January 2011

Is the U.S. ready dive into hard core entitlement reform? Wisconsin Republican Paul Ryan thinks it might be, so he’s floating his proposal to revamp Medicare in his new powerful position as chairman of the House Budget Committee.

Ryan’s idea is to give Medicare recipients a voucher so they can buy an insurance plan of their choice. The amount of the voucher would increase with the inflation rate, but if health care costs rise faster than the overall rate, well then, best of luck in finding affordable coverage.

His plan would exempt current Medicare recipients and those Boomers age 55 and older. People under the age of 54 would be turned loose in the market place, and you can bet that as you go down the age ladder fewer and fewer would receive vouchers that come anywhere close to covering premium costs.

Republicans see openings, though. Historically, the GOP game plan for achieving its goals – and it makes a lot of sense – is to take an issue that polls close and then promote the bejesus out of their position. If they can ultimately poll a bare majority for the plan, they’ve laid the groundwork for success.

And the door of public opinion on Medicare reform is far from being completely closed. Fifty-one percent oppose the voucher system, according to an Associated Press poll, with 35 percent in support.

But look a little deeper at the data, and you find that people born after 1980 support the concept by 47 percent to 41 percent. So, it looks like there is in fact a window of opportunity for major changes to Medicare.

Once the proposal is on the table, and that could happen by summer, the rest comes down to politics. How successful will each side be in reshaping and fine-tuning public opinion? The Democrats have been able to score points by defending both Medicare and Social Security in the past, but these aren’t ordinary times.

Rock-solid public support is not a given. This time, there really IS a debt crisis brewing and something has to be done to control health care costs.

Here’s a place to start, without resorting to the extreme structural changes proposed by Paul Ryan. In a word, the answer is telemedicine. Yeah, I know. Sounds simplistic. But in my view, the potential efficiencies and cost savings that could be achieved through virtual health care are staggering.

There is no reason, for example, why basic patient checkups can’t be conducted over the Internet. We’ve certainly reached the point where blood pressure, glucose monitoring and other tests can be done at home and uploaded to a primary care provider who can then consult with the patient via teleconference.

The technology is there – it just hasn’t been pieced together. Not only will telemedicine save vast amounts of money, it will make health care more satisfying to patients. I can guarantee you no senior likes running out to two or three doctor appointments every week just to have this or that checked.

Right now, most insurance companies won’t cover telemedicine. So if House and Senate members want to address Medicare expenses in a meaningful way, passing legislation requiring insurers to pay for telemedicine is a great place to start. There’s plenty of room for expansion of the idea as time goes on, particularly in Medicare.

It would be great to see Washington discussing innovation rather than the hackneyed “cut” and “don’t cut” arguments you usually see on the House and Senate floor and Cable news channels. But I won’t be holding my breath.

Photo: http://www.flickr.com/photos/roebot/2454143641/

Most Americans blame “the mental health system” – not easy access to guns or sharp political rhetoric – for the recent shootings in Tucson, Ariz.

A fairly solid 55 percent majority put “a great deal” of blame on mental health system failures and said health care professionals should be identifying people who are a danger to the community, according to the USATODAY/ Gallup Poll.

There have been published stories that the alleged shooter, Jared Loughner, could have been involuntarily committed under Arizona law.

That question aside, Americans don’t understand what a paltry amount this country spends on treatment for mental health problems. The above graphic, originally from the Substance Abuse and Mental Health Services Administration (SAMHSA), a government agency charged with monitoring substance abuse trends, shows an underwhelming 6.2 percent of health care dollars going to treat mental health issues.

That little green slice in the sea of blue looks meager enough. But in truth it’s generous, and probably includes the growing amount spent on high-priced pharmaceuticals. And it includes a lot of hard core cases that have been thrown into the Medicaid system, where institutionalization may be involved.

I’ve spoken with health care consultants who tell me that the overall percentage spent on mental health in the U.S. – minus prescription medication – stands at about 1.3 percent, and it’s been sinking rapidly over the last decade.

Part of the reason for the trend is that mental health expenditures have remained stagnant while other medical costs have increased wildly. There is less psychotherapy taking place these days as primary care physicians address depression, anxiety and other issues with a prescription pad.

Any idea of spending more on health care runs into the mantra of the day: “We just can’t afford it.”

But consider this perspective on the Tucson shooting from E. Fuller Torrey, founder of the Treatment Advocacy Center and author of The Insanity Defense: How America’s Failure to Treat the seriously Mentally Ill Endangers Its Citizens.

In a recent Wall Street Journal column, Torrey points out that the U.S. began emptying state mental hospitals in the 1960s due to civil rights concerns. The policy was enacted without a backup plan for the former patients. They were left to drift through society, homeless and untreated.

Two attacks related to Congress occurred in the 1980s. Dennis Sweeney, a man with untreated schizophrenia, shot former congressman Allard Lowenstein in 1980. Another attack by an untreated schizophrenic occurred in 1998 when two police officers were killed as the man was trying to shoot his way into the Capitol Building.

Torrey neglected to mention the most infamous example of all –John Hinckley Jr. who, in 1981, shot and seriously wounded President Reagan in a bizarre bid to impress actress Jodie Foster. He was found not guilty by reason of insanity and has been in institutional psychiatric care ever since.

“Over the past three decades, things have only gotten worse,” Torrey writes. “A 2007 study by the U.S. Justice Department found that 56% of state prisoners, 45% of federal prisoners, and 64% of local jail inmates suffer from mental illness.”

Sure, addressing these mental health issues will cost money. But it may be something we can’t afford NOT to do.

Illustration: SAMHSA via National Institute of Mental Health

Many years ago, way before iPhones, Lady Gaga, and cars that tell you when to turn, the kid at the end of the supermarket checkout lane would ask: “Paper, or plastic?”

But now, at least in many parts of the country, the guy bagging your groceries is more likely to be 60, coming off his third unemployment extension and trying to scrape up a little spare cash for his next bottle of Lipitor. And he says to you: “Plastic, or do you have a green bag?”

And a growing number of people opt for the green bag because well, it’s just such a nice thing to do for the planet.

Even though the supervisor down at the plastic bag factory gathers everybody on the line together and says: “We’re going to have to start doing some rolling layoffs. The whole green bag thing, you know.”

Here’s a question for you flower-powered environmentalists. Just how green do you suppose all of these green bags are?

I hauled out our collection of green bags from the same cupboard where we keep our plastic bags, which we recycle. So it’s jammed-up with plastic, and there are so many cloth bags stuffed into the same spot you can hardly close the cupboard door.

I noticed that most of them are made in China, which means they’re produced by people making 18 cents an hour in a city with smog so thick you could move it around with a forklift.

They are then loaded on to a ship, which burns diesel fuel to lug the products 6,200 miles to California where they’re stacked on a truck or train, and then shipped cross country another thousand miles or so to a climate-controlled company warehouse.

The bags cost anywhere from a buck (50 cents at The Dollar Store) up to $3 or more depending what sort of trendy design you’d like on the front. The cheap ones, I’m told by my wife, last for a few trips to the store and then they’re ready for the landfill.

Then of course there’s the problem that some of these bags have tested positive for lead, which is a heck of a thing for a container you’re supposed to use to carry around fresh food. It’s in the paint on the bags, so the fancier the bag is, the more likely it is to have some lead in it.

U.S. Sen. Charles Schumer, D-N.Y., is calling for a federal investigation into green bag contamination. (Hey, I knew the Democrats would finally get the lead out.)

“Lead, when it gets into your system, it takes years to accumulate to have harmful effects, and these bags are relatively new,” he said. “So, if we can get rid of the lead in these bags now the danger to people is negligible or nonexistent.

“Adding insult to injury, guess where most of these bags are made? China, a country that has flaunted safety when it comes to American imports over and over again. Whether it’s toys or food or now bags, China has no regard for American safety.”

If you don’t keep these bags clean – people tend to put them away and use them over and over – you can find that some nasty bacteria has built up. And the bags are not machine washable. That’s what the note on the label says. The note from China.

Actually I know that there are some stores that still offer paper, and this makes sense to me. Paper is inherently friendly to the environment and breaks down in landfills over a long enough time period. Plastic bags are convenient and if everybody recycled them, they would probably leave a minimal footprint on the planet.

See? And you thought you were the consummate environmentalist. But it’s not so easy being green.

Photo: http://www.flickr.com/photos/lukaquinn/2955601699/

The tragic shooting in Arizona may have put off, for a week, the sharp partisan debate in Congress over health care reform repeal. But it still looks like the Republican controlled House and White House are headed for a showdown over the issue.

President Obama released a letter over the weekend promising to veto any legislation that lands on his desk attacking the health care overhaul. The GOP may counter by attempting to cut off funds for implementation.

Against this backdrop, the Centers for Disease Control released an ominous report showing that the number of uninsured was the highest ever in 2010.

The CDC says 30 million adults were uninsured for the 12-month period prior to the survey, which took place from January to March 2010. And a record 50 million, or one in four adults, were without insurance for at least a portion of the previous 12 months.

“During each of the past few years, the number of adults this age who went without health insurance for at least part of the past 12 months increased by an average of 1.1 million,” the CDC said in its November issue of the newsletter Vital Signs.

There was some regional variation. There were more uninsured in the South, and in Nevada, Oregon and Idaho, where the uninsured rate ranged between 21.5 percent and 29.1 percent. Lowest rates were in the upper Midwest and the Northeast, where they pegged at between 6.2 percent and 13.8 percent.

Note that people in all income brackets have been affected, not just adults living in poverty. In 2009, about 32 percent of middle-income families ($43,000 to $65,000 household income) were uninsured for at least a portion of the preceding year.

This is the problem that the health care reform law was intended to address. And a few adults, such as college students, are already being added to the rolls of the insured as a result of the law. But most of the impact won’t be until 2014 when state Medicaid programs are supposed to be expanded. That’s where the real controversy lies.

But if the law is repealed or voided by the courts, look for the growth in the rate of the uninsured to accelerate even further.

I don’t expect any organic improvement, not with the jobs reports we’ve seen lately. Statistics also show that the jobs being created aren’t the type that come with health insurance benefits. These are the part-time retail and service positions that are replacing middle-class sustaining jobs lost during the recession.

A lot of financial bloggers are warning that the U.S. is headed toward becoming a Third World country with the devaluation of our currency and the dramatic gap between rich and poor. Letting the health care gap continue to grow is yet one more troubling sign.

Graphic source: Vital Signs, Centers for Disease Control

Holiday stress comes in all shapes and sizes. You’re making a special dish for Christmas dinner, for example, and even though you’ve prepared it a thousand times before, this time the crust won’t hold together.

At dinner, the conversation deteriorates when your uncle Harry starts talking about his latest gout flare-up, and the topic lingers into dessert.

Then there’s the cross-country holiday drive. It can be relaxing if you don’t run into car problems – or a traffic jam. But on long holiday trips at least one jam-up is almost inevitable. I inched my way through two of them this year during a 2,000-mile round-trip from West Palm Beach to Baltimore.

Stop. Roll 5 feet. Stop. Get up to 10 mph, slam on your brakes. This is tough enough, but more stress comes from what you can’t see: the source of the problem, or how long it might go on.

There’s a theory that getting into a traffic jam actually may have some psychological benefits because it gets your mind off other, even more stressful things, like work. But what’s the good of trading one brand of stress for another?

Instead, I like the idea of viewing the traffic jam as a temporary community. You have neighbors you see again and again, sometimes behind you, or to the right or left.

After a second or third glance, you know a little about them. You know what state they’re from and sometimes what city. You know what kind of car they drive, and whether they are self-important enough to have a vanity plate. You know roughly what age group they fall into and whether they are a family unit.

You can speculate that the middle aged guy in the silver Mercedes convertible who’s talking non-stop on his cell is recently divorced, living in an urban bachelor pad just up the block from a Starbucks. You figure that the elderly couple driving the SUV and pulling a travel trailer with New York plates, heading south, are on their way to a Florida RV park until April.

You may spot a narcissist. He’s the guy going 50 mph in the far-right lane, the one marked “Exit Only” a half-mile ahead. And when he reaches the exit, at the very last second, he pops his turn signals on and squeezes back into traffic where he finds it most convenient.

You may see an outlaw. These are the ones who abandon the road completely and take to the shoulder, gambling that an emergency vehicle won’t be coming the other way, or will need to pass him from behind. And if the state patrol sees him he will be written a ticket for a very, very large amount of money, but justice is as rare on the road as it is everyplace else, and chances are he’ll cut back into the flow miles ahead.

The traffic jam community also has its own primitive form of communication. If you need to change lanes, the first thing you have to do is get the attention of the driver to your right or left. If he refuses to acknowledge your wave and point, it’s either because he’s day dreaming, agitated, or listening to a self-improvement CD.

A stronger message comes from the person who looks at you, sees you pointing at the space in front of his car, and then turns away. This is a power play. It’s a big world, and his vehicle occupies only a tiny part of it, but you will never, ever get into the lane in front of him and that’s that. He is protecting his territory.

One of the most mystifying things about a traffic jam is that you often come to a resolution without any sign of the original cause. That leaves you troubled, because it reinforces the idea of randomness, that things happen for no particular reason.

Wikipedia has a long-and-winding entry on traffic jam theory and points out that a jam without obvious reason is often triggered by “a pinch” in the road, a narrowing of the highway or an influx of cars up ahead.

But some jams are caused by the butterfly effect. An event takes place that has ripple effects miles away. It may be “an abrupt steering maneuver by a single motorist.”

A wrong turn of the wheel, and a new community is born.

Photo: http://www.flickr.com/photos/danielle_scott/3767637774/