Political Science 317
Study Guide #1
Mama Might Be Better Off Dead
This is a troubling, at times appalling, study of one family’s interaction with the American health
care system. You should keep in mind as you read this book that this study is intended to
document the weaknesses in the American health care system, and you should remember that the
system also has strengths. We could, I suppose, also read a book about how well the American
health care system works for, say, an affluent highly educated family, but I believe that is
unnecessary, since many Wellesley students are quite familiar with the “good side” of American
health care—its endless innovations, sophisticated technology, and high standards of treatment.
The other side, the health care system used by the less fortunate, is less visible to many.
My purpose in assigning this book is not to get your blood boiling (though that may be useful
too), but to introduce you to some basic facts about how health care is delivered in the United
States. You will use the book to learn the basics of Medicare, Medicaid, SSI and health care
finance. One point I hope you will see is how incredibly fragmented and complex these
programs are, even to us reading about them in a book. Imagine yourself as a sick, poor, less
educated person trying to navigate the complicated bureaucratic rules in these programs, as
Jackie Banes does in the book, and you get a sense of the consequences of the way the United
States organizes health care finance and delivery. For the rest of the course we will have a “top-
down” view of American health policy, as we study the elites (elected officials, interest groups,
academics) who make health policy, but I hope you will always keep in mind the “bottom-up”
story that is told here—and that all the policies and politics we examine has life or death
consequences for real people.
After you read each section of the book you should be able to answer the following questions:
Coverage Issues (pages 1-59)
What is Medicaid? What is Medicare? How do they differ? Who in the family uses which
program? (That’s a much more complex question than you might think at first!)
Why didn’t Robert get treatment for his kidney condition before it became life threatening?
(Again a more complex question than you might think.)
How is Robert’s dialysis paid for?
Why is Highland Park’s dialysis unit more posh than the one Robert uses?
What are “DRG’s”? How do they affect the care given to Mrs. Jackson?
What kinds of medical care aren’t paid by Medicare? If Medicare won’t pay for Mrs. Jackson’s
care, where can she get coverage?
What is a “Medicaid spend-down”?
How does coverage vary depending on whether you are receiving standard Social Security, as
Mrs. Jackson does, or SSI (Suplementary Security Income) as Tommy Markham does?
According to the author, what are the consequences of a “patchwork” system of coverage like the
one in the United States?
Why was it important for Mrs. Jackson to be considered “disabled”?
If you know anything about the new prescription drug law recently signed into law by President
Bush, how would this law have helped Mrs. Jackson and her family?
Consider the following statements:
“In a just society, everyone would receive exactly the same level of health care coverage. Health
care is a basic human right and you should not get more or less depending on your ability to pay
“Forcing everyone into the same health care system violates basic American values. We don’t
provide everyone with the same house, or the same college education, why would we provide the
same level of health care? Such a system would deter innovation, encourage mediocrity, and put
government bureaucrats in the business of deciding whether you deserve medical treatment.”
What arguments can be made for either side?
Health Care Organization (60-133)
Why did Mrs. Jackson sometimes miss appointments with her primary physician?
If Medicare serves everyone over 65, why do minorities and the poor seem to get worse care?
(Again, a complicated question.)
Why did Mrs. Jackson get Coumadin poisoning?
Imagine Mrs. Jackson as an upper-class retiree, maybe a retired Wellesley professor. How do
you think her medical story might be different? If you had to explain the poor outcomes of Mrs.
Jackson’s medical treatments, how would you do it? (To what extent is Mrs. Jackson herself
Why is the rehabilitation center that Mrs. Jackson goes to more profitable than the hospital?
How is Medicare biased toward “in-patient” psychological care?
Why do emergency rooms get used for routine care?
How are emergency rooms like the one the Banes family uses funded?
Why is Mt. Sinai Hospital in such bad financial shape? How has it survived?
What is “demarketing”? How is it used? What are its consequences?
Based on this section of the book, suggest one reform to improve the American health care
system. What is the best argument against your proposed reform? What factors might affect its
political feasibility? (Who would oppose it?)
Who is responsible for Tommy Markham’s health?
Why was Mrs. Jackson’s home care so limited?
Medicaid covers nursing home care for everyone who “spends down,” and many middle-class
people use this strategy successfully. Why then do many poor African-Americans have trouble
getting into a nursing home?
Jackie had the chance to be paid for caring for her mother. Why didn’t she sign up for it?
Why didn’t Brianna get her measles vaccination?
What is “the original sin of American health policy”?
Why isn’t most Medicaid money spent on poor children? Who does it go to?
Why does being poor affect your chances of getting a transplant?
Why did whites in Illinois receive transplants at higher rates than blacks?
Consider the following statements:
“Although I sympathize with the Banes family, the truth is that most of their health problems are
the result of bad choices they have made—poor diets, bad habits, not following doctor’s
directions, not seeking medical treatment even when it was free. We could spend a lot of money
treating all the problems that result, but I would rather spend the money promoting healthy life
choices. Let’s use all that money on prevention and provide incentives and education to
convince them to improve their health choices, rather than wasting money on treatments for
diseases they never would have gotten if they had lived better.”
To what extent do you agree? According to the account in this book, do poor families like the
Banes have bad health because of flaws in the American health care system, or because they
simply make bad health choices?
Why do some blacks distrust white doctors? Why does Tommy Markham distrust his doctor?
Mrs. Jackson received extremely expensive high technology care at the end of her life. Why was
so much spent on her in the last three months of her life compared to previous years?
According to the author, how does the American health care system compare to the systems of
Canada and Great Britain?
According to the author, what changes in Medicaid might affect children like Brianna?
What reforms to the American health care system does the author recommend?
Looking back over this story, what lessons do you draw about the American health care system?
Why do you think the system is at it is? How would you change it, if you were queen?