14 October 2013

Yeah, Right, "Affordable" Care - Wow, Are We Ever Dumb

I don’t get writings from my beloved brother Rev. Jim Norton very often. When I do, I read them very closely because whether I agree with Jim or not, he has a gift for speaking forcefully yet kindly and always logically.

I got an e-mail today which he sent to his voluminous e-mail list. It had a letter to him from “our” Congressional Representative, David McKinley, and Jim’s thoughtful reply.

The subject: The Affordable Care Act. I will not call it JonesCare, SmithCare, or even YouKnowWhoCare. Let’s show a little dignity for a change.

Rep. McKinley’s letter starts out:

“Thank you for contacting me about the Affordable Care Act, also known as *****care. I appreciate hearing from you on this important issue.”

Fortunately, we can be fairly confident that the Representative never saw the letter and has never heard of Jim. I also sincerely hope that the Representative had little or no part in writing the policy statements in the letter. It doesn’t bother me what he was saying, since he’s a Republican and toes the party line.  It’s just it was so damn dull.

Well, Norton is a regular reader of these Dispatches and perhaps he will choose to tag them with his text. It is not for me to quote him and besides I’m heading off on a slightly different tangent.

The Affordable Care Act is a massive tax scheme which no Representative actually read before voting on it.  The ACA was a dream come true for lobbyists, the insurance industry, consultants, lawyers, accountants, actuaries and lots of other people who make their way in the world in the non-care aspects of the medical industry.  I hardly blame the consultants, accountants, actuaries or most of the lawyers – They have been handed an impossible mess with instructions to make it work.

No system of healthcare will work until we can answer the following questions. If we cannot answer these questions, we do not have a system of healthcare. We have a system of commercial transactions where some people happen to get medical care.

The questions are:

1 - Who gets care?

2 - What care does what patient get?

3 - Who pays for that care?

4 - How much does the provider of the care get paid for the care?

Until you can answer those questions, this is a meaningless discussion. Moreover, these questions are apolitical. You can design a system that is very “conservative,” or very “liberal,” or even very innovative.

(Incidentally, the terms “conservative” and “liberal” historically are economic categories that have now been made into cartoons.)

So let’s look at some scenarios:

A - Grandma is 85. She has had a stroke and is in an ICU. She is on a vent. She has some minimal response to external stimuli such as following things with her eyes and feebly squeezing on command with one hand. Every physician who has looked at her believes that she has about a month to live, but will never come off the vent.  The current sticker price for an ICU bed is about $3000 a day.  With the negotiating power of some sort of huge payors, let’s dial that back to $2,000.  Grandma has left no advance directives.

Does she get the $60,000 worth of care?

B - John is an undocumented visitor/illegal alien from North Elbonia. He has been in the United States for 20 years working under the table. He has no savings and no health insurance. He shows up at emergency department with symptoms that are typical of a heart attack.  The cost of hospital care is all over the map, but $15,000 is a reasonable price for a modest little hospital.

Decide. Is John in or out? It’s no longer a political question, it’s a guy.

C - Edna has cancer of the funny bone. It’s a real bad thing to have and statistically 5 in 100 patients survive more than one year.  Wegottumgooddrug Labs develops the Supercalifragelistic injection.  One injection increases the one-year survival rate to 10 in 100 patients. It cost $250,000.  Edna is 75. Does she get it?

Okay, Edna is 60. What now?



Oh my God, rationing healthcare!

Oopsie, we’ve been doing that since the first Medicine Woman found the first medicinal root. Why do you think Dick Cheney is about the only 70-year-old who have gotten a heart transplant in the last decade? (I like Dick Cheney, by the way.)

D - Mary is a really great specialized surgeon.  Unionburg General Hospital wants to hire her.  In her field, the “market” price is $600,000 per year.  Because she is exceptional, the hospital wants to pay her a cool million.  Then, they will use that to justify a rate increase request that somebody has to pay for.  UGH is a not-for-profit hospital with a self-perpetuating Board of Directors.

Does “Government” interfere with the hiring decision by holding back the money?

I have opinions about these things. For today’s discussion, they are not relevant. 

What is relevant is that we need to find the courage to have the discussion.

05 October 2013

Stream of Consciousness, Sissies in Congress and Other Ruminations

I will say that it is my normal policy to write things which I think are to the point, to the extent that I ever get to the point. And I write things with some forethought.  OK, I try.

On occasion, I just sit back and let my mind talk through my typing fingers, without much clue where I’m going.  These occasions occur often after some hiatus in my writing.

This is such an occasion.

Now and then, I get wry comments about the little sting of things I say or about the fact that some of my thoughts and approaches are unconventional. And that’s okay with me. I know that young people, especially young lawyers, generally are careful about what they put into a public record. How many times do we see in the news that some unguarded comment has come back and bitten the person who made it?

Mostly, this is more a weakness of those making the objections than those making the comments. If the Marketplace of Ideas is to have any validity at all, it has to be honest.

Some years ago, I just quit caring very much about who might agree or disagree with my opinions. That was a remarkable liberation. That was a remarkable release. Then, I could edit myself for grammar, readability and logic without worrying whether the honesty annoyed anyone. Maybe that has a downside to others, but I enjoy it.

There came a time I was seeking an open judicial seat.  Part of the application process was to attach all of my public writings. Honestly, I got a kick out of that. With this blog and its predecessor, and with several newspaper or magazine columns and articles running back 30 years, such a package would have been several hundred pages long. So I attached the hard-to-find stuff, attached some of my blog posts which were more relevant, and invited the appointing authority to stroll through my other writings however it wanted. As I looked back upon them, I found comments on blogs about lots and lots of social issues and about the illogic of of lots of social processes, including that of selecting judges.

By the way, I don’t believe that had anything to do with the fact that somebody else was selected for the judgeship. The guy selected was eminently qualified and came from a field of other eminently qualified contenders.

So when I look for turns of phrase or “the right word,” I’m really not worried about having the right opinion or the popular opinion.

By the way, that makes being a blindly loyal adherent to either political party quite impossible. That too is okay with me.

Political Parties:

We might as well start there this evening. The bottom line is this: A pox on both their houses. The national leadership of both major political parties have shown judgment which is inflexible, doctrinaire, personally aggrandizing and separated from the reality of citizens’ lives. The current government shutdown is not the apex of that, rather it is just another of the continuing symptoms.

I was a Republican until the mid-1980s. Like Lyndon Johnson, “I always split my ticket.” While I had a great deal of respect for President Reagan and Pres. Bush I, nevertheless the policies of the Republicans became more and more irrational. So I switched.

It was not a bad time to become a Democrat. There we were heading into the Bill Clinton years. He was the recipient of some of the growing skill of political sappers, but he continued to chart a very centrist course against attacks from several sides.

Yes, I know: Blow jobs, blue dress, “I didn’t [whatever] that woman.”

On the whole, however, it was a positive and productive time. Let’s remember balanced budgets, debt reduction, prosperity and relative peace in the world. (I never considered the Balkan incursion or the Somalia retreat to be very solid foreign policy moves.)

Now, conservative political sappers who have quite a bit less skill than those who assaulted Clinton have taken off on Obama. That is been one major cause of the growing political extremism in America.

Incidentally, the fact that Obama is the target of constant political hack jobs has absolutely nothing to do with whether the course he has charted makes one damn bit of sense.

Now, I’m finding my current political party becoming an uncomfortable place for me. Locally and regionally, I’m mostly okay with it but I’m largely okay with at least some of the local and regional Republican efforts. It seems that not very many people around here are self-righteous morons.

But the fundamental assumptions of the national political parties are equally obnoxious, if for different reasons.

Let me start with the Democrats: The Obama/Pelosi/Reid machine is in its ascendancy. The fundamental assumptions driving that machine are that there is a “they” who are passive and unable to make decisions in their own interests and an “us” who are smart enough and kind enough and moral enough to make wise decisions for “them.”

This fundamental belief system has driven an insane cycle of “free money” and freedom from responsibility.

This belief system has driven the Democratic side of the gun debate. Incidentally, I disagree vehemently with the national Democratic position about the responsibility of citizens with firearms.

But that extends to lots of other measures by which people can take responsibility and do things for themselves and their neighbors. Take the issue of keeping all those nasty, sharp blades out of aircraft. Never mind “Man the Toolmaker.” Never mind the current near-impossibility of someone with a blade taking over a commercial aircraft. It is positively demeaning to think that I can’t fly without handing over anything sharp.

I read something about the crash not so long ago at San Francisco International Airport. Apparently, one of the big inflatable slides around one of the hatches inflated inside the aircraft, creating an obstacle. The crew was looking in vain for something – like a knife – to deflate it. So Congress has a case of the willies and the power of the people is diminished.

Something else bothers me about the current Democratic national leadership is the focus on social tokenism. After George shot Trayvon, nobody appeared to care about anybody else being maimed, mugged, shot, stabbed, beaten or abused.  Trayvon became the convenient – and unknowing – poster boy for politicians who themselves are afraid to walk through any part of town.

But the thought of returning to the Republican fold in some ways makes me ill at ease and in lots of ways makes me downright nauseous.

I bet that John Boehner has children and grandchildren, and friends and neighbors, and with them his face softens into something other than that of pre-ghosts Ebenezer Scrooge. But we don’t see it. I bet that Sen. Cruz is a nice and affable fellow  who thinks straight and logically and who doesn’t get carried away in his normal life doing really stupid shit like arguing against something he’s going to vote for for 20+ continuous hours.

When you get right down to it, the Republican representation of support for individual responsibility is a falsehood. The party still pushes a burdensome tax structure, only one will have their base pay less. They still support burdensome regulations, just different burdensome regulations.

Democrats passed the Affordable Care Act which is positively an abomination. (Incidentally, tagging it as “Obamacare” was fairly decent conservative politics, and accepting and using that tag by the Administration is a political gaffe of great size.)  The ACA is full of opportunities and perks for the well-connected and fails to address the fundamental issues of healthcare such as “just who will get what care?” The Republican response? Screw it, do nothing.

Oh, I understand that this is a rambling polemic. Was there some part of Stream-of-consciousness that was confusing?

Sissies in Congress

Oh, for that matter, there are sissies damn near everywhere. The color pink which has long been associated with sissies has been appropriated for a far more noble and useful purpose of late. So I will have to contend content myself with calling for a lot more frills and lace to be handed out to all the poor little incapable schmucks who purport to do the public business.

Here, I’m thinking of the mentally ill woman who was shot by the Capitol police as she was running into various barricades around the Capitol. By the way, I’m not qualified to have an informed opinion on the propriety of the use of deadly force. I wasn’t there. I do know that her little family sedan was not actually going to penetrate any of the vehicle barriers at the White House or the Capitol building. Had that been all she was trying to do, police agencies could have sat back smiling until she disabled her vehicle on the immovable barricades.

But when this one-woman-with-family-sedan “attack” was going on, somebody hit the metaphorical (or maybe actual) red panic button and locked down the Capitol, and advised the occupants of the Capitol to “shelter in place.”  The pathetic thing is that not a one of them noted that was idiotic and insulting and poked their political noses outside perhaps to demonstrate that they had a pair.

Walking into a conflict can be stupid. But hiding two blocks away from conflict is cowardly and demeaning.

That reminds me of a little story. We (our rescue company) were called to assist a state trooper with a mentally ill armed guy who refused to come out of a barn.  The trooper, by the way, was Greg Coram, who later obtained a doctorate in psychology and has become a leading national criminal justice expert. As he was talking to the gentleman to calm him down, he told him that “The paramedics and I just want to come in and help you.)” One of the guys I was with snidely asked Greg, “What is this ‘we’ shit?”

The Good Guys

I continue a casual association with various participants in the Great American Medical Machine. (For reasons which are irrelevant.) And I continue to note the genuine caring of those who deliver medical care. Indeed, there is some positive correlation between the amount of blood or shit a caregiver gets on his or her hands and them being genuinely nice people.

I confess that I do have a little bit of fun with these people at times. Some weeks ago, a nurse asked me “Do you use oxygen at home?” My answer: “Of course I do.” Her follow-up: “How much?” My reply: “The 21% which is in our atmosphere.”

I think these caregivers do seem to appreciate patients who are not whining all the time.  Smartasses may not be as fully appreciated.

More Good Guys:

The Monongah Fire Department Facebook page had a photograph on it very recently. The family of a little girl which the fire department and rescue squad saved from some medical event was there, and the family was kind enough to come to the firehouse to thank the responders.

People in our church know of my concern for our responders. When in service we are discussing those for whom our particular prayers should be lifted, often I will mention someone who’s died in the line of duty or been injured or just the dedication of those folks generally. 

EMS people work hours you would not want to work and see things that definitely you would not want to see. 

Owing to hostile publicity and inaccurate media, police are largely perceived negatively now even though there are about two police line of duty deaths every week in America. 

And firefighters? Picture this: They are asleep in a nice warm bed. An alarm comes in. They get up, step into their boots and night pants, and in about 45 seconds are driving out of the garage into subzero temperatures. They arrive at a fire and need to enter a house where the temperature near the ceiling is several hundred degrees. (That’s why they stay on the floor.) How close does your job get that kind of stress?

More Than A Peeve:

I’m disturbed by all of the efforts to make exceptions to the First Amendment because the opinions will be unpopular or someone’s feelings will be hurt. And I’m more disturbed at the fact that this does not motivate Americans to stand up, speak up and take back our country from all the extremists.  Normal people have lost their voices - hopefully, temporarily.