American Exceptionalism

The good people at New England Journal of Medicine have made available, free, to the Great Unwashed, an interactive graphic that lets you compare various categories of health care spending among the wealthy countries. I expect everyone to have fun checking it out but here are a few points that might surprise you.

Obviously, the U.S. spends far more per capita than any other country -- we already knew that.

But, what you might not have known:

Government spending per capita is higher in the U.S. than in any country but Norway.

Out of pocket spending per capita is higher in the U.S. than in any country but Switzerland. (Congrats Anna, you beat us there.)

Spending on inpatient care is higher in the U.S. by far --actually about double the #2 country, which in this case is Switzerland.

Private insurance spending in the U.S., at $2,877 per capita beats the number 2 country by more than 5 times. Can you guess who is #2 on this one? It's Canada, at $555.

The U.S. is #1 in public health services, but only by a tiny bit -- $272 per capita, compared with $261 in Canada. But our total spending on health care is $8,175. In other words, we spend 30 times as much money trying to fix sick people than we do preventing disease.

This is a ridiculous, inexcusable, disgraceful waste. Making people buy private insurance and pay out of pocket isn't even saving tax money -- we spend more taxpayer money on health care than just about everybody else anyway. If we had a single payer system that was as cost-efficient as Canada's, we could cover everybody with excellent health care for the same amount of tax money we're spending right now, and you wouldn't have to pay one dime out of pocket. 

Truth.
 

Only in New York

Guy goes to emergency department with a rash. He's sitting in the waiting room for 8 hours then a security guard finds him dead in his chair.

My sister lives in Manhattan. Once the subway came and she saw one car miraculously empty, so she got on. Turns out there was a dead guy at one end. He'd been going back and forth from Yonkers to the Battery, apparently, and nobody bothered to remove him.

But you know, New York is the greatest city in the world.

What I can't really figure out

Not sure whether you uncredentialed rabble are allowed to read this, but here's a thumbsucker by Abeezar Sarela, a British surgeon, in BMJ, which is the jumping off point for this post.

It used to be, before the Great Humanitarian Cultural Revolution of the '60s (which lasted from 1964 to 1972), that everybody took it for granted that you went to the doctor, he (and it was he) told you what to do, and you did it. "Doctor's orders." In the formulation of Talcott Parsons, that was an obligatory social exchange. If you were sick, you maybe got out of some responsibilities, but that was only morally acceptable if you took on the full responsibility of obeying the doctor.

Well then, lots of smart and humane people, including notably among many others my mentor Irving Zola, started to question that. There are tradeoffs that come with medical interventions -- risks and side effects -- and we ought to have a say in making them. Doctors may be are motivated by financial incentives that we have a right to question. They aren't just writing prescriptions, they're deciding if we can get time off from work, receive disability compensation, have sex. Once we started to audio record physician-patient interactions we discovered doctors giving people lectures about morality and responsibility. This is our body, our life we're talking about and we ought to be the ones in charge. Medicine was viewed by men as patriarchal; oppressive in terms of gender, race and class; imperialist in trying to colonize more and more domains of life and classify difference as disease. You get the idea.

So we saw the rise of patient-centered medicine. It's supposed to be about us, as whole people. Doctors need to understand our lives and our values, and respect our goals and preferences. Even that turned out to be too weak and now we have shared decision making and concordance -- the doctor is supposed to do what we want. And we've had forests laid to waste publishing studies showing that they don't.

Sarela gives us a wake-up call. The whole point of going to the doctor, the reason they make the big bucks, is because they're experts and we aren't. It's hard enough for them to figure out what treatment is likely to be most effective, let alone tell us to do it. And the fact is, patients don't want to decide, for the most part. They don't have the requisite knowledge and they don't trust themselves. When doctors try to push decision making off on patients, patients often feel abandoned.

So exactly how we can be empowered in our dealings with physicians is far from clear. If my auto mechanic tells me the reason my car won't start is because I need a coil, I'm not about to say no, please replace the fuel injectors. That would be idiotic.

Crime Pays

This happens all the time, though not necessarily on this scale: a for-profit hospital chain is sued by whistleblowers for conspiring to admit patients who did not need to be hospitalized, in order to bill Medicare and Medicaid. (The law allows whistleblowers to sue in cases of Medicare fraud. The Justice Department has joined several of these lawsuits against Health Management Associates.)

This is nothing new. As big, for profit corporations take over more and more of health care we're likely to see ever more of this. But here's the point of this here blog post. First:

[W]hen H.M.A. announced the Justice Department’s involvement in the lawsuits, investors and analysts shrugged, and the stocks for both companies involved in the merger barely budged. Sheryl R. Skolnick, who follows health care for CRT Capital, recently wrote in a note to investors, “Investors seem to think that D.O.J. investigations, qui tam suits and allegations of serious Medicare fraud are simply a cost of doing business.” Many settlements run only into the tens of millions of dollars. That’s a corporate slap on the wrist for companies whose stocks typically soar when executives push the profit envelope. Only if the penalty is at least $500 million, Ms. Skolnick said, are corporations likely to find the cost a deterrent.

Okay, that's nothing new either. Actually this story appears right next to the story about Jamie Dimon getting a $20 million raise. But what the Times story doesn't mention is that admitting people to the hospital is very bad for them. .

Elderly people who are hospitalized often suffer a decline in health. They become disoriented and delirious, lose physical fitness as they lie in bed, and eat poorly. There is a danger of hospital acquired infections. And of course you worry, you lose your freedom, and you may not have the opportunity to do essential chores at home, lose work time -- there's all sorts of danger and damage.

In other words, this is not just a financial crime, its kidnapping and assault and battery. Who knows, it might even have killed people. Oh -- the corporate president who drove the scheme, Gary D. Newsome, was paid $22 million before he quit and went to Uruguay to, err, lead a religious mission. Really. Any chance he will ever be separated from any of that $22 million, or do 20 years to life? What do you think.

Another open door crashed through

But still, worth noting. The Robert Wood Johnson Foundation has issued a report with the astonishing conclusion that medical care isn't the most important determinant of people's health.

We have always known this but it just has to be repeated and repeated and repeated until it finally penetrates the concrete skulls of the voters and policy makers.

Most people think about health and health care together, said Mark McClellan of the Brookings Institution, who co-chaired the Commission with Brookings colleague Alice Rivlin, in a webcast marking the report’s release.  But “when you start looking at the evidence, looking at what’s working on the ground to actually have a meaningful impact on the health of people,” you realize that “you can’t get there just by putting more resources into health care.”

Well duhhh. They recommend investment in early childhood education, community development and integration of social services ("for example, investments in housing or transportation could reduce health care costs, and a portion of those savings could then be invested back into health-promoting neighborhood development."), along with finding ways of integrating social and medical services.

Sounds great, but of course we're going in the opposite direction. I'd like to pick out transportation, just for the heck of it. Excellent mass transit gives people in poor communities access to jobs, educational opportunities, better and cheaper groceries and other goods, and cultural resources. It also reduces air pollution that causes ill health (as I have discussed here earlier), and it reduces greenhouse gas emissions. It encourages mixed use development around transit stops and builds stronger community ties. And building mass transit will give people jobs.

Oh wait. Rich people would have to pay taxes to pay for it. Okay, forget about it.

On religion

Martin Luther King Jr. was of course a Baptist preacher and a doctor of divinity. The organization he chaired, the Southern Christian Leadership Conference, was an association of preachers.

But is he remembered as a religious leader? Definitely not. He would use biblical quotations and references in his speeches, but only as a source of rhetoric, not to make any theological claims. The movements he led were secular. Their goals were cultural and political, their membership had no regard for religious affiliation, and they had no particular religious content. That the civil rights movement was based in the black churches of the south was a function of social reality: the churches were the principle organizational infrastructure that existed in the southern black community. They were the place to find leaders, buildings and affiliation.

I say movements, plural, because of the effort to scrub King's legacy clean of elements that make the powerful uncomfortable. He moved on from the civil rights movement to what he called the poor people's movement -- a broad demand for social justice without regard for race -- and of course the anti-war movement which went beyond opposition to the war in Vietnam to a fundamental criticism of U.S. imperialism.

The latter two movements have, so far, utterly failed. If anything we have regressed.

That said, as a youth I admired King and all he stood for, and I still do. His example made me think of religion largely in benign terms, though I abandoned it myself as soon as I was old enough to think independently. But I no longer see religion as a potential force for good. Any worthy cause is better off without it. Yes, some people are inspired by it but it's just as easy and as likely that they'll be inspired on behalf of evil ends as good ones. Religion is irrational and arbitrary. If you're going to advocate for any worthy end, the only honorable and constructive way to go about it is to make arguments based in reality.

King's causes are a prime example, of course. Christianity was the common source of moral justification for slavery, just as today politically active Christianity in the United States is a champion of plutocracy and militarism. Some Christians feel otherwise but there's no sense arguing about what Jesus really wanted because nobody really knows and the entire exercise consists of just making up whatever you want to believe.

I don't understand why religion persists. It belongs to the childhood of our species. It's long past time to abandon it.

Too much month at the end of the money

With Congress poised to cut benefits of many food stamp recipients by $90 a month, as a "compromise", it's worth noting what actually happens to the lazy moochers when their benefits don't last the month.

People with low incomes generally get most of their benefits near the beginning of the month, and run out of money before the end. People with diabetes who are taking medications to lower their blood sugar, but who don't eat, get hypoglycemia -- acute low blood sugar -- a medical emergency which can result in brain damage or death.

It turns out, according to the linked study, that hospital admissions of low-income people for hypoglycemia in California increase by 27% in the last week of the month. This doesn't happen to high income people, and it doesn't happen for conditions that aren't triggered by starvation. The authors don't translate this rate into raw numbers, so I can't tell you exactly how much this costs, but a back of the envelop calculation tells me the number is many hundreds per year, at least. The average cost of a hospital admission is about $10,000. You could feed a lot of people with that money.

The Big Buffoona

The MSNBC evening yackers are obssessed with Chris Christie and Bridgeghazi. I can see why. They figure he's gonna be nailed like a sheet of 1/2" CDX*, so they're strapping on the tool belts and picking up the hammers because they want to be in on the pounding. What fun!

I expect they're right. Christie's story is utterly preposterous, even though his fawning acolytes in the corporate media are still granting him credibility. There are at least five or six people who as far as I can tell have no reason not to flip like pancakes, first and foremost Bridgette Kelly. He kicked her into the storm drain, by his own account without a word to her, and publicly denounced her as an idiot and a liar. Now she's unemployed and unemployable, divorced from an impecunious husband, according to the NYT profile, and what the hell does she owe to Christie at this point?

Then there's David "Wildthing" Wildstein. Christie says he barely knew the guy, because back in high school Christie was a BMOC and Wildthing was a nobody nerd who a popular jock like Christie wouldn't let sit down at the same lunch table. If it strikes you that there's something unattractive about a man who would say that, you might also note that the guy he said it about isn't going to exactly be grateful. Wildthing ostentatiously stapled his lips together at the legislative hearing on the affair, but he let it be known that if he gets immunity, he'll sing like the Mormon Tabernacle Choir.

Christie is still full of bluster and braggadocio, and he doesn't seem to believe he's really going down. But I'll be very surprised if he doesn't.

*That's plywood used for sheathing houses. It gets an 8d nail every 8 inches on every stud. Studs are on 16" centers, so that works out to 64 nails for a 4' X 8' sheet. Plenty for everybody!

Our bodies, our selves

My cousin-in-law talked me into buying a guitar. I was learning to play a little bit several years ago (I play horns but I wanted to be able to play more than one note at a time, basically), then I loaned my strat to my brother and never saw it again. So what the heck, I need a new hobby. I bought a beautiful Gibson Les Paul guitar and a Fender mustang amp.

So I'm relearning what little I could do and hoping to go beyond. But, unlike the previous episode, I now have arthritis in my left hand and I'm not sure I'll really be able to achieve the level I hope for. Fortunately this is not a major issue for me, except maybe for blowing $1,200, since being a guitar God has not been among my ambitions. But it did make me think about professional musicians or dedicated amateurs who run into physical problems -- including a friend of mine who will probably read this, who had to give up his career as a trumpet player.

A physical disability that directly aborts your profession or avocation is obviously a huge challenge to identity. But in fact any chronic disease -- even one that is so far asymptomatic, and exists only as a label -- forces a person to remake the sense of self. It means taking on new obligations for self-care, perhaps abandoning some cherished goals, being forced to present yourself to others differently, maybe even planning for a shorter life.

Many people wonder why people don't take their pills, or keep their medical appointments, or make other changes they need to improve their health. This is called the problem of "non-adherence." Much of the time, it's pretty simple: if I take these pills every day, that will mean that I have this disease. I don't want to have it. Therefore I won't take the pills.

My arthritis is obvious to me, denial is impossible. But I don't like to tell people about it. I hesitated about fessing up here, in fact. Why? Because it means I'm telling people I'm getting older and the machinery isn't working as well as it used to. And I don't want people to think of me that way. I still want to be in my 20s. Well, I'm not. Now you know.

One more reason we need single payer

One of the major flaws in the Affordable Care Act is that, as with Medicare Part D and Medicare Advantage plans, it puts the burden on the consumer to wade through a lot of complicated choices and try to pick what's best for that individual. So, another open door crashed through: most people don't have a clue about key concepts of health insurance.

Since the link is to a subscription-only journal, I'll do my usual unpacking for you. The survey didn't actually test people's knowledge; it just asked if they were "confident" that they understood concepts such as co-payments, co-insurance, deductibles and premiums. Most people said they were not. But I'll bet it's even worse than that -- if you ask people whether they understand something, they'll say "yes" even if they don't. Because a) they don't want to seem ignorant and b) you don't know what you don't know.

And for people with limited education, cognitive impairments, mental illness, or just plain too much in their lives to deal with, having to take the initiative to do this and wade through complicated choices they don't understand is just not going to happen. The ACA did of course provide some money for "navigators," people in community organizations who can help. But Republican governors are doing everything they can to sabotage the navigator program, and even where it is available people have to be connected with a community organization to avail themselves.

BTW, are you confident that you know the difference between premiums, co-payments, co-insurance, and deductibles? Do you feel confident that based on knowing about these, you know how to pick the plan that's best for you?

If we had universal, comprehensive, single payer national health care, everybody would automatically have good insurance, already paid for through progressive taxes. It would cost less overall and deliver far more. Insurance company executives wouldn't be hoovering up the cash, it would be much easier to detect fraud, control overuse and control prices, and care would be much better coordinated. Anything else is a travesty.

Just a small personal observation

You've probably seen the news about the people who stole the FBI files showing J. Edgar Hoover's FBI smashing the constitution like a crystal goblet have finally come forward. This happened in 1971, at the Media, Pennsylvania FBI office. I arrived as a freshman at Swarthmore college in 1972. Media is just down the street, and as it happened I wound up living in Media.

Swarthmore had been a major hub of student activism and some people who became prominent in Students for a Democratic Society went there. We had more than our fair share of radical professors as well. Everybody assumed that the perps were associated with Swarthmore but it turns out the ringleader was a physics professor at Haverford College, our archrival in men's sports. (Haverford was male only at the time, with women attending Bryn Mawr college next door.) So my alma mater has lost that special distinction I thought it had.

Anyway, what those folks did was heroic and 100% praiseworthy. They evaded capture but they were prepared for it -- they even made arrangements for people to raise their children if need be. They exposed the FBI actively trying to disrupt and destroy anti-war and civil rights organizations, including an attempt to blackmail Martin Luther King Jr. into committing suicide. But Hoover's name is still on the FBI building. How about that?

Edward Snowden is just as much a hero. He deserves a presidential pardon or at least a plea bargain to 200 hours of community services talking to high school kids about the Fourth Amendment. But it won't happen.

Well, at least he apparently believes in evolution

"Republican" has apparently become synonymous with "idiotic." Here's Newt Gingrich claiming that global warming is not to worry, because the earth did just fine back in the age of the dinosaurs when it was much warmer than it is now.

I don't imagine I need to explain to any of my readers why this doesn't make perfect sense, since I presume I don't attract blithering idiots. But this malignant clown gets to go on all the Sunday morning yack shows and otherwise get all of his ignorant pronouncements transcribed by corporate media throughout the nation. It's truly baffling.

Philosophicalness

One important reason we often fail to understand each other is what we call a category error. Jurgen Habermas's formulation is congenial to me so let me restate it in fairly simple terms (something Habermas, alas, is incapable of doing.)

Most of what we say to each other, contrary to centuries long obsessions of linguistic philosophers, is not actually about representing reality. Words create reality. The umpire says you're out, you're out. Doesn't matter whether the ball hit the glove before the foot hit the bag. That's actually an entirely different question. But we also create reality with very mundane speech. I make a promise, I've created an obligation. I ask a question, I place a social obligation on you to answer, assuming my question was appropriately put. I give you an instruction, you may be obliged to follow it if I have social standing to give you orders; or you may choose not to thereby creating resentment in me. Whatever, you can play out all the examples in your mind.

What I actually say, the content of my utterance, is called the locutionary act. But depending on context, the same locutions can constitute many different illocuations, that is the social act embodied in the utterance. Then there's the perlocution -- what happens inside your head in response to what I say.

Okay then. There is a diverse category of illocutions called assertions or assertorial acts. Yes, they do purport to represent reality but they also create reality. You now may have a new belief -- either that what I have told you is true, or perhaps that I'm a liar or a fool. You may form a new intention. You may have an emotional response to the information. (E.g., your cat is dead.)

Habermas reminds us that there are three main kinds of "validity claims" contained in assertions, and we get into a lot of trouble by confusing them.

The First World -- the world "out there," intersubjective reality, facts that can be proved or disproved by evidence accessible to anyone in the right place and the right time with the right sensory apparatus. (Maybe aided by a telescope.) This world is subdivided into what we can directly apprehend, and the realm of inference perhaps requiring expert knowledge or rigorous deduction. This is the realm of The True, as Plato has it.

The Second World is the social world, including norms and values, status and social structure. These can be asserted in first world terms, e.g. "England was ruled by a hereditary monarch in 1600," but the assertion that England should be ruled by a monarch or that you have a duty to bow to the queen is a different kind of claim. You can't prove it by a randomized controlled experiment, or by observation. You might try to support it by an argument that IF England is ruled by a monarch THEN some desirable consequence will ensue, which is at least partly back in the First World although probably very hard to demonstrate. But we have to know exactly what kind of claim you are making in order to criticize it validly. This is the realm of The Good.

The Third World is what's inside us, what each of us feels and wants individually. The only validity claim here is sincerity. Do I really love you? You can perhaps make a Second World claim that people should not feel that way but that is different from saying that I don't feel what I say I feel. This is the realm of The Beautiful.

So what's really going on when I say that Jahi McMath is dead and her parents say she isn't? Are we talking about the same thing? If they truly believe that she will one day open her eyes and say "Hi Mom," then I suppose we are. But I don't think that's what's going on, not at all.

That river in Egypt runs deep

No doubt you have noticed the disturbing case of Jahi McMath, the fourteen year old girl who died from complications of routine surgery, whose parents do not agree that she is dead. Terry Schiavo's family has gotten involved in the case and is trying to "save" Jahi.

Jahi is dead because her brain has no function. There is no circulation to her brain, she is brain dead. However, she is on a respirator and her heart is beating. Here's what the Schiavo spokesperson says:

Jahi McMath has been labeled a 'deceased' person. Yet she retains all the functional attributes of a living person, despite her brain injury.This includes a beating heart, circulation and respiration, the ability to metabolize nutrition and more. Jahi is a living human being.

 Actually, her respiration is provided by a machine, and the whole dispute is that the hospital wants to turn off the machine. The family and the meddlesome Schiavos want to move her to a long term care facility in Long Island -- on the opposite side of the country -- but first they need a physician to perform a tracheotomy and insert a feeding tube. No physician will do so, because physicians don't operate on corpses. The family is trying to get a court order to force the hospital to comply with their wishes.

Now, Jahi doesn't just have a brain injury: she does not have a brain, other than the kind you might find pickled in a jar. In this respect, she is not like Terry Schiavo was at the time of her own controversy. Terry Schiavo was allowed to die, at her husband's request, but Jahi is already dead. It is technically possible to keep almost any corpse in a state of oxygenation, with circulating blood, for an indefinite but typically quite a long time. If we accept this definition of human life, we will ultimately have millions of corpses in warehouses, attached to machines, at a cost of a couple of hundred thousand dollars a year apiece.

So what is going on in these people's minds? Before the availability of current technology, for all of human history, we defined death as the absence of a heartbeat. The new definition is compelled by the changed reality -- that we can keep the hearts of dead people beating. This wasn't really widely discussed publicly or decided democratically. If it had been, we might have a stronger consensus.

But still, I find this ridiculous. Having a beating heart and artificially supplied respiration does not give someone "all the functional attributes of a living person." A living person has a mind. That is what is valuable about us. What is most puzzling is that the people who claim otherwise generally -- and I don't know about the McMath's but this is true of the Schiavos and their allies -- base their claim in religion. Obviously the Bible, and religious tradition more broadly, don't address this question. They can't, because it was inconceivable until the last few decades.

So what is the religious source of this bizarre claim? I have some thoughts, but I'll let you ponder.

Two points for the price of one

I wouldn't ordinarily link to Dana Milbank as a main source but he gives me a useful twofer.

First topic of discussion: according to a new Pew poll, almost half of Republicans say humans have existed in their present form from the beginning, i.e. evolution is a lie from the pit of hell, while only 43% accept evolution in some form, including that yeah, it happened but it was divinely guided. That's apparently down by 11% from the last time they asked four years ago. Since the total percentage of the population that believes in evolution -- 60% -- hasn't changed, this seems to mean that the people who are willing to self-identify as Republicans is increasingly restricted to religious fanatics.

Okay, that's not a surprise. But then Milbank says this:

This continues a long-term trend in which both parties are shrinking into smaller entities at opposite extremes. The gap on social issues between Democrats and Republicans (and independents who lean toward one party or the other) has nearly doubled over the past quarter-­century.

It's obligatory, of course. If you're a DC-based corporate media yammerer, you face a $50,000 fine and three years in the penitentiary if you fail to say that both sides are equally extremist and both sides do it. What's weird about this is that in the next few sentences, Milbank totally disproves the above paragraph. He does say that Democrats have become more secular, which I suppose he considers to be an "extreme" view. But then he says "The Republican Party is achieving the seemingly impossible feat of becoming even more theological. Democrats and independents haven’t moved much in their views, while Republicans took a sharp turn toward fundamentalism." Evidently the only position that is not "extreme" is non-fundamentalist religiosity. Or is he just compelled to utter the balance mantra even though he is fully conscious that it is nonsense?

I can't tell.