Knoxville Town Hall: ACA – Repeal, Replace or Repair?

Town hall meetings have been in the news a great deal, recently. Congress is currently on recess and the custom has been to use the recess to meet with constituents in one forum or another, with the town hall being a popular format. As with the rise of the Tea Party several years ago, some of the recent such meetings have gotten emotionally intense. Some senators and representatives, including our own, have said they will not participate in the meetings because they are too confrontational and, thus, not productive.

Organized by a local non-partisan grassroots group in conjunction with the City of Knoxville, Tennessee Health Care Campaign and the League of Women Voters Knoxville/Knox County, the town hall meeting was originally the idea of Randy Kurth and his wife Barbara Nicodemus. Kurth is being treated for cancer and fears if regulations go back to pre-ACA standards, he will not be insurable. It’s a common kind of personal story which was heard throughout the evening.

Madeline Rogero introduced the event noting that she has joined a group of 136 mayors urging congress to build upon the successes of the Affordable Care Act, rather than dismantling it. Writing in a News Sentinel editorial last Sunday, she pointed out that just under 50,000 of our neighbors in the Knoxville area are covered by insurance through the Affordable Care Act. If it is lost, over half a million Tennesseans and around 20,000,000 Americans will lose their insurance. She also recognized the city council members and other officials who were present and said she would share the link to the recording of the meeting with our representatives who, “could not be here tonight.”

Senator Corker issued a statement supporting “repeal and replace,” and Representative Duncan echoed the sentiment. Senator Alexander, noting that Humana, the last provider in the plan for east Tennessee has announced they will withdraw at the end of this year, said, ” I have proposed immediate congressional and administrative action to rescue those trapped in the collapsing market. I regularly meet with Tennesseans in my offices to discuss the damage Obamacare has caused– including how it has increased premiums and deductibles and cut patients off from the doctors and hospitals they counted on– and how to replace it with more health care choices that cost less.”

The meeting featured a panel including Jerry Askew (Tennova Administrator), Carole Myers (UT College of Nursing) Michael Holtz (American Cancer Society Cancer Action Network), Matt Harris (UT Department of Economics), and Richard Henighan (TN Health Care Campaign). The audience was encouraged to write questions for the panel and many of these were read aloud for their response by moderator, Lori Tucker of WATE.

Major Rogero, Open Enrollment for the ACA, Knoxville, November 2015

After the mayor spoke and Lori explained the format, the panelists were give an opportunity to make opening remarks. Jerry Askew said a joke circulating says that congress will soon repeal Obama Care and replace it with the Affordable Care Act. He pointed out that Hillary Clinton proposed a form of universal health care in the 1990s and it was derided with the name “HillaryCare,” and the Republicans countered with a plan very much like the Affordable Care Act, down to and including the now much hated, “individual mandate.”

The individual mandate was discussed at some length through the evening as panelists explained you can’t have care that is only optional because only the sick will take it. The penalty for not getting insurance is so low that healthy people gambled and paid the penalty, figuring with no pre-existing clause, if they got seriously ill, they would get the insurance.

Matt Harris pointed out that, in general, we want to diversify our risk, as individuals. The U.S. system of having insurance offered through employers means that citizens insured that way lose not only their jobs, but their insurance if they lose employment, thus increasing risk. Our current structure, pre-ACA, he pointed out was not an open market, but employer based, which works well for people whose employer offers good insurance and for whom no job loss occurs. Even then, the ACA has allowed those employee’s children to stay on their insurance longer, removed lifetime and annual caps and pre-existing clauses.

Mr. Henighan also started with a joke summarizing his view of the current situation, saying it is analogous to a group of suited white men attempting to push an ambulance off a cliff, sentencing the medical workers and patient inside to certain death. The occupants of the ambulance protest that they only need a flat tire repaired. He also noted that in many supportive states – particularly those which agreed to expanded medicaid – continue to have multiple providers. Tennessee declined expanded medicaid, a move which Mr. Henighan’s group says has cost the state nearly three trillion dollars over the last three years.

In advocating a health care system in which, “those who need the most, get the most,” Carole Myers said there are only so many ways to approach the health care issue and that there will be winners and losers. She advocates a value-based approach, which is reflected in the Affordable Care Act and feels the market-based approach pursued in the proposed plans will hurt the poor and help the rich. Michael Holtz, himself a cancer survivor who would have been denied insurance in the past, added that cancer treatment is so expensive that if a system can take care of cancer patients, he feels that will work for everyone.

Open Enrollment for the ACA, Knoxville, November 2015

What followed were stories from some people directly impacted by the ACA. Randy Kerr got cancer and had to retire early. Now five years shy of Medicare eligibility he’s uncertain if he will be able to get insurance. He likely can’t afford the plans being offered because he would be relegated to one of the high risk pools which are being discussed and can’t afford the higher ratios being proposed for seniors.

Kristina McLean, also a cancer survivor, held her infant, Madeline, and said without ACA neither would likely be there and, if so, she would likely be bankrupt after complications in pregnancy forced her to be hospitalized for a month. She pointed to the gains women made under the legislation: Preventative care like pap smears must be covered, women are no longer charged more, pregnancy is no longer a pre-existing condition preventing insureability and the requirement of the law that pre-natal coverage be included in acceptable policies. She concluded by saying, “Health care is not a partisan issue, it is a human rights issue.”

Valerie (I didn’t catch her last name) spoke for she and her husband, south Knoxville residents. He has COPD and Rheumatoid arthritis and the “donut hole” in medicare was filled by the ACA. This allowed them to afford his medication which was reduced from $1201.97 per month to $54 per month. Their income would make paying the $1200 a month impossible, forcing them to choose between housing and medication. She also noted they can’t pay it through the year and wait for tax time to get a credit, nor do they have money to put into an H.S.A.

Melissa Nance works as a director for a local non-profit which cannot afford to offer insurance for its employees. She went five years without insurance, but gained it when the Affordable Care Act put it within her reach. A year later she was diagnosed with leukemia. Nine months of chemotherapy paid for by her insurance has her in remission, but she knows it will return. If the pre-existing clause isn’t kept, if the lifetime cap isn’t kept, she will not be able to get treatment. She also advocated for the Cancer Fairness Treatment Act which would allow oral chemotherapy to be covered just as is the case with intravenous chemotherapy. The new drug she will likely need is an oral medication costing $5,500 per month.

Carol Lee worked full time at a job which did not include insurance, but when her mother was diagnosed with Alzheimers, she was able to change to a more flexible job in order to help care for her mother and gained insurance through the ACA. Her daughter, who was a National Merit Scholar, was able to be covered because she was under twenty-six years old. When her daughter was diagnosed with anorexia, she was able to get four months of in-patient treatment which both mother and daughter say allowed her to survive. Still recovering, she gets counseling and support from a nutritionist and would likely lose that under all the current plans being floated in congress. Lifetime caps removal and mental health care are critical components in her situation.

The law and the issue are complex. Many questions were taken and each answer added nuance. WATE’s video of the town hall is posted above and I hope you’ll take the time to watch it. The group pointed out that Health Savings Accounts only work for people with money and that block grants are limited to a set amount of money and once that is gone for the year, there is no more care. Each of these are part of various plans being promoted. Only one of the four plans being promoted has any mental health component.

The group ended by pointing out that everyone will get some level of medical care. In our previous system, about 40,000,000 Americans had no insurance and, so, got no preventative care or early detection, but rather arrived in emergency rooms when their sickness was at its worst, prompting far more expensive care and worse outcomes. That cost, of course is passed on to those of us with insurance in the form of higher premiums as a result of hospitals passing on the charges. We pay more in the end.

If you’d like to express an opinion to our representatives before a decision is made, you are encouraged to call their offices. You aren’t likely to see them at a town hall meeting, which is unfortunate because, last night’s meeting as an example, these are our neighbors and they are very afraid of losing their insurance. I kept wishing that the representatives and senators had been there to hear the honest stories and questions. No signs, no shouting, just many worried people. Maybe they will watch the video.

Road Diets: What Are They? What Does a Good One Look Like?

 

The above video came across my Twitter feed recently and helped me understand road diets in various formats better than I’d ever understood them before. Several points stood out, no matter which of the four designs is under discussion: First, the lane widths are ten feet, which has no impact on travel times or traffic capacity, as opposed to twelve feet, and the reduction is shown to slow traffic (77% in one example) and reduce crashes (63% in the same example.)

Additionally, in every example, bike lanes of some sort are included. The cycle track, particularly caught my attention and, as noted in the video, it’s the one most likely to make non-cyclists cycle again because of the buffer afforded by the parked cars in the example. It was also instructive for me to notice that a single, one-direction bike lane included as a part of the project, though perhaps not a first choice, is still helpful if that is all that the space involved allows.

I also came across an article written by Subha Ranhan Banerjee and Ben Welle on the City Fix website entitled, “Bigger Isn’t Always Better: Narrow Traffic Lanes Make Cities Safer,” which makes the point the title indicates it would make. The site is globally networked, so the data was taken world-wide and you see the conclusions included in the excellent graphic below. To make your job easier, here are the conversion in feet for the four lane widths shown, left to right: #1: 8.5 to 9.1 feet, #2: 9.1 – 10.6 feet, #3: 10.6 – 11.8 feet and #4: 11.8 feet and up. As you can see, their conclusion based on fatalities per 100,000 is that the safest lane width is roughly 9 to 10.5 feet and the worst width for safety is about twelve feet and up.

Intuitively, for many of us, this seems illogical. Wider lanes should mean more room for error, fewer crashes and increased traffic capacity. The problems include: The wider the lane, the faster the speeds the cars travel. Wider lanes increase pedestrian risk as they have to travel farther to cross the streets. The authors point out that pedestrians struck by an automobile driving 30 mph have a ninety percent chance of survival. Raise that speed up to 50 mph and the survival chance drops to 15%.

The authors also echo the point from Jeff Speck’s examples above to state that traffic capacity is not reduced and congestion is generally due to traffic lights, not car speed. They note that it takes about 18 seconds longer to drive a kilometer at 30 mph than at 50 mph, which seems like a small sacrifice to ask drivers to make if it increases survival chances for pedestrians in crashes from 15% to 90%. It’s 18 seconds.

All of this put me in mind of our highest profile road diet: Cumberland Avenue. While the area is beyond that which I have included in this space, it really isn’t far from downtown. Perhaps the changes in form will make it seem more unified with downtown, whereas traditionally, the UT area and downtown have been considered separate entities.

Years in preparation, the Cumberland Avenue Corridor Plan is much more extensive than a simple re-striping of roads, of course. The project involves moving utilities underground, changing the codes for acceptable construction in an effort to make the strip more urban and less suburban. To that end, parking lots in front of businesses should largely disappear. More height in new construction has already begun to take shape. Sidewalks are being widened and street furniture and trees are being added.

The effort has the intention of making Cumberland feel like more of a destination and less a spot for traveling through. With the amenities added and the wider sidewalks, the stretch should be more appealing to pedestrians. With utilities and street-facing parking lots removed or hidden, the area will have a more upscale feel.

After focusing on the Jeff Speck video above and considering the article below, including the information contained in the graphic, I noticed, however, two obvious issues: There are no accommodations for cyclists and the lanes are twelve feet wide – the most dangerous width according to the articles above. Had the lanes been ten feet, four feet would have been gained. Several more feet would have been required for bike lanes and that footage appears to have gone to wider sidewalks and right-of-way concerns. I was told that given the inadequate footage for bike lanes, the vehicular lanes were made wider with the plan to have bikes and cars share the lanes.

There is no doubt that the Cumberland Avenue area will be safer for pedestrians because there will be fewer lanes. It will be more pleasant for pedestrians because the sidewalks will be wider and the buildings closer, as opposed to being fronted by parking lots. Still, it seems unfortunate that bike lanes could not have been added to an area which probably contains the most potential cyclists in the city. It’s also a concern that vehicular lanes would remain at 12 feet when everything I read suggests that is the least safe width.

You can read more about the plan and follow the progress of its implementation here. It is slated to reach or approach completion by the end of this year.

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