Homelessness: Action or Complicity?

With the recent revelations that the homeless population in New York City is now at its greatest numbers since the Great Depression, we are again face to face with a public health crisis of astronomical proportions.

Nursing: Trouble in Paradise?

Despite the consistently wonderful press about the trust that Americans place in the nursing profession, not to mention the heady days of new nurses being assured a plethora of jobs upon graduation, the nursing zeitgeist seems just a little diminished and subdued these days. At least for now, many new grads are hard pressed to find work and there is little to cheer about when it comes to nurses' economic standing.

Ballast

Seeing the new independent film "Ballast" several days after Barack Obama's inauguration was a stark reminder that, once the party is over, economic and social change will be hard won.

According to Merriam-Webster's online dictionary, ballast represents "a heavy substance placed in such a way as to improve stability and control" or "something that gives stability (as in character or conduct)".

If ballast is indeed what this country needs in order to lift those who live in abject poverty out of their plight, then it will take a lot more than hundreds of billions of dollars thrown at banks and car manufacturers to accomplish what looks to be, at best, a Herculean task.

In many rural, urban, and---let's face it---suburban American homes, putting food on the table and into the stomachs of our children hasn't been so difficult in a generation. When it comes to making mortgage payments or keeping up with rent, that is a task made even more challenging by the scores of jobs being slashed each week as prices rise and families struggle to keep up. People with Master's degrees are applying at Wal-Mart and Starbucks, and retirees eke out their survival by joining the ranks of the unemployed at job fairs.

In the deep South, in California, in Harlem and Detroit, most everyone is waiting to see how the new economic recovery plan will create jobs, stimulate the economy, and bring some sorely needed ballast to a nation afloat in uncertainty.

Just as we all need stability and accountability in our personal relationships and communities, we also expect the same from our government and our leaders. With a new leader wielding the power and speaking from Teddy Roosevelt's proverbial "bully pulpit", all eyes are turned towards Barack Obama and his stated desire to reverse the course of trickle-down economics, creating instead a trickle-up economy that first feeds those in most dire need of an infusion of hope and hard currency.

I am personally waiting on the edge of my seat, hoping with all my heart that whatever is undertaken will accomplish what needs to be done. There are vulnerable people among us who need the succor of the state and a way out of their economic plight. May the tears and hopes of last week's celebrations give way to the hard work and clear decisions that lead us to where we truly need to be.

(c) 2009, NurseKeith

The Economy and Its Discontents

In this historic period of a global economic downturn, my thoughts have been turning towards those whose personal economies have already arrived to a place of significant decline.

Here in the United States, the use of soup kitchens, food pantries, and other emergency assistance has skyrocketed, and applications to Medicaid continue to climb. An astronomical number of individuals are truly wondering how they will put food on the table, gas in their tanks, or heat in their homes, and those individuals are often living in households with members who are children, elderly, or disabled.

Government figures show that unemployment applications are increasing exponentially, and although Congress has passed legislation to extend unemployment benefits, we all know that the end of such assistance does not always coincide with the procurement of new employment opportunities. As the economic slowdown continues, jobs are being slashed daily in a variety of sectors, the consequence being even more people fiercely competing for a dwindling supply of jobs, many of which offer less-than-stellar compensation frequently without health benefits.

With Christmas and Hannukah upon us, bargain hunters scour the shelves for affordable gifts for friends and family, and the ingredients for holiday meals and celebrations are sought through every frugal means necessary. Granted, we all need to celebrate, but this year has brought a level of economic uncertainty not seen in many decades, ostensibly throwing a wet blanket over many families' ability to partake of the holiday season as they might in a more robust financial climate.

But what of those who were already struggling? What about those who have been visiting soup kitchens and food pantries all along? As more and more jobs are slashed and as individuals use up their unemployment benefits, how will we as a society care for those who cannot make ends meet? And as the facilities who support those struggling families see their own operation costs rise amidst an increase in utilization, how will the needy be cared for?

These are uncertain times, and as I have pointed out on Digital Doorway before, food insecurity is real, and the number of families unable to provide for their children has been increasing like never before.

I offer no solutions here, and I have no grand plan or scheme to short-circuit this calculus of need and insecurity. I only know that I awoke at 4am this morning thinking about the millions of people---in this country alone---who cannot honestly say how they will feed their families this week, let alone provide the makings of a holiday celebration.

With the New Year around the corner, there is always desire for a fresh start and an infusion of hope. On January 20th, an historic event of enormous proportions will take place in Washington, D.C., and all eyes will be on the new President and his administration's ability to turn the economy around as soon as possible. And while I understand the need for inaugural celebrations---especially due to the historic nature of this president's unprecedented accomplishment---I cringe when I think of the millions of dollars that will be spent on dinners, formal balls, and lavish parties as millions of Americans wander the streets in search of low-paying jobs and food pantry handouts. Yes, we all need to celebrate, but that astronomically expensive celebration does indeed give me pause as I ponder the plight of those without the means to even feed their families.

My wife and I are both very blessed to have recently found satisfying and relatively well-paying work right in our own town. No longer commuting forty miles per day, we are among the lucky few who have new jobs, short commutes, and robust benefit packages. We realize how very fortunate we are to be in our current position at a time when so many others have experienced the opposite economic reality. We do not take our situation for granted and fully recognize our blessings.

Perhaps my recent luck in finding gainful employment is what has me awake at 4am, thinking about those who have not been so lucky. Admittedly, we will have no problem putting food on the table this holiday season, and while we are indeed being frugal in terms of gifts for family and friends, we are fully cognizant of the fact that buying those gifts is not a significant burden, even as we write checks to our favorite local, national and international charities. Having the economic means to care for ourselves and give to others is not something we take lightly, and we recognize that it is our ethical responsibility to donate to worthy causes at a time when our donations mean so much.

I am saddened by the current plight of millions of deserving individuals and families, and even as I watch the holiday season unfold, my thoughts turn to those who may feel less than celebratory. These are times requiring a great deal of thoughtful reflection, selflessness and compassion, and I hope that the suffering of so many amidst this global crisis will soon be alleviated. In whatever way I can, I choose to be a part of the solution, and I invite you, dear Reader, to do the same.

Temporarily Joining the Ranks

So, dear Readers, as of 12:01 am today, my wife and I are officially uninsured. Caught in that painfully ubiquitous American conundrum, we are both gainfully employed, both starting new jobs (that, admittedly, don't pay exceedingly well), and our new insurance will not kick in until January 1st. With several chronic illnesses between us and a number of medications we take on a regular basis, this could be cause for concern.

Counting our blessings, we indeed realize that, unlike the majority of the other 38 million uninsured Americans waking up this morning, our uninsured status is, in fact, temporary. A month from now, as we ring in the New Year, we will also ring in the renewed security that paying monthly health insurance premiums can bring. Our privilege is not lost on us, but having just been to the emergency room on Thanksgiving Day, I am given pause to remember that life and illness do indeed sometimes happen on their own schedule. But like I've said before, middle class privilege is something we do not take for granted, and our very survival is in no way threatened by this unfortunate but temporary turn of events.

Meanwhile, my incredulous friends in Canada and Europe wonder how such a "powerful" country can leave so many of its citizens in the lurch, many actually going bankrupt when they cannot pay their medical bills. My response is that the United States' free market system coupled with an ingrained Puritan work ethic and "pick-yourself-up-by-your-boot-straps" cowboy mystique leads many mainstream Americans to think of themselves rather than of others, assuming that those who "have not" probably don't deserve it anyway. Ronald Reagan's evisceration of Public Assistance---further decimated by Bill Clinton in the 90's---painted "Welfare Moms" as deadbeats who purportedly birthed children just to get on the dole. We were all expected to make it on our own, and those who didn't were expected to eat our crumbs.

If I sound cynical, it's because there has been a great deal to be cynical about in the last decade of American life. With the economy in shambles, healthcare on the rocks, two never-ending wars, and poverty and hunger on the rise, some healthy cynicism is indeed in order.

So, as the Obama administration revs its engines, I wait patiently along with my fellow citizens, hoping for some change, but admittedly less starry-eyed than many of my brethren. I honestly expect little to change in the next year in terms of the machinations of American healthcare economics, although I do hold out hope that the ranks of the uninsured will somehow be decreased as rapidly as possible. Changing such an entrenched system will not be easy, and some say it is truly impossible with so many economic and political toes to be stepped on. Well, the poor, uninsured and hungry in this country have been repeatedly stepped on throughout the decades, so if the insurance industry cries "foul" as it suffocates, let's simply call it just desserts.

This next month of "insurancelessness" does certainly give me a lot of food for thought. I am grateful that this chapter will be short-lived, but I am all too well aware that, for many others, it is a chapter that seems to never end.

Hospitals and Consumers on the Edge

Economically speaking, times are tough all over. People are losing their jobs, the unemployment rate is rising, and retailers and consumers alike seem to be facing a lean holiday season.

On the healthcare front, a number of U.S. hospitals are now in the difficult position wherein they now must buy back debt incurred from "Variable Rate Demand Notes" (VRDNs) and other forms of loans that hospitals use to do many things, including making capital improvements to their facilities. According to some reports, U.S. hospitals may be forced to buy back up to $8 billion dollars of debt, not an easy task in these cash-strapped times.

For hospitals, the economic times are indeed challenging. Patients with outstanding bills are less likely to be able to pay on time, if at all. Many employers are scaling back health insurance coverage for their employees, thus patients are often stuck with hospital bills that they cannot afford. Additionally, the numbers of uninsured and under-insured patients is rising in most states, and charity care is becoming increasingly burdensome for hospitals and health systems that provide such services. As some patients shift to Medicaid, hospitals also understand that reimbursement rates from Medicaid and Medicare often cannot match those from some private plans, thus revenues hemorrhage from numerous economic blood vessels simultaneously.

Equally troubling for hospitals, borrowing is exceedingly difficult, despite dire need for improvements to facilities, upgraded IT equipment and systems, and rising labor costs. With increased costs of utilities, food, supplies, and health insurance premiums for their own workers, hospitals also understand that many patients will continue to cancel or postpone many elective surgeries and procedures that bring much needed revenue to hospitals' bank accounts. With consumers charged co-pays of $200 to $400 for elective procedures such as colonoscopies and vasectomies, hospitals face a serious decrease in such procedures which are much less costly since they generally involve a stay of less than 12 hours from registration to discharge.

From The Wall Street Journal to regional news outlets in the mid-West, the signs all seem to be the same: hospitals are in for a difficult season as the economic belt tightens on the healthcare industry.

As a self-appointed advocate for the uninsured and vulnerable in this country, I am seriously concerned that an enormous cohort of Americans currently face a significant decrease in the availability of affordable preventive healthcare in all regions of the country, not to mention access to many specialists and other providers.

Overall, my fear is that the availability of free and low-cost care will suffer in the current economic climate, and patients in need of care will need to travel further and further afield in search of providers willing to see them, a burden that may keep numerous people from seeking medical attention at all. When access to medical attention is limited, it is frequently the uninsured and under-insured who are left in the healthcare dust, and there are millions of children who will fall into this unfortunate group as their parents simply struggle to make ends meet.

There will be much for the new Obama administration to consider when assessing the current (horrible) state of the American healthcare system. As impatient as we all are for change, it may be many months before any improvements are even suggested for fixing healthcare in this country.

Meanwhile, as hospitals struggle with their bottom line and millions of uninsured Americans struggle to stay healthy, we all must hope that there is still a possibility that the damage, as extensive as it may seem, can still be undone. And as for those millions of uninsured children out there, it should never get any worse than this.

Blog Action Day---Poverty Around the World

Today is Blog Action Day 2008, and this year's goal is to raise awareness about global poverty by having thousands upon thousands of bloggers use their blogs as virtual soap boxes. With the global economy in turmoil and governments planning massive bailouts of banks the world over, we must not lose sight of those for whom the news of a stock market plunge or a failed bank means nothing. Yes, we must do something to keep the economy afloat, but a bailout of the world's poor is more than paramount, and it doesn't even seem to be part of the conversation.

Almost half the world's population---more than 3 billion people---live on less than $2.50 per day. The Gross Domestic Product (GDP) of 41 of the most indebted countries in the world is less than the combined wealth of the seven richest countries.

Meanwhile, a billion people around the world cannot read or write, and an estimated one billion children live in poverty. Speaking of children, 640 million children live without adequate shelter, 400 million lack access to clean water, 270 million have no access to healthcare, and 29,000 children die every day due to the ravages of poverty. (Please click here for source material.)

29,000 children. Every day. Dying, perhaps in their parents' arms. Perhaps alone. Perhaps in the arms of a sibling or a stranger in a refugee camp. 29,000 children dying every day while we go about our business, fret about our 401(k)'s, and fill our gas tanks on the way to the movies.

29,000 dead children every day. Or, 1 child every 3 seconds, or 20 every minute. That's like a tsunami similar to the one that occured in 2004 happening every day.

What's wrong with this picture?

Many countries have apparently been irreversibly impoverished by the actions of the International Monetary Fund (IMF) and The World Bank as loan programs and economic restructuring policies destroy indigenous food production, flood markets with cheap subsidized grain from the United States, and otherwise cripple developing nations, cutting off their economic legs at the knees.

I'm no economist, but it's plain to see that the global economic and banking organizations that lend money to struggling nations do so by imposing conditions that create a level of servitude and financial share-cropping that is inhumane at best, and criminally nefarious at worst. The gap between rich and poor in the United States is ever widening, and the gap between rich nations and poor nations is so vast as to be unfathomable.

And what kills children around the world in the face of crumbling economies, market bailouts, subsidized American grain, decaying infrastructure, and crippled healthcare systems?

Hunger kills children. Diarrhea and dysentery kill children. AIDS kills children. Measles, mumps, rubella, malaria and tuberculosis kill children. War kills children, as does living in refugee camps without adequate shelter, food, clothing and medical care.

If even a fraction of the world's annual military spending was redirected towards ending poverty, we would be well on our way. In 2006, approximately $1200 billion was spent globally for military purposes. Many experts agree that the eradication of poverty and the forgiveness of the developing world's debt on a massive scale would do more to decrease global terrorism and promote peace than any possible amount of increased spending on military might.

So, as a race of beings living on this troubled planet, we weigh our options. Even as 29,000 children die each and every day, we make choices which do nothing to alleviate the suffering that poverty brings to so many. Even as the American economic system implodes upon itself and drags the rest of the world with it, we choose to rescue those who do not deserve to be rescued, and we turn a blind eye to those who've been waiting in vain for a fabled rescue that may never arrive.

In the hour or so that it's taken me to write this blog post, 1200 children have died somewhere on this planet. 1200 children have given up their lives and joined the scores of others who have also died wholly unnecessary and preventable deaths. Tuberculosis, hunger, measles, diarrhea, dehydration---the reasons are many, as are the causes.

Humanity holds the answer to such problems in the palms of its collective hands. But will we ever act? Will we ever wake up and realize that the fate of all is inextricably bound, that our actions have repercussions far beyond our borders?

Today's 29,000 children all lived lives as valuable as any others. We are too late to prevent today's unnecessary deaths, but perhaps we can still prevent tomorrow's.

Economics and Confusion

Thinking further about the economic issues that I touched on in my last post, it's so hard to get one's brain around what's happening here in the U.S. this week. With such dire news and warnings of financial Armageddon, how does one tease out the truth from all of the hyperbole?

Articles abound about what will happen if the bailout doesn't pass. Blame is passed from hand to hand. But where do we ordinary citizens fit in? What do we stand to lose or gain in the process?

Economics is one area where this nurse is most weak when it comes to understanding the bigger picture. Understanding my own personal economy is difficult enough. But I just can't stop thinking that many of the people in need of a bailout themselves are going to be left in the dust no matter what happens.

Whether we look at the notion of fighting poverty, rejecting what seems like a rescue of Wall Street, or using that $700 billion to help Americans keep the homes they are about to lose, there is enough confusion and different versions of "the Truth" to keep us all reeling from a dose of 21st century financial vertigo.

At this time in history, there are intelligent arguments in favor of nationalized healthcare, while Americans are going into bankruptcy just to pay for healthcare they can't afford but literally can't live without. Meanwhile, many people are losing their homes in record numbers and Wall Street speculators and investment banks look to the federal government to rescue them from their own excesses.

So, where is the bailout for the thousands of poor Gulf Coast residents who lost their homes and have still not been able to return home?

Where is the bailout for first responders disabled in the aftermath of 9/11 and unable to return to work and normal life?

Where is the bailout for the homeless, the uninsured children, the wrongly incarcerated, the disenfranchised, the disabled?

Where are the reparations for slavery? For Native Americans?

These are just some of the questions that come to mind as the sum of $7 billion is bandied about so blithely.

Economics and the Elderly

(Note: This is my eighth post under the auspices of the nurse blogger scholarship which I recently received from Value Care, Value Nurses.)

So, as the bad news splashes across the headlines and the denizens of Wall Street throw up their hands to ward off the falling sky (that they themselves created), the elderly here in the United States are facing some tough economic times of their own as we turn the corner to 2009.

Reports now tell us that premiums for drug coverage under Medicare Part D will rise an average of 31% in the coming year. For some seniors, most of whom are on fixed incomes, a monthly increase of $50 to $100 could spell economic disaster, especially when one considers the simultaneous (and often astronomical) rise in the cost of food, gas, general healthcare costs, home heating, and other necessities.

As I recently reported in an article on Nurse Linkup, Bloomberg, The Associated Press, medical websites, and other independent news outlets are all reporting the inevitability of these increases, the writing already being on the proverbial wall.

To add insult to injury, changing Medicare rules may make some seniors' lives a living hell as they attempt to navigate the shifting sands of Medicare Part D.

And just as the economic climate intensifies with bad news and dire forecasts, American seniors also face the daunting task of negotiating the spending caps created under the Medicare Part D regulations. These rules limit annual reimbursements for medications to $2,510. When this magic number is reached, Medicare recipients must then be on their own purchasing medications until they have spent a total of $5,726, whereby Medicare will begin paying for medications once again. Confused? You should be. If some fortunate seniors are able to purchase expensive "gap coverage" for this period of time, they may break even or come out slightly ahead. For those unable (or too confused or intimidated) to do so, their economic peril may await.

So, what does this say about our country? Who are we? What are we doing to our seniors and disabled citizens? When pharmaceutical lobbyists have more influence than seniors (and their advocates) in the writing of the Medicare Part D regulations, we all know who loses.

Senior citizens are vulnerable members of our society, many of whom have worked all their lives, diligently paid their taxes, and now must struggle to make ends meet in the Autumn and Winter of their lives. Sure, the global economic crisis has indeed cast its pall on almost everyone, but even as the U.S. Congress holds midnight meetings to rescue Wall Street from its excesses and errant ways, no one is talking about how to rescue vulnerable and sick seniors as they fall down their own financial rabbit hole.

No doubt, even as the "rescue" ensues, some CEOs and others in power will somehow come out ahead, making off with money that is not rightfully theirs at a time when that money should be trickling down rather than up.

When I think of the cold months of winter ahead, I think of middle class and working class senior citizens who honestly don't know how they'll make ends meet. Meanwhile, in the halls of Power, there's money to be traded----and made.

Of Heroes, Parity, and Economics

Last night's post only scratched the surface of the culturally accepted norm dictating that mental health is not on par with physical health when it comes to one's needs for rest and rejuvenation---especially where work is concerned.

Work is, for better or worse, part and parcel of our lives, a veritable necessity for putting food on the table and clothes on our backs. As we moved out of an agricultural society into an industrial---and eventually technological---society, it obviously became necessary for an astronomical number of individuals to become workers who performed duties under the auspices of companies and corporations which held our livelihoods in their hands. Granted, an agrarian society is no panacea---share-cropping and slavery are excellent examples of that scheme's miserable failings---yet the industrial age brought with it abuses and restrictions on individual freedom which, while not necessarily slavery in name, certainly have kept many segments of society in quite similar and dire economic straits.

So, when one has chosen to enter a field of work in which the vagaries of the economy and the edicts of one's employer shape one's destiny, there is a certain amount of freedom that is abdicated. That said, even the self-employed feel that they too must abdicate some freedoms in the face of restrictive tax codes and the high cost of health insurance and healthcare.

For myself, I have chosen to enter the "Medical Industrial Complex", to riff on a phrase originally popularized by Dwight D. Eisenhower in 1961. Within said Medical Industrial Complex, a hierarchy exists, similar to the hierarchies within other disciplines and professional societies. The members of such systems are rewarded for their work based upon algorithms which take into account such notions as experience, education, applicable skills, and other factors which make one a candidate for the assignment of various tasks and responsibilities.

As I stated in yesterday's post, certain segments of society are held in higher esteem than others, earning astronomically higher salaries and benefits than those of us who slog away in blue-collar, "pink-collar" and even many white-collar positions. Most of us would agree that celebrities---including many actors, some entertainers, as well as many professional athletes---receive remuneration for their efforts which far seems to outstrip the relative value and social import of their (cultural and economic) contributions to society. CEOs are another story, and the scale of their remuneration is also sorely out of balance (think Ken Lay, may his soul never rest).

I stated yesterday that the hypothetical baseball player who experiences occupational stress could be pretty certain that his salary---often in the millions, or at least hundreds of thousands---would not suffer in the face of a leave of absence for reasons related to stress.

In my post, I compared myself to that stressed-out baseball player. Let's imagine that I was a nurse who was experiencing incredible levels of stress and burnout by caring for the destitute, chronically ill, and elderly who live in that baseball player's hometown. Maybe several members of his extended family---saddled with substance abuse, mental illness, or other disabling medical conditions---were actually on my caseload. When I decide that I need to take a leave of absence due to stress related to my work, why is it that I---a person providing essential services related to the health, well-being and survival of members of that baseball player's family and community---must do so without pay and with risk of economic hardship, while the baseball player (who essentially swings a piece of wood at a leather ball and catches balls hit by others with the same piece of wood) rests on his laurels and fat bank account, taking a break from his on-the-job stress on Maui? What is wrong with this picture?

Teachers, nurses, police officers, EMTs, substance abuse counselors, social workers, senior center directors, outreach workers, AIDS workers, hospice counselors, homeless advocates, housekeepers, medical assistants, home health aides, daycare workers, laborers----we all experience on-the-job stress, yet it seems only the rich and famous can have respite without negative economic consequences. The families of people in the military live on food stamps in decrepit barracks for the enlisted, yet we say we "support the troops". Again, what is wrong with this picture?

Our measure of "heroes" is askew. Who truly are the heroes? Who should be celebrities? Where are the trading cards of famous nurses and home health aides? When will substance abuse outreach workers have their day? Something is wrong in a culture wherein those who care for the dying must themselves struggle to survive. This is an emergency of priorities, one for which parity and balance seem far beyond reach.

In essence, the true heroes go unsung, and the make-believe heroes take home the prize.