Calm
Calm is to operate without illusions
Securely between the dreams of childhood
and the lessons since.
Calm is to plan maturity for old age
and be patient for both.
Saturday, February 27, 2010
Calm
After spending the day Thursday watching the entire healthcare summit -- an exhausting but informative and useful exercise -- I felt a need for poetry; something simple and calming. Here goes.
Calm
Calm
Wednesday, February 17, 2010
Into the Wilds of Thailand
This is an excerpt from an email from my son, Roy, who works for a Bangkok based organization called The Freeland Foundation, whose mission is to prevent wildlife trafficking. Here he describes a recent trip to a national park in Thailand.
Been pretty busy with work, lots of fundraising to do at the moment - lots of writing. Last week, I got to go to the national park that we are focusing on now with one of our conservation experts. It was about a two and a half hour drive east from Bangkok, toward Cambodia where the plateau that separates the countries abruptly ends, creating a steep, mountainous landscape that is still well forested and now protected by a series of parks. Protected is a relative term of course - one of the parks, called Khao Yai, receives a lot of money and is thought of as a 'model park' by the Thai government. Unfortunately this isn't a good thing for wildlife – the park is full of tourists, the park managers easily take quite a bit of the extra money they get for themselves or to construct new bungalows and resorts to draw even more visitors; rangers become guides and shirk their real responsibility to actually patrol the park; poachers find that its really easy to go in and hunt; and the park has slowly become nothing more then a pretty forest. Next door to Khao Yai is the park, That Lan, that we are working in, which is not provided much funding at all. It’s a large area that has been forgotten and ignored by the government and tourists alike. Communists used to control the area in the 70's and kept the local population away, while the government encouraged resettlement of growing rural populations in other areas. These have been great for wildlife.
We drove into the park from the north on a dirt road that slowly vanished among the forest. The forest was thick and green - not exactly jungle, or at least what I would think of as jungle because trees here were not evergreen and branches were bare this time of year - but bamboo and other plants seemed to fill up all spaces. The reason for being there that day, besides having a look around, was to change the film in camera traps that were set up along the road and a little ways into the forest. Because of the nice path the road cut and the few people who actually used it, the road was actually a convenient highway for all the wildlife that lived around it. There are paths cut by wild elephants around all over the place, and those are handy as well, but the road presents them with a nicely graded path to the river. The camera traps have a movement sensor that sets them off whenever something passes by.
The story behind all this was that we were previously working in Khao Yai, the famous park next door. We were training rangers but getting frustrated by their disinterest in doing their jobs. We set up a program that would create a permanent training center there on a small budget. In the end, the managers there decided that they couldn't afford it and used the money to paint the bungalows or something. At the same time the manager for That Lan attended one of our training sessions and kept asking us to come visit his park, because they have wild tigers. Tim, the conservationist guy I was traveling with on my trip, had originally thought he was making stuff up to get money. There were no tigers found in Khao Yai in years, why would there be any in the ugly stepsister of a park next door? After subsequent pleadings from the That Lan manager though, he agreed to set up some of these camera traps. In one month (last October) they had identified 7 individual tigers who had walked in front of cameras that were only spread in a line about 3 km on the road. In addition, there were elephants, civits, leopards, wild dogs and huge amounts of wild pigs and deer (which tigers like to eat, as well as stray dogs). It was an amazing find - a forest that had no resources applied to it, that had been thought to be empty, and was just a few hours from the center of Bangkok turns out be one of the most intact ecosystems in South East Asia. Our focus has switched from Khao Yai to Tat Lan rather fast.
So we collected pictures and I learned about the forest. It was amazing how many animal tracks and signs were all around us. Tim is an expert at this stuff and pointed them out along the way. I didn't see any actual animals (they tend to get out of the way), but I did see tiger poop, elephant poop, assorted animal tracks, elephant wallows, places that wild pigs and elephants had scraped against. Oh, I saw what Tim called a 'jungle chicken'. I also saw a wild ginger.
So, one of my many missions now is to get us a little bit of funding to help support rangers in this place. The camera traps can be used to measure activity and density of wildlife throughout the park. More information about this, combined with GPS data (each trap location is mapped out on google maps using GPS data), helps rangers target their patrols where they are needed the most. This requires a little money to support the rangers, give them the equipment and show them how to use it. In a park like this, rangers are actually grateful for the help, unlike Khao Yai where they are annoyed they are wasting time when they could be raking in tourist dollars. It could work. The fact that there are tigers here is very good - tigers=money as the [recently attended] conference showed. Everyone loves the tigers (even the Chinese, who love to eat them). Yes, the Chinese year of the tiger has a lot to do with the push to save them too, but I think the last report I saw was that the last remaining Chinese tiger had been killed and eaten by a rural farmer. He had to pay a fine. China would tell you that they had hundreds of tigers - in farms though. Not the same thing.
Last weekend I went with Tom to see his Buddhist teacher. She was an impressive old Thai woman who I guess goes against the grain of most Thai Buddhists in that she is a woman monk, she doesn't believe that meditation is necessary and she doesn't believe that Buddha statues are necessary. She sort of quizzed me right away on what was reality, which was not what I was expecting and gave a few weak answers. I don't think I am any wiser but I guess I have a better idea about what Buddhism is about. There was another person who was there for the first time, although he went to a Buddhist center in San Francisco apparently. He had very hardened ideas about what Buddhism was all about (because as an American living in San Francisco, he's gotta be an expert) and took umbrage at a lot of what Tom and the teacher was saying about ritual and all this other gobblity-gook. At the end he turned to me and told me that 'I shouldn't get the wrong impression because this is NOT what Buddhism was about!' before he stomped off. Tom and I found that amusing. Seemed a little self-righteous for a Buddhist, but what do I know?
Not much else to report. I will be sure to read the Gladwell book [Outliers]. I'm in the middle of 'What the Dog Saw' which is a collection of his New Yorker articles, some of which I had read but not really known the author. He definitely has a unique perspective, I like how he is able to see connections between things that aren't on the surface similar, in order to somehow make his argument clearer. Usually, going out on those asides confuse things and are edited out, its got to be a rare talent that can do what he did. Wish I knew how to do that.
Monday, February 15, 2010
Republican "Healthcare"
Who needs death panels? People are dying of neglect.
Healthcare cost American’s two and a half trillion dollars a year. This is what 2.5 trillion dollars looks like: 2,500,000,000,000. That’s about $9,000 per American per year.
Have you noticed that just about every hospital in the country is expanding and hundreds of new “Medical Centers” are being built? One under construction just off of I-95 north of Trenton, NJ is being built at an estimated cost of $500 million, and another, less than 20 miles away near Princeton is being build with a similar price tag of $500 million. I liken these facilities to those inflatable sports arenas that depend on air compressors to keep them inflated – only in this case, we’ll be pumping in a constant stream of money. These facilities need to be staffed, cleaned, maintained, powered and heated forever. The more medical facilities we build, the higher the costs. Even in my small NH town, our local hospital has been expanding for over 10 years, with no end in sight. Clearly, the demand for services has grown – the question is, what’s driving the demand?
I used to think that healthcare was a finite resource, but given the unchecked growth in just one decade, I’m not so sure. I used to argue that, because it is a finite resource, decisions to spend money on, say, cosmetic surgery, would limit resources spent on more important medical care, like preventative care for children. But, as we spend more and more of our GDP on healthcare, and a growing part of that on boutique healthcare like “breast enhancement” – there’s actually a lobby demanding insurance coverage – I’ve become convinced that rational decision making has been overrun by a plethora of special interests. Of course, end-of-life care takes up the largest share of our healthcare dollar, but we’re a long way from dealing with that rationally, so I just as soon leave that subject for another day.
What has become clear is that our ability to fix problems, any problem, is hamstrung by competing interests in Washington. (Is this how civilizations fail; under the weight of competing, entrenched interests? Is this why China has been able to accomplish so much in such a short period of time – because they aren’t replacing anything, entrenched or otherwise; they’re building infrastructure from scratch?) Anyway, moving on…
Here are some suggestions that Republicans have made. A few are worth considering, with caveats.
People should pay. One Republican proposal that has currency is this: if people had to pay for their own healthcare and had insurance only to cover catastrophic expenses, they would more likely know how much healthcare cost. This knowledge would be all that would be needed to hold down costs. People would, the argument goes, seek out less expensive services and demand that doctors charge less. The “commonsense” simplicity of this idea is its attraction. However, in recent years, as insurance premiums have grown, families have been saddled with higher and higher deductibles and less and less coverage. It’s not unusual for group plans to have $1500 or $2000 deductibles. Yet there’s little evidence of pushback by patients. Why? While some people may be bold enough to negotiate prices or challenge their doctor’s fees, most people are less inclined. It takes a confident, well-educated patient to challenge his/her doctor. Most people are intimidated by their physicians. It’s not in their nature to challenge a doctor’s fees, much less the fees assessed by their hospital or health center. The more likely response is that people will avoid seeing a doctor and, worse, avoid taking their children for checkups, until a problem is serious and they end up in the emergency room. In fact, the effect of higher deductible is twofold; it discourages families from utilizing services and it increases insurance company profits. (Note: even for plans that increased deductible limits, premiums increased. And, Anthem Blue Cross in California just announced a 40% increase!) Most plans require co-payments of anywhere from $15 to $25. While that may not seem like much, to someone who is struggling financially, it’s enough to discourage irresponsible over-utilization of services.
While I don’t reject the need for people to be aware of the cost of care or of having to bear some of the responsibility for their healthcare, these aren’t a solution to escalating costs. We need to employ other mechanisms. But what?
I find it ironic that while Republicans complain that the bills in Congress do nothing to hold down costs – a debatable point – they’ve resisted remedies like comparative effectiveness research, which can provide doctors with information about the most cost-effective remedies, and they resist Medicare cuts. That they vigorously fought the establishment of Medicare in the 60s and now fight attempts to reduce its costs 50 years later is a puzzle, but there you have it.
Selling insurance in any state. The argument is that insurance companies ought to be able to sell policies in any state; that the increase in competition, especially in states with only a few plans available, would lower costs. Here’s the objection: Consider the recent history of credit cards. What has happened to that industry since federal law pre-empted state regulation? State usury laws were overturned, interest rates and fees escalated, credit card promotions to individuals least able to pay exploded, and so on. (“Hey kid -- want a credit card”?) OK, so the health insurance industry wants the same freedom. As was the case with credit card companies, insurance companies want to be able to establish headquarters in states with the fewest restrictions and offer insurance to other states, overriding local state regulations. If this were just one feature of a comprehensive healthcare bill that specified a reasonable floor of coverage nationwide, it might be acceptable. But that’s not what the Republicans are promoting. If the credit card analogy holds, a piecemeal approach that overrides states’ ability to write rules for their own citizens would result in less coverage and higher costs.
Malpractice reform. When asked on the PBS NewsHour what he thought healthcare reform should consist of, former congressman Dick Armey’s only suggestion was “malpractice reform”. That from the former Republican Majority Leader and now chairman of FreedomWorks. Malpractice reform. It’s hard to take Republican proposals seriously when virtually all lead with “malpractice reform”, as if this would miraculously provide coverage to 50 million (or more) Americans. That said, I think that some sort of malpractice reform to tamp down the most egregious lawsuits is worth considering, even if for purely political reasons. But, what are the details of the Republican proposal? According to the NY Times (2/14/10), “Republicans … are bent on capping damages for pain and suffering at $250,000 and generally want punitive damages capped at $500,000.” The NY Times doesn’t mention compensatory damages, which covers direct economic affects of an injury including such things as medical cost and loss of income. Assuming that the legislation is mute on compensatory damages, it seems to me there should be room for compromise here. Several states already set limits for pain and suffering and punitive damages. The question is, how have these affected doctors premiums and medicals costs generally, and, most important, are injured patients being treated fairly? Are the caps on punitive damages sufficient to serve as a deterrent? (Note that punitive damages are rarely applied, since, according to the website law.freeadvice.com, you have to prove “willful, wanton or malicious” actions by a physician.)
When contemplating award limits, several questions come to mind. 1) Do the limits only apply to doctors, or would they applied more broadly to medical facilities or drug and equipment manufacturers? 2) Wouldn’t a larger damage award be appropriate for these corporate entities? 3) Are there other ways to punish or fine a corporate entity for corporate malfeasants other than by rewarding the victim and his/her lawyer inordinately large amounts of money? 4) Instead, should larger punitive awards be applied to some kind of damage fund designed to improve healthcare generally? 5) Should limits be written with cost of living clauses? (Ans: Yes.)
So, yes, I can accept that some limits (and perhaps a less confrontational tort system) might be helpful to ameliorate doctor’s malpractice premiums; everyone’s legal fees; and unnecessary defensive medical practices, but the mechanism must put the welfare of the patient first. And, consider this question. With or without threat of malpractice, do doctors have a financial incentive for ordering tests? Many unnecessary procedures performed today are due to the fact that many doctors have a vested interest in the equipment used such as MRI, CATscan or robotic surgical systems, or in the services provided by outside vendors in which doctors have a ownership stake. Too often doctors order tests to boost equipment utilization and their own profits. In this case, so-called defensive medicine plays a minor role. And, might doctors refer you to another doctors because of finder’s fees or for mutual financial benefit, rather than to address a medical need? (I’ve had this happen to me.)
The reality is that we don’t have the answers to the malpractice conundrum. That’s why the healthcare legislation in Congress offers funding for states to experiment. That, it seems to me, is the sensible way to approach this problem. Even if it were determined that the savings from malpractice reform had a minimal effect – such as the 1% the GAO predicts – that’s still $50 billion a year. Experimental state programs may confirm or improve on these predicted savings. One can only hope.
Don’t touch my Medicare! As for Medicare savings, I think there’s a lot that could be done to cut costs there without undermining quality. My father relates the story that when his wife lie dying in a hospital, doctors would stick there head into the room (literally), ask how she was doing and then send a bill. He received many bills from doctors he didn’t know, frequently months later, amounting to tens of thousands of dollars. Medicare paid all of them. Admittedly this is anecdotal, but I’ve heard enough stories just like it to be reasonably certain this problem is epidemic. What better time to curb this kind of abuse then when expanding coverage? All of the physicians wandering around padding their bills will be needed to serve the millions of new healthcare customers. Here’s a chance to put them to work. A goal of $400 billion savings over 10 years when compared to the 50 trillion (do you want to see what that looks like? No?) is less than 1%! Why would Republicans object to provisions to curb Medicare abuse by 1% except to needlessly worry seniors and kill the bill?
Returning to the question of escalating costs, one reasonable objection to the bills now in Congress is that neither does enough to slow medical costs. I agree. They’re not devoid of remedies, but nobody can claim they’re comprehensive. But, the healthcare bills do greatly expand insurance coverage and make it more affordable, and that’s a good first step. No one disagrees that the cost question – “bending the curve” – is a tough one. That’s why the healthcare bills address this by promoting experimentation by the states. Replacing fee for service with a system that rewards physicians for keeping people healthy sounds promising, but we need to see how such as system works on a smaller scale before adopting it nationally. Meanwhile, there are millions of people desperately in need of care who aren’t receiving any services, fee-based or otherwise. They should be our first priority.
Another cost-cutting remedy that has gotten too little press is medical information technology. The rollout of medical information systems, some financed by the stimulus package, is our best opportunity to improve quality of care and reduce costs. The only thing standing in the way is grey haired docs – and all doctors need to be pressed to make it happen. But is a topic that is best discussed in a separate paper.
As President Obama sits down with Republican to debate healthcare next week, it’s important that we all have a clear understanding of what is being proposed by both sides. It’s our responsibility to press for solid answers, not sound bites. One thing that Republicans need to explain is this: Why is it that in 1993 Republicans were in favor most of the provisions now in the healthcare bills, but now are against them? And we’re not talking about different legislators; were talking about people like Orin Hatch and Chuck Grassley. In fact, the only real difference in the bills they sponsored in 1993 and the one before them now is that it included provisions for malpractice reform. Mark Pauley, one of the authors of that 1993 bill, recently voiced regret that Republicans have shifted their position (NPR website, 2/15/2010.) President Obama needs to press these Senators, in particular, for answers as to when and why they’ve changed their positions. Sadly, today politics depends on short memories.
Most Americans have recoiled at the legislative process, complaining about deals and concessions. Get over it. That’s how democracy works! David Brooks (NY Times) recently suggested on the PBS NewsHour that our government has become too transparent and that if it were more opaque, it would be easier to get things done in Washington. There may be wisdom in this, but another way to look at it is that maybe, just maybe, the long-term benefit of this new openness is that Americans are being educated and eventually will come to understand and accept how the system really works. Hmm. As I write that, I recall the recent Pew Research Poll that found that only 25% of Americans know that it takes 60 votes to pass a bill in the Senate and the just 27% knew that no Republicans voted for the healthcare bill. (Whatever happened to Olympia Snow?) When you add those finding to other measures of mass misconception (a.k.a. ignorance) – geography quiz anyone? – Well, maybe David’s right.
Printable version >>
Healthcare cost American’s two and a half trillion dollars a year. This is what 2.5 trillion dollars looks like: 2,500,000,000,000. That’s about $9,000 per American per year.
Have you noticed that just about every hospital in the country is expanding and hundreds of new “Medical Centers” are being built? One under construction just off of I-95 north of Trenton, NJ is being built at an estimated cost of $500 million, and another, less than 20 miles away near Princeton is being build with a similar price tag of $500 million. I liken these facilities to those inflatable sports arenas that depend on air compressors to keep them inflated – only in this case, we’ll be pumping in a constant stream of money. These facilities need to be staffed, cleaned, maintained, powered and heated forever. The more medical facilities we build, the higher the costs. Even in my small NH town, our local hospital has been expanding for over 10 years, with no end in sight. Clearly, the demand for services has grown – the question is, what’s driving the demand?
I used to think that healthcare was a finite resource, but given the unchecked growth in just one decade, I’m not so sure. I used to argue that, because it is a finite resource, decisions to spend money on, say, cosmetic surgery, would limit resources spent on more important medical care, like preventative care for children. But, as we spend more and more of our GDP on healthcare, and a growing part of that on boutique healthcare like “breast enhancement” – there’s actually a lobby demanding insurance coverage – I’ve become convinced that rational decision making has been overrun by a plethora of special interests. Of course, end-of-life care takes up the largest share of our healthcare dollar, but we’re a long way from dealing with that rationally, so I just as soon leave that subject for another day.
What has become clear is that our ability to fix problems, any problem, is hamstrung by competing interests in Washington. (Is this how civilizations fail; under the weight of competing, entrenched interests? Is this why China has been able to accomplish so much in such a short period of time – because they aren’t replacing anything, entrenched or otherwise; they’re building infrastructure from scratch?) Anyway, moving on…
Here are some suggestions that Republicans have made. A few are worth considering, with caveats.
People should pay. One Republican proposal that has currency is this: if people had to pay for their own healthcare and had insurance only to cover catastrophic expenses, they would more likely know how much healthcare cost. This knowledge would be all that would be needed to hold down costs. People would, the argument goes, seek out less expensive services and demand that doctors charge less. The “commonsense” simplicity of this idea is its attraction. However, in recent years, as insurance premiums have grown, families have been saddled with higher and higher deductibles and less and less coverage. It’s not unusual for group plans to have $1500 or $2000 deductibles. Yet there’s little evidence of pushback by patients. Why? While some people may be bold enough to negotiate prices or challenge their doctor’s fees, most people are less inclined. It takes a confident, well-educated patient to challenge his/her doctor. Most people are intimidated by their physicians. It’s not in their nature to challenge a doctor’s fees, much less the fees assessed by their hospital or health center. The more likely response is that people will avoid seeing a doctor and, worse, avoid taking their children for checkups, until a problem is serious and they end up in the emergency room. In fact, the effect of higher deductible is twofold; it discourages families from utilizing services and it increases insurance company profits. (Note: even for plans that increased deductible limits, premiums increased. And, Anthem Blue Cross in California just announced a 40% increase!) Most plans require co-payments of anywhere from $15 to $25. While that may not seem like much, to someone who is struggling financially, it’s enough to discourage irresponsible over-utilization of services.
While I don’t reject the need for people to be aware of the cost of care or of having to bear some of the responsibility for their healthcare, these aren’t a solution to escalating costs. We need to employ other mechanisms. But what?
I find it ironic that while Republicans complain that the bills in Congress do nothing to hold down costs – a debatable point – they’ve resisted remedies like comparative effectiveness research, which can provide doctors with information about the most cost-effective remedies, and they resist Medicare cuts. That they vigorously fought the establishment of Medicare in the 60s and now fight attempts to reduce its costs 50 years later is a puzzle, but there you have it.
Selling insurance in any state. The argument is that insurance companies ought to be able to sell policies in any state; that the increase in competition, especially in states with only a few plans available, would lower costs. Here’s the objection: Consider the recent history of credit cards. What has happened to that industry since federal law pre-empted state regulation? State usury laws were overturned, interest rates and fees escalated, credit card promotions to individuals least able to pay exploded, and so on. (“Hey kid -- want a credit card”?) OK, so the health insurance industry wants the same freedom. As was the case with credit card companies, insurance companies want to be able to establish headquarters in states with the fewest restrictions and offer insurance to other states, overriding local state regulations. If this were just one feature of a comprehensive healthcare bill that specified a reasonable floor of coverage nationwide, it might be acceptable. But that’s not what the Republicans are promoting. If the credit card analogy holds, a piecemeal approach that overrides states’ ability to write rules for their own citizens would result in less coverage and higher costs.
Malpractice reform. When asked on the PBS NewsHour what he thought healthcare reform should consist of, former congressman Dick Armey’s only suggestion was “malpractice reform”. That from the former Republican Majority Leader and now chairman of FreedomWorks. Malpractice reform. It’s hard to take Republican proposals seriously when virtually all lead with “malpractice reform”, as if this would miraculously provide coverage to 50 million (or more) Americans. That said, I think that some sort of malpractice reform to tamp down the most egregious lawsuits is worth considering, even if for purely political reasons. But, what are the details of the Republican proposal? According to the NY Times (2/14/10), “Republicans … are bent on capping damages for pain and suffering at $250,000 and generally want punitive damages capped at $500,000.” The NY Times doesn’t mention compensatory damages, which covers direct economic affects of an injury including such things as medical cost and loss of income. Assuming that the legislation is mute on compensatory damages, it seems to me there should be room for compromise here. Several states already set limits for pain and suffering and punitive damages. The question is, how have these affected doctors premiums and medicals costs generally, and, most important, are injured patients being treated fairly? Are the caps on punitive damages sufficient to serve as a deterrent? (Note that punitive damages are rarely applied, since, according to the website law.freeadvice.com, you have to prove “willful, wanton or malicious” actions by a physician.)
When contemplating award limits, several questions come to mind. 1) Do the limits only apply to doctors, or would they applied more broadly to medical facilities or drug and equipment manufacturers? 2) Wouldn’t a larger damage award be appropriate for these corporate entities? 3) Are there other ways to punish or fine a corporate entity for corporate malfeasants other than by rewarding the victim and his/her lawyer inordinately large amounts of money? 4) Instead, should larger punitive awards be applied to some kind of damage fund designed to improve healthcare generally? 5) Should limits be written with cost of living clauses? (Ans: Yes.)
So, yes, I can accept that some limits (and perhaps a less confrontational tort system) might be helpful to ameliorate doctor’s malpractice premiums; everyone’s legal fees; and unnecessary defensive medical practices, but the mechanism must put the welfare of the patient first. And, consider this question. With or without threat of malpractice, do doctors have a financial incentive for ordering tests? Many unnecessary procedures performed today are due to the fact that many doctors have a vested interest in the equipment used such as MRI, CATscan or robotic surgical systems, or in the services provided by outside vendors in which doctors have a ownership stake. Too often doctors order tests to boost equipment utilization and their own profits. In this case, so-called defensive medicine plays a minor role. And, might doctors refer you to another doctors because of finder’s fees or for mutual financial benefit, rather than to address a medical need? (I’ve had this happen to me.)
The reality is that we don’t have the answers to the malpractice conundrum. That’s why the healthcare legislation in Congress offers funding for states to experiment. That, it seems to me, is the sensible way to approach this problem. Even if it were determined that the savings from malpractice reform had a minimal effect – such as the 1% the GAO predicts – that’s still $50 billion a year. Experimental state programs may confirm or improve on these predicted savings. One can only hope.
Don’t touch my Medicare! As for Medicare savings, I think there’s a lot that could be done to cut costs there without undermining quality. My father relates the story that when his wife lie dying in a hospital, doctors would stick there head into the room (literally), ask how she was doing and then send a bill. He received many bills from doctors he didn’t know, frequently months later, amounting to tens of thousands of dollars. Medicare paid all of them. Admittedly this is anecdotal, but I’ve heard enough stories just like it to be reasonably certain this problem is epidemic. What better time to curb this kind of abuse then when expanding coverage? All of the physicians wandering around padding their bills will be needed to serve the millions of new healthcare customers. Here’s a chance to put them to work. A goal of $400 billion savings over 10 years when compared to the 50 trillion (do you want to see what that looks like? No?) is less than 1%! Why would Republicans object to provisions to curb Medicare abuse by 1% except to needlessly worry seniors and kill the bill?
Returning to the question of escalating costs, one reasonable objection to the bills now in Congress is that neither does enough to slow medical costs. I agree. They’re not devoid of remedies, but nobody can claim they’re comprehensive. But, the healthcare bills do greatly expand insurance coverage and make it more affordable, and that’s a good first step. No one disagrees that the cost question – “bending the curve” – is a tough one. That’s why the healthcare bills address this by promoting experimentation by the states. Replacing fee for service with a system that rewards physicians for keeping people healthy sounds promising, but we need to see how such as system works on a smaller scale before adopting it nationally. Meanwhile, there are millions of people desperately in need of care who aren’t receiving any services, fee-based or otherwise. They should be our first priority.
Another cost-cutting remedy that has gotten too little press is medical information technology. The rollout of medical information systems, some financed by the stimulus package, is our best opportunity to improve quality of care and reduce costs. The only thing standing in the way is grey haired docs – and all doctors need to be pressed to make it happen. But is a topic that is best discussed in a separate paper.
As President Obama sits down with Republican to debate healthcare next week, it’s important that we all have a clear understanding of what is being proposed by both sides. It’s our responsibility to press for solid answers, not sound bites. One thing that Republicans need to explain is this: Why is it that in 1993 Republicans were in favor most of the provisions now in the healthcare bills, but now are against them? And we’re not talking about different legislators; were talking about people like Orin Hatch and Chuck Grassley. In fact, the only real difference in the bills they sponsored in 1993 and the one before them now is that it included provisions for malpractice reform. Mark Pauley, one of the authors of that 1993 bill, recently voiced regret that Republicans have shifted their position (NPR website, 2/15/2010.) President Obama needs to press these Senators, in particular, for answers as to when and why they’ve changed their positions. Sadly, today politics depends on short memories.
Most Americans have recoiled at the legislative process, complaining about deals and concessions. Get over it. That’s how democracy works! David Brooks (NY Times) recently suggested on the PBS NewsHour that our government has become too transparent and that if it were more opaque, it would be easier to get things done in Washington. There may be wisdom in this, but another way to look at it is that maybe, just maybe, the long-term benefit of this new openness is that Americans are being educated and eventually will come to understand and accept how the system really works. Hmm. As I write that, I recall the recent Pew Research Poll that found that only 25% of Americans know that it takes 60 votes to pass a bill in the Senate and the just 27% knew that no Republicans voted for the healthcare bill. (Whatever happened to Olympia Snow?) When you add those finding to other measures of mass misconception (a.k.a. ignorance) – geography quiz anyone? – Well, maybe David’s right.
Printable version >>
Sunday, February 14, 2010
Poetry Inside
There’s poetry in each of us
Buried deep by life’s distractions,
which accumulate
like thick-witted plaster
densely layered and papered over;
poetry residing at our core
obscured by self-delusion;
those dreams we honor
like hollowed-out rituals
in which we’ve stopped believing.
Sometimes life’s jarring dislocations
-- its jagged edges --
rents the paper, blisters the paint,
revealing something ethereal
exposed like a frayed wire
electrifying the source,
the poetry in each of us,
– call it inspiration –
compelling us to speak plainly
of death, of hurt
and suffocation,
and sometimes
of birth,
of love,
or even profoundly simple things,
like words
of affection
that give us pleasure.
Friday, February 5, 2010
Save Us From Ourselves
If people only had been able to borrow what they could afford, would we have had a housing bubble and the ensuing “Great Recession?” Is the problem that banks are too big to fail? Should we blame the Fed for keeping interest rates too low for too long? Or is the problem that subprime, NINJA mortgages (No Income, No Job or Assets) were marketed with abandon to starry-eyed Americans addicted to “Flip This House?”
Paul Krugman (NY Times, Op-Ed, 2/1/2010) points out that there are only six major banks in Canada. Nevertheless, Canada weathered the financial storm quite well. And yes, throughout the last decade, Canada’s interest rates tracked closely to ours. But, what Canada has that we don’t is a financial consumer agency that blocked the industry’s slide towards irresponsible lending practices. In Canada, banks are required to maintain “skin in the game” – that is, to hold on to some portion of their loan portfolios rather than pass them on to be “securitized” by Wall Street. If adopted by the US, this one requirement alone could be the keystone needed to prevent a future housing bubble and collapse.
The seismic failure that caused the Great Recession was a failure to make prudent mortgage and commercial loan decisions. This was the quicksand upon which everything else rested and the entire economy got sucked under. Establishing a financial consumer agency is the most important remedy we can adopt to ensure future stability and regain confidence in the markets. Yes, there are other things could and should be done, but let’s start at the foundation. If the loans written over the last decade had been sound, would all the speculation have made any difference? If you agree that the house of cards came tumbling down because it was erected on a seismic fault-line called imprudence, than we’re all to blame. Now let’s fix it.
Paul Krugman (NY Times, Op-Ed, 2/1/2010) points out that there are only six major banks in Canada. Nevertheless, Canada weathered the financial storm quite well. And yes, throughout the last decade, Canada’s interest rates tracked closely to ours. But, what Canada has that we don’t is a financial consumer agency that blocked the industry’s slide towards irresponsible lending practices. In Canada, banks are required to maintain “skin in the game” – that is, to hold on to some portion of their loan portfolios rather than pass them on to be “securitized” by Wall Street. If adopted by the US, this one requirement alone could be the keystone needed to prevent a future housing bubble and collapse.
The seismic failure that caused the Great Recession was a failure to make prudent mortgage and commercial loan decisions. This was the quicksand upon which everything else rested and the entire economy got sucked under. Establishing a financial consumer agency is the most important remedy we can adopt to ensure future stability and regain confidence in the markets. Yes, there are other things could and should be done, but let’s start at the foundation. If the loans written over the last decade had been sound, would all the speculation have made any difference? If you agree that the house of cards came tumbling down because it was erected on a seismic fault-line called imprudence, than we’re all to blame. Now let’s fix it.
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