On Wyden-Bennett

August 13, 2009 at 4:38 pm (By Maxwell James)

Like President Obama, if I could wave a magic wand and create an all-new healthcare insurance system for the United States, I would probably choose single-payer. Yes, it can create rationing problems, but with proper incentives to expand supply this can be managed reasonably well (as it is in Canada, France, and the Netherlands). It is inherently more cost-efficient – as Nate Silver argues, health insurance competition, particularly the sort of mini-monopolistic competition we have here, does little to control costs or improve services. It would cover everyone. And it has the attraction of being simple and easy to understand.

But, that’s not the world we live in. Most Americans don’t agree with me; they don’t want single-payer healthcare. And increasingly they don’t seem to want the “public option” either, either because they think it will constitute single-payer by stealth, or that it will turn into another Fannie Mae. So it goes.

And yet healthcare reform remains necessary. Healthcare costs have been rising at an unsustainable rate for decades now. Those costs will bankrupt Medicare in just a few years if nothing is done. We also have de facto rationing by the market, along with priviliged care for the wealthy who can jump lines the rest of us cannot. And for all that we spend on healthcare – 17% of our GDP – we don’t get quality of care that is especially good when compared to peer nations.

So with all that said, I’d like to put in a few kind words for the other healthcare bill floating around Congress – the Healthy Americans Act, or Wyden-Bennett.

Wyden-Bennett strikes me as a definitive example of radically moderate legislation. It’s radical because it breaks the key feature of our current insurance system for people under 65: the tax break on health insurance when it’s paid for by your employer. It’s moderate because it achieves near-universal health insurance while actually increasing market competition. And according to the Congressional Budget Office, not only would it be budget-neutral by 2014 (as of 2008), but in time it could actually reduce our government’s expenditures.

How does it work? Wyden-Bennett mandates that all Americans and permanent residents (other than the elderly and the military) must purchase private health insurance  through a state-based pooling system. This purchase would be facilitated by a large tax exemption ($6000 for individuals, up to $15,000 for families) that decreases as income rises, eventually disappearing for earners in the top tax bracket. People under a certain percentage of the poverty line would be eligible for a voucher on top of that. The premiums you would pay for your insurance would be community-rated on the basis of your pool – i.e., sicker people would not have to pay higher premiums.

For most people this would replace their employer-based insurance; it would also replace Medicaid and SCHIP programs, as well as the individual insurance market.This is of course the most radical aspect of it, since the conventional wisdom is that most Americans like their current insurance and want to keep it. Of course, that conventional wisdom was formed in 1993 during the Clinton attempt at healthcare reform; things have changed since then.

For example, portability of healthcare insurance, has become far more important. Very few of us keep the same job our whole lives. And very few of us remember the last time our country approached 10% unemployment. If you would resist Wyden-Bennett on this basis, it’s worth asking: if you were to lose your job, how quickly do you think you could get a new one in this economy? What kind of job could you replace it with? The simple fact is that for anyone who does not have tenure, relying on your employer for your health insurance is considerably more risky than it used to be.

Wyden-Bennett would establish standards for the new plans offered through the pools that would be actually equivalent to the Blue Cross/Blue Shield plan that is currently the standard for federal employees. It would control costs by offering incentives for insurance providers and healthcare providers to improve efficiency, and for purchasers to engage in preventive care. It’s not perfect by any means – and it desperately lacks a constituency to get behind it. But it’s the best option currently on the table.

For further reading:

Here is a balanced analysis of Wyden-Bennett by the Center on Budget and Policy Priorities.

Here is a tool from the Kaiser Foundation that allows you to compare the current health care reform plans side-by-side.

Here is an interview between liberal health care policy wonk Ezra Klein and conservative senator Lindsey Graham on Wyden-Bennett.

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Hyperbole and Hysteria: Immune System of the Body Politic?

August 13, 2009 at 11:57 am (By Amba)

I’ve never heard the word “fear” used so much on television.  “Do you fear a government takeover of health care?”  The conservative and Republican strategy has been to block this bloated reform package by frightening the citizenry with unfounded rumors about “death panels” and the like.

Maybe, in the fog of Too Much Information, scare tactics are the only way to get citizens involved.

I know that what I feel for that 1,000+-page bill I’ve read only bits of isn’t fear; it’s loathing.  Prove to me if you can that big government bureaucracy isn’t the most inefficient, wasteful, and unaccountable way to do most things.  (Exceptions like the CDC, which facilitate a swift, centralized, coordinated response, often turn out to be subsets of defense — and I’d hate to start reading about what’s wrong with the CDC.  FEMA should have been a subset of defense, too.)  Government can play an excellent role in establishing ground rules and incentives that reward economic efficiency and quality care — learning from the best private innovations and creating circumstances that make it easy to study, adapt, and reproduce those best practices (which cannot be assumed to work exactly the same way in different places). 

I like this image and so will repeat it for about the third time:  government is meant to fine-tune the engine, not to be the engine — as such, it’s a gas guzzler with tailfins! 

But that isn’t fear.  I’m very struck by the way conservatives see the federal government as sinister and inimical, as if it were some alien cancer on the body politic, while liberals tend to view it naïvely as just “us” — a basically healthy organ of the will of the people.  If representative government has mutated into a cancer, it isn’t alien — it’s one that arose from within.  In my view, it’s really more like a large benign tumor:  more burdensome than toxic.  Yet there’s always been a suspicion, which flared up in the Red Scare of the 1950s and is baa-aack in the claims that Barack is “furrin,” that alien ideas are being injected into the system and causing some citizens to mutate into aggressive enemies of freedom.  On this analogy, fear is inflammation.  “Inflammatory” rumors, or humors, are arousing citizens to surround and attack “un-American” ideas, as white blood cells recognize and destroy anything in the body that’s “not-me” — and sometimes, in their zeal,  turn on the body itself.

You tell me whether the town hall shouting matches are a healthy immune response or a runaway autoimmune disease.  Then I’ll tell you what I think.

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Max’s Last Meal [UPDATED]

August 12, 2009 at 3:18 pm (By Amba)

I feel like an idiot, just like I knew I would.

I knew I was going to break and spend several hundred dollars I can’t afford to hear a vet tell me what I already know:  that our cat Max is at the end of his life.  And sure enough . . .

Max has been failing:  losing weight, sleeping by the water bowl despite the subcutaneous fluids I had begun giving him.  He was eating hungrily, but that was one of two things:  Max has always loved food more than anything, and it was his last pleasure (I can relate); and/or he was feeding a cancer.  He came to us as an adult so I’m not precisely sure of his age, but seventeen is a good guess.  When a seventeen-year-old cat starts to go downhill, it’s usually kidney failure, cancer, or both

The last couple of days, Max was unable to eat much (though still interested), drinking less, breathing a little fast, a little labored.  Two days ago his belly began to swell with fluid.  He just lay in a corner, and I thought it was time to have a vet come to the house and euthanize him.

Then he got up, ate, drank, washed his face, scratched himself (staggering a bit), and came over to hang out with me.  He still seemed interested in living, so (after consulting my beloved vet friend Rick from New York who now lives in SC) I decided I had to look into the slim chance that it was something treatable for a little while, like heart failure.

This always happens.  And it never ends well.

*     *     *

Max was given to us in the mid-’90s, along with his portrait, by the artist Bill Adams (an old family friend of the Love Goddess), who was about to marry a video artist who was allergic.  (Freed from reality, the cats in Bill’s art have gone on to become quite fantastic, even a little scary.)  A few months after the transfer, Bill came over to visit.  As we sat across the table from each other, Max went and lay down on the table in front of Bill.  As the time approached for Bill to leave, Max pointedly got down from the table and lay down on my feet.  He could not have made himself clearer.  I was greatly touched.

The editorial asssistant.

The editorial asssistant.

It’s a rare cat that can walk into a household of strange adult cats and not cause a ruckus.  Max was that cat.  It’s the territorial terror of the newcomer, the stink of fear, that usually sets off aggression from the homeboys.  Max simply walked in calmly like he owned the place, so the other cats shrugged and guessed he did.

He was just a Humane Society kitten, but he had the air of a portly and faintly melancholy gentleman, and the tastes of a reincarnated gourmet chef.  Max doesn’t just love food, he loves well-prepared food with spices and sauces, much preferring it to raw or plain cooked meat.  Dinnertime approaching?  He ‘s on the table, purring with anticipation.  We let him, because it’s usually just us.  Our occasional guests either roll their eyes and tolerate it or remove him gently to the floor, where he is consoled with his own plate in the kitchen.

maxbowl

Max is deeply kind.  Lucky, the cat we rescued from Romania, who had been a tom for many years, used to attack him.  And yet, when Lucky was blind, deaf, and dying of kidney failure, Max lay down touching him.  Again he made his meaning clear.  There was no other way to understand it than as an attempt to comfort and orient.  Since then I’ve called him Dr. Max.  Other effanineffable nicknames; Perp (from “he’s so orange he’s almost purple”) and Roadie (from “Roadblock,” because he’s always right where you want to go).

maxshoes

*    *    *

The vet cut to the chase, doing an x-ray and a tap of the fluid in Max’s abdomen as the best way of getting the big picture.  The x-ray showed fluid in his chest as well as belly, probably making him feel as if he’s suffocating.  The tap showed lymphocytes in the fluid.  Probable lymphoma.

We could either do more tests to be sure, plus some palliative, temporary fluid removal, or put him to sleep.  Only the latter made any sense, and not just financially.  I was prepared for this.  I hadn’t wanted to cry and get the professional comforting, but of course I did that too.

I wasn’t tough enough to have him put down right then and there in the vet’s cold, bright office.  I wanted J to see him again and I wanted Max to be at home, comfortable and happy.  So I’ve arranged to have one of the vets come over tomorrow morning.  Costs more, but what the hell.  It’s the diagnosis I should’ve skipped.  This is the good part of my folly, the part that’s not negotiable.  The vet gave Max a lasix shot to reduce the fluid and keep him comfortable.  He’s much more able to purr and express his relief at being home.  (And of course J is saying, “Maybe you shouldn’t be in too much of a hurry to put him to sleep.”)

So now I’m pondering what to make for dinner tonight.  Tilapia, I think, dusted with flour and cumin and browned in a mixture of canola and toasted dark sesame oil.  Max loves that.  So do we.  He’ll be on the table, and we’ll eat together for the last time.

One year ago

One year ago

UPDATE: We did make the fish; and as the aroma of cooking circulated through the apartment, Max did indeed appear.

Max's last meal.

Max's last meal.

But he didn’t lie down on the table and purr afterwards the way I hoped he would.  Instead, he hurried back to the bathroom to lie down behind the toilet — a cat’s way of saying “I feel like shit.”  (I’ve actually seen a sick cat express this by lying down in its litterbox.)  He reappeared twice more tonight asking with rueful eyes for more fish, ate, and after eating, retreated back to the bathroom rather than lying down comfortably and companionably.  While that was a disappointment, it was also a heavy-hearted confirmation that we’re on the only possible path.

There’s been a change in J from a year ago, too.JMax's

THURSDAY MORNING: Ave atque vale, Max.  He came out and spent the better part of an hour purring with me before the vet came.

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Exactly

August 12, 2009 at 2:55 pm (By Maxwell James)

What E.D. Kain said. I don’t think I’ve seen a blog post on healthcare reform that I agree with more.

I am increasingly of the opinion that the president made a major mistake when he came out swinging for the public option. The core problem for the insured and uninsured alike in this country is that quality health care is increasingly unaffordable. Universal coverage is important, but more for its portability than for the myth of efficiency that surrounds it. Obama should have come out for any health care plan that a) rewards innovation and efficiency in the delivery of healthcare services, b) disentangles coverage from employment,  and c) provides an affordable subsidy to support the unemployed or otherwise uninsured. He decided to name the means instead of the ends, and that was a serious unforced error.

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On Marshmallows and Willpower

August 12, 2009 at 10:01 am (By Maxwell James)

Amba’s recent post on the elements of a successful life, along with Pat HMV’s response, put me in mind of this New Yorker article I read while at the doctor’s office.  Here’s a taste:

In the late nineteen-sixties, Carolyn Weisz, a four-year-old with long brown hair, was invited into a “game room” at the Bing Nursery School, on the campus of Stanford University. The room was little more than a large closet, containing a desk and a chair. Carolyn was asked to sit down in the chair and pick a treat from a tray of marshmallows, cookies, and pretzel sticks. Carolyn chose the marshmallow. Although she’s now forty-four, Carolyn still has a weakness for those air-puffed balls of corn syrup and gelatine. “I know I shouldn’t like them,” she says. “But they’re just so delicious!” A researcher then made Carolyn an offer: she could either eat one marshmallow right away or, if she was willing to wait while he stepped out for a few minutes, she could have two marshmallows when he returned. He said that if she rang a bell on the desk while he was away he would come running back, and she could eat one marshmallow but would forfeit the second. Then he left the room . . .

Carolyn was in the thirty percent of the test subjects able to hold out until the researcher returned fifteen minutes later. But most of the kids couldn’t. They either ended up ringing the bell, or scarfing down one or more of the pieces of candy outright.

The initial goal of the experiment was to identify the mental processes that allowed some people to delay gratification while others simply surrendered. After publishing a few papers on the Bing studies in the early seventies, Mischel moved on to other areas of personality research. “There are only so many things you can do with kids trying not to eat marshmallows.”

Well, so he thought at the time. Actually, it turned out that there was a lot he could do with the kids trying not to eat marshmallows. In 1981, Mischel began to follow up with his test subjects of old, and found that the “high delayers” who were successfully able to hold out for two treats were also largely more successful than the “low delayers” in terms of academic and career achievement, and were considerably less likely to have suffered from behavioral problems. Self-control, it turns out, is significantly more important than even raw IQ in predicting success in life. Score one for M. Scott Peck.

Since then, he and his collaborators have continued to track them through their adulthood, for a while relying on self-reporting, but recently also adding MRI’s and brain imaging technology to the mix, in the hope of producing a neurological map of the parts of the brain involved in self-control. Even more interestingly, their research has already begun to hint at what the essence of self-control actually is:

At the time, psychologists assumed that children’s ability to wait depended on how badly they wanted the marshmallow. But it soon became obvious that every child craved the extra treat. What, then, determined self-control? Mischel’s conclusion, based on hundreds of hours of observation, was that the crucial skill was the “strategic allocation of attention.” Instead of getting obsessed with the marshmallow—the “hot stimulus”—the patient children distracted themselves by covering their eyes, pretending to play hide-and-seek underneath the desk, or singing songs from “Sesame Street.” Their desire wasn’t defeated—it was merely forgotten. “If you’re thinking about the marshmallow and how delicious it is, then you’re going to eat it,” Mischel says. “The key is to avoid thinking about it in the first place.”

In other words – to have willpower is to have some knowledge about how your brain works, and to be able to effectively distract yourself from being overwhelmed by desire or fear. The journalist likens this to Odysseus, tying himself to the mast of his ship in order to hear the Sirens’ song without committing suicide.

The implication of this is that what we think of as “willpower” or self-control may not actually be a force of mind so much as a kind of creativity that relies on self-knowledge and shows itself under duress. If true, I think this thesis would go some way towards reconciling liberal and conservative views over the importance of, and effective approaches towards, teaching ourselves and our children how to self-discipline and delay gratification.

The article ends by noting that the researchers have begun a partnership with KIPP, arguably the most successful of the charter schools, to see if such an approach to self-discipline can be effectively taught in the classroom. Read the whole thing.

UPDATE: I neglected to mention that the article is by Jonah Lehrer, who has a nifty science blog. Thanks, Donna!

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Summer Fun

August 10, 2009 at 10:43 pm (By Randy)

Bruno Kammerl’s Megawhoosh, a 35.2 Meter Slip-N-Slide in action

(Via within the crainium)

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I Play Ear.

August 10, 2009 at 2:09 am (By Amba) (, , )

Thinking of jazz (but this would apply to other musical forms just as well), it seems to me that the listener is the fifth member of every quartet, the seventh member of every sextet, the silent duet partner shadowing every soloist. The ear is also a musical instrument. And the quality of the music depends also on how well it is played.

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Scary Reading Material. [UPDATED YET AGAIN]

August 9, 2009 at 3:29 am (By Amba)

A web forum on Lewy Body Dementia, which is probably what J actually has.  Sample post:

I have just had a few days break from it all, I will pick R. up tomorrow from respite. I am dreading starting back into it all again. I phoned him every day, and yes I had the same thing, who are you with? I love you? when will you pick me up? what time exactly? It is so hard for them, but it is so hard for us as well. I believe one must try and have some life for oneself, if you don’t the disease will destroy you, we have a duty to ourselves as well. All the nurses, doctors, and aides that I deal with have finally convinced me that I must look after myself, it may sound heartless, but I admit that I am beginning to believe them. They tell me they have seen so many carers go before their LO, that is not what God wants. We are all on a journey, and sadly this is our LO journey, we cannot change that. Believe me when I say that I have cried an ocean, I miss the old R. so much, I have all the best care for him,but I do want to survive this, and I don’t feel guilty for feeling this way anymore.

Something else sticks in my head:  I forget who told me a common piece of folk wisdom is, “He got sick and she died.”

I try not to haunt such places, to accept that this is the real community to which I now belong.  But what I see when I do go there is that this is a very long haul, and that the disease can in fact be fatal — to the caregiver.

UPDATE: Another woman on the forum who’s taking care of her husband did a kind of “intervention” on me, saying that when you respond to every suggestion with “That won’t work,” it’s a sign of “severe burnout.”  She then made about eighteen suggestions, sixteen of which — excepting bankruptcy and antidepressants — I’m going to check out starting tomorrow.

When I said that, she kind of leaned on me a little bit to take antidepressants. “Better living through chemistry — your husband is on drugs to improve his quality of life. Why would you not take advantage of the same for yourself right now? If you were cold, would you insist on continuing to run in place to try and keep warm rather than accept a blanket?”

I wonder what that’s about.  I am pretty anti-drug, and karate workouts are a very effective antidepressant for me.  Why wouldn’t someone say “Great, more power to you”?  Why would they try to convince you that you ARE depressed (I’ve been depressed, I know depressed, this ain’t it!  fatigue, stress, frustration, loneliness, yes; depression, no) and SHOULD take medication?  To validate their own choices?  Or just on the assumption that everybody is like them and will benefit from the same things?  It’s scary to me, the medicalization and medication of ordinary unhappiness.  Take a pill when things get rough??

Many of these women have more help than I do and seem more unhappy.  (Maybe I should urge them to take up karate?)  Their husbands sound generally more mobile than J, but also more demented.  Some of them have been at this already for half a decade longer than we have.  They are giving me a preview of what’s ahead.

UPDATE II: A part of the advice I received was to have J evaluated for hospice, because they can give you some in-home care relief paid for by Medicare, a nurse who knows the patient well who’s on 24-hour call, etc.  I never tried that because I figured he wouldn’t qualify:  he’s so not terminal, God bless ‘im.  I thought hospice was for terminal care only.  But it turns out the criteria are somewhat elastic.  What could disqualify him is that he can still communicate pretty well.  What could qualify him is that he’s so immobile and utterly dependent — in the doctor’s words, “degenerative disease and basic care dependency needs.” Hospice can come and go:  if the person stabilizes and is doing pretty well they may kick you off it until you really need it again.  But even to have that kind of help for a while . . . I can hardly imagine.

And — this is big — the doctor is for it.  For my sake, I know.  That could count for a lot.

Duke Hospice has a residential respite care facility.  That means if I ever needed to, say, have surgery, or just visit my family for a whole week, he could go in and stay there for the duration.

I can’t count on this, because he may not qualify.  If it doesn’t work out, we’ll try something else.

I was thinking that the relentless incontinence, day in and day out, is one of the things that wears you down, especially when combined with dementia (which insures that the carefully placed urinal will be removed to a spectacularly useless location — like the Statue of Liberty’s Torch — just in time).  And then I thought, maybe they ought to have a special, nonterminal branch of this service called “Hoss Piss.”

UPDATE III: Took J to the swimming pool.  He’ll never get into hospice — nor should he.  He’s doing too well.  I’m the one who needs it — LOL.

Rather like people who fall into the gap between Medicaid (too rich for it) and private health insurance (too poor to afford it), (though that’s not literally our problem, thanks to J’s Screen Actors Guild), J falls into the gap between sick enough for hospice and well enough to walk, wash, whiz, and wipe for himself.  In that gap, the considerable burden must be borne by a family member — physically or financially.

You can liquidate your assets and be cared for in a nursing home, but you can’t hardly get help being cared for in your own home, even though it’s cheaper for all concerned.  I can’t figure out if this is nutty or simply as it should be.  It’s “the natural way” (as I witnessed in Eastern Europe where they didn’t have nursing homes), except that we don’t have extended families living together any more and sharing the chores.

By the way, the county social worker told me about a five-star nonprofit nursing home out in the country to investigate just as backup (were I to get sick or something), and then insinuated if I checked it out I might like it . . . Like antidepressants, nursing homes are pushed on you.  “Placement,” they call it.  Placement in the basement.  “Save yourself!” is the cry.  She also urged me to come to a caregivers’ support-group meeting August 20.

If I go, it will be to see if the other caregiver I’ve seen here and there in Chapel Hill goes to them. He’s a soft, stoical man my age or a bit younger, patiently accompanying a ruin of a beautiful woman with some kind of wild, high-stepping palsy.  You can see that before she got sick she must have been proud and temperamental in the good sense, like a thoroughbred Tennessee walker.  I’ve seen them in an outdoor café and in UNC’s neurology waiting room.  He and I both avert our eyes when our paths cross, poignantly and paradoxically together in this salute to each other’s privacy.  I’ve seen her, exhausted by her wayward body, lean her head on his shoulder.

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Speechless (Appropriately enough, it seems)

August 7, 2009 at 2:08 pm (By Ennui)

I just watched the “don’t do a lot of talking” snippet via Breitbart via Drudge.  I don’t think I’ve ever seen or heard its like.  Where to begin?  There’s the snarky tone in which he declares “I’m President”; there’s the apparent command (I don’t know what else to call it – whatever it was, it wasn’t a “suggestion”) to his political opponents – “don’t do a lot of talking”;  there’s the muted, baffled crowd response immediately following (it required an “Am I wrong, Virginia?” from the One.  Well, at least he didn’t tap the microphone and say “is this thing on?”).

Here is the most generous spin I can put on this:  he wasn’t talking about citizen protesters but about Republican Rep.s in the House and Senate.  As I say, this is the most generous, least scary reading.  But it’s still pretty scary (question: has any other President actually voiced the opinion that his opposition shouldn’t speak?) 

It is also nonsensical.  As others have pointed out, the Republicans can’t do a damned thing to stop him from doing whatever he wants in either the House or the Senate.

Scary.  Weird.

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Tweet Defeat: Twitter Sputters

August 7, 2009 at 12:28 am (By Amba)

I’m not the only one to have problems with Twitter today.  I’ve been unable to post on it at all tonight; I don’t even get the fail whale, it just tries for some period of time and then quits.  (Fortunately, I have been busy with other things and have not wasted a lot of time trying, but I’ve left the little wheel spinning in various tabs and returned to find my tweets still lying there raw and unposted.)

If I were a boofer doofus conspiracy theorist, I’d say the Obama admin is jamming it (ask not how) because they don’t want people talking about their mediocre-to-failing grades on CNN’s second-hundred-days “report card” tonight.

That was the subject of one of my tweets:  someone on CNN’s panel said that in contradiction to his stated objectives “Obama is polarizing the country,” and the panel itself demonstrated that:  the two conservatives, Alex Castellanos and Bill Bennett, both gave him a D, Donna Brazile gave him an A- including an A for just showing up! (Maybe in the age of Sarah Palin, that is praiseworthy??)  His score with the public, averaging out the poles, was C-.  (Yes, I actually said the essence of this in 140 characters.  What I miss about Twitter:  the enforced concision.)

Another lost tweet was a quote from Darwin, which I think has cultural resonance as well (echoing someone’s comment on creative destruction that I now can’t find):

“It is not the strongest among the species that survive nor is it the most intelligent. It’s those that are most adaptive to change.” – Charles Darwin

(I’m fact checking some utterly mind-blowing stuff about how retroviruses have incorporated themselves into the human genome and could even have catalyzed our becoming human, diverging from the line that led to chimps.  To make it worse, I’ve lost the source that said that, which makes me feel as if I dreamed it.  Apparently this is leading the Intelligent Design folks to say “junk” DNA is God’s tool kit.  That is not helping the dizzy feeling.)

Oh, OK, here’s one version of it.  What next??!!

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