Since early this spring, a flood of patients infected with the novel coronavirus has stressed many of the nation’s hospitals to their limits, revealing like never before what’s good, bad, and ugly about our health care system.

On the positive side, we’ve seen extraordinary selflessness and heroism from the people who work in hospitals. Doctors have come out of retirement to lend a hand. Nurses have separated themselves from their families to avoid infecting them. Respiratory therapists, technicians, janitors, patient transporters, and even administrators are literally putting their lives on the line. As of April 7, the Centers for Disease Control and Prevention estimated that COVID-19 had infected 9,000 health care workers and killed at least 27, though the true numbers are undoubtedly far higher. Even some hospital CEOs have done their part by forgoing a few months of pay in order to avoid having to furlough workers.

On the not-so-heroic side, this crisis has also brought news of misbehavior. One major teaching hospital, the University of Pittsburgh Medical Center, continued scheduling lucrative elective surgeries long after the state’s governor ordered hospitals to stop such surgeries so they could prepare for the surge of COVID-19 patients. One uninsured woman in Boston who had symptoms of COVID-19 got a $34,000 bill for her emergency room treatment. Some hospitals have maintained aggressive bill collection practices, dunning working-class patients whose incomes have plunged in the pandemic-induced recession. Still others have threatened to fire workers who speak publicly about the lack of personal protective equipment (PPE) and refused COVID-19 tests for people with symptoms while offering them to the rich and famous.

More than anything, the crisis is driving home the cruel inequities between neighborhoods and the hospitals that serve them. Numerous reports show that black and Hispanic Americans are being hospitalized and dying of COVID-19 at much higher rates than other groups. That’s likely a consequence of several factors, like the fact that they disproportionately work in higher-risk professions like food service, and live in more vulnerable circumstances, such as multigenerational homes. 

They’re also being cared for, often, in hospitals with fewer resources. Places like Elmhurst Hospital Center, a large safety net hospital serving a mostly working-class and immigrant population in Queens, New York, struggled to find PPE for its frontline workers as an apocalyptic number of patients descended at the height of the infection. Across the East River in Manhattan, Mt. Sinai, the prestigious teaching hospital on Central Park, was able to procure N95 masks from a hospital in China with private jets owned by Warren Buffett. 

These inequities are built into the way hospitals in America are allowed to do business. A majority of them are technically nonprofits, but the largest, most prestigious ones often earn returns that would make a Fortune 500 CEO envious. Mt. Sinai’s operating revenue grew nearly 7 percent in 2019, and it had more than $700 million in reserves. It achieved this bonanza in part by marketing high-margin elective procedures, like cardiac stents, to wealthier patients with good insurance. Prestigious hospitals also stay profitable by not serving their fair share of lower-income patients and people of color—people who may lack insurance altogether and often have multiple chronic conditions, like diabetes, that are not very profitable to manage.

That sort of behavior forces safety net hospitals like Elmhurst to pick up the slack, which  typically leaves them struggling financially to find the revenue, personnel, and equipment to do their jobs. An audit a decade ago found that Elmhurst patients had to wait an average of 148 days for routine mammograms, the longest wait in the city.

The current structure of our hospital system doesn’t just reflect the inequities of the American economy, it also helps drive them. Over the last decade, health care costs per capita have risen twice as fast as wages. In fact, a major reason why wages have barely kept up with inflation for decades for most middle- and lower-income Americans is that more and more of their income is being funneled, via payroll deductions, into the health care system. The system’s costs keep rising in part because hospitals have been merging, creating local monopolies with the power to demand higher prices, and indulging in “overtreatment”—that is, performing tests and procedures, like knee arthroscopies, that studies have shown are either completely ineffective or no better than less invasive and less expensive treatments. Overtreatment also puts patients at needless risk of everything from medical errors to hospital-acquired infections to drug mishaps, which together kill as many as a quarter of a million hospital patients each year.

The pandemic has been a great equalizer in one sense: Regardless of which class of patients they serve, hospitals are getting financially creamed because of the high costs of treating COVID-19 patients and a nationwide drop in profitable surgeries. The federal government has responded with more than $100 billion in aid to hospitals. But that will almost certainly wind up just being a down payment. Hundreds of billions more tax dollars will be needed.

Rather than hand that money over with no strings attached, federal lawmakers should treat the bailout as a chance to fundamentally rethink the nation’s entire health system and the role hospitals should play in it. After all, a third of the more than $3.6 trillion we spend annually on health care flows through America’s hospitals—much of it tax dollars, from Medicare payments to research grants to the enormous monetary benefits that come with tax-exempt status, on top of the bailout funds. Taxpayers have a right to demand some accountability for all that money.

If we want to start holding hospitals more accountable for improving their performance, however, we first need a reliable set of metrics to hold them accountable to. Unfortunately, those metrics don’t exist—not in government or the private sector.

The most well-known and influential rating of hospital performance, U.S. News & World Report’s “America’s Best Hospitals” list, is certainly not up to the task. More than one-fourth of a hospital’s score on the U.S. News rankings is based on a survey of medical specialists. As such, it is largely reflective of high national brand-name recognition, which is fueled in part by the rankings themselves. Its other metrics focus almost entirely on the outcomes of the patients a hospital admits, paying no attention to a propensity to overtreat or the degree to which it is treating the health needs of the broader population of its community. And the magazine’s rankings have real power. Hospital administrators spend time and money in order to climb up the list, because doing so gives them bragging rights they can use to bring in more well-insured patients. Other rating systems, like IBM Watson Health’s “Top 100 Hospitals,” aren’t much better. If you want to know where to get your hip replacement, these guides do a fine job. If you want to know which hospitals are using their resources wisely to provide quality care to everyone in their communities, they tell you literally nothing.

That’s why the Washington Monthly teamed up with the Lown Institute, a nonpartisan health care think tank, to create our “Best Hospitals for America” ranking. We used data drawn from the Lown Institute Hospitals Index not only to measure how well hospitals care for their patients but also to gauge the contributions hospitals make to the country and their communities. Our rankings use three main criteria. First, patient outcomes: a hospital’s patient mortality, safety, and satisfaction record. Second, civic leadership: the degree to which a hospital treats patients with the same income and other demographics as its surrounding community; how much it contributes in community benefit, from providing charity care to building and operating free clinics; and how much it pays its senior executive compared to its frontline workers. Third, value of care: how much a hospital overuses low-value tests and procedures.

We then created an “honor roll” of 20 hospitals, each of which achieved the rare feat of scoring notably better than average—in the top 45 percent—in each category. We excluded hospitals from the honor roll that were missing data for one or more of the components. For like-to-like comparisons, we also ranked the 50 best major teaching hospitals out of 224 nationally and the 100 best safety net hospitals out of more than 650 nationally.

(For a more detailed methodology, click here. For the full ranking of more than 3,200 hospitals, see the Lown
Institute Hospitals Index. For the backstory on how these rankings came about, see the Editor’s Note here and brief explanatory essay from the Lown Institute here.)

Given our different approach to measuring success, we expected that our lists of top hospitals would look different from U.S. News and other rankings. We had no idea just how different. 

Like the Monthly, U.S. News publishes an “honor roll” of its top hospitals. Amazingly, not one of the 20 institutions on the U.S. News honor roll appears on ours. U.S. News’s list is made up entirely of brand-name teaching hospitals, including Mt. Sinai, which it ranks 14th. None of its winners are safety net hospitals. Our honor roll, by contrast, contains a mix of well-regarded (if not necessarily world-famous) teaching hospitals, such as University of Colorado Hospital in suburban Denver; safety net hospitals, like Oroville Hospital in California’s Central Valley; and an assortment of community hospitals of varying sizes whose names almost no one outside their communities has ever heard of—like Mercy Health–West Hospital in Cincinnati, Ohio, and Providence Centralia Hospital in Washington State.

With a couple of exceptions, such as Boston Medical Center, our top institutions are not at the cutting edge of advanced medical research, and they may not be at the forefront of experimental surgical techniques, like those on the U.S. News honor roll. Rather, they are succeeding at something that is arguably more difficult, because so few hospitals manage to pull it off: They are doing a great job, simultaneously, of treating a diverse patient population representative of their communities, healing those patients, and not overtreating them.

The reason it is so hard to strike this balance, as our colleagues at the Lown Institute discovered in the process of putting these rankings together, is that some of the metrics we chose are negatively correlated. For instance, a typical safety net hospital that treats a disproportionate share of working-class and poor patients is likely to have a lower patient outcomes score than a typical major teaching hospital. In some instances, that might be because the former’s medical staff is less skilled. But it might also be because its patients have more severe cases of the conditions—heart disease, say—than the more affluent patients that teaching hospitals are treating with the same conditions. It might also be that the safety net hospital is discharging its patients into environments that are less healthy—a crowded fourth-floor walk-up in Queens, say, as opposed to a five-bedroom home in suburban Scarsdale with a private visiting nurse—so that their post-hospital mortality rates (which we measure) are higher. Based on currently available data, it’s hard to tell.

That is all the more reason to be impressed with the hospitals on our honor roll. Take number one–ranked JPS Health Network, a large, public safety net hospital with more than 500 beds and 40 outpatient clinics in Fort Worth, Texas. JPS is also a teaching hospital, which means it provides graduate-level training to residents, or to doctors who have finished medical school. It has the largest residency program in the country for young physicians going into family medicine, a primary care specialty whose practitioners are in short supply in every community in America. JPS also takes care of a largely Hispanic and black, working-class and poor population, relative to its surrounding community. JPS scores well across all of our categories, ranking in the 83.8th percentile for patient outcomes, the 99.5th percentile for civic leadership, and the 90th percentile for avoiding overuse of low-value care. It sets the standard, in our estimation, of what a great hospital should be.

Contrast JPS to the Mayo Clinic, in Rochester, Minnesota, which sits in the number one slot of the U.S. News honor roll. The Mayo Clinic is world renowned, and for good reason. It provides top-notch specialty care, such as organ transplants, open-heart procedures, and cancer surgery. In fact, people from all over the world fly in for their specialty care. But not only does the Mayo Clinic fail to make our top 20 honor roll, it doesn’t even rank on our list of top 50 teaching hospitals, coming in instead at number 100—that is, the middle of the pack. That’s because, though its patient outcomes score is excellent (99.2nd percentile), it does abysmally on civic leadership (10.6th percentile) and value of care (7.4th percentile). The Mayo Clinic is a great place, in other words, to get a major surgery—as long as you aren’t poor, have excellent insurance, and actually need the surgery.

Ranked 10th on our honor roll and fourth on our major teaching hospital list is the Boston Medical Center, a world-renowned institution affiliated with Boston University Medical School. It also happens to be a safety net hospital, coming in at number two on our best safety net hospital ranking just after JPS Health Network. Boston Medical Center, known locally as the BMC, serves as the city’s largest tier one trauma center, which means it cares for patients who come in with severe injuries, the type that result from things like gun violence and car crashes. Like JPS, Boston Medical Center also cares for a sizable share of Boston’s working-class and poor population.

Less than three miles away from BMC is Massachusetts General Hospital, one of the most renowned research and teaching institutions in the country. Mass General comes in second on the U.S. News honor roll, but doesn’t make our honor roll or our top 50 teaching hospital list, clocking in at 51st on the latter ranking. To be sure, Mass General scores in the 93.7th percentile on patient outcomes, higher than BMC, which ranks in the 69.1st. But again, that may be because Mass General’s “inclusivity” score—a measure of the degree to which it treats patients with the same income and other demographics as its surrounding community—is in the 43rd percentile, whereas BMC scores in the 99.7th.

What Americans should be asking is, why can’t all hospitals be more like JPS or BMC? Shouldn’t every person in this country have access to a hospital that provides high-quality care, welcomes all comers regardless of wealth and insurance status, avoids unnecessary care, and contributes to the health of the larger community?

The next wave of bailouts for the hospital sector would be an excellent time to raise these questions, and to begin passing three sets of policies that will incentivize hospitals to behave better. 

First, the federal government needs to get serious about defining what hospitals must do to continue to enjoy the benefits of their nonprofit status—and states, which grant and police hospitals’ nonprofit charters, need to start enforcing those standards. The standards should include some version of the Lown Institute’s inclusivity metric.

Second, we need to move to a hospital payment system in which prevention, primary care, and effective management of disease are better compensated, while payments for specialty care fall more in line with prices paid in other wealthy nations. One way to do this would be to readjust Medicare and Medicaid reimbursement rates, as well as other public subsidies, to better reward providers for community-focused health care. Even better would be to create a system of administered prices plus global budgeting for hospitals and insurers, public and private, as the Washington Monthly has recommended.

Third, if we ever want to get health care costs under control, we need the federal government to require insurance companies to disclose the actual prices they pay for individual procedures at individual hospitals—something that, bizarrely, providers and insurers both consider a “trade secret.” We also need those companies’ claims data—which includes information about individual patients’ various illnesses and what was done during their hospital visits—in order to gauge the quality of a particular hospital’s care and, together with the price data, calculate its value.

In addition to mandating the release of commercial price and claims data, the government could help outfits like the Lown Institute and the Washington Monthly do their jobs of evaluating hospital performance by requiring the release of other data in better form. For instance, the reports that nonprofit hospitals are required to send the Internal Revenue Service documenting the “community benefit” investments they are making in order to justify their tax-exempt status are often incomplete, and the IRS lets hospitals get away with it. The agency also permits hospitals to claim several kinds of spending as a community benefit that shouldn’t count—like the costs of residency programs, which the federal government already underwrites. It would also be nice if the government standardized requirements for disclosure of hospital CEO pay—right now it takes a ton of sleuthing to figure that out. (Hmm, wonder why?) 

Even with these gaps in and difficulties with the data, we and the Lown Institute are confident that our new rankings reveal important realities about the performance of the nation’s hospitals. We also believe that they set a better standard for what we should expect from our hospitals than any other rating system out there. That includes U.S. News, whose rankings both reflect and incentivize much of what is wrong with the current health care system. Hospitals that do well on the U.S. News rankings are ones that excel at lucrative specialized treatments and procedures, period. The ranking gives them no incentive to control overtreatment or serve patients of modest means—in fact, hospitals do better if they keep such folks out. 

Imagine, however, if hospitals were motivated to rise in our rankings. They would compete to bring in patients from all levels of society, not just the well insured. They would find ways to get their staffs to stop performing unnecessary procedures and tests. They would try to reduce the pay differential between hospital workers and chief executives. (Do we really want our hospital workers earning so little that they feel they can’t afford to stay home when they’re sick, especially during a pandemic?) And they would put more of their earnings into improving the conditions that affect the health of their communities. 

If more hospitals had done these things before the pandemic, how many Americans might have been in healthier shape to fend off the virus, or survive it if they did get it? Of course, it’s impossible to say. But it’s not impossible to use this moment to remake our health care system so that next time we don’t have to ask the question.  

Research assistance was provided by Cole Garcia.

The post Introducing the Best Hospitals for America appeared first on Washington Monthly.

What makes for a good hospital? Good treatment, of course, is a bedrock. No matter who we are, we all want to get better when we are seriously ill. But do medical responsibilities begin and end with the act of caring for patients? That idea never sat well with Dr. Bernard Lown, the founder of our organization. 

Lown was the co-inventor of the modern cardiac defibrillator, a pioneer of coronary care units, a world authority on sudden cardiac death, and a consummate clinician. He was also a champion of the idea that the medical community has a duty to address the health of the wider society. In the 1960s and ’70s, when Lown was a Harvard University professor at the height of his career, there was no greater threat to communal health than nuclear proliferation. This belief drove him to cofound International Physicians for the Prevention of Nuclear War, which was instrumental in opening a dialog between the Soviet Union and the West, and which won the Nobel Peace Prize in 1985. 

Lown’s expansive vision of the role of medicine has very much informed the Lown Institute Hospitals Index. American hospitals are justifiably admired for their innovative technology and highly skilled physicians and nurses. Their acute care is second to none. But the health of our nation lags behind every other wealthy country on the planet. One reason is a highly commercialized health care system that forces hospitals to chase revenue to stay afloat—or, as hospital CEOs sometimes say, “No margin, no mission.” That means a focus on filling beds, attracting patients with well-paying (read: private) insurance, and prioritizing high-margin procedures. Uneven quality of care among different hospitals, varying rates of unnecessary tests and treatments, and very different profiles in social responsibility are the natural result. 

Existing hospital rankings have examined only one of these aspects of hospital performance—quality—and those rankings have changed hospitals’ aspirations. But we believe that hospitals can and want to avoid unnecessary treatments too. They also want look beyond their four walls to engage more directly with the needs of their communities. What’s been lacking is a context that both expects them to move in that direction and provides them with clear guidance on how to do it. The Lown Institute Hospitals Index put its shoulder to that wheel.

To build our index, we talked to a wide variety of policy experts, physicians, nurses, patient activists, researchers, and hospital CEOs. Everyone said patient outcomes had to come first, so we examined how more than 3,300 hospitals are doing in terms of deaths, readmissions, patient safety, and satisfaction—all widely used measures for patient outcomes. In order to adjust for the different risks of individual patients and their communities, we applied the Risk Stratification Index, or RSI, a machine-learning algorithm in the public domain. After that, we measured unnecessary and inappropriate care using proven data methods, applying them for the first time to individual hospitals. 

Everyone we spoke with encouraged us to find ways to measure hospitals’ fulfillment of their social mission, or what we call “civic leadership.” This was more difficult. The Internal Revenue Service requires nonprofits to disclose how much they spend on “community benefit,” such as charity care, which comprises one aspect of civic leadership. But the reporting is patchy, and much of what is reported seems barely to meet the intent of the rule. We took this all into consideration. 

We also measured the ratio of hospital CEO pay to worker pay, a yardstick in other industries for fairness and corporate citizenship. Inequality is a powerful factor in determining health, and as the largest employers in many locations, hospitals’ pay equity can have an impact on the health of the entire region. To the best of our knowledge, this ratio has never before been reported for hospitals.

Finally, we invented an entirely new metric, which we called “inclusivity,” to identify hospitals that do an especially good job of caring for all the people in their area. This metric shows the degree to which a hospital’s patients reflect the demographics of the community around it and allowed us to acknowledge hospitals that welcome people regardless of income, education, or race. (For more information, see our methodology.)

The actual number crunching, using a huge range of data sets, has been a two-year odyssey that has taxed the resources of a very small organization. We’re thankful to have had the Washington Monthly as a thought partner during the development of the Lown Institute Hospitals Index and are grateful that they used it to power their rankings. The fact is, some hospitals are “doing it all,” performing well on patient outcomes, civic leadership, and avoiding overuse. Based on our conversations, we believe that most, if not all, hospital leaders and staff want to succeed in each category. The Lown Index points the way forward and creates a fresh set of expectations for the health system Americans both want and need.

The post A Note From Our Partner, the Lown Institute appeared first on Washington Monthly.

A cynic, Oscar Wilde famously observed, is “a man who knows the price of everything and the value of nothing.” Yet when it comes to health care in the United States, the quip doesn’t get it quite right. In that realm it’s not too cynical to say that no one even knows what the prices are, much less what the value of any particular doctor or hospital really is. 

Take hip replacements. What happens if you call your local hospital and ask how much they charge to perform one? Even if you get past the phone tree, chances are that no one you talk to will even understand your question. Which price do you mean, and who’s paying? Do you mean for the surgeon or the anesthesiologist, for your meds or for your meals? There are different prices for each, and each price is different for different people. 

For example, there’s the price the hospital charges people without insurance, which is the highest of all. Then there’s another, government-set price that hospitals are paid for treating people on Medicare, and still another for people on Medicaid. And how much will the hospital bill for treating people with employer-sponsored health care plans or other private insurance (the majority of working-age, middle-class Americans)? Well, there’s one price for me and one price for you and another for Uncle Joe and another for that guy on Facebook you went to high school with. In other words, it just depends, even if we are all getting the same operation by the same surgical team in the same hospital on the same day. 

Here’s how that works. Suppose you have a standard health insurance plan that covers 80 percent of your hospital expenses and leaves you responsible for the remaining 20 percent. The big question is, 20 percent of what? If your insurer has a big market share in your town and knows how to throw its weight around, it may have negotiated with the hospital for “in network” prices that are substantially discounted. This means that your out-of-pocket cost will be substantially lower than what people on some other health care plan with the same benefit structure have to pay for the same operation. Alternatively, if the hospital is a local monopoly (which is more and more common these days), even the biggest purchasers of health care—whether insurance companies or large employers—won’t be able to negotiate much of a discount, or even any terms at all, and a lot of people will just have to pay whatever “surprise bills” the hospital sends their way. 

There’s also a third possibility. In the increasingly likely event that both your local hospital and your insurance company face little competition in your town, they may just wind up fixing high prices, making the cost of getting a hip replacement or a stent or a scan higher in your town than in other towns where some real competition still exists. And, in fact, research has revealed that the price of such procedures varies by as much as elevenfold from place to place across America in part for this exact reason. 

Adding to the absurdity, all this rampant price discrimination in U.S. health care is not only legal, but also legally hidden from the public. “The actors charging these prices are doing everything they can to keep prices secret,” says James Gelfand, senior vice president for health policy at the ERISA Industry Committee, which represents large companies that fund their own employee health plans. Often, not even employers get to know what prices their own health care plans are paying doctors and hospitals. Meanwhile, mere policy makers and individual citizens are left completely in the dark—because, well, reasons.

“Between overpriced providers not wanting to share prices publicly because they don’t want to lose business, and some insurers not wanting their competitors to know what they are paying, there are a lot of powerful interests against transparency,” says Suzanne Delbanco, executive director of Catalyst for Payment Reform, which represents employer-sponsored health care plans. In other words, both insurers and hospitals have something to lose by disclosing prices. It’s worth noting, too, that in secret negotiations between the biggest and most powerful insurers and providers, both sides of the table usually wind up doing quite well for themselves while most of the pain is borne by the rest of us. So why would they ever change their secretive, collusive ways of doing business?

And that’s not the end of the absurdity. Because of American health care’s black-box pricing system, it’s impossible even for sophisticated researchers, let alone individual patients, to know which hospitals offer the best value. It’s like trying to choose the best barber shop when you can only learn after the fact how much a haircut costs—and each barber in the shop charges different customers different secret prices based on private negotiations with the customers’ employer or insurance company. 

In recent years, it has occurred to many people that just maybe the U.S. health care system would not be so expensive and inefficient if folks could at least see what the price of everything is. It’s not so much that, as some market conservatives hope, such a measure would necessarily make a big change in how individuals decide where to get care. True, it might influence where people with high-deductible health plans chose to get a scan or a purely elective surgery. But few of us are in a position to comparison shop, much less haggle, when it comes to the really expensive stuff, like when we are bleeding from a car accident or in the midst of a heart attack. Even in the best of circumstances, it’s hard to judge the quality of different health care providers, so a lot of us wind up assuming that the most expensive doctor or hospital will give us the best treatment, or we just go where our doctor sends us. 

And it is not as if making prices transparent would, by itself, end the rampant price discrimination against weaker market players that is among the most egregious, yet little-remarked features of our health care system. That particular injustice is brought to you by health care monopolists who use their market dominance to impose higher prices on those who lack the power to resist. 

But making all prices public would at least satisfy an essential precondition for health care researchers—like the Lown Institute and the Washington Monthly—to be able to rank hospitals according to their cost-effectiveness. Good data on health outcomes and other quality measures is needed as well, but without knowing the price of care we cannot know who provides the best value for the money. And being able to do that is critical, because it would give large insurers and employer-sponsored health care plans (including those run by state and local governments) an actual evidence-based foundation for deciding which hospitals, doctor groups, or other health care providers deserve their business and which do not.

In developing our “Best Hospitals for America” rankings, we and our partners at the Lown Institute spent many months trying to get data on how much different hospitals charge people with private insurance and how they treat them. But in the end, we could not pierce the veil of secrecy. Some states collect such data by collating it from private insurance claims, and the RAND Corporation has data on hospital prices in 25 states. But until until all hospitals and insurers publicly report prices in a consistent way, national rankings remain unobtainable. Two nonprofit organizations, the Health Care Cost Institute (HCCI) and FAIR Health, have managed to get their hands on valuable proprietary price information and have used it to document vast disparities among hospitals, nationally and regionally, in their costs and use of different tests and procedures. But insurers demand that both organizations never disclose specific hospitals’ price and claims information, Niall Brennan, CEO of HCCI, says. (A spokesman for FAIR Health declined to comment for this story.)

Going forward, at least some health care prices may become more transparent. The Trump administration, for example, released rules last November requiring hospitals and health insurers to publish their privately negotiated rates for hundreds of non-emergency, “shoppable” services. More recently, in the wake of the coronavirus crisis, it has threatened to make greater price transparency a precondition for hospitals receiving bailout funding. Hospital groups are fighting in court to block the yet-to-be-enforced hospital rule, arguing that it’s overly burdensome and that the government lacks authority to require the disclosure of prices, which the groups call “trade secrets.” On June 23rd, a federal judge upheld the rule, but the American Hospital Association has announced it will appeal the decision.

The conservative policy wonks who have sold the Trump administration on this position may be misguided in believing that it will, by itself, do much to drive down health care prices, not least because most of the money in health care goes for medical services that are not “shoppable.” Moreover, transparency in pricing alone does not fix the monopoly problem in the United States or provide the kind of quality metrics needed to evaluate cost-
effectiveness. 

But even if based on faulty assumptions, these new rules are still a step in the right direction. Government could, of course, just end price discrimination by setting uniform prices in health care, as is done in most other industrialized countries. The state of Maryland has actually done this since the 1970s, making it an ongoing experiment in price setting within the United States. Uniform prices are also part of “Medicare for All” plans like those proposed by Elizabeth Warren and Bernie Sanders. But short of that, any other policy to make our health care system more cost-effective—like a public option, advanced by Joe Biden—can’t be done smartly unless we know what the price of health care is for everyone.

This story has been updated since it appeared in print to include the June 23rd ruling.

The post Why Hospitals Keep Their Prices Secret appeared first on Washington Monthly.

In early March, public health officials issued warnings about what the spreading coronavirus could mean for the Pittsburgh region. Debra Bogen, director of the health department for surrounding Allegheny County, forecast that between 40 to 60 percent of the adults in western Pennsylvania could come down with COVID-19 unless strong mitigation measures were taken. The Harvard Global Health Institute predicted that Pittsburgh-area hospitals could need between 480 to 720 percent more beds than were currently available. Meanwhile, federal officials, ranging from the surgeon general of the United States to scientists at the Centers for Disease Control and Prevention, warned that hospitals would spread the contagion further if they continued performing non-urgent care. 

Heeding this expert advice, Pennsylvania Governor Tom Wolf issued an executive order on March 19 requiring all the state’s hospitals and doctors to stop performing elective procedures. Such surgeries are highly lucrative. But hospitals understood the gravity of the situation, or at least recognized Wolf’s authority. Systems throughout the state quickly complied. 

Except one. 

In their headquarters atop the 64-story former U.S. Steel Tower in downtown Pittsburgh, executives of the University of Pittsburgh Medical Center (UPMC), a $21 billion hospital chain and health insurer, took a different course. Ignoring not only the governor’s order but also an open protest letter signed by 291 of their own doctors, UPMC decided on March 20 that the 40 hospitals they control would continue conducting elective surgeries. 

At a press conference, UPMC tried to justify its decision by asserting that there were only five known COVID-19 cases in the Pittsburgh area at the time, and that, despite insufficient numbers of tests, they were monitoring the situation closely. They also argued that they weren’t technically violating the governor’s order because the elective procedures weren’t really elective, at least as they used the term. “ ‘Elective’ commonly means scheduled cases, but scheduled does not mean unnecessary,” Donald Yealy, UPMC’s chair of emergency medicine, said. Bogen disputed those semantics. “We ask that UPMC, like all the other health care providers in our community, begin to address this request from the governor and from us,” she said. The Pittsburgh Post–Gazette, the city’s leading newspaper, lambasted UPMC for its decision. The hospital system, they wrote, was “endangering lives by continuing to perform elective surgeries despite pleas by state and local health officials to postpone them.” 

It wasn’t as if UPMC’s managers could not afford to do the right thing. Though chartered by the state of Pennsylvania as a nonprofit, charitable institution affiliated with the University of Pittsburgh’s medical school, UPMC has morphed over the past three decades into a money-making machine. According to its latest financial statement, the corporation commands reserves amounting to $5.5 billion in unrestricted cash and investments. Nor are UPMC’s executives hurting for money. In 2018, UPMC President and CEO Jeffrey Romoff, who has said he seeks to make UPMC “the Amazon of health care,” took home $8.54 million, while 33 other executives each earned more than $1 million. As the editors of the Post–Gazette wrote, “This cannot be a medical decision. It’s a greed decision.”

The tense relationship between UPMC and its surrounding communities has been building for years. A wide range of voices—from civil rights and labor leaders to local politicians and Pennsylvania’s attorney general—have long accused the corporation of shirking its civic responsibilities, jeopardizing access to health care for millions of local residents, stripping doctors of their independence, and leaving rank-and-file health care workers struggling to make a living wage. 

Pittsburgh, however, is not the only city with growing acrimony surrounding a nonprofit hospital. Most major metropolitan areas of the United States now feature large medical systems, typically affiliated with a local university, that wield extraordinary economic and political power. These institutions typically enjoy high margins because they face little competition, having spent the last several decades buying up, and often shutting down, rival hospitals. They are then able to charge monopoly prices for highly lucrative specialty treatments while downplaying medical services, like mental health and primary care, that don’t pay well. They advertise these high-end treatments to rich medical tourists from across the world, offering them deluxe accommodations, while ignoring the poor and working-class residents who live, quite literally, next door. 

Legally, however, these institutions are still considered charities. That’s despite not just negligent attitudes toward their communities, but also their bottom lines. Many major academic medical centers make big profits. According to a study published in Health Affairs, seven of the 10 most profitable hospitals in United States are officially “nonprofits.” An analysis by Axios of 31 prominent nonprofit hospital systems found that their margins are on par with some pharmaceutical corporations and medical device makers, and well beyond those of insurers and drug distributors.

These corporations have escaped intensive countrywide (if not local) scrutiny because they enjoy strong national reputations, based mostly on the specialized procedures they practice. UPMC’s flagship hospital, Presbyterian Shadyside, regularly appears on U.S. News & World Report’s “honor roll” of the top 20 hospitals in America and draws in well-heeled patients from around the world with procedures like angioplasties and pacemaker implants. But as a rule, these same institutions tend to do poorly on measures that people in their surrounding communities rightly consider part of the mission of charitable institutions. Presbyterian Shadyside, for example, treats a disproportionately large number of wealthy patients relative to the demographics of its surrounding community. Partly as a result, in the Washington Monthly and Lown Institute’s “Hospitals for America” rankings, which give weight not just to clinical excellence but also to public service (see page 14), UPMC’s Presbyterian Shadyside scores poorly. Out of 3,285 hospitals ranked nationwide, it places 3,138 for civic leadership and 2,424 overall. 

How did this happen, and what can we do about it? By examining the evolution of UPMC’s culture and business practices, we get a case study in the creeping corporatization of America’s “nonprofit” health care sector and the steps needed to once again make it serve the public interest. 

UPMC’s origins trace to the 1920s, when local industrialists and civic leaders looked for ways to help Pittsburgh overcome its image as a social and cultural backwater. Toward this end, they focused on creating a teaching hospital for the University of Pittsburgh’s medical school that they hoped would attract more talented doctors and students. Through heavy investment, they succeeded. By the early 1950s, Pitt’s medical center had attracted the right physicians and was becoming world famous. The most renowned member of its faculty was the virologist Jonas Salk, who along with his close colleagues pioneered the polio vaccine. 

The hospital continued to rise throughout the latter half of the 20th century, with broad benefits for Pittsburgh’s residents. The medical center created jobs both for high-paid professionals and for rank-and-file health care workers. That included a large share of African American women who, though grossly underpaid, found employment at the medical center as nurse’s aides, food service workers, and cleaning staff. During the late 1960s, the medical center partnered with local foundations and the federal government’s “Model Cities” initiative to create the highly successful Freedom House ambulance service, which focused on creating a career path for low-income black youths to become middle-class medical technicians. Moreover, many residents, including substantial numbers who lacked insurance, gained access to a modern, highly sophisticated hospital system.

But over time, UPMC’s relationship with the surrounding community became increasingly fraught. An early flash point came in 1970 when Coretta Scott King, widow of the slain civil rights leader Dr. Martin Luther King, came to the medical center to rally support for striking hospital workers, as she had previously done at Johns Hopkins Hospital in Baltimore. Before a large crowd she argued, “The truth is that the large majority of hospital workers are black, most of them women. Their campaign for a union is part and parcel of the struggle going on everywhere for dignity.” But even in a strong union town, her efforts were to no avail. The hospital broke the union. To this day, UPMC’s labor force remains un-unionized, and many of its workers still protest that they do not receive a living wage. “We’re understaffed, underpaid,” Nila Payton, an administrative aide, says. “We do not have affordable health care even though we work for the health system.” 

During the 1980s, the medical center’s power relative to other local institutions grew stronger and stronger. One reason was the collapse of the local steel industry. But another was the medical center’s own rapid expansion into lucrative lines of specialty medicine, particularly  leading-edge operations like liver transplants, that gave it huge financial leverage. 

A key figure in that transformation was Thomas Detre, a psychiatrist who became a powerful hospital administrator. According to a corporate history of UPMC by Mary Brignano entitled “Beyond the Bounds,” Detre raised eyebrows when he arrived in Pittsburgh for his habit of “chain-smoking Marlboros through an ebony holder” and his tendency to wear a topcoat draped around his shoulders. Detre built his own fiefdom within the University of Pittsburgh based initially on his ability to raise large amounts of grant money from the National Institutes of Health, and later by forming a cancer center that brought in huge revenue streams. By controlling so much money, Detre was able to consolidate power from other parts of the university into a stand-alone corporation that came to be known as UPMC, with himself in charge. 

The other key figure was Jeffrey Romoff, UPMC’s current president. A brash and outspoken Bronx native, Romoff emerged as UPMC’s leader after Detre suffered a heart attack in 1992. In a lecture to the faculty of the University of Pittsburgh’s medical school in 1995, he set the tone for his administration by articulating his vision for the future of American health care. “At the heart of the matter is the conversion of health care from social good to a commodity,” he told the assembled doctors and professors.

To increase UPMC’s profits, Romoff moved aggressively to acquire free-standing outpatient facilities, such as surgery centers, particularly in Pittsburgh’s affluent suburbs. Then he started buying up local community hospitals and independent doctor’s practices, converting them into referral networks for UPMC’s main medical center. UPMC’s empire now stretches across Pennsylvania and even includes dozens of foreign ventures, from Ireland and Italy to Kazakhstan and China. 

At least some of UPMC’s acquisitions include hospitals that combine clinical excellence with strong community services. McKeesport Hospital, founded in 1894 in what was then a great hub of steel production, was acquired by UPMC in 1998. Unlike UPMC’s flagship hospital, Presbyterian Shadyside, this small community hospital scores exceptionally high in the Washington Monthly hospital rankings because it manages the rare feat of achieving strong medical outcomes while treating a local patient population deeply threatened by poverty and other adverse socioeconomic determinants of health. It’s proof that, when it wants to, UPMC can manage socially responsible hospitals.

But McKeesport is the exception. More typical is Braddock Hospital. Located in a predominantly low-income African American suburb of Pittsburgh, Braddock was acquired by UPMC in 1996. It served as the area’s only emergency room and largest source of employment until 2010, when UPMC shut it down. It’s not alone. Since 2008, UPMC has shuttered three additional previously acquired major hospitals. This March, just in time for the pandemic, UPMC closed UPMC Susquehanna Sunbury hospital, in central Pennsylvania. Meanwhile, UPMC is spending $2 billion to build three new specialty hospitals in Pittsburgh, closer to its flagship. 

Romoff has had no problem raising the capital UPMC needs to finance these expansions. Revenue has climbed by nearly $5 billion since 2017, a 30 percent increase. Not only does the corporation have abundant cash flow, but as a nonprofit hospital and technically “charitable” institution, it has access to the tax-exempt municipal bond market. UPMC can also finance its empire building, as well as its generous executive compensation packages, by soliciting tax-deductible donations from individuals, foundations, and corporations, as well as grants from governments. Between 2005 and 2017, the public and private grants received by UPMC totaled $1.27 billion.

Romoff’s business model for UPMC has also included moving it into the health insurance business. UPMC now boasts being the “largest health insurer in Western Pennsylvania” with more than 3.7 million members. Last year, its health insurance division took in roughly $800 million more in premiums and other enrollment revenues than it paid out in medical claims. Even better for UPMC’s bottom line, 40 percent of the medical claims its health care plan does pay out goes for health care performed in UPMC’s own medical facilities, meaning that UPMC is effectively paying itself. 

Romoff and his executives don’t have to justify their business plans and compensation packages to stockholders, because as a nonprofit corporation, UPMC has no stockholders. Its 24-member board, which includes representatives from local banks and businesses that work with UPMC, has theoretical control over policy direction, but has consistently been criticized for its passivity by local politicians, community activists, and Pennsylvania’s attorney general. 

UPMC’s financial power also derives in part from its ability, as a nonprofit institution, to escape paying taxes on its ever-expanding property holdings. The system, as the single largest private employer in the Pittsburgh area, accounts for a dominant share of the local economy. Its exemption from local property taxes costs Pittsburgh’s schools and local-area governments a total of some $40 million per year. For decades, local governments and UPMC sued and countersued and lobbied against each other in the state capital over the fiscal imbalance this creates. Over the last ten years, the battle has reached a fever pitch. It’s become a long-running conflict known in Pittsburgh simply as “the war.”

The war started in 2011 when UPMC demanded that Highmark Blue Cross Blue Shield, one of the biggest insurers in the country, pay it higher rates for care performed in its facilities. By this point, UPMC not only controlled most hospital beds in the greater Pittsburgh area but was also a major insurance company itself. In response, and to try to level the playing field, Highmark purchased a small network of local hospitals in the Pittsburgh area that were not yet under UPMC’s control. 

In retaliation, UPMC sent a certified letter to its patients with Highmark insurance telling them they would need to find a new doctor. Without access to any of UPMC’s pervasive facilities, millions of people throughout western Pennsylvania found their access to health care and choice of doctor deeply constrained. One patient in the middle of cancer treatments had to find a new oncologist. Another with a debilitating autoimmune disease said she was dismissed from UPMC’s Arthritic and Autoimmune Center. A breast cancer survivor had to give up the doctor who had treated her since she was first diagnosed five years before. 

In 2012, state officials managed to negotiate a five-year truce between UPMC and Highmark. But it didn’t last. UPMC continued violating parts of the agreement. When it expired, the system announced that all Highmark enrollees would again be denied access to its system. Indeed, UPMC went further. It decreed that going forward it would require out-of-network patients, including seniors on Highmark Medicare Advantage, to pay all estimated charges up front and in full before receiving treatment for non–emergency room services. 

The resulting public outrage prompted Pennsylvania State Attorney General Josh Shapiro to sue UPMC in February 2019, arguing that it “willfully engaged in unfair, fraudulent or deceptive acts or practices,” such as “excessive and unreasonable billing practices inconsistent with its status as a non-profit charity providing healthcare to the public.” UPMC countersued, but after a federal judge threw out its case, the corporation decided to resolve the attorney general’s suit out of court. It agreed to sign a contract with Highmark giving Highmark’s customers in-network access to UPMC doctors and hospitals for another decade. In exchange, UPMC got to keep its tax-exempt, nonprofit designation. 

For now, that may stabilize the situation. But in the wake of the coronavirus, it’s likely that UPMC’s monopoly power will grow still more. For many independent rural and community hospitals in Pennsylvania, which were already losing money or barely getting by, the blow from the pandemic will be mortal. At a media briefing in April, Andrew Carter, president and CEO of the Hospital and Healthsystem Association of Pennsylvania, told reporters that “it won’t take long for some hospitals to collapse.” But not UPMC. While the system’s revenues took a hit after the spreading contagion eventually forced it to postpone many lucrative elective procedures, the situation should prove quite manageable. A memo leaked to the Pittsburgh Post-Gazette dated April 15 showed that UPMC was by then already ramping up to do more elective surgeries. It has told its surgeons to reclassify these procedures with terms such as “urgent,” “cancer,” “unstable,” and “relief from suffering” in reports.

There was a time when America’s leading “nonprofit” hospitals were, in fact, nonprofits. When they were first established, institutions like UPMC, the Cleveland Clinic, and Johns Hopkins combined three public missions: They engaged in medical research; they educated the next generation of doctors; and, in the process, they cared for patients who often could not afford to pay. All of these missions were money losers. And because of that, these institutions were typically viewed, both in public opinion and under law, as charities. Governments supported these charities by granting them charters to operate as nonprofit corporations, and then offered deep direct and indirect subsidies, including sweeping tax exemptions. 

But today, the arguments that have historically justified the public’s mostly unqualified support for these institutions are virtually divorced from reality. Unlike when most of these hospitals were founded, the cost of medical research is now largely covered by government grants (23 percent) and private industry (65 percent). The cost of medical training is largely borne by grants from Medicare and other federal programs that more than reimburse hospitals for graduate medical education programs. Indeed, teaching hospitals make money on the medical services their residents provide.

Finally, the type of medicine now practiced by many elite academic medical centers isn’t focused on the broader health care needs of their surrounding communities. Instead, it’s care delivered almost exclusively to patients with public or private insurance. Indeed, at the largest and most famous academic medical centers, the focus is often on attracting VIPs from around the world who pay top dollar for specialized treatments in luxury surroundings, even as residents in the surrounding neighborhoods see their health care needs go unmet. 

The main campus of the Cleveland Clinic, for example, is surrounded by low-income neighborhoods that are federally designated as “medically underserved areas.” Most lack access even to adequate primary care. Yet the clinic focuses on its services to VIPs, including large contingents from Saudi Arabia’s royal family, who enjoy the privileges of being “Premier Executive Health patients.” These privileges, boasts the clinic’s website, include “personal attention and luxurious suite accommodations found on the exclusive Club Floor of the InterContinental Hotel on Cleveland Clinic’s campus.” Not to be outdone, Johns Hopkins’s main hospital, located in inner-city Baltimore, counters with its newly renovated Marburg Pavilion, which, according to its website, offers “deluxe rooms” with “original wood details,” “patios with view of the medical campus,” “special dining service,” “fine bed linens,” and “specialty bath products.” 

All these trends have come together to create a new thing in the world: the charitable nonprofit hospital that has morphed into a profit-driven, tax-exempt, publicly subsidized monopolistic corporation focused on lucrative luxury care for the well-to-do. 

What can be done to make these institutions once again serve the public? One powerful potential lever is threatening to take away their nonprofit status and all the gigantic subsidies, tax breaks, charitable contributions, and other privileges that go with it. Nonprofit hospitals, after all, operate under binding charters that require them to serve the public interest. According to the law, they can enjoy the protections of incorporation only so long as they serve some public purpose and not inure to the benefit of any private shareholder or individual. This means that it is well within the statutory powers of state attorneys general to put any nonprofit corporation operating within their states under new management if it fails to act in the public interest, or, alternatively, to strip it of its nonprofit status. It was just such a threat that enabled Josh Shapiro, Pennsylvania’s attorney general, to force UPMC to deal fairly with Highmark customers. 

Legislation sponsored by Dan L. Miller, the Pittsburgh-area state representative, would go further. It would cut off state funding for any nonprofit that failed to adhere to fair labor standards or failed to set aside at least 20 percent of the seats on its governing board to people elected by workers.

Similarly, if a nonprofit hospital acts uncharitably or otherwise fails to produce real community benefits, the federal government has ample statutory authority to yank its nonprofit status and force it to pay federal income taxes. Moreover, both the federal government and the states have all kinds of antitrust and other anti-monopoly laws that, if properly enforced, would put an end to the kind of predatory and anticompetitive business practices that now pervade the world of “nonprofit” corporate medicine. If UPMC or other nonprofit hospitals decided that they wanted to convert to for-profit corporations, they would still need a state license to practice medicine, meaning that governments would still have a lot of power to demand more responsible corporate citizenship. 

Of course, if health care providers like UPMC return to their historic mission, they will need a way to pay their bills. Quality health care and health promotion—the kind that actually improves public health through prevention and helping patients manage chronic conditions—is by its nature a public good. And that means it generally does not, cannot, and should not earn a profit. If we want nonprofit hospitals to operate truly in the public interest, we can’t put them in a position in which they either bend their practice of medicine to maximize revenues or else get eaten by predators who do. Public interest medicine needs public funding, and control. 

In the battle with COVID-19, we are learning how much we owe to the sacrifices of frontline doctors and other health care workers and how much public health depends on everyone having access to quality, affordable health care. But “Medicare for All” or other means of expanding health care coverage won’t get it done if our health care delivery system remains dominated by corporations that put self-enrichment before social mission.

The post Elite Hospitals Have an Epidemic of Greed appeared first on Washington Monthly.

We defined our set of hospitals based on the ability to calculate mortality rates using the Medicare Provider Analysis and Review administrative claims data set. Hospitals with fewer than 50 admissions per year were excluded. Hospitals specializing in cancer care and orthopedic or cardiac procedures were also excluded. Information on hospital characteristics was obtained from the American Hospital Association annual survey and from Medicare. We excluded hospitals that were not acute care or were located outside the 50 states and Washington, D.C. We also excluded federal hospitals, such as hospitals in the Veterans Health Administration, and hospitals where a majority of patients are covered by Medicare Advantage (Kaiser Permanente, for example). This left 3,359 hospitals, 542 of which are for-profit, 2,188 nonprofit, and 629 public.

Patient Outcomes

The patient outcomes category is made up of three components: clinical outcomes, patient safety, and patient satisfaction, which were weighted in a ratio of 5:2:1 respectively. This weighting ensured that clinical outcomes had the greatest impact on the final patient outcomes score. Clinical outcomes is composed of risk-standardized rates of mortality and readmission, weighted 4:1. Mortality includes rates of in-hospital, 30-day, 90-day, and one-year mortality. These were weighted in a ratio of 4:4:2:1 respectively in an effort to balance the effects of hospital-based care with post-discharge care and coordination in the community. For the readmission component, we equally weighted 30-day readmission rates, a standard measure of quality, and seven-day readmission, as published data suggests that the hospital-attributable component of readmission rates wanes by the seven-day mark.

Hospitalization and readmission rates were calculated after adjusting for patient risks using the Risk Stratification Index (RSI), a Lown Institute–specific version of a machine-learning algorithm in the public domain that has been validated on multiple national, state-based, and hospital-based data sets using billions of insurance claims. The RSI has been shown to predict outcomes with greater discriminatory accuracy compared with other publicly available risk-adjustment tools. 

For patient safety, we used well-established indicators such as rates of pressure ulcers, accidental punctures, and central intravenous line infections, provided by the Centers for Medicare and Medicaid Services (CMS) on its Hospital Compare website. This included the CMS composite measure (PSI 90) from 2017, which comprises 11 different measures of patient safety. It also included measurements of hospital-acquired infections. Like the CMS, we excluded critical access hospitals since almost all were missing data. The CMS was also the source of our patient satisfaction ranking. The CMS relies on the annual Hospital Consumer Assessment of Healthcare Providers and Systems survey to give a rating of patient experience across 11 variables. (For more detail and a listing of the 11 measures used, please see the Lown Institute’s methodology white paper, available on the Lown Institute’s website, and the CMS Hospital Compare website.)

Civic Leadership 

Our second category, civic leadership, comprises three components: community benefit, inclusivity, and pay equity. 

Community Benefit

For nonprofit hospitals, we used the Community Benefit Insight (CBI) data set generated from Internal Revenue Service 990 forms. We looked at the subset of community benefit spending we deemed to be meaningful: charity care (free or discounted care provided on the basis of the patient’s financial situation); subsidized health services, such as free clinics; community health improvement activities such as free immunizations; contributions to community organizations; and community-building activities, such as setting up farmers’ markets and providing housing for homeless patients. We did not use several categories of community benefit reported on 990 forms, including the following: shortfall from Medicaid and other government means-tested insurance programs (the difference between the amount Medicaid or other programs pay and the costs to hospitals for caring for such patients); health professional training (which is already largely subsidized by the federal government); and research (also heavily subsidized by the federal government). The final score for community benefit is the ratio between community spending over total hospital expenses, which were gathered from IRS data and CMS’s Healthcare Cost Report Information System (HCRIS). 

Of the categories of community benefit we deemed meaningful, charity care was the only one available across all hospital types via the HCRIS data set. It was therefore the central community benefit measure used. For nonprofits we also used other meaningful categories that were available via CBI and IRS data.

For hospitals with both HCRIS and IRS data, we weighted the results equally. Finally, we adjusted for the fact that hospitals in states where Medicaid did not expand are likely providing more charity care compared with hospitals in expansion states. We calculated the percent of gross revenue from Medicaid and added it to the final community benefit score with a weighting of 1:2 respectively. 

Inclusivity

Inclusivity is a novel metric we have developed to measure the degree to which a hospital’s patient population reflects the demographics of its catchment area. We defined catchment area by using the zip codes of the hospital’s patient population, sorted by the number of patients each zip code supplied. We then defined the radius of the catchment area as the distance to those zip codes whose contribution to the total patient population became insignificant. The median radius was 26.6 miles, with urban settings having far smaller radii than rural hospitals. We calculated the demographics by using census data on income and education as proxies for social class, and self-reported race/ethnicity for race. For each variable, inclusivity is the ratio of patients coming to the hospital compared to that measure’s prevalence in the population of people who could have come to the hospital from within its catchment area. 

To calculate the denominator, we applied the U.S. Census Bureau’s American Community Survey data for people over the age of 65 on race, income, and education levels within all zip codes that fell within the defined hospital catchment area. We calculated each rate using the total population counts. We exponentially reduced the contribution from zip codes beyond the point at which 50 percent of a hospital’s patients had come. We created the numerator of the ratio by using the demographics from zip codes of patients admitted, weighted by contribution to the total, and without a distance attenuation. We then compared the catchment area score to the hospital score to obtain an inclusivity ratio. 

Pay Equity

For pay equity, we obtained data about CEO compensation from three sources: for nonprofit hospitals, we used the IRS 990 forms; we acquired information on for-profit, publicly traded hospital systems from Securities and Exchange Commission filings; and we gleaned information about public hospital CEO pay from publicly available records. When CEO pay was unavailable, we imputed it using known values in regression models. 

We obtained average worker wages from two sources: HCRIS and the Bureau of Labor Statistics (BLS). HCRIS wage index information contains hourly wages for all employees. We included lower-wage staff, such as janitorial and medical records personnel, and excluded professional staff such as physicians and nurse practitioners, whose jobs require specialized degrees. For the 704 hospitals that had incomplete wage index information in HCRIS, we used BLS estimates of wages for health care employees within those metropolitan and non-metropolitan statistical areas. We estimated hourly wages for CEOs based on a 60-hour workweek and then calculated a ratio of CEO pay to average worker pay. For hospital systems, we distributed the system CEO salary among the constituent hospitals using the percentage of total revenue each hospital generated.

We then combined a hospital’s community value, inclusivity, and pay equity scores with equal weighting to obtain the civic leadership score. 

Value of Care

The value of care category is based on a single component measure: overuse. This includes rates of overuse for 13 low-value medical services, including: hysterectomy for benign diseases; laminectomy and/or spinal fusion without radicular pain; arthroscopy for knee arthritis; vertebroplasty or kyphoplasty for osteoporotic vertebral fractures; carotid endarterectomy in asymptomatic patients (those with no history of stroke, transient ischemic attack, or focal neurological symptoms); carotid artery imaging for syncope; EEG for syncope; head imaging for syncope; EEG for headache; inferior vena cava filter; pulmonary artery catheter placement in nonsurgical conditions; coronary artery stenting for stable coronary angina; and renal artery angioplasty or stenting. We chose these based on a substantial literature on overuse. Some of these services have been shown in high-quality clinical trials to be ineffective and are always considered overuse. Others are considered overuse whenever prescribed to patients without certain symptoms or indications.

We used the methods reported in the literature by reputable researchers to calculate rates of overuse. We used the 100 percent Medicare claims data sets to search for instances when these services were used. Hospitals without the capacity to perform a specific service were excluded from a rating for that service, and hospitals without the capacity to perform any of the 13 services were excluded entirely from the overuse ratings. We counted the number of instances of overuse by hospital for each service. We adjusted observed overuse rates to account for volume differences. We then used a statistical method called principal components analysis to reduce the data down to one variable to create an overuse score. 

The post How We Calculated the Best Hospitals for America appeared first on Washington Monthly.

Ten years ago this fall, two dear friends of mine, the journalists Shannon Brownlee and Phillip Longman, joined me at the Washington Monthly offices to hash out an idea: creating a ranking of the nation’s hospitals to compete with U.S. News & World Report’s “Best Hospitals” list, just as the Monthly had done with its alternative college guide.

The three of us had worked at U.S. News in the 1990s, and Shannon and Phil had recently published seminal books about health care quality and cost that had been road-tested as articles in the Monthly. So we had an inside sense that U.S. News’s hospital rankings suffered from the same basic design flaws as its college rankings. Both elevated (and still do) prestigious institutions that primarily cater to the elite at the expense of those that serve the rest of us, using metrics that are as dubious as they are destructive. Their hospital rankings focus almost exclusively on expensive specialized treatments and surgeries, like organ transplants. Meanwhile, they ignore the bulk of what most hospitals do, which is treating patients for more routine ailments, like broken bones and pneumonia. And they rely heavily on a survey of medical specialists, effectively boosting the ratings of hospitals with high national brand-name recognition, while downgrading or ignoring others that score better on measures of cost and value. The latter failing is especially damaging, given that health care costs for most privately insured Americans have been rising for years at twice the rate of wages. 

Taking on U.S. News made sense to us because its rankings have real power. Hospital administrators all over the country devote considerable energy to climbing them—and then bragging about it on expensive billboard ads—because doing so helps bring in more well-insured patients. Yet such behavior also fuels the profligate and inegalitarian tendencies of our health care system.

We spent weeks back in 2010 looking into the specifics of building a robust alternative hospital ranking and quickly realized that it would take considerable funds, especially for computational expertise we lacked. When we couldn’t find a funder, we shelved the project. But whenever we’d get together after that—often over dinner at each other’s homes—we’d wind up excitedly talking about reviving the idea. It was our data journalism white whale.

Then, a couple of years ago, we had a breakthrough. Shannon was by then working at the Lown Institute, a health care think tank that was pioneering a new machine-learning algorithm to assess hospital care quality and overuse. She and her colleague Dr. Vikas Saini saw a way to apply the tool to the task of ranking hospitals, and the Lown board agreed to fund the effort. They then hired a crack team of data researchers and empaneled an expert advisory board (on which I was the least qualified member) to provide feedback to the data team, a process that took the better part of two years. After two more months of biweekly Zoom calls with the Monthly’s editors, Lown completed the rankings we’re debuting in this issue.

Though the 10-year wait was frustrating, it had a couple of upsides. First, it delayed publication of our rankings until a moment—the middle of the COVID-19 crisis—when citizens and policy makers are more aware than ever before of the public service role America’s hospitals play. This is very un-Monthly-like. Typically, the magazine tries to focus its reporting on subjects that the nation isn’t paying attention to but should be—like the growth of monopoly capitalism, or the promise of voting by mail, ideas we were a lone voice in covering for nearly a decade before they became popular topics of conversation. As Phil likes to say, we write about “solutions to problems people don’t know they have.” But with this issue, we’re actually on top of the news. What a concept!

Second, the long deferment gave us time to sharpen our thinking about the key role hospitals play—or in many cases don’t play—in serving the health care needs of the less well off in their surrounding communities. This is a subject that cannot be morally ignored now that we’ve seen the disproportionately high rates of COVID-19 infection and death among black and Hispanic Americans. The Lown Institute devised smart new ways of assessing the degree to which hospitals behave equitably, along with their clinical outcomes and record of curbing overtreatment. This gave us a set of metrics that are very different from U.S. News. Rather than rate hospitals narrowly—on how they do with complex surgeries regardless of the amount they spend or who they treat—the Monthly rates them broadly: on how well they save lives, save money, and serve everyone. 

Not surprisingly, the results of our rankings are quite different, too. All of the names on U.S. News’s top 20 “honor roll” are famous teaching institutions, like the Mayo Clinic and Johns Hopkins Hospital. Not one of those institutions made it onto our top 20 list. Instead, ours is comprised of a mix of teaching, safety net, and community hospitals whose names—Mercy Health–West Hospital in Cincinnati, Ohio; Providence Centralia Hospital in Washington State—are largely unknown outside their local areas. While they might not be on the cutting edge of medical research, they are arguably doing something much harder, because so few hospitals can manage it: They are taking in a diverse patient population, healing those patients, and not overtreating them. 

We think every American ought to have access to institutions like these. And if the hospital sector needs another bailout because of the pandemic—as it almost certainly will—we hope lawmakers, inspired by our rankings, will demand some accountability for all that money. We’d also like to see Washington mandate that hospitals and insurance companies make public the prices paid for specific procedures—which, amazingly, they don’t—and crack down on hospitals that abuse their nonprofit status by acting like predatory for-profit monopolies.

Can an alternative hospital ranking from a small magazine really have a substantive impact on America’s health care system? Well, there’s no doubt that over the past decade and a half our alternative college rankings have helped shift the national policy conversation about higher education—from a reverential preoccupation with the exclusive, expensive universities that dominate the U.S. News list to a greater focus on colleges that provide quality degrees at reasonable prices to students of modest means (and do well on our rankings). So, yeah, we think we can make a difference.

Elsewhere in this issue of the magazine you’ll find another project we hope will have a positive impact on the world—in a more modest if no less personal way. It is an announcement of the finalists and winners of the Kukula Award for Excellence in Nonfiction Book Reviewing. 

The award, new in 2020, is named for the late Kukula Kapoor Glastris, the magazine’s longtime and beloved books editor (and my wife of 31 years). After she passed away, three years ago—from, of all things, a respiratory illness—my kids and I decided we wanted to honor her memory by creating some kind of award for a cause she believed in. We quickly settled on a prize for nonfiction, public affairs–oriented book reviews—the kind that Kuku devoted herself to commissioning and editing. 

Amazingly, no such prize existed, despite the vital role nonfiction book reviews play in the ecology of journalism. As a practical matter, they transmit hard-won reporting, research, and ideas to policy makers, influencers, and plugged-in citizens who aren’t remotely able to read more than a tiny fraction of the important books released each year. At their most elevated, they provide writers with a platform to develop their own ideas.

As with the hospital rankings, it took longer than we expected to launch the Kukula Award; we managed it only thanks to the generous support of friends and family and long hours of work from my colleagues. We received more than 100 entries from scores of publications large and small. An esteemed panel of judges joined me in reading through them, and—with some difficulty, because the quality of the submissions was generally quite high—we chose the finalists and winners. The two winners each received a prize of $1,000.

After years of financial distress, media outlets are less and less inclined to devote the resources necessary to publish these kinds of reviews—or, at any rate, to pay writers enough to do the job well. But the positive response we got from publications and the overall excellence of the submissions shows that quality nonfiction book reviewing is not yet a lost art. Our hope is that the Kukula Award will inspire more publications to practice it.

Kuku had a special talent for this kind of work—a combination of a fine literary ear and an expansive view of the kinds of books the Washington Monthly should review. If it were up to me, we’d have mostly focused on policy tomes, but she insisted on also commissioning reviews of books on everything from history and religion to pop culture. In celebration of the award, we’re publishing an expanded edition of our book review section in this issue. It, too, covers an eclectic range of subjects—from the psychology of boredom to the capacity of animals to create culture. My heart is filled with joy to know that the young Monthly editors who chose the books and commissioned and edited these reviews are channeling Kuku’s spirit. 

The post A Hospital Ranking That Makes Sense appeared first on Washington Monthly.

In the long and mostly disappointing history of women in American politics, 1992 is widely considered a pivotal year. Fueled in part by outrage over Anita Hill’s treatment by an all-male Senate Judiciary Committee during Clarence Thomas’s Supreme Court nomination hearings the previous fall, voters elected a record number of women to the House and Senate.

Headline writers would soon dub 1992 “The Year of the Woman.” In the popular imagination, that phrase has come to evoke the beginning of a decisive upward trajectory for women in elective office. But it was always a bit of a misnomer. Of the 24 women elected to the House in 1992, 20 were Democrats—as were all four of the newly elected senators. A more accurate description would have been “The Year of the Democratic Woman.”

That label would also have foreshadowed the path of progress for women in the years since.

The next 30 years of data tell a consistent story of two lines diverging. In 2004, 52 Democratic women were elected to Congress, compared to 30 on the Republican side. But by 2008, the Republican women’s caucus was reduced to 21, while Democrats had climbed up to 69. Today, partly on the strength of another “year of the woman” in 2018, Democrats are up to 105 women. And Republicans? Twenty-two. In fact, while there are currently more Democratic women serving in the House than at any point in history, the number of Republican women in the House is the lowest it’s been since 1992. 

In light of the attrition, some Republicans are making a push to get more women elected in 2020. As of this writing, a record 220 (and counting) Republican women have filed to run in congressional primaries. Susan Brooks, a Republican congresswoman who has been vocal about getting more women to run, was put in charge of the National Republican Congressional Committee’s (NRCC) candidate recruitment efforts. Elise Stefanik, another House Republican, launched E-PAC, a political action committee, to support and raise money for GOP women candidates, with a focus on supporting their primary bids. (The “E” stands for “Engage, Empower, Elevate, and Elect.”) And more than half of the NRCC’s 22 “young guns”—House candidates that the party identifies as especially promising—are women. 

If Republicans are going to reverse the trend of the past nearly 30 years, it’s going to be thanks to candidates like Tiffany Shedd, who is running to represent Arizona’s First District. Her CV boasts a wide range of talents: natural resource lawyer, farmer, bilingual kindergarten teacher, homeschool mom, and 4-H certified shotgun coach. She grew up in Arizona and stuck around for law school. She realizes that she checks certain boxes for the party. “I don’t really have to guess or figure out, like, so-called ‘messaging,’ because I am the demographic we’re trying to win,” she told me in April. Her campaign ad tells the story of facing off drug smugglers trying to cross her land, interspliced with video of people climbing over border walls, clips of Alexandria Ocasio-Cortez speaking angrily, and Shedd shooting a rifle. On her campaign site, she pledges to work with Donald Trump to secure the border. 

The Republican establishment has lined up behind her. House Minority Leader Kevin McCarthy has endorsed her, and the NRCC named her a “contender,” one tier below a young gun. She’s got support from more than a dozen members of Congress, the Arizona Farm Bureau, a handful of woman-focused conservative PACs, and more. She ran in 2018 and didn’t make it out of the primary, but this year she has outraised her only remaining primary opponent by more than five to one. Her district is currently represented by a Democrat, but it voted for Trump in 2016. With all that backing, Shedd and candidates like her are a test case. The GOP has been remade in Trump’s image. Is there any room left for Republican women? 

There’s a Godwin’s law of conversations about women running for office: As a discussion runs longer, the probability of someone bringing up EMILY’s List approaches 100 percent. Founded in 1985 to back Democratic women who support abortion rights, it’s the bar against which other efforts to support women candidates are measured. The name is an acronym for “Early Money Is Like Yeast”—as in, it makes dough rise. Financial support at the start of a campaign signals a candidate’s legitimacy and helps bring in other donors. 

Many of the women it has backed have not only gone on to win office but have stayed in power for decades. Barbara Mikulski, one of the first two women the group supported in the 1986 midterms, went on to become the longest-serving woman in the history of Congress. (She retired in 2016.) In 1992, the organization was profiled on 60 Minutes, drawing national attention, and it grew its network of donors by more than sixfold. Some of the women elected in 1992, like Patty Murray and Dianne Feinstein, are still serving and have ascended to leadership roles in the Democratic Party. In 2000, EMILY’s List started to help women who were running for state and local office as well, in effect building out the front end of the congressional candidate pipeline. For the 2018 midterms, the organization raised more than $100 million for the candidates they had endorsed. (Between Trump’s election in 2016 and the 2018 midterm elections, the group says, an unprecedented 42,000 women reached out to them to talk about running for office, compared to just 900 in the previous cycle.)

In addition to fund-raising, EMILY’s List recruits women to run for office. Staff spread across the country often spend months identifying women with potential. “Take a look at somebody like Kyrsten Sinema,” said Emily Cain, the organization’s coincidentally named executive director. EMILY’s List worked with Sinema when she was a state legislator running for the U.S. House, and then backed her again when she ran for Senate. It was the same with Maggie Hassan, who springboarded from the New Hampshire state senate to the governor’s mansion to the U.S. Senate. EMILY’s List backed all six of the current Democratic women governors, who outnumber Republican women governors two to one. Some, like Gretchen Whitmer in Michigan, have gained national exposure during the coronavirus pandemic. Whitmer has become the subject of Trump’s harshest attacks on governors, and is widely considered to be on Joe Biden’s list of potential running mates.

EMILY’s List is so effective that it plays an important complementary role to the formal Democratic Party. “The party in any given state is quite happy if they can nominate a woman who is going to get EMILY’s List support,” Debbie Walsh, the director of the Center for American Women and Politics at Rutgers University, told me. “It takes the pressure of fund-raising off the local party, and they can use those resources elsewhere.” 

Other factors have driven Democratic women’s steady gains. First, many of the Democratic women elected in the 1990s—like Nancy Pelosi—are now in powerful positions, setting off a positive feedback loop. Democrats have five women in leadership roles in the Senate and 11 in the House, compared to one and one on the Republican side. More women in the caucus means more advocates for promoting women within the party, and more role models for those considering a run for office. 

Policy commitments are also important. The party has consistently focused on issues that disproportionately affect women, like abortion, sexual assault, paid leave, and, more broadly, safety net programs, which women are more likely to access. Democrats have also almost exclusively benefited from the gains in Congress made by women of color, who helped drive the Democratic wave in 2018. Currently, there are 47 women of color serving in Congress, and 46 of them are Democrats. 

On the Republican side, there’s a long history of failed attempts to copy the success of EMILY’s List. WISH List, founded in 1992, was a PAC aimed at backing Republican women who were in favor of abortion rights. But by the early 2000s, its fund-raising was in decline, and in 2010 it folded in with another group. Then that group, Republican Majority for Choice, shut down in 2018. The Susan B. Anthony List PAC was created in 1992 to support women, on either side of the aisle, who oppose abortion access. (The name is an apocryphal reference to the legendary suffragist’s supposed pro-life worldview. The editor of Anthony’s papers has called that notion an “invented memory.”) The SBA List still exists, but it has shrugged off its rule of only supporting female candidates. VIEW PAC was founded in 1997 to elect more Republican women to Congress, but according to the organization, it has raised a total of less than $10 million since its founding. She-PAC, a group formed in 2012 to back Republican women running for state and federal office, barely got started before it shut down in 2016. 

Other groups have formed in the past decade—Maggie’s List in 2010, Winning for Women in 2017, and Representative Stefanik’s E-PAC in 2019 are a few. They point to the record number of women running this year as evidence that the tide may be turning. The Republican Party typically avoids supporting one candidate over another during the primaries, so when Stefanik pledged to throw her weight behind women in primaries, she got pushback. Tom Emmer, then the incoming NRCC chairman, said it was a “mistake.” Stefanik fired back, tweeting, “NEWSFLASH: I wasn’t asking for permission.” It seems now, though, that party leaders back the effort. “Kevin McCarthy and Steve Scalise have stepped up in tremendous ways,” Stefanik told me, referring to GOP leaders in the House, “and I think our model is working.” Both McCarthy and Scalise wrote checks to E-PAC soon after its launch. 

Still, history suggests tempering optimism. Women voters have shifted sharply away from the GOP under Trump. But even before Trump, Republican pro-women groups were making an identity politics pitch at odds with conservative ideology. Republican donors “reject affirmative action–type activities,” Laurel Elder, a political scientist and sociologist at Hartwick College in New York, told me. The candidates with the most merit, the thinking goes, will rise to the top. “They’re essentially opposed to making specific efforts to recruit women—or to recruit any group based on demographics—so it makes it challenging for these groups that are explicitly designed to try to recruit women to have a comfortable home in the party.”

This aversion to identity politics gets in the way of the groups’ ability to make a full-throated case for their cause. When I asked Olivia Perez-Cubas, spokesperson for Winning for Women, why her organization thought it was important to get more women into Congress, her first answer was that Congress should reflect the country. But that quickly came with a caveat. They’re backing their chosen candidates, she said, “not because they’re women, but because they’d be great members of Congress, and they’re great fits for their districts.” Winning for Women, though, doesn’t support male candidates—even if they’d be great members of Congress and great fits for their district. 

Above all, the effort to elect more Republican women has sputtered because there simply isn’t much demand for change among Republicans. A survey by the Public Religion Research Institute in 2016 found that just under 40 percent of Republicans agreed that the country would be better off with more women in public office. According to another study from the Pew Research Center, a majority of Republicans think we’ve already done enough on gender equality as a society, and almost 20 percent say we’ve gone too far. That puts groups like E-PAC in a pickle. Republican voters don’t think the problem they’re trying to solve is really a problem at all. 

Meanwhile, the trends that drove Democratic gains were mirrored on the Republican side, cutting in the opposite direction. The party, which had once had room for Nelson Rockefeller–style liberals, grew uniformly conservative, its base of power shifted to the South, and it became increasingly dependent on the votes of white evangelicals. The result of this ideological sorting, Elder said, is that that conservatism, “which used to hold back women across the board, is only holding back Republican women.” Her research demonstrates that the more conservative a district is, the less likely it is to elect a woman. “When the Republican Party started moving in a more conservative direction, that tracks almost perfectly with the emergence of the partisan gap and deteriorating performance of Republican women,” she told me. Michele Swers, a political scientist at Georgetown University, makes a similar point. If you look at the type of congressional districts over time that tend to elect women, these districts are usually more urban, more racially and ethnically diverse, and higher income, she says. “These days, that kind of district is electing Democrats.” 

As a result, not enough Republican women have risen through the ranks to create the kind of virtuous cycle that Democrats benefit from. Typically, leadership positions are filled by members who have been in Congress for years, often decades. There simply aren’t many Republican women who fit that description; many of the women elected decades ago have since lost their seats or resigned. Research shows that elected Republican women have historically been more moderate than their male colleagues, which has driven their attrition as the party has drifted ever rightward. “One of the lessons is that you have to have Republican women in all sorts of seats, not just swing seats,” Stefanik said. When women win office in deep red districts, they’re more likely to stick around in Congress and build seniority. “To some extent,” she continued, “that’s still a challenge we need to work through.” 

A week after the 2018 midterm elections, newly elected members of Congress descended on the Capitol for orientation. Ethical guidelines were reviewed; services of the Capitol police explained; catered meals eaten. Newcomers to the House gathered to take a group photo. Included in the snapshot were a record 38 women: 36 Democrats and two Republicans.

Then, that caucus of two faltered. As California’s Young Kim had headed to D.C. for orientation, votes in her Orange County district were still being counted. When the tabulation was complete, it turned out that her (male) Democratic opponent had narrowly won. Out of the more than 120 Republican women who had run for the House, only one new member, Carol Miller of West Virginia, would be taking a seat in the Capitol. 

Democrats had beaten their own records. Including incumbents, 89 women had been elected to the House on the Democratic side, a cohort that included the first two Muslim women, the first two Native American women, and the youngest woman ever elected to Congress. But in a year of record wins for women in Congress overall, Republican women had actually posted losses. A combination of retirements and unsuccessful campaigns meant that their ranks in the House had shrunk by almost half. In the Senate, the news was better, as the GOP increased from six to eight women—but still lagged behind the Democrats’ 17. (Since then, Kelly Loeffler of Georgia was appointed to fill an open seat, bumping their total up to nine.) “A record number of [Republican] women ran, but that certainly wasn’t reflected in the Election Day results,” said Perez-Cubas, the Winning for Women spokeswoman. “It was disappointing.”

Two thousand eighteen seemed like a low point, and yet 2020 could be worse. Two out of the 13 Republican women currently in the House have announced that they won’t be running for reelection—including Susan Brooks, who chairs the candidate recruitment efforts for the NRCC. Nearly half of the nine Republican women serving in the Senate are at risk of losing their seats in November: Martha McSally in Arizona, Susan Collins in Maine, Joni Ernst in Iowa, and Kelly Loeffler in Georgia. 

Loeffler, in fact, may turn out to be a good case study in how Republican efforts to promote women lose steam. She was appointed to the Senate by Georgia Governor Brian Kemp to fill a vacancy created by a resignation. Kemp’s logic appeared to go like this: Democrat Stacy Abrams had come within striking distance of the governor’s mansion on the strength of a young, diverse, urban coalition. The reliably red state was at risk of shifting to purple. If the Republican Party was going to maintain its power, it needed to expand its support among white suburban women. But most Republican elected leaders in the state were white men. Enter Loeffler, a longtime conservative donor, CEO of a financial services company, and co-owner of Atlanta’s WNBA team—and, of course, a woman. Trump, however, preferred Doug Collins, a loyal defender of his in the House and on many a cable news show. Kemp stuck with Loeffler, who took office in January and is up for election in November. 

During her first few months in the Senate, though, Loeffler has already gotten into hot water. In late January, before the public was alerted to the severity of the coronavirus crisis, she began selling stocks that would be adversely affected by it. In fact, she commenced the sell-off the same day the Senate Health Committee, on which she sits, held a members-only hearing about the pandemic. (Loeffler says that a third party makes trades on her and her husband’s behalf, without their knowledge.) Her odds of winning in November look shaky for other reasons, too; Collins has declared that he’ll be challenging her in Georgia’s primary. Since her appointment, The Cook Political Report has downgraded the Georgia Senate race from “Likely Republican” to “Lean Republican.” If Loeffler loses her seat—either to Collins or a Democrat—Trump will be emboldened to say “I told you so” and other Republicans may be less likely to promote women with the goal of expanding the party’s voting base in the future.

If GOP women are to expand their footprint, it will likely be thanks to people like Tiffany Shedd: candidates with ample backing and funding who are running in swing districts or districts where the incumbent isn’t running for reelection. There are other women who fit that description, like Young Kim, the Orange County Republican, who is running again in 2020. Or Beth Van Duyane, who is competing for an open seat in a Texas district rated “Republican toss up.” Or Ashley Hinson, campaigning for a toss-up district in Iowa currently represented by freshman Democrat Abby Finkenauer. If these Republicans do well in 2020, it could give the effort to elect more women some momentum.

But a spate of congressional wins would almost surely mean that Trump, at the top of the ticket, had won as well. A man who has driven women voters away from the party in striking numbers would continue to define its goals and values. “Frankly, at this point, the Republicans are still able to win elections, even though they’re fielding such a paltry share of female candidates,” Jennifer Lawless, a political scientist at the University of Virginia, told me. “Unless there are electoral consequences, it doesn’t really seem likely that there’s going to be a fundamental shift.”

But say 2020 is a bad year for the GOP—an increasingly likely outcome given rising unemployment claims and coronavirus deaths. Republican political elites might draw the opposite conclusion: that their efforts to elect women like Shedd were a waste, and that trying to get more women elected isn’t worth the investment. It’s possible, Rutgers’s Debbie Walsh said, that Democrats could elect equal numbers of men and women to Congress in 2020. “But,” she said, “we are never going to get to parity overall if only one party is working on recruiting and supporting women.”  

Kristina Karisch contributed reporting.

The post Why Can’t Republicans Elect Women? appeared first on Washington Monthly.

What’s the deal with Hispanic Republicans, anyway? For anyone following Hispanic politics, it’s a perplexing question. The GOP is associated with the rollback of policies that are intended to benefit minorities and communities at the economic margins—the very policies that made the vast majority of Latinos Democrats. The current standard-bearer of the party launched his presidential campaign by calling Mexicans rapists, and is regularly, famously, deeply insulting. And yet roughly 30 percent of Hispanics voted for him. Indeed, Republican candidates for the presidency have generally been able to count on 25 to 35 percent of the Latino vote for most of the past century. How could the party build a base of support stable enough to withstand what seems like constant attack? 

It’s a question that Geraldo Cadava, a professor of history at Northwestern University who specializes in politics, policy, and American Latinos, gets from his students and attempts to answer in his most recent book, The Hispanic Republican. As he explains, there are many reasons why some Latinos have embraced the GOP. Among Cuban Americans, Republican support has deep roots in Cold War anticommunism. Some Mexican Americans in the Southwest identify strongly with Spanish roots going back centuries, and, as Cadava writes, for complex reasons, identification with Spain became one of the hallmarks of Hispanic Republican identity. Some Puerto Ricans, for their part, connected to the party in the years during which Republicans flirted with the possibility of statehood for the island. And many Hispanics, like other Americans, simply embraced the GOP for its generalized commitments to free enterprise and liberty. 

But Cadava makes the point that Hispanic loyalty to the party can’t be understood through the simple lens of conservatism, and the book is a deep dive into the specific history that created a relatively stable and resilient base of Hispanics among the Republican ranks. Cadava introduces us to individual leaders who fostered ties between the Republican Party and their communities and details the outreach efforts that Republicans ultimately adopted in order to keep—and hopefully grow—a Latino base. What results is a chronicle of the ways in which a segment of the community, inclined toward Republicanism for historical reasons, worked with the party to create both substantive connections and symbolic signals of respect and inclusion. These tactics helped ensure that roughly 30 percent of Latino voters remain stalwart Republicans even now. 

Cadava introduces us to the political evolution of various Hispanic subgroups, beginning with the Eisenhower years. The book gets off to a bit of a dizzying start (there are a lot of constituencies to get to know, and each of them is quite different), but it hits its stride as it takes the reader through time. After Eisenhower, one of Cadava’s first major subjects is Arizona Senator Barry Goldwater, who in some ways symbolizes the GOP’s tortured political relationship with Latino constituents. Like many future Republican candidates, Goldwater’s staunch anticommunism attracted some Hispanics, but his opposition to civil rights put others off. “The views Goldwater expressed about civil rights contributed to his extremist reputation and to the suspicion of many Hispanics that he just didn’t like them,” Cadava writes.

In a sense, then, it’s paradoxical that the Republican Party’s abandonment of the civil rights mantle—firmly seized in the 1960s by Democrats—helped spur its aggressive courting of Hispanics. But after the Civil Rights Act was passed, the party had to search for ways to make up the support it knew it would no longer receive from African Americans. To help do so, Republican operatives turned to leaders in the Mexican American and Cuban American communities who had a deep allegiance to values like religion, free enterprise, and anti-communism. These leaders, not willing to abandon civil rights altogether, hoped that they could move the GOP toward adopting greater respect for immigrants and greater educational opportunity. They became some of the party’s earliest Hispanic boosters.

The Nixon administration worked with these leaders to nurture a strong anti-communist base (remember those Cuban American Watergate burglars?) and devise new patronage-focused strategies to engage Latino leaders. Nixon concentrated on delivering federal programs to support minority entrepreneurs, including Hispanics. He also oversaw important milestones. Notably, Nixon became the first president to appoint a Latina as treasurer of the United States. His selection of Romana Acosta Bañuelos was understood at the time to be a strong signal of Nixon’s respect for the community and his inclusionary intent. She also provided an irresistible PR opportunity; he could point to the dollars people carried in their pockets, which for the first time had a Latina’s signature on them. It is worth noting that this strategy has been followed by nearly every president since Nixon to diminishing effect; of the past 11 U.S. treasurers, seven have been Latinas. 

Showing respect via political appointment helped provide a foothold for Hispanic loyalists who were eager to show their community that the party was responsive to their presence. And as time went on, these activists became more visible and influential in the GOP. The first Hispanic presidential candidate, Republican Benjamin Fernandez, made three runs for the presidency starting in the late 1970s, and became a significant party power broker. Hispanic Republicans proved important to electing candidates in the Southwest like Texas Senator John Tower, and in helping Ronald Reagan wrest Texas away from President Jimmy Carter, who had won the state in 1976. This had policy impacts. As Cadava chronicles, Reagan shifted toward a more ideological approach, including policy positions intended to demonstrate respect, rather than just appointments. For example, Reagan opposed a border wall and signed the Immigration Reform and Control Act of 1986, which ultimately legalized three million undocumented immigrants. 

If Reagan’s more balanced approach provided a more solidified, loyal Hispanic base, the years under both George H. W. and George W. Bush illustrated the ways in which demonstrating familiarity and respect can help such a base grow. Both Bushes appointed multiple Latinos to their cabinets as well as other key posts, and both took policy positions that showed a better understanding of the community and its concerns, if not alignment with the majority of its people. They were visibly pro-immigrant, and both made policy overtures on issues like education and trade, which were important to Hispanic Republican leaders. Both Bushes were important counterweights to the GOP’s growing restrictionist wing. The younger Bush, for example, resisted attempts to deny nonemergency health care, public schooling, and other services to undocumented immigrants while governor of Texas, and supported bilingual education. He was rewarded with high-water marks of Hispanic support for a Republican presidential candidate: 40 percent in 2000, and 44 percent in 2004.

Republican politicians at the presidential level are not positioning themselves to win the majority of Hispanic voters. They don’t have to. A Republican presidential candidate who can push that support north of a generally reliable 30 percent, as Ronald Reagan and George W. Bush did, can take the Electoral College. And the ones who don’t get close to that marker, like Bob Dole in the 1990s, will lose. This is what makes Cadava’s examination of how the loyal 30 percent was built, and what it took to sustain it, so interesting and important. 

But it also highlights a big weakness of the book, which is that it does so little to explore the decade between George W. Bush and Donald Trump. The departure of the Bush family from the GOP center stage left the party’s virulent anti-immigrant wing unchecked. Cadava spends too little time exploring what this meant for the party’s relationship with its loyal Latino voters and its ability to climb above roughly 30 percent. He entirely misses a chance to explore the career and candidacy of John McCain, for example, who had strong relationships and excellent Hispanic vote margins during his career as a senator. Republican presidential primary politics forced McCain to reverse the pro-immigrant positions of his Senate career, causing his Hispanic support to plummet. 

In the end, Cadava gives only modest insight into the most vexing question: why even 30 percent of Hispanics remain loyal to the party despite the insults of its current standard-bearer in 2016, and what they might do after a devastating four years. It’s an admittedly difficult topic, but Cadava’s answer, which amounts to a tentative suggestion that people are choosing their party over the man, is unsatisfying. The issue would benefit from a look at what can be gleaned from survey data, and an honest conversation with Hispanic functionaries within the party. The uncomfortable gyrations of prominent figures like Florida Senator Marco Rubio and Texas Senator Ted Cruz, who have visibly struggled to adjust to this moment in their party, would also be worth some exploration. 

Still, the story of Hispanic Republicans has been misunderstood, and in its detailed history, Cadava’s book provides a useful introduction. The Hispanic community may not get the respect we deserve, especially from Republican leaders, but at least we have the satisfaction of knowing that, for most of your lives, you have carried dollars in your pockets with a Latina’s signature on them.

The post How the GOP Built a Loyal Hispanic Base appeared first on Washington Monthly.

It was mid-April, and the petals from Washington, D.C.’s famed cherry blossoms had just fallen to the ground. Several weeks into my coronavirus self-isolation, the most frequent visitors to my third-story apartment were songbirds that alighted on my tiny balcony—the doves, starlings, blue jays, mockingbirds, and, most frequently, sparrows, shrilling and swirling as they searched for mates. 

I spend a lot of time staring out the window nowadays. While COVID-19 sweeps the planet, infecting millions of people, the birds’ courtships continue uninterrupted. I can’t decide whether to find solace or malice in their unchanged rituals. Nature is neither cruel nor kind, but simply carries on.

Chief among the sparrows is one I’ve named Puffy, for his glorious abundance of feathers. On an overcast Sunday afternoon, Puffy lands on the railing and cocks his neck sideways as he preens his chest feathers, making sure everything is ready for the big show. And then he chirps—sometimes faster, sometimes slower; sometimes he punctuates a high-pitched refrain with a gruffer note at the end. He hops a bit along the railing, perhaps checking the acoustics.

Now a female has appeared, light brown and smaller. Their courtship is brief and clumsy. Puffy is nearly a perfect sphere, with russet-brown feathers on his head. I can’t help but imagine the iconic British nature film narrator David Attenborough making gently humorous observations.

But the remarkable thing is that Puffy wasn’t born a chanteur; his skill, as with many other songbirds, was learned. Several decades ago, scientists assumed that most birds and other animals were born with a set of innate skills, and then simply lived their lives according to instinct—as mechanical as a wooden cuckoo in a clock. But while some utterances are innate (much like a human scream), birds’ mating songs are generally learned. And depending on where a bird learned to sing, and from whom, their tunes may vary considerably, even among the same species.

Birds that scientists consider “vocal learners”—including sparrows, canaries, zebra finches, and many others—gain the ability to sing by imitating the birds by whom they are raised. It takes practice. Local variations are passed down between generations, like family stories. Sometimes knowing the hometown song is an advantage in finding a sweetheart. Perhaps that’s because it implies other shared preferences, like valuing the same twigs for nests, or preferring the same berries for snacks, or supporting the Nationals.

While birds were once assumed to be, well, bird brained, scientists now marvel at the complexity of what they can learn—and how varied individual communities are. Some birds learn new songs each mating season, and others, like mockingbirds, can imitate the songs of many other species. Parrots can famously mimic human speech. This is especially remarkable when you consider that our closest genetic relatives, the great apes, never developed such sophisticated vocal communication. Many scientists believe that birdsong may be the closest analog to human language in the nonhuman world, perhaps rivaled only by whales’ and dolphins’ underwater sonatas. 

The ecologist and nature writer Carl Safina takes these ideas of generational learning even further in his new book, Becoming Wild. Not only do animals develop distinct strategies for living and communicating in different locations, he argues, but the useful habits learned and preserved through generations constitute distinct “animal cultures.” There is no single way that sperm whales rear their young, or that scarlet macaws select mates, for instance. How they live depends on what they learn.

Here’s how Safina explains it: “The natural does not always come naturally. Many animals must learn from their elders how to be who they were born to be. They must learn the local quirks, how to make a living, and how to communicate effectively in a particular place among their particular group.” He’s anticipated that some readers may object to the word culture, or insist that such knowledge is a uniquely human attribute. But we’re not so special, he argues. “Learning ‘how we live’ from others is human. But learning from others is also raven. Ape and whale. Parrot. Even honeybee.”

Recent scientific research indicates that many species have more complex minds than we once assumed. So why not grant that some animals may also have learned traditions, perhaps even cultures? A recent trickle of academic articles makes a similar case, but Safina has written one of the first popular and accessible books to present this idea to a general audience. “We become who we are not by genes alone,” he writes. “Culture is also a form of inheritance. Culture stores important information not in gene pools but in minds.” 

The mission of Becoming Wild is twofold: to document how cultural learning works, focusing on three intelligent species—sperm whales, parrots, and chimpanzees—and to show why that matters for how we think about conservation. 

In these early months of the COVID-19 pandemic, Safina’s travel seems dreamlike and luxurious. He reports from the Peruvian Amazon and from a ship traversing the Caribbean, among other sites. His work is deeply grounded in science, but he writes with passion and a sense of humor. For instance, he observes that scarlet macaws in Peru have figured out how to distinguish tourists from locals, knowing that the visitors are likely to bear it with more equanimity if the big parrots descend noisily at breakfast to snatch some pancakes.

Sixty years ago, Jane Goodall observed that some chimpanzees had learned to use sticks to fish termites out of a mound—a simple demonstration of “tool use.” Before that, many researchers believed that only humans were capable of using tools. Since then, scientists have documented that different groups of chimpanzees have fashioned sundry tools to exploit their various local habitats. Some use rock anvils to crack open nuts; others don’t eat nuts at all. Some use moss sponges to soak up water.

These local variations are not only fascinating, but also vital to the chimps’ survival. It’s not easy to guess that a tasty morsel lies within the hard shell of a nut. You have to learn it from someone else. If there’s no one around to teach such tricks to youngsters, the knowledge dies out—and, with it, the access to the food source. 

Safina wants scientists to re-frame how they generally talk about conservation and biodiversity. “Ecologists usually think of biodiversity as having three main levels: the ‘genetic diversity’ within any particular species; ‘species diversity,’ or the number of species in a given region; and ‘habitat diversity,’ ” he explains. “But does that cover it? Not really. There’s a fourth level we are just becoming aware of: cultural diversity. Skills, traditions, and dialects that animals have innovated and passed along culturally are crucial to helping many populations survive and perpetuate.”

While Safina is evidently fascinated by animal ingenuity—his last book, Beyond Words, was about nonhuman minds—he is also making a pragmatic argument. Most conservation programs set goals around the number of individuals or species present. Often those targets are too low, he believes, leaving little margin for error in the event of further catastrophes, such as outbreaks of infectious diseases. Diversity, both genetic and cultural, allows species the best chances of adapting to new circumstances. “What I do hope is that conservationists can advance the case for preserving wide cultural diversity and ease the public out of a perilous satisfaction with precariously minimal populations,” he writes.

Safina’s aim is to raise ideas and question assumptions, not to lay out precise policy blueprints. But there are a handful of real-world examples of conservation programs that have stumbled, and sometimes adapted, after initially failing to account for the fact that many young animals need to learn from past generations. 

For instance, efforts to reintroduce bighorn sheep in parts of the American West revealed that the animals aren’t born knowing how or where to migrate to take advantage of the changing foraging landscape in different seasons, as biologists documented in a 2018 research paper in Science. Of 80 translocated sheep, 73 at first showed no inclination to migrate. The seven sheep that did were ones that had previously been integrated into established large herds. The researchers ascribed the sheep’s knowledge to “cultural transmission.”

Sometimes conservationists have tried to troubleshoot the cultural learning question in advance. Because whooping cranes learn to migrate socially, scientists faced a puzzle when attempting to reintroduce the birds back to areas of the U.S. where they had become locally extinct. The solution was to fly light aircraft between western Florida and Wisconsin, training the cranes—with the planes acting, in effect, as surrogate parents—to follow on their first northward migration.

While it’s handy that the cranes could learn to trail planes, it might not be so simple for humans to teach wild chimps how to crack open nuts. Or to explain to wild elephants where to find water after a long drought—something that experienced elephant matriarchs can do, drawing on their famously long memories. In general, the simplest conservation strategy is to protect enough animals to allow species to learn from their own kind.

The idea of cultural learning in animals is becoming more mainstream, at least among field biologists. Last year, 12 researchers with expertise in the behavior of whales, gorillas, birds, and other species coauthored a “policy forum”—a reported editorial—in Science, making the case that “animal cultures matter for conservation.” 

The challenge is always in translating such research into policy, especially at a time when global pandemic recovery will likely drain away government resources and attention. But perhaps Safina’s book will help in that regard, by appealing to a larger audience and reminding readers to contemplate the natural world as they think about their own points of vulnerability and resilience.

The post Humans Don’t Have a Monopoly on Culture appeared first on Washington Monthly.

In the fall of 2014, the Obama White House was busy trying to stop the spread of Ebola. The administration sent advisers from the Centers for Disease Control and Prevention to assist the afflicted countries’ health ministries, and it sent troops to West Africa to build emergency hospitals. It began screening people arriving in the United States from at-risk nations. It isolated and treated several American medical personnel who contracted the virus abroad and brought it back home.

Toward the end of his new book, The Imposters, Steve Benen reminds us of what the Republican Party was doing while all of this was happening:

As Election Day neared . . . Kentucky Republican [Rand Paul’s] eagerness to exploit public anxieties started to spin out of control. Paul publicly questioned Ebola assessments from the actual experts, blamed “political correctness” for the Ebola threat, and traveled to battleground states questioning whether Obama administration officials had the “basic level of competence” necessary to maintain public safety.

He added soon after, describing a hypothetical flight, “If this was a plane full of people who were symptomatic, you’d be at grave risk of getting Ebola. If a plane takes twelve hours, how do you know if people will become symptomatic or not?”

Fast-forward five and a half years. In March 2020, Paul was infected with COVID-19, the disease caused by the novel coronavirus, and did not self-quarantine. Instead, he spent time in the Capitol Hill swimming pool while waiting for his test results, potentially exposing his Senate colleagues. After he recovered, Donald Trump appointed him to a task force focused on quickly “reopening” the economy.

Benen, a blogger and producer for Rachel Maddow at MSNBC (and, as it happens, my predecessor as principal contributor to the Washington Monthly’s Political Animal blog), obviously could not have anticipated the pandemic when he wrote of Paul’s exploits. But the example does show his eerie ability to identify GOP hypocrisy. And in many ways, it’s representative of what the entire book is: a staggering chronicle of Republican duplicity. Benen shows that in order to score points and win elections, the Republican Party is willing to engage in completely contradictory behavior—even when it’s a matter of life and death.

The Imposters is a skillful illustration of how rank cynicism allowed Donald Trump to easily take control of the Republican Party. Republicans, Benen shows, already had subordinated their traditions and alleged values to unprincipled hypocrisy, indifference to facts and empirical data, and self-serving partisanship long before Trump arrived. The GOP created a vacuum in its own soul that the 45th president was easily able to fill with his inflated self-regard and his uninhibited politics of lies and polarization.

To prove this, Benen focuses much of his attention on the eight years of Barack Obama’s presidency, when Republican politicians made everything the 44th president did or tried to do the object of unremitting hostility. The book is most effective in analyzing the destructive austerity policies Republicans insisted on during and immediately after the Great Recession. The party, he notes, now cheers for budget deficits and debt (as it did under George W. Bush), but it posed as fiscal disciplinarians as long as Obama was in office. Benen writes,

The economic conditions that Barack Obama inherited couldn’t have been more dire. And yet, upon taking office, the Democrat from Illinois faced immediate demands to balance the budget from the same Republicans who’d uprooted the nation’s fiscal foundations. The GOP’s overwhelming hypocrisy and cynicism were obvious, but what was less appreciated was the degree to which the party was generally incoherent on the subject.

In the first year of the Obama era, for example, many Republican leaders with indefensible fiscal records struggled to explain their metamorphoses. Senator Orrin Hatch, for example, told the Associated Press that “it was standard practice not to pay for things” during the Bush-Cheney era.

When Trump came along, it became standard practice again:

Eight years of rhetoric about a “debt crisis” came to an abrupt halt on Inauguration Day, January 20, 2017—not because the fiscal picture changed, but because the need to maintain the scam ended. To believe that the GOP changed its mind between the Obama and Trump presidencies is to believe that Republicans were occasionally sincere about their fiscal philosophy. 

Benen is rightfully concerned with the consequences this flip-flopping has for America. And in a long chapter on Republican brinkmanship, which was expressed in threats to shut down the federal government and the actual shutdowns the GOP engineered in and out of power, he displays the ultimate fruits of post-policy politics: a complete inability to govern: “In 2013 the Washington Post’s Karen Tumulty described the dynamic as ‘governing by near-death experience,’ adding, ‘It is as though Washington has had backward evolution—
operating as a primitive, leaderless village where petulance passes for governance.’”

And that was before Trump took office. Since his election, the GOP has effectively proved that non-governing is its operating procedure. The party closed down the government for 35 days, from December 2018 to January 2019, the longest shutdown in U.S. history. For part of it, Republicans controlled both houses of Congress. It ended with Trump, who proudly took ownership over the shutdown, accepting a deal he could have had from the get-go.

The Imposters is a valuable reference book on Republican irresponsibility. But I believe the hollowness and cluelessness on which Benen focuses is not purely the product of wanting to win, as he sometimes implies. Instead, it has roots in conservative ideology that go deeper than partisan expediency. And this ideology helps explain the party’s ruthlessness. 

Over the last several decades, the Republican Party has been conquered by the Christian right and the overwhelmingly white Tea Party movement. The former has a theocratic vision for America. The latter militantly opposes economic redistribution. These movements converged with a realization that demographic trends were unfriendly to their party’s older base, generating a white identity politics that found its natural expression in the intensely divisive and intermittently racist stylings of Trump.

Consider, for example, Trump’s promise to “Make America Great Again.” It is effectively a pledge to return to the days when white men walked tall in America, Christianity was a quasi-official creed, and foreign influences were on the margins of national life—precisely the world that most Republicans yearn for. Trump’s steady appointment of conservative judges gives evangelicals, many of whom believe that abortion is literal murder, exactly what they want. His heavy (if erratic) investment in restrictionist immigration policies has always been central to his appeal, and the sudden lurch of the GOP in that direction after George W. Bush and John McCain championed a more diverse future was far from being just another area of Republican electoral opportunism. 

Indeed, some of what Benen sees as simple cynicism is arguably ideological as well. Consider, for example, the party’s embrace of devious voter suppression and gerrymandering. Benen treats these as a by-product of Republican opportunism. But for a party existentially committed to restoring (or preserving) white, Christian supremacy in the face of increasing diversity, they are a direct means of delivering that dominance. Similarly, the determination of Republicans to resist any hint of gun regulation, despite public opinion (which The Imposters documents thoroughly), isn’t just a matter of gun lobby campaign contributions. Instead, it comes from a genuine belief among grassroots conservatives that armed struggle against what Trump calls “radical Democrat elites” must remain an option if conventional politics fails.

Arguably the root problem with the GOP, then, isn’t extreme partisanship or a lazy dependence on lobbyists or a taste for fact-free demagoguery. It is the belief that a virtual civil war is necessary to impose Red America’s will on Blue America, now and forever. Donald Trump, with his contempt for democratic norms and his authoritarian narcissism, knows about as much as he needs to for the task of banana republic rule. He is a suitable vessel for this project.

But regardless of whether Benen is right about the GOP’s motivations, he knows what must occur to make them to stop their assault: 

Throughout American history, the most powerful force for partisan change has been the incentive to win elections. Major parties overhaul their tactics and perspectives not after victories but in the wake of multiple defeats. With this in mind, the Republican Party is likely to become a governing party again when American voters tell the GOP it has no other choice.

It needs to happen sooner rather than later.

The post What Motivates the Republican Party? appeared first on Washington Monthly.