harmful. There’s a lot of fear and uncertainty among our patients. These are people who struggled without health insurance who finally got a chance at taking care of their health and are now very afraid of the possibility that’s all going to be taken away. We hear this every day from people coming into the marketplace and coming into see us for care, I think the capricious statements made by this administration have fueled that.”
More recently, talk of flat-out repeal has given way to amend or modify in acknowledgment of the gains made under ACA and the difficulty of dismantling its far-reaching, interrelated tentacles, absent a ready-to-implement replacement. The political fallout of taking away or weaken- ing protection people have come to rely on would be severe.
“Once leadership has really started to
dig into what it would mean to repeal this outright and try to replace it they’re finding it is not a simple thing to do and the health and coverage of millions of people are at stake,” said James Goddard, an attorney with the public advocacy group Nebraska Appleseed. “So things are slowing down with the recognition they need to be careful with this, and of course they do.
“I think the change in the way it’s being discussed is a reflection of the reality that this is a dramatic thing you’re discussing altering and they need to do it the right way. Much of the ACA hangs together and one thing relies on another and if you start pulling pieces of it apart, you have the potential for the whole thing to fall down.”
Zetterman said he and fellow physicians favor a cautionary approach.
“Most of us would say the Affordable Care Act should be maintained and improved. There are dangers in taking it away and replacing it because it’s now in so many different places.”
Nebraska Appleseed attorney Molly McCleery said total repeal would affect many. “Initial Congressional Budget Office projections show 18 million people would lose coverage, and then in the out years, 32 million would lose coverage – both private and public. The Urban Institute’s state-by- state impact study found 200,000-plus Nebraskans with a pre-existing condition would be impacted if that consumer protection would be taken away.”
Jeff Francis said, “The new ‘r’ word I’m hearing is repair. The consensus seems to be to keep what’s popular and working and change what’s not.”
EDITOR’S NOTE: Details of the recently proposed GOP replacement had not been released as of this printing.
Daniel DeBehnke said of the current climate, “I think it’s extremely confusing because it’s complicated. It’s like a balloon – you poke in one area and something bulges out in another. I think people are frustrated, and rightly so, they pay a lot for healthcare. It’s not just as simple as I-pay- a-lot-for-my-healthcare, ACA is bad, let’s get rid of it.’ There are layers of complexity. We may not like exactly how things are funded or how some components are dealt with. We may not agree totally with all the tactics to get there, but at the end of the day we’ve got more people covered.
I don’t think anybody has the appetite to change that back.
“We just have to figure out how to incrementally lessen the financial burden while maintaining the real goal – more people covered and providing value for the money being spent.”
He said the best course of action now for providers is to “just take really good care of patents and decrease unnecessary utilization and duplication of services,” add- ing, “It’s what everybody wants anyway.”
Fixing the marketplace
Meanwhile, on the insurers’ side, some carriers have left public health exchanges after incurring major losses. This state’s largest healthcare insurer, Blue Cross Blue Shield, opted out of the volatile marketplace.
“Since we started selling on the ACA marketplace we’ve lost approximately $140 million,” executive vice president Steve Grandfield said. “We have a responsibility to all our members to remain stable and secure, and that responsibility was at risk
if we had continued to sustain losses. The public marketplace is unstable, which has driven increased costs and decreased com- petition and consumer choice. The higher premiums go, the more likely people, especially healthy people, drop their coverage. That means the majority of people remain- ing on ACA plans are sick, with increasingly higher claims, which drives premiums up even further.”
He cited instances of people gaming the system by buying plans when they need care, then dropping them when they longer need it.
Granfield said Blue Cross supports a well modulated ACA overhaul.
“It’s important to put in place a smooth transition. We would like to see regula- tory authority for insurance returned to the states, including rate review and benefit design and closing the coverage loopholes that lead to higher consumer costs.”
He has a long wish-list of other changes he wants made.
The leaders of two major Nebraska health provider systems say they haven’t seen any impact from the BCBS defection because there are many other insurers and products on the market. The executives were not surprised by the move given the fluid healthcare field.
Nebraska Methodist’s Jeff Francis said, “There were a lot of unknowns. I think it takes several years through the insurance cycle to be able to correct those kinds of unknowns, especially the way the federal government handles the bidding and setting of rates That’s why you won’t see craziness or changes in the rates in the years to come because they now have several years of experience with this new population and they’re then able to price accordingly.”
Daniel DeBehnke of Nebraska Medicine said, “Regardless of what happens in Washington, if the exchanges are kept in place there will be some changes made either in the pricing or pool that will help organizations like Blue Cross perhaps get back in that business.”
Quality Health Care Starts with Collaboration
Collaboration is key for containing costs in a system of competing interests. More U.S. healthcare decisions are happening outside silos.
Francis said, “A big change in the last 10 years is opportunities to work more collaboratively. In the past it would have been much more stand-alone. Now the hospitals and physicians are working more closely. Nebraska Methodist is part of an account- able care organization – Nebraska Health Network, along with Nebraska Medicine and Fremont Health. We recognize the importance of learning better practices from each other so we can pass that along to make healthcare better for the community and for employers paying for their employees insurance.”
One result, he said, is “less antibiotics pre- scribed by our family doctors at Nebraska Medicine and Methodist Physicians Clinic.”
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