Too Important to be Left in the Hands of Congress

Watching "Prime Minister's Questions" Wednesday nights, I have come to understand why England has universal health care and we, in the United States, do not.

About 25% of all the questions asked of the Prime Minister had to do with health care or the public health. A promised new clinic was behind schedule and the Member of Parliament from that district was indignant. 

Oh, to see our own President in a setting like that every Wednesday, where a 140 character Tweet would not be sufficient, but where the President has to respond immediately to the question on behalf of a Representative's constituents in real time.

When government undertakes a health care system, the people running government find themselves face to face with an aroused public. This is not a question of whether we are going to build a war plane in somebody's home district; this is something which actually affects lives where people live. If the war plane or the border wall never gets built, who cares?  But if your mother hasn't got her hip replacement and winds up parked in your house because she cannot get about, you will care about that.

Pia Guerra

The last thing Mitch McConnell or Jon Cornyn or Paul Ryan wants is to be responsible for something that actually matters in people's lives, something which would require them to be competent or be quickly exposed.


It is said there is no such thing as a mediocre heart surgeon. Either you are excellent enough to get those blood vessels and valves sewn in tight, or you are not and your patient dies. There is no room for second rate, half smart or just okay.

Pia Guerra

Of course, government bureaucrats do things every day which profoundly affect the well being of the public: keeping mad cow disease out of the food supply, doing air traffic control to keep thousands of flights from running into each other, maintaining bridges and levies, treating veterans in veterans' hospitals, rescuing boats caught in storms off the coasts, but most of these things are functions which keep systems which work well out of disaster's way.
Health care is more than watchful supervision--it requires active intervention in many cases; you are not just watching competent people do things right. You are actually one of those well trained competent people, doing the job right.


That, to most Congressmen, is a terrifying thought.

What Europe has to Teach America About Health Care

NPR ran a story about two of its reporters who live in Europe and what they experience in getting their health care in Spain and Britain respectively.

The woman who lives in Spain said she could be seen the next day for an urgent problem, but for a less urgent visit to the dermatologist, or for other specialties, it took a month. 
She noted there were no cash registers or credit card machines in doctors' offices or hospitals. Prescriptions were generally about $2.  
Hospital wards might not feature single rooms. 
Quality of care was high, as far as she could tell--Spain does more organ transplants than any country in the world, which she used as an indicator of how high tech their medicine is.

British hospital ward

From the point of view of the doctors, a cardiologist makes about $2100 a month, in a country where $1800 monthly is the median. Her friend, a cardiologist, does Botox injections on the side to supplement her income.

The British reporter said that pretty well described British health care, except if you had private insurance to supplement the National Health Service, you could go to the private systems which functions alongside the no frills government service; you could go to a swanky upscale hospital with high thread count bed linens. 
The medical care is the same quality in both private and public and in fact, the doctors are often the same. It is more or less like flying first or business class as opposed to economy class: It is more comfortable for the rich in the private British system, but you are landing in the same place, at the end of the flight.

Upscale American hospital room for the 1%

From the point of view of British doctors, in a country where the median income is about $35,000, a specialist can make $140,000 in the public health system, although most of the GP's (general practitioners) who have only an MB (Batchelor of Medicine), the wage is closer to $40,000. British GP's go to medical school straight out of high school and skip college. They are upper middle class. Competition to become specialists is intense and the rewards get you to the upper 10% in income in the country.

Both reporters said the fundamental difference in Europe is Europeans think health care is too important to be corrupted by the profit motive, where most Americans think health care is too important to be trusted to government.

Americans simply do not trust government, nor any authority. Some wag once said medical care is simply too important to be left in the hands of doctors. What the Right believes, and what they've convinced Americans to believe, is the profit motive and private enterprise are always superior to cooperative group efforts. 

In Britain, about 7% of public spending is on health care. In the United States, if you put together spending on Medicare, Medicare, CHIP and other public health care spending is closer to 17%.  If you are challenged by numbers, that means we spend, from government more than twice as much as our European friends, in the name of keeping our health care system out of the hands of government.

This is no secret and no surprise: Medicare has for decades had an administrative cost of around 3% where the private sector it's said to be over 20%. If those numbers don't mean much to you, think of your doctor's office: How many people are working in the billing and front office vs the number of nurses and doctors you see in the rooms. And those are just the people you see.

Think of those huge health insurance company buildings you see scattered around, filled with people processing bills, fighting with doctors' offices over bills, sending you bills. To pick a number more or less out of the air, somewhere in the neighborhood of 3 million people make a living as employees of the health insurance in this country. (The number of people employed in doctors' offices to deal with the insurance companies could bring the number of people working on health care billing as high as 20 million.)

Those jobs are unnecessary here and do not exist in Europe. 
There are roughly 13 million jobs in actually delivering health care in this country, although who knows what the number really reflects. Is the guy who sweeps the hospital room included in that number, or the woman who works in the hospital cafeteria or the hospital plumber?

Swedish hospital room 

By many measures, American health care is inferior to European health care. In terms of public health, we are clearly inferior, because the upper 10% get excellent care but the rest do not. Infant and maternal mortality and morbidly are better in a dozen European nations and life expectancy stagnant in the US is improving in Europe and beyond ours. There are many other technical measures which all suggest the Europeans enjoy a better health care system and the government runs the show in European health care, even if there are private options swirling around that. 

I can give the worm's eye view, from our annual national medical conferences, where new science is presented:  the Europeans are as good or better than we are when it comes to the medical science they do.

What may be lost in all this is a more difficult, more intangible thing:  If we went to the Spanish system, where doctors' pay puts them into the upper middle class, rather than the British system, where doctors beyond the GP level are in the upper 10% of earners, we would see an entirely different sort of person in the white coat. Like it or not, when you look at 500,000 people making decisions about whether to go down a career track in medicine, you will not find more than 50,000, I would wager, who will choose medicine for the love of the science, the calling of service, even though they could make more money elsewhere. 

On the other hand, even with our profit motivated system, I cannot prove it, but it's my sense based on worm's eye view observations, that that shift has already taken place.  The quality of worker among doctors is not what it once was.  "Good" people, i.e., smart, intelligent, driven people do tend to follow the money. 

What we mean by "good" in doctors would require a dozen blog postings. The qualities you are looking for across that very broad spectrum which constitutes medicine are diverse. What you want in a surgeon is very different from the qualities which make for a good psychiatrist. And even if you could choose the perfect medical school class, the person you get at age 26 will not be the same person 30 years later. 

Look around at your own community. Do the physicians you see look like the top students you went to high school with? Put another way, do you feel comfortable trusting the health of your family to the doctors you see? 

This is not to say the doctors out there in the community are inadequate to the task. You don't need to be Warren Buffet or Zuckerberg or Steve Jobs to practice pediatrics and you don't need to be Einstein or Jonas Salk to practice endocrinology, but overall, the more money you pay doctors, the more you will see competition for those doctor jobs rise. Whether a driven, Type A doctor is going to give you better care is an open question, but it is a question.
But to say, "You get what you pay for" in medicine has proven to be a canard--we have been getting considerably less than we paid for in medical care in this country for decades.

The Way We Were

When we despair about the alt right, Steve Bannon, President Snowflake, the reactionary Supreme Court, nativism, Kris Kobach, Fox News and the Tea Party, it is therapeutic to look back to the 1960's and reflect how much better the country  is now, than it was then.

Pia Guerra 

Look at the election map which put John F. Kennedy into office.

Yes, those are blue, Democratic states: Texas, Georgia, Louisiana, North and South Carolina, West Virginia and Arkansas. The only two Southern states not won by Kennedy, the Democrat, were Alabama and Mississippi, which went for the third party candidate, Strom Thurmond and some guy named Byrd, the segregationist party. 

Yes, there was a segregationist party. It was fine to say: "Segregation now, segregation tomorrow. Segregation forever."  Freedom riders going to the South were murdered. Dogs bit and hobnailed booted Southern police bludgeoned Black protesters, fractured skulls. 

But the Democrats needed the Dixiecrats to win and that was because New England and the West Coast were Republican strongholds. 
A John Birch Society stalwart reigned supreme in Manchester, New Hampshire, editor of the Manchester Union Leader. 
Can you imagine a Democratic Party held hostage by Senators from Georgia, Louisiana and South Carolina? Can you imagine the compromises Kennedy made daily?  After the Civil Rights Act and Voting Rights Act, the South defected to the Republican party, and if ever there was a case of good riddance, that had to be it.


But in the 1960's Kennedy and the Democrats dared not speak out to support Martin Luther King and his movement. The Democrats were captive to the racist South.
King and King's people went right on without help from any political leader. As King said, echoing Gandhi: There go my people. If I am to be their leader, I must catch up to them. 

The Communist witch hunts had just petered out. Sex education was verboten. Sex was unclean and suppressed. Women had not yet entered the work force in any substantial numbers and drank themselves numb as bored suburban housewives.

 The federal government insisted on segregated communities by forbidding federal  mortgage home loans to communities like Levittown if they dared sell to coloreds. Segregation was a federal government policy, de facto. 

The federal government spent its energies prosecuting "Playboy"magazine; books were banned in Boston, like "Lady Chatterly's Lover." Inter racial marriages were illegal in some Southern states, and homosexual behavior was criminal. J. Edgar Hoover, a closeted homosexual, made recordings of Martin Luther King's extramarital trysts, while Kennedy and LBJ got a pass. 

The country had defeated Nazi Germany and Imperial Japan and brooked no criticism of itself. 

True, there was a post war economic boom which had been driven by government spending on returning veterans who went to college on the GI bill, got better jobs than their fathers, got inexpensive mortgages on the GI bill and unions protected wages and people with high school educations could marry, support a family, a house and have a summer place with a boat,
But that was all clearly not going to last, once Europe finally recovered from the war and became competitive again. The post WWII prosperity was an anomaly in American history. That rosy time, the source of such nostalgia among Trump voters, was a one off era because it was fueled by unprecedented government spending, which the Republican party has been fighting ever since. It was the closest this country ever got to a socialized state and the Koch family has been suffering from that post traumatic stress ever since. 

It could not last, given the forces against it; and it became a crumbling, degraded, cesspool, our America. 
Then the wave of assassinations. Black men had been assassinated--Medgar Evers, Malcom X, and that didn't even rate a headline, but when John Kennedy and Bobby Kennedy got shot, Americans began to wonder if there was a problem. 
Oh, there was a problem all right, and that became even more clear when Martin Luther King was assassinated. Of the three, King mattered most, historically. Neither Kennedy did much to change the country; King and his people changed the country.

Almost as soon as JFK died, the war in Vietnam exploded. Oh, that was a lovely time. American boys were being drafted, trained as remorseless killers and killing babies in Southeast Asia. 

If I had to choose to live in today's America vs. that America, I'd take today in a heartbeat, even with President Snowflake. 

Pia Guerra 

Eventually, there's a thaw.

Pia strikes again

The American Way of Healthcare

Malcom Gladwell was on Meet the Press yesterday, talking about the healthcare system in Canada and opining about the lack of a healthcare system in the United States. He said the Canadians actually had a discussion about 60 years ago and they realized they could not have everything at once: Gleaming hospitals where the sheets had 500 thread count and healthcare for all. They decided they would provide the basics for everyone and they would accept that they might not have the Rolls Royce for every procedure, every medication, but they would have what was required for a reasonable effort.

Drawing by Pia Guerra

Of course, in this country, we have Rolls Royce care for the upper 1-10% and very limited health care or no health care for the rest.

Since the 1950's there have been vested interests which prevented a rational discussion--the American Medical Association acted as a vociferous trade group, bellowing that we were headed straight to Armageddon if we took even a single set toward government participation, which would lead directly to "socialized medicine" which was as unthinkable as "peace without honor" or other fates worse than death.

Since then, various groups have stood between Americans and really good health care, but for the past forty years, far as I can see, it's been the Republican Party, which has, in it's most unvarnished moments, simply said it's intolerable for rich people to have to pay for poor people's health care.  In the most revealing moment, Paul Ryan sputtered that under Obamacare, healthy people had to pay for the care of sick people and that is un-American and unfair and the road to Hell.

It was later pointed out to Mr. Ryan that's the way insurance works--a lot of people who are good drivers pay for all the wrecks those bad drivers cause, and people whose houses burn down get paid by insurance companies who collect premiums for years from all those well behaved people who do not allow their houses to burn down.

England, of course, has a two tiered system: You can fly economy class with the National Health System or you can fly first class with a coexisting private system which has its own upscale gleaming hospitals. Doctors can flit between the two systems, and the quality of care is comparable; both get you to your destination, but one gives you more leg room and a more comfortable ride.

It is on this crucible the real differences between the two parties becomes apparent for all to see: The Republicans really are a party for people who do not like the idea they may be giving their money so that others may benefit; the Democrats say they are willing to pay for others, as long as everyone gets a good deal in the end.

Doubtful the Donald Snowflake crowd sees it this way.

It used to be said there is no more virulent anti Semite than the disaffected Jew; now it is clear there is no more dedicated hater of the underclass than the lower middle class, the next step up on the ladder, the folks who see that with a turn of bad luck, an accident, an illness a lay off, they could slid right back down to that rung below them. 

One nation, under God, indeed.
E Pluribus Unum.

President Snowflake

Snowflake.

Jennifer Granholm, the former governor of Michigan, called President Trump a "snowflake" on CNN, after Mr. Trump frothed fretfully about Mika of "Morning Joe" bleeding from her face (or from wherever) when Mika visited  Mara Largo.
Mr. Trump may have been confusing her with Meghan Kelly, but no matter: It was the Tweet which was important. 

Mr. Trump apparently sees bleeding women frequently, and is much impressed by the sight.

Trump's woman problem--Pia Guerra

But I digress. 

"Snowflake" has been a word much discussed lately.

Of course, it's really a compound word: "Snow," which is white, delicate, easily destroyed and many find beautiful and "Flake" which is commonly used to describe someone of little substance, a zanny person, someone not attached to reality.

Jennifer Granholm

There has been some discussion of the use of the word in the book and movie "Fight Club" in which twenty something men, who feel, if not castrated, at least domesticated, in their sterile offices, where they sit in front of computers and machines and they resort to fist fighting in parking lots after drinking at bars. This makes them feel alive and virile.  They are roused by a member of the club who says they are not "snowflakes" by which he means they realize they are not special--each snowflake is supposed to be unique--and they are durable, not delicate like snowflakes. They live in opposition to the delicate, neutered life they lead at work and  at home.

"Snowflake" was used to deride people who embraced slavery in the 1860's--presumably because snowflakes are white and cover the earth. So it was the white aspect of snowflakes which was being derided. White as snow. Pure as the driven snow. Make the country white. 

All this feeds into the description of Trump as a snowflake: celebrated for his whiteness, attached to people like Kris Kobach who feel whiteness is under attack and needs to be rescued, and snowflakes are delicate, apt to dissolve into a puddle, and flaky, as in irrational, distracted, as in a walking non sequitur. 
Yes, the Donald is a flake. A snowflake. 

And you're special, too

The Tweet which prompted Governor Granholm's remark was classic Trump. Mika was not just bleeding, she was low IQ, and afflicted by low ratings.

Trump's cabinet meeting--Pia Geurra

There has been much discussion about Mr. Trump's own IQ, which, apparently in his case, is a measurement which has entered into the realm of mythology. Presumably, at some point he sat down with a Number Two pencil as an adolescent and took some sort of "IQ" test, the way every child of his cohort did in America and the results must have scarred him in some way.  
His own IQ test scores are as buried in the same misty past as that birth certificate for Barack Obama.  
All these bits of information buried in the pre cyberspace past. 
Reminds me of going to the Department of Motor Vehicles to get my  nifty new driver's license, which is now part of a federal security system: I needed my Social Security card, and I was very proud to have preserved this relic, laminated in my wallet all these years. I got it went I was 14 and it survived over 5 decades in various wallets because I had thought to laminate it. 
But when I arrived, the clerk said laminated cards were unacceptable. 
"But if I hadn't laminated it, it would have been dust by now," I protested.
"I'm just the messenger here," she said, in a voice which sounded like an automaton. "I don't make the rules."
But my point is, some of these things, like IQ test scores and birth certificates are dust in the wind, really. And yet, to some people, like Kris Kobach of Kansas, they matter a lot. They are the most important things about us. 

Our leader--Pia Guerra

For Trump, it's his IQ.

There are, of course, many types of intelligence, we all appreciate now. Mr. Trump has some sort of intelligence which allows him to look for what people--some people--will respond to and to tap into that. At that his intelligence quotient must be very high.

But in terms of being able to collect a set of "facts" or statistics or reports of studies and to assemble these under general headings to support conclusions, he demonstrably scores very low in that type of intelligence.
His talents are more like Ronald Reagan. Nobody ever accused Ronald Reagan of being able to analyze an issue or to organize a coherent argument, but boy could he deliver the message once his script was written. 
Thing is, he was smart enough to let other people write his lines for him.
Can you imagine Reagan with a Tweet machine? 
Well, he could hardly be any worse than Trump.

No Snowflake Her

There are two excellent books about intelligence: "The Intelligence of Birds" and "Are We Smart Enough to Know How Smart Animals Are?" Read these, and you realize how very narrow a stripe the standard IQ test of the 1950's and 1960's were. They were a sort of infant science. So, Mr. Trump, don't feel too badly about how you did on those tests. It was a long time ago, and those tests were made by failed psychologists with low ratings. 

As for the low ratings of "Morning Joe," well, that's like the "failing New York Times." Failure is in the eye of the beholder and neither succeeds in Mr. Trump's eyes.

Then again, this is the man who lined up his cabinet members around a gleaming conference table and demanded each come forth with some adulatory attestations to his wonderfulness, his eminence, his most holy highness and highest excellency. 

Personally, I'm looking forward to the next Tweet. 

Trump Care: It Doesn't Hurt Until 2021

Republicans aren't stupid, at least the Republicans in Congress are smart enough to know they should not vote for any law which will cause pain before they are up for election any time soon.

So the new version of Trumpcare is not going to really hurt until after Trump's 2020 election. 
It's like that cancer in the tip of the colon polyp, it doesn't hurt now, so it's really no problem. It'll take 5 years to work down that stalk and infiltrate into the wall of the colon. Until then. you'll be just fine.
Today's Senate plan  will raise the cost of health insurance to citizens over 50 about 5 fold and it will eliminate health insurance to the really poor--but they don't vote much anyway.  And those 50+ citizens are really past their prime, so who cares really? The fifty somethings in the audience in Iowa were just fine with Trumpcare.


And now the health insurance companies will gradually be able to reject people for "pre existing conditions" in any state which feels strapped for cash, but hey, you can keep your kid on your policy until he is 27, just like Obamacare.


The thing about making insurance companies insure people with pre existing conditions is you were making them do something their whole machine is set up to avoid doing--the last person you ever want to insure is somebody who you might actually have to pay out. Have you never heard of profit?  If you have to spend money on "benefits" that means your profit goes down.


What was Obama thinking?


Fact is, as the customer, you'll never figure out how the law will affect your own particular pocketbook until you actually have to--when you get your bill, but that's what marketing is for.

Fact is, as President Trump realized, health insurance is complicated, at least with a profit driven system like ours. It's that old conundrum: you never want to insure a customer who might really benefit from the product you sell and the customer never wants to spend his money unless he thinks he needs to spend the money.


If we agreed to do what Bernie Sanders suggested: Simply offer "Medicare for All" then it would be simple, in most ways.





Medicare is simple because its mission is not profit. It's mission is paying for medical care, which is exactly what commercial health insurance companies do not want to do.


What would not be simple is what would happen if  commercial insurance companies would had  to compete with Medicare. The commercial insurance company CEO's are smart enough to know they cannot do this and customers would flock to basic Medicare.
That's only about 6% of the market, but the insurance companies have not been willing to allow that.


For most people, who get subsidized "Cadillac" plans through work, Medicare would be less attractive, bare bones coverage, and they would opt for their Cadillacs.


Paying for Medicare for all would be easy if you extended the current system which taxes payroll up to $118,000 but not beyond. If you taxed incomes up to say, $ 4 million, then the money would be there.


But, as Paul Ryan would say: Taxing wealthy people is just so unfair. That's like taxing healthy people, very unfair.  
After all, you are taxing healthy people to pay for sick people, which he only recently discovered is what happens with Medicare and Obamacare, and that isn't just so outrageous.
And now you talking about taxing wealthy people for more money than you ask from poor people.


That's really just about Communism, right there.

National ID Cards: The Kobach Solution

When I was a little kid there were lots of movies about Nazi Germany, and there was always the cold sweat scene where the Gestapo officer looks over the heroine or hero and demands, "Unt vere are your papers?"  The papers are produced, whew, they were not lost but then the Gestapo man inspects them, sniffs them, just about licks them and says, suspiciously, "Vell, your papers appear to be in order."

Mr. Kobach

As a kid, I knew I could never keep anything in my pockets for very long and I just knew I'd have wound up in the Gestapo prison, chained to the wall.


Now we have guys like Kris Koboch of Kansas who believes Hispanic immigrants are not just rapists and drug thugs charging across the Mexican border, but he thinks they are intent up committing "ethnic cleansing" of the White population of the lower 48 and wiping out good, White, Christian Americans.


Given that concern, it's only reasonable to assume anybody who looks like a swarthy Hispanic from South of the Border might be part of this race war and it would be reasonable to demand his driver's license, birth certificate--the long form with the signature of the doctor, his Baptismal certificate, his grade school diploma and his library card to be sure he is legally in this country.


About that long form birth certificate--Mr. Kobach has said he did not accept the birth certificate produced for Mr. Obama because it was a short form and did not have a doctor's signature, which of course is important, because Mr. Kobach intended on tracking down the doctor who delivered Mr. Obama and hauling him before a grand jury to testify unequivocally he remembered delivering Mr. Obama.


Failing that testimony, Mr. Koboch would not be satisfied Mr. Obama was a natural born citizen and would revert to his default suspicion that Mr. Obama was born in Kenya to Martian parents.

He's got his scanner to check you out

Mr. Koboch was no fan of Mr. Obama because:
1/ Mr. Obama is half Black, which makes him un-American ipso facto.
Of course some Blacks were born in this country to slaves.
Now slaves and the descendants of slaves, are they really here legally?
I mean, you can make an argument they arrived here pretty much as gate crashers, like those Mexicans who were brought across the border by handlers and coyotes.
In fact, there was a Supreme Court decision that said Black people (slaves) were not real Americans. It was called the Dred Scott case, which actually held Black people were not human beings, but only property,  which is like saying they are not citizens because only human beings can be citizens, except for therapy dogs, who have official state licenses, which must make these dogs citizens.


2/ Under Mr. Obama, Black people could not be convicted of crimes, or at least civil rights crimes. Someone said that on a radio show and Mr. Kobach agreed that was, in essence, true.

If every American had a national ID card it would be unnecessary to pass  laws Mr. Kobach proposes about police having to demand proof of citizenship whenever they talk to anybody of the swarthy persuasion.


The problem is people don't always have their birth certificates on them, like when they are at the beach or hunting or fishing or walking their dogs.


At one point we considered dog tags, which seemed to work well enough in the Army during the big War, but even dog tags got pulled off or caught on the airplane door when you were jumping out.  Kids were issued dog tags when I was a kid, just in case there was a nuclear attack. Don't ask. It seemed to make sense at the time.  Actually, my father refused to allow me to wear dog tags, and I've been wanting to compensate for that early childhood loss ever since. I wanted to be official. Accepted. American. I was born in Washington, D.C. and that means I could never answer that question all the computer security programs ask: In what state were you born?  I am stateless. But I'm a citizen, I think. I'd feel more secure if I had some dog tags.


Funny thing is, I signed up to get my lab results after my blood was drawn, with Quest lab and to verify I was who I really said I was I had to answer questions about my addresses from 40 years ago, which I had long forgotten but the computer knew. And it knew about automobiles I had registered in 1981, stuff I could not remember but the computer knew. So why do I even need to have dog tags if the computer knows me so well? That's what I'd like to know.


But, wait. There's another solution. Mr. Kobach might be pleased at the latest proposal from Attorney General Sessions ("General Sessions," as the Senators call him. Quite a promotion from "Senator") that every American infant have a computer chip implanted in the delivery room, like those things dogs get at the vet, and this would be an official U.S. government chip which could be scanned and would verify the American citizenship of the person with the chip.
It would also allow the government to follow you, should you feel inclined to cross the border into Mexico and sell your chip down there.

I got my chip. I'm a citizen!

How cool would that be?
There are some details to be worked out, like where would you put the chip? Abdomen? Back? Thigh?
And what would happen if you took a hit during football practice and damaged the chip?  Would you lose your citizenship?
And what if a black market for chips got launched--people no longer knocking you out to get your organs, but they get your chip.


And what if the Russians hacked American chips and made every American an official alien and every Russian a U.S. Citizen?


The possibilities are really intriguing. Watch for this to play out on "The Americans" or "The Leftovers" or "The Beverly Hillbillies."