Affordable Care Act: How To Stay Relevant

What do we know and not know about the Affordable Care Act? Plenty.  

We know it’s helping families by keeping young adults on their parents’ policies, and it’s helping individuals by eliminating exclusion from insurance plans because of preexisting conditions. We know it creates options for middle class wage earners who benefit from marketplace exchanges offering a range of plans. And though public dialogue may at times be heated, the ACA has put new energy into the healthcare conversation. There are considerable issues to talk about, so this is good.

However, we don’t know whether the conversation will successfully transition from talking about who has an insurance card to what real health means and where it comes from. The ACA is silent on a wide array of topics that contribute to health and the economic mobility generally associated with better access to healthcare.

We don’t know whether more states will eventually expand Medicaid to care for the poorest part of the population. We don’t know whether the exchanges will eventually work as smoothly as intended after a seriously rough start.

Questions swirl, but this one thing we know: There will still be gaps in coverage.  

Using the Church Health Center’s uninsured patient population as an informal case study, it’s clear to us that more than 60 percent of our patients will see no change. The Affordable Care Acts makes no difference to them. Because Tennessee did not expand its Medicaid program—and most states opted not to—our low-wage patients still do not qualify for this form of healthcare assistance. Yet neither do they qualify for subsidies for the cost of premiums. In a backward logic sort of way, the people with the least income were left off the charts. Hopefully the state will clarify this soon.

And even with the availability of plans that cannot exclude applicants because of preexisting conditions, the working uninsured are still choosing between paying for insurance premiums or essentials like food and housing.

When the exchanges first opened, I was encouraging one patient to explore the possibility of a simple plan that would cost about $150 a month. It seemed to me it would give her some good coverage. She responded by essentially daring me to find $150 in her monthly budget that had somehow escaped her attention. While insurance was available to her now, whereas it had not been previously, she still couldn’t pay for it.

I used to hear from people who assumed that after the Affordable Care Act took effect, there would be no need for faith-based health ministries like the Church Health Center.

That couldn’t be further from the truth.

A more accurate assumption is that in order to remain relevant in the context of the Affordable Care Act, we need to stay on the job. We can’t let up.  

I offer these two words as touchstones for our efforts going forward.

1. Nimbleness. We can’t be encumbered by loyalty to old ways of doing things. The Church Health Center is constantly seeking to innovate with the goal of improving health. None of us should be waiting to see what state or federal governments will do about healthcare. It’s up to us to dig in and find ways to bring real change at the local level.

2. Community. The government can’t buy love, yet we know that love improves health. Faith communities reflecting the love of God have an enormous opportunity to care for their communities and address not only clinical health needs, but also the socioeconomic factors that contribute to inequitable health access and outcomes. Love God and love your neighbor, the Scriptures tell us.   Healthcare reform starts with changing how we look at health not as a card or pills or office visits, but as how we relate to each other, from individual relationships to matters of injustice too long ignored. At every level, people of faith can raise their voices and bring change. The Affordable Care Act hasn’t changed that fundamental truth.

How Understanding Culture Matters To Healthcare

If you do not take cultural and religious beliefs seriously, you will not fully understand your patient’s concern.

My wife, Mary, and I have what we consider to be our adopted son, Menachem. He worked at the Church Health Center after he graduated from Rhodes College in Memphis, and then he went to University of Tennessee for medical school. Last year he finished his family medicine residency at Beth Israel in New York.

Menachem is an African American kid from Tupelo, Mississippi. How did he get a name like Menachem? Menachem was born during the time of the Camp David Accord. His mother, a social worker’s assistant, was so enamored with the idea of peace in the Middle East that she was going to name her baby Menachem, Anwar or Jimmy. She chose Menachem Begin for the honor.

So this poor black kid from Mississippi was named Menachem. He then went to Tennessee. I made the really big mistake—because my plan was for him to come back to work at the Church Health Center—of taking him to the Big Apple, and he falls in love with New York. He ended up matching with Beth Israel for his residency. Beth Israel has a large population of Hasidic Jews who use their clinic. The doctors who see them are residents. Patients look at a sheet of paper and pick who is going to be their doctor.

Menachem! What Hasidic Jew is not going to say, “I’m picking Menachem!”

When it first happened, patients were very surprised to meet Menachem, and Menachem had no idea what a Hasidic Jew was. Then he was doing his family practice OB rotation, and a woman was in labor. Menachem was doing his thing, and the father was pacing constantly around the room looking at his watch and asking Menachem how long was going to take. Menachem is sort of a laid back guy and he said, “Look, hang on, it’s going to happen.”

Finally, the father said, “So, look, are you going to get the baby out by Shabbat?”

Perhaps you don’t know what Shabbat is. The Jewish Sabbath starts on sundown on Friday. “Are you going to get the baby out by Shabbat?” Menachem had no ability to answer that question. First of all, he didn’t know what Shabbat was, and second, it wasn’t up to him when the baby would come. When Menachem finally figured it out, he had to tell the father, “I can’t do this!”

All of a sudden he was more on the same page. I’m not sure the father was ever on Menachem’s page, but Menachem now had a cultural understanding that the father was anxious that the baby wouldn’t come before the Sabbath began and work should cease.

Today, three years later, Menachem understands the Hasidic culture a whole lot better than he did then. But it took some effort on his part. Patients now choose Menachem not because of his name but because they know the kind of doctor he is. They know he has taken the time and effort to learn what Hasidism is all about. It makes him a better doctor.

It’s pretty powerful.

A Spoke in the Wheel

Antony Sheehan, president of the Church Health Center, is here to talk about a key concept that helps keep our organization focused on changing the healthcare landscape.    

I’m a good Brit, but these days the words of a German pastor and theologian are what stick in my head. Dietrich Bonhoeffer wrote,

“We are not to simply bandage the wounds of victims beneath the wheels of injustice, we are to drive a spoke into the wheel itself.”  

I’ve spent my career in healthcare and have seen up close the effects of injustice in my own field. Many people with impressive clinical credentials are now poking at the true causes behind diseases and chronic conditions, and the realities are far more complex than anything a blood test will show.

The social and economic conditions people live in correlate both to access to healthcare and health outcomes, and one aspect is particularly important: education.  

The reality is that the number one predictor of length of life and quality of health is education. A large body of research consistently supports this truth.

The more formal education a person completes, the more likely the person is to live longer, to experience better health, to engage in behaviors that promote health, and to receive screenings that can catch disease in early stages.

Of course, multiple factors go into an individual’s ability to complete higher levels of schooling—the quality of the neighborhood school, time parents spend reading with children, family finances, the need to leave school to earn money, the truth that a weak start before age five may mean a student will not be prepared to study at a college level, or even complete high school.

The World Health Organization defines health inequities as inequalities that are avoidable—in other words, we can do something about them. So if health inequities are linked to educational inequities, where should we start?  

Michael Marmot, a British public health researcher, develops the notion of life chances versus life choices. He observes that our public health intervention is predicated largely on telling people that if they make different choices, they’ll have healthier lives. Choose to eat differently. Choose to have better relationships. Choose to have a meaningful career. Choose to get an education.

But can people who do not have life chances actually make life choices? Marmot doesn’t think so. Neither do I. People without socioeconomic chances are not in a position to make life choices.

Education is a spoke that we can drive into the wheel of health injustice before it crushes another generation. 

The Church Health Center already operates one of the best preschool programs in Memphis, giving many children from low-income households a head start on being ready for lifelong learning. Two years from now, when we are housed in the redeveloped Sears Crosstown building, we’ll be alongside a charter school. Young children cannot choose where they are born, what their environment is, or how much money their parents earn. Focusing on their education now creates decades of future life chances—in employment, in problem-solving, in a sense of self—that will result in life choices leading to health.

A Clinic and a Community

I am pleased to have Antony Sheehan on the blog today. Antony came to the Church Health Center last year after holding senior positions in the British health system and a fellowship at the Institute for Healthcare Improvement in Boston. I value Antony’s leadership and partnership as the Church Health Center moves into its future.    

For all of its history the Church Health Center has valued collaborations within Memphis, Tennessee. We are concerned not only for our own stability as an organization, but for also seeing results in the wider community’s effort to improve the health of the city.

Now we stand on the brink of our most complex collaboration to date as part of a coalition of business and community leaders committed to redeveloping a massive vacant structure that once housed a Sears catalog order distribution center. Unquestionably it would have been less expensive to implode the building and start over, and the owners could have embarked on any number of commercial schemes sure to earn a profit.

And while the Church Health Center could raise money and erect our own campus to solve some of the challenges that come with our continuing growth, we’ve chosen to lean into our mission alongside educators, artists, small businesses, and residential space by moving our operations to Sears Crosstown as an anchoring partner.

Why? Because we’ve learned a few things in our first quarter of a century.

When the Church Health Center opened its doors to the first 12 patients in 1987, we stood in the gap. Some people had access and means to receive the best healthcare in the region, largely because they had good insurance offered through employers. But thousands and thousands of other people worked hard in low-income jobs without health benefits. They could afford neither insurance premiums in the open market nor the typical fees of healthcare providers.

The Church Health Center has stood in this gap for a long time, and every year we understand it better. Making sure people can see doctors is important, but every person who visits our clinics comes with a life context and personal narrative that often contribute to illness or pain, and the Church Health Center has worked to address those issues. Our 80,000-square-foot wellness facility is a testament to our effort to treat not just the pain or illness, but also the causes of pain or illness by helping people achieve better balance in the various dimensions of their lives.

But it’s not enough. We’ve seen that we have to peel yet another layer away from the health issues of our patients. We have to get to the causes of the causes of pain and illness. The circumstances people live in, work in, and relate to others in affect their health—but they often have no ability to control or change these circumstances, or even to express how they feel about their lives.

Where you live affects health. Whether you can express yourself affects health. Whether you perceive that you have choice—even about what you eat—affects health. Too often low levels of education, income, and health are bound together in a multigenerational cycle that is hard to break out of.  

And that’s where Crosstown comes in.

Rather than being torn down, the old Sears building will be transformed into a thriving community. By moving all our operations into Crosstown, the Church Health Center will contribute to creating a health-giving community and health-promoting environment. We’ll be participating in “village life” with teachers and painters and writers and musicians and store owners and residents. A tilt toward issues of health and wellness will not be accidental. Rather, all the elements of Crosstown will intentionally seek to support the health of individuals who live and work at Crosstown, those in the surrounding neighborhood, and those who come to the Church Health Center for care. The wellness benefits of these dimensions of life will not depend on income brackets.

A community is as essential as a clinic to better health. People cannot make a choice for a richer more fulfilling—and healthier—life if they do not first see the possibility of such a life. By offering such a vision, we will crack the causes of the causes of the pain and illness of our patients.

Antony Sheehan is president of the Church Health Center, Memphis, TN.