Archive | July, 2010

Issue XL: The War on Public Education

27 Jul

“Rarely is the questioned asked, ‘Is our children learning?'” – George W. Bush

When Hurricane Katrina blew into New Orleans, it washed away much of the historic city’s buildings, neighborhoods, boats, demographics, and culture.  What you may not know is that it washed away the school’s public school system.  The ailing public school system was essentially privatized and contracted out to charter schools.  Over 60% of students now go to charter schools in Orleans Parish.  It’s not alone, but the city’s school system was just the most radically transformed school district in America’s escalating thirty year war on public education.

People don’t realize it, but America invented public schools.  What first started out in Massachusetts had spread across the United States after the Civil War.  By 1900, the United States had more educated and literate people than any other developed nation.  Also around the Civil War, the Morrill Land Grant Act funded the construction of agriculture and mechanical colleges teaching “practical” subjects like farming, engineering, and science instead of Greek and Latin like those “gentlemanly” Ivy League schools in the Northeast.  In every other area of the country, the great state universities (Michigan, Illinois, Texas, California, Wisconsin) arose to give the regular folk the kind of book learnin’ only noblemen and the clergy got in the Old World.  The University of Michigan, for example, aimed to give an “uncommon education to the common man.”  It was government by and for the people dammit.

Origins
Like most bad ideas, it came from California.  De-funding of the nation’s best K-12 education began in the 1970s. California voters passed Proposition 13 (see last year’s Dispatch from California) which limited the amount of property taxes the government could collect.  Property value assessments could not rise more than a few percent a year and could only be completely reassessed when a property changed hands.  This favored old-timers, long-term owners, and corporations over newcomers because the former could pay 1970s taxes on property that may have multiplied in value over the decades.  As the amount of money per student declined (and the number of poor minority children in the school system increased), the state fell to next to last of the 50 states for education by the 2000s.  The fact that the California middle class emigrated en masse to other Western states didn’t help, and neither did those who send their kids to private school instead.  The result?  The most segregated school system in America, according to UCLA.

But that was okay, because California still had the best public university system in the world: the University of California System.  Under its Master Plan, the system planned for a tuition-free future for those qualified to attend  Then the right-wingers and the limousine liberals got to work.  How do you do mess up a good thing?  Bring in the Ivy Leaguers!

Back in the day, the Northeast never developed good state universities because its elite went to the older schools founded under British rule.  The State University of New York (SUNY), for example, never even developed a flagship school because the private universities smothered the system in its infancy by lobbying Albany (strangely enough, Cornell snatched the land-grant money and a non-compete clause from the state system).  Now that’s all well and good for Connecticut and New Jersey (two of the richest states in America), but what happens when notable Ivy League dickheads like UPenn graduate Mark Yudof get exported west to Minnesota, Texas, and California?  Turn it into a rich man’s racket, just like back East!

First, start destroying tenure by hiring more and more non-tenured faculty who work on poverty-level semester contracts.  Then, start making questionable investments in high risk sectors.  Start acting like your mission is to make money by investing in construction over instruction.  Outsource everything and cram more students into bigger and bigger classes.  Make your accounts very opaque and then just claim financial crisis at every opportunity despite having record revenue.  Sometimes make two different budgets for your different audiences (investor and bond makers versus the state and students).

Tuition has skyrocketed to $10,000 per year.  The system actually has a stake in destroying nonprofit, state education because the University of California has invested millions of dollars into ITT Tech and other for-profit educational institutions.  This investment coincidentally overlaps with Regent Richard Blum’s San Francisco hedge fund.  It’s good being a senator’s husband.

If you think investing in the failure of your school system is dumb California limousine liberal groupthink, think again because our brilliant Texas State Board of Education decided to invest $100 million of the Permanent School Fund into charter schools.  Which brings us to our next topic.

Obama, the Foundations, and the Charter Schools
A key element on the war on public education has been the voucher movement to have the state sponsor poor children to go to private schools.  A key sponsor locally has been Dr. James Leininger who has pumped millions into supporting Republicans that endorse vouchers.  Critics argue this will de-fund an already strapped education budget and increase educational inequalities.  The private schools can discriminate (by religion, disability) and cream skim the brightest and most committed students.  A coalition of Democrats and rural Republicans (not many private schools in the sticks) defeated these initiatives in Austin.  But the voucher movement and James Leininger’s checkbook don’t even compare to Barack Obama’s privatization plan: “The Race to the Top”.

George W. Bush dreamed of being  the “Education President” back in 2000 saying his education record in Texas showed his commitment to young people.  Bush claimed that standardized testing, choice, and accountability for low performing schools had produced the “Texas miracle” of rising test scores without increases in funding.  Congress and he framed this philosophy into the No Child Left Behind Act (NCLB) by requiring all states to start standardized testing and to improve low performing schools or shut them down.

Of course, the Texas miracle was a myth and high-stakes testing encouraged states to dumb down tests and for school districts to falsify test scores and drop out rates.  Outside measures (SAT scores, federal surveys, and rates of remedial classes in college) showed no improvement in Texas during his governorship.  But this was now a national policy and opposed by many Democrats in 2004.  What happened when Obama walked into the Oval Office?  He double-downed and pushed the Bush policy into overdrive.

Education Secretary Arne Duncan, a private-schooled Ivy Leaguer, moved from his job pushing the privatization of school systems in Chicago to Washington.  The Administration started pushing charter schools and mass firing of teachers in low-performing schools.  Stimulus money provided billions for the “Race to the Top” grant program which brings the business mentality to public schools: perform or perish.  The charters will have non-union labor pulled from hordes of fresh college grads who will be motivated to teach unlike the old timers.  It’s an attractive idea, until you consider that in Texas, charter schools perform worse than public schools in meeting statewide standards (66% versus 98%).  Nationally, only 17% of charter schools outperform public schools while 37% are worse.  Research in Sweden, which pioneered charter schools in the 1990s, showed similar or worse performance by charter schools.

In fact, former Education Secretary for George H.W. Bush, Diane Ravitch, has come out furiously against the ideas of she supported as a conservative.  The ideas of accountability, choice, and testing simply don’t work, and may do huge harm to public schools.  In her book, The Death and Life of American Public Schools, she goes through history of education reforms and finds that this trend is just another (harmful) fad.  Schools will be dumbed down and focus on teaching to test taking skills.  Only with a nationally agreed upon content standard, can testing have any meaning as an assessment.

But in the neoliberal era, where money talks and bullshit walks, silly ideas like “an uncommon education for the common man” are seen as quaint throwbacks to the eras of Jefferson and Lincoln.  Critical thinking and a common knowledge base as supported by Ravitch would lead to dangerous thinking if it were tuition-free.  When the American oligarchy can opt out of state education (and privatize what remains), do you really think they care that millions of Americans are functionally illiterate?

For if the people started to really settle down and do some book learnin’, they might start to ask from whence our oligarchs came.  But America’s emerging oligarchy is next issue’s topic.

Democracy Now – Diane Ravitch Interview

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Issue XXXIX: The Kaiser, the Economist, and the Communist (Part II)

13 Jul

Semashko

                In the Soviet Union’s health care system was designed by a Nikolai Semashko who exported his health system to other Eastern European countries under communism.  These health systems are completely controlled by the government and have no forms of private practice but also no charges at all for hospitals, prescriptions, or GP visits.  In practice, there were many inefficiencies and underfunding of the health system which led to patients having to bribe physicians to get services needed.  The systems also over-relied on hospitalizations for essentially healthy people.  These practice patterns continue in the post-Cold War era.  One man told me his girlfriend in the Ukraine was being hospitalized for a dermatology biopsy.  She had to spend the entire month in the hospital waiting for the biopsy.  To escape on the weekends, she used to bribe the hospital staff.   

                After the Velvet Revolution, these systems were abandoned in Eastern Europe as they moved to their pre-communist systems of social health insurance.  In Russia, Ukraine, and “the ‘stans”, these state systems are still largely in place but have become even more underfunded except for the top state hospitals in the capitals.  The opening of private practice has encouraged the best doctors to quit working for the state and serve only the rich elite of the nation in the private sector.  For more information on Russia’s current post-Semashko system, read report from The Lancet.  Anecdotally, I hear that physicians were just given raises to the average Russian salary ($600 a month) while I’ve read that historically physicians made less money than factory workers under communism.          

                It is worth noting that system wasn’t all bad.  Health services were undoubtedly worse or non-existent in tsarist Russia while the collapse of the Soviet Union led to large drops in life expectancy.  Tuberculosis rates (a proxy for public health system performance) in Eastern Europe went through the roof in the 1990s.  Unemployment, alcoholism and economic crisis were certainly part of the problem, but the collapse of the state health care system certainly contributed to that fall in life expectancy.  Russian men currently only live to 59.        

Beveridge

                The British equivalent of the New Deal started during World War II.  Winston Churchill, a Conservative, commissioned a report by the economist William Beveridge, a Liberal, to look into the needs of postwar British society.  Beveridge’s report concluded that Britain needed a “welfare state” that would provide support to people from cradle to grave.  A proper secondary school system would be needed (unlike America at the time, there was no universal secondary school system) as well as a health care system.      

Meanwhile the democratic socialist Labour Party had also come up with ideas for a health system.  Their Left Book Club in the 1930s featured a book on a new health system by a certain Clement Atlee.  In the shocking 1945 election landslide, Atlee and the Labour Party defeated war hero Winston Churchill on a program of nationalization and the welfare state.  For this reason, the Labour Party is seen as the party of the National Health Service. 

                Aneurin Bevan became health minister.  Bevan was a high school dropout who had to work in the Welsh mines at 16.  His lack of formal education was made up by his unquestionable brilliance.  As minister of health, he navigated the opposition of the British Medical Association by dividing the general practitioners from the specialists.  After three years in government, the National Health Service debuted in 1948 under the principle that health care should be free at the point of service in both hospitals and clinics.  All outpatient prescription drugs cost £7.20, no matter how much they cost, but there are exemptions for the elderly and others.  All inpatient care is free.     

                The British health care sytem is one of the most completely government-controlled systems in the post-Cold War era.  Depending on who you talk to (doctors, economists, the common man), at least 82% of all funding from the system comes from the government and probably more like 90% by what normal people consider health (clinic and hospital visits and prescriptions).  Incidentally, it is the biggest employer in Europe and only Wal-Mart and Indian Railways employ more people in the world. 

                The system is fairly straightforward when you understand that there is a strong division between primary care and specialists.  Primary care means general practitioners, nothing else.  GP’s are in private practices of 1 to 7 people contracting with the government.  Everyone in Britain registers with a GP and gets on their list of patients.  The government pays a capitation fee for the size of the GP’s list.  No one can see a specialist without first seeing the GP, who is only responsible for outpatient care.  When a patient is admitted to hospital, he is under the care of the specialists who can only work at hospitals as employees.  Specialists include pediatricians, cardiologists, surgeons, and anyone else not a general practitioner.  There is no such thing as general internists in either outpatient or inpatient care, everyone is admitted to a specialist ward.

                Another interesting feature is the difference in the ranks compared to American medicine.  Medical school usually begins at 18 and finished at 23.  All doctors must do two years of “foundation” which are rotating internships in different specialities as house surgeons (like the internships for anesthesia residents).  They then go into their specialty tracks and are called junior doctors.  Once they have fully finished training, they are called registrars because they are on the register of the board of specialists.  You can continue to work as a registrar or you can look for a job as a “consultant” which is similar to an American attending but actually higher.  A consultant is somewhere between an attending and a department chairman and has a special interest in a certain part of the body.  An oncology consultant, for example, would only focus on kidney or bone tumors in a hospital.  To get a job as a consultant, you must publish lots of papers and do lots of cases (for procedural specialties).  Overall the system is more inclined towards academics than the American system because papers are used for promotions and publications are encouraged in what would be considered a private practice job in the U.S.       

                  GPs now make more money than specialists, which is a recent trend from the latest NHS contract.  NHS GPs now generally make over £100,000.  Specialists (who are hospital employees) make salaries similar to academics with consultant salaries starting at £70,000 and seem to peak at about £100,000.  Again, this can vary depending on where you practice and if you take private patients (only consultants can see private insurance patients) and how long you want to work.  Overall, the lifestyle is more relaxed than in America, and it is closer to a 9-5 job (the government even sponsors 10 days of CME training a year.) 

Interestingly, this doesn’t mean that physicians lack power or autonomy.  The British Medical Association acts in effect as a union for the physicians when it comes to contract negotiations with the government.  An interesting discussion with an ophthalmologist revealed to me that the medical specialties have a large amount of control over the procedure volumes at hospitals.  For example, the Royal College of Ophthalmology has guidelines for what the appropriate amount of time a postoperative visit should be for optimal medical care.  The Royal Colleges will de-credential hospitals that do not follow their volume and time guidelines, guaranteeing a leisurely pace for physicians.  And yes, the NHS physicians do get to have time for tea breaks.  Unthinkable, really.         

Sure, but does it really work?

                Measurement of health systems performance is a multimillion dollar industry filled with hacks, know-it-alls, and people with business agendas.  But the evidence from neutral sources is pretty clear: the United States consistently underperforms in health care despite spending the most in the world.  Most reports score the United States very low on access, particularly for the poor, black, and uninsured.  The Commonwealth Fund, for example, scores the US last in patient safety, access, coordination, efficiency, and equity.  One pediatric nephrologist in Wales told me that 80% of his patients would die if it weren’t for the NHS. 

The United Kingdom spends much less than the United States and considerably less than most industrialized countries like Germany and France.  In fact, the United States government health spending (Medicare, Medicaid, VA, CHIP, county hospitals, military) is actually more as a percentage of GDP than the UK.  A majority of spending in the US is now public, even before health reform passed. 

A recent article described the outcomes differences between the two countries.  The United States is known to have superior outcomes in cancer than the UK which has one of the worst in Europe.  However, this article states that while this is true, it is slightly exaggerated because older data excluded many African-Americans who have much poorer outcomes.  Also screening for certain diseases (especially prostate cancer screening which has not been shown to decrease mortality according to USPTF) is more aggressive in the US and gives them a higher number of early stage cancers to treat.  However, the US performs very badly in chronic care and no longer has a longer life expectancy than the UK.  Interestingly, racial disparities disappear in the American VA health system, which is actually more socialist than the NHS because all physicians are employees of the government and more free-spending.     

                So what’s the best health care system?  Really, it is all about values and culture.  What a society measures is what it values.  Under communism, the Russian system was about striving for an equal society and promotion of science and rationality over religion and moneymaking.  In Continental Europe, the social health systems are about having a neutral health system separate from government that are co-managed by business and unions.  In the UK, the health and political system is about eliminating the shocking health inequalities across this very unequal nation.  Life expectancy in parts of Glasgow (54) is worse than much of Africa.     

                If American medical schools, state medical societies, and politicians gave monthly reports on how bad disparities are and how they are striving to close them instead of how many millions of dollars in research grants they scored then our system would be totally different.  In my borough of London, I can tell you exactly where life expectancy is highest and lowest by neighbourhood.  Can anyone do that in America?  And if no one asks the question, how can anyone answer it?       

Links

Commonwealth Fund – U.S. Health System Performance      

WHO – Year 2000 Health Rankings (controversial)