Julia's Advise!

Some of you remember Julia Child, whose TV cooking show changed the way Americans eat. The health-conscious criticized her for using too much butter. Her acerbic retort was that she was cooking for four people, and a stick of butter wasn’t too much. “Everything in moderation," she told us, "including moderation.” 

I was reminded of Julia recently while reading newspaper accounts of our leader’s tweets. They and those who respond on Twitter and other social media seem to have never met Julia. The insults come like heightened metabolism, the hyperbole races to a rant, and the general tenor of conversations stretch the definition of politeness. We could all tolerate a bit more moderation. They could be civil.

Talking heads on cable TV dull our senses. They say horrible things about our leaders, slant the news to their advantage for one hour each day, and then turn the microphone over to someone else with a rapid heartbeat. These folks are paid to be rude, to support one political party over another. One channel exists to praise Trump, the other to bury him. Yet, we lend them our ears! Civility vanquished?

How did we lose it? The unprincipled commentators are only one ingredient of the messy stew we’ve become. Vast numbers of people don’t watch cable news, millions of others don’t read newspapers, and still more don’t listen to current events on the radio. Those who do watch, listen and follow just abet them, encourage them, and are complicit with them. I do, and I am, I admit it.

Something changed in the last three or four decades. Civility is something you learned at home at an early age. You learned how to speak when spoken to, how to treat people well, how to call your elders Mr. or Mrs. or Miss, or Sir and Ma’am. No parent intentionally raises kids to be uncivil. No school intentionally teaches kids to be uncivil. Yet it happens. Maybe it starts when we don’t correct incivility when we experience it. Everyone is their own snowflake, you know. Let’s not stifle their creativity. Those who haven’t been taught politeness don’t recognize impoliteness when they see it. In the end, we elect national leaders who are on daily marathons of incivility, trying to reach 10,000 steps of crassness. If our leaders and the talking heads speak that way, why should I worry? Some moderation, please.

Everyone has the power to express their opinion on social media, with no need to be polite about it, or factual for that matter. Unimpeded free speech is a great freedom. We can speak our minds without fear of retribution from the government or those we dislike. We can be as uncivil as we want knowing there is no recourse, and we can start most arguments with IMO. But, should we? Can’t we do it in moderation?

If we can assume that 90%[i] or more of us are reasonably civil toward each other, why do we allow the other 10% to drag down our society, to let it wallow in presidential hubris? Two years from now, or six years from now will a new leader be able to turn us back to a nation that treats science with respect, that doesn’t lead by calling people names or calling them the enemy? Perhaps we could convince people, in the meantime, to be uncivil with a bit more moderation. Maybe we can take that first step in the journey back to civility among ourselves, with and from our leaders,

I’ve seen civility, I’ve experienced it, I witness it from time to time in the present, and aspire it for ourselves in times ahead. St. Francis supposedly told his followers to spread the Gospel to all they met and to use words if they must. Can we spread the good news of civil society by being civil ourselves? Think of it as the butter of life; not too much moderation.                                                                                                                                                                              

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[i] A number I picked out of the air, but which I believe to be true with no data to back it up, and you know where this is going ….

Healthcare for All? Really? (part 1)

Most Americans believe that we have the best healthcare system in the world. It is a myth!

“My doctor said I needed the operation, but he didn’t know if my insurance would approve the payment. He sent in the paperwork last week. We still haven’t heard back.” Sound familiar?

                   

Ten years ago, the notion that healthcare was a human right was novel, if not a revolutionary idea. A recent Reuter’s survey, however, found that 70 percent of Americans now support a universal single-payer health insurance program and a Gallup poll reported that 71 percent believe healthcare is in a state of crisis.[i]

So, what is good healthcare? A person has good healthcare when they can see a doctor of their choice when they are sick, when they can go to the hospital when they need to and get the procedures they need when they need them, when they can get other professional help when they need it. Not everyone has that kind of healthcare today.

Let’s look at the data. America has highly trained doctors, nurses, and other medical professionals. Our hospitals are first rate. We do amazing research that discovers cures for diseases and improves lives. Yet, our very expensive healthcare doesn’t deliver world-class outcomes.

The US spends 17.8 percent of its gross domestic product on health care, while other countries spend 9.6-12.4 percent, with better outcomes.[ii] Our life expectancy is the lowest of 11 comparable countries, and going down each year. Our infant mortality rate is among the highest in the developed world. We go to the doctor less often and spend less time in hospitals than those in other industrialized countries. Our prescription drugs cost twice as much as other countries. Our administrative costs are the highest in the industrialized world, 8% vs. 1-3%.[iii] Two-thirds of all ER visits are avoidable, at an average cost of nearly $30 billion per year.[iv] In other words, we pay twice as much as other countries for lesser outcomes. Why?

Our processes or systems for delivering high quality medical outcomes are antiquated and inefficient, including how we pay for it. Nearly half of our doctors are in private practice. How 1850s is that? A medical office with ten doctors is small according to the AMA. Most doctors in private practice don’t know what they will be paid for a patient’s visit because it depends on the type of insurance involved – HMO, PPO or EPO, the age, and gender of the patient, and the way the doctor codes the procedures. Most insurance plans require that we use doctors and hospitals in their network. None of those networks crosses state lines. Patients are at the mercy of the insurance companies, who contract different fees for each procedure, with the hospital and with the doctors.

Medicare, one of the largest customers for drugs, is prohibited from negotiating prices.[v] The US doesn’t regulate drug prices as the rest of the world does. Manufacturers doubled the price of insulin from 2012-2016, with four percent annual increases since. Why? Because they could. The current administration is trying to implement a plan that allows drug stores and hospitals to import drugs from Canada where the price is much lower, but still the second-highest in the world. Would it surprise you to know that Big-pharma is fighting the idea?

In March 2010, Congress passed the Affordable Care Act (ACA), an attempt to provide better healthcare options for those who had no insurance, and to set new standards for all healthcare practices. People seem to forget what medical insurance was like before ACA: no coverage for pre-existing conditions like high blood pressure, coverage for preventative care, no coverage after a $1million in expenses, no coverage for children after age 19, and it goes on. The bill was a compromise, so it didn’t address all the issues. It was a start.

A key provision of the Act required everyone in the country to have medical insurance. It also required insurance companies to offer comparable policies with roughly the same premiums. So much of the plan’s provisions are burned into our way of thinking about healthcare now, that we would not tolerate them being taken away. One political party has tried, from day one, to eliminate the plan. It was a key provision of their platform in 2016. In the 2018 mid-terms, it lost them the majority in the House.

Large insurance companies, Big-pharma, medical device companies, and hospitals don’t want to change the current system, because it will impact their bottom line. Large trade groups contribute millions of dollars to campaign war chests, $23 million in the first quarter of 2019, large companies, and hospitals that spend millions lobbying Congress As recently as this month a bill passed the California Assembly that would eliminate “surprise bills” resulting from hospital stays. It was pulled before the Senate could vote on it, right after a huge inflow of money from hospitals, anesthesiologist, and other medical groups.[vi] Most of the discussion isn’t about healthcare; it’s about politics and money. So, what are we to do?

Let’s study how other countries provide healthcare to their citizens. They will surely be able to teach us what works and doesn’t, demonstrate advantages and disadvantages to different processes, and help us with the cultural issues. We are different from those other countries, so we shouldn’t implement their plans wholesale. We need plans that meet our cultural needs and our traditions. We also need healthcare we can afford.

This is an election year, so those to the right of moderate will label any proposed change as socialism. It is an effective tactic because so many people don’t know what socialism is and so many older people can remember what it was in the Soviet Union and East Germany. President Trump, in a State of the Union address said that we would not allow socialism to get a foothold in our country. I agree with him. I’m a big fan of capitalism, knowing it has to be reined in from time to time. Harry Truman said, “Socialism is a scareword they hurled at every advance the people have made in the last 20 years. Socialism is what they called public power (TVA)…social security …farm price support … bank deposit insurance … labor organizations… anything that helps all the people.”[vii] 

While we don’t want a socialistic economic system for our country, we already have many examples of socialized medicine, where the government owns the hospitals and clinics and employs the doctors and nurses. The Veterans Administration is a good example. Many large cities and counties own and operate hospitals and clinics, and employ doctors, nurses, and other medical professionals. The government manages many other insurance plans, which are not socialized medicine.

 Forty-four million people already have Medicare, a single-payer insurance program. It pays hospital and doctor bills for nearly everyone over the age of 65.[viii] Medicaid is another single-payer insurance plan for people with low incomes that insures 72 million people, 40% of whom are children.[ix] Fifteen million people have military insurance and about 22 million people have ACA insurance. Put another way, 153 million Americans, 44% of the population, already have a single-payer medical insurance plan managed by the government. Medicare works and it is less expensive than private insurance.

Nearly 155 million people under the age of 65 have insurance plans through their employers or that they purchased themselves. It is very expensive and often limits the care one can receive. Examples abound of insurance companies denying coverage for needed procedures, or Pharmacy Management Companies denying cancer medicines to patients.[x] Most private insurance plans require that members choose doctors and hospitals in their network of contracted providers, with options for deductibles and co-pays.

I’m leaning very much toward the idea of a universal single-payer health plan. Think about it. Everyone in the country is in the same health plan, which is available in every state, not just limited area networks. Everyone keeps their favorite doctor because there is only one insurance plan to which all doctors must belong. Companies that provide insurance for their employees would continue to pay in some form because they can’t afford to lose good workers. One million workers change jobs each month and must hunt for new doctors, and use expensive COBRA plans. Millions more stay in jobs they do not like because they can’t be without insurance.  

“They” say that major cultural changes take upwards of twenty years to take hold. The idea of a universal single-payer insurance plan has been working its way through our national debates for about ten years now. It may take another ten years to implement single-payer in some form, but when seventy percent of the people agree on an issue, the die is cast. Change is in the wind. “The past is over.”[xi] We will cross the Rubicon.

Part #2, Can we pay for it?

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[i] CNBC article in late 2017, quoting both Reuters and Gallup polls.

[ii] Karen Feldscher – What’s behind high U.S. health care costs – The Harvard Gazette – March 13, 2018

[iii] Ibid

[iv] UnitedHealth Group –  Study of patient costs – Reported by Axios July 22, 2019

[v] Medicare Modernization Act of 2003

[vi] Axios – July 28, 2019

[vii] President Harry S. Truman – October 10, 1952

[viii] Peter Ubel – Forbes Magazine – November 21, 2018

[ix] Medicaid.gov – April 2019

[x] Sacramento Bee – July 10, 2019

[xi] George Bush -2000 Campaign speech

POP, POP, POP, POP

Another mass shooting! No, wait, another one! What, another one? Wait!

Gilroy, El Paso and Dayton had mass shootings in the last few days. We are numb; twenty-nine mass shootings so far this year. It is, as one commentator said, “It’s the new common, but it’s not normal.” I spent last weekend in Yosemite National Park without wifi and spotty reception on the phone. Truth be told, we shouldn’t take phones and tablets to a place so majestic. It was a lesson in how attached we have become to those little computers and how connected we are to the rest of the world.

We only had a hint of what was happening outside the forest. It was uncomfortable not knowing the details. The beauty of nature should be our normal, should be our tranquilizer, and should be our common. But, it isn’t, is it?

Mass shootings, one after another, bring out all usual suspects to cure our ills. We know them by heart: guns don’t kill, people do; we have to get the guns off the street; we need to keep guns out of the hands of the mentally ill; we need better background checks. This time, we heard some new ones: it’s the video games, it’s the culture of hate, it’s the white supremacists. Sunday news programs showed appropriate amounts of hand wringing, as usual. It will all be for naught, until the next mass shooting, in the next few days, when we will start all over again.

The President called for an end of hate in America, and lots of prayers.

Nothing changes, because we love our guns, for some valid reasons but most not so valid. We have more guns in the US than we have people. Actually, I don’t have a problem with that, if people have guns for the right reason. If someone wants to go hunting, fine, own a hunting gun. If a rancher needs to protect his or her livestock, fine. If a person likes to shoot competitively, skeet shoot whenever. But let’s be honest about it, hunters don’t need AK47’s to kill Bambi’s father. Guns of war have no place except on the battlefield. Automatic and semi-automatic weapons have no place in the home or on the street, and arguing about the precise definition of each is wasted energy. Most countries outlaw handgun ownership. We don’t need them either. Some people want them to protect their home and families, or for self-defense; they buy into a huge myth. There is no valid evidence that guns are effective protection, except as intimidation.

When someone wants to buy a gun, they submit to a not very thorough computerized background check of their criminal history. It only takes a few minutes. In other countries, the background check is a real background check that can take three to six months. It includes an interview with the local police, certifications from doctors, as well as statements from neighbors and friends about the applicant’s behavior and suitability to have a gun. Guns and ammunition are sold only to people who have a license. Some states don’t even require a background check. Most gun shows exempt people from background checks. None of these background checks, it seems to me, fly in the face of the Second Amendment.

There is too much hatred. Leadership at the top cannot escape complicity with the White Nationalist and Nativists when it doesn’t condemn anti-immigrant riots in the streets, saying there are good people on both sides of the argument.

Our President didn’t pull any triggers this weekend, and he said there was no place for hatred. However, a couple of weeks earlier, he basked in the limelight of a crowd of MAGAs shouting, “Send her back,” referring to a duly elected member of Congress. That rally may go down as one of the most racist’s events in the history of our country; it gave permission for every immigrant hater to come out of the woodwork with guns at the ready.

We rely on our leaders to help us find our better angels, not to point us in the opposite direction. We rely on our leaders to look at the facts and understand that there is a culture of hatred; a toxic brew is how one pundit described it, growing across the land and much of Europe. We need them to lead us to be better than we are, to help us curb the hatred that leads to these killings. We need them to get weapons of war off the streets, out of our schools, and out of our stores.

There were nearly one-hundred-thousand people in the seven-mile-long valley this weekend. There was little noise except when the rangers fired beanbags to convince a bear to leave the campground, or the helicopter helping with a search and rescue. The solitude, the politeness of the people, the diversity of the visitors from all over the world, and the opportunity to be free of distractions should be the new normal, the common. If we need to be shocked, one view of any of the domes of Yosemite will give us all the awe we crave.

 Returning to reality will not be an easy transition.