New Hampshire, Fair and Free

North Hampton Rocky Beach--Obadiah Youngblood

Mad Dog considers himself lucky to be living in New Hampshire. But watching the legislature dither over whether or not to provide its citizens with health insurance is painful to behold. It's one thing when you see old time New Hampshire codgers struggle with the idea of agreeing to taxes and a government which actually has ambitions to help its own citizens--they look quaint and honest and plain spoken.

But it's quite another when those tough old Yankees start to look like superstitious ignoramuses, clinging to some mystical, religious notion that we shouldn't help our neighbors because it makes them weak and it makes us enablers.

The big argument against accepting federal dollars (which Granite staters have already paid into the federal coffers) is that, down the road, some day, it will  have meant we have actually bought into the notion we might get involved with the federal government. As if we have compromised our virtue by allowing the local woman of easy virtue to contribute to our collection for widows and orphans.

It puts Mad Dog (pictured below) into a funk.

What's Eating The Right Wing Now?

Tweedle Dee and Tweedle Dom: Aka Koch Bros.

Have you noticed how quiet the Tea Party has been lately?  Is it just that Mad Dog has not been paying attention or is it simply that Congress is not in session?

They are still out there, even when you don't see them. But you know they are there, like cockroaches, busy, unseen, ready to come out when they think the time is right.

President Obama has been taking punches on the roll out of Obamacare, but now, as more and more people have locked down policies, you are, at least if you listen to NPR, beginning to hear stories from more or less ecstatic people who have health insurance, who either never had it before or who had dreadfully inadequate policies.

If this keeps up, people might just get to like having health insurance; they may even get to depend on it like Medicare and Social Security, and if that happens, people may just begin to believe government is good for something.  And if the government is good for something, then what can those anarchists in the Tea Party sell?

Well, maybe  they can always try to kill Obamacare with a thousand cuts and bleed it anemic until people start to dislike it  because it cannot run up the mountain in its weakened state.

Presumably, Ted Cruz and Eric Cantor and the entire Congressional delegations from South Carolina and Texas and Arizona are huddling with the Koch brothers and Carl Rove and other luminaries of the Tea Party Thought Palace, rehearsing their songs.

Charles M. Blow, notes in today's NY Times that 43% of Republicans (Pew Research) are now "staunch conservatives" in terms of their ideas on the size and role of government, economic policy (trickle down good,  government rescues bad),social issues (gay marriage, bad, guns good, government restrictions bad) and moral concerns (Heaven only knows what constitutes moral concerns in Tea Party Republican eyes nowadays.) A majority of these "staunch" types watch Fox News regularly.

 Of white evangelical Protestants 73% disbelieve evolution. This is in contrast to all Republicans, of whom 54% believe in evolution.  This means 73% of evangelicals and 46% of all Republicans believe "humans and other living things have existed in their present form since the beginning of time."

Billy O'Reilly has been inveighing against the "War on Christmas," which he hears in the greeting "Happy Holidays" as opposed to "Merry Christmas."  Newt Gingrich picked up the Christians-under-attack theme, "There's a lot more anti-Christian bigotry today than there is concern on the other side, and none of it gets covered by the news media." Apparently, Mr. Gingrich does not watch Fox News.

Tea Party Republicans, which is to say, Republicans, or at least 43% of Republicans, the staunch set,  depend on anger, resentment and a sense of having been wronged.  (Actually, Mad Dog would like to know who those other 57% of Republicans are who are, who are not staunch. And who represents them? John Boehner? Mitch McConnell? How are these guys different from staunch?) Republicans are the party of anger. 

This is not the first time the Republican party has been the party of grievance. Of course, there was the McCarthy era Republican party of Who-lost-China?  and deep paranoia. But, originally, when the Republican party emerged from the Whigs, and nominated Abraham Lincoln, a lot of them were abolitionists, and being angry about slavery, even today, more than 150 years later, that seems appropriate. But there is a world of difference between being angry about slavery and being angry about Obamacare.

During Mad Dog's youth, there was the war in Vietnam. America was killing peasants in their rice paddies, burning babies with Napalm, and sending off its sons from America to die for "honor" and glory and to "fight for freedom" and to "defend our country."  That was something to get mad about. Republicans weren't bothered by all that then. It was disaffected Democrats who roiled about Vietnam. It was Democrats who served notice on their own sitting President he would not be renominated and it was Democrats who rejected the candidate of smoke filled rooms, Hubert Humphrey, because he supported the war in Vietnam, and it was Democrats who self destructed and handed the election to Richard Nixon because Democrats were angry at their own for having blundered into Vietnam.

But what issue today rises to the level of evil reached by the institution of slavery or  war? The War on Christmas?  Gun control?  Teaching evolution in schools? 

Mad Dog must be missing something here. But what have the Republicans got to get America boiling mad about now?

Republican Orthodoxy: You Match 'Em Quiz

John Boehner

Carl Rove

Ted Cruz

John Q. T-Party

Okay:  It's time for one of those end of the year quizzes.  Let's play, "Who Said That During 2013?"

Match the statement to the Republican who said it: 
1. "Jesus never once admonished government to create social justice. He admonished us personally to be our brother's keeper...Our nation's founders, creators of the American Dream, did not form the Constitution based on social justice and inclusivity, but on the pursuit of happiness and equal opportunity...It is a personal responsibility to be our brother's keeper...It is easy to palm off our neighbors to the government."

2. "Society...does not have an obligation to even the playing field. Those who choose to be needy [italics added]over choosing to be responsible are literally robbing from people who have no choice."

3. "Our welfare system has created the fatherless black child trapped in a prison of violence and hopelessness. Before the invasion of The Great Society, the African American family was intact. Check the statistics of the 1950's versus those since the act creating the Great Society in 1965. Watch the news in Chicago, Detroit and Los Angeles. We have slipped from ghetto to the new plantation... And we want to broaden this failure by forcibly taking hard-earned money and giving it, rather than jobs, to more people? It is morally reprehensible. So, what would Jesus say?"

4. "There is hard-earned dirt under my fingernails, and I have never had the luxury of getting callouses on my behind rather than my fingers."

Mad Dog may indulge himself over the next few posts, as the spirit moves, to deconstruct each of these jewels, which as a group are a delicious screed against that most foul bogeyman which delights and titillates the dark cockles of the Tea Party heart: The Welfare Queen, immortalized by Ronald Reagan, as that reprobate who gamed the welfare systems for "hundreds of thousand dollars a year," and drove a Cadillac, laughing all the way to the bank while her fellow citizens worked hard to support her profligate ways with their taxes. (More on her to come, stay tuned.)

But for now, Mad Dog admits the answer to the quiz is: None of the Above, or, alternatively, "All of the Above" because, while this was all written by a single author, one Ramona Charland, of Portsmouth, in a letter to the Portsmouth Herald; she was wittingly or unwittingly quoting chapter and verse from the same text, the Republican Bible, the book of Tea Party Pslams, aka The Book of Sore-man.

And, yes, Mad Dog, got a new software program as a Christmas present--what would Jesus say?-- from one of his sons, so he can now create cartoons which, eventually, will be a lot more polished than his old hand drawn attempts. Still working on the software, and it's tons of fun.

Obamacare: Hey It Works For Me

Van Gogh

Okay, here's an early Christmas present. The phone rings at 10 o'clock at night and the caller ID shows it's our thirty something son. 
He  is living his bohemian life in Brooklyn and we worry about him. 
We have told him how important it is he have health insurance. He shrugged that off, being young and invulnerable as he is.
But my wife appeals to him on the one level she knows will appeal to him. From early youth, this particular son has been a person who feels responsible for the rest of humanity. Give him a $5 bill for his lunch money for a week and he gives it to a pan handler on the street and he eats crackers and ketchup from the school cafeteria that week.
 When his younger brother found a living sand dollar on the beach and proceeded to carry it  home to show his mother his living treasure,  the good son lambasted him the whole way home, saying the sand dollar would die out of the water, would die just so the younger brother could have the pleasure of showing off  it to their mother. 

So his mother, my wife, appeals to that most reliable, entrenched part of him--concern for others:  "Look," she says, "If you get hit by a truck and wind up in the ICU at $50,000 a day, you know your father and I will not just let you die there. We will have to mortgage the house and go bankrupt trying to save you. So, do us a favor, get yourself health insurance."
So he got a policy called a "catastrophic" policy which covered almost nothing and cost $800 a month--a major part of his budget. His rent costs $800 a month.

Now, it's a phone call from New York at 10 PM. 
A phone call at 10 PM from this son could not be good. 

But, he sounds happy. Not just happy, euphoric.
He had got on the Obamacare website, got a policy for $300 a month which covers just about everything you can think of, including dental. He has not seen a dentist in 5 years. (News to us.) 
Of course, he lives in New York, where there are many insurance companies competing for business, not New Hampshire, where there is no competition, where Blue Cross has a monopoly. 
But for him the unsung truth, Obama care has proven a great blessing.
We'll see if his anecdote is more representative than the other anecdotes we have been bombarded with in the Times and the Portsmouth Herald.

Strip Searching Again. This time Dr. Khobragade. The New York Times is All For It.

He bemoaned that public outrage was focusing not on Khobragade's alleged treatment of the housekeeper and her spouse, but on the U.S. government's treatment of the diplomat.

"Is it for U.S. prosecutors to look the other way, ignore the law and the civil rights of victims (again, here an Indian national), or is it the responsibility of the diplomats and consular officers and their government to make sure the law is observed?" he asked rhetorically.

Bharara defended the handling of the arrest and custody, though his office was not involved. "Khobragade was accorded courtesies well beyond what other defendants, most of whom are American citizens, are accorded," he said. "She was not, as has been incorrectly reported, arrested in front of her children. The agents arrested her in the most discreet way possible, and unlike most defendants, she was not then handcuffed or restrained."

In addition, she was allowed to keep her phone and make calls to arrange personal matters, including child care, he said.

"Because it was cold outside, the agents let her make those calls from their car and even brought her coffee and offered to get her food. It is true that she was fully searched by a female deputy marshal -- in a private setting -- when she was brought into the U.S. Marshals' custody, but this is standard practice for every defendant, rich or poor, American or not, in order to make sure that no prisoner keeps anything on his person that could harm anyone, including himself. This is in the interests of everyone's safety." [italics added]

--CNN report about the arrest

There are all sorts of issues connected to the arrest of Devyani Khobragade in New York.
She is (or may be) a diplomat from India and may or may not have diplomatic immunity. New York accuses her of abusing a domestic worker by underpaying her. She is not accused of human trafficking or selling the worker in to a life of prostitution, but of underpaying her.

1. The arrested woman was strip searched and had her vagina probed, just in case this mother and diplomat was carrying a concealed switch blade in her vagina. Just in case she carried an explosive in her vagina, with which she might harm some of the other prisoners (or herself !)  Of course, this is a legitimate concern for the New York prosecutor, because, Heaven knows, this woman, who apparently had just dropped her child off at day care might have known the arrest was coming and loaded up her vagina to do battle at the jail. Might have locked and loaded that very morning. 

You never know.

Some have described this as "finger rape" in jail. Some would not. It's just what every female American citizen can expect when taken into custody by their government at any time in any jail. Ain't not big thing, according to the New York state prosecutor. A little vaginal probing, stripping. Endorsed by Justices Scalia, Roberts, Alito and Thomas, too. They are all for it. Got to protect those jailors from dangerous criminals like Dr. Khobragade. Feed her coffee and doughnuts  first, just to get her in the mood.

2. The New York Times ran an editorial supporting the state, saying the treatment befitted the crime. Of course, the venerable Times completely ignored the idea of punishing (by finger raping and stripping) someone who has been only accused and not convicted of a crime. One might ask what was in the coffee of the Times editorial board that night. 

3. Diplomats are typically protected from dingy cells and in jail genital manipulation.  Mad Dog recalls a conversation he had with an American foreign service officer some years ago. Mad Dog was speaking to this foreign service officer because the son of a Mexican diplomat had crossed the double yellow line on a Friday night, in his car, which was loaded with eight other teenagers. There may or may not have been drinking involved. 
You guess. 
And the car wound up in Mad Dog's windshield. Mad Dog's wife, riding in the passenger seat was air lifted to the trauma center, unconscious, spent two weeks in intensive care and did not walk without crutches for six months.
 Mad Dog had to hire an in house au pair to care for his 9 month and 2 year old sons, and Mad Dog was just starting his practice in Washington, DC and did not have the money to pay for his wife, his sons and still try to go to the office and hospital.  
The son of the diplomat was not arrested at the scene. The police told Mad Dog the father arrived "waving his diplomatic card around like it was a credit card," and the father took him home, leaving the wreckage of the two cars and the seven other injured teenagers behind. 
"Well," the American foreign service officer told Mad Dog, "If we don't honor the diplomatic protection here, our foreign service officers in Mexico, Turkey, Beirut and the Soviet Union are all exposed."

Not only could Mad Dog not see the son locked up, Mad Dog could not sue the father. 

Diplomatic immunity. 

But here today we have a diplomat (or some family member) finger raped before she is even tried in court for a non violent crime.

(And the New York Times sees nothing wrong with this and upbraids the Indians for getting angry.)

America looks at the rest of the world and sees barbarians. 
What do the Indians and the British think, when they look at America and see Texas executing people with all the abandon of an afternoon barbecue?  What do they think when they learn women, a mother having dropped her child off at day care, is hauled off for a strip search in an American jail?

What do Americans think about strip searching?
Oh, won't happen to me. Won't happen to my wife or daughter. 
Not my problem.
Live free or die.

The Most Wonderful Time: When the Seabrook Plant Blows

Hey boys and girls! It's what we've been looking for in our mailboxes all year, and it's finally here: Our 2014 Emergency Public Information Calendar (for neighbors of the Seabrook Station) "DO NOT DISCARD. SAVE FOR USE DURING AN EMERGENCY."

And what a wonder of invaluable information it is! My favorite is the Emergency Bus Information map for Hampton. When those sirens go off because the power plant is melting down, just go right out to Route 27 and wait for the bus to safety. (18 pages of emergency bus routes from the surrounding towns. What haven't they thought of at the power plant emergency planning office?)

Just climb on board. 
Don't need no luggage. 
All you need is faith. 
Hear the diesels humming. 
There's a bus a coming, 
Just thank the Lord.

It is reassuring to see that they plan to evacuate towns as far away as Dover and Rochester. Makes one feel better about living just two miles as the crow flies from the plant.  Wouldn't matter if you lived at a "safe distance." The safe distance appears to be Canada.

Oh, and what to take with you when the siren goes off. Things I would not have thought of: 1. Dentures  2. Toothpaste 3. Medical insurance card --we might radiate you, but nobody's going to treat you for free. 

If things get, how shall we put this? Constricted. Just shelter in place. "Keep pets inside. If you are in your car close the windows." 

And do not breathe more than necessary.

 "Remember, in an emergency, you will be better prepared if you know how to help yourself and others, as well as how to receive help from others." 

There are some lovely photos in this calendar: Look at July, with the picture of gentry getting on board the Portsmouth Electric Railway car, which apparently ran from Rye to Portsmouth. Look at those folks. There was a time along the seacoast when living was elegant. Those folks did not have to worry about a nuclear power plant blowing up. Judging from their clothes, they were living about maybe 1900:  All they had to worry about was Diptheria, tetanus, pertussis, measles, strep bacteria, influenza, polio, world wars, and crop failures. 

Life was simple then. No worries about computer viruses and nuclear power plants. 


 

The Private Sector vs The Government in Health Care

One of the core Republican Tea Party tropes is that "Government cannot do anything right; the private sector, motivated by profit and competition is always more efficient and effective."

Obamacare's troubled roll out has played into this cant, and Republicans have been frothing and delighted.

The problem is, the profit motive is not always the most functional motive: Consider medicine.

In medical school, nascent doctors are taught relentlessly what constitutes good medicine: Every medical student admits patients to hospital and each new patient begins a series of quality control exercises, as the student presents the case to the ward attending and to each attending who visits the patient from each specialty. So a diabetic admitted for chest pain who is found to have an infection of his big toe will get seen by the ward attending, the attending cardiologist, the attending infectious disease faculty. Every chart note the student writes, every presentation he makes is reviewed by his intern, his resident, his attending, the specialists, the faculty member who hears the case presented at morning report. Feedback is critical, constant, valuable. 

You learn, through this process to judge quality: the infectious disease consult who sees the patient for his toe infection should cut away the dressing from the toe, inspect it daily, to see how it is healing or not.  Some attendings are lazy. They don't remove the bandage, which often takes time to search for the nurse for a kit to use and then to rewrap. Some never fail to examine the toe. That is quality care. The doctor who does not unwrap the toe may miss the fact the antibiotics he has ordered are not working.  He may save time by not unwrapping, and he may be able to see twenty five patients on his rounds, and bill and profit more than the plodding doctor who does it right, but the rapid moving, lazy doctor is not practicing high quality medicine. The doctor who sees fewer patients, unwraps every toe, bills less, but does more good.

Mad Dog has worked for medical care organizations in which the work the physicians do is never reviewed for quality by another doctor. No chart note is ever read, not case is ever required to be presented. No conference to review performance is ever done. The only metric that matters  in such organization is the metric of dollars in and dollars out. When contract renewal negotiations occur, there is never a mention of whether you unwrap toes, examine hearts or lungs because the contracts are negotiated by MBA types, not doctors. And the MBA types don't have any mechanism to check which of the doctors they are negotiating contracts with are practicing low quality medicine and who is high quality. But those MBA's can add up dollars just fine.

There is a big push in medicine now for "quality metrics" which often means some easily quantifiable thing which can be collected easily, with a minimum of effort, by an entry level staff person and plugged into a spread sheet. The glycohemoglobin fits all these criteria.  It is a number which tells how high the blood sugar as been for the past three months.  Want to know if a doctor is good at treating diabetes? Add up all his patients' glycohemoglobin, divide by the number of patients and presto: Quality assessment.

The problem with such easy metrics is they can always be gamed. They invite gaming.  So the organization announces you will be judged by glycohemoglobins: What to do?  Well, first fire all your overweight, non compliant, under performing patients. Or send them to some other doctor, an endocrinologist or a nurse practitioner; let someone else carry these neer do wells. Keep all your thin, compliant diabetics with their good glycohemoglobins and you look great. 

The problem with this good assessment of diabetic control is that it attributes to the physician the entire burden of the outcome. Doctors may find themselves in the same position as  teachers in the South Bronx, the poor  scores of their students do no mean they are bad teachers; these teachers are not working with cooperative subjects. Doctors who work with patients who cannot or will not do the things they need to do to control blood sugar, who are judged by poor results,  know they can do nothing to affect those results. So they will game that system.

All this is happening because the wrong people have been given the task of judging doctors. MBA's can only judge how much money the doctor brings into the coffers.  CPA's and economists might dream up a metric or two which sounds reasonable, but they cannot see where the metric fails and how it can be gamed. 

Health care systems, whether they are for profit corporations, or "voluntary hospitals" are all failing in the same way: They have excluded the very people who can judge the work of the doctors in the system, namely other doctors. 

The emergence of the profit motive as the driving force in medicine, combined with the flight of doctors from being independent shop keepers to hired help has meant the culture of business has, by default, assumed control of the way doctors are evaluated, paid and ultimately what kind of quality they provide their patients. 

Next time some Republican says,  "Keep your government hands off my Medicare, get the private sector control of medicine, let the profit motive prevail,"  just tell them government may not be as efficient as we'd like, but it is still worlds better than profit driven private companies. At least the government has the motive of providing good health care. The company cares only about the bottom line.

Much as doctors love to complain about Medicare, they mostly agree Medicare generally does what is best for the patient.  The private insurance company will deny a diagnostic test for its customer, knowing that two years later the patient may be much sicker because the diagnosis was missed. But, two years later the customer will likely have another insurance company, and paying for his illness will be that company's problem. Medicare knows they are stuck with every patient for life. 

So Medicare will pay for a pair of shoes designed to prevent ulcers on the feet of diabetics. The shoes may cost $100 a year. A single visit to the ER for a foot ulcer is $500. Medicare makes the investment because keeping the patient out of the hospital is cost effective. The private insurer is hoping to keep the patient out of the hospital only for the term of the policy. 

Democracy may be the worst form of government ever devised, as Churchill noted, except for all the other forms of government which have ever been tried. The same may be true of government guided medicine--the worst form of management except for all the other forms which are currently out there.