Failure of the Profit Motive in Driving Good Medical Care (Part 1)

An article of faith among every Republican is the profit motive is the best possible driver of human behavior. From Ayn Rand to Paul Ryan to Mitch McConnell, every deep red Tea Party Republican believes what Ronald Reagan preached, the "9 most scary words in the English language are, 'I'm from the government and I'm here to help."

It's a catchy and absolute simple minded concept, but it's dead wrong when it comes to medical care.


As Alexandre Yersin once observed, when asked why he did not practice medicine--and he was a fabulous physician who discovered the cause and first treatment for bubonic plague--he said, "I simply could never bring myself to say to a patient, 'your money or your life.'"


Examples of this come up daily in every doctor's office, but I'll start with a first installment which occurred at a bar.


I was telling a guy who worked for a major health insurance company about this patient whose father, brother, sister and paternal aunt had all died of colon cancer before the age of 50.  I advised him to have a colonscopy but the insurance company rejected this because he was only 46 years old.  The company official explained the company does not approve or pay for colonoscopy before the age of 50. When I asked why they said the rate of colon cancer deaths does not skyrocket until age 50. The curve of deaths rises abruptly only after that age.
"But this guy does not want to be on the DEATH curve," I pointed out. He wants to get to that polyp with the cancer in the tip of the polyp before the cancer has worked its way down to the wall of the bowel, invaded the lymphatic vessels and blood vessels there and metastasized."
"I don't know of any company which would approve that," my beer drinking insurance guy told me.
"But, tell me," I persisted. "The colonoscopy costs, I don't know, say $2000--overpriced but that's another story--but even at that price it's a lot cheaper than the partial colectomy and the chemotherapy and the radiation therapy you'll be paying for when the disease is finally discovered 5 years from now."
"Ah, that's the rub," my beer guzzler pointed out. "The average customer stays with us 3 years. Then his employer buys his coverage from some other company. By the time that guy arrives with his widely metastatic disease on the doorstep, he'll be some other insurance company's problem."

Insurance Companies Have to Pay Rent, Too

Now this insurance guy is not really a monster. He is doing his job, which is not to save this patient but to protect the profit of the share holders of the insurance company. And if he can spare the cost of the colonoscopy this year, his books look good. That's his mission.


That's the profit motive, pure and simple.

Swat Team on Wild Pasture Road

Eager to get out on my bicycle, upon my return from New York City, I took off along one of my favorite paths, which takes me down Towle Farm Road to Nason Lane to Drinkwater. I actually pass through borders of three townships, Hampton, Hampton Falls and Kensington, on this route.  Just after entering Kensington, I start to ascend Wild Pasture road, which is canopied by tall sycamores and other sorts of trees.

Today, as I huffed and puffed up the hill I saw something I'd never seen before, never expected to see. I could see it half a mile off, a long black sedan with blue lights flashing fore and aft, T boned across the road, blocking it. 

Slowing as I approached, I tried to guess what this might be about.  Police sometimes stop their cars to slow traffic for work crews, tree trimming, but this was a Sunday when no work crews are out, and in any case, they usually just slow everyone down and there was nobody with one of those slow/stop signs, no workers in hard hats, in fact, no police visible.

Suddenly, I remembered where I was:  New Hampshire! That drug infested den!  I have it on the highest authority, that's what this state is now. And this might be some sort of drug bust. 

About fifty yards from the police car I could just dimly perceive someone sitting behind the wheel. He was tough to see because he was dressed in all black and wearing a black baseball cap and as I approached, he leaned from the driver's side so he could shout through the open right door window,

"Hey, the rules apply to bikers, you know!"

I started to ask him to which particular rule he was referring, but I thought better of it, and simply turned around and headed back in the direction from which I came and another biker, who I hadn't noticed, just behind me, wheeled about and passed me saying, "Well, he was a little over the top, wasn't he?"


As we headed back I noticed  utility truck pulling up near the police car and a drooping over head power line.

I looked  to see if there might have been a power line 0n the road, but if it was a wire the cop was worried about, why was he not standing outside his car in the road to stop traffic?

Meanwhile, a steady stream of cars, half a dozen at least, headed past me toward the cop, and I presumed he would remind them the rules applied to cars as well and they would be turning around and following me back down the road.

I thought of the cop. He was one hostile cop. Maybe he had seen bicycle riders just swerve around roadblocks and continue through. Bicyclists do sometimes do things which motorists would not do.  Coming up a blind curve to my house, I cut across the road and ride facing traffic as if I were walking because if I stayed in the lane I would force trucks and cars into the oncoming traffic. I also cross a closed covered Bridge which has a sign, "No vehicular traffic" and I rationalize a bicycle is not really what they mean by vehicle. Clearly, the intent is to prevent the weight of cars and trucks on the bridge.


Some of the cop's reaction may have been based on prior anger at what he'd seen other bikers do which had offended him.  More likely he was just a cop, like most cops I know: Basically volatile to the point of explosion, high strung. I suspect if President Obama had invited the two of us to the White House for a beer, I might have seen his point of view. But I don't think either of us will be invited to the White House any time soon. I would not be interested at the present time, even to get to know the cop better.

I had just spent the weekend in New York City, where you see cops who walk the sidewalks.  They go by in cars, too, but mostly you see them in pairs on the sidewalks, on street corners. These NYPD cops do not seem ready to explode. They look annoyed, amused, sometimes indifferent, but they are not the sort of people you cross the street to avoid. 

I was happy to get back to Hampton, where the dens are less drug infested. The worse infestations we have in Hampton are borer beetles who eat birch trees.


Up here in the Live Free or Die Drug infested Den, the police are cooped up in their cars and it seems to make them resentful and irritated.

Can't be fun having to deal with this drug infested population.

Refugees and the Democratic Party

We have not yet figured out where to stand on refugees.

It may be there is not one single immigration/refugee problem but many, but the question often seems to devolve down to how do you decide who you want to allow to cross your border and who you want to turn away.

We have dealt with people crossing borders since before American independence and the Europeans have had border laws for far longer.

So it is puzzling to see so many countries looking so confused and conflicted about what to do with the waves of refugees from all around the Mediterranean basin, and from Afghanistan.

You would think we would have had some modicum of agreement about what to do for and with these desperate people.

It's the old lifeboat question: Can we afford to bring everyone on board the lifeboat at the risk of sinking it and saving no one?

I really do not know how to even begin thinking about this.

I do know when I see a report about African refugees adrift in the Mediterranean and boats headed out to deny them entry and other boats headed out to haul them over to Sicily, I have the feeling both crews on both sides are wrong.  

Those who say simply we must head out to sea and load all the Africans we find in the boats and haul them off to Sicily seem so certain this is the only humane response. Well, we can't just let them drown at sea.

But I have to ask: Once you open that door, are you not encouraging even more to take that risk? You will say, these people are so desperate, it's foolish to talk about encouraging them. But one cannot look at them and not see they are throwing themselves on the mercy of others. They are appealing to the same streak of compassion the man lying on the street with his hand outstretched is tapping. Pity me. Do something for me in my suffering.

Which is not to say the refugees are wrong to do this, to appeal to our compassion. But can we hand out change to everyone?  
I once decided to simply give every street beggar something, just so I would not have to feel badly walking by them. I soon discovered my pockets were empty long before my path brought me to my destination.

After World War II there were more refugees moving in larger groups over a shorter time than what we are dealing with, but in the case of the European refugees, you could see the cause of their displacement was limited and discrete. Once all those Jews leaving Europe, those bombed out Italians and Poles got resettled, that would be it. 
In fact, there are at least two categories of immigrants, as far as I can see from Professor Google, the vast majority being people who were not displaced by war, crime, famine, but who simply lined up in a more or less orderly way and got in. And, surprisingly, although the biggest immigrant population in this country is (predictably) Mexican, i.e. people who now live here legally either as citizens or not, are Mexican, but if you look at the past few years, more people moved here from India than from Mexico or from any other nation and more from China than from Mexico. The numbers are around 140,000 from each country per year.

For Europe, when it comes to the Africans and the Syrians, there is no end in sight. There are simply too many desperately poor, failed states in Africa. For the United States it's  Central America from which the desperate and the equivalent of "boat people" emanate.

To some extent, it's a question of numbers. How many can we anticipate? How much will they cost to absorb, if we decided to absorb them, rather than turn them away?

Are there any good ways to estimate the numbers?
I once heard a story about a survey which reported that 1/4 of the entire nation of China would emigrate to the United States tomorrow if they were allowed to do so. That would be around 300 million Chinese moving to the US. We would have more Chinese speakers than English speakers.  India is about the same size as China, and what if 1/3 of the Indians decided they'd like to come, too? These reports may be absurd, but it raises the reductio ad absurdum argument: is there a point at which we would all agree there is a limit on what we can absorb? On the other hand, this "horror show" scenario has some basis in reality in the sense we are seeing the greatest number of immigrants seeking to leave their countries come from India and China.
We rarely hear Donald Trump or any of his frothing minions scream about the threat from the Trojan horses of India and China because people from these nations do not scare the White men without college degrees living in rural Ohio and Pennsylvania.

The argument is that if we had 300 million Chinese speakers and 300 million Indians move into the USA overnight, it would change the nature of our country. People who might welcome the diversity afforded by some new people may well recoil if there are more of them than "us."

One thing Democrats should be doing right now is thinking about all these issues and not simply reacting reflexively: If Trump wants to keep them out, I want to let them all in. 

There is a real problem here. We have to get serious about solving it.

The War Against White America

I was wondering when Donnie Snowflake would get back to fighting the war against White America.

Look at that Black guy. He took some white kid's place!

He did go to that Carrier Air Conditioner factory in Indiana to rescue those 800 jobs, and he did get about 500 coal miners jobs in a mine. So his war against unemployment is going well. And he keeps going to places where lots of white men show up for rallies, but really, where has he been when it comes to college admissions?


Well, now we know. He's got his good friend Jeff Sessions sending in Justice Department G men to probe and intimidate colleges about their admissions of Black, Hispanic, undocumented terrorists instead of  good White, Christian Americans.




Kris Kobach, protecting you against ethnic cleansing of Whites

He's soul mate out there in the great insane state of Kansas, Kris Kobach, has observed there is a war against White America going on, launched from over our Southern Border by dark skinned Mexicans who aim to carry out ethnic cleansing of all the White Americans. Louie Gohmert and Joe Arpaio can't hold back all those invading hordes by themselves.
I have to ask: If you were a marauding darked skin Hispanic from Latin America, would you go try to cleanse in the state of Kansas? Have you ever seen the movie "Infamous" based on Truman Capote's novel, "In Cold Blood"?  That place is just empty spaces and open fields--it makes Wichita Falls in "The Last Picture Show" look like Gay Paree. Kansas is just bleak. Why would you want to maraud in Kansas?


But back to the point: Donnie Diva has to ride to the rescue to save the White people.

If they need any advice on where to start, I'd send them to the Cornell University Medical College, now known as Weill Cornell, after Sandy Weill, a Wall Street robber baron gave them $150 million (which for him was lunch money) to get Cornell to name their medical school after him.

Even the bricks are white at Cornell

Cornell for decades was the bastion of white upper class men.  There were 90 students in each class, 4 women and 86 men. Most of these were selected because they were the sons or nephews of alumni, and that place was just as WASPy as you could get.  Jews were expressly forbidden.

But when Sandy Weill got rich enough, he decided it would be a good joke for him, a man of Jewish ancestry, to buy himself a medical school which formerly excluded people like him.  Jews not good enough for you blue bloods? Well, I'll just take control and see how superior you are then.
But then, sometime in the late Twentieth century, somebody at the school decided if they were going to owned by a Jew, they ought to go full Monty and just admit all sorts of non Christian, even non White people. Shoot the moon.
They even opened a branch in Qatar, which is somewhere in the Muslim Middle East.  Donnie Diva's got no use for Qatar,  even though we have a big military base there. Seems Saudi Arabia's got some grudge against Qatar and that's good enough for Donnie Dubious after the wonderful time he had in Saudi Arabia, where they really know how to throw a  party and they gave him a nifty sword and they know how to treat women in that country. They have still harems there, in case you were wondering. Which just goes to show not all the good ideas in the world come from America.

Anyway, to get back to the war on White America:  all those dark skinned students have displaced all the blondes and real Americans who wanted to go to Cornell medical school. They've had to find other places. 
My own son, who happens to be White and male had to settle for Columbia College of Physicians and Surgeons.  As it turned out, he had a wonderful time there.  But he never even got an interview at Cornell, despite his astonishing MCAT score and his great grades and his wonderful recommendations. I called up some of my old friends at Cornell, who still fester in various departments, and was told, variously, "He's got into a way better school, across town," and "He's a bit too pale for current tastes at Cornell" and all like that.

Personally, I'd be okay with "blind" admissions to medical school, and to college. It might work like those auditions   at Lincoln Center, where they put up a curtain and you play your violin or cello behind the curtain and they chose you no matter what your color or your gender or your gender preference, based just on the sound you make.

But when you are talking about glittering prizes, like college and medical school admissions, they haven't yet figured out how to do the equivalent of the curtain thing.


"Qualified" in America hasn't meant "capable and good at the job you are seeking" but it means you have the right color, look, family background.


If that isn't a meritocracy, well then I don't know what is.

Something to Believe In

Watching "Leftovers" I had a revelation about the Republicans.
You know how Barack Obama said there are people who cling to their guns and their religion, and like the "deplorables" comment, that was just too close to the bone and it was used to cement the resentment against him, and later against Hillary.

Well, in the episode I saw tonight, Second Season, Laura, has freed herself from a cult formed after the great disappearance of 1/10th of the world's people. The cult embraced nihilism but Laura finally realizes it is possible to do something to confront big problems in life, and she embarks on a program to rehabilitate the nihilists. 

But liberating people from the cult does not solve their problems. Laura has the  epiphany that while she has been able to help people who sought salvation in a cult of nihilism, she had been unable to help them find what they were really seeking in the cult in the first place: Something to believe in.

Nobody knows what to believe about the disappearance, about the departed. And the randomness of the culling is what bothers people. If it could happen to those people, chosen for no apparent reason, just randomly, then it could happen to me. It's the unnerving feeling I had as a new intern on the wards of the Memorial Sloan Kettering Hospital for Cancer and Allied Diseases--all these people, living their lives, not smokers, no apparent reason and then, poof! They're gone, or on their way out, just random, no explanation. 

In "Leftovers" there's a cult which says it's coming for all of us, just stop trying. This is familiar to anyone listening to Republicans: Oh, there's nothing to be done. 

This fleshes out the wonderful song which plays at the opening of every episode in the second season, which says we are all afraid of going back to where we came from before we were born. There's that deep fear we all live with of not knowing how the universe works or our place in it.

And, you know, I think that's what Donnie Dubious offers people. It's why he has that unctuous Lee Greenwood sing that gooey song before his rallies: 

If tomorrow all the things were gone
I'd worked for all my life
And I had to start again
With just my children and my wife

I'd thank my lucky stars
To be living here today
Cause the flag still stands for freedom
And they can't take that away

I could just puke every time I hear that and see the tears streaming down those bloated, stupid faces of the audience.

The song which opens "Leftovers" is haunting.

Some say that they're comin' back in a garden
Bunch of carrots and little sweet peas
I think I'll just let the mystery be

Everybody's wonderin' what and where they they all came from
Everybody's worryin' 'bout where they're gonna go
When the whole thing's done
But no one knows for certain
And so it's all the same to me
I think I'll just let the mystery be

Once upon a time, Democrats said there was something to try. They called it the New Deal. Said it would work, or at least it might work, but as Roosevelt said, it's better to try something, anything, even if it doesn't work, rather than being frozen into inaction by the fear of failure. 
What the Democrats need is that cleansing hug, that something people are looking for.

I don't know, maybe Bernie knows what it is.
Maybe the thing people want to believe in is it is possible to help people at the bottom. Republicans have basically said the same thing since Herbert Hoover: "There's just no helping it." 
They look at health care, pensions, you name it and they say government can't help. 
I heard a Republican Congressman talking about Obamacare and how it was really just a souped up version of Medicaid and well, there are just all those able bodied people out there who want free health care without working for it--as if Medicaid is for slackers.
And I thought, this guy does not understand the Obamacare Medicaid went to working people, to people who had jobs but no health insurance. Private enterprise did not provide the option. Government had to act, and did, finally. 

Maybe we can make people believe that. Government can help.
Oh, I know Reagan and the nine scariest words in the English language: "I'm from the government and I'm here to help."
Very cute. Ronnie could always deliver a good line. Everyone laughed, even some Democrats.
But the fact is, Reagan was offering the ultimate in Republican nihilism: Nobody can help you, certainly not the government. You're on your own. 
But the fact is, when FEMA swoops in after a hurricane, when Social Security saves people from poverty and when Medicare saves the elderly ill, nobody's laughing. 

 FDR said it, four score and seven years ago: when ideology paralyzes politics into frozen inaction, when government ceases to make any effort to save its citizens, then we are staring failure in the face and we must do something.  We must dare to try something new. 
As our problems are new, so we must strive to think anew. 
Anything is preferable to surrender.

Finding Our Herblock: Pia Guerra

At the depths of the McCarthy era, when Tail Gunner Joe was terrifying every liberal with a past, when anything he said was inhaled by millions of Americans as received truth, when lies became the norm, a wonderful cartoonist, an accomplished artist at the Washington Post began drawing McCarthy, always with a dark five o'clock shadow looking unappetizing and scurrilous.

Herblock

And people took heart, came out of the their crouch and began to stand up.

Sadly, Herblock is gone, dead and gone, but there is a spiritual heir, Pia Guerra, who has captured the essence of today's man of the hour, Donnie Diva, the drama queen, who sees dark threats everywhere, from which he must rescue us.

She sees him as infantile, as we all do, the great amplifier.

She sees him for what he is and for what he is not.


And she sees the damage done.


We need to see more of her, and less of him.

The Next Act

So three Republican Senators finally figure out what voting for the Republican pout would do to the country:  Alaska's Mirkowski knows what it would do to her state which as been sucking on the government teat since it was born; Susan Collins has enough neurons rubbing together to know destruction of a hamstrung system is still worse than no system at all and John McCain may have come to Jesus when he had to face the fact that health care is important to actual human beings.

That did not stop the Senators from West Virginia or from Kentucky or from South Carolina voting for the assassination of the ACA, but to paraphrase Lincoln, you can count on some Republicans to be deplorable all the time, and you know some will be deplorable some of the time, but you can't count on all the Republicans being deplorable all the time.


Of course, Donnie Dubious tweeted that Collins, Mirkowski and McCain let the country down, which once again displays his uncanny ability to hone the big lie--these were the three who did the very opposite, who saved the country from driving right off the cliff, but in Snowflake speak, that translates into they acted against the best interests of their country.


And then Dubious ate breakfast, and forgot all about it and tweeted:

Departing for Long Island now. An area under siege from #MS13 gang members. We will not rest until #MS13 is eradicated. #LESM

Say what?

Oh, right in the best Apocalyptic absurdity Republican mode, the conspiracy train moves on.  The new most threatening host is not the Syrian hordes or the North Koreans or the Iranians but the gang members of MS#13.