Health Progress - March-April, 2020

JOURNAL OF THE CATHOLIC HEALTH ASSOCIATION OF THE UNITED STATES

HEALTH PROGRESS MARCH - APRIL 2020

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FEATURE

PUBLIC POLICY AND THE COMMON GOOD

46 THE PEOPLE OF GOD: HEALING THROUGH MOURNING FR. GERALD A. ARBUCKLE, SM, PhD

100th ANNIVERSARY 51 FORM FOLLOWS FUNCTION: THE EVOLUTION OF MISSION INTEGRATION IN U.S. CATHOLIC HEALTH CARE BRIAN SMITH, MS, MA, MDiv

DEPARTMENTS 2 EDITOR’S NOTE MARY ANN STEINER 61 POLICY Here We Go Again: Could The ACA Be Struck Down?

KATHY CURRAN, JD 63 ETHICS Encouraging Conversations on Health Care Decisions NATHANIEL BLANTON HIBNER, PhD

Illustrations by Roy Scott 4 CHA’S ADVOCACY EFFORTS: CHALLENGING THE STATUS QUO AND PROMOTING CHANGE Lisa Smith, MPA 6 ADVOCACY, PROPHECY AND THE COMMON GOOD Charles Bouchard, OP, STD

65 COMMUNITY BENEFIT Anchor Institutions Advocate for Policies To Benefit Communities BICH HA PHAM, JD, and DAVID ZUCKERMAN, MPP 68 THINKING GLOBALLY The Guiding Principles: More Than Sentiment BRUCE COMPTON

13 CAN PUBLIC POLICY SAVE RURAL HEALTH CARE? Rachel C. Tanner, MJur 20 MOVING THE NEEDLE: HOW HOSPITAL-BASED RESEARCH EXPANDED MEDICAID COVERAGE FOR UNDOCUMENTED IMMIGRANTS IN COLORADO Lilia Cervantes, MD, and Nancy Berlinger, PhD

19 POPE FRANCIS — FINDING GOD IN DAILY LIFE 70 EXECUTIVE SUMMARIES 72 PRAYER SERVICE

27 ECONOMIC INEQUALITY AND THE 2020 CAMPAIGN David Sheets 31 FIGHTING FRAGMENTATION: MENTAL HEALTH BENEFITS FROM INTEGRATED CARE Benjamin F. Miller, PsyD 37 MEDICAID EXPANSION IN MICHIGAN REFLECTS CATHOLIC SOCIAL PRINCIPLES Alisha Cottrell, Sean D. Gehle and Linda Root, RN, MAHCM 42 REFLECTION: MOVING FROM DESIRE TO ACTION Sr. Doris Gottemoeller, RSM, PhD

IN YOUR NEXT ISSUE

RACISM AND DIVERSITY

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EDITOR’S NOTE

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rom the beginning, Catholic health care has embraced the parable of the Good Samaritan as its own. We take the moral of the story to go and do likewise as our mission to heal the sick and protect the vulnerable. The parable is powerful to other ministries and purposes as well.

The day before he was assassinated in Memphis, Rev. Martin Luther King Jr., spoke to the city’s striking sanitation workers.

There had been tense confrontations the week before, and King returned to the city hoping to reverse the mood from volatile MARY ANN back to nonviolent. Toward the STEINER end of the speech, after he had exhorted the strikers and their supporters to hold tight to their unity and reject violence in favor of boycotts and other economic pressure, he cited the Good Samaritan as the one who could move beyond fear of consequences, unlike the priest and Levite who couldn’t. Fear, he said, should not be what stopped America from being what it was meant to be. Known as his “I’ve Been to the Mountaintop” speech, King concluded it with prophetic words. He warned the people about the incredibly hard days ahead, he confirmed that he had already seen the Promised Land, and he lamented that he might not be in the company of the people when they arrived.

King’s speech is as pure an example of prophesy and expression of the common good as exists anywhere. Prophesy not in that he foretold his death, but that he called out the vision as well as the hostile forces that stood against it. Expression of a common good not necessarily attainable at the time, among those whom King was addressing, or in light of those circumstances, but one that was worth pursuing at almost any cost.

In his article on advocacy, prophesy and the common good (pages 6-12), Fr. Charles Bouchard, OP, writes about how the common good lives in the liminal space between the vision of the Reign of God and its final realization. The role of prophets like Moses or John the Baptist or Martin Luther King Jr., is to inspire us and challenge us

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with their vision and their tenacity.

Sr. Doris Gottemoeller, RSM, offers a reflection on how we can move from a desire for the common good to action and policy (pages 42-45). It explores the individual actions each of us can take as well as the responsibility for advocacy and public policy that our health systems have.

Between these two excellent bookends are a number of efforts to initiate good policies and revise problematic ones for the better health of people in our care and communities. This issue’s authors have written compelling articles promoting better coverage and access to mental health; adjusting Medicare guidelines for rural hospitals that are especially strapped; instituting changes to improve care for undocumented immigrants who have end-stage renal disease; and creating policy for the uninsured as part of Medicaid expansion in Michigan. They are all examples of how belief in the common good inspires policy and how policy helps flesh out the common good.

We conclude our series of articles celebrating Health Progress’ 100th anniversary with Brian Smith’s thorough history of the field of mission integration in Catholic health care. As one of CHA’s most important initiatives and one of the magazine’s most consistent themes, the integration of mission among leaders, clinicians, partners and support staff has been an important priority. It is good news to report that mission leaders are recognized for their expertise, professionalism and commitment across Catholic health care.

Whether you’re a mission leader, a global health worker, an ethicist, a policy expert, a community benefit advocate, a sponsor, or any one of the dedicated people in Catholic health care’s special areas, we thank you for reading Health Progress and helping us celebrate its 100th year anniversary.

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VICE PRESIDENT, COMMUNICATIONS AND MARKETING BRIAN P. REARDON EDITOR MARY ANN STEINER masteiner@chausa.org MANAGING EDITOR BETSY TAYLOR btaylor@chausa.org GRAPHIC DESIGNER LES STOCK

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OPINIONS expressed by authors published in Health Progress do not necessarily reflect those of CHA. CHA assumes no responsibility for opinions or statements expressed by contributors to Health Progress.

2018 AWARDS American Society of Healthcare Publication Editors: Gold for Publication of the Year; Gold for Best Human Interest Story.

Catholic Press Association: First Place for Magazine of the Year; First, Second, Third Place & Honorable Mention for Best Feature Article; Second Place for Best Article Layout; First, Second Place & Honorable Mention for Best Essay; Second Place, Best Coverage on the Sexual Abuse Crisis; Second Place, Best Short Story.

Produced in USA. Health Progress ISSN 0882-1577. March - April 2020 (Vol. 101, No. 2).

Copyright © by The Catholic Health Association of the United States. Published bimonthly by The Catholic Health Association of the United States, 4455 Woodson Road, St. Louis, MO 63134-3797. Periodicals postage paid at St. Louis, MO, and additional mailing offices. Subscription prices per year: CHA members, free; nonmembers, $75; foreign and Canada, $75; single copies, $10.

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EDITORIAL ADVISORY COMMITTEE Kathleen Benton, DrPH, president and CEO, Hospice Savannah, Inc., Savannah, Georgia Sr. Rosemary Donley, SC, PhD, professor of nursing, Duquesne University, Pittsburgh Fr. Joseph J. Driscoll, DMin, director of ministry formation and organizational spirituality, Holy Redeemer Health System, Meadowbrook, Pennsylvania Marian Jennings, MBA, president, M. Jennings Consulting, Inc., Malvern, Pennsylvania Tracy Neary, regional vice president, mission integration, St. Vincent Healthcare, Billings, Montana Sr. Kathleen M. Popko, SP, PhD, president, Sisters of Providence, Holyoke, Massachusetts Laura Richter, MDiv, system senior director, mission integration, SSM Health, St. Louis Gabriela Robles, MBA, MAHCM, vice president, community partnerships, Providence St. Joseph Health, Irvine, California Michael Romano, national director, media relations, CommonSpirit Health, Englewood, Colorado Linda Root, RN, MAHCM, chief mission integration officer, Ascension Michigan, Warren, Michigan Fred Rottnek, MD, MAHCM, director of community medicine, Saint Louis University School of Medicine, St. Louis Becky Urbanski, EdD, senior vice president, mission integration and marketing, Benedictine Health System, Duluth, Minnesota Brian Yanofchick, MA, MBA, senior vice president, sponsorship, Bon Secours Mercy Health, Marriottsville, Maryland

CHA EDITORIAL CONTRIBUTORS ADVOCACY AND PUBLIC POLICY: Lisa Smith, MPA COMMUNITY BENEFIT: Julie Trocchio, BSN, MS CONTINUUM OF CARE AND AGING SERVICES: Julie Trocchio, BSN, MS ETHICS: Nathaniel Blanton Hibner, PhD; Brian Kane, PhD FINANCE: Loren Chandler, CPA, MBA, FACHE INTERNATIONAL OUTREACH: Bruce Compton LEADERSHIP AND MINISTRY DEVELOPMENT: Brian P. Smith, MS, MA, MDiv LEGAL: Catherine A. Hurley, JD MINISTRY FORMATION: Diarmuid Rooney, MSPsych, MTS, DSocAdmin MISSION INTEGRATION: Dennis Gonzales, PhD THEOLOGY AND SPONSORSHIP: Fr. Charles Bouchard, OP, STD

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CHA’s Advocacy Efforts

Challenging the Status Quo And Promoting Change LISA SMITH, MPA

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s a vital ministry of the church, Catholic health care has long been called to bring healing and hope—to provide care for patients and communities as well as to advocate for the changes needed in our society to protect human dignity and promote the common good. We believe every person is created in the image of God, that each life is sacred and possesses inalienable worth, and that access to health care is essential to protecting the inherent dignity of every individual.

Even as we continue to provide health care and assistance for patients, friends and neighbors, it is just as important to address the problem of lack of access to care and other obstacles to maintaining healthy communities. These include the affordability of health coverage; housing and food insecurity; cycles of poverty caused by inadequate education, work training and affordable child care; the particular challenges faced by refugees and undocumented immigrants and their families; and the environmental hazards that are sickening our planet and its people. Caring for those who suffer from these ills will always be a hallmark of Catholic health care, but we should equally be advocating for the changes needed to address these root causes of poor health and broken communities.

This is an enormous challenge, but fortunately the Catholic Health Association has many resources and allies in this work. Above all, our health ministry is able to draw upon a rich history of social thought and action within the Catholic Church. That tradition is shared with our partners at the U.S. Conference of Catholic Bishops and Catholic Charities USA, with whom we work in advocating for a more just and equitable society. CHA also has a tremendous resource in our members, whose passion and expertise inform and guide our efforts. Our Vision for U.S. Health

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Care, crafted in collaboration with advocacy leaders throughout the health ministry, establishes the foundational principles for a health care system that truly serves everyone in our nation. With the Vision as a guide, CHA works together with the membership and with the guidance of our Board of Trustees to develop a biannual advocacy agenda and public policy priorities coinciding with each new Congress. CHA’s advocacy agenda is rooted in the same core values as our Vision for U.S. Health Care — human dignity, common good, concern for people who are poor and vulnerable, stewardship, justice and pluralism—and enables the Catholic health ministry to speak with a united voice on key policy issues. Our current advocacy

Caring for those who suffer … will always be a hallmark of Catholic health care, but we should equally be advocating for the changes needed to address these root causes of poor health and broken communities.

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agenda focuses on five issue areas: 1) ensuring viding valuable perspective for those making laws access and coverage for everyone; 2) maintain- and setting public policy. We have seen many sucing a strong safety net; 3) strengthening services cesses arising from our collective efforts over the in aging and chronic care; 4) protecting life and years, from passage of the Affordable Care Act ensuring conscience protection; and 5) improving and protection of the law from repeal efforts to the 10-year funding extension of the Children’s the health and well-being of communities.

In order to be as effective as possible, CHA also Health Insurance Program; passage of major menidentifies areas where we can lead the ministry by framing the dialog Advocacy is everyone’s responsibility. around such issues as health care for everyone, building healthy Everyone in the ministry, no matter communities through community where you live or what your job is, can benefit programs, and protecting and enhancing the Medicaid prohelp bring about the real changes that gram. We also identify areas where we can add our voice and partwill improve our nation’s health and ner with others to advocate good health care system. public policy. Finally, we identify issues we will need to monitor for potential opportunities to work with Congress tal health and substance use disorder-opioid legor the Administration in order to further our islation; and continuing efforts to raise awareness of the importance of palliative care and the 340B priorities.

The success of our advocacy efforts wholly prescription drug discount program.

Advocacy is everyone’s responsibility. Everydepends on the ministry working together with a united voice on key issues. The strength of that one in the ministry, no matter where you live or voice is reinforced by direct engagement with what your job is, can help bring about the real members of Congress. Catholic health care is a changes that will improve our nation’s health and trusted voice, an established provider of compas- health care system. I urge you to visit the advosionate and quality care and a valuable commu- cacy page on CHA’s website to find out more about nity partner. Our reputation and tradition provide these efforts and explore the many resources we excellent opportunities to serve as a voice for the provide to engage everyone in advocacy. Downvoiceless in advocating improved systems of care load and share our Vision and the current Advoand coverage to uphold human dignity and the cacy Agenda with your lawmakers; utilize our background information and policy analyses to common good.

Members of Congress are receptive to our help inform your advocacy work; and take advanissues because of our reputation and because tage of the many outlets to inform and engage our concerns cross the political divide at a time the Catholic health ministry, including receiving of unfortunate and ever-increasing partisanship. weekly updates on legislative developments, parEngaging with your representative or senators, ticipating in monthly advocacy calls and using our expressing concern or support for proposed poli- grassroots e-Advocacy program that is housed on cies, and providing examples of what their impact our website and updated regularly. CHA’s advowould be on patients and communities or the abil- cacy and public policy team is always available to ity to provide care are important in influencing help you in getting started with advocacy work members of Congress. There are different levels or build upon the work you are already doing. of engagement that range from messages or calls Together, we can help make our Vision for U.S. to congressional offices to in-person meetings Health Care a reality. in Washington or in district or state offices, all of which have impact. Whether meeting or cor- LISA SMITH is vice president, advocacy and responding with a member of Congress or with public policy, the Catholic Health Association, their staffers, that engagement is key to building Washington, D.C. relationships with congressional offices and pro-

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PUBLIC POLICY

Advocacy, Prophecy And the Common Good CHARLES BOUCHARD, OP, STD

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ll of us would like to see the ministry of Catholic health care as prophetic and oriented to the common good. That should be easy, except for two things. First, the common good is widely misunderstood, and second, prophets have an image problem.

The popular image of a prophet is a wild-eyed, marginal character who promotes extreme and anti-social ways of life. John the Baptist is a perfect example. He wandered around in the wilderness, clothing himself in animal skins and living on bugs. Or we confuse prophecy with foretelling the future, and not in a good way. We dub someone a “prophet of doom” when they are always predicting bad things to come. The prophet Jeremiah was so identified with that notion that the term “jeremiad” entered our vocabulary just to describe a long, plaintive lament that predicted the downfall of society. It is not surprising that we view prophets with skepticism and that “prophetic” has come to be associated with a kind of political extremism that involves demonstrations, confrontation and generally bad news. It is no wonder that prophets, as Jesus said, are not welcome in their own countries.

Biblical scholar Walter Brueggemann has made it part of his vocation to rescue prophecy from these misperceptions. 1 Prophets are not future tellers, he says, nor is every prophet a radical social activist. Their message was sometimes harsh, but it was by no means a message of doom.

The prophet’s job is to reveal God’s plan and call us to participate in it, whatever the cost.

In his view, the authentic prophets of the Scriptures were mainly concerned with uprooting what he calls a “royal consciousness.” In the time

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of the classic prophets, and even for Jesus, this consciousness involved actual royalty — kingdoms or rulers who oppressed and persecuted people. For the Jews under Moses, it was Egypt’s Pharaoh; for Jeremiah, it was King Zedekiah and the priestly class that opposed him; for Jesus, it was King Herod, the Pharisees and the Sadducees.

In each case, royal privilege and power created an interlocking system that favored royalty and wealth and relegated everyone else to cycles of poverty and dependence.

We may not have a monarchy in the U.S., but something like a “royal consciousness” is alive and well in our society. It is marked by collusion among the privileged to secure their own interests, often at the expense of the poor. Bruegge-

We may not have a monarchy in the U.S., but something like a “royal consciousness” is alive and well in our society. It is marked by collusion among the privileged to secure their own interests, often at the expense of the poor.

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mann describes this dynamic as having three leads us step-by-step through the decidedly nonaspects: an economics of affluence, in which transparent process, pausing for occasional minimost of us are well enough off that others’ pain seminars that explain how new and dangerous is not noticed; a politics of oppression, in which investment strategies hid the pending disaster. the cries of the marginalized are not heard; and a religion of immanence For the ministry of health care, the and accessibility, which means we contemporary equivalent of the have domesticated God and stripped God of transcendence. We choose royal consciousness is the market, idols or what C.S. Lewis referred to as “kingdom substitutes.” God is so the power of big business (especially present to us, but so minimized, that pharma and the insurance industry), “his abrasiveness, his absence, his banishment is not noticed, and the and the political influence they wield. problem is reduced to psychology.” If God is not transcendent, there is no The Laundromat provides an equally sobering higher law, no route to appeal. The goal of royal power is to make people numb and superficially picture that starts with the story of a widow satisfied so that they stay in their place. It takes (played by Meryl Streep) being deprived of her little imagination, Brueggemann says, to see the rightful insurance payment. It reveals how the leaked Panama Papers uncovered a system of parallels with our own cultural situation.2 We see interests today that maintain the sta- offshore banking that maintains the wealth of tus quo, widen the gap between rich and poor, “15 million millionaires in 200 countries.” In penalize minorities, and inequitably distribute showing things we’d rather not see (like details basic goods like health care, education and pub- of human organ trafficking), the film uncovers lic safety. For the ministry of health care, the con- aspects of how this global “royalty” relies on temporary equivalent of the royal consciousness shell corporations, human exploitation, secrecy is the market, the power of big business (espe- and deceit.

These two movies show in detail how the “royal cially pharma and the insurance industry), and the political influence they wield. The leaders of consciousness” functions in our own time. They these organizations all live securely and have easy show exactly what the prophets would denounce. access to health care and education, so they may not feel the pain of those who lack them.

THE PROPHET AND THE COMMON GOOD Brueggemann says that then and now, the The common good is an antidote to royal con“loop of power” limits our vision and leads to a sciousness. It focuses on equity rather than perfailure of imagination. We become used to the sonal gain, on participation rather than disenfranway things are and we can’t even see how differ- chisement, and on the many rather than the few. ent things might be. This “royal consciousness” The Catechism of the Catholic Church defines the and the structure it creates are complicated and common good as the sum total of social conditions opaque. Most of us could not trace it if we tried, that allow people, either as groups or as individueven though we are trapped and victimized by it. als, to reach their fulfillment more fully and more These structures short-circuit the common good easily. The common good concerns the life of all.3 and, by extension, the Reign of God. They engen- I sometimes describe it as those things that we der a state of numbness that makes us feel as if all need, but which none of us can acquire on our there is no alternative. own. The common good is second only to the idea If you doubt this, there are two movies you of human dignity itself; it is to society what human need to see. The Big Short is a brilliant, humorous dignity is to the individual. It is so important that and ultimately depressing explanation of how the we cannot become fully human unless we are part housing collapse of 2008 occurred. It shows how of a network of relationships that enables us to many financial organizations, including some seek it. Health care providers have a special role in banks, were able to generate enormous profits shaping and realizing the common good because for themselves, leading to a mortgage crisis that health care is such a key element of it. destroyed the housing market in the process. It The common good is an eminently human

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good. It has social, economic and political dimensions. But it has theological significance, too, in that it foreshadows and to some extent begins to realize the Reign of God in the temporal order.4 The Reign of God was the focus of Jesus’ mission: not only did he come to proclaim the Reign of God,5 he is the Reign of God, incarnate.6 Ultimately, the Reign of God will come into its fullness, but this does not mean that we wait around as passive spectators. Like the disciples originally called by Jesus to help bring about this new world, we too are called in baptism to be active participants. Within health care, we have done this largely through political advocacy and our sponsored ministries.

PROBLEMS WITH THE COMMON GOOD

the whole society, own it or at least steward it. We may use various forms of government to help realize aspects of the common good, but the government is our servant in this, not our master.

Finally, people might think the common good is socialism, which costs too much and involves “free stuff” for people who didn’t earn it or who don’t deserve it.7 This is a common objection to health care reform, including “Medicare for All” and even Medicaid expansion. Policy analyst and commentator Sally Pipes paints an apocalyptic vision of what universal health care might look like. It might make health care “free,” she says, but taxes would skyrocket. There would be no referrals to specialists, no private coverage and health care would be rationed, especially for the elderly.

Doctors would become lower-paid employees of the government, the best and brightest would no longer go into medicine and a million people employed in the health insurance industry would lose their jobs.8 These misperceptions of the common good are part of a prosperity myth that tells us hard work and self-reliance are all we need. It is based on a capitalist, consumerist vision of the world where even heath care is understood as product.

Brueggemann says the “task of prophetic ministry is to nurture, nourish and evoke a consciousness and perception alternative to the consciousness

Despite its political and theological importance, the common good, like prophecy, gets a bad rap. It often is regarded with suspicion and even hostility in the secular and political world, especially in the United States. Politicians invoke the concept with caution, and some do their best to avoid it altogether.

There are a number of reasons for this. First, Americans love independence and autonomy, and there is a fear that the common good is code for a massive collectivity that will suppress individual achievement and individual persons who might then be seen as dispensable for purposes of the “greater good.”

The common good is an eminently The greater good, however, should human good. It has social, economic never be confused with the common good. Communism or totalitarianism and political dimensions. But it has might see individuals as dispensable for the sake of the greater good (i.e., theological significance, too, in that the state), but Catholic social teachit foreshadows and to some extent ing does not. We understand the common good to serve both the group begins to realize the Reign of God in and the individual. Human dignity the temporal order. is inalienable, so no one can ever be dispensable.

Sometimes the common good gets confused and perception of the dominant culture around with big government, which can threaten indi- us.”9 This requires a “prophetic imagination” that vidual freedom and diminish the proper role of sees the world as it is but refuses to accept it. It smaller groups like families and associations. means taking hurt seriously, refusing to accept it This is a legitimate concern, especially in light as normal and natural, but rather as “an abnorof the principle of subsidiarity, which means that mal and unacceptable condition for humanness.”10 matters should be handled at the lowest com- Taking hurt seriously is our mission. Preventing petent level of an organization in order to maxi- hurt is our prophetic calling. If our ministry is mize participation. For us, however, the common prophetic, it needs to see a different future, enable good is not the government or the state, neither of others to believe it is achievable, and prove that which owns the common good. We the citizens, the Reign of God is more than a dream.

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PROPHECY, POLITICS AND ADVOCACY

There are some individuals who are graced with a prophetic imagination. Martin Luther King Jr. spoke openly about his dream; many of our founders had an uncommon vision of human dignity.

Social activist Dorothy Day, St. Mother Teresa, St. Francis of Assisi, Jesuit and pacifist Daniel Berrigan were all iconic prophets, uncompromising and hard to imitate.

Yet the gift of prophetic imagination is not restricted to saints. Every one of us shares in the prophetic office by virtue of baptism.11 Prophecy is a gift of the Spirit that animates all of our activity for the common good and the Reign of God. Each of us has a personal prophetic call, but the gift of prophecy also extends to our institutional ministries that serve the common good.

Our prophetic efforts toward the common good require a kind of inspirational public preaching which says, “this life is not what God intended.” But our preaching can’t remain purely inspirational. Our vision and preaching have to take flesh through advocacy and politics.

The Catechism says “Each human community possesses a common good which permits it to be recognized as such; it is in the political community that its most complete realization is found.

It is the role of the state to defend and promote the common good of civil society, its citizens, and intermediate bodies” (#1910).

The good news is that we have a political system that can, in principle, deal with inequity and distribute the world’s goods in a way that serves the common good. The bad news is that political life is messy and the common good is a moving target that is realized in various ways in different times and places. The difficulty of arriving at consensus about what constitutes human flourishing or “the good life” in a pluralistic society is daunting.

Advocacy and politics play a much bigger role today than they did in the past when health care was primarily a work of charity that involved little public funding. Today Catholic health care is part of a much larger network of providers that all depend to some extent on public funding. Our mission now includes not only clinical considerations and individual patients, but also social determinants like education, economic status, race and climate. These are all aspects of the common good.

Both the Catholic Health Association and the U.S. bishops have policy experts at the federal

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level. Every state has a Catholic Conference that lobbies on the state level. These policy experts continually fine tune the delicate political structures — laws, rules, regulations and elections — that determine who gets what, how much it will cost and whether the votes are there. They do their best to wring some justice and equity from the complications of a political system that barely tolerates familiar voices, much less prophetic ones.

HOW CAN ADVOCACY BE PROPHETIC?

Stefano Zamagni is an economist from the University of Milan who says we need people “who

The good news is that we have a political system that can, in principle, deal with inequity and distribute the world’s goods in a way that serves the common good. look ahead and dare to gaze beyond the obstacles to find a way through, who are prophetic. The current economic and social models no longer work.

The prophetic economy offers liberation from the old ways of thinking by daring to try out new pathways.” This is what Brueggemann means when he talks about the prophetic imagination — not just fine-tuning but re-visioning.

Jeffrey Sachs, an economist at Columbia University, says, “Prophetic economy means an economy that operates in the vision of the prophets and…in the vision of justice, a vision of peace, a vision of meeting the needs of the poorest people, a vision of protecting creation. We need an economy of sustainable development which means an economy in which prosperity is shared, [one] that is socially fair and environmentally sustainable.”12 As an international Catholic organization, CHA has a foot in both worlds. We stand in the economic and political reality in which we live, full of balance sheets, bonds and strategic plans.

We also stand in the transcendent promise of the Gospels. The common good needs the practical, the political and the prophetic. It needs ethicists, theologians, advocacy experts and economists.

Let me suggest three steps that might help

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us bridge the gap between the political and the prophetic.

First, we need more sustained conversation among ethicists, advocates and policymakers. Ethicists need to help advocates discern the ethical and “kingdom” dimensions of policy, and advocacy officers need to help ethicists understand the complexity of policy. All of us need to remind our politicians of their primary responsibility for the common good and to demand greater accountability.

Second, we need to implement our entire advocacy agenda more fully. The Catholic Church in the U.S. has a broad agenda, which is outlined in Forming Consciences for Faithful Citizenship: A Call to Political Responsibility. This guide is put out by the U.S. bishops and used by many Catholics in advance of their voting decisions.

It includes explicit reference to every important policy issue: human life, peace, marriage and family, ecology, discrimination, immigration, violence and more. Yet in practice, this broad agenda often gets boiled down to a single “pro-life” issue.

Catholics who would not dream of dissenting from the church’s teaching on unborn life feel perfectly free to oppose immigration, gun control and even religious tolerance. It is hard to be credible about pro-life if we appear to tolerate other kinds of injustice. If the common good has to do with human flourishing, it must include more than just getting born.13 Excessive focus on this aspect of the common good enables others to dismiss us as single-issue, or to see our concerns as merely “religious” rather than the full scale of human dignity and human fulfillment. It also creates the illusion that we can solve the abortion problem by legal interdiction alone. I believe that our most effective pro-life tool is improving social conditions like education, health care and poverty that lead to abortion in the first place.

A PROPHETIC SPIRITUALITY

Finally, all of us need to cultivate a “prophetic spirituality” even if we are deep in the weeds of clinical care or public policy or advocacy.

Religious historian and theologian Philip Sheldrake says we tend to see spirituality as private and otherworldly, but he says it is more than that.14 He quotes the great scholar of mysticism, Evelyn Underhill, who says, “The defining characteristic of Christian mysticism is that union with God impels a person towards an active, outward, rather

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than purely passive inward life.” He also notes that “all sanctification, all inner transformation, is ultimately for the sake of transformative action and redemptive practice in society.” The mystical contemplative life is “not carried out only in the sacred space of prayer, or in the sacred precinct of the church … it also finds its place in political and social practice.”15 Asceticism is necessary, too, because commitment to any noble endeavor requires self-sacrifice. The Jewish scholar Abraham Heschel says that the fundamental experience of a prophet is a “fellowship with the feelings of God, a sympathy with the divine pathos … the prophet hears God’s voice and feels it in his heart.”16 This means that prophets need to develop a deep interior life, but not a private interior life. Because humans are essentially social, and because the “purpose of human conduct is to have an effect on others rather than to be primarily ascetical,” prophetic spirituality must have an outward focus.

Holding spirituality, contemplation and political life together is not easy. My own religious community, the Dominicans, was founded in the 13th century and sought to foster a contemplative life in the city rather than in the rural monasteries that were the norm at the time. Many thought this was a crazy idea that would never work. In the 800 years since we were founded, we have had our struggles and pushed this unlikely charism to the limit many times. But we are still here.

Policymakers, too, are “in the city” with all the actual and political noise urban life suggests so they too need the stability and centeredness of the contemplative and the mystic. They need political skill as well as a prophetic imagination to keep them focused on the Common Good, God’s own self, who is our ultimate destination.

FR. CHARLES BOUCHARD is senior director, theology and sponsorship, the Catholic Health Association, St. Louis.

NOTES 1. Walter Brueggemann, The Prophetic Imagination, 40th Anniversary Edition (Minneapolis: Fortress Press, 2018) 31, 35.

2. Brueggemann, The Prophetic Imagination, 35-36.

3. The Catechism outlines three essential aspects of the common good: First, respect for the person as such. In the name of the common good, public authorities are bound to respect the fundamental and inalienable rights

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of the human person; second, the social well-being and development of the group itself. Development is the epitome of all social duties; finally, the common good requires peace, that is, the stability and security of a just order. (CCC, #1907-1910) 4. See, for example, David Hollenbach, The Common Good and Christian Ethics (Cambridge, England: Cambridge University Press, 2002): “The terrestrial common good of human society is thus analogous to the full communion of the Trinity and to the full union with God and neighbor that Christians hold will be a gift of divine grace in heaven,” 132; and “For the communion of the Kingdom of God can have an anticipatory, though incomplete, presence in the political sphere just as it can in friendships, family life, and other terrestrial communities,” 135.

5. See Luke 8:1, 4:43; Matthew 4:17, 9:35.

6. See Benedict T. Viviano, “The Kingdom of God in Albert the Great and Thomas Aquinas,” The Thomist 44, no. 4 (October 1980) 502-22. Viviano points out that the early Christian scholar Origen held that “the kingdom was identical with Jesus himself,” the “self-kingdom,” 503.

7. In the 2016 presidential campaign Jeb Bush implied that Democrats were luring black voters with promises of “free stuff,” presumably including health care.

See Charles Blow, “Jeb Bush, Free Stuff and Black Folks,” The New York Times, September 28, 2015, https://www.nytimes.com/2015/09/28/opinion/ charles-m-blow-jeb-bush-free-stuff-and-black-folks. html. Sally Pipes, a columnist and commentator, appeared on the Bob Zadek Show on August 15, 2019 in a segment entitled, “The High Cost of Free Stuff,” http://www.bobzadek.com/past-shows/2019/6/20/ public-option-single-payer-medicare-for-all.

8. Pipes is the author of The False Promise of Single Payer Healthcare (New York: Encounter Books, 2018) and False Premise, False Promise: The Disastrous Reality of Medicare for All (New York: Encounter Books, forthcoming 2020).

9. Brueggemann, The Prophetic Imagination, 3.

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10. Brueggemann, The Prophetic Imagination, 85.

11. “The holy people of God has a share, too, in the prophetic office of Christ, when it renders [us] living witnesses, especially through a life of faith and charity.” Documents of the Second Vatican Council, Lumen Gentium, 12.

12. Stefano Zamagni and Jeffrey Sachs are both part of Prophetic Economy (www.propheticeconomy.org), an intergenerational and international assembly of thinkers who want to raise up current prophetic economy actions and imagine new ones. These quotes are taken from talks given at the 2018 conference in Italy.

13. Efforts to place more weight on other aspects of our policy agenda, notably by Cardinal Blase Cupich of Chicago, were rejected by the U.S. bishops at their November 2019 meeting.

14. Philip Sheldrake, “Christian Spirituality as a Way of Living Publicly: A Dialectic of the Mystical and Prophetic,” Spiritus 3 (2003) 19-37, at 19, quoting Archbishop Rowan Williams. This idea of spirituality as private and having little to do with political life (or prophecy, for that matter) has a long history, perhaps going back as far as Augustine, whose views may have led Christians to regard the public and political life with suspicion. Sheldrake, 20.

15. Evelyn Underhill, Mysticism: The Nature and Development of Spiritual Consciousness (Oxford/One World, 1993) 172, quoted by Sheldrake on 24; the second quote is from John Eagan, “The Mystical and the Prophetic: Dimensions of Christian Existence,” The Way Supplement (2002) 92-106, Sheldrake on 25; third quote from liberation theologian Leonardo Boff, “The Need for Political Saints,” Cross Currents 30, no. 4 (Winter 1980-81) 371.

16. Abraham Heschel, The Prophets (New York: Harper and Row 1969) 1:26. Cited in Ormond Rush, “The Prophetic Office in the Church,” in When the Magisterium Intervenes: The Magisterium and Theologians in the Church, ed. Richard Gaillardetz (Collegeville, Liturgical Press, 2012): 100.

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Can Public Policy Save Rural Health Care?

RACHEL C. TANNER, MJur

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cross the United States, rural communities are facing enormous pressure to survive.

Younger generations are leaving to find economic opportunity elsewhere, employers are shutting down, the remaining population is aging, and health care providers and facilities are stretched nearly to the breaking point. In fact, more than 160 rural hospitals have closed since 2005, and 21% of all rural hospitals are at high risk of closure due to financial instability.

One question must follow: if rural communities are facing such difficult challenges, how can Catholic health care leaders help? The answer may lie in public policy. While rural communities face serious policy hurdles, such as workforce sustainability, a challenging payer mix or overly burdensome regulations, we may be able to impact change through advocacy. By contacting our federal elected officials, federal regulators and state leaders, people both in and out of rural America can fight for changes that will shore up rural health care.

the influence of broader health care ministry.

Indeed, many of the founding congregations of Catholic health systems started in rural areas.

The women religious looked across our country and saw a need for education, housing, child services and health care. They went where they were needed, regardless of the hardship or economic opportunity. As leaders in Catholic health care, we have a chance to continue that vision and advocate for public policies that serve the vulnerable people and communities found in rural America.

WHY RURAL MATTERS

STATE OF RURAL HEALTH CARE

You may be asking yourself why the plight of rural health care is important to people who live in urban or suburban areas. If we set aside the financial implications of closing hospitals, including the overall economic impact to the community, we recognize that the need for care does not go away, but simply shifts to urban and suburban facilities. We must embrace our mission and recognize that people living in rural communities are as much our brothers and sisters as anyone else living on this planet. They often do not have the number of voices needed to advocate for important policy changes, but we can bolster them with

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The challenge is daunting. As individuals move away from rural areas to more economically

We must embrace our mission and recognize that people living in rural communities are as much our brothers and sisters as anyone else living on this planet.

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PUBLIC POLICY

Sadly, the rate of hospital closures is increasing: more rural hospitals closed in 2019 than in any year since 2005.

ical school graduates do not want to practice in rural areas, rural providers are disproportionately disadvantaged by the nationwide shortage of doctors, which exists largely because of the 1997-level limits on Medicare-funded residency slots that remain in place today. Further, rural providers are much more likely to face difficulty navigating the complex and disparate systems governing fraud and abuse rules, particularly as they relate to physician employment, patient transportation distance limits, and value-based bundled payment programs.

Many rural hospitals were built decades ago when the communities they served were larger, younger and healthier. Over time, rural hospitals have cobbled together new services to aid their aging patient base, closed floors or entire wings of their buildings, or made other changes to try to meet the needs of their patients. Unfortunately, however, there is no regulatory pathway for hospitals to downsize even further.

The two main types of rural facilities are small, rural hospitals and critical access hospitals. Both types have some special consideration given to them based on their status as pillar institutions within their rural communities. For example,

viable cities and suburbs, rural hospitals and health providers are becoming less financially stable and more at risk of closure. Politico reports that since 2005, 162 rural hospitals have closed across 35 states, with a large concentration in southeastern states.1 Sadly, the rate of hospital closures is increasing: more rural hospitals closed in 2019 than in any year since 2005. And it isn’t only hospitals that face closure. According to The Washington Post, over the last decade rural communities have lost 250 maternity wards, 3,500 primary care doctors, 2,000 medical specialists and hundreds of nursing homes.2 When a rural hospital closes, the entire community suffers. Hospitals often are the first- or second-largest employer in a small community, providing a vital economic boost to the local community. A hospital makes communities feel safer and provides much-needed community-based primary care, outpaPerhaps the greatest burden faced tient therapies and other health services. Local hospitals allow people to by rural health care facilities is the receive care closer to home, which is vitally important for seniors, people regulatory burden placed on them by who do not have transportation, or the Medicare Conditions of Payment people who cannot miss work for a doctor’s visit. Additionally, larger and Conditions of Participation. employers who may want to invest in or relocate to a community may choose to go elsewhere if adequate health ser- small rural hospitals that have fewer than 100 vices are not available, thus perpetuating the beds may be classified as a “Medicare Depencycle of economic decline for both the town and dent Hospital,” based on their payer mix, or as a “Sole Community Hospital,” based on the hospithe hospital. tal’s distance in relation to other hospitals. Both designations carry special Medicare reimbursePUBLIC POLICY CHALLENGES AND OPPORTUNITIES Perhaps the greatest burden faced by rural health ment mechanisms. Critical access hospitals are care facilities is the regulatory burden placed on unique in that they must have fewer than 25 beds, them by the Medicare Conditions of Payment be located a specific distance from any other hosand Conditions of Participation. For example, pital, and operate under special Medicare reimrural critical access hospitals must have a physi- bursement and Medicare conditions of participacian certify in advance that an admitted patient tion. Critical access hospitals generally are paid is expected to leave the hospital within 96 hours. at 101% of Medicare costs, minus the 2% withhold Additionally, since a large percentage of new med- due to budget sequestration since 2013. For Medi-

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care eligibility purposes, critical access hospitals payers will under-reimburse hospitals (and other must maintain an annual average length of stay providers) because the hospital can recoup these of 96 hours or less for acute care patients. How- losses from the rates paid by private payers. But ever, they are granted greater flexibility than tra- what if you do not have enough private payers?

For CommonSpirit Health, which was formed ditional hospitals in their staffing requirements, such as the requirement that a physician must in February 2019 through the merger of Catholic be available within 30 minutes in the case of an Health Initiatives and Dignity Health, the Medicare population accounts for approximately 35% emergency.

Many small, rural hospitals would like to tran- of acute care days in our hospitals, but the Medisition to critical access hospital status, but there care population accounts for an average of 60% is no easy path to do so under Medicare’s guide- of acute care days in our critical access hospitals. lines. Critical access hospitals often were created And while critical access hospitals are reimbursed through a governor’s designation as a “necessary differently by Medicare due to their special status, provider,” but states have not been allowed to use these hospitals do not get nearly enough reimthat designation since 2008. Further, to transi- bursement to cover the true cost of care. With tion to a critical access hospital, the hospital must significantly more than half of inpatient days paid be located in a state that has established a State through a system that under-reimburses providMedicare Rural Hospital Flexibility Program, which a few states Many of the issues facing rural health still have not done.

Additionally, some critical care providers often tie back to one access hospitals would like to transition to become an even main problem: lack of available funding. smaller facility, such as an emerThe financial reality of critical access gency department with one or two inpatient beds, but, again, hospitals highlights the problem. there is no mechanism to allow for this change without risking their current cost-based reimbursement. Instead, ers, it is no surprise that the average critical access both types of rural hospitals are left operating in hospital in the U.S. operates with a total margin a manner appropriate to the situation they were around 1.5%.

Public policy advocacy is the only way this built for decades ago rather than the situation dynamic will change. We can all use the resources they face today.

Rural hospitals need flexibility to meet the of our system advocacy teams, national advoneeds of their communities today, not the onerous cacy groups like the Catholic Health Associarequirements of Medicare or the needs of their tion or American Hospital Association, and other communities in past decades. And we have oppor- membership organizations to ask our members tunities! The Trump Administration has made of Congress to fully fund Medicare, to stop cutregulatory relief a priority in its first three years, ting reimbursement for providers and to support with calls for comments on antitrust rules, qual- rural health care specifically. Additionally, we can ity measurement requirements, nursing scope of ask for an end to budget sequestration cuts, which practice and more. Engaging in public policy to have reduced Medicare reimbursement by 2% for help lift the regulatory burden could provide a all hospitals, including rural facilities with costway for rural hospitals to “right size” their facili- based reimbursement, since 2013.

Of course, under-reimbursement by Medities and services.

Many of the issues facing rural health care pro- care is only part of the problem. Rural commuviders often tie back to one main problem: lack of nities face higher rates of unemployment, and available funding. The financial reality of critical thus lower access to employer-based insurance, access hospitals highlights the problem. Ameri- than their urban counterparts. In these areas, can health financing is built largely on the idea expanded access to government insurance is key. that Medicare, Medicaid and other government For example, in rural areas of states that have

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expanded Medicaid eligibility under the Affordable Care Act,3 the uninsured rate is 4 to 8 percentage points higher than the urban areas of the state; however, the uninsured rate in expansion states (both urban and rural areas) is significantly lower than that of non-expansion states. We know that people without insurance still get sick, of course, but they very often are unable to get preventive treatment because it is not available. By advocating for health care access and coverage for everyone, which is a key goal of Catholic health care, we can help make rural health providers more financially stable while also ensuring that those who are most vulnerable are able to access needed health services.

Payer mix and underfunding often lead to numerous other problems. For example, rural communities face serious workforce shortages due in part to financial woes and in part to regulatory restrictions. Rural hospitals are not as likely to attract new medical or nursing school graduates as urban areas. As a result, hospitals must entice clinicians to practice at their hospital, but are prevented from providing certain incentives by rules against overpayment and anti-kickback laws. The Centers for Medicare and Medicaid Services (CMS) recently proposed changes and

Rural medical practices and hospitals need generalists in an era of medical specialty.

They need greater leeway to use advanced practice providers, like physician assistants and nurse practitioners, for general medical services. asked for stakeholder input to improve some of these rules (known as the Stark Law and AntiKickback Statute). Individuals and organizations across the country were given the opportunity to provide feedback to the federal government on ways to improve the existing laws and, therefore, the overall health system. Regulatory comment opportunities like this are an excellent way to use public policy for the greater good.

Payment isn’t the only barrier to a sufficient workforce, of course. Rural medical practices and

QUESTIONS FOR DISCUSSION Rural communities are facing numerous threats to their survival, and the health care they need is at significant risk. More than 160 rural hospitals have closed since 2005; many more are in danger of closing because of financial instability. Rachel Tanner of CommonSpirit Health poses the question of what can and what should Catholic health care do to help the communities, patients and clinicians in such vulnerable situations. While the challenges seem overwhelming, Tanner thinks there are opportunities to update policy decisions, especially around the Medicare Conditions of Payment, to reflect the current realities of rural communities and their providers.

1. Rural communities may be served by either small, rural hospitals or critical access hospitals — both of which struggle with Medicare Conditions of payment. What can your system do to help rural facilities deal with the lack of funding they face? What kinds of community benefit support could help offset the inequitable Medicare conditions?

2. Many recently licensed clinicians prefer to take positions in urban rather than rural settings. What educational support or residencies does your system offer to make rural placements more attractive?

What ideas do you have in terms of tuition tradeoffs, paid internships, job security or other opportunities for new clinicians to help bring new talent to rural hospitals in your system?

3. What do you think of Tanner’s view of rural health care as an issue of justice at the ministry level (Catholic health care), the health care system level (your system and how it is advocating for its rural facilities) and the individual level (what you can bring to the table and how you can speak to your state senators and representatives)?

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hospitals need generalists in an era of medical specialty. They need greater leeway to use advanced practice providers, like physician assistants and nurse practitioners, for general medical services.

Hospitals and clinics must have increased flexibility when hiring foreign medical graduates, both in terms of the number of visas allowed and the bureaucratic paperwork nightmare that comes when trying to hire these individuals. The federal government could utilize greater student loan paybacks to entice clinicians to rural areas.

Loosening some of the regulatory burden around workforce would help reverse the trend of physicians opting for urban over rural practices.

This is where public policy continues to make a difference. Just last year, CMS finally ended rules that required a greater level of supervision for outpatient therapies than was required in the rural emergency room. This year, the federal government is seeking input on ways federal scope of practice laws prevent advanced practice providers from practicing at the top of their license and training. While these rules apply to far more than rural facilities, their positive impact on rural hospitals is disproportionately significant.

The challenges facing rural health care are discouraging, but as leaders in Catholic health care it

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is our privilege and responsibility to work toward a better health care system for everyone. By advocating with and for our rural brothers and sisters, we can use public policy to bring about positive change.

RACHEL C. TANNER is the system vice president of regulatory affairs and state relations for CommonSpirit Health. She is based in Denver.

NOTES 1. Janie Boschma, “Record Number of Rural Hospitals Closed in 2019,” Politico Pro Datapoint. See also Alya Ellison, “Rural Hospital Closures Hit Record High in 2019Here’s Why,” Becker’s Hospital CFO Report, Dec. 5, 2019.

2. Eli Saslow, “Traveling the Loneliest Road,” The Washington Post, Dec. 21, 2019, https://www. washingtonpost.com/national/traveling-the-loneliest-road/2019/12/21/f8ec26b2-21ca-11ea-bed5880264cc91a9_story.html.

3. “Health Insurance Coverage in Small Towns and Rural America – The Role of Medicaid Expansion,” Rural Health Policy Project, https://ccf.georgetown.edu/wp-content/ uploads/2018/09/FINALHealthInsuranceCoverage_ Rural_2018.pdf.

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Riccardo De Luca – Update / Shutterstock.com

Finding God in Daily Life “The overriding consideration, never to be forgotten, is that we are all members of the one human family.

The moral obligation to care for one another flows from this fact, as does the correlative principle of placing the human person, rather than the mere pursuit of power or profit, at the very center of public policy.�

Pope Francis in a message to the 2020 World Economic Forum delegates in Davos-Klosters, Switzerland, Jan. 21, 2020

Moving the Needle How Hospital-Based Research Expanded Medicaid Coverage For Undocumented Immigrants in Colorado

LILIA CERVANTES, MD, and NANCY BERLINGER, PhD

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ealth policy that serves the common good in America’s unequal society should aim to mitigate health-related disadvantages. Low income, minority race/ethnicity, and lack of insurance are examples of social (non-medical) determinants of health associated with barriers to health care access and/or poorer health outcomes. Health equity starts by confronting inequality, then using tools of research and policymaking to reduce built-in – structural disadvantages a patient or population cannot fix.

Immigration status is a social determinant of health for undocumented immigrants and for low-income populations. Longstanding federal policy excludes undocumented immigrants from a range of federally funded benefits such as Medicaid; states have the authority to extend statefunded Medicaid to this population. Immigration policy prioritizing enforcement, detention and deportation has observable “chilling effects” on health care-seeking behavior by undocumented immigrants and by low-income authorized immigrants.1 A chilling effect occurs when a perceived or actual policy interferes with a person or population’s ability to use a right by triggering fears of authority and the consequences of disclosing identifying information.

“Toxic stress,” which is the prolonged experience of anxiety and/or depression resulting from hardship, is a related observable health effect of immigration policy.2, 3 Immigration enforcement also may cause or worsen housing insecurity, nutritional insecurity and other social determinants of health due to loss of household income from a detained or deported wage earner and/or chilling effects on household entitlement use. Social determinants also affect citizen members of immigrant-led households, notably children born in the U.S.

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The stresses and hardships on low-income immigrant households are evident to health care providers in metropolitan areas, where most immigrants live and work.4 They are also evident to rural providers who care for immigrant agri-

Immigration status is a social determinant of health for undocumented immigrants and for low-income populations. cultural workers. Two-thirds of the estimated 10.5 million undocumented immigrants in the U.S. have lived here for more than 10 years.5 Clinical research on the experiences and outcomes of this settled population in metro-area health systems can guide systems and policymakers toward policymaking opportunities to mitigate disadvantages experienced by these community members.

At one health system, hospital-based research moved the needle, resulting in policy change to Colorado’s Medicaid program. This policy change has resulted in more effective and humane and less costly care for immigrants with end-stage kidney disease, a life-threatening illness that can be managed as a chronic condition. By support-

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PUBLIC POLICY

ing clinical research on the consequences of substandard practice, health systems produce evidence that justifies policy change. By aligning health care for a disadvantaged population with standard medical practice, public policy supports the health of state residents. So many problems of health care access lack ready policy solutions.

This is one problem with a solution.

END-STAGE KIDNEY DISEASE The role of Medicare in financing appropriate treatment

The function of the kidneys is to filter blood, removing excess fluid and toxins excreted as urine. When a person’s kidneys lose their ability to filter blood, levels of fluid, electrolytes and waste build up in the body: this life-threatening condition is termed end-stage kidney disease. To survive with end-stage kidney disease, a patient must receive a kidney transplant and lifelong antirejection medication to sustain the transplant, or undergo dialysis, a blood-filtering technology compensating for kidney function. In the U.S., the most common form of dialysis is intermittent hemodialysis, involving three sessions per week of 4-6 hours per session at a dialysis clinic; dialysis is also used as a bridge to transplant.

Since 1972, people with a diagnosis of end-stage kidney disease have qualified for Medicare, which ensures that U.S. citizens and lawful permanent residents (green card holders) have access to standard treatment. The dialysis system in the U.S. is shaped by Medicare and equivalent provisions in private health insurance. The difference between standard treatment and what is available to low-income patients ineligible for federal benefits is stark in the context of end-stage kidney disease. There are currently an estimated 5,050 to 8,857 patients locked out of the “universal” benefit and clinic system associated with this diagnosis because they are undocumented.6 These patients are excluded from the federally funded insurance provisions of the Affordable Care Act as well as from federally funded Medicaid insurance. Therefore, they have no ready alternative to insurance coverage for standard treatment.

In most states, undocumented immigrants’ access to life-sustaining treatment for end-stage kidney disease is limited to emergency-only hemodialysis, provided after a patient presents critically ill, week after week, to an emergency department.7, 8 The 1986 Emergency Medical and

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Treatment and Active Labor Act (EMTALA), requires hospitals with public emergency departments to provide all patients with appropriate medical screening and, if a patient is found to

In most states, undocumented immigrants’ access to lifesustaining treatment for end-stage kidney disease is limited to emergency-only hemodialysis, provided after a patient presents critically ill, week after week, to an emergency department. need emergency medical treatment, to deliver treatment until the patient’s condition stabilizes.

Hospitals’ EMTALA duties are mandatory as a condition of Medicare participation. Services to uninsured patients are financed by state-level “Emergency Medicaid” programs to which hospitals apply on behalf of a patient, and by municipal and/or charity-care funds.

“Emergency” care that is potentially eligible for reimbursement through Emergency Medicaid provision is associated with a medical condition (including labor and delivery) causing severe acute symptoms, including pain, such that failure to treat could jeopardize the patient’s life or health or result in organ or bodily impairment. Within this framework, each state’s Medicaid program determines which diagnoses and services will be reimbursed through Emergency Medicaid.

This authority allows policymakers to consider a state’s duties to uninsured patients excluded from public insurance coverage for reasons that include immigration status. Through Emergency Medicaid, a state helps hospitals comply with the EMTALA mandate to ensure that care is available to those unable to pay for it. How best to fulfill this duty concerning patients with a lifethreatening, treatable illness that can be managed as a chronic condition arises in the treatment of end-stage kidney disease.

In Colorado, Denver Health is the safety-net hospital for Denver County. Denver is one of the

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top 20 cities in the U.S. with immigrant population hubs. Most undocumented immigrants with end-stage kidney disease in Colorado rely on Denver Health for emergency-only hemodialysis. In 2013, an estimated 60 to 70 patients were admitted to the hospital for emergency-only hemodialysis after presenting to the emergency department with signs of critical illness associated with kidney failure: high potassium, fluid volume overload and symptoms from high urea. A patient in this condition is often experiencing chest pain and symptoms of breathlessness. Scheduled dialysis typically prevents these burdens of uncontrolled end-stage kidney disease. The protocol for emergency-only hemodialysis includes two inpatient dialysis sessions plus an overnight hospital stay.

To prevent death, this cycle must be repeated each week.9

RESEARCH TO SUPPORT POLICY CHANGE

tize research questions. Stakeholders included patients with end-stage kidney disease ; clinicians such as emergency medicine physicians, hospitalists, nephrologists, nurses, physician assistants, medical social workers, dialysis technicians and interdisciplinary palliative care specialists; hospital executives; health policy experts; representatives of for-profit and nonprofit dialysis organizations, and community-based advocacy groups focused on immigrants, health and human rights.

These early consultations proved crucial to the success of this effort. The stakeholders subsequently helped disseminate findings, and their involvement demonstrated wide support for policy change. Based on these consultations and other background research, the team designed a set of studies. The studies were funded by a fouryear grant from the Harold Amos Medical Faculty Development Program with additional two-year support from the Doris Duke Foundation.

After an undocumented patient with end-stage kidney disease died, having opted to withdraw THE EXPERIENCE FOR PATIENTS AND THEIR FAMILIES from dialysis under emergency-only conditions The first study focused on the qualitative expeand repeated hospital admissions, Denver Health riences and perspectives of 20 undocumented clinicians decided to create a research program to immigrants with end-stage kidney disease who inform public policy supporting medically appro- relied on emergency-only hemodialysis. Participriate care for all patients with end-stage kidney pants described the weekly stress of waiting for disease. It has long been clear that the standard their accumulating symptoms to trigger an emerof care for end-stage kidney disease (if trans- gency department visit and meet the clinical plant is not an option) is scheduled dialysis. What threshold (determined via potassium levels) for the Denver Health team sought to clarify was emergency-only hemodialysis. As one participant the burden of avoidable suffering that non-stan- told researchers, “I don’t want anyone to resusdard management of end-stage kidney disease citate me if my heart or lungs stop. It’s not that I imposed on patients, families and clinicians when a population lacked coverage Denver is one of the top 20 cities in for standard care. The team also sought to clarify the avoidable financial costs of the U.S. with immigrant population emergency-only hemodialysis, mindful hubs. Most undocumented that emergency treatment with hospitalization is typically a much more expenimmigrants with end-stage kidney sive route than outpatient care. The goal was to change health policy in Colorado disease in Colorado rely on by building an evidence-based case for Denver Health for emergency-only recognizing end-stage kidney disease as an emergency medical condition and hemodialysis. including scheduled dialysis in the Emergency Medicaid scope of services. This policy change would create a reimbursement don’t want to live, but sometimes the symptoms pathway for outpatient dialysis after end-stage make one feel that one would be better off dead kidney disease diagnosis. than alive.”10 Participants described their anxiTo create the research agenda, the team ety about the possibility of death should hypermet with stakeholders to identify and priori- kalemia (elevated blood potassium level) trigger

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a fatal arrhythmia (heart rhythm disturbance), and reported near-death and resuscitation experiences. They explained how emergency-only hemodialysis caused distress among their families, who watched patients cope with symptom accumulation, fear of death and disruptive hospitalizations, week after week.11

THE BURDEN OF NON-STANDARD CARE ON CLINICIANS

in a state (California) where scheduled dialysis is covered under Emergency Medicaid (Zuckerberg San Francisco General Hospital, San Francisco).

The team found that patients who received emergency-only hemodialysis had a 14-fold greater risk of death five years after initiating dialysis compared to patients who received standard hemodialysis, and spent nearly 10 times as many days in acute care settings.14 A second retrospective cohort analysis described the circumstances of death among undocumented immigrants who relied on emergency-only hemodialysis and died between January 2006 and January 2017 at Denver Health. In this study, most of the patients who died in the

The team’s second study focused on the qualitative experiences and perspectives of clinicians providing direct care for undocumented immigrants who rely on emergency-only hemodialysis. The team interviewed 25 clinicians in Denver and 25 clinicians in Houston, also among the top 20 U.S. metro areas for undocumented immigrants. Participants Participants explained how described emotional exhaustion from witnessing avoidable suffering and emergency-only hemodialysis high mortality among patients: “People caused distress among their become hyperkalemic and can die in 2 seconds. They go into an arrhythmia. families, who watched patients It just seems like we are playing Russian roulette to some extent with cope with symptom accumulation, people’s lives.” 12 Some participants fear of death and disruptive distanced themselves from patients to avoid empathy; it was distressing to hospitalizations, week after week. be conscious of a patient’s humanity while providing substandard care that increased suffering and risked harm. Some hospital had a diagnosis of hyperkalemia and an participants reported physical exhaustion as electrocardiogram rhythm disturbance, suggestthey attempted to bridge gaps in care through ing that delaying dialysis until a patient’s emercase-by-case advocacy. Clinicians also expressed gent symptoms reached the threshold needed to confusion about the financing and sustainability receive emergency-only hemodialysis created of emergency-only hemodialysis, given its life-threatening critical events.15 To quantify the reliance on repeated, avoidable use of high-cost symptom burden faced by undocumented immiservices. While participants reported feelings of grants who rely on emergency-only hemodialysis, burnout, they also felt strong admiration for their we conducted an observational descriptive study patients, which motivated them to advocacy.13 using a validated measure of physical and psychological symptom distress (Edmonton Symptom Assessment System Revised: Renal). Our team OUTCOMES ASSOCIATED WITH NON-STANDARD found that nausea (a symptom of end-stage renal VERSUS STANDARD CARE The research team also designed several disease caused by urea accumulation) was more quantitative and mixed-method studies to capture often reported by patients who relied on emerdata on clinical outcomes on emergency-only gency-only hemodialysis, compared to patients versus scheduled dialysis for undocumented receiving standard dialysis.16 immigrants. A retrospective cohort study compared mortality and health care use among SHARING FINDINGS AND FRAMING undocumented immigrants who received THE POLICY CONVERSATION emergency-only hemodialysis (Denver Health The team disseminated the findings through and Harris Health, Houston) versus those who peer-reviewed medical journals to garner supreceived standard, thrice-weekly hemodialysis port for policy change from clinicians reflecting

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the range of specialties involved in the care of undocumented immigrants with end-stage kidney disease. The investigators published research articles in high-impact journals such as JAMA and Annals of Internal Medicine. The team also published research articles and commentaries in specialty journals in palliative care, nephrology and hospital medicine.17-19 For each publication, the team created a media pitch to journalists in Colorado and nationally. Describing the research to reporters expanded the audiences for the case they were making about how Colorado, and potentially others, should enable frontline clinicians to provide standard care and prevent needless suffering. The patient stakeholders volunteered to be interviewed for local and national media, giving human faces and voices to the findings.20

MOVING THE POLICYMAKING NEEDLE — LESSONS FROM COLORADO

concerning medications and interventions (such as vascular surgery for catheter implantation) associated with standard hemodialysis.

FACTORS FOR SUCCESS

What were the ingredients of success in Colorado? We have identified three factors: 1. Support for clinical research and communications aimed at public policy change. This research was initiated by a team of clinicians who perceived an opportunity to improve care for uninsured patients via public policy. Denver Health was integrally involved in stakeholder engagement, media outreach, dissemination and research support.

2. Collaboration and trust across stakeholder groups. Colorado Medicaid officials worked with Denver Health staff, health care providers, nonprofit organizations and patients to understand the consequences of emergency-only dialysis and the feasibility of policy change to support standard of care. Undocumented immigrants participated in advocacy and entrusted journalists with their stories.

3. Conducive state-level policymaking environment. Colorado Department of Health Care Policy and Financing had been interested in making this policy change but lacked clinical data, which this set of research studies provided. That Colorado’s elected leaders were all members of

Following nearly two years of dialogue between the Denver Health research team and the Colorado Department of Health Care Policy and Financing, on Feb. 1, 2019, Colorado became the 12th state to allow Emergency Medicaid funds to be used for standard treatment of end-stage kidney disease by including the diagnosis of endstage kidney disease as an “emergency medical condition.”21 Previously, undocumented immigrants with this diagnosis could access dialysis only after meeting clinical criteria (chiefly, elevated potassium The maintenance of a city and region’s level) reflecting critical illness, pushing patients to the brink of health care safety net involves death each week. By including all levels of health policy: federal, the diagnosis of end-stage kidney disease itself in the Emergency state, municipal, organizational, Medicaid scope of services, Colorado Medicaid created a policy professional. It involves private pathway that allowed clinicians nonprofit institutions and systems as to practice to standard, prevented suffering and lowered costs. This well as public hospitals and clinics. sub-regulatory language change made scheduled dialysis accessible to 137 undocumented immigrants with end- the same political party during this time frame stage kidney disease management residing in this likely reduced barriers to policy change. state. Colorado Medicaid expects a cost savings of The data from the Denver Health studies, $17 million per year, reflecting the significantly including comparative data from Houston and lower cost of outpatient versus emergency treat- San Francisco, is now a resource for other cliniment.22 As the policy has rolled out, discussions cian-investigators, health systems and state poliamong policymakers, researchers and stakehold- cymakers who aim to improve end-stage kidney ers have continued, to resolve coverage issues disease care and outcomes for an uninsured, low-

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income population. The research team welcomes opportunities to share their experiences and to mentor similar efforts throughout the U.S. Team members also are involved in new research to understand barriers to medically appropriate hospice care for patients who meet clinical criteria but are ineligible for the Medicare hospice benefit due to immigration status.23

CONCLUSION

The maintenance of a city and region’s health care safety net involves all levels of health policy: federal, state, municipal, organizational, professional. It involves private nonprofit institutions and systems as well as public hospitals and clinics.

Colorado’s experience in making publicly funded health care more effective, more humane and less costly for patients with end-stage kidney disease demonstrates that, even in the current national political climate, there are opportunities to improve access to needed, medically appropriate health care. It is time to seize those opportunities on behalf of our patients, their families, our clinical work forces and the communities we serve.

LILIA CERVANTES is an associate professor in the Division of Hospital Medicine, Office of Research, Denver Health, and Division of General Internal Medicine, University of Colorado Anschutz Medical Campus. NANCY BERLINGER is a research scholar at The Hastings Center, a bioethics research institute in Garrison, N.Y., and the cofounder of the Undocumented Patients project, a Hastings Center initiative providing analysis, tools and solutions on health care access for undocumented immigrants and other low-income immigrant populations.

NOTES 1. Kathleen R. Page and Sarah Polk, “Chilling Effect? PostElection Health Care Use by Undocumented and MixedStatus Families,” New England Journal of Medicine 376, no. 12 (2017): e20.

2. Emilie Bruzelius and Aaron Baum, “The Mental Health of Hispanic/Latino Americans Following National Immigration Policy Changes: United States, 2014-2018,” American Journal of Public Health 109, no. 12 (2019): 1786-88.

3. Samantha Artiga and Petry Ubri, “Living in an Immigrant Family in America: How Fear and Toxic Stress Are

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Affecting Daily Life, Well-Being, & Health,” Kaiser Family Foundation (December 13, 2017), https://www.kff.org/ disparities-policy/issue-brief/living-in-an-immigrantfamily-in-america-how-fear-and-toxic-stress-are-affecting-daily-life-well-being-health/.

4. Jeffrey S. Passel and D’Vera Cohn, “Twenty Metro Areas Are Home to Six-in-Ten Unauthorized Immigrants in U.S.,” Pew FactTank (March 11, 2019), Washington, DC: Pew Research Center, https://pewrsr.ch/2J4tr3W. 5. Jens Manuel Krogstad, Jefferey S. Passel and D’Vera Cohn, “5 Facts About Illegal Immigration in the U.S.,” Pew FactTank (June 12, 2019), Washington, D.C.: Pew Research Center, https://pewrsr.ch/2WzwRgy. 6. Rudolph A. Rodriguez, Lilia Cervantes, and Rajeev Raghavan, “Estimating the Prevalence of Undocumented Immigrants with End-Stage Renal Disease in the United States,” Clinicial Nephrology (2019), Published online first, https://www.dustri.com/article-response-page. html?artId=185697&doi=10.5414%2FCNP92S119.

7. Rodriguez et al., “Estimating the Prevalence.”

8. As of March 2019, these 12 states include standard outpatient dialysis in their Emergency Medicaid scope of services: Arizona; California; Colorado; Illinois; Massachusetts; Minnesota; New York; North Carolina; Pennsylvania; Virginia; Washington; Wisconsin. Standard outpatient dialysis is also covered by Emergency Medicaid in Washington, D.C. Lilia Cervantes, William Mundo and Neil R. Powe, “The Status of Provision of Standard Outpatient Dialysis for US Undocumented Immigrants with ESKD,” Clinical Journal of the American Society of Nephrology 14, no. 8 (2019): 1258-60. https:// doi.org/10.2215/CJN.03460319.

9. Lilia Cervantes et al., “Association of Emergency-Only vs Standard Hemodialysis with Mortality and Health Care Use among Undocumented Immigrants with EndStage Renal Disease,” JAMA Internal Medicine 178, no. 2 (2018): 188-95.

10. Lilia Cervantes et al., “The Illness Experience of Undocumented Immigrants with End-Stage Renal Disease,” JAMA Internal Medicine 177, no. 4 (2017): 529-35.

11. Lilia Cervantes et al., “The Illness Experience.”

12. Lilia Cervantes et al., “Clinicians’ Perspectives on Providing Emergency-Only Hemodialysis to Undocumented Immigrants: A Qualitative Study,” Annals of Internal Medicine 169, no. 2 (2018): 78-86.

13. Cervantes et al., “Clinicians’ Perspectives.”

14. Cervantes et al., “Association of Emergency-Only.”

15. Lilia Cervantes et al., “Circumstances of Death among Undocumented Immigrants Who Rely on Emergency-Only Hemodialysis,” Clinical Journal of the American Society of Nephrology 13, no. 9 (2018): 1405-06.

16. Lilia Cervantes et al., “Symptom Burden Among

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Latino Patients with End-Stage Renal Disease and Access to Standard or Emergency-Only Hemodialysis,” Journal of Palliative Medicine 21, no. 9 (2018): 1329-33.

See also Lilia Cervantes et al., “Peer Navigator Intervention for Latinos on Hemodialysis: A Single-Arm Clinical Trial,” Journal of Palliative Medicine 22, no. 7 (2019): 838-43.

17. Lilia Cervantes, Monica Grafals and Rudolph A. Rodriguez, “The United States Needs a National Policy on Dialysis for Undocumented Immigrants with ESRD,” American Journal of Kidney Diseases 71, no. 2 (2018): 157-59.

18. Christine C. Welles and Lilia Cervantes, “Hemodialysis Care for Undocumented Immigrants with End-Stage Renal Disease in the United States,” Current Opinion in Nephrology and Hypertension 28, no. 6 (2019): 615-20.

19. Lilia Cervantes, “Dialysis in the Undocumented: Driving Policy Change with Data,” Journal of Hospital Medicine (2019), published online first, https://www.journalofhospitalmedicine.com/

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jhospmed/article/212344/hospital-medicine/ dialysis-undocumented-driving-policy-change-data.

20. Sanjay Gupta, “CNN: Undocumented Immigrants on Dialysis Forced to Cheat Death Every Week,” (2018); https://www.cnn.com/2018/08/02/health/kidney- dialysis-undocumented-immigrants/index.html.

21. Emergency Medical Condition: End-Stage Renal Disease [policy announcement], Colorado Department of Health Care Policy and Financing (December, 2018): https://www.colorado.gov/pacific/sites/default/files/ ESRD%20Emergency%20Memo%2012-6-18.pdf.

22. Jennifer Brown, “Immigrants Here Illegally Were Waiting Until Near Death to Get Dialysis. A New Colorado Policy Changes That,” The Colorado Sun, Feb. 25, 2019, https://coloradosun.com/2019/02/25/undocumentedimmigrants-dialysis-colorado-medicaid-policy/.

23. Nathan A. Gray et al., “Hospice Access for Undocumented Immigrants,” JAMA Internal Medicine 177, no. 4 (2017): 579-80.

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Economic Inequality And the 2020 Campaign DAVID SHEETS

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ith the 2020 presidential campaign well underway, economic inequality continues to gain strength as one of the top issues in the election. Six in 10 U.S. adults believe the level of inequality is too high, according to the Pew Research Center.1 Of those, most say the solution requires a wholesale change to the economic system.

One year from now, the occupant of the White House will potentially shape our economic evolution for the next generation, so perhaps now we should ask: How did we get here? And what solutions to the problem of economic inequality do the 2020 presidential candidates offer?

THE PATH TO ECONOMIC INEQUALITY

For nearly 40 years after World War II, America existed as a social democracy. High wealth taxes and other government interventions imposed for the post-war recovery bolstered the social justice framework, spurred a post-war economic boom and laid the foundation for the largest group of middle-class Americans in the nation’s history.

The turnaround began in earnest in 1981 when free-market advocate Ronald Reagan entered the White House, insisting the rich had paid too much for too long.2 Despite persistent evidence that free markets do not distribute wealth evenly, Reagan’s strategy has dominated domestic policymaking ever since.

Today, America has two sides to its economy.

One appears to indicate we are on an unrelenting trajectory upward. Job creation entered its 110th month in January 2020 — a record in the postWorld War II era — and unemployment hovers around 3.7%, a level unmatched in 50 years. Gains in employment raised median household income (income allows a family to get by, while wealth enables a family to get ahead) to $74,600 at current levels, or 49% higher than 1970.3

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The numbers are starker on the other side.

Fewer people constitute the workforce since the Great Recession of 2007-2009. Part-time job growth outpaces full-time job growth. Household incomes on average grew at an annual average rate of only 1.2% in 2000-2018 against an inflation rate that moved between 3.4% and 2.5% during the same period.4 Analysts point to several reasons why the gap between the two sides keeps growing wider: Middle-income Americans in 2007 were still recovering from the March-November 2001 dotcom recession when the Great Recession struck.

Together, those downturns slowed household income growth to an annual average rate of only 0.3%. Without the downturns, income gains sustained since 1970 would have continued, making the current median income $87,000.5 By contrast, top corporate executives across the board have seen their salaries grow by more than 1,000% over the past 40 years, nearly 100 times the rate of average workers.6 Besides dragging down income growth, the Great Recession dragged down home values. Home ownership, then as now, represents the single biggest investment by typical families.

When home values plummeted between 20072009, the median net worth of families fell 40% to $87,800 by 2013 from a peak of $146,600 in 2007.

By 2016, the last year for which current data is available, the typical American family’s net worth had climbed to $101,800, still well below where

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they were in 2007. The wealthiest families are the only ones who experienced gains in wealth during the Great Recession. From 2007 to 2016, the median net worth of the richest 20% of Americans increased 13%, to $1.2 million.7 The digital revolution, in place since 2001, has reduced demand for what economists consider to be high-income “middle-skill” jobs and replaced those with lower-paying automated responsibilities managed by computer software and industrial machines. Today, the job force cherishes workers with abstract problem solving, interpersonal and organizational skills and devalues cognitively repetitious tasks in offices and on production lines, thus putting more pressure on low- and middle-income laborers to acquire more skills.8 When manufacturing labor declined, so did the number and influence of labor unions. Their disappearance — compounded by the easy, efficient movement of ideas, products and people around the planet, or globalization — shrinks the power workers have to bargain for higher wages and benefits. Currently, only 10% of workers have labor representation. Four decades ago, that percentage was 50% . The resulting decline in representation means reduced buying power for workers. Because the national $7.25 per hour minimum wage has not risen to keep pace with inflation, the value of America’s minimum wage has fallen 16% in the past half-century.9 As globalization grows, American workers compete for fewer jobs against workers in other nations. Leading among them is China, the biggest economic story of the past 50 years. In the period that America saw employment and economic declines, China enjoyed a reversal from an impoverished backwater with persistent political turmoil to a frontier manufacturing economy that has produced skilled, well-educated laborers using modern technology. This reversal resulted from internal allowances for free mobility of labor and the practical application of science to commerce and industry. China began making gains in the 1990s, but the floodgates truly opened in 2001, when it entered the World Trade Organization.

Suddenly, the United States found itself competing for jobs once solely held by Americans.10 Giant breakthrough companies such as Amazon and Apple attract revenues from around the world at a rate unmatched by other enterprises.

Their dynamism enables executives to reap immense salaries while paying workers relatively little. These companies set up in metropolises

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instead of rural areas, further widening the gap between cities and less-populous towns.11 With great wealth comes great power. Economic winners and private institutions tend to reward themselves further through the government policies they advance. The 2017 Republican tax cut, for example, produces disproportionate benefits to the affluent at the expense of low- and middle-income families.12

THE SEARCH FOR A CONSENSUS

Finding a consensus solution to the problem of economic inequality is tricky. The Pew Research Center recently surveyed U.S. adults on what measures contribute to economic inequality in this country, and those surveyed believe no single measure is responsible.13 Pew’s findings cited roughly equal shares among a series of structural issues, including the outsourcing of jobs to other countries (45%), the tax system (45%) and problems with education (44%). About 4 in 10 cited factors such as different life choices (42%) and more opportunities at birth than others (40%).

Six in 10 Republicans believe economic inequality lies in the choices people make, while only 27% of Democrats hold that view. Republicans also tend to think that some people work harder than others (48%) as opposed to Democrats (22%). Their Democratic counterparts believe discrimination against racial and ethnic minorities contributes a great deal to inequality, a view held by only 11 % of Republicans.

Within the party coalitions, some divisions crop up. While 60% of Republicans overall say that people’s different choices in life significantly impact economic inequality, lower-income Republicans (46%) are less likely than Republicans with middle (63%) or higher (74%) incomes to say this. Lower-income Republicans also point to structural concerns. About half of lowerincome Republicans (52%) say problems with the educational system significantly affect inequality, compared with 38% of upper-income Republicans and 33% of middle-income Republicans.

Overall, there is less division among Democrats; however, upper-income Democrats are less likely than those with middle and lower incomes to say discrimination against racial and ethnic minorities, automation and outsourcing are contributors to economic inequality.14 Another recent Pew survey on Americans’ values finds that a majority (60%) say most people who want to get ahead can make it if they work hard.15 About 39% say hard work and determina-

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tion are no guarantee of success for most people. proposal — originally a 2% annual levy on houseAmong Republicans, 78% say you can get ahead hold assets over $50 million, with a 3% rate over on hard work alone, while 22% dispute that. A slim $1 billion — certainly would help restructure majority of Democrats (54%) dismiss hard work America’s wealth. Warren upped the tax in November 2019, to 6% as part of her plan to fund as a guarantee of success.

Americans also are divided over whether Medicare for All. To finance expanded affordable poor people have it easy or hard these days. Half housing programs, she proposes lowering the of Americans say poor people have hard lives threshold that triggers the federal estate tax from because government benefits fall short of helping them live decently.

Americans also are divided over A similar share (47%) say poor whether poor people have it easy or people today have it easy because they can get government benefits hard these days. Half of Americans say without doing anything in return.

Democrats and Republicans hold poor people have hard lives because diametrically opposing opinions government benefits fall short of on this issue.16

THE PRESIDENTAL CANDIDATES

helping them live decently.

Each of the frontrunning 2020 presidential candidates at press time has promised to pursue a different course if elected. Here are summaries of their approaches: 17, 18 Donald Trump — President Trump has said his tariffs on goods produced in Europe and China and the reductions to welfare programs have pared down trade debt and restored manufacturing and middle-income stability. President Trump continues to believe, as he did in 2016, that a regime of tax cuts, regulatory rollbacks and protectionist trade policies will minimize economic inequality.

Bernie Sanders — Among the Vermont senator’s plans are an 8% annual wealth tax on fortunes exceeding $10 billion. Major corporations would have to transfer at least 2% of company stock to their workers annually until employees owned at least 20% of the corporate operation. Also, in 2010 the Dodd-Frank Act made publicly traded corporations disclose their annual ratio of CEO to median pay. Sanders would place consequences on these disclosures, insisting that corporations with CEOs making more than 50 times the typical worker’s pay would face higher corporate income tax rates. The broader their corporate pay gap, the steeper the tax. Sanders introduced legislation for this pay-ratio tax plan in November of 2019, with Elizabeth Warren as a co-sponsor.

Elizabeth Warren — The Massachusetts senator has said the nation needs to make the investments that give every child in America a chance to succeed. The wealthy need to “pitch in” to help make that opportunity possible. Her wealth tax

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$22.8 million to $7 million and raising the estate tax to as much as 75% on bequest values over $1 billion. (Bequest values are the premiums that people place on their satisfaction from preserving natural or historic environments, in other words natural heritage or cultural heritage for future generations. It is often used when estimating the value of an environmental service or good.)

Joe Biden — Wall Street bankers, CEOs and hedge fund managers consider Biden’s tax plan “far less extreme” than those of his two chief rivals, Elizabeth Warren and Bernie Sanders.19 The former U.S. vice president has not proposed a wealth tax or a marked increase in the highest income tax rate, but he does support undoing the 2017 Trump tax plan, which gives preferential treatment to the rich. And unlike the other top Democratic contenders, he has not yet given support to a financial transaction tax that targets the Wall Street elite.

Pete Buttigieg — In a New York Times interview, the South Bend, Indiana, mayor declared support for a wealth tax and welcomed the idea of raising the top income tax rate from its current 37% to 49.99% (under Obama, the top tax rate was 39.6%). Otherwise, his campaign website chiefly highlights standard Democratic anti-poverty prescriptions, from a $15 minimum hourly wage to increased federal funding for “schools with the highest economic and racial inequity.” The website’s section describing an inclusive economy highlights limited goals for knocking down “unfair barriers to entrepreneurship.”

Amy Klobuchar — The Minnesota senator

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said that in her first 100 days as president she would move to equalize tax rates for capital gains and ordinary income, ensure that incomes over $1 million are subject to a minimum 30% tax and close the carried interest loophole that lets fund managers sidestep billions of dollars in taxes.

Other priorities include expanding Medicare and Medicaid, improving the Patient Protection and Affordable Care Act (ACA) and creating a public option.

DAVID SHEETS is a freelance journalist based in St. Louis.

NOTES 1. Juliana Menasce Horowitz, Ruth Igielnik and Rakesh Kochhar, Pew Research Center, “Most Americans Say There Is Too Much Economic Inequality in the U.S., but Fewer Than Half Call It a Top Priority,” Pew Research Center, Jan. 8, 2020, https://www.pewsocialtrends. org/2020/01/09/most-americans-say-there-is-toomuch-economic-inequality-in-the-u-s-but-fewer-thanhalf-call-it-a-top-priority.

2. Sheelah Kolhatkar, “Embarrassment of Riches,” The New Yorker (Jan. 6, 2020) 32-41.

3. Horowitz et al., “Most Americans Say.” 4. “The Gap Between Poor and Rich Neighborhoods is Growing,” The Economist, Nov. 13, 2018, https://www. economist.com/democracy-in-america/2018/11/13/ the-gap-between-poor-and-rich-neighbourhoods-isgrowing.

5. Horowitz et al., “Most Americans Say.” 6. Kimberly Amadeo, “Income Inequality in America,” The Balance, Dec. 16, 2019, https://www.thebalance. com/income-inequality-in-america-3306190.

7. “In a Politically Polarized Era, Sharp Divides in Both Coalitions,” Pew Research Center, Dec. 17, 2019, https:// www.people-press.org/2019/12/17/in-a-politicallypolarized-era-sharp-divides-in-both-partisan- coalitions/.

8. Bill Chappell, “U.S. Income Inequality Worsens, Widening to a New Gap,” NPR, Sept. 26, 2019, https://www. npr.org/2019/09/26/764654623/u-s-income-inequalityworsens-widening-to-a-new-gap.

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9. Kimberly Amadeo, “Which States Are the Richest, Poorest, and Have the Best Economies,” The Balance, June 25, 2019, https://www.thebalance.com/ which-states-have-the-best-economies-3980690.

10. Ana Kent, Lowell Ricketts and Ray Boshara, “What Wealth Inequality in America Looks Like: Key Facts and Figures,” Federal Reserve Banks of St. Louis, Aug. 14, 2019, https://www.stlouisfed.org/open-vault/2019/ august/wealth-inequality-in-america-facts-figures.

11. Derek Thompson, “Wealth Inequality Is a Problem, but How Do You Begin to Solve It?” The Atlantic, March 6, 2013, https://www.theatlantic.com/business/ archive/2013/03/wealth-inequality-is-a-problem-buthow-do-you-even-begin-to-solve-it/273769/.

12. Amadeo, “Income Inequality in America.”

13. Horowitz et al., “Most Americans Say.” 14. “Democrats vs. Republicans: Which Is Better for the Economy?” Dec. 7, 2019, https://www.thebalance. com/democrats-vs-republicans-which-is-better-for-theeconomy-4771839.

15. “In a Politically Polarized Era, Sharp Divides in Both Coalitions,” Pew Research Center, Dec. 17, 2019, https:// www.people-press.org/2019/12/17/in-a-politicallypolarized-era-sharp-divides-in-both-partisan-coalitions/.

16. Bill Chappell, “U.S. Income Inequality Worsens.”

17. Martha C. White, “Trump says ‘American Worker’ Is Top Priority – but Economists Are Skeptical,” NBC News, Jan. 21, 2020, https://www.nbcnews.com/business/ economy/trump-says-american-worker-top-priorityeconomists-are-skeptical.

18. 2020 Presidential Campaigns for: President Donald Trump: https://www.donaldj trump.com/ Joe Biden: https://joebiden.com/ Elizabeth Warren: https://elizabethwarren.com/ Bernie Sanders: https://berniesanders.com/ Pete Buttigieg: https://peteforamerica.com/ Amy Klobuchar: https://amyklobuchar.com/ 19. Tony Nitti, “Reviewing the Democratic Candidates’ Tax Plans: Joe Biden,” Forbes, Sept. 30, 2019, https://www.forbes.com/ sites/anthonynitti/2019/09/30/reviewing-the- democratic-candidates-tax-plans-joe-biden.

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Fighting Fragmentation Mental Health Benefits from Integrated Care

BENJAMIN F. MILLER, PsyD

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he data is going in the wrong direction. While life expectancy has been on the rise since the 1960s, its sharp decline over the last three years is a sign that something is fundamentally broken in the United States.1 It’s 2020, and we are losing more lives to preventable causes than ever before. Deaths due to drugs, alcohol and suicide are at an all-time high, and our country is hurting in ways that are multifaceted — attributable to overlapping issues and circumstances. For some, it may be access to affordable health care.

For others, it may have more to do with social and economic factors.2 Loneliness, worry, isolation and issues of belonging are key drivers of despair, and we must be bold in our vision and courageous in our decision making if we are serious about making a difference in our country’s health.3

Annual Deaths from Alcohol, Drugs, and Suicide in the United States, 1999–2017 151,845

73,990

64,591

47,173

Total Deaths

Drug Deaths

Suicide Deaths

2017

2016

2015

2014

2013

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

35,823

2001

2000

29,199 19,469 19,128 1999

160,000 150,000 140,000 130,000 120,000 110,000 100,000 90,000 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0

Alcohol Deaths

Source: Trust for America’s Health and Well Being Trust analysis of data from National Center For Health Statistics, CDC

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PUBLIC POLICY

For more than a decade, the dominant health tors were also new and in need of policy to suppolicy landscape has focused on improving out- port them. These critical first steps of the third comes, decreasing cost and enhancing the patient mental health reform were essential in establishexperience.4 And while these goals are impor- ing a new system of care — and yet in 2020, while tant, health policy strategy has often treated scientific knowledge and mental health polimental health as an afterthought. Although there cies have advanced, President Kennedy’s vision have been many well-meaning but disconnected remains aspirational.

People still have to wait too long to get access attempts to integrate, we have yet to see a robust policy agenda that centers on mental health. Our to mental health care, and stigma — both social country has a mental health problem, and the solu- and structural — remains a barrier to addresstions have been as fragmented as the systems we have created to address it.

People still have to wait too long to Faced with unprecedented urgency, it get access to mental health care, and is time to bring mental health to the top of our agenda. stigma — both social and structural This article describes a way forward — a specific policy framework — remains a barrier to addressing and options to consider if we are serimental health issues. ous about doing something different for mental health. Beginning with a brief history, flowing into possible solutions and ing mental health issues. While well-intentioned, closing with a framework and policy call to action, clinical and programmatic fragmentation have this article will attempt to be a primer for mental had unintended consequences, including the creation of an entirely separate system of care that is health policy. often disconnected from the rest of health care.

In addition, community mental health centers, an HOW WE GOT HERE While the history of mental health has been docu- entirely sound idea, were never given adequate mented extensively elsewhere,5 at a high level one resources to develop the capacity needed to meet could describe the United States as having gone the needs for mental health treatment. through several phases of mental health reform, with the most current one being the need to treat A REVOLUTION IN INTEGRATION mental health in our communities.

If a culture of fragmentation is the dominant probThis current reform dates to 1963. President lem for addressing mental health, then integration John F. Kennedy made the momentous decision to must be the solution. Many have touted the bendeinstitutionalize mental health, which was seen efits of more integrated programs, and the eviby many as a positive step in the right direction. dence is robust about its impact.7 However, like The inhumane and often brutal treatment of those many good ideas in health care, without systemic with mental illness served as examples of misun- implementation, even the most effective proderstanding mental health and failing the people grams run the risk of failing or, even worse, not who needed help the most. President Kennedy being scaled and sustained despite initial success. described the 1963 law: Integrating mental health and primary care “This approach relies primarily upon the new provides one of the best-use cases for successfully knowledge and new drugs acquired and devel- integrating mental health into a medical team oped in recent years which make it possible approach. The Agency for Healthcare Research for the most mentally ill to be successfully and and Quality defines this as: “The care that results quickly treated in their communities and returned from a practice team of primary care and behavto a useful place in society.”6 ioral health clinicians, working together with A multitude of policies, all intended to sup- patients and families, using a systematic and costport this new approach, have been instituted and effective approach to provide patient-centered codified. The emergence of a separate system for care for a defined population. This care may mental health had officially been created, which address mental health and substance abuse conmeant that new financing and delivery models, ditions, health behaviors (including their contrihealth insurance benefits and other related fac- bution to chronic medical illnesses), life stressors

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and crises, stress-related physical symptoms, and ineffective patterns of health care utilization.”8 At a health system level, there are multiple opportunities to apply an integration lens to more traditional medical care. Consider some of the elements from the lexicon: a team approach to care that is rooted in the full continuum of how patients and their families present with mental health needs. Because of the pervasiveness of mental health across all health conditions, it is likely that patients’ clinical outcomes and overall experience will be enhanced because they had access to another expert who could help them with their mental health.

However, like so many good ideas on mental health and integration, sustaining these models is challenging in part because of the historical roots of how we pay for mental health care (separate), and the policies that limit how well we integrate.

This is a propitious moment to do something about mental health in this country, and policy is one meaningful mechanism to help address this crisis.

EVERYONE HAS A ROLE IN POLICY

Recently, Well Being Trust, in partnership with several key collaborators, launched a federal policy guide entitled “Healing the Nation: Advancing Mental Health and Addiction Policy.” The title tells a bit about the story: People are hurt-

ing, and policies should be responsive to the pervasive mental health needs that are being unmet.

The goal is to provide members of Congress a comprehensive guide on ways to impact mental health through policy. Leveraging a framework for action, “Healing the Nation” offers a plan that will start with the federal government and extend into our states and communities.

The framework within “Healing the Nation” focuses on multiple angles for engagement with a specific emphasis on five main entry points for policy: health systems; judicial systems; education systems; workplace and unemployment; and the whole community. The framework also highlights populations that have been impacted differently by the mental health and addiction crisis.

The end goal of the policy guide and framework is to offer a more integrated approach that could bring mental health into all our health policies.

Below are some examples of the types of health system policies in “Healing the Nation.” All policies as well as the framework can be found at http://healingthenation.wellbeingtrust.org/ The federal government should ensure that hospital payment models and quality programs incentivize assessing mental health at every interaction as a vital sign, and not only during well visits. This should include integrating screening and treatment into episode-based payment models for health conditions that often are diagnosed and

Framework for excellence in mental health and well-being The framework for excellence in mental health is a guide for changemakers at every level of society who seek to improve mental health outcomes and promote well-being for millions of Americans.

PROMOTION

PREVENTION

TREATMENT

VITAL COMMUNITY CONDITIONS

COVERAGE

MAINTENANCE

ENGAGEMENT

OUTCOMES

BARRIE RS

Belonging & Civic Muscle

Humane Housing

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Lifelong Learning

Meaningful Work & Wealth

Basic Needs For Health & Safety

Primary Care / Emergency Department / Hospital

Stigma / Cost / So cial Isolat ion / Acce ss

Reliable Transportation

HEALTH SYSTEMS

Thriving Natural World

WORKPLACE & UNEMPLOYMENT Comprehensiveness

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Employees / Employers

WHOLE COMMUNITY

Improved community conditions and available access to care Advanced integration Structures for evidence-based care

Parity

Individual and family reported outcomes

JUDICIAL SYSTEM Diversion / Treatment / Re-entry

EDUCATION SYSTEM Students / Teachers / Programs

Smarter use of technology

FOCUS POPULATIONS

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treated simultaneously with mental health condi- for institutions that educate health care profestions, such as cardiovascular diseases, cancers sionals to offer training in integrated mental and pulmonary diseases. health care.

Suicide and mental health crises should be Providers should be incentivized to take included as part of hospital safety initiatives, and additional continuing medical education classes evidence-based strategies should be integrated on current best practices.9 Federally funded quality improvement orgainto federally funded hospital quality improvement programs. Examples include Zero Suicide, a nizations should focus resources on mental health program that helps health systems embed systems integration across diverse primary care practices to identify and treat individuals at risk for suicide. and for serving diverse populations, and finance The federal government should invest in additional learning collaboratives as necessary. piloting and scaling innovative information technology solutions Without seamlessly integrating mental to improve the successful triage and coordination of care for indihealth across our health systems, viduals with mental health condiwe are failing people, families, tions that present to emergency medical services or the emertheir communities, and ourselves, gency department, including and policies should reinforce this connections with social services.

The federal government integrated model of care. should fund the development and dissemination of evidence-based Though not exhaustive, these lists give a sense training and continuing education materials on of the health system solutions within “Healing the mental health for emergency department staff.

And in critical ambulatory care settings, such Nation.” The document delves into specific solutions within the workplace, educational and judias primary care: The federal government should require that cial systems, and for especially impacted popuall primary care payment models initiated by the lations like youth, LGBTQ+, African Americans, Centers for Medicare and Medicaid Services or by Native Americans and those with co-occurring the states through waivers include consideration conditions. of whether the model would equip the participating practices with the resources they need to pro- THE TIME FOR REFORM IS NOW vide integrated mental health care. This should Without seamlessly integrating mental health include auditing and revising existing models or across our health systems, we are failing people, initiating new ones and may include carving cer- families, their communities, and ourselves, and tain mental health services out of the cost bench- policies should reinforce this integrated model of mark to ensure that there are adequate incentives care. With so much focus on health care in polifor building out integrated care. tics, it’s a shame that so little centers on mental The federal government should mandate health. While some presidential candidates have prioritization of mental health screening and out- brought forth policies that could be transformacome measures in federal value-based payment tive for mental health, most debates leave the models and ensure that the measures are weighted topic out altogether. Isn’t it time for mental health to reflect their importance for population health. to be on the agenda of every administrator, every Congress should also create a fund that can help elected (and running) official and every stakelow-performing systems improve by implement- holder, including each of us as patients and family members? The rallying cry for the next generation ing evidence-based integration approaches.

Additional policies should support our will be integration, so let’s begin to do what’s right for all of us now. workforce: The federal government should provide incentives, through graduate medical education, BENJAMIN F. MILLER is chief strategy officer, graduate nursing education and other programs Well Being Trust, a national foundation commit-

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ted to advancing the mental, social and spiritual health of the nation. He lives in Denver.

NOTES 1. Steven H. Woolf and Heidi Schoomaker, “Life Expectancy and Mortality Rates in the United States, 19592017,” JAMA 322, no. 20 (2019): 1996–2016, https://doi. org/10.1001/jama.2019.16932.

2. “Pain in the Nation” report, Well Being Trust, Trust for America’s Health, http://www.paininthenation.org/ assets/pdfs/TFAH-2017-PainNationRpt.pdf.

3. Carol Graham and Sergio Pinto, “The Geography of Desperation in America: Labor Force Participation, Mobility Trends, Place, and Well-Being,” Brookings website, October 15, 2019, https://www.brookings.edu/ research/the-geography-of-desperation-in-americalabor-force-participation-mobility-trends-place-andwell-being/.

4. Donald M. Berwick, Thomas W. Nolan and John Whittington, “The Triple Aim: Care, Health, and Cost,” Health Affairs 27, no. 3 (2008): 759-69.

5. Benjamin F. Miller and Samuel H. Hubley, “The History

of Fragmentation and the Promise of Integration” in Handbook of Psychological Assessment in Primary Care Settings, ed. Mark Maruish (New York: Routledge, 2017), 55-73.

6. Journal of the Senate of the United States of America, Eighty-eighth Congress, First session beginning January 9, 1963.

7. “Integrated Care,” National Institute of Mental Health, https://www.nimh.nih.gov/health/topics/integratedcare/index.shtml.

8. Charles J. Peek et al., “Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus,” AHRQ Publication No.13-IP001-EF, (Rockville, Md: Agency for Healthcare Research, 2013), accessed January 16, 2020, https:// integrationacademy.ahrq.gov/sites/default/files/Lexicon.pdf.

9. “Navigating the New Frontier of Mental Health and Addiction: A Guide for the 115th Congress,” The Kennedy Forum, https://thekennedyforum-dot-org. s3.amazonaws.com/documents/9/attachments/The_ New_Frontier_CongressGuide.pdf?1485267841.

QUESTIONS FOR DISCUSSION Benjamin Miller is chief strategy officer for Well Being Trust, a national foundation committed to advancing the mental, social and spiritual health of the nation. He is concerned that we are losing more lives to preventable causes — such as addiction and suicide — than ever before. Given what he identifies as the fragmented approach to mental health, he is convinced the solution is in integration: standardizing practice, bridging the silos of health care specialties, funding and insuring mental health on a par with other medical conditions, reducing stigma and social isolation and coordinating efforts for mental health policy.

1. Do you experience topics of mental health as a secondary stepchild within health care overall? Can you give examples of how a patient who presents primarily with a physical medical condition might be treated differently than one who presents primarily with a mental health condition?

2. Our foundations in Catholic social teaching direct us to uphold the dignity of the whole person.

How does your hospital or health system screen for overall health — physical, mental, social, spiritual — in assessing a patient’s well-being? Do you think the right questions are being asked? Do you think the right people are asking them? Are your community benefit dollars addressing disparities of care? Do you think you are maximizing a team approach for patient-centered care?

3. Miller thinks the time is right for bold action on mental health policy and identifies the five main entry points to move on policy as health systems, judicial systems, education systems, workplace and unemployment, and the broader community. Do you think your health system is primed for such an initiative? Are the right partnerships in place and highly operable? What might your leaders, advocacy experts and mission leaders need to move forward?

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Medicaid Expansion in Michigan Reflects Catholic Social Principles ALISHA COTTRELL, SEAN D. GEHLE and LINDA ROOT, RN, MAHCM

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atholic health care is called to assure and promote the common good and Catholic social tradition, thought and practice. We answer the Gospel call to affirm that each person’s life is a treasure and everyone should have the opportunity to flourish.

Access to quality health care is a right and is necessary for everyone to achieve that vision.

We need to understand the impact of the call of Catholic health care on assuring that our words, deeds and actions inform the care we provide, especially to people who are poor and vulnerable. The preferential option to provide particular attention to those who are poor must be more than the words we profess in Catholic health care.

If we commit to the transformation of health care, we are promising to support social structures that embrace health care for the least among us. As part of this transformation, we know that Catholic health care is best suited to undertake and support a cultural change that acknowledges and addresses health care benefits for everyone.

Promotion of the common good distinguishes the well-being of each person in relation to the broader community. When we speak of care for those who are poor and vulnerable, we must be aware of the social conditions that perpetuate their inability to escape poverty and live healthy lives. Jesus calls us to justice throughout his Gospel message. Our goal of the right relationship between our ministry and those we serve must support structures that address basic human needs, especially access to affordable health care.

Such a hallmark of our very existence as Catholic

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health care providers flows from our foundational belief that every person is sacred and possesses inalienable worth.

Access to health care is necessary for an individual to flourish. Catholic health care ministries provide services that are accessible to all despite social or economic status. In a ruling on the Affordable Care Act, the U.S. Supreme Court decided each state could determine whether or

Promotion of the common good distinguishes the well-being of each person in relation to the broader community. When we speak of care for those who are poor and vulnerable, we must be aware of the social conditions that perpetuate their inability to escape poverty and live healthy lives.

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PUBLIC POLICY

not to expand Medicaid. Michigan responded to behavior incentive for beneficiaries who agree those most in need by creating the Healthy Michi- to address or maintain healthy behaviors on the gan Plan, the state’s unique response to Medicaid Healthy Michigan Plan health risk assessment.

The incentive can be a reduction in required costexpansion.

Healthy Michigan aims to ensure that every sharing, as enrollees are required to contribute low-income Michigan resident who was unin- modest premiums and co-pays (based on income) sured or underinsured has access to medical care to health savings accounts.

The Healthy Michigan Plan is achieving and services. The plan primarily focuses on prevention and primary care access through a num- results. A recent paper in the Journal of General ber of key elements including: an increase in Internal Medicine, based upon a survey conducted healthy behaviors that would manifest as healthy by members of the Healthy Michigan Plan evalbehavior change; management of chronic condi- uation team at the University of Michigan, contions; provision of preventative care; and a reduction As a result of Michigan’s decision to expand in emergency room utiliits Medicaid program as provided for zation and inpatient hospitalization. Though this under the Affordable Care Act and the plan has its limitations, it is an example of how we can corresponding establishment of Michigan’s influence and support our health care exchange, Michigan’s vocational call to provide health care for those most uninsured rate has been cut by an average in need.

The Healthy Michigan of 40%, according to a study provided by Plan was launched in the the Center on Budget and Policy Priorities. spring of 2014. The program opened enrollment for beneficiaries up to 133% of the federal poverty cluded that after enrolling in Michigan’s Mediclevel. Early enrollment projections of 300,000- aid expansion program beneficiaries reported 400,000 were quickly exceeded, and the enroll- less foregone care and improved access to priment over the last several years has averaged mary care and preventive services. The report over 600,000. In early February 2020, more than also cited survey results indicating that prior to 650,000 Michigan residents were enrolled in the Healthy Michigan Plan enrollment, three quarters of enrollees reported having a regular source of plan.

A key component of the plan, the Healthy care compared to 92% reporting such a regular Behaviors Incentives Program, encourages source of care following enrollment. Additionally, Healthy Michigan Plan managed care members the percentage of enrollees identifying the emerto maintain and implement healthy behaviors in gency room or urgent care center as their regular collaboration with their health care provider, to source of care fell dramatically from pre-enrollcomplete a standardized Healthy Michigan Plan ment to post enrollment.1 health risk assessment and to identify healthy The study also found that Healthy Michigan behavior goals. Beneficiaries are expected to Plan enrollees received significant preventative remain actively engaged in their health by see- screening. The study indicated that more than ing a primary care provider within the first three 70% of the women over 50 had received breast months of enrollment and by establishing at least cancer screening in the past 12 months under the one healthy behavior goal each year they are in Healthy Michigan Plan, and more than half of the plan. Healthy behaviors could include, but are adults over 50 had received colon cancer screennot limited to, attending preventive care visits, ing. Cancer screenings, and other proven prevenreceiving vaccinations, having regular screen- tative screenings and vaccinations, are covered by ings, assistance with smoking and tobacco cessa- the Healthy Michigan Plan with no co-pay. Addition and preventive dental care. There is a healthy tionally, 60% of enrollees had seen a dentist in the

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past year through their Healthy Michigan Plan coverage, and more than 10% of enrollees who reported using tobacco had gotten a prescription for an FDA approved product to help them break their nicotine habit.

The utilization of non-emergent emergency room visits has decreased due to those utilizing primary care and those who are being seen for chronic conditions and learning proper care and management techniques for their conditions.

Those with chronic conditions also saw a decrease in inpatient stays after seeking primary care, filling out a Health Risk Assessment and identifying one healthy behavior they could work on.

One example of the impact that the plan is having in the lives of its beneficiaries can be seen in an example from Muskegon. A 49-yearold single male covered by the Healthy Michigan Plan has been working with a community health worker from Mercy Health’s Health Project Hub in Muskegon since July 2019. Coverage through the Healthy Michigan Plan has been critical to him being able to see a primary care provider for his general health and a neurologist for seizures. He has obtained medication to manage his diabetes and counseling services for behavioral health. Working with his community health worker, he has begun a smoking cessation program and learned how to access his health plan’s transportation assistance benefit to get rides to medical appointments. Without the Healthy Michigan Plan, he could not afford to pay for his medical care out of pocket. Because of his fragile health, he is not able to work at this time and will be applying for an exemption to the work requirements.

As a result of Michigan’s decision to expand its Medicaid program as provided for under the ACA and the corresponding establishment of Michigan’s health care exchange, Michigan’s uninsured rate has been cut by an average of 40%, according to a study provided by the Center on Budget and Policy Priorities.2 Hundreds of thousands of Michigan residents who did not have health insurance before the plan was passed have it now.

Unfortunately, there may be some unintended consequences. Increased co-insurance will be implemented in July of 2020 as part of the original requirements of the Healthy Michigan Plan.

The Michigan Department of Health and Human Services has been working with Medicaid health

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plans administering the Healthy Michigan Plan to communicate the change in coverage to enrollees and to determine the best methods of collection.

In addition, some of the coverage gains under the plan will be challenged as a result of work engagement requirements adopted by the Michigan legislature and signed by Michigan’s governor in 2018. Under these requirements, the law mandates non-elderly, non-disabled Healthy Michigan Plan enrollees ages 19-62, who do not meet other exemptions, to document an average of 80 hours of work per month to maintain eligibility for Medicaid benefits. The implementation for work requirements began January 1, 2020, and is

Medicaid expansion is a step in the right direction to improve circumstances for those in need and struggling most. currently being challenged in court. The legislature decided to move forward instead of waiting for the court decision to determine whether or not work requirements would be enforced.

While not supportive of these work requirements, Catholic health care organizations in Michigan worked with other stakeholders to include a number of category exemptions and qualifying activities. As a result, exemptions exist for those age 63 and older, the disabled and medically frail, full-time students, caregivers, pregnant women, those who were recently incarcerated, those with medical conditions resulting in work limitations, those receiving unemployment compensation, former foster care youth and those who qualify for a good cause exemption. A number of qualifying activities also were included that satisfy work requirements such as job training, community service, education, unpaid workforce engagement (such as an internship), tribal employment program or drug treatment. Despite this, there continues to be significant concern, based on the experiences of other states, of significant loss of coverage due to the imposition of work requirements. Loss of coverage could lead to relatively minor conditions becoming more serious, and those with chronic conditions may expe-

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rience interruption in their care and health complications in the future. Furthermore, conditions that might be identified in a preventive screening could be missed. Loss of coverage (due to “noncompliance”) puts enrollees at a disadvantage and curtails gains they may already have made by having health insurance provided to them.

There is also continuous risk in the change of the policy itself. This is true especially because expansion in Michigan is predicated on seeking a Section 1115 waiver, which allows a state to expand Medicaid managed care while preserving hospital funding, provides incentive payments for health care improvements and directs more funding to hospitals that serve large numbers of uninsured patients. Evaluation of the waiver by the Centers for Medicare and Medicaid Services happens approximately every three to five years.

Medicaid expansion is a step in the right direction to improve circumstances for those in need and struggling most. However, we can assist in efforts to enhance its opportunity for success.

We should encourage eligible people to sign up during open enrollment periods, despite barriers that may present themselves due to changes to the Healthy Michigan Plan. As Catholic health care providers, it is not only our calling, but also our duty to provide an environment in which we

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effectively communicate changes people might experience with the Healthy Michigan Plan. We also need to assist our patients in successfully navigating those changes — whether by providing education about the Healthy Michigan Plan or explanations of programs our health systems offer to help enrollees live the fullest, healthiest lives possible. As Catholic health care providers, we are committed to doing our part — whether in the state Capitol or in our hospitals — to ensure everyone has an opportunity to access quality health care.

ALISHA COTTRELL is vice president, advocacy, for Ascension Michigan. SEAN D. GEHLE is vice president, advocacy, for Trinity Health – Michigan Region. LINDA ROOT is chief mission integration officer – Ascension Michigan Ministry Market.

NOTES 1. Susan Dorr Goold et al., “Primary Care, Health Promotion, and Disease Prevention with Michigan Medicaid Expansion,” Journal of General Internal Medicine, December 2019.

2. Jesse Cross-Call, Michigan Medicaid Proposal Would Harm People in All Parts of the State, Center on Budget and Policy Priorities, May 21, 2018.

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A REFLECTION

Moving from Desire To Action SR. DORIS GOTTEMOELLER, RSM, PhD

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othing is as intuitively simple to grasp and as complex to implement as the concept of the common good. According to the U.S. Catholic bishops, the common good comprises “the social conditions that allow people as individuals and groups to reach their full human potential and to realize their human dignity.”1 It would be hard to make an argument that the common good is not something to be universally valued and sought.

But the devil is in the details. What “people” are included? Myself and my family? All U.S. citizens? Workers and management? Immigrants and refugees? People in other countries, whether or not they’re allied with the United States? What is the measure of “full human potential”? What are the obstacles to achieving one’s potential and realizing one’s human dignity? Or put in a positive way: what are the social conditions that promote and ensure the common good, that are based on a bedrock of respect for human dignity? A short list would include adequate housing, a healthy diet, education, a safe environment, adequate health care, employment with a living wage and the opportunity to participate in social and political life.

Looking at this list, we can see that public policies and laws that promote the common good for all citizens and residents in the United States are still goals to be reached. It is also obvious that these social conditions are mutually supportive.

For example, a healthy diet promotes good overall health and a good education facilitates access to a good job. Focusing on health care, we often name these conditions the social determinants of health.

SHAPING POLICY TO BENEFIT COMMON GOOD

What makes it so hard to craft laws and public

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policies which promote the common good, especially good health care? First of all, the size and diversity of the population make generalizations about needs and preferences difficult. In the United States a federal law will impact persons in densely populated cities as well as remote rural areas. Statewide legislation is similarly challenging. Elderly retirees, young families, immigrants, the wealthy and those on welfare will all identify different needs. Federally qualified health clinics are typically located in cities. Persons in the countryside needing care beyond what a small rural hospital can offer may have to be airlifted to a distant city.

Secondly, the influence of the social determinants of good health are beyond the control of health care providers. Health systems typically invest in or partner with housing initiatives for low-income persons or contribute to local food pantries, but ultimately, they cannot ensure that patients avail themselves of these resources. Similarly, hospital leaders and staff can support local schools by volunteering in the classroom and at fundraisers, but the provision of an adequate education for all students is beyond their reach.

Thirdly, the sheer number of differing health care stakeholders is daunting. Providers include the government, for-profit, nonprofit, religious and secular institutions and systems. Pharma-

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ceutical companies, equipment manufacturers cies that promote the common good. The way and professional groups are all vital to care, but forward is motivated by the love of God and the each has its own agenda, one that favors a specific personal commitment to love of neighbor from group, its shareholders or members. Similarly, which flows specific actions, in other words, the funding flows from multiple sources.

Laws and policies that favor one of these The way forward is motivated by actors inevitably disadvantage another.

Fourthly, loyalty to one’s political the love of God and the personal party sometimes overrides considercommitment to love of neighbor ation of the common good. While uniting behind a promising piece of legislation from which flows specific actions, put forward by one’s party leaders can be in other words, the two great beneficial, it is refreshing once in a while to see a party member question its purcommandments. ported wisdom and take another stand.

An example is the expansion of Medicaid coverage in some states. Despite the obvi- two great commandments. To surrender oneself ous advantage to the underserved, it is associated to God; to feel the joy and gratitude for being the with the Affordable Care Act, that is, Obamacare son or daughter of God; to recall all the ways one and hence off-limits to some Republicans. Ohio’s has been gifted, despite one’s failings; to know Republican Gov. John Kasich was one executive that God’s love is real and deep and everlasting; who countered the party line and expanded cov- all of this gives us hope. erage in Ohio.

Flowing from this sense of being loved, despite our personal failings, is a love for one’s neighbor, which encompasses those nearby and those far IMPORTANCE OF INDIVIDUAL RESPONSIBILITY In light of these obstacles, is the common good too away, those known and those unknown. It is a love elusive a goal to pursue, even in the specific area which transcends judgments about “the other,” of health care? In enumerating some of the social including implicit racism or religious prejudice. conditions which promote the common good of It encompasses the panhandler on the street, individuals and groups, we don’t want to over- the immigrant at the border, the terrorist in the look individual responsibility. The realization of Middle East. It includes both the political leader one’s human dignity begins with oneself; it is not whose views are most antithetical to mine and it conferred by another. I am created by God and includes the wealthiest of our citizens. In other destined for eternal life with God. These years on words, to embrace the “common good,” I have earth are an opportunity to grow in this awareness to desire good for every person and for creation and to recognize the same reality and destiny in itself. every other human being.

But sometimes we fail. We choose behaviors TAKING ACTION that diminish our own health or the potential of How can we transform this desire for the common good health for others. With respect to others, good from a vague feeling to a way of life? Our especially those in poverty, we can fail to support efforts can be both individual and institutional. public policies which would provide adequate Love of my neighbor begins with those near at housing, nutrition and health care because we hand. One strategy is to participate in the efforts perceive that there would be some cost to our- of some local group, such as the St. Vincent de selves. The circle of those affected by our inaction Paul Society or Catholic Charities. It may involve can widen to include national and international visiting the sick, tutoring or staffing a food pantry. needs.

These encounters help us give names and faces to those less advantaged. They can also lead to an understanding of the causes of the neighbor’s MOTIVATED BY LOVE OF GOD AND NEIGHBOR Despite this rather somber scenario, there is need.

This personal understanding can be aughope for the enactment of laws and public poli-

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mented by investigation into the causes of chronic credibly advocate for policies such as paid sick illness, inadequate insurance, an unhealthy diet leave, paid family-care leave or child care, instituand much more. It can be said that the easiest clue tions themselves need to lead the way.

Another institutional contribution to the comto one’s health status and life expectancy is his or her zip code. What contributes to zones of pov- mon good stems from the use of investment dolerty and unmet need within the city? This study lars. The Interfaith Center on Corporate Responcan be facilitated by looking at the resources of sibility coordinates the efforts of over 300 global organizations such as the NETWORK Lobby for institutional investors to press companies on Catholic Social Justice, Catholic Charities USA environmental, social and governance issues.

Numerous issues such as clean water, greenhouse and the Catholic Health Association.

A deepening understanding leads to a com- gas reduction, drug pricing, opioid accountability mitment to advocate for change, another area and others directly impact the health status of the where trusted organizations can be helpful. Their human community.

Institutional support for the common good is research staffs are often positioned to make recommendations to promote the common good. A also reflected in the so-called community benefit commitment to advocacy can be overwhelming dollars that nonprofit institutions are obliged to for an individual unless one focuses on a specific invest. Federal law mandates what qualifies as area such as access to affordable health insurance community benefit (for example, unfunded care or pharmaceutical pricing. Also, issues will differ for Medicaid patients and voluntary community at the local, state and federal levels. The secret projects) and what is the minimum required of for someone who wants to make a difference is any institution claiming a tax-exemption. Addito focus on a vital few issues and make sure your tional support for the common good also is legislator hears from you. Enough pressure from directed through charitable foundations associconstituents can lead to beneficial policy changes. ated with hospitals and health systems. While Another individual commitment to the com- the aggregate investment of various tax-exempt mon good has to do with taxation, including the willingness to fund serThe secret for someone who wants vices to persons even when I will not personally benefit. A familiar examto make a difference is to focus on a ple is voting for a school tax levy, vital few issues and make sure your even if one’s children are no longer in school. With respect to health care, legislator hears from you. Enough it is generally known that European pressure from constituents can lead countries provide universal health coverage, for which citizens agree to to beneficial policy changes. be taxed. However, in some countries additional private insurance is common, which often entitles the owner to quicker health care entities in a specific community may and better service. A recent article in “Common- be quite large, it does not always make a signifiweal” magazine discusses this practice and points cant impact on the social determinants of good out that the Nordic countries have largely elimi- health, on the common good. Health care leader nated the market for private insurance because Chris Allen makes this point in a recent Health care funded by the government insurance is of Progress article. An individual “hospital’s commusuch high quality. Naturally this commitment nity health projects often aren’t large enough in to quality is reflected in the taxes citizens have scope and scale to make a meaningful change in agreed to pay.2 improving a population’s health.”3 What is needed Institutions, as employers, can make a signifi- is greater coordination and planning among the cant contribution to the common good. Ensuring contributors and public policies that promote that each employee has a family-friendly salary or such coordination.

International players such as Catholic Relief wage, with appropriate benefits, directly impacts the welfare of a community. Similarly, in order to Services and the Catholic Medical Mission Board

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initiate projects and distribute resources beyond the United States, with the goal of enhancing the common good in other countries. The same observation about the value of coordination among these players could probably be made, but the field is so vast that no effort is wasted.

THE SPIRITUAL GOOD

In this reflection on the obstacles and resources to achieving the common good, we have not explicitly referenced our neighbor’s spiritual good. To love one’s neighbor and to desire that they experience God’s love is a challenge that takes us even deeper into the quest for the common good. What would a public policy look like that supported spiritual well-being? It would begin with a resolution by executives and legislators to avoid disparaging remarks about any individual or group of people, no matter their history or recent behavior. Similarly, media spokespersons need to avoid generalizations about all persons in a specific geographic, racial, ethnic or religious group. Together we need to create a culture which honors all persons, respecting their innate human dignity.

In his apostolic exhortation, The Joy of the Gospel, Pope Francis remarks that “the worst discrimination which the poor suffer is the lack of spiritual care.”4 When someone is injured or ill they are most vulnerable to feelings of helplessness and hopelessness. Our efforts to relieve their suffering must include the affirmation of their inherent goodness, whatever the circumstances.

Our desire is not their religious conversion, but feelings of being included in the prayer of Jesus, “So that all may be one, as you, Father, are in me and I in you.” (John 17:21) Concluding this reflection on our commitment to the common good and its inherent challenges, we recognize that it begins and ends with

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a love for God and God’s people that transcends every boundary. Circumstances will make some efforts more inclusive or effective than others.

An elected official has a primary obligation to the well-being of the persons who elected him or her. But in an increasingly integrated world with porous boundaries, we are called to a love for all of God’s people. Let us join hearts and hands in that common effort!

SR. DORIS GOTTEMOELLER is vice chair of Bon Secours Mercy Ministries, the public juridic person of Cincinnati-based Bon Secours Mercy Health. She is a former chair of the Catholic Health Association board of trustees.

The author wishes to thank Jon Fishpaw, chief government relations officer at Bon Secours Mercy Health, for his helpful counsel in the preparation of this article.

WEBLINKS NETWORK Lobby for Catholic Social Justice: https:// networklobby.org/ Catholic Charities USA: https://www.catholic charitiesusa.org/ NOTES 1. “Sharing Catholic Social Teaching, Challenges and Directions,” Revised Edition, United States Conference of Catholic Bishops, 2009, 38.

2. Max Foley-Keene, “Equality Isn’t Cheap,” Commonweal, November 2019, 23-25.

3. Chris Allen, “Wise Use of Community Benefit Dollars Requires Greater Partnership,” Health Progress 100, no.

5 (September-October 2019): 66-69.

4. Francis, Evangelii Gaudium (The Joy of the Gospel), para. 200.

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The People of God: Healing Through Mourning FR. GERALD A. ARBUCKLE, SM, PhD

“Knowing how to mourn with others: that is holiness. Today we are challenged as the People of God to take on the pain of our brothers and sisters wounded in their flesh and spirit.”

— POPE FRANCIS

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oday so many people are overwhelmed with grief, a consequence of the global revelations of appalling sexual abuse scandals and cover-ups. Church hierarchies, priests and religious feel demoralized by what has happened. Lay people feel betrayed, ashamed, disillusioned and angry, their trust in their leaders destroyed.1 Beyond listening to and supporting victims of abuse, what can we do — ­as individuals, institutions and ministries — to heal our grief ? We must, as William Shakespeare says in Macbeth, “Give sorrow words: the grief that does not speak/ Whispers the o’er-fraught heart, and bids it break.”

The Scriptures have a simple, but profound, even paradoxical, answer to give words to sorrow. We actually are invited to mourn through complaining! Jesus on the cross agonizingly and publicly complained to the Father in the words of Psalm 22: “My God, my God, why have you forsaken me?”

(Matthew 27:46).

GRIEVING AND MOURNING

A clear distinction must be made between grieving and mourning. Grief is the internal experience of sadness, sorrow, anger, loneliness, anguish, confusion, shame, guilt and fear as a consequence of loss. Grief can be shared by an entire culture.2 Recall how great was the international grief after the 9/11 terrorist disasters in New York in 2001 or the suffering in Haiti in 2010. We were collectively traumatized. Such is the case in the church today.

So great is the grief of many Catholics that we must call it “cultural trauma.” Sociologist Neil Smelser defines cultural trauma as “an invasive and overwhelming event that is believed to under-

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mine or overwhelm one or several ingredients of a culture or the culture as a whole.3 People lose their established sense of belonging. They feel stunned and rudderless. Psychiatrist Arnon Bentovim describes cultural trauma as an incident when helplessness is overwhelming, normal defenses and responses fail, and the memory of the event intrudes and replays itself repeatedly.4 These descriptions of cultural trauma and its impact on individuals aptly describe how many Catholics feel today as more and more scandals of abuse are revealed.

Mourning, on the other hand, shows us how we are to handle grief or cultural trauma so that healing can occur. It embraces two simultaneous

The scriptures are a plentiful source for mourning or lamentation rituals that provide welcoming spaces for people to tell their stories of loss.

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and complementary dynamics. First, it refers to the cultural rituals which publicly acknowledge that the people who are bereaved are experiencing real grief.5 Second, it also connotes the agonizing inner journey that the bereaved must make to let go of what is lost in order to be able to move on in life.

Unless grief can be publicly articulated in mourning rituals, it will haunt the living, evoking both heartache and anxiety.6 The Roman poet Ovid wrote centuries ago: “Suppressed grief suffocates.”7 It is of overriding significance for people to say grief hurts and to be able to express this freely and unashamedly.8 Alfred Lord Tennyson offers this crucial advice: “Ring out the grief that saps the mind.”9 And in the words of the psalmist: “Weeping may linger for the night, but joy comes with the morning … You have turned my mourning into dancing,” (Psalm 30:5, 11). Through mourning we can rediscover inner peace, joy and energy to move forward in hope to a revitalized spirit. True, we must not forget the past and its lessons. But we must be released from excessive attachment to it.

An example illustrates this point. One day in 1987 I accidentally visited the central square of Onset, a small village in Massachusetts, where an anonymous Vietnam war veteran had erected a large notice board that featured these amateurishly painted words: Please understand that we are not asking for a parade, a monument or pity. But we do ask you to remember in your own way the 58,129 Americans who died at the [Vietnam] war …

We as individuals and as a nation learned something of human value for having been in S.E. Asia. Give us space to mourn.

All they were asking for was the public space to mourn and tell their stories. Without this there could be no final healing for them. “Healing,” wrote Henri Nouwen, “means, first of all, the creation of an empty, but friendly space where those who suffer can tell their story to someone who can listen with real attention.”10

LAMENTATION PSALMS: MOURNING RITUALS OF HEALING

The scriptures are a plentiful source for mourning or lamentation rituals that provide welcoming spaces for people to tell their stories of loss.

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The lament psalms teach us how to mourn by complaining in the midst of the dark nights of our great sadnesses: “You have put me into the depths of the Pit, in the regions dark and deep” (Psalm 88: 7). These psalms are rituals of mourning through which griefs are recognized and then yielded in order to allow the bereaved to look to the future with hope. If bereaved people truly complain to God from the very depths of their souls and trust in God’s willingness to listen, hope will come alive once more: “He put a new song in my mouth, a song of praise to our God.” (Psalm 40:4) This is the message of the lamentation psalms.11 Elisabeth Kübler-Ross, MD, developed her well-known dynamic for a ritual of mourning by identifying its five stages: denial-isolation, anger, bargaining, depression and finally acceptance.12 Her ritual process contains two key functions of all rituals: it articulates/legitimizes how people move through the process; it also prescribes how they should act in expressing their emotions.

Anger, the second stage of Kübler-Ross’s model of grieving, has its counterpart in the lament psalms. In her model the person who is suffering may lash out at loyal friends, even blaming them for the misery they feel. The friends and family, who are part of a culture that tends to deny loss, rarely know how to cope with such anger. Instead, they themselves become annoyed and frustrated at what they see as ingratitude on the part of the bereaved.

Kübler-Ross

Lament Psalm

Denial and isolation

Address to God

Anger directed at friends

Anger directed at God

Bargaining

Trust in God/Hope

Depression Petition Acceptance Assurance

Vow to praise God

However, the pattern in the lament psalms is significantly different, in that they recognize that anger as a powerful human expression that should not be suppressed. Because the people are united in one covenant with God, they have every right to let God know what they feel about their sufferings and how God is expected to help them. They know God can “handle it.” The Israelites want to make their problems God’s problems. Then, it

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is hoped, God will be obligated to do something about them. Ponder the public lament of the Israelites as they agonizingly view the destruction of the temple, the most pivotal symbol of God’s presence in their midst. Desolation reigns supreme.

God gets all the blame, but once their sadness has been so dramatically proclaimed and put aside, the Israelites discover space within their hearts for a hopeful trust in God: O God, why do you cast us off forever? ...

Your foes have roared within your holy place … with hatchets and hammers, they smashed all its carved work …

Rise up, O God, plead your cause; remember how the impious scoff at you all the day long (Psalm 74:1, 4, 6, 22) Unlike Kübler-Ross’s model, in which there is denial and a sense of isolation, the lament psalms proclaim from the beginning that the psalmist or the community is profoundly afflicted. There is no camouflaging of the loss. So miserable is the sufferer that there is nothing left but to trust God. The declaration of trust sparks a hope-filled petition to God that is counter to the stage when in Kübler-Ross’s framework where the bargaining that leads to depression sets in. In the lamentation psalm, no matter how horrible the situation may be, there is still the hope that God will intervene, just as God has done in the past. Listen to the psalmist as he ponders the desperate situation confronting the Israelites after the capture of Jerusalem by the Babylonians: Give hear, O Shepherd of Israel …

Stir up your might, and come to save us!

Restore us, O God, let your face shine, that we may be saved … (Psalm 80:1, 2, 3)

call upon your name.”

The words of assurance in the lament psalms and the stage of acceptance in Kübler-Ross’s model of mourning may at first appear to have an identical function. For Kübler-Ross, “acceptance” seems to mean a stoic resignation in the face of the inevitable. But this view is contrary to a fundamental assumption in the lament psalms. While loss or death is inevitable at some point, there is always the belief that God can transform every crisis into a stunning new beginning. The task of covenant members is never to give up hope. This is the mark of every true Israelite.

Scripture scholar Walter Brueggemann does not denigrate the importance of Kübler-Ross’s model of mourning (or other stage theories of mourning). Rather, his focus is to show that those whose faith is like the Old Testament believers — those who believe in their covenant with God — see things at a quite different level.13 They do not deny trauma or loss of any kind. On the contrary, they see chaos in its many forms as the occasion to rediscover the historical fact that God can intervene in human affairs to “create new heavens and a new earth …[where] no more will the sound of weeping be heard” (Isaiah 65:17, 19).

PASTORAL HEALING IN THE CHURCH

Later in the psalm, the psalmist recalls the very actions that God has taken to mold the Israelites into God’s chosen people: how he led them out of Egypt and brought them to the promised land.

These interventions of God gave meaning to their lives then; the hope is that God will again intervene to restore meaning in the midst of their misery and chaos. The lament proceeds from petition to trust and then praise: “give us life and we will

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Today the lament psalms can still teach us how to complain to God prayerfully in the midst of our shame and sadness, resulting from the revelations of sexual abuse.

Today the lament psalms can still teach us how to complain to God prayerfully in the midst of our shame and sadness, resulting from the revelations of sexual abuse. Our loud faith-based laments become rituals of mourning through which our griefs can be exercised and abandoned so we can again look to the future in hope. But mourning rituals need ritual leaders. At Emmaus, Jesus himself was the ritual leader, challenging the two disciples to own up to the trauma of loss. He gave

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them space to express their anger and sadness that things did not turn out as they had hoped.

Jesus did not judge or condemn their anger (Luke 24: 17-24).

To be effective, rituals must also be carefully planned. For example, Moses was sensitive to the fact that the experience of intense mourning throughout the Exodus, was a pre-condition for forming a new people, but if it were not guided prudently, it could lead to further collective trauma. Therefore, he sought the advice of his father-in-law Jethro, who instructed him to group the people into small units for mourning, under the direction of “men who fear God, are trustworthy, and hate dishonest gain” (Exodus 18:21).

An example of a simple lamentation-based mourning ritual could be the following.14 The paschal candle is lit and the ritual leader invites people to come together into small groups and in silence. The leader reads Matthew 27:57-61 and invites all to enter into the darkness of the tomb so that they may discover the newness of the resurrection. A moment of silence is held until Psalm 143 is read. Participants are invited to ponder the tragic trauma of abuse survivors and the church.

After a period of silence, they are encouraged, if they wish, to call out in a word or phrase what they feel. There is no discussion. The paschal candle is extinguished followed by a period of short meditative silence. Lamentation Psalm 88 is read.

After a longer period of silence, the leader invites people to identify some newness emerging in the church, again in a word or phrase. When all are finished the paschal candle is relit. The group reads Revelation 21:1-7, which is followed by sharing the sign of peace.

FR. GERALD A. ARBUCKLE is a director of the Refounding and Pastoral Development Unit in Sydney, Australia. He is the author of multiple books including Abuse and Cover-Up: Refounding the Catholic Church in Trauma.

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NOTES 1. See Gerald A. Arbuckle, Abuse and Cover-Up: Refounding the Catholic Church in Trauma (Maryknoll: Orbis Books, 2019).

2. See Ron Eyerman, “Cultural Trauma: Emotion and Narration,” in eds. Jeffrey Alexander et al., The Oxford Handbook of Cultural Sociology (Oxford: Oxford University Press, 2012), 564-82.

3. Neil Smelser, “Psychological and Cultural Trauma,” in eds. Jeffrey Alexander et al., Cultural Trauma and Collective Behavior (Berkeley: University of California Press, 2004), 38.

4. Arnon Bentovim, Trauma-Organized Systems: Physical and Sexual Abuse in Families (London: Karnac, 1992), 24.

5. See Kenneth J. Doka and Terry L. Martin, Grieving Beyond Gender: Understanding the Ways Men and Women Mourn (New York: Routledge, 2010), 28-30.

6. Doka and Martin, Grieving Beyond Gender, 18-25; Therese A. Rando, Treatment of Complicated Mourning (Champaign, IL: Research Press, 1993), 146-47, 177-78, 185-240, 380-81, 584.

7. Ovid, Tristia, Book V, eleg.1, line 63.

8. See C. Charles Bachmann, Ministering to the Grief Sufferer (Philadelphia: Fortress Press, 1964), 46-51.

9. Alfred Tennyson, In Memoriam, cvi.st.3.

10. Henri Nouwen, Reaching Out (London: Collins, 1976): 88.

11. The lamentation psalms constitute a third of all the psalms. See Gerald A. Arbuckle, Grieving for Change: A Spirituality for Refounding Gospel Communities (London: Geoffrey Chapman, 1991): 61-85.

12. See Elizabeth Kübler-Ross, On Death and Dying (New York: Macmillan, 1969).

13. See Walter Brueggemann, The Message of the Psalms (Minneapolis: Augsburg, 1984): 54; “The Formfulness of Grief,” Interpretation: A Journal of Bible and Theology 31, no. 3 (1977): 265-75; “Psalms and the Life of Faith: A Suggested Typology of Function,” Journal for the Study of the Old Testament 17, no. 1 (1980): 3-32.

14. This ritual by Gerard Whiteford is more fully explained in Gerald A. Arbuckle, The Francis Factor and the People of God: New Life for the Church (Maryknoll, NY: Orbis Books, 2015): 220-22.

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Form Follows Function The Evolution of Mission Integration in U.S. Catholic Health Care BRIAN SMITH, MS, MA, MDiv

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he architect Louis Sullivan is credited with the maxim, “form follows function.” To appreciate the full beauty and poetry behind his words, one must study the full quote, written by Sullivan in 1896:

“Whether it be the sweeping eagle in his flight, or the open apple-blossom, the toiling work-horse, the blithe swan, the branching oak, the winding stream at its base, the drifting clouds, over all the coursing sun, form ever follows function, and this is the law. Where function does not change, form does not change. The granite rocks, the ever-brooding hills, remain for ages; the lightning lives, comes into shape, and dies, in a twinkling. It is the pervading law of all things organic and inorganic, of all things physical and metaphysical, of all things human and all things superhuman, of all true manifestations of the head, of the heart, of the soul, that the life is recognizable in its expression, that form ever follows function.

This is the law.”1

Although this principle is usually associated with late 19th- and early 20th-century architecture and industrial design, Sullivan would say this law can be applied to anything–including human organizations. The “manifestation of the head, heart and soul” in Catholic health care, especially as it relates to the preservation and promotion of Catholic identity, has greatly changed in the last 50 years. The functions of sponsorship, governance, management and mission have greatly changed over the last five decades and so has their form.

That is good, according to Sullivan. It shows Cath-

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olic health care is adapting, changing and alive!

This article focuses on one particular aspect of Catholic health care that has been evolving for almost 50 years — mission integration. “Mission integration is the sum of the processes, programs, and relationships that serve to enhance our understanding and commitment to the tradition and values from which the healing ministry originated and in which it continues. It is more than programs and celebrations; it is the work of the soul. It translates into day-to-day language and struggles with complex issues and brings light to significant decisions.”2 The form of mission integration has greatly changed through the decades. The position of mission leader has grown in prominence and influence. Competency models continue to change to express the increasing functions and responsibilities associated with the role. This article weaves together the historical highlights of mission integration, with the shifts in function and form in Catholic health care, so the reader will see how mission has always adapted to serve the needs of the ministry.

EARLY BEGINNINGS — MID 1970s

The role of the mission leader in Catholic health care in the United States was created in the mid1970s. The process began when sponsoring congregations had fewer members to send into Catholic hospitals as nurses and administrators. They

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assigned women religious to leadership positions at the system headquarters under a title we now refer to as “mission services,” although the title then varied from system to system.

CHA’s archives indicate the first reference to this role was in 1976. The Sisters of Mercy Health Corp. system in Farmington Hills, Michigan, started a department of ministerial development. It was led by Sr. Concilia Moran, RSM. Other systems soon followed with their own version of mission departments including Holy Cross Sr. Moran Health System’s office of apostolic development in Indiana and the philosophy department of Mercy Health System, Burlingame, California.3 The early system mission leader’s primary role was to keep the connection between the church and the ministry alive and to develop a structure for identifying and training mission leaders for the member facilities. “Mission leader positions were sometimes held by sisters experienced in health care, but frequently one of the congregation’s educators or even former member of its leadership team took the job.”4 “The early mission leaders usually had to define, as well as legitimize her own position in the organization.”5 The skill set varied from leader to leader with some having backgrounds in theology, formation, pastoral care and spirituality and others with clinical and administration backgrounds. As a result, there was great variation in job descriptions, functional responsibilities and salaries. Accountability varied across the systems.

In some cases, the mission leader was appointed by and reported to the sponsoring congregation; in other cases, the leaders were appointed by the congregation and reported to the congregation and the corporation’s CEO, while still others were appointed by the congregation and reported solely to the CEO.

CHA SHIFTS ITS FOCUS: 1973–1987

Meanwhile, CHA recognized the health care environment was rapidly changing and new member needs were emerging, especially in the area of sponsorship. In 1970, the Board of Trustees of CHA appointed Sr. Mary Maurita SengeSr. Sengelaub laub, RSM, as chief executive director. By far the most significant development during her administration was the work of the

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CHA Study Committee which began in 1973.6 It addressed CHA’s long-term needs, and in 1975 a committee for long-range planning was formed.

In early 1976, the Long-Range Planning and Development Committee commissioned the consulting firm of Arthur D. Little to determine how well members’ expectations and needs were being fulfilled by CHA. In September 1977, the consulting firm made 30 recommendations. Some of the most notable recommendations that were implemented over the next three years included: Expediting the movement toward a more dynamic and responsive CHA with a major leadership role in the health ministry of the church Giving CHA a more Catholic and ecclesial orientation Having CHA’s central mission to focus on education and advocacy as its primary functions Placing less emphasis on the technical aspects of health services (for instance, eliminating CHA’s dietary, X-ray and housekeeping departments, which at the time collected and shared related best practices) that duplicate the work of other associations and are unrelated to CHA’s mission Developing alternatives for sponsorship, with an emphasis on building systems (the formation of larger health care systems required sponsors to think more strategically and as a system) Encouraging initiatives to establish and strengthen relationships with appropriate church-related and other national and regional organizations by building formal and informal communications networks and relationships Taking the initiative for developing guidelines and criteria for a self-evaluation process that members may use in assessing their apostolic effectiveness Changing CHA’s name from the Catholic Hospital Association to the Catholic Health As-

The early system mission leader’s primary role was to keep the connection between the church and the ministry alive and to develop a structure for identifying and training mission leaders for the member facilities.

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mission services departments were expected to sociation of the United States Strengthening the association’s advocacy help educate staff on how to live the mission and and government efforts and opening an office in values. This second phase Grant referred to as the “Mentor” period. Mission began to be seen as Washington, D.C.7 With this new focus, CHA restructured and something everyone in the organization was recreated the mission services department in 1980, sponsible for. The mission leader provided mishiring Sr. Margaret John Kelly, DC, PhD, as its sion education and formation to help staff see how first vice president of mission services. The de- their work contributed to the mission and how they could live the organization’s partment grew and developed in values through their behaviors. the early 1980s and included staff HEALTH PROGRESS This meant mission services and responsible for mission, sponsorhuman resources began to work ship, theology and ethics, church closely together. At times this was relations and pastoral care. expressed by human resources In 1980, CHA published the reporting to mission services and Evaluative Criteria for Catholic vice versa. Sometimes this led to Health Care Facilities, to enable tension between the two departmembers to evaluate their mission ments as both sought resources effectiveness. In 1987, a new CHA to shape organizational culture publication, The Dynamics of INTEGRATING MISSION and provide the educational and Catholic Identity in Healthcare: A formational programs needed for Working Document subsumed the leaders and others working in the Evaluative Criteria as an instruministry. ment for assessing and enhancing By the mid-1990s, system coma health care facility’s Catholic identity. It was written primarily by Laurence J. petency models for executives, including mission O’Connell, STD, PhD, then CHA’s vice president, leaders, began to emerge. System mission departments were trying to elevate the role of the facility Division of Theology, Mission and Ethics.8 mission leader so they would become part of the EVOLUTION OF THE MISSION LEADER ROLE: 1980–1995 senior leadership team and participate in strategic In the early 1980s, the mission leader’s responsi- planning and decision making. Grant called this bilities and roles were often unclear and as a re- third phase in the evolution of the mission leader sult, some mission leaders lacked legitimacy in role, “Mainstream.”10 While these early mission their organizations. Those without health care leader competency models showed some variexperience reported feeling marginalized and ability, they all concurred that mission leaders relegated to leading prayer at meetings, organiz- needed to have “pastoral” qualities like compasing retreats and overseeing charity drives. This sion, approachability and the ability to listen; as early phase was labelled the “Mascot” period by well as business savvy and organizational skills.

Mary Kathryn Grant, PhD, Holy Cross Health CHA had been hosting an annual forum for System’s vice president of sponsorship and mis- system mission leaders since the mid-1980s to sion services. The mission leader was viewed share learnings and find solutions to common as a cheerleader, reminder or symbol that the challenges. By the early 1990s, one theme that sponsors were trying to ensure a connection be- emerged from these forums was the need for a tween themselves and the organization. In real- common set of mission leader competencies and ity, mission leaders were rarely able to influence a way for mission leaders to grow in order for the strategy, operations, budgets or decision-making profession to develop, become relevant and truly processes. Some reported their CEOs felt threat- “mainstream.” ened because they saw themselves as the primary mission leader; while others experienced resent- EMERGENCE OF SENIOR LEADERSHIP AND MISSION ment during times of staff reduction because the LEADER COMPETENCY MODELS mission leader position, usually held by a woman It is important to know that during the time the religious, was secure.9 ministry was discussing a set of mission leader As systems were coming together in the late competencies, CHA was simultaneously work1980s and early 1990s, new mission statements ing on a general senior leadership competency and core values were developed by sponsors, and model. In 1992, the Center for Leadership ExcelJOURNAL OF THE CATHOLIC HEALTH ASSOCIATION OF THE UNITED STATES

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March - April 2016, Vol. 97, No. 2 Health Progress Integrating Mission

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lence of CHA began and initiated a project in 1993 with the Center for Applied Social Research of DePaul University in Chicago and Hay McBer in Boston to conduct a large-scale competency research effort. The research methodology included 1,200 CHA members nominating leaders they felt exhibited the leadership skills and competencies necessary for carrying the ministry forward. From those nominated, the top 10% (60 individuals) were interviewed and given leadership tests. The resulting study, Transformational Leadership for the Healing Ministry: Competencies for the Future, provided a unique framework for identifying and fostering the qualities that define excellence in health care. The research found Spirituality, Professional Expertise and Integration and Action are the key components of leader

competencies necessary to preserve the Catholic healing tradition.

The most revealing finding in the research was that the majority of competencies that drive superior performance in executives are rooted in the “Spirituality Cluster.” That is the presence of a personal, integrated spirituality which is comprised of three elements: 1) positive affiliation or concern for relationships, 2) faith in God and 3) finds meaning through reflection.11 The Mission Services department of CHA conducted the first survey of all known mission leaders (approximately 100 people) within the ministry in 1993. Because the profession was so new at this point, the purpose of this non-scientific survey was to simply gain demographic information on who was filling these positions and

A Shared Statement of Identity for the Catholic Health Ministry We are the people of Catholic health care,

a ministry of the church continuing Jesus’ mission of love and healing today. As provider, employer, advocate, citizen — bringing together people of diverse faiths and backgrounds — our ministry is an enduring sign of health care rooted in our belief that every person is a treasure, every life a sacred gift, every human being a unity of body, mind, and spirit.

We work to bring alive the Gospel vision of justice and peace.

We answer God’s call to foster healing, act with compassion, and promote wellness for all persons and communities, with special attention to our neighbors who are poor, underserved, and most vulnerable. By our service, we strive to transform hurt into hope. © The Catholic Health Association of the United States

AS THE CHURCH’S MINISTRY OF HEALTH CARE, WE COMMIT TO:

—Promote and Defend Human Dignity —Attend to the Whole Person v—Care for Poor and Vulnerable Persons v—Promote the Common Good v—Act on Behalf of Justice v—Steward Resources v—Serve as a Ministry of the Church v v

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The Neiswanger Institute for Bioethics and what professional development they could use to further their development. The survey revealed Healthcare Leadership at Loyola University Chithat 66% of the respondents had been a mission cago, began a master’s program in health care misleader less than two years and 78% had never sion in 2012 and also offers a certificate in health worked in a health care organization prior to be- care mission. The university, which also closely coming a mission leader. Only 12% were lay per- collaborated with CHA, will offer the first PhD sons. The majority of respondents indicated that program in mission leadership beginning in the a background in theology, ethics, spirituality and fall of 2020. ministry would be the best way to professionally prepare for the role of mission leader.

A SHARED STATEMENT OF IDENTITY In 1999, CHA published its first mission lead- Sr. Doris Gottemoeller, RSM, PhD, president of er competency model. These the Sisters of Mercy of the Americompetencies were primarily cas and chair of the CHA Board of designed for academic instituTrustees at the time, helped steer tions to develop courses and the ministry to name what constiprograms that would help edututes Catholic identity in Catholic cate and form mission leaders health care. Writing in Health Progto have the desired knowledge ress in 1999, Sr. Gottemoeller acbase and necessary personal knowledged this was a difficult task qualities. The CHA Mission but strongly laid out the case for Leader Competency model aswhy this was necessary: “Why is the sumed that the formation of the question of Catholic identity so difmission leader would include ficult to address? We all agree that theological, spiritual, ethical Catholic identity involves concern and social knowledge as well for the poor, adherence to the Ethias practical understanding of cal and Religious Directives, recogEMILY FRIEDMAN ON THE FUTURE OF MANAGED CARE the operations and dynamics nition by the church, and the other SR. DORIS GOTTEMOELLER, RSM, ON PRESERVING CATHOLIC IDENTITY of health care organizations, as characteristics I’ve mentioned. But well as life-long learning to respond to changing the topic remains painful, confusing, and even needs in the ministry.12 divisive because of our respect for pluralism of beliefs and legitimate diversity; because of what sometimes seem like arbitrary and inconsistent COMPETENCY DEVELOPMENT PROGRAMS exercises of church authority; and because of the FOR MISSION LEADER CHA started an in-person workshop for new mis- difficulty of quantifying and measuring adherence sion leaders named Prophetic Voice in 1998, later to ideals.” She proposed fundamental characterrenamed in 2016 to Essentials for Leading Mission istics. …” To be effective, they will have to be enin Catholic Health Care. In addition, CHA began acted and interpreted by real people in real situto offer bi-annual mission leader seminars begin- ations within the context of the entire Christian ning in 2003, aimed at competency and skill devel- community. Doing so will never be easy, neat, or without controversy. But the struggle itself can be opment for entry and mid-level mission leaders.

In 2006, the Aquinas Institute of Theology productive.”13 sought to expand its academic programs to inIn 2000, the membership of CHA voted and clude offerings in health care mission. The Ash- approved a new Shared Statement of Identity for ley-O’Rourke Center for Health Ministry Leader- the Catholic Health Ministry and listed seven core ship (named for theologian Fr. Benedict Ashley, commitments recognizing that formation of the OP, and ethicist Fr. Kevin O’Rourke, OP) was ministry’s leaders would be necessary to succeed, created to provide educational and formational an updated version of the shared statement is still programs for those who are leading health care in use today.14 mission. Offering both an Executive Master of Arts in Health Care Mission and a Certificate in Mission Leadership, the Aquinas Institute has col- 2006 CHA MISSION LEADER SURVEY laborated closely with CHA to ensure their offer- Knowing the number of mission leaders had ings parallel with the current CHA mission leader greatly increased since 1993, CHA launched its competency model. second mission leader survey in 2006. This surOfficial Journal of The Catholic Health Association of the United States

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vey was sent electronically to approximately 700 mission leaders with over 50% responding.

A comparison of responses between the 2006 and 1993 mission leader surveys showed tremendous advances in the field. More people were serving as mission leaders throughout the ministry.

An additional 600 mission leader positions had been added to the ministry over 13 years at both the vice president and director levels. In addition, they were now serving across the continuum of care (acute, non-acute, long-term care and man-

aged care offices). The percentage of religious to lay mission leaders was now 64% to 36%. Responsibilities, salaries and benefits for mission leaders had increased and now were closer, though not yet on par, to the salary and benefits of other senior leaders.15 Thirty years into the profession, it was becoming clear there were three distinct pathways by which people were coming to the mission leader field. The first pathway by which the majority of mission leaders, then and now, enter the field is

PERSONAL QUALIFICATIONS

ORGANIZATIONAL MANAGEMENT

Mission leaders are talented, faithful and competent executives who embody holistic and healthy qualities which enable them to make a positive and lasting impact on their organizations.

LEADERSHIP

Mission leaders have the management competencies needed to be recognized as productive contributors to the organization.

They understand the interrelationship of shared beliefs, behaviors and assumptions of the organization.

Mission leaders bring strategic direction, thinking and guidance as well as a collaborative spirit to the organization to ensure that it is faithful to its purpose, identity and values.

ETHICS

Mission leaders have a working knowledge of Catholic theology and are acquainted with the plurality of religions that will be encountered among the employees, physicians, trustees, patients and others who are served within our institutions.

THEOLOGY Mission leaders promote ethical behavior throughout the organization with a focus on organizational ethics, clinical ethics and the Church’s social justice tradition.

SPIRITUALITY Mission leaders are able to articulate their lived faith experience and the meaning it brings to their lives as well as encouraging and empowering individuals and organizations to do the same.

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the “external” model. These were women and tion and a person of faith who is committed to men who come to health care leadership as a and models the mission and values of the orgasecond or third career, bringing their excellent nization. The second competency, Leadership, educational and leadership backgrounds. They calls out the ability to bring strategic direction eagerly embrace the health care learning curve by and guidance in a collaborative spirit to ensure entering graduate studies, internships or mentor- the organization is faithful to its purpose, identity and values. Theology (pastoral, ecclesial and ing programs.16 The second pathway, the “internal” model, canon law) is the third competency; followed by was taken by women and men already in health Spirituality (personal, communal and change).

The fifth competency, Ethics, includes care, sometimes clinicians, promotion of organizational and clinichaplains, patient advocates HEALTH PROGRESS cal ethics as well as justice. Finally, Oror community activists. Ofganizational Management includes the ten these are individuals in necessary management competencies whom administrators recogof communication, collaboration, businize key characteristics that ness acumen and human relationship seem to naturally fit them skills. for mission leadership. The learning curve for these persons is in theology and minLEADERSHIP FORMATION istry, and many of them have AND MINISTRY IDENTITY entered graduate programs to Reflecting on her 15 years at CHA, first complement other skills.17 as senior director of theology and ethics (2000-2003) and then as vice presiThe third model weds dent, sponsorship and mission services the “external” and “internal” models. Some system mission leaders appeal di- (2003–2015), Sr. Patricia Talone, RSM, PhD, stated rectly to young people currently enrolled in minis- that from 2000–2015, “the highlights for mission try programs in Catholic universities and schools integration was the increased professionalism for of theology and bioethics. To help them consider the role of mission and the growth and develophealth care mission as a career path, internships ment of formation programs for health care exand fellowships are created to help them transi- ecutives and sponsors.”18 The simultaneous protion from the theoretical to the practical. fessionalization of the mission leader role and the development of formation programs can not be underestimated.

2009 CHA MISSION LEADER The first formation programs began in the earCOMPETENCY MODEL Remembering Sullivan’s maxim, “form follows ly 1990s and were primarily developed for execufunction,” it was no surprise with the huge influx tive leaders (sponsors, governance and C-suite of new mission leaders and new expectations for executives) by system mission leaders. Programs the role, the CHA Mission Leader Competency for new and mid-level leaders like Foundations Model needed to be revisited. There were now of Catholic Health Care Leadership, followed in clear areas of responsibility that mission leaders the late 1990s and were primarily facilitated by were overseeing: mission integration, church re- system and regional mission leaders. This two to lations, ethics, pastoral care, spirituality and com- three-day program, intended for all leaders new to leadership in Catholic health care, has been replimunity benefit.

Working with The Reid Group of Seattle, CHA cated and adapted by other systems over the past engaged the ministry in a series of online surveys, 20 years. It has become the gold-standard for new focus groups and personal interviews with over leaders who are beginning ministry formation.

Under the guidance of Brian Yanofchick, CHA’s 200 key senior leaders to understand the challenges, needs and hopes of sponsors, CEOs and senior director, mission integration and leadership development at the time, the ministry came other stakeholders.

The 2009 CHA Mission Leader Competency to consensus on a Framework for Senior LeaderModel begins with Personal Qualifications which ship Formation, published in 2011 which gives a includes being well formed in the Catholic tradi- common description of ministry formation and JOURNAL OF THE CATHOLIC HEALTH ASSOCIATION OF THE UNITED STATES

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names the ten core content areas for senior leadership formation.19 One of the “next steps” articulated in the Framework was to establish effective assessment frameworks that measure the impact of formation on individual leaders and the organizations they serve.

Mission leaders began to realize the best metric to demonstrate the effectiveness of the formation process is by measuring the strength of the organization’s ministry identity. The ministry’s adoption of A Shared Statement of Catholic Identity for the Catholic Health Ministry in 2000, prompted the creation of more rigorous ministry identity assessment tools including: the Catholic Identity Matrix (2005), which is the collaborative work of Ascension Health, St. Louis, and the Veritas Institute at the University of St. Thomas in Minneapolis, Minnesota; a tool called produced in 2012 by CHAN Healthcare, St. Louis, and Dignity Health; the Promoting Catholic Identity appraisal (2104) developed by Trinity Health,20 and Ministry Identity Assessment (2019). The mission leader of an organization typically oversees their ministry identity assessment process and corresponding quality improvement plan.

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2013 MISSION LEADER SURVEY

The 2013 Mission Leader Survey was designed by Brian Smith and Sr. Talone of CHA’s Mission Services Department in collaboration with The Reid Group. The CHA Mission Advisory Committee gave feedback and piloted the survey tool before it was sent to 702 mission leaders and returned by 50% of them.21 About 70% of the respondents were female, 62% of whom were between the ages of 55 and 65.

The vast majority (93%) of the mission leaders returning the survey were white/Caucasian. One noticeable demographic shift between 2006 and 2013 was the percentage of mission leader roles filled by religious sisters, brothers and clergy compared to lay women and men. The survey showed the majority of mission leaders, 55%, were lay and 45% were religious or clergy. Approximately 87% of those responding noted they were Roman Catholic, down from 94% in 2013.22 The largest number of respondents were between ages 55-65. Thirty percent of the mission leaders surveyed planned to retire by 2017 and 60% of them plan not to be working by 2022.23 This

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telling piece of information resulted in an all-out effort by the ministry to recruit and form the next generation of mission leaders and to especially strive for recruiting a diverse team of leaders that better reflects the communities we serve.

The results of the 2013 Mission Leader Survey demonstrate that, indeed, mission leaders have become part of senior leadership teams in most Catholic health organizations and that the types of competencies and skills of these leaders continue to expand as their profession evolves. Their salaries and benefits also have increased.

The mission leader role has evolved beyond acute and long-term care, and in many cases includes outpatient services, home care and rehabilitation services, hospice and palliative care, physician practices and new models of Ministry Identity Assessment care delivery. Many mission leaders have oversight of mission integration in more than one of these areas. This requires ongoing professional development and formation, and mission leaders are asking for more resources (such as formal courses, mentoring and projects) to further their development.

In addition to the traditional responsibilities mission leaders have overseen (mission integration, ethics, spirituality, pastoral care and community benefit), the survey indicated there are new areas of responsibility. Not surprising, formation is a new and major area of responsibility for mission leaders. Over 50% reported their organizations were in some stage of discussions or negotiations with possible new partners.24 Many mission leaders report they need more expertise in working in situations where Catholic health organizations are merging or partnering with other Catholic institutions or other-than-Catholic entities.

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THE NEXT GENERATION OF MISSION INTEGRATION

The next generation of mission integration is already taking shape. CHA’s Mission Leader Competency Model is currently being revised and updated. Again, CHA is partnering with The Reid Group. The process began in June 2019 and so far includes interviews with over 30 key stakeholders (sponsors, CEOs and other senior executives), a survey of over 600 mission leaders and three focus groups with system mission leaders, who reviewed a first draft and gave input in De-

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Mission leaders began to realize the best metric to demonstrate the effectiveness of the formation process is by measuring the strength of the organization’s ministry identity. cember 2019. System mission leaders and other key stakeholders will review the second draft in spring 2020 with publication of the revised model expected in summer 2020.

One thing already determined is that the new model will be a three-tiered model (entry, midlevel and executive). While the competencies to be named will be the same for all three levels, the behavioral expectations will vary depending on the tier. The hope is this will create a better understanding for mission leaders and those they work with as to what is expected of them and how they can progress on their career path.

After the competency model is published, CHA will be working on the next mission leader survey in the fall of 2020. We already know from the CHA database that the demographics of mission leaders is changing as are their titles and the location of ministry. The percentage of religious and clergy in the mission leader role as compared to laity is now 32% to 68%. In 2013, it was 45% to 55%. The number of men entering into the profession has increased. In 2013 the ratio of female to male was 70/30 and in 2020 it is 66/34.25 More levels of mission leaders have been created in the last five years. While there are fewer senior vice presidents and vice presidents according to the CHA database, there are more directors and managers. It may be that systems are creating entry-level positions and creating a career path for mission leaders that parallels that of their peers in other departments. Hopefully, it does not mean the mission leader is being marginalized from the senior leadership table and key strategic and decision-making processes. The 2020 mission leader survey will attempt to answer that question.

Finally, the CHA database shows approximately the same number of mission leaders working at a system level as in 2013, with more working at a regional level and fewer working at a facility level.

It appears some systems have eliminated facility mission leader positions and consolidated these

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roles into a regional vice president who oversees the mission activities of several facilities, physician groups, and outpatient services, with perhaps a director or manager to assist. As a ministry we will need to closely watch what impact these new structures of mission leadership have on the dayto-day operations of a facility and the way mission integration and Catholic identity are impacted.

CONCLUSION

Mission leadership in 2020 looks very different than it did when it started in 1976 with Sr. Moran in Farmington Hills. The profession has grown through the “Mascot, Mentor and Mainstream” periods Kate Grant described in 1999 and appears to be at the threshold of a new period — still too soon to be named, but one that perhaps can be described. In the next generation, there will be a presumption that mission leaders will already have general leadership skills such as strategic thinking, business acumen, communication and organizational skills. Their unique contribution to the senior leadership team and the ministry they serve will be the ability to translate and apply theological and ethical principles into strategy and day-to-day clinical decision-making and operations. They will be responsible for measuring Catholic identity within the organization and developing process improvement plans so ministry identity is seen as part of continuous quality improvement. In short, mission leaders will have responsibilities and areas of accountability with objective metrics, just like their senior leader counterparts.

Many mission leaders will continue to have oversight over the traditional areas of responsibility like mission integration, Church relations, ethics, pastoral care, formation and community benefit; but we will also see new types of mission leaders who will specialize in areas such as ministry formation, population health, managed care and in new technological arenas like virtual care and artificial intelligence.

This history of mission integration in Catholic health care is still unfolding and will continue to do so as the needs of the community change, health care delivery is transformed, and sponsorship and governance models evolve. The architect Louis Sullivan would remind us that as function changes, so will the form. And that is a good thing.

It means the ministry is alive and thriving.

A longer version of this article, with more details about the evolution of mission integration in

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U.S. Catholic health care is at www.chausa.org/ mission/mission-leader-toolkit.

BRIAN SMITH is vice president, sponsorship and mission services, the Catholic Health Association, St. Louis.

NOTES 1. Louis Sullivan, “The Tall Office Building Artistically Considered,” Lippincott’s Magazine (March 1896): 403–409.

2. Regina Clifton, CHA Archives, 2002.

3. Mary Kathryn Grant, “Mission at the Millennium,” Health Progress, (March-April 1999): 18.

4. Grant, “Mission at the Millennium,” 18.

5. Grant, “Mission at the Millennium,” 18.

6. Christopher J. Kauffman and Pamela Schaeffer, A Passionate Voice for Compassionate Care: Celebrating 100 Years of the Catholic Health Association of the United States, (St. Louis: The Catholic Health Association of the United States, 2015), 76-77.

7. Report of the 1977 CHA Study Committee, The Catholic Hospital Association, CHA Archives, 7.

8. Kauffman and Schaeffer, A Passionate Voice, 84.

9. Grant, “Mission at the Millennium,” 18.

10. Grant, “Mission at the Millennium,” 19.

11. John Larrere and David McClelland, “Leadership for the Catholic Healing Ministry,” Health Progress 75, no. 5 (June 1994): 29.

12. Competencies for Mission Leaders, CHA Archives, 1999.

13. Sr. Doris Gottemoeller, “Preserving Our Catholic Identity: If the Health Ministry Is to Remain Faithful to its Basic Elements, It Must First Spell Them Out,” Health Progress 80, no. 3, (May-June 1999): 21.

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14. A Shared Statement of Identity for the Catholic Health Ministry, Catholic Health Association, 2000.

15. Sr. Patricia A. Talone, “2006 CHA Mission Leaders Survey 2: A New Study Compares the Role’s Strengths, Weaknesses with Those Seen in 1993,” Health Progress 87, no. 5, (September–October 2006): 17-22. For more, see also Sr. Patricia A. Talone, “2006 CHA Mission Leaders Survey 1: A New Study Compares the Roles, Strengths, Weaknesses with Those Seen in 1993,” Health Progress 87, no. 4, (July-August 2006).

16. Talone, “2006 CHA Mission Leaders Survey 2,” 22.

17. Talone, “2006 CHA Mission Leaders Survey 2,” 22.

18. Sr. Patricia Talone, email to Brian Smith, vice president of sponsorship and mission, CHA, January 3, 2020.

19. A ministry-wide definition for “ministry formation” was developed in 2019 and published by CHA in 2020: “Ministry formation creates experiences that invite those who serve in Catholic health care to discover connections between personal meaning and organizational purpose. These connections inspire and enable participants to articulate, integrate, and implement the distinctive elements of Catholic health ministry so that it flourishes now and into the future.” From the Framework for Ministry Formation, CHA, 2020. See also the Framework for Senior Leadership Formation, CHA, 2011.

20. Brian Smith, “Ministry Identity and How We Measure It,” Health Progress 99, no. 3 (May-June 2018): 73.

21. Brian P. Smith and Sr. Patricia Talone in collaboration with John Reid and Maureen Gallagher, “New Survey: Mission Leaders Respond, Executive Summary of the 2013 Mission Leader Survey,” Health Progress 94, no. 6 (November – December 2013): 70.

22. Smith and Talone, “New Survey,” 71.

23. Smith and Talone, “New Survey,” 71.

24. Smith and Talone, “New Survey,” 75.

25. CHA membership database, January 8, 2020.

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POLICY

HERE WE GO AGAIN: COULD THE ACA BE STRUCK DOWN? KATHY CURRAN, JD

T

he Affordable Care Act has been peppered with lawsuits since its inception. The law was only hours old when the first lawsuit, challenging its constitutionality, was filed in federal district court. President Barack Obama signed the ACA into law on March 23, 2010, and that same day, 14 state attorneys general asked the U.S. District Court for the Northern District of Florida to nullify the law. They were later joined by private entities and 12 other states. Since then, lawsuits have challenged several aspects of the law, including the contraception mandate, payment of premium tax subsidies by federal health exchanges and payments to insurance companies, at least six of which have made it all the way to the U.S. Supreme Court. Through it all, the ACA has endured, providing access to health care for tens of millions of people through the health insurance exchanges and, in states that took up the ACA expansion, the Medicaid program.

But in January 2020, we were back where we authority to impose a mandate to buy insurance. started: the Supreme Court was again asked to But the Court ruled that Congress does have the hear a case that could overturn the entire law as power to tax people if they do not have health inunconstitutional. The court refused an expedited surance, and it upheld the constitutionality of the appeal but could still decide, as soon as this spring, ACA because the penalty was basically a tax. In to hear the case. Or it will send the parties to the lower court for further The ACA has endured, providing consideration and to begin the climb back up to the Supreme Court once access to health care for tens of again. millions of people through the health To understand the current challenge, we have to go back to the begininsurance exchanges and, in states ning. The initial lawsuit claimed that Congress did not have the constituthat took up the ACA expansion, the tional authority to require people to Medicaid program. purchase health insurance, which it did by creating a federal mandate for all U.S. citizens and lawfully present immigrants the same case, the Supreme Court also found that to have insurance and imposing a penalty on those Congress does not have the power to order states who did not comply. This argument is based on to expand Medicaid, turning the ACA’s Medicaid Article 1 of the Constitution, which sets out the expansion into a state option.

Opposition to the ACA continued, despite its powers of Congress; if a congressional action exceeds those limits, it is unconstitutional. But success in expanding health coverage. Congresalso under Article 1, Congress can regulate inter- sional Republicans tried and failed many times to state commerce and it can levy and collect taxes. repeal all or part of the ACA. But in December The Supreme Court agreed with the states that 2017, the penalty for not having health insurance the commerce clause does not give Congress the was repealed in the tax overhaul bill known as the

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Tax Cuts and Jobs Act of 2017. The individual mandate remains but is unenforceable.

On February 28, 2018, Republican attorneys general and governors from 20 states sued the federal government, arguing that the repeal of just the penalty but not the mandate renders the entire law unconstitutional. Their theory is that because the mandate by itself is unconstitutional and because the mandate is essential to and unseverable from the operation of the entire ACA, the whole law must be overturned. U.S. District Judge Reed O’Connor of the Northern District of Texas agreed, finding that the ACA must be nullified but allowing it to remain in force while the case is appealed.

The Fifth Circuit Court of Appeals heard oral arguments on the case in July 2019. By then, the courts had permitted 21 Democratic state attorneys general and the House of Representatives to join the case to defend the law, as President Donald Trump’s administration had largely agreed with the positions taken by the states challenging the ACA. The Fifth Circuit issued its decision on December 18, 2019, agreeing with the lower court that the individual mandate is unconstitutional but sending the case back to that court on the question of severability — that is, whether the unconstitutional mandate can be severed from the ACA or is so central to the law that the entire ACA must be struck down. The House of Representatives and Democratic state attorneys general have appealed that decision to the Supreme Court and asked it to consider the case on an expedited basis. The court could: agree to take up the case during its current term; agree to hear it in the term that begins in the fall; or let Judge O’Connor examine the question of severability. If it goes back to Judge O’Connor — and his earlier opinion makes it pretty clear that he does not think the mandate is severable — his decision will be appealed back to the Fifth Circuit and then on up to the Supreme Court. It might be this summer, it might be next summer, it might be in 2022 or 2023 — but the Supreme Court will once again have to rule on whether the ACA can continue or whether some or all of it must be abandoned.

The stakes are enormous. Overturning the ACA means the health exchanges would cease to exist. Premium and cost-sharing subsidies would end, as would Medicaid expansion. About 20 million people would lose their health care coverage,1 and millions more would face much higher costs. Insurance companies would again be able to deny coverage for pre-existing conditions and

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impose annual and lifetime limits on coverage.

Young people would be kicked off their parents’ insurance plans. But the ACA did not just address insurance coverage. If the ACA goes away, so does the legal authority for Accountable Care Organizations, the Center for Medicare & Medicaid Innovation and the shift to value-based payment in Medicare. The Kaiser Family Foundation details what else could be lost.2 The Catholic Health Association has been actively weighing in on the litigation. At each step — district court, appeals court and now Supreme Court — we have joined with other hospital associations to file briefs, arguing that the mandate is severable. Congress made its intent clear that the ACA can and should continue without the mandate when it repealed only the penalty. Both Congressional Budget Office projections of the impact of repealing the penalty3 and the continued strength of the ACA since the penalty was repealed demonstrate that it is not essential to the structure of the law.4 Furthermore, Congress could not have intended that losing the mandate would overturn the entire ACA, given the catastrophic results of such an action.

CHA will continue to follow this litigation closely and actively work to protect the health gains realized by tens of millions of Americans, thanks to the ACA. KATHY CURRAN is senior director, public policy for the Catholic Health Association, Washington, D.C. NOTES 1. “Suit Challenging ACA Legally Suspect, But Threatens Loss of Coverage for Millions,” Center on Budget and Policy Priorities, https://www.cbpp.org/sites/default/ files/atoms/files/11-4-19health2.pdf.

2. “Potential Impact of Texas v. U.S. Decision on Key Provisions of the Affordable Care Act,” Kaiser Family Foundation, https://www.kff.org/health-reform/factsheet/potential-impact-of-texas-v-u-s-decision-on-keyprovisions-of-the-affordable-care-act/.

3. Alexandra Minicozzi, “Modeling the Effects of the Individual Mandate on Health Insurance Coverage,” Presentation at the 2017 Annual Meeting of the American Academy of Actuaries, https://www.cbo.gov/system/ files/115th-congress-2017-2018/presentation/53310presentation.pdf.

4. “Individual Insurance Market Performance in Late 2019,” Kaiser Family Foundation, https://www.kff.org/ private-insurance/issue-brief/individual-insurancemarket-performance-in-late-2019/.

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ETHICS

ENCOURAGING CONVERSATIONS ON HEALTH CARE DECISIONS

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pril 16, 2020, is National Healthcare Decisions Day, an event that “exists to inspire, educate and empower the public and providers about the importance of advance care planning.”1 As leaders in the Catholic health care ministry, we, too, are encouraged to promote conversations about one’s health care decisions. In part three of the Ethical and Religious Directives for Catholic Health Care Services, Directive 24 states our requirement to “make available to patients information about their rights, under the laws of their state, to make an advance directive for their medical treatment.2 To follow this directive is to ensure that patients’ decisions are honored and that their inherent dignity is upheld when their decision-making capacity has been lost.

Even though the importance for one’s planning is known, the facts show that most people still do not take the time to fill out the necessary forms. According to a study by the U.S. Agency for Healthcare Research and Quality, less than 50 percent of paNATHANIEL tients with a severe or terminal BLANTON illness had an advanced direcHIBNER tive in their medical chart. Of those, only 12% had discussed the writing of their document with a physician.

This led to the majority of physicians, 65 percent to 76 percent, unaware that their patients even had an advanced care document.3 How can we help to change these statistics?

Several organizations share our mission of promoting conversations about health care decisions.

As mentioned in the beginning of this text, National Health Care Decisions Day is not only an event but an organization with resources to educate people about advanced care planning. You can visit their website at https://nationalhealthcare-decisi.squarespace.com.

Another resource is designed to focus on positive attributes to one’s end-of-life experience.

Jim Towey, who developed the resource, labeled them the Five Wishes. In this process, the person is encouraged to discuss their spiritual needs, speaking about prayer, forgiveness and reconciliation. The program has become popular in

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Catholic nursing homes and diocesan workshops on end-of-life as well as in hospice and palliative care departments. You can learn more at his website, fivewishes.org.

A third group promoting advanced care planning is The Conversation Project. This organization is “dedicated to helping people talk about their wishes for end-of-life care.” Their website provides countless resources, such as starter kits with example documents that include fill-in-theblank guided questions, a series of scales that will help one home in on what is truly important for their care, and answers to common legal and ethical questions. All of this can be downloaded for free at theconversationproject.org.

Finally, CHA also has created excellent resources on these topics. Available for download through our website or ordered in the online store, these three brochures, in both English and Spanish, discuss a variety of topics regarding endof-life planning.

“Palliative Care and Hospice: Care Even When We Cannot Cure” “Advance Directives: Expressing Your Health Care Wishes” “Teachings of the Catholic Church: Caring for People at the End of Life” These three brochures highlight the Catholic views regarding end-of-life care, treatment and planning. They are excellent documents to be shared with patients, families and parishioners.

They can be found on our website at chausa.org.

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We will all face a time when our journey here on Earth is at an end. It is a time of great unknown and will be different for each of us. As our Catholic faith has taught us, we should prepare ourselves. Having conversations with loved ones about our hopes for transition into the next life is not only to protect ourselves but also gives comfort and strength to the decision makers.

Preparing advance care documents helps to guide those who may have to decide for us. Would it not be better

for them to feel confident in their decisions?

NATHANIEL BLANTON HIBNER, PhD, is director, ethics, for the Catholic Health Association, St. Louis.

NOTES 1. “About Us,” National Healthcare Decisions Day, https://nationalhealthcare-decisi. squarespace.com/about#about-us.

2. Ethical and Religious Directives for Catho-

lic Health Care Services, United States Conference of Catholic Bishops, Fifth Edition, http://www.usccb.org/issues-and-action/ human-life-and-dignity/health-care/upload/ Ethical-Religious-Directives-CatholicHealth-Care-Services-fifth-edition-2009. pdf.

3. Barbara L. Kass-Bartelmas and Ronda G. Hughes, “Advance Care Planning: Preferences for Care at the End of Life,” Journal of Pain & Palliative Care Pharmacotherapy 18, no. 1 (2004): 87-109.

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COMMUNITY BENEFIT

ANCHOR INSTITUTIONS ADVOCATE FOR POLICIES TO BENEFIT COMMUNITIES BICH HA PHAM, JD, AND DAVID ZUCKERMAN, MPP

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ealthcare Anchor Network members are at the forefront of a movement of hospitals and health systems working to deploy their institutional resources — like hiring, purchasing and investment — to address economic and racial disparities. The goal is to improve the financial well-being of area residents and strengthen local economies. The growing network includes 50 health care systems representing more than 700 hospitals.1

Member health systems believe that to improve outcomes and ensure long-term affordability, they must address the social determinants of health and invest in strategies that create equitable, engaged, connected and economically strong communities. They must help residents and the neighborhood to build community wealth that is long lasting.

Early on, network members decided to work at the system level on policy advocacy to have maximum impact on addressing health and economic inequity. Its Healthy Communities Policy Framework outlines the foundational elements of healthy communities, a healthy economy and a healthy planet. These elements include: employment and education for financial security connected and safe neighborhoods affordable, nutritious food access healthy and affordable housing safe, sustainable and affordable transportation Both this framework and the network’s advocacy efforts are based on shared values that align with Catholic social justice principles of collective action to address the root causes of poor health by achieving more systemic and impactful policy change.

EARLY POLICY IMPROVEMENTS

As health care systems implement regional or systemwide work to enhance their communities, they also are finding success in working together

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for advocacy improvements at the federal level.

Consider the case of Jeisson, a young man living in Richmond, Virginia. He was born to an immigrant family, which did not have any generational wealth or savings. Jeisson was the first in his family to graduate from college and was just starting out in a new job. Bon Secours Mercy Health’s investment in the Maggie Walker Community Land Trust helped him buy his home — a home that will be permanently affordable in that community.2 The federal HOME Investment Partnerships Program, which helps affordable homes like Jeisson’s to be built, has contributed to the production of 1.3 million housing units since 1990.3 When the ACTION campaign — the coalition that works on advocacy efforts to strengthen the Low-Income Housing Tax Credit — asked the Healthcare Anchor Network to urge U.S. senators to co-sponsor the bill, Bon Secours Mercy Health responded to the call for support. The health system’s leadership wrote a letter to key senators, and one of them co-sponsored the bill shortly thereafter. The health system’s staff also worked with the ACTION campaign to see what additional help they could provide.

HOUSING FOR HEALTH POLICY DAY

The Healthcare Anchor Network held its first federal Housing for Health Policy Day on Feb. 28, 2019, in Washington D.C., to highlight the links between housing and health and to advocate for improvements in federal funding for affordable, healthy housing. Trinity Health, based in Livo-

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nia, Michigan, brought the largest delegation to the event and met with representatives from Senate offices representing eight states and numerous House Congressional districts, including the current chair of the House Ways & Means Committee. Similarly, CommonSpirit Health held key meetings across the geographic and political spectrum including a meeting with the Senate Majority Leader’s staff.

In total, 17 Healthcare Anchor Network member health systems attended Policy Day 2019, and 21 health systems signed onto the Principles for Healthy and Affordable Housing. Together, the health systems attending the policy day and signing onto the principles represented more than 500 hospitals in 37 states.4 The second Housing for Health Policy Day is scheduled for Thursday, March 12, 2020, on Capitol Hill. The Healthcare Anchor Network is thrilled that the Catholic Health Association, Bon Secours Mercy Health, Advent Health, the America’s Essential Hospitals association and RWJBarnabas Health system in New Jersey have signed on as co-sponsors to date.

BENEFITS FOR HEALTH ORGANIZATIONS

In addition to their work on policy issues such as affordable housing, health systems continue to build relationships and good will with policymakers. For example, leaders and senior staff who participated in the policy day shared their anchor mission strategies and their activities to support the broader health and social needs of their com-

WORKING TOGETHER The Healthcare Anchor Network has a leadership team that helps to inform and shape network initiatives and provides strategic guidance. The leadership team consists of representatives from Catholic health systems CommonSpirit and Trinity Health, as well as Kaiser Permanente, ProMedica, Rush University Medical Center, and RWJBarnabas Health.

Several Catholic health systems are part of the Healthcare Anchor Network including AMITA Health, Bon Secours Mercy Health, CHRISTUS Health, CommonSpirit Health, Franciscan Missionaries of Our Lady Health System, Providence St. Joseph Health, and Trinity Health.

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munities with congressional leaders.

Healthcare Anchor Network members reported that the congressional offices appreciated (and some were pleasantly surprised) to see health systems talking with them about housing and how that impacts health. Network members view their advocacy on issues related to social determinants of health as a contribution toward the larger community good. This advocacy is also important to health systems operating under value-based care where health care’s bottom line depends on trying to encourage healthy populations and the availability of affordable housing, as well as other social determinants such as nutritious food, income security, reliable transportation and more.

WORKING TOGETHER ON SOCIAL DETERMINANTS

The Healthcare Anchor Network works with national issue groups to make it feasible and easier for network members to engage in policy advocacy related to the social determinants of health.

For the most part, health system government relations, community benefit and other staff are not experts on housing, food, workforce development or other issues that come into play with social determinants of health. The network partnered with Enterprise Community Partners, a nonprofit focused on affordable housing, to provide ongoing housing policy information and suggestions regarding advocacy strategies. Enterprise Community Partners has presented to the network on advocacy group calls, and its representatives spoke at the Housing for Health Policy Day Congressional Briefing. The Healthcare Anchor Network conducts policy research and creates policy documents that include examples of its members’ programs to help further brief members in these areas. This assistance allows network members to bring their health expert voices to the policy making arena on these vital issues.

THE SIGNIFICANT IMPACT OF THE HEALTH CARE SECTOR’S VOICE

Health care professionals and their institutions have the potential for significant public policy influence. Health care professionals are among the top trusted professions in the country, giving them a prominent voice in the policy arena.5 In addition, hospitals and health systems are some of the largest employers in their regions and states, making them key stakeholders and economic players.7 They often are seen as more impartial voices since the issues and programs around so-

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cial determinants that they support are not for funds that go directly to the health systems. Since health institutions also know their elected officials and understand the local political dynamics, their voices are likely to be heard when they address these issues in terms of their impact on individual and public health —including the potential cost-savings.

In addition, health care institutions know about the needs identified in their Community Health Needs Assessments and can speak to how policy issues connect to those needs. Many also encourage their staffs to volunteer locally, such as on boards of local nonprofits, school boards, chambers of commerce and more. This helps them to get to know and tell the story of the community and its needs, as well as resources.

JOIN THE ADVOCACY EFFORTS

The Healthcare Anchor Network is collaborating on policy advocacy related to social determinants of health with many of the other hospital associations, including CHA, which is co-sponsoring the Housing for Health Policy Day 2020. We urge other health care organizations to join us and add more important voices to this effort so that all families can be healthy, economically thriving and live fulfilling lives.

NOTES 1. Healthcare Anchor Network, www.healthcareanchor. network/.

2. “Homeowner Stories,” Maggie Walker Community Land Trust, https://maggiewalkerclt.org/newsroom/ homeowner-stories/?mc_cid=a8b904b837&mc_ eid=9f7e2e4412.

3. “A Call to Invest in Our Neighborhoods,” ACTION Campaign, http://rentalhousingaction.org/. See also Housing and Urban Development www.hud.gov.

4. “Housing for Health Policy Day Draws Attention to the Need for Stable, Affordable Housing,” Healthcare Anchor Network, March 1, 2019, https://healthcareanchor. network/2019/03/housing-for-health-policy-day-drawsattention-to-the-need-for-stable-affordable-housing/.

5. Megan Brenan, Gallup, “Nurses Again Outpace Other Professions for Honesty, Ethics,” December 20, 2018, https://news.gallup.com/poll/245597/nurses-againoutpace-professions-honesty-ethics.aspx.

6. ”Hospitals and Health Systems: Significant Employers Making a Difference in Their Communities,” Healthcare Anchor Network, December 2019, https://healthcareanchor.network/2020/01/the-health-sector-and-thehealthcare-anchor-network-employer-maps/.

BICH HA PHAM is manager, communications and policy for the Healthcare Anchor Network, part of the Washington, D.C.-based Democracy Collaborative. DAVID ZUCKERMAN is director of the Healthcare Anchor Network.

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T H I N K I N G G L O B A L LY

THE GUIDING PRINCIPLES: MORE THAN SENTIMENT

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hrough its global health initiatives, the Catholic Health Association works to assist its members, our church partners and the greater global community to promote and implement goals supported by our deepest religious and ethical values. These goals are spelled out in the Guiding Principles for Conducting International Health Activities. Developed in collaboration with CHA members and published in 2015, the principles call for accountability, authentic partnership and evaluation.

But do they matter? Five years after publication, are the Guiding Principles relevant, recognized and part of conversations? I feel that the answer to all three questions is “yes,” and I base this on feedback from colleagues across the globe and BRUCE of many faiths who feel a conCOMPTON nectedness to the points they convey and a desire to share our work more widely. Consequently, this column is the start of a series in which CHA members and global partners will highlight one of the six Guiding Principles in the context of their own global efforts.

The series should underscore the rallying cry I frequently hear in meetings with global actors including our members, staff of the World Health Organization, the National Academies, USAID, and so many more.

It is a call for all efforts to be more sensitive to the realities on the ground, understanding of the local culture and respectful of the authority that exists, and the call continues to get louder. Not everyone is crying or listening, but it is becoming a topic in the media domestically and internationally; in conversations with development experts in high-income countries; with health professionals who travel as part of their work; and most importantly, among the many voices of those who host or receive the mission trips in low- and mid-

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dle-income countries, including faith-based collaboratives and ministries of health.

In an opinion piece from Goats and Soda, National Public Radio’s regular blog on global health and development, author Abraar Karan, said: “Today, the field of ‘global health’ strives to create equitable and just relationships between wealthy and impoverished regions, places and peoples. But it is still a field with markedly unequal power dynamics: racism, classism and many of the residual exploitations of a terrible colonial past. I fear that this point often goes missed or ignored, possibly because we are subconsciously or consciously engaged in a neocolonial narrative in which wealthy people are ‘saving’ poor people even as they build their own careers. It is not a relationship in which Western visitors and local people are collaborating equally — or perhaps even more appropriately, where local leaders take the dominant role.”1 That’s tough to hear. We position our work on that of our founders and foundresses — and we know they focused on breaking down the structures that create poverty and dependence.

Yet, in the current format, even when we’ve been going to a place for decades, do we see real progress in the population’s health? Can we clearly show that the host community’s medical providers — no matter how differently that is defined in the norm of that community from how we define health care providers in the U.S. — are involved,

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actively participate and openly evaluate the successes and failures?

Those being served through or participating in medical missions include patients and their families, and their voices too are rising. When foreign medical mission teams come in, locals have high expectations for the health care to be provided. While appropriate care is offered to many, stories are coming to light when physicians have practiced well beyond their scope and specialty, or incidents when medical and nursing students were involved in clinical procedures even though they had no certifications that allow them to practice medicine. This is addressed in the Guiding Principles, which outline such situations as opposed to both our standards for ethical behavior and our social tradition for excellence in each encounter as a ministry of the church.

Be assured that our means and methods will be coming under closer scrutiny in years to come by governments around the world. It is already happening, and it is affecting the way Catholic health care continues these efforts.

Governments are developing policies in low- and middle-income countries to address such quality issues. Local health providers whose careers are affected both positively and negatively by the work being done, as well as members of the World Health Organization and others expecting more empowerment and capacity development of the local providers are participants in those conversations.

An example of the key stakeholder voice related to donations is in Kenya, where the government now requires inspections of all donated equipment and supplies before they leave the U.S. and again upon arrival to ensure that the items being delivered are in working order and will not immediately go into storage or junk piles.

Another situation in which an African government stepped in occurred in Uganda in 2019. In August of that year,

American Renee Bach — who created a charity nutrition center in that country — was sued by parents of children who died in her care. It’s a complicated story, but in the end, Bach had no clinical experience and 105 of her nearly 1000 “patients” died; it was an Ameri-

very existence and through faith-filled people wanting to do good by doing good that will be addressed in the upcoming series of articles, they will provide us with opportunities to see one another’s perspectives and learn from others’ experiences as we tweak

Be assured that our means and methods will be coming under closer scrutiny in years to come by governments around the world. can nurse volunteering at the center who stepped up and became a whistleblower.2 While this is an extreme case, we must look at the duties of our own mission trip volunteers. Are we asking people to willingly practice outside of their scope – and sometimes entire career field – in the name of “mission”?

The case in Uganda is an opportunity to broach the subject, and the Guiding Principles include questions for reflection to pursue important conversations.

The principles also call for partnership. Thankfully, there is progress in this vein. USAID Administrator Mark Green has said, “We could help our partners by prioritizing programs that show measurable impact, incentivize reform, diversify our partner base, foster local capacity-building and mobilize their own domestic resources.”3 After a recent meeting with USAID, I can say that the Guiding Principles are well-regarded. As USAID undertakes its New Partnerships Initiative, Catholic health care and our partners globally could work toward receiving funding, particularly if we can show use of the guidance relating to evaluation and upholding self-sustainability.

Overall, the Guiding Principles cannot make any one group assess their international programs. They cannot end shipments containing unusable materials or machines from being shipped, and they cannot rein in potential medical malpractice. But, by their

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existing or develop future global health initiatives. We have progressed since the Guiding Principles were shared in 2015, and we hope this series helps them become more of the lived experience in global health in the decade to come.

BRUCE COMPTON is senior director, international outreach, the Catholic Health Association, St. Louis.

NOTES 1. Abraar Karan, “Opinion: It’s Time to End the Colonial Mindset in Global Health,” NPR, Goats and Soda, December 30, 2019, https://www.npr.org/sections/ goatsandsoda/2019/12/30/784392315/ opinion-its-time-to-end-the-colonial-mindset-in-global-health?utm_source=npr_ newsletter&utm_medium=email&utm_ content=20200102&utm_term=4318241 &utm_campaign=goats-and-soda&utm_ id=47309513&orgid=.

2. Nurith Aizenman and Malaka Gharib, “American with No Medical Training Ran Center for Malnourished Ugandan Kids. 105 Died,” NPR, Goats and Soda, August 9, 2019, https://www.npr.org/sections/goatsandsoda/2019/08/09/749005287/americanwith-no-medical-training-ran-center-formalnourished-ugandan-kids-105-d.

3. New Partnerships Initiative, USAID, https://www.usaid.gov/npi.

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EXECUTIVE SUMMARIES Advocacy, Prophecy and the Common Good FR. CHARLES BOUCHARD, OP — All of us would like to see the ministry of Catholic health care as prophetic and oriented to the common good. That should be easy, except for two things. First, the common good is widely misunderstood, and second, prophets have an image problem. The popular image of a prophet is a wild-eyed, marginal character who promotes extreme and anti-social ways of life. It is not surprising that we view prophets with skepticism and that “prophetic” has come to be associated with a kind of political extremism that involves demonstrations, confrontation and generally bad news.

Biblical scholar Walter Brueggemann has made it part of his vocation to rescue prophecy from such misperceptions. The

Can Public Policy Save Rural Health Care?

RACHEL C. TANNER — Across the United States, rural communities are facing enormous pressure to survive. Employers are shutting down. Younger generations are leaving to find economic opportunity elsewhere. The remaining population is aging, and health care providers and facilities are stretched nearly to the breaking point. In fact, more than 160 rural hospitals have closed since 2005, and 21% of all rural hospitals are at high risk of closure due to financial instability.

How can Catholic health care help? The answer may lie in public policy. While rural communities face serious policy hurdles, such as workforce sustainability, a challenging payer mix or overly burdensome regulations, we may be able to im-

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prophet’s job is to reveal God’s plan and call us to participate in it, whatever the cost.

We may not have a monarchy in the U.S., but something like “royal consciousness” is alive and well in our society. It is marked by collusion among the privileged to secure their own interests, often at the expense of the poor.

The common good is an antidote to royal consciousness.

It focuses on equity rather than personal gain, participation rather than disenfranchisement, and the many rather than the few. The Catechism of the Catholic Church defines the common good as the sum total of social conditions which allow people, either as groups or as individuals, to reach their fulfillment more fully and more easily. The common good concerns the life of all.

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Under-reimbursement by Medicare is only part of the problem. Rural communities face higher rates of unemployment, and thus lower access to employer-based insurance, than their urban counterparts. In these areas, expanded access to government insurance is key.

Rural medical practices and hospitals need generalists in an era of medical specialty. They need greater leeway to use advanced practice providers for general medical services. The federal government could utilize greater student loan paybacks to entice clinicians to rural areas. Loosening some of the regulatory burden around workforce would help reverse the trend of physicians opting for urban over rural practices.

Moving the Needle — How Hospital-Based Research Expanded Medicaid Coverage for Undocumented Immigrants in Colorado LILIA CERVANTES and NANCY BERLINGER — Hospital-based research moved the needle at one health system, resulting in policy change to Colorado’s Medicaid program. Following research at Denver Health and nearly two years of dialogue between the research team and the Colorado Department of Health Care Policy and Financing, Colorado in 2019 became the 12th state to allow Emergency Medicaid funds to be used for standard treatment of end-stage kidney disease by including the diagnosis of end-stage kidney disease as an “emergency medical condition.” Previously, undocumented

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immigrants with this diagnosis could access dialysis only after meeting clinical criteria for diagnosis of critical illness, pushing patients to the brink of death each week. By including the diagnosis of end-stage kidney disease itself in the Emergency Medicaid scope of services, Colorado Medicaid created a policy pathway that allowed clinicians to practice to standard of care, prevented suffering and lowered costs. This language change made scheduled dialysis accessible to 137 undocumented immigrants with end-stage kidney disease residing in the state.

Colorado Medicaid expects a cost savings of $17 million per year, reflecting the significantly lower cost of outpatient versus emergency treatment.

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Economic Inequality and the 2020 Campaign DAVID SHEETS — With the 2020 presidential campaign well underway, economic inequality continues to gain strength as one of the top issues in the election. Six in 10 U.S. adults believe the level of inequality is too high, according to the Pew Research Center. Of those, most say the solution requires a wholesale change to the economic system.

Today, America has two sides to its economy. One outwardly appears to indicate we are on an unrelenting trajectory upward.

Job creation entered its 110th month in January 2020 and unemployment hovers around 3.7%, a level unmatched in 50 years. Gains in employment raised median household income

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to a level 49% higher than in 1970.

The numbers are starker on the other side. Fewer people constitute the workforce since the Great Recession of 20072009. Part-time job growth outpaces full-time job growth.

Household incomes on average grew at an annual average rate of only 1.2% in 2000-2018 against an inflation rate that lurched between 3.4% and 2.5% during the same period. Each of the frontrunning 2020 presidential candidates at press time had promised to pursue a different course if elected. The article summarizes their approaches.

Fighting Fragmentation — Mental Health Benefits from Integrated Care BENJAMIN F. MILLER — It’s 2020, and we are losing more lives to preventable causes than ever before. Deaths due to drugs, alcohol and suicide are at an all-time high, and our citizens are hurting in ways that are multifaceted. For some, it may be access to affordable health care. For others, it may have more to do with social and economic factors.

Loneliness, worry, isolation and issues of belonging are key drivers of despair, and we must be bold in our vision and courageous in our decision making if we are serious about making a difference in our country’s health.

Integrating mental health and primary care provides one of

the best-use cases for successfully integrating mental health into a medical team approach.

Recently, Well Being Trust, a national foundation committed to advancing the mental, social and spiritual health of the nation, in partnership with several key collaborators, launched a federal policy guide. It is “Healing the Nation: Advancing Mental Health and Addiction Policy.” The goal is to provide members of Congress a comprehensive guide on ways to impact mental health through policy. Leveraging a framework for action, “Healing the Nation” offers a plan that will start with the federal government and extend into our states and communities.

Medicaid Expansion in Michigan Reflects Catholic Social Principles ALISHA COTTRELL, SEAN D. GEHLE and LINDA ROOT — Michigan responded to those most in need by creating the Healthy Michigan Plan, the state’s unique response to Medicaid expansion.

Healthy Michigan aims to ensure that every low-income Michigan resident who was uninsured or underinsured has access to medical care and services. The plan primarily focuses on prevention and primary care access through a number of key elements including: an increase in healthy behaviors that would manifest

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as healthy behavior change; management of chronic conditions; provision of preventive care; and a reduction in emergency room utilization and inpatient hospitalization. Though this plan has its limitations, it is an example of how we can influence and support our vocational call to provide health care for those most in need.

The Healthy Michigan Plan was launched in the spring of 2014. The program opened enrollment for beneficiaries up to 133% of the federal poverty level. Early enrollment projections of 300,000-400,000 were quickly exceeded, and enrollment over the last several years has averaged more than 600,000.

A Reflection — Moving from Desire to Action SR. DORIS GOTTEMOELLER, RSM — Nothing is as intuitively simple to grasp and as complex to implement as the concept of the common good. According to the U.S. Catholic bishops, the common good comprises “the social conditions that allow people as individuals and groups to reach their full human potential and to realize their human dignity.”

What makes it so hard to craft laws and public policies that promote the common good, especially good health care? The size and diversity of the population make generalizations about needs and preferences difficult. The influence of the social de-

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terminants of good health are beyond the control of health care providers. The sheer number of differing health care stakeholders is daunting. And loyalty to one’s political party sometimes overrides the common good.

Efforts to transform a desire for the common good from a feeling into a way of life can be both individual and institutional. In an increasingly integrated world with porous boundaries, we are called to a love for all of God’s people. Let us join hearts and hands in that common effort.

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P R AY E R

SERVICE

Prayer for the Common Good and the Reign of God FR. CHARLES BOUCHARD, OP, STD SENIOR DIRECTOR, THEOLOGY AND SPONSORSHIP, THE CATHOLIC HEALTH ASSOCIATION, ST. LOUIS

OPENING PRAYER AND READING Leader: The City of God, the new Jerusalem, is our heavenly home, but it is foreshadowed in our earthly city through the common good. Since health care is a prominent aspect of the common good, let us reflect on this city, here and in the presence of God.

needs of our neighbors, the more effectively we love them. Every Christian is called to practice this charity, in a manner corresponding to his vocation …” (Benedict XVI, Caritas in Veritate, #7)

Reader 1: A reading from the Revelation to John “Then I saw a new heaven and a new earth; ... And I saw the holy city, the new Jerusalem, coming down out of heaven from God, prepared as a bride adorned for her husband. And I heard a loud voice from the throne saying, “See, the home of God is among mortals. He will dwell with them; they will be his peoples, and God himself will be with them.” (Revelation 21:1-3 NRSV)

Lord, you have shown us the vision of the Holy City Jerusalem, as our home. Help us to imitate that city in the world we inhabit, we pray.

SILENT REFLECTION “The only absolute is God with whom human beings enter into full relationship only in the heavenly Jerusalem, the City of God. But the political domain has the potential to become a practical embodiment of this full human Good when it seeks greater human solidarity, not just toleration or the protection of individuals in their solitude. The quality of this republic will be proportional to the quality of the loves found among its citizens” …1 Reader 2: Central to the common good is the group’s “social well-being and development…[and] authority’s proper function is to arbitrate between various particular interests in society.” Essential to this is ensuring the accessibility to each person of “what is needed to lead a truly human life: food, clothing, health, work, education and culture, health care, the right to establish a family, and so on.” (Catechism #1908) SILENT REFLECTION Everyone has responsibility for the common good as an embodiment of charity and justice. “The more we strive to secure a common good corresponding to the real

PRAYER Please respond: Lord hear us

All: Lord, hear us.

Lord, political life helps us create an earthly city that brings justice and equity and an end to suffering.

Give our politicians and civil leaders prudence, good judgment, and a firm commitment to just distribution of the goods of the earth, we pray.

All: Lord, hear us.

Help us in our own lives to reject fear and to prefer solidarity with others to the security of individual solitude, we pray.

All: Lord, hear us.

May our health care ministry be a sign to the world of God’s heavenly city, we pray.

All: Lord, hear us.

Leader: Bless us with the gift of solidarity and justice.

Help us to be a holy, transforming presence in the world around us, especially as we care for the sick and improve social conditions that lead to illness and hasten death.

We ask this of you who live and reign forever, with your Son and in the unity of the Holy Spirit.

All: Amen.

NOTE 1. Portions of this prayer were inspired by David Hollenbach, SJ, The Common Good and Christian Ethics (Cambridge, England: Cambridge University Press, 2002), 127-36.

“Prayer Service,” a regular department in Health Progress, may be copied without prior permission.

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Divinity and the universe seem Deeply biased in favor of the future.

Both celebrate emergence.

Call it: Resurrection.

Call it: New Life or New Creation.

Call it: Evolution or Creativity.

I believe in the future and the possibilities For hope and new leadership. ­­— M AT T H E W F O X , C O N F E S S I O N S

Let us pray We are a people of hope. We hope for the future. We hope for change.

We hope for the healing of the Earth. Let us also be a people of action, moving to protect and heal our home.

Rooted in faith and propelled forward by our traditions, we work for a future unseen and already emerging.

God of all Creation, mold us to be leaders ready to meet the struggles before us.

Together, we dare to hope, commit to change and join hands in service to heal our planet and lead the way to a better tomorrow for God’s good creation. We are a people of hope.

Amen.

Visit CHAUSA.ORG/EARTHDAY to see all of our 2020 Earth Day resources for your use! © 2020 Catholic Health Association of the United States