Monday, April 28, 2014

Duke Lacrosse and the American Campus: Exception or Rule?

Duke Lacrosse Scholars 
Stanford Undergraduates Contemplate Charles Darwin
As the "student athletes" at Northwestern cast their votes about unionization, a new book about Duke University and its relationship with the "student athletes" of its now infamous lacrosse team has hit the bookstores and the Kindle screens. 

It's not a pretty picture.

What is really astonishing about college athletics is that so many millions can be so blind to its hazards.

A former president of Princeton, William Bowen, has written in "The College Game" and "Reclaiming the Game" about the poisonous effect on the integrity of academic scholarship of merging commerce (in the form of college sports) and academia .

The reigning opinion has been that college sports may not be central to the mission of an academic institution,  but it is a harmless way to raise cash for cash strapped institutions. The impact of admitting 100 people to play football and 50 to play basketball on a student body of 10,000 is minimal.  In the Ivy League, where there are smaller class sizes and far more teams (lacrosse, swimming, volleyball, equestrian, soccer--an average of 15-20 sports teams) the impact is actually higher, there you may have 300 or 400 people on campus to do a sport,  out of a class of 1000. 

All this  brushes by the story of Lenny Moor, who, when called on in class,  told his professor, "My name is Lenny Moore. I carry the ball. I don't answer no questions."  Does having people on campus who reject the value of scholarship and academic effort really injure the academy?

Does filling a stadium with 100, 000 paying fans at Ann Arbor really harm the integrity of a great university?  What is the harm of smiling fans in blue and maize and pom poms and little kids in the college colors having a good time at the football game?

The president of the University of Chicago, long ago, said he could not abide the thought of sending a team of 19 and 20 year old boys across the country to California to play in a game which consisted of chasing an inflated bladder around a field. His school ultimately eliminated football. Johns Hopkins does not have a football team, but it does have a lacrosse team. The Ivies all have football teams.

There are, of course, stories about football players raping young women off campus at or after visiting local bars.

But the real issue is the difference between a culture of physical and mental contest living alongside a culture of the mind. We value diversity on campus, and perhaps we should value the diverse cultures of athletes and engineers.  Why then, if we value these different perspectives, do we not include in that mix tradesmen, farmers, assembly line workers? 

Faculty, particularly in the humanities have always been something of an impoverished priesthood, suffering the insults of materially successful people while the scholars pursue their arcane interests. Of course, faculties are now also filled with "stars" who command great salaries and interest free mortgages at some universities, who cut rap albums and who appear on TV shows. 

Mad Dog has no real insight into how healthy life is on America's college campuses  today. 

But he has his doubts.

Tuesday, April 22, 2014

Pat Tillman: The Desire to be a Hero

 Ten years ago, Pat Tillman, a National Football League player, who joined the Army after 9/11, was shot to death by mistake, by his own compatriots in a friendly fire incident. 

This raises, for any American, the question of how can you best serve your country.  

Tillman wanted, it must be supposed, to be a hero. That is nothing to disparage. Men become doctors and surgeons and astronauts wanting to be heroes.  Wanting to be a hero is not a bad thing. 

Tillman made a genuine sacrifice, giving up a lucrative NFL career, a life of violence on the field but luxury off it. For many of his fellow Army recruits, the Army was the best job, financially and socially they could get. Not true for Tillman.

As most of us understood his decision, he was motivated by a desire to really make a difference in the effort to seek revenge or simply to prevent another terrorist attack. He wanted to take the fight to the enemy, not just go on living his safe, comfortable life.

But he was killed through the incompetence of the American military.
When you think about it, more American soldiers have likely been killed through the incompetence of their officers than through the effectiveness of their foes. How can anyone say something so outrageous?  But consider this: More Americans were killed during the Civil War, by a country mile, than in all other American wars combined. 

And for the most part, most of those Americans were killed because officers and generals were still sending waves of men running across fields at entrenched enemy riflemen who could shoot them down from 80 meters away.  The generals simply did not appreciate that the rifled gun barrel meant that heroic charges across a field or up a hill were a senseless waste of life,  once the technology of weaponry changed. Nobody would send a company of soldiers running across a field against machine gun fire today. That would be seen as gross incompetence. It was no less incompetent during the Civil War, just more widespread and  more widely accepted. 

So, yes. Mr. Tillman joined the masses of American soldiers killed through the incompetence of the American military.

Which is not to say the American military is, overall, incompetent.  Despite many sizable incompetent plans, execution of plans, the American military has often achieved its ultimate mission, by accruing overwhelming numbers and force against a smaller opponent.  Grant had more men and he used that advantage to grind down a more agile and more ably led opponent.  Maria Sharapova, in the tradition of Russian warfare compensates for a lack of elegance and finesse with grinding power and tenacity. The American Army can execute the occasional attack effectively.   Just ask the Iraqi soldiers who fought the American army  during  the first gulf war, or ask the soldiers who fought with Richard Winters in Easy Company of the 101st Airborne. 

But all too often the command simply does not ask enough questions, or play smart, and substitutes bravado for intelligence: consider the chaos of the Normandy air drop  and the entire game plan for the war in Vietnam. 

If you want to be effective, why would you put your life and your own decisions in the hands of American military officers? When the Vietnamese, or any other underdeveloped country facing the force and bluster of the American military looks at our Civil War, they must shake their heads in wonder. Why would you waste lives and military effectiveness in displays of senseless valor, when you can ambush, and then melt away and kill by a thousand cuts?

So how can you react to Al Qaeda terrorists blowing up buildings in your cities?  How does a citizen who wants to react take effective action in behalf of his nation find a way to do this,  if he cannot trust his leaders to provide an outlet?

Mad Dog does not have the answer. 

War on Terror; War on Drugs, War on Cancer: Fantasy in American Policy Ideology

 Kima: "You suckers just kill me: Winning the War on Drugs-- one police brutality case at a time."
Carver: "Girl, you can't even call this a war."
Kima: "Why not?"
Carver: "Wars end."
--The Wire

"If I could free all the slaves and save the Union, I would do that. If I could free none of the slaves and save the Union, I would do that. If I could free some of the slaves and leave others alone, I would do that, too."
--Abraham Lincoln

When Lincoln finally issued the Emancipation Proclamation, he gave legal cover to what was already happening in the field--as the Union army advanced, slaves left their bondage, fled their "owners" and followed their liberators. 

Lincoln was afraid if he declared the Civil War was actually about freeing the slaves that half of his Union Army officers would throw down their swords and quit and all the border states--Maryland, Kentucky, Tennessee--would join the Confederacy. Southern Maryland was very much slave country. There were riots in Baltimore over emancipation and abolition. The Maryland legislature was about to vote to join the Confederacy when Lincoln sent in the troops to send the legislators home.

Lincoln issued the Proclamation in September. By January, in his annual address to Congress he had seen the true importance of that document:

Fellow-citizens, we cannot escape history. We of this Congress and this administration, will be remembered in spite of ourselves. No personal significance, or insignificance, can spare one or another of us. The fiery trial through which we pass, will light us down, in honor or dishonor, to the latest generation. We say we are for the Union. The world will not forget that we say this. We know how to save the Union. The world knows we do know how to save it. We -- even we here -- hold the power, and bear the responsibility. In giving freedom to the slave, we assure freedom to the free -- honorable alike in what we give, and what we preserve. We shall nobly save, or meanly lose, the last best hope of earth. Other means may succeed; this could not fail. The way is plain, peaceful, generous, just -- a way which, if followed, the world will forever applaud, and God must forever bless.

As Lincoln said in his second Inaugural Address, everyone hoped for a less drastic solution to the problem but there was none to be had, and the war came. Of course, not everyone hoped for a less drastic solution--the slaves and the abolitionists hoped for the most radical solution, complete abolition of slavery in both the slave states of the South and in the new territories. 

Lincoln was, hands down, our greatest President, but even he could not see how a powerful will for doing the right thing could overwhelm even entrenched wrong. After he issued the Proclamation he went before Congress and told the representatives there could be no ducking destiny. We had to either gloriously succeed or meanly concede defeat, and if we lost, then the last best hope on earth would be lost.

That document, limited as it was, changed the course of the war--England and France, missing Southern cotton dreadfully, with cotton mill workers left idle by the Northern blockade were about to intercede and the South would have won independence, just as the French intervention won the Revolutionary War for the American colonies. 

But anti slave sentiment in England was crucial and when Lincoln made the war a war to end slavery, that ended all talk of intervention. It turned out to be a master stroke, necessary but not sufficient to win the war.

We do not have a war with armies in the post 9/11 age. Like Lincoln, President Obama faces a new phenomenon in history, and like Lincoln, he wants to use the tools of the past to fight a new reality. As Radio Lab notes, in its examination "Sixty Words" a legal document, written by a George W. Bush lawyer in the White House has served to justify, legally, the "War Against Terror," voted through Congress. No declaration of war has been voted through Congress since World War II. There are simply no real circumstances appropriate. A nuclear war between the USA and USSR would not have allowed time for a declaration of war.  All the other wars have been undeclared.  Korea was a UN "police action."  It looked a lot like World War II, with armies and air forces battling for territory but it did not end in a peace treaty ceremony. Technically, it's not over.  Vietnam was justified by the Gulf of Tonkin resolution, not a declaration of war and Iraq and Afghanistan were justified by the resolution writing by the Bush lawyer to say the President could do what he damn well please to protect the USA against terrorist, i.e. stealthy, attacks. 

Those 60 words are just words, just lawyer games and fool nobody. They cannot compare to the Emancipation Proclamation, which actually meant something. 

We are operating now in a world of practical action taken as a police force takes its action. Someone is about to hurl a bomb, you don't read him his Miranda rights--you shoot him. 

The time for talkers has past.

Of course, that has left us with problems like Guantanamo. 

Too bad the Congress was too cowardly to oppose Iraq, and even Afghanistan, after they got Bin Laden.

We will see how useless those lost lives in the War on Terror have been as we see Iraq and Afghanistan sink back into their respective morasses.  

We needed to get Osama. For that, we needed bases in Afghanistan. But once that was done, good riddance to bad garbage.

Bring 'em home. Don't pretend we were there for any other reasons. And no document written by lawyers will protect anyone. The generals at Nuremberg all had their documents. Didn't help them. Soldiers are not governed by words as much as by bullets. 

Saturday, April 19, 2014

Jill Lepore Deconstructs Fear and Loathing of Elizabeth Warren

Elizabeth Warren

 Jill Lepore, in the 21 April New Yorker fulfills the highest aspiration of the literary critic in her review of Elizabeth Warren's new book, "A Fighting Chance," by placing it in an historical context. Lepore sometimes exasperates Mad Dog with strained incorporation of historical antecedents to modern events, but in this case she uses the life and work of Louis Brandeis to enrich our appreciation of what Elizabeth Warren is all about.

She begins with Warren's own stump speech, which terrifies and infuriates all the self made men of the right wing, the Republican part, the right wing talk show set. 
"There is nobody in this country who got rich on his own. Nobody, You built a factory out there, good for you. But I want to be clear. You moved your goods to market on the roads the rest of us paid for. You hired workers the rest of us paid to educate. You used other people's money. You built a factory and turned it into something terrific or a great idea--God bless! Keep a big hunk of it. but part of the underlying social contract is you take a hunk of that and pay forward for the next kid who comes along."

This of course, gets to the heart of the Right Wing's fantasy about how much they deserve all their wealth and how nobody else is entitled to any share of it.

Warren is careful not to denigrate the effort of the man who took risks to build the factory or launch the idea, but what she is adding is the big "But."

Brandeis argued in a famous brief that women ought not be put in a position of having to work 12 hour days or lose their jobs. Brandeis argued in "Other People's Money" that monopolies of capital captured by big banks resulted in great harm, no matter how legally they may have been won. Three New York banks controlled more wealth than all the property in the twenty two states lying west of the Mississippi. Even if the bankers were angels, which they most assuredly were not, this could not be good for a democratic republic.

Rush Limbaugh would, of course, cry foul. This is not how the "game " is played. You cannot change the rules, especially if those changes disadvantage the winners.  And, anyway, the winners deserve to be in control.

Certainly, Mad Dog is familiar with the psychology. Mad Dog looked out from the chemistry laboratory window as his fellow college students danced by, in togas, on their bacchanalian way, with their arms around the girls they would take to bed,  and he heard his fellow pre-medical students mutter. "They're getting theirs now, but I'll get mine. And when I graduate from medical school and they are whining about how tough things are for them, it'll be my turn to laugh." The ants and the grasshopper.

And Mad Dog thought. Yes, you are working really hard and sacrificing the present for the future, but you are doing it in an Ivy League college, and you are working in a college lab paid for by someone else, and you are going back to sleep in your dorm room, paid for by somebody else--your parents, your bank, taxpayer dollars. 

When Mad Dog opened his office to practice medicine, he was lucky enough to not have to take out a loan. He had written a book which provided the capital. He was lucky to get it published. He had worked hard writing it, but he was still lucky. And the success of that book depended every bit as much on other people who sold it as on his own efforts.

Mad Dog had to hire a secretary. She had never finished high school. She answered the phones, made appointments, filed charts, took phone messages, called in prescriptions, created bills for the patients, collected their payments, billed Medicare, entered the payments into the computer system, and when she went on vacation the income in the office plummeted because the temporary worker replacement could never approach her productivity.  When the secretary was out sic, Mad Dog, thought, "I don't need her. I can do all this myself. I'll just work harder."  But Mad Dog learned quickly, that was a fool's errand.

Mad Dog paid her the same check every week no matter what. if she missed time for a doctor's appointment, had to take her husband to the doctor, had to leave early for a nightclub gig--she was a country singer on the side--Mad Dog still paid her in full. No time clock. When she asked why he was willing to do this, Mad Dog observed she often stayed late to finish up work, and he hadn't paid her any more for that. He paid her for doing the job, not by the hour. 

She was not above drawing her own lines:  She left for lunch at the stroke of noon, even if a patient was finishing up and on her way to the window and could have paid her bill right then. Lunch time was sacred.  She would not call repairmen for the photocopier or the computer or the telephone system. That was not her job.  When she finally left after 20 years, a new secretary did all that without a murmur.  But the fact is, that employee was essential to the financial success of Mad Dog's practice. Patients did not come to the office to see the secretary, but had she not been there, they could not have been scheduled at all, and no money would have been collected for Mad Dog's efforts.

So Mad Dog knows Warren is correct: Every self made man stood on the shoulders of others. Even Coltrane, who practiced hours every day, had to be taught the saxophone by someone and someone had to set up the clubs he played in. 

Jill Lepore
Lepore includes a scene from a dinner with Larry Summers who told Warren she had to decide whether she wanted to be an insider or an outsider. To be an insider, he told her, she could not break the rule: Don't criticize other insiders. Doesn't that just say it all about Larry Summers and the stupidity of those who think they know what the rules are and ought to be? I was surprised Lepore did not mention Lincoln and his shrewd and brilliant idea that he needed his critics close at hand, in his own cabinet. 

People like Summers, and Kissinger before him, always want to play the savant. The fact is all they know is how to promote themselves.

Lepore sums up her own take on Warren as she hurdles through the last page of her analysis: 1. Most candidates elected to office in the United States in the past two centuries abandoned their children.  2. Warren had better have the sense to turn a deaf ear to political advisers who will try to do with her what they had done with all others: "Include, when telling the story of their lives, gauzy intimacies, silly-little-me confessions of domestic ineptitude, stagy performances of maternal devotion, and the shameless trotting out of twinkle eyed tots."

Warren has fallen into that trap once before, as she ran for U.S. Senate, but who can blame her? She had never run for office before. She needed to trust someone and people were telling her how to win in the real world where the voters were not Harvard undergrads.

In the end, Lepore comes up with the most powerful image and statement of all. Warren tells about how Warren went to her grand daughter's crib and scooped the baby  up and held her, "Not because she needed it, but because I did."
And Lepore observes: "Her brief is really about the abandonment of children, not by women who go to school or to work but by legislatures and courts that have allowed the nations social and economic policies to be made by corporations and bankers. Writing about her children and grandchildren--rocking that baby--is more than the place where Warren leaves Brandeis behind. It's an argument about where our real debts lie."

Louis Brandeis
Where Our Real Debts Lie

Tuesday, April 15, 2014

Where Have All The Leftists Gone? Long Time Passing.

 Mad dog never thought he would miss the 1960's, but he is edging toward that now. 
In the 1960's the left had cause to take to the streets. The War in Vietnam, oppression of Blacks, the suppression  of women. Now, there were some heavy wrongs to right. 
But now, Jane Fonda has short hair, diamonds and designer suits. Gloria Steinem got married and the War in Afghanistan is fought by other people's kids, so we can all go out and make money, buy nice cars and homes and live lives of comfort.
Oh, how Mad Dog fantasized about women like that, when he was in college. But look at them now. They're all grown up and they look like the suburban housewives back in the day.
 Trouble is, this comfortable life, as wonderful as it is, does seem bereft of...purpose.
It is outrageous that 1% of the nation's population controls whatever, 70% of the wealth, but the 7% of the wealth that's left to the 80% is livable. It's not like seeing your sons come back in body bags or sans legs or arms.  And, yes, women are not paid what they are worth, but it's not like they are limited to teaching, nursing and secretarial work--just look at Mad Men to see how far we've come.
 Blacks were being knocked off their feet by fire hose jets. "Freedom riders" were murdered for trying to enroll Black voters. The governor of Alabama stood in the school house door with hate dripping from his lips. Martin Luther King was murdered for being an uppity Nigra.
But the war in Vietnam eventually limped to its ignominious conclusion; Blacks got the vote, got to use public rest rooms and restaurants; medical school and law school classes opened up to women; women left the home and entered the workplace and young men and women could have sex before marriage, even with members of other races or the same sex, and nobody got thrown into prison because of that. 

So most of these liberal causes, most of the fights ended in victory for the right side, if not for the Right. 
We have become victims of our own success. The left has been defanged, become irrelevant. All the thunder now comes from the Right. Rush Limbaugh and that smarmy guy on Squawk Box, Joe Kernen, with the lush hair and smirk baits a college professor this morning calling him a "pseudo academic, but then again, that is a tautology." And the Johns Hopkins professor, who has left Wall Street for the Ivory Tower responds meekly, "Well, I turned forty."

So now it's okay to say academics are pseudo. Of course, this is something that wells up from people like Rush Limbaugh, Glenn Beck, Sean Hannity. We expect this because there's not a diploma with any of their names on it among them.  They resent academics because when they were at the academy, they likely got taken apart limb by limb by professors and instructors who would not let them get away with saying outrageous things. They were scarred by the experience and that resentment, that burning flame of self doubt is still in there.
Joe Kernen, however does hold a BA and an MS, and worked at MIT, so in a sense, he has more right to assert that academics have clay feet. But nobody challenged him. Nobody said, "Well, academics may disappoint you, but consider the alternative: The ignoramus."
But, qui tacit constentit, silence implies consent. If we do not answer these ignoramuses we will allow their narrative to become the prevailing wisdom: "Obamacare is a disaster." 
No, actually, it is a triumph. 
But where are the liberal voices to sing that song to the unwashed masses?

Thursday, April 10, 2014

Does the Profit Motive Work in American Medicine?

Fat Cat Doctor
Furnish me the picture, and I will furnish you the Scandal

For Republicans, the private sector does everything better than the government. We ought to get the government out of everything, but especially we ought to throw the government out of medical care.

The Mitch McConnell's and Eric Cantor's and, Heaven Knows, the Koch brothers of the world all will tell you the greatest efficiency and the greatest good in any endeavor is gained by unleashing the powerful stallions of incentive and the drive for profit. That's what makes a system lean, mean and competitive.

But just show these same Republicans doctors who have been driven by that same incentive to bilk the government and Whoa!  Oh, the profit motive is just foul! When doctors seek to profit from the government, then the system is rigged and ought to be destroyed!

The New York Times, having set off the bombs in Market Square with a story about doctors raping the system to the tune of $21 million dollars a year is now feeling a little guilt stricken and today publishes an article in the business section which gives the response. Aude alterum partum. Hear the other side.  And, just as Mad Dog predicted, it turns out the amount paid for that $21 million dollars of eye care did not go to the bank accounts of the doctors, but to the bank accounts of the drug manufacturers. Well, mostly. The doctors kept 3% for profit, and many would argue that is too much. Why should doctors get any share of the drug profits? 

The Times, of course, had the perfect image of the perfect, porcine villain in the Florida ophthalmologist who led the money list.  Doesn't he just look like the prototypical fat cat rich doctor who has grown fat off the suffering of his fellow human beings?

Trouble is, likely he did nothing illegal. He just saw an opportunity, in this case afforded by Medicare, a government system, and he did just what the Koch brothers have always done: He moved in to take his profit. 

"Much of what Medicare pays them, they say, goes to the cost of the drugs they administer to patients in their offices and the bulk of that money ultimately goes to the drug companies." (NY Times--well, that's what they say!)

Defending himself, a Nebraska ophthalmologist who makes 3% profit on the injections (and that's just for the drug, not what he gets paid for the procedure) he says, "It's basically a problem created for us by the Medicare system."

See that? How neat is that trick? This doctor, a fat cat Republican no doubt,  profits from the system and then bites the hand that feeds him by denigrating Medicare as a flawed system! Now that's chutzpah! Well, it was right there for the taking! I had to take it! 

"If an internist admits someone to the hospital with pneumonia and they go to the I.C.U. and have a $300,000 bill,  that is not tagged to the physician,"  says the president of the American Society of Retina Specialists. "But when we treat someone for macular degeneration that gets attributed to the physician."

Yes, doctor. That is because the internist doesn't get a dime of that $300,000, but you, the retina specialist get at least 3% of the cost of the drug plus whatever you can collect for the injection. 

The eye doctors are right about one thing:  The system allowed them to profit. There is no way the government should pay the doctor for the drug and allow the doctor to profit for simply opening the bottle. The government should have paid the drug company, should have negotiated that $2000 a bottle price down to $200 (at which level the drug company would still accrue a profit of $100) and the government should pay the doctor for the service of doing the injection.  The government has allowed the doctor a "handling fee," and all the doctors did was to take advantage of that. In days of yore, the doctor was allowed an "interpretation" fee for the lab tests he ordered in his office and then sent out to a commercial lab, which did the work.  But that was ultimately disallowed because it was seen as providing a perverse incentive for doctors to order more tests to interpret. The interpretation of those labs was part of the service involved in the office visit and that was that.

Orthopedists may have to pay for the hardware they use to do a hip replacement. For that reason, orthopedists now do hip replacements in the hospital so the hospital pays for the hardware and the doctor collects his fee for the service of installing it. For other procedures, the orthopods take their patients to outpatient centers they own themselves and they profit from the fees for the nursing care, the inexpensive dressings and other equipment rather than allowing the hospitals to profit from all that.

All this is driven by our perverse "private only" and "incentive driven"  system of medicine, which we will never escape as long as Republicans control the Congress and the debate.

Other countries have long since addressed this profiteering. But we are the exceptional Americans. 
Aren't we lucky?

Wednesday, April 9, 2014

New York Times to Medicare: You Furnish Me the Pictures. I Will Furnish You the Scandal!

Some years ago, an endocrinologist in Providence, Rhode Island awoke to his morning paper to see his name plastered across the front page: He had collected over $4 million dollars from Medicare the previous year. What a scoundrel! How could he have possibly done enough service to justify such an enormous amount? (In today's dollars that would be about $20 million.)

The endocrinologist happened to be  the Chief of Medicine at Rhode Island Hospital, and all the billing for every intern, resident and for some attendings were billed under his Medicare number. Of course, he did not get a dime of it. He was on salary. The money went to the hospital and to Brown University School of Medicine.

This morning, something similar may have happened to some ophthalmologist in Florida, who found he led all doctors in Medicare payments at $21 million dollars.  Maybe this guy is a scoundrel, but maybe he is injecting a lot of intra occular medicine (Lucentis)  at $2,000 a pop,  to prevent blindness in his patients. Maybe he is paying $2,000 for that medicine and Medicare is reimbursing him. I don't know. I'm just saying. There are all sorts of accounting quirks in any insurance bureaucracy. 

There are other wrinkles in this story: a drug called "avastin" may work as well as Lucentis, and costs only $150 a pop, but the manufacturer and the FDA would have to agree to allow this treatment. Lucentis has gone through the process of proving efficacy and safety. Avastin would have to do the same. But the $21 million dollar opthalmologist would not be in control of any of that.  If the opthalmologist, or his associates did 10,000 injections a year, or 5,000 patients a year or 14 patients a day, that would account for that staggering $21 million. But we do not know, because the New York Times did not do the basic journalism. They did not get answers to the basic questions.

The trouble is, nowhere in the New York Times front page, lead article, above the fold article is there an analysis of exactly what was going on with this $21 million pay out. They clearly just got the number and ran the story, the way, say, The Daily News would have done. Why ruin a great headline with a detailed analysis?

William Randolph Hearst  once sent Frederick Remington  to Havana to gets pictures of Havana in  the coming war with the Spanish. Remington wired Hearst, saying there was no war. "You furnish me the pictures and I will furnish you the war." This newspaper tradition of fanning the flames goes all the way back to Hearst. The New York Times, as great a newspaper as it is, or once was, is not above that tradition.

This all comes at a time when the US Congress has, once again, decided to simply renew Medicare funding for a single year rather than for 5 years, which is what hospitals and doctors' groups want so they can plan ahead. But when the Congressmen and Senators read this headline they are going to think no deeper and they will say, "Well, good thing we didn't give those hospitals and doctors what they wanted--we would have allowed these doctors to rape the system for 5 years. Next year, we can go get those scoundrels."

The system we have is a commercial system. It is based on profit and the game, one might say, is to maximize profit. Maybe the $21 million dollar ophthalmologist just learned how to play Liar's Poker better than everyone else.  He may say, "Hey, I didn't make the rules. I just played the game."

Maybe we ought to think more about the game. Maybe it shouldn't be a game. Maybe we should devise a system which can't be gamed, because it's not about profit, but about service.

Oh, but there I go again. Politically incorrect. 

Sunday, April 6, 2014

The New American Doctor and The Single Payer

Lost in all the discussion of Obamacare and the direction health care will take in this country is a demographic change which Mad Dog has not seen mentioned yet: The sea change in the make up of the health care work force in the United States.

In today's New York Times "Sunday Review" are two articles about what the future holds for heath care in this country.  The first, by Molly Worthen, a history professor at UNC, Chapel Hill, is an insightful piece about why Canada was able to follow such a different course with respect to fashioning its health care system.
She notes the difference in the political climates of the two countries:
"Canada inherited something else from Britain besides the Westminster system. It retained the full spectrum of English politics. This includes the socialist left and the Tory right--both traditions that, despite their differences, call for a strong central government and the restraint of individual liberty in the interest of the community.
     The United States, by contrast, is a revolutionary state. The founders feared both kingly tyranny and the rule of the mob, and they bequeathed to us a political spectrum that is the narrowest in the Western world."

 And there was something different about the mechanics of politics: 
"American doctors succeeded where Canadian doctors failed (despite multiple doctors' strikes) because the American political system left individual politicians vulnerable to lobbying. They capitalized on the rhetoric of the Cold War, insisting that 'socialized medicine' was on step short of Soviet tyranny."

And there was another factor: Homogeneity in Canada but not in the USA:

"There is also no denying the ugly role that race played in this story: Too many white Americans have rejected reforms for fear that their tax dollars would help black Americans."

She is correct about all three factors, but her most interesting point is about race. Mad Dog would substitute "class" for this idea; here in New Hampshire, where there simply isn't as much race consciousness, because there simply are hardly any non whites here--outside of Manchester.  But you certainly, if you scratch the surface of the white Yankee resistance to Obamacare, find the resistance to the idea that I should help the poor--read that the "lazy"--when I've got problems of my own. 

Europeans cannot understand why Americans reject universal health care, until you ask the Swede, who has universal health care,  whether he'd be willing to support universal health care for all Europe, if that meant his tax dollars would support clinics in Spain, Italy or Greece. The Northern Europeans see themselves much as our New Hampshire Yankees do: We are the hard working, self sacrificing Northerners; they are the lazy, indolent, free-loading Southern Europeans, who sing and dance all night and are too hung over to go to work the next morning. Why should we worker ants support those slackers?

A great deal of the resistance to insuring the uninsured and extending health care to all derives from the resentment of the hard working to the notion of providing for the less enterprising --or less fortunate, depending on how you see the less economically successful.

Ross Douthat notes  we will see:
"A grinding , exhausting argument over how to pay for health care in a society that's growing older, consuming more care, and (especially if current secularizing trends persist) becoming more and more invested in post-poning death."

What neither Douthat nor Worthen focus on is the change in the American medical community, which as been theboiler room of resistance toward movement from a cash and carry system to a government paid system. 

In the 1950's and 1960's, American doctors were, overwhelmingly, white, male and the main if not the sole providers for their families.  Returning from World War II, they rode the post war economic boom, made money easily, built practices by simply hanging up a shingle and enjoyed a dream come true life. 

Even in the early 1970's, when Mad Dog went to London on a medical school rotation, he was struck by the differences in expectations between his American and British medical student friends.  The Brits were younger, just out of high school essentially, about 19 years old, and they expected a life of genteel respectability, but not wealth. They hoped to have a modest car, a flat to start off and, then a house, likely an attached house, in a middle class neighborhood. Their financial prospects were roughly equivalent to what an American kid with a high school education might expect if he were a good machinist and there was work in the factories.  Britain was simply nowhere near as rich as America. Doctors in Britain, if they could successfully emigrate and get past all the hurdles American doctors had erected at the border, could take a leap from modest comfort to dazzling luxury. 

The British students reflected these modest expectations in their modest commitment to patient care. They were out of the hospital at 5 PM, no matter what.  When they became the equivalent of interns and residents (Registrars), they were not up all night the way their American counterparts were. Their days were more contemplative, leisurely and far less filled with effort, management of details. They simply could not order the same range of tests for their patients, so there was less to do for them. They could not command the same range of therapies, so there was less to do.

American students, in those days, thought, "Ah, this is the difference between the rationing and tight budget restrictions in the British system and the more vigorous, incentive driven American system." And that was true, but the implication may not have been true: It may not have been true that the American system, hard driving, piston churning as it was, was better for the patient or for the country. In fact, much of what American doctors and hospitals did for patients may have been worse for patients, and it was most certainly far more expensive for everyone. The Brits, in retrospect, were driving Toyota Camrys and getting where they needed to go, while the Americans were driving fully loaded Mercedes, too fast, and wrecking a lot more often.

But now, decades later, as insurance companies have squeezed the American doctor far harder than Medicare ever did, the nature of the American doctor has changed. And changes have occurred in the demographics:  Virtually half of MD's are now female, and many of these are committed to their families first and their patients second. So, they take time off for pregnancies, choose specialties which allow them to get home early, refuse to take call on nights or weekends, retire in their 40's or 50's and generally spend less time at work. This is not to say they are not good doctors when they are at work; they are simply committed elsewhere.

And just as the Brits realized in the 1950's, it has finally dawned on American payers  that perhaps 50% of visits to doctor's offices for things like sore throats, cough, fever, back pain, injuries can be taken care of by nurses or somebody with far less expensive training than the MD:  a nurse practitioner in a CVS pharmacy, not even a "doc in the box" but a "nurse in the store."  The Brits had GP's doing the screening, referring patients who they had identified with more serious conditions back in the 1950's. Americans would have told you then they would not have tolerated being "pawned off" to a nurse. They wanted to see the doctor.

Now, the American doctor is not paid in the upper 10% any more. The primary care doctor, depending on where in the country she or he practices, makes $80,000 to $160,000.  You can do as well owning a McDonald's franchise. Own two, and you're doing way better than the pediatrician, the family practitioner or the internist.

And 85% of American doctors are not surgeons.  In fact, an increasing number are not MD's--they are "DO's" (doctors of osteopathy.)  The DO's are often among the most business savvy and do as well or better, financially,  than the MD's. They are often masters of marketing.

The surgeons can make $300,000-500,000, and some make millions. But things are changing there. The cardiac surgeons now face a loss of patient volume because angioplasties, stents and other procedures have cut down on the need for the basic heart surgery procedure: The CABG (coronary artery bypass grafting.) Training programs for heart surgeons which once may have had ten residents finishing a year, are now down to two or three. Simply not enough business out there.

So American medicine is now pretty much where British medicine was in 1970--a respectable, relatively secure profession, which promises a middle class life, and can be managed with a family in a decent community. You'll get a house, not a McMansion, and be able to afford a vacation. You'll also likely have significant medical school debt, which will diminish what you can afford for mortgage and you'll expose yourself to significant legal risks the average worker, the McDonald's franchise owner will not have:  Malpractice judgments. 

In short, your mother will be proud. Your father will tell all his friends about his daughter or his son the doctor, but the bloom is off the rose.

And this group of doctors will not, has not objected to the idea of a government salary to replace their commercial insurance company hassles.  Nearly ninety percent of American doctors get W-2 forms now, because they are employees, not the free wheeling, hardy, independent, self-employed doctors of yore.

Single payer?  American doctors now say:  Bring it on. 

And cover my malpractice insurance, while you're at it.

Wednesday, April 2, 2014

The Best Congress Money Can By: Just Ask the Supreme Court

Dweedledee & Dweedledom

Free speech sounds like such a simple idea.
There's a reason it's the First Amendment in our Bill of Rights.
It's the fundamental right on which all others are standing.

But consider this: You are in a crowded theater and someone stands up and shouts, "Fire! Run for your lives."
But there is no fire. The speaker is just exercising his right to free speech.

Or this: You are gathered in a huge stadium. There are 100,000 people there. You stand up to say, "I think every citizen should be able to use the bathrooms here, regardless of his or her color."  But on the public address system a man says:  "The bathrooms are for whites only. It is God's will. It's in the Bible."  Your voice has carried far enough for maybe 100 people to hear you. The man on the PA system has reached all 100,000.

Or, consider this: The local town police officer stops your daughter daily, on her commute to school, asking her for a date. Finally, one day, she refuses again and he hauls her off to  the police station, where she is stripped searched, has her vagina examined just in case she is carrying any lethal weapons there--we are only concerned about the safety of the jailers and the other prisoners-- and she is ultimately released, with a speeding ticket. The newspaper, which is owned by the police officer's father, prints a story saying she was driving erratically, that she propositioned the officer. The article appears in the paper, which is distributed to the entire town. 

Free speech, 100%. 
Rye Lobsterman, Obadiah Youngblood

If you are an absolutist, decisions become simple:  Limit speech and you violate freedom, and you violate the 1st Amendment. If you tell the Koch brothers they cannot spend $100 million to buy TV commercials for Rand Paul or for the senate candidacy of Rush Limbaugh, then you have violated their rights to express their opinions in a free society. It's really very simple. They have a right to say what they please, publish their opinions, in whatever form they can pay for, and to communicate their ideas to the public as widely as they can afford to disseminate them.

Suppose, in the not too distant future, technology becomes available so the purchaser can slip his message into your cell phone, your computer, your television, your radio and into your iTunes?  If they can afford to do it, is there any problem with that? Is access not one aspect relevant to considerations of free speech?

For Justice Thomas, there should be no limits on the amount the Koch brothers can spend to elect the particular man they want. For Justices Roberts, Alito and Scalia and now Kennedy, there may be no limits, but that will be for the next case. Right now, all they'll say is an individual can give up to $2500 per candidate every two years, but he can give $2500 toe each of  10,000 different PAC's, which are buying ads for that candidate. It's just a matter of book keeping, really.

So, for the United States Supreme Court, buying elections is no problem. It's like the game Monopoly--if you can gather up control of enough blocks, eventually you can control what everyone else is doing.

There is a reason 1% control the wealth.
They can buy the people who make the rules. They can make sure all the office holders are in their pockets.

And our current Supreme Court smiles and winks and says, "Fair is Fair."

Our Constitution, our Revolution was a reaction to the overwhelming authority of a king, of government, so rules were written to limit the power of government. What those bewigged 18th century gentry did not anticipate was a threat from oligarchs, from non governmental rich men who owned the country. Hell, Washington, Jefferson, most of the delegations from the South ruled over their plantations like little monarchs. They were concerned about a government taking from them. They were not concerned about a rich man having too much power. They were the rich men.

Want a definition of "Smug?"  Look at the photo of the Koch brothers above, or, alternatively, go look at a photo of our current Supreme Court.