The Economist - USA (2020-02-22)

32 United States The EconomistFebruary 22nd 2020

P

eopleoftenslowdowntobopas

theypassDonaldCampbell’smobile-

phoneshopinShaw,a neighbourhoodin

Washington,dc. Until7pmeveryday

speakersoutsideblastGo-Go,a drum-

basedfusionoffunk,r&bandsoulthatis

indigenoustothecity.Inanareathatwas

oncedottedwithGo-Goclubs,severalof

themownedbyMrCampbell,thisisone

ofthelastpublicplacesthemusicis

playedregularly.It isalsothesceneofa

rowthathasforceda reckoningonhow

gentrificationiserodingthecultureofa

onceblack-majoritycity.

Lastspringresidentsofa glossynew

apartmentblock,mostlyinhabitedby

young,whitenewcomerstothearea,

complainedabouttheracket.T-Mobile,

whichownstheshop,askedMrCampbell

toturnit off,whichhedid.Thatun-

leasheda torrentofangerfromAfrican-

AmericansacrossWashington.There

werelargestreetprotestsatwhichGo-Go

bandsplayed,a #DontMuteDCsocial-

mediacampaignandanonlinepetition.

Aftera fewdaysofthisJohnLegere,

T-Mobile’sboss,tweetedthat“themusic

shouldnotstopind.c.” MrCampbell

turnedit backon.

DontMuteDChassincemorphedinto

a widerprotestmovementagainstgen-

trification,withGo-Goitssymbol.

Createdinthe1970sbyChuckBrown,

whose“Bustin’Loose”wasforyearsthe

WashingtonNationals’home-runcele-

brationsong,Go-Gowasthelastflourish

ofa black-majoritycity’svibrantmusical

culture.Shaw wasatitscentre.Bythe

1980s,Go-Gobandsplayedeverynightin

theneighbourhoodandbeyond.

Go-Go’sdeclinebeganthefollowing

decadewhen,inanefforttocurbvio-

lence,thecityforcedclubstocloseearli-

erandtostopservingalcohol.Around

thesametimeblacksbeganmovingout

totheMarylandsuburbs.Gentrification

hasacceleratedthatprocess.By 2015 the

proportionofblackWashingtonianshad

droppedbelow50%forthefirsttime

sincethe1950s.

Thesechangeshaveparticularly

harmedGo-Gobecauseit wascreatedto

beexperiencedlive.Itscharacteristics

includecall-and-response,whichturns

theaudienceintopartoftheperfor-

mance,andtheuseofpercussivesolos

insteadofpausesbetweensongs—which

ishowGo-Gogotitsname.Thatmakes

themusicunsuitableforradioorthree-

minutehits.Withoutlivevenues,a new

generationhadmostlygivenit a miss.

That,saysMrCampbell,haschanged

sincelastyear’sprotests.Heisdevel-

opinganinternetstreamingservicefor

hishugecollectionofliverecordings.A

Go-Gomuseumisintheworksandthis

weekdcCouncildeclaredGo-Gothe

city’s“officialmusic”.Thoughit isnot

clearquitewhatthatwillentail,it seems

likelytoinvolvetourists.Theeffortsto

preserveGo-Gomayendupgentrifyinga

formofmusicthatwascreatedtobe

anythingbut.

A noGo-Goarea

GentrificationinWashington,DC

Thecapital’sdecliningblackpopulationfightstopreserveitsmusicalheritage

Missinga beat

I

n 1971, anunemployed salesman named

Shep Glazer upended the typically som-

nolent hearings of the House Ways and

Means Committee by giving a live demon-

stration of dialysis before aghast congress-

men. The shock seemed to pay off. Mr Glaz-

er’s goal—to ensure that all patients reliant

on blood-filtering dialysis machines, be-

cause of failing kidneys, would be covered

by a then-newfangled programme called

Medicare, the government health-insur-

ance scheme for the elderly, regardless of

age—soon became law. Through the new

end-stage renal disease (esrd) pro-

gramme, Medicare for All became a reality

for a certain portion of the sick, and has re-

mained so for nearly 50 years.

What seemed like a small exemption

then has morphed into something much

larger. Originally designed to cover 10,000

patients, the esrd programme now in-

cludes 512,000. Dialysis is expensive: a

machine must filter out toxins and excess

fluids from the blood, often for several

hours a day and several times per week. It is

a life-or-death treatment. Still, two-thirds

of patients with esrddie within five years.

A year of treatment in a specialised centre

costs $91,000. The small programme

created in the 1970s now costs over $35bn,

or roughly 6% of all Medicare spending.

Much of this is due simply to rising

need. Diabetes and high blood pressure,

which have been rising, are precursors of

chronic kidney disease. Because Medicare

sets prices, costs for dialysis have grown

more slowly than for other health-care pro-

cedures. The operation of dialysis centres

has nonetheless become brisk business (in

part because private-insurance companies

pay more). A near-duopoly controls 70% of

the market, earning net profits of 18%.

For many patients a kidney transplant is

a much better option than several years of

dialysis before death—life expectancy is

much longer, and that life is of higher qual-

ity. It also saves money for the taxpayer,

notes Mario Macis of Johns Hopkins Uni-

versity. “The math is such that every kidney

transplant generates savings for Medicare

of about $150,000,” says Mr Macis.

The problem is that there are almost

100,000 people on the waiting list, and the

typical waiting time is more than four

years, meaning thousands die before their

turn. Incentivising organ donations is

morally fraught. But at present, there are

strong disincentives to living organ dona-

tions. Though there is no medical bill for

giving up a kidney, costs for transport,

lodging and lost wages during recovery are

not reimbursed. For three-quarters of pros-

pective donors, these can amount to one

month of income. Research from Mr Macis

and two colleagues shows that Americans

are much more keen on reimbursement if

it is offered by a public agency—as opposed

to direct purchase—and if it meaningfully

increases the supply of organs.

The curious case of the kidney gives a

few insights into the larger workings of the

American health-care system. Small, fos-

silised provisions morph into huge pro-

grammes decades later. Government influ-

ence over prices may limit overall growth

in costs, but can coincide with abnormally

high profits for a few operators. And com-

paratively clear ideas for reducing billions

in costs while improving thousands of

lives can go ignored for years.^7

NEW YORK

A quirk in the law means that a kidney

shortage costs taxpayers billions

Medicine and the law

Kidney failure