Category Archives: Health and Healthcare Policy

Uninsured in Idaho: Policy Brief

This brief is offered as a contribution to current deliberations regarding Medicaid expansion and healthcare reform in the Idaho state legislature. Idaho, like many other “blue” states, did not accept the Affordable Care Act’s Medicaid expansion. As a consequence, Medicaid in Idaho, at this time, is only available to children, pregnant women, parents of children under the age of 19, disabled people and the elderly. Even within those categories not many meet the Idaho Medicaid criteria: A family of 4 must earn less than $650 / month to qualify.

Research Findings

In 2003 I conducted in-depth interviews with uninsured individuals and families in northern Idaho, south-central Illinois, Texas, Mississippi and Massachusetts. All 37 Idahoans – at the time – were in the work force, though many were struggling to maintain a level of health sufficient to allow them to continue working and caring for their families. As I wrote in Uninsured in America: Life and Death in the Land of Opportunity (University of California Press, 2015), I was struck by the “rugged Idahoans” who shared with me stories of swallowing handfuls of Ibuprofen each day in order to manage pain, using a pocketknife to shave off bone spurs from their feet, turning to friends who worked as aides at nursing homes for help bandaging wounds, and confronting medical bills of $100,000 or more in the wake of an accident or health crisis.

In 2015 I returned to Idaho and the other four states in which I had carried out research in 2003.

  • In Idaho I looked for 37 people and was able to re-interview 20 of the 37.
  • Five of the 37 were dead: all five had passed away prematurely (in their 40s, 50s or early 60s).

One of the dead, who passed away at the age of 58, had worked in the mines his entire life. He left behind a wife and children.

  • Five are now recipients of SSI or SSDI by virtue of having become too disabled to continue working.

Jane used to work at three jobs: cleaning houses, doing laundry in a nursing home, and waitressing at a café. “Eventually I cut back to just the café job because it was my social life,” she explained, “but finally I couldn’t do it anymore. I even kept working through double pneumonia because I had to pay my bills, but eventually I had to stop because of my legs – you see my feet and ankles hurt and then turned black.” When she was finally diagnosed with diabetes at a free clinic she was told that she most likely already had diabetes for seven to ten years, but it had never been diagnosed or controlled. The staff at the free clinic would give her free samples of her medication whenever they had it available, but that was not a consistent source. At age 57 Jane was granted Disability (SSDI), but then had to wait two more years to become eligible for Medicare. By 2015 was able to access care through Medicare and Medicaid, but it was too late. She now is housebound.

  • Five now receive insurance through their employers and none of the five are able to cover their dependents through their employers. According to the Idaho Department of Labor, approximately 95% of Idaho businesses employ less than 50 workers, exempting the businesses from the ACA mandate to provide health insurance.

Marla and Peter, parents of three young children, were uninsured when I met them in 2003 and remained uninsured until a year or so ago. This was challenging because Peter has a blood disorder, ulcerative colitis and glaucoma. Throughout his adult life he has worked steadily for a company that he likes and likes him, but does not provide health insurance. When their kids reached school age Marla took an office job, but it did not provide health insurance. To take care of her family’s health needs, Marla drove them to doctors all over the northern part of the state – sometimes putting hundreds of miles on the car. At each office she would accumulate a manageable bill that they tried to pay off over time. Typically, the doctor would not see them again until they fully paid the bill. Knowing they needed healthcare coverage, Marla began to work for another small business owner who agreed to pay half of their monthly health insurance premium. But the remaining half was so high that after it was deducted from her salary she ended up taking home about $5 / hour. In 2015 she moved to a job with somewhat better insurance. Her premium now is $250 / month, but the deductible is $3000 per person and there are hefty co-pays and co-insurance.

Al, a farmer in his early 60s, was embarrassed to admit to liking “Obamacare.” But he certainly has benefitted from expanded healthcare access. Diagnosed with lung cancer a number of years ago, he had not been able to obtain health insurance before the ACA because of his pre-existing condition. During those years, hospital bills were as high as $300,000 annually, leaving him in horrendous debt. Now he pays $12 / month for insurance through the Exchange and his doctor is satisfied that “there are no new tumors.”

  • Four had moved out of state, primarily in order to access healthcare in Washington or other states that have expanded Medicaid under the ACA. No one in Idaho was receiving Medicaid in 2015.

Chris and Brittany, a vivacious couple in their thirties, moved from Idaho to Washington several years ago after Chris injured his leg on a construction job and the workers compensation ran out before the surgeries he needed were completed. While Chris was out of work Brittany took a job at a restaurant in order to tide them over. With her salary they earned too much for Chris to qualify for Medicaid and get his leg fixed. But without that salary they couldn’t survive. Today, they both are healthy and productively employed in the state of Washington, where they are raising their children and waiting for the day when it will be possible for them to return home to Idaho.

 Policy Recommendations

  • Senate Bill No. 1204, an act that proposes expanding Medicaid eligibility to persons under age 65 whose modified adjusted gross income is one hundred thirty-three percent (133%) of the federal poverty level or below, is an excellent first step towards allowing all Idahoans access to appropriate healthcare services and thus the ability to maintain better health.
    • Those with incomes below 133% of the federal poverty level cannot afford to pay for appropriate medical services. As a consequence, their health deteriorates and/or they amass medical bills that eventually are passed on to the counties or the state.
    • Idaho hospitals and clinics, for the most part, already accept Medicaid payments. Thus, the infrastructure is in place and implementation of this expansion should not involve additional costs or bureaucratic complications.
  • The proposed Primary Care Access Program (PCAP) is unlikely to substantially improve access to healthcare for Idaho’s low income residents.
    • While primary care is the core of any healthcare system, the reality of today’s complex medical world is that primary care visits alone are rarely sufficient for diagnosing or treating serious illness. For primary care providers it is frustrating not to have the capacity to send patients for tests, procedures or specialist care. Patients will find themselves in the frightening position of being told by a primary care provider that they need certain treatments but that the primary care program does not cover them.
    • There is no evidence that access to primary care alone, without parallel access to other medical services, improves the health of populations.
    • According to the published description, “The program requires payment for services on a sliding scale fee, which encourages greater personal responsibility for the patient’s own health.” Given that this program is aimed at people with very low incomes, it is more likely that fees will function as deterrents to care rather than as encouragement of personal responsibility.
    • In my research in Idaho I have never spoken with a single individual who can afford healthcare but irresponsibly chooses not to seek it. The most common reasons for not seeking care are: lack of insurance, deductibles that are too high to meet, lack of transportation to healthcare centers, inability to take off time from work during clinic hours.
    • By limiting access to healthcare to specific health centers, this proposal fails to address the needs of many Idahoans who do not live near any of the specified health centers.

 

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Acknowledgments: In addition to the uninsured and formerly uninsured individuals whom I interviewed, I spoke with Terri Sterling, ICAN; Charlotte Ash, Snake River Community Clinic; Ken Whitney, Jr., Mayor of Troy; Dr. Richard Thurston, St Maries Volunteer Clinic; Donald Duffy, Panhandle Health District; Moriah Nelson, Idaho Primary Care Association; Pam McBride, Clearwater Valley Hospital, Orofino; Ashley Piaskowski, Heritage Health, Coeur d’Alene; Dr. Ted Epperly, Idaho Healthcare Coalition and Family Medicine Residency of Idaho; Stephen Weeg, Board Chair, Idaho Health Insurance Exchange. I thank all of these people for taking the time to share their expertise with me. All opinions and errors are my own.

 

Contact Information: Susan Sered, PhD; Department of Sociology, Suffolk University; 73 Tremont Street, Boston MA 02108

Email: ssered@suffolk.edu

For more on this research see Health is Where the Home Is   Health Insurance Roulette: The House Always Wins   The State(s) of the Affordable Care Act     

A Feminist Sociologist’s Thoughts on the Zika Virus

Courtesy of Independent 1.23.16

The emergence and spread of the Zika virus is worrisome on many levels: the impact of global warming on the spread of infectious and mosquito-borne diseases (see “Getting Dumped On: Snowmaggedon, Women’s Health and Human Rights“); indiscriminate aerial spraying of poisonous chemicals — especially in poor regions — whether well-intended or not; and the reality that the poorest families in Brazil and other countries disproportionately bear the burdens of global warming and are disproportionately exposed  to Zika virus due to living in crowded neighborhoods, reliance on public water pumps that often are surrounded by pools of standing water, and lack of adequate public health resources.

A related set of worries are products of structural gender inequalities: prohibitions on abortion in countries and US states at the same time as women are being warned not to become pregnant because of the presence of the Zika virus (see “Pregnant Bodies as Public Property“); the power of ‘rape cultures’ in which women may not be able to control access to their own sexuality and fertility (see “Fighting Rape Culture: Real Tips“); and a problematic history of public responses to viruses (such as HIV-AIDS) that may be spread through sexual contact, especially when the virus initially impacts disenfranchised or stigmatized groups.

In addition to alarm regarding the vectors of spread of the virus, there is cause for concern for the well-being of families affected by Zika virus. Here in the United States, Zika virus-bearing mosquitoes have shown up in Florida and other southern US states where many people are unable to access appropriate medical care because their state governments have refused to expand Medicaid under the Affordable Care Act (see “The State(s) of the Affordable Care Act“). Shocked and saddened by the pictures we are seeing in the press of babies born with microcephaly, the US’s continued refusal to sign the International Convention on the Rights of Peoples with Disabilities (see “Disabled Rights“) seems particularly indefensible at this time.

For updated (August 19, 2016) information and further analysis, click here: The Social Implications of Zika

See also this statement put out by the Women’s Global Network for Reproductive Rights: A Feminist Approach in Responding to the Zika Virus

Posted on February 5, 2016

In light of the recent outbreak of the Zika virus in Latin America and the Caribbean, the Women’s Global Network for Reproductive Rights (WGNRR) and the Latin American and Caribbean Women’s Health Network (LACWHN) join the voices of our feminist and women’s rights partners[1] in admonishing regional governments’ limited public health advisories for women. In particular we denounce the calls of countries such as Colombia, Jamaica, Ecuador, and El Salvador, advising women to delay pregnancy until the virus is eradicated, and particularly the call of El Salvador for women to avoid becoming pregnant for a full two years.[2]

Governments must recognize that when combatting the Zika virus, any public health strategy that does not have human rights, including sexual and reproductive health and rights (SRHR) at its core, will be limited in its impact and sustainability, while also creating massive grounds for human rights violations.

As a region, Latin America and the Caribbean is characterized by: high rates of unplanned pregnancy, where upwards of 56% of pregnancies are unintended;[3] high levels of sexual violence; limited access to contraceptives and sexual and reproductive health services; and restrictive laws on abortion, where in some cases such as El Salvador, abortion is prohibited under any circumstances and women are routinely persecuted and even criminalized on suspicion of having abortion.[4] Moreover, women who are young, from remote or low-income communities, and/or living in other vulnerable situations, disproportionately face multiple barriers when it comes to exercising meaningful decision-making power and control over their sexual and reproductive lives. In such a context, calls for women to simply delay or avoid pregnancy are not only unrealistic but irresponsible and negligent.

The rapid spread of the Zika virus and its strong association with marked increases in microcephaly and other neurological abnormalities is in many ways new terrain, with new elements continually coming to light, demonstrating a clear need for more research. This uncertainty makes it all the more imperative for governments to undertake from the beginning a holistic, sustainable, and rights-based approach to eradicating the virus and mitigating its effects. Anything less is careless and counter to governments’ human rights commitments under regional and international human rights law.

We thus urge the governments of affected countries both in Latin America and the Caribbean as well as other regions worldwide to undertake a rights-based, reproductive justice, and sustainable development approach towards the Zika virus and any other emerging health issue. Such an approach must be holistic, while recognizing gender equality and women and girls’ empowerment as a cross-cutting priority, in keeping with governments’ agreements and commitments under the 2030 Agenda.[5]

In practice, this approach to combatting the Zika virus must include:

  • Ensuring universal access to a full range of high-quality, voluntary, and user-friendly contraceptive methods, including barrier methods such as female and male condoms, and emergency contraception, as well as comprehensive SRH information and services, including antenatal services to enable early detection of microcephaly.
  • Targeting both men and women in public health awareness campaigns, especially in light of recent evidence that Zika may be sexually transmitted,[6] recognizing that the responsibility for safer sex methods falls on both men and women and cannot be shouldered by women alone.
  • Decriminalizing abortion, and removing all legal and implementation barriers to expand and ensure access to safe, comprehensive, free and high-quality procedures for pregnancy termination, free of requirements for marital or parental consent. As has been flagged by partners,[7] in the context of the many uncertainties and increasing public fears surrounding the Zika virus, calling on women to simply not become pregnant when access to safe abortion is limited or even completely criminalized will inevitably risk driving up rates of unsafe abortion, and ensuing maternal mortality and morbidity. Moreover, restrictive and punitive abortion laws that force a woman to carry an unwanted pregnancy violate women’s right to be free from inhuman and cruel treatment, as noted by Human Rights Bodies.[8]
  • Supporting pregnant women in Zika-affected countries who decide to remain pregnant to be able to carry the pregnancy safely to term, including access to comprehensive pregnancy, safe delivery, pre- and post-partum care and neo-natal care services; as well as the provision of special needs therapy, health and educational services as needed for children with microcephaly.
  • Systemic policy and programme changes that account for the intersections between climate change and SRHR.[9]
  • Immediate implementation of related recommendations under the Montevideo Consensus as well as targets under the Sustainable Development Goals of the 2030 Agenda, particularly those related to health and gender equality, in order undertake effective and holistic protection measures and help curb the spread of the virus.

Health is Where the Home Is

Christmas House Decorations wallpapers

Maybe it’s because of the bitterly cold temperatures at night this week, or maybe it’s my own visceral response to overdosing on television shows with happy family Christmas scenes and neighborhood holiday lighting competitions, but I’ve been giving a lot of thought recently to how housing and homes impact health.

About a decade ago I traveled to the Mississippi Delta, Texas’s Rio Grande Valley, south-central Illinois, the mountains of northern Idaho and the cities of eastern Massachusetts to speak with individuals and families scraping by without health insurance. Most of these people worked in construction, retail, agricultural or service jobs. The details varied, but across the country I heard about spiraling poor health, declining employability and growing poverty. In 2015 I made return trips to check in with the people I’d met ten years earlier.[i] While I was able to locate nearly all of the original interviewees who owned their homes (including very modest homes of immigrants in colonias in the Rio Grande Valley), I only located a minority of the renters. Typically, their original phone numbers were disconnected and original addresses belonged to subsequent tenants. When I knocked on neighbors’ doors the most common response was, “I don’t know [so-and-so]. I’ve only lived here for a few months myself.”

In previous posts I’ve written about marginalized Boston-area women who cycle through shelters, jails and the streets. In those contexts the “problem of homelessness” is relatively easy to see and define – all I had to do was visit shelters or walk through the public parks in which people without homes congregate during the day. But for me, it took weeks of trudging through muddy housing developments on the outskirts of Mississippi towns and knocking on doors in public housing complexes in a central Illinois cities to get a glimpse of the lives of those less visible Americans who generally manage to rent housing of some sort for periods of time but teeter on a financial edge that keeps them moving from place to place.

Unfinished housing project at 47-04 198th St. in Auburndale stands abandoned for several years.

On my 2015 reprise tour I looked for a total of 145 people in five states and was able to locate 98 of them. The missing people were not evenly distributed either geographically or by race. In Mississippi, the state that consistently has the poorest health profile in the country, I managed to locate only 11 of the 28 people whom I sought. The utter disappearance of 17 of 28 people did not surprise one local healthcare advocate (he asked to remain anonymous): “People move away to Birmingham or Tupelo to look for work. There is very little home ownership in Mississippi. The common thing is ‘lease to own’ in which a developer arranges for people to ‘lease’ (pay rent) and after 20 years they have an option to buy – to switch the rent to a mortgage. But people almost never make it to the 20 years so the developers keep leasing the same houses over.” Many of these houses would not pass even the most cursory safety inspection in other states.

I was able to locate 70 out of 88 white people I’d originally interviewed and 21 of 28 Latinos / Latinas (mostly in the Rio Grande Valley), but I only found 10 of 29 African Americans. This is consistent with national patterns. According to the US Census, the homeownership rate for the fourth quarter 2014 for non-Hispanic White householders was highest at 72 percent. The rate for All Other Races householders was 55 percent. And for Black householders it was only 42 percent. According to researchers Gregory Sharp and Matthew Hall, “The 1968 passage of the Fair Housing Act outlawed housing market discrimination based on race. …  However, emerging racial disparities over the next three decades resulted in black owners who bought their homes in the 2000s being 50 percent more likely to lose their homeowner status than similar white owners.” Even after adjusting for socio-economic characteristics, debt loads, education, and life-cycle traits like divorce or job loss, blacks were more likely to lose their homes than whites.”

Shanice’s Story

I first met Shanice in 2003 at one of the larger Black churches in Decatur, IL – a church known for its strong fellowship and advocacy on behalf of the community. She was happy to share her story with me:

“When I was 18 I worked a job, it was right after coming out of high school. No insurance and they said I wasn’t eligible for Medicaid. My doctor said that I needed to get my tonsils taken out cause they were so swollen it was almost causing me not to be able to breathe. … And so I had to go on like a payment plan with the doctor. … The whole surgery, the surgeon, the day at the hospital and then I had a setback and had to go back into the hospital cost $15,000. During the following year collection agencies called day and night, often making threats. They’d [especially] call on Sunday nights. Said that I would be going to jail if I didn’t pay them.” At age 20, Shanice filed for bankruptcy.

A few years later Shanice gave birth to her daughter. By this time Shanice was working for a storefront loan company that provided health insurance for her, but not for her daughter (she would have had to pay a premium that she could not afford on her salary.) A few years later their statuses reversed: When Illinois expanded Medicaid for children (Kid Care) her daughter became covered but Shanice, having made the decision to go back to school and learn a skill, became uninsured. Shanice was well aware of the risk she was taking was determined to build a better future for herself and her daughter. “It wasn’t just me living this carefree don’t worry about tomorrow life. Now I have someone that was dependent on me so I had to make decisions for the future. … We moved into a nice apartment, we got power, cable, phone and I got a new car.” During that time Shanice began to eat healthier meals and lost over one hundred pounds. In order to pay tuition, “I got Pell grants and student loans.” I asked Shanice how she was able to get credit to buy a car so soon after declaring bankruptcy. “Oh, they go after bankruptcy people like crazy [to sell them stuff]. I was getting credit cards in the mail every night.”

In 2003, after spending time with Shanice and her daughter at the church where they sang in the choirs, participated in groups and clubs that helped them focus on making good decisions, and volunteered helping out the poor in their community, I described Shanice in my notes as “a young woman on the way up.” She was working part-time at her church with youth and looking for her first professional job. “I just completed 1540 hours of cosmetology school and I just graduated last Friday.”

When Shanice and I walked out of the small room where the church choir stored its robes, I asked her if as a cosmetologist she would get health insurance. She answered, “I can get a job but in this field they don’t give insurance. You have to arrange that yourself.”

….

A year or so later I spoke with Shanice again. With a sense of resignation, she told me that medical and credit card debt had piled up and she was preparing to declare bankruptcy a second time.

….

Fast forward twelve years. I returned to the address at which Shanice was living when I initially met her. She had moved on and none of the current neighbors even knew her name. On USSearch I found six other addresses for her and visited each one of them. Two of the addresses did not exist. One was in a decrepit housing project that had been shut down for several years, though some people continued to squat in the apartments. (I was warned that mostly gang members were there and that it wouldn’t be safe for me to go poking around.) One address was in a middle-class, white neighborhood – none of the neighbors whom I could find knew of anyone named Shanice. Two were inhabited by other Black families who had moved in recently. Stopping by her church, I was told that, “Shanice is no longer a member of this church. She’s moved.” No one at the church knew where.

Health and Housing

It’s not hard to understand the devastating health consequences of homelessness. Living on the streets exposes people to cold, rain and assault. Without a home it’s a challenge to eat proper meals, get enough sleep and keep oneself and one’s clothing clean. The stress of not knowing where one can lay one’s head contributes to misuse of drugs and alcohol. And infections of various sorts tend to spread quickly in crowded homeless shelters. Like the people in the shelters, these health consequences are easily identified and counted.

The health consequences of moving around are less immediately visible to the casual eye. But at a community health center in Decatur Illinois, nurse administrators Karen Schneller and Tanya Andricks elaborated on ways in which churn in housing is related to churn in healthcare. Different states and even different counties and towns have different healthcare resources available to residents. Different providers have different medication preferences and treatment protocols so people stop and start treatments. Even with dedicated staff efforts, it is impossible to provide follow-up care for patients who can’t be reached – whose phones are turned off and whose mail is returned “addressee unknown.”

Jenny Trimmell, public health administrator and Melissa Rome, community liaison at the Vermilion County (Illinois) Health Department explained that children like Shanice’s daughter particularly suffer from frequent moves. “When the Cabrini Green housing project in Chicago was closed to pave the way for gentrification former residents were offered vouchers by the Housing Authority and promised housing and jobs in towns in central Illinois. But there was not enough housing and not enough jobs, so people go back and forth to Chicago. There was a cultural adjustment for many moving from Chicago to more rural downstate.  People were unaware that services outside of the city of Chicago may be limited, such as access to health care providers; bus services that do not run 24/7, etc.  Everyone is frustrated. The kids are in and out of schools and medical records kept by parents are incomplete or non-existent. It is difficult for the Health Department to determine immunization status for these children and frequently immunization series have to be started over due to the unknown immunization status.” Trimmell and Rome went on to explain that without the kinds of community support children develop when they stay put in one school, “there are high drop-out rates, teen pregnancies and drug use.”

Musings

Getting to know and then losing track of Shanice and others in similar situations has made me more attuned to the health privileges of stable and secure housing. My home allows me to accumulate the material objects that anchor and enhance my life, both in immediate ways by giving me space to store medication and in less tangible ways by grounding me in the photos, books and furnishings that tie me to my past and to the people I love. My home provides a hidey-hole for times when the outside world feels overwhelming. It gives me a familiar bed and private bathroom when I am sick, and a kitchen in which I can cook the food that I want to eat when I want to eat it. My home allows me to cultivate neighbors who can lend a hand at times of need and offers me the space to nurture those special bonds with the family that looks out for my well-being. In my own home I have the power to keep out rats, roaches, mold and the dust and down that I am allergic to. I am not dependent on the vagaries of landlords or property management companies. No less important, my home gives me an address at which I receive and retain the paperwork that helps keep my financial, medical and legal life in order as well as reminders of when and where to exercise my right to vote (yes – for candidates who support legislation that makes my community healthier).

I plan to return to Decatur next week and resume my search for Shanice. Maybe she has found another supportive church community somewhere else in the area. Maybe she finally has her healthcare coverage straightened out. Maybe her daughter has escaped being one of the kids who’s been subjected to multiple rounds of vaccinations. Maybe she’s become the star of her high school marching band or debate team. I hope so.

 

 

[i] In each community I began with the contact information people had given me when we first met. Only a minority still lived at the same address or had the same phone number. Then I turned to phone books, social media, Google and other public-access online search engines, including USSearch that listed multiple address histories for many of the people. In each community, if my initial attempts to make contact failed, I then called on common acquaintances, knocked on doors of neighboring houses, and asked at local grocery stores, libraries and churches.

For more on this project:”The State(s) of the Affordable Care Act”

For more on housing struggles, take a look at this article about “Carly”

Pinktober: A Consumer Dystopia

(Thank you to Lois Ahrens for bringing the pink handcuffs to my attention.)

Each October, as national breast cancer month rolls around, I find myself fluctuating between pink-nausea and pink-rage. The pink ribbon extravaganza, a month-long consumer fest that turns women’s suffering into cold hard cash makes the absence of a national commitment to identifying and eliminating the environmental causes of breast cancer seem that much worse. The sanitized cuteness of pink-ribboned teddy bears makes the slash and burn treatments of the bio-medical cancer industry feel all the more painful. And the pink-painted messages praising “strength” and “optimism” reinforce the “holistic sickening” at the core of many of the complimentary and alternative healing modalities that “explain” breast cancer in terms of poor lifestyle choices, suppressed anger, or denial of one’s true femininity.

This year I’ve collected a few of the new (or at least new to me) egregious efforts to commodify, to normalize, to exploit — and to “cutefy” — breast cancer. Click here and here for more serious analyses. And as always, to learn more about “pinkwashing” and to support the work of Breast Cancer Action, click here.


As you can see in the feature photo, the pinkwashing Olympics have their new champion: the police department of Greenfield, Massachusetts announced on Facebook that for the month of October, they’ll be using pink handcuffs. Officers will also sport pins reading “Arrest Breast Cancer.” Because there’s no problem you can’t solve that way.

The news of this very well-intentioned, probably, gesture comes via CBS Boston and also the department’s own exuberant press release:

October is National Breast Cancer Awareness month. While most people are aware of breast cancer, many forget to take the steps to have a plan to detect the disease in its early stages and encourage others to do the same.

Many of our community members, including some of our own friends and family members, have been affected by breast or other types of cancer.

Officers of the Greenfield Police Department have “gone pink” in order to raise awareness for the disease! All of our officers have changed their collar pins, which were blue and white state seals to pink and white pins which states “ARREST BREAST CANCER – UNLOCK THE CURE” surrounding a pink ribbon and a pair of handcuffs. Some of our officers have even replaced their on duty silver handcuffs with pink ones and will be using them during the course of their work day.

Help us ARREST BREAST CANCER by spreading the word and by making your own early detection plan.

 

Remember: when placing a suspect in a light chokehold or frisking them against a vehicle, always ask if they’ve performed a monthly breast self-exam. There’s no awareness like the kind that takes hold in the back of a squad car.

Pink Car
(Photo courtesy of ctpost)

In this era of stop and frisk, rising rates of incarceration among women and continued sexual abuse of women in prison it’s hard to get excited about a pink police car. “In 2006, a Department of Justice (DOJ) study found that women in prison are at significantly greater risk for cancer than their male counterparts. Out of every 10,000 incarcerated women, 831 had cancer, compared to 108 per 10,000 men.” According to the Department of Justice there are over 1,000 incarcerated women who either have or have had breast cancer. To learn more about  the suffering of “breast cancer behind bars” click here.

Pinkwashing has also expanded in the usual commercial way:

Capture5
(Image courtesy of the Shultz Shoes Website.)

Just what every woman needs to stay healthy: Pink stilettos. Perhaps the message is: Don’t worry about dying of breast cancer when you can kill yourself running for the train in pretty pink shoes.

Capture
(Image courtesy of the Hard Rock Hotel Website.)

This year the Hard Rock Hotels are offering “Pink Rooms” with pink bed sheets and an option to purchase pink bathrobes. The activists among us will be relieved to know that we can stop organizing, lobbying, researching and lecturing. All we need to do to eliminate breast cancer is “Get into bed” and “relax for the cause.”  And in case you’re more of a “party for the cause” than a “relax for the cause” kind of gal, Hard Rock Hotels have you covered as well. Who knew that pink margaritas prevent (or is it cure?) breast cancer?

Capture

Pink ribbon and other cause marketing can mask conflicts of interest, like when companies promote the idea of cancer research but also manufacture ,disseminate, or sell products that contain toxic or carcinogenic ingredients. I’ve recently seen dry cleaning companies jumping on the Pinktober bandwagon:

https://i0.wp.com/susan.sered.name/wp-content/uploads/2015/10/Capture3.png?resize=604%2C411
(Image Courtesy of Westportnow.com)

What this and similar ads leave out is that PERC, the solvent used in most dry-cleaning, is a known carcinogen.

bca-matthew-williamson-square-w352
(Image Courtesy of Glamour.com)

Recent studies also show the harmful effects of working in a nail salon surrounded by fumes from chemicals in nail polish and yet companies are selling nail polish to “promote breast cancer awareness.”

And finally, to take away the sour tastes in our mouths (whether caused by chemo or by pinkwashing): Nothing promotes the health and wellness of women quite like sugar filled candies with cute little pink ribbons all over them.

Capture
(Image courtesy of orientaltrading.com)

 

 


We Can Do Better

While spending on breast cancer detection and treatment continues to increase, funding for prevention – for learning about the causes of breast cancer – is far less marketable. In past years my home state, the Massachusetts legislature failed to fund research on potential carcinogenic impacts of chemical exposure despite clear findings that there are specific communities in Massachusetts with particularly high rates of breast cancer.

As for me, I’ll skip the pink bathrobes, candy, nail polish and (hopefully) police cars, and spend my money on real research into breast cancer prevention. For more on the Silent Spring Institute click here.

Thank you to Robin Yang and Ashely Rose Difraia for help with this post.

Paid Sick Leave: It’s Still a Big Deal

During the first week of August 2015, newspapers reported that the White House is drafting an executive order requiring federal contractors to provide their employees with at least seven days of paid leave per year for illness or to care for family members. The notion that workers are are flesh-and-blood human beings who sometimes get sick, sometimes need to care for family members who are sick, and often cannot absorb the loss of salary while they are sick should be pretty self-evident. And, one would assume, acknowledgment of basic human rights should be sufficient reason to require employers to provide their workers with at least some paid sick leave. Yet, within days of reports of this seemingly modest policy move, industry leaders have made it clear that they will oppose this executive order in court; that they will do their best to dilute it’s provisions; and they will do their best to ensure that it applies to as few workers as possible.

Fortunately, despite harumphing out of Washington that paid sick leave would kill job growth, interfere with the free market and turn American workers into sniveling babies, a number of states have gone ahead and passed paid sick leave ballots or legislation. I’ve re-posted here an essay on the critical importance of paid sick leave that I wrote right after the 2014 elections.  Continue reading Paid Sick Leave: It’s Still a Big Deal

The State(s) of the Affordable Care Act

A decade ago I traveled to the Mississippi Delta, Texas’s Rio Grande Valley, the rust belt of Illinois, the mountains of northern Idaho and the cities of eastern Massachusetts in order to learn how uninsured Americans manage (or don’t manage) their health and healthcare in diverse circumstances. This spring and summer I returned to these communities to seek out the same individuals and families I’d met ten years ago. I wanted to hear how they’ve fared in the wake of the Affordable Care Act.

It is clear to me that June 23, 2015’s Supreme Court ruling in King v. Burwell is good news for millions of middle-class Americans living in states whose leaders chose not to set up insurance marketplaces (“exchanges”). People in those states will not lose their insurance subsidies because the federal rather than the state government facilitates the exchange.

The states impacted by King v. Burwell are, however, mostly the same ones impacted by the 2012 Supreme Court ruling (NFIB v. Sebelius) which allowed states to opt out of the ACAs Medicaid expansion. Lower income people in those states will continue to fall into the coverage gap — the no man’s land for people who earn too little to qualify for subsidized insurance through the exchange but who do not qualify for Medicaid in their home states. In some of those states only extremely poor parents and children are eligible for Medicaid, leaving large numbers of people who are childless or near elderly or poor but not destitute unable to access healthcare.

Texas, one of the states that did not expand Medicaid, has a federally facilitated marketplace. During my return trip to the Rio Grande Valley, I was able to locate 18 of the 26 individuals and families (all adults) I’d met a decade ago. At the time, all were uninsured. Fourteen of the 18 are now insured – a figure that, on the face of it, looks encouraging.

However, of the 14 who are insured, 5 now are covered by Medicare via Disability (as a consequence of becoming sufficiently disabled to qualify for SSI or SSDI). In other words, a third of the newly insured people are covered because their health deteriorated to a the point in which they no longer are able to work. One person is covered by Medicare because she is over 65. Two people have Medicaid but only as a supplement to Medicare; no one qualified for Medicaid as their primary insurance.

All 4 of the uninsured people fall into the coverage gap – when they applied for insurance on the exchange they found that their incomes are too low to qualify for subsidies. The experiences of the Martinez family (a pseudonym) are typical. Maria works full-time in a food service job that provides health insurance for her but requires a bi-weekly payment of $250 to cover her children. Her bi-weekly income is $500, so she had to turn down the coverage. Her husband, Enrique, is a truck driver whose employer does not offer insurance but he earns too little to qualify for a subsidized premium on the exchange. For a short time their youngest child was eligible for Medicaid (CHIP), but then Enrique’s income went up (marginally) and she no longer qualified. In 2013 Enrique spoke with an ACA enrollment specialist who helped him apply for an exemption from the penalty for not having insurance. In 2014 he forgot to re-apply and had to pay $190 in fines ($95 for himself and $95 for their 21 year old child.) In the meantime, he takes medication for high blood pressure when the border with Mexico is safe enough for him to cross over and buy pills there. I make no claim to extraordinary prophetic powers, but my guess is that in another five years he will join the ranks of disabled Texans.

That leaves 5 who are insured via the exchange and 5 now insured through employers – certainly a step up from when I first met them. However, all 10 of these Texans are unhappy with their insurance, for the most part because of high deductibles and co-pays. Rosa, an energetic and articulate middle-aged woman, is reimbursed by her employer for part of the cost of the premium she purchased through the exchange. Because of her low salary she chose a “bronze” plan with a low monthly premium (all that she could afford) but a $4500 annual deductible and $1000 co-pay for hospitalization. With a history of tumors in her breast and kidney, she needs scans that she cannot afford even with insurance. I fear that she too, will join the growing ranks of Americans who are disabled.

Shortly after the Supreme Court’s ruling on the ACA, President Obama spoke from the Rose Garden celebrating our national declaration that health care is a right, not a privilege. Now the challenge is to turn that declaration into reality on the ground – even in states whose leaders would rather thumb their noses at the feds than allow residents of their state to access the care that they need in order to remain healthy.

For more on health insurance read  Health Insurance Roulette: The House Always Wins

For more on the original research in the five states read  Uninsured in America: Life and Death in the Land of Opportunity

 

 

Penny and Pound Foolish: Governor Baker’s MassHealth Savings Plan

After running on a campaign of new and smart ways to reduce government spending, Massachusetts Governor Charlie Baker (R) has proposed budget cuts for fiscal year 2016 that are neither new nor smart — going after the low-hanging fruit of government funded Medicaid (MassHealth) for the Commonwealth’s poorest, sickest and most vulnerable residents. Most of the proposed savings to MassHealth in Gov. Baker’s plan are merely a matter of bookkeeping – shifting costs from fiscal year 2016 to fiscal 2017. But the Administration also aims to reduce spending by requiring over one million residents enrolled in MassHealth to prove that they are still eligible. Though the Administration has not provided an estimate of how many ineligible people are enrolled, Baker’s budget team estimates that this move will save the Commonwealth $210 million.

The immediate plan is for the Commonwealth to contact 1.2 million people who were automatically re-enrolled in MassHealth when the Health Connector (‘Exchange’) website experienced technical failures in 2013. Each of these people will receive two letters asking them to reconfirm their eligibility. After 60 days those who do not respond will lose coverage. That may not sound unreasonable, but as a sociologist who works with low income women, I suspect this plan presents disproportionate hardships for residents who do not have permanent addresses or who struggle with understanding government forms and with gathering the required documentation; that is, the people who most need consistent healthcare coverage. Individuals who lose eligibility will be allowed to re-certify in the future, but the immediate effect will be disrupted care and an uptick in expensive emergency department usage.

The scanty information released by Governor Baker’s office indicates three categories of potentially ineligible people who would be eliminated from the MassHealth rolls. The most straightforward are people who still are on MassHealth plans but have moved out of state and receive coverage elsewhere. These people, however, would not seem to account for much spending given that they have other insurance where they actually live so are unlikely to use MassHealth benefits. The second category is people who have had a change in income sufficient to place them over the eligibility threshold. Given the absence of a meaningful economic recovery for low wage workers in Massachusetts, this category likely consists of individuals and families whose current earnings push them marginally over the eligibility line. Switching these people from MassHealth to the heavily subsidized insurance policies that they are eligible for through the Health Connector is unlikely to make much of a difference in the budget.

A third category – people who are purposely cheating or “working the system” — has not been explicitly singled out in statements from the Governor’s office. But given 2010 gubernatorial candidate Charlie Baker’s fake electronic benefit cards that said: “Deval Patrick’s Massachusetts EBT Welfare Card. Swipe me for booze, cash, cigarettes, and/or lottery tickets at taxpayers’ expense,” weeding out Medicaid cheaters certainly lurks behind the call for re-certification. Again, we have no information regarding numbers, but we do know that hunts for fraudulent welfare claims consistently turn up very little cheating and thus very little cost-saving. Last year, for example, Maine Gov. Paul LePage (R) released data intending to prove widespread welfare abuse but in fact showed that 99% of all welfare benefit transactions were legitimate and legal.

The re-certification process in and of itself will be costly. If we calculate (modestly) 15 minutes for a government worker to process a straightforward re-certification, the 1.2 million re-certifications will take approximately 300,000 hours. And if we assume (modestly) a salary of $15 / hour for the workers who process re-certifications, the bureaucratic cost will come to 4.5 million dollars – a substantial chunk of what the Administration is looking to cut from the MassHealth budget and money that surely could be spent in a manner more conducive to protecting the health of Massachusetts’ residents.

These numbers are just an estimate, and I assume the Governor’s staff has more accurate numbers. But even if I’m off by 50%, we’re still looking at a cost cutting plan that is likely to cost the Commonwealth a great deal both in terms of salaries and in terms of health.

For more on the larger picture of  health care coverage click:  Health Insurance Roulette: The House Always Wins

Paid Sick Leave: It’s More Than Just a Day Off

feature image via Cody Glenn, The Daily Journal

Francesca, a woman I have come to know during the past seven years, has tried hard to rebuild her life after fleeing an abusive marriage, overuse of pain medication, homelessness and a stint in prison. She popped into my mind this week when I read an article about Maria Fernandez who died of exhaustion. Working more than eighty hours a week at minimum wage jobs in fast food chains, she sat down in her car to take a nap between shifts. A gas container tipped over and Maria never woke up.

With a prison record, Francesca can barely find one job, let alone the four that Maria juggled. But she certainly understands what Maria was going through at Dunkin Donuts. A couple of years ago Francesca was hired at a Boston-area Dunkin Donuts where she worked erratic, long shifts at the whim of the manager. She rarely knew ahead of time when she’d be called into work, or for how many hours. After a few weeks she found herself in pain — bone spurs in her foot had been exacerbated by the long hours standing on her feet. Her manager told her that if she took off time or reduced her shifts he would let her go. Fortunate to be a recipient of Massachusetts’ generous health insurance coverage, she went to her doctor who gave her an orthopedic boot to wear at work. Unfortunately, the boot caused her to trip at work and she was fired on the spot.

Paid Sick Leave

In a mid-term election cycle that resulted in few reasons for young, sick, poor or vulnerable Americans to look forward to positive changes in their circumstances, there was at least one bright light. Massachusetts voters (yes, the same folks who voted in Republican Charlie Baker for governor) approved a ballot measure in support of the country’s most robust requirements for providing paid sick leave to workers. The new Massachusetts law entitles people to earn up to 40 hours of paid sick time each year if they work for businesses with 11 or more employees; staff at smaller companies would earn 40 hours of annual unpaid sick time. Sick leave could also be used to care for a sick child, spouse, or parent.

With that vote, Massachusetts joins two other states (California and Connecticut) and about a dozen municipalities. Paid sick time questions were also on the ballot in three cities in this election, and passed in all three.

It’s not hard to argue that paid sick leave is good for everyone, not just for Francesca or Maria. For parents, it means being able to take off from work to care for sick children. For consumers, it means less likelihood that the people serving your meal, ringing up your groceries or checking you in at the doctors’ office will spread germs by coming into work sick. It also means less likelihood that someone doped up on Nyquil will be at the wheel of a car or truck. Or that construction workers, bank tellers and security guards will make the kinds of illness-induced errors that can lead to roofs collapsing, money going astray, or weapons making it into public institutions. But it doesn’t end there. Paid sick leave is also good for employers: Productivity and profitability go down when workers are forced to come to work when they are sick. One study on the impact of illness on productivity estimates that businesses lose twice as much money to workers who show up at work while sick then when workers stay home due to an illness.

Tip of the Iceberg

But there are more macro reasons that the four sick leave ballot votes are a cause for elation. On a deep level, paid sick leave pushes back against a corporate culture in which workers, and especially low-wage workers, increasingly are treated as replaceable cogs in the money-making wheel.

In the best of all possible worlds (actually, in the world that the labor movements of the early twentieth century fought hard to create), employers and employees would collaborate in creating a safe working environment, a first rate product, and profits for the company and livable wages and solid benefits for the employees. In that world, the health and safety of the employee would be seen as serving not only the moral but also the financial good of the employer. Employers would understand that they could not prosper without the dedicated services of their employees. They would nurture that dedication through an occupational culture of respect and fairness, and they would do everything in their power to hold onto their employees’ services. These employers would know that it is in everyone’s interest to ensure that the workplace environment minimizes the risk of injury and thus minimizes lost workdays, and that in the case of accidents or illness employees receive the best possible medical treatment so that their return to work is expedited. These employers would also respect that their workers have lives outside of the factory or store or restaurant or office. They would understand that workers, like themselves, are also human beings living in the frail bodies. And workers, like employers, are embedded in the family and social networks of mutual obligation that provide the truest safety net when we – as all humans do – are born, give birth, become ill, age and die.

This scenario is rooted in an idealized business ethos of respect that recognizes the mutual dependency between owners and workers, and it is actualized through specific health and safety programs that employers support on both moral and business principles. Employers know that it is economically inefficient to deal with frequent turnover in their workforce so they want employees to work for them for a good long time, to improve their job skills, and to develop company loyalty. To some extent, it is irrelevant whether this goal is driven by pure altruism, by the profit motive, or by a combination of the two. Whatever the motive, in our ideal world, it wouldn’t be such a bad idea to link health care to employment or for workers to depend upon their employers to compensate them for work related injuries.

Unfortunately for American workers, however, that ideal world does not exist (at least, not outside of occasional nostalgic TV sitcoms). The current American work world is highly mobile and transient; many of the largest employers in, for example, the fast food industry, seek ways to structure employment so that workers are easily interchangeable; multi-national conglomerates neither feel loyalty towards their employees nor expect their employees to feel loyalty towards them; small businesses go under faster than they get started; and manufacturing and other business associations spend billions of dollars lobbying Congress and state legislatures to limit laws requiring and enforcing workplace safety standards.

In the real world, employees and employers often experience their relationship as more adversarial than cooperative. Rather than collaborate on a mutually beneficial social contract that balances the well being of workers with profits and productivity, employers increasingly have chosen to pursue immediate profits. Employers frequently view living wages, strong worker benefits, and safe working conditions as coming at the expense of profits. Investing in the health of employees often is seen as superfluous in an economic climate in which the growing caste of the working poor can be hired on a temporary or contingent basis, and in which plants and factories can be moved to South America or Asia — places where employers need not bother with things like paid sick leave, health insurance or worker’s compensation, labor unions, environmental regulations, or child labor laws.

What’s Next?

Successfully passing paid sick leave ballot questions in a few states and cities cannot reverse decades of policies that created the work environments in which Francesca and Maria live, and die. But it is a meaningful move pragmatically for hundreds of thousands of people, and a meaningful move symbolically in terms of collective recognition of basic human rights of workers.

So, as I write this I can, for a few minutes at least, feel a bit better about the 2014 mid-term elections. That is, until I remember that Republican leaders have made clear that one of their highest priorities will be the repeal of Obamacare, which while far too watered down for my own tastes, does require employers of large companies to offer health insurance to their employees.

You can read more about these issues in Uninsured in America: Life and Death in the Land of Opportunity by Susan Sered and Rushika Fernandopulle.

Pink Ribbon Extravaganza

A newer version of this post (with more great photos) can be read here. And click here to get to the Bitch podcast “Popaganda Episode: Liberal Problems in which I read part of this post.

It’s October – the leaves are turning yellow, porch ornaments are coming up pumpkin orange, the first frost is sparkling silver, and everywhere I turn the sight of pink ribbons assaults my eyes and affronts my sensibilities. The annual pink ribbon extravaganza, surely one of the most successful marketing campaigns in history, has millions of Americans walking, running, racing and selling merchandise “for the cure.” Having spent the first half of my career studying religious rituals, I can’t help but think that many of the ribbon bearers see their little scraps of pink as an amulet or a charm, a means of warding off an enemy over whom one feels impotent. If we just wear or sell enough pink ribbons during the month of October, we hope or we bargain with the cancer gods, then maybe we’ll be safe from breast cancer for the coming year.

10well_ribbon-blogSpanMaybe I’m a cynic, or an agnostic, but as a means of averting breast cancer I’d rather put my money on cleaning up toxic chemicals from the environment than on adding a bunch of pink ribbons to our November trash piles or on painting pink ribbons on football fields while the NFL allows known rapists and batterers to play in the league.

Winners and Losers

When my mother became ill with and eventually died of breast cancer in 1971, no one talked about it – not even her close friends were present to offer aid or comfort. Yet, today, as we paint the town pink, I am concerned that we have come to see breast cancer as a relatively normal part of the female life course: puberty, pregnancy and childbirth, followed by menopause and breast cancer. Pushing against this cultural tide, I feel a need to yell: Breast cancer is not normal; nor is it pinkly feminine or cute. The rise in rates of breast cancer over the past century is a palpable sign that something is wrong with our world.

America loves winners, and we have come to regard women who are diagnosed with but do not die from breast cancer as heroic battlers. Those women who die are hidden, lying somewhere outside of the victory circle, “victims” in a culture that at best pities and at worst blames victims for their own misfortunes. It feels absurd to have to say this, but it needs to be said: Breast cancer can’t be cured by the optimism or will power or athleticism or fighting spirits or strength of character of women who are afflicted with the disease. Breast cancer should not be treated as a challenge or as a measure of one’s moral fiber.

And it should never, ever be treated as a commodity.

Big Bucks

Gayle A. Sulik draws attention to some disturbing implications of the ubiquitous pink ribbon. First, pink ribbon marketing, like all “cause marketing,” primarily benefits the company, not the charity or cause. Second, as a result of cause marketing, people actually give less to charities. And third, pink ribbon and other cause marketing can mask conflicts of interest, like when companies promote the idea of cancer research but also manufacture, disseminate, or sell products that contain toxic or carcinogenic ingredients.

timberland-komen-01

Over the past few years the failure of the pink ribbon movement was brought home to many of us when the Susan G. Komen for the Cure foundation, the most visible promoter of pink racing for the cure, announced that it would no longer fund breast cancer screenings at Planned Parenthood, the health care home for millions of young and low-wage women. This decision, believed to reflect the Komen’s Foundations’ capitulation to anti-choice advocates, was reversed when donations to the organization plummeted in response.

 

Where is the Evidence?

Victory laps in races for the cure, together with the ubiquitous pink ribbons, may lead people to believe that far greater strides have been made in preventing and treating breast cancer than have actually been made. In a 2014 article published in the New England Journal of Medicine, Nikola Biller-Andorno, M.D., Ph.D. and Peter Jüni, M.D. report that data show no evidence that routine mammography screening of women at average risk saves lives. A high-quality study made public by the Swiss Medical Board, “acknowledged that systematic mammography screening might prevent about one death attributed to breast cancer for every 1000 women screened, even though there was no evidence to suggest that overall mortality was affected.”

The NEJM article also cites research showing that many American women overestimate their personal risk of breast cancer and the benefits of mammograms. In a study of U.S. women’s perceptions, “717 of 1003 women (71.5%) said they believed that mammography reduced the risk of breast-cancer deaths by at least half.” Exacerbating the dangers, as a major Canadian study discovered, 21.9% of breast cancers found through mammography screening represented over-diagnoses. In other words, thousands of women each year undergo surgery, radiation and chemotherapy for non-life threatening cancers.

Breast Cancer Action, a national non-profit organization calling for transparency in breast cancer research, treatment and education, has these harsh words to say: “While corporations [such as manufacturers of mammography equipment] have made billions off the disease, progress in breast cancer treatment, prevention, survival, and inequities has not been forthcoming. Three million women in the U.S. are living with breast cancer. Up to one-third of all breast cancers will metastasize, even when found in the early stages. Black women are still 40% more likely to die of breast cancer than white women. And each year, 40,000 women die of breast cancer.”

We Can Do Better

PieChartWhile spending on breast cancer detection and treatment continues to increase, funding for prevention – for learning about the causes of breast cancer – is far less marketable. This year, in my home state, the Massachusetts legislature failed to fund research on potential carcinogenic impacts of chemical exposure despite clear findings that there are specific communities in Massachusetts with particularly high rates of breast cancer. According to reports, “The Massachusetts Senate [2015] budget … did not include a $500,000 request to fund water quality and public health research by Silent Spring Institute.  The Massachusetts Breast Cancer Coalition requested this funding on behalf of its sister organization, Silent Spring Institute to study exposure to toxic chemicals in drinking water and homes in Central Massachusetts and on Cape Cod. Earlier this month, the House of Representatives failed to approve funding for Silent Spring Institute in the FY 2015 House budget. This is the second year in a row that budget requests for important water quality research in both the House and Senate have been excluded.”

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Today, when I walked past the Massachusetts State House on my way to work and saw pink ribbons everywhere, women’s health pioneer Barbara Ehrenreich’s words came to mind. Writing about her own experiences with breast cancer, Ehrenreich wrote, “What sustained me through the ‘treatments’ is a purifying rage, a resolve, framed in the sleepless nights of chemotherapy, to see the last polluter, along with say, the last smug health insurance operator, strangled with the last pink ribbon.”

In honor and memory of my mother, Bernice C. Starr, let me say “Amen.”