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the early-modern welfare state + dual currencies ]

FYI: Conversations About a Wiser Use of Our Health Care Dollars & Resources

Graphical rendering of quotation: "Let Nature, and let Art do what they please / When all's done, Life is an Incurable Disease."

— Abraham Cowley (1618–1667)

Concluding verse couplet from Cowley’s poem, “To Dr. Scarborough,” first printed in 1656. (Poems ... Written by A. Cowley, 4 parts, 1656, 3.37)

As of May 2013, here in Southern California the acrimonious debate over the Affordable Care Act (also known as Obamacare) is heating up again, with President Obama — anticipating yet another effort in Congress to repeal the law — announcing in the national media that, although “We still have a lot of work to do in the coming months to make sure more Americans can buy affordable health coverage,”

The law is here to stay.          

(see the Associated Press story filed on 5/10/2013 by Julie Pace and Jim Kuhnhenn, “Obama Declared Health Care Law ‘Is Here to Stay’”; and for the most recent attempt to scuttle the law — “House Republicans have voted more than 40 times to disable all or part of the health care law.” — see the Associated Press story filed on 9/20/2013 by Andrew Taylor, “House Votes to Derail Obamacare, Fund Government: The GOP-controlled House voted Friday to cripple President Barack Obama’s health care law as part of a risky ploy that threatens a partial shutdown of the government in a week and a half.”)

while vociferous detractors such as San Diego’s Union-Tribune editorial board launch a week-long TV and print campaign — “our series on the broken promises used to win passage of the Affordable Care Act” — designed “to discredit a law that will go in effect in 2014 and have broad consequences for most Americans” (U-T Letters to the Editor, posted 9 May 2013).

 
[ Available as of May 2013 (when this webessay was first posted) in the U-T San Diego’s series of editorials on the Obama administration’s overhaul of the U.S. health care system, entitled “Affordable Care Act: Broken Promises” ]

pointer  Obamacare: This is going to hurt (posted 4 May 2013)

pointer  Broken promise No. 1: You can keep your doctor (posted 5 May 2013)

Compare responding Letters to the Editor (entitled “Obamacare: good medicine or bad policy?” and framed as “Readers debate fact and fiction about president Obama’s health care policy”), posted 6 May 2013.

pointer  Broken promise No. 2: More people will have health coverage (posted 6 May 2013)

Compare responding Letters to the Editor (entitled “Obamacare: coverage and care” and framed as “What will Obamacare cover? And who will provide care? Readers examine the U-T editorial series”), posted 7 May 2013.

pointer  Broken promise No. 3: Your health care will get better (posted 7 May 2013)

Compare responding Letters to the Editor (entitled “Obamacare: Coverage concerns” and framed as “‘Greedy insurance companies’ is a tiresome mantra, a reader says”), posted 8 May 2013.

pointer  Broken promise No. 4: The cost of your health care will go down (posted 8 May 2013)

Compare responding Letters to the Editor (entitled “Obamacare: costs concerns and more” and framed as “Will Affordable Care Act provisions slow the ascent of premiums?”), posted 9 May 2013.

pointer  Broken promise No. 5: Government health care spending will fall (posted 9 May 2013)

Compare the op-ed by Richard S. Ledford, Gregory E. Knoll, and Irma Cota (entitled “Obamacare Improving Health of San Diegans”, U-T San Diego, 24 May 2013, p. B7; retitled “Obamacare a Strong First Step to Improving Health of San Diegans” for posting online) which responds to “the recent series of editorials published by the U-T.”

 
[ with continuing updates ]

pointer  Admitting Obamacare an Unpopular Mess (U-T San Diego editorial, 5 July 2013, p. B6)

The U-T San Diego Editorial Board weighs in on the recently-announced delay for implementing the Affordable Care Act’s “employer mandate” (which “requires businesses with 50 or more workers to provide health care coverage for full-time employees or face government fines”).
   Like some other conservative critics of the ACA (e.g., see below pointer for the entry dated 3 July 2013 in the “First Catalog of Annotated Links”), the newspaper’s editors interpret the government’s action as “a tacit admission that Obamacare is deeply unpopular — and that its implementation will only make it more so.”

pointer  Repeal Obamacare Now (U-T San Diego editorial, 16 August 2013, p. B6)

The U-T San Diego Editorial Board ramps up its attack on Obamacare, here excoriated as a “stinking mess.” (B6)
   Attributing broad socioeconomic trends (such as the “stunning” growth in part-time employment) to perverse “financial incentives” associated with Obamacare (instead of, e.g., the high-tech-driven shift to a “gig” economy), the editorial emphasizes the health care act’s “plummeting” public support and accumulating “wreckage.” (B6)
   Summarizing “the vast wave of bad news about the Affordable Care Act in recent days,” the editorial warns that Obamacare threatens to destroy — not strengthen — “the middle class” (“small-business owners, union members, restaurant managers, school administrators and many more”) with its soaring costs for government-mandated health insurance coverage.

facsimile of full-color newspaper cartoon

^  Obamacare Rx (℞ being the common abbreviation for medical prescriptions). Editorial cartoon, by Steve Breen, for the 8/16/2013 issue of the San Diego Union-Tribune, rebranded U-T San Diego (p. B6) under the proactive ownership of Douglas F. Manchester.
     Graphically depicts Obamacare, also known as the Patient Protection and Affordable Care Act (PPACA), as destructive medicine for all that ails USers (the bright red syrup burns through and destroys the very spoon with which it is dispensed).
     Click/tap here to view a larger digital facsimile (226KB) of Breen’s visual commentary.

pointer  Unions Join Obamacare’s Many Critics (U-T San Diego editorial, posted 22 September 2013)

In Sunday’s paper, the U-T San Diego Editorial Board approvingly quotes Terence M. O’Sullivan, president of the Laborers’ International Union of North America, as saying: “If the Affordable Care Act is not fixed and it destroys the health and welfare funds that we have fought for and stand for, then I believe it needs to be repealed.” (U-T San Diego, Opinion section, 22 September 2013, p. SD8)
   Here, the usually anti-union editorial board “stands with the Laborers’ International Union of North America in arguing that unless this immense mess can be fixed, it should be repealed. The sooner, the better.”

pointer  Obamacare: It Only Gets Worse from Here (U-T San Diego editorial, 6 October 2013, p. SD6)

Focuses on the “vast sticker shock” felt by some after Oabamacare’s roll-out on 1 October 2013, and sounds an alarm about “the toll its negative incentives will take” (even on the institution of marriage).

pointer  Implementation Exposes Lies Used to Sell Obamacare (U-T San Diego editorial, 18 October 2013, p. B6)

Contends that the problematic launches of the federal-government and state-of-California websites during “Obamacare’s awful first few weeks” go beyond technical “glitches” to “deep-rooted” policy flaws, leading to botched website design: “Is this just a ‘glitch’? Or another example of trying to make sure Obamacare began without reminders that its passage was built on lies?”
   (For my very different take on website design flaws, see below pointer for the entry dated 18 October 2013 in the “First Catalog of Annotated Links”.)

pointer  President Obama’s Obnoxious Bait-and-Switch (U-T San Diego editorial, 1 November 2013, p. B6)

 
[ and some post-presidential election
(8 November 2016) updates ]

pointer  “Here Is what Donald Trump Wants to Do in his First 100 Days” (posted to the website for San Diego’s local PBS station — KPBS Public Broadcasting — on 9 November 2016)

A “Repeal and Replace Obamacare Act” was No. 5 of 10 in the section of presidential-candidate Donald Trump’s 100 Day Plan (issued in October 2016) where he pledged “I will work with Congress to introduce the following broader legislative measures and fight for their passage within the first 100 days of my Administration.”
   The “Repeal and Replace Obamacare Act” which President Trump intends to nursemaid through the U.S. Congress during his first 100 days in office “Fully repeals Obamacare and replaces it with Health Savings Accounts, the ability to purchase health insurance across state lines, and lets states manage Medicaid funds. Reforms will also include cutting the red tape at the FDA: there are over 4,000 drugs awaiting approval, and we especially want to speed the approval of life-saving medications.”

pointer  Replacing Obamacare — in Bipartisan Way (San Diego Union-Tribune editorial, 13 November 2016, p. B12)

Three years after the U-T San Diego launched its “Broken Promises” series on the Affordable Care Act, the re-branded San Diego Union-Tribune Editorial Board began advocating for repeal-and-replace of Obamacare.
   “The San Diego Union-Tribune Editorial Board has long urged Congress and the White House to try to fix the ACA, believing that it would never be replaced so long as Democrats held the White House or controlled part or all of Congress. When the GOP runs Washington, a better idea is to dismantle the ACA while keeping what’s best about the 2010 law.”
   The Editorial Board argues now that repeal-and-replace is the best course of action for the nation, because “while ACA has worked out reasonably well in California and some other large states, it is on its way to being a disaster in many small and midsized states, with insurers pulling out of money-hemorrhaging state exchanges, premiums soaring and deductibles going ever higher. A recent analysis predicts that by next year, in one-third of the nation, Obamacare enrollees will have only one insurer option.” (The San Diego Union-Tribune Editorial Board, B12)

facsimile of greyscale newspaper cartoon

^  Editorial cartoon by Steve Breen, for the 11/13/2016 issue of the San Diego Union-Tribune (p. B12). Shows President Donald Trump taking a chainsaw to Obamacare, also known as the Patient Protection and Affordable Care Act (PPACA).
     Click/tap here to view a larger digital facsimile (148KB) of Breen’s visual commentary.

pointer  Crafting Trumpcare: Be Careful, GOP (San Diego Union-Tribune editorial, 8 January 2017, p. B10)

The more measured tone of 2016–2017 San Diego Union-Tribune editorials (reflecting another change in ownership of the newspaper) is evident. Here, the Editorial Board acknowledges that “finding an approach that is superior to both Obamacare and the cruel old days of broad indifference to millions of families without health insurance isn’t easy.” (The San Diego Union-Tribune Editorial Board, B10)
   “So what is America to do? A smart option is to copy what works in nations that have effective but less expensive health care systems. Some European nations have strictly enforced individual health insurance mandates, increasing the risk pool and limiting the ‘free rider’ problem. Some have basic government health care and specialized care through private insurers. But given the anti-government, anti-regulation ethos of the modern GOP, a European copy is highly unlikely to be embraced.  ¶  Perhaps the most promising outcome is that technology comes to the rescue, disrupting health care by driving down medical costs and increasing efficiency as it has in so many other fields. A promising era looms in which body-monitoring technology combined with Big Data insights into medicine can catch early-warning signs of declining health. IBM software, for one, grows steadily more adept at evaluating radiology images.  ¶  But the most likely outcome is a return to the cruel old days. We hope that doesn’t happen — because while Obamacare has disappointed many, its enactment was a response to real problems.  ¶  Soon the GOP will own them — or the solution.” (B10)

facsimile of greyscale newspaper cartoon

^  The Doctor’s Bag, editorial cartoon by Steve Breen, for the 1/8/2017 issue of the San Diego Union-Tribune (p. B10). Shows President Donald Trump’s Republican Party (the GOP, whose traditional mascot is an elephant) personified as a physician, standing helplessly next to an open tool bag (labeled “Obamacare Replacement Ideas”) which is empty.
     Click/tap here to view a larger digital facsimile (137KB) of Breen’s visual commentary.

pointer  Trump, IRS Already Made Obamacare Worse (San Diego Union-Tribune editorial, 19 February 2017, p. B11)

Contends that a hurried and ill-conceived “Trump executive order from last month requiring federal agencies to provide relief from provisions of what’s widely known as Obamacare has magnified the law’s key weakness.”
   Intent on repealing rather than improving Obamacare, President Trump’s executive action further undermines its funding mechanism by cutting the already weak federal tax penalties for not buying insurance. “This has long led to fears that state exchanges will face ‘death spirals’ in which insurers have to pay for the cost of care for the sickest people without benefiting from the premiums paid by healthier individuals who don’t use nearly as much medical care — driving premiums higher and increasing the incentive for people to not buy coverage until necessary.” (The San Diego Union-Tribune Editorial Board, B11)
   The Editorial Board notes that California is not one of the states facing a certain “death spiral”: “California, with its massive population and its competition among insurance providers, has its own state exchange [Covered California] and doesn’t use the federal marketplace.” But for those states that are, it’s “time for the Trump administration and lawmakers of both parties to begin the overhaul of a health care system that’s under siege.” (B11)

pointer  House GOP’s Stingy Version of Obamacare Is Not True Reform (San Diego Union-Tribune editorial, posted to their website on 7 March 2017)

Here, the Editorial Board argues that true reform would entail “a 50-state insurance market, subsidies for uncovered lower-income families and an individual mandate strong enough to ensure nearly everyone has at least catastrophic coverage.” (n. pag.)

pointer  “U.S. Health Care: Where from Here?” (San Diego Union-Tribune editorial, 25 March 2017, p. B6), retitled Donald Trump’s Inartful Health Care Deal: What Now? for online posting

A Republican plan (Trumpcare) to overhaul the Affordable Care Act (Obamacare), was pulled from the House of Representatives floor on Friday, 3/24/2017, when GOP leaders failed to secure enough votes to pass the bill. On 3/25/2017, the San Diego Union-Tribune’s Editorial Board criticized “Trump’s desperate deal-making and inartful ultimatums. The bill was prepared with the misguided notion of giving the president an early win instead of vastly improving health care.... As many pundits observed, the new bill was a cold-hearted spending cut masquerading as health reform. Good riddance.” (B6)
   But Trump’s subsequent threat that “Obamacare may well ‘explode’ in many states” means that “sooner or later, health reform has to come back before Congress, and major changes must be made.” While California is not directly affected, 14 states — with only one or two health insurers offering ACA coverage — are already locked in “the Obamacare ‘death spiral’” and “that number is likely to rise next year, when Humana says it will stop offering ACA policies in 11 states.” (B6)
   Once “both blue states and red states see their health care systems plunge into chaos, it’s possible to imagine public outrage forcing Republicans and Democrats to work together. At that point, perhaps finally a grand compromise could emerge and a system modeled on good ideas seen around the world could be adopted.... If this happened, America would be much better off than it is today — or than it was eight years ago, before the Affordable Care Act was adopted.” (The San Diego Union-Tribune Editorial Board, B6)

facsimile of full-color newspaper cartoon

^  Is There a Doctor in the House?, editorial cartoon by Steve Breen, for the 3/25/2017 issue of the San Diego Union-Tribune (p. B6). Shows Donald Trump’s ego prostate (after Trumpcare was voted down in the Senate), while a narcissistic president seeks emergency care for his alterego.
     Click/tap here to view a larger digital facsimile (135KB) of Breen’s visual commentary.
     Breen provided the Editorial Board with 6 sketches themed around the failed GOP Health Care Bill, from which the Board selected the above “Is There a Doctor in the House?” design to illustrate their editorial. Click/tap here to view all 6 cartoon sketches.

pointer  Senate Health Bill Shows GOP Lost Its Way (San Diego Union-Tribune editorial, 25 June 2017, p. B10)

Argues that when it comes to repealing and/or replacing Obamacare (the Affordable Care Act), “Republicans haven’t solved their conundrum: The uproar over how the Affordable Care Act’s mandates made health insurance so expensive has driven the GOP’s nationwide success since 2010, but the party’s proposed fixes offer little or no relief to many Americans.” (B10)
   It is “inconceivable” that the new Trumpcare would sacrifice “disaffected populist voters — people who think the system is rigged against the little guy” — millions of whom helped Trump become president, and “strongly support preserving the social safety net.” (B10)
   But that is what’s happened. Instead of improving the public’s access to health care, the GOP bills crafted by both houses of Congress will “hammer the little guy, batter the middle class and most help those who don’t need help.” (B10)

pointer  Killing California’s Single-Payer Health Care Bill Was Right Call (San Diego Union-Tribune editorial, posted to their website on 27 June 2017, n. pag.)

Argues that Assembly Speaker Anthony Rendon deserves “applause for not continuing to indulge the fantasy that pretended that Senate Bill 562, championed by state Sens. Ricardo Lara, D-Bell Gardens, and Toni Atkins, D-San Diego, was ever a serious proposal.” (n. pag.)
   Dismissive of “the cruel, sloppy alternatives proposed by House and Senate Republicans” in Washington — “not reforms so much as barely disguised tax cuts for the very rich that would be devastating to millions of Americans” — the newspaper’s Editorial Board also objects to the “political posturing” going on in Sacramento: “it was downright silly for the California Senate to approve SB 562 without an explanation of how its estimated $400 billion annual price tag — triple the state’s general-fund budget — would be covered in a way that wouldn’t hammer taxpayers and the state economy. Nor did Lara or Atkins ever explain how California could get around a powerful federal law regulating health insurance — a law the RAND think tank recently warned would pose major hurdles for Oregon if it tried to implement single-payer.” (n. pag.)

N O T E :  I have similarly opined on this subject (interpolation posted 8/6/2017), at a companion website (see content in Quick Links sidebar at right of page).

pointer  “Finally, GOP Common Sense on Obamacare” (San Diego Union-Tribune editorial, 8 July 2017, p. B6), retitled Fix Obamacare? McConnell Finally Shows Some Common Sense for online posting

Again: there’s “no denying that while Obamacare may be working for millions of Californians, it isn’t in many states.” (B6)
   And the Editorial Board looks to the few glimmers of bipartisanship it thinks can light the way forward, applauding the new “pragmatism” of Senate Majority Leader Mitch McConnell (of Kentucky): “Now a Republican from a state where the ACA is struggling has figured out that it might be wise to try to seek a bipartisan fix of the existing law’s problems rather than replacing it with something even more unpopular.” (B6)

pointer  “Two Roads Diverged in the Senate” (San Diego Union-Tribune editorial, 29 July 2017, p. B6), retitled If the Senate Is the World’s Greatest Deliberative Body, It Should Act Like It for online posting

Noting that “we met Senate Majority Leader Mitch McConnell of Kentucky’s supposed call for a bipartisan solution three weeks ago with ... optimism,” the Editorial Board agrees with critics that the resulting “so-called ‘skinny’ repeal of Obamacare that the Senate rushed to a vote in the wee hours of Friday morning in Washington, D.C.” was “a farce.”
   The Board rejects “the half-baked GOP health care plan that supporters said could be fleshed out in later meetings with the House of Representatives,” and agrees with Senator John McCain’s impassioned call for real bipartisanship: “Democrats and Republicans must work together now to repair Obamacare, and President Donald Trump should foster such collaboration instead of letting it ‘implode,’ as he keeps saying he will. Yet our deal-making president instead said Friday the Senate should change its rules to do business with 51 votes instead of 60. Here’s hoping McCain’s message resonates far more than Trump’s in the Senate.” (B6)

pointer  Medicare for All? Let’s Copy What Works with Health Care in Other Nations Instead (San Diego Union-Tribune editorial, posted to their website on 5 September 2017, n. pag.)

Calls for Republicans to start “thinking big about health care”: “Instead of tinkering with — or gutting — the Affordable Care Act, the Trump White House and congressional GOP leaders should consider setting up a commission to examine how to emulate other nations which deliver better outcomes at a lower cost.” (n. pag.)
   The newspaper’s editorial board thinks we can do better than “Medicare for All” by following T. R. Reid’s advice “to learn some lessons about health-care administration from the other industrialized democracies.” (n. pag.)
   I agree that Reid’s research in the late-2000s unearthed some bold new ideas, and is relevant for Republicans, and Democrats, and Independents alike. Reid’s book about health care systems around the world and what the U.S. can learn from them — entitled The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care (New York: Penguin, 2009; rev. edn., 2010) — made the New York Times Bestseller list, and remains a useful resource today.
   In addition, Reid was interviewed by the PBS NewsHour’s Betty Ann Bowser on 28 August 2009 (“Health Systems Abroad Offer Lessons for U.S. Reform Plan”) and collaborated with PBS’s Frontline on an interesting documentary, Sick Around the World: Can the U.S. learn anything from the rest of the world about how to run a health care system? (2008).
   I also recommend visiting the introductory page for Sick Around the World at the Frontline website, since it includes another link to “Watch the Full Program Online,” along with such extras as supplementary analysis of important issues, interviews, Q&A, and the summary report, “Five Capitalist Democracies & How They Do It.”

N O T E :  T. R. Reid’s latest comparative research project — tax reform — culminated in another bestseller, A Fine Mess: A Global Quest for a Simpler, Fairer, and More Efficient Tax System, issued by Penguin in April 2017. This time, the PBS NewsHour’s economics correspondent, Paul Solman, interviewed Reid: you will find Part 1 of the interview here (“Dreading Doing Your Taxes? Other Countries Show Us There’s Another Way”); Part 2 of the interview here (“What Other Countries Can Teach America about Taxes”); and an excerpt from Reid’s book, A Fine Mess, here (“Why We Need to Rewrite Our Tax Code from Scratch”).

pointer  “New Plan, Same Cuts Disguised as Reform” (San Diego Union-Tribune editorial, 24 September 2017, p. B9), retitled Here We Go Again: GOP bill replacing ACA is about budget cuts, not reform for online posting

pointer  “California Democrats, Don’t Start Binging” (San Diego Union-Tribune editorial, 29 September 2017, p. B6), retitled 3 Reasons California Democrats Need to Scrap their Free-Spending Fantasies for online posting

Again, the Editorial Board defends “politicians who dare to ask the most basic question — how are we going to pay for this?” about California’s Senate Bill 562 (SB 562), the single-payer health care measure introduced by state Sens. Ricardo Lara (D–Bell Gardens) and Toni Atkins (D–San Diego). Noting that the California Constitution’s balanced-budget mandate is not “a minor detail” when it comes to figuring out the financing for single-payer, the newspaper’s editorial board selects just 3 “grim facts about state finances ... rarely acknowledged by anyone other than Gov. Jerry Brown” which augur “massive future budget crises as bills come due” (B6) to prove its point.
   In response, readers castigated the newspaper for its right-wing and left-wing extremism:
   •  “... This editorial, typical of the right-leaning Union Tribune, is just a partisan witch hunt....” (posted 9/28/2017 by “mattparker619”)
   •  “SD Union....nothing but LIBERAL GARBAGE” (posted 9/29/2017 by “bootenberg2601”)
making the San Diego Union-Tribune a rare bipartisan organ in this age of shrill political debate (an accomplishment which should please the editors! ;-).
 

While the former U-T San Diego’s opening “Affordable Care Act: Broken Promises” series of 2013 was more about venting than serious investigative journalism — it was, after all, a series of editorials (i.e., opinion pieces, not rigorous analyses) — such passionate conversations are a necessary starting point if we are to make any real headway along the path leading to a wiser use of our health care dollars and resources.

In other words, ideology matters, and should not be dismissed or ignored.

We’ve always needed spaces where we can engage honestly with one another’s biases, beliefs, interests, fears, prejudices, and values, because these things define us as human beings, and guide our choices and actions.

Divisions over the really big questions — is health care a right for all? does society have a responsibility to care for the poor? what is an individual worth? what is fair? wise? just? good? what is life? what is health? what is disease? what is a cure? who owns our bodies? who should control our bodies? does profit-seeking improve health care? what is the proper role of the marketplace? etc. — will never go away.

The historical context

In 17th-century Europe and the Americas, debates over health care reform and legislation were every bit as emotional and polarizing as we find today, and with plenty of name-calling, too. Indeed, many of the topics provoking such impassioned debate back then will be familiar:

At the time, physicians felt embattled — their profession overrun from without by unorthodox medical practitioners of all sexes, and undermined from within by the low standards of practicing physicians who had only “some years of Duncery spent in a Gown” (academic training) but lacked the solid learning and right combination of theory and practice required for exemplary professional conduct. London’s medical establishment, a quasi-governmental body known as the Royal College of Physicians of London, founded by Henry VIII, had a metropolitan emphasis and limited jurisdiction. College physicians, several of whom were connected with the major London hospitals as well as the London medical corporations, were few in number, and “not very rigorous in asserting their Privileges” (Chambers’ Cyclopaedia, 1728, i. 256), which meant that the unlicensed medical practitioner also flourished, even within the regulated city limits. Although he was not a member of the College, as far as we know (and we don’t know much about his life), the “sober and rationall Physitian” Richard Whitlock (b. 1615–16) identified strongly with the London medical establishment. A Galenist, a royalist sympathiser, and an enthusiastic promoter of health care reform in mid-17th-century England, Whitlock followed the polemical tradition of establishment physicians such as Francis Herring (d. 1628) — a fellow of the College of Physicians from 1599, and author of the treatise, The Anatomyes of the True Physition, and Counterfeit Mounte-Banke: wherein Both of Them, Are Graphically Described, and Set Out in their Right, and Orient Colours (1602 and 1605), in which those who “falsely usurp this title of Physitian” were excoriated as “the scum of Mankind.” In 1654, Whitlock published his deeply partisan “live Dissection” of errors and prejudices in human behaviour, including those affecting the theory and practice of medicine, in a work of “Morall Anatomy” cast in the entertaining invective of the pamphlet wars, which then dominated public discourse.

In his Zoötomia, Whitlock exposed medical malpractice to scorn and ridicule, railing against everyone involved, practitioners and patients alike. Questions of financial motivation figured prominently in Whitlock’s satire: he dismissed the she-physician’s pro bono charity work as mere ostentation (“on stricter Scrutiny, [their] Benevolent Practise will appeare to be begun in vain glory, and to end in injuriousnesse, and that to more than the Patient”), and he censured the empiric who charged for consultations, medicines, and lab tests as driven entirely by greed and as preying on gullible folk:

In nothing more doth that many-headed (but slender-witted) judge, the Vulgar, betray their weaknesse of Judgment, than in their choice liking, or Admiration of their Divines, and Physitians. For their Divine commonly, let his Doctrine be new, and his Chin not old; and he is compleatly qualified. But would you know their Physitian? (On whose skill though they venture no wagers on it, they will their lives) Them they will trust with those they would scarce trust for an Angell. And would you know the Attractions that are in him? Why,
     1. He is a Native with an Outlandish Name; A Renegado from some Trade, or Profession, hee could not fadge with: By whose Dulnesse, no Mystery, but scorned to be Master’d: and banckrupt of all waies to live, He resolves to kill; but his Valour would not endure the way of killing Folke against their wills, but setteth on a slier way of feeding Himselfe, (and the wormes too,) with bold, (because Lawlesse) and ignorant Adventures in Physick, in which, (after a Prentiship to the Plague, or some Disease, so Epidemicall, that his Miscarriages cannot be heard, for the Din of Knells) Opinion, and the commendations of poore inconsiderable People, (no more able to judge of worth, than to satisfie it;) maketh Him Free: (for I cannot afford him, the Title Graduates him, hee doth handle a Liberall Art, (or Science) so Mechanically). And now Hee being to work too fast for the Grave-maker, or will by that Time he is furnished with necessaryes for such Practice, his Tooles and Impudence. As for his Tooles, They are Books in the Mother Tongue. 1. Some Obsolet Anatomy, ... Out of which he learneth to miscall the parts of the Body, but in hard words (and those mistaken,) that sound to the wonder and cheating of much people: and believe it, this is none of the Peoples ordinary Physitians, for in many it matters not if they can read or write any thing but boasting Bills; wherein be sure S. begins Chirurgery, and F. Physick: or at most if his English Library can furnish him with but the confused Notions of some diseases, and he can but discourse them to fit all Waters: Their Patient is ready to admire and cry, right Sir, you have hit, (as it is hard but he may in reckoning the Symptoms, or pains that usually accompany distempers mingled, be they acute, or Chronicall) and Hee must be the only Man can cure Them. Is not this the usuall Practise of Patients, to go from one Doctor to another, (in places that afford them choice) and to like none for sufficient, but him that by Chance, or undiscerned cunning in Questions, &c. hit upon any part of their Distemper....

(R. Whitlock, Zoötomia, or, Observations of the Present Manners of the English: Briefly Anatomizing the Living by the Dead. With an Usefull Detection of the Mountebanks of Both Sexes, 1654, 62–4)

The fee-for-service model corrupted the practice of many licensed physicians, as well. Whitlock criticized those colleagues who “saw money might be got by the Profession, be he able or no” and abused the system for personal gain:

His Prescriptions are Syllanae Proscriptiones (as my Lord Bacon excellently) Sentences of death, rather than directories of Recovery, because made rather in set form, tedious and impertinent, more for shew than propriety of application, to disease or Patient, to vary ex re nata, according to variety of occasion, is besides his Formulae Receptarum, Modell of Receipts: He considereth not the parability, or Propriety of Medicines, it is not unusuall with him to prescribe things out of use, or reach, or season, so his Bill may but make a shew on the stile, it mattereth not. Hee pretendeth to Magistralls, that none but his Apothecary and he must understand. He will put Nostrum, to Album Graecum (it may be he keepeth a Dog on purpose to make it, and then he may indeed) Pilulae de Tribus, or the like he wraps up in this blind Nostrum; and hee, and his Apothecary must keepe them for a Secret from the world (least their Theft be betrayed) who together study all sordid waies, to keep the Nap on the Scarlet, and his Doctorship from being thread beare....

(R. Whitlock, Zoötomia, or, Observations of the Present Manners of the English: Briefly Anatomizing the Living by the Dead. With an Usefull Detection of the Mountebanks of Both Sexes, 1654, 102–3)

And Whitlock complained about patients who were willing to pay for such specious medical shows, but not for health outcomes: once they were feeling better, these patients would attempt to renegotiate or cancel professional fees which, in retrospect, appeared extravagant for the less-than-spectacular “honest and rationall Endeavours of a Physitian” (Whitlock, 132).

Should a Patient be bound to give all his Advisers a Fee, he must quickly be removed (though an Alderman) to the Hospitall, there to bee sick sub forma Pauperis. I know no true reason of the length, or dodging of some Diseases (and chiefly Agues) than the inconstant hearkening to (and use of) any remedy taught them: No that golden Rule of Montanus might save silver in their Purses, and easier renew the Lease of mens lives; were it embraced, and followed: it is in his 31. Counsell, for a noble Matron. Si curari vult, indigebit, diuturnâ Perseverantiâ & pertinaci Patientia, obediendo fidelibus Medicorum Consilys, &c. If she will be cured, she must have lasting Perseverance, pertinacious Patience, and obedience to the faithfull advises of Physitians, &c. But I passe to the Disease of their Recovery, the Gout in their hands, that Martiall found in a Client.
 
          Litigat, & Podagra Diodorus, Flacce, laborat,
          Sed nil Patrono porrigit, haec chiragra est.
          No Fees for’s Law? Diodorus Gout
          More lyeth in his hands than feet, no doubt.
 
And now our Patient hath gon through all his own crosse Purposes, and Mis-behaviours, yet is of the mending hand (no, in his Body, I would say, for his Gratitude sickneth) all the ill humours of his body ad manus amandantur (as they term it) run into his hands; where such a Gout settleth, he cannot reach the Physitian his hand (if you would never so fain) and such a costivenesse hath seised his Purse, nothing but a Tax, and Suffimigium, or smell of Match (a strang course for Costivenesse) can loosen it, much lesse the Spirit of Gratitude (some drops whereof, all Chymistry can scarce promise us)[.] And now me-thinks I heare the Parrot change his note, from a hundred pounds for a Boat, to give the Knave a Groat: and whereas at beginning, it may be twelve pence was little enough for casting the Water, now a few of them are too much for the cure. Which sordid Ingratitude is maintained by a worse (for this may fall upon Inabilities) but (that which the poorest may afford) they are now niggardly of good words and a malevolent Palsie of their Tongues must make good this Gout of their hands; for what is their language now? but slandring all the Physitians care, by fathering the Cure on some other; if it be but a Neighbours Gelly of Harts-horn, or some confortable Messe of somewhat or other they last took; what ease they found? it did them more good than all the Physick they had from the Doctor, or Apothecaries. How did a little Violl of the Syrupe of Clove Gilly-flowres that I had from Mrs. such a one, how it refreshed me! I might have saved money in my Purse, and have been sooner well (for ought I know) had I hearkened to my friends that bid me not meddle with these Doctors: But suppose he was obedient, and pretty orderly, and took little, or nothing but by the Doctors directions; why then either he was quickly well (which is worth double Praise, though not Fees) or longer under the Doctors hands. What work doth the Sophistry of Ingratitude make with this Dilemma? If quickly well, it was but a small matter to do, or a small matter did it, scarce worth speaking of (much lesse paying for) if longer, he doubteth he took too much Physick; he might have been better if he had given over sooner. Nay (which is the lowdest lye of all) some are not backward to impute their Recovery, to leaving off: a fine compendious way of thanking the Doctors care, if not an Atheisticall slighting of Medicines appointed by the Grand Physitian, God himselfe, Ecclesiasticus 38. 4. The short, and long is now no sight so unpleasing as their unsatisfied Doctor; his feet are cloven now, according to the Epigrammatist,
 
          Praemia cum poscit Medicus; vade Satan.
          Doctors ill Angels are, that Golden Aske.
 
When they are brought at last to some satisfaction, to Doctors and Apothecaries: What strange Topick, and Argument for Abatement do they use? that they never mention to Mercer, Brewer, Butcher; &c. I am a poor man, Sir, and have a charge of Children; perswasives the Chandler, and Ale-house would be deafe to. Nay, the length of the sicknesse (which implyeth the longer attendance, and pains of Doctor, and Apothecary) shall bee urged. I have been at great Expences severall waies in my sicknesse, and losse of time, &c. Such crosse-graind reasoning hath Ingratitude. They never use any of this stuff to their Sow-gelder, or Farrier; onely every penny bestowed on their own health they count lost, and flung away, and pray give the Doctor (thus used by your unworthiness) leave to think so too; and give him leave to repent the Cure, as having injured the World, in longer cumbring the ground with such Cattel, though good man he is to be excused; without he should go to a Figure-flinger, and know before hand how the Patient would behave himselfe after the Cure: he cannot tell it by the water (it were the best discovery the Water could afford) or his Charity blindeth him so (if it be to be discerned there) that he cannot believe such basenesse under the visage of a man. And so I leave the Doctor sicker then the Patient, with the smell of Karkasse and Carrion Gratitude: ....

(R. Whitlock, Zoötomia, or, Observations of the Present Manners of the English: Briefly Anatomizing the Living by the Dead. With an Usefull Detection of the Mountebanks of Both Sexes, 1654, 126–31)

As Whitlock shows, the value of medical services (whether they cured you or not) was always circumstantial and wildly variable. Everyone thought the delivery of health care fell into a unique category, and was not like other “mechanical” arts & sciences. But what exactly this category was, and how it fit into the larger economy, was unclear. Whether health care was a public good or a professional service — whether it should be paid for like all other professional services, or given away free, or made available on a sliding scale — were contentious issues, then as now.

To the famous Flemish iatrochemist, Joan Baptista van Helmont (1577–1644), the profit motive had no place in the delivery of health care, since “deceit, and the adulterating of Medicines have always been annexed to gain.” Furthermore, self-aggrandizement displaced the Christian theological virtue of charity which, for the Paracelsians, was at the heart of the healer’s ethos and divine calling.

For it is easie to deceive the ignorant in things which they professe themselves to be ignorant of: For there are essential oiles set to sale, and the which are valued at a great price, they being all and every of them adulterated: whether nine parts of oyle of Almonds were co-mixed with one part of essential oyle, is a metter of easie experiment: For cast it on a sponefull of Aqua vitae, and whatsoever shall swim atop, let it be the essential oyle; but the rest, oyle of Almonds: And that thing thou shalt the more certainly know, if thou shalt make tryal in a Bath: The oyle of Sulphur is for one half of it raine water, but the distillation of Vitriol is brought wholly into deceit, and is more frivolous dayly: The which will presently be manifest through a simple examination by a Bath: That scarce a sixth part thereof is the pure distillation, and that as yet loaded with the tincture of oaken bark.
     ... [T]he works of charity do not defame any one: But they who have not charity, account all things disgracefull besides gaine and Lucre. Depart ye from this pride, and be mercifull, as your Father which is in heaven is mercifull: For else he will say, I know you not that live for gaine and deceite: But indeed disgrace hinders not these somewhat ambitious ones, but ignorance, and the covetous desire of Lucre: For they make more account of the number of visits, than of the glory of curing, which wholly buries it self in having done well.
     For as soon as they are dismissed from the Schooles with the title of Doctour, they enqure through the Streets and Inns, with the eyes of a Lamprey, whether there are not sick folks which may entrust them with their life: But stop your proceedings, Medicine is not to be exercised after the manner of Mechanick arts.
     And because Physitians err in this point, the Father of Lights withdrawes his gifts, after that Medicine is managed as a Plow. Possess ye Charity, and gain Will voluntarily, follow you with Honour and Glory, the which take hold of a Physitian that shuns them, whom the most High hath commanded to be honoured.
     ... I grant, that all kind of Knaves have most licentiously thrust themselves into Chymistry, no less than into Medicinal Affairs, and that a various destruction doth thereby daily arise unto mankind; on whom surely the Magistrate ought of right to be severe in punishment: But these things do not defame honest men. It is certain, that deceit, and the adulterating of Medicines have always been annexed to gain. But as to what pertains to the reproach of Remedies, & Chymists, that is to be sifted by a larger Discourse.
     First of all, it is suitable in this place, That Science or Knowledge hath no enemy but the ignorant person; Nor any such one, but him that is proud, and refuseth to learn: ... Therefore they who at this day keep the keyes of medicine, seeing themselves do not enter the passages, they drive mortals from the usefull fruite of those gifts which the most high hath dispersed in nature.
     Therefore the powers of the most excellent things cry to heaven, that they have come as it were in vain, that there is scarce any one who can loosen their bonds, that they may bestow the benevolence which is due to mortal men; but rather, that they have become the rewards of whoredomes and adulteries: That science therefore which teacheth how to look, into bodies shut up, by a re-solution of themselves, and to extract their hidden virtues, is not the servant of the practick preparatory part of medicine (as the reproaches of the ignorant do sound) but it is the chief interpretation of the history of nature.
     For the Apothecaries shop began at first, from Merchants, the collectours of simples and herbs: but afterwards when Physitians saw that it was not meet for every one to boyle, season, and prepare simples, that businesse was also comitted to the sellers of simples.
     In the mean time, Physitians kept the more choyce and secret remedies to themselves, whereby they might procure honour with their posterity: But at length the sluggishness of Physitians increasing, they were contented to run through the streets from house to house, to have made gain by the frequency of visits; at length Dispensatories succeeded thereupon, for the compiling of formes of medicines here and there selected according to the pleasure of ignorance, that they might be kept in the shops, and in a bravery set to sale, rather for expedition than for their property. Whence at length, Physitians joyning compositions to compositions, give sometimes the hotch-potch of a thousand simples to the sick, to drink, that if one thing help not, at leastwise another may help; or at least, that they may excuse themselves that they have managed the cure of the sick according to the common rule. This is the preparation of medicine at this day, from which, how far the Philosophy of Chymistry differs, they indeed have known, who even but from the entrance, have saluted the same; but unskilfull haters only, are ignorant thereof....

(J. B. van Helmont, Oriatrike or, Physick Refined. The Common Errors therein Refuted, and the Whole Art Reformed & Rectified: Being a New Rise and Progress of Phylosophy and Medicine for the Destruction of Diseases and Prolongation of Life, trans. by John Chandler, 1662, 990–1)

As he deplored the effects of “the desire of gain” among Galenist physicians, so van Helmont warned against any shift to new “Chymical Medicines adulterated by the covetous.” But the preparation of chemical compounds and production of synthetic drugs were soon commercialized and, as always, found a ready market among the culturally elite. In 1664, Margaret Cavendish (1623–1673), then the marchioness of Newcastle, gave her opinion on the proper role of the marketplace in medicine. She offered the perspective of an educated aristocratic patient, with an interest in the theory and practice of medicine. She also had access to state-of-the-art therapies and treatments, and was attended by some of the best physicians in Europe, whose services were paid for by her husband’s creditors when the exiled couple lived abroad.

... as I respect the Art of Physick, as a singular Gift from God to Mankind, so I respect and esteem also learned and skilful Physicians, for their various Knowledg, industrious Studies, careful Practice, and great Experiences, and think every one is bound to do the like, they being the onely supporters and restorers of humane life and health ... therefore those Persons that are sick, do wisely to send for a Physician; for Art, although it is but a particular Creature, and the handmaid of Nature, yet she [art] doth Nature oftentimes very good service; and so do Physicians often prolong their Patients lives. The like do Chirurgeons; for if those Persons that have been wounded, had been left to be cured onely by the Magnetick Medicine, I believe, numbers that are alive would have been dead, and numbers would die that are alive ... Concerning the Covetousness of Physicians, although sickness is chargeable, yet I think it is not Charitable to say [as does Van Helmont] or to think, that Physitians regard more their Profit, then their Patients health; for we might as well condemn Divines for taking their Tithes and Stipends, as Physicians for taking their Fees: but the holy Writ tells us, that a Labourer is Worthy of his hire or reward; and, for my part, I think those commit a great sin, which repine at giving Rewards in any kind; for those that deserve well by their endeavours, ought to have their rewards; and such Meritorious Persons, I wish with all my Soul, may prosper and thrive. Nevertheless, as for those persons, which for want of means are not able to reward their Physicians, I think Physicians will not deal so unconscionably, as to neglect their health and lives for want of their Fees, but expect the reward from God, and be recompenced the better by those that have Wealth enough to spare.

(Margaret Cavendish, duchess of Newcastle, Philosophical Letters: or, Modest Reflections upon Some Opinions in Natural Philosophy, Maintained by Several Famous and Learned Authors of this Age, Expressed by Way of Letters, 1664, 354–5)

Responding to obvious health disparities in a class-based society, and critics’ doubts concerning the efficacy of clinical practice, Cavendish pointed to the fallibility of common-sense observation (here probably influenced by William Petty’s new “political arithmetic”), and to the need for preventative as well as curative medicine:

But you may say, Country-people and Labourers, take little or no Physick, and yet grow most commonly old, whereas on the contrary, Great and rich Persons take much Physick, and do not live so long as the common sort of men doth. I answer: It is to be observed, first, that there are more Commons, then Nobles, or Great and rich persons; and there is not so much notice taken of the death of a mean, as of a noble, great, or rich person; so that for want of information or knowledg, one may easily be deceived in the number of each sort of persons. Next, the Vulgar sort use laborious exercises, and spare diet; when as noble and rich persons are most commonly lazie and luxurious, which breeds superfluities of humors, and these again breed many distempers ....

(Margaret Cavendish, Philosophical Letters: or, Modest Reflections upon Some Opinions in Natural Philosophy, Maintained by Several Famous and Learned Authors of this Age, Expressed by Way of Letters, 1664, 376–7)

The then Lady Marchioness of Newcastle was very much an activist patient, with her own ideas about how to reform and improve on clinical practice, much of which she published in her scientific works. She was certainly not shy about demanding different or alternative treatments from the British physicians-in-exile who attended her, and related one such encounter as evidence for her argument against “that famous Philosopher and Chymist, Van Helmont” concerning whether drinks ought to be forbidden to those in a feverish state (in Cavendish’s opinion, “the best way is to drink little and often”):

[W]hen I was once sick beyond the Seas, I sent for a Doctor of Physick who was an Irish-man: and hearing of some that knew him, and his practice, that he was not successful in his Cures, but that his Patients most commonly died, I asked him what he used to prescribe in such or such diseases? where amongst the rest, as I remember, he told me, That he allowed his Patients to drink Wine in a Fever. I thought he was in a great error, and told him my opinion, that though Wine might be profitable, perhaps, to some few, yet for the most part it was very hurtful and destructive, alledging another famous Physician in France, Dr. Davison, who used in continual Fevers, to prescribe onely cooling Ptisan, made of a little Barley, and a great quantity of Water, so thin as the Barley was hardly perceived, and a spoonfull of syrup of Limmon put into a quart of the said Ptisan; but in case of a Flux, he ordered some few seeds of Pomegranats to be put into it, and this cold Ptisan was to be the Patients onely drink: Besides, once in Twenty four hours he prescribed a couple of potched Eggs, with a little Verjuice, and to let the Patient blood, if he was dry and hot; I mean dry exteriously, as from sweat; and that either often or seldom, according as occasion was found: Also he prescribed two grains of Laudanum every night, but neither to give the Patient meat nor drink two hours before and after: Which advice and Practice of the mentioned Physician concerning Fevers, with several others, I declared to this Irish Doctor, and he observing this rule, cured many, and so recovered his lost esteem and repute.

(Margaret Cavendish, Philosophical Letters: or, Modest Reflections upon Some Opinions in Natural Philosophy, Maintained by Several Famous and Learned Authors of this Age, Expressed by Way of Letters, 1664, 385–6)

Were she alive today, Margaret Cavendish would no doubt be demanding the latest and best of whatever proven therapies medical science had to offer, although she would probably not be asking the non-noble public to subsidize her utilization of these.

Of course, were she alive today, Margaret Cavendish would be living under the British system of “socialized medicine,” of which she would most likely approve.

As a monarchist and vested member of a class society, the duchess of Newcastle (cr. 1665) was wedded to the aristocratic concept of noblesse oblige, which for centuries undergirded the symbiotic relationship between peasant and lord. According to this feudal tradition, the great lords at the top of the socioeconomic hierarchy had a responsibility to those at the bottom, and if enough noblemen shirked this responsibility, the whole class system was in peril.

To Cavendish’s mind, patronizing those below her in the social order promoted the magnificence and the grandeur of nobility. As the economic engine for the aristocracy, the peasantry must not be alienated; it was imperative that laborers continue to see their class interests as inseparable from those of the landed élites. Universal access to health care was part of this bargain, as Cavendish noted when the character named Ambition in her play, Wits Cabal, day-dreams out loud, fantasizing about what she would do with absolute power:

O that I might enjoy those pleasures which Poets fancy, living in such delight as nature never knew ... and that I might be praised by all mankind, yet not vulgarly, as in a croud of others praises, but my praises to be singularly inthron’d above the rest ... Also I wish that Nature had made me such a Beauty, as might have drawn the Eyes of the whole World as a Loadstone to gaze at it ... then would I have had Nature, Fortune, and the Fates, to have given me a free power of the whole World, and all that is therein, that I might have prest and squeezed ou[t] the healing Balsomes, and sovereign Juices, and restoring Simples into every sick wounded and decayed body, and every disquieted or distemper’d mind: Likewise, that I might have been able to have relieved those that were poor and necessitous, with the hidden riches therein, and that by my power I might not only have obliged every particular creature and person, according to their worth and merit, but to have made so firm a peace amongst mankinde, as never to be dissolved.

(Margaret Cavendish, Playes Written by the Thrice Noble, Illustrious and Excellent Princess, the Lady Marchioness of Newcastle, 1662, 260)

Cavendish was in her late 30s when she wrote this, having lived through a civil war that toppled a king (Charles I was executed on 30 January 1649) and ushered in a republican regime which later succumbed to factionalism within the military and Parliament, resulting in a restored Stuart monarchy in 1660. To old-school Cavaliers like William Cavendish, Margaret’s husband, the continuing threat of revolution and a growing sense of grievance among the people rendered even more urgent the need for social contracts like the doctrine of noblesse oblige. But the changing political world had little interest in the great and splendid nobleman ideal of a bygone era. There was simply no role for Newcastle’s old-fashioned exercise of princely magnificence in the new power centers which emerged from the political settlement of 1660.

The Early-Modern Welfare State

Of note, both Margaret and William Cavendish were mercantilists, who believed in governmental control of commerce and the economy as the best means by which to enrich a country and its people. William, in particular, contributed to 17th-century debates over mercantilist domestic policy, eventually writing a prince’s handbook (speculum principis) in which he advised the future king of Great Britain, Charles II (1630–1685; r. 1660–1685), to pursue policies that would stimulate production over consumption, “for one doth Inrich the kingdoume the other doth Impoverish Itt.” (For proof of this core mercantilist principle, Newcastle pointed to members of the clergy and lawyers, who are “good for nothinge butt Bread Eaters bringes no honye to the Hive off the Com[m]on wealth like laborius Bees, Tradsmen, farmers, or soldiers butt devoers the Honye off the Com[m]on wealth like Hornitts or waspes, bringes nothinge In time off Peace to the Com[m]on wealth, & will nott defende Itt In time off warr.”)

Arguing that “Itt Is Imposible for anye man to bee a good States-man thatt doth nott understande trade In some measure,” and drawing a memorable lesson for Charles in recalling “whatt fell oute In Queen Elizabethes Rayne” to prove this point, Newcastle counsels Charles at some length on consequential matters relating to

Newcastle concludes his prince’s handbook’s section on trade with a plea that the Caroline government subsidize the development of new British industries (such as the production of silk and of linen):

I shoulde humblye advise that your Matie woulde bee pleased to Increase manufacture all thatt posible coulde bee all over your kingdome as makinge all severall man[n]er off Stuffes as the Duch-men doe att Norwhich,—so silke stuffes Cloth off Golde, & Silver, as theye doe att Genoa, & Millan, Silke wormes Itt maye bee will finde Englande to Colde for them, but Itt weare well Itt shoulde bee tried, & mulberye trees sett for their foode butt iff this fayle Rawe silkes & to bee wraughte upp in Englande,—Makinge off Linen cloth, off all sorttes, as Hollandes demye Hollande Cambricks Lawne, & for which much fine flaxe Is to bee Soed,—so for all man[n]er off fine thred lases, as flanders famous for Itt,
     Butt some maye saye this will hinder Trade what hindringe off trade doth Itt in Flanders & Brabante,—& Is Itt nott as good to gett moneye for these Comodeties, as to give moneye for these Comodeties yes & much better sertenlye for one doth Inrich the kingdoume the other doth Impoverish Itt,—Butt Iff Itt weare for nothinge Else butt to sett your Subjectes a worke both male & female nott onlye to busie them, butt thatt by their labor theye mighte live, & manye growe Rich withoute beinge a burthen to the Com[m]on wealth,—which will bee a mightye advantage both for your Maties Govermente & for the Peace off the kingdome,—which otherwise by Povertye & Idlnes, mighte produce manye Inconvenienceies both to your Matie & your kingdome.

(William Cavendish, 1st duke of Newcastle, Letter to Charles II, a scribal publication written c.1650s)

In his own work in the tradition of the medieval Fürstenspiegel or “advice to a ruler,” entitled Della Ragion di Stato Libri Dieci [The Reason of State in Ten Books] (Venice, 1589), the Italian political philosopher and diplomat Giovanni Botero (c.1544–1617) also recommended that the state take an active role in promoting the manufacture and production of goods:

A prince, therefore, who wishes to make his cities populous must introduce every kind of industry and craft by attracting good workmen from other countries and providing them with accommodation and everything convenient for their craft, by encouraging new techniques and singular and rare works, and rewarding perfection and excellence. But above all he must not permit raw materials, wool, silk, timber, metals and so on, to leave his state, for with the materials will go the craftsmen. Trade in goods made from these materials will provide a livelihood for a far larger number of people than will the raw materials; and the export of the finished manufactured article will provide the ruler with greater revenues than will the material alone. Velvet, for example, will yield more than silk, cloth more than wool, linen cloth more than flax, ropes more than hemp. Some years ago the kings of France and England, and then the Catholic King, prohibited the export of raw wool from their kingdoms for this very reason. These ordinances could not, however, be rigidly observed at once because so much fine wool is produced in these kingdoms that there were insufficient workmen to make use of it all. Perhaps these princes took this step only because the revenue accruing to them from the traffic in woollen cloth is far greater than that from raw wool, but the effect is also to increase the population of their countries. For more people can live by wool that is woven than by wool in its crude state, and it is the numerical strength of a people which makes a land fertile and by labour and art gives a thousand different forms to the produce of nature, and hence power and wealth to their king.

(Giovanni Botero, The Reason of State [Della Ragion di Stato, 1589; rev. 1598], English trans. by P. J. and D. P. Waley, 1956, Bk. 8, Ch. 4, p. 153)

Government intervention in the economy, especially to produce and/or protect jobs, had been recommended for centuries. In his best-selling Della Ragion di Stato Libri Dieci (running to 10 editions in Italian, as well as 6 in Spanish, 4 in Latin, and 1 in French during the author’s lifetime), Giovanni Botero singled out Vespasian (Roman emperor from 69–79 AD) as an ideal ruler, giving several examples from Vespasian’s emperorship of the methods by which states should be governed and administered. Among these, Botero approved Vespasian’s prudence in warding off populist discontent by suppressing a new labor-saving technology that threatened to idle great numbers of the working poor:

But since not everyone can possess land or exercise a trade and there will always be others besides, the ruler should either himself provide the poor with some means of livelihood, or make others do so. Dionysius of Halicarnassus says that nothing is more dangerous to a prince than an idle populace. To this end Augustus Caesar caused many buildings to be erected and encouraged the leading citizens to do the same, to keep the poorer elements in tranquillity. When an engineer proposed to Vespasian a method for transporting large columns to the Capitol at little expense, the Emperor rewarded him and said that he was pleased with the invention but preferred to have some way of giving a livelihood to the populace; meaning to say that he was willing to spend money in order to give a means of living to many who would have been deprived of it by this ingenious discovery.

(Giovanni Botero, The Reason of State [Della Ragion di Stato, 1589; rev. 1598], English trans. by P. J. and D. P. Waley, 1956, Bk. 4, Ch. 7, p. 93)

Titus Flavius Vespasianus (9–79 AD), a distinguished general who came to power during the civil wars that followed the death of Nero, was widely acclaimed for restoring financial and military order. He also initiated a massive public works program, which included the rebuilding of the Capitol and the beginning of the construction of the Colosseum in the year 75.

“Descended but of a base stocke,” Vespasian rose to power based on merit (“in valiaunt prowes and knightly courage to be compared to the beste”) and was not afraid to pursue ignoble “avarice” to achieve his ends, which diminished his emperorship in the eyes of some. Vespasian’s habit of creatively taxing his subjects (most famously, his urine tax: “He ordeyned a tribute to be gathered on the quantitie of uryne made in every house.”) and extorting courtiers (“It is sayde he advaunced to high promotions divers in covetousnesse moste notable, to the ende that, when they had well gathered, he might use them as spunges, and by makynge some pretensed quarell against them, to wryng from them that whiche by extorcion they hadde gotten.”) drew criticism from contemporaries, but ensured a good flow of revenue for the state, which Vespasian was reputed to have managed with “honestie and wisedome.” (Thomas Cooper, Thesaurus Linguæ Romanæ & Britannicæ, 1st edn., 1565, sig. R3r)

Margaret Cavendish gave the following character of Vespasian:

... he was very greedy of Gain, to the height of Covetousness, and yet he was very Generous; for whatsoever he got, though ill, yet he bestowed it well: he was a very mercifull Prince, and very few Faults to be found in him. He sprung from a Family of no great growth.

(Margaret Cavendish, The Worlds Olio. Written by the Right Honorable, the Lady Margaret Newcastle, 1st edn., 1655, 129)

Whether one was a booster or a critic of technological advances during the early-modern period, social commentators generally condoned the suppression of another new technology (the Polish weaving machine) which threatened the social order with mass-scale unemployment (anticipating by two centuries the uprising of textile workers and weavers popularly known as Luddites):

In Dantzick in Poland there was set up a rare invention for weaving of 4 or five Webs at a time without any humane help; it was an Automaton or Engine that moved of it self and would work night and day: which invention was supprest, because it would prejudice the poor people of the Town; and the Artificer was made away secretly (as ’tis conceived) as Lancellotti the Italian Abbot relates out of the mouth of one Mr Muller a Polonian that had seen the device.

(Thomas Powell, Humane Industry: or, a History of Most Manual Arts ... Shewing Forth the Excellency of Humane Wit, 1660/1, 85)

Mercantilists on the political right (e.g., the 1st duke of Newcastle) and left (e.g., the Diggers leader, Gerrard Winstanley, and the Levellers leader, Richard Overton) alike advocated and pursued policies that they hoped would eradicate poverty from England, identifying a secure and prosperous state with the well-being of its people. To Newcastle, good paternalist government played an important role in guaranteeing a certain quality of life. In his Letter to Charles II advising on statecraft,

Newcastle stressed with Hobbesian shrewdness the necessity of authority and justice in both church and state, but he particularly emphasized popular amusements as essential to the people’s contentment. The poorer folk of London must have playhouses, he wrote, and spectacles, music and dancing, and “all the old holidays, with their mirth and rites set up again; feasting daily will be in merry England, for England is so plentiful of all provisions, that if we do not eat them, they will eat us, so we feast in our defence.” And the country folk, too, must be satisfied by the restoration of all their old pleasures: “May games, morris dances, the Lord of the May, the Lady of the May, the Fool and the Hobby Horse must not be forgotten; also the Whitsun Lord and Lady; thrashing of hens at Shrovetide; carols and wassails at Christmas, with good plum porridge and pies, which now are forbidden as prophane ungodly things ... after evening prayer every Sunday and holiday, the country people, with their fresher lasses, to trip on the town green about the maypole to the louder bagpipe, there to be refreshed with their ale and cakes.... Then there should be players to go up and down the country.”

(Douglas Grant, Margaret the First: A Biography of Margaret Cavendish, Duchess of Newcastle, 1623–1673, 1957, 149–50)

Machiavellian and/or moral arguments for judiciously managing the poor featured in the policy and counsel of princes for centuries. Botero, for example, advised the autocratic ruler to “secure himself against” malcontents among the poor “either by driving them out of his state or by giving them an interest in its internal peace.” Colonies and the military served as the favorite dumping grounds for trouble-makers, while an “interest in the state can be secured,” notes Botero, “by compelling them to undertake some work, such as agriculture or any trade which will give them a sufficient income to live on.” His models for this approach are the Egyptians under Amasis, the Areopagites, the Alexandrians, and the Chinese (Botero asserts that under Chinese law, “The lazy and the workless are not tolerated, and even the blind and crippled do such work as they are capable of; only the completely disabled are admitted to hospitals.” and that “King Wu Ti who gave to China much of that discipline by which that country is now maintained wished women either to follow their father in his craft or keep themselves busy with distaff and needle.”). With remarkable prescience, Botero warns that those who are downwardly mobile pose the greatest threat of all to the status quo: “Those who are most ready to do evil are poor men who have been rich, and extreme poverty is as dangerous in a man of reputation and authority as extreme wealth.” (G. Botero, The Reason of State [Della Ragion di Stato, 1589; rev. 1598], English trans. by P. J. and D. P. Waley, 1956, Bk. 4, Ch. 7, p. 91)

To ensure the well-being of the masses, Botero recommended “profitable expenditure” by the state on “works of charity and munificence” (The Reason of State, Bk. 7, Ch. 2, p. 132). Botero was an early tax-and-spend conservative, who believed that “a prince who spends much will gain much because he gains by what he spends” on behalf of the public good (The Reason of State, Bk. 7, Ch. 10, p. 143 and Ch. 8, p. 139). To this end, the rich should bear the bulk of the tax burden:

... it is reasonable that the wealth of individuals should serve the public good, which cannot be maintained without it. These taxes, however, must not be personal but real, that is, not paid per head but according to property owned; otherwise the whole burden of taxation will fall upon the poor, which is the usual case: the nobles pass it on to the populace, the large towns to the countryside.

(Giovanni Botero, The Reason of State [Della Ragion di Stato, 1589; rev. 1598], English trans. by P. J. and D. P. Waley, 1956, Bk. 7, Ch. 4, p. 136)

and the regime should invest heavily in “public works” (e.g., infrastructure) which employ those who are otherwise a drag on the state — slaves captured in war, prisoners condemned to death, vagabonds, soldiers idled during peacetime, and the disabled,

... whom it is better to employ to some public good than to let them go begging. In China, an extremely well-administered country, begging is forbidden; everyone is engaged according to his ability: the blind, if they have no other means of livelihood, turn handmills, the maimed perform some similar task within their power, and only those who are completely helpless are admitted to the public hospitals.

(Giovanni Botero, The Reason of State [Della Ragion di Stato, 1589; rev. 1598], English trans. by P. J. and D. P. Waley, 1956, Bk. 8, Ch. 2, p. 150)

Conversely, “Unprofitable expenditure is that made without benefit to the public good, which serves no useful purpose, bringing no security to the state nor greatness or prestige to the king: and because there is no end to vanity, the instances of unprofitable expenditure are infinite.” (The Reason of State, Bk. 7, Ch. 8, p. 139) Botero did not approve of plundering the public sector for private profit, recommending instead a strategic use of “liberality” (dispensation of state resources, in moderation, to deserving “persons of merit”). For example,

Excellent and skilled craftsmen of every sort are a source of pleasure to others, so that the ruler by patronising them may easily make himself loved and esteemed by all. Charlemagne was such a ruler. Apart from his respect for religion and his constant patronage of letters he was immensely liberal in giving to the poor, and there is no more pleasant and successful way than this of winning gratitude and affection, nor one that is more generally honoured and praised....

(Giovanni Botero, The Reason of State [Della Ragion di Stato, 1589; rev. 1598], English trans. by P. J. and D. P. Waley, 1956, Bk. 5, Ch. 1, p. 96)

But all who have need, in principle, should be provided for by the state:

It is not sufficient, therefore, for a prince to encourage marriages and fertility if he does not also assist the rearing and upkeep of the young, by charity towards the poor and by helping the needy and those who have not the means to marry their daughters or instruct their sons or to support themselves and their families. He should provide employment for those who are able to work and means of subsistence for those who are not. The Emperor Alexander Severus performed charitable works of this kind with devotion, and the boys and girls of poor families whom he brought up at his own expense were called Mamei and Mameae after the name of his own mother, Mamaea. Constantine the Great was the first to institute hospitals for the sick and for the aged, and Julian the Apostate reproached the priests of idolatry with the humanity of the Christian priests who founded hospitals for the poor.

(Giovanni Botero, The Reason of State [Della Ragion di Stato, 1589; rev. 1598], English trans. by P. J. and D. P. Waley, 1956, Bk. 8, Ch. 4, p. 156)

Both Margaret and William Cavendish idealized the monarchical state as the protector and enabler of markets and people, which is why I believe they would have supported some form of socialized medicine, had they been able to envision state action beyond the private patronage of the great — the almshouses, hospitals, and schools founded by royals (e.g., the royal hospital for disabled soldiers, commonly called Chelsea College, which was founded by Charles II, carried on by James II, and finished by William & Mary; and the home for naval heroes and retired seamen known as the Royal Naval Hospital, Greenwich, designed by Sir Christopher Wren for William III and Mary II; and Christ’s Hospital, converted by Edward VI from a Grey Friars monastery “to an Hospital for poor Children, who are supply’d with all Necessaries and Conveniencies, cloath’d, dieted, and taught”) and by wealthy nobles (e.g., Lady Anne Clifford [1590–1676], countess of Pembroke, Dorset, and Montgomery, with an annual income of about £8000, “completed the building and endowing of her mother’s Beamsley almshouses near Skipton” and “between 1651 and 1653 she erected almshouses in Appleby, St Anne’s Hospital, initially a retirement home for her women attendants”).

By the end of the 18th century, the first duke and duchess of Newcastle’s advocacy on behalf of prudent government intervention in the economy had been eclipsed by renewed notions of a privatized noblesse oblige, such as later dominated at the court of Queen Victoria:

All government business passed across Victoria’s and Albert’s desks; Albert’s conscientiousness ensured that it all received due attention. Victoria involved herself wholeheartedly less often. The issues which caught her attention and seemed to her to be of paramount importance fell broadly into two categories: matters concerning British security and prestige, and matters concerning royal authority, prestige, and security. In the substantive domestic debates of the 1840s—over the corn laws, the effects of industrialization, the implications of organized working-class radicalism—she expressed little interest. Neither Lord Ashley’s Ten Hours Act (which reduced working hours for women and children in factories) nor the agitations of the Chartists could expect sympathy from the queen. It was not that Victoria lacked compassion. She believed profoundly in the obligations of the rich towards the poor, and dispensed large sums in personal charity: between 1837 and 1871 she gave £8160 (nearly 15 per cent of her privy purse) annually to charities ... and the figure rose thereafter. But like most of the upper classes, she regarded charity as an individual, religious duty, not a matter for government or collective action, which could damage trade and industry. She used her position to encourage others to be charitable, and became patron of some 150 institutions. She periodically issued orders that ladies appearing at court should wear gowns of British manufacture, to support native industry, while the bal costumé of 12 May 1842 (at which the queen and prince appeared as King Edward III and Queen Philippa) was intended to provide work for the unemployed Spitalfields silk weavers. A regularly repeated calumny, that Victoria gave only £5 to the many appeals on behalf of the starving Irish during the famine years, is belied by the evidence: she headed one subscription list with a donation of £2000, made contributions to other projects brought to her attention by her ladies-in-waiting, and attended a charity performance at the opera as well as other fund-raising events. But her sympathy with the sufferings of the Irish peasantry waned rapidly when they turned to political action to improve their lot, threatening the security of her realm. The agitation in Ireland and the murders of landlords in 1847–8, coinciding with the year of revolutions on the continent, filled Victoria with foreboding for the safety of her throne; the Chartists’ Kennington Common meeting of 10 April 1848, though ultimately a damp squib, sent the royal family scurrying from London to the safety of the Isle of Wight.

(H. C. G. Matthew and K. D. Reynolds, “Victoria (1819–1901), queen of the United Kingdom of Great Britain and Ireland, and empress of India,” Oxford Dictionary of National Biography, online edn., May 2012, n. pag.)

The centuries-old Anglo-Saxon debate over the virtues of mercantilism versus laissez-faire principles that government should not interfere with the action of individuals continues into the 21st century, recently brought to the fore in the U.S. by the election in November 2016 of real-estate magnate and entrepreneur, Donald Trump, who promised during his presidential campaign to promote exports, restrict imports, bolster fair trade, provide millions of good-paying jobs, rid the government of corruption and inefficiency, roll back taxes and government regulation, “create a better health care system for all Americans,” and boost Middle America’s prosperity and well-being. Within this avowed entrepreneurial political context, the first duke of Newcastle’s speculum principis, written during the 1650s, is surprisingly instructive.

Who knew that 17th-century dynastic politics would be so relevant to a Trump-style revival of “American exceptionalism” in 2017?

There are lessons here even for President Trump’s disruptive postmodern administration — with its postmodernist embrace of deconstruction, “alternative facts” and falsified truths — and for all of us within its reach, struggling to navigate our own postmodern moment.

Changing our choices

As we in the post-industrial world begin to renegotiate our own social contracts, there is much we can learn from this earlier “age of scientific revolution” — an era of religious and political polarization, with such a rapid rate of technological advance that political, social, and cultural institutions had great difficulty adapting to all the changes underway.

In the United States, we are engaged in a vigorous debate over whether or not we can afford the social contract we have with society’s most vulnerable constituencies: the poor, the sick, the differently abled, the elderly, the very young. Our affordability problem is greatly exacerbated by health care costs that are rising at an alarming (and unsustainable) rate, as documented in March 2012 by Los Angeles Times columnist Steve Lopez, who exclaimed:

This is the kind of insanity that exists when medicine and medical insurance are about private profit rather than public health, when 50 million people are uninsured, when Medicare and Medicaid reimbursements don’t always cover true costs and when polarized politics prevent the kind of reasonable discussions that could lead to solutions.

(S. Lopez, “The Bizarre Calculus of Emergency Room Charges,” Los Angeles Times, 1 April 2012, p. A2)

One such solution — a single-payer system, such as that recommended by Jerome P. Helman, M.D. in his Letter to the Editor of the Los Angeles Times:

What we need is improved Medicare with cost controls, and for everyone.

(Jerome P. Helman, M.D., “Letters to the Editor: Pricey Healthcare — It Isn’t Your Fault, posted 3 April 2013)

— has drawn the most acrimony, causing some to look elsewhere for more palatable solutions. And Steven Brill did just that, expostulating in his cover story for Time magazine that

The real issue isn’t whether we have a single payer or multiple payers. It’s whether whoever pays has a fair chance in a fair market. Congress has given Medicare that power when it comes to dealing with hospitals and doctors, and we have seen how that works to drive down the prices Medicare pays, just as we’ve seen what happens when Congress handcuffs Medicare when it comes to evaluating and buying drugs, medical devices and equipment. Stripping away what is now the sellers’ overwhelming leverage in dealing with Medicare in those areas and with private payers in all aspects of the market would inject fairness into the market. We don’t have to scrap our system and aren’t likely to. But we can reduce the $750 billion that we overspend on health care in the U.S. in part by acknowledging what other countries have: because the health care market deals in a life-or-death product, it cannot be left to its own devices.
     Put simply, the bills tell us that this is not about interfering in a free market. It’s about facing the reality that our largest consumer product by far — one-fifth of our economy — does not operate in a free market.

(S. Brill, “Bitter Pill: Why Medical Bills Are Killing Us,” accessed at Time magazine website, 26 February 2013)

Brill concluded his cover story with a section entitled “Changing Our Choices,” and gave the following action list:

We should tighten antitrust laws related to hospitals to keep them from becoming so dominant in a region that insurance companies are helpless in negotiating prices with them....
     Similarly, we should tax hospital profits at 75% and have a tax surcharge on all nondoctor hospital salaries that exceed, say, $750,000. Why are high profits at hospitals regarded as a given that we have to work around? Why shouldn’t those who are profiting the most from a market whose costs are victimizing everyone else chip in to help? If we recouped 75% of all hospital profits (from nonprofit as well as for-profit institutions), that would save over $80 billion a year before counting what we would save on tests that hospitals might not perform if their profit incentives were shaved....
     We should outlaw the chargemaster.... [F]or patients, the chargemasters are both the real and the metaphoric essence of the broken market. They are anything but irrelevant. They’re the source of the poison coursing through the health care ecosystem.
     We should amend patent laws so that makers of wonder drugs would be limited in how they can exploit the monopoly our patent laws give them. Or we could simply set price limits or profit-margin caps on these drugs. Why are the drug profit margins treated as another given that we have to work around to get out of the $750 billion annual overspend, rather than a problem to be solved? ...
     Similarly, we should tighten what Medicare pays for CT or MRI tests a lot more and even cap what insurance companies can pay for them. This is a huge contributor to our massive overspending on outpatient costs. And we should cap profits on lab tests done in-house by hospitals or doctors.
     Finally, we should embarrass Democrats into stopping their fight against medical-malpractice reform and instead provide safe-harbor defenses for doctors so they don’t have to order a CT scan whenever, as one hospital administrator put it, someone in the emergency room says the word head....
     Other options are more tongue in cheek, though they illustrate the absurdity of the hole we have fallen into. We could limit administrator salaries at hospitals to five or six times what the lowest-paid licensed physician gets for caring for patients there....
     Or we could require drug companies to include a prominent, plain-English notice of the gross profit margin on the packaging of each drug, as well as the salary of the parent company’s CEO. The same would have to be posted on the company’s website. If nothing else, it would be a good test of embarrassment thresholds.
     None of these suggestions will come as a revelation to the policy experts who put together Obamacare or to those before them who pushed health care reform for decades. They know what the core problem is — lopsided pricing and outsize profits in a market that doesn’t work. Yet there is little in Obamacare that addresses that core issue or jeopardizes the paydays of those thriving in that marketplace. In fact, by bringing so many new customers into that market by mandating that they get health insurance and then providing taxpayer support to pay their insurance premiums, Obamacare enriches them. That, of course, is why the bill was able to get through Congress.
     Obamacare does some good work around the edges of the core problem. It restricts abusive hospital-bill collecting. It forces insurers to provide explanations of their policies in plain English. It requires a more rigorous appeal process conducted by independent entities when insurance coverage is denied. These are all positive changes, as is putting the insurance umbrella over tens of millions more Americans — a historic breakthrough. But none of it is a path to bending the health care cost curve....
     Put simply, with Obamacare we’ve changed the rules related to who pays for what, but we haven’t done much to change the prices we pay.
     When you follow the money, you see the choices we’ve made, knowingly or unknowingly.
     Over the past few decades, we’ve enriched the labs, drug companies, medical device makers, hospital administrators and purveyors of CT scans, MRIs, canes and wheelchairs. Meanwhile, we’ve squeezed the doctors who don’t own their own clinics, don’t work as drug or device consultants or don’t otherwise game a system that is so gameable. And of course, we’ve squeezed everyone outside the system who gets stuck with the bills.
     We’ve created a secure, prosperous island in an economy that is suffering under the weight of the riches those on the island extract.
     And we’ve allowed those on the island and their lobbyists and allies to control the debate, diverting us from what Gerard Anderson, a health care economist at the Johns Hopkins Bloomberg School of Public Health, says is the obvious and only issue: “All the prices are too damn high.”

(S. Brill, “Bitter Pill: Why Medical Bills Are Killing Us,” accessed at Time magazine website, 26 February 2013)

So much for the problems plaguing health care’s “real economy.” But what’s possible if we choose to tap into society’s hidden wealth in what David Halpern calls the complementary “economy of regard” (an economy of reciprocal and caring relationships)?

Halpern is a UK policy wonk, and a former Chief Analyst for the UK’s Prime Minister’s Strategy Unit (PMSU), where he worked “on almost every area of domestic policy” including “life satisfaction, social capital, public service improvement, personal responsibility and behaviour change.” Concerned with promoting economic growth and well-being, he recommends creating state-sponsored, complementary currencies that can be used to support care of the elderly and infirm, “rather like the Japanese system of Fueai kippu, or the US Elderplan system,” and he points to Bali’s centuries-old dual currency, which pairs conventional cash with a complementary currency of “Narayan banjar” (work for the common good of the community), as an even more impressive model.

A recurrent theme of these complementary currency systems is that the interactions they stimulate are experienced as qualitatively different from those within the real economy. They seem to be powered by, and reinforce, a different motivation. Apart from the regard that undertaking such acts brings in the eye of the receiver or community, acts are undertaken with an unknown and uncertain distant reward — they are primarily motivated by care for others and a sense of connection to the community.
     Why not just volunteer? It is estimated that, on average, around a third of people who engage in such schemes in Western countries have never volunteered before. There seem to be several reasons why such currencies stimulate extra activity above volunteering, not least being that people seem to value the reciprocity or gift exchange built into complementary currencies. We seem to be hard-wired not just to be good Samaritans, but to be reciprocators. Researchers have found that volunteering seems to boost well-being, but these positive feelings soon evaporate if volunteers just feel they are being “used”. There seems to be a hormonal system that lies behind this effect linked to oxytocin — sometimes known as the “trust and lust” hormone because of the role it plays in reinforcing our positive feelings in relationships. Studies have shown that this “feel-good” hormone is released in our brains when we do a good deed for another person, but it is actually triggered when that other person acknowledges or reciprocates the good deed.
     This seems to be evolution’s neat way of achieving the great advantages of cooperation, but without turning us into dupes. Complementary currencies resonate and amplify this mechanism, and can also help solve the informational problems about keeping track of who has been a “good citizen” over long periods of time.

(David Halpern, The Hidden Wealth of Nations, 2010, 108)

Halpern’s Chapter 3, “The Politics of Virtue,” closes with a provocative reflection on what health care might look like in a different kind of state with a dual currency:

Viewing the world through the lens of the economy of regard has deep implications, and I cannot claim to know them all. Does it mean a bigger role for local and neighbourhood governance? What does it mean for regulators, and what they do? What does it mean for the nature of our economy itself, how we measure what it is we produce and the implicit incentives built into our “real” currencies and market institutions?
     At the very least I think it means shifting policies in the direction promoting virtue rather than squeezing vice. We are now moving into the realm of speculation, but to cut back to the topic of well-being in Chapter 1, it feels like happier nations are better at this balancing act. Their instinct is to see the best in a troubled youth, not just the problem. Their natural public campaigns are about opportunities for betterment and mutual service, not stamping out knife crime or anti-social behaviour (and the inadvertent reinforcement of the problematic “declarative norm” that this brings).
     Let’s end this chapter with a final example that spans my personal and policy life. In the UK we have massively increased our spending on the health service, from a little over 5% of GDP to nearly 10% in the space of about 10 years. Clearly, part of what we want to achieve is a health service with better health outcomes, and preferably with a reasonable degree of efficiency so that it doesn’t swallow our entire economy. But the health service we want for our children and our grandchildren is surely more than an efficient machine. It’s about treating each other with respect, dignity and compassion — a way of building the hidden wealth of our society. In that sense, it is not something that we can just leave to some doctors in white coats — it is something that we all need to be a part of.
     I have a younger son, now [Halpern’s book was published by Polity in 2010] ten, who needed a tracheotomy for the first four years of his life. This involved a lot of contact with the health professionals — most of it fantastic, some of it terrible — and lots of carrying around pumps and equipment, sleepless nights of care, and periodic crises just like a scene from ER. As he grew older, and fortunately no longer needed his artificial airway, my wife and I offered via the health professional we had dealt with, to help any other family or parents who had a child with a tracheotomy — such as if they wanted to talk about it or just wanted someone else to look after their child so they could take an evening off. Of course, we were never asked. Maybe no one had the need, though I doubt it. More likely, our health service with its professionalism and worry about litigation doesn’t really know what to do with such offers, and perhaps other parents would hesitate to ask. But it is not so difficult to imagine a future in which our institutions, our markets and our habits have more room for a different kind of exchange. It must be possible to combine our drive, as policymakers and citizens, for efficient and effective public and private institutions with our human desire for affiliation and care.

(David Halpern, The Hidden Wealth of Nations, 2010, 122–3)

The experiment with dual currencies has already caught on in pockets of the United States, as reported by David Bollier in his 2017 article for The Nation wherein he documents the “bricolage of projects and movements” for social change he has labeled the “commons sector” — “a world of DIY experimentation and open-source ethics that holds itself together not through coercion or profiteering but through social collaboration, resourceful creativity, and sweat equity, often with the help of digital platforms. Its fruits can be seen in cooperatives, locally rooted food systems, alternative currencies, community land trusts, and much else.” (D. Bollier, 17)

Another impressive innovation in regional self-determination is the BerkShares currency, launched in 2006 by the Schumacher Center for a New Economics (where I work) in the largely rural Berkshires of western Massachusetts. The goal is to strengthen the local economy and community life by reengineering the flow of money. Anyone can exchange $100 in US currency for $105 worth of BerkShares at any of four banks with a total of 16 branches throughout Berkshire County, and then spend them at 400 participating businesses. Consumers get a 5 percent bump in purchasing power from this buy-local strategy while boosting the regional economy and strengthening the region’s identity. The BerkShares story is part of a global trend in which dozens of localities worldwide are deploying their own currencies to reclaim some measure of control from hedge funds and banks.

(David Bollier, “To Find Alternatives to Capitalism, Think Small: Why co-ops, regional currencies, and hackerspaces are pointing the way toward a new economic vision,” The Nation, 305.5 [28 Aug./4 Sept. 2017]: 18)

Bollier does not apply alternative currencies to health care, but it is not difficult to see how “service-swapping platforms like TimeBanks, which uses a currency of hours contributed to helping people meet needs and build circles of mutual support” (D. Bollier, 18–19) has real potential.

Phronesis (practical wisdom)

Making wiser choices was also the theme of Daniel J. Stone’s op-ed for the Los Angeles Times in which he proposed two solutions for “Our Big Appetite for Health Care”: Accountable Care Organizations and

a new national project called Choosing Wisely. A joint initiative of Consumer Reports and the American Board of Internal Medicine, the program is aimed at encouraging both physicians and patients to carefully consider the wisdom of medical procedures. The program asks each of 25 medical sub-specialty societies to identify five commonly used tests or procedures that both patients and their doctors should question. When such procedures and tests are done without need, they are not just a waste of money; in some cases they may subject patients to additional risk without the potential to improve their health.

(D. J. Stone, “Our Big Appetite for Health Care,” Los Angeles Times, 31 March 2013, p. A22)

I have long been an advocate myself for a more robust exercise of “practical wisdom” in all aspects of our lives and work, but as Helman points out in his letter to the editor responding to Stone’s op-ed, Choosing Wisely “appears to be an altruistic approach to cost control” and is “doomed unless cost control is mandated from the top.”

This concession to realpolitik doesn’t mean that a virtue-based ethic for medicine, the health professions, and health care isn’t worth pursuing though.

Significant movement in this direction has already been made by Barry Schwartz and Kenneth Sharpe, who have revived the Aristotelian virtue of phronesis (practical wisdom) and documented its implementation within the modern health care industry in Practical Wisdom (New York: Riverhead Books, 2010). Schwartz has also explained the concept and its application in two accessible TED (Technology, Entertainment, Design) talks:

pointer  Schwartz’s 2009 TED conference talk: “Barry Schwartz on our loss of wisdom” (20:45 mins.; filmed and posted in Feb. 2009)

pointer  a follow-on TED talk in 2010: “Barry Schwartz: Using our practical wisdom” (23:23 mins.; filmed Nov. 2010; posted Dec. 2010)

This second talk includes the Aristotelian definition of “practical wisdom” as “the moral will to do the right thing, and the moral skill to figure out what the right thing is.”

Long before this, Edmund D. Pellegrino launched a renaissance in the philosophy of medicine by recasting phronesis as “medicine’s indispensable virtue,” as was historically the case. In the Western Classical-Medieval Conception of virtue, explains Pellegrino,

Phronesis fuses the intellectual virtues, which have truth as their end — e.g., science, art, intuitive wisdom — with the moral virtues, which have the good as their end.

(The Philosophy of Medicine Reborn: A Pellegrino Reader, ed. H. Tristram Engelhardt Jr. and Fabrice Jotterand, 2008, 259)

This reorientation “promises a deeper understanding of medicine, as well as an opportunity for recapturing a moral sense of medical-professional identity.” (Introduction, The Philosophy of Medicine Reborn: A Pellegrino Reader, ed. Engelhardt and Jotterand, 2008, 17) And, as early medical reformers such as van Helmont and Whitlock well knew, it has major implications for clinical practice and health care costs.

For millennia, human beings around the world have sought wisdom, and wanted to make wise choices. This seems to be a universal human quest. But in health care, as in all else, wisdom must become an aim of practice and policy before it can become a habit. Pellegrino explains:

Thus, for Aristotle, the teleological orientation of virtue is twofold — the fulfillment of the natural end of human life, namely happiness, and also the attainment of the end of human work. Aristotle links being a good person with doing well whatever one does and with achieving, to the greatest extent possible, the end of any human activity, whether it be the conduct of the whole of one’s life or the conduct of a particular work related to the role or roles one plays in everyday life.
     On this view, virtue is a character trait under rational control. Virtue is not a “habit” in the sense of being an unconscious reflex. Rather it is a habitus, a predictable disposition to choose the good whenever confronted with a choice (Nicomachean Ethics 1105a27-33). A virtuous person has knowledge of the good and chooses it for its own sake and from a firm character with regard to the passions (Nicomachean Ethics 1105b2i-23). The virtuous person must not only know the good but be good (Nicomachean Ethics 1102b26, 1144b18). In contrast to Plato and Socrates, Aristotle takes account of emotion more clearly, but defines the virtuous person as one whose emotions are ordered by reason to the end of happiness.
     Virtue is also practical in its orientation. For this reason, Aristotle’s central virtue is phronesis or practical wisdom. Moral agents must consider what is appropriate to the occasion: “Virtue determines the end; practical wisdom makes us do what is conducive to the end” (Nicomachean Ethics 1145a5-6). Thus, phronesis is the virtue that enables one to deliberate well in making moral judgments and to choose the means most suited to the end of the activity in which one is engaged. Practical wisdom is a “... true and reasoned capacity to act with regard to the things that are good or bad for men” (Nicomachean Ethics 1140b5). Phronesis fuses the intellectual virtues, which have truth as their end — e.g., science, art, intuitive wisdom — with the moral virtues, which have the good as their end. The good person is the phronimos, the person of practical wisdom; the virtuous act is the act as it would be chosen by the phronimos.

(The Philosophy of Medicine Reborn: A Pellegrino Reader, ed. H. Tristram Engelhardt Jr. and Fabrice Jotterand, 2008, 258–9)

Presently, our political and economic problems are so complicated and intractable that it seems impossible for a single person or small group of individuals — lacking the nobleman’s princely magnificence and resources — to make a difference.

But a personal and public pursuit of wisdom levels the playing field a little, creating new transgressive opportunities for all.

Each time one of us acts wisely, there is hope.

Media coverage of related issues

N  O  T  E

As of February 2014, I stopped maintaining the list of annotated links on this Roses Web page. Learn why here.
   As of March 2017, I am resuming work on this project. Following the election of Donald Trump in November 2016, Congressional Republicans are once again hell-bent on repealing the Affordable Care Act (Obamacare), and replacing it with the GOP bill known as the American Health Care Act (Trumpcare). Responding to the uncertainty surrounding Trump’s promise to repeal Obamacare, California has launched trial-balloon “legislation that would establish a comprehensive universal single-payer healthcare coverage program and a healthcare cost control system for the benefit of all residents of the state.” We have hence moved beyond 7 years of political posturing to enacting actual legislation that could affect the health & well-being of the entire U.S. population. The stakes are high, and so is public passion about legislative reforms underway at federal and state levels.
   The contentious politics of health care reform are a product of the struggle over values, especially the national debate concerning health care as a right (versus a commodity, to be sold for profit). This struggle over values is playing out in town halls across the country. Here in San Diego, about 1,000 people attended Duncan Hunter’s meeting with constituents on 3/11/2017, during which Hunter (conservative Republican congressman representing California’s 50th District) voiced support for the GOP repeal-and-replace bill because “he thinks it will make insurance cheaper, and therefore, more accessible than the current plan”: “‘We know it is going to disrupt the market,’ Hunter said. ‘I don’t believe in guaranteed health care [emphasis added]. I believe in guaranteed access to health care that people can afford.’” (“Hunter, Issa Face Raucous Crowds at Town Halls”) Plenty of protestors disagreed.
   With withdrawl of the Republican bill to repeal Obamacare on 3/24/2017 (“Trump, GOP Leaders Abruptly Pull Health Care Bill in Stunning Defeat”), the struggle continues over how best to extend health care coverage, reduce the cost of care, and make the health care system work better. Regardless of whether Obamacare is repealed or repaired, health care reforms are needed at local, state, and federal levels.
   I hope the following catalog of annotated links to selected news coverage of related subjects contributes to democratic debate and improved health care policy. The new entries, arranged chronologically (with the most recently-published reference at the top of the list), begin with that dated 16 September 2015 (scroll up from there).

Newest entries (posted in or after March 2017) to the annotated catalog of links:

pointer  “Former Drug Users Work on the Front Lines of the Opioid Crisis in Rhode Island,” an episode in Chapter 3 of PBS NewsHour’s feature series, America Addicted (first aired: 6 October 2017).

SUMMARY: “They visit overdose victims in the hospital. They hand out lifesaving drugs on the streets and educate their peers about their own relapses. In Rhode Island, former drug addicts are the most valuable fighters on the front lines of the war against opioids. William Brangham reports as part of our series, ‘America Addicted.’”
   Another inspirational example of how regular folk are coming together and changing our health care choices — here pioneering an innovative bottom-up approach to treating devastating disease that is ravaging families & communities across the U.S.
   “WILLIAM BRANGHAM: They call themselves recovery coaches. They work for a group called Anchor Recovery in Pawtucket, Rhode Island. It’s a government-funded program started in 2010.  ¶  The idea here is that people who’ve struggled with addiction themselves, and specifically opioids, are uniquely qualified to serve on the front lines of the addiction crisis at this critical moment.” (n. pag.)
   I agree. I consider this government-funded program a great use of my tax dollars. And I would like to see more health care resources directed this way, especially given current conditions of supply and demand.
   “KIMBERLY JOHNSON, Director, Center for Substance Abuse Treatment: [...] When people say, yes, I want treatment, it has to be available, because it may only be a moment. [...] One of the places that we are struggling with is the whole counseling piece. And if we have to have everybody that’s master’s-level trained counselors, we aren’t going to have enough people to do it.  ¶  So that is a critical role for recovery coaches, to help people navigate the system and get the services and the care that they need when they need it.” (n. pag.)
   Still, there are too many obstacles obstructing the timely delivery of critical care.
   “WILLIAM BRANGHAM: Jonathan Goyer says recovery coaches are crucial for navigating the system, but, often, what the coaches have to offer comes down to what kind of insurance the patients have and what kind of treatment they can afford.  ¶  Treatment options range from short-term detox programs and various levels of counseling. It can be residential inpatient treatment, which can last a few days to a few months. It can be intensive outpatient programs, like this one that meets 15 hours a week, or it can be various medically assisted treatments, such as this methadone clinic.  ¶  But openings in all these places are scarce, at the very moment, when the demand for them is spiking. Rhode Island has seen a 90 percent increase in overdose deaths in the last five years.
   “ROXANNE NEWMAN [recovery coach]: My job is to convince somebody to get treatment. And then when they say yes, sometimes, the treatment is not available. Put me in a funky situation. Here I am pouring my heart and soul and trying to help them, and I call, and there is no bed.” (n. pag.)
   Click/tap here for links to video podcasts, transcripts, and comments relating to the other episodes in the NewsHour’s America Addicted series. (Highly recommended.)

pointer  “Repeal Bill Would Hit California the Hardest,” by Noam N. Levy (Los Angeles Times, 24 September 2017, pp. A1 and A18), retitled “California Would Take Biggest Hit under Senate Republicans’ Latest Obamacare Repeal Plan” for online posting.

The Graham-Cassidy-Heller-Johnson bill, “which Senate leaders want to bring to a vote this week, would slash more than $100 billion in federal funding for the state over the next decade and tens of billions more in the years that follow.  ¶  That would force unprecedented cutbacks to the state safety net, hobble hospitals and clinics across California and likely leave millions of Californians without access to regular medical care, government and health officials warn.” (N. Levy, A1)
   “Those hit hardest in such a shift would likely be California’s most vulnerable residents, many of whom have gained insurance in recent years.” (N. Levy, A18)
   “California still faces challenges under Obamacare [aka the Affordable Care Act], including rising costs.... But the new coverage has dramatically improved many patients’ access to medical care and reduced financial strains, research indicates.” (N. Levy, A18)
   “The gains are no accident.  ¶  State leaders, including former Republican Gov. Arnold Schwarzenegger, decided soon after President Obama signed the Affordable Care Act in 2010 that California, which at the time had among the highest uninsured rates in the country, would aggressively implement it.  ¶  That meant expanding eligibility for the state’s Medicaid program, known as Medi-Cal, and creating a robust insurance marketplace that would set high standards for health plans and actively negotiate to control prices.  ¶  Most states, instead, allowed the federal government to run their marketplaces. And 19 states, all with GOP governors or legislatures, still have not taken federal aid made available by the health law to expand Medicaid.  ¶  These states have much lower levels of insurance coverage, and patients there have worse access to medical care, studies show.  ¶  Even with Medicaid expansion in California, the state remains among the least reliant on federal assistance, ranking 43rd in a recent measure by the nonprofit Tax Foundation.  ¶  But under the latest GOP repeal plan — authored by Sens. Lindsey Graham (R–S.C.) and Bill Cassidy (R–La.) — California’s large coverage expansion makes it the biggest target.” (N. Levy, A18)

pointer  “High On Drugs? Anthem Cites Soaring Drug Costs To Justify 35% Rate Hike in California,” by Chad Terhune of Kaiser Health News (posted to the KHN website, 22 September 2017).

In light of growing market volatility, “Anthem Blue Cross has forecast a 30 percent jump in prescription drug costs for 2018. Such a sharp increase is nearly double the estimates of two other big insurers, and it runs counter to industry trends nationally.” (C. Terhune, n. pag.)
   Of note, “Anthem emphasizes rising drug utilization over higher drug prices when justifying its rate increase — an argument Consumers Union challenged as unusual. Most other insurers in California have cited rising prices as a bigger factor in filings to state regulators.  ¶  ‘Anthem projects an extraordinary increase in its enrollees’ use of prescription drugs at four or more times the rate of enrollees at other carriers,’ said Dena Mendelsohn, a staff attorney for Consumers Union in San Francisco.” (C. Terhune, n. pag.)
   Because Anthem’s cost projections are so much higher than its competitors, “Some experts wonder if Anthem made a mistake in its California rate filing. It wouldn’t be the first time.” (C. Terhune, n. pag.)

pointer  “GOP Health Bill Offers Provisions Aimed at Helping 2 States,” by Alan Fram of the Associated Press (posted to AP News website, 22 September 2017).

Wheeler-dealing over the eleventh-hour Graham-Cassidy-Heller-Johnson health care bill in the U.S. Senate continues. “The 140-page measure, which top Republicans hope to push through the Senate next week, is stuffed with language making some states winners and others losers. Aides say the legislation is still changing as leaders hunt the 50 GOP ‘yes’ votes they’ll need” to repeal and replace Obamacare with the Graham-Cassidy-Heller-Johnson bill, which “would end Obama’s Medicaid expansion and subsidies for people buying private insurance and combine the money into new block grants for states.” (A. Fram, n. pag.)
   Of note, “Provisions shoehorned into the Republican health care bill dangle extra money for Alaska and Wisconsin”: “The measure would shield Alaska from some cuts it imposes on Medicaid .... It would also increase federal Medicaid funds for states with high American Indian populations, including Alaska ....” And “the bill allows a state that turned down extra federal funds to expand Medicaid under Obama’s statute to count the rejected money in determining how large its block grant will be,” with analysts “unaware of states other than Wisconsin that would benefit from [this] provision.” (A. Fram, n. pag.)
   It is no accident that Sen. Ron Johnson, R–Wisconsin, is one of the bill’s co-sponsors, while Alaska’s Sen. Lisa Murkowski is “among a handful of Republicans who’ve not said how they’ll vote” on the bill, and “whose vote party leaders desperately need.” (A. Fram, n. pag.)
   Critics complain that the GOP bill “would shift money from states that expanded their Medicaid programs for the poor under Obama’s statute, which tend to be run by Democrats, to the largely Republican-run states that shunned that expansion.” But the bill’s sponsors and supporters argue that the new funding formulas merely “correct ‘the grossly unfair’ distribution of money under Obama’s law.” (A. Fram, n. pag.)

pointer  “What You Need to Know about the GOP’s Graham-Cassidy Health Care Bill,” a PBS NewsHour report, first aired 20 September 2017.

SUMMARY: “Republican’s long-fraught effort to repeal the ACA has regained momentum in the Senate just as a critical deadline looms for the GOP. The new health care bill, sponsored by Sen. Lindsey Graham and Sen. Bill Cassidy, would bring sweeping changes to the current system. Lisa Desjardins and Sarah Kliff of Vox join John Yang to explain the policy and politics behind the bill.”
   According to Lisa Desjardins, this latest GOP bill gives states “more options”: Republicans “want more power to states. And some specific states win in this deal, red states.  ¶  The states that lost the most are states like California and New York. States that gain the most seem to be states like Kansas, Alabama, Mississippi. Those are Republican red states and it’s a significant shift in resources.” (n. pag.)
   Desjardins has created a handy chart comparing the 3 GOP health care plans of 2017 (the House plan, H.R. 1628, known as the American Health Care Act, passed on 5/4/2017; the Senate leadership’s bill, released on 6/22/2017, known as the Better Care Reconciliation Act; and the Senate’s Graham-Cassidy-Heller-Johnson bill, released on 9/13/2017) for the NewsHour’s Rundown.
   For a detailed history of GOP efforts in 2017 to repeal and replace Obamacare (the Affordable Care Act of 2010), along with a chart summarizing “Differences and Similarities between the ACA, AHCA, BCRA, and the HCFA,” see Wikipedia’s page on the “American Health Care Act of 2017.”

pointer  Op-ed, “Does Sanders’ Single-Payer Plan Have a Shot?” by Doyle McManus (Los Angeles Times, 17 September 2017, p. A18).

McManus argues that while polls show “most Americans agree that the government should guarantee that everyone has adequate health insurance” and “a growing number support a government-run ‘single-payer’ plan as the way to do that,” “when the details are introduced, public opinion turns contrary. According to the same Kaiser polls, most Americans want better insurance, but they don’t want taxes to go up to pay for it. Most of them also dislike increasing government control over the healthcare system.” (A18)
   “That’s why the most important health insurance bill to watch over the next few years may not be Sanders’ Big Bang approach, but a less ambitious proposal from Democratic Sen. Chris Murphy of Connecticut. He calls it “Medicare Buy-In.”  ¶  Murphy’s plan wouldn’t put everyone into a single government-run health plan. But it would give everyone access to Medicare, the enormously popular government-run plan mainly for those 65 or older.” (D. McManus, A18)

pointer  “Bipartisan Obamacare Fixes Possible: Several states offer Congress examples of ways to cooperate and end its long standoff,” by Noam N. Levey (Los Angeles Times, 3 September 2017, p. A18), retitled “As Some in Congress Look to Move Past the Obamacare Standoff, States Offer a More Bipartisan Model” for online posting.

Again re. the growing interest in bipartisan fixes for the troubled health care law popularly known as Obamacare (with a short-term focus on stabilizing insurance markets which President Trump’s administration is undermining and/or allowing to “implode”).
   The last week in August 2017, “a bipartisan group of eight governors, led by Ohio Republican John Kasich and Colorado Democrat John Hickenlooper, sent congressional leaders a five-page letter calling for a set of specific steps to strengthen insurance markets, including helping insurers cover high-cost patients and assuring federal funding to lower deductibles and co-pays for low-income insurance customers.” (N. Levey, A18)

pointer  “Governors Urge Keeping US Health Law’s Individual Mandate,” by Julie Carr Smyth and James Anderson of the Associated Press (posted to AP News website, 31 August 2017).

Another bipartisan call for fixing Obamacare, this time from 8 governors “urging Congress to retain the federal health care law’s unpopular individual mandate while seeking to stabilize individual insurance markets as lawmakers work on a long-term replacement.” (n. pag.)
   “The governors support creating a temporary stability fund that states could tap to reduce premiums and limit losses; continuing to fund educational outreach and enrollment efforts under the Affordable Care Act; exempting insurers that agree to cover underserved counties from the federal health insurance tax; and supporting states’ efforts to find creative solutions for covering the uninsured.” (n. pag.)
   “The penalty and coverage requirement, or individual mandates, were intended to nudge healthy people into the insurance market. They have consistently polled negatively with Americans. In an Associated Press-NORC Center for Public Affairs Research poll conducted in July [2017], 48 percent of those surveyed favored repealing the mandate, while 35 percent opposed repeal.” (n. pag.)

pointer  “Scripps Health to Shut Hospice Service: 114 county residents must select new provider by Monday,” by Paul Sisson (San Diego Union-Tribune, 31 August 2017, pp. A1 and A10), retitled “Scripps to Shutter Its Hospice Service” for online posting.

This is a cautionary tale about what happens when we apply cost-benefit analysis (CBA) to the provision of expensive, compassionate end-of-life care at a facility located on a prime piece of real estate.
   San Diego Hospice, with 24 beds, “opened in 1992 with the help of a $18.5 million grant from the late Joan Kroc, the philanthropist and wife of McDonald’s chief, Ray Kroc, and former owner of the San Diego Padres.” The hospice went bankrupt in 2013, at which point “Scripps purchased the facility during the San Diego Hospice bankruptcy auction for $16.55 million and recently sold it to a Texas real estate development company for $20 million. The company plans to build apartments on the 8-acre property which has sweeping views across Mission Valley and Mission Bay all the way to the Pacific.” (P. Sisson, A10)
   End-of-life patients are being dislocated, along with the hospice memorial garden and wall where families have donated thousands of dollars in gifts and remembrances for their loved ones. Sisson reports that “The property is home to tributes to hundreds of San Diegans who died at the hospice. Anyone who wants to remove their loved-one’s memorial from the property before construction begins can contact Scripps coordinator Jamie Nelson at ....” (P. Sisson, A10)
   Needless to say, family members who thought they were paying for enduring memorials are anguished (and angry) about such cavalier destruction of a San Diego legacy (see the Comments section appended to the online version of Sisson’s article).

pointer  “California Lawmakers to Hold Universal Health Care Hearings,” by the Associated Press (posted to the AP News website, 24 August 2017).

Following “weeks of backlash from members of his own party” after he shelved SB 562 (which “would have eliminated insurance companies in California and implemented a government-run health care system, known as a single-payer system”), California Assembly Speaker Anthony Rendon has announced that “California lawmakers will hold hearings on universal health care during the Legislature’s year-end recess.” (The California state legislature adjourns on 15 September 2017.)
   The speaker’s vociferous critics have not been won over by this legislative manoeuvre: “The California Nurses Association has harshly criticized Rendon over his decision to shelve Lara’s bill [SB 562, sponsored by state senators Ricardo Lara (D–Bell Gardens) and Toni Atkins (D–San Diego)]. They said the Assembly should hold hearings on the existing bill instead.  ¶  ‘California does not need a Select Committee to hold hearings to develop a plan for achieving universal health care,’ Executive Director Bonnie Castillo said in a statement.” (n. pag.)
   Cf. the response (published 9/5/2017; see above pointer) by the San Diego Union-Tribune Editorial Board, which wants even more hearings and bold new ideas about how we achieve universal health care, and argues that we can do better than what has been proposed thus far.

pointer  “Lawmakers Set Sights on Prescription Drug Prices: Supporters are hopeful, with five measures having been proposed in Sacramento, and they now can count on help from Democratic activist Tom Steyer and some Republicans” by Melanie Mason (Los Angeles Times, 20 August 2017, pp. B1 and B5), retitled “With New Allies and Approaches, California Lawmakers Try Again to Confront High Prescription Drug Prices” for online posting.

Noting that drug companies “raised more than $100 million to defeat a 2016 ballot measure to cap what state agencies could pay for drugs,” Mason reports that California legislators have stepped up to rein in pharmaceutical costs with 5 measures (3 Assembly bills, and 2 Senate bills) put forth during the 2017 legislative session:
   •  AB 265  (measure limiting drug rebate and coupon offers, by Assemblyman Jim Wood)
   •  AB 315  (measure controlling pharmacy benefit managers (PBMs), by Assemblyman Jim Wood)
   •  AB 587  (requires regular review of drug pricing by state agencies, by Assemblyman David Chiu)
   •  SB 17  (price disclosure bill, by state Senator Ed Hernandez)
   •  SB 790  (places new restrictions on gifts to doctors from pharmaceutical companies, by state Senator Mike McGuire).
   Affordability issues are of growing concern since “Around $320 billion was spent in the U.S. on prescription drugs in 2015, according to the federal Centers for Medicare and Medicaid Services. After relatively slow growth in drug spending in the early 2000s, spending surged by 12.4% in 2014, mostly due to expensive new specialty drugs hitting the market. In 2015, spending grew at a lower rate of 9%.” (M. Mason, B5)
   The California state legislature adjourned on 15 September 2017. You can find out which — if any — of these bills passed into law at the websites for the California State Assembly and the California State Senate.

pointer  “Feds Say S[an] D[iego] County Marines Used in $67M Fraud: Government program billed for highly expensive drugs” by Kristina Davis (San Diego Union-Tribune, 19 August 2017, pp. A1 and A5), retitled “Pharmacy and Medical Practice Accused of Using San Diego Marines in $67 Million Healthcare Fraud” for online posting.

For centuries, compounded drugs have been a lucrative sideline for medical practitioners able to charge well-heeled patrons exorbitant prices for the exotic mix of ingredients used in their preparation. Nonetheless, given modern regulatory reforms and medical ethics, it is surprising that the early-modern practice of overcharging the government for medicinal compounds continues into the 21st century.
   The $67 million scam reported on here is one of “a growing number of investigations into fraudulent prescriptions of compound medications — high-priced drugs custom-made by pharmacists to tailor to a patient’s specific needs. The investigations have led to arrests in similar cases across the country and a change in how TRICARE — which serves 9.4 million active, retired and reserve military and their families — bills for such drugs.... In just the first four months of 2015, the costs of claims to TRICARE for compounded drugs surged to more than $1 billion, according to the insurer.” (A1)
   According to Davis, “Retired Rear Adm. James Johnson of San Diego, who was the director of TRICARE’s western region more than a decade ago, said he got a glimpse into the recent compounding scheme a few years ago when a doctor friend in Los Angeles asked him to investigate a telephonic ‘seminar’ he’d been privately invited to. The doctor gave Johnson a special invite code and he listened in. The anonymous sales pitch described how to evaluate military members suffering from chronic pain over the phone and prescribe them compounding creams at an astronomical profit.  ¶  ‘I said this sounds really suspicious and bogus,’ recalled Johnson, who serves as a member of the Governor’s Military Council. ‘I warned that a bunch of people would be going to jail who are behind this.’” (K. Davis, A5)

pointer  “Trump Moves to Impede Consumer Lawsuits Against Nursing Homes,” by Robert Pear (posted to the New York Times website, 18 August 2017).

As reported by Robert Pear, “The Trump administration is pushing to scrap a rule that would have made it easier for nursing home residents to sue nursing homes for injuries caused by substandard care, abuse or neglect, bringing its campaign to relax federal regulations to the delicate business of care for older Americans.  ¶  The push would undo a rule issued by the Obama administration that would have prevented nursing homes from requiring that consumers agree to resolve any disputes through arbitration rather than litigation. Nursing homes routinely require consumers to sign an arbitration agreement as a condition of admission to the home.  ¶  The proposed rule brings together a broader private-sector effort to slip binding-arbitration clauses into the fine print of consumer contracts with the Trump administration’s expansive efforts to roll back regulations and reduce the costs to businesses.” (n. pag.)
   “Nursing homes generally welcomed the proposal, but other reaction has been overwhelmingly negative.  ¶  The attorneys general of 16 states, led by Brian E. Frosh of Maryland and Xavier Becerra of California, strongly opposed the Trump administration proposal.” (n. pag.)
   In addition, “Thirty-one senators, led by Ron Wyden of Oregon and Al Franken of Minnesota, both Democrats, also objected to the Trump administration proposal. With Medicaid and Medicare spending more than $80 billion a year on nursing home care, they said, nursing homes should not be able to cover up wrongdoing by forcing patients to relinquish the right to sue.” (n. pag.)

pointer  “Why Are More American Women Dying after Childbirth?,” a PBS NewsHour interview, first aired 17 August 2017.

SUMMARY: “Doctors and nurses have worked hard to reduce the U.S. infant mortality rate, and yet there’s been a rise in maternal mortality in recent decades, a trend that is less understood. Judy Woodruff sits down with Renee Montagne of NPR and Nina Martin of ProPublica to discuss their collaboration on this topic.”
   “NINA MARTIN: ... So, Lauren Bloomstein is an example of the kind of person that everyone assumes doesn’t die in childbirth or pregnancy-related causes in the U.S. She had great health care. She was a nurse herself. Her husband, Larry, who we just heard, was a doctor. He was with her in the delivery room.  ¶  He basically never left her side, except to take the baby up to the nursery. She came in with a condition called preeclampsia, that is, pregnancy-induced hypertension. She had not had it. And she came in and her symptoms were not recognized from the moment she came to the hospital.” (n. pag.)

pointer  Op-Ed, “Bipartisan Health Care Reforms within Reach,” by U.S. Senator Dianne Feinstein (San Diego Union-Tribune, 11 August 2017, p. B7), retitled “Feinstein: Health Care Reform Will Work if Trump Abandons ‘Sabotage’” for online posting.

Another call for a bipartisan approach to health care reform. (The San Diego Union-Tribune Editorial Board has been seeking a bipartisan solution to our health care woes since November 2016. See above section of pointers.)
   Calling on President Donald Trump to “abandon his efforts to sabotage the market by threatening to stop reimbursing insurance companies for reducing co-pays for low-income enrollees,” Feinstein seeks bipartisan “proactive solutions to strengthen the individual market.”
   “One idea is to fix the steep cut-off for tax-credit subsidies in the individual market. Under current law, those making just one dollar more than 400 percent of the federal poverty level — $47,520 for an individual and $80,640 for a family of three — receive no financial help at all.  ¶  This means that a 60-year-old making $50,000 spends up to $900 per month on premiums. That’s clearly unaffordable at more than 20 percent of income.  ¶  We have a bill to eliminate this fall-off by ensuring that no one in the individual market pays more than 9.69 percent of their income on monthly premiums.  ¶  This proposal would increase the cost of federal subsidies by just 1 percent, while motivating healthier individuals who may have opted to go without insurance to get covered. The Commonwealth Fund estimates that 1.2 million people would sign up — 96 percent of whom would be ages 50 to 64.  ¶  Increasing the number of relatively healthy, low-cost individuals in the market would in turn help tamp down premium increases. By attracting healthier people to the market and lowering premiums, the federal government would spend $2.6 billion less on subsidies for those who already receive them.” (D. Feinstein, B7)

pointer  “How One Woman Brought Life-Saving Maternity Care to Somaliland,” a PBS NewsHour report by Special correspondent Fred de Sam Lazaro (part of his series “Agents for Change”), first aired 9 August 2017.

SUMMARY: “Somaliland, a region of Somalia that lay in ruin from years of war, suffers some of the world’s highest rates of infant and maternal mortality. But 15 years ago, Edna Adan fulfilled a lifelong dream by building a nonprofit hospital and nursing school to address the health needs of women. Special correspondent Fred de Sam Lazaro reports.”

pointer  “Campaign to Recall Rendon over Single-Payer Issues Advances,” by Melanie Mason (Los Angeles Times, 30 July 2017, p. B8), retitled “Single-Payer Healthcare Supporters Take First Step to Launch Recall against California Assembly Speaker Anthony Rendon” for online posting.

California’s single-payer health care bill (SB 562), which passed the California state Senate early in June 2017, was “shelved” (delayed) by Assembly Speaker Anthony Rendon later that month.
   I have given my opinion of the bill and subsequent recall effort in an interpolation (posted 8/6/2017) at a companion website (see content in Quick Links sidebar at right of page).
   For a link to the San Diego Union-Tribune’s editorial of 27 June 2017 on this same subject, see above pointer.

pointer  “Trump Administration Ends Affordable Care Act Assistance Contracts in 18 Cities,” by Carla K. Johnson, Associated Press (posted to the PBS NewsHour’s The Rundown: A Blog of News and Insight on 20 July 2017).

Pertinent to the debate over whether the Trump administration is actively sabotaging Obamacare, and not just leaving it to “implode” (in some states) of its own accord.
   With this executive action, “President Donald Trump’s administration has ended Affordable Care Act contracts that brought assistance into libraries, businesses and urban neighborhoods in 18 cities, meaning shoppers on the insurance exchanges will have fewer places to turn for help signing up for coverage.” (n. pag.) Two federal contracts (one worth $12.8 million, and the other, $9.6 million) expire 29 August 2017, and will not be renewed for another year, as originally set forth.
   Discussants (see the Comments section below Johnson’s piece) linked this latest political manoeuvre with the new “MAGAnomics” (Make America Great Again economics) driving Trump-style health care reform, and the related stepping up of White House attempts to undermine the Affordable Care Act (Obamacare).
   But even Trump’s critics wondered about the cost effectiveness of the cancelled ACA program:
      [comment posted by “Truth_the_Whole_Truth” on 7/20/2017:] “Based on the information provided it costs $6.50 per person who used the[s]e service to be enrolled. How many of the 14,500 assisted would have been enrolled in any case? Was the assistance planned to exist forever? Is there a less expensive and.or more effective approach?” (n. pag.)
      [comment posted by “CurtCarpenter” on 7/20/2017:] “I come up with a figure of over $1500 per person that these two contractors assisted. What did I miss?  ¶  I don’t doubt that Price [Tom Price, Secretary of Health and Human Services] cut these contracts with glee as part of an overarching desire to sabotage the ACA, but in this case, it seems like he had some legitimate cause.” (n. pag.)

pointer  “Medi-Cal’s Big Problem with Its Own 1%,” by Soumya Karlamangla (Los Angeles Times, 16 July 2017, pp. B1 and B6), retitled “One Child, a $21-Million Medical Bill: How a tiny number of patients poses a huge challenge for Medi-Cal” for online posting.

Describes the “challenges policymakers are facing,” even in a rich state like California, “with possible cuts in the federal government’s contribution to Medicaid proposed in the House and Senate Obamacare repeal bills.” (S. Karlamangla, B1)
   “Medi-Cal, which is jointly funded by the federal and state governments, provides health coverage to 13.5 million Californians, or a third of state residents.  ¶  State data show that the most expensive 1% of patients in Medi-Cal account for 23% of the program’s spending. Ten percent of patients create 63% of total costs.” (B1)
   Given that “The half of Medi-Cal patients with the lowest annual expenses account for just 7% of Medi-Cal spending” (B6), GOP nostrums about giving states an incentive to reform their Medicaid programs and cut down on fraud and abuse that could be driving up costs — in the words of Ed Haislmaier, healthcare policy expert at the conservative Heritage Foundation, “If you do a better job managing how people utilize services, you can certainly provide better care at a lower cost.” — do not address the most pressing problems associated with high-cost, medically-necessary treatments for individuals with, e.g., “severe genetic disorders such as cystic fibrosis, hemophilia, Duchenne muscular dystrophy and sickle cell disease.” (B6) “For patients like these, there often isn’t anywhere to reduce costs, experts say.” (B1)
   “That’s why state officials say they’re concerned about the Senate healthcare bill.  ¶  GOP legislators unveiled a proposal last month that would dramatically scale back Medicaid, making funding 35% lower in two decades than under current law, according to an independent analysis by the Congressional Budget Office. A revised version of the bill released Thursday includes the same changes to Medicaid.  ¶  California officials estimate that the bill would leave Medi-Cal with $115 billion less through 2027 than it would receive otherwise.” (S. Karlamangla, B6)

pointer  “Senate Health Bill Puts Many Moms and Babies at Risk, Says March of Dimes President,” a PBS NewsHour interview, first aired 3 July 2017.

SUMMARY: “How would the current Senate Republican health care plan affect pregnant women, mothers and babies? Judy Woodruff speaks with Stacey Stewart, president of March of Dimes, about how many women depend on Medicaid to get prenatal care and have healthy pregnancies, and how early intervention and prevention programs can help reduce health care costs.”
   “STACEY STEWART, President, March of Dimes: ... Medicaid today covers about half of all pregnancies in the United States and there are about 30 million children that are covered by Medicaid.  ¶  Under what the Senate has proposed, about 6.5 million low-income women of child-bearing age would lose their coverage under Medicaid. And we think that that puts at risk those women in terms of them being able to access prenatal care and all the things they need to do to have a healthy baby, have a healthy pregnancy.
   “JUDY WOODRUFF: So, about half of pregnant women in this country depend on government help in order to have a healthy pregnancy?
   “STACEY STEWART: Right....” (n. pag.)
   Stewart argues that the current system “is funding a lot of chronic disease and illness” whereas we ought to “put more emphasis on early prevention efforts and fund a system that actually focuses on that” — e.g., maternity coverage and prenatal care — to “improve health outcomes, reduce cost, reduce premiums, which is what I think everybody wants.”
   Stewart agrees with Republican critics of the ACA (the Affordable Care Act, better known as Obamacare) that “the costs of Medicaid are exorbitant and they’re growing. But let’s look at what’s really going on in the Medicaid market. You have got a lot of low-income women, many women of color.  ¶  And what we see are health outcomes not improving.... [T]he government just issued some statistics showing that pre-term birth rates have now increased for the second time in the past two years, after some decline over the past seven years.  ¶  Health outcomes are not improving for pregnant mothers and babies. It’s actually going down. And so, one of the things that we can do to control the costs of Medicaid and health care in general, again, is to focus on ... what prevention methods could be put in place to educate and inform and provide the support and the health care coverage that women need, so that both kind of health outcomes can be avoided.  ¶  If we can avoid those health outcomes, then we can avoid the cost in the system, and then we can keep those costs under control, so that we have a much more manageable system over time.” (n. pag.)
   This raises several questions pertinent to Medicaid reform efforts — especially for those committed to ensuring that Medicaid is “going to be there in the long term for people who need it” — as noted in a thoughtful comment posted by “Diana Moses” on 7/4/2017: “I am in favor of Medicaid and the Medicaid expansion under the ACA (and was frustrated that the expansion was unable to be fully implemented under the Supreme Court’s decision). I don’t doubt that more pre-natal care and preventive measures increase the likelihood of positive pregnancy outcomes, but I would have liked to have heard some greater detail about the recent rises in pre-term births and whether they are associated with any particular factor (including lack of health care). During the past two years during which the rises reported occurred we have had traditional Medicaid in place and its expansion under the ACA, so the argument would seem to me to be that even under that coverage scenario, we can still experience negative trends, and so we need to figure out what we can do even better (and not backtrack) — which, I think, requires knowing more detail about what goes wrong and its possible causes. I also want us to be realistic about the extent to which we can eliminate negative pregnancy outcomes — as I said, I don’t doubt that better care helps, but I don’t want us to set unrealistic expectations, either, since pregnant women with good care and compliance with medical advice may experience negative outcomes nonetheless, from what I understand — ‘avoidance’ of negative outcomes seems to me to elide reduction with elimination.” (n. pag.; see the Comments section following the transcript)

pointer  “This Simple Correction for Clubfoot Is a Life Changer for Kids in India,” a PBS NewsHour report by Special correspondent Fred de Sam Lazaro (part of his series “Agents for Change”), first aired 3 July 2017.

SUMMARY: “Clubfoot, a treatable birth defect that can bring pain and social isolation, is often not treated in the developing world. But a treatment developed a half century ago by a doctor in Iowa is less invasive, less expensive and less painful than the corrective surgery that was once required. Special correspondent Fred de Sam Lazaro reports on how a charity is trying to bring the cure to children in India.”

pointer  PBS NewsHour interview with Warren Buffett (Part 2 of 2), “Billionaire Warren Buffett Says GOP Health Reform Bills Are Relief for the Rich,” first aired 27 June 2017.

SUMMARY: “What does billionaire Warren Buffett think of Republican health care bills that would roll back taxes for wealthy Americans like him? Buffett discusses everything from how he’s giving away billions in philanthropy to how much sleep he gets to what’s on his personal income taxes in the second part of Judy Woodruff’s exclusive interview.”
   Buffett here reiterates that the current corporate tax rate is not what’s putting his company at a competitive disadvantage. Rather, rising health care costs are placing U.S. companies, and the economy as a whole, at a competitive disadvantage. And since proposed GOP health care “reform” (Buffet mischievously suggests retitling Congressional Republicans’ bills “Relief for the Rich Act or something”) does nothing to address rising health care costs, it misdirects and avoids tackling the real problem.

pointer  PBS NewsHour interview with Warren Buffett (Part 1 of 2), “America Should Stand for More than Just Wealth, Says Warren Buffett,” first aired 26 June 2017.

SUMMARY: “Dubbed the ‘Oracle of Omaha,’ Warren Buffett is an investment rock star. What’s his take on the state of the economy? He recently sat down with Judy Woodruff for a wide-ranging, two-part interview on inequality, the Paris climate agreement, health care reform and much more.”
   Re. unsustainable health care costs and a single-payer system:
      “JUDY WOODRUFF: Something that affects all businesses is the cost of health care in this country.
      “WARREN BUFFETT: Right.
      “JUDY WOODRUFF: And you have been vocal about that.  ¶  You have argued that, right now, in effect, that the cost of paying for health care can affect a company even more than taxes.
      “WARREN BUFFETT: Well, it does, I mean, in terms of our competitiveness in the world.  ¶  Health care in 1960 was 5 percent of GDP. And there’s only 100 cents in the dollar. So, it’s gone from 5 cents — 5 percent to 17 percent. And it keeps going up. Corporate taxes have gone down from 4 percent to 2 percent.  ¶  So, corporate taxes are way less of a factor in American competitiveness than — I’m talking about overall business — than medical costs.
      “JUDY WOODRUFF: And as we sit here today in Omaha, the Republicans in Congress are madly trying to figure out what to do to replace Obamacare, the Affordable Care Act.
      “WARREN BUFFETT: Yes.
      “JUDY WOODRUFF: Do you have a firm idea in your mind of what ought to be done about Obamacare? Everybody acknowledges there have been some problems with it.
      “WARREN BUFFETT: I think that’s way outside of my circle of competence.  ¶  But I would say this. You can’t have that 5 go to 17 and move on to 20 and 22 or 24 percent, because there are only 100 cents in a dollar. And health care is gobbling up well over $3 trillion a year. It’s just about the same as federal — the federal budget is getting up there.
      “JUDY WOODRUFF: Are we now at the point where the country does need to think about some sort of single-payer system in some form or another?
      “WARREN BUFFETT: With my limited knowledge, I think that probably is the best system, because it is a system — we are such a rich country. In a sense, we can afford to do it.  ¶  But in almost every field of American business, it pays to bring down costs. There’s an awful lot of people involved in the medical — the whole — just the way the ecosystem works, that there is no incentive to bring down costs.
      “JUDY WOODRUFF: And it sounds like you’re saying, with a single-payer system, it would be easier to figure out a way to get those costs down.
      “WARREN BUFFETT: It would be more effective, I think.” (n. pag.)

pointer  “Conservatives Are Targeting the Wrong Things to Bring Down Health Care Costs, Says Hospital System CEO,” a PBS NewsHour interview, first aired 26 June 2017.

SUMMARY: “Every major hospital group has criticized the health care bill crafted by Senate Republicans, especially for deep reductions in Medicaid spending for the poor and those with disabilities. At the Spotlight Health Conference at the Aspen Institute, Judy Woodruff talked to Kenneth Davis, president and CEO of the Mount Sinai Health System, to get his take on the health care bill and more.”
   Re. needed cost controls:
      “DR. KENNETH DAVIS: Well, the margins in many hospitals are so small that, if you are not fixated on costs, you are bankrupt.  ¶  And in New York state, we have seen 30-plus hospitals go bankrupt in recent years.
      “JUDY WOODRUFF: So the lesson is?
      “DR. KENNETH DAVIS: The lesson is, we are focused on expenses. We have to be fixated on expenses. But what we really need to do — and we were trying to do this previously — and hopefully we can continue to do this — is ask, how can we deliver health care in a different, more efficient, cost-efficient way?  ¶  The system is failing us. The macroeconomics of health care are such that the government can’t afford it, the states can’t afford it, the employers can’t afford it, and the employees can’t afford it. What we have got to ask is, what’s wrong with the system and how do we change it so that it’s more efficient for everybody?” (n. pag.)
   The comments section (following the transcript) includes an interesting discussion of California’s flawed single-payer legislation (proposed May–June 2017), here criticized for similar reasons (lack of cost controls):
      [comment posted by “Ellen A”:] “As of last Friday, California Single Payer is officially stuck in committee. The bill passed by the CA Senate was right in spirit, but woefully incomplete. In principle, Gov Brown has made clear many times that he is in favor of universal coverage.  ¶  Practice becomes much harder, particularly as it will require cooperation from Congress on Fed dollars, which the Republicans are unlikely to approve. Also, for instance, it would up-end insurance for the 18 million Californians who are on employer-based plans...how do the employer contributions for those 18m people make it into the California budget on a continuing basis? (Hint: state taxes are not a good answer...too easy to game that system.)  ¶  Bigger picture, how do you keep some uninsured person (or every uninsured person) diagnosed with kidney cancer or diabetes in Indiana or Kentucky from moving to CA the moment they are diagnosed, claiming care toward which they haven’t contributed a single penny? If CA effectively pays for sick people, it will get sick people!  ¶  Having a test-run single payer system in California that fails because it is not economically sustainable over the long haul would be an enormous setback for the national cause. It is critical (and worthy) to get the plan right.” (n. pag.)

pointer  “California Shelves Single-Payer Plan for this Year,” by Melanie Mason (Los Angeles Times, 24 June 2017, p. A13).

pointer  “For Vulnerable Californians, Expanded Medicaid Is a Lifeline at Risk of Being Cut,” a PBS NewsHour report, first aired 21 June 2017.

SUMMARY: “Fourteen million Medicaid recipients could lose their health coverage under the GOP House Obamacare replacement bill, and reports suggest the Senate version would make even deeper cuts. California, where 1.2 million resident[s] gained health insurance under the Medicaid expansion, stands to lose more than any other state. Special correspondent Cat Wise reports from Los Angeles.”
   See also the response to this piece posted by “Candid One,” who often raises important issues about California’s unique status (meaning, California is not a good model for the bulk of states):
      [comment posted by “Candid One”:] “Using Los Angeles County health care programs as a ‘front page’ example needs more context than this segment provides. LA Co. is the nation’s most populous county. Of itself, LA Co.’s population would rank it as #10 among the states in population. The distortion implicit in that uniqueness sorely needs to be addressed by the PBS editors.  ¶  There’s also an erroneous implication in the portion including the Cato Institute researcher. Medicaid is not a Federal program; in CA, it’s known as MediCal. The PPACA (‘Obamacare’) augments those state-level programs where accepted, which nominally exist despite Federal interplay. Counties in California also have been historical clinical health care providers. There’s too much glossing-over, too much over simplification, too much from-the-hip generalization in this segment.  ¶  How addressing of these above-mentioned shortfalls changes the presentation would be interesting.” (see Comments section below transcript)

pointer  “Cervical Cancer Is Most Deadly in India. This Program Is Trying to Change That,” a PBS NewsHour report by Special correspondent Fred de Sam Lazaro (part of his series “Agents for Change”), first aired 12 June 2017.

SUMMARY: “Cervical cancer afflicts a half million women across the world every year, but it’s most deadly in India. For many Indian women, seeing a doctor is the last resort and an unaffordable luxury. A pilot program aims to change that with a low-cost testing and simple procedure, but hurdles remain to get women in the door. Special correspondent Fred de Sam Lazaro reports.”
   “FRED DE SAM LAZARO: ... Vaccines are available and have proven effective in preventing HPV. But the cost puts them out of reach of most Indian women.” (n. pag.)
   Fortunately, the economic barrier to much-needed preventive care is being addressed by a low-cost alternative.
   “FRED DE SAM LAZARO: In rich countries, Pap smears and follow-up treatment are the standard, but that’s neither affordable nor practical here. Instead, obstetrics professor Uma Singh demonstrated to students a low-tech, low-cost alternative being used in the pilot, a simple swab of the cervix with vinegar.
   “DR. UMA SINGH: So, after one minute, what you do is, do — do the inspection with good light. So, if you see a white area, you treat it by a procedure which is called cryotherapy.
   “FRED DE SAM LAZARO: Literally freezing it off.... The approach here is to remove any lesions right away. There’s no time or resources to monitor or biopsy, no assurance the women will return for follow-up treatment.  ¶  It is likely that in many, if not most cases, you are over-treating the patient.
   “DR. UMA SINGH: Yes, it may be a little bit of over-treating, but it has been seen that it doesn’t produce any substantial harm to the woman in relation to producing any long-term effects on the cervix.” (n. pag.)
   Unfortunately, there are still cultural barriers to overcome in promoting early screening and treatment of cervical cancer in India.
   “FRED DE SAM LAZARO: But even as there’s fear of cancer, getting women to the screening was a tough sell. These women complained that they need help for far more mundane health care issues, which no one provides.” (n. pag.)

pointer  “Neglect of Guidelines to Prevent Cancer High,” by Paul Sisson (San Diego Union-Tribune, 4 June 2017, pp. A1 and A17, A2), retitled “Half of All Cancer Deaths Are Avoidable. Follow these Key Prevention Steps” for online posting.

Sisson here zeroes in on 4 cancers: cervical, colorectal, breast, prostate, and the plethora of cancers linked to smoking (lung, mouth, larynx, throat, esophagus, bladder, kidney, liver, stomach, pancreas and cervix, as well as a form of leukemia).
   HPV (human papillomavirus) vaccination, approved by the U.S. Food and Drug Administration in 2006, is the recommended preventative for cervical cancer: “Yet nearly a decade after the vaccine’s introduction, HPV vaccination rates remain relatively low.  ¶  As of 2015, according to a recently released report from the American Cancer Society, only 52 percent of girls and 39 percent of boys ages 13 to 17 had received the two doses of HPV vaccine deemed necessary to confer immunity.  ¶  HPV immunization rates have not yet come close to the 80 percent or 90 percent ‘super majorities’ seen with other vaccines routinely given to children.” (P. Sisson, A17)
   Colorectal cancer screening (a colonoscopy or stool test) is “very accurate and early detection is very effective at preventing the spread of malignant cells,” with the American Cancer Society pushing for 80% screening rates by 2018 “in order to prevent more than 200,000 deaths over the next 20 years.” As of 2015, the screening rate was only 63% for U.S. adults aged 50+, and specialists admit that it “will take a broader approach than is sometimes employed today” to reach the 1 in 3 who do not comply with screening advice. (A17)

pointer  “What Is this Thing Called Single Payer?” by Melanie Mason (Los Angeles Times, 4 June 2017, pp. B1 and B7), retitled “Q&A: What Would California’s Proposed Single-Payer Healthcare System Mean for Me?” for online posting.

pointer  “Californians Like Universal Care, Unless They’re Taxed,” by Dan Walters (posted to The Sacramento Bee website on 2 June 2017).

pointer  “State Single-Payer Plan Is Doable,” by Michael Hiltzik (Los Angeles Times, 28 May 2017, pp. C1 and C6), retitled “The Challenges in Setting Up a California Single-Payer System Are Daunting — But Not Insurmountable” for online posting.

pointer  “Bid to Make Tampons Tax-Free Delayed,” by John Myers (Los Angeles Times, 28 May 2017, p. B6), retitled “The Effort to Make Tampons Tax Free in California Has Been Delayed until 2018” for online posting.

“Legislation to eliminate California sales taxes on the purchase of tampons was delayed Friday by the Assembly’s fiscal committee until 2018, a blow to advocates who say the tax is an unfair burden on low-income women and families.
   “The delay imposed on AB 9 is the second setback this month for efforts to eliminate taxes on products for women and children. A separate bill that included a tax-free provision for diapers [authored by Assemblywoman Lorena Gonzalez (D–San Diego)] was killed in a legislative committee on May 8.
   “The bill that was held back on Friday, written by Assemblywoman Cristina Garcia (D–Bell Gardens), would have excluded tampons, sanitary napkins and other menstrual products from sales taxes. A legislative committee analysis estimated the proposal would reduce state general fund revenues by $10.5 million a year.
   “Dozens of other bills with a cost to state government were killed by the Assembly Appropriations Committee, while AB 9 was instead reclassified as a ‘two-year bill,’ meaning it is eligible to be heard again in the second year of the legislative session.
   “Gov. Jerry Brown last year rejected a similar measure that sought to make tampons tax-free, writing in his veto message that ‘tax breaks are the same as new spending – they both cost the general fund money.’” (J. Myers, B6)

banner graphic labelled: FEATURED LINK

pointer  “This Innovator Is Trying to Make Sanitary Pads Affordable for Women in India,” a PBS NewsHour report by Special correspondent Fred de Sam Lazaro (part of his series “Agents for Change”), first aired 17 April 2017.

SUMMARY: “Arunachalam Murugananthan is known as India’s pad man. Breaking a strict taboo in India’s tradition-bound society, Murugananthan worked to perfect an affordable sanitary pad in hope of starting a movement to help women in the developing world. Special correspondent [Fred de Sam Lazaro] reports.”
   This is another inspiring report from Fred de Sam Lazaro about a market-driven approach to addressing what has become a huge public health issue for girls & women around the world: the high cost of commercially-supplied sanitary pads, which makes them unaffordable for far too many families. “Some experts say millions of girls across the developing world miss school during their periods and remain susceptible to infection throughout adulthood.” (transcript, n. pag.) “In India, approximately 70% of reproductive diseases are caused by poor menstrual hygiene.” (closing note to video podcast; see around the 7:23 minute mark)
   Arunachalam Murugananthan prides himself on being a “solutions provider,” with more interest in improving women’s quality of life than in amassing personal wealth. His commitment to building an alternative “low-cost sanitary pad movement across the globe” empowers women, by involving them at every step of the industrial process, starting with technology transfer. After Murugananthan’s dog revealed the secrets of cellulose which, “when scratched vigorously, becomes sponge-like and highly absorbent,” it took the entrepreneurial inventor another two years to perfect an award-winning machine “to fluff up the cellulose” in locally-sourced cotton — a technology described by Murugananthan as “a modified food blender in which the blades have to be angled just so.” (n. pag.)
   “FRED DE SAM LAZARO: [Murugananthan’s machine is] simple, easily replicated, and can be modified to work without electricity, he says. The pads can be made and sold for a fraction of the commercial varieties.  ¶  This is the model for how Muruganantham would like to see his product distributed, thousands of small factories run by groups of women producing these sanitary pads at very low cost and selling them directly to women.” (n. pag.)
   “FRED DE SAM LAZARO: Helped by awards and his own advocacy, more than 4,000 small factories have started making his sanitary pads across India, each with its own local branding and language.... He gets no royalties from any of this. His workshop does sell the machines, enough to earn him a modest living. But nothing is patented. He wants others to copy or even improve the machines and methods.” (n. pag.)

pointer  “Fact Check: Are the Things Lawmakers Say in their Letters about Obamacare True?,” by Charles Ornstein, ProPublica (posted to the NewsHour’s The Rundown: A Blog of News and Insight on 23 March 2017).

“As the debate to repeal the law [Obamacare, aka the Affordable Care Act] heats up in Congress, constituents are flooding their representatives with notes of support or concern, and the lawmakers are responding, sometimes with form letters that are misleading. A review of more than 200 such letters by ProPublica and its partners at Kaiser Health News, Stat and Vox, found dozens of errors and mischaracterizations about the ACA and its proposed replacement. The legislators have cited wrong statistics, conflated health care terms and made statements that don’t stand up to verification.  ¶  It’s not clear if this is intentional or if the lawmakers and their staffs don’t understand the current law or the proposals to alter it. Either way, the issue of what is wrong — and right — about the current system has become critical as the House prepares to vote on the GOP’s replacement bill Thursday.” (n. pag.)
   “‘Do most people pay that much attention to what their congressman says? Probably not,’ said Sherry Glied, dean of New York University’s Robert F. Wagner Graduate School of Public Service, who served as an assistant Health and Human Services secretary from 2010 to 2012. ‘But I think misinformation or inaccurate information is a bad thing and not knowing what you’re voting on is a really bad thing.’  ¶  We reviewed the emails and letters sent by 51 senators and 134 members of the House within the past few months. Here are some of the most glaring errors and omissions ....” (n. pag.)

pointer  “Why Are U.S. Health Care Costs Most Expensive in the World? Patients here spend far more for doctors, drugs than in any other nation” by Paul Sisson (San Diego Union-Tribune, 19 March 2017, pp. A1 and A17), retitled “Why Our Health Care Costs So Much — and Why Fixes Aren’t Likely” for online posting.

“Practically everyone knows health care in the United States is expensive — the most expensive in the world by seemingly every measure. But judging by the raging debate over the Affordable Care Act, few really understand why.  ¶  At the moment, the GOP-led push in Congress and the White House to overhaul Obamacare is focusing on premiums and deductibles, coverage rates and co-pays. Yet they are just the mechanisms of paying for a system that continues to consume a larger percentage of the nation’s gross domestic product than in any other highly industrialized country.” (A1)
   In this in-depth report, Sisson gives “several key reasons why Americans are shelling out more money for what’s often less quality,” with explanations grouped into 5 categories: Price Variations, Prescription Drugs, Technology, Doctors’ Compensation, Waste & Fraud.
   Of note for the debate around the successes of Obamacare and other reforms in controlling costs: “After decades of steady increases, the amount of GDP consumed by health-care services has flattened in recent years.” (A17) But we have a long way to go.
   Dear to my own heart, after numerous frustrating experiences of my own with hospital “waste” and mismanagement and record-keeping that would drive your average entrepreneur out of business, is Sisson’s eye-opening write-up on category 5 (Waste & Fraud): “A 2012 report from the Institute of Medicine estimated that the U.S. health system wastes about $750 billion per year.  ¶  Unnecessary services made up the largest category of waste. Other major segments were excess administrative costs and an over-abundance of efforts to document care given to patients.  ¶  Fraud — even though it tends to grab the public’s attention because of high-profile prosecutions of such criminals — was one of the least significant categories of waste, according to the institute.  ¶  The Affordable Care Act has had mixed results in reducing these costs.  ¶  A massive move toward computerized record-keeping for medical centers was supposed to achieve greater efficiency and thus lower expenses, but that campaign remains fragmented, said Cox at the Kaiser Family Foundation. For instance, systems designed and installed by different vendors still don’t communicate with each other as they should.” (A17)

pointer  “Opinion: Should Americans Have the ‘Freedom’ to Forgo Health Insurance — and Increase Costs for Everyone?,” by Paul Thornton (posted to the Los Angeles Times website, 18 March 2017).

“Here’s an example of the deep polarization in politics today: Many liberals and conservatives apparently do not agree on the meaning of the word ‘freedom.’  ¶  In response to a letter published Wednesday that supported the Republican proposal to replace the Affordable Care Act and touted the repeal of the individual insurance mandate as striking a blow for freedom (which, as the writer said, ‘used to count for something in this country’), several readers offered their own versions of what it means to be free in the context of healthcare.  ¶  Both sides in this debate may use the same words, but if these letters to the editor are any indication, they might as well be speaking a different language.” (n. pag.)

pointer  “Obamacare Replacement Hits Trump Voters Hard: Some of the biggest losers in Republican plan are in counties that supported him,” by Noam N. Levey (Los Angeles Times, 12 March 2017, pp. A1 and A10), retitled “Trump Voters Would Be Among the Biggest Losers in Republicans’ Obamacare Replacement Plan” for online posting.

“For years, Trump and other Republicans have relentlessly attacked the healthcare law for saddling some consumers with unaffordable healthcare.  ¶  But many of the areas where Trump won big have been helped most by Obamacare’s system of subsidies, which were designed to assist Americans who earn too much to qualify for government Medicaid but can’t afford to buy health insurance on their own.” (A10)
   “The House Republican plan would upend this system. There would be no extra aid for low-income consumers or for residents of regions with high insurance costs.” (A10)
   “Trump and other Republicans say that these voters will nevertheless reap the benefits of the GOP alternative.  ¶  The president last week pledged an Obamacare replacement that would ‘lower costs, expand choices, increase competition and ensure healthcare access for all Americans.’” (A10)
   In fact, “Americans who swept President Trump to victory — lower-income, older voters in conservative, rural parts of the country — stand to lose the most in federal healthcare aid under a Republican plan to repeal and replace the Affordable Care Act, according to a Times analysis of county voting and tax credit data.  ¶  Among those hit the hardest under the current House bill are 60-year-olds with annual incomes of $30,000, particularly in rural areas where healthcare costs are higher and Obamacare subsidies are greater.” (A1) Whereas, “The House Republican plan would benefit older, lower-income consumers who currently get relatively small subsidies and live in a few parts of the country including areas in and around Boston and New York City, Kaiser data show. ... The Republican legislation also would help middle-income Americans who make more than $48,000 a year. These people currently don’t qualify for assistance under Obamacare. But under the GOP plan, consumers with incomes as high as $114,000 could get subsidies (though the subsidies are smaller for people making between $75,000 and $114,000).” (A10)

pointer  Letter to the Editor by Brian Dzyak, “Universal Care Isn’t Socialism” (Los Angeles Times, 12 March 2017, p. A23), responding to “Universal Healthcare in State? Dream On” column published in the 3/9/2017 issue of the LA Times.

Dzyak’s letter usefully points out that “Medicare for all” and “single payer” are not the same thing as “socialized medicine”: “An example of socialized medicine is the care delivered through the Department of Veterans Affairs, where medical professionals are government employees and the facilities are paid for by we the people. In contrast, single payer and Medicare for all are universal health insurance, not socialism.  ¶  Nobody is talking about government taking control of doctors and hospitals and nurses and everyone else. It’s about we the people creating our own insurance pool with no profit seekers skimming off the top and trying to deny healthcare. Our 250 million-strong pool of people contributing to this program would lower costs for everyone and give more money to actual medical professionals.  ¶  This would give true freedom to people who are trapped in circumstances like a bad job or a bad marriage who remain just to have medical insurance.” (B. Dzyak of Encino, A23)

pointer  “Employees Who Decline Genetic Testing Could Face Penalties under Proposed Bill,” by Lena H. Sun (posted to the website for The Washington Post, 11 March 2017).

In a direct challenge to existing federal laws which protect genetic privacy and nondiscrimination, U.S. House bill HR 1313, known as the Preserving Employee Wellness Programs Act — introduced by Rep. Virginia Foxx (R-N.C.), who chairs the Committee on Education and the Workforce — would allow employers to impose hefty penalties (up to 30 percent of the total cost of the employee’s health insurance) on employees who decline to participate in genetic testing as part of workplace wellness programs.
   “The bill’s supporters in the business community have argued that competing regulations in federal laws make it too difficult for companies to offer these wellness programs. In congressional testimony this month, the American Benefits Council, which represents major employers, said the burdensome rules jeopardize wellness programs that improve employee health, can increase productivity and reduce health care spending.” (n. pag.)
   Critics contend the legislation “would undermine basic privacy provisions of the Americans With Disabilities Act and the 2008 Genetic Information Nondiscrimination Act (GINA).” (n. pag.)
   “‘It’s a terrible Hobson’s choice between affordable health insurance and protecting one’s genetic privacy,’ said Derek Scholes, director of science policy at the American Society of Human Genetics, which represents human genetics specialists. The organization sent a letter to the committee opposing the bill.” (n. pag.)

pointer  “Capitol Journal: A State Single-Payer Healthcare System? Nice Idea, but It’s Just California Dreaming,” by George Skelton (posted to the Los Angeles Times website, 9 March 2017).

“Now, with congressional Republicans and President Trump trying to repeal and replace Obamacare, some Sacramento Democrats think they see an opening to finally adopt a California version of single-payer.  ¶  Under single-payer, healthcare costs are paid for by the government, rather than by private insurance. The healthcare itself is still delivered by private physicians.
   “Some version that would allow people to buy supplemental private insurance — call it ‘Medicare-for-all’ — presumably could fit into the system these Democrats envision.  ¶  We really don’t know because they haven’t actually proposed anything. They’re promising details in two weeks. So far, they’ve just tucked the concept of single-payer into an essentially hollow bill, SB 562, by Sens. Ricardo Lara (D-Bell Gardens) and Toni Atkins (D-San Diego).  ¶  The bill merely declares: ‘It is the intent of the Legislature to enact legislation that would establish a comprehensive universal single-payer healthcare coverage program and a healthcare cost control system for the benefit of all residents of the state.’  ¶  Yes, that means ‘all’ — whether they’re in the country legally or not.” (n. pag.)
   Elsewhere in another of his “Capitol Journal” columns (“Here’s an Idea for Legislators: Figure Out How to Pay for a Spending Bill Before Proposing It”) Skelton remarks: “Recently I wrote about an effort by two state Senate Democrats — Ricardo Lara of Bell Gardens and Toni Atkins of San Diego — to enact a single-payer healthcare system for California.  ¶  It’s a great idea, in my view, but there would be heated opposition from conservatives and insurers. Regardless, it seems a nonstarter because of the multibillions in cost.  ¶  Lt. Gov. Gavin Newsom has picked up the idea and incorporated it into his 2018 campaign for governor. He wants to model a state plan after a San Francisco universal healthcare system he installed as mayor. But it would require billions from the state and federal governments. Good luck on that.” (n. pag.)

pointer  “Top U.S. Hospitals Promote Unproven Medicine with a Side of Mysticism,” by Casey Ross, Max Blau, Kate Sheridan, STAT (posted to the NewsHour’s The Rundown: A Blog of News and Insight on 9 March 2017).

An excellent study of 15 academic research centers in the U.S. that have embraced a constellation of unproven therapies known as “complementary and alternative medicine” (CAM) in order to bring in patients and revenue. Includes a summary chart showing which alternative therapies are on offer at 15 top academic hospitals.
   “There’s no question that patients want alternative medicine. It’s a $37 billion-a-year business.  ¶  The typical American adult spent about $800 out of pocket in 2012 on dietary supplements and visits to alternative providers, such as naturopaths and acupuncturists, according to the federal Centers for Disease Control and Prevention.  ¶  Hospitals have taken note. A national consortium to promote integrative health now counts more than 70 academic centers and health systems as members, up from eight in 1999. Each year, four or five new programs join, said Dr. Leslie Mendoza Temple, the chair of the consortium’s policy working group.  ¶  In most cases, insurers won’t cover alternative therapies — there’s simply not enough evidence that they actually work — so patients pay out of pocket: $85 for acupuncture, $100 for reiki, $38 for pills made from thyme and oregano oils that promise to ‘harmonize digestive and respiratory function.’  ¶  To be sure, not all such integrative medicine clinics are big profit centers. Many are funded by philanthropists, and some hospitals say their programs operate at a loss — but are nonetheless essential to woo patients in a highly competitive marketplace. If they failed to offer ‘natural’ therapies, some hospital executives fear they would lose a chance to attract patients who need more lucrative care, such as orthopedic surgeries or cancer treatments.” (C. Ross, M. Blau, and K. Sheridan, n. pag.)
   Hoping to transcend the controversy over “conventional medicine” — the dominant modern biomedical model of the Latin West, also known as “evidence-based medicine” or EBM — versus “alternative medicine,” prestigious hospitals and medical schools have created the relatively new academic discipline known as “integrative medicine” (“quackademic medicine” to its detractors). Prominent academics contend that there is only one medical science; e.g.:
   •  “It is time for the scientific community to stop giving alternative medicine a free ride. There cannot be two kinds of medicine – conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work. Once a treatment has been tested rigorously, it no longer matters whether it was considered alternative at the outset. If it is found to be reasonably safe and effective, it will be accepted. But assertions, speculation, and testimonials do not substitute for evidence. Alternative treatments should be subjected to scientific testing no less rigorous than that required for conventional treatments.” (Marcia Angell, a former editor of The New England Journal of Medicine; qtd. at Wikipedia page on Alternative Medicine; accessed 9/28/2017)
      •  “... any alternative cancer cure is bogus by definition. There will never be an alternative cancer cure. Why? Because if something looked halfway promising, then mainstream oncology would scrutinize it, and if there is anything to it, it would become mainstream almost automatically and very quickly. All curative ‘alternative cancer cures’ are based on false claims, are bogus, and, I would say, even criminal.” (Edzard Ernst; qtd. at Wikipedia page on Alternative Medicine; accessed 9/28/2017)
   The authors of this STAT investigation note that academic research centers are sensitive to such criticisms from the medical establishment, and try not to overstep in their claims for popular unproven/disproven therapies, but that they are only partly successful at controlling the new brand: “Lee [i.e., Linda Lee, a gastroenterologist, and director of the Johns Hopkins Integrative Medicine and Digestive Center] and others who promote alternative therapies are careful to say that they can supplement — but can’t replace — conventional treatments. And they make a point of coordinating care with other doctors so that, for instance, patients don’t get prescribed herbal supplements that might interact badly with their chemotherapy.  ¶  ‘Here at UF [University of Florida], we do not have alternative medicine. We do not have complementary medicine. We have integrative medicine,’ said Dr. Irene Estores, medical director of the integrative medicine program at the University of Florida Shands Hospital in Gainesville, Fla.  ¶  But while those cautions may come through in the clinic, the hospitals also promote alternative medicine online — often, without any nuance.” (C. Ross, M. Blau, and K. Sheridan, n. pag.)
   Of note, “Wellness programs — which are designed to ease stress and encourage healthy behaviors — are seen by many clinicians and hospitals as key to slowing America’s epidemic of chronic disease. They don’t tend to draw sharp criticism, except for their cost.  ¶  It’s the alternative therapies promoted as a way to treat disease that raise eyebrows.” (C. Ross, M. Blau, and K. Sheridan, n. pag.)

pointer  “Proton Therapy Center Files for Bankruptcy: Investment group seeks Chapter 11 protection and $16M short-term loan,” by Paul Sisson (San Diego Union-Tribune, 3 March 2017, pp. C1 and C3).

pointer  “A Matter of Life and Death: The American Health Care Act, aka Trumpcare, will shorten lives for many in the service of cutting taxes for a few,” by Mark Paul and James K. Boyce (posted to the website for Dollars & Sense magazine, March 2017).

“The Affordable Care Act [Obamacare] has lengthened tens of thousands of lives. Before the Act was signed into law, one in six Americans were uninsured. Now, only one person in eleven lacks insurance. With over 20 million people gaining insurance, we saw real-life impacts. The expansion of health insurance coverage directly translated into reduced morbidity and mortality for Americans. Fewer Americans are sick, fewer are dying, and millions more are getting the dignity and care they deserve. [...] Harold Pollack, a University of Chicago professor, estimates that the Affordable Care Act saves around 24,000 lives per year.” (n. pag.)
   “The Republican health care bill would roll back these gains, leading many Americans to lose coverage. We don’t yet know exactly how many, but we are talking here about millions of people. The Congressional Budget Office estimates that this bill would cause 14 million Americans to lose health coverage in the coming year, and 24 million to lose it over the coming decade.  ¶  But just how many people will lose their lives—not only their coverage—due to the proposed changes? That’s hard to estimate, but it’s going to be in the thousands, at least. Researchers at the Harvard School of Public Health studied mortality rate changes in Massachusetts after the rollout of the state’s health insurance platform in 2006. They found that overall the death rate from treatable illnesses declined by 4.5%. The decline in death was even greater even in areas of the state where there were more low income people who didn’t have health insurance before health reform.” (n. pag.)

pointer  Text of President Donald Trump’s first address to a joint session of the U.S. Congress on 28 February 2017.

Includes the president’s description of his counter-plan to Obamacare, subsequently nicknamed Trumpcare. Pitting Trumpcare against Obamacare, President Trump sketched out his signature health care plan as follows:
      “Tonight, I am also calling on this Congress to repeal and replace Obamacare with reforms that expand choice, increase access, lower costs, and at the same time provide better health care.  ¶  Mandating every American to buy government-approved health insurance was never the right solution for our country.  ¶  The way to make health insurance available to everyone is to lower the cost of health insurance, and that is what we are going to do.  ¶  Obamacare premiums nationwide have increased by double and triple digits. As an example, Arizona went up 116 percent last year alone. Governor Matt Bevin of Kentucky just said Obamacare is failing in his state, the state of Kentucky, and it’s unsustainable and collapsing.  ¶  One third of the counties have only one insurer, and they’re losing them fast, they are losing them so fast. They’re leaving. And many Americans have no choice at all. There’s no choice left.  ¶  Remember when you were told that you could keep your doctor and keep your plan? We now know that all of those promises have been totally broken. Obamacare is collapsing, and we must act decisively to protect all Americans.  ¶  Action is not a choice; it is a necessity. So I am calling on all Democrats and Republicans in Congress to work with us to save Americans from this imploding Obamacare disaster.  ¶  Here are the principles that should guide Congress as we move to create a better health care system for all Americans.  ¶  First, we should ensure that Americans with pre-existing conditions have access to coverage and that we have a stable transition for Americans currently enrolled in the health care exchanges.  ¶  Secondly, we should help Americans purchase their own coverage, through the use of tax credits and expanded health savings accounts, but it must be the plan they want, not the plan forced on them by our government.  ¶  Thirdly, we should give our state governors the resources and flexibility they need with Medicaid to make sure no one is left out.  ¶  Fourth, we should implement legal reforms that protect patients and doctors from unnecessary costs that drive up the price of insurance and work to bring down the artificially high price of drugs and bring them down immediately.  ¶  And finally, the time has come to give Americans the freedom to purchase health insurance across state lines, which will create a truly competitive national marketplace that will bring costs way down and provide far better care. So important.  ¶  Everything that is broken in our country can be fixed. Every problem can be solved. And every hurting family can find healing and hope. Our citizens deserve this, and so much more, so why not join forces and finally get the job done and get it done right?  ¶  On this and so many other things, Democrats and Republicans should get together and unite for the good of our country and for the good of the American people.  ¶  My administration wants to work with members of both parties to make childcare accessible and affordable, to help ensure new parents that they have paid family leave, to invest in women’s health, and to promote clean air and clean water, and to rebuild our military and our infrastructure.  ¶  True love for our people requires us to find common ground, to advance the common good, and to cooperate on behalf of every American child who deserves a much brighter future.  ¶  An incredible young woman is with us this evening who should serve as an inspiration to us all. Today is Rare Disease Day, and joining us in the gallery is a rare disease survivor, Megan Crowley.  ¶  Megan was diagnosed with Pompe disease, a rare and serious illness, when she was 15 months old. She was not expected to live past five. On receiving this news, Megan’s dad, John, fought with everything he had to save the life of his precious child. He founded a company to look for a cure and helped develop the drug that saved Megan’s life. Today she is 20 years old and a sophomore at Notre Dame.  ¶  Megan’s story is about the unbounded power of a father’s love for a daughter. But our slow and burdensome approval process at the Food and Drug Administration keeps too many advances, like the one that saved Megan’s life, from reaching those in need.  ¶  If we slash the restraints, not just at the FDA but across our government, then we will be blessed with far more miracles just like Megan.” (President Donald Trump, 1st speech before Congress on 2/28/2017, n. pag.)
   The Associated Press fact-checked the President’s speech, including his claims about Obamacare — “Obamacare is collapsing” and “this imploding Obamacare disaster” — with results reported here.
   President Trump’s claim that Obamacare is collapsing in Kentucky — “Governor Matt Bevin of Kentucky just said Obamacare is failing in his state, the state of Kentucky, and it’s unsustainable and collapsing.” — was countered by former Kentucky Governor Steve Beshear, the senior Democrat who put the Affordable Care Act into effect in that deeply conservative state, and the politician chosen to give the Democrats’ response to the Republican president’s speech on 2/28/201. Similarly pitting Trumpcare against Obamacare, Beshear argued for shoring up the latter:
      “And even more troubling, you [Donald Trump] and your Republican allies in Congress seem determined to rip affordable health insurance away from millions of Americans who most need it. Does the Affordable Care Act need some repairs? Sure, it does. But so far, every Republican idea to ‘replace’ the Affordable Care Act would reduce the number of Americans covered, despite your promises to the contrary.  ¶  Mr. President, folks here in Kentucky expect you to keep your word. Because this isn’t a game. It’s life and death for people.  ¶  These ideas promise ‘access’ to care but deny the importance of making care affordable and effective. They would charge families more for fewer benefits and put the insurance companies back in control. Behind these ideas is the belief that folks at the lower end of the economic ladder just don’t deserve health care, that it’s somehow their fault that their employer doesn’t offer insurance or that they can’t afford to buy expensive health plans.  ¶  But just who are these 22 million Americans, including 500,000 people right here in Kentucky, who now have health care that didn’t have it before? Look, they’re not aliens from some distant planet. They’re our friends and our neighbors.  ¶  We sit in the bleachers with them on Friday night. We worship in the pews with them on Sunday morning. They’re farmers, restaurant workers, part-time teachers, nurses’ aides, construction workers and entrepreneurs working at high-tech start-ups. And before the Affordable Care Act, they woke up every morning and went to work, just hoping and praying they wouldn’t get sick, because they knew that they were just one bad diagnosis away from bankruptcy.  ¶  You know, in 2010, this country made a commitment, that every American deserved health care they could afford and rely on. And we Democrats are going to do everything in our power to keep President Trump and the Republican Congress from reneging on that commitment. But we’re going to need your [U.S. populace] help by speaking out.” (Steve Beshear, 2/28/2017 counter-speech to the nation, n. pag.)
   Reporters from The New York Times fact-checked Beshear’s speech, including his defense of Obamacare, with results reported here.
   For 2 in-depth reports on the fate of Obamacare in Kentucky, see below, pointer for the entry dated 2 February 2017 and pointer for the entry dated 7 January 2017.

pointer  “Hospitals Worry an ACA Repeal Could Harm their Financial Health,” a PBS NewsHour report, first aired 27 February 2017.

SUMMARY: “Efforts by the Trump administration and congressional Republicans to dismantle the Affordable Care Act are underway, unnerving to some hospital executives who see uncertainty for their bottom line. If large numbers of people lose their insurance under a replacement, hospital finances could be at risk. Special correspondent Sarah Varney reports.”
   Obamacare “shifted the business model for U.S. hospitals. It offered them financial incentives to move away from expensive E.R. visits to primary care and managing chronic conditions. [...] Before the Affordable Care Act, hospitals had little incentive to reduce E.R. visits, especially from Medicare patients who generate a lot of revenue.  ¶  At the University of Chicago Medicine, an academic medical center, Dr. Kenneth Polonsky says that if those incentives are rescinded and patients forgo preventive care, they will clog up already strained emergency rooms.” (n. pag.)
   “Two hospital trade groups, the American Hospital Association and the Federation of American Hospitals, have warned of — quote — ‘an unprecedented public health crisis’ if the law is hastily scuttled.  ¶  They say if Congress repeals the law entirely and 20 million people are kicked off their insurance, hospitals will lose $166 billion in Medicaid payments alone in the next decade and face much steeper losses if certain Medicare cuts that were part of the law aren’t restored.” (n. pag.)
   “Edmund Haislmaier, a senior fellow at the Heritage Foundation, a conservative think tank, says U.S. taxpayers already spend too much on health care.  ¶  Haislmaier, who was a member of President Trump’s transition team on health policy, says communities and states and local governments shouldn’t rely on hospitals to create new jobs and fill their budget holes.” (n. pag.)
   The comments section for this piece includes another commonly-expressed criticism of the current hospital business model, voiced under the pseudonym “ABC_AS” who argues that Cadillac health care is not a right; different levels of care should be provided according to one’s ability to pay:
      “But you should be able to buy catastrophic coverage for that amount [i.e., $333/mo = as paid for with GOP-proposed “tax credits ranging from $2,000 to $4,000”]. People are treating medical insurance as prepaid medical care these days.  ¶  But I get your [i.e., comment by “Eugene_2016”] point and we need to do something about the cost of medical care, not come up with more gimmicks to pay for it. This means that we need to open up the market to competition so people can legally buy the level of medical care they can afford. This means that if you’ve never really worked and contributed to society, and thus never got paid much, you may not get a half a million dollar heart operation, you may just get a bottle of pills, or an operation performed by a doctor trained in Bolivia.” (comment posted by “ABC_AS”)
      & again: “They should allow all those poor people to buy the level of care people can access in other countries instead of setting up a new hospital with the same standard of care as people that pay their own way in life. People like to talk about how cost effective and great health care in Cuba is, make that level of care available to the poor. Since those hospitals are basically being supported by tax-charity, how about if they [sic] people working their [sic] have some skin in the game also and work at a reduced rate instead of just getting full salary handing out charity care.” (comment posted by “ABC_AS”)

pointer  “With Healthcare, They Think It’s Time to Go Solo: Amid the fight over Obamacare, some California politicians and advocates again promote idea of a state-run ‘single-payer’ system,” by Soumya Karlamangla (Los Angeles Times, 26 February 2017, pp. B1 and B5), retitled “With Obamacare in Jeopardy, California Considers Going It Alone with ‘Single-Payer’ System” for online posting.

“State Sen. Ricardo Lara (D-Bell Gardens) introduced a bill Friday [2/24/2017] that would make California the first state to adopt single-payer, also called ‘Medicare for all.’ Canada has such a system.” (B1)
   While “we know that universal healthcare is popular in the minds of Californians,” even supporters worry that “It’s just not feasible to do as a state.” For example, “a 2008 report from California’s Legislative Analyst’s Office found that even with a tax on Californians and the state’s pooled healthcare funds, the state would still be short more than $40 billion in the first full year of single-payer implementation.” (B5)
   Various alternatives to improving on Obamacare have also been floated: “If Congress repeals the Affordable Care Act, California could pass its own mandate requiring that everyone have insurance and that employers provide insurance. The state could go a step further, requiring that employers cover part-time workers, who are currently not included in the law’s employer mandate.  ¶  The state could also create a public option — its own health plan to sell on Covered California — that could be open to immigrants who are in the country illegally. They are barred from signing up for Obamacare under federal law. If the health plan is successful, it could one day morph into a single-payer system, Katz said.” (B5)

pointer  “Health Care’s Future: Turning Patients into Savers, Shoppers,” by Tom Murphy of The Associated Press (posted to the website for the Telegraph Herald, 26 February 2017).

“Republicans indicated recently that they will encourage wider use of insurance that comes with a health savings account [HSA] aimed at pushing patients to save and shop for care.” (n. pag.)
   “More than 20 million people are covered by plans with HSAs, according to various estimates. Patients who used these accounts for years say they save money, and the coverage changes how they approach health care. But these plans also might push patients to skip care or quickly pile up debt. The shopping they encourage also is limited.  ¶  While these plans might help patients save on doctor visits, they do little to curb spending on the priciest care like major surgeries.” (n. pag.)
   Murphy gives 3 people’s perspectives on the use of HSAs — a 41-year-old Boulder, CO resident confronted with a medical emergency; a 48-year-old real estate broker from Windermere, FL; and a 58-year-old financial adviser from Orlando, FL. All three stress the need for advance planning (which is not always possible) and that “You have to learn to play the game.”

pointer  “New Federal Rules Require Home Health Agencies to Do Far More for Patients,” by Judith Graham, Kaiser Health News (posted to the NewsHour’s The Rundown: A Blog of News and Insight on 9 February 2017).

“The federal regulations, published last month [January 2017], specify the conditions under which 12,600 home health agencies can participate in Medicare and Medicaid, serving more than 5 million seniors and younger adults with disabilities through these government programs.  ¶  They strengthen patients’ rights considerably and call for caregivers to be informed and engaged in plans for patients’ care. These are ‘real improvements,’ said Rhonda Richards, a senior legislative representative at AARP.  ¶  Home health agencies also will be expected to coordinate all the services that patients receive and ensure that treatment regimens are explained clearly and in a timely fashion.  ¶  The new rules are set to go into effect in July [2017], but they may be delayed as President Donald Trump’s administration reviews regulations that have been drafted or finalized but not yet implemented. The estimated cost of implementation, which home health agencies will shoulder: $293 million the first year and $234 million a year thereafter.  ¶  While industry lobbying could derail the regulations or send them back to the drawing board, that isn’t expected to happen, given substantial consensus with regard to their contents. More likely is a delay in the implementation date, which several industry groups plan to request.” (n. pag.)

pointer  “Does this Obamacare Experiment Offer Significant Savings?,” a PBS NewsHour report, first aired 6 February 2017.

SUMMARY: “One of the goals of the Affordable Care Act was to develop organizations that offer doctors and hospitals a deal: In exchange for more efficient care for Medicare recipients, providers receive a share of the savings as a bonus. Now that ACOs [Accountable Care Organizations] have become embedded in the health care system, are they really working? Special correspondent Jackie Judd reports.”
   Early indications are that “Medicare has saved only a modest amount of money.  ¶  Ashish Jha, a doctor and health policy researcher at Harvard, was an early supporter of ACOs and he still is. But he also is questioning whether early expectations for dramatic cost savings and quality improvements will ever be met.” (n. pag.)
   “Even with its early success, Coastal Medical and other ACOs are still searching for that elusive formula of better care at a lower cost.” (n. pag.)
   “Whatever the fate of Obamacare, this experiment likely will be given several more years to prove whether personalized, coordinated care really does in the end save large amounts of money.” (n. pag.)
   The piece opens with news from Donald Trump’s 2/5/2017 interview with FOX News in which he acknowledged that it might take longer to repeal and replace Obamacare than he’d indicated previously. Bill O’Reilly, host of The O’Reilly Factor, asked: “Can Americans in 2017 expect a new health care plan rolled out by the Trump administration, this year?” to which President Donald Trump replied: “In the process, and maybe it will take until some time into next year, but we are certainly going to be in the process. Very complicated. Obamacare is a disaster.  ¶  You have to remember, Obamacare doesn’t work, so we are putting in a wonderful plan. It’s statutorily takes a while to get. We’re going to be putting it in fairly soon. I think that, yes, I would like to say by the end of the year, at least the rudiments, but we should have something within the year and the following year.” (n. pag.)

pointer  “The Economics and Potential Emotional Cost of Repealing Obamacare,” a PBS NewsHour report, first aired 2 February 2017.

SUMMARY: “Repealing and replacing the Affordable Care Act was a top priority for President Donald Trump during his campaign. But there are hurdles — both economic and in the expectations of the millions who are now covered. Economics correspondent Paul Solman reports from Kentucky, a region that’s seen one of the biggest drops of the uninsured rate in the country due to Obamacare.”
   From Solman’s telling exchange with a cancer patient in Kentucky about Obamacare’s hated insurance mandate:
      “PAUL SOLMAN: Bobbi Smith, who owns an antiques store, was diagnosed with breast cancer in the fall of 2015, a year in which, having missed the open enrollment deadline, she’d accidentally gone without health insurance. She waited until January to buy coverage on healthcare.gov and get treated.  ¶  But, says this Trump voter:
      “BOBBI SMITH: I think if I were to walk around here with no health insurance, and that’s what I choose to do, then that’s my right.
      “PAUL SOLMAN: But you’re thankful you have that insurance?
      “BOBBI SMITH: Oh, yes, I am, yes.
      “PAUL SOLMAN: So, you’re kind of torn here?
      “BOBBI SMITH: That’s right.” (n. pag.)
   and again later:
      “PAUL SOLMAN: But to Bobbi Smith and Perry Partin, it’s the very principle of a mandate that rankles, no matter the economics.  ¶  [asking Bobbi Smith] How can there be health insurance if the healthier people don’t participate? Because then it’s just going to be the sicker people who are going to be insured, and then the cost is going to be too high, no?
      “BOBBI SMITH: You made a point. [laughter]  ¶  I didn’t say I necessarily agreed. You made a point I will think about.
      “PERRY PARTIN: I would say you’re right. But I’m just like her [Bobbi Smith]. If you want insurance, it would be your option.” (n. pag.)
   Smith’s commonplace assertion of her right to remain uninsured undermines both a public insurance option and the private insurance markets:
      “ROBERT FRANK, Economist, Cornell University: If you don’t have a mandate, you cannot have an insurance system.  ¶  The only way a system of insurance can work is if everybody’s in the pool together, healthy and sick people alike. And if you want healthy people in the pool, you have essentially got to mandate that they be a participant.  ¶  The insurance company needs a large number of people, only a few of whom are going to make claims against it.” (n. pag.)
   Of note, the health savings account (HSA), an alternative to traditional insurance plans promoted by Trumpcare and favored by conservative House Republicans who want people to fund more of their own health care, is deemed a poor substitute by one discussant in the comments section to this piece:
      “I knew a guy that decided to go without the insurance and use a savings [account] for any medical costs. After cancer hit him he was stone cold broke in 4 months. He had saved a quarter million dollars and it was gone. And he still didn’t have any insurance.” (posted by “disqus_0fotImVld4”)
   For more re. Kentucky’s experience with Obamacare, see above pointer for the entry dated 28 February 2017 and see below pointer for the entry dated 7 January 2017.

pointer  “How Doctors View Obamacare: Most oppose repeal and GOP plan to shift costs to patients, survey finds,” by Melissa Healy (Los Angeles Times, 29 January 2017, p. A8), retitled “Here’s What Primary Care Doctors Really Think about Obamacare” for online posting.

“Among the survey’s most striking findings was strong support for an extension of the Affordable Care Act that is absent from any GOP proposals: Two-thirds of primary care physicians endorsed the idea that any healthcare reform should include a public insurance option resembling Medicare that would compete with private plans.” (A8)
   Yet, Obamacare’s universal mandate is almost as unpopular with doctors, as with the general public seeking its repeal: “That ‘universal mandate’ is the mechanism the ACA used to ensure that young and healthy people join the insurance pool and help offset the costs of the pool’s sickest participants, spreading the costs of care. The finding that fewer than half of doctors support the mandate underscores the ‘important need to educate healthcare providers and the public about the fundamental inseparability of these provisions,’ the authors wrote.  ¶  Grande said that physicians’ tepid support for a universal mandate is stronger than that in the general public, indicating that ‘they probably understand that connection’ a little more than some. ‘But health insurance and policy is very complex for consumers and for physicians as well. So I’m not terribly surprised,’ he added.” (A8)

pointer  “Reassessing the Value of Care for Chronic Health Conditions,” a PBS NewsHour interview with health care reformer Atul Gawande, by William Brangham, first aired 18 January 2017.

SUMMARY: “Surgeon Atul Gawande says we need to reconsider health care’s focus on generously rewarding physicians who practice heroic interventions, rather than those who practice incremental medicine for chronic conditions. Gawande talks with William Brangham about the value of that kind of care, and the potential effects of a Republican repeal of the Affordable Care Act.”
   “DR. ATUL GAWANDE: My biggest fear — so, first of all, where we are right now, 27 percent of Americans under 65 have an existing health condition that, without the protections of the ACA, would mean they would — could be automatically excluded from insurance coverage.  ¶  Before the ACA, they wouldn’t have been able to get insurance coverage on the individual market, you know, if you’re a freelancer or if you had a small business or the like. [...] So, the first thing is that the ACA protections have to be preserved, or those people get pitched out.  ¶  But the big thing that’s happened is, in the time since the ACA has been going on, our medical science has been advancing. We have now genomic data. We have the power of big data about what your living patterns are, what’s happening in your body. Even your smartphone can collect data about your walking or your pulse or other things that could be incredibly meaningful in being able to predict whether you have disease coming in the future and help avert those problems.  ¶  That is the transformation that’s coming. But one of the consequences of if the ACA is repealed, is that all of us now are at risk of being a preexisting — of having a preexisting condition waiting to happen. Life, increasingly, is a preexisting condition waiting to happen, now that we have more and more of this data available.” (n. pag.)

pointer  “A Way to Save Money When Half of All Health Costs Is Spent on a Fraction of Patients,” a PBS NewsHour report, first aired 17 January 2017.

SUMMARY: “Health care ‘super-utilizers’ make up just 5 percent of the U.S. population but they account for 50 percent of health care spending. As health care costs continue to rise, providers are trying to figure out how to find these patients and get to the root of their problems. But the looming repeal of the Affordable Care Act may disrupt those efforts. Special correspondent Sarah Varney reports.”

pointer  Kentucky’s Medicaid Expansion Under ACA Could Soon Change,” a PBS NewsHour report, first aired 7 January 2017.

SUMMARY: “The Affordable Care Act has brought insurance coverage to millions of low-income Americans. But with President-elect Donald Trump and Republicans in Congress vowing to repeal the law, its future is uncertain. NewsHour Weekend Special Correspondent Chris Bury traveled to Kentucky, a state with one of the biggest drops in uninsured residents since the law went into effect.”
   “Here in Kentucky the rollout of the Affordable Care Act in 2013 was considered such a success, it became a model for other states. In the first few months, more than 300,000 people qualified for Medicaid coverage under the new law, and Kentucky saw a dramatic decrease in the percentage of uninsured residents. One of the biggest drops of its kind in the country.  ¶  In 2013, nearly 19% of Kentucky’s non-elderly population had no health insurance. By 2015, the uninsured rate had fallen to less than 7%. That’s better the national rate of the uninsured, which has dropped to 10.5%.  ¶  Former Kentucky Governor Steve Beshear — a Democrat — pushed for both a state exchange and Medicaid expansion under the Affordable Care Act.” (n. pag.)
   A study published by the Journal of the American Medical Association in October 2016 “found Kentuckians newly insured in the first two years of Medicaid expansion received more primary and preventive care, made fewer emergency room visits, and reported better health.  ¶  But in Kentucky, like many states that usually vote Republican for president, ‘Obamacare’ became a political punching bag. And in 2015, Republican Matt Bevin successfully ran for governor promising to roll back parts of the law if elected.  ¶  Last year, Kentucky eliminated its state exchange, saying it was redundant given the federal exchange. To help control costs, Governor Bevin also asked the federal government for permission — known as a waiver — to overhaul the state’s Medicaid program, which now covers 1.3 million people, almost one in three residents.” (n. pag.)
   For more re. Kentucky’s experience with Obamacare, see above pointer for the entry dated 28 February 2017 and pointer for the entry dated 2 February 2017.

pointer  “‘Repeal and Replace’? More like repeal and collapse, warns HHS Secretary Burwell,” a PBS NewsHour conversation, first aired 12 December 2016.

SUMMARY: “During the presidential campaign, President-elect Donald Trump promised to repeal and replace the Affordable Care Act, also known as ‘Obamacare.’ But undoing the law and creating a new one may be more difficult than his campaign rhetoric suggested. Judy Woodruff speaks with President Obama’s Secretary of Health and Human Services Sylvia Burwell about the future of the health care law.”

pointer  “Op-Ed: Trump Should Keep this Part of Obamacare,” by Catherine Rampell (posted to the website for The Washington Post, 1 December 2016).

Rampell’s op-ed wonders what effect President-elect Donald Trump’s pick for Secretary of Health and Human Services, orthopedic surgeon and 6-term Rep. Tom Price (R-Georgia), will have on “Medicare’s efforts to move away from fee-for-service-based care, and toward more value-based care.”
   “Tucked into Obamacare was a little-noticed provision that was, in a way, a stealth attempt at entitlement reform. I say ‘stealth’ because it didn’t involve cutting seniors’ benefits or raising their premiums or taxes, the more visible and painful tools that fiscal hawks sometimes offer.  ¶  Instead, it created a sort of internal R&D shop for government health-care payment reform, called the Center for Medicare & Medicaid Innovation.  ¶  The Innovation Center runs experiments to find ways to eliminate waste in government health spending.  ¶  These are generally not experiments in what kinds of drugs work, or in telling doctors what kinds of treatments or clinical interventions to give their patients. (That is, they’re not the much-hyperbolized ‘death panels.’) Rather, they’re experiments in whether paying health-care providers differently can give those providers room to figure out how to treat patients more effectively, and more cheaply, on their own.” (n. pag.)
   Designee Price “has vocally expressed his displeasure with the Innovation Center, as well as other recent policy measures designed to move toward Medicare value-based payments. (The powerful pharmaceutical lobby has as well.) ...” (n. pag.)

pointer  “Drug Costs Surge for the Elderly: Competition among insurers fails to hold down prices, spurring calls to let Medicare negotiate them,” by Melody Petersen (Los Angeles Times, 24 November 2016, pp. C1 and C4), retitled “Drug Costs Skyrocket for Many Older Americans, Despite Medicare Coverage” for online posting.

“When Congress added a prescription drug benefit to Medicare in 2003, the pharmaceutical industry did not just get millions of new customers. But Congress also placed language in the law explicitly banning Medicare from using its power to negotiate lower drug prices.  ¶  The argument for the ban on such bargaining was that each insurer offering a Medicare drug plan would compete and keep prices under control through their own negotiations with the pharmaceutical companies.  ¶  For years, Medicare drug costs have been lower than analysts’ initial projections, which seemed to confirm the system was working. Now, however, as is the case for prescription drugs covered by other programs, the cost to retirees is skyrocketing.” (C1 and C4)
   Among those affected are cancer patients, like 71-year-old Roberta Solar, who “has to take a medicine called ursodiol, perhaps for the rest of her life” to avoid liver damage; “Next year her annual out-of-pocket costs for the drug will jump from $93 to $1,878 – a rise of almost 2,000%, according to information that she and her husband recently received from the insurer that covers their medicines under Medicare.” (C1)

pointer  “As Obamacare Enrollment Nears, Some Californians Face Big Hikes: Many finding increases in health rates far higher than announced in July,” by Melody Petersen (Los Angeles Times, 29 October 2016, pp. C1 and C4), retitled “Some Californians See Health Premiums Rise Sharply as Obamacare Enrollment Nears” for online posting to the Los Angeles Times website.

“California has been lauded for creating its own online insurance market, which experts say helped to sharply reduce the share of people without coverage and kept rate hikes lower than elsewhere for the vast majority of policyholders.... But as Californians receive their premium rates for next year, some — including those who make too much to qualify for those government subsidies — are learning that their hikes will be far higher than the average statewide increase of 13.2% announced by the state insurance exchange in July.” (C1 and C4)

pointer  “An Obamacare Success Story: Critics aside, the state is proving health law works,” by Noam N. Levey (Los Angeles Times, 16 October 2016, pp. B1 and B6).

“Though health coverage has faltered in other states where politicians worked to undermine the law, California highlights what can be accomplished if government officials and industry leaders work together to expand insurance, control costs and protect consumers.” (B6)
   “More than three-fourths of newly insured Californians said their health needs are now being met, a recent survey by the nonprofit Kaiser Family Foundation found.” (B6)

pointer  “Op-Ed: Reports of Obamacare’s Demise Are Greatly Exaggerated,” by Catherine Rampell (posted to the website for The Washington Post, 13 October 2016).

“The popular narrative that health-care prices and spending are growing at ludicrous speed is completely, utterly false. On nearly every metric, health care today is actually much cheaper than anyone predicted when Obamacare was signed into law.  ¶  I know, I know. Readers will call baloney because their own health-related costs have gotten so high.  ¶  Yes, they are expensive and, yes, they are growing. But the aim of the Affordable Care Act was never to make health-care prices fall; it was merely to prevent them from growing at the insane rates we saw in the decades before the law.” (n. pag.)
   “Since Obamacare passed, health prices have been rising at the slowest rate in 50 years.” (n. pag.)
   Naturally, “[t]he Obama administration likes to take credit” for the price & spending slow-down. Nevertheless, “Given that we don’t exactly know what caused the slowdowns, it’s hard to predict whether they’ll continue. There are some worrying signs that they may not, including: hospital and provider consolidation; reduced competition among insurers (especially on the exchanges); delayed implementation of the ‘Cadillac tax’ on high-cost insurance; and recent approval of expensive, potentially blockbuster drugs.  ¶  But in the meantime, those claims that Obamacare would destroy the economy and send health-care prices through the roof? So far that dog hasn’t barked.” (n. pag.)

pointer  Op-ed, “A Doctor Delivers Bad News: American Healthcare Is Selling What You Don’t Need at a Ridiculous Price,” by Michael Jones (Los Angeles Times, 8 May 2016, p. A23), retitled “Op-Ed: There’s No Place for Rampant Capitalism in Treating the Sick” for online posting.

Jones, a gastroenterologist, opines: “The American healthcare system is capable of many wonderful things, but not all of them are about health or care. It is just as often about selling you things you probably don’t need at a ridiculous price, or finding ways to charge you a ridiculous price even for what you do need.” “No healthcare system is perfect, but here’s what the rest of the civilized world understands: Healthcare is a right. There is no place for rampant capitalism in treating the sick. This advice is harsh but true: When it comes to your healthcare, buyer beware.” (A23)
   And a discussant using the moniker “Canyon63” countered: “Healthcare is not a right that has to be delivered and paid for by other people for your benefit. You have a right to buy health care from willing sellers. You do not have the right to make someone else pay for it. Get the government force and regulation out of the market for health care. Let buyers and sellers sort it out based on their personal values.” (posted by “Canyon63” to the comments section below the transcript)

pointer  Dollars & Sense magazine column by Gerald Friedman, “Bernie Sanders’ Health Care Revolution,” from the March/April 2016 print issue (No. 323, pp. 32–3).

“While Senator Sanders has made single-payer health care, or ‘Improved Medicare for All,’ a cornerstone of his presidential campaign, Secretary Clinton has attacked the proposal, claiming that it would lead to higher taxes on ordinary Americans while threatening the coverage gains already achieved under the Affordable Care Act (ACA, or ‘Obamacare’). In fact, Improved Medicare for All would substantially reduce health care costs (especially for low- and middle-income families), expand coverage, and improve access to care.” (32)
   Of note, Dollars & Sense columnist Gerald Friedman, a professor of economics at the University of Massachusetts-Amherst, “has been in the spotlight — or you could say, the hot seat — for his analysis of Sen. Bernie Sanders’s economic program. Four former chairs of the Council of Economic Advisors pulled rank on him for what they viewed as overly rosy projections of economic growth should the program be implemented.  ¶  As the dust settled on the Friedman affair, one lesson seems to be that mainstream economists have lowered their expectations — and are trying to lower everyone else’s — about what changes in economic policy can accomplish. Friedman’s analysis has helped broaden the sense of the possible. As the New Yorker’s John Cassidy put it, ‘He offers a timely reminder that economic growth rates aren’t set in stone, and that changes in policy ... can have a substantial impact.’” (p. 1 of 3/12/2016 fundraising letter to journal subscribers from the editors and the Dollars & Sense collective)
   “Those interested in reading more about the controversy [initiated on 2/17/2016 when a group of former chairs of the Council of Economic Advisors issued an open letter criticizing Gerald Friedman’s estimates of the economic growth effects of presidential candidate Bernie Sanders’ proposed policies], or about the methods Prof. Friedman used to estimate the combined growth effects for six of Sanders’ proposed spending programs for a recent column in Dollars & Sense (Nov/Dec [2015]), are invited to visit the D&S blog” (Editor’s note, Dollars & Sense, 323 [March/April 2016]: 3).

pointer  How this Indian Medical Chain Makes Heart Surgery Affordable,” a PBS NewsHour report by Fred de Sam Lazaro (part of his “Agents for Change” series), first aired 16 September 2015.

SUMMARY: “Dr. Devi Prasad Shetty, one of the world’s most prolific heart surgeons, is the founder of a for-profit medical chain in India that offers top-notch surgery at very low prices. It serves wealthy patients and some medical tourists, but their goal is to bring the latest advances to the poor. Special correspondent Fred de Sam Lazaro reports.”
   Some notable quotes from the piece:
1.  “DR. DEVI PRASAD SHETTY: This patient would have paid us about $2,500 to about $3,000, but in the U.S., an operation of this nature would cost, I guess, more — anything from $30,000, $100,000.” (n. pag.)
2.  “FRED DE SAM LAZARO: That’s about $1,300, a lot of money in India, where hundreds of millions earn $2 a day or less, a country where 80 percent of all medical bills are paid out of pocket. A few patients receive care from a charitable trust Narayana set up, but Shetty says most have scrounged together the resources before coming here.
   “DR. DEVI PRASAD SHETTY: They virtually sell everything that they have and come for treatment. Half the country’s population borrow money or sell assets to pay the medical bills.” (n. pag.)
3.  “FRED DE SAM LAZARO: That meant a daylong train journey to this hospital. But once here, another Narayana benefit kicked in: an insurance program developed with farmers groups and state governments in South India.  ¶  The insurance policy covers only major medical costs, like surgery, but the premium of just 10 U.S. cents a month makes it widely affordable, says Narayana’s CEO, Dr. Ashutosh Raghuvanshi.
   “DR. ASHUTOSH RAGHUVANSHI, CEO, Narayana Health: It’s amazing that such a small amount of money could provide that care. The number of people who are covered under this scheme is about 10 million now, and it has performed close to about 100,000 operations of various kinds.
   “FRED DE SAM LAZARO: We were assured 3-year-old Chitrashri was in no physical pain, just anxious as nurses removed her stitches from a successful heart operation, a huge relief medically and financially for her parents, who struggle to get by selling milk from their two cows.  ¶  The insurance coverage for this extended family and many others, the first of its type in [being] aimed specifically at the poor, has also been a significant source of income for Narayana Health.
   “DR. ASHUTOSH RAGHUVANSHI: About 25 percent.” (n. pag.)
4.  “DR. DEVI PRASAD SHETTY: We have 32 hospitals across India. Twelve percent of the heart surgery done in India is done by us. When we implant one of the largest number of heart valves in the world, obviously, you pay for it less than others. And, also, more than the cost, your results get better.
   “FRED DE SAM LAZARO: He says the sheer volume of surgery not only means more productivity. It makes better surgeons, attracting those focused on their surgery, rather than their income. They’re paid well by Indian standards, but far less than they could earn elsewhere, especially in the West.
   “DR. DEVI PRASAD SHETTY: We can address the need of the doctors, but we cannot address the greed of the doctors. And I’m pleased to say that our attrition rate among doctors is virtually zero percent. They love working here.
   “FRED DE SAM LAZARO: What qualities are you looking for specifically to work in a place like this?
   “DR. DEVI PRASAD SHETTY: The most important quality is the passion. The second most important quality is the compassion.
   “FRED DE SAM LAZARO: Despite his compassion, he says, he’s not running a charity.
   “DR. DEVI PRASAD SHETTY: Charity is not scalable. It doesn’t matter who you are. You may be the richest person living on this planet, but if you want to offer free surgery, free treatment to everyone, you will go broke within a month. But good business principles, standard business policies are scalable.
   “FRED DE SAM LAZARO: Narayana Health has branched out beyond cardiac surgery into cancer and kidney care, and Shetty says it will become the largest hospital system in a few years.” (n. pag.)

Panel from "Roses", a mixed-media work by Tuck Contreras

[ A note about the 18 hover-box notes (or “pop-ups”) used on this Web page.
To view all 18 of this Web page’s hover notes in a second-window aside, click/tap here. ]

go to start of MEDIA LINKS section

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First Catalog of Annotated Links
(no longer maintained after February 2014)

N  O  T  E

   Those of you looking for a quick link to California’s state agency tasked with creating and running the new health insurance exchanges mandated by the Affordable Care Act of 2010 can connect directly to Covered California here.
   For new information affecting the next Open Enrollment period — which runs from 11/15/2014 through 2/15/2015 — see the post to our What’s Blooming news page dated 9/30/2014.
   For dated information concerning the 2013–2014 launch of Covered California, see below, pointer for the entry dated 2 August 2013.

For many years, I have been collecting mass-media accounts of news relating to spiralling health care costs, along with suggestions for health care reform. As a consequence, I now have 27 fat folders filled with print-media clippings in my filing cabinet, and nowhere near enough free time to hunt down working URLs for all of it. Hence, I’ve had to be very selective in my starting list of media links, first assembled and posted here on 15 May 2013.

For the most part, I’ve favored recent over older material, and indulged my bias for content that is freely accessible online.

I have also chosen to focus on areas of particular interest to me (such as “Medicare for all” proposals).

Some of the media reports linked to below cover important changes in medical technology (such as affordable genetic testing of the sort pioneered by 23andMe) and law (such as the legal disputes over patented genes), which are going to impact us and our health care delivery system in all sorts of unknown ways.

Other media reports focus on health care administrivia (thanks to Conrad Taylor for this coinage ;-) such as billing codes and the problems with implementing electronic medical records — because, as the saying goes, the devil is always in the details — and some delve into larger administrative matters, such as questionable (ab)uses of non-profit status.

As always, I will continue to post new links to interesting media coverage of related issues as I find them (in reverse chronological order, according to the date when the news item was published).

pointer

N O T E :  Updates are sometimes filed with an earlier story if there is a close thematic tie, as with the debate over food stamps (see below, pointer for the entry dated 6 June 2013), the debate over automation (see below, pointer for the entry dated 25 February 2013), and with ongoing reporting about veterans’ health care issues by Los Angeles Times columnist Steve Lopez as well as the PBS NewsHour (see below, pointer for the entry dated 7 July 2013).  ::

With open enrollment in the new health insurance marketplace beginning 1 October 2013, media coverage of Obamacare is so intense I can’t keep up with it all ... which is in this case a good thing, since huge numbers of us need to become better educated about the issues, so that we can make wise health care choices for ourselves and our families, our businesses and our communities.

The more media coverage, the better.

Given the tsunami of information that’s coming, I must continue to be selective about what gets included below. Even so, the (mostly) chronological ordering of pointers makes it all too easy for some of the more interesting stories to get buried under the steady stream of updates.

To adjust for this, I have decided (as of 5 October 2013) to add a roving “featured link” to this page, which I can use to call attention to a theme or storyline I believe bears thinking about for a little longer than our postmodern news cycle encourages. Each featured link will be announced on our What’s Blooming news page, along with my reasons for choosing it.

pointer  “Connecticut’s ‘Health Exchange-in-a-Box’ for Struggling States,” a Marketplace public radio segment by Sarah Gardner, first aired 25 February 2014.

“Connecticut is getting entrepreneurial with its healthcare exchange. Access Health CT has done so well that it started getting calls for help and advice from other states.” A new business model for the state is emerging: “Connecticut is now setting up a consulting business to help other states copy its success.”
   As reported by Marc Sollinger in his 2/25/2014 companion piece for Marketplace — “Consulting: A New Source of State Revenue?” — “ Bad news seems to be the theme of the Affordable Care Act rollout. But Connecticut seems to be bucking that trend. The state has seen 55,000 people sign up for health care on the state’s website, far in excess of the federal government’s goal of 33,000. The state has been so successful in fact, that it’s starting a consulting business to help other states with their own websites. The state’s exchange, Access Health CT, is looking to either license or franchise the technology it used to create its website, making it much easier for states like Arkansas or Iowa to control their own health care policy while not having to hire a large staff.”

pointer  “Paying Doctors for Value instead of Volume,” a Marketplace public radio segment by Dan Gorenstein, first aired 25 February 2014.

Gorenstein here raises some of the difficulties involved in moving away from fee-for-service payment systems, and the challenges confronting medical professionals “contemplating what would happen if they got paid for value instead of volume.”

pointer  “Former Health Care CEO Argues America’s Medical System Rewards Bad Outcomes,” a PBS NewsHour conversation, first aired 17 January 2014.

“SUMMARY: Judy Woodruff talks to George Halvorson, former CEO of Kaiser Permanente and author of Don’t Let Health Care Bankrupt America, who argues we spend too much money on care that doesn’t deliver optimal benefits. How can the U.S. alter its approach to serve all Americans more cost-effectively and with better outcomes?”
   And there’s more from Woodruff’s conversation with Halvorson online at The Rundown: A Blog of News and Insight: “How Does Health Care in America Differ from that of Other Countries?” (posted by Murrey Jacobson, 1/17/2014). I recommend listening to this “extra online conversation.” Halvorson has an interesting perspective on how we change the business model of care in the U.S., and recommends introducing market forces, rather than relying on government pricing mandates, to ensure lower costs and better health outcomes.
   At one point, Halvorson tells Woodruff: “I can’t imagine that our government would ever be allowed to set prices for everything. And I don’t think we should go there. What I think we should go to, though, is a market model where prices are visible and relevant, and where the care givers who charge less are rewarded by having more patients. And what we do right now, we have these deductible plans, and these deductible plans disguise the cost of care for 90% of the people. ... But we have chosen in this country not to use the market model, which is really ironic, because in everything else in our economy, we’re the king of the market model.” (George Halvorson, PBS NewsHour interview, 1/17/2014)
   Halvorson also adds his voice to the growing call for better transparency, so that patients have access to the data they need to make more informed health-care decisions: “If you have breast cancer, your chance of dying can be double or triple if you go to the wrong care site. That data’s all available, and what we need to do is mandate that it be made available to consumers. And once we do that, two things will happen. One is that care will get better. And the other is that all the care givers who are not doing a good job — I talk about that in the book, I give examples — the other care givers will get better. Right now they don’t know what their own death rate is. There are cancer sites that do not know their death rate. And if you force that to happen, those sites will get better.” (George Halvorson, PBS NewsHour interview, 1/17/2014)

pointer  “The Koch Brothers Are Spending on the Midterm Elections. Already,” a Marketplace public radio segment by David Gura, first aired 15 January 2014.

Tim Phillips, president of Americans for Prosperity (an organization backed by the Koch brothers), just announced a $1.8 million ad buy, telling Gura: “We are determined to make Obamacare front and center, the number one issue for the American people.”

pointer  “Why Investing in the Health of Americans Should Start Early,” a PBS NewsHour conversation, first aired 13 January 2014.

“SUMMARY: A group of doctors from the Commission to Build a Healthier America has issued a list of recommendations to improve health in America, noting relationships between socioeconomic status and wellness. Judy Woodruff talks to David Williams of Harvard University about the importance of laying foundations for health in childhood.”

pointer  “The Religious Alternative to Obamacare,” a Marketplace public radio segment by Lauren Silverman, first aired 10 January 2014.

Silverman reports here on health-care sharing ministries — an alternative to standard insurance programs, developed for a self-selecting group of devout Christians who “agree to a strict set of principles. To attend church, abstain from extramarital sex, and avoid alcohol and drug abuse. You violate these rules, and you could lose health coverage.” (Silverman, 1/10/2014 Marketplace program)
   “It’s worked this way for twenty years,” reports Silverman, “and supporters successfully lobbied Congress for an exemption in the Affordable Care Act — so people like Diane Cozart [of Texas] can stay with their faith-based alternative without penalties.”
   The Texas woman prefers the restrictions and requirements for personal accountability that come with a sharing ministry (“When we got our statement this month, it told me the names of the people who were getting my money, and I could write them a little note of encouragement, or I’m praying for you ...”) and is happy with her coverage, which she says paid in full for her breast cancer treatment in 2005, capping her out-of-pocket expenses for medical care (which she estimates cost over $100,000) that year at $1,200 (her annual deductible).
   Critics point out that the sharing ministries are unregulated, and offer only limited coverage. “But lack of consumer protections and guarantees hasn’t stopped thousands of people from signing up.  ¶  They’re turning to fellow believers and putting their health in God’s hands.” (Silverman, 1/10/2014 Marketplace program)
N O T E :  The text summary given on this Web page is not a complete transcript of Silverman’s reporting for Marketplace. The 4-minute audio podcast (which you can play using the operating controls at the top of the page) contains additional content not transcribed here. E.g., the discussion of Cozart’s cancer coverage starts at about the 1:30 minute mark.

pointer  “Health Care Sign Up Improves, but Some States Seek Workarounds for Tech Issues,” a PBS NewsHour health-care law update, first aired 9 January 2014.

“SUMMARY: The process of enrolling in health care coverage appears to be going smoother, but problems persist for some state-run exchanges and consumers. Judy Woodruff gets an update from Sarah Kliff of The Washington Post, who also discusses an effort by the GOP to put a spotlight on security issues facing HealthCare.gov.”

U P D A T E :  “The Obama administration is changing lead contractors on the healthcare.gov Web site. Medicare/Medicaid officials confirmed today [1/10/2014] that CGI Federal will not be retained. It oversaw a disastrous rollout of the site in October. The administration plans to hire Accenture instead.” (News Wrap, PBS NewsHour, 10 January 2014)

pointer  “Vermont Gov. Confronts Deadly Heroin Crisis as Public Health Problem,” a PBS NewsHour conversation, first aired 9 January 2014.

“SUMMARY: Gov. Peter Shumlin devoted his entire State of the State address to a ‘full-blown heroin crisis’ ravaging Vermont. Shumlin joins Judy Woodruff to discuss his shift in focus on the issue of opiate addiction and Ryan Grim of the Huffington Post offers context on why heroin has made a major comeback in the United States.”
   For more on the swirl of issues relating to prescription opiates, see below, pointers for the entry dated 7 July 2013 (No. 3, PBS NewsHour reporting on growing addiction to narcotic painkillers among wounded veterans) and for the entry dated 30 December 2012 (Los Angeles Times investigation into California’s epidemic of prescription drug deaths).

pointer  “Rafael Campo’s Student Physicians Embrace Poetry to Hone Art of Healing,” a PBS NewsHour report, first aired 9 January 2014.

“SUMMARY: Doctor and poet Rafael Campo thinks medical school distances doctor and patient at the cost of human understanding. A possible cure? He uses poetry to help close the gap. Jeffrey Brown and Poet Laureate Natasha Trethewey continue to seek ‘Where Poetry Lives’ by visiting Campo’s reading and writing workshop for medical students.”

pointer  “How Obamacare Will Change the Emergency Room,” a Marketplace public radio segment by Dan Gorenstein, first aired 2 January 2014.

According to Gorenstein, “A new report looking at the Oregon Medicaid program compares emergency room use between the uninsured and people with Medicaid — the healthcare program for primarily low income and disabled people.  ¶  And the report already has pundits worked up.... The reason this is so hot — at least politically — is because the report over turns conventional healthcare thinking.... Based on this report, there are already estimates that increased ER use will cost taxpayers half a billion dollars a year.”
   But analysts caution that the truly onerous costs to taxpayers are not ER-related (increased use of the Emergency Room by those whose access is paid by Medicaid). “‘The spending is on high cost patients. These are cancer patients. Many of them in the end of life,’ [Amitabh Chandra] says.... Chandra says it would be easy to use this report and argue that the Affordable Care Act is too costly.  ¶  He says the big question — the tough question — is how to limit the care everyone agrees is inefficient and expensive, regardless of who gets it or where that care is received.”
   Another perspective on this story aired 3 January 2014 on the PBS NewsHour: “Study on ER Visits by People with Medicaid Challenges Theory They Would Go Less. “SUMMARY: A new study published in Science found that low-income people who have Medicaid insurance go to the emergency room for care 40 percent more than their counterpoints without any insurance. Katherine Baicker of Harvard School of Public Health, a co-author of the study, joins Hari Sreenivasan” in conversation.

pointer  “Concerns Linger about Enrollment Glitches as Millions Start New Health Coverage,” a PBS NewsHour health-care law update, first aired 2 January 2014.

“SUMMARY: On Jan. 1, health coverage under the Affordable Care Act kicked in for millions of Americans, but concerns remain about whether people who bought new insurance will encounter issues with their enrollment. Jeffrey Brown talks to Julie Appleby of Kaiser Health News for an update on the latest milestone in the rollout of the law.”

pointer  “What the Health Law Does and Doesn’t Do,” retitled “Seeing the Positive Changes Brought by the Federal Health Law” for online posting, by columnist Michael Hiltzik (Los Angeles Times, 29 December 2013, pp. B1 and B7).

SUMMARY: “It gives 20 million people access to care. But it only begins to address the cost and waste that have plagued the U.S. system for decades.”
   “Despite a troubled rollout, as many as 20 million people have gained access to coverage. But GOP lawmakers have blocked wider access to Medicaid, and House Republicans’ hostility is making it impossible to fix flaws.”

pointer  Healthcare Watch column, “Signed Up for a New Policy but Waiting for Proof,” retitled “Waiting for Confirmation under Obamacare” for online posting, by Lisa Zamosky (Los Angeles Times, 29 December 2013, p. B3).

SUMMARY: “Those who enrolled under Covered California by Dec. 23 should be covered Jan. 1. But some may not hear from their insurers until late January.”
   Zamosky relays “tips for the anxious among us, eager to be officially enrolled and ready. Experts offer insights about how long you should expect to wait to hear from your insurer once you have signed up for coverage, what information you should expect to receive and what to do if the paperwork never arrives.” (Zamosky, B3)

pointer  “What Makes Olga Run?: Lessons from a 94-year-old star athlete on how to get your health on track — at any age,” retitled “6 Lessons on Living Longer and Staying Sharp from a Nonagenarian Track Star” for online posting, by Bruce Grierson, with photographs by Grant Harder (Parade, 29 December 2013, pp. 8–13).

This Parade cover story is excerpted from Bruce Grierson’s forthcoming book, What Makes Olga Run?: The Mystery of the 90-Something Track Star and What She Can Teach Us about Living Longer, Happier Lives, and includes a link to a video where you can catch the amazing Olga Kotelko in action.
   It is one of those feel-good stories I can’t resist, even though I also agree with the reader who criticized: “Articles like these really irritate me. Write a story about a one-in-a-billion anomaly and hold it up as an achievable example. Come on man! That’s like showing highlights of Michael Jordan or Lebron James to school kids to plant unrealistic dreams.”

pointer  “Reviving the Fight for Single-Payer: Rep. Jim McDermott of Washington is optimistic that it will come — if we give states the tools to adopt it at their own pace,” by William Greider (The Nation, 23–30 December 2013, vol. 297, nos. 26 & 27, pp. 18–19).

This is a very interesting article.
   The Nation has since provided this update on “Vermont’s Single-Payer Experiment”: “As everyone else wrangled over even the mildest Affordable Care Act reforms, Governor Pete Shumlin and his legislative allies were busy preparing a single-payer system for Vermont. Yes, they worked with federal officials to set up the Vermont Health Connect exchange as part of the ACA. But they also allocated resources to study development of a state-based single-payer system and prepared to seek the federal waiver required to implement it in 2017. It isn’t all studies and waivers, however; Shumlin is also building a constituency for what he calls ‘the most ambitious policy lift in Vermont history,’ vowing ‘to gear up our staff and engage Vermonters from all walks of life.’” (John Nichols, “2013 Progressive Honor Roll,” The Nation, 6/13 Jan. 2014, 298.1-2, 14 and 17)

pointer  “Feds Extend Health Care Sign Up by One Day,” a PBS NewsHour health-care law update, first aired 23 December 2013.

“SUMMARY: The Obama administration pushed back the government health care enrollment deadline to Dec. 24, giving consumers one more day to sign up for coverage that begins Jan. 1. Officials say the extensions will also help HealthCare.gov deal with the last-minute surge. Gwen Ifill talks to Alex Wayne of Bloomberg News.”

pointer  “Obama Administration Announces Special ACA Hardship Waiver for Canceled Policies,” a PBS NewsHour health-care law update, first aired 20 December 2013.

“SUMMARY: The Obama administration announced a new offer for individuals who had insurance policies canceled: the chance to buy cheaper, catastrophic coverage if new plans are more expensive. Judy Woodruff discusses the details of the special waiver and how many are expected to sign up for it with Mary Agnes Carey of Kaiser Health News.”

pointer  “Can Memory Video Games Deliver on Brain-Boosting Claims?,” a PBS NewsHour report, first aired 20 December 2013.

“SUMMARY: A new breed of video games are designed to exercise aging brains and improve players’ attention, speed and memory. But critics say the claims made by developers are not supported with evidence. Could these mental workouts make a difference? Special correspondent Jake Schoneker reports on the science behind cognitive training.”

pointer  “When Soldiers Break: Years after returning from Iraq, Charlie sank into a depression that changed him,” retitled “The Colonel, the Veteran and the Caregiver: How the War Changed Charlie” for online posting, by Ann Jones (The Nation, 16 December 2013, vol. 297, no. 25, pp. 18–23).

pointer  “The Selling of Health Insurance,” a Marketplace public radio segment by Dan Gorenstein (aired 16 December 2013).

Gorenstein reports here on one way that the ACA is changing the insurance market. Of note, not just industry “big guys” are winning market share: in Maine, “the smaller of two players in the state market, Maine Community Health Options, has signed up 73 percent of consumers on the exchange, according to federal figures, far more than the other provider, Anthem Blue Cross.”
   For more on the emergence of alternative insurance solutions linked to Obamacare (e.g., the Colorado Health Insurance Cooperative, sponsored by the Rocky Mountain Farmers Union Educational and Charitable Foundation), see below, entry for the pointer dated 25 June 2013.

pointer  “Some Health Coverage Deadlines Changed to Prevent Insurance Gaps,” a PBS NewsHour analysis, first aired 12 December 2013.

“SUMMARY: The Obama administration announced some changes to the health care law implementation. Payment extensions have been offered, as well as special temporary coverage for seriously ill people with pre-existing conditions. Jeffrey Brown talks to Alex Wayne of Bloomberg News about efforts to prevent coverage gaps and spur enrollment.”

pointer  “What Role Should the Government Play in the Health Care of Its Citizens?,” a PBS NewsHour report, first aired 28 November 2013.

“SUMMARY: The ACA roll-out has raised questions on where the government should draw the line in the personal welfare of its citizens. How does the new health care law complicate the ideas of individual rights and collective responsibilities? Jeffrey Brown talks to Jacob Hacker of Yale University and Avik Roy of the Manhattan Institute.”

pointer  Healthcare Watch column, “Wait, What’s Household Size?,” retitled “Confused by California’s Health Insurance Exchange? Here Is Help,” by Lisa Zamosky (Los Angeles Times, 24 November 2013, p. B3).

SUMMARY: “How to estimate income, what ‘household size’ means and answers to other questions that can arise when applying for health insurance through Covered California.”

pointer  “Obama’s Plea to Extend Policies Rejected: Calif.: Canceled health plans to lapse Dec. 31,” by Paul Sisson (U-T San Diego [formerly San Diego Union-Tribune], 22 November 2013, pp. A1 and A6).

SUMMARY: Board members of California’s health insurance exchange (Covered California) voted to “allow an estimated 900,000 health plans to lapse at the end of the year because they do not comply with all of the requirements of the Affordable Care Act.” (Sisson, A1) “About 310,000 Californians with canceled plans are expected to qualify for subsidized policies on the exchange and will pay less than they do today. But that leaves about 590,000 Californians who don’t qualify for a subsidy and either have a policy comparable to, or less comprehensive than, those offered on the exchange.  ¶  For these Californians, rates are likely to increase” (Sisson, A6).
   For anecdotal evidence of the level of dissatisfaction over cancelled policies, even by Californians who will personally benefit as a result, see below, pointer for entry dated 10 November 2013 (USC Dornsife/Times Poll results).
   For more on proposed administration and congressional “tweaks” to the health care law, intended to help people coping with health insurance cancellations, see below, pointer for entry dated 8 November 2013.

pointer  “Government Budget Cuts and the Crisis in Scientific Research,” by columnist Michael Hiltzik (posted to the Los Angeles Times website, 22 November 2013).

Hiltzik identifies a major threat to the growth of science in the U.S.: declining government investment in research. “The U.S. is a big spender on science, but not enough.”
   “‘Basic research leading to scientific discovery is ... a public good,’ [William H. Press of the University of Texas] wrote. ‘It will benefit all.’ But because it’s hard for private enterprise to extract direct benefits from it, the private sector underinvests in it. That’s why the government role is crucial.  ¶  But over the last 50 years, the government’s share of total research and development funding has fallen from more than 60% to about 30%. That’s seed corn that’s not getting planted. Meanwhile, industry investment in basic research is stagnating. As the graphic above shows, America’s investment in basic research handily outstrips that of all other industrialized countries — but as a percentage of gross domestic product we’re behind Korea, Japan, Sweden, Finland and Israel. Consequently, we’re also behind several other countries in scientists and engineers per capita.” (Hiltzik, 11/22/2013, n. pag.)
   Moreover, “As Yale’s James E. Rothman, one of three laureates in medicine, observed, the purchasing power of grants from the National Institutes of Health has declined by 28% over the last seven or eight years.  ¶  What’s worse, he said, is that much of that funding is going to bureaucratically dictated research, not to promising young scientists following their noses in basic science. ‘I doubt very much that in today’s environment I would have been able to do the work that led to my sitting here today,’ he said.” (Hiltzik, 11/22/2013, n. pag.)
   See also Hiltzik’s earlier column, “Science Has Lost Its Way, Costing All of Us,” about the faulty biomedical research — including in the fields of cancer research and blood biology — undergirding a $59 billion-per-year industry for the industrialized countries (below, pointer for entry dated 27 October 2013).
   And for discussion of financial issues affecting the science of stem cells and “regenerative medicine,” see below, pointers for entries dated 10 November 2013 and 12 October 2013.

pointer  “Boehner Describes Frustrating ‘Obamacare’ Experience: It takes him 4 hours to get his coverage” (U-T San Diego [formerly San Diego Union-Tribune], 22 November 2013, p. A6).

This brief article includes some interesting information on “messaging tools” for Obamacare detractors.

UPDATE #1:  “Oops! John Boehner’s Obamacare Stunt Backfires,” by Michael Hiltzik (posted to the Los Angeles Times website, 11/22/2013).
   Hiltzik’s bottom line: “Boehner’s getting a good deal.”

UPDATE #2:  “The Dirty Secrets Behind Boehner’s ‘Spiking’ Obamacare Premiums,” by Michael Hiltzik (posted to the Los Angeles Times website, 11/25/2013).
   Responding to claims by Speaker Boehner’s office that his family healthcare premiums will be much higher next year than now because of the Affordable Care Act, Hiltzik contends that “Boehner’s spiking premiums is one of those claims that may be true as far as it goes, but leaves out so much that it’s at best a half-truth. And the contention that Boehner’s experience is at all representative of what most Americans will experience under the Affordable Care Act jumps it up from half-truth to outright lie.”
   Hiltzik looks at the numbers, and concludes: “Boehner is plainly an outlier as an Obamacare client. He’s way older than the average individual policy applicant, and his family income is way beyond the U.S. average. Boehner gets a further break as a smoker — under the law, the state exchanges could charge as much as 50% more for them, but D.C. is one of the few that has decided not to.... What Boehner’s experience underscores is that for the vast majority of individual insurance customers, the Affordable Care Act is a real plus.”

UPDATE #3:  “The Obamacare Success Stories You Haven’t Been Hearing About,” by Michael Hiltzik (posted to the Los Angeles Times website, 11/25/2013).
   Hiltzik here reports on some of “the stories you’re not hearing amid the pumped-up panic over canceled individual policies and premium shocks — many of which stories are certainly true, but the noise being made about them leads people to think they’re more common than they are.”
   See online story for link to a companion piece by Hiltzik: “Yes, men should pay for pregnancy coverage. Here’s why.”

pointer  “Facing Rising Health Costs, Massachusetts Seeks Cost-Cutting that Improves Care,” a PBS NewsHour report by Paul Solman (part of his “Making Sense of Financial News” series), first aired 19 November 2013.

“SUMMARY: With an outcome of near universal health coverage for residents of the Bay State, the 2006 reform of Massachusetts’ health care system has also come with higher prices. Paul Solman reports on the state’s effort to slow rising costs by looking for ways to cut spending on care that doesn’t add value or improve health.”
   Another of Paul Solman’s reports on the Massachusetts model. (See below, pointer for entry dated 1 October 2013, to access an earlier report.)
   Again, I want to recommend the comments section (below the transcript), which includes such thought-provoking posts as: “The idea of a single small state having such influence on national health care economics is not realistic. Ironically, the efficacy of Romneycare will depend on the efficacy [of] Obamacare.”

pointer  Healthcare Watch column, “Sorting through Health Insurance Plans,” retitled “How to Sort through New Health Plans: Experts offer advice on how to sort through the options when shopping for a new insurance policy,” by Lisa Zamosky (Los Angeles Times, 17 November 2013, p. B3).

pointer  “7 Tips for Receiving Better Cancer Care Near the End of Life,” a PBS NewsHour feature in their Health Care Reform series, posted to The Rundown: A Blog of News and Insight, by Jason Kane, on 12 November 2013.

SUMMARY: “A recent review of Medicare patients by the Dartmouth Atlas Project revealed some glaring discrepancies in care throughout the nation.” “These wide variations should be cause for alarm nationwide, according to the authors of the Dartmouth Atlas report. They believe that the numbers run counter to the fact that ‘most patients with cancer who are approaching the end of their lives prefer supportive care that minimizes symptoms and their days in the hospital.’ And they conclude that ‘unfortunately, the care patients receive does not always reflect their own preferences, but the prevailing styles of treatment in the regions and health care systems where they happen to receive cancer treatment.’”
   Kane offers “seven tips from Dr. David Goodman, co-principal investigator for the Dartmouth Atlas of Health Care Project, and Dr. Ira Byock, a palliative care physician, professor of medicine at the Geisel School of Medicine and author of The Best Care Possible” “to ensure that you or a loved one have control over your care.”
   See also Alex Wayne’s reporting on this for Bloomberg News (pointer for entry below dated 4 September 2013).

pointer  “Dick Cheney Reflects on How Medical Care Kept Him Active Despite Heart Disease,” a PBS NewsHour interview with the former vice president, by Gwen Ifill, first aired 12 November 2013.

“SUMMARY: From his first heart attack at age 37 to a full transplant in 2012, Dick Cheney says he’s proud to have lived an active life despite battling heart disease. Gwen Ifill sits down with the former vice president, author of Heart: An American Medical Odyssey, to discuss how his health concerns affected his time in office.”
   Among other subjects touched on in the interview: “this debate that we’re having now about health care and insurance and mandated insurance around the country.”

pointer  “Wisconsin Aims to Convince ‘Young Invincibles’ to Sign Up for Health Coverage,” a PBS NewsHour report, first aired 11 November 2013.

This is the first segment in a week-long PBS NewsHour “series on reactions to the Affordable Care Act, now that Americans have had time to read the fine print.”
   “SUMMARY: Experts have said the success of the Affordable Care Act will depend on Americans aged 18–34 signing up. Often referred to as the ‘young invincibles,’ this pivotal, generally healthy demographic must weigh the option of signing up for coverage or paying a fine. Frederica Freyberg of Wisconsin Public Television reports.”

UPDATE #1:  The 2nd segment in the series of personal stories of health reform: “Understanding Why Americans’ Insurance Plans Are Being Canceled,” a PBS NewsHour analysis, first aired 12 November 2013.
   “SUMMARY: Despite being happy with her health care plan, Deborah Persico of Washington, D.C., received notice that her insurance policy was being canceled. To understand some setbacks and some successes of the law, Judy Woodruff speaks with Mary Agnes Carey of Kaiser Health News.”

UPDATE #2:  The 3rd segment in the series of personal stories of health reform: “Sick Americans Find Solace in Health Reform’s Pre-Existing Conditions Guarantee,” a PBS NewsHour analysis, first aired 13 November 2013.
   “SUMMARY: After Martha Monsson was diagnosed with cancer, her husband lost his job and their health care. In our series of personal stories about the effects of health reform, Monsson voices support for the law’s guarantee of care for those with pre-existing conditions. Mary Agnes Carey of Kaiser Health News joins Judy Woodruff for more.”
   I want also to recommend the several thoughtful comments posted in the discussion section, following the transcript (31 comments as of 11/14/2013, around noon, PST).

UPDATE #3:  The 4th segment in the series of personal stories of health reform: “In Some States, More Poor Americans Get Health Care under Expanded Medicaid,” a PBS NewsHour analysis, first aired 15 November 2013.
   “SUMMARY: Aaron Macholl-Stanley, a 25-year-old culinary arts student from California, is in the process of enrolling in Medi-Cal, that state’s insurance program for the poor. Health policy analyst Susan Dentzer joins Judy Woodruff to discuss how the ACA’s expansion of Medicaid has made 400,000 additional Americans eligible to enroll.”
   Once again, respondents have raised several interesting issues (see the Comments section below the transcript).

UPDATE #4:  The 5th segment in the series of personal stories of health reform: “Tax Credit Helps End One Family’s Search for Health Insurance,” a PBS NewsHour analysis, first aired 18 November 2013.
   “SUMMARY: The Montez family of Colorado have been living without insurance, forcing them to avoid care and pay for medical expenses out of pocket. But now they are able to afford a health care plan under the Affordable Care Act. Julie Rovner of NPR joins Judy Woodruff to explain how tax subsidies are helping families get coverage.”
   Again, such a personal story has provoked an interesting discussion (122 comments as of 11/19/2013, about 10:40pm PST).

UPDATE #5:  The 6th segment in the series of personal stories of health reform: “Move to Extend Canceled Health Care Plans Has Legal, Practical Complications,” a PBS NewsHour analysis, first aired 20 November 2013.
   “SUMMARY: Kathleen Baker of Denver hoped to keep her health care plan into the future. But like millions of others, her policy was canceled under the Affordable Care Act. Judy Woodruff talks to NPR’s Julie Rovner for the bigger picture on whether Americans will be able to extend their canceled policies through 2014.”

pointer  “Stem Cell Effort, Off to Slow Start, Makes Gains: S.D. Center Aims to Advance Clinical Use of Treatment,” retitled “Stem Cell Program Is Making Progress” for online posting, by Bradley J. Fikes (U-T San Diego [formerly San Diego Union-Tribune], 10 November 2013, pp. A1 and A15).

Fortunately, this digital edn. of the article includes the color photo by Earnie Grafton documenting an artist’s vision of the science, as captioned in the print copy of the newspaper: “Dr. Larry Goldstein, head of UC San Diego’s stem cell program, will head the new Stanford Stem Cell Clinical Center, which is meant to hasten development of therapies derived from stem cell research. Behind him is a mural by LuAnn Beardmore based on stem cell neurons.” (A15)
   Fikes reports here on developments following California voters’ passage of Proposition 71 — “a $3 billion program to accelerate stem cell research and bring cures for everything from paralysis to Parkinson’s disease.... Now, as the agency established by Prop. 71 begins to run low on funds, it’s clear that treatments haven’t come as fast as optimists had hoped. No therapies funded by the agency have been approved.  ¶  As it turned out, researchers simply didn’t know enough about stem cells to rush them into clinical trials....” (A1–A15)
   As Dr. Goldstein sums it up: “If you’re someone who has a terrible disease, you want a therapy right now. Unfortunately, that’s not the way it works. It takes time and energy to get from good idea to proof of concept, to clinical trials, to the actual therapy that works.” (A15)
   See below, pointer for entry dated 12 October 2013, for further discussion of financial issues affecting the science of stem cells and “regenerative medicine.”
   And see below, pointer for the entry dated 27 October 2013, for related comments (by Henry Bauer, emeritus professor of chemistry and science studies) on the difficulties attaching to government funding of potentially revolutionary science.

pointer  “Californians Uneasy about Healthcare Law,” retitled “Californians Have Their Doubts about Healthcare Law” for online posting, by Chad Terhune (Los Angeles Times, 10 November 2013, pp. A1 and A19).

SUMMARY: “[A USC Dornsife/Times] Poll shows California is more supportive of Obamacare than the U.S. at large, but many fear higher costs and economic damage.”
   I was especially struck by the story of Kathryn Davis, one of the Californians whose health insurance plans have been cancelled. Terhune notes that Davis “already had her doubts about Obamacare. Then she received a cancellation notice from her insurer, joining an estimated 1 million Californians who have received similar termination letters in recent weeks.  ¶  ‘It makes me angry I will be forced to purchase a new policy I don’t want, and fined if I don’t,’ she said.  ¶  Davis said she paid $130 a month for a Blue Shield of California policy. On the state exchange, she saw a mid-level Silver plan from Blue Shield that would cost her $96 a month thanks to a federal subsidy of $187 a month based on her income.  ¶  Her annual deductible would decrease, and the coverage would be more comprehensive, including benefits such as maternity care. Even though it may be a better deal for her, Davis said she feared government spending on insurance subsidies would trigger huge tax increases.” (Terhune, A19)

pointer  Rick Karr’s report for PBS NewsHour Weekend, aired 9 November 2013: “Maine’s Prescription for Drug Savings: Go Foreign.”

“SUMMARY: Maine employers and consumers say that importing prescriptions from foreign mail-order pharmacies saves them a lot of money — and legislators passed a law legalizing imports. The drug industry and the state’s pharmacists say imports can be dangerous — supporters say the drugs are identical. Now, a federal court will decide.”

pointer  “Obama Apologizes for Cancellations: President signals possible tweaks to health care law,” by Julie Pace of the Associated Press (reprinted in U-T San Diego [formerly San Diego Union-Tribune], 8 November 2013, p. A2).

SUMMARY: “In recent days, focus has intensified on the president’s promise that Americans who liked their insurance coverage would be able to keep it. He repeated the line often, both as the bill was being debated in Congress and after it was signed into law.  ¶  But the health care law itself made that promise almost impossible to keep. It mandated that insurance coverage must meet certain standards and that policies falling short of those standards would no longer be valid unless they were grandfathered, meaning some policies were always expected to disappear.  ¶  The White House says under those guidelines, fewer than 5 percent of Americans will have to change their coverage. But in a nation of more than 300 million people, 5 percent is about 15 million people.  ¶  Officials argue that those forced to change plans will end up with better coverage and that subsidies offered by the government will help offset any increased costs.... The President’s critics have accused him of misleading the public about changes that were coming under the law, which remains unpopular with many Americans.” (Pace, A2)

UPDATE #1:  From the 11/8/2013 Associated Press story by Ardo Alonso-Zaldivar, “Few Options for Obama to Fix Cancellations Problem”: “Website woes have been eclipsed by the uproar over cancellation notices sent to millions of people who have individual plans that don’t measure up to the benefits package and level of financial protection required by the law.  ¶  ‘It was clear from the beginning that there were going to be some winners and losers,’ said Timothy Jost, a law professor at Washington and Lee University in Virginia, who supports the health overhaul. ‘But the losers are calling reporters, and the winners can’t get on the website.’”

UPDATE #2:  Congress is weighing laws to stop the cancellations of individual policies: “Keeping Health Insurance at Issue,” by Renee Schoof of the MCT News Service (reprinted in U-T San Diego, 9 November 2013, p. A3).

pointer  “New Rules Set Standard to Ensure Mental Health Care Coverage Parity,” a PBS NewsHour analysis, first aired 8 November 2013.

“SUMMARY: The Obama administration made the final step Friday to expand mental health care, five years after a law requiring the coverage passed. The new regulations mandate that insurers cover mental illness and addiction the same as they would a physical ailment. Hari Sreenivasan talks to Dr. Carol Bernstein of New York University.”

pointer  “How Tourists Are Raising Insurance Rates for Residents of Summit County, Colo.,” a PBS NewsHour analysis, first aired 7 November 2013.

“SUMMARY: Summit County, Colo. has an estimated 6,000 uninsured residents, and none of them have signed up for health insurance under the Affordable Care Act. Why? Because premiums there are sometimes twice as high as other parts of the state because of a discrepancy in Colorado law. Mary Jo Brooks reports on what’s behind the imbalance.”

pointer  “Doctors Treat New Condition — Questions about Health Law,” by Anna Gorman of the non-profit investigative news organization, Voice of San Diego, posted to the VOSD website on 4 November 2013.

pointer  “Benefits in 2014,” retitled “What to Expect from Company Health Insurance Plans in 2014” for online posting, by Lisa Zamosky (Los Angeles Times, 3 November 2013, pp. B1 and B8).

SUMMARY: “Higher premiums, higher deductibles and smaller doctor networks are ahead. But companies also will be emphasizing worker wellness.”
   For a critical review of employers’ increasing reliance on “wellness programs” to control healthcare costs, see below, pointer for entry dated 15 September 2013.

pointer  “The Key to a Happy Society,” retitled “How Much Are We Willing to Pay for the Pursuit of Happiness?” for online posting, by columnist Michael Hiltzik (Los Angeles Times, 3 November 2013, pp. B1 and B8).

SUMMARY: “Research by Notre Dame political scientist Benjamin Radcliff suggests that social programs produce a happier population.”
   Hiltzik here summarizes Radcliff’s research, noting that “One obvious criticism of Radcliff’s work is that it plays into a partisan narrative,” and concluding with: “Our decades-long debate over Social Security and Medicare is now joined by a messy debate over Obamacare, its beneficiaries and its discontents. Underlying them all is the fact that the pursuit of happiness is established as one of America’s founding principles. What we’re really arguing about is how much to pay for it.” (Hiltzik, B8)
   These days, research into “happiness” abounds. Some may think this is a frivolous concern, and there is no shortage of critics out there pointing to the pseudo-scientific nature of some happiness research and complaining about the waste of research dollars expended on such academic folly.
   But at least since Aristotle in the Latin West, behaviorists and political theorists have known that “happiness” — however a culture defines it (and for the ancient Greeks, happiness followed from the right exercise of “virtue” and self-control) — is a fundamental constituent of the good society, and of human health and well-being.
   As such, the happiness doctrine was already central to English republicanism by the time Thomas Jefferson wrote “the pursuit of happiness” into the Declaration of Independence for the fledgling American republic: “... We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness....” (U.S. Declaration of Independence)
   I am not an 18th-century scholar, so I don’t know whether Jefferson’s sources for this still-powerful statement included Algernon Sidney (1623–1683) or not. But the concept of citizens free to pursue “a happy human life” was integrally linked to the classical republican ideal which Sidney so eloquently refashioned for modern society (click/tap here to open a second-window aside with more information about Sidney and his adaptation of Aristotle), and this in turn had a profound influence on Enlightenment Britain, America, the United Provinces, Germany, and France.
   Because he was “a whig patriot–hero and martyr,” Sidney’s life and thought received intense scrutiny. At least 14 editions of his Discourses Concerning Government (written between 1681 and 1683) were printed between 1698 and 1805, and his ODNB biographer considers Algernon Sidney “the most influential of the English republicans. In particular his works exemplify two features of seventeenth-century English republicanism. The first is its debt, within a religious framework, to the moral philosophy of Greek antiquity (its Christian humanism). The second is its Machiavellian and Roman militarism.” (Jonathan Scott, “Sidney [Sydney], Algernon (1623–1683), political writer,” Oxford Dictionary of National Biography, online edn., Jan. 2008, n. pag.)
   Whatever Jefferson’s source — and I personally believe the happiness doctrine was by then just “in the air” being imbibed by most of the age’s intellectuals — his ambiguous phrase still bestirs the American psyche, with substantial consequences for U.S. politics and our debates over health-care reform, as Hiltzik observes.
   As for me, I long ago took to heart Albert Einstein’s modern insight about human happiness: “We act as though comfort and luxury were the chief requirements of life, when all that we need to make us happy is something to be enthusiastic about.”
   (And I am happy to thank Dave Crossland again for passing me that pearl of wisdom several years ago! ;-)

pointer  Megan Thompson’s report for PBS NewsHour Weekend, aired 2 November 2013: “Generic Drugs Don’t Necessarily Mean Low Prices.”

“SUMMARY: NewsHour Weekend’s Megan Thompson reports on the surprising disparity in pricing for generic drugs. Generics, generally thought to be cheap, can actually vary widely in price from pharmacy to pharmacy, causing some to skip medications altogether.”
   This was an eye-opening report for me, and I expect may be for others, too. Thompson here documents the experience of her mother (diagnosed with breast cancer in 2009) who was quoted prices ranging from $11.04 (at her local Costco) to $455.00 (at her local Target) for a 30-day supply of a generic drug called Letrozole (generic of Femara, a breast cancer drug).

pointer  “U.S. Loosening Rules on Health Spending Accounts: Up to $500 a year can be carried over,” by Stephen Ohlemacher of the Associated Press (reprinted in U-T San Diego [formerly San Diego Union-Tribune], 1 November 2013, p. A12).

According to Ohlemacher, “an estimated 14 million people use the accounts.”

pointer  “Science Has Lost Its Way, Costing All of Us,” by columnist Michael Hiltzik (Los Angeles Times, 27 October 2013, pp. B1 and B9).

SUMMARY: “Researchers are rewarded for splashy findings, not for double-checking accuracy. So many scientists looking for cures to diseases have been building on ideas that aren’t even true.”
   Hiltzik opens with a newsworthy story: “A few years ago, scientists at the Thousand Oaks biotech firm Amgen set out to double-check the results of 53 landmark papers in their fields of cancer research and blood biology.  ¶  The idea was to make sure that research on which Amgen was spending millions of development dollars still held up. They figured that a few of the studies would fail the test — that the original results couldn’t be reproduced because the findings were especially novel or described fresh therapeutic approaches.  ¶  But what they found was startling: Of the 53 landmark papers, only six could be proved valid.  ¶  ‘Even knowing the limitations of preclinical research,’ observed C. Glenn Begley, then Amgen’s head of global cancer research, ‘this was a shocking result.’  ¶  Unfortunately, it wasn’t unique.” (Hiltzik, B1)
   Partly at fault is the modern business model for scientific publishing, “in which leading journals pay nothing for papers often based on publicly funded research, then charge enormous subscription fees to universities and researchers to read them.” (Hiltzik, B9) As a result, “‘The journals want the papers that make the sexiest claims,’ [Michael Eisen, a biologist at UC Berkeley and the Howard Hughes Medical Institute] says. ‘And scientists believe that the way you succeed is having splashy papers in Science or Nature — it’s not bad for them if a paper turns out to be wrong, if it’s gotten a lot of attention.’” (Hiltzik, B9)
   One fix for this is what critics have dubbed the “emerging Wild West in academic publishing” (embraced by this website ;-). “Eisen is a pioneer in open-access scientific publishing.... But concern about what is emerging as a crisis in science extends beyond the open-access movement. It’s reached the National Institutes of Health, which last week launched a project to remake its researchers’ approach to publication. Its new PubMed Commons system allows qualified scientists to post ongoing comments about published papers. The goal is to wean scientists from the idea that a cursory, one-time peer review is enough to validate a research study, and substitute a process of continuing scrutiny, so that poor research can be identified quickly and good research can be picked out of the crowd and find a wider audience.  ¶  PubMed Commons is an effort to counteract the ‘perverse incentives’ in scientific research and publishing, says David J. Lipman, director of NIH’s National Center for Biotechnology Information, which is sponsoring the venture.” (Hiltzik, B9)
   Such fixes are worth pursuing; however, there are always going to be limits on how much we can correct for uncertainty and invalid knowledge at the frontiers of scientific research, especially given what Henry Bauer (politically-conservative, emeritus professor of chemistry and science studies at Virginia Polytechnic Institute and State University) calls “the predictability and mediocrity of peer review,” as well as widespread “misconceptions about how science works, even among those who manage it and fund it and make public policy about it” (Bauer, Scientific Literacy and the Myth of the Scientific Method, 1992, 118). A sociological account of scientific knowledge such as Bauer’s teaches us that ultimately “the scientific method is an unattainable ideal” (Bauer, 150).
   Bauer’s Scientific Literacy and the Myth of the Scientific Method (Champaign, IL: University of Illinois Press, 1992) is one of my favorite introductions to Science and Technology Studies (STS) for the uninitiated, because it’s a fairly easy read. Click/tap here to open a second-window aside with three excerpts from Bauer’s book re. science in the news, government funding of goal-oriented research, and understanding the differences between science vs. applied science vs. technology.
   Somewhat more difficult, but especially relevant in this context for its probing discussion of “journal science,” is Ludwik Fleck’s Genesis and Development of a Scientific Fact (an “interpretive translation,” published in 1979, of Fleck’s original German-language monograph of 1935, Entstehung und Entwicklung einer wissenschaftlichen Tatsache. Einführung in die Lehre vom Denkstil und Denkkollektiv, edited by Thaddeus J. Trenn and Robert K. Merton, with a foreword by Thomas S. Kuhn). Fleck’s brilliant analysis of scientific cognition in terms of historical processes and social interaction is the introduction to STS preferred by my colleague, John Day (author of Patterns in Network Architecture: A Return to Fundamentals and the inspirational force behind The Pouzin Society). It was John Day who recently reminded me to take note of Fleck’s theories here, and I wish to thank him for that prompt now.
   No discussion of “evidence-based medicine” is complete without acknowledging how medical facts — such as the apparently objective “Wassermann reaction” (the first diagnostic proof procedure for syphilis) studied by Fleck — are constructed (i.e., historically and socially conditioned), and not simply empirically discovered. Ludwik Fleck (1896–1961) — a Polish physician, microbiologist, and philosopher of science who, among other clinical achievements, found a new method to strengthen the sensitivity of the Wassermann reaction, “discovered” an original method for distinguishing true serological reactions from pseudoreactions, and “discovered” a new phenomenon Fleck named “leukergy” (a clumping of white blood cells which occurred during inflammation) — published extensively on various aspects of general serology, hematology, experimental medicine, immunology, and bacteriology (textbooks and over 130 scientific articles, in Polish, German, Hebrew, English, French, and Russian). His highly original work in the philosophy of science, including several papers and articles on methodology, is directly concerned with problems of scientific progress, the truth of the scientific fact, and the role of error in science — in all of which, Fleck was appreciably ahead of his time. Click/tap here to access our digital edition of two excerpts from Fleck’s Genesis and Development of a Scientific Fact (“interpretive” Eng. trans., 1979; original German edn., 1935).

pointer  “Will the Rush to Correct the Health Care Website Problems Add More Complication?,” a PBS NewsHour analysis, first aired 23 October 2013.

“SUMMARY: The Obama administration has said it is making efforts to improve the health care website, but tech experts warn the problems are far from fixed. For more on what contributed to the flawed launch and the challenges ahead, Hari Sreenivasan speaks with John Engates of RackSpace and Bill Curtis of CAST Software.”
   This is excellent. Finally, “a technology-focused take on the troubled launch of the health insurance exchanges.”
   I especially enjoyed Bill Curtis’s memorable line: “You’re not going to get a baby in one month using nine women. It’s going to take a full nine months.” (Someone ought to put that on a T-shirt. ;-)

pointer  Hunting the Nightmare Bacteria, a FRONTLINE special by investigative journalist David Hoffman, first aired 22 October 2013 on PBS stations.

“DESCRIPTION: ‘Nightmare bacteria.’ That’s how the CDC describes a frightening new threat spreading quickly in hospitals, communities, and across the globe. FRONTLINE reporter David Hoffman investigates the alarming rise of untreatable infections: from a young girl thrust onto life support in an Arizona hospital, to a young American infected in India who comes home to Seattle, and an uncontrollable outbreak at the nation’s most prestigious hospital, where 18 patients were mysteriously infected and six died, despite frantic efforts to contain the killer bacteria. Fueled by decades of antibiotic overuse, the crisis has deepened as major drug companies, squeezed by Wall Street expectations, have abandoned the development of new antibiotics. Without swift action, the miracle age of antibiotics could be coming to an end.”
   See also Ray Suarez’s conversation with David Hoffman for the PBS NewsHour (first aired 10/22/2013), where the two talk about how societal and economic factors (such as leaving critical R&D decisions about drugs in the hands of a for-profit pharmaceutical industry) play into the rise of drug-resistant bacteria.

pointer  “Medicare Recipients, Review Your Coverage to Save Money,” by Lisa Zamosky (Los Angeles Times, 20 October 2013).

SUMMARY: “As the annual Medicare enrollment period gets underway, experts urge beneficiaries to look at changes in their plans and shop around.”
   Given the complexities of modern health care and financial systems, most of us feel overwhelmed by so much “choice” and by the commitment of time and mental energy it takes to choose wisely. Once we force ourselves to study the issues in detail, and finally make our big decision, we want to congratulate ourselves on having taken control of the process (at least a little ;-) and then quickly move on, assuming that unpleasant chore won’t need to be done again unless some major change happens in our lives.
   But it doesn’t work that way. Insurance plans are dynamic, and reviewing our coverage options is an annual chore: the best outcomes require that we spend precious time and thought on this unpleasant task every year.
   According to Zamosky, “Experts urge seniors to review and compare plans every year, even if they’re happy with their current coverage.  ¶  ‘These plans do change dramatically year over year,’ says Ross Blair, senior vice president of eHealthMedicare.com, which provides tools and information on Medicare insurance issues. ‘Most people are in the wrong plan, and few take time to look at their options.’”
   So read Zamosky’s column, which offers practical recommendations (e.g., “Avoid Obamacare exchanges”) to help you and your loved ones shop for Medicare Advantage and Part D plans, and schedule some quiet time each year to sit down and review your coverage. “Every year, the nation’s 50 million Medicare beneficiaries have a chance to change their coverage during an enrollment period. It started last week and runs through Dec. 7.”

pointer  “Glitches Far from Fixed for Online Insurance Exchange Shoppers,” a PBS NewsHour analysis, first aired 18 October 2013.

“SUMMARY: Beset with glitches and registration problems, the launch of the online insurance exchanges at the start of October were rockier than expected. For an update on the status of the site and user experiences, Ray Suarez talks to Sarah Kliff of The Washington Post and Louise Radnofsky of The Wall Street Journal.”
   There is now a rash of stories in the media about “glitches,” malfunctions, and technical problems with the new online insurance exchanges created to implement the Affordable Care Act. For Obamacare detractors, the symbolism is hard to resist (i.e., the failed “government-made website” launch becomes a potent metonym for what critics see as an unworkable, over-reaching mess of government-made, health-care reform law). Steve Breen’s cartoon for the 13 October 2013 issue of San Diego’s Union-Tribune is a great example of this (and I’ll be featuring more of San Diego Union-Tribune editorial cartoonist Breen’s graphics in a forthcoming essay for this website delving into the history of the medical cartoon).

facsimile of full-color newspaper cartoon

^  When Questions Answer Themselves, editorial cartoon by Steve Breen, for the 10/13/2013 issue of the San Diego Union-Tribune, rebranded U-T San Diego (p. SD6) under the proactive ownership of Douglas F. Manchester.
     Click/tap here to view a larger digital facsimile (198KB) of Breen’s visual commentary.

   However expressive and appealing such symbolism may be, it is not, in this case, representative of the truth. I have commented on this before, as have others (e.g., see below, pointer for the entry dated 2 October 2013). And this particular NewsHour feature of 10/18/2013 has again drawn several good, smart comments from viewers (scroll down to the comments area following the transcript of the video podcast; and if a glitch prevents the comments from loading, as happens sometimes, try again later).
   I do want to comment one last time on the implied argument that the private sector does it better.
   All of us who work in the Information, Communications & Technology (ICT) field wish that our engineered technologies worked better than they do, and most of us are hard at work trying to meet the unrealistic expectations of the marketers and users who want to be able to do very complicated tasks, easily, without having to think much about it, or worry about “techie” issues such as security and fraud.
   But the reality is that anything high-tech (software, hardware, firmware) is always a process, as well as a product. Nothing developed in the private sector works perfectly the first time, either, which is why commercial “best practices” include what is known as a “software release cycle,” described at Wikipedia as: “the sum of the stages of development and maturity for a piece of computer software: ranging from its initial development to its eventual release, and including updated versions of the released version to help improve software or fix bugs still present in the software.” And it is why industry recognizes and relies on “alpha testers,” and “beta testers,” and “early adopters” to identify “the problems, risks, and annoyances common to early-stage product testing and deployment.” (Wikipedia, s.v. Early Adopter, viewed 10/20/2013)
   Moreover, the glitches don’t stop there (with early-stage product testing and deployment), but continue throughout the life cycle of all Internet-enabled information, marketing, & control systems, as we recently saw with the critical Adobe Systems security breach (disclosed on 10/3/2013): “A security researcher characterized this Adobe breach, which affected Acrobat, ColdFusion and numerous other applications, as ‘one of the worst in US history’.” (Wikipedia, s.v. Adobe Systems, viewed 10/20/2013)
   ... And we saw in the energy sector with the computer-driven blackout of 8–9 September 2011, which affected over 5 million people in Southern California, Arizona, and northwestern Mexico, contributing to the debate over blackout inevitability and electric sustainability: “It has been argued on the basis of historical data and computer modeling that power grids are self-organized critical systems. These systems exhibit unavoidable disturbances of all sizes, up to the size of the entire system. This phenomenon has been attributed to steadily increasing demand/load, the economics of running a power company, and the limits of modern engineering. While blackout frequency has been shown to be reduced by operating it further from its critical point, it generally isn’t economically feasible, causing providers to increase the average load over time or upgrade less often resulting in the grid moving itself closer to its critical point. Conversely, a system past the critical point will experience too many blackouts leading to system-wide upgrades moving it back below the critical point. The term critical point of the system is used here in the sense of statistical physics and nonlinear dynamics, representing the point where a system undergoes a phase transition; in this case the transition from a steady reliable grid with few cascading failures to a very sporadic unreliable grid with common cascading failures. Near the critical point the relationship between blackout frequency and size follows a power law distribution. Other leaders are dismissive of system theories that conclude that blackouts are inevitable, but do agree that the basic operation of the grid must be changed....” (Wikipedia, s.v. Power Outage, viewed 10/20/2013)
   ... And we find even with the “very sophisticated exchanges” of the Stock Market model touted in a 10/19/2013 NewsHour analysis by David Brooks, who must have forgotten about the “May 6, 2010 Flash Crash” caused in part by computer-driven, high-frequency trading: “An analysis of trading on the exchanges during the moments immediately prior to the flash crash reveals technical glitches in the reporting of prices on the NYSE and various alternative trading systems (ATSs) that might have contributed to the drying up of liquidity. According to this theory, technical problems at the NYSE led to delays as long as five minutes in NYSE quotes being reported on the Consolidated Quotation System (CQS) with time stamps indicating that the quotes were current. However, some market participants (those with access to NYSE’s own quote reporting system, OpenBook) could see both correct current NYSE quotes, as well as the delayed but apparently current CQS quotes. At the same time, there were errors in the prices of some stocks (Apple Inc., Sothebys, and some ETFs). Confused and uncertain about prices, many market participants attempted to drop out of the market by posting stub quotes (very low bids and very high offers) and, at the same time, many high-frequency trading algorithms attempted to exit the market with market orders (which were executed at the stub quotes) leading to a domino effect that resulted in the flash crash plunge.” (Wikipedia, s.v. 2010 Flash Crash, viewed 10/20/2013) (A note to Obamacare detractors: this same Wikipedia page includes comments by Dr. David Leinweber, director of the Center for Innovative Financial Technology at Lawrence Berkeley National Laboratory, criticizing “the government’s technological capabilities and inability to study today’s markets.” ;-)
   My argument is not that “government-made” websites are better or worse than those created by businesses, but that all websites are works-in-progress, subject to unforeseen technical problems from the minute they launch. This holds for the simplest websites, such as the one you’re visiting right now; and it is especially true for websites operating on such a massive scale as HealthCare.gov.

pointer  ProPublica’s report, “Here’s Why Healthcare.gov Broke Down,” by Charles Ornstein, posted to the ProPublica website on 16 October 2013.

With “excerpts from five of the better stories [in The Wall Street Journal, Politico, The New York Times, Washington Post, Buzzfeed] explaining what happened.” See also the comments responding to Ornstein’s piece (at the bottom of the page).

UPDATE #1:  “Is Healthcare.gov Turning the Corner? Not So Fast,” by Charles Ornstein, posted to the ProPublica website on 21 October 2013.

UPDATE #2:  “A Tale of Two Obamacares: Which Is Right?,” by Charles Ornstein, posted to the ProPublica website on 21 October 2013. See also the comments responding to Ornstein’s piece (at the bottom of the page).

pointer  “Dr. Sanjay Gupta Will See You Now,” by Leah Rozen, with photographs by Spencer Heyfron (Parade, 13 October 2013, pp. 6–7).

SUMMARY: “In this weekend’s issue of Parade, Dr. Sanjay Gupta opens up about Obamacare, medical marijuana, and what he loves about surgery.”
   Gupta is a practicing neurosurgeon and “CNN’s globe-trotting chief medical correspondent.” (Rozen, 6)
   Re. Obamacare: “... he applauds the Affordable Care Act, calling it ‘an important step.’ But he cautions that offering most Americans access to insurance is not a cure-all. ‘If you don’t make America healthier, you’re not going to control costs,’ he says. ‘And ultimately that’s what we have to do.’” (Rozen, 6)
   Paul Solman makes much the same point in his reporting for the PBS NewsHour on what we’ve learned from the Massachusetts Exchange Model (see below, pointer for the entry dated 1 October 2013).
   Also see the brief report, “We’re Going to Be Spending Even More on Health Care” — regardless of any changes wrought by Obamacare (scroll down to the pointer for 28 July 2011).

pointer  “Three Months to Healthy: Things to Do [and] Stop Doing,” retitled “12 Ways to Keep You and Your Family Healthy” for online posting, by Melinda Wenner Moyer (Parade, 13 October 2013, pp. 8–9).

SUMMARY: “When it comes to our health, most of us make a fresh start with the new year. But fall may be an even better time to focus on wellness: You’re not mentally spent from the holidays, and with a bit of effort now, you can go into the crazy season feeling energized and fit. To help you kick things off, Parade dug into the latest research to find 12 simple, proven ways to keep you and your family healthy. Start today, next week, or even next month—and reap the benefits by New Year’s.” (8)
   Wenner Moyer has here compiled a list of nine DOs:
   1.  “Eat breakfast.”
   2.  “Ease stress with sound.”
   3.  “Cut down on salt. (But not as much as you think.)”
   4.  “Get a flu shot.”
   5.  “Stick to an exercise schedule.”
   6.  “Use a dental irrigator.”
   7.  “Volunteer.”
   8.  “Get a whooping cough booster.”
   9.  “Buy more houseplants.”
   and three DON’Ts:
   10. “Rethink the annual physical.”
   11. “Quit washing raw chicken.”
   12. “Say no to sports drinks.”

pointer  “Stem Cell: Regenerative Medicine Is Next Wave,” retitled “Meeting Tackles Stem Cell Field’s Business Challenges: La Jolla conference will look into practical research applications” for online posting, by Bradley J. Fikes (U-T San Diego [formerly San Diego Union-Tribune], 12 October 2013, pp. C1 and C2).

SUMMARY: “The business push into what’s called regenerative medicine takes place as the United States is adopting a new health care system. Biotech executives speaking at the conference said their job is to document the benefits in restoring patient health and replacing less effective and more costly alternatives.” (Fikes, C1)

U P D A T E :  “Stem Cell Businesses Keep Growing,” by Bradley J. Fikes (posted to the U-T San Diego website, 10/15/2013).
   In sum: “Biotech companies continue to attract investor interest, speakers said at the meeting this week in La Jolla, pointing to a stream of biotech initial public offerings as well as purchases of biotechs by large pharmaceutical companies.... The challenge for stem cell companies is to convince investors that their science is actually geared toward products that can be sold, said Ted Roth, president of Newport Beach-based Roth Capital Partners. Compared with 20 years ago, investors are much more sophisticated and aren’t dazzled by technology, he said.  ¶  ‘How can you convince me this is not a science project?’ is the question these companies need to answer, Roth said.” (Fikes, 10/15/2013, n. pag.)

pointer  “Health Exchange Takes Down Doctor Directory,” by Paul Sisson (U-T San Diego [formerly San Diego Union-Tribune], 11 October 2013, pp. C1–C2).

SUMMARY: “Discrepancies in doctor listings on state insurance exchange site prompt removal.” (C1)

U P D A T E :  Paul Sisson reports that 2 weeks after launch, Covered California “still doesn’t have a working doctor directory so that shoppers can see which physicians are included in each health plan.... And certification of private insurance agents who want to sell exchange plans is moving slowly.” (Sisson, “State’s Health Exchange Still Has Glitches: Doctor directory, other functions not working,” U-T San Diego, 20 October 2013, pp. A1 and A17).
   The spokeswoman for California’s exchange has explained “that insurance companies incorrectly coded the specialties of some doctors whose information was submitted to the exchange for inclusion in the directory. Fixing that coding, she said, is taking time.  ¶  ‘We needed to retool the data, which is a lengthy process. We are also working on verifying the data in the directory and testing the system,’ Gonzales said.  ¶  She said the exchange realizes that knowing which doctors are included in each plan is important.  ¶  ‘We recognize that many consumers will base their plan selection on the provider network, so we’re anxious to get the directory online,’ she said.” (Sisson, A17)

pointer  “High Volume, Complex Software Led to Troubled Launch of Insurance Exchanges,” a PBS NewsHour analysis, first aired 10 October 2013.

“SUMMARY: Software bugs and system ‘bottlenecks’ have plagued the new health insurance exchanges since their online launch. Will the site be able to handle the high volume of traffic? Ray Suarez talks to Craig Timberg of The Washington Post about the outlook for solving the site’s problems.”

pointer  “States Taking Medicaid Opt-Out Option Leave ‘Larger Impact than Expected’,” a PBS NewsHour analysis, first aired 7 October 2013.

“SUMMARY: As the effects of the shutdown take hold, longer-term fights over safety net programs continue. Jeffrey Brown talks to Jacob Hacker of Yale University and Stephen Parenti of the University of Minnesota about how states opting out of the Affordable Care Act’s Medicaid expansion has stranded some uninsured Americans.”

pointer  “Ability to Choose Wisely May Decline with Age,” retitled “Do We Make Poorer Decisions as We Age?” for online posting, by Monte Morin (Los Angeles Times, 6 October 2013, p. A26).

SUMMARY: “A new study suggests that decision-making skills decline with age.”
   This latest study found that even the healthiest seniors were more likely than adolescents, young and mid-life adults to “show profoundly compromised decision-making”: “the findings fall in line with a growing body of research that suggests older adults make decisions detrimental to their wealth, health and general well-being,” raising “potential policy issues, considering that seniors are more likely to fail to choose health plans correctly and more likely to make voting errors.” (Morin, A26)
   Significantly, this new finding that “our ability to make wise choices changes over time, and actually declines with old age” is at odds with centuries’ of thinking about human character and its development. Starting with Aristotle in the Latin West, behaviorists have argued that phronesis (practical wisdom, or the application of good judgment to human conduct) is an age-related virtue acquired with maturity and experience. Past models of the phronimos held up for emulation throughout history include Nestor (a centenarian) and Solomon (an octogenarian). But neither man was thought wise because of his financial savvy.
   As far as I know, the study reported on here by Morin is the first to identify the phronimos using “a series of ‘lottery questions’ ... designed to gauge risk aversion, consistency of thought and rationality” (Morin, A26) — none of which are traditional indicators of wisdom.
   For another modern study of wisdom more in line with historical and cultural precedent, see the account by Randolph E. Schmid of the Associated Press, published on p. A2 in the 9 April 2010 issue of San Diego’s Union-Tribune: “When It Comes to Wisdom, Age Has Advantages.” Here, the researchers studied “social wisdom,” not rationality, and “found that older people were more likely than younger or middle-aged ones to recognize that values differ, to acknowledge uncertainties, to accept that things change over time and to acknowledge other points of view.” (Schmid, A2)
   “Lynn A. Hasher, a psychology professor at the University of Toronto, called the study ‘the single best demonstration of a long-held view that wisdom increases with age.’” (Schmid, A2)

pointer  “Health Law Debut Is Full of Surprises,” retitled “Flood of Consumer Inquiries Could Make — Or Break — Obama Health Law” for online posting, by Noam N. Levey and Chad Terhune (Los Angeles Times, 6 October 2013, pp. A1 and A24–A25).

SUMMARY: “Strong consumer interest heartens backers of Obama’s healthcare law, but persistent glitches could spell trouble.”

pointer  “Op-Ed: The Unsettled Healthcare Law,” by Doyle McManus (Los Angeles Times, Opinion section, 6 October 2013, p. A30).

SUMMARY: “Law or not, expect a long battle ahead, with the 2014 congressional races key to deciding whether Obamacare survives.”

pointer  “How to Deal With Your Crowded Health Exchange: Try applying in off hours, or waiting a few weeks,” by Daniel Lippman (The Wall Street Journal Sunday section, U-T San Diego [formerly San Diego Union-Tribune], 6 October 2013, p. C5).

pointer  “How Obamacare Benefits Older Workers: Coverage for People Who Might Have Been Denied Insurance,” by Tom Lauricella (The Wall Street Journal Sunday section, U-T San Diego [formerly San Diego Union-Tribune], 6 October 2013, p. C6).

pointer  “Obamacare Aims to Close Medicare ‘Doughnut Hole’: Shrinking Since 2010, It Will Close in 2020,” by Jennifer Waters (The Wall Street Journal Sunday section, U-T San Diego [formerly San Diego Union-Tribune], 6 October 2013, p. C6).

pointer  “Examining Affordability of Health Care via More Accessible New Exchanges,” a PBS NewsHour analysis, first aired 2 October 2013.

“SUMMARY: In its opening days, the new online insurance exchanges have experienced a rush of interest and some technical difficulties along the way. Despite the glitches, will consumers find affordable plans? Gwen Ifill gets views from Sabrina Corlette of Georgetown University and Joe Antos of the American Enterprise Institute.”
   On the matter of HealthCare.gov website glitches, all of us who design and develop websites for a living can attest that such malfunctions are perfectly normal, and not related to, or predictive about, the new law itself. As one commentator responding to this 10/2/2013 NewsHour story rightly noted, “In the IT world, for large system deployments, such bugs and glitches are frustratingly routine. Although the PR doesn’t mention this ‘feature’, it’s essentially unheard-of for problem-free launches. For a system as declaredly incomplete and varied—and of this size, this is not technical news, it’s only political news.”

pointer  “Opening Day of Insurance Exchanges Overwhelmed by Online Rush,” a PBS NewsHour analysis, first aired 1 October 2013.

“SUMMARY: Americans eager to explore or sign up on the new online insurance exchanges were confronted with technical glitches due to the rush of traffic on the website. Judy Woodruff talks to Julie Rovner of NPR and Louise Radnofsky of The Wall Street Journal about who was shopping for health care coverage on day one of the program.”

pointer  “As Government Closes, Health Reform Marketplaces Officially Open,” a PBS NewsHour feature in their Health Care Reform series, posted to The Rundown: A Blog of News and Insight, by Jason Kane, on 1 October 2013.

pointer  “5 Things to Keep in Mind While Shopping in Insurance Marketplaces,” a PBS NewsHour feature in their Health Care Reform series, posted to The Rundown: A Blog of News and Insight, by Michelle Andrews and Kaiser Health News, on 1 October 2013.

pointer  “[Massachusetts] Exchange Model Shows Vast Coverage for Citizens, High Care Costs for State,” a PBS NewsHour report by Paul Solman (part of his “Making Sense of Financial News” series), first aired 1 October 2013.

“SUMMARY: October 1 was the opening day nationwide for new health care exchanges under the Affordable Care Act. But Massachusetts has been using its own online insurance marketplace since 2006. How has that program fared in the Bay State? Economics correspondent Paul Solman explores the Massachusetts model.”
   This is an interesting report on the vexing problem of soaring health care costs, even when everyone has easy access to affordable insurance plans.

pointer  “California Reaches Out to Educate Latino Community on New Insurance Exchange,” a PBS NewsHour report by Kwame Holman, first aired 30 September 2013.

“SUMMARY: On the eve of open enrollment for insurance exchanges as part of the Affordable Care Act, the state of California is making a big push among Latinos, who make up a third [of] the uninsured nationwide. Kwame Holman reports on the $60 million effort to educate and enroll Californians in the new health care program.”

pointer  “A Family Legacy of Healthcare Reform,” retitled “California Insurance Exchange Chief Has Health Reform ‘in His Bones’” for online posting, by Chad Terhune (Los Angeles Times, 29 September 2013, pp. A1 and A21).

SUMMARY: “Peter Lee’s father and uncle fought for then-controversial Medicare 50 years ago. Now the Covered California chief must enroll millions in Obamacare, and his performance may set the tone for other states.”
   And “It’s déjà vu all over again.” “Some of the early obstacles [Philip Lee] encountered [while implementing the new Medicare program in 1965] are similar to what his nephew [Peter Lee, executive director of Covered California] faces, including a potential shortage of medical providers as an influx of patients seek care.” (Terhune, A21)
   “When Kennedy pushed for Medicare legislation, Philip [Lee] and the elder Peter Lee were among a handful of doctors nationwide to speak publicly in support. ... Philip Lee, now 89, endured a ... backlash after squaring off in debates against other prominent doctors across the country.  ¶  ‘The San Francisco Medical Society called me a communist,’ [Philip Lee] said. ‘They were calling it the end of Western civilization back then. It’s such a flashback to today.’” (Terhune, A21)

pointer  “Op-Ed: “When Push Comes to Nudge,” by Michelle N. Meyer and Christopher Chabris (Los Angeles Times, Opinion section, 29 September 2013, p. A24).

The science of “choice architecture” — using our predictable and systematic human biases (e.g., cognitive bias, hindsight bias, status quo bias) in designs that “nudge” us towards certain actions and behaviors — was popularized by Richard Thaler and Cass Sunstein in their book, Nudge: Improving Decisions about Health, Wealth, and Happiness (Yale University Press, 2008). As explained by media expert Peter Kirwan, “Nudging is the name given by the authors Richard Thaler and Cass Sunstein to describe the art of influencing user behavior by presenting options in specific ways. When they nudge us, businesses and government erect what Thaler and Sunstein call an architecture of choice around us.” (“Love Google. Hate Facebook. Here’s Why,” posted to Wired’s website on 10.02.10)
   Thaler & Sunstein referred to nudge-oriented public policy as “libertarian paternalism,” and it is the Obama administration’s interest in government nudging — to advance health care reform — that Meyer & Chabris assess in their op-ed for the Los Angeles Times. Here, they point out that “Nudges enjoy an additional, overlooked advantage over other forms of regulation: Before they are enacted, they can be evaluated with randomized, controlled trials to ensure that they are effective.” But, “just because nudges can be tested does not ensure that they will be.” (Meyer & Chabris, A24)
   Take the case of Obamacare, which “requires chain restaurants to post calorie counts for standard menu items, a policy similar to one enacted by New York City in 2008. It seems intuitive that this should nudge consumers to make better choices, thereby reducing obesity and saving potentially billions of dollars in healthcare spending.  ¶  But that intuition was not tested experimentally in advance, and observational studies of calorie displays are inconclusive. One study found that they had no effect, but another found a 6% decrease in calories purchased. The federal rule added a requirement that chain restaurants also post a suggested total daily caloric intake, perhaps on the assumption that telling consumers that a Big Mac has 550 calories will mean more when framed by the advice that an adult should eat about 2,000 calories a day. But a recent study undermined this intuition too: Benchmarks did not reduce purchased calories, and may have ironically promoted consumption of higher-calorie items.  ¶  Implementing untested nudges has real costs. According to the federal government, the Obamacare calorie rule imposes a new 14.5-million-hour paperwork burden, and first-year compliance costs for businesses could total $537 million. If the benefits of a government intervention are not expected to outweigh its costs, then doing nothing will often be the better policy choice.” (Meyer & Chabris, A24)

pointer  Healthcare Watch column, “Examining Your Options in New Insurance Marketplace,” retitled “Examining Your Health Insurance Options under Obamacare,” by Lisa Zamosky and Chad Terhune (Los Angeles Times, 29 September 2013, p. B3).

SUMMARY: “With open enrollment in the state’s new health insurance marketplace beginning this week, it’s a good time to answer some commonly asked questions.”
   Zamosky and Terhune answer 13 FAQs:
   1.  “Do I need to do anything right now?”
   2.  “Where do I go to enroll?”
   3.  “I get my insurance through work. Will that be affected next year?”
   4.  “How much will this new health coverage cost?”
   5.  “Can I wait until I get sick to enroll?”
   6.  “What are the penalties if I don’t buy health insurance?”
   7.  “Will I pay more for being a smoker or having cancer in the past?”
   8.  “What kind of income is counted in determining whether I qualify for premium subsidies?”
   9.  “Does my employer have to offer me coverage now?”
   10. “What will it cost when I see a doctor?”
   11. “Who qualifies for Medi-Cal?”
   12. “I have a small business with five employees. How does this affect me?”
   13. “I’m an undocumented resident in California. Can I get financial help with my premiums?”
   [14. “I have Medicare. Do I have to buy a new health plan through the marketplace?” (Bonus question, online edn. only)]
   And they ask readers/website visitors to submit more: “Please share your comments or ask questions at healthcare@latimes.com. Submissions must include names and phone numbers.” (Zamosky and Terhune, B3)

pointer  “Rx for Savings: 8 Ways to Cut Your Health Care Costs,” by Frank Lalli (Parade, 29 September 2013, pp. 12–13 and 15).

SUMMARY: “What’s the scariest thing about October? For many working Americans this year, it’s not Halloween; it’s deciding what to do about your open enrollment choices and 2014 health care costs.  ¶  The decisions we face are more complex than ever because of new options offered under the Affordable Care Act. (The online insurance marketplaces, called exchanges, are scheduled to open Oct. 1 for all 50 states and D.C.) To help Parade readers navigate the process, we asked Frank Lalli, former editor of Money magazine and author of an upcoming book on finding affordable health care, for his advice on reducing your costs. ‘These tips,’ says Lalli, ‘can save you hundreds, maybe thousands, of dollars.’” (Lalli, 12)
   For Tip No. 7, Lalli advises “Take a Closer Look at Obamacare”: “According to a study by HealthPocket.com, an insurance company rating site, the 2014 health insurance plans on your state’s online exchange will provide better benefits than 98 percent of the individual health plans sold today.” (Lalli, 15)

pointer  “State Health Exchange Set to Open Tuesday,” by Paul Sisson (U-T San Diego [formerly San Diego Union-Tribune], 29 September 2013, p. A12).

The print edition of this has 4 charts (“Covered California Metal Tiers,” “San Diego County Monthly Premiums,” “Doctors in County,” “Affordable Care Act Essential Benefits”) which are not included with the online edition of Sisson’s report.
   However, the accompanying graphic by Aaron Steckelberg, “Health Insurance Coverage and Penalties,” can be viewed here.

pointer  “Obamacare Divides in D.C. and San Diego” (originally titled “Health Care at Heart of D.C. Battle”), by Paul Sisson (U-T San Diego [formerly San Diego Union-Tribune], 29 September 2013, pp. A1 and A13).

SUMMARY: “As clock ticks toward possible shutdown of government, lawmakers face off in intense struggle over Obamacare.” (print edn., A1)

pointer  “What You Need to Know About the Affordable Care Act: Next Year Will Bring Some of the Biggest Changes to the Health-Care System,” by Avery Johnson (The Wall Street Journal Sunday section, U-T San Diego [formerly San Diego Union-Tribune], 29 September 2013, p. C6).

The WSJ’s brief rundown covers topics relating to: “If You Need Insurance,” “Plans,” “Tax Credits,” “If You Need Help,” “The Fine,” “Medicaid,” “Protections,” “Kids and Women,” “Businesses.”

pointer  “10 Things Obamacare Won’t Tell You: The health exchanges, central to the law, are also its biggest mystery” (originally titled “10 Things ... Health Exchanges Won’t Tell You”), by Jen Wieczner (The Wall Street Journal Sunday section, U-T San Diego [formerly San Diego Union-Tribune], 29 September 2013, p. C7).

The WSJ’s top-10 list:
   1.  “You might want to avoid signing up on Day One.”
   2.  “Yes, some workers are being kicked off employer plans and sent to exchanges — but not these exchanges.”
   3.  “We’re very misunderstood.”
   4.  “Don’t ask our staff for advice.”
   5.  “Blue states do it better.”
   6.  “Abuse our honor system at your peril.”
   7.  “You’ll still pay for this, even if you don’t need it.”
   8.  “We’re a magnet for hackers and con artists.”
   9.  “You might not be able to keep your doctor.”
   10. “Marketplace competition is a work-in-progress.”

pointer  “Navigating Employer Mandate: Businesses have time to comply with health care reform, but some local firms are already grappling with challenges of providing coverage,” by Jonathan Horn & Katherine Poythress (U-T San Diego [formerly San Diego Union-Tribune], 29 September 2013, pp. C1 and C4).

pointer  “Q&A: Health Care Reform for Business Owners: Health care reform raises compelling questions, which U-T San Diego begins to answer” (originally titled “Businesses Raise Some Compelling Questions”), by Katherine Poythress (U-T San Diego [formerly San Diego Union-Tribune], 29 September 2013, pp. C1 and C4).

The 13 questions answered here:
   1.  “How do I know if I’m required to provide health insurance?”
   2.  “OK, so I have more than 50 full-time employees, or the equivalent. Who do I have to insure?”
   3.  “My employees work irregular hours — some weeks under 30 and some weeks more than 30. Do I have to offer them insurance?”
   4.  “What happens if I don’t cover my eligible employees?”
   5.  “What kinds of penalties?”
   6.  “What if I insure just my most valued workers?”
   7.  “Is it true that it might be less expensive to pay the penalty than to offer health insurance to my employees?”
   8.  “I already have a health insurance policy that my employees like. Do I have to change it in order to meet the new federal regulations?”
   9.  “Is the Small-Business Health Options Program (SHOP) exchange the only way to get a new group health insurance plan for my employees?”
   10. “How will health plans differ inside and outside the small-business exchange?”
   11. “Do I need a broker to purchase insurance?”
   12. “I have a multistate business, so do I have to use a different exchange in each state?”
   13. “I heard that enrollment on the SHOP exchange has been delayed. Does that mean I have to wait?”

pointer  “What Kinds of Changes Can Older Americans Expect Under Health Reform?,” a PBS NewsHour analysis by Ray Suarez, first aired 26 September 2013.

“SUMMARY: How does the Affordable Care Act alter Medicare or other insurance coverage for older Americans? Mary Agnes Carey of Kaiser Health News joins Ray Suarez to answer some of your most frequently asked questions.”
   Segment No. 7 in the NewsHour series (“Healthcare FAQ”) on the Affordable Care Act (aka Obamacare).
   Among the several questions Carey fields is one about the unique situation of IBM retirees, who “are being placed in a private exchange.” Carey emphasizes that “This has nothing to do with the exchanges created in the health law. IBM and other employers have decided to give their retirees a set amount of money, let them go into an exchange that sometimes offers more coverage choices for their retirees and let them pick that.  ¶  But, again, I want to stress it has nothing to do with the exchanges in the health care law.” (Carey, PBS NewsHour interview, 9/26/2013) See below (pointer for the entry dated 13 September 2013) for more about IBM’s action.
   For earlier segments in the NewsHour’s “Healthcare FAQ” series, see below, pointers for the entries dated 25 September 2013 (Segment No. 6), 24 September 2013 (Segment No. 5), 20 September 2013 (Segment No. 4), 19 September 2013 (Segment No. 3), 18 September 2013 (Segment No. 2), and 17 September 2013 (Segment No. 1).

pointer  “No, Mr. Jenkins, I’m Not Rooting for Obamacare to Fail,” by columnist Michael Hiltzik (posted to the Los Angeles Times website, 25 September 2013).

This brief essay is part of the fall-out from Hiltzik’s earlier column, “Health Law’s Ailments Can Be Cured by Single-Payer System: All the shortcomings of the healthcare restructuring result from the decision to leave it in the hands of private insurers,” posted to the Los Angeles Times website on 10 September 2013.
   In his column of 9/10/2013, Hiltzik argued that “The country should progress on to a single-payer system.” — which is exactly the sort of logic that worries Sally Pipes, whose op-ed of 2 August 2013 (see below pointer for this date) in San Diego’s Union-Tribune voiced her suspicion that Obamacare is “paving the way for [a] single-payer system.”
   And Pipes may well be right. As Hiltzik reported on 9/10/2013, “The ACA’s critics observe that a plurality of Americans still view the ACA unfavorably (43%, according to an opinion poll released in June by the Kaiser Family Foundation). They rarely acknowledge, however, that nearly 1 in 5 of those critics think the law doesn’t go far enough — that is, further toward single-payer.”
   Predictably enough, Hiltzik’s column provoked a heated online discussion, with 155 comments (as of 9/27/2013), which you can delve into here.
   Hiltzik’s column also caught the attention of The Wall Street Journal’s Holman Jenkins, who accused Hiltzik of “rooting for the Affordable Care Act to be a train wreck.”
   On 9/25/2013, Hiltzik denied that his 9/10/2013 remarks concerning known ACA flaws and expected glitches during the forthcoming period of implementation equate to “‘rooting’ for Obamacare to fail.” Rather, “The only people in this debate who really are rooting for Obamacare to fail are conservatives who have decided to make an ideological crusade out of denying millions of Americans access to health coverage.  ¶  Where they can, they’ve taken every step possible to make their rooting goal a reality. Some Republican governors have refused the expansion of Medicaid in their states, even though that provision of the ACA would provide coverage for millions of people. House Republicans have harassed the ‘navigator’ organizations tasked with helping people use Obamacare as it’s designed; Republican Sen. Marco Rubio of Florida pitched a fit over the government’s plans to spend money educating the public about how to make use of this landmark program.”
   Indeed, among the surprises for those of us who believe in the efficiencies of a single-payer system is the finding that, thus far, “insurance exchange premiums across the nation ... will average 16% less than the projections produced earlier by the Congressional Budget Office.... In other words, the free market is working, better even than anyone expected.” (Hiltzik, 9/25/2013 post to Los Angeles Times website)
   For a more detailed discussion of the concerted effort, mentioned by Hiltzik, to obstruct the “navigators” tasked with helping people enroll in insurance plans under the Affordable Care Act, see below (pointer for the entry dated 8 September 2013).

pointer  “From Bronze to Platinum Plans, What Will New Insurance Exchange Premiums Cost?,” a PBS NewsHour analysis by Ray Suarez, first aired 25 September 2013.

“SUMMARY: New details were released about coverage choices for consumers in the new health care exchanges. What will their premiums cost? Ray Suarez is joined by Louise Radnofsky of The Wall Street Journal to answer some of your most frequently asked questions.”
   Segment No. 6 in the NewsHour series (“Healthcare FAQ”) on the Affordable Care Act (aka Obamacare).
   Suarez and Radnofsky here touch on one of the least-ballyhooed boons of Obamacare: the huge data sets being amassed for the 36 states where the federal government is running some or all of the marketplaces. When we combine “data mining” with the government’s data aggregation, we may well discover all sorts of evidence that will help each of us — and policy-makers in a variety of related fields — make better, more-informed decisions, reign in health care costs, and improve our health outcomes.
   Radnofsky hints at this when she notes: “One of the states that came in with very low premiums is ... Tennessee, and particularly in the Nashville area. It may have something to do with the way that the health economy there operates or it may just be something else to do with Tennessee. It’s certainly a really interesting study. And there’s more grist to really [delve] into it in future years than there ever has been before.” (Radnofsky, PBS NewsHour interview, 9/25/2013)
   For earlier segments in the NewsHour’s “Healthcare FAQ” series, see below, pointers for the entries dated 24 September 2013 (Segment No. 5), 20 September 2013 (Segment No. 4), 19 September 2013 (Segment No. 3), 18 September 2013 (Segment No. 2), and 17 September 2013 (Segment No. 1).

pointer  “How Does Health Care Reform Change Options for Young Adults?,” a PBS NewsHour analysis by Gwen Ifill, first aired 24 September 2013.

“SUMMARY: Under the new health care reform law, young adults can stay on their parents’ insurance until they are 26. What options are available for young adults with limited income? Gwen Ifill looks to Mary Agnes Carey of Kaiser Health News to answer some of your most frequently asked questions.”
   Segment No. 5 in the NewsHour series (“Healthcare FAQ”) on the Affordable Care Act (aka Obamacare).
   As usual, tempers flared among those commenting on the touchy subjects covered in Carey’s interview (at base, the whole concept of insurance, where risk is pooled, and those who believe they won’t ever need insurance, never want to pay for it, especially when they think they won’t directly benefit).
   One commentator smartly quotes Ezra Klein — “The people overpaying to keep costs low today are the people underpaying 10 or 20 years from now.” — after despairing over the amount of misinformation, “dishonest argument,” and militant ignorance on display in most public discussions of Obamacare: “There’s a better chance of the US curing cancer, erasing our deficit and amending our constitution to ban the use of the acronym ‘yolo’ than having an informed, civilized debate over the best way to improve health care coverage[.]” (comment posted by Scott Matthews, 9/25/2013, in response to the PBS NewsHour interview of 9/24/2013).
   For earlier segments in the NewsHour’s “Healthcare FAQ” series, see below, pointers for the entries dated 20 September 2013 (Segment No. 4), 19 September 2013 (Segment No. 3), 18 September 2013 (Segment No. 2), and 17 September 2013 (Segment No. 1).

pointer  “Drugstores Vie for Bigger Role in Care,” retitled “Healthcare Reform Heats Up Drugstore Battle” for online posting, by columnist Michael Hiltzik (Los Angeles Times, 22 September 2013, pp. B1 and B8).

SUMMARY: “CVS, Rite Aid and Walgreens aim to play a bigger role in healthcare as the reform law is due to expand access to medical services for millions of people.”
   The rivalry between physicians and apothecaries or “druggists” (a term that first took hold during the 17th century) — competing for market share, professional status, and perquisites — dates to the beginning of both as organized trades, and continues unabated today. In his article on the profession of apothecary, the enlightenment encyclopedist, Ephraim Chambers (1680?–1740), observed wryly that the eminent Danish physician and natural philosopher, Thomas Bartholin (1616–1680), had complained “of the too great number of Apothecaries in Denmark; tho’ there were but three in Copenhagen, and four in all the Kingdom beside: What would he have said of London, where there are upwards of 1300?” (Chambers’ Cyclopaedia, 1st edn., 1728, i. 119) Imagine Bartholin’s negative reaction to the omnipresence of the pharmaceutical industry today, in the era of the ever-expanding chain drugstore: “the jockeying for market share isn’t over, and the transformation of the pharmacy may be just beginning. Your corner druggists will be doing more than ever before, and they’ll be on more corners too.” (Hiltzik, B8)
   I’m planning a series of essays on professional rivalries within the field of medicine for this website’s forthcoming History section, to include examples of early-modern advertising, marketing and branding by 17th-century medical professionals and para-professionals. Despite significant differences between modern medical organizations and their early-modern counterparts, the continuity in English-language medical rhetoric across the centuries is striking.
   For more on the retail competition coming to health care in the 21st century because of Obamacare (aka the Affordable Care Act), see below, pointer for the entry “Walk-In Clinics Are Gaining Popularity,” dated 16 June 2013.

pointer  Healthcare Watch column, “Appealing Decision to Deny Medical Care,” retitled “Challenging a Health Insurer’s Decision to Deny Medical Care” for online posting, by Lisa Zamosky (Los Angeles Times, 22 September 2013, p. B3).

SUMMARY: “Experts recommend taking advantage of well-established appeal processes and consumer rights, along with some new appeal rights, to challenge an insurer’s decision.”
   Zamosky uses the case study of cancer patient Maureen Belle to warn that “health insurance has its limits” and “Challenging insurance decisions, no matter who pays the bills, can be tricky.” (Zamosky, B3)

pointer  Op-Ed Dialog on Obamacare — a “Healthy Solution?” — by Robert K. Ross and Brian Jones (U-T San Diego [formerly San Diego Union-Tribune], 22 September 2013, pp. SD6 and SD8).

SUMMARY given in the print copy of the newspaper: “Changes to health coverage are set to take full effect next year as a result of the Affordable Care Act, also known as Obamacare. Open enrollment in California starts Oct. 1 and the state agency overseeing the health-insurance exchange has been gearing up to help the uninsured learn about available options. While proponents say the overhaul is a fair, affordable way to improve health coverage, critics say the costs are too high and the plan will serve to kill jobs. Below are two views on Obamacare.” (U-T San Diego, SD6)
   1.  Op-ed FOR the Affordable Care Act: “Fixing an Unfair System,” retitled “Obamacare: New Law Will Fix an Unfair System” for online posting, by Robert K. Ross (U-T San Diego [formerly San Diego Union-Tribune], 22 September 2013, pp. SD6 and SD8).
     SUMMARY: “Obamacare deploys an affordability strategy to improve health coverage for the uninsured. It accomplishes this through a tried-and-tested American value: competition on a level.” (U-T San Diego, SD6)
     Ross, an M.D., “is president and CEO of California Endowment, a health foundation, and is on the board of the California Health Benefit Exchange Board.” (U-T San Diego, SD6)
   2.  Op-ed AGAINST the Affordable Care Act: “New Law Will Sink Economy,” retitled “Obamacare: Health-Care ‘Reform’ Will Sink Economy” for online posting, by Brian Jones (U-T San Diego [formerly San Diego Union-Tribune], 22 September 2013, pp. SD6 and SD8).
      SUMMARY: “Uninsured Californians will be forced to buy insurance or pay a fine to the IRS. Either way, it means more money plucked from the pockets of the industrious in order to fuel the runaway growth of government.” (U-T San Diego, SD6)
      Jones, a Republican currently serving in the California State Assembly, “represents the 71st Assembly District, which includes the eastern San Diego County communities of Alpine, Borrego Springs, Casa de Oro-Mount Helix, El Cajon, Lakeside, Ramona, Rancho San Diego, Santee, and Spring Valley; and southern Riverside County.” (U-T San Diego, SD6)
   Juxtaposed with these two op-eds in the printed version of the paper is the over-sized number $5,290, glossed by U-T editors as: “The average government subsidy for each individual enrolled in government health insurance ‘exchanges’ in 2014, up 33 percent from 2010 estimates. / Source: Congressional Budget Office.” (U-T San Diego, Opinion section, 22 September 2013, p. SD8)

pointer  “Re-Engineering Veterans’ Health Care in San Diego: VA hospital in La Jolla is in the middle of a $28 million renovation project,” by Jeanette Steele (U-T San Diego [formerly San Diego Union-Tribune], 22 September 2013, pp. A23–A24).

SUMMARY: “The VA Medical Center in La Jolla is undergoing a more than $28 million renovation to update the 41-year-old complex. The lead administrator [Jeff Gering] wants the federal institution to be competitive with private San Diego hospitals, including having shorter wait times and a more pleasant atmosphere.” (Steele, A23) In addition, “the VA is talking to Sanford-Burnham Medical Research Institute in La Jolla about partnering on brain research, along with UC San Diego.  ¶  Sanford-Burnham researchers are looking at Alzheimer’s disease and traumatic brain injury, a common wound among post-Sept. 11 veterans. There are early signs that treatment for both problems may be related.  ¶  ‘This is a unique opportunity with the number of Iraq and Afghanistan veterans coming to us in San Diego County and the educational institutions we have … to really be a research hub in the area of TBI and Alzheimer’s for the nation,’ Gering said.” (Steele, A24)
   With a companion piece, also authored by Steele, “Local Aspire Center Will Be One of a Kind” (U-T San Diego, 22 September 2013, pp. A23–A24).
   Scheduled to open during the spring of 2014, “The Aspire Center is a five-year, $30 million VA project to create a short-term residential center for veterans with post-traumatic stress disorder and traumatic brain injury, two signature wounds from Iraq and Afghanistan.” (Steele, A23)

pointer  “Medical Devices Must Have Unique Identifiers in U.S.,” by Anna Edney of Bloomberg News (posted to their website, 20 September 2013).

SUMMARY: “Makers of heart stents, artificial joints and other medical devices must begin adding unique identification codes to their packaging by next year to help U.S. regulators accurately track adverse health events.”
   A related story by Matthew Perrone, Health Writer for the Associated Press, was published to the U-T San Diego website on 20 September 2013: “FDA Requires Tracking Codes on Medical Implants.”
   “The FDA tracking system follows years of highly-publicized recalls involving defibrillators, artificial hips and drug pumps, which have been plagued by design and manufacturing flaws.... The FDA will begin phasing in the new system in the coming year, requiring identification codes on high-risk devices like heart stents and defibrillators. The tracking requirement will then be expanded to moderate-risk devices such as X-ray systems, surgical needles and power wheelchairs. Makers of those devices will have three years to implement the tracking codes. Many low-risk devices, such as bedpans and examination gloves, will be exempt from the requirements.” (Perrone, n. pag.)
   And see below, pointer for the Jan./Feb. 2012 print issue of The Women’s Health Activist (“Prescription for Change” column), wherein the authors examine the multibillion-dollar joint-replacement devices industry in the U.S., and, “with at least 50% of the bill footed by U.S. taxpayers through Medicare and Medicaid,” call for wise regulation of the industry in order to improve patient outcomes and save costs.

pointer  “How Do the Health Reform Law’s Financial Incentives and Disincentives Work?,” a PBS NewsHour analysis by Ray Suarez, first aired 20 September 2013.

“SUMMARY: Even as Republicans are trying to shut off funding for the law, the Obama administration and some states are preparing for implementation of the Affordable Care Act. Julie Rovner of NPR [National Public Radio] joins Ray Suarez to answer some of your frequently asked questions on tax credits and subsidies, as well as penalties for not having insurance.”
   Segment No. 4 in the NewsHour series (“Healthcare FAQ”) on the Affordable Care Act (aka Obamacare).
   For earlier segments in their “Healthcare FAQ” series, see below, pointers for the entries dated 19 September 2013 (Segment No. 3), 18 September 2013 (Segment No. 2), and 17 September 2013 (Segment No. 1).

pointer  “Recession Not Health Law May Be Responsible for Cost Curb,” by Alex Wayne of Bloomberg News (posted to their website, 19 September 2013).

Wayne reports here on a new study disputing those who have argued that the Affordable Care Act will reduce costs.
   IN SUM: “President Barack Obama has said the 2010 health-system overhaul helped curb national medical spending, which that year rose 3.9 percent, or about half pre-recession levels. Actuaries at the Centers for Medicare and Medicaid Services [CMS], who don’t answer to the White House, said yesterday in the journal Health Affairs that costs eased because of the economy, not Obamacare. ... The report also contradicts independent economists who had attributed spending reductions more to the Affordable Care Act and changes in the health system, such as shifts in employer benefits. The CMS actuaries, who track medical spending by the government, individuals and insurers, examined 50 years of data and found no evidence of costs deviating much from the economy. ... Spending on hospital visits, medications and other care rose 3.9 percent to $2.8 trillion in 2012, roughly matching growth in the previous two years, the report shows. Growth is projected to be 3.8 percent this year and 6.1 percent in 2014.”
   In contrast: “David Cutler, a Harvard economist and former Obama campaign adviser, published a study in Health Affairs in May that calculated the recession accounted for only 37 percent of the slowdown in health costs from 2003 to 2011, with the majority of the change being ‘unexplained.’ And Ceci Connolly, the managing director of PriceWaterhouseCoopers Health Research Institute, said last year that the lower growth rates are a ‘new normal’ that can’t be attributed to the recession alone.  ¶  ‘We believe the slowdown is a combination of the recession hangover, actions taken by employers and individual consumers and some structural changes in the industry,’ Connolly said yesterday in an e-mail response to questions.  ¶  There is evidence to support her argument....”
   Wayne also quotes Joanne Peters, a spokeswoman for the Department of Health and Human Services, who responded: “The Affordable Care Act holds insurers accountable for cost increases and encourages smarter care, two factors which are contributing to the slowdown of growth in costs.... Already consumers have saved billions of dollars in premiums thanks to the rate review, medical-loss ratio provisions, and policies to promote quality and value in Medicare.” For more on this claim (e.g., “Health Law Rule Saves Consumers $3.9 Billion in Premiums”), see below, pointer for the entry dated 21 June 2013.

pointer  “How Does Health Care Reform Affect the Cost of Insurance Premiums?,” a PBS NewsHour analysis by Ray Suarez, first aired 19 September 2013.

“SUMMARY: Whether you already have health insurance or will soon be shopping for coverage through one of the insurance exchanges, what can you expect to happen to the cost of your premiums? NewsHour analyst Susan Dentzer joins Ray Suarez to answer some of our most frequently asked questions about the new health care reform law.”
   Segment No. 3 in the NewsHour series (“Healthcare FAQ”) on the Affordable Care Act (aka Obamacare).
   For earlier segments in their “Healthcare FAQ” series, see below, pointers for the entries dated 18 September 2013 (Segment No. 2) and 17 September 2013 (Segment No. 1).

pointer  “What Are the Effects and Requirements for Employers Under Health Reform?,” a PBS NewsHour analysis by Ray Suarez, first aired 18 September 2013.

“SUMMARY: The health care reform law was designed to help give people without health insurance an affordable avenue to buy it. But how does it affect Americans who get their insurance through their workplace? NewsHour analyst Susan Dentzer joins Ray Suarez to help answer frequently asked questions about how companies are affected.”
   Segment No. 2 in the NewsHour series (“Healthcare FAQ”) on the Affordable Care Act (aka Obamacare).
   For the first show, which launched their “Healthcare FAQ” series, see the pointer for 17 September 2013.

pointer  “Navigating the October Launch of Health Insurance Exchanges for Americans,” a PBS NewsHour analysis by Ray Suarez, first aired 17 September 2013.

“SUMMARY: Polls show that a majority of Americans don’t understand how the health reform law and the new insurance exchanges — slated to open Oct. 1 — work. Who can sign up and what will be covered? Ray Suarez poses your frequently asked questions to NPR’s Julie Rovner.”
   This is the first segment in a NewsHour series (“Healthcare FAQ”) on the Affordable Care Act (aka Obamacare) and its impact on insurance coverage.
   Ray Suarez explains that the series is designed “to help people out this week and allay some of their fears and also explain the mechanics of the law.”
   As such, the NewsHour is asking people to submit their questions: “For our part, we want to continue to hear from you. Online, we’re collecting questions about the new health care law, and we will be answering those in the coming days.”
   You can post a comment/question for NewsHour experts at the Web page for this story, or contact the NewsHour using their e-mail link on this same page (scroll down to the small button right above the Comments section, and just below the SUPPORT YOUR PBS LOCAL STATION donations button).
   I encourage anyone reading this to participate.

pointer  “Obama Extends Minimum Wage to 2 Million Home Health Aides,” by Jim Efstathiou Jr. (posted to the Bloomberg News website, 17 September 2013).

SUMMARY: “The U.S. Department of Labor extended minimum wage and overtime benefits to the mostly female and minority workforce of nearly 2 million home health-care workers in a ruling issued today.  ¶  The Fair Labor Standards Act will be extended to direct care workers, U.S. Secretary of Labor Thomas Perez said today on a conference call with reporters. Those affected by the rule will receive the same protections as people providing similar services in hospitals and nursing homes, effective Jan. 1, 2015.  ¶  ‘Home-care workers are no longer treated like teenage babysitters providing casual services under this rule,’ Perez said. ‘A fair wage will further stabilize and professionalize this critical line of work.’”

pointer  “Narrow Networks: Insurers hold down premiums by making fewer doctors available, raising concerns about patients’ access to care,” retitled “Insurers Limiting Doctors, Hospitals in Health Insurance Market” for online posting, by Chad Terhune (Los Angeles Times, 15 September 2013, pp. A1 and A18).

SUMMARY: “Insurers in California’s new health insurance exchange are holding down premiums by limiting choices, raising concerns that patients will struggle to get care.”
   Includes handy charts showing: 1. “Doctors by plan: Insurers and their number of doctors in L.A. County for state health exchange” and 2. “Prices in California’s health exchange.”
   As of 9/17/2013, there were 275 comments posted to the Los Angeles Times website responding to this investigative report.

pointer  “Op-Ed: Do Workplace Wellness Programs Work?” by Rahul K. Parikh (originally titled “Weighing Worker Wellness” for publication in the Los Angeles Times, Opinion section, 15 September 2013, p. A24).

SUMMARY: “With some studies casting doubt on the cost savings and the sustainability of such efforts, more research is needed.”

pointer  “Trader Joe’s to Shift Some Health Insurance,” excerpted from story by Alex Nussbaum of Bloomberg News (reprinted in U-T San Diego [formerly San Diego Union-Tribune], 13 September 2013, p. C4).

Compare the U-T San Diego’s abbreviated version to the original Bloomberg News story, “Trader Joe’s Sends Part-Timers to Obama Health Exchanges,” posted to their website on 9/12/2013.
   Trader Joe’s is a Southern California icon, so this is significant news for our region.
   Other companies in the news looking to trim their health care costs:
   1.  “UPS Will Drop Health Coverage for Some Workers’ Spouses: Company trying to cut costs, partly because of Affordable Care Act,” excerpted from Bloomberg News story (U-T San Diego, 23 August 2013, p. C4). Compare the U-T San Diego’s abbreviated version to the original Bloomberg News story, “UPS Ending Health Coverage for Spouses Signals Cost Cuts,” posted to their website on 8/22/2013.
   2.  “IBM to Transfer U.S. Retirees to Healthcare Exchanges Next Year,” by Nicola Leske (corrected story, posted to the U.S. edition of the Reuters website, 7 September 2013).
   3.  The restaurant industry, as reported on by the PBS NewsHour’s Paul Solman: “Businesses Weigh Bottom Line of Health Reform’s Employer Mandate,” first aired 23 September 2013.
     “SUMMARY: Under the Affordable Care Act, employers who have at least 50 full-time employees are mandated to provide affordable insurance or pay a penalty. Most employers already comply, but some business-owners, especially in the restaurant industry, argue it will be a major burden. Economics correspondent Paul Solman reports.”

pointer  “Medicare Recipients Get Reassurance: Seniors confused by Obamacare learn benefits unchanged,” by Kelli Kennedy of the Associated Press (reprinted in U-T San Diego [formerly San Diego Union-Tribune], 13 September 2013, p. A2).

Federal health officials have hit the road, holding workshops on the Affordable Care Act for seniors, many of whom are worried about their Medicare benefits and confused by overlapping enrollment periods for Medicare and the Affordable Care Act.
   Federal health officials are assuring medicare recipients that their benefits will not change when the Affordable Care Act starts.
   “Next month, roughly 50 million Medicare beneficiaries will get a handbook in the mail with a prominent Q&A that stresses Medicare benefits aren’t changing. Federal health officials have also updated their training for Medicare counselors, and are prepping their Medicare call center and website.  ¶  ‘We want to reassure Medicare beneficiaries that they are already covered, their benefits aren’t changing, and the marketplace doesn’t require them to do anything different,’ said Julie Bataille, spokeswoman for the Centers for Medicare and Medicaid Services.” (Kennedy, A2)

pointer  “Op-Ed: Obamacare: New Fight, Old Tactics,” by Nelson Lichtenstein (Los Angeles Times, Opinion section, 8 September 2013, p. A29).

SUMMARY: “Opponents of the healthcare law are following in the footsteps of Southern segregationists half a century ago.”
   This opinion piece, authored by an historian and director of the Center for the Study of Work, Labor and Democracy at UC Santa Barbara, has raised angry remarks from readers who object to what they interpret as the author playing “the race card”: e.g., “The clear implication of Mr. Lichtenstein’s opinion piece is that anyone who opposes Obamacare is a racist or is inherently opposed to healthcare for the poor.” (comment posted at 10:47 AM September 8, 2013 to the Los Angeles Times website)
   In my opinion, Lichtenstein neither says — nor “clearly implies” — any such thing, as was pointed out by at least one other reader: “He also never said anyone was a bigot. He said they were using the same tactics Southern bigots had used.” (comment posted at 7:02 PM September 7, 2013 to the Los Angeles Times website)
   My take-away: Lichtenstein’s focus is on obstructionist attempts “to cripple the work of ‘navigator’ organizations and volunteers that will begin this fall. ... Last month I attended a meeting in Santa Barbara packed with more than 50 health professionals and civic organization leaders, many ready to sign up as navigators in Santa Barbara and Ventura counties. Their task will be difficult even in Obamacare-friendly California, where a staggering 6.7 million uninsured people may need help in signing up for insurance in the new health benefit exchange or enrolling in Medi-Cal.  ¶  Like-minded men and women in Texas, Georgia and across the South face even greater obstacles. They are truly the civil rights workers of our day whose dedication and hope will help transform the insecurity of millions into a set of healthcare rights and thus crack the massive resistance still faced by so many of the poor and uninsured.” (Lichtenstein, A29)
   Nor is Lichtenstein the first to link what Martin Luther King, Jr. called “injustice in health care” with the civil rights movement (see below, pointer for the entry dated June 2006).

U P D A T E :  Alex Wayne of Bloomberg News has reported on Texan obstructionists who are actively thwarting federally-sponsored efforts at patient education and the work of “navigators” who will help people enroll in insurance plans under the Affordable Care Act: “Texans in Dark on Obamacare as Enrollment Startup Looms,” posted to Bloomberg’s website on 9/12/2013.

pointer  “Keeping the Beat Alive: In New Orleans, a low-cost clinic helps the city’s musical community stay strong and healthy,” by Linda Marsa (Parade, 8 September 2013, p. 12).

The weekly news magazine, Parade, describes the New Orleans Musicians’ Clinic (NOMC), which provides low-cost medical care to the city’s at-risk music community. “Today, the NOMC, located near the historic Garden District, treats more than 2,500 musicians and their families annually for everything from heart disease to the flu.” (Marsa, 12)
   The city of Austin, Texas, also offers an alternative health care model for low-income musicians: see below, pointer for 24 June 2013.

pointer  Healthcare Watch column, “How to Protect Yourself from Medicare Scam Artists,” retitled “How to Avoid Becoming a Victim of Medicare Fraud,” by Lisa Zamosky (Los Angeles Times, 8 September 2013, p. B3).

SUMMARY: “Crooks are looking for access to Medicare numbers, which are used to fraudulently bill the government-run healthcare program.”
   It’s a huge problem: “... Medicare fraud is rampant. Although exact numbers are not known, it’s estimated that between $60 billion and $90 billion is lost each year to Medicare fraud and abuse.” (Zamosky, B3)

pointer  “Deadly Neglect: Fatal cases at assisted living facilities raise questions about tough family choices, limited state oversight,” by Deborah Schoch (U-T San Diego [formerly San Diego Union-Tribune], 8 September 2013, pp. A1 and SD1–SD4).

This is the first in a 3-part series on privately-owned assisted living facilities, for seniors who need some help with the tasks of day-to-day living, but want to avoid more-expensive nursing homes.
   SUMMARY: “Safety is often a reason to move to assisted living, but what happens when facilities themselves are the danger?  ¶  They wanted a safe, comfortable place to spend their sunset years. Instead, at least 27 San Diego County seniors found something else — death, often in excruciating circumstances, in an assisted living facility.  ¶  Behind the bright lobbies, flowers and chandaliers in some of these homes is a story of suffering and neglect in a system with breakdowns from end to end — homes that fail to properly care for residents, families with little access to information and a state agency that doesn’t always monitor the well-being of those it is charged to protect. A U-T Watchdog special investigation series begins today.” (U-T San Diego, 9/8/2013, p. A1)

UPDATE #1:  Watchdog Ricky Young summarizes a 9/12/2013 online discussion with the investigative reporters reponsible for the “Deadly Neglect” series: “Series Reporters Discuss Assisted Living Centers” (U-T San Diego, 15 September 2013, p. A6).

UPDATE #2:  Op-ed by Sally Michael, president of the California Assisted Living Association, entitled “Another, Positive, More Common Side of Assisted Living” (U-T San Diego, 4 October 2013, p. B7).

UPDATE #3:  “Answers Sought at Assisted Living Hearing: State senator says a lot of issues revealed in U-T series need committee’s attention,” retitled “Q&A with Yee” (U-T San Diego, 13 October 2013, p. A6).

N O T E :  Another investigative series on assisted-living facilities was conducted by the PBS program FRONTLINE, in collaboration with ProPublica; see below, pointer for the entry dated 30 July 2013.

pointer  “Hospice Care Overlooked for End-of-Life Cancer Care,” by Alex Wayne of Bloomberg News (posted to their website, 4 September 2013).

Wayne reports here on a new study from the Dartmouth Atlas Project showing an increase in cancer patients in intensive care units in the last month of life: “Too many advanced-cancer patients receive invasive hospital treatments such as feeding tubes while they are dying instead of being directed to hospice and other palliative care that could ease suffering.”
   Medicare policy is partly to blame for this: “Medicare policy, which requires patients to forgo curative care if they enter hospice, may discourage palliative care, Goodman [David Goodman, co-principal investigator for Dartmouth Atlas] said. Patients can and should seek palliative care, which is not the same as hospice, even while they’re undergoing treatments aimed at curing their cancer, he said.  ¶  ‘Palliative care in particular has lots of advantages when it’s introduced concurrently with efforts to prolong a patient’s life,’ Goodman said. ‘If it looks like a patient is likely to pass away in weeks or months, it makes sense to have a wider range of options and transitions, and not what is often felt as a black-and-white situation.’”
   As I have stated elsewhere, the binary opposition between palliative and curative medicines is modern. During the 16th and 17th centuries, “a palliative cure” was usually recommended for metastasized cancers, including gynecologic cancers, by leading physicians and surgeons.

pointer  “Age Friendly New York City Helps Seniors Stay Active in the Big Apple,” a PBS NewsHour health report by Hari Sreenivasan, first aired 4 September 2013.

“SUMMARY: Seniors now account for roughly one out of every six New Yorkers. A recent initiative aims to assist older citizens stay healthy, active and connected to the community. Hari Sreenivasan reports on how that program has been making New York more accessible and affordable for its elders.”

pointer  “Advocates: VA Still Needs Work to Get Fully Wired,” by Jeanette Steele (U-T San Diego [formerly San Diego Union-Tribune], 1 September 2013, p. SD2).

Steele here reports on recent improvements in the medical system run by the U.S. Department of Veteran Affairs (for a sampling of the barrage of criticism prompting government action on this front, see below, pointer for the entry dated 7 July 2013).
   She also notes that San Diego “has the second-highest number of Iraq and Afghanistan veterans getting care at a VA hospital,” and that “the San Diego VA is the pilot site for development of the agency’s next-generation electronic medical records system.” (Steele, SD2)

 

**  F E A T U R E D   L I N K  **

pointer  The Women’s Health Activist newsletter article by Cynthia Pearson, “Health Care Coverage: It’s Finally Happening!,” from the September/October 2013 print issue, vol. 38, no. 5, pp. 1, 3 and 5.

The National Women’s Health Network (NWHN) is actively campaigning for effective implementation of the new health law, known as Obamacare and the Affordable Care Act, with their Raising Women’s Voices for the Health Care We Need initiative. “Starting October 1, millions of Americans will be able to enroll into new affordable health insurance plans through marketplaces set up by the health care law. Learn more about how this affects you and what you can do to make sure that the promise of the health care law become a reality for women!”

 

pointer  The Women’s Health Activist newsletter article by Wells Wilkinson, “Let the Sunshine In! New Law Ends Secret Drug Industry Payments & Gifts to Doctors,” from the September/October 2013 print issue, vol. 38, no. 5, p. 4.

A discussion of The Physician Payments Sunshine Act (PPSA) — “intended to disclose any conflicts of interest arising from drug and device industries’ financial relationships with, or marketing to, physicians” — one of the reforms enacted along with Obamacare (the Affordable Care Act). (Wilkinson, 4)

pointer  The Women’s Health Activist newsletter column by Charlea T. Massion and Adriane Fugh-Berman, “Prescription for Change: The Low-Down on Low-T (or Menopause for Men),” from the September/October 2013 print issue, vol. 38, no. 5, p. 11.

Critiques the aggressive marketing of Low-Testosterone Syndrome, for which “testosterone in gels, patches, and roll-ons is now being promoted to middle-aged and older men as a virility-enhancing, anti-aging, and disease preventing panacea.” (Massion & Fugh-Berman, 11)
   The authors note that “Low-T Syndrome is being marketed as a disease for men in the same way that menopause was marketed as a disease for women: by preying on our fear of aging and selling hormones as an elixir of youth.” Indeed, one pharmaceutical company “spent $20.8 million on testosterone ads in 2011 alone” with a predicatable outcome: “All this promotion is working. Sales of testosterone products have risen 90% over the past 5 years. In 2011, global sales of testosterone products reached $1.9 billion and are expected to reach $5 billion by 2017.” (Massion & Fugh-Berman, 11)
   But, caution the authors, “Hormones are powerful compounds that affect many of the body’s organs, and there’s no such thing as a harmless hormone. Let’s take a lesson from menopausal hormone therapy. Don’t believe industry-funded research, and don’t let the men in your life take a dangerous hormone on the basis of hype and hope.” (Massion & Fugh-Berman, 11)

pointer  “Proton Therapy Is Dealt Blow: But Scripps says new center’s viability not challenged by Blue Shield ruling,” by Paul Sisson (U-T San Diego [formerly San Diego Union-Tribune], 30 August 2013, pp. C1 and C2).

Blue Shield of California’s recent decision “to stop covering proton beam therapy for prostate cancer” raises yet more questions about our rush to adopt such an expensive technology, when other more cost-effective approaches are available.
   For more, see below, pointer for entry dated 23 June 2013.

pointer  Healthcare Watch column, “Who Pays for the Ambulance?,” by Lisa Zamosky (Los Angeles Times, 25 August 2013, p. B3).

SUMMARY: “It’s common to be dinged with an extra-high bill for ambulance services. Here’s how to ensure you’re treated fairly.”
   According to Zamosky, “In Southern California, it’s a common misconception that ambulance transportation is a free public service, says Cathy Chidester, director of the Los Angeles County Emergency Medical Services Agency. ‘Though people think that their tax dollar pays for the paramedic service, it really doesn’t,’ she says. ‘It pays for fire service.’” (Zamosky, B3)
   I had a recent personal experience with this, and hope others will benefit from my story, as well as Zamosky’s column.
   In my case, after I called 9-1-1 when a family member lost consciousness, we were billed $1,895.44 for a leisurely ambulance ride of only 8 miles (I actually beat the ambulance to the ER, and it took me quite a while to get organized and leave the house after the ambulance departed). Our insurance paid for $979.99 of the bill, leaving us to pay $915.45 ourselves. Luckily, a friend long ago told me of her experience with exorbitant ambulance charges, incurred during an emergency, so I knew it was important to clearly tell the paramedics exactly which hospital I wanted my loved one taken to. Even so, the bill was about twice what I expected.
   In San Diego, private ambulance and paramedic service has been contracted out to a Scottsdale, Arizona-based company, Rural/Metro Corporation. For more on San Diego City’s recent one-year extension of its ambulance contract with Rural/Metro Corporation, see “Ambulance Contract Bids Didn’t Happen: Competitive process was promised two years ago, hasn’t come through,” by Craig Gustafson, with contributions by Lee Ann O’Neal (originally titled “City Forced to Extend Ambulance Pact: Long-awaited competitive bidding process hasn’t occurred; contract expires next week” for publication in the U-T San Diego, 23 June 2013, p. A4).
   According to Gustafson, “The downside for consumers [of the no-bid contract extension] is that the average cost of an ambulance ride will increase from the current $1,670 to $1,820 under the extension. That’s a 39 percent increase from the $1,305 average cost in 2011.” (Gustafson, A4)
   I’m not sure what these “average prices” are based on, since my family’s $1,895.44 Rural/Metro Corp. ambulance ride occurred before the recent contract extension. Nor do I understand why a leisurely 8-mile ambulance ride, transporting a patient who was conscious, rational and coherent for the entire journey, fell within Rural/Metro’s above average pricing category. Given that it did, I would say the price gouging had already begun, even before the city’s contract with the company was summarily extended.
   If our experience is any indication, all San Diegans should be prepared for a hefty bill from Rural/Metro Corp., with payment “due upon receipt,” if you use 9-1-1 service.

pointer  “Prepping Docs on DNA Mapping: Scripps Developing Online Videos that Explain Genomic Medicine,” by Karen Kucher (U-T San Diego [formerly San Diego Union-Tribune], 23 August 2013, pp. B1 and B4).

SUMMARY: “Rapid advancements in DNA mapping have created new tools to personalize medical treatment, but many doctors remain ill-informed on how they should use genetic information to manage patient care.” (Kucher, B1)
   With the growing popularity of consumer-driven DNA testing, there is growing “demand for health providers to have more knowledge about genomic medicine.” But continuing-education programs and credentialing for medical professionals doesn’t come cheap. Scripps Translational Science Institute’s “education program has been delayed because there’s not enough money to fully produce and launch the videos, along with the need to find an adequate platform that would reach targeted physicians.” (Kucher, B4)

U P D A T E :  Dr. Eric Topol, director of the Scripps Translational Science Institute, argues again that “medical schools would do well to have each of their students’ DNA sequenced. It would then be made available on an iPad so the students could study their own genome as a regular part of the curriculum.” (“Doctor: Med Students Should Study Own DNA: Scripps’ Topol says with lower sequencing costs, genetics will be used frequently,” by Paul Sisson, U-T San Diego, 15 September 2013, p. A7)
   For another U-T San Diego reporter’s account of his mixed experience attempting to translate his own 23andMe scan into improved personalized care, see below (pointer for entry dated 5 May 2013).

pointer  U-T San Diego editorial board interview with Dr. Maria Carillo (who leads the Alzheimer’s Association’s International Research Grant Program), Dr. Paul Aisen (director of the Alzheimer’s Disease Cooperative Study at UC San Diego), and Mary Ball (president/CEO of the San Diego/Imperial Chapter of the Alzheimer’s Association), entitled “Fighting Alzheimer’s” (U-T San Diego [formerly San Diego Union-Tribune], 18 August 2013, pp. SD5 and SD7).

“A recent study labels Alzheimer’s disease the costliest disease in America today. And it’s growing at a rate of no other.” (pull quote, p. SD5)
   All is not bleak, however, as researchers explore new approaches for communicating with people who have dementia, which build on less-afflicted skills such as reading, and focus on what people with memory problems can do, rather than on what they’ve lost. E.g., back in November 2010, Parade magazine reported on the effectiveness of using captioned pictures to reclaim memory: “Unlocking the Silent Prison,” by Christine Wicker (Parade, 21 November 2010, p. 18).
   One feel-good story for Alzheimer’s patients and their caregivers was broadcast by the PBS NewsHour on 9/12/2013: “Poetry Project Helps Dementia Patients Live in the Moment.”  ¶  “SUMMARY: In our new series, ‘Where Poetry Lives,’ Natasha Trethewey, poet laureate of the United States, and Jeffrey Brown [spend] time at the Alzheimer’s Poetry Project in Brooklyn. The international program works with people with dementia to try to trigger memory by playfully engaging with language.”

pointer  “There’s No Place Like Home: Seniors Hold on to Urban Independence into Old Age,” a PBS NewsHour health report by Ray Suarez, first aired 8 August 2013.

“SUMMARY: A new community model lets seniors enjoy all of the security and social amenities of a retirement community without leaving their homes. The alternative is called ‘aging in place.’ Ray Suarez reports on how this village concept may help seniors retain their independence into their golden years.”

pointer  “How One Group of Seniors Bucked Convention and Avoided the Retirement Home,” a PBS NewsHour feature in their Health Care Reform series, posted to The Rundown: A Blog of News and Insight, by Mary Jo Brooks, on 8 August 2013.

A companion piece for Ray Suarez’s 8/8/2013 report on “aging in place.”

pointer  “Seven ‘Life Hacks’ to Help Keep You Out of the Nursing Home,” a PBS NewsHour feature in their Health Care Reform series, posted to The Rundown: A Blog of News and Insight, by Jason Kane, on 8 August 2013.

Another companion piece for Ray Suarez’s 8/8/2013 report on “aging in place.”

pointer  Op-Ed: “Obamacare Paving the Way for Single-Payer System?,” by Sally Pipes (U-T San Diego [formerly San Diego Union-Tribune], 2 August 2013, p. B7).

Pipes worries here that the U.S. is headed for a “British-style, government-run health care system,” leading to “rationed care and subpar health outcomes.” (Pipes, B7)
   According to Pipes, “Cancer patients in Britain wait up to nine years for the country’s rationing body to green light the use of medicines that have already passed clinical trials. Political and financial concerns often take precedence over patient well-being.” (Pipes, B7)
   And Canada “ranks 13th out of 17 developed countries for cancer survival — just one spot above the United Kingdom.” (Pipes, B7)
   And “In Sweden, 55 percent of patients wait more than four weeks for a specialist appointment. That’s more than double the share of patients who do so in the United States.” (Pipes, B7) (Apparently, I am among that 27% of USers whom Pipes describes as already getting rationed care. Unless it’s urgent, I, too, usually “wait more than four weeks for a specialist appointment,” at a convenient time and date of my choosing. But I would frame this as a wise use of limited resources — not as rationing.)
   See below (pointer for the entry dated June 2006) for a populist take on “the four Big Lies about universal health care” which continue to have traction.
   See below (pointer for the entry dated 15 April 2008) for a more detailed look at the modern British health care system.
   And see above for a detailed look at the early-modern British (and British-American) system of health care.
N O T E :  To broaden our historical perspective, I will continue to document the culture and politics of medical practice in England and her North American colonies during the 16th and 17th centuries. Publication of the new historical material will be announced on our What’s Blooming news page. (As of 3 August 2013, there are dozens more of these historical features in the works.)

pointer  “Exchange Unveils Small-Business Rates,” by Paul Sisson (U-T San Diego [formerly San Diego Union-Tribune], 2 August 2013, pp. A1 and A10.

“San Diego County small businesses will be able to save 12 percent on health insurance premiums for their employees if they buy coverage next year from the state’s newly created health exchange, officials announced Thursday.” (Sisson, A1)
   Find out more at Covered California, “the state agency tasked with creating and running the new health insurance exchanges mandated by the Affordable Care Act of 2010.” (Sisson, A1)
   As explained on the About Us page at their website: “Covered California is a new, easy-to-use marketplace where you and your family may get financial assistance to make coverage more affordable and where you will be able to compare and choose health coverage that best fits your needs and budget. By law, your coverage can’t be dropped or denied even if you have a pre-existing medical condition or get sick.”
   Sisson and others continue to track new developments relating to Covered California; for a selective sampling of updates, see:
   1.  “Outreach for New Health Exchange Ramps Up: Stakes are high for spreading the word on Affordable Care Act, which needs millions to enroll to suvive,” by Paul Sisson (U-T San Diego, 18 August 2013, pp. A1 and A18).
   2.  “San Diego One of Three Insurance Exchange Test Markets: Affordable Care Act TV spots to air here before statewide rollout,” by Paul Sisson (U-T San Diego website, posted 27 August 2013).
   3.  “Bill Aims to Protect Calif. Insurance Enrollees: Legislation on the way to governor will protect people from identity theft through state’s new health exchange,” by the Associated Press (U-T San Diego, 8 September 2013, p. A20). To learn more about what you, as an individual, can do, see our FYI page on Protecting Yourself against Medical Identity Theft.
   4.  “Health Exchange Projects Budget Deficit [in 2015]: Covered California unsure how it will bridge gap when federal funding dries up,” by Paul Sisson (U-T San Diego, 29 December 2013, pp. A1 and A11).

pointer  The Hightower Lowdown newsletter article by Jim Hightower, “The Trans-Pacific Partnership Is Not About Free Trade. It’s a Corporate Coup d’Etat — Against Us!,” from the August 2013 print issue, pp. 1–4.

Texan populist Jim Hightower warns here that the Trans-Pacific Partnership (TPP) free-trade agreement, currently under negotiation, contains little-known provisos that will lead to increased drug prices for all of us: “Big Pharma would be given more years of monopoly pricing on each of their patents and be empowered to block distribution of cheaper generic drugs. Besides artificially keeping everyone’s prices high, this would be a death sentence to many people suffering from cancer, HIV/AIDS, tuberculosis, and other treatable diseases in impoverished lands. The deal would also restrict the rights of our government to negotiate with drug giants to get lower consumer prices with bulk purchases, as Medicare and Medicaid do in the US.” (Hightower, 2)
   With formal negotiations of TPP set to wrap up by October 2013, Hightower is urging us to educate ourselves now, and mobilize for what’s ahead.
   While Hightower mentions TPP’s potentially deleterious effects on government regulation of food safety in the U.S., the Institute for Food and Development Policy known as Food First devoted the Summer 2013 issue of its Food First Backgrounder to broader concerns over diet and democracy. Authors Anders Riel Muller (a fellow at Food First and the Korea Policy Institute), Ayumi Kinezuka (an organic tea farmer in Japan and member of La Vía Campesina), and Tanya Kerssen (Research Coordinator at Food First) write in their backgrounder, “The Trans-Pacific Partnership: A Threat to Democracy and Food Sovereignty,” that TPP “has become one of the primary tools in the United States’ geopolitical pivot towards the Asia-Pacific region. The agreement — negotiated in secrecy — will dramatically expand the rights of corporations over those of food producers, consumers, workers and the environment. This Backgrounder outlines the agreement’s assault on democracy and food sovereignty and examines the TPP’s likely impacts on food and agriculture in Japan, the latest country to join negotiations.” (Muller, Kinezuka, and Kerssen, Summer 2013 Backgrounder, vol. 19, no. 2, p. 1)

pointer  “Doctors Propose New Cancer Definition to Avoid Unnecessary Treatments,” a PBS NewsHour analysis, first aired 30 July 2013.

“SUMMARY: A panel of doctors and scientists proposed a change to the definition of cancer, in hopes of shifting the way we think about and treat the disease. Gwen Ifill discusses the recommendation with Dr. Barnett Kramer of the National Cancer Institute and Dr. Larry Norton of the Memorial Sloan-Kettering Cancer Center.”

pointer  Life and Death in Assisted Living, a FRONTLINE investigation, in partnership with ProPublica, by filmmakers Eric Boice and Cheryl Morgan, aired 30 July 2013 (with online updates posted 7/30/2013–8/1/2013).

The investigation took FRONTLINE and ProPublica to seven states over 14 months, and included an examination of more than 100 lawsuits against Emeritus (the nation’s largest assisted-living provider) over the last decade.
   See also the series of investigative stories, Life and Death in Assisted Living published to ProPublica’s website.
   And see Jeffrey Brown’s conversation with A. C. Thompson of ProPublica for the PBS NewsHour (first aired 7/30/2013), where the two discuss some of the more troubling cases of elder care uncovered by Thompson’s investigation.

pointer  “Is Health Care Reform a Good Bargain or Burden for Young Americans?,” a PBS NewsHour debate moderated by Ray Suarez, first aired 23 July 2013.

“SUMMARY: Under the Affordable Care Act, getting young people into the health insurance market will be critical to offsetting the cost of caring for older, sicker Americans. Ray Suarez gets two views on how health reform will affect young adults from Jen Mishory of Young Invincibles and Generation Opportunity’s Evan Feinberg.”
   This segment has initiated a lively online debate. See also below (pointers filed under the dates of 14 September 2012 and 3 June 2011) for another take on the brewing intergenerational conflict hinted at by Evan Feinberg.

pointer  “First Lady’s Food Effort Stumbles,” retitled “Michelle Obama’s Nutrition Campaign Comes with Political Pitfalls” for online posting, by Matea Gold and Kathleen Hennessey (Los Angeles Times, 21 July 2013, pp. A1 and A12).

SUMMARY: “The first lady has pledged to fight junk-food ads aimed at children. But some say her desire to work with businesses kept her quiet when she was needed most.”

pointer  “Leave the Patient Satisfied,” retitled “Healthcare Overhaul Leads Hospitals to Focus on Patient Satisfaction” for online posting, by Anna Gorman (Los Angeles Times, 21 July 2013, pp. A1 and A16).

SUMMARY: “Under healthcare overhaul, federal payments to hospitals are tied to patient satisfaction. Customer service efforts are underway.”

pointer  “Will Health Reform Law Make Premiums More Expensive or More Affordable?,” a PBS NewsHour analysis, first aired 18 July 2013.

“SUMMARY: President Barack Obama defended the benefits of the Affordable Care Act in a news conference, part of a broader effort to sell the law amid continuing criticism from Republicans. MIT’s Jonathan Gruber and Avik Roy of the Manhattan Institute join Jeffrey Brown to debate the cost of coverage under the health reform law.”

pointer  “Op-Ed: Night Terrors,” retitled “Night Terrors of the Uninsured” for online posting, by Diana Wagman (Los Angeles Times, Opinion section, 7 July 2013, p. A29).

SUMMARY: “For all of the promise of the Affordable Care Act, it has holes.”
   This opinion piece, authored by a cancer survivor and unemployed college teacher whose family no longer has job-based health insurance, struck a chord with many readers. As of 7/12/2013, there were 100 comments posted to the Los Angeles Times website, with printed Letters to the Editor available here.

pointer  “Op-Ed: Alluring But Risky Medicine,” for online posting, by Paul A. Offit (Los Angeles Times, Opinion section, 7 July 2013, p. A29).

SUMMARY: “We should insist that alternative medications be held to the same standards of safety and effectiveness as those regulated by the federal government.”

pointer  “No Time for that Pity Party: College and Military Goals Trump a Grim Cancer Diagnosis,” retitled “When Unyielding Ambition Challenges an Unrelenting Cancer” for online posting, by columnist Steve Lopez (Los Angeles Times, 7 July 2013, p. A2).

SUMMARY: “Despite his grim diagnosis, Navy veteran and MBA student Bryan Fazio refuses to set his goals aside.”
   Columnist Lopez, whose sister has struggled with ovarian cancer since 2006, continues to chronicle the plight of California veterans in desperate need of jobs, housing and health care. In this case, Fazio’s mother, who worked as her son’s primary caregiver, “lost her job because of the time she spent being Fazio’s caretaker. She’s gone to court trying to get her job back, but whatever happens, Silver doesn’t regret being there for her son when he was fatigued, when he vomited blood, when he couldn’t walk without a cane and needed a ride to yet another medical appointment.” (Lopez, A2)
   An earlier Lopez column (posted 7/2/2013) on “Veterans Still Struggling to Get Their Bearings” is available here and documents how veterans in need of mental health counseling are often unable to get it in a timely fashion. One outside organization attempting to fill the void is: “The Soldiers Project, a national network of volunteer therapists, confidentially treats veterans and their loved ones for free, for as long as it takes, with no red tape, says founder Judith Broder. For more information, call (818) 761-7438 or go to http://www.thesoldiersproject.org.”

UPDATE:  A new Lopez column describes another “thriving nonprofit” helping veterans for over 20 years: U.S. VETS, which took root in the Los Angeles area, but now “has 11 sites nationally and provides housing, supportive services and job connections for thousands of veterans.... Funding comes from government sources, nonprofit partnerships and private donations.  ¶  ‘The VA simply doesn’t have enough money to deal with the number of veterans coming back’ from Iraq and Afghanistan ‘who need help, and with the number of aging veterans who need housing,’ said Peck, who put the number of homeless vets nationally at 60,000. Hundreds of thousands more suffer from post-traumatic stress disorder and other service-related health issues, Peck said.” Lopez’s column, “Help from an Old Warhorse: Judge Harry Pregerson, wounded at Okinawa, was the vision behind U.S. VETS, which has assisted thousands of veterans,” was published in the 11/10/2013 issue of the Los Angeles Times (p. A2).

IN ADDITION, the PBS NewsHour provides excellent ongoing coverage of veterans’ health care issues, including:
   1.  “Veterans Going Back to School Find Benefit in Specialized On-Campus Support” (a PBS NewsHour report, first aired 11/11/2013).
      “SUMMARY: More than a million veterans of the Iraq and Afghanistan wars have used the GI bill to pursue college, but combat injuries and stress can add challenge to the transition to student life. At City College of San Francisco, a VA clinic is on-campus to support student vets and their needs. Special correspondent Aaron Glantz reports.”
   2.  “Americans Afflicted with ‘Phantom Noise’ Seek Relief from Ringing in Their Ears” (a PBS NewsHour report, first aired 11/6/2013).
      “SUMMARY: Among combat veterans who’ve suffered powerful explosions, tinnitus — or ringing in the ears — remains a daily battle. But they’re not alone. Fifty million Americans also suffer from the ‘auditory phantom.’ Science correspondent Miles O’Brien reports on the science behind the nagging noise and the search for a cure.”
  3.  “For Some Wounded Veterans, Strong Prescription Drugs Can Be Cause of More Pain” (a PBS NewsHour report, first aired 10/3/2013).
      “SUMMARY: Some veterans from the wars in Iraq and Afghanistan have returned home to face another battle: addiction to narcotic painkillers prescribed by their doctors. Aaron Glantz of the Center for Investigative Reporting takes a look at whether these wounded warriors are being overmedicated with prescription opiates.”
      An investigation into OxyContin over-prescribers was launched by the Los Angeles Times; see below, pointer for their investigative series on California’s epidemic of prescription drug deaths and the doctors who may have recklessly prescribed opioids (entry dated 30 December 2012).
   4.  “Veterans Affairs Backlog Files Stacked So High, They Posed Safety Risk to Staff,” by P. J. Tobia (posted on 4/2/2013 to the NewsHour’s The Rundown: A Blog of News and Insight).
   5.  “Returning Veterans Face Huge Backlog, Disorganization in Fight for Benefits” (a PBS NewsHour report, first aired 3/29/2013).
      “SUMMARY: Returning from combat, many veterans face another battle: waiting for medical claims to be processed. A recent report found that 245,000 veterans wait a year or more for help from the Veterans Administration. Hari Sreenivasan talks with veterans and Secretary of Veterans Affairs Eric Shinseki about the delays and backlog.”
   6.  “Veterans Voice Frustration over Benefits Backlog to VA Secretary Shinseki,” by Hari Sreenivasan (posted on 3/29/2013 to the NewsHour’s The Rundown: A Blog of News and Insight).
   7.  “Veterans Face Uphill Battle for Benefits when Field Records Are Lost, Destroyed” (a PBS NewsHour report, first aired 11/12/2012).
      “SUMMARY: ‘History is the last thing we care about during war, and the last thing we think about when we get home,’ says ProPublica’s Peter Sleeth, who talks to Jeffrey Brown about the challenges facing veterans who need access to benefits but whose records have been wiped out.”
   8.  “VA Adds 1,600 Workers to Fix Backlog, but ‘Always More We Can Do’” (a PBS NewsHour analysis, first aired 4/19/2012).
      “SUMMARY: Responding to a backlog of mental health cases and a blistering federal appeals court ruling, Veteran Affairs Secretary Eric Shinseki said Thursday that the agency will hire 1,600 more professionals — including psychiatrists, psychologists and social workers. Jeffrey Brown and the VA’s Sonja Batten discuss the new hires’ goals.”
   9.  “[Colorado] Program Allows Wounded Vets to Recover One Step at a Time” (a PBS NewsHour report, first aired 4/4/2011).
      “SUMMARY: Tom Bearden reports on LifeQuest, a Colorado organization helping wounded Afghanistan and Iraq veterans heal from physical and mental war wounds.”
   10.  “Women Veterans Face Unique Obstacles, Needs” (a PBS NewsHour report, first aired 11/30/2010).
      “SUMMARY: Women make up about 14 percent of the U.S. military and now serve in more combat situations than in past wars. As part of our NewsHour Connect series, Scott Shafer of KQED in San Francisco met with female veterans about the particular challenges women face after their military service and what support is available.”
   11.  “Rules Change for Vets’ PTSD Benefits” (a PBS NewsHour analysis, first aired 7/12/2010).
      “SUMMARY: New government rules will make it easier for military veterans to claim disability benefits for those diagnosed with PTSD. Health correspondent Betty Ann Bowser reports.”
   12.  “New PTSD Treatment Rules for Vets Come Too Late for Some,” by Betty Ann Bowser (posted on 7/12/2010 to the NewsHour’s The Rundown: A Blog of News and Insight).
   13.  “Panel Calls for Changes to Wounded Veterans’ Care” (a PBS NewsHour analysis, first aired 7/25/2007).
      “SUMMARY: A presidential commission called for ‘fundamental changes’ to the military health system. Former Health and Human Services Secretary Donna Shalala and former Sen. Bob Dole, R-Kan., explain the panel’s findings.”
   14.  “Veterans Struggle for Adequate Disability Compensation” (a PBS NewsHour report, first aired 7/23/2007).
      “SUMMARY: U.S. soldiers coming home from Iraq and Afghanistan receive disability compensation based on the extent of their injuries and other factors. The NewsHour reports on how the military determines the amount injured veterans receive and efforts to improve the process.”
   15.  “Care for Brain-Injured Veterans Carries High Financial, Emotional Costs” (a PBS NewsHour report, first aired 4/12/2007).
      “SUMMARY: The Veterans Affairs system cares for an estimated 1,600 Iraq and Afghanistan veterans with traumatic brain injuries and other severe wounds. The NewsHour takes a look at the challenges of treating these veterans.”
   16. “Veterans Hospitals Struggle to Treat Brain Injuries” (a PBS NewsHour debate, first aired 2/28/2007).
      “SUMMARY: The Veterans Administration is unprepared to care for brain-injured Iraq war veterans once they leave rehabilitation centers and return home to VA hospitals, a new documentary reports. An advocate and the VA secretary discuss treating the injuries.”
   17.  “Doctors Scramble to Handle War Veterans’ Brain Injuries” (a PBS NewsHour report, first aired 9/14/2006).
      “SUMMARY: Medical experts are witnessing an increase in the number of brain injuries sustained by soldiers fighting in Afghanistan and Iraq, prompting Veterans Affairs hospitals to set up special centers to handle the severe cases.”

pointer  “U.S. Employers Get Year Reprieve on Health Care Mandate,” a PBS NewsHour debate moderated by Gwen Ifill, first aired 3 July 2013.

“SUMMARY: The White House announced a year reprieve on the Affordable Care Act mandate that says companies with 50 or more full-time workers must provide insurance by Jan. 2014. Gwen Ifill gets debate from Ron Pollack of Families USA and Tom Miller of American Enterprise Institute about how the delay affects businesses and workers.”
   Three related analyses were posted on 7/3/2013 to the NewsHour’s The Rundown: A Blog of News and Insight:
   1.  “Republicans Hail Employer Mandate Delay as Defeat for Obama,” by Christina Bellantoni.
   2.  “What the Delay in Health Reform Law Provision Really Means,” by Jay Hancock and Julie Appleby.
   3.  “Selling Obamacare: Is the White House Ready?,” by Beth Summers.
   Critics of the ACA, left and right, believe this delay further disadvantages small businesses. E.g., responding to Rundown post No. 2 above, one critic writes: “Anyone who was ever in favor of this piece of garbage legislation can suck it. I don’t even care if your intentions were good anymore. You were told it wouldn’t work, you were told it would be expensive, you were told large companies would find ways out of their responsibilities according to the law and that small companies would take the brunt of this.”

pointer  Op-Ed: “People with Aids Living Longer, but Aging Can Be Challenging,” by Alberto Cortés (U-T San Diego [formerly San Diego Union-Tribune], 6 July 2013, p. B7).

Cortés is the executive director of Mama’s Kitchen, an AIDS service organization which also helps those in need who have cancer.
   Because HIV treatments are now much more effective, AIDS no longer draws the media attention it once did, even though the disease continues to pose significant problems for us.
   Cortés is keen to point out that HIV/AIDS has not been cured or “resolved,” and that “aging with HIV has brought on new health challenges.” “As people with AIDS are living longer, we have to ask ourselves: What does it mean to live with HIV for upward of 20 or 30 years?” (Cortés, B7)
   “According to Office of National AIDS Policy Director Grant Colfax: ‘growing older with HIV may present multiple medical challenges. Because the immune systems of people living with HIV are constantly fighting infection, they are more prone to ongoing inflammation which is associated with co-morbid conditions associated with aging, such as diabetes, heart disease, hypertension, and cancer.’” (Cortés, B7)
   This means that AIDS service organizations such as Mama’s Kitchen face unprecedented challenges going forward. “As this population grows older, the need for community support will increase .... We must be vigilant to have a comprehensive system of services and support that is ready and responsive to the increased needs of this population.” (Cortés, B7)
   The payback for such community investment is real & measurable. “Research consistently demonstrates that a steady and dependable source of nutritious food improves health outcomes and significantly reduces healthcare cost. For example, a study executed by MANNA, our sister organization in Philadelphia, shows the average monthly healthcare costs of their clients fell 62% for three consecutive months after beginning service, for a drop of almost $30,000.” (Cortés, Oct. 2013 letter soliciting donations to Mama’s Kitchen capital campaign)

U P D A T E :  PBS NewsHour’s Jason Kane recently “traveled to Tanzania with the Global Fund to Fight AIDS, Tuberculosis and Malaria. The international financing institution provides funding to countries to support evidence-based programs that prevent, treat and care for people living with the three diseases.” Kane reports on his trip in “The HIV Rebound Nobody Is Discussing,” a PBS NewsHour feature in their Health Care Reform series, posted to their website on 5 November 2013.
   In sum: “Is an AIDS-free generation on the horizon? Not without the help of sex workers and other marginalized ‘key populations,’ public health officials say.”

pointer  “Epigenetics: It’s What Turns You On ... and Off,” by David Schardt, from the July/August 2013 print issue of CSPI’s Nutrition Action Healthletter, vol. 40, no. 6, pp. 9–11.

Because the Center for Science in the Public Interest (CSPI) “is primarily funded by the 900,000 subscribers to its Nutrition Action Healthletter and individual donors,” feature articles from its award-winning healthletter are seldom made available online. As such, I am delighted to report that David Schardt’s excellent cover story on epigenetics has recently been posted to the CSPI website for all to read, whether you can afford to be a subscriber or not.
   SUMMARY: “Why don’t identical twins always have the same personality and the same risk of disease, even though they have identical genes? How does a brain cell know to make only more brain cells and not heart or kidney cells? Could a woman’s diet or weight while she’s pregnant influence whether her child has a higher risk of illness decades later?  ¶  The answers may lie in how our cells turn our genes on and off. If scientists can better understand that process, they may be able to prescribe specific foods or drugs that can slash our risk of obesity, cancer, diabetes, and more.” (Schardt, 9)
   The new science of epigenetics is expected to improve our understanding of how “diet, body weight, physical activity, stress, or exposure to chemicals may increase or decrease our risk of heart disease, cancer, diabetes, and other diseases.” (Schardt, 11)
   “In 2008, the National Institutes of Health announced that $190 million had been earmarked for epigenetics research over the next five years. In announcing the funding, government officials noted that epigenetics has the potential to explain mechanisms of aging, human development, and the origins of cancer, heart disease, mental illness, as well as several other conditions. Some investigators, like Randy Jirtle, PhD, of Duke University Medical Center, think epigenetics may ultimately turn out to have a greater role in disease than genetics.” (Wikipedia, s.v. Epigenetics, accessed 10/8/2013)
   As for cancer: “‘We used to think that cancer was caused mainly by mutations of genes, but we now believe that epigenetic aberrations are responsible for more than half of cancer cases,’ says Trygve Tollefsbol, who is senior scientist at the University of Alabama at Birmingham’s Comprehensive Cancer Center.  ¶  ‘That’s an important change because genetic mutations are very difficult, if not impossible, to correct, while epigenetic marks are potentially reversible,’ he explains.” (Schardt, 10)
   As always, the research is complicated, with studies giving contradictory results, making interpretation hard even for experts. “Not all epigenetic changes are beneficial, so until researchers learn more, don’t try to alter your epigenetic marks with food or supplements.” (Schardt, 11)
   But the potential is obvious, I think.

pointer  “Op-Ed: Another Kind of Gene Pool,” retitled “Building the Internet of Genes” for online posting, by Rajaie Batniji (Los Angeles Times, Opinion section, 30 June 2013, p. A26).

SUMMARY: “Crowd-sourcing genetic data could help unravel the causes of disease.”
   Batniji writes here about a new global alliance “to enable the secure sharing of genomic and clinical data, aiming to end the era in which only the people who collected your genetic data had access to it.”
   The advantages for personalized medicine and public health are obvious: “crowd-sourcing genetic data and sharing it freely online could lead to incredible discoveries. It could help scientists unravel the complex genetic causes of disease and focus on early prevention. It could help democratize research, allowing researchers equal access to data that can help answer questions that matter to them.”
   There are, however, considerable risks in making “genetic data collected by your doctor ... widely available in the cloud, for researchers around the world to analyze,” and Batniji lists several. Issues having to do with privacy and ownership are paramount: “Building the Internet of Genes demands that we strike a delicate balance between broad access and tight privacy for genetic data. Our efforts with ‘open data’ platforms have failed thus far to allow individuals to actually own their data.” (Batniji, A26)
   There is more about patients’ new role as “information donors” below; see the pointer for the entry dated 24 September 2012.

pointer  “Health Care Law Aims to Reduce Need to Rehospitalize Medicare Patients,” a PBS NewsHour health report by Betty Ann Bowser, first aired 28 June 2013.

“SUMMARY: Every year, nearly 2 million Medicare beneficiaries are readmitted to the hospital within 30 days of being discharged, at a cost of $17.5 billion. Health correspondent Betty Ann Bowser reports on provisions in the new health care law that aim to limit the need to rehospitalize Medicare patients.”

pointer  “Health Reform Brings Heavy Fines for Hospitals with High Readmissions,” a PBS NewsHour feature in their Health Care Reform series, posted to The Rundown: A Blog of News and Insight, by Sarah Clune, on 28 June 2013.

A companion piece for Betty Ann Bowser’s 6/28/2013 reporting on the complex of issues driving almost 2 million Medicare patients back into the hospital within 30 days of a discharge.
   Clune reports that the Centers for Medicare and Medicaid Services (CMS) began fining hospitals with high patient readmission rates in October 2012, with the twin goals of “improv[ing] the quality of care for seniors by preventing return trips to the hospital” and of “sav[ing] the government millions (a whopping $17.5 million dollars this year alone).”
   “Since October, the policy has been widely studied, reported and analyzed. And its penalties have been revised.”
   As always, nothing about this kind of reform — which asks hospitals “to take this sort of broader overseer role, and make sure that even though they didn’t benefit from it financially, they would start paying attention to patients once they left the door” — is straightforward.
   Clune explores some of the issues involved with Kaiser Health News reporter, Jordan Rau, who has “been following the policy since the Affordable Care Act was passed in 2009.” His insights are wide-ranging and informative.

pointer  “Seven Tips for Staying Out of the Hospital After You Leave,” a PBS NewsHour feature in their Health Care Reform series, posted to The Rundown: A Blog of News and Insight, by Jason Kane, on 28 June 2013.

Another companion piece for Betty Ann Bowser’s 6/28/2013 reporting on the complex of issues driving almost 2 million Medicare patients back into the hospital within 30 days of a discharge.
   Kane’s “Seven Tips” are excellent. Unfortunately, as some of the respondents note (4 comments as of 6/29/2013), they won’t always work for everyone.
   But “tips” never do. They’re intended as guidelines, and at their best, give us a starting point — and some good ideas — about how to adapt general advice to our own situations.

pointer  “Colorado Struggles to Educate, Enroll Residents in New Health Insurance Exchange,” a PBS NewsHour health report by Betty Ann Bowser, first aired 25 June 2013.

“SUMMARY: Colorado is in the midst of preparing to roll out a new way for residents to get health coverage using an insurance exchange. Health correspondent Betty Ann Bowser reports on the challenges for the state in spreading the word about the program and getting Coloradans to enroll.”
   Bowser’s report on the PR difficulties of the new insurance marketplace, called Connect for Health Colorado, did not delve into some of the more innovative solutions on offer through the state’s insurance exchange.
   One such model, a Colorado state health insurance CO-OP, deserves a special mention, I think: “Colorado Health Insurance Cooperative (Colorado HealthOP) was formed as a nonprofit organization in March of 2012. Sponsored by the Rocky Mountain Farmers Union (RMFU) Educational and Charitable Foundation, Colorado HealthOP builds on the strength and traditions of cooperative development that has been their cornerstone since 1907.”
   “Colorado HealthOP is a nonprofit health insurance cooperative — a consumer operated and oriented insurance plan. When the CO-OP’s revenues exceed its expenses, the excess revenues will be reinvested to directly benefit members — through lower premiums, more benefits and improvements in plan quality. Colorado HealthOP also offers resources and incentives to help members improve their health.”

pointer  “Austin Musicians Don’t Let their Babies Grow Up without Health Care,” a PBS NewsHour feature posted to The Rundown: A Blog of News and Insight, by Jason Kane, on 24 June 2013.

Describes HAAM (the Health Alliance for Austin Musicians) — “an unusual program” designed to link “[m]usicians making less than 250 percent of the poverty level ... with health care providers offering reduced rates for everything from primary care to vision and hearing.”
   HAMM is the creation of activists in the city of Austin, Texas who wanted to support the local music industry that “brings in about $2 billion to our economy.” The innovative group functions like — but is not — a health insurance company, and has instead tapped non-traditional means for getting health care to the city’s low-income creative talent.
   It’s an interesting piece (and Kane has included some great music clips for it, too ;-).

pointer  “Scripps Health Faces Change, Challenges: Hospital system needs to evaluate plans as the Affordable Care Act’s initiatives kick in,” by Jonathan Horn (U-T San Diego [formerly San Diego Union-Tribune], 23 June 2013, pp. C1 and C4).

Horn interviews Scripps Health Chief Executive, Chris Van Gorder, about the “uncertainty and unprecedented change” roiling today’s medical industry, due to “the rising cost of health care, serving an aging population, and the implementation of the Affordable Care Act, President Barack Obama’s 2010 overhaul of the health insurance industry.”
   Scripps Health is a tax-exempt organization with an operating revenue of $2.6 billion; 13,557 employees, including 2,663 medical staff; 5 hospitals, with 1,397 licensed beds; and 10 non-hospital facilities. In 2012, Scripps Health logged 2,102,905 outpatient visits. (Horn, C1)
   Considered a major company and one of the biggest employers in San Diego county, Scripps’ take on “competition” is of interest: “Van Gorder said it’s illegal to economically entice patients to come to Scripps, so it uses marketing and educational programs to relay messages about the quality of health care provided. Van Gorder said the system probably spends less money in marketing than other hospital systems, but it does communicate to educate the public about services offered.  ¶  ‘The community doesn’t like hospitals competing against each other, and yet the law requires us to compete. We’re subject to antitrust regulations just like any other business,’ Van Gorder said. ‘We compete fiercely at times, and we also collaborate fiercely at times. It’s kind of an odd business in that way.’  ¶  Van Gorder said Scripps will advertise to educate the public about a new proton beam radiation treatment center, scheduled to open in the fall.” (Horn, C4)

pointer  “Devious Ban on Abortion at Hoag,” by columnist Michael Hiltzik (Los Angeles Times, 23 June 2013, pp. B1 and B8).

SUMMARY: “In Newport Beach, a new ban on abortions means that Hoag Hospital’s OB/GYN services are constrained not by medical resources, medical judgment or the law, but by Roman Catholic doctrine.”
   Hiltzik raises a number of issues relating to the recent corporate partnership arrangement between Hoag Memorial Hospital Presbyterian and St. Joseph Health System, “a Roman Catholic chain with five hospitals in Orange County.” (Hiltzik, B1)
   He notes that “Those faith-based hospitals receive billions of dollars in taxpayer support — reimbursements from Medicare and Medicaid and legal status that allows them to operate tax free and their donors to take a tax deduction. But instead of providing the full range of reproductive services, they limit them in accordance with the Ethical and Religious Directives of the Catholic Church. These include prohibitions or stringent limits on in vitro fertilization, abortion and many contraceptive practices.  ¶  The issue is important for all communities because Catholic hospitals now account for 15% of the nation’s total hospital beds, serving 1 in 6 patients. Their reach is expanding, as they enter into management affiliations with non-Catholic hospitals and move to impose their doctrinal rules on their partners.” (Hiltzik, B8)
   Indeed, “The Hoag and St. Joseph affiliation aims to serve fully one-third of Orange County’s 3 million residents. Hoag has the highest market share in obstetrics of any hospital in its area, at 26%. The seven partnering hospitals are linchpins of charity and community care in the county. That’s a significant chunk of healthcare capacity closed to women seeking a legal medical procedure.  ¶  There’s no evidence that Harris [Kamala Harris, state Attorney General, whose office must approve mergers involving California nonprofit medical institutions] considered the basic complications that arise when any medical treatment is compromised by non-medical considerations, especially when they’re suddenly imposed on a facility boasting a tradition of full-service healthcare dating to 1952. Hoag physicians are wrestling with these complexities already.... In oncology, doctors and patients sometimes choose to terminate a pregnancy because it can compromise the effectiveness of cancer treatment. ‘For me to say, “My hospital won’t allow that” makes a bad situation so much worse,’ says Lisa Abaid, a gynecological oncologist at Hoag and a signer of the open letter. ‘It would be a terrible thing for me to say that I can’t provide my patients a safe and legal and simple procedure.’” (Hiltzik, B8)
   Letters to the editor responding to Hiltzik’s 6/23/2013 column can be viewed here.

pointer  “Gadgets Geared toward Seniors: Pill bottles that give reminders, easy-to-see apps examples of new focus,” by Tamara Chuang (U-T San Diego [formerly San Diego Union-Tribune], 21 June 2013, pp. C1 and C3).

SUMMARY: “Between now and 2018, $20 billion in revenues is the projected opportunity for technology products and services aimed at improving seniors’ health, according to Parks Associates, a market researcher.”
   Chuang gives an “an overview of what’s here now and what’s to come.”
   Unfortunately, the online version of the article lacks pictures of the gadgets included with the print version. My favorite: the Quovis, “a one-person car built for wheelchair users. Drivers roll their chair right into the driver’s seat area using a ramp.”
   For more relating to how companies are using technology to educate seniors on health issues, see below, pointer for the entry dated 31 May 2013.

pointer  “Feds: Health Care Plan Saved Consumers $3.9B: Insurance industry says cap on premium increases is arbitrary, doesn’t improve care,” adapted from story by Alex Wayne of Bloomberg News (reprinted in U-T San Diego [formerly San Diego Union-Tribune], 21 June 2013, p. C4).

Compare the U-T San Diego’s adaptation to the original Bloomberg News story, “Health Law Rule Saves Consumers $3.9 Billion in Premiums,” posted to their website on 6/20/2013.
   IN SUM: “Consumers avoided $3.9 billion in health premium increases in 2012 partly because of the U.S. Affordable Care Act’s limits on what UnitedHealth Group, Aetna and other insurers can charge, the government said.  ¶  About $500 million in excess premiums will be rebated to 8.5 million people this year, while the rest of the money is reflected as ‘upfront value’ in the plans, the Health and Human Services Department said Thursday. Last year’s savings are more than triple the $1.1 billion from 2011.”

pointer  “Some States Have Second Thoughts about Refusing Medicaid Expansion,” a PBS NewsHour analysis of the issues, first aired 17 June 2013.

“SUMMARY: Republican governors from Florida, Michigan, Ohio and Arizona were originally opposed to the health care law, but are now pushing to expand Medicaid. Hari Sreenivasan talks with Ohio Public Radio bureau chief Karen Kasler and Mary K. Reinhart, reporter for The Arizona Republic, about what’s behind the changes in their states.”

pointer  “Telemedicine Makes Its Way into the Emergency Room,” retitled “UCSD Flips Script on Telemedicine Practice: Pilot Project Brings in Extra Doc when ER Gets Busy” for online posting, by Paul Sisson (U-T San Diego [formerly San Diego Union-Tribune], 16 June 2013, p. A11.

“What we’re trying to show in this program is that this use of telemedicine is safe and that it’s cost-effective,” said “Dr. David Guss, the program’s principal investigator and the university’s outgoing chair of emergency medicine”; “the idea is to add extra doctors just for when they are needed.” (Sisson, A11)

pointer  Healthcare Watch column, “Walk-In Clinics Are Gaining Popularity,” by Lisa Zamosky (Los Angeles Times, 16 June 2013, p. B3).

SUMMARY: “Urgent care centers and retail, work site and community clinics attract patients aiming to avoid longer waits and higher prices at doctor’s office or hospitals.”

pointer  “Bills in Congress Are Putting Farms before Families: Families on Food Stamps Would Suffer while Farms Get Fat,” by columnist Michael Hiltzik (Los Angeles Times, 16 June 2013, pp. B1 and B8).

Another opinion about the federal food stamp program, formally known as SNAP (the Supplemental Nutrition Assistance Program).
   SUMMARY: “Bills inching through the House and Senate would hack away at the food stamp program, yet protect — or even expand — farm subsidies.”
   With 54 comments (as of 6/17/2013), which you can read here.
   Compare Hiltzik’s column with the PBS NewsHour’s moderated debate over SNAP cuts, which also provoked some passionate commentary (see below pointer for 6/6/2013).

pointer  “Op-Ed: No One Can Own a Gene,” retitled “Supreme Court and DNA: No One Can Own a Gene” for online posting, by Jessica Wapner (Los Angeles Times, Opinion section, 16 June 2013, p. A22).

SUMMARY: “The ruling helps ensure that the science of genetics will remain accessible to all, and not restricted to boardrooms and bank accounts.”

pointer  “Patently Mind-Bending: Few Were Disappointed in Supreme Court’s Human Gene Ruling,” retitled “Human Gene Patenting Is a Thing Most of Us Aren’t Ready For” for online posting, by columnist Robin Abcarian (Los Angeles Times, 16 June 2013, p. A2).

SUMMARY: “Few were disappointed in the Supreme Court’s ruling that the natural human gene cannot be commercially owned. Just ask Angelina Jolie.”

pointer  “Supreme Court Unanimously Rules Human Genes Cannot Be Patented,” a PBS NewsHour analysis of the issues, first aired 13 June 2013.

SUMMARY: “In a unanimous decision, the Supreme Court justices ruled that a company cannot patent an isolated human gene. To look at the implications of the decision and its impact for patients and medical research, Judy Woodruff talks to Todd Dickinson of the American Intellectual Property Law Association and Sandra Park of the ACLU.”
   Another analysis of the Supreme Court ruling — which affects Myriad Genetics’ patenting of two genes, BRCA1 and BRCA2, correlated with hereditary breast and ovarian cancers — was published in the U-T San Diego for 14 June 2013: “High Court Ruling on Human Genes Greeted Positively,” pp. A1–A2.
   And the U-T San Diego earlier ran a pro-and-con op-ed dialogue on the pending court case: for bibliographic data and links, see below (pointer for entry dated 28 April 2013).

pointer  “John Kitzhaber’s Oregon Dream,” by Sasha Abramsky (The Nation, 10–17 June 2013, vol. 296, no. 24, pp. 23–26).

SUMMARY: “The third-term governor is rethinking healthcare and education in holistic ways.”
   Abramsky here describes how Kitzhaber, a former emergency-room physician, is approaching health care reform as part of a “Unified Theory of Everything”: tackling his state’s problems of poverty, ill health, and inadequate education, in tandem with “the need to invest in clean technologies and renewables, to open routes to prosperity that neither denude the environment nor leave millions unemployed.” (Abramsky, 23)
   “‘We have,’ explains Kitzhaber, ‘been relentlessly pulling money out of investments in early childhood, children, families and education, and spending it on healthcare and public safety.’ The governor knows he can’t get more money for education until he reforms these other systems.” (Abramsky, 25)
   “This isn’t about big versus small government; it’s about clever government. It’s about using limited resources combined with new technologies effectively, and it’s about rewarding schools and health systems that generate good outcomes rather than those that simply throw resources at their problems without planning or coordination.” (Abramsky, 26)

pointer  “Smarter CT Scanning of Kids Would Prevent 3,020 Cancers Each Year,” by Karen Kaplan (Los Angeles Times, posted 10 June 2013).

pointer  Healthcare Watch column, “Help with Finances When Fighting Cancer,” retitled “Financial Help for Patients Fighting Cancer” for online posting, by Lisa Zamosky (Los Angeles Times, 9 June 2013, p. B3).

Zamosky, who covers healthcare and health insurance for the Los Angeles Times, notes here that “The high cost of treating cancer is often a barrier to needed care, and can wreak havoc on a person’s finances. A recent study published in the journal Health Affairs found that cancer patients were nearly three times more likely to go bankrupt than people without cancer.” (Zamosky, B3)
   Fortunately, “There are many resources available to cancer patients to help lower their costs while undergoing treatment.”
   Zamosky’s “Healthcare Watch” column gives several helpful pointers and links to some of these resources, including information on California’s Breast and Cervical Cancer Treatment Program, which provides assistance to low-income women.

pointer  “With 47 Million Americans on Food Assistance, Congress Considers Cuts,” a PBS NewsHour debate of the issues, first aired 6 June 2013.

“SUMMARY: The Senate will soon vote on the farm bill, which includes funding for food assistance programs that help roughly 47 million Americans. How would spending cuts impact needy families? Judy Woodruff hears debate from Chris Edwards of the Cato Institute and Lori Silverbush, co-director of the documentary A Place at the Table.”
   With 128 comments (as of 6/17/2013), which you can read here.
   The debate over food stamps reached a crescendo late-summer 2013 with the sensationalized story of a “29-year-old La Jolla ‘beach bum’ ... causing waves around the country for claiming to rely on $200 a month in government food stamps in a Fox News report that showed him buying sushi, lobster and coconut water, driving what looks to be a Cadillac Escalade and describing his typical day like so: ‘Wake up, go down the beach with my friends, hit on some chicks, start drinking.’” (“‘Beach Bum’ Stirs Food Stamp Debate,” U-T San Diego, 18 August 2013, p. D2)
   San Diego’s Union-Tribune is to be commended for its two-week investigation, by U-T Watchdog Lee Ann O’Neal, of the Fox network’s “cartoonish portrayal” of a local “beach bum.” In sum, O’Neal “found that the main points were true, if somewhat embellished.” “Greenslate does exhibit a nonchalance about his benefits that’s infuriating to some taxpayers. But experts and advocates say he is by no means the typical food-stamp recipient, as some might have thought after watching Fox.” (“Food Stamps Rock for Fox News Subject,” U-T San Diego website, posted 29 August 2013)
   More missing context for the controversy over the Pacific Beach rocker on food stamps was uncovered by reporter Evan Halper in “California No Friend to Food Stamps” (Los Angeles Times, 18 August 2013, pp. A1 and A19). Here, Halper points out that “The state’s participation rate is the lowest in the U.S. — only about half of those qualified get the aid — making it the envy of more-conservative states.”

UPDATE #1:  “Food Stamp Cuts Force Families to Get By with Less,” a PBS NewsHour analysis, first aired 1 November 2013.
   “SUMMARY: Cuts to the Supplemental Nutrition Assistance Program mean that the more than 47 million food stamp recipients will now receive less money each month to buy groceries. To examine the issue, Jeffrey Brown speaks with Ellen Teller of the Food Research and Action Center and Robert Rector of the Heritage Foundation.”
   With 216 comments (as of mid-afternoon 11/4/2013), and counting!

UPDATE #2:  The political and cultural repercussions of the controversy over government-run food assistance programs continue to mount in the San Diego region. Eleven days ago (10/25/2013), El Cajon Mayor Mark Lewis resigned after comments he made about local Chaldeans with children receiving “free, tax payer-funded lunches” provoked outrage: see “El Cajon Mayor Issues Apology to Chaldeans, Others,” by R. Stickney and Wendy Fry (posted to the NBC San Diego website, 10/24/2013) and “With Mayor Gone, El Cajon Planning for What’s Next,” by Karen Pearlman (posted to the U-T San Diego website, 11/1/2013).

UPDATE #3:  “One NYC Family’s Struggle to Survive on a Fast Food Salary,” a PBS NewsHour report, first aired 4 November 2013.
   “SUMMARY: Between food, housing and baby supplies, Shenita Simon struggles each week to support her family of seven. The 25-year-old from New York makes $8 per hour and is one of the fast food workers nationwide advocating for higher wages. Hari Sreenivasan brings us Shenita’s story of surviving on a near-minimum wage salary.”
   With 364 comments (as of 11/5/2013), and counting!
   Several respondents argue that the fast-food industry’s McJobs were never intended to be a career path, comparing this kind of work to the casual labor of your average teenage babysitter and the neighborhood kid hired to rake leaves. But according to Sreenivasan’s report, Ms. Simon is “a full-time shift supervisor, helping manage other workers and filling in wherever she’s needed, from being a cashier to running the fryer.” So her $8/hr job has supervisorial responsibilities.

UPDATE #4:  “Food Stamp Program Changes Lead to ‘Staggering’ Increase in Need,” a PBS NewsHour report, first aired 25 November 2013.
   “SUMMARY: Stimulus funds used to boost the Supplemental Nutrition Assistance Program during the recession ran out Nov. 1, meaning the growing pool of Americans who rely on food stamps will have to make do with less. The *NewsHour*’s Mary Jo Brooks reports on how the cuts impact families and how other organizations are picking up the slack.”

pointer  “Ultrathin Vital-Sign Monitors among Wireless Innovations,” retitled “The Latest Wireless Health Gadgets” for online posting, by Bradley J. Fikes (U-T San Diego [formerly San Diego Union-Tribune], 31 May 2013, p. C3).

But, Buyer Beware: It’s easy to get carried away by the lure of glamorous new technologies, and by our bionic fantasies, as human beings start to have more and more mechanical parts.
   There are always downsides, though, to any technological fix for human frailties. And these days, the affordances which propagate from the unglamorous underworld of computer hacking, viruses and malware threaten personal health and well-being.
   For a sobering reminder of medical technology’s double-edged effects, see the news brief “FDA Wants Medical Devices Cyber Secure,” published in the U-T San Diego, 14 June 2013, p. A6.
   And for another cautionary tale, see the PBS NewsHour report, originally aired 9/5/2013, “Smart Devices that Make Life Easier May Also Be Easy to Hack, Says FTC.”  ¶  “SUMMARY: Wireless devices let us control our household appliances through the Internet with ease, but do they also make it easier for hackers to disrupt our daily lives? Hari Sreenivasan speaks with Kashmir Hill of Forbes on a recent finding by the Federal Trade Commission of inadequate security protections for some products.”

pointer  “How Growth of Elderly Population in U.S. Compares with Other Countries,” a PBS NewsHour health report by Francesca Colombo, posted to The Rundown: A Blog of News and Insight on 24 May 2013.

SUMMARY: “Francesca Colombo, an OECD [Organisation for Economic Co-operation and Development] expert on economic impact of ageing, examines the the rapid growth of the elderly population in many nations — and what might be done to help alleviate some of the looming costs.”

pointer  “California Picks 13 Health Plans for State-Run Insurance Market, by Chad Terhune (Los Angeles Times, posted 23 May 2013).

pointer  “Medicaid to Deepen the Divide,” retitled “Medicaid Opposition Underscores States’ Healthcare Disparities” for online posting, by Noam N. Levey (Los Angeles Times, 19 May 2013, p. A14).

“SUMMARY: In states where Republican leaders are rejecting expansion of the government health plan for the poor, residents already have lower rates of coverage.”

pointer  “Saving More Time to Save Lives,” retitled “Saving Precious Minutes Is Goal of Remodeled Trauma Center” for online posting, by Paul Sisson (U-T San Diego [formerly San Diego Union-Tribune], 17 May 2013, pp. B1 and B4).

pointer  “Patient Is Out of Network, Out of Luck,” by Chad Terhune (Los Angeles Times, 12 May 2013, pp. B1 and B8).

SUMMARY: “After Kaiser advised him to enter hospice, Jalal Afshar sought out-of-network treatment that he says saved his life. Now he’s suing for the $2-million cost of care.”

pointer  “Auditor: Change Vets Care: Base Retirement Fees on Assets, Not Income,” retitled “Auditor Raises Questions on Veteran Home Operations” for online posting, by Michael Gardner (U-T San Diego [formerly San Diego Union-Tribune], 10 May 2013, pp. A1 and A8).

THE UNDERLYING ISSUE: “Lawmakers have been raising alarms over the escalating costs of the retirement homes while at the same time the state is hard-pressed to provide services to troops returning home from conflicts in Afghanistan and Iraq.  ¶  ‘We want to keep in mind the bigger picture: Is this the wisest use of limited state tax dollars to serve our veterans?’ said Assemblyman Al Muratsuchi, a Torrance Democrat and chairman of its Veterans Affairs Committee....”
   Auditor Elaine Howle thinks not, faulting the California Department of Veterans for “for foot-dragging when it came to acting to improve its bottom line, even as the state was in a prolonged budget crisis”: “‘The state has not maximized its ability to generate revenue for the care provided to veterans,’ Howle states.”

pointer  “Hospital Prices Diverge Wildly, U.S. Data Show,” by Chad Terhune and Ben Poston (Los Angeles Times, posted 8 May 2013).

SUMMARY: “Medicare data on hospitals’ disparate prices spotlight ‘practices that don’t seem to make sense.’”

pointer  “Seeking Method Behind the Madness of Hospital Billing Disparities,” a PBS NewsHour analysis of the issues, first aired 8 May 2013.

“SUMMARY: Different hospitals charge wildly different amounts for the same procedures, even in the same city. New data from the Center for Medicare and Medicaid shows a vast billing disparity between health care centers. Jeffrey Brown explores some striking examples and what these numbers mean with Barry Meier of The New York Times.”

pointer  “Let’s [Go] Shopping for Surgery: New Government Data Shines Light on Health Care Cost Variations,” Marketplace Morning public radio report commentary by Sabri Ben-Achour (aired 8 May 2013).

pointer  “Most Men Can Skip PSA Test for Prostate Cancer, Urologists Say,” by Karen Kaplan (Los Angeles Times, 5 May 2013, p. A22).

“The new recommendations are based on medical evidence from clinical trials instead of the ‘consensus opinion’ of urologists, as was done in the past.” (Kaplan, A22)

pointer  “Twists of Fate,” by science reporter Gary Robbins, describing his $99 DNA test through 23andMe.com (tagline: “Genetics Just Got Personal”), leaving him “more puzzled than enlightened about the findings” (U-T San Diego [formerly San Diego Union-Tribune], 5 May 2013, pp. SD1 and SD4).

“My results were available online eight weeks later, sending my stress level soaring. I was about to read my relative risk of everything from colon cancer to Alzheimer’s disease.” (pull quote, p. SD1)

pointer  Triton: a UC San Diego Alumni Publication news brief by Kim McDonald, “Cancer Drugs and Algae,” from the May 2013 print issue, p. 13.

pointer  Op-Ed Dialog on gene patents — “DNA’s Day in Court” — by Lisa A. Haile and Eric J. Topol (U-T San Diego [formerly San Diego Union-Tribune], 28 April 2013, pp. SD5 and SD7).

SUMMARY given in the print copy of the newspaper: “The science of genetics was in the spotlight this month as the U.S. Supreme Court heard arguments over whether human genes can be patented. Patents on human genes have been awarded for more than 30 years, but one company’s practice of claiming a monopoly on research and testing of two key gene mutations associated with breast and ovarian cancer has attracted critics who say an isolated gene is a product of nature, not human invention. Below, a geneticist [Eric J. Topol, M.D.] and life sciences patent attorney [Lisa A. Haile] offer their views on the issue.” (U-T San Diego, SD5)
   1.  Op-ed FOR gene patents: “Ruling’s Impact on Biopharma Industry,” by Lisa A. Haile (U-T San Diego [formerly San Diego Union-Tribune], 28 April 2013, pp. SD5 and SD7).
     SUMMARY: “Investors may balk at sinking millions of dollars into development of a product if other companies can freely develop the same product.” (U-T San Diego, SD7)
     Haile, a J.D. and Ph.D., “is a patent attorney and partner at the law firm DLA Piper and based in San Diego. She is co-chair of the firm’s Global Life Sciences Sector.” (U-T San Diego, SD5)
   2.  Op-ed AGAINST gene patents: “Nature Cannot Be Patented,” by Eric J. Topol (U-T San Diego [formerly San Diego Union-Tribune], 28 April 2013, pp. SD5 and SD7).
      SUMMARY: “We can’t afford to have another monopoly of mutation screening and it’s clear that this matter took much too long to resolve.” (U-T San Diego, SD7)
      Topol, an M.D., “is chief academic officer at Scripps Health, professor of genomics at The Scripps Research Institute and author of The Creative Destruction of Medicine.” (U-T San Diego, SD5)

pointer  “The New (Business) Left,” retitled “Meet the New Left: Small-Business Owners” for online posting, by William Greider (The Nation, 8 April 2013, vol. 296, no. 14, pp. 23–26).

SUMMARY: “Surveys demonstrate remarkably progressive attitudes on everything from taxation to regulation to the environment.”
   This article deals only indirectly with rising health care costs. I am including it here because it offers a fresh perspective on the role for-profit businesses can play in lowering health care costs when their mission includes building more healthy, “resilient communities”: “serving people, profit and the planet.”
   Greider’s article gives voice to small-business people around the U.S. who are innovating and investing in ethical economics (including things like ridding our communities of known carcinogens), and who support “injecting the concept of the public commons back into the marketplace.”
   It turns out that there is more small-business support, both for the Affordable Care Act and for expanding Medicaid, than many of us might think.

pointer  “Is Cap and Trade Fair?”, retitled “Will California’s Cap and Trade Be Fair? Allowing Polluters to Trade Carbon Could Keep Poor Californians Breathing Unhealthy Air” for online posting, by Madeline Ostrander (The Nation, 8 April 2013, vol. 296, no. 14, pp. 28–31).

I have included this article here because it points to the growing costs associated with putting entire communities at risk for cancer and other diseases linked to toxic air pollution, and explains the ongoing debate in California over proposed cap-and-trade solutions. The issues are complex, but also important for health care reform.
   For example, compare James Hansen’s dismissal of “trickery and gimmicks, such as carbon cap-and-trade and offsets, with their inevitable horse-trading and lobbying” in his acceptance speech for the Ridenhour Prize of 2013 (“Courage to Fight Climate Change,” The Nation, 27 May 2013, vol. 296, no. 21, p. 17).
   Hansen concluded his speech by outlining a new “progressive conservative approach” that “puts an honest price on fossil fuels, making them pay their costs to society.” He also warned that all sustainable alternatives to dirty fuels must be allowed to “compete on a level playing field”: “We must demand that the liberal left keep their hands off of our wallets. Not one dime of the carbon fee should be used to make the government bigger. One hundred percent of the money must go to the public. Nor should any of this money be used for subsidizing research on specific government-selected industries. The government is not competent to choose the best technologies — let them all compete. There are existing government resources and departments for research, development and demonstration, which can assist early development of candidate technologies.”
   The full text of Hansen’s acceptance speech is available at The Nation’s website.

pointer  “What Do Federal Spending Cuts Mean for Science and Researchers?,” a PBS NewsHour analysis of the issues, first aired 3 April 2013.

“SUMMARY: Major science organizations rely heavily on government funding, including top federal programs like the National Institutes of Health, the Centers for Disease Control and NASA. Jeffrey Brown talks to Matt Hourihan of the American Association for the Advancement of Science on how the sequester will impact researchers.”
   See also below (pointer filed under the date of 11 December 2011) for an earlier controversy over the funding of clinical trials by the National Institutes of Health.

pointer  “Rural Doctors Slow to Adopt Electronic Medical Records,” Marketplace public radio story by Kristofor Husted (aired 3 April 2013).

pointer  “Letters to the Editor: Pricey Healthcare — It Isn’t Your Fault,” written in response to Daniel Stone’s 3/31/2013 op-ed (“Our Big Appetite for Health Care”), by Jerome P. Helman, M.D., Bernard W. Freedman, and Charles Berezin (posted 3 April 2013).

pointer  “Op-Ed: Our Big Appetite for Health Care,” retitled “The Starbucks Syndrome in Healthcare” for online posting, by Daniel J. Stone (Los Angeles Times, Opinion section, 31 March 2013, p. A22).

With 28 comments (as of 5/10/2013), which you can read here.

pointer  “Why Long-Term Care for U.S. Seniors is Headed for ‘Crisis’,” a PBS NewsHour health report by Betty Ann Bowser, posted to The Rundown: A Blog of News and Insight on 20 March 2013.

U P D A T E :  Another segment in the NewsHour’s “occasional series on aging and the challenges of providing long-term care”: “Increasing Demand Moves Long-Term Care Centers to Cater to Latino Elders,” a PBS NewsHour health report by Mary Jo Brooks, first aired 3 January 2014. “SUMMARY: Traditionally, Latino American seniors have lived out their years at home, receiving care from family members. But as economic factors shift, more Latino elders are moving to nursing homes or going to day centers to receive additional support. The NewsHour’s Mary Jo Brooks reports on how some facilities have addressed the need.”

pointer  “Op-Ed: A Multibillion-Dollar Brainteaser,” retitled “Multibillion-Dollar Map of Human Brain Might Not Be Worth It” for online posting, by Christopher Chabris (Los Angeles Times, Opinion section, 17 March 2013, p. A29).

SUMMARY: “Obama’s proposal to map the human brain could yield important data. But it shouldn’t distract scientists from other inquiries.”
   Chabris here cautions that the ROI (return on investment) for mapping the human brain is being oversold, and that the ambitious 10-year project will consume resources which could be used to fund “many other levels of explanation” which are “just as important as mapping out the brain’s component elements: understanding how the brain represents information, the algorithms it uses to process information and the way it is designed by evolution to solve certain problems with ease but other problems only with great difficulty.” (Chabris, A29)
   “As the Obama administration’s plan moves forward, the decision-makers should keep in mind that maps, while incredibly useful tools, don’t answer all the important questions.” (Chabris, A29)

pointer  ProPublica’s investigative report, “Dollars for Docs: How Industry Dollars Reach Your Doctors,” by Jeremy B. Merrill, Charles Ornstein, Tracy Weber, Sisi Wei and Dan Nguyen (updated 11 March 2013).

Another good resource for information about how pharmaceutical companies influence prescribing is PharmedOut, a Georgetown University Medical Center project, directed by Adriane Fugh-Berman, “that advances evidence-based prescribing and educates healthcare professionals about pharmaceutical marketing practices.”

pointer  “The Country Doctor Is In: A Day in the Life of a Vanishing Breed — the Small-Town American Physician,” by Jennifer Kahn, with photographs by Melissa Golden (Parade, 3 March 2013, pp. 6–12).

The weekly news magazine, Parade, profiles Dr. Howard McMahan, general practitioner for the small town of Ocilla, Georgia (population 3,414).
   Doctors like McMahan do some of the most demanding work in the U.S. health care industry, for little pay, and even less glory. “Since starting out ... cutbacks by insurance companies have eaten away at the modest profit margin [McMahan] once relied on. ‘For many family doctors, it’s nearly impossible to make a living now,’ he says. ‘You have to make enough to pay the light bill, and to pay your employees — while still trying to be compassionate and not overcharge patients. That’s why so many physicians these days are selling their practices.’” (Kahn, 12)
   Predictably, “Over the past 15 years, the number of new general practitioners (physicians trained to handle a wide range of ailments) has been significantly declining, as med students drift away from the field in favor of more lucrative and less demanding specialties. By 2020, the Association of American Medical Colleges projects, the U.S. will be short 45,000 primary care doctors. The scarcity is felt keenest in rural areas, home to nearly 20 percent of the nation’s population but just 9 percent of its M.D.’s.” (Kahn, 7)

pointer  “Adding Up and Breaking Down Health Care’s Big Price Tags,” a PBS NewsHour analysis of the issues, first aired 25 February 2013.

“SUMMARY: Why does a few days of lab work end up costing more than the price of a car? Judy Woodruff interviews journalist Steven Brill about his Time magazine cover story about how and why the private marketplace isn’t working in the health care industry.”

pointer  “Forget WebMD. Hello, Robot, M.D.,” Marketplace public radio interview with The Atlantic Magazine’s Jonathan Cohn, by Kai Ryssdal (aired 25 February 2013).

This issue has also been explored by Martin Ford in a monograph entitled The Lights in the Tunnel: Automation, Accelerating Technology and the Economy of the Future (USA: CreateSpace Independent Publishing Platform, 2009). Ford’s provocative book unleashed a heated debate among Amazon.com reviewers, which included 203 posts (at the time I read each and every one of them in November 2012).
   I will be writing about Ford’s thesis myself (for a different website), because our ongoing debate over the predicted displacement of human labor by automation and the impact of this on our economic, social and political systems — including, of course, our health care system — extends even further back than the iconic Luddites of the 19th century. Well before this, a late-17th-century science textbook reminded English youth of the newfangled Polish weaving machine that “was suppressed, because it wou’d have ruin’d the poor people” (The Athenian Society, The Young-Students-Library, 1692, xi).
   Indeed, concern over the right use of technologies dates back at least to the Renaissance; for example, Ludovico Ariosto, favoring the separation of mechanical from liberal arts (such as medicine), foretold in L’Orlando Furioso (1516) that the “murderous engine” (associated with the new mechanical warfare) would destroy the virtues of chivalry (Edgar Wind, Pagan Mysteries in the Renaissance, 2nd edn., 1968, 108). And so it did.

UPDATE #1:  “What Did the Tech CEO Say to the Worker He Wanted to Automate?,” a Marketplace public radio segment by Krissy Clark, reprise airing, 1 January 2014.

UPDATE #2:  “Tech Industry Looks to Robots to Tackle Problems But Finds Hurdles on the Way,” part 1 of a 2-part PBS NewsHour analysis, first aired 2 January 2014.
   “SUMMARY: Robotic devices are everywhere: in factories, law enforcement, caretaking. They even suck up dust bunnies. Today they are smarter than ever, but they only excel when the task is clearly defined. Science correspondent Miles O’Brien reports on why it’s hard to teach robots basic human things, like walking and problem solving.”

UPDATE #3:  “What Role Does the Human Touch Play in the Digital Age?,” part 2 of a 2-part PBS NewsHour analysis, first aired 2 January 2014.
   “SUMMARY: In a digital age that creates more automated services at ever lower prices, how can we retain the value of human work and relationships? Hari Sreenivasan ponders this with computer scientist Jaron Lanier, author of Who Owns the Future?, and Andrew McAfee from MIT’s Center for Digital Business at the Sloan School of Management.”

pointer  “Herbalife Cozies Up with UCLA,” by columnist Michael Hiltzik (Los Angeles Times, 24 February 2013, pp. B1 and B8).

SUMMARY: “UCLA’s Medical School has an unusually close relationship with Herbalife, which constantly promotes its connection to doctors there. Where do sensible ideas end and the shilling for Herbalife begin?”
   Click/tap here for Letters to the Editor (posted 27 February 2013) responding to Hiltzik’s column, which highlighted “a serious issue for the medical school. At what point does it lose its reputation as a source of objective scientific knowledge, and become instead an arm of Herbalife’s (or the Resnicks’) P.R. machine? At what point does it begin to look like a university for sale?” (Hiltzik, B8)

pointer  Time magazine article by Steven Brill, “The Profit of Prestigious Cancer Care,” posted 21 February 2013.

pointer  Time magazine cover story by Steven Brill, “Bitter Pill: Why Medical Bills Are Killing Us,” posted 20 February 2013 (revised 26 February 2013 and 12 March 2013).

Unfortunately, this article, which was freely available online to all in February 2013 is no longer accessible as a digital edition, unless you are a subscriber to Time magazine.
   I have included its URL here because I quote from and refer to it elsewhere, and because it was the initial prompt for creating this page.

pointer  The Women’s Health Activist newsletter article by Nicole Dubowitz, “Device Marketing to Doctors, In and Out of the OR,” from the January/February 2013 print issue, pp. 1, 3, and 10.

pointer  The Women’s Health Activist newsletter article by Debra L. Ness, “Supporting Female Caregivers, Who Are Indispensable to Families, Communities, and Our Country,” from the January/February 2013 print issue, pp. 4–5.

pointer  The Women’s Health Activist newsletter column by Charlea T. Massion and Adriane Fugh-Berman, “Prescription for Change: Refuse InFuse,” from the January/February 2013 print issue, p. 11.

pointer  “Electronic Health Records Aren’t Cutting Costs So Far,” Marketplace public radio story by Dan Gorenstein (aired 11 January 2013).

pointer  “Lifeline for Worried Parents: Resource Helps Cut Through the Mental Health Care Labyrinth,” by columnist Steve Lopez (Los Angeles Times, 30 December 2012, p. A2).

SUMMARY: “NAMI [National Alliance on Mental Illness] is a valuable resource for parents searching for help in a labyrinthine and bewildering mental health care system.”

pointer  “A Times Investigation: Dying for Relief,” by Lisa Girion and Scott Glover (Los Angeles Times, 30 December 2012, pp. A1 and A22).

This is the 4th report in a Los Angeles Times investigative series on California’s epidemic of prescription drug deaths. In part 4, the authors focus on the state attorney general’s inability to use the CURES (Controlled Substance Utilization Review and Evaluation System) database to scrutinize doctors’ prescribing, which some have argued is the most effective way to prevent prescription drug abuse.
   In California, “CURES is ‘on life support’ because of state budget cuts and is barely able to fulfill its primary mission of helping doctors and pharmacists track patients’ use of medications.” (Girion and Glover, A22)
   “State officials said it would cost about $2.8 million to make CURES more accessible and easier to use, and $1.6 million more per year to keep it running.  ¶  State Sen. Mark DeSaulnier (D-Concord), a longtime supporter of CURES whose father struggled with substance abuse, said he would propose legislation in January to finance such an upgrade, and would like to see the system used to track doctors as well as patients.” (Girion and Glover, A22)
   On 28 May 2013, “California lawmakers fail[ed] to pass a measure calling for higher fees for pharmacists and doctors and a tax on drug makers to improve CURES’ narcotics-tracking database.” (“Senate Rejects Bill on Prescription Monitoring Program,” posted 5/28/2013 to Los Angeles Times website)
   But 2 days later, on 30 May 2013, the California State Senate unanimously passed a revised bill that “would create a steady stream of funding for the [CURES] program by raising licensing fees on pharmacists and doctors and other prescribers. Initially, the bill also called for a tax on drug makers to allow the attorney general to hire teams of investigators to crack down on drug-seeking patients and doctors who recklessly prescribe to them.  ¶  But that provision drew opposition from several pharmaceutical companies and trade groups that succeeded in defeating the bill earlier this week by a margin of just four votes.  ¶  In a last-ditch bid to keep the bill moving forward, its sponsors removed the drug maker tax — sacrificing the enforcement squads. The pharmaceutical companies and trade groups dropped their opposition, and the bill passed unanimously.  ¶  Bob Pack, an Internet entrepreneur who helped modernize CURES after a driver under the influence of pain pills and alcohol swerved off the road and killed his two children a decade ago, said he was disappointed by the ‘watering down’ of the bill.  ¶  Pack said he would pursue a ballot initiative to restore funding for the enforcement teams and require doctors to check CURES before prescribing narcotics, a provision that was earlier dropped to win physician support.” (“California Senate Passes Bill to Curb Prescription Drug Abuse,” posted 5/31/2013 to Los Angeles Times website)
  Meanwhile, there is ongoing debate over the mandated use of a computer database to track narcotics prescription transactions throughout California. Some, like Los Angeles Times columnist Sandy Banks, worry that proposed “Restrictions would deprive patients and physicians of options” while her “Readers with chronic pain and doctors afraid of a backlash weigh in on a complex issue that appears headed for a heavy-handed, oversimplified attempt at a solution.” (“A Shortsighted ‘Cure’ for Prescription Meds’ Abuse,” posted 4/12/2013 to Los Angeles Times website) Banks thinks that “There’s a cocktail of forces that brought us to this epidemic level: clueless doctors, reckless patients, highly potent medication, and the difficulty inherent in trying to assess someone else’s pain.  ¶  Science may be headed to the rescue: A pharmaceutical company is working on developing non-addicting opioids. And research into the ‘neural signature’ of pain suggests that doctors may soon be able to measure physical discomfort by scanning images of our brains.”
   Others have suggested that a wise use of CURES poses no threat to proper palliative care involving pain medication. “Ronald Wender, former president of the state medical board, said physicians who are prescribing appropriately would have nothing to fear from such scrutiny.  ¶  ‘If you are an oncologist and you are taking care of people in cancer pain, that’s one thing,’ said Wender, an anesthesiologist who oversees a large pain-management practice in Los Angeles. ‘But if you are a general practitioner and writing loads of opioid prescriptions, then something is wrong.’” (Girion and Glover, A22)
   Glover and Girion have continued their investigative reporting of this matter; for a selective sampling of updates, see:
   1.  “A Closely-Guarded List: As sales surpass the $27-billion mark, OxyContin’s maker has privately identified about 1,800 doctors who may have recklessly prescribed the drug to addicts and dealers, yet it has done little to alert authorities,” by Scott Glover and Lisa Girion (Los Angeles Times, 11 August 2013, pp. A1 and A14–A15).
   2.  “Nevada State Senator Joins Call to List OxyContin Over-Prescribers: Richard ‘Tick’ Segerblom of Nevada joins California lawmaker Ted Lieu in asking Purdue Pharma to provide names of doctors it suspects of recklessly prescribing the painkiller,” by Scott Glover (Los Angeles Times website, posted 16 August 2013).

pointer  “Are Annual Mammograms Necessary? Physicians Debate Tool’s Prevention Capability,” a PBS NewsHour report by Betty Ann Bowser, first aired 25 December 2012.

“SUMMARY: Annual mammograms have been seen as an important screening tool: They are very effective in helping find small, slow-growing cancers. But how good are they at finding fatal tumors? Health correspondent Betty Ann Bowser reports on a recent study published in the New England Journal of Medicine that has reignited the debate.”

pointer  “S.D. [San Diego] Kaiser Hospital Fined; Removed Wrong Kidney,” retitled “Kaiser Hospital Fined for Removing Wrong Kidney” for online posting, by Paul Sisson (U-T San Diego [formerly San Diego Union-Tribune], 21 December 2012, pp. B1 and B5).

Such costly “wrong-site surgery” is reportedly “a growing area of focus in recent years.  ¶  According to The Joint Commission, the main hospital accreditation organization in the United States, wrong-site surgeries have increased from 60 in 2001 to 152 in 2011.” (Sisson, B5)

pointer  Dollars & Sense magazine article by Alejandro Reuss, “The Big Lie About the ‘Entitlement State,’” from the November/December 2012 print issue.

pointer  “The You’re-on-Your-Own Society,” Katha Pollitt’s “Subject to Debate” column for the 26 November 2012 printed issue of The Nation (vol. 295, no. 22, p. 9).

Pollitt’s post-election column, arguing “In this election, the deepest division was over whether we are all in this together.” — e.g., “If you want an example of how approaching social issues from an individualist mindset harms everyone, consider lung cancer....” — drew 278 comments.

pointer  “Rooting Out Waste in Health Care by Taking Cue From Toyota Assembly Lines,” a PBS NewsHour report by Betty Ann Bowser, first aired 24 October 2012.

“SUMMARY: When the Virginia Mason Medical Center in Seattle was losing money for the first time in its history, CEO Dr. Gary Kaplan turned to an unlikely place for help: giant automaker Toyota. Health correspondent Betty Ann Bowser reports on the hospital’s success in lowering costs and improving health outcomes.”

pointer  “First Comprehensive Genetic Analysis of Breast Cancer Could Change Treatment,” a PBS NewsHour interview with Dr. Harold Varmus, on behalf of the National Cancer Institute, by Judy Woodruff, first aired 24 September 2012.

“SUMMARY: Research published by Nature shows there are four distinct types of breast cancer and that genetic changes occurring as cancer cells spread are vastly different for each type. Judy Woodruff talks to National Cancer Institute’s Dr. Harold Varmus for more on what the research could mean for treatment in the future.”
   And for those of us fixated on gynecologic cancers: “Among other discoveries, researchers say that a rare but deadly form of breast cancer bears a genetic resemblance to the kinds of tumors found in lung and ovarian cancers.”
   While the interview does not directly address our topic of health care costs and wise use of limited resources, I have included it here because of the issues it raises about funding future research when we “think imaginatively about how we prevent cancers” — including “what the environmental causes of cancer might be” — and when cancer patients become “information donors who can benefit not just others who will have cancer later, but themselves over the next few years.”
   (As I write this, Angelina Jolie has just gone public with her own choice to undergo a double preventative mastectomy, based on her strong genetic predisposition for developing breast and ovarian cancers. For more on this, see Betty Ann Bowser’s 5/14/2013 post to the NewsHour’s The Rundown: A Blog of News and Insight, “Jolie’s Decision Sheds Light on BRCA Gene, Importance of Genetic Counseling,” including an interview with Dr. Sandra Swain, President of the American Society of Clinical Oncology. And also see Gwen Ifill’s interview with genetic counselor Beth Peshkin of Georgetown University and Dr. Kenneth Offit of Memorial Sloan-Kettering Center in New York, “Understanding Angelina Jolie’s Decision to Undergo Preventative Double Masectomy,” first aired 15 May 2013, which includes more discussion about managing ovarian cancer risks.)
   Critics are already voicing concerns. See the viewer comments appended to the Varmus interview, with one respondent claiming that what the NewsHour and NCI present as a promising new research model is really “pseudo science benefiting Drug Companies and now the socialized medical industry.”

pointer  “An Age-Old Pre-Occupation: The Fountain of Youth,” Marketplace Money public radio commentary by Judy Muller (for 14 September 2012).

Judy Muller closes her commentary with a reference to comedian Albert Brooks and his satirical novel 2030: “That’s the year, by the way, when nearly 20 percent of the U.S. population will be over the age of 65. Brooks imagines a time when cancer has been cured and rejuvenation drugs are taken for everything from failing joints to failing memories, leaving hordes of spry senior citizens to hog most of the country’s resources. Young people, in response, have formed ‘resentment gangs,’ which begin to hunt down ‘the olds,’ as they call them.”
   See below (pointer filed under date of 3 June 2011) for an interview with Albert Brooks about his 2030: The Real Story of What Happens to America.

pointer  “The Battle over Billing Codes,” Marketplace public radio story by Gregory Warner (aired 10 April 2012).

pointer  “Gambling on Cancer Treatments,” Marketplace public radio story by Gregory Warner (aired 9 April 2012).

Warner reports on a study of cancer patients in the April 2012 issue (vol. 31, no. 4, pp. 676–682) of the journal, Health Affairs: “How Cancer Patients Value Hope and the Implications for Cost-Effectiveness Assessments of High-Cost Cancer Therapies,” by Darius N. Lakdawalla, John A. Romley, Yuri Sanchez, J. Ross Maclean, John R. Penrod, and Tomas Philipson.
   Their study demonstrates that value for patients is still — as was the case during the 17th century — circumstantial and wildly variable.
   The ABSTRACT for Lakdawalla et al.’s article: “Assessments of the medical and economic value of therapies in diseases such as cancer traditionally focus on average or median gains in patients’ survival. This focus ignores the value that patients may place on a therapy with a wider ‘spread’ of outcomes that offer the potential of a longer period of survival. We call such treatments ‘hopeful gambles’ and contrast them with ‘safe bets’ that offer similar average survival but less chance of a large gain. Real-world therapy options do not have these stylized forms, but they can differ in the spread of survival gains that patients face. We found that 77 percent of surveyed cancer patients with melanoma, breast cancer, or other kinds of solid tumors preferred hopeful gambles to safe bets. This suggests that current technology assessments, which often determine access to such cancer therapies, may be missing an important source of value to patients and should either incorporate hope into the value of therapies or set a higher threshold for an acceptable cost-effectiveness ratio in the end-of-life context.”

pointer  Dollars & Sense magazine article by Gerald Friedman, “Funding a National Single-Payer System,” from the March/April 2012 print issue.

pointer  “The Bizarre Calculus of Emergency Room Charges,” by columnist Steve Lopez (Los Angeles Times, 1 April 2012, p. A2).

SUMMARY: “Readers share their experiences about the bewildering fees charged by hospitals. Even medical professionals can be baffled by the way costs are determined.”

pointer  “An Emergency Room Story to Make Anyone Ill,” by columnist Steve Lopez (Los Angeles Times, 25 March 2012, p. A2).

SUMMARY: “The tale of an 11-year-old’s $5,000 stomachache reveals the Twilight Zone of hospital billing. The charges seem arbitrary if not indefensible.”

pointer  “Rethinking Hospital Readmissions,” Marketplace public radio story by Gregory Warner (aired 7 February 2012).

pointer  “Kids and Cancer: Why Pediatric Cancer Cure Rates Have Improved So Much,” a PBS NewsHour report by Betty Ann Bowser, first aired 12 January 2012.

“SUMMARY: Four decades ago, President Nixon signed a law that would change the way cancer research was funded in an effort to develop better treatments and cure more patients. Health correspondent Betty Ann Bowser explores the positive developments pediatric cancer research has realized in the last 40 years.”
   See the viewer comments appended to the story for the related debate over costs and wise use of resources.

pointer  The Women’s Health Activist newsletter column by Charlea T. Massion and Adriane Fugh-Berman, “Prescription for Change: Excuse Me, Is that a Metal-on-Metal Device You’re Wearing?,” from the January/February 2012 print issue, vol. 37, no. 1, p. 11.

SUMMARY: “Each year, over 600,000 Americans have hip and knee replacement surgeries; hospital costs alone from the procedures will exceed $65 billion in 2015. Despite leading the world in joint replacement procedure frequency, however, the U.S. has no comprehensive joint replacement registry, nor is one planned by any government agency, the American Academy of Orthopedic Surgeons, or the highly profitable joint replacement manufacturing industry. As a result, Americans’ health is jeopardized by unsafe and ineffective devices.” (Massion & Fugh-Berman, 11)
   The authors argue that “one U.S. health insurer can show us the way. In 2001, Kaiser Permanente started its own joint replacement registry, which has improved quality and saved costs.”
   Their recommendation: “If you, or anyone you know, had hip replacement from 2005–10, learn the device’s make and model. If it is an ASR or other MoM device, take this article to your primary care doctor AND your orthopedic surgeon, and get both an in-depth evaluation of the device and blood tests to assess cobalt and chromium levels. We can all contact our Congressional representatives to demand the U.S. catch up with other nations and Kaiser by creating a state-of-the-art, national joint replacement registry.” (Massion & Fugh-Berman, 11)

pointer  “Studying Alternative Medicine with Taxpayer Dollars,” retitled “Federal Center Pays Good Money for Suspect Medicine: Feds dole out millions of dollars for questionable studies on treatments ranging from energy healing to acupuncture” for online posting in 4 parts, by Trine Tsouderos (Los Angeles Times, 11 December 2011, p. A32).

The original news story by Trine Tsouderos, a reporter for the Chicago Tribune, is no longer available at the website for the Los Angeles Times, but the Letters to the Editor responding to Tsouderos’s reporting, as published in the Los Angeles Times, are still posted there.
   Tsouderos reported on the debate over clinical trials funded by the National Center for Complementary and Alternative Medicine (NCCAM), including “pay[ing] scientists to study whether squirting brewed coffee into someone’s intestines can help treat pancreatic cancer (a $406,000 grant) and whether massage makes people with advanced cancer feel better ($1.25 million). The coffee enemas did not help. The massage did.” According to Tsouderos, “The cancer treatment involving coffee enemas was based on an idea from the early 1900s, and patients who chose to undergo the risky regimen lived an average of just four more months.”
   Tsouderos also pointed out that “The spending comes as competition for public research money is fierce and expected to get fiercer, with funding for the NIH expected to plateau and even drop in coming years.” “‘Lots of good science and good scientists are going unfunded,’ said Dr. David Gorski, a breast cancer researcher at Wayne State University, who has been a vocal critic of NCCAM. ‘How can we justify wasting money on something like this when there are so many other things that are much more plausible and much more likely to result in real benefit?’” (Tsouderos, A32)

pointer  The Women’s Health Activist newsletter column by Charlea T. Massion and Adriane Fugh-Berman, “Prescription for Change: Avast Avastin!,” from the September/October 2011 print issue, vol. 36, no. 5, p. 11.

SUMMARY: “Why won’t ineffective treatments go away? The story of the use of Avastin for breast cancer treatment is a cautionary tale about how pharmaceutical companies dupe health care providers and consumers into accepting — even demanding — inferior drugs, and bully Federal agencies trying to protect the public.” (Massion & Fugh-Berman, 11)

pointer  “We’re Going to Be Spending Even More on Health Care,” Marketplace Morning public radio report by Stacy Vanek Smith (aired 28 July 2011).

Government spending for health care is projected to reach $2.2 trillion in 2020. Stacy Vanek Smith asks JB Silvers, who chairs the department of banking and finance at Case Western Reserve University, how much of this spending increase is due to health care reform (aka Obamacare). The answer: “a fairly small amount.” According to Silvers, the cost surges are “mostly due to expanded use of services — we just keep using more healthcare every year.” In sum: “We need to change how we use health care and how much of it we use in an intelligent way.”

pointer  “Some Hospitals Think ‘Lean’ When It Comes to Health Care,” Marketplace public radio story by David Weinberg (aired 27 June 2011).

pointer  “2030: Albert Brooks’ Somber Look at America’s Future,” Marketplace public radio interview with comedian Albert Brooks about his first novel, 2030: The Real Story of What Happens to America, by Tess Vigeland (aired 3 June 2011).

Another vision of the future, after cancer and other killer diseases have been eradicated, was offered by scientist Tom Kirkwood at the end of his book, Time of Our Lives: The Science of Human Aging (Oxford and New York: Oxford University Press, 1999). I was intrigued by this part of the book when I read it years ago, but a reviewer for Publishers Weekly deemed Kirkwood’s futurism “a weak science fiction scenario.”
   The Publishers Weekly review of Time of Our Lives reads in full: “‘Aging is neither inevitable nor necessary,’ declares British gerontologist Kirkwood in this unorthodox study. According to his hypothesis, which he calls the ‘disposable soma theory,’ aging occurs because genes treat organisms as dispensable, investing just enough in body maintenance to enable an organism to get through its life expectancy in the wild. Kirkwood believes that freshwater hydra — tubular pond animals with remarkable regenerative powers — are immortal, a claim made by Argentinean biologist Daniel Martinez in the early 1990s. When it comes to humans, though, Kirkwood concedes that a fountain-of-youth elixir, whether obtained through gene-repair therapy or other means, is far in the future or may never exist. His survey of scientific research into the human aging process reveals clues about the origins of arthritis, memory loss, Alzheimer’s disease and immune-system impairment. He dispenses sensible if unsurprising advice on how to slow one’s own aging (exercise, eat fewer calories, keep up a healthy sex life, etc.) and examines anti-aging fads, including those involving melatonin, the steroid hormone DHEA and hormone replacement therapy for women. Kirkwood’s more provocative ideas include an evolutionary theory to explain menopause and his argument that cancer is an accidental throwback to ‘immortal’ cell-growth mechanisms that were meant to be switched off. He concludes with a weak science fiction scenario in which aging has been conquered and babies are created infrequently to replace individuals who die from accident or suicide.”

pointer  “What’s in a Drug Name?,” Marketplace public radio story by Gregory Warner (aired 12 May 2011).

pointer  Dollars & Sense magazine article by Marianne Hill, “Health-Care Reform: Will It Work?,” from the November/December 2010 print issue.

pointer  “For Med Students, Financial Lessons Learned Outside the Lab,” Marketplace public radio story by Gregory Warner (aired 22 July 2010).

pointer  “End of Life Care: More or Less of It?,” Marketplace public radio story by Caitlan Carroll (aired 20 July 2010).

pointer  “Will Overhaul Lead to Doctor Shortage?,” Marketplace public radio story by Nancy Marshall-Genzer (aired 25 March 2010).

pointer  “Health Care Costs Can Be Hard to Define,” Marketplace public radio story by Gregory Warner (aired 16 March 2010).

pointer  “Exasperation with U.S. Health Care,” Marketplace public radio interview with author Lionel Shriver about her novel, So Much for That, by Kai Ryssdal (aired 9 March 2010).

pointer  “A Health System that Works for All,” Marketplace public radio commentary by physician Calvin Brown (aired 14 January 2010).

pointer  “Harvard, Heal Thyself (Why Journalism Matters),” Eric Alterman’s “The Liberal Media” column for the 28 September 2009 printed issue of The Nation (vol. 289, no. 9, p. 9).

pointer  “Kaiser CEO Calls for Health Care for All,” Marketplace public radio interview with George Halvorson of Kaiser Permanente, by Kai Ryssdal (aired 28 July 2009).

In his Marketplace interview, Halvorson points to “one of the really fascinating things about this wave of reform”: “in the Clinton era, people were talking about reconfiguring the care delivery system. This most recent reform has been more heavily about cost savings. And the president has said repeatedly that he wants higher-quality care, better care, and wants to get to the right outcome by making care more affordable by making it better. But the debate has gone off track from that point.”

pointer  The New Yorker magazine article by Atul Gawande, “The Cost Conundrum: What a Texas Town Can Teach Us about Health Care,” posted 1 June 2009.

pointer  “Hospitals Consider Paper-Free Records,” Marketplace Money public radio report by Sally Herships (for 11–12 April 2009).

pointer  “Network is Key to Digital Health Records,” Marketplace public radio commentary by physician Peter Bach (aired 2 April 2009).

pointer  Dollars & Sense magazine article by Roger Bybee, “Crisis = Opportunity for Single-Payer,” from the March/April 2009 print issue.

pointer  Dollars & Sense magazine article by Joel A. Harrison, “Paying More, Getting Less,” from the May/June 2008 print issue.

pointer  PBS Frontline special, “Sick Around the World” (posted 15 April 2008).

This Frontline special asked “Can the U.S. learn anything from the rest of the world about how to run a health care system?” and reported on “Five Capitalist Democracies & How They Do It.”
   The 5 capitalist democracies described here are: the United Kingdom, Japan, Germany, Taiwan, and Switzerland.

pointer  The Hightower Lowdown newsletter article by Jim Hightower, “The Four Big Lies about Universal Health Care: Our system, designed by Big Business, is ranked 37th in the world,” from the June 2006 print issue, vol. 8, no. 6, pp. 1–4.

The 4 “Big Lies” about a single-payer system which Hightower tackles here: 1. “It’s socialized medicine.” 2. “Private is always better than public.” 3. We can’t afford to cover everyone.” 4. “There’ll be waiting lists.”
   The feisty Texan populist has long been a vocal critic of the health-care status quo in the U.S., describing it as a “health-industrial complex” which is a “mess”; a “sick health-care system” which Hightower believes is more accurately described as “Sick Care”: “Even if you’re insured, our corporate-based system really isn’t in the business of delivering health care—rather, it’s a ‘sick-care’ system. Get sick, and we’ve got diagnostic tests, the latest technology, and lots of medicines for you. But preventive care to keep you from getting sick, or health regimens to manage a chronic disease — sorry, we don’t cover those.  ¶  Insurance companies refuse to pay $150 for a diabetic to visit a podiatrist who can help prevent foot ailments caused by diabetes — but they will shell out $30,000 to cover a foot amputation.  ¶  Also, insurance companies — with their eye always on the bottom line — have drastically altered the human touch of family doctors. Changing ‘patients’ into ‘consumers of health-care resources’ reduced human beings to units, and the medical emphasis shifted from care to speed. Hospital patients are now called ‘throughputs’ by insurance beancounters, and a visit to the doctor is termed an ‘encounter.’ Each encounter is not supposed to last more than seven minutes.” (Hightower, sidebar on p. 2)
   For Hightower, reforming our health-care system is a moral choice: “Years ago, Martin Luther King, Jr., said, ‘Of all the forms of inequalities, injustice in health care is the most shocking and inhumane.’ Allocating health care according to the size of your bank account or to your privileged position in society is fundamentally (even biblically) immoral. It’s also a shameful embarrassment for any wealthy nation.” (Hightower, 3–4)
   In sum: “Universal health care is not an economic issue — our country is the richest in the history of the world, and we already throw more money into the health-care trough than any other nation in history. Nor is health care even a health issue — our doctors, nurses, technicians, nutritionists, pharmacists, and others are phenomenally skilled, having both the intellectual and technical capability to meet the health needs of everyone in our land.  ¶  Universal care is a moral issue — and that’s where our country has gone all slippery....” (Hightower, 2–3)

Please let me know if I’ve missed a good report or conversation about the issues that you think should be added to the above list of links (any online opining and analysis should be freely available, so that everyone, everywhere, has access).

Panel from "Roses", a mixed-media work by Tuck Contreras

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To view all 18 of this Web page’s hover notes in a second-window aside, click/tap here. ]

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Cowley’s poem, “To Dr. Scarborough” — Cowley was a metaphysical poet of such celebrity and influence that his posthumously-published Works were printed 14 times between 1668 and 1721. He was only 15 when his first collection of poems (composed even earlier, at ages 10 and 12) was published.
  Cowley studied medicine at Oxford (where he was part of William Harvey’s circle), spent time in Kent collecting samples, and proceeded to the degree of doctor of physic in 1657. His scientific interests ranged from pedagogical reform (in 1661, he proposed founding a scientific research institute, with its own college) to botanical studies (his Latin poem, Plantarum Libri Sex, was an early contribution to the literature of medicine, poetizing botany and the physic garden in the Virgilian manner).
  The addressee of this particular poem, Sir Charles Scarburgh (1615–1694), was a physician, natural philosopher, and friend to the physician and discoverer of the circulation of the blood, William Harvey (1578–1657), who chose Scarburgh as his successor as Lumleian lecturer in the College of Physicians. Scarburgh met Cowley through Harvey, and after Cowley was arrested as a royalist agent by the Cromwellian regime, it was Scarburgh who stood bail of £1000 for Cowley in 1656. ::

with plenty of name-calling — Richard Whitlock’s vituperative Zoötomia, or, Observations of the Present Manners of the English: Briefly Anatomizing the Living by the Dead. With an Usefull Detection of the Mountebanks of Both Sexes (London, 1654) was exemplary in this regard. His “Medicinall characters” of the “Shee Doctor and Apothecary” — aka “the quacking Hermaphrodite,” “Petticoat Practitioner,” “Doctor Wise-akers,” “our cunning Women,” “Shee Practitioners,” “Shee Empyricks,” “these simple Chapwomen,” “Herbe-women,” the “shee-physitian,” “this Sister-hood of Physitians,” and the grand-daughters of Eve who “kil’d us all at one blow, [while] you kill us one by one” — along with “the Peoples Physitian” and “the Valentian Doctor” and “Selfe-killers, and their Accessories, or of Patients and their Tenders,” makes our online discussions look quite tame in comparison!
  The satirist’s goal is the improvement of practice, grounded in an appeal to a shared sense of normal conduct from which vice and folly are seen to stray. As such, Whitlock’s medical satires, while ruthless, were not relentlessly negative or counter-productive in the way that much criticism of Obamacare operates. Rather, Richard Whitlock (b. 1615–16) used ridicule and scorn in order to promote his ideal of the “sober and rationall Physitian” and to improve patient outcomes. In the very same work where he skewered the she-physician by reducing her to a satiric Theophrastan Character in a simplistic morality play, Whitlock also included an essay on the excellence of women. ::

the “sober and rationall Physitian” — Richard Whitlock (b. 1615–16, d. 1666) styled himself “M.D.” on the title-page of his published work, Zoötomia, in which he agitated for medical reform. Historians believe that this medical degree was not acquired in England, but abroad, probably from the universities of Leyden and Padua, both of which played a prominent role in training 17th-century Englishmen seeking medical qualifications.
  Whitlock returned to England and practiced medicine during the Civil War and Interregnum periods, after which his zeal for the medical profession apparently waned, and he switched to a different divine calling, that of clergyman, ministering to the souls of parishioners in Stowe, Buckinghamshire and Ashford, Kent, where he served as vicar following the restoration of Charles II.
  The poet and physician to the king, Martin Lluelyn (1616–1682), contributed commendatory poems to both William Harvey’s Anatomical Exercitations (1653) and to Whitlock’s Zoötomia (1654), indicating that Whitlock had close ties to the London medical establishment, despite his lack of an English medical degree.
  And the College of Physicians clearly modelled Whitlock’s “Congregation of sober, and rationall Physitians” who practiced medicine as both an art and a science: they “understand the order of Art, [and] the Art of order” and “steer by ... those three Sea marks guiding to the Haven of Healths”: i.e., “the compasse of Theory and Reason, [and] Rudder of experience (but broken and imperfect) without either of which, they must necessarily Shipwrack, or float in uncertainties.” (Whitlock, Zoötomia, or a Morall Anatomy of the Living by the Dead, 1654, 65 and 89) ::

iatrochemist — Iatrochemistry, or chemistry applied to medicine, was the forerunner of modern chemotherapy. The use of chemical remedies has a long history: from the 1st century BCE onwards in ancient China; from the 2nd century in India, although iatrochemistry didn’t flourish in Hindu science until c.1300–1550; and from the Middle Ages, c.854–925, in Islamic science. In the Latin West, the therapeutic use of chemicals was introduced during the 16th century by Paracelsus (1493–1541), who argued that health could be restored by ingesting alchemically-prepared mineral drugs. Since many of these chemical compounds were poisonous, contemporary traditionalist physicians who followed Galen (129–c.200) and Avicenna (980–1037) had grounds, beyond professional jealousies, for warring with the Paracelsians.
  J. B. van Helmont further refined Paracelsian thought and founded what would become the dominant Iatrochemical School. His medical works, published posthumously by his son, Francis Mercury van Helmont (1618–1698), were enormously popular in revolutionary England (c.1650), where Galenism in medicine was associated with ancient authority which empowered the church and the crown, more than it helped or healed the people. Van Helmont thus played a key role in shaping the new science. According to John Schuster, “Van Helmont stood for a transformed and sanitised alchemical natural philosophy, toning down the potential excesses — religious, psychological and political — of Paracelsianism, without sacrificing its stress on ‘experience’. He, like certain other reformers of the Paracelsian tradition who exploited Ramus’s pedagogical tenets, emphasised a new dispensation of a ‘chemical philosophy’ under the aegis of sober pedagogy and methodology.” (Companion to the History of Modern Science, ed. R. C. Olby et al., 1990, 237) ::

attended by some of the best physicians in Europe — E.g., Cavendish gave a personal reminiscence of her own life-threatening bout with “a Purging Flux” (dysentery), while in Paris at the court of Henrietta Maria, for which she was given laudanum, by the renowned chemist and physician, William Davisson (aka D’Avissone; c.1593–1669): “[I]n all sorts or degrees of Fluxes, there is nothing better than Laudanum, such as is prepared by Doctor Davidson’s Prescription; the Quantity must be from One Grain to Two and Three, but above Four must not be taken, and to put it in a Small Pill of Bread, and so Swallow it down; the time of Taking is, when the Patient goes to Sleep, but the Patient must not Eat nor Drink in Three Hours before the taking of it, and when taken, lie still to Rest; as for this Laudanum I have had Experience, for when I was in France with the Queen of England, I had Died of a Purging Flux if I had not taken Doctor Davidson’s Laudanum, and he gave it to me every Night for a Week together, and I was Cured.” (Cavendish, Philosophical and Physical Opinions, 2nd edn., 1663, 391–2) ::

William Petty’s new “political arithmetic” — William Petty (1623–1687) — who contributed to agriculture, industry, technology, population studies, architecture, surveying, cartography, and medicine — is now best known as the father of “political arithmetick” (that is, the sciences of statistics and economics).
  “Petty examined the wealth, potential and actual, of England. He saw labour as the key to increased national prosperity. Like other commentators he sought lessons from the evident successes of the United Provinces and France under Colbert. The novelty in Petty’s approach was to quantify. Yet sometimes his willingness to give numbers invested his calculations with a spurious authority. Just as the down survey [of Ireland, conducted by Petty during the 1650s] was found wanting as to its accuracy, so in his later endeavours too often he seemed to pluck numbers from the air, usually when solid figures were lacking. Nevertheless, by abstracting numbers and using these as the basis of calculation, whether of profit and loss in his own Irish ironworks or English trades and industries, he constructed the method known as political arithmetic which was widely copied in the later seventeenth century (and beyond). In addition, by isolating such issues as the velocity of circulation, the difference between the natural and market price of a commodity, and the theory of economic surplus, he established important themes and methods for classical economists.” (Toby Barnard, “Petty, Sir William (1623–1687), natural philosopher and administrator in Ireland,” Oxford Dictionary of National Biography, online edn., May 2007, n. pag.)
  Petty was a pivotal member of numerous protoscientific organizations (e.g., the Oxford Circle, the Hartlib Circle, the Cavendish Circle) dating from the 1640s, as well as a founding member of the Royal Society, the first president of the Dublin Philosophical Society, and a fellow of the College of Physicians.
  He dedicated his lecture Concerning the Use of Duplicate Proportion in Sundry Important Particulars: Together with a New Hypothesis of Springing or Elastique Motions (1674) to William Cavendish, 1st duke of Newcastle, in appreciation for Newcastle’s patronage of Petty 30 years earlier while both men resided in Paris. ::

an argument against “that famous Philosopher and Chymist, Van Helmont” — I.e., Joan Baptista van Helmont (1577–1644). Cavendish’s argument with van Helmont’s theories, as published in his Ortus Medicinae, Opuscula Medica Inaudita, and Tumulus Pestis, was conducted entirely in absentia. The whole of Section 3 of her Philosophical Letters (1664) is devoted to confrontation with van Helmont over topics ranging from earthquakes and meteors to plague and more mundane matters such as what kind of drinks — wine or cooling drinks (juleps) — is better for a fever. ::

“another famous Physician in France, Dr. Davison” — I.e., William Davisson (aka D’Avissone; c.1593–1669). Davisson was born in Aberdeen, but after his mother’s holdings were seized by relatives, he emigrated to France. There he sided with the Paracelsian protestants of Montpellier against the Galenist Catholics of Paris in arguments over medical theory, and as an outspoken advocate of chemical medicine, physician to Louis XIII, and holder of the first chair of chemistry in France (created in 1647 at the Jardin du Roi), Davisson was invited by the Polish Queen Marie-Louise to Warsaw, where he moved in 1651, becoming first physician to King Jan Kazimierz and keeper of the royal garden. In 1669 Davisson returned to Paris, where he died that same year.
  Margaret Cavendish, while a Maid of Honour at the court of Queen Henrietta Maria, left England for France with the queen in July 1644. She was resident at Paris from 1644–1647, until she and her new husband moved to Antwerp, so it must have been during this period when she was treated by Davisson for a life-threatening “Purging Flux” and other ailments. ::

continuing threat of revolution — The 17th century was an age of intense political and religious strife. And regime change did come again with the Glorious Revolution of 1688–89, in which James II (and a Roman Catholic succession) was removed from the throne, and Stuart attempts at despotism yielded to the establishment of a constitutional form of government under the protestant William and Mary. ::

the great and splendid nobleman ideal — Edward Hyde (1609–1674), 1st earl of Clarendon, “Late Lord High Chancellor of England, Privy Counsellor in the Reigns of King Charles the First and the Second,” and often critical of Newcastle, described William Cavendish as a “very fine Gentleman” with the following political philosophy: “He lov’d Monarchy, as it was the foundation and support of his own greatness, and the Church, as it was well constituted for the splendour and security of the Crown; and Religion, as it cherished, and maintain’d that Order and Obedience that was necessary to Both; without any other passion for the particular Opinions which were grown up in it, and distinguished it into Parties, than as he detested whatsoever was like to disturb the publick Peace.” (E. Hyde, The History of the Rebellion and Civil Wars in England, Begun in the Year 1641, 3 vols., 1702–4, 2.392) ::

as flanders famous for Itt — Newcastle adds a marginal note for this which reads: “Iper & Gaunte hath been famous above 300 yeares for chaser [i.e., the accomplished civil servant and poet, Geoffrey Chaucer (c.1340–1400), whose best-known work today is probably The Canterbury Tales] speakes off Itt.” ::

the Diggers — Seventeeth-century agrarian communists who cultivated waste lands during 1649–50, when food prices had risen sharply, to feed the poor. Led by the radical Puritan, Gerrard Winstanley (bap. 1609, d. 1676), the Diggers started seizing common land in Surrey and sharing it out. They called themselves the True Levellers (their first published manifesto in 1649 was entitled The True Levellers Standard Advanced), but were opposed by the Levellers, who denounced their communistic attitude towards property. (With the notable exception of the Leveller political theorist, Richard Overton [fl. 1640–1663], the urban-based Levellers paid little attention to mounting grievances in the countryside caused by profiteering from enclosures of land subject to rights of common — rights to take the produce from land of which the right-holder is not the owner. Although penalized by statutes and royal proclamations from Tudor times, the financial advantages were so strong that enclosures continued to be carried out by rural landlords, to the detriment of small farmers, peasants, and villagers who lost both employment and tillage as a result.)
  Although the Diggers rejected the use of force, their settlements in Surrey were dispersed by the authorities in March 1650. ::

the Levellers — Originally a political party which arose during Charles I’s reign, but later used more broadly to describe radical republicans, revolutionaries, and egalitarians who would level all differences of position or rank among men. As described in a news sheet from 1647, “They have given themselves a new name viz. Levellers, for they intend to sett all things straight, and rayse a parity and community in the kingdom.” ::

the Japanese system of Fueai kippu — The Japanese complementary currency of “Fueai kippu” translates as “caring relationship tickets.”
  “Japan currently has the most aged population of any nation, with roughly a fifth of the population already over 65. It also has a strong tradition of family based care, not least in relation to its tradition of ritual bathing. These demographics present a big problem, but one that the system of Fueai kippu greatly helps to address. Imagine I am living in Tokyo, but my elderly parents live 200 miles away so it is difficult for me to care for them. Instead, I care for an elderly person who lives close by, and I transfer my credits back to my parents. They can then use these to ‘buy’ care where they live. But because Fueai kippu are earned through care, not money, the whole transaction feels different and far more acceptable. And the evidence shows that this system leads to more caring activity, not just displacement — just as theory predicts.” (David Halpern, The Hidden Wealth of Nations, 2010, 107) ::

US Elderplan system — Elderplan is a social HMO “within which more able members provide care to others in exchange for credits. Hence someone having fully recovered from a medical procedure might help someone else who has just gone through it, with shopping or getting around. As members age, the type of help that they might offer may change from more physical work towards offering company or advice.” (David Halpern, The Hidden Wealth of Nations, 2010, 107–8) ::

major implications for clinical practice and health care costs — I.e., by changing the way in which some life events, such as dying (often expensive when care is technologically-driven), are managed.
  Pellegrino, who has been Professor Emeritus of Medicine and Medical Ethics at the Center for Clinical Bioethics at Georgetown University Medical Center since 2001 and chairs the President’s Council on Bioethics, advocates taking a more philosophical approach to our health care, arguing that bioethics should not be restricted to topics such as abortion, third-party-assisted reproduction, physician-assisted suicide, or cloning, because such issues are shaped by foundational views regarding the nature of the physician-patient relationship and the goals of medicine.
  “Not only has Pellegrino creatively examined the foundations of a philosophy of medicine in the strict sense, but he has also shown how it can redirect the medical humanities and bioethics. In so doing, he has succeeded in articulating a vision of how medicine can meet the challenges of the future.” (Introduction, The Philosophy of Medicine Reborn: A Pellegrino Reader, ed. Engelhardt and Jotterand, 2008, 17)
  Although Pellegrino’s work is directed primarily at physicians, the resulting reorientation of medicine within a larger vision of the human enterprise affects patients, too. ::

To locate this title at your bookstore or library, look for:
  Day, John D. Patterns in Network Architecture: A Return to Fundamentals. 2008; rpt. Upper Saddle River, NJ: Prentice Hall, 2008.
  ISBN-10: 0132252422 and ISBN-13: 978-0132252423.
  John is a maverick who wants to see the Internet redesigned. “I am trying to work out the principles by which the innards of networks and other computing systems should work. It turns out the Internet is probably one of the most bungled engineering jobs of the last century. It could be much simpler, more secure, and much more powerful.” (John Day, private e-mail communication, 12/9/2013)
  His book “shows how socioeconomic forces derailed progress and led to the current crisis” (publisher’s description) so it is relevant to topics under discussion in this section and elsewhere at Roses. ::

the eminent Danish physician and natural philosopher, Thomas Bartholin (1616–1680) — This identification may be in error. Chambers gives only a surname: “Bartholin complains of the too great number of Apothecaries in Denmark....” But as Wikipedia explains, “Three generations of the Bartholin family made significant contributions to anatomical science and medicine in the 17th and 18th centuries”: Thomas Bartholin (1616–1680); his father, Caspar Bartholin the Elder (1585–1629); his brother, Rasmus Bartholin (1625–1698); and his son, Caspar Bartholin the Younger (1655–1738).
  Between them, the four Bartholins published over 20 works, all in Baroque Latin, totaling thousands of pages. It could easily take me several months to locate copies of, and read through, all of this archival material before finding the original source for Chambers’ claim. Unable to devote so much time to this one research project, when I’m already juggling dozens of others, I chose to spend several days on it instead, before I traded in the pedant for the rhetor, and just made an educated guess about which Bartholin — Caspar the Elder, or Thomas, or Rasmus, or Caspar the Younger — had commented on the number of Danish druggists at some point during the 17th century.
  In the end, I settled on Thomas, based on my interpretation of the variety of Bartholin citations elsewhere in Chambers’ two-volume Cyclopaedia. But I could well be proven wrong in this hasty identification, which requires more time than I have right now to fact-check properly. ::