At the health care inflection point

The Thinker by Rodin

Back in January I mentioned a mindful eating course I was enrolled in. A full discussion of the course is probably for another time if I think it warrants a blog post. (I’ve become pickier about what I blog about, as I post less frequently and am trying hard to make my posts more relevant and topical.) One of the interesting takeaways from the course though was to learn to trust your body.

It turns out this is a really hard thing to do, particularly here in America. For most of us spend lives trying to respond to conformance requests coming mostly from outside ourselves. It’s constant and incessant. In the area of eating, you get endless “shoulds” and guilt-laden advice about what to eat, when, how much and using which techniques. These techniques rarely work in the long term because they are not natural to us, which is why so many of us are overweight and obese. Trusting to your own inner wisdom shouldn’t be hard, but it is hard because we simply don’t know how.

Of course it’s much more than food. We spend much of our lives being inauthentic to ourselves. We pray to gods we don’t really believe in. We chase after status symbols thinking we’ll be better or happier when we possess that McMansion or that BMW. We take advice from popular people in our class or some loudmouth on the TV or talk radio thinking they are actually wiser than we are. More topically, we vote for people who don’t have our best interest at heart, ending up more unhappy and miserable as a result.

We do this at least in part because we’ve learned that to get along you got to go along. We want to belong and since most of us don’t have local tribes anymore, we join our virtual tribes instead. They are often led by people looking to screw us over, if not monetarily then at least mentally. Facing the reality of our bad choices is hard. If we were to face them, we would often realize we were played for a fool. So rather than face them we continue to work against our own self-interest.

Logically most of those who voted Republican or for Trump should be regretting their choices. Many of them are but of course even Trump has a dependable group who will stick with him no matter how much he sticks it to them. As I noted recently, ninety percent of Republicans voted for Trump, despite knowing full well what he was about: a bankrupt-prone, pussy-grabbing businessman with zero common sense and a racist streak a mile wide.

It seems though that many who voted for Republicans are waking up. We see this not in a pressing desire to vote for a Democrat, but in polls showing waning enthusiasm for their fellow Republicans. There are other polls that show even majorities of Republicans disapproving of their party’s actions. Both the House and Senate health care “reform” bills are widely despised, even among Republicans.

Trump ran partly on a platform of reforming health care. It would be easy to reform he told us, and you would get better coverage for less. Whereas the sad reality is that Trump really has no idea what’s in the bills he has been promoting, other than he heard the House bill was “mean” so he instructed the Senate not to make their bill “mean”.

Trump is not being mendacious; he is simply unable to absorb detail. But if the Congressional Budget Office is to be believed, either 22 or 23 million people will be uninsured within ten years if either of these bills become law, with 14 million losing health insurance within the first year and likely a majority of them will be Republicans. Those with insurance will pay a lot more, both in higher premiums and higher deductibles. Technically these don’t amount to higher taxes since this money is not going to the government. If it did, it might buy something useful. It will feel like a tax hike however as your standard of living rapidly erodes.

If either of these bills becomes law, it will be a disaster. It certainly will be for those losing health insurance. The reality however will be much more brutal. Health care spending is a huge part of our economy. It will close hospitals, mostly in rural areas. Without insurance people won’t see doctors, so doctors will bill fewer hours and make less money. The cost of emergency care will be foisted on those still with insurance, raising the cost of insurance even higher. It will have a huge cascading effect of not only people dying prematurely and in misery, but in creating huge amounts of medical debt and lost health care jobs. It will careen like a locomotive off its tracks and wreck much of our economy. It won’t affect just the healthcare industry, but all those businesses that depend on health care employees and health care spending, which is most of the economy.

All this is to give huge tax cuts to the 1% who don’t need the money. Arguably the taxes these rich people pay pay for themselves in sustained economic growth, which is keeping stock prices and their portfolio rising.

Some lessons for me:

  • Our current healthcare system must be fundamentally changed if it is to survive at all. The current system works poorly, but it works a whole lot better than it will if either of these bills pass.
  • It’s really in everyone’s best interest to reform our health care system, as it is unsustainable. If there is any industry too big to fail, it’s not on Wall Street but our health care system. It feeds off patients. And patients need insurance to see doctors because only the top 1% can pay for their own healthcare.
  • Obamacare is dying, but not for the reasons people think. It’s dying because it tried to work using a system of private insurance. It’s the private health care system that no longer works as it puts profits first, not people.
  • Expanded Medicaid is demonstrating to new generations that socialized medicine does work. Ask most of Mitch McConnell’s constituents, who are on the program. Only to them it’s something called KyNect.
  • Like it or not we are at a health care inflection point. We must solve this fundamental issue in the only way it can be solved: through comprehensive national legislation that addresses its critical defects. Obamacare does not need amending. And it needs to be replaced with something that is the complete opposite of what both bills in Congress purport to call “health care”.
  • My life, and yours, depends on us rising to the occasion.

Open season on a fixed income

The Thinker by Rodin

It’s open season time and you know what that means. For most of us it means not bothering to take the time to see if there is a better medical, dental or vision plan out there. And by “us” I definitely mean “me”, at least until this year. Although I retired in 2014, I was working for most of it so it was easy to go on autopilot in 2015.

This year though I am fully retired and living on perhaps seventy percent of my previous income. This year although our expenses have gone up, for some reason my fully indexed cost of living pension won’t be, a factor somehow of falling gas prices. I’m not alone. Lots of pensioners and social security recipients feel like they have been cheated. The problem is that the official cost of living index is bogus. While I might spend a couple of hundred dollars less in gasoline this year than I did last year, food prices have gone up and eating is not optional. If prices are holding steady, the word hasn’t gone out to my city. The real estate assessment was $15.80 per thousand dollars of assessed value this year. In 2016 it jumps to $16.16. Moreover I just bought a new house for about $486,000 but it’s been assessed at $500,000. This means we need to pay $401 more just in property taxes yet with no increase in income.

So value is becoming more important. We’ve been on Blue Cross for more than a decade, but Blue Cross too is tightening the screws. With no changes we would pay over $650 a year more in premiums. Copays have been increased as well, up $5 each for primary care and specialists. We (my wife in particular) see lots of doctors. It’s not hard to rack up a hundred visits between the two of us per year. We could easily spend another $1000 a year on health costs next year for no increase in services. We would have to do this with no cost of living raise.

Thus I felt I no longer had the luxury of inertia. As I started to examine my options, I quickly realized why I had punted all these years. It’s because while choice is good in theory when it comes to health insurance it is mind-numbingly exasperating and time consuming. It’s something of a crap shoot as to which plan offers you the best value, since you have no way of knowing how much care you will actually need. About all you can do is use past years as a benchmark, and that means analyzing all your health expenditures. (Note: if you are a federal employee, federal annuitant or survivor of either, Checkbook has a useful guide that costs less than $10 that can help a lot.)

Since I spent a day just analyzing health insurance options, it’s a good thing I am retired. I doubt I would have this sort of leisure if I were still working. I had to sift through the details of all the various plans and see if I could find some magic combination that is not overly expensive, rated reasonably well and with most of our doctors “in network”. I had to analyze premiums, deductibles, copays, limitations on types of services, and which of our doctors were on each plan. I’m still not entirely clear which plan offers the best value, but it’s pretty clear it’s no longer Blue Cross.

I can also change my dental insurance and add vision insurance during open season. I already have a long term care policy, but no insurer would insure my wife so when that time comes we’ll have to depend on savings. Which opens up another can of worms that retirees have to grapple with. If you have some major and unplanned costs, where do you get the money?

Since we recently settled on a house a lot of our reserves have gone to pay lawyers and other busybodies. We’re hardly without savings but if I had to put my hands on $75,000 or so in cash it would be a challenge. A 401-K or IRA is not like a faucet that you turn on and off at whim. You generally get just a one chance a year change to adjust the spigot – during open season.

We supplement my pension with a modest monthly withdrawal from my 401K. On the advice of my financial adviser, I’m limiting withdrawals to 3% of the portfolio. This will in theory keep our nest egg secure, not growing in value (over inflation) but not losing value either. I can up the withdrawals to say 4% and slowly build up cash reserves at the expense of paying more income taxes and a smaller portfolio. I can hope no major expenses like this happen. I can get another home equity loan and use that when needed, but that money certainly won’t be free. The other alternative is to get another job, something I’d prefer to avoid since leisure is the whole point of retirement.

Since when you are retired you can’t easily change your income and expenses are hard to control sober retirees have to look forward a lot. Our new house is nice but like every other house it will move toward decay. We’ll eventually need money to replace the air conditioner, roof and buy cars when the old ones expire. This didn’t used to be a problem. I had enough income where I could pay for most of these expenses out of pocket or from our savings account. Now I have to anticipate them.

Unable to think of a better strategy, I looked at what these expenses cost us before. I made some realistic estimate of when these expenses would hit and what they might cost then with inflation. So I’m setting aside some of our income to draw from for these expenses in the future. It’s not an exact science, but it’s a start. It’s also sobering. I’ve created a car replacement fund assuming we’ll buy two cars for $25,000 each in today’s dollars, one in 2019 and one in 2023. To reach the goal I must place $481 of our income monthly into an escrow account. Similarly for all these future house expenses, I’ve created a capital fund. If my numbers are accurate, $343 a month set aside for these expenses should cover them.

All this is well and good but it leaves less money to actually enjoy your retirement particularly when your expenses go up when the government says they haven’t. Which is why I’m reluctantly becoming value-driven in retirement. Every expense needs a second look, including our health care costs. So I need to shop around.

As for health insurance, since I am an ex-federal employee I’ll probably bid adieu to trusty but expensive Blue Cross and say hello to the National Association of Letter Carrier’s plan instead. Lower premiums, lower deductibles, similar services and a reasonably good choice of doctors will probably go a long way to keeping these expenses unchanged in 2016. We’ll see. If not I’ll be crunching the numbers again in a year at the next open season.

Health insurance in the United States is needlessly complex. If there must be competition then the government should require that all plans offer the same services so we could shop around more easily. Or perhaps we could do what every other first world country does: create a national health care system. Then instead of figuring out how much health you can afford you could simply get the care you need instead. Sign me up for that!

The point of the Affordable Care Act

The Thinker by Rodin

Sometimes you want to cheer and shake your fist at the same time. That was my reaction to this Washington Post article that curiously arrived on my birthday, Saturday, when I turned 57:

Nine days into the new year, the 41-year-old call-center worker headed to the health clinic on Highway 15. She saw a doctor about her chronic stomach ulcers, had her blood drawn for tests and collected referrals for all the specialists she had been told she needed but could never afford.

Health insurance finally came last month to Breathitt County, Kentucky and a lady named Mary Combs. Previously, like many of the people in this part of Appalachia, she saw a doctor irregularly if ever. She could not afford health insurance or even to see a doctor most of the time. She could occasionally afford to see a doctor at the local clinic, which at least had a sliding scale of payment based on her meager income. But even twenty dollars came hard to her and many of those who form the working poor of this country. Seeing specialists was simply out of the question. She was uninsured and in the eyes of many, principally Republicans, she did not deserve health insurance. Let them be miserable. C’est la vie.

Of course because she was working, albeit at starvation wages, she made too “much” money to qualify for Medicaid. At least that was the case until the Affordable Care Act finally caught up with her, which made it possible for her to enroll in Kentucky’s version of Medicaid, thanks to a healthy subsidy from the federal government. Mary Combs, like many of the people documented in this article, finally could do something to heal herself. Finally, at last, government gave a damn.

So many people like Mary Combs live in a world of hurt, always a paycheck or less away from losing all they have, and rarely with enough cash to see a doctor, even one with a sliding payment fee. Life for them is mostly suffering, something that is largely endured. Sometimes it ends abruptly and prematurely with a stroke, but often it means slow declines and frequent hospitalization for bills they cannot pay, but which simply adds to their indebtedness and drive overall health care costs higher. Often they come home from the hospital without a job. It left them when they couldn’t show up for their shift for a week. The hurdles just to stay alive simply grow higher every day for people like Mary Combs.

However, now she can afford to see a doctor, and specialists, and maybe start treating one of her many medical conditions. She can do so without going bankrupt, and by avoiding the hospital perhaps without losing her job as well. She had a chance not just to live, but to get better and maybe eke out some modest enjoyment from life again. It’s still a very long road and with her chronic conditions the odds are still against her. But she is getting some relief: psychological as well as medical.

Elsewhere in the article:

“Yeah, sometimes his face will get real red like he’s going to blow up?” Terri said. “Then he gets sick.”

“Okay,” Freeman said, pressing a stethoscope to his chest. “Big breaths.”

“Sometimes my heart hurts,” her new patient said as she listened to his stomach. “All I know is when you get 30, you start falling apart.”

No, at fifty you start falling apart. You don’t start falling apart at thirty unless you simply cannot afford to get treated and your job and environment stress you like a professional football player. At thirty you should be able to go three years without a physical. You should not have crushed discs in your back, suffer from sleep apnea and have already filed for bankruptcy. But if you live in Appalachia like John Wagers profiled in the article, and repair heaters for a living and never had health insurance before, then maybe you do fall apart at age thirty. This is what happened to our ancestors a few centuries back when medicine was more black art than science and most people never escaped a poverty they were born into.

Having affordable health insurance is something I have taken for granted. I can spend most of my life out of pain. I can enjoy most days. I can look forward (I hope) to an active and happy retirement. Now perhaps can the John Wagers and Mary Combs of the country too. Maybe as their health improves they will be able to compete for better paying jobs, because they are healthier and can be productive but also maybe because the minimum wage is raised, as us Democrats want to do. Maybe they will be able to attend a community college when they are healthy and have a few more dollars in their pockets. Just maybe they will get a real chance at the American dream, which needlessly denied them by tactics like only allowing those who can afford it to see a doctor.

The Affordable Care Act is hardly perfect, but it is a start. It warms my heart that in our fractured way we are finally moving people like John Wagers and Mary Combs out of misery and into health. They are being treated like human beings now instead of someone in a lower caste. It’s why elections matter and it’s why I am a Democrat and progressive.

Republicans: Let’s talk real national security

The Thinker by Rodin

There is a little irony that a day after the Supreme Court narrowly decided the Affordable Care Act was constitutional after all, that I would undergo surgery. The surgery to correct a deviated septum (known as septoplasty) was actually scheduled six weeks earlier. My mother in law’s untimely death and my plastic surgeon’s busy schedule meant I had to wait until today for the outpatient surgery. It went well, but my time in the recovery room took longer than usual, perhaps due to aging. While waiting for the surgery, the TV playing in the waiting rooms was all about the Affordable Care Act decision.

My surgery was theoretically elective, but that did not seem to be the case for others in the waiting room. They included a ninety plus woman, virtually deaf due to plugged inner ears, who needed to get some tubes put into her ear so she could hear again. She looked miserable and her son acting for her largely could not communicate with her. Yet she was lucky. She was covered by Medicare. I was lucky too as I am covered by Blue Cross, and they approved my surgery. Even so I know there will be a whole slew of bills waiting me. It was nearly $900 just for the hospital to admit me. Doubtless the anesthesiologist and surgeon will bill as well, and there will be substantial copays for their services too. I’ll be lucky to escape this surgery for less than $2000, and that’s just for the copays. Blue Cross pays 85%.

I was back home by noon, my septum duly aligned and with various sinus polyps removed. Maybe this surgery will mean that I won’t need to spend my sleeping life tethered to a BiPAP machine for my sleep apnea. It’s a big maybe. Most likely I will continue to need the machine, but with the improved airflow, perhaps I can adjust the pressure settings downward, which would likely make sleep far more restful. Meanwhile I am downing Keflex and extra strength Tylenol every six hours and wearing a guard over my nose that is attached to little diapers to capture the bloody discharge from the surgery. Recovery from this sort of surgery is generally straightforward, and involves lots of use of QTips and hydrogen peroxide.

Mostly I am lucky because I am insured. My employer cares enough about me to provide it as a benefit, with me providing about a third of the cost of premiums. I am even luckier because even before the ACA I was already in a plan that required insurers to accept all comers. You see we federal employees have been been enjoying “Obamacare” for decades, and those employees I might add include members of Congress eager to repeal the ACA. And I must say, I like it. For decades I have been covered by health insurance, as has my wife and daughter. Insurers in the Federal Employees Health Benefit Plan have to accept people into their plans regardless of age and preexisting conditions. There are dozens of plans to choose from. On rare occasion, a health insurer will drop out of FEHBP, but it is a very rare occurrence. Mostly, health insurers are glad to cater to our market.

As I age, unsurprisingly, I have been using more health care services. I am quite certain that in spite of premium and my voluminous copays, we consume more in services than we pay in direct costs. It’s likely to be this way for the rest of my life. I don’t feel guilty about this. I feel grateful. I also feel like I’ve paid my dues. For the first twenty years or so that was likely not the case. I was paying for those older and sicker in the system. I did not resent this. It comes with the insurance territory. Health insurance only works if we are all in this together.

Essentially, the Supreme Court agreed yesterday. While Chief Justice Roberts surprisingly voted with the majority to uphold the law, and while he was silent about whether he personally thinks the ACA is a smart decision, he decided it is constitutional. This is good for our nation because by upholding the law at least for the moment he has likely fended off our devolution to a second world country.

Republicans are always anxious to vote more dollars for national security. I find it sad but curious that they don’t understand that national health insurance is also vital to national security. Most other first world countries figured this out decades ago, but we dithered. It is not surprising to me that since then we moved from greatest creditor country to greatest debtor country, and that our standard of living has devolved. National security is measured in many ways and it’s not just in the strength of our armed forces and intelligence. It is also measured by our willingness to invest in the human capital of its citizens so we can stay a prosperous country. In this we have been getting failing grades for some time.

We seem unwilling to pay the freight when it comes to education. We cheapen our public schools by increasing class sizes and shortening school years. We shortchange our public universities and expect students to mortgage more of their future by increasing tuition rates so they need to take out larger and larger student loans. This is keeping many from even attempting college, although many also have the talent. We also dumb down our curriculums. Courses like art, music and civics are considered expendable. Instead, we push highly structured and dumbed down standardized tests. Colleges are not immune from the phenomenon. As The Washington Post reported recently, college educations are becoming dumbed downed, or at least less time consuming. The Internet certainly makes research faster and more efficient. For most majors, the need for a full time college student to spend twelve hours a day on education, including often on weekends, as I did, is a thing of the past. I suspect this is to our detriment.

Education is vital to our national capital, but so also is our national health. It baffles me why this is not completely obvious. A healthy workforce is going to be more productive than a non-healthy one. If you are suffering from a health condition, your productivity is going to be compromised. If you suffer from a chronic condition, you may not be able to work at all. Where’s the good in that? Aside from inflicting needless misery on our citizens, why throw away the talent of so many of our citizens because they have a chronic condition? It’s such a tragic and needless waste and speaks poorly about what we really think about our fellow Americas. By throwing away our most precious asset, the skills of our own citizens, we guarantee our devolution as a nation. This is equally as dangerous to our national security, if not more dangerous, than securing our borders from illegal immigrants.

Mostly though while I waited for my surgery today I felt a mixture of relief and anger, not nervousness. The ACA, if we can keep it the law of the land, will do enormous amounts to make us a healthier and more productive nation, not just those like me still lucky enough to have health insurance. It will also relieve incredible amounts of unnecessary misery. Mostly though I felt anger that so many of my citizens are so ideological that they can no longer see our common humanity, who appear to think sadism is a virtue. These people, in the name of ideology would, like that heckler at a GOP debate last year, be enthusiastically rooting for people to be miserable and die.

The ACA gives us the opportunity once again to show our better nature. Let’s hope we find it again.

Solving the medical forms hassle

The Thinker by Rodin

Seven years ago, I suggested that the ubiquitous thumb drive should become our electronic wallet. You would simply plug it into the point of sale device, authorize the transaction (a PIN is acceptable, but a thumb scan would be better), and an electronic receipt would get stored on the device. The receipt could later be imported into your personal money management software, such as Quicken, for automatic categorization, giving you better insight into your spending.

Some years of experience using thumb drives regularly shows that it is not the ideal device for an electronic wallet, in part because the USB terminal can wear or tear, rendering the device useless. Today, a smart card might make more sense because it would fit in our wallet right where the credit and debit cards go. My point was that to be useful the device would show you your balance at a glance, and it could receive as well as send data. Today, the device could also be network aware, making secure connections to your bank periodically to get the latest balance. You might call it a smart cash card.

A few weeks back I had an annual physical. As is typical of someone fifty plus, I left with a stack of prescriptions and referrals. As a consequence, I have since been making my way to various specialists. Yesterday I visited an endocrinologist, who was examining some minor cysts in my thyroid. Naturally before I could see him I had to go through a daunting process of filling out four pages of forms, listing for the umpteenth time my long and tedious medical history. I am sure you have had the same experience many times. List all your medications and dosages. List all your surgeries. List current and past conditions that you have had, including hospitalizations. List your family’s medical history, parents and siblings. Provide an emergency contact. Oh, and don’t forget your name, address, phone numbers (home, cell and work), email address, date of birth, social security number, current employer, current employer’s address and phone number not to mention, of course, your almighty health care insurer, their phone number, your policy number and your group number.

As someone who works in information technology, filling out these forms repeatedly is an obvious problem that should just be solved. Yes, as part of the Affordable Care Act, health care providers are being nudged into electronic medical records. I can understand the reluctance of doctors’ offices to go there, given the voluminous information they collect and the chance of clerical errors. Still, much of the information is route and common. It could be provided by the patient in an electronic fashion very easily. All it needs is a law to make it happen.

This is a job for government, not to make such devices, but to set standards for them and to require health care providers to accept them. Such a government standards entity already exists:  the National Institute of Standards and Technology. Other agencies, probably the Department of Health and Human Services, through regulation could require health care providers to accept electronic data provided by the patient in lieu of filling out those awful and painful new patient forms.

Here is how it might work. Next time I visit a new doctor, I would take out my medical smart card. It would be more than an electronic wallet, but also have my medical history. I would wave the smart card over the card reader at the receptionist’s desk and it would ask for permission to transmit certain types of data. Ideally, it would show me on a screen all the information requested. I would be able to change it (in the process changing the data on the card, since it would be inaccurate) or blank out fields I don’t want to share. I would then give my permission to share the data using some sort of authorization mechanism. Ideally I would do this by pressing my thumb on a spot on the card. However, a PIN or retinal scan might be okay as well.

There are devices out there that get part of the way there. For example, MedicTag is one of a number of devices that puts your medical history on a USB drive that you wear at all times. The problem with devices like this is that there is no guarantee that your health care provider will even think to check for the device. Even if they can, there is no standard for encoding the information so that it can be easily read into a provider’s health care database yet stay secure. To make sure that the data can be read in an emergency, it is likely unencrypted. Worst of all, since most health care visits are not for emergencies, then routine trips would likely require you to fill out paper forms anyhow. Certain providers, principally emergency rooms and ambulance companies, would have permission to read your card without your authorization.

I would bet that most health care providers would be glad to install devices that could read structured medical information from these devices. They would quickly pay for themselves in productivity savings and accuracy of these data. Most health care providers already have a records management system, generally Medics Elite. These companies would find plenty of incentive to build software for point of presence terminals to collect the data.

I am sure that a smartphone could be configured to do this. It can already be your electronic wallet. That seems to be the thinking behind Google Wallet, but so far vendors have been lukewarm embracing the technology. Doubtless apps could be created that would comply with any NIST standards for sharing medical information. With cloud services now becoming standard, most of us would be glad to pay a reasonable fee to have our medical and other private information backed up in the cloud, in case we lose the smartphone. The real problem is that there is little in the way of standards for transferring frequent medical information, at least from patient to provider. This is why we need the benevolent hand of government. Once standards are in place and providers create interfaces, any number of vendors could compete to provide devices and apps to make this a reality. Just as many of us now have electronic boarding passes that are scanned off our cell phone, there is no reason why the same data could not be transmitted using an infrared or wireless connection, once authorization is granted.

As an aging human being who doubtless has many hundreds or thousands of doctors’ appointments ahead of him before I die, a device like this cannot come soon enough. After all, as you age you realize time is short, and you can save heaps of it not filling out redundant medical forms.

Republicans and their bogus notion of federalism

The Thinker by Rodin

Texas Governor Rick Perry is one of the latest entrants into the 2012 Republican presidential primary race. In fact, in barely a week he has managed to displace former Governor Mitt Romney in polls as Republicans’ favorite choice. Clearly, Republicans are more enamored with his record than voters overall will be, once they get the facts on his “Texas miracle”. One thing Perry is very adamant about, aside from the usual whines about cutting taxes, is federalism.

I’m betting some of you don’t know what federalism is. Just incase you don’t know, federalism is not the philosophy that the federal government should do more and states less. What federalism really means is that sovereignty is split between the national government and state governments. In the usual dopey Republican thinking, federalism means that the federal government should do almost nothing and the states should do almost everything else. “Republican federalism” generally means they choose to ignore the constitutional provision that the federal government is empowered to “promote the general welfare”. Moreover, they would also be happy to ignore, if not outright repeal the Supremacy Clause of the U.S. Constitution that says U.S. federal laws are the supreme law of the land. In short, they believe states are more than peers to the federal government; states are superior to the federal government. States are the masters, and the federal government is a little yappy dog that they occasionally throw dog biscuits at to keep happy. The federal government is a servile little puppy that amuses the states and is good at growling at strangers that come near its borders.

Rick Perry’s latest personal beef is that he thinks “Obamacare” is unconstitutional and thus should be repealed. He believes states have the authority to create statewide health insurance plans, or not, but definitely not the federal government. The states should be incubators of laws to see what works in the real world. At the same time, Perry is being a typically schizophrenic Republican by castigating Mitt Romney for the Massachusetts’s health care law, because it requires citizens to have health insurance, except in some limited cases.  Massachusetts’s law, of course, was something of a model for “Obamacare”, known by its proper name as the Affordable Care Act. If this dichotomy bothers you then congratulations: you are a rational person. If you a Republican, it should not bother you at all. Of course you can be for states’ rights while at the same time being selectively against state laws that you believe impinge on personal freedom, even if you don’t live in the state. In fact, you can be for federal laws requiring that all states prohibit gay marriage or abortion, while still believing in states’ rights and ignoring the Supremacy Clause. It’s crazily confusing to those Americans who retain their sanity, but wholly sensible to Republicans.

Anyhow, Perry wants to repeal “Obamacare” natch, and let states be laboratories for health care reform, unless it looks anything like Massachusetts’s health care law. In that case, at best he will hold his nose and accept it as the price of federalism. At worst, he will argue that the original intent of the constitution does not allow states to encroach in this area because it impinges on personal freedom. In general though he believes the federal government’s authority should be much more limited than it is, probably limited to providing for the common defense and controlling immigration, and not much else. Why? Because he thinks this was the founding fathers’ original intent, in spite of the words in the constitution ratified by the many states saying otherwise!

In Rick Perry’s ideal world, agencies like the Food and Drug Administration would be abolished and the money saved on these wasteful agencies returned to taxpayers. States would choose whether or not to regulate drugs. In fact, states already can regulate drugs. Here in Virginia, for example, I cannot buy Sudafed over the counter without giving them my driver’s license, which is scanned. A record of the purchase is put into a database that tracks how many times I bought Sudafed. Basically, Virginia wants to know if I might be running a meth lab. Virginia can extend federal law, but cannot selectively override federal law. This is perfectly clear to most of us who have read the Supremacy Clause.

I do hope that Rick Perry’s idea of federalism at least extends to allowing the federal government to regulate the airwaves and airline traffic. Because otherwise, goodness, it would be a hell of a mess trying to fly anywhere or keeping deviant radio waves from illegally crossing a state’s boundaries. However, neither of these is directly mentioned in the U.S. constitution so maybe they are not allowed. After all, original intent triumphs everything.

The Supremacy Clause exists specifically to answer the question that Rick Perry and so many other Republicans raise. You would think that they might, like, actually read it. The Supremacy Clause also has the side effect of allowing activities that affect the country as a whole to be done nationally once, instead of replicating it inefficiently and piecemeal up to fifty times across the fifty states. Do we really want to take federalism to the extreme where the New York State health department says that heroin is an addictive drug and hence illegal, while California judges it is a matter of individual liberty and should thus not be regulated? Do we really want one state to allow shoddy Chinese drywall while another state prohibits it?

It all sounds so dreadfully confusing and, worse, incredibly inefficient. Granted the federal government has lots of bad laws, but at least if it is repealed it is gone nationally. If federalism existed the way Rick Perry envisions it, most of us would find it too risky to ever leave our state, simply because there are too many ways you can get in trouble with the law moving to another state. You couldn’t count on any law being consistent. We’d probably want an opinion from our lawyers before we moved to another state. Our lifestyle, say living with our gay spouse, could be criminal in a neighboring state. One state may be okay with Miranda rights, another prohibit them.

My wan hope is that as Americans learn more about Perry and other Republicans’ bizarre idea of federalism that they will come to my conclusion: it’s crazy and wrong. But it’s more than that: it’s unconstitutional. Let’s just hope if someone like Perry does get elected president and tries out this notion of federalism, our federal judges will apply the U.S. constitution as it was actually written in judging the cases. This includes those inconvenient clauses like the Supremacy Clause that plainly say what they plainly say.

If I was the president

The Thinker by Rodin

Gah! The amount of disinformation going on about the debt ceiling, the budget deficit and the economy continues to astound me. That so much of it is sticking goes to prove that money can buy pretty much anything. The oligarchy is clearly in charge, which is why closing loopholes for people who own private jets is viewed as anathema by the Republic Party. We’re talking freakin’ corporate jets, jets that cost tens of millions of dollars at least. Chances are if you or your corporation own one or more corporate jets, you are beyond rich. You are filthy rich and the last thing you need is yet another tax break aimed at your jet. It’s amazing Republicans aren’t laughed out of the room when they try to defend these and other outrageous tax breaks.

It’s probably a good thing I am not president right now because here is what I would say to Republicans: I dare you not to extend the debt ceiling. In fact, I double dare you. If you are anxious to end your party in one fell swoop, and make it as irrelevant as the Whigs, go right ahead. It’s not like we don’t already have a budget passed into law. You have already agreed how much we can spend through the end of the fiscal year but you won’t even pony up the money to pay for that? What does “law” mean to you? Is it a recommendation or something binding on the country? In any event, if we have another fiscal calamity because your party would not extend the debt ceiling just to cover the spending we already signed into law, your party will go straight over the cliff in 2012. It would be nice if the Senate could start first, but the constitution requires all spending bills originate in the House. The Senate could easily pass an extension of the debt ceiling under budget reconciliation rules. So go right ahead, Republican Party. Die by putting principle before pragmatism. The price may be horrendous to our livelihoods and economy, but at least the cancer of your party will be gone and saner heads can rule again.

Furthermore, I would not sign any omnibus spending bill into law until every current lawmaker who voted for the Medicare Part D legislation, the Bush tax cuts and two wars on borrowed money first said they were sorry and that they regretted their decision in writing. You cannot have it both ways. You cannot cause the problem in the first place and then refuse to raise taxes to address the problem you created. It’s one thing to say “I’m sorry”, it’s another to follow through with an act of contrition. I am interested in deeds, not words. Now is the time to pay for your mistakes not by just admitting they were wrong but helping us get out of them. You have to undo your mistakes. You must swallow hard and let the Bush tax cuts expire. You must agree to sizeable defense cuts because there is no way to be fiscally solvent otherwise.

And Democrats, you are not scot-free either. Medicare and Medicaid are a mess. They are definitely more efficient than private health insurance, but they cost way too much and Medicare in particular is riddled with incentives to cheat. It needs fundamental changes, not vouchers. It can be fixed by adopting proven best practices in other similar health care systems across the globe. Get to work.

And America, you don’t get off scot-free either. You are a mess and you need to shape up. Seniors, since you are on Medicare, you need to get annual physicals and follow your primary care physician’s guidance because in general you weigh too much, eat the wrong crap and don’t exercise, and this is costing the nation a fortune in outpatient and hospital care. If you miss the benchmarks in your physician’s action plan, you must pay a premium because it is people like you, being either stupid, or oblivious, who are driving up costs. You’re old enough to know that life is not free. If you want health care in retirement, you must do your part to restrain costs.

Doctors, you don’t get exempted either. You have to practice better medicine and work more efficiently. You have to stop billing for all these unnecessary tests and submit bills only when you have achieved an effective outcome. Yes, I know many of you are still paying off your loans from medical school. Deal with it. You have plenty of company.

Here’s some of our new rules of governing:

  • Unless you are severely disabled or destitute, you must contribute part of your income to the betterment of society. That means you must pay some percentage of your income in taxes.
  • Every single program in the federal government must meet goals written into its legislation and terminate after five years if they have not achieved those goals. We will empower the Government Accountability Office to find out whether the goals were met for the agreed upon budget. If it’s not working as planned and for the agreed upon cost, it’s gone. No more open-ended legislation is allowed. There must be a funding mechanism attached to all new spending, and it must be certified as reasonable by the Congressional Budget Office before it can be accepted as legislation.
  • We will borrow money to pay for war only, but we will also make it part of the Department of Defense’s mission to avoid wars in the first place. The agency will work intimately with the Department of State to ensure we avoid as many wars as possible. Wars are costly. Our military plans must include plans to limit the scope of a war as tightly as possible, and withdraw our forces as fast as possible.
  • Once we achieve a balanced budget, at least five percent of revenues annually will be dedicated to paying down our budget deficit.
  • We will not be afraid to raise taxes when needed. We need to repair the bridges and highways we got that are crumbling. Transportation taxes must be raised. Coincidentally, we will stimulate the economy and the middle class in a major way. This probably means increasing the federal tax on gas to at least fifty cents a gallon. Yes, it will hurt in the short term but it’s money that will be spent right here in America and will encourage more fuel efficient transportation.
  • No more partisan nonsense is allowed. Taxes are not evil. They are the cost of civilization. People who can afford to pay more should, because their wealth is due largely to those lower than them on the income scale.

I believe that this is what we need to make our country great again. President Obama, I hope you are listening.

A day without pain

The Thinker by Rodin

Daily pain is a fact of life for many of us, particularly as we age. Pain can range from acute (migraines) to the intangible but devastating (depression). Regardless of the kind of pain, pain is a warning that something with us is not right and needs fixing.

I have been dealing with the pain of sciatica for years. At least now I have a name for what I have been going through. It started many years ago with numbness in my toes, escalated into general foot pain, particularly when standing, then slowly migrated toward my spinal cord. For the last few years the sciatica was most painful on the backs of my thighs. As the day progressed, and particularly when I was sitting most of the day, the pain radiated from a slow burning sensation to an acute burning sensation. At its worst, it is sort of like sitting on burning matches. I did not like it, but I got used to it. It helped that in the morning I was pain free and it wasn’t until I engaged in more sedentary tasks that the condition progressed.

Regular readers may recall that I consulted various specialists. I endured shoe inserts, surface vein removal surgery, tarsal tunnel surgery, as well as other invasive and non-invasive tests. It was all for naught. Part of my problem was that sciatica is a syndrome. This is a fancy way of saying it was caused by lots of multiple factors, none of which could necessarily be pinned down. Trying to cure sciatica is thus a lot like trying to shoot a bull’s-eye while wearing a mask. It also means that physicians are of little use because they are as baffled as you are, just not honest enough to tell you.

Ibuprofen offered no relief. Physical therapy offered some relief, but could consume up to an hour a day. The best relief was to not sit, which was hard to do and stay employed. Doctors were willing to do deep tissue steroid injections at the base of my spine that might reduce the pain or make it go away for a while, but would not cure the problem. My spine was not damaged so spinal surgery would have been useless. I was driven to the mighty search engine Google to try to figure out what I had. The only thing that came up was a condition called piriformis syndrome. My prognosis for a full recovery: not great.

Today, while the pain of sciatica is still not completely gone, it is nearly gone. A few weeks back the chiropractor I see examined the soles of my feet when I complained that it felt like I had a flat stone under my feet after using the elliptical machine in the gym. He pressed certain spots and had me yelping in pain. “You need metatarsal pads in your shoes,” he told me. It took me about a week to see the podiatrist who said, “they will help but what you really need are custom foot orthotics”. The orthotics are on order but in the meantime I have metatarsal pads glued to my Superfeet shoe inserts. Those three-dollar pads have done more to reduce my sciatica than all the other treatment combined. I am hopeful that when the orthotics arrive the pain, which is now a very mild burning sensation that appears from time to time, will vanish altogether.

Yet I doubt custom foot orthotics alone is curing my condition. If I have piriformis syndrome then compression of the sciatic nerve near my piriformis joints (the joints that connect the hips with the legs) is part of my condition. How did this happen? According to Wikipedia many of us have a congenital condition wherein the sciatic nerve goes through the piriformis muscle, which can then compress the nerve. Exercise, particularly the weight lifting I was doing at the gym likely contributed to this problem. This weight also contributed to something akin to the collapse of the bones in my feet, making certain bones lower than they should be. This put more stress on certain parts of my feet, triggering pain. The custom foot orthotics should even out the foot pressure.

In addition, my chiropractor has been aligning my spine and loosening joints. My spine was bent a few degrees toward my right side, not that I never noticed. After three months of chiropractic therapy and a lot of traction, my spine is now straight, meaning that my body mass is now aligned evenly and symmetrical. Nerves that were stretched because my spine was not straight are no longer artificially stressed. It is hard to say for sure but these are also likely contributing toward my recovery. Body symmetry, in addition to helping people attract mates, is good for the body in general. Your body wants to be symmetrical. Over fifty-plus years my body symmetry changed. Regular jostling of my piriformis joints by my chiropractor have opened up those joints as well. Whether it will relieve pressure on the sciatic nerve remains to be seen, but it appears that enough pressure is being released. And by solving the pressure problems in my feet, pain signals are not regularly going back to the brain. All these are likely contributing to relief.

I feel tangibly close to going a whole day without pain. I cannot remember how long it has been since I have had a pain free day. My guess is that it has been at least five years. I remain frustrated by how incompetent our medical establishment proved to be to diagnose and treat my condition. However, I have a lot more respect for chiropractors now than I used to have. I know the medical establishment tends to look down on chiropractors with their fussy insistence on holistic medicine. For me, a competent chiropractor and lots of traction over many months seems to be solving my very complex problem that the medical establishment simply could not solve, and at a fraction of their hefty fees.

I am fortunate to be well insured. I know that there are millions of other Americans who are uninsured, and many of them are as old or older than me and dealing with chronic pain as bad, if not worse, than what I have been dealing with. For the most part, we cannot be bothered to insure them. If they cannot afford medical care on their Wal-Mart wages then to hell with them. It is more important to be principled than to collectively organize so all of us can get relief from needless pain and suffering. At some level, we appear to be a country for whom “personal responsibility” is effectively enshrining sadism toward the less moneyed among us. Having gone through years of often disabling pain, the only ones I feel a lack of compassion for are for those whose ideology keeps them inured from doing something to address  so much pointless suffering. Shame on them.

Some ways to cut medical costs

The Thinker by Rodin

Are we paying too much for medical treatment? Ask a physician and they would probably tell you that you are not paying enough. Ask the rest of us and we would say, “Hell yeah!” One clue that physicians may be myopic on this is to compare how much Americans pay for health care vs. other countries. In general, Americans pay much more money for inferior outcomes.

It’s well known that a lot of the money we spend on health care is wasted on unnecessary procedures and treatments. Other spending is fraudulent. Medicare is a fee for service insurance program. All sorts of fraudulent and fly by night outfits bill Uncle Sam for bogus, superficial or overpriced treatments. These costs amount to billions, if not tens of billions a year. The problem is hardly limited to Medicare. The same is true in the private insurance market. I have a Blue Cross/Blue Shield standard option plan. My insurance company blithely went along with all sorts of medical treatment for me that turned out to be a waste of money. I had veins removed on my leg a couple of years back. Remove extra veins and the theory went the remaining veins would better take up the slack, relieving pressure on my foot and thus the numbness I was experiencing. My legs look great but the surgery had no effect on solving my problem. Indeed, it might have exacerbated it because I had to wear compression stockings for weeks after surgery. If you have a nerve impingement issue, this makes symptoms worse.

All sorts of parts of our medical system are ineffectual. We depend on physicians, but it is clear that many of them are ethically compromised. No doubt you have witnessed what I have seen many times in doctors’ offices. It’s amazing physicians can get any work done with all the drug representatives coming in and out of their office. Like Santa Claus they come loaded with Christmas presents, often including catered lunches for the doctors, but also plenty of drug samples for their pricey proprietary drugs. (I know this because I get reports from my wife, who works in a neurology practice and sees this happening regularly.) More than one physician I have encountered are on a first name basis with these drug company salesmen and women. This is not surprising since they see a whole lot more of the physician than I do.

A little legislation is in order. My physician suggested a statin for my high cholesterol. He wrote a prescription for Lipitor, which came with a $75 copay for me and costs Blue Cross hundreds of dollars for each bottle. He has done this for other drugs he has prescribed for me, even though I have repeatedly told him I prefer to start with a generic drug, and use a branded drug only if necessary. I am currently trying to get my Lipitor prescription changed to a generic. It may be that I need Lipitor, but I doubt it. I seem to have garden-variety cholesterol issues. I suspect that he prescribed Lipitor by default because of the Lipitor brochures in the examining rooms and likely on his desk. (I sometimes wonder if he is on the take, and gets a percent of any prescription he makes.) It rarely occurs to my physician to give me a generic drug. I’ll bet that your physician is the same way.

Only one physician I associate with has the presence of mind to start with a generic drug (my cardiologist). As a result my heart medicines cost about ten dollars a month instead of hundreds. No one seems empowered to tell physicians what they can and cannot prescribe. It is clear that many are in the pocket of drug companies. There needs to be a law: physicians must treat with a generic drug if available and escalate to a branded drug only for a compelling and urgent need, to be enforced by local medical boards. Moreover, the AMA should change their code of medical ethics. It should be unethical for physicians to meet with drug company representatives unless it is at neutral forums where counterpoint is possible. It should be unlawful to accept any of the bountiful gifts they receive from these drug companies either.

If we cannot enact common sense laws like these, then physicians offices should at least have a prominent policy statement in their lobbies saying how they interact with drug and similar medical companies, so patients like me can know in advance and maybe shop elsewhere. They should record and annually publish statistics on the companies that came to call, who they saw and what freebies they received from these companies. As consumers, we have a right to know if our physicians are being influenced. Right now we have to trust that the physician is looking out for our best interest.

Our primary care physicians must remain our speed dial, but it is clear to me that the primary care system is breaking down. PCPs are generalists by training. As medical knowledge has increased, it is clear that they can no longer sort it all out. What we need now are centers of expertise that can assist PCPs. A PCP would still be the one we would go to for physicals, urgent cares, cold, flus and the like. When an issue reaches a certain degree of complexity, the physician would elevate it to a center of expertise. I can use myself as an example. Both my vein surgery and tarsal tunnel surgeries were clearly a waste of time and money because they did not solve my problem. However, if it had been presented to a team of specialists (who should not be on the payroll of any health insurer), they might have had me follow a more logical course. They might have researched foot numbness like I had, figured out the tests I need, diagnosed sciatica as a likely condition and treated for that first, starting with physical therapy, then chiropractic therapy. My PCP suspected neuropathies and sent me to a neurologist. What I needed were teams of experts: a neurologist, a podiatrist, an orthopedist and likely others to put their heads together and present a step by step treatment plan, probably moving from most likely to least likely, based on my symptoms. My problem was beyond what my PCP could handle, beyond writing me referrals. Besides he had boatloads of other patients he also had to juggle.

The Affordable Care Act is moving toward elements of what I have in mind, which proposes outcome-based reimbursements rather than for a fee for service model. It all starts with a proper and intelligent assessment. The patient is the ultimate person that should approve final payment. Did the treatment solve his problem? Did the treatment persist?

A new payment model might look something like this. Unless the problem is simple enough that a PCP can handle it, the first payment would be to an outcome center for a treatment plan. It would be based on as complete a medical record as exists for the patient. The second would increase payment to 75% when the treatment plan is completed, with perhaps staggered payments if the treatment plan will require months or years. The outcome center would reimburse specialists as needed. The balance would be paid three months later when the patient certifies that the outcome was satisfactory. This would give everyone incentive to get the treatment right the first time. Moreover, physicians would begin to align themselves to meet the market for what are medical needs actually are.

There is no socialized medicine here. Those who want to see a specialist on their own would still have complete freedom to do so. The government would not dictate treatment plans or what are reasonable patient outcomes, although existing institutions like the National Institutes of Health can shepherd the creation and certification of outcome centers and best practices. Patients would get better, faster and more effective treatments. Physicians could take pride that they are doing what is best for their patient as part of a holistic approach. PCPs would find their jobs more manageable. Moreover, health care resources would align toward the efficient needs of consumers. Of course change is always scary, but changes like these are long overdue.