Tuesday, December 22, 2009

Congressional Failures and Health Reform

“so we cheated and we lied and we tested
and we never failed to fail – it was the easiest thing to do”

- Stephen Stills

It’s hard to avoid the spin being put on health care reform by all sides. The left would have us believe that they have succeeded in creating a utopia where all citizens will have health insurance, people won’t be denied coverage because of pre-existing conditions and costs to individuals and families will be controlled. Meanwhile, the right would have us think that “Obama-care” will mean higher taxes on families to pay for additional government spending, and massive expenses for businesses that will now be required to provide insurance benefits for all employees.

So who’s spin is correct – or at least, closer to the truth? Actually, I don’t buy either side’s arguments as I consider the bills that are about to be reconciled as a complete failure for average citizens.

First of all, the major failing of the current bills is that they don’t address cost control by creating a public option that would compete directly with private insurers. Without this competition, insurance companies can and will still increase premiums. In fact, since insurers will be “forced” to take all comers and not limit their “risk pool” by taking on only those least likely to need their services, they will, without a doubt, increase premiums from day one to reflect their added costs. They are for-profit entities after all, and their first priority is to shareholders.

Secondly, I believe that (as I have discussed here last March) the insurance industry has as much exposure to toxic debt as banks do, but Fannie and Freddy aren’t shoring up their balance sheets ala the banks, thus insurers face a pending financial disaster as their investments tank. But after the TARP fiasco, absolute public outrage would be unavoidable if Congress proposed a bailout of insurers. This new “reform bill” has become a publicly palatable way to support the insurance industry by mandating that all citizens buy coverage. Translation: 20% of the population not currently spending money on insurance policies is about to – viola, problem solved.

Finally, if anyone thinks that the pharmaceutical manufacturers and insurance industry don’t love this bill, they should take a peek at the money spent lobbying for it. Politico has reported that:

“A closer look at some of the health care lobbying expenditures shows just how high the stakes are. PhRMA, a top trade group for drug makers, spent as much as it did in all of 2008 — $20.2 million — during the first nine months of 2009. America’s Health Insurance Plans is also on pace to outspend its 2008 lobbying budget, spending $6.3 million during the first nine months of this year."

And these numbers are from only 2 individual special interest groups. There are many more who have spent millions in addition to these sums. Think they didn’t get it the way they wanted it? You’d better think again.

So what’s the bottom line? For me it’s simple: the beneficiaries of the supposed health care reform effort will be the same ones who need to be regulated and better controlled – insurers and drug manufacturers. Will there be benefit for citizens? Maybe. But since we don’t pay as well as the special interest groups, it’s likely that our benefit will be much less than what Congress is about to hand over to insurance and drug companies. And why shouldn’t our benefit be less? After all people get what they pay for.

Wednesday, November 18, 2009

The Return of the Gold Standard

Waiting for the Dow Jones to implode has been a long and frustrating process for those who have been anticipating financial Armageddon since long before most people in the U.S. had ever heard the terms “credit default swap” or “derivative”. While there definitely was a sudden and steep drop in the market’s valuation from October of 2008 until about mid-March of 2009, as steep as that correction was, it was very brief and the resulting rise that followed has stubbornly defied the law of gravity. This correction or over-correction if you will, from the March lows has not been supported by much of anything substantive.

Since March, employment has continued to crater; housing sales have largely consisted of foreclosures picked up on the cheap by vultures or first time homebuyers taking advantage of an $8,000 tax credit; and retail numbers have failed to improve significantly, yet retailer stocks have been bolstered - not by improving sales, but by cost cutting and overhead reduction that has come most often in the form of layoffs.

In this same time frame, banking has also been salvaged. Again not because of its own decisions and practices, but because of the government’s willingness to utilize Fannie Mae and Freddy Mac to purchase banks’ toxic assets at close to, if not full, face value despite the lack of any realistic market for these products. To support these purchases and to reload banks’ vaults, the Fed has resorted to printing money. The actual dollars in circulation have nearly doubled in the last 12 months, yet the government insists that inflation is low.

And despite all the propaganda spewed by the government, the media and all the parroting talking heads who have worked tirelessly to convince the American public that “all is well”, fewer and fewer people outside the U.S. are acting as though they believe it. Foreign interest in U.S. debt, specifically in U.S. treasuries, has waned enough that the Fed has been purchasing its own treasuries for the better part of the last year when they have failed to generate sales at auction. This is akin to someone writing themselves a check from their own empty account and expecting it to clear.

But the curtain that has shielded the wizard, as it were, is being pulled back.

Watching gold climb to new records on a near daily basis has tipped the government and Federal Reserve’s hand. They have been printing money like demons and since it has to go somewhere, it inevitably finds its way into the stock market. This sets people up to think all is well, but our creditors know the score. They don’t think we have done anything other than debase the dollar and so they are starting to bet that we will default on our debt.

Think we won’t? You’d better think again. The U.S. economy, one that is more than 70 % based on consumerism, is still in very real trouble. We went from the largest creditor nation on Earth to the largest debtor nation in less than fifty years. Our economy has moved away from manufacturing and production and moved into consumption and consumer debt servicing. The wall we have hit, largely a production of our spiraling debt and declining incomes, is not one that will be easily remedied.

And our creditors, with reality staring them in the face, have begun to hedge their bets on a medium that has been around far longer than any other currency – gold. While the precious metal’s price has been climbing to new highs, the Dow has followed suit and continued its march back toward unrealistic levels. The difference being that when the Fed is done printing in its desperate effort to maintain civility by preventing a panic in the U.S., the dollar won’t be worth the paper it’s printed on and gold will again be the world’s baseline currency.

Wednesday, September 30, 2009

Sold Out

We have been duped. That’s all there is to it. There’s no other way to describe the actions perpetrated on the citizenry by the corrupt and fouled human garbage that passes as governmental leadership in this country. Yesterday, our elected officials voted against creating a government funded health insurance option. Not a “takeover” of the health care system (which by the way, the government already heavily regulates thanks to its Medicare and Medicaid reimbursements), but simply the creation of publicly funded insurance policies that would offer some relief to those of us who pay increasingly handsomely to our insurance companies for ever diminishing coverage.

We were told by our bloviating talking heads and too many congressional members that a government run health insurance option would lead to socialism. We were told that the government would deny care to those who are too young or too old or too sick. We were told that capitalism and free markets are the only true American way to fix anything. Quite simply, we were lied to.

First, there’s that socialism thing. There are many democracies and capitalistic nations that offer a public health insurance option – in fact, the list includes all of them except the U.S. We are the lone wealthy, developed nation that does not provide its citizens this basic service. And why? Well, the insurance companies would be forced to compete with a more efficient, non-profit entity that would put them and their staggering profits to shame. They would be forced to become more efficient (reducing obscene pay and bonuses for the executives), cover more claims (they currently work to pay out as little as possible on all claims – profits are the goal, remember?) and offer more reasonably priced policies. Yeah, that’s a bad idea.

Socialism, as defined by the Merriam-Webster Online Dictionary, is “any of various economic and political theories advocating collective or governmental ownership and administration of the means of production and distribution of goods”. It is not a situation where the government provides a service to its citizens. No one cries socialism when they talk about the public school system or the police or Emergency Medical Services or the military. There are private companies that compete with the government on all of these fronts (private schools, private security services, etc.), and they don’t complain about their businesses being unfairly harmed by publicly funded services. The socialism argument is a red herring.

How about the argument that the government would deny care? The last time I checked, the private insurers were the ones who refused to pay claims. It’s the private insurance companies that pre-screen and deny applicants and pre-approve claims. They are the ones who refuse payment for anything that’s new or expensive. They are the deniers of care, not the government funded programs Medicare or Medicaid.

To be clear, Medicare and Medicaid often don’t reimburse (pay) for all the costs, but no one dies while waiting for pre-approval and they don’t work diligently to deny care so they can make money.

How about that whole free market thing? Well, if the government began a publicly funded insurance option, it would compete in a free market. How much more capitalistic can you get? If one company can offer the same thing as another for a lower price, the other company has to become more efficient, find another niche, or get out of the business, right? What could be more American?

But insurers don’t want competition. They all work together to set prices and extort payments from us to make them wealthy. They tell us we need them. They tell us they will take care of us. The only ones they are interested in are themselves. They want huge profits so they can get large bonuses and make even more money. Competition will reduce their ability to make those staggering profits, so they have spent billions on convincing us and our representatives that somehow competition is not capitalism.

Now, from what I have seen, the insurers are winning. We have no public option that seems imminent and thus, the insurers have no competition. Prices for health care won’t be coming down anytime soon. But rest assured - our noble and fearless leaders are considering MANDATING that every citizen have health insurance. That is, if our employer does not provide it, we will be forced by law to purchase insurance from one of the major insurers. So instead of promoting efficiency by competition, the government has forced us (and our money) into the waiting arms of……you guessed it, the insurance industry. What a country!

Apparently, our government is more interested in representing the insurance industry than those who actually voted them into office. We have been sold off like so much garage sale merchandise – on the cheap and without a care. Until the populace wakes up and becomes outraged, nothing will get better. It will only become worse.

“We do not have to visit a madhouse to find disordered minds; our planet is the mental institution of the universe.” ~Johann Wolfgang von Goethe

Friday, September 18, 2009

On The Fringes By Choice

I couldn’t help but smile when I saw his name on my patient list. I thought, “There must be more than one ______ ________ in the world, but certainly not in this area”. I checked the records, and sure enough, it was him. I won’t use his real name here, as he has a right to his privacy, so I’ll use the pseudonym “Bob”.

I got to know Bob when I was a very young man - both emotionally and chronologically – and we worked together as guides for a whitewater rafting outfitter. He was, I thought until this week, much older than me. It’s funny how years and distance can actually make you seem closer to people, at least in age, than you once were.

His face had not changed much, though it was perhaps a bit more weathered. I couldn’t help but think this was the first time I had seen him without a cigarette in his mouth, sunglasses on his face, and completely sober. The lifestyle of a rafting guide can be as variable as the personality of each individual, but for a large number, it involves excessive alcohol consumption, heavy smoking (tobacco as well as marijuana) and telling stories that are upwards of 10-20% true.

Some guides are college kids who need seasonal work and don’t want to spend four months away from school flipping burgers at fast food joints. Many are near migrant workers, following the transient seasonal work from the rivers to the mountains, working winters as ski instructors or patrollers. These would be the ones who may or may not have dropped out of college, or just have not found or accepted what society has to offer them. Bob embodied the latter group.

I have long since given up the life of a guide – spending more than I earned in the company bar, chain smoking and trying desperately (and mostly unsuccessfully) to convince attractive women customers that a fling with a grungy, unshaven man who sported a tan that outlined a lifejacket on his upper body was a good idea. But back then, I thought guys like Bob were the ones who had it together: they had no permanent homes, no wives or children (that they knew of), few bills and worked “real jobs” sporadically at best. At the ripe old age of 20, it was my bohemian dream to follow in their footsteps.

Alas, time moves forward and most of us grow up and become adults – or at least more emotionally mature – and move closer to the center of society. That is, we find regular work, satisfying personal relationships and become more main stream. Bob never did though. He still hangs on to much of the old lifestyle - it has been too hard for him to give it up. He still makes his annual or bi-annual pilgrimage to the canyon so he can row the greatest river in North America; still has no wife or kids (that he knows of); still does not have a “regular” job as it would interfere with his play time; and still smokes like he’s sponsored by Philip Morris.

As a result of his own choices, he is one of our millions of uninsured in America. Not that he minds, or that he wants more from the health care system than he is willing to pay for out of his own pocket. He had a blocked coronary artery several years ago that required the placement of a stent and he paid for it himself – eventually. He now takes bottles of nitroglycerin with him on his canyon trips, because as he told me, “you never know and it’s a long ways away from anywhere”.

The cardiologist in our office who saw him told me Bob needed to stop smoking and make some significant changes if he was going to have a shot at growing old. I told the cardiologist that Bob would do no such thing – it’s just not who he is.

Bob would rather die relatively young doing what he enjoys and without regrets than stop being himself and live longer. He has followed the “live fast, die young and leave a good looking corpse” philosophy to the letter, except that he has made it farther than he likely ever thought he would. He has managed to outlive many of our old comrades and friends despite maintaining the lifestyle. Too many of the people we knew died young as a result of poor choices and bad luck.

I don’t know where people like Bob fit into the health care debate because he’s such a rarity: he’s non-compliant for the most part, but does not hold anyone but himself responsible for his problems. He throws off the curve, if you will. People like Bob will not buy health insurance (even if forced at gunpoint) because they just don’t see a need. He’s self sustaining and uses only the services he needs when he needs them. And he pays for it himself. He’s not our typical member of society by a long shot.

He’s Peter Pan – but older now and all too vulnerable to those things that affect mere mortals. And even though it’s for different reasons now, he still has my respect.

Friday, September 11, 2009

Returning The Hope I Bought

"No, I'm not disillusioned. I'm just not illusioned, either.” – Bob Dylan

In this response to a question posed by an interviewer in 1965, Dylan captures simply and completely my feeling about President Obama and his attempts to rehab the health care system in the U.S. Indeed, after watching the president speak to Congress the other night and witnessing the response from both sides of the chamber, I was left with a feeling that’s significantly less than excited, but not quite apathetic. I do believe that some reforms are on the way, I just don’t think they will be immediately or significantly effective.

My wife watched the speech live, but I was only mostly attentive to it from across the room. She was disappointed with my response and lack of enthusiasm – especially since the topic is discussed almost daily in our house. I listened to Obama talk as I typed an email to a friend about an upcoming backpacking trip. My wife questioned me about my restrained excitement and I replied that I was less than enthralled with what I deemed theater from a president for whom I had much higher hopes. I have seen little of what was promised actually get done and am left, again, feeling jilted by our governmental leaders.

It’s not that I’m cynical enough to think nothing will happen with health care reform – it’s just that I’ve been paying attention to politics and government for too long to think any changes made will be right the first, second or third time around. Reform will be something that’s tinkered with in small increments and over a long period of time. Eventually, it may be done right, but perhaps that won’t happen for the next 20 years.

Sitting there, trying to understand my own sentiments, I couldn’t help but think about the reforms that were enacted on the credit card industry this past spring and summer. They were supposed to help consumers by limiting why and how quickly the card issuers could raise rates. They were touted as a big “win” for regular folks against issuers who had been able to seemingly raise rates and change the rules whenever they wanted. In the end, the unintended consequence of those credit card reforms was that the issuers hiked rates on cardholders before the laws prohibiting the same took effect. As a result of “helping” out the consumer, rates on most cardholders are now 3-4 times what they were previously. This kind of help “fixing” health care we don’t need.

While Obama was getting heckled, I decided to take a quick tour of opensecrets.org and peruse their charts detailing money donated by the insurance industry to candidates up for re-election in 2008. It’s an impressive list that includes politicians from both major parties – the largest donations going to the leaders of each party and those with positions of influence over potential reforms. I quickly reminded myself that hope is often sold and seldom redeemed for any value - but campaign contributions almost always pay dividends.

I decided to go to bed and not go over it all again. When my daughter is old enough, I’ll show her how our government, and indeed our country, really works. I’m sure I will almost feel guilty for showing her the things I have learned over time and through repeated frustrations. But she’ll need to learn these things while she’s still young enough to not fall prey to the theatrics that pass for political statesmanship. When I’m done, she’ll be no one’s fool and she’ll be able to spot the Shakespearian influences immediately.

Ultimately, I think health care reform will get close to where we need it to be - but today I am stuck somewhere between hopeful and hopeless. The simple truth is that while most citizens will feel as though they are helped by the reforms that ultimately get enacted, a select few – the wealthiest citizens – will no doubt benefit disproportionately thanks to a government that is only too happy to receive their donations and “support” when it comes to election time.

As for me, I have no utopian visions for our health care system. I just want to see that something worthwhile gets done so that people get the care they need. I’ve heard enough talking about what, who, how much and why – now I want to see what can be accomplished. It’s time to put up or shut up. Come on Mr. President and Congress – I’m not hard to impress and my expectations are minimal.

Friday, September 4, 2009

A letter to our President and Congressional leaders

Citizens have been listening to all the talking points and arguments thrown back and forth for years now. The debate about health care reform in the U.S. is nothing new – indeed it was only 16 years ago that political leaders last wasted a similarly endless amount of time and energy on the same issue. But the situation in the U.S. this time is different. Many believe the U.S. has entered into what history will call the Greater Depression when this era is compared to the 1930’s. The numbers (GDP, unemployment, housing sales, etc.) that the government agencies report are all suspect and have been shown to be manipulated for political reasons and cover. But they can only becloud for so long, as too many Americans have felt the fiscal crunch of living in the U.S. today. Indeed, it is more difficult than it has been in a very long time (for many different reasons), and as a result, people have learned to doubt what you tell them.

There are the obvious reasons for the pressure citizens feel, of course: unemployment; under-employment; higher costs of living; increased prices on essentials like food and fuel. But these realities are primarily felt by those who are not well-off. And by well-off, let’s qualify that not with numbers, but with this: if a family does not have to choose between essentials each week or pay period (i.e. “How much can we spend on groceries this week because the mortgage payment is due?”) they are better off than most. You, the political leadership in this country, as well as those who would advocate for policies that protect and maintain the status quo, fall into the well-off category.

You, our political leaders, don’t have to adjust your family budgets because essentials have risen in cost. You don’t have to cut back on the weekly grocery bill because your insurance premiums have risen as your employer continues to try and cut costs. You don’t have to worry about co-pays and out-of-pocket minimums that cut into your stagnant or declining wages. You don’t have to think about declining wages or lost hours that allow for you to pay the mortgage. In short, though you represent all citizens, you are not like the vast majority of them because your lives are devoid of the above realities.

The lower and middle classes do not have powerful lobbyists or organized industry groups. They don’t take you out for expensive meals or on trips to play golf in foreign countries. What they are, however, is the largest segment of that group you vowed to represent. Whether you like it or not, you represent the families who have taken up residence in one of the many tent cities that have become increasingly common. You represent the single parent who works more than 1 full-time job to try and make ends meet, yet just can’t seem to get there. You represent the family that struggles, not to move up the ladder, but to hang onto the rung they have called home for years. You represent people who have lost jobs, homes, work hours, take home pay and benefits, retirement and savings portfolio assets, and last but not least, a chance at the American Dream.

Your continued advocacy for a small percentage of the population – the wealthiest ones – who have been so generous to your re-election campaign coffers, is proof enough for a growing number of the rest of Americans that your votes and positions are for sale. While this is nothing new in the political system of the United States, it has become more and more dramatic as the largest corporations and financial firms continue to receive taxpayer dollars despite their contempt for citizens: as customers; as individuals; and as human beings. Simply stated, the populous has had enough. The level of contempt on that side of the fence is growing as fast as their increasing numbers.

You, our leaders, have the opportunity to implement a program that will help millions of people get and stay healthy. You have the opportunity to remove the threat of financial ruin due to medical conditions. You have the opportunity to make sure that some of their tax dollars are spent on programs that help more than just the few. The choice is not really yours – it is theirs. Polls have shown that the majority of Americans want a government funded insurance option or a single-payer system. It is not socialism (unless you consider the U.K., Japan and Germany all socialist countries and not capitalistic ones) to give the populace what it wants and needs. It is not “new” – universal health programs work everywhere else in the world. Indeed, the U.S. should be ashamed that the wealthiest nation on Earth does not provide this basic service to its citizens.

As it stands today, you have given away trillions to banks so that they can remain in business despite their poor decisions and yet demanded nothing of them. You have asked for no reforms that will prevent another disaster, yet the banks have access to unending amounts of cash from the Federal Reserve (at no interest, no less) while charging customers interest rates that approach 30%. Banks get to shed worthless assets at elevated prices because fair accounting standards and practices have been halted and the government backed entities Fannie Mae and Freddy Mac have been green lighted to purchase these worthless debts at close to face value. You have created a welfare system for the wealthiest, and left the rest of your charges to their own devices.

You have provided bailouts to everyone except your represented individual citizens. Don’t you think it’s time you did your jobs and represented the people who actually voted for you? Don’t you think it’s time to help the less fortunate and the rest of those who deserve better than what they have gotten from you and your cohorts? You should all hang your heads in shame for your petty bickering, blatant pandering and political grandstanding. You have had your opportunity to get your faces on T.V. – now go and do something the rest of the citizens of the U.S. deserve and will benefit from. Enact health care reform that will work.

If you need help, there are plenty of us out here with a solid understanding of the system’s real problems and the real solutions that will make it more efficient, more cost-effective and more beneficial. All you have to do now is your job.

Friday, August 28, 2009

Mr. Potter's Lullaby

After reading Nick Kristof’s column in the New York Times yesterday (available here), I was moved to investigate his chosen subject, former insurance industry executive Wendell Potter. After a quick Google search, I found an interview of Mr. Potter conducted by Bill Moyers that I thought might be good viewing. So last night, my wife and I sat down after getting our daughter to bed and began an evening of emotional distress.

The video (from PBS’s Bill Moyers’ Journal) with Potter (available here) was, to say the least, unsettling. In it, Mr. Potter describes how the largest insurance agencies in the country deplore competition and have worked tirelessly over the years not only to consolidate their hold on the market by buying up smaller companies, but to convince the public that any insurance not offered and provided through them is a wrong headed and un-American idea.

He talks specifically about the insurer’s aggressive pursuit of profits and the lengths to which they go to maintain them. Two such practices described were the canceling of policies as soon as holders are diagnosed with conditions that are expensive to treat, and increasing premiums on smaller business whose employees file expensive or too frequent claims so that the small business is priced out and forced to cancel coverage.

He describes the industry organization, Americas Health Insurance Plans (AHIP), and their concerted efforts in the early 1990’s to control the messages and talking points that most Americans would see and hear on the news or TV commercials. He is blatant in his descriptions of pressure being applied and bribes offered to legislators by the industry and their lobbyists. The goal was to direct the conversation away from fact and towards ideological lines, thus obfuscating any real attempt at conversations about reform. Quite simply, they wanted things to stay just as they were and they used every way possible to portray anyone who suggested reform as a danger to our society.

Potter’s description of the AHIP’s response to Michael Moore’s film, “Sicko” in 2007 is nothing short of astonishing. The coordination and logistics utilized to try and cut off debate about health care reform and blunt the impact of Mr. Moore’s film illustrate just how desperate the industry is to remain in control of health care in this country. Their companies are at stake, as well as the fortunes of the executives who run them, and they fight as though they have everything to lose – because they do.

The information gleaned from the video was not surprising. Neither my wife nor I were shocked to hear that Cigna and other insurers don’t want competition and that they are willing to lie and manipulate the message through media to maintain the status quo. What was surprising, and disturbing to watch, was this man – who has worked in the industry for decades and helped design the PR responses to such threats to their crystal towers – sit there and explain why he now decides to come forward and let the rest of America know just what he has been doing for the past 15-20 years. He claims he was moved when he attended a health fair in Virginia at which thousands of people sought care because they had no insurance and no access to affordable care because of it.

His descriptions of what he saw and how it moved him only served to infuriate me. He had never seen people suffer and go without because they had no ability to pay for care. It had never dawned on him that people who were removed from his company’s roles would be left with no way to pay for care they needed. He had lived in that ivory tower and had never bothered to look down and see what was under him. I was nauseous as he described flying on the Cigna corporate jet, eating a meal on a gold rimmed plate with gold plated utensils while his company worked diligently at not paying for the care of policy holders who had dutifully paid in their premiums.

I don’t know what to make of all of this yet. I’m still too unsure and unconvinced of this man’s motives to be sure he’s telling us all that we need to know. I don’t doubt anything he said, but I suspect that there’s much more and worse that we should have heard.

One thing is very clear though - the insurers have attempted to make their own actions invisible as much as possible. They have levied accusations of rationing and denying care against an as yet unexisting government run insurance plan, yet they themselves conduct these practices. It’s like Fox News accusing another network of bias while denying their own.

The former administration taught us all that if you accuse your opponent of something you yourself are doing, they spend lots of time and effort trying to disprove a negative and you are free to do whatever you want. Advocates of universal health have been defending the idea from almost everyone; meanwhile Cigna and its brethren are hiking rates and dropping expensive policy holders.

It’s enough to make me sick.

Friday, August 21, 2009

Getting Closer

Health care reform, so we are being told, is being debated hotly all across the country. From town hall meetings to lunch rooms everywhere, people are arguing (sometimes forcefully) about how to remake the health care system better and reduce costs while still having a viable system. We have heard everything, from the arguments that “Obama Care” will kill grandma, to those that say anyone in the U.S., even illegals should get whatever they need for care.

I have been arguing for reform for a long time. Many of my friends and coworkers in the health care field disagreed for many years about what things should look like in any reform of the system. One friend in particular and I used to spar over what each of us thought should be included, and what the likelihood was that anything would ever really change.

My friend Mike is an ER physician. His career has involved taking care of people with life-threatening injuries, conditions and traumas as well as those with nothing more than a hang nail they feel needs to be evaluated. While he would be the first to tell you he has not seen it all, he has actually seen most of it and the rest is really just more of the same. His opinions, however, are not always based on his professional experience. They are often based on his ideological slant. He is a financial conservative who abhors large government spending and waste. Thus, for years he has argued against any government run single payer system due to his fear of spiraling cost and added bureaucracy that would stand in between his patients and himself. His biggest argument to me was often that the population would never accept any system that made patients more responsible for their own outcomes and limited care to reasonable levels.

We have been going back and forth on this for years. But last week, all that changed. When I started to talk to him about the proposals being considered in the House of Representatives, he became frustrated. He had actually tried reading the bill online and after more than 300 of the 1017 pages, he turned to me and said, “You know, you and I could fix this whole thing in about 10 pages and have a better system than the mess this is going to create.” He is right, of course. He looked at me and then told me that the only way to really do this and do it right would be to cover the basics for all citizens (preventative care, office visits, necessary tests and hospitalizations, medications, etc.), figure out how much that will cost, and then tax something everyone needs or uses so that no one escapes paying in something to keep the system solvent. Then the legal reforms would need to be put in place to protect providers from unreasonable lawsuits.

It was simple. It was brilliant. It would work. It was exactly what I had been saying to him for several years. The difference now, is that he believes the public will go for it. I don’t know what really changed his mind, but he has become convinced that not only is it possible, but now the above plan is the only real option.

I smiled and told him he was starting to sound like a Democrat. Not because he was really, but because it made him mad. That’s the kind of friend I am. Then I sat back and thought, “Hell, if the two of us have come to consensus, the debate is really not all that hard”. If a staunch fiscal conservative and a borderline socialist can agree on how to fix this mess, we need to hold the policy makers accountable – or go after their jobs.

So here’s your warning politicians – get your act together and get it done or else you won’t be getting emails and letters from people like me, you’ll be getting challenged for your coveted positions. Now shut up and get back to work.

Sunday, June 21, 2009

Keep Pushing

I'm fifty two minutes into a seventy minute run. Almost three quarters of the way home. My muscles are tired but they keep moving. I have three minutes before I get another sixty second break. The sweat is pouring out of me, running down my legs and into my shoes. I can feel the fluid squish with each stride and can hear it over the music pumping in my ears. Two and a half minutes left. Just keep going. Run with the beat of the drums. The Counting Crowes begin to play just a bit faster and I find the rhythm I was looking for. Two minutes to go. Stop looking at the time and just run with the beat. Squish. Squish. Squish.

When I began to run regularly just over a year ago, I would run for twenty minutes three to four times a week. Those twenty minutes seemed like an eternity then, but they paved the way forward and soon my times increased to thirty and forty minutes per workout. When I began to extend my runs to sixty minutes, I found that I tired so much that the majority of my last fifteen minutes was spent taking frequent thirty second rest breaks.

Then I read some advice in a blog about training for marathons that talked about the benefits of building a sixty second walk period for each mile run into a runner's routine. The theory was that because running was very intense, a brief break from it gave the muscles a chance to recover a bit, allowing the runner to run longer distances and times, while not being as tired at the end of the run. After using this method for a while now, I have found it works very well.

My job as a nurse is not really that different from my workouts. It is intense and consumes much energy, both physical and mental. It has been sixteen years that I have considered emergency medicine my home. It has been a comfortable place for long stretches, and I am good at it, but the years have worn me into a certain groove that occasionally requires some self extrication.

I have taken brief periods away from emergency work to try other venues, but direct patient care is never easy or simple. Working in management was a nice change for a while; the pace was good – a little slower and with regular and predictable hours. But it was filled with its own issues. After just a couple of years behind a desk, I was ready to return to what I did best. I had recharged my batteries and could again face the patient care world with a renewed enthusiasm.

My last break away from patient care was several years ago. It's time for another rest period. I can feel it in me like the sweat in my shoes. It's building and making it hard to continue. I go to work now and feel good for the first hour or so, then it goes to hell. I see things that just make me want to scream: another patient who was too lazy to call their doctor and ask for an appointment; another pregnant teenager who's smoking and is completely oblivious to what she is doing (and will be doing) to her child; more people who try to manipulate us to get pain meds because they have no other way to deal with their realities; another doctor who pissed off a patient that I now have to calm down so they don't leave ready to call their lawyer; another drunk looking to fight with the whole world. Squish. Squish. Squish.

I can't find my rhythm. Unlike when I run, at work the music has stopped and now the fatigue is too much to take. It's time to slow down and let myself heal a bit before I am too damaged to finish – and at my age I have too far to go to quit now. But a rest is just what I need. Less intensity – just for a while – so I can come back and go for another stretch at my natural speed.

My application for a new job is in and I am awaiting the call for an interview. I find myself daydreaming about working Monday through Friday, no nights or weekends and no holidays. In medicine, this is like winning the lottery. It's a twenty four hour a day world we work in, and the “regular” jobs with good hours and every weekend off are few and far between. The job I am applying for is in an office doing diagnostics. Not exactly what I see everyday now. In fact, it's a far cry from the ER. But if I can land this one, just have it for a while, it might just provide that break I need.

Just a few minutes left. Keep going. Find the rhythm. It won't be long now. I can make it. Squish. Squish. Squish.

Wednesday, May 13, 2009

It's Well Past Time

Another day, another disaster.

The news yesterday that the “trust funds” for Medicare and Social Security will both be depleted before previously thought left me with the sense that the only way forward is through an honest and frank discussion about our current financial predicament. But too often those conversations, even between people who care about the subject, are so overwhelming that they don't proceed very far. To understand how much debt we already carry and the trillions more we face in the very near future is to understand what hopelessness feels like.

Some will want to focus on what happened to bring us to this brink of financial disaster. Others will just want to scream from the rooftops until everyone is outraged enough to act. But neither approach will move us closer to fixing the mess – and fix it we must. We can talk about how we got here later, but for now the focus needs to be on how to get out of this mess.

So let's talk.

The Medicare trust fund will pay out more than it takes in this year for the first time since it was created. It will continue to do so over the next 8 years until 2017 when it will be completely depleted. This projection assumes that the tax rates do not increase. As of today, only the first $100,000 (or so) that a person earns each year is taxed to fund Medicare and Social Security. That means the bulk of funding comes from low to middle wage earners.

But so what if Medicare fails? What does it have to do with those of us who don't utilize Medicare? Well, for those of us who work in health care, we can expect that hospitals, clinics and nursing homes will close. Quite simply, health care cannot survive on reimbursements from private insurers alone – even if those insurers were in better financial shape and not in danger of going off the cliff themselves. Health care providers (and our patients) would have to make due with much less and accept it as the norm.

If Medicare fails, those who pay for private health insurance plans through their employers will see their rates go up dramatically. Since the health care system will have to function at some level, if Medicare is underfunded and/or not available, the private insurers of the world will have to make up the difference. Thus, premiums will rise as will co-pays and out of pocket expenses, and the list of uncovered conditions and procedures will grow as insurers quickly go broke.

It's likely that tens of millions of people would be added to the 48 million currently without insurance in this country. How pathetic. As the last wealthy industrialized nation on Earth who does not provide even a minimal health care safety net for its citizens, we should hang our heads in collective shame. That we will abandon citizens who have faithfully paid their taxes each year and believed that they would have at least some level of care available to them should make people furious.

As has long been the case with the United States, we have waited until the last possible moment to address major issues with more than just rhetoric.

What will need to happen is that taxes will need to be raised. It's really that simple. We need to bring in more money than we are now so that we can collectively pay for the programs we will all need. And before anyone starts to complain about how our taxes are too high already, just remember that without a social safety net like universal health care in place, financial disaster is as close as any traffic accident, stroke, heart attack or major surgery for too many. You think the financial world is in tough shape when people default on home loans? Wait until millions of families go into bankruptcy every year because of health care related debts.

We are well past the time to fix our health care system. A new system must be created that is adequately funded, financially responsible, realistic, fair and accessible. We need a system that will approach care from the direction of doing the most good for the greatest number with the funds available.

We do not need a system that is wasteful, or panders to what patients feel they need. We need a system that is responsible in its care decisions and realistic in its judgments. We can no longer afford to pay specialists outrageous sums to perform procedures that have little to no impact on outcome or quality of life. Our new system must cover the basics like preventative care, medications and necessary hospitalizations. We need to stop spending massive amounts of money on care that only benefits the providers and not the patients.

And people need to understand that we cannot live forever. People die. It's what we are all destined to do – no one is exempt. But we have a hard time with this reality in the U.S. We feel like we should go on forever if we so desire.

Well, thinking like that is why we spend a majority of Medicare dollars in the last 6 months of a person's life. It's O.K. to want to live as long as possible. It's unacceptable to expect the rest of society to pick up the tab for those extra few months that can cost more than the previous 25 years.

Because any new responsible system would be available to all, it should be funded by all. This can be done via a tax on all things consumable. If we had such a tax, it would collect from those who eat caviar as well as those who live on cheap booze and everyone in between. No one would be exempt from paying, just as no one would be exempt from utilizing. And we can afford this – especially if we all stop paying premiums to insurance companies. Insurance can be handled here as it is in most other countries – as a supplement to the government provided minimum plan.

Fixing this mess will not be easy. The lobbyists are out there already, spending their money and exerting their influence on our government trying to keep the status quo. It will be necessary for all of us to be willing to vote out any representative who refuses to help build a realistic universal health system. Show them their jobs are not our concern. Get involved – write letters, educate yourselves, call offices of representatives and let them know you expect more from your government. Turn off Fox News and get real. The truth is painful, but it must be faced.

If we don't fix health care now, all the other things that need fixing won't matter.

Thursday, May 7, 2009

Better Than Expected

The dream may very well be over.

The dream of economic recovery in 2009 that is. The rally in the markets that began in March of this year is about to fizzle and take the next big legs down. Why? Well, it seems that reality is about to take hold. The results of the stress tests done on the banks are due out today (in about 90 minutes from now as I write) and they will show that many of the tested institutions need more capital on hand because their reserves are not large enough to withstand additional defaults from tapped out, strapped and unemployed borrowers. The real problem, though, is that the stress tests were conducted using better than current figures.

So if the stress tests are fundamentally flawed, yet they show that the banks are largely under-capitalized, then banks are in even more trouble than we are about to be told. If BOA needs an additional 34 billion per the regulators, reality dictates that they need a lot more than that.

I have read over and over that the numbers, while very bad, have been “better than expected”. Talk like this swirls around the financial media and news outlets. But while “better than expected” may sound good in the twenty second sound bite that encapsulates it, it really still means “bad”. Unemployment numbers “better than expected” as only 490,000 people lost their jobs. Housing sales “better than expected” as people buy foreclosed properties. Bank losses and under capitalization “better than expected” as banks pass faulty stress tests.

But the fundamentals have not changed. The numbers of unemployed in the U.S. continue to CLIMB, not decrease. That's still nearly a half million people who lost jobs – not who got jobs – they LOST them. Housing sales are still down when you break out new construction and existing homes, separating them from sales of foreclosures. Banks have made “profits” this quarter, but have received boatloads of money from the government via TARP and through cheap loans via the FED, which have kept costs down and coffers partly filled.

So, if BOA and its like are “making money” it's all a farce, because they are using our bailout funds to make themselves look better than they are. I can look well capitalized too if someone gave me billions of dollars, but if I have to pay it back, it's not really mine now is it? And if some regulator comes to look at my books and says that I may need to save a lot more money because the future looks pretty bad, but reality is already worse than what they used for the evaluation, then I am up the proverbial creek sans paddle.

Tomorrow may be a very bad day in the markets, or it may not. But I know that until I start to see more substance and less flash, I'm still not going to be spending money I don't have on things I don't absolutely need. And that goes for stocks as well. I don't absolutely need to own any – especially not now.

And the number of people like me is growing. That's a bad sign for the "better than expected" crowd because ultimately, they need us.

Wednesday, April 29, 2009

Before You Panic About the Pandemic

It seemed like a good idea at the time.

A couple of days ago, my boss called to see if I would be willing to work a few extra hours this week because the ER was short staffed. Against my first instinct, which is always to say “No”, I agreed and told her I would work the four hour slot that was open today. Imagine my surprise as I walked in and saw my co-workers wearing masks – the ones we use to prevent us from inhaling any number of viruses – and looking for all the world like they would rather be anywhere else.

One girl quickly pulled down her mask to talk. “Did you hear about the positive cases of Swine Flu?" Her face was tense and I knew there was going to be a good story – I just wasn't sure I wanted to hear it. She told me that in my home state today the CDC had confirmed 3 cases of Swine Flu (2 of those 3 coming through our hospital) and that now seemingly everyone in the area who had a cough or fever was coming to the ER to get checked out. Earlier (I missed it because I don't have TV) the governor had held a press conference to discuss the 3 confirmed cases and warned that more were certain to follow. Now, individuals were scared and coming to the ER; primary care providers were also getting into the act and sending their patients to us so we could test them.

To make matters worse, hospital personnel who had any contact with the confirmed cases in our facility were also being sent to us for evaluation – some from work still in scrubs. We were called by news crews and reporters; the regional Emergency Medical Services office called to see if the rumor was true that we had closed (really - I cannot make this stuff up). The phone never stopped ringing.

By 6:00PM I was wishing I had not been such a team player and agreed to work the shift.

I don't know how many flu swabs we did or even how many people we saw, because my 4 hours there were a complete blur. I went over the same instructions with patients, answering as best I could their questions and trying to allay their fears of certain and impending death from Swine Flu. I talked to our infection control officer, the CDC and any number of potential patients on the phone. Now, as I sit here, my feet tired and my frustrations high, I am happy it has become someone else's problem. Now, I am happy that I am not going back to that nightmare tomorrow.

At 6:45 PM I was notified that 1 of the positive 3 cases was a mistake. My understanding is that the other 2 confirmed cases are still actually pending confirmation. Someone must have jumped the gun. The result of that little mistake was chaos in my ER for the better part of the day.

What I wanted to do all afternoon was tell people, "Look, just go home. You don't have to worry. Most of you don't even appear to be ill. We only want REALLY sick people in here. The rest of you are just risking exposure to something you don't currently have." But that would never fly. People don't think about things like prevention when they are already convinced they have something. And all of our patients today just "knew" they had the Swine Flu. They knew all about it because they saw it on TV. Good for them.

As for me, the best thing I could think to do was to write this and pass along some advice to those interested. Here's the basics folks:

1. Don't panic - I cannot stress this enough
2. Wash your hands after you touch things in public areas and before you touch your face
3. Cover your mouth and nose when you cough or sneeze
4. Take it easy – rest when you are sick
5. Stay home from work or school so you don't become a vector of disease
6. Don't call the ER and ask us to tell you if we think you have Swine Flu – we have no idea and can't diagnose people over the phone

The CDC has good information on their site about the Swine Flu. Read it and help to limit the spread of the virus.

Oh, and don't come to the ER looking for me. I will be off for the next several days. And just to make sure I don't do anything stupid, I'm not answering any calls from my boss.

Tuesday, April 21, 2009

Kicking the Credit Card Habit

My name is John and I'm a recovering credit-aholic.

When I was younger (read: without children and less concerned about money) I had a habit of buying things with a credit card. It was not the smartest thing I ever did, and one day I found myself wondering just how I had managed to build such a huge amount of debt. So several years ago, my wife and I began the process of weaning ourselves off credit cards. We have managed to reduce our credit card debt to very reasonable levels today (though we still have balances) and we did it without taking out home equity loans to do so. We just worked harder at not buying stuff we didn't need and began to purchase only what we could pay for with cash. If the cash was not available, the item was not purchased. It seems we changed our ways just in time.

Last week I was sent a letter from Bank of America. They own one of the 2 credit card accounts I have. They wrote to notify me of a pending rate change – a big one. After more than 15 years, first with MBNA and later with Bank of America (BoA) following a buyout, I would have thought that perhaps someone there appreciated my business. But apparently not.

It seems BoA does not care that my outstanding balance is less than 25% of my available credit line. It would appear that my predictable and reliable monthly payments (on which I am never late) also don't matter to them. They have decided that effective May 2, 2009 my rate should be more than doubled from 8% to 19%. That seems a bit excessive to me for an account in good standing that is being paid without issue.

According to the notice, I had the option to refuse the increase in writing, which I did (and not in a nice way I may add). But refusing the increase means that any charge to the account from that moment on results in the higher rate being applied to current and future balances. Thus, the card came out of my wallet and I began to track down any automatic charges from places like Maine's Turnpike Authority that resupplies my EZPass account with the card. Luckily, this process was short and I was able to turn the automatic payment options off.

My balance is small enough that I can pay it off in a few months, which will be my focus from today forward. I will then cancel the account and never do business with BoA again.

I am left by the experience feeling more than angry. First of all, BoA received TARP funds in a tax-payer funded bailout for their losses. Now, they are coming after more of my money via a massive rate hike. There just never seems to be an end to their need for cash. Therefore, I can only deduce that they are in even more trouble than we have been led to believe. If BoA is in enough trouble that they are willing to sacrifice the future for today – because I am sure I will not be the only account holder they will lose as a result of this tremendous increase – then they must be looking at the very real possibility of not being around in a few years.

But they are not alone in their fear. The government is also very concerned that the financial industry is falling down around us, and will do almost anything to boost confidence in the banks. The recent “stress tests” the government conducted on the biggest banks in the country (BoA included) was mostly smoke and mirrors (see Nouriel Roubini's blogpost from April 13, 2009) and thus should not be relied upon for any accurate picture of the banks' stability.

But it's not just big banks that are in trouble. All financial companies are facing huge defaults on auto loans, mortgages and credit cards. No one appears to be immune in today's environment.

I have only one other credit card and that is through Discover. While I have been writing this post, I received a notice from them as well (ironic, no?) that also advised me of a rate hike on that account. While that one is not as steep (from 7% to 13%) I don't have a balance there to worry about. But that makes the next step that much easier. The letter canceling the account will be what I type as soon as I am finished here.

Like any addict in recovery, I have learned to live without my abused substance. Now, I will just take the final step and remove what I had considered to be an insurance policy from my wallet. It's long past time to operate strictly on a cash only basis.

Sunday, April 12, 2009


It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change. - Charles Darwin

The most successful people are those who are good at plan B. - James Yorke

I have always paid attention to the world around me, but over the last two years I have become a daily reader of financial and economic sites and blogs in addition to the several news sites I had always read. I have tried to learn as much as possible about the deteriorating economic situation around the world and its pending impact on individuals as well as nations. It has become like a train wreck from which I could not avert my eyes. My focus has been too intense at times, and my time spent reading and blogging has only increased as things have gotten worse. But recently, I stopped paying attention.

Over the last several weeks, I have been unable (or more accurately, unwilling) to watch the larger world around me as it has continued on its downward tack. I have also been unavailable to do so because the smaller world - specifically my world – has been through its own changes that took time to navigate and to understand. As I wrote here a couple of months ago, my wife's employer has been poised to layoff workers in an attempt to bring costs under control. We had been worried that her time there may be short, and so began the process of looking for a new job for her.

After finding a comparable job, albeit with significantly fewer benefits, she applied. After being interviewed, she was offered the position. She then began a very real and painful grieving process.

She was not happy to be leaving a facility where she had worked for 11 years. She was not happy to be forced into a decision she was not ready to make. She was not ready to leave those who had become a second family over time – those who have been there for her as she has grown both personally and professionally over the years and who will be missed as much as any other loved one. She felt traitorous; like she was leaving a sinking ship and her friends were still on board.

Adding to this stress, we both have parents who are retiring within months of each other – the first coming on the same day my wife finished work for her previous employer. Both families have some resources, but after all the recent losses of retirement savings, no one is feeling certain that they will have the means to be self sufficient as long as they thought they would.

Needless to say, my focus had shifted inward towards my own family and away from the world at large. My wife and I had many difficult discussions, some emotional moments, and a few frustrating times over the past weeks, but we have begun to come around. I believe a corner has been turned in our small world – my wife has begun her new job and feels better about her decision. She is encouraged so far by the people she has met and again feels fortunate to have a job she likes in our small city. For the moment, our changes seem smaller and easier to accept than many people's. We still have jobs; we still have our health; we still have our home. We continue to be fortunate. We have adapted for the moment and continue to avoid major disaster.

As I turned my attention back to the larger world yesterday, I noted that not much has changed: the bear market rally has continued, the economic commentators are calling a bottom (still) and people want to believe that the worst is close to ending. But the jobs numbers still seem shocking, the cost of oil is increasing, Goldman Sachs is looking at raising capital, and the Toll brothers (owners of one of the largest home manufacturers in the country) are selling their own company's stock. Yeah. That's better. Nothing new here. I have not missed much. The rest of the world is still falling apart.

But my own small family has reluctantly (and hopefully successfully) moved on to Plan B.

Wednesday, March 25, 2009

Silk Purses, Sow Ears and Reality

I spoke with a friend yesterday about his new change of career. He is going to become a hedge fund manager. To start his business, he's going to get a business loan from Citi. This should be easy because my friend's going into business to help Citi out. He'll be independent of Citi of course, at least on paper, but they will work closely together. After he starts his business, he's going to get a government loan to buy some bad assets from Citi that have been hard to value. Even though Citi can't sell these assets for more than about 10-20% of their book value in the open market, they still insist that the assets are worth closer to 80-90% of book value currently. These are the so-called “toxic assets” that people talk about on the news.

What my friend will do is negotiate with Citi (a mere formality, really) to purchase these toxic assets at near what Citi wants for them, thus limiting their write downs, and then try to sell the assets himself on the open market. If it becomes obvious that they really are worthless, he will walk away and leave the government with the bad assets and default on the loan he received from them. That's because it's a non-recourse loan and there will be no action against him for defaulting – because really, he was just trying to help.

If the bad assets do increase in value from what he paid for them, then he and the government will split the profits 50-50, despite the fact that the government put up 93% of the money for the purchase.

Wow. And the best part is it's all legal.

Okay, so I don't have a friend who is planning on starting a hedge fund. But the above scenario is not only plausible, but likely. Large banks and financial companies will soon have the ability to set up third-party organizations to buy troubled assets at close to face value to get them off their books. The banks and financial companies get to be made whole, or close to it with government funded purchases of the toxic assets made by the third parties who will negotiate directly with the banks on price. The government puts up money via non-recourse loans to the third party purchasers and bears all the risk, yet only gets 50% of any potential profits on the future sale of the toxic assets.

Fine. If the government and their regulators want to believe that these toxic assets really are worth more than they would get today on the open market, then buy them outright and keep all the profits if they increase in value. Why expose taxpayers to risk and simultaneously limit their potential for profit?

But more importantly, why is it O.K. for the taxpayers to take a huge loss on these toxic assets, but not the banks. Why is it that these banks, the ones who wrote the bad loans to begin with, are excused from their poor decisions and the rest of us are made to pay for their greed and short-sightedness?

Well, that is what happens when the guy who runs the treasury department is in the pocket of the banks. Timothy Geithner is the financial industry's whore and we are all being played for fools.

Saturday, March 14, 2009

Journalism 101

It may have been the very best 24 minutes of television I have ever seen.

On Thursday March 12, 2009, a comedian proved to be the absolute best investigative reporter in America. Well, that might have been the easy part because what he actually proved was that he is THE ONLY investigative reporter in America.

For several nights this past week, the main stream media has been called on the carpet by the less than main stream media, namely The Daily Show, for their complete lack of credible coverage of what has turned into the greatest financial disaster of generations. The host of The Daily Show, Jon Stewart, showed clip after clip from CNBC and their myriad of shows whose hosts / reporters / commentators were proven to not only be wrong, but to be completely oblivious about the risks and pending collapse of the financial world. On Thursday night, Stewart finally got one of the CNBC bozos on his show.

Jim Cramer from CNBC's Mad Money had been a frequent target of Stewart's over the previous several nights and had been shown in various clips encouraging his viewers to buy stocks that then tanked. The clips were juxtaposed with simple black and white text that then detailed exactly what happened to the stocks he was hocking. Simple. Effective. It left little doubt that a man of Stewart's caliber should be taken lightly.

On the show Thursday, Cramer was reduced to a fool and hack who not only missed the signs of impending doom, but actually knew the game being played and encouraged people to continue to invest their hard-earned money into banks and investment companies who could not possibly continue in their march forward. Several clips of Cramer speaking to another man about how to manipulate stock prices and whip up speculation were shown, much to Mr. Cramer's dismay. He was seen and heard on one saying, “I'd never say this on television”, implying that he wanted his TRUE nature and thoughts kept from the public. He became red and very uncomfortable after being exposed for who he really is.

Time after time, Cramer and the Daily Show audience and viewers were shown proof of his own inside knowledge of the gaming of the system. It was right there on video for all to see and appreciate. Stewart managed to get Cramer on one video basically admitting to committing fraud while running a hedge fund. It was a thing of beauty.

Now the whole premise was not to go after Cramer personally. Stewart's point was that CNBC had done a very poor job of reporting, and that, in fact, they had more or less been a cheerleader for the same financial system that has now reduced the retirement savings of most Americans by nearly half. His questions to Cramer were mostly in the vein of “where were you?” and “why didn't you tell people what you knew?” about what was going on. He actually held Cramer's feet to the fire and made him squirm on national television.

What does this say about America as a nation? Why is it that the single best piece of investigative reporting on the economic disaster occurring right now has come from Comedy Central? We should all be disgusted with where we are as a nation. Where is our fourth estate when the only reporting I trust on television comes from a comedy news show?

Hey main stream media people – were you paying attention? Did you learn anything Thursday night? Like maybe, HOW TO DO YOUR JOBS? What the hell have you folks been doing over the last 10 years? You who work in the news media should all be ashamed and hang your heads today – and for many days. You have been shown to be inconsequential and soft by a guy who makes “fart noises” for a living.

Perhaps those in the main stream media will go back and watch that tape from Thursday night and learn just how a professional reporter operates. It should become mandatory viewing from now on in all journalism classes as well. Perhaps we can expect more from our next generation of journalists than what we have today. Maybe someday soon, the spirit of Edward R. Morrow won't have to be invoked by a comedian.

Tuesday, March 10, 2009

On Being Realistic and Hopeful

In the midst of the greatest financial crisis to come along in more than a generation, I am beginning to find hope. Not the kind of hope that allows me to think the crisis is going to be short or painless; though that would be nice, I am not foolish enough to think it a possibility. Instead, my hope centers around the fact that with great upheaval there is a tremendous potential for change. Not the kind of change that occurs in increments or at a glacial pace, but real change like the dismantling and rebuilding of entire systems.

With the pending failures of health insurers – a high likelihood because of the stress on financial companies at present – and with 78 million boomers expecting a health care system that is intact and functional, the best option will soon be for the nationalization of health care. The U.S. is the last holdout among advanced nations not to provide this basic safety net for its citizens, and now may be the best time to restructure our system to provide the most good for the largest number with the resources available. That is to say, it may be the best time because it will soon be unavoidable given the situation.

“You'll never get people to accept limits on health care. That won't happen in this country.” These words were spoken to me by a friend at work. He is convinced that citizens will not allow for any health care system that does not cater to them. He argues that people want what they want, when they want it and therefore, they will not accept any decrease in services they currently receive. But really, that “drive thru” mentality (as my wife refers to it) of patients exists only because we have allowed it. Ever since health care administrators started calling patients “customers” and decided “market share” was an important aspect of treating the people of our communities, we have invited those patients to dictate what it is we do because we have sought their approval.

But, as I see it, those days are coming to an end.

In the midst of a depression - when millions will be unemployed, without savings and without retirement accounts to fall back on - what's to prevent them from understanding the limits on health care? My sense is that the majority of Americans will soon begin to understand that something is much better than nothing. After all, when you can have anything you want, you want everything – but when you have nothing, you will accept anything. Don't buy that? Check out your local soup kitchen for proof I'm right.

Our next health care system needs the following to be functional: 1. It needs to be reality based; 2. It needs to include legal reform; 3. The cost of education must be reduced; 4. Funding should be adequate and provide basic coverage for all citizens. It is well past time for a reality based, adequately funded, practical and responsible health care system in this country.

We can do more with less if we do it reasonably. We need to stop performing tests simply to prevent a lawsuit; we need to stop doing procedures that will have little to no impact on outcome; we need to stop performing heroic measures when it is obvious they will not change the outcome. We have lost all sense of reasonableness and have instead clung to the mantra of honoring patient wishes.

As an example of how a reasonable system can work, consider how organ donation is handled. Today, there are waiting lists for patients who need transplants. These lists only include patients who are most likely to survive (they cannot have several other major medical problems) with the new organ so that the precious resources are not squandered. Thus, patients in need of a liver must not be actively drinking alcohol or abusing drugs; those in need of lungs cannot be smoking. Break the rules and you lose your shot. It's simple and prevents organs from going to those who can't show the ability to maintain their health.

A rebuilding of heath care in the U.S. must also include legal reform that removes the threat of frivolous lawsuits against providers and limits damages awarded for mistakes that are not life-impairing. We work and live in an imperfect world and deal with imperfect patients – with few exceptions most of us do our best and then some to make sure patients are cared for appropriately. We spend more money (via unnecessary tests and procedures) trying to cover our backsides than we do actually doing the things that matter. This needs to stop. Medicine should never be practiced from a defensive posture. Fear wastes resources and the constant threat of legal action makes many leave the field prematurely.

Educational costs need to come down to levels that encourage people with the ability to enter the field. Physicians are typically saddled with $200K-$300K loans upon completion of their residencies. This level of debt is daunting and prevents many from entering fields like primary care where reimbursements are minimal compared to other specialties like anesthesia. As of 2005, of the 800,000 physicians licensed in the U.S., less than 1/3 were working in primary care. Primary care physicians should be able to manage the ongoing care and treatment of their patients. To do this, they need to have fewer patients attached to their practices, while making an income that allows for them to not have to take on more patients than they can manage safely. To achieve this, more primary care physicians are needed – period.

Universal health should cover the basics for all citizens. Things like regular office visits, preventative care and screenings, necessary medications, valid emergent care and EMS services and hospitalizations. Necessary surgeries and tests should also be covered. Unnecessary treatments should not be covered by the plan. By unnecessary, I am talking about such things as emergency room visits for non-emergent complaints, the use of EMS for non-emergent transportation and tests like CT scans done at the insistence of patients and families. If patients want to pay out of their own pocket, then they are welcome to request such things, but if the government funded system is to work, it cannot be permitted to pay for nonsense.

None of this is revolutionary. All of what I have described above is practiced almost everywhere else in the world – and with good results. We are the ones who spend more on health care than anyone else, and we are also the ones who rank about 40th in the world for life expectancy and infant mortality. Clearly, we have gone off course.

The group most opposed to such a system includes those who benefit most from the current system and those who stand to lose with the new one. People who have worked as physicians and made a very good living (albeit while saddled with massive debt thanks to the cost of education) can be some of the most vocal about arguing against universal health. Also, many employed by insurers are quick to denounce universal health as an impossibility. Often, they go further and argue that no government could possibly run a universal health system with any sort of ability. Well, insurance companies spend upwards of 30% of their capital on administrative costs. Medicare, a government run entity, by comparison spends a paltry 4% - in line with other universal health systems.

But the group of detractors is getting smaller and stands to get smaller still. The chances of large health insurance companies surviving this crisis intact is absolutely zero. There have been and will be more layoffs and write downs. The reality of our new financial world is coming into view for many more people and the ones who will see most clearly will be the ones who have lost the most. Sadly, that number is increasing on a daily basis.

My own hopefulness rests with the assurance that very soon, the best option will be the only possible one left on the table and the number of citizens who insist on it will be unable to be ignored. Someday soon, I will work in a system that is fair and makes sense.

Wednesday, March 4, 2009

Re-thinking the System - While in a Staff Meeting

I hate staff meetings and rarely attend them. I went to one yesterday – but only grudgingly.

It's not that I dislike my co-workers, or my boss for that matter, but getting together for a morning meeting to hear what the plan will be for the next month or two is always an exercise in frustration. I deplore the minutia of health care. I am not one who likes to dot the “i's” and cross the “t's”. I like to look at the bigger picture. Except for the time I spent in management, that preference has always been an issue.

The problem with seeing the big picture is that you usually have a good idea of just where things are headed. Since I am fascinated with economics and politics, I am well read on and all too well aware of the financial crisis that is just getting started. I see nothing but problems for health care on the horizon unless certain things are done and done correctly. Because I like to pull back my view, sitting in a meeting listening to someone enthusiastically discuss details I consider trivial and wastes of time quickly sends my mind wandering.

I have written here before about the pending failures of major health insurers. It is my belief that health care will be nationalized as a result of these failures and the threat they pose to the industry. The cost will be staggering, though it will come in much lower than the cost of rescuing the banks. One benefit of a new universal health program that will be forged in today's financial dire straits may just be a necessary change in the attitudes within and outside medicine about just what health care is and should be.

At the meeting, I listened to my manager talk about the “service” we provide to our “consumers” and how it is the goal of our hospital to not only meet the expectations of our “consumers”, but to exceed them.

While she was talking, my mind began to race and got stuck on the words “consumers” and “service”. I started thinking about just when health care sold its soul. The “consumers” of health care used to be called patients. We did not treat patients like they had money in their pockets and could go spend it anywhere they wanted. We didn't used to approach our jobs in the same way retailers approach theirs. What happened?

While my mind was working on the above discussion in my head, my boss continued to talk about a pending visit from the state to inspect the facility. This is a huge deal for hospitals because, in theory anyway, the state can reduce funding and reimbursement levels if you don't get rated high enough by the inspection team. In this state, where Maine owes hundreds of millions of dollars for care already delivered several years ago, I am wondering just why the inspection is a threat. What is the state going to do if they don't think we are worthy – not pay us? That's already happening.

And so my mind again went off – wandering through all the things nurses and others have to do to jump through ridiculous regulatory hoops to appease someone who finds such things important. I spend more of my work time on silliness, like adding certain phrases to orders so we can make sure we get reimbursed for things like CT scans, or documenting the same actions in multiple places, that I can get distracted from doing the other things that patients actually need me to do. Recently, my wife and I compared our workdays today with what they were like 10 years ago. We realized that up to a third of our workdays can now be spent away from patients, documenting on paper as well as in computerized charting systems. We both concluded that the levels of bureaucratic garbage which detract from actual care is getting to be too much to take.

Still in my meeting, I began thinking that when health care does get nationalized, it will force all of us to re-think just what health care is. It is a service to be provided for the sick and the injured. It's not something that should be looked at as if it were a retail store in need of customers. Simply stated, a hospital is not Wal-Mart.

And that's one of the biggest problems today – we approach our jobs as if we need the “customers”, not the other way around. We have and offer too many choices, yet people are always asking for more. Well, when the money to fund this system runs out, we will be forced to let our “customers” know that they can no longer demand tests and procedures that providers feel are unnecessary. They can't expect that every last possible thing will be checked or tested because they feel it should be done. They will have to accept that reality dictates that not every person will get everything they wish for from the system because we will have to care for more patients than we do today – but with even less money.

A realistic health care system will look more like a military chow line from the Korean War than an all you can eat buffet in Las Vegas. It will keep you alive and sustain you when you need it, but it will not fulfill your every whim and desire. In fact, since the government is going to be so short of funds, even the chipped beef may be substituted for peanut butter.

I missed most of the rest of what was said at the meeting. But I had a smile on my face thinking about just how good my big picture began looking to me. It even began to smell good. Maybe these meetings aren't so bad after all. I may just go to another so I can flesh out the details of our new system.

In the meantime, I'll start looking for an apron and hairnet to replace my scrubs.

Friday, February 27, 2009

Why Health Care Jobs Are Not Safe

Just recently, someone commented to me how fortunate I was to work in health care. They believed that a job in our industry must be lucrative and secure with excellent benefits – somehow untouched by the collapse of the financial industry specifically, and the economy as a whole. “You'll always have work. People will always need medical care”, was what they told me.

I was quick to point out that while health care may be necessary, it is not always funded. Hospitals in the U.S. operate in an environment where we cannot turn people away for emergent care regardless of a patient's ability to pay. Because people who lack insurance also usually lack a primary care physician they can call and see, they come to the ER. Remember when Bush told us that America had the best health care in the world and all people had to do to access it was go the ER? Well, that was his big plan for health care. Kind of like the Nike ad - “just do it” - people were just supposed to go the ER for whatever they needed. Of course, no one pays for care given to people without insurance. There is little we can do other than to write off the care as a loss.

Over the past several decades, insurance companies have been collecting higher and higher premiums from policy holders and actively working to pay out less and less in reimbursements for care given. They are for profit agencies and they are doing what our system allows them to do. But over the years, as health care sees and treats more and more people, and people expect more and more care and insurers pay less and less, we have been left with fiscal instability.

Adding to this imbalance is the current budget shortfalls of most states – the suppliers of the Medicaid programs. With states having less money available to fund their Medicaid programs, reimbursements have dropped. In some states, like Maine, the state owes hundreds of millions of dollars to hospitals over the past several years that have yet to be paid.

What makes me most concerned at the moment however, is the current state of the insurance companies. Without a funded national health care plan in place – that means actually funded, not just some numbers on paper – we are at the mercy of insurers. When they can't pay for medical care, we are all in trouble.

We have all heard about banks and financial companies and the troubles they are having, but much less discussed is the sad state of most insurance companies. Banks have been in the news for huge losses, but insurers have managed to slip by unnoticed as their losses, less impressive in size, have been as consistent over the past two years.

Check out a few stock charts on some of the largest insurers over the past 2 years. Below are charts on Cigna, Aetna, Humana and UnitedHealth.

Now, it might just be me, but I think there is a definite trend here. Notice the sharp downward turn each large company has taken over the last 2 years. That translates to less reserves on hand, bad investments, credit default swap exposure, and poor choices by management. The only reason the insurers have not been in the forefront of this disaster is because the banks have been so much more impressive in their losses. But not for long.

When the insurance companies start to fail, they will be unable to pay for health care provided for policy holders. The government will be forced to step up and fill the void. Of course, they could just try and bail them out (like they have already begun to do with AIG), but it would make much more sense at that point to just nationalize health care and be done with it. Like their larger siblings the banks, insurers will require support at unprecedented levels if they are to remain solvent - but that may not be the best plan.

What all this means for heath care workers is this: without a revenue stream to pay for care, we are all at risk until someone admits the current system is unsustainable and decides to rebuild it from the ground up, removing private insurers as the main source of reimbursement. How that should be done is another topic for another day.

Wednesday, February 25, 2009

Savings, Savings, Savings

I did not see Obama's speech last night – I was too tired to watch it after a couple of long days at work and little sleep. I did read the text this morning in the NYT and was mostly satisfied with what I read. The tone is upbeat (more honest than we have been used to over the past 8 years) and there are good things in what he proposes. But the one thing I did not read was any acknowledgement that Americans have been and still are addicted to debt.

I read it was important to start lending again. I read that banks and regulators were going to be accountable. I read that we needed to be able to finance that college education or new car. What I didn't read was that we need to stop borrowing so much and saving so little.

Why is that still some sort of taboo topic? Why is it not OK to say to the American populace, “hey, stupid – don't have three credit cards with balances that are larger than your annual income”? Why is it not OK to tell people that not everyone can AFFORD a new BMW or a McMansion? I'll accept that many credit card offers in the mail seem just too good to pass up, and that all that credit is tempting – but come on! Like Chris Rock has noted - “Just because you can drive a car with your feet don't make it a good idea”.

In 2002 the San Francisco Fed reported in a letter regarding savings rates:

“From 1980 through 1994, the U.S. saving rate averaged 8%; thereafter, it fell steeply, and since mid-2000, with allowance made for the tax rebates that boosted household saving in the months of July, August, and September 2001, it has averaged approximately 1%. By contrast, the personal saving rates from 1980 through 2001 averaged 13% in Japan, 12% in Germany, and 15% in France, with no steep declines after 1994; in fact, in France, the saving rate rose slightly. For the United Kingdom, the personal saving rate was close to the U.S. rate during the 1980 to 1994 period, averaging 9%, but it has since declined only modestly to an average of 7% after 1994, while exhibiting very large swings throughout the sample period. For Canada, the personal saving rate did decline sharply during the latter half of the 1990s, but it is still higher than the U.S. rates, averaging 16% from 1980 through 1994 and 7% since 1994.”

And that was before we actually went negative in 2005. Today, we are moving back into positive territory and as of the end of 2008, we are just below 3%. But we still have a long way to go to get to where most other G20 nations are, and to add to our problems, we carry more household debt than anyone.

Just getting credit thawed won't get the economy running again. First, we need people worthy of getting loans to apply. Most people who don't absolutely need money today are not borrowing, so who's going to be looking for a loan? Oh, that's right - people who are high risk. Just what we need - more bad debt. Is anyone else seeing an issue here?

Now, I do agree that there was and (still is) predatory lending, confusing paperwork and too many other bad practices out there for the banks not to be blamed for a good part of this mess. And we encouraged people to borrow more and more without consideration for tomorrow - just like our government does. But Americans should have understood that all their debt was going to be a problem at some point - yet we ignored common sense for euphoria over a new plasma TV (to watch bad shows, no less).

The other thing we need to do is to stop believing that adding money into our retirement accounts is going to get us anywhere. People, those funds are invested. That's another reason why we are broke. We put no cash into an account at the local bank, but "save" significant amounts into retirement (which goes right into the stock market) and thus we find ourselves with no cash on hand AND smaller retirement savings than we planned on. I have stopped the retirement garbage. It's my money - I worked hard for it - I will take care of it, thank-you.

To read Obama's speech, you could be forgiven for thinking that we just need to free up credit lines so we can borrow again. But is the problem really that we can't borrow – or is it that we have already borrowed too much? I'm happy that the bankers and the regulators are going to get scolded for their role in all of this, but I think Americans need to be taken to task as well for being so greedy and short sighted.

Some times you just have to take a good, long, hard look in the mirror to see your problem.

Sunday, February 22, 2009

What ever happened to personal accountability?

Some days even my jaw can hit the floor.

Recently, a patient came into our ER with a request to be evaluated after surgery. This struck me as odd since surgical patients are expected to follow up with their surgeon after they are discharged. They normally are given instructions for home care and an appointment to meet with the surgeon in the next 1-2 weeks. This patient explained that he was not going to be following up with his surgeon because he had moved. Not the surgeon - but the patient. And on the day of his discharge from the hospital no less. The patient then further offered that he had moved to our state from one over a thousand miles away.

The patient had surgical drains still in place and wounds that were still fresh. When asked why he decided to move to our state, he replied that his cousin lived here and told him how good our state Medicaid program was and that it would be easy to move here and collect disability so he would not have to work. Since the patient was relatively young and untethered to a family, he decided to come north and try and make a go of it (on the state's dime).

I'm not sure what was worse – the fact that the patient thought this was a good plan, or the fact that he was willing to share it with people.

The patient, not surprisingly, was dumbfounded when we asked if he had told any of his physicians about his decision to move. He also seemed more than a bit confused when asked if he had contacted any providers here to follow up with him and his on going medical problems and needs as time went forward. A simple “no” was all that was provided in response.

The patient has complicated medical problems that will be expensive to address and will likely not improve. His complete lack of understanding about what medicine can and cannot do for him is not much of a surprise, as many people struggle with this, but his absolute disconnect from responsibility was amazingly irritating. This patient, through his own personal choices, had managed to severely damage his body to the point that his life expectancy is likely less than 5 years. But he wants us (that's a collective us, as in the American public) to take care of him. That, he feels, is his right - to be taken care of despite his egocentric behavior and without delay (hence the move to Maine).

It was not clear to me when exactly this patient had resigned his position within the banking industry. He was a young man, and so he must have moved up the ranks in a quick fashion. Interestingly enough, he left his previous state on a bus instead of his private jet. He must have left it behind so it would be easier to make his case for disability and Medicaid. A trick he learned, no doubt, by watching the auto industry executives on their second trip to Washington to beg for aid.

What has become of us? If this is the mentality that is prevalent throughout all socioeconomic levels in our country, we are in more trouble than I have feared. When the poor, the middle class and the wealthy all feel like they are victims and deserve to be made whole again by the rest of society, despite any and all evidence that their situation has been self-inflicted, then perhaps it is time for a serious discussion about the permanence of consequences.

Bank executives who watched and encouraged their loan officers to give large sums of money to people who should have had a hard time borrowing cab fare; home buyers who thought they should be able to afford a $750,000 home on a $50,000 salary; investors who bought real estate at over inflated prices thinking the value could only ever rise; alcoholic drug abusers who trash their liver and pancreas before they reach 40 because the only thing that mattered was the “high” - all these people have the same disease. None of them have the ability to take responsibility for their actions and live with the consequences. They represent the worst in us as a society.

I think I may just take a page out of the Alcoholics Anonymous book and start my own support group for people who feel entitled to everything at everyone else's expense. I can see it now – a poorly lit church basement with bad coffee brewing and white styrofoam cups on the folding table. A man stands and walks to the front of the group to address them:

Speaker - “Hi everyone. My name is Ted.”

Group - “Hi Ted.”

Speaker - “I'm a greedy and irresponsible American.”

Group - “Suck it up Ted! And that coffee's not free you know.......”