James Fallows

James Fallows is a national correspondent for The Atlantic and has written for the magazine since the late 1970s. He has reported extensively from outside the United States and once worked as President Carter's chief speechwriter. His latest book is China Airborne. More

James Fallows is based in Washington as a national correspondent for The Atlantic. He has worked for the magazine for nearly 30 years and in that time has also lived in Seattle, Berkeley, Austin, Tokyo, Kuala Lumpur, Shanghai, and Beijing. He was raised in Redlands, California, received his undergraduate degree in American history and literature from Harvard, and received a graduate degree in economics from Oxford as a Rhodes scholar. In addition to working for The Atlantic, he has spent two years as chief White House speechwriter for Jimmy Carter, two years as the editor of US News & World Report, and six months as a program designer at Microsoft. He is an instrument-rated private pilot. He is also now the chair in U.S. media at the U.S. Studies Centre at the University of Sydney, in Australia.

Fallows has been a finalist for the National Magazine Award five times and has won once; he has also won the American Book Award for nonfiction and a N.Y. Emmy award for the documentary series Doing Business in China. He was the founding chairman of the New America Foundation. His recent books Blind Into Baghdad (2006) and Postcards From Tomorrow Square (2009) are based on his writings for The Atlantic. His latest book is China Airborne. He is married to Deborah Fallows, author of the recent book Dreaming in Chinese. They have two married sons.

Fallows welcomes and frequently quotes from reader mail sent via the "Email" button below. Unless you specify otherwise, we consider any incoming mail available for possible quotation -- but not with the sender's real name unless you explicitly state that it may be used. If you are wondering why Fallows does not use a "Comments" field below his posts, please see previous explanations here and here.

James Fallows: Health care

  • The Electronic-Medical-Records Email of the Day, No. 1

    "Just as cars are not all the same, Electronic Medical Records vary greatly. A Mercedes, a Maserati and a Yugo are all cars, but you certainly wouldn't accuse someone of rejecting a used Yugo as being a Luddite and hating all cars. Similarly, you shouldn't generalize physicians who reject terrible programs as hating EMR."


    Background: In last month's issue (subscribe!) I had a brief Q&A with Dr. David Blumenthal, who had kicked off the Obama Administration's effort to encourage use of electronic medical records. Since then, the mail has kept gushing in, as reported in previous as reported in in our April issue, about why the shift has been so difficult and taken so long. Previous multi-message compendia are available in installments onetwothreefourfive, and six

    As an operational matter, I am going to start doling these out one or sometimes two at a time, on a every-day-or-two basis. They'll have headlines based on this one's, and I will try to figure out some standardized image or illustration as cues that these are part of a series. Generally I'll post these without comment; they're meant to be part of a cumulative conversation among medical professionals, technologists, and the rest of us who are merely patients and bill-payers.

    Let's start with two—one from a patient, one from a doctor.

    Patient (and tech veteran): I can't stand filling out these damned forms over and over again.

    I've been in the high tech industry since I graduate college in 1986, watching it grow from a specialized industry to the giant, interpenetrated octopus it is now. My wife also is in high tech, and indeed started out ... installing EMR systems in hospitals in the early 90s.  Just a couple of quick thoughts:

    First, if someone—ANYONE—can come up with a system that would prevent me from having to fill out THE SAME information over and over again just because I'm seeing a different doctor, I WILL TAKE IT. You get the same information requirements, but they're all on different forms, in different formats, from different doctors. But all the base information is exactly the same: Name, address, social security number, marital status, kids, insurance info, and so on. It's all the same. I'm seeing a doctor who was recommended by my GP; why in god's name am I filling out yet another form by hand. In 2014. When what most offices do is take my information and ... enter it into their databases by hand. How inefficient can you get? Hell, some doctors require you to put the exact same info *on multiple forms*. There has got to be a better way. [JF note: This is also my experience-as-patient, and I share the exasperation.]

    I've long thought what we need is a card that is programmable, the size of a credit or insurance card, that you swipe through a reader, punch in a security code, and it downloads the info to the new doctor's system. Why no one has implemented this I have no idea.

    Another note: I'm sure that a lot of the difficulty is incompatible systems, systems that don't play nice with various insurance companies, systems that don't interact with each well, and so on. This is not an inherent flaw of the technology—it would be no different if they were doing everything on paper, and then found, shit, we're using legal-sized, but the insurance requires 8.5 x 11! Or some other mundane problem with paper records. I don't know of any way around the problem other than mandated standards—"Everyone will use Oracle," or some such—and that's not going to happen. But the answer isn't to go backwards, or we'll end up with ink pots and quills.

    Finally, I have to believe that the second doctor whom you quote is forced to use three systems partly by insurance-company requirements. I have to believe that if we had single-payer, that would simplify the record-keeping and IT problem considerably.

    Doctor: A female doctor—as she notes, her gender is relevant to one of her points—says it's important to distinguish between good and bad systems.

    I am a 50+ yo hospitalist (yes, the dreaded hospitalist bogeyman) and have been one for 17+ years. A couple of points, if I may:

    1- there's a lot of talk about EMR as an entity without really addressing the quality of the EMR's. Just as cars are not all the same, EMR's vary greatly. A Mercedes, a Maserati and a Yugo are all cars, but you certainly wouldn't accuse someone of rejecting a used Yugo as being a Luddite and hating all cars. Similarly, you shouldn't generalize physicians who reject terrible programs as hating EMR.

    They just enacted an EMR/CPOE [CPOE=Computerized Physician Order Entry] at my hospital. The reason this particular program was selected was money, savings by choosing a cheap program and avoiding the federal penalty. It is so difficult to use and (as many other commenters noted) fills your noted with drek and making the useful information difficult to find.

    The program is so awful, in addition to parts of it being mouse driven, you need to use function keys and arrow keys to navigate. (Just hit F9, Dr. Smith...) When was the last time, in 2014, you were forced to learn a new program that required you to navigate that way? You can't search, you need to know the specific names for tests (CT chest rather than chest CT, dysphagia exam versus video swallow) and you need to click up to 30-40 times to get through something that previously required you to write 1 order. You can accidentally (and dangerously) erase the patient's entire plan of care with 2 clicks (one poor nurse spent 2 hours trying to recreate it) but you need click to confirm and verify multiple things that are clinically insignificant.

    I would love an elegant program that enhanced patient care, was safe and made my job easier. Love, love, love it. But instead, I am painted (per lots of your communicants) as a intransigent luddite who doesn't want to move forward. Nothing could be further from the truth.

    (By the way, that picture you posted on March 24, with Xrays accessed on the left, trending labs and graphs, looked great! All that info at your fingertips, integrated into the system. What program was that?) [JF note: it appears to have been an "artist's conception" image rather than a real program.]

    2-I am an Apple fan. I don't care what the computer has regarding the hardware, I just want it to work, be intuitive and be reliable. (Not unusual for a woman, regarding computers or cars.)  However, many of my colleagues are uber-geeks. Just being over 40 doesn't mean we can't handle the technology. We are just less patient of bad technology. I don't use the same phone I used in 1997, don't expect me to use an antiquated, poorly written program which was developed in 1997.

    3--Another topic, but: Hospitalists are seeing patients because the primary care physician [PCP] chose that option. There are trade-offs for any system and thehospitalist system is no different. We may not have the longstanding relationships with people and families but we replace that with relationships forged under very emotional and intense circumstances. As with any physician, experiences vary  greatly. You wouldn't slam all orthopedic surgeons because you had one bad experience or bad doctor, so you should not generalize one experience onto the whole specialty.

    Also, the actual number of times people would actually see their PCP is lower than perceived, usually because of call schedules (seeing your doctor's partners instead) and going to hospitals where your PCP does not have privileges. I addition, your PCP is generally only in the house early morning and after office hours. When families come by in the middle of the day, I am available to talk to them. When someone crashes midday, I can handle it because I am there.

    I got hugs from 2 patient families yesterday, one for spending the time to explain why the orthopedic surgeon was recommending an amputation ( he was at another hospital by the time the family got there) , another for transferring a patient after a terrible, prolonged, critical illness to rehab. Neither had PCP's on staff.

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  • If Doctors Don't Like Electronic Medical Records, Should We Care?

    "Yes, there are problems in any technology implementation and there always will be. But fewer people die. Yes, it is important to connect with the patient. But fewer people die. Yes, the opportunity to pad billing is obscene. But fewer people die."

    How critics imagine the new record-keeping system. ( Wikimedia commons )

    Dr. David Blumenthal, who now is head of the Commonwealth Fund, has been a friend since we both were teenagers. It was a sign of his medical / tech / policy skills that the newly arrived Obama administration put him in charge of encouraging a shift toward use of electronic medical records. It is evidence of his admirably good-humored big-tent personality that David still takes my calls after the many rounds of back-and-forth we've posted here in response to his original Q&A in our April issue, about why the shift has been so difficult and taken so long.

    For those joining us late, you can check out installments onetwothree,  four, and fiveHerewith number six, on the particular question of how the non-expert public -- those of us who experience the medical system mainly as patients and bill-payers -- should assess the opinions of physicians, nurses, and other inside participants. Should we give them more weight, because of their first-hand expertise? Less weight, because of possible institutional bias or blind-spots? Both at once? See for yourself.

    First, the concerns of two physicians. One on the West Coast writes:

    I am a family practice physician in western Washington state. I have been practicing for 25 years.  Ten years ago I was excited about about the potential of electronic technology to improve patient care. Today I am profoundly disappointed.  

    I am currently working in three different EHRs (electronic health records). Two are OK, i.e. allow me to efficiently document a patient visit with clinically relevant data.  The other one is cumbersome beyond belief. It is a company with outstanding marketing capability that won over our administrators. It falls far short of meeting the needs of those of us trying to improve patient care.  Intrinsically it fails to produce a note useful for other doctors. To achieve that end, I use time-consuming work arounds. Sad I think. 

    I believe that primary care is valuable to patients but also has potential to limit costs.....

    I have included a reference to one of my favorite articles from the New England Journal of Medicine, including the first paragraph of the article:

    "It is a widely accepted myth that medicine requires complex, highly specialized information-technology (IT) systems. This myth continues to justify soaring IT costs, burdensome physician workloads, and stagnation in innovation — while doctors become increasingly bound to documentation and communication products that are functionally decades behind those they use in their 'civilian' life.

    And from a doctor in Kentucky:

    As a 50 y/o it infuriates me when I read that only physicians less than 40 are comfortable with EMR’s because they grew up with them. Well that’s crap. My first computer was a Commodore 64 which I learned to program. I am very familiar with computers and have 4 networked together in my home.

    That being said I would agree with Dr. Wait [from this post] in that EMR’s are not ready for primetime. If EMR’s were so great, no one would have to bribe and penalize us to use less. They generate a tidal wave of information. The important data gets lost in the overwhelming volume of mostly useless information. I used to dictate my notes and they would then scanned into the computer. The note was legible and concise. I could find it anywhere. Then the EMR came. It takes 20 minutes to do what used to take 30 seconds. I get a note that is less than useful. It is full of errors that I can’t correct. Information that others have entered that is clearly wrong that I can’t remove. I no longer try. The only important part now of my notes are the HPI and the plan. The rest is just garbage.

    To give you an example my EMR won’t let me enter a subtotal hysterectomy in the past surgical history. Even when I supply the correct CPT code the EMR calls this  a Total hysterectomy, which is not correct and can lead to errors in determining who needs a pap smear.

    So EMR remain not ready for primetime. I’m not sure why I can’t continue to dictate and allow the transcriptionist to fill in the EMR. It would work so much better.

    Now for a different view, from an informed non-expert. This reader, a physics professor at a university in the South, uses the distinctive phrase of the day to suggest that we apply a discount to complaints from today's practitioners:

    I've been reading the back and forth over electronic medical records. It seems the opposition comes, by and large, from doctors. Because why?

    Because problems. There's lots of smoke and mirrors about interconnectivity, about interacting with the computer instead of the patient, about sleazy increased billing but all of that is in service of a single point of view: let's never change until we can change to something perfect. In other words, the underlying point is "don't make me change the way I'm used to doing things."

    This all misses the main point. To me, what is overriding importance is the undeniable fact that ANY system that does NOT rely on the memory of the patient for long term medical history storage is NECESSARILY a better system no matter how badly it sucks. The VA has proved this over the last couple of decades as measured by the fact that fewer people die. Better information management beats clever doctoring every time.

    Yes, there are problems in any technology implementation and there always will be. But fewer people die. Yes, it is important to connect with the patient. But fewer people die. Yes, the opportunity to pad billing is obscene. But fewer people die. Any large scale IT rollout has problems. The question is do the benefits outweigh the time invested in ironing out those problems. Most of us would say yes because fewer people die. I wonder why physicians are so reluctant to say that? Didn't they swear an oath or something?

    I also wonder how many of these physicians, when directing their gimlet eye to another field such as public education, are equally skeptical of, say, massive online courses or teachers attending to the computer instead of their students, or teaching to the test? I somehow doubt it.

    I think when you are the person dealing with a system day after day, it is easy to let your detailed knowledge of its problems overwhelm the vaguer notion of its benefits. You don't have a direct experience of a patient who didn't die, but you do have a direct experience of a technical snafu. 

     Thanks to experts and non-experts for writing in, and to David Blumenthal for opening this view into a world that affects us all.

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  • Electronic Medical Records: A Way to Jack up Billings, Put Patients in Control, or Both?

    "Digital records are also being aggressively used to maximize patient billings," and other imperfections on the route to a more sensible health care system.

    What we are leaving behind. ( Money and Medicine )

    Previously on this topic: my Atlantic Q&A with Dr. David Blumenthal, who supervised the Obama administration effort to move medical records into electronic form; and installments one, two, and three. Here is another round of reader responses.

    1) A new way to maximize billings. From Ronald Russell of Kenmore, Washington:

    As a member of Group Heath Cooperative in Puget Sound for over 20 years, I've seen first hand many positive aspects of computerizing patient records. Whomever you see, your records are instantly accessible- that's comforting when you land in the ER in the middle of the night.  Web access means you have access to some of those records yourself, and can communicate with your providers easily. 

    Unfortunately, I've also seen a negative aspect in how EMR's are being used that got only the slightest passing mention in this discussion, one that gets the incentives exactly backwards.  This is the reason I'm now a former GHC member. 

    Digital records are also being aggressively used to maximize patient billings. At GHC, it used to be the case that a standard office visit was a flat charge- most recently $80. Now, when your physician asks a question, responds to one of yours, and makes a note in your record, this becomes another billing code. The result is that a 15 minute office visit can easily run to several hundred dollars, perhaps just because you mention a concern or the physician asks another question.

    Every patient note entered in the digital record rings the cash register again in billing- and not in a way that anyone seems able to explain, or that physicians are aware of. The cynic in me wonders how long until they are compensated on commission, or get bonuses for entering more billing codes per visit. 

    The dollar amounts charged are often absurdly high, there is no accessible "price list" for consumers. My auto mechanic is legally required to explain his charges in advance, my health care provider never has to.

    Of course, for consumers with full coverage or copay-only plans, this would pass unnoticed, as just an accounting detial.  But for those of us with high deductibles that mean we essentially pay out of pocket for everything, this is a powerful disincentive  to discuss concerns with your doctor or interact beyond the minimum business at hand.  I don't believe this is good for patient care.  

    Fortunately, due to the ACA, I've been able to move to another insurance plan that mandates a flat charge for standard office visits, even before you meet the deductible. So perhaps that one small part of the market is working. Unfortunately, this brought up another problem with these records- ours are now locked up inside the Group Health system, and no longer accessible to me- at least, apparently, without paying for them. 

    These issues are not so much inherent problems with EMR's as they are symptoms of a broken health care system, in particular where the provider and the insurer are one and the same.  I put them out there to add to the discussion. 

    2) A way to get the doctor to look at you. In response to a previous complaint about doctors stare at their computers rather than their patients:

    [A previous reader says:] "No, at Kaiser, Northern California, they do not.  The computer is on a roll-around stand, and the doctor or nurse is facing me while using it."

    I'm in IT, and have worked at several hospitals where these stands are used, and the usual nomenclature is COW (computer on wheels, of course). I'm often reminded to be careful there are no women around when discussing the COWs in the room...

    3) Once again the VA is doing it right:

    I'm a 68 yr. old Vietnam vet (USMC) who is rated 90% 'Service Connected' disabled: hearing aids (I was in an artillery battery in Nam for 19 months); Type II Diabetes and Ischemic Heart Disease (Agent Orange exposure) and assorted other things.

    I can't praise the VA enough. Through HealtheVet I can re-order meds and have them mailed to me, same with hearing aid batteries. I can set up or cancel appointments or ask my Primary Care doc, or any of the physicians who treat me, questions and get an answer within 24 hours. I can go to ANY VA facility in the world (yes, there are VA clinics and hospitals outside the US) and they will have total access to my medical records.

    From the hell holes that VA hospitals were in the '70's, as depicted in the movie Born On The Fourth of July, they now are as good as it gets in the US. I give Bill Clinton props for the revamping he and his VA Secretary undertook that got the VA to where it is today. It may be struggling a little with the overwhelming influx from the Bush/Cheney/Rumsfeld fiascos but I have no complaints here in NYC. Semper Fi

    4) Promise from the patients' point of view:

    The use of EMR is obviously in early days, and flaws are easy to identify. My experience, however, shows the great promise of EMR to improve medical care and help patients make medical decisions.

    I have a mild case of MS, and go to [a major medical center] every year for a check-up. These include MRIs of my head every two years or so. I travel 200 miles to visit the clinic, so I want to get everything done on the same day. On MRI years, I’ll have the scan in the late morning at the imaging center that is allied with the clinic. When I see the nurse practitioner or physician’s assistant a few hours later, pictures of my brain are available in my electronic chart, and my medical professional looks at the scan with me, and explains what he or she sees. The reports of my last two scans are available to me right now on the MyChart website that [the center] makes available to its patients. And yes, my case is so boringly stable that there is no current need for me to see “the big man”.

    That’s cool, but the real power was revealed to me in 2011, when the radiologist who reviewed my scan discovered that I have a small benign brain tumor, a meningioma. I was referred to a neurosurgeon, also allied with Strong, where it was recommended that I should have my head screwed painfully into a frame so that a surgeon could aim what is essentially a killer death-ray at my brain.

    Except… when the medical professional and I looked together at the series of scans in my EMR dating back to 2002, there that pesky meningioma was, seemingly the same size as in the 2011 scan. This empowered me to turn down the surgery. I’d had that tumor for a decade or more with no ill effects. Prove to me that it’s growing, and I might consent to the surgery. A repeat scan a year later confirmed that the tumor is not growing.

    There’s one key element here, of course: all of the professionals involved are allied with the same large medical center, so communication between them is smooth and nearly instantaneous. My GP 200 miles away is not part of their system. Still, I’m very happy that I had access to a decent EMR system in this case, which helped me to make an informed decision.

    5) As long as the systems stay in touch:

    I have several chronic illnesses, and because of the specialized nature of them, I have a lot of doctors. I live in the San Francisco Bay area, and have specialists at Stanford, in San Francisco, and then my local team near home. Here’s the thing - all of these facilities have have state of the art EMR systems, but the systems don’t talk to each other.

    This means I spend a lot of my time bringing copies of records between various specialists, and communicating what one doctor said to another. As in telling my primary care  doctor “My rheumatologist is concerned that the medicine you want me to take will have an impact on my spine issue”.  Sometimes I get letters from one doctor that I have to carry to another. I keep my own records of my latest test results, culled from the various sources (included the online tools provided by some medical facilities), and bring them with me to appointments, so I can answer questions about when I last had a test, and what the results are.

    I also have a list of every medicine and treatments I have tried, and the outcomes, as new doctor often has a standard approach to the first thing they want to try. And they haven’t had time to go through all the records that were sent to them. Since the systems are designed around billing, they don’t have easy ways to extract care info, such “Show me the medicines to which this patient has had an adverse reaction”.

    Until there is a well integrated way for your doctors and their systems to communicate, coordination of care is going to be an issue. My career was in computer tech, and I know how hard it is to create interoperability standards.

    To me, yet another argument for single payer system, is that we could standardize on some basic data collection and exchange.

    6) From a Yank in Canada:

    I moved to British Columbia eight years ago from California.

    The first thing I had to get used to when I went to the doctor here was just... walking... out.  No stopping at the receptionist to deal with payment and/or insurance.  Just... walk... out.

    My clinic in California had started doing electronic records before I left, but I recall it as being kind of clunky.  Here, however it doesn't seem as clunky; it seems more integrated into the appointment.  Perhaps it is because I see young doctors (my clinic is a teaching clinic), but I think it's because the appointments are structured differently.  

    Here, the appointment starts with me sitting, fully clothed, in a chair, to the side of a desk.  The doctor sits at the desk with both me and the screen visible.  He or she asks me if anything has changed, and talk about why I came in.  Frequently, the doc will look something up on the web that is out of his/her area of expertise, and they are not shy about doing so.  (Usually not Wikipedia, something more like PubMed.)  If he/she needs to examine me, *then* I get given a gown.  

    By contrast, my recollection of appointments in the US is that they started with height/weight/blood pressure measurements by a nurse.  (This was true even when I was in my 20s and now seems like overkill.  Why did they need to take these measurements every time, when my measurements didn't budge for years at a time?)  Then the nurse would give me a gown, and I'd get undressed and sit on the exam table.  That meant that I would *start* the consultation sitting uncomfortably on the exam table.  (There often weren't even two chairs in the room; maybe there was a chair and a lower stool.)  In that configuration, it is not easy to position the computer so that the doc can see both the screen and the patient.

    Another thing that is different: I almost never fill out a form before my appointment at my regular clinic.  If I am going to a new practice (like an after-hours clinic), yes.  If I am getting some new and different procedure, yes. But they don't ask me to tell them who I am and where I live and what my insurance is and who my next of kin blah blah over and over again.  Occasionally they ask me verbally if anything has changed, and that's it.

    7) Allowing doctors to do more than just fill in the forms. From a librarian:

    One comment based on my experience, I appreciate the doctor who said the system would not let him record what he wanted to say. I think these systems should allow writing free-form notes, sketches, scanned items, etc. 

    I am a retired librarian and early in my career I worked on several of the early computer systems for recording the arrival of issues of magazines in libraries. I'm sure this is much less complex than medical records, but it is more complex than one might think. These early computer systems couldn't accommodate the creativity/inaccuracy of journal publishers and printers when there was an issue number 12 1/2, or, more often, the printer did not change the volume number in the new year until he discovered the mistake midway, so you have volume 14 for a year and a half but number 1-6 in one year were not the same as 1-6 in the next.

    In medicine, the doctor's free-form notes can express his knowledge of how complex things really are, in his best estimation at the time, or the questions he has (another issue, do you want this in a record that will be shared with the insurance company, and thus perhaps used out of context in litigation -- but if the electronic record is the only one you have, where else do you put the information?) 

    I'm all for having evidence-based guidance in medicine, but I want the doctor to be able to take all of this information and then see if I fit the profile the computer predicted. How is this going to happen if the information isn't even recorded?

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  • Our Eyes Have Adjusted ...

    Reports from Oregon, and Hawaii

    Hundreds of messages and photos have arrived, in response to two previous items (one, two) about the transformation in the physical types Americans have gotten used to seeing in daily life. I will start with these two.

    First, a reader who was raised in America but now lives in Australia (and has changed citizenship) sends this image from a record jacket. It's a scene from pre-WW II America:

    An image from the Library of Congress, 'Race, 4th of July, 1941, Vale, Oregon' (the last stop on the Oregon Trail).  Note uniformity of physiques of children.


    The people in this photo, if they're still alive, would now be in their 80s. Apart from the racial diversity, I wonder how photos of their grandchildrens' (or great-grandchildrens') school races would compare.

    For what it's worth, Australia has its version of the same problem. The urban(e) young population of Sydney tends to be super-fit; Australians as a whole are getting very heavy.

    2) A reader who is very familiar with Hawaii sends this cautionary tale:

    In my youth [Baby Boomer era], poor people were skinny because they couldn't afford enough to eat.  That's part of how we recognized them.  Not so today.  If you see a skinny poor person today, you may think - as I initially do, fairly or not - that drugs are the explanation, not hunger... Obesity has become a matter of economic class - but with rich and poor having switched positions at the over-weight vs. under-weight poles.
    A book published in 1971, by a Japanese-American living in Hawaii, tries to explain why Japanese-Americans have done so much better fitting in (and even dominating) Hawaiian society than on the Mainland.  One of his arguments is that Japanese people tend to have body types that approximate the Hawaiian ideal - which he illustrates, with a slender muscular man and a curvaceous but by no means Rubenesque beauty.  This was in 1971! 

    Today it is an article of faith that Native Hawaiians are just naturally "heavy."  [JF note: the same assumption obviously is now made for Pacific Islanders as a whole.] This always amazes me.  The traditional Hawaiian queens were heavy, because they were not allowed to walk and they were fed all day.  But apart from that one exception, every Captain Cook-era engraving, every 19th Century photograph, and every 20th Century photograph up until the 1980s or even the 1990s shows the Hawaiians as slender, well-built people.  Obesity in Hawaii is an overnight phenomenon, something that has occurred within a few decades - surely someone has written about it; it is just so appalling that the mythology can so quickly spring up and condition people to believing the opposite.

    As it happens, I know the book being referred to here. It is Jan Ken Po, by Dennis Ogawa. And the reader's recollection of an image in that book from 40-plus years ago is correct. Here is how the "local image of what is beautiful"  -- with the "slender, muscular man and the curvaceous but by no means Rubenesque beauty" -- was conveyed at that time. (Via a photo I took of a page in the book just now.)


    More in the queue.
  • Yes, There Were Fat People in the Olden Days Too

    Even before there were Big Gulp sodas...

    I will soon get back into "false-equivalence" coverage of the filibuster and similar depressing themes (on which there is a very good update at 'Poison Your Mind,' including a link to this incredible piece). So let's forestall that with something different: updates on "adjusting our eyes."

    One reader says:

    image001.gifI share your surprise at how we've re-calibrated the size of Jackie Gleason and Raymond Burr. But one actor of the period, who seemed fat even on the radio, was J. Scott Smart who played "The Fat Man," a radio detective series (late 40s) that produced one movie (1951), and he played the title role in both.
    Here's a picture of him on the scale, a weigh-in that preceded each episode and that was carried over to the film. He's not in Henry's class, but he qualifies for the title of the series.

    A little while later this reader wrote back:
    But wait! I just listened to an old episode, and at the opening weigh-in he the Fat Man tips the scale at [only] 239 pounds. Not extraordinary today. And now I'm heading to the gym.
    Another offers the counterexample of Oliver Hardy, of Laurel and Hardy fame, shown here in a shot apparently from the 1930s:


    And about Jackie Gleason himself, whose relative svelteness even as the "fat guy" on The Honeymooners I had mentioned:

    jackie-gleason-steve-mcqueen-between-scenes-of-soldier-in-the-rain.jpgYour point about our evolving sense of what obesity looks like is well taken. But your reference to Jackie Gleason reminded me of the movie "Soldier in the rain" made in 1963, which really illustrates the dangers of being overweight. There's a fight scene where one is sure that Gleason will collapse from heart failure before it's over - it's difficult to watch. This link  features pictures of Gleason with Steve McQueen [including the one at right, as they sat between takes].

    The weight contrast is clear.

    Many people of the Boomer era wrote in to mention an early soft-drink ad. As one put it:

    When I was young in the 50's the standard Coca Cola bottle was 6.5 oz. Pepsi Cola had a jingle, "12 full ounces -- that's a lot!"

    Finally, about adjustment in the other direction, an American who has lived for a long time in China writes:

    I work around a lot of fashion models over here, and it occurs to me that our eyes have adjusted to thin as well as fat.  That is, if you pull out a picture of a fashion model from the 40s, 50s and 60s, many of them look positively plump compared to a contemporary fashion model.  They would never get work today.  It's funny how our eyes can adjust to two contrary trends, one in real life and one in photos.  Maybe we're getting used to extremes?

    And, fittingly:

    "Our eyes have adjusted" is clearly the nutritional equivalent of the boil-the-frog idea. Except this time it's our children  who are in hot water and don't know how to get out before it's too late.
  • 'Our Eyes Have Adjusted': Here's What That Means

    Our eyes, our stomachs -- something has adjusted.

    (Please see update below.) I am not going to get in the middle of the Mayor Bloomberg giant-soda-ban controversy, though I lean in favor of anything that might offset the public-health costs and human tragedies of America's obesity epidemic.

    Here is why I bring this up. Today in the NYT, Frank Bruni quotes one of Bloomberg's allies on part of the reasoning behind the policy:

    "Our eyes have adjusted over time," said Thomas A. Farley, the city health commissioner, during a phone conversation on Thursday, when he and Mayor Bloomberg were out explaining and defending the proposed ban amid threats of lawsuits from restaurant-association lawyers and a hue and cry from the body politic unlike any I've heard in a while.

    What does Farley mean? Here's what, illustrated with pictures I used in an item a few years ago while still living in Beijing.

    First we have Jackie Gleason, at the left in this scene in The Honeymooners from the late 1950s. I was a school kid then and remember that he was famous as a fat man whose comic schtick involved his incredible girth:


    Now, Alfred Hitchcock from his TV show in the 1960s. He too was famous for being so fat:


    And, tubby Raymond Burr from Ironside in the late 1960s and early 1970s:


    Have our "eyes adjusted" in the years since then? Judge for yourselves. And while you're doing that, I'll mention one more thing that has gotten my attention.

    While in a gym at hotel outside Shanghai last week, I happened to see an episode of TLC's 'My 600-Lb. Life' featuring the amazing struggles and determination of Henry, one of the four starring characters the program follows over their many-year sagas of attempted weight loss. Despite an unavoidable freak-show overtone, I thought the show was incredibly powerful about the consequences of this problem -- and respectful of its subjects. Here is Henry:


    Maybe Mayor Bloomberg can arrange for the series to be shown in subways, or in those NYC taxi-cab advertising videos, or on the big-screens in Times Square.

    Take another look at Jackie Gleason, and tell me that Commissioner Farley is wrong.
    Update A reader points out that the commissioner could have had a different sort of eye-adjustment in mind:
    I think Farley may have meant something different. Our eyes have adjusted over time to portion sizes, where now a 32 oz soda is considered normal to some people. 32 oz is obviously a hell of a lot of soda, but now it's a common size at fast food chains. Even 20 oz, the standard size for bottled soda, is too much for one sitting. Farley went on to make a similar point later in the article, where he said that people will consume what's in front of them, within reason, even if it's more than they need.

    Fair enough. The two kinds of adjustment obviously complement each other. I'm still more amazed by the Jackie Gleason pics though.

  • Readers Dissent About HHS and Plan B

    For better and worse, a political choice

    Thumbnail image for Thumbnail image for sebelius.jpg

    (See UPDATE at the end.) Let me try to work through some items today, naturally in LIFO order. Here are some sample notes disagreeing with my argument that the Obama Administration had swung to the "anti-science" side, when HHS Secretary Kathleen Sebelius overruled the FDA recommendation to permit over-counter-sales of "Plan B" pills to young girls.  First the complaints, then my reply.

    One reader says: 

    It's not really accurate to say "Anti-Science" because a) it is not clear that scientific tests have been conducted on 10/11/12 year old's of reproductive age to see what the side affects are, b) the panel aren't making a decision based on science if they are using precedence of other powerful drugs as a reason to permit it and c) public policy is ultimately determined by Government.

    Sebelius isn't saying that the science is wrong, she's saying that they haven't done enough of it. They have not conclusively proven that there will be no side affects for a girl of any age if she takes this drug.

    Lastly, once the science has been solidly established that doesn't end the discussion, it then becomes a moral issue for society to digest. Science does not dictate public policy. People and their morals do.


    I must disagree with you and others about this charge of the administration and President Obama.  I'm a father and have a precious daughter who will turn two in less than two weeks.
    I'm also a fan of the President and will vote for him in 2012; I agree with him on this decision.  While science may be right, I just don't feel comfortable with allowing my daughter to have access to this medication especially if she's a minor (or younger than 18).  The analogy that the President used, having this medication, "next to bubble gum or batteries" is 100 percent correct.  This is not a question about science but a question about parenting.


    I believe that some clarification as to how the FDA and HHS are viewing Plan B and drugs in general could help shed some light as to why Plan B being widely available OTC is different than other OTC drugs on the market.  It probably has less to do with politics and more due to a different standard being applied by the two agencies.  With a standard OTC there can be a general assumption that there is some level of parental involvement for children.  An 11-year old child has little reason to purchase a drug like aspirin on their own, so its expected that its use will be monitored by an adult.

    Plan B is different.  If there is a parent involved, then the parent can purchase it themselves and administer it to the child.  If a prescription is given by a doctor, there is an adult that can explain the proper use of Plan B to the child.  However, if it's OTC the intended use population for the drug changes.  You'd expect an 11-year old going to the store alone to purchase Plan B is doing so because the parents are not involved in the decision.  That's why the maker of Plan B, Teva, had to prove to the FDA not just that Plan B was safe and effective, but that adolescent girls understood how to use Plan B properly and that it's not to be used as a primary birth control before the FDA would allow it to be sold OTC.

    However, what Teva didn't prove is highlighted by the HHS.  Teva didn't prove that the drug could be properly used by 11-year old girls, and 10% of girls start menstruating at this age.  The HHS takes exception to this, while the FDA probably had told Teva that 12 or 13 was good enough for a general OTC.  The HHS believes that there may be a significant cognitive difference between an 11 year old and a 12 year old which is why they rejected the application as a general OTC.

    I'm not saying that there are no politics at play here, since that would be naive concerning Plan B.  However, to say that the HHS reasoning is anti-science is not a fair label either.

    One more from a former public health official, then brief reply, after the jump.

    More »

  • The Poison Ivy Update

    "You can look but you better not touch"; ways to cope with the results if you do

    Poison-ivy-uma.jpgLast week, advice on the miracle protector against/cure for poison ivy, Tecnu. (Uma Thurman's rendering of Batman-world character Poison Ivy at right.)

    This week, readers' additions and clarifications. One writes:

    >>Maybe you don't know it, but soap and cold water usually works if used quickly. Even more effective is rubbing alcohol. No need for Tecnu.<<

    No "need," perhaps, but it's worked for me. Next, on the surprising fruit-world parallels to poison ivy:

    >>I too am crazy sensitive to poison ivy. My family physician once told me that one of my outbreaks was the worst case he had ever seen.

    You probably know this, but mangoes are in the poison ivy family (this was the next thing my physician told me).

    A couple of summers ago I broke my mango fast and had a mango smoothy. I was hideously itchy all over my body for weeks. My wife nearly killed me because I was driving her nuts with my self-inflicted itching.

    Stay away from mangoes!<<

    Hmm. So far I have coexisted with them without harm. The Japanese angle:

    >>No poison ivy here in Japan that I know about, but we do have lots of lacquer (aka urushi).  I found out the hard way doing some lacquer repairs that the active toxin in poison ivy and poison oak is called urushiol, which, no surprise, is present in copious amounts in uncured urushi.  I read somewhere that American troops returning from Japan after WWII with souvenir Japanese rifles--with the lacquered stocks--were coming down with mysterious rashes after killing time on the boat home sanding down their toys.  If only we all had Tecnu.<<

    More low-tech alternatives:

    >>Actually chlorine-free bleach works very very well for getting rid of poison oak! tecnu is many times more expensive.... I was skeptical at first. its a pretty wonderful trick. it does dry out your skin a bit at first.<<

    And another:

    >>Up here in northern MN, where I have now spent 63 summers, the standard treatment for exposure to poison ivy is Fels Naptha laundry soap, which comes in a bar.  It's brown, it's unattractive, it looks toxic, but it works, and has for a long time.  One merely slices off a small sliver of the soap and then uses it in the shower, just like any other soap.  Our household has been using the same bar of Fels Naptha for at least a decade, so it's economical, too.  I've used it when just exposed to poison ivy and I've used it when poison ivy has taken hold, and it has always been effective.  It has been around a long time.<<

    Thanks to all; may this be of use. Back to politics, the economy, and language shortly.

  • While I'm Still in the Churl-Free Mood: #5, Tecnu!

    From the bowels of the military-industrial research complex, a product to make life better, especially in the summer time

    I mean to bring this up at the beginning of every summer, and it always keeps getting put off. So I'll do it now: if I had my own Nobel Prize for chemistry to award, I would give it to Dr. Robert Smith of Oregon, in recognition of his genius in inventing Tecnu. [Update: I should say the late Dr. Smith, since he died at 88 last November. That would be disqualifying for the actual Nobel prizes but not for mine.]

    If you don't care about poison ivy (or its western counterpart, poison oak) -- if there's none where you live, if it doesn't bother you -- you can stop reading now. Otherwise, gaze in admiration at the Tecnu giant-size bottle I keep on hand between April and November, shown below ready for action inches away from a bathroom sink, and follow along if you will:

    Thumbnail image for TechNu.jpgI feel very lucky in the general health category, and perhaps in karmic atonement I am pathologically sensitive to poison ivy and similar plants. I don't even need to touch them; walking within a foot or so of their leaves can lead to trouble. One of the few public-health benefits for me of living in China is that poison ivy didn't seem to exist there. Or at least not in places I visited, since otherwise I would have known via instant outbreaks of boils and inflammation. The pictures at the gruesome Poison-Ivy.org site are not of me. But I know how the Job-like victims shown there feel.

    Poison ivy (with its related Toxicodendron plants) is a specific challenge in some places I frequent around DC, notably the otherwise-perfect running paths along the C&O Canal. And it's on on the march nearly everywhere, thanks to greenhouse gases. Predictably, it thrives on extra CO2.

    Comes now Tecnu. It is part of America's endowment from the Cold War years. As the Tec Lab company history says:

    >>Tec Labs' flagship product is Tecnu Original Outdoor Skin Cleanser.  Tecnu was originally developed in 1960, during the cold war years, by chemical engineer Dr. Robert Smith as an effective, waterless cleanser capable of removing radioactive dust [!!!] from skin and clothing.

    His wife accidentally discovered that Tecnu would cleanse poison plant oils after exposure to poison oak in their own backyard. She didn't want their children to keep suffering from the plants so she went out back and pulled them out with her bare hands, even though she knew she was highly allergic to poison oak and ivy.  She decided to clean up with Tecnu afterwards and it worked for her.

    Years later, Dr. Smith's son, Steven Smith, researched and found out that poison oak was the number one workers comp claim for local utility workers in the summer. He began selling Tecnu as a solution to decrease workers comp claims.<<
    Now it's mainly available through forestry-supply outlets or direct from the manufacturer. If you use it to wash your skin as soon as possible after you're near poison ivy, it really does the job. Within an hour or two of exposure, a Tecnu bath amounts to a "cure." The longer you wait, the more of a head start the poison ivy gets. But at any stage it helps.

    Don't thank me; thank Dr. Smith. Well, you can thank me too. Back to bad news soon.
  • Those Wacky Canadians!

    People from up north say they have a better approach to covering and controlling medical costs. And you know what?...

    Several items from up North, in response to the "serious" Rep. Paul Ryan proposal to get rid of Medicare. Previous entries: why Ryan's plan -- approved by the House last week with only four Republicans voting against it -- would indeed mean the end of Medicare, and larger problems with controlling late-in-life medical costs.

    First, a primer from a reader in Montreal (I think - or someplace up there):

    >>Here is how health care is financed in Canada.

    1- The state determines how much money is available for heath care from the budget of the year. Say $1.00 [billion] etc

    2- The state then asks the various medical professionals for a price for say 50,000 broken legs to be repaired, 20,000 births, you name it. The statistics of the needs of the country are known from previous experience.

    3- The medical professionals discuss between themselves how to divide the available money for the various procedures. They know that it takes 10 minutes to do this and two hours to do that.

    4- They return to the state with a price list for each procedure.

    5- The state then guarantees that every medical act will be paid according to the price list.

    6- The medical professionals know that they will get paid immediately upon completion of services. The only paper to fill is a credit card slip of paper containing the identification number of the physician and the procedure with the agreed price.

    7- That is it. No collection agency, no discussion with an insurance about the need to do an MRI etc.. Whatever is ordered by the doctor is executed. If a question arises, then it is the medical association that looks into the matter and decides. The association has the power to remove the license of the offending doctor.<<

    In a follow up note, the same reader adds:

    >>There is a social impact as well.   Since health care is free, when a doctor screw things up (yes it happens in Canada) fixing the problem is also free. Hence the patient does not develop the anger of paying his bills and losing his home for the mistake of somebody else.

    Result: A Montreal friend orthopedic surgeon specializing in spine surgery told me that he pays $5,000 per year for malpractice insurance per year.  

    Compare that with the $250,000 for insurance of the average surgeon in Dallas, TX. The doctor must recover the insurance fee by charging more, and you end up in a vicious loop.

    Fairness and justice makes life easier for everyone.<<

    Also in the North American Solidarity theme, note this passage from (Toronto-born) David Frum's recent essay on why Republicans have lost their political and philosophical bearing by treating society as an atomized chaos of Ayn Randian standalone economic units, rather than as an organic whole in which public programs play an important part:

    >>I cannot take seriously the idea that the worst thing that has happened in the past three years is that government got bigger. Or that money was borrowed. Or that the number of people on food stamps and unemployment insurance and Medicaid increased. The worst thing was that tens of millions of Americans - and not only Americans - were plunged into unemployment, foreclosure, poverty. If food stamps and unemployment insurance, and Medicaid mitigated those disasters, then two cheers for food stamps, unemployment insurance, and Medicaid.<<

    I am a proudly nationalistic Yank, but I look with respect to these pensées septentrionale.

    To round things off, a view from a practicing physician right here in the USA:

    >>The real winners in the Ryan plan are the same as for Obamacare: the insurance companies. 

    As always, follow the money.  Who gives the most money to whom and whose lobbyists are writing legislation.

    My father was also a doctor who originally was against Medicare, in fact, his partner at the time, Dr. Ed Annis was leading the charge against Medicare.
    The real reason health care costs are out of control is how Medicare was set up to begin with.  It encouraged fee increases and paid for any and all new equipment.  Practically every time Medicare has come up with new rules and regulations to save money by screwing the doctors, doctors have found new and creative and mostly more expensive ways of practicing.  It's largely a great stupid expensive game.<<

    The reference to Dr. Edward Annis shook up something in the childhood memory bank. It is worth reading about his extraordinary efforts, as a public speaker for and then the president of the American Medical Association, to oppose the creation of "socialized medicine" through Medicare. These included renting out Madison Square Garden for a big anti-Medicare doctors' gathering. American politics has been fractious for a long time.

  • More on the Ryan Plan, Medicare, and the 'Death Tax'

    Readers weigh in on the pluses and minuses of changing Medicare after the GOP House passes a bill to radically alter it

    I mentioned yesterday Merrill Goozner's contention that Rep. Paul Ryan's "serious" plan to undo Medicare should be considered the real "death tax." Now, some readers' views.

    From reader AS:

    >>We [already] have that de facto "death tax" in connection with nursing care.

    Every family that doesn't have a spare 100k/year effectively rolls the dice regarding how much of an estate may be eaten up by nursing care at the end of life. The only private remedies are 1) LTC [long-term care] insurance, a highly uncertain and problematic product, and 2) strategies to offload assets to children while there's still time.

    Perhaps this system is the best we can do right now. There's certainly no will in the U.S. to tax ourselves to the extent that would be needed to provide something like universal LTC coverage. (In an ideal world, how about this bargain: a massive [by US standards] estate tax earmarked for LTC coverage.) But as you suggest, adding near-complete exposure to medical expenses for the elderly would make this risk burden intolerable. I can't believe we're seriously considering it. And in fact, we're not (unless we get a GOP president and Congress before the party changes course...)<<

    From a reader with similar experience:

    >>Medicare provides a cushion from insolvency only in certain circumstances. If one has cancer or is hit by a truck, it's great. However, if one has Alzheimer's...tough luck.

    My Mother had Alzheimer's. In a few short, but excruciatingly painful years, her total nursing home care consumed just under the $250K she had hoped to pass on to me.

    I also had to refund MediCal, and pay accumulated legal fees from her trusteeship, another $25K, and was forced to sell the home she was able to pass on. Fortunately for her, she had no understanding of this happening, but the consequences for me and my children have been significant. We need an expansion, not any contraction, of what Medicare will cover..<<

    From GP, a scientist:

    >>Imagine the tax on a Dr's office staff to manage billing to 23 different insurance plans. That's how many different billing systems my immunologist's receptionist deals with.

    My ENT stopped taking anything but Medicare and cash.  He said that his staff was overwhelmed with learning the intricacies of dozens of plans when he decided enough was enough. Medicare doesn't reimburse the most, but billing is simple and they pay promptly. The same cannot be said for private, for-profit insurers. He did the cost benefit analysis and he's been running his practice this way for 2 years.<<

    Another reader:

    >>Here is what I see happening if the Ryan plan is adopted:

    1. As you note, trying to purchase insurance upon retirement will be prohibitively expensive. I'd guess $25,000/ year for a healthy 65 year old. For someone with health problems or pre-existing conditions, impossible. How much of this will vouchers cover? Very very little.

    2. Workers will negotiate-like-crazy to have employment-based health insurance extend into post-retirement years. This type of policy will be much more expensive than current plans, to be payed for by employers and workers. Not good.

    3. The elderly will die really fast, and use emergency-room healthcare.<<

    From an American working in the Middle East:

    >>The most obvious question out there for Americans outside of the USA discussions, is "whatever happened to the more liberal version of Obamacare?"

    As I understood it, the critical thing about the original White House health care proposal of last year (from the macroeconomics point of view), was to create a govt-managed alternative to private health care insurance, in order to create competition against the private sector and force them to keep rates low. In the polemic that followed, the false accusation of "death panels" arose to kill the initiative, and eventually Obama/Dems had to concede defeat and come up with a more lukewarm version. Which meant abandoning the "government alternative" [aka "public option] proposal. I recall at that time that some economic critics were pointing out that this was the most critical shortcoming in the compromise Obamacare solution, in that it failed to take the opportunity to cap the steady escalation in health care expenses.

    We're now a year later and debate is SURPRISE coming up about escalating health care expenses, while in the meantime everybody seems to have forgotten last year's original "government health care alternative in order to cap the expenses". How can that "I told you so" point be brought to the public debate now?<<

    Also, from TC:

    >>Like yours, my father was a physician. Private practice in Southern California from about 1968 to 1973, then working for a Federal clinic until the big social welfare cuts in Reagan's first term, and then again in private practice in rural Oregon until his retirement a few years ago.

    Like many others my father also took notice have when and where medical dollars were spent and to what effect, and I remember about 20 years ago he offered a novel solution to the cost of "dying American style" and it's implication for an aging population.

    My father suggested that a elderly person could take a buy out, at (just guessing at a number) 50% of their actuarial benefit. They could travel the world, give to charity, leave to their descendants, or even spend all or some on the cost of dying.<<

    After the jump, a dissenting view and a reply.

    More »

  • Undoing Medicare: The Real 'Death Tax'

    Life before Medicare was worse. The 'death tax' is part of the reason.

    See UPDATES below and followup items about doctors' views and about the Canadian approach.

    From my days as a school kid I remember the original debate over creating Medicare. At the time, my dad -- a small-town doctor and at that stage a conservative -- was, like most doctors and the AMA as a whole, strongly against the plan, as a step toward "socialized medicine." After all, when his patients couldn't pay, he found ways to reduce or forgive their fees. The opposing argument, which in the long run convinced nearly everyone (including the AMA, and my father) was that leaving older people exposed to the threat of open-ended and potentially ruinous medical expenses, or dependent on individual doctors' charity, was harmful all around.


    Controlling the open-endedness of medical spending is of course a major public and private challenge. To repeat: "bending the curve" of health-care expenses is absolutely necessary. But until recently it had been taken as settled wisdom, on both policy and political grounds, that insuring people against the risk of complete financial ruin from late-in-life medical expenses left everyone better off. Old people, their families, doctors and the medical system too. Our health care system is out-of-control and unsustainable in countless ways. But very rarely has anyone argued that removing universal coverage for older people would make things better rather than worse.

    That's the understanding being challenged by Rep. Paul Ryan's "serious" budget plan. I've been trying to find the way to convey what it would mean to go back to the pre-Medicare era in which each family had to prepare for unknowably large late-in-life expenses. Merrill Goozner, on his GoozNews site, has just now put it in the way I was looking for. He writes (emphasis added):

    >>Here's the real argument young and middle-aged people need to hear, and the real reason why the "more skin in the game" argument can never work for seniors or other vulnerable populations, including them when they reach that age. Seniors and the poor account for over half of health care spending. Within those groups, 5 percent of the population accounts for 50 percent of health care costs; and 20 percent of the population accounts for about 80 percent. These costs come for the most part at times when economic incentives have no influence at all on medical decision-making: in medical crises; in treating chronic conditions; and, for most Medicare patients, in the last six months of life.

    That's why a voucher program for Medicare, which will shift an increasing share of those inevitable costs onto the elderly themselves, can fairly be categorized as a 100 percent estate tax or death tax. People under 55 need to know that if the plan crafted by Rep. Paul Ryan were passed, most of them will never have a cent to leave to their children. It will all go to the health care industry to support the American way of dying.<<

    Here's a bit of real world evidence supporting that view: Why is the savings rate so unbelievably high in China -- as much as 50 percent of the GDP? There are many reasons, crucially including exchange-rate policy. But a very powerful individual motivator is each family's knowledge that there is no Medicare-like system for their older members. Health care is on cash-payment basis there, and so every family must save like crazy against the risk that the parents or grandparents will require very expensive late-in-life care. More savings would be good for America, but that's not the right way to induce them. It's hard to believe that the Republicans will seriously embrace a plan to undo Medicare.
    UPDATE: Two points I thought of making, but skipped, earlier today.

    1) If one major goal is containing overall health spending, it is flat-out delusional to think that older people, in their role as patients or individual purchasers of insurance policies, can be more effective negotiators than Medicare in its entirety dealing with the health system as a whole.

    Doctors gripe about Medicare, but they hardly love the private insurers. And every bit of real-world evidence suggests that private insurers are worse at containing total costs, and of course administrative overhead, than Medicare or especially the VA. I won't give all the details now, but Phillip Longman on the VA is a great place to start. Moreover, the people shopping for insurance will be in a terrible position: older, retired, many or most with preexisting conditions. In short, if you want to "bend the curve" of medical spending, this is exactly the wrong way to do it.

    2) If another major goal is reducing the non-purely-economic costs and anxiety of disease and treatment, then this is also a terrible idea. It means that, potentially, every older person, plus his or her family, must factor in a risk they're not now exposed to: the "what if??" of absolutely ruinous medical costs.

    In short: the overall economic price tag for medical care is likely to go up under this plan; and the number of people who will have to live with worry about ruinous medical bills will be much greater. This is part of the reason why, until very recently, no "serious" person proposed getting rid of Medicare. 

    ALSO, a reader in New Mexico writes to say that it's not quite accurate to call this a "100 percent estate tax":

    >>It's actually more ironic than you write. This 100% tax only applies to modest estates (ie, those of about 99% of the US population). No matter how hard a billionaire tried to hang onto life, he couldn't possibly spend his entire fortune on end-of-life care. Hence, this tax is something like 100% on estates under, say, $1 million. Above that, if the Republicans have their way, there will be no tax. That's about as regressive a tax as ever suggested.<<

    Drop-down image credit: Reuters

  • Going To Hell #999: Maybe We're Not

    The impact of a presidential win today on presidential power tomorrow.

    As soon as I find a video link to President Obama's comments just now on passage of the health-care reform bill, I will put it up and say a little more about his theme and performance. (Hint: I will welcome and thank anyone who can send such a link.) Listening to it in real time, I was struck by the forcefulness of the ending, which was less about the health-care issue itself than about the overall question of how the American political system can deal with largest-scale public challenges. It was as passionate as I have heard this always-"cool" character ever sound on any theme. Update: thanks to reader Jeffrey Schroeder, the link is here, and an embedded player is below. The whole thing is effective, but the part I'm referring to begins just before time 14:00 and runs for the next two minutes. Very last words of the speech are unfortunate, but otherwise...

    Visit msnbc.com for breaking news, world news, and news about the economy

    The question is of interest to me because of the fundamental "Is America going to hell" issue I raised in this article -- and have discussed in a series of reader "going to hell" responses that I was posting last month. Until our "categories" feature is repaired, I can't do a link to the whole series; after the jump, and thanks to reader Joshua Cypess, a list of specific item links.

    I have many more responses in the queue, which I'll rev up again soon.  For the moment, one more reader response. This is part of a note sent by a political veteran, now in private business, to his Democratic Congressmen, who has decided not to run for re-election and was one of the "undecideds" until the very end. The note was written just a day before the vote; a day after the vote, it's worth reflecting on this passage. It alludes to the late professor Richard Neustadt, the great theorist of presidential power. From the letter urging the Representative to vote for the bill:

    What are the consequences for the country if the President and Congressional Democrats fail on tomorrow's vote? Professor Richard Neustadt did a good job teaching generations of students (including me) that the president's power to accomplish things in the future is always driven by his success or failure in getting things done today. It's terribly unfortunate that we find ourselves in the awful and presumably once-avoidable situation that we do today. It's terrible that the mess in Congress has driven out or otherwise cost us thoughtful Members such as you. But, having said all that, I can't see any good for the country coming from losing the vote tomorrow. I can see a whole lot of harm.  I'm sure you can, too.

    It may be galling for you to "reward" the Leadership, the White House, the bill's proponents with your vote. But I hope you'd find it abhorrent to reward the other side.

    This Representative finally voted "Aye."

    More »

  • Health-Care Reform, the Morning After

    More on what the health-care vote means for America, and for the two parties, and for the creation of "Obama Democrats."

    Two brief updates, on the substance and the politics. On the substance, I mentioned yesterday what I thought was the significance of the vote. A reader from Minnesota puts the point in more specific and personal terms:

    When I was 15 I developed a chronic condition, and received excellent care under my mother's insurance plan. When I turned 23 and graduated from college, I lost eligibility. Tagged with a pre-existing condition, I was black balled from the private insurance market for life. Since then when my condition's gotten bad enough that I couldn't put off treatment, I've made myself unemployed to qualify for Minnesota's General Assistance Medical Care [GAMC] program, which has taken good care of me . . . because I live in a prosperous, progressive county and I know how to use the system.
    Now Gov Pawlenty is trying to unilaterally kill GAMC. Until tonight, I have been a Democrat because of people like Gingrich and Bush, Palin and Pawlenty. After tonight, I am an Obama Democrat in the sense that my grandparents were Roosevelt Democrats. For all the problems with HCR, for all the compromises and deals and disappointments and inefficiencies, tonight the Democrats stood up and took a political risk to say that I deserve medical coverage, that it's no longer okay to treat my health as sad but acceptable collateral damage in a Social Darwinist system. That's why this moment matters to me.*

    On the politics, I mentioned last month this exchange on the House floor during "negotiations" over last year's stimulus bill, sent in by someone who was there:

    "GOP member: 'I'd like this in the bill.'

    "Dem member response: 'If we put it in, will you vote for the bill?'

    "GOP member:  'You know I can't vote for the bill.'

    "Dem member:  'Then why should we put it in the bill?'

    "I witnessed this myself."

    As we have now seen, this was in essence how all "negotiations" over the health bill worked too. There simply was nothing that the Democrats could have put in the bill that would have made voting for it more attractive to Republicans than voting against it, with the implied promise of stopping Obama himself, his Administration's other objectives, and the general momentum of the Democratic party. In 1994, William Kristol's advice that Republicans should vote against the Clinton health care bill -- no matter what was in it, just to ensure a defeat -- was seen as shocking enough that Kristol put it in the form of a confidential memo. (More here, here, here.) This time, simply "going for the kill" was the quite open Republican strategy -- as advocated by Kristol here and by Republican legislators passim.

    Fine: that's their strategy, they had every right to choose it, although as David Frum very eloquently argues, this time it didn't work.** I raise it now in response to a new wave of interpretive hogwash: namely, the idea that although Obama may have "won," he did so in a fashion that was polarizing, hyper-partisan, and extreme. Please. The quite open GOP strategy was that they were not going to vote for this bill. They had every right to that as a strategic choice. But they can't now claim that their bloc opposition to the bill is proof that the Democrats were too partisan. Rather, they can and will claim it, but they shouldn't be believed.

    "You know I can't vote for the bill" -- the phrase by which this era in politics may be known. We witnessed it ourselves.
    * A reader from Texas writes just now: "Because I have an individual policy following cobra/divorce and having breast cancer, my health insurance costs almost $30,000 a year.  They deny me dental coverage after cobra. Feel free to use this factoid."

    ** As Frum says, "At the beginning of this process we made a strategic decision: unlike, say, Democrats in 2001 when President Bush proposed his first tax cut, we would make no deal with the administration. No negotiations, no compromise, nothing. We were going for all the marbles. This would be Obama's Waterloo - just as healthcare was Clinton's in 1994.... This time, when we went for all the marbles, we ended with none."

  • Why This Moment Matters

    Despite the mess that is this health-care reform bill, it represents an important -- and positive -- step.

    We'll talk some other time about the political consequences, in 2010 and 2012 and beyond, of the health-care reform vote. (My guess: this will not seem anywhere near as poisonous seven months from now as it does today. Jobs jobs jobs is what will matter most then. But we'll see.)

    We'll talk about the many things that will prove to be wrong with the bill, and the many more steps that will need to be taken as far into the future as anyone can see, so as to balance and rebalance the potentially-limitless cost of new medical procedures with the inevitably-limited resources that individuals, families, companies, and governments can spend.

    For now, the significance of the vote is moving the United States FROM a system in which people can assume they will have health coverage IF they are old enough (Medicare), poor enough (Medicaid), fortunate enough (working for an employer that offers coverage, or able themselves to bear expenses), or in some other way specially positioned (veterans; elected officials)... TOWARD a system in which people can assume they will have health-care coverage. Period.

    That is how the entire rest of the developed world operates, as noted yesterday. It is the way the United States operates in most realms other than health coverage. Of course all older people are eligible for Medicare. Of course all drivers must have auto insurance. Of course all children must have a public school they can attend. Etc. Such "of course" rules offer protection for individuals but even more important, they reduce the overall costs to society, compared with one in which extreme risks are uncontained. The simplest proof is, again, Medicare: Does anyone think American life would be better now, on an individual or a collective level, if we were in an environment in which older people might have to beg for treatment as charity cases when they ran out of cash? And in which everyone had to spend the preceding years worried about that fate?

    There are countless areas in which America does it one way and everyone else does it another, and I say: I prefer the American way. Our practice on medical coverage is not one of these. Despite everything that is wrong with this bill and the thousand adjustments that will be necessary in the years to come, this is a very important step.


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