Category: Healthcare

Long Time Coming, This Virus Crisis

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So, we are now in the world flavored with corona. A world where many still claim that the virus is no worse than the seasonal flu, and that there is absolutely no reason to accept economic damage due to a stated need of preventing an exponential rise of cases from completely overwhelming our medical capabilities. These deniers of all things uncomfortable to them refuse to accept any evidence that hasn’t slapped them upside of their heads with a 2×4. They may be a small fraction of the total population of the US, but they speak loudly, and are prone to simultaneously demonstrate many of their rights, as they parade with placards, guns, and the incongruous mash-up of the US flag and the Confederate battle flag. The images of unmasked faces spitting their hatred towards state legislators will be engrained in the history textbooks of the future as they describe this episode in our nation’s narrative.

These bloviators are encouraged by their cult leader, who speaks in the Twitter language. This is a strange language, where thoughts are compressed to bullet points, and ….. becomes the joining conjunction. I can foresee a future library where these masterful expositions of momentary blips of what passes for thought, are portrayed as the speech form of the future. Forget writing meant to last longer than the moment. That is so elitist! Instead, we need to speak directly to the common man, bypassing the superfluous filter of the media. For too long those people have held sway over the agenda of this nation. No wonder we’ve become the laughingstock of the world, pretending that we cared about anything other than gross economic growth. For the sweet nirvana of growth is the only thing that matters,.

It is truly amazing that this nation can be brought from the “Greatest economy in the history of the world,” within two months to a basket case where people line up for miles in cars in order to access a food handout. One might say that the apparent prosperity we enjoyed was an illusion, sustained by the necessary labor of those we now celebrate as the indispensable ones. You know, those who we truly valued by paying wages that precluded any ability to save. Instead, we encouraged overconsumption by the easy availability of credit. Credit for vehicle payments, credit for mortgages, credit in the form of credit cards that ensnare millions into a life of making minimum payments, credit traps like payday lenders. All it took to pierce this illusion of prosperity has been a simple little invader, the tiniest subdivision of life.

The hollowing out of the economy has taken decades. Every so often, we saw what could go wrong with the increasing financialization of our economy. The practice of using junk bond financing in order to make hostile bids for existing stable companies got a little too brazen. Michael Milken, one of the early users of this technique, found that using insider trading in conjunction with the purchasing of a company worked even better, and eventually he was charged and convicted of securities fraud back in 1989. It is not a surprise to learn that he was pardoned by President Trump in February 2020. But it has not been the actual effect of the technique that has caused the most damage to this nation. No, it has been the modification of corporate behavior as a response to the vulnerability exposed from corporate raiders which has inflicted the damage and greatly increased the inequality we have in our nation.

Once corporate boards realized they were liable to be attacked by outside financial wizards, they took many of the actions those wizards would inflict on their victims. No longer was it beneficial to play a beneficial role in the local economy by paying more in wages, and supporting the local economy through donations. Nay, now all that matters is to reward the stockholders. When you combine that with the opening of China, and its legions of low wage workers and its ignoring of environmental restrictions, you saw company after company outsource production to this new savior of the world’s economy. This nation could survive by doing the design work, and the marketing and sales for the products returning via container ships. Component cost is the sole determinant of what is good. The lower the component costs, the more gross margin can accumulate on the final product.

The next piece in this financialization nightmare came about when computer technology made it possible to arbitrage taxation rates among the various countries. If you establish a subsidiary in a low tax location, then use it to move product from one country to another, you can take some vigorish off the top and allocate some of the supply chain profit to this new entity. Now all nations became engaged in the race to the bottom for corporate taxation rates, since all were liable to be victimized by this new technique, and were likely to see taxable profits disappear from their shores.

Then layer debt onto this structure. Not debt for new facilities, for opening new markets, but debt to directly reward the shareholders and corporate executives by enabling the buyback of shares and goosing the stock price. All are happy (except for those who lose their jobs when business does turn down and the debt repayment leads to bankruptcy of the company).

Of course, there are those people who do not fit into this new world so neatly. They are those who have to provide their labor in a single location, who cannot leverage their skills across the globe. People like those who remove our trash, and serve us coffee, and wait tables or bartend, those who provide health care services, those who are in the first responder ranks. As we’ve seen in these past two months, they are the ones who stitch together the threads of society. Without them, we unravel. That is why this original stand at living in quarantine was so important, since we saw in other nations and in New York what could happen when one essential part of this structure became at risk. When health care workers are overwhelmed, the entire health care system becomes dysfunctional at the very time it is being depended on by so many.

But in the corporate environment we live in, every action has its down sides. By closing the health care facilities to discretionary procedures, only a fraction of the personnel employed at these facilities were needed. Therefore it is the nurses and orderlies and service personnel not engaged in the ICU who became expendable, and were furloughed. So we see the extreme irony of health care workers joining the army of the unemployed at the same time as we are depending more heavily than ever on health care workers. Similarly, as assisted living facilities and nursing homes were co-opted by for-profit companies, the need for profit resulted in fewer and fewer resources being available in the front line of these facilities. For the investors, what was important is that the facilities paid their rents for their buildings, which were owned by corporations separate from the health care companies. Thus, we see deaths concentrated in these facilities as they become overwhelmed by the flood of illness.

When even pandemics are viewed through a partisan lens, it is very likely that no real structural change will happen if and when we return to “normal” lives. Even if the power in the Senate and the White House change in the upcoming election, we know that a substantial minority in this nation will never accept the legitimacy of the government. Somehow, we must break the hold of the personality cult that has poisoned the minds of so many, so much so that they ignore all signs of incompetence and mental illness in their leader. It remains to be seen whether the death and illness caused by this virus will suffice to loosen the bonds of this confederacy of dunces.

Existential Threats Revisited

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Back in 2018, I wrote about existential threats to humanity, or at least to the way of life we have enjoyed. In that post Where the Wild Threats Are , I highlighted seven threats that face humanity. Two of those threats are very germane to the current situation in which we find ourselves. I expanded them into separate posts that I wish to revisit now. They are The Bugs We Fear and the Rise of Willful Ignorance .

In The Bugs We Fear, it covered the overuse of antibiotics leading to reduced effectiveness of those critical medicines, and the increase in viral diseases that we may be prone to. Additionally, the post talked about the increased resistance to vaccinations from those who fear the vaccine more than they fear the disease. Even now, when the entire world is straining to develop an effective vaccine against COVID-19, you see more and more people suggesting that the whole purpose of this virus was to enable the evil globalists to activate their diabolical plots to depopulate the world, and enable a need for a new vaccine that would incorporate the “Mark of the Beast” via nanobots, or some other advanced technology. Once the vaccine is in place, all of us will be mandated to show our proof of vaccination or infection, or else we will not be allowed to participate in society. It is disgusting to see this entire episode of a global pandemic decried as a deliberate attempt to subjugate the world’s population and institute a one-world government, but that is exactly what many people are claiming at this time.

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Which brings me to the second post that is appropriate to revisit. The Rise of Willful Ignorance discusses the attitude of dismissal towards experts and anyone who dares to show expertise. Unfortunately, the actions of the US administration towards the oncoming pandemic showed how this attitude can result in orders of magnitude more collateral damage than if we had heeded the warnings of experts and actually taken effective action before it was too late. Since science presents a reality that cannot be bullied into submission by a personality cult, it has been the scientists at the Federal agencies who have had to deal with the petulance of the leader of this nation. And then when the leader ponders aloud totally ignorant ideas like using oxidizers or disinfectants internally, prompting spikes in calls to state poison control hotlines, it only shows how deeply the willful ignorance runs in this administration. Because the appearance of a disruptive pandemic would wreak havoc in the crowning glory of this administration (the best economy EVER!), the pandemic had to be hushed up. Until the actual rates of infection grew too large to ignore, that is what our leader tried to do. He tried to willfully ignore the existence of this inconvenient new truth. In a pandemic, days matter. The weeksand months that were lost in denial have borne fruit in the enormous number of infections we’ve suffered.

Existential threats are just that. They provide a threat to our very existence, or to the foundations of our society. When you combine two of them as this crisis has done, it becomes a perfect storm and the strings that have held together our society are becoming unraveled. Now we are conducting a gigantic experiment upon ourselves. Can we end up relaxing our mitigation efforts before we have the tools to quickly determine the infection status of all individuals? If we do, and the virus asserts its preeminence over humanity again by successive tsunamis of infection, then the damage done to our economy will be magnified several fold. And the original tolls of hundreds of thousands dead in this country will come true. It was only through the extreme measures we’ve taken that has caused the predictions of the number of dead to be reduced. I fear the unbridled rush towards reopening the economy will result in secondary outbreaks of the virus, and this time, we will not have the will or means to combat it. We’re already in a weakened state from the first onslaught.

May we hope to gain wisdom from our struggles against this horrible disease. And imagine how we would fare against an even more potent microbial adversary, like the ones that used to sweep over civilizations and reorder human relations and economies for decades. The economy we’ve built is too fragile to sustain many more attacks. We will all learn what is to follow in the viral aftermath.

 

Only a Cold

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2020 daffodils 1

I caught a cold last week. It showed its ugly presence on Saturday, with spasms of sneezing, a sore throat, and a developing cough. In the four days since that time, I’ve persuaded myself that it is not the dreaded new disease (no fever or chills), and that the disease is receding as I would expect it to. But its appearance even in the time of increased precautions against viral invaders shows that the new virus can be just as sneaky and opportunistic.

It is amazing how quickly the world has changed. Last week at this time, we were still looking forward to taking a trip to Key West for some hedonism. That was before I saw a cumulative display of disease cases day by day since January. When you see for yourself that the rate of reported cases was increasing by 12% per day, the numbers came alive for me and told me that if we ran the risk of taking a trip, we were not going to have a good time. Even if we safely ran the gauntlet and did not catch the disease, our time of relaxation would be ruined by worrying about making it back in one piece.

Having a background in math and statistics made it clear to me that we are in a global exercise we’ve not gone through since 1919. When a new virus emerges and passes into the human population, one that no one has immunity to, and one that appears to have a significant mortality factor, you have to watch it closely in order to gauge its infectivity and its effects. What is ironic is that China and the US shared an initial response to belittle the potential harm that this virus posed. In China, this resulted in the doctor who raised the initial alarm being censured by the Chinese state, prior to the time that the doctor succumbed to the disease. In the US, the potential for an epidemic was ridiculed by the President and his favorite press sources. We heard about the Democratic hoax that was aimed at bringing down the President. Even today, as of March 17, you can see a post by Dr. Ron Paul decrying the response to this epidemic as being overblown. In both cases, China and the US, precious time was lost in responding to the emergence of this disease. They will only take this disease seriously when family members are stricken by the pneumonia this disease can cause, and those family members are turned away from all hospitals because they’ve had to ration respirators and only those under age 80 will be treated. That’s the decision they are making in Italy, having to ration their available slots to the younger population.

It is a bit jarring to hear myself described as elderly, but since I’ve now crossed the age 65 divide, I now fall into the target demographic for this virus. So far the effect for us has been canceled concerts and canceled trips, and a lack of church services. The chorus we’ve been working on for months, a performance of Carmina Burana scheduled for April, has not been canceled formally but since no one can rehearse for it, it is on borrowed time. Our children are out of the house, and though one son is working in retail and will likely take a hit, we are able to help him out if needed. If we are not hit ourselves by the virus, we will weather the storm relatively easily.

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But for the economy of the world, we are now seeing the issues caused by the streamlining of supply chains by linking to non-domestic sourcing of parts. For decades now, the maxim of running public corporations solely for the maximizing of return to the shareholders has caused businesses to rely fully on foreign partners, either for finished goods, or for creating semi-finished goods that get completed elsewhere in the world. Quality improvement processes preached the benefits of lean assembly lines, since excess inventory hid systemic inefficiencies. So more and more businesses performed global integration of their supply chains. That process worked well until there was a supply disruption at the original point of manufacture. If the ultimate goal is to have product available to sell, then some inefficiency may be needed to allow for supply chain interruptions.

The disruptions in supply chains will continue to ripple through the world’s economy for months to come. Add to that the immediate disruption in the lives of service providers who will be laid off from their retail and food service jobs in the coming weeks, and we have the potential for a huge decrease in economic activity during the year. Already the governments of the world are generating proposals for helicopter money to be shoveled out and spread across the land. All of it with money borrowed from our distant descendents. This crisis has the potential to turn into a debt implosion, with the destruction of much of the seemingly secure capital in the world through waves of bankruptcy and discharge of debt. Will this black swan event be the one that causes the world to fundamentally reset its economic system? Growing economic inequality and growing dependence upon government debt to sustain the illusion of economic growth are at the point of totally collapsing. When no one can keep the appearances up, what happens to the world?

The barren shelves in the stores and the anecdotes about pitched battles for the last shreds of toilet paper have shown us how close we are to unraveling as a civilization. As long as we had sports, and access to material goods when desired, and good restaurants to pig out at, then we were happy. But let us have one week where demand outstripped supply, and we see how thin the veneer of civilization is.

I figured that the tone of this post is so much bleaker than most of my posts, that I needed to leaven it with a reminder that there is still beauty in the world. The pictures are of my daffodils that have burst into glorious flower within this past week. Every year I have a couple of weeks of peak daffodils. This is their time, and a reminder that spring is coming, and better times are ahead. I leave you with a delight of daffodils. Stay well in the days ahead.

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Transition to Medicare

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There must be one heck of a lot of money to be made in signing people up for Medicare Advantage and/or Medigap policies. Otherwise, I would not have been subjected to literally hundreds of phone calls over recent months leading up to my 65th birthday. I have been extremely fortunate, having held family health insurance since retiring from my corporate job nearly 5 years ago. So I had been insulated from any external sales pressure trying to entice me to buy health insurance. That ended this year, when hordes descended on my phone lines (both land-line and cell), attempting to get me to establish a relationship with someone who cold-called me asking if they could be my friend to assist me in choosing Medicare supplemental insurance coverage.

I was fortunate in that my employer, anxious to shed me from their legacy cost structure, offered both a stipend for ongoing medical insurance, and the assistance of a contractor that steered me through the enrollment process. The stipend will not cover the total amount of Medigap and Medicare part D insurance, but it will pay a good portion of it. I am now through the process, although I now am vulnerable to the annual enrollment period for Medicare recipients where I can change my supplemental carrier, if I so desire. Having had all of 2 months of coverage, so far I do not have adequate experience to want to change carriers.

The summer months, though, were filled with calls asking if I needed assistance. It became obvious that the coverage rates were high enough to justify scores of call centers placing calls to me, solely because I was identifiable in their databases as a 64 year old and therefore needing their assistance. The best one was one that my wife fielded when I was not available, where they asked her if she was the one in the family who made health care decisions. We are phone luddites, with both a land line and cell phones, and the land line does not have caller ID, so any call was at least answered. In most cases when I could learn their purpose in calling me, I said firmly but politely, “I’m sorry, I’m not interested,” then hung up before someone could begin their sales pitch. I feel sorry for those whose job is in a call center, since they encounter the worst of humanity. I definitely do not wish to inflict them with additional angst from an uninterested caller.

What is interesting in this day is that we are hearing a call for adoption of a Medicare for All program as part of several candidate’s platforms. These platforms also call for the abolishment of private health insurance as part of an implementation plan to convert to a single-payer system. Well, the current Medicare system certainly has room for private insurance plans to fill in the gaps around the basic core. And it is clear that a government mandate to forcibly give up current insurance coverage, however inadequate it has become due to higher deductibles and higher copayments, will create significant resistance among many American voters. What would seem to be a better way would be to create an alternative option for health care coverage. For those who currently hold health insurance, a mandate could be placed upon employers that they offer the public option as one of the available options for employees to choose, and that employers have to provide a subsidy equivalent to what they are providing with their current insurance package. Then the public option would be enabled to begin to unravel the excessive overhead found in current for-profit insurance coverage. Over time, this will result in the public option costing employees less, while providing better coverage due to reduced deductibles and co-payments.

For those who do not currently have employer-based health insurance, this public option would be placed upon the health care exchanges, and people would be able to select a plan with greatly-reduced premiums. If the marketplace is allowed to function properly, the competition from a public option will result in insurance providers trying to match the public pricing. The cost for health care will bend lower over time, and if the public option ends up becoming the preferred option, then we may find ourselves in a situation where a Medicare for All system is the de facto choice, without it ever being mandated as a de jure choice.

The march towards progressivism in the Democratic party at present has flaws built into its logic. It presumes that there is such a pent-up demand for their prescriptive solutions to the ailments of our society that this nation will choose a mandated big-government program. My fear is that if such a proposal is adopted officially by the Democratic nominee, the disgust that permeates US society towards Federal Government mandates will result in the re-election of the current President. That would be the greatest tragedy of all.

 

The Bugs We Fear

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Back in May, I wrote a post detailing some of what I perceive to be threats facing humanity. This is the second of what will be seven posts providing more details on each of these threats. This one concerns infectious diseases.

Starting in the 1940’s, modern medicine discovered the magic bullet of antibiotics. Antibiotics have prolonged the lives of hundreds of millions of people by enabling bacterial diseases to be stopped before they created sepsis inside of humans, and caused massive organ failure. The practice of medicine soon became the story of the prescription of antibiotics, and the eventual over-prescription of the same. Once the knowledge of the power of antibiotics became known, the customer (i.e., the patients) were insistent on being prescribed antibiotics even when they suffered from a viral infection, like a cold. All of society believed that antibiotics were able to put the suffering of the past from bacterial infection out of the memory of humanity.

Except. Except that human greed and the needs of commerce got in the way. Except that human behavior caused the effectiveness of antibiotics to be compromised. Now, barely 77 years after the first widespread use of an antibiotic to treat diseases, the news is full of stories about bacteria that are resistant to all but the most powerful antibiotics, and even some strains of bacteria have developed resistance to all forms of antibiotics. How did we get here? It started when agricultural researchers discovered that by applying low-dosages of antibiotics to animal feed, weight gain for the animals was increased and disease incidence was reduced. Since agriculture in the US relies upon high animal density in farms and feed lots, and since anything helping the profit margins of farmers was viewed as a God-send, commercial animal feeds began to incorporate antibiotics as a key additive. Unfortunately, this served as an ideal breeding ground for bacteria to show the powers of evolution. Ever wonder why all antibacterial commercial products claim that their product kills 99.99% of bacteria? It’s because there are always a few bacteria that have a mutation that enables them to survive the onslaught of the chemicals aimed at killing them. It may not be a concern for a kitchen countertop to have some bacteria that survive bleach or other similar kitchen cleaner. But it is totally different when a strain of bacteria survives a dosage of antibiotics inside of a farm animal. That strain now faces less competition since many other bacteria were inhibited by the antibiotics in the feed. Soon, the resistant strain is circulating among farm animals, and slowly the antibiotic in the feeds lose their effectiveness as the population of resistant bacteria increases in the environment. Since they began to incorporate antibiotics, animal feeds have used most of the types of antibiotics, which means that effectiveness of many antibiotics have been lowered over time. Market demand is now pushing agricultural firms to proclaim that their animals are antibiotic-free, but only time will tell if that movement will grow fast enough to keep antibiotics at least partially useful.

Human behavior also plays a role. As noted earlier, patients often demand a prescription for an antibiotic even when their infection is viral. This dosage of unneeded antibiotics increases the chance of developing a resistant strain directly inside of a human. Add to this the tendency for some folks to stop taking a medicine once they feel better, and you end up with the worst case for developing antibiotic resistance. By not taking the full course of antibiotics, it is more likely that some of the bacteria will survive, and then their traits will be passed on to subsequent generations of bacteria. One way or another, the bacteria will outwit us as we currently use antibiotics.

But bacterial infections are only a part of the disease story. Viruses cause many more diseases, and there are several factors in our modern world that enhance the possibility of a viral infection causing huge problems in our society. First, viruses are mobile. They can hitch a ride upon any animal infected with the virus. Whether that is a chicken carrying the latest variant of bird flu, or whether it is an international traveler that had unknowingly been exposed to the latest version of Ebola or Marburg disease from Africa, viruses can travel amazingly fast in our modern, interconnected world. Then there is this little issue about climate change. Regardless of the source of a warmer climate, one result is that mosquitoes that are intolerant of cold, are now expanding their ranges into temperate climates. Thus malaria is expanding its range. Other viral diseases that once were known only in Africa are now showing up in Sardinia, a handy stopping place on the way to infect southern Europe.

Yet another factor is affecting viral disease transmission. Through extensive research, humanity has managed to control the immune system to enable it to react to viral invaders that can cause diseases. Thus, humanity has wiped out the dread disease smallpox as a scourge. Only remote pockets of polio remain, which means this crippler of people is nearly extinct. Who remembers iron lungs where the sufferers of polio were kept, enabling them to breath until they regained at least a semblance of muscle strength? The use of vaccines has greatly limited tetanus, and diphtheria, and whooping cough. The old childhood diseases of measles, mumps, and chickenpox are no longer rites of passage for children. All have been vanquished through the use of vaccines.

Except. Except that a growing percentage of the population no longer believes that the benefits of vaccination exceed the perceived costs. Especially with the growth of the internet, there are groups convinced that vaccines are causing the growth of conditions such as autism. And therefore they are opting out of mandatory vaccination protocols. Either opting out, or spacing vaccinations out over a longer period than recommended, all in a belief that they are protecting their children from a fate worse than the disease that the vaccine is intended to prevent. What this is doing is increasing the percentage of the population who does not have immunity to the disease, and as a result, diseases that had been nearly eliminated are making a comeback. In 2017 there was an outbreak of measles, mainly within the Somali immigrant population around Minneapolis. According to the CDC, the rate of measles vaccination of Somali children was only 54% in this area. This enabled measles imported from a visit from Africa to spread throughout the community, until 65 cases were recorded. Of those, 20 required hospitalization. I remember my own case of measles, back in 1961. I contracted it right after my tonsillectomy, another rite of passage that is no longer nearly universally prescribed. It was not fun, but I did not suffer any of the permanent effects that could have resulted.

How should we deal with infectious diseases in the future? Certainly there is a need for more pharmaceutical research in antibiotics. If we can stay ahead of the resistance curve, we may still be able to keep the tragedy of blood poisoning from killing thousands and thousands each year. Unfortunately, pharmaceutical companies are not investing heavily into antibiotic research. The perceived market is deemed too small to justify the vast expenditures required for drug development. This is an area where government-directed research is required since the lack of private company research does not appear to be amenable to a market-based solution. The current trend towards reducing antibiotic supplementation in animal feed needs to become universal. This may be a problem though, in other countries where a simple and cheap way to control animal disease and increase animal yield is not viewed as an existential threat.

Finally, for viral diseases, there may not be good ways to deal with them. The warming of the climate will result in the spread of many diseases beyond their current tropical ranges. Unless we can put the climate warming genie back into the bottle, we may have to deal with the effects. Vaccine development is required, and investment in additional vaccine capacity for diseases such as yellow fever. But the hardest problem to deal with may be the human resistance to acknowledge that science has the answer for disease prevention. It may never be possible in this fractured society to convince a large enough percentage of the population of the benefits of a vaccine. There will always be self-sustaining groups who convince themselves that they know more than all of the scientists in the world. After all, the scientists are the elites who have failed us, right?

 

Modern Medical Morass

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Medical maze

I had a very interesting discussion with my orthopedic physician a while back (as I age, I seem to collect more and more physicians of different specialties). He was helping me to decide a course of action to take with my balky knees that have deteriorated over the course of my lifetime, and as we discussed the specifics of my knees, we diverged and ended up discussing a wide range of topics concerning the US health care system.

He was of the opinion that the current system we have for health care is incredibly inefficient, and shared an anecdote to illustrate his point. A woman came into his office complaining of leg pain and weakness. She had been to multiple physicians in the past but had found no relief. As his assistants were taking her history, and conducting an initial assessment, they sensed that her problems were not in her legs, but were caused by back problems. They discussed this with the doctor, and he agreed that an x-ray of the back was justified.

The x-ray revealed that the patient had significant arthritis in the back, resulting in bone-on-bone contact for at least one set of vertebra. This had caused impingement on nerves going down the legs, accounting for her symptoms. The normal progression of the diagnostic process would call for a MRI exam to confirm the extent of the back issue.

But. The insurance company response to this type of diagnosis is firm and consistent. No MRI will be authorized until the patient has exhausted all other options. In this case, it means that the patient was referred to physical therapy for a 6-week course of treatment. So the insurance company was willing to spend $3,000 on a course of therapy in order to avoid a MRI expense (I have no idea what an MRI costs), with its potential diagnosis of a need for back surgery at much greater cost.

The doctor had referred the patient to therapy, and the course of therapy had not yet been completed. He said that he fully expected that the patient will have no improvement from this expensive course of treatment, and then he will be able to get the approval for the diagnostic tool he knows is necessary for this patient to finally find relief through treatment. He speculated on the reason why insurance companies would go this route – refusal to fund an expensive diagnostic tool but approve an even more expensive course of treatment. His speculation is that actuarial analysis shows that if even a few patients do receive help from physical therapy, or a few patients die during the course of therapy, or a few patients give up on the process and just keep suffering with their ailment, then the avoided surgeries more than offset the cost of the therapy.

My doctor was very generous with his time with me. We did discuss my options, and my preference for lower levels of intervention. Right now I am receiving periodic injections of cortisone. More intrusive means of treatment are available if I don’t have relief from this level of treatment, up to and including knee joint replacement. I am very grateful that my doctor has allowed me to have enough information to make an informed decision and to be an active participant in my treatment.

We discussed the problems that the current insurance-based systems impose upon doctors being able to provide options to patients. He presented a hypothetical case where a patient with a high-deductible insurance policy, but with a health savings account, would come in with symptoms that indicated a need for further investigation. The two choices would be an MRI (expensive, but comprehensive), or an ultrasound (less-expensive, but not as sensitive and potentially could miss rare issues that an MRI would pick up). The current environment would indicate that the standard of practice is to insist upon an MRI, and if the physician should ever be in the position where he / she went with an ultrasound, and that patient happened to have that obscure condition that only an MRI would detect, he / she would be liable under malpractice litigation for not following the standard of care.

But if the doctor and the patient could enter into an agreement where the patient accepted the risk of a potential for a missed diagnosis for a rare condition, in exchange for a lowered payment for the test, then overall costs for the medical industry would be reduced. That is just not possible right now, but with the huge increase in insurance deductibles, it may be coming back. No, my doctor said that at present, he has the need to reduce his liability risk to zero by over-prescribing diagnostic tests since there exists no mechanism to transfer the risk for a missed diagnosis to the patient. This is where my doctor says that the malpractice industry has raised medical rates, by insisting that all illness can be detected or treated if only the patient is tested for all potential conditions related to their symptoms, regardless of the likelihood of a rare condition. Thus a huge cost results from the excess diagnostic tests required to detect the condition that afflicts a few tenths of a percent of the population.

My doctor expressed hope that a single-payer system would emerge out of the morass of the current health-care system. He acknowledged that any such system could have its own set of problems, but he seemed to be comfortable to accept standards such as Medicare has established for treatment to be extended to the population at large. Insurance companies would still have a role in administering claims, but the ability of doctors and patients to have a say in the treatment protocol would be greatly increased.

During the uproar with the Affordable Care Act, much was made of the imposition of “death panels” who would represent government imposing life and death decisions upon poor helpless upright citizens of the US. What opponents of the Affordable Care Act have always refused to acknowledge is that the “death panels” they feared have always existed, and they belong to the faceless bureaucracy of the insurance companies, doing their darnedest to increase both the complexity and costs of the medical profession, and actually harming patients in their insistence to adhering to rigid and often obsolete standards of diagnosis and treatment.

But what do I know? I’m only a consumer of the medical industry, with very little input on treatment options and zero input on the cost of the approved treatment. I am very thankful for physicians like my orthopedist, who is treating me as a full partner in my own treatment, and who is willing to share his thoughts on the medical system.

 

Let the Games Begin

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Let’s get ready to rrrrruuuummmmbbbblllle! The Senate Republicans have now laid down the gantlet, and it is now time for us to have a complete and thorough discussion and debate about government involvement in the health care system. One where open suggestions and ideas may be freely floated, and where hearings will bring forth legions of experts, putting forth the benefits of the case for both parties.

Oh. You mean that’s not going to happen? We’re going to barely have a week to discuss and debate this immense change being proposed to our already dysfunctional health care system, then a vote will be forced through? No other alternatives except for what 13 white male Senators came up with will even be considered?

I am truly disgusted by the spectacle of our legislators working hard to craft a bill aimed at causing the greatest amount of harm to the greatest number of people. The old adage was that the legislative and bill drafting process was akin to making sausage. That may still hold true, but it seems that a new step is added whereby the sausage has to pass through the digestive system before the new legislation is laid, steaming fresh, at the feet of its admiring partisan supporters.

It has come down to this. Both parties repudiate any notion of working across the aisle in order to craft a thoughtful comprehensive approach to dealing with the huge problem we have with excessive costs and maldistribution of health care services. Instead, one party works diligently behind closed doors to create a tax cut that only affects those who have income greater than $200,000 per year ($250,000 for joint filers). True, it also removes $19 billion in taxes imposed on medical insurers, pharmaceutical firms, and medical device manufacturers. The removal of these taxes shows the value of campaign contributions to the Senators who drafted this legislation. I saw today on TV that over the past few years, these Senators received about $0.5 million in campaign contributions from these entities. $19 billion / $0.5 million = $38,000 in tax benefits for each dollar in campaign contributions.

So we have a bill nominally posited as a health care bill, but in reality it’s a tax cut favoring the top 1% of income earners, and favoring those whose businesses greatly benefited by the increased demand attributable to the Affordable Care Act. And in order to frame this as a win for the average person, we will enable states to allow for limited insurance products, much like it was prior to the ACA’s implementation. Can’t wait to see the expression on the face of some poor schmuck who grabbed on to one of the new cheap health care insurance plans only to find out it pays a total of $400 per day for hospitalization expenses when they have to cover a heart attack hospitalization.. But it’s all good, since the health insurance consumer could have chosen a better plan (but couldn’t afford it).

Let’s have a real debate as the outcome of this faux discussion. Let’s make a determination whether we believe the US is an outlier from the rest of the civilized world, and make health care an independent responsibility, or whether we wish to join the rest of the world and enable a single-payer system to provide health care for all citizens.

My confidence that this type of discussion will occur in the hallowed halls of Congress? Less than the square root of negative 1. My reasoning? There is zero incentive for members of Congress to reach across the aisle and actively involve the opposition party in legislative negotiation. As the French have said, La Plus ça Change, la plus c’est la même chose. The more things change, the more they remain the same. It sounds better in French.

Whatever happens with the current health care bill negotiations, I sincerely doubt whether the outcome will improve the situation for the majority in this country who are dependent upon either government policies directly, or dependent upon the structures set up by the ACA.

I call for the creation of a brand new party that is no beholden to the existing power structure. I call for a Macron-like entity to take over US politics from the completely corrupt and compromised party structures that we are burdened with. Part of our problem in the US is that we do not have a parliamentary structure. If we did, then Nancy Pelosi would have been driven from her leadership position in disgrace over the last few election cycles as her position would have been exposed as having a fatal flaw. Meaning, the vast majority of voters in this country do not agree with a San Francisco liberal.

Nothing will happen unless enough of us speak out and demand change. Even then, there is no guarantee that we will see significant change. But I do know that if no one speaks out, there will be no change. I am speaking out, here and now.

Ghosting, or Sloth? You Decide

evenabrokenclock101 Comment

Targets

We are in the midst of a target-rich environment. There are so many manifestations of incompetence and evil in the current administration that it is difficult to single out one as representative of the whole. So let’s bore in on a single area that most reasonable people feel is important. Let’s look at the number of roles in the Department of Defense that require Senate confirmation, where a nominee has been confirmed and is serving. The Department of Defense has 55 such roles. As of April 24 (last date I could find easily through search engine), guess how many people had been confirmed.

Give up? Exactly 1, Secretary of Defense General Jim Mattis.

How many of the 55 roles have had people nominated? Again, as of April 24, exactly 4, and two of those failed confirmation. How many more have been announced, but the nomination has not been transmitted to the Senate? Exactly 7, and one of those nominations for Secretary of the Army (replacing one of the failed nominations) has been withdrawn since April 24.

How many positions remain to be announced, nominated and confirmed? Forty-three positions are in Trump-limbo, awaiting any action to be taken. Now, this is the Department of Defense. Few people would argue that this is one of the governmental functions that should be staffed expeditiously in order to ensure that the department is able to perform its prime directive of keeping the nation safe. And yet here we are, 3 1/2 months after the inauguration and nearly 80% of the roles needing Senate confirmation have not even had an announcement of a candidate for the role.

It appears that one of the guiding principles of this administration is that they consider governmental agencies to be grossly overstaffed, and therefore substantial savings can be made by refusing to fill roles within the government. But to this outside observer, failure to staff essential roles will soon lead to paralysis within governmental agencies, leaving them unable to fulfill their duties. Many small-government champions may view this as a victory in the case of departments like Labor, or Education, or other similar agencies viewed as hotbeds of excess regulatory activity. But the Department of Defense?

If the act of leaving roles requiring Senate confirmation vacant is a deliberate decision being made as part of a strategic process to force administrative shrinkage, then let that be announced and we can debate the merits of the strategy. But if what we have is the Trump administration simply ghosting the agency positions, deliberately ignoring the need to fill them so as to hope that they go away, then we have yet another glaring example of the incompetence of the Trump administration.

There is one other possibility that comes to mind. What if there have been attempts to identify candidates for these roles, but either those candidates refused to be considered, or they were considered and then failed their background and security clearance process? Given the nature of this administration to be an information black hole, we may never know the full story.

So this is one simple example of how this administration has hit the ground and immediately assumed the prone position. An administration led by a caricature of a leader, who only knew how to drive his businesses into bankruptcy. An administration which found an eager legislative partner, looking for ways to implement Randian philosophy and effect a total reversal in government direction. This is where the discussion of evil comes into play. There are undoubtedly sincere conservatives who still believe that the country ran off the rails of Constitutional intent when the New Deal was adopted. That is a valid perspective, and it could be debated through the electoral process.

But this election offered a bait and switch. Campaign promises to drain the swamp of undue influence by banks like Goldman Sachs, only to reverse that pledge and fill the swamp with hordes of Goldman Sachs employees and alumni. Campaign promises to get this great new improved health care system that will cost less and provide better services. These promises were co-opted by the Ayn Rand wing of the Republican party into the AHCA, and once the bill passed the first step in the legislative process, they celebrated with Bud Light as they had designated bus drivers take them down the mall towards the White House. You know, that last bit may be the worst of all of this. To think that Republicans believe Bud Light is actually beer says more about them than all of their pronouncements of the moral inferiority of those who develop pre-existing conditions.

We now have a massive tax cut for the truly wealthy disguised as a revamp of health care legislation. If failure to staff the government is one of the manifestations of incompetence of this administration, then allowing this reversion to the bad old days of insurance company death panels represents the evil side of the administration. And still, the true believers do not realize that they have been trolled by experts as they pledge undying support for their supreme leader. If this legislation actually does pass, then their undying support will likely turn into dying support as states requesting waivers to the mandated treatment standards remove drug abuse treatment from insurance. The waivers will reinstitute lifetime caps on payments. But for those who are fortunate enough to remain healthy, they will save a pittance, and the Republicans will say, “See! We came through for you!”

Are You Calling Me A Socialist?

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Disgruntled Republican Voter: I’m sure glad that I’m not one of those takers who expect the government to subsidize their health care. Everyone who takes a subsidy from the government is lazy and needs to get a better job that covers them.

Disembodied omniscient voice from above (think James Earl Jones): I’m glad you don’t want your health care subsidized by the government. So you will be in favor of having your health care from your employer being declared as income, and then you can pay taxes on it, right?

Disgruntled: I say – what are you talking about?

Disembodied: Health care benefits have never been considered as taxable income. This is a historical artifact from the time that health care was first provided to employees in WWII as a way to skirt wage controls.

Disgruntled: So what difference does it make who pays for it?

Disembodied: If businesses had to declare the value of health care as income for their employees, then the employees would be liable for taxes on this income. You just said you’d be happy to pay the taxes, right? Just so you wouldn’t be taking a subsidy from the government.

Disgruntled: I’m not sure … how much are we talking about here?

Disembodied: Let’s just use average figures here. You have family coverage, right?

Disgruntled: Yeah.

Disembodied: Average employer cost for a family policy last year was $12,600 per year. Now you are pretty successful, you make between $19,000 and $75,000 per year, right?

Disgruntled: Yeah.

Disembodied: Then you are in the 15% tax bracket. So if you had to declare $12,600 more in income, that means that the federal government is giving you about $1900 in tax subsidy for your policy from your employer. The one that distinguishes you from the moochers who get a government handout, right?  But then there’s more.

Disgruntled: More?

Disembodied: You live in a state with an income tax, right? Say the tax bracket for your state is 5% for your income. Then the state is giving you a tax subsidy of over $600.  That brings your total tax subsidy to about $2500 per year. But then, there’s the FICA tax to consider.

Disgruntled: What?

Disembodied: Since your taxable income just went up, you owe social security and medicare tax on this new income. So for $12,600, your tax that you don’t have to pay at all is almost another $1000 per year.  And your employer also avoids another $1000 per year that they’d have to pay to match your contribution.

Disgruntled: Ouch!

Disembodied: I calculate that due to the way that health care is accounted for in the tax code, your avoided tax is just about $3500 per year, and your employer avoids paying an extra $1000. So I’m glad that you’ve decided not to be a taker of government money, because your government could sure use the extra $4500 that you said you’d be willing to pay.

Disgruntled: Now wait a minute, I never said …

Disembodied: Oh yes you did. You said that you’d never want to be one of the takers who takes a subsidy from the government. That means you want to correct this problem in the tax system. Of course, if you were in a higher tax bracket, like 25%, you’d be getting even more free money from the government.

Disgruntled: You’re using fake facts. You’re probably part of the lying media. I’ve never seen anything about this on Facebook.

Disembodied: Believe what you will. Reality does not change based upon your beliefs. The facts are that you get money from the government to subsidize your health care benefit that you earn. Of course, you still pay all of the out-of-pocket and shared premium as well.

Disgruntled: And they keep going up and up. It’s all due to Obamacare.

Disembodied: Health care costs have been going up faster than inflation for decades before the ACA came into being. One reason is due to the screwy way health care gets paid for. We spend over 25% just on the administration. Funny thing is, when you have a single payer system like Medicare, that administrative burden goes down to about 5%.

Disgruntled: You mean single-payer would cost less? Why don’t we consider it?

Disembodied: Because the 1% class you put into the government believes that only moral reprobates who have immoral habits get diseases or have accidents, and they are the ones who drive up costs for the superior class of folks who have employer-paid health care. Besides, the 1% gets a hell of a lot of tax cuts when the taxes that supported the ACA are backed out.

Disgruntled: Yeah, but isn’t single payer socialism?

Disembodied: You mean the current system that gives free money to taxpayers and employers to have employer-based coverage isn’t socialism? Isn’t that government picking winners and losers? You’re a loser if you work three part time jobs and 60 hours a week but none of your employers provide health care and you don’t deserve any government subsidy? You’re a winner if you work for someone who provides health care as a benefit?

Disgruntled: Nobody knew health care could be so complicated.