Hank Kalet

A story in today’s edition of The New York Times once again raises questions about how we manage health care in the United States.

Data being released for the first time by the government on Wednesday shows that hospitals charge Medicare wildly differing amounts — sometimes 10 to 20 times what Medicare typically reimburses — for the same procedure, raising questions about how hospitals determine prices and why they differ so widely.

 

The data for 3,300 hospitals, released by the federal Center for Medicare and Medicaid Services, shows wide variations not only regionally but among hospitals in the same area or city.

The data, as the story points out, does not account for a variety of factors — regional differences in pay scales and costs, the relative health of particular patients, etc. — but it does raise questions about how hospitals determine prices and what recourse we have to address this system. One factor cited by the hospital industry is health insurance, though insurers counter that hospitals make it difficult to account for the real costs of any procedure.

An official at the American Hospital Association, a trade group, said there was a cat-and-mouse game between hospitals and insurers that affects what hospitals charge.

As insurers demand bigger discounts from a hospital, a facility may raise its charges to protect its bottom line, that official, Caroline Steinberg, said. “The hospital raises its rate to cover the discount,” said Ms. Steinberg, who is the group’s vice president for trends analysis.

Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, the nation’s largest association of health insurers, said some member companies were reporting sharp price increases of 20 to 30 percent for some services. Some insurers are seeking similar price increases from policy holders.

“There’s very little transparency out there about what doctors and hospitals are charging for services,” Mr. Zirkelbach said. “Much of the public policy focus has been on health insurance premiums and has largely ignored what hospitals and doctors are charging.”

That this back and forth is occurring in a nation with the highest per capita health costs of any in the industrialized world is particularly galling. As PBS Newshour pointed out in October, the $8,233 we spend per person on health care in the United Staets is “more than two-and-a-half times more than most developed nations in the world, including relatively rich European countries like France, Sweden and the United Kingdom.” Our health-care costs, the report adds, “now eat up 17.6 percent of GDP.”

And, as the report goes on to show, we are not getting our money’s worth. While a “sizable slice of Americans — including some top-ranking politicians — say the cost may be unfortunate but the U.S. has ‘the best health care in the world,'” we generally rank poorly on most health indicators.

According to the most recent report from the Organization for Economic Co-operation and Development (OECD) — an international economic group comprised of 34 member nations — it’s not as much as many Americans expect.

In the United States:

• There are fewer physicians per person than in most other OECD countries. In 2010, for instance, the U.S. had 2.4 practicing physicians per 1,000 people — well below below the OECD average of 3.1.
• The number of hospital beds in the U.S. was 2.6 per 1,000 population in 2009, lower than the OECD average of 3.4 beds.
• Life expectancy at birth increased by almost nine years between 1960 and 2010, but that’s less than the increase of over 15 years in Japan and over 11 years on average in OECD countries. The average American now lives 78.7 years in 2010, more than one year below the average of 79.8 years.

There’s a bright side, to be sure. The U.S. leads the world in health care research and cancer treatment, for instance. The five-year survival rate for breast cancer is higher in the U.S. than in other OECD countries and survival from colorectal cancer is also among the best, according to the group.

are flexible in responding if they think certain costs are exceeding what they budgeted for. In Japan, if spending in a specific area seems to be growing faster than projected, they lower fees for that area. Similarly, in France an organization called CNMATS closely monitors spending across all kinds of services and if they see a particular area is growing faster than they expected (or deem it in the public interest), they can intervene by lowering the price for that service. These countries also supplement lowering fees with other tools. For example, they monitor how many generic drugs a physician is prescribing and can send someone from the insurance fund to visit physicians’ offices to encourage them to use cheaper generic drugs where appropriate. In comparison, U.S. payment rates are much less flexible. They are often statutory and Medicare cannot change the rates without approval by Congress. This makes the system very inflexible for cost containment.

There are few methods for controlling rising costs in private insurance in the U.S. In running their business, private health insurers continually face a choice between asking health care providers to contain their costs or passing on higher costs to patients in higher premiums. Many of them find it hard to do the former.

That the Affordable Care Act — Obamacare — is viewed as major systemic and historic change should tell you just how distorted this argument has become. It does extend coverage, but it leaves in place much of the current system. Its improvements are, really, little more than tinkering with the machinery.

My proposal would be to cut to the heart of our system and cut private insurers out of the mix. I continue to think a single-payer system makes the most sense. But, more importantly, I think we need a full reimagining of health care that moves away from paying fees for individual services toward one in which coverage is based on the holistic treatment of individual patients; that takes profit out of the game as a motivation and makes overall health the driver of all decisions; and that views access to affordable, high-quality health care a right, rather than a privilege.

Health care is not the same as buying a car. We need to stop treating it as though it were.

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http://www.msnbc.msn.com/id/32545640

Growing up, I was taught that we were the indispensable nation, that we rise to the occasion and that we, as a country, always do the right thing. That’s what the history books say.

The reality has never matched this. We are, as the novelist Sinclair Lewis pointed out, small-minded and parochial. We believe in retribution, but not in penance or forgiveness. We are jingoistic, disdain difference and we’re often just plain mean.

This nastiness is now in full view, thanks to a Facebook meme that demands that burial on U.S. soil be denied to Boston Marathon bombing suspect Tamerlan Tsarnaevas’ body and that, if another nation will not take him off our hands, he should be dumped unceremoniously in the ocean.

The anti-burial sentiment has sparked a Facebook meme, pushed by a reprehensible outfit calling itself Uncle Sam’s Misguided Children. The group describes itself this way:

Uncle Sam’s Misguided Children is a Highly Conservative Page. Founded in 2012 by an honorable discharge Marine who after growing up 13 years in a communist country was enamored by what America offered him. After serving in the military he knew what he wanted to stand for; God, Country, & Corps. He believes that our military puts their life on line every day for a country he came to love for its freedoms and rights that were not an option to him growing up. He believed that Uncle Sam’s Misguided Children could allow an opportunity for a band of brothers and sisters whether military or civilian to have a chance to stand for their beliefs as Americans. He firmly stands behind the constitutional rights and believes that all Americans should come together as a Band of Brothers to fight for those rights together. Uncle Sam’s Misguided Children is a symbol of freedom and core values to bring Americans to stand up and be United rather than divided to fall.

Don’t let the rather flaccid and empty rhetoric of the group’s description fool you. The nonsense posted on its Facebook page is a stereotypical mix of every trope tossed up by the right in recent years: anti-Mexican and anti-Muslim; anti-Obama (not just critical, but virulently and personally so); pro-gun; anti-government; and very, very militaristic.

Groups like this have been very active over the last decade, exploiting the fear and anger of average Americans to further their xenophobic and fascist agendas.

Look, I don’t have a problem with the anger — that is to be expected, following something like the Boston bombing. I even understand the desire for retribution.

What I have trouble with is the notion that we must give in to these feelings, that we must become the worst parts of ourselves.
  
The humane thing to do is to let the body be buried as per religious requirements, whether here or somewhere else, even if it means in a Potter’s Field. And, acting like this makes us look bad as a nation and only proves the caricature of the Ugly American correct.

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Kathleen Graber and Susan Wheeler, National Book Award nominees for poetry in 2011 and 2012, will be reading at my reading series on Sunday in South Brunswick, with an open reading to follow.

Sunday, May 5 @ 2 PM
South Brunswick Library
110 Kingston Lane
Monmouth Junction, NJ

Contact: 732.329.4000 x7635
email: arts@sbtnj.net
Hank Kalet, otherhalf@comcast.net

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I want to pass along something by Timothy Donnelly, the poetry editor of The Boston Review. Donnelly was one of the poets manning the helm of the Poetry Foundation’s Harriet the Blog this month and he offered a series of posts/essays on what he calls “quasi-unintelligibility.” His most recent focuses on Wallace Stevens, but really attempts to get at what I think is a problem we have teaching poems.

Wallace Stevens, he writes, “always disliked explaining” his poems.

He disliked reducing them to single authoritative readings that pretended to render them completely intelligible. He didn’t think a poem should be completely intelligible, as we have seen, but rather, as if in a bid to retain its particularity, its non-fungible whatness, the poem should be endowed with that which surpasses paraphrase, and should defy full absorption into our intellects.

The poem, essentially, should be more than just a prose argument broken up into lines. It has to exist on many other levels and can — as with so much of what Edgar Allan Poe wrote — be little more than musicality or image. Great poems often do more, but the point is they don’t have to.

I had the chance for the first time to teach a composition class — composition II at Middlesex County College, which is a class on rhetoric and argument. Unlike most schools — at least, that’s what they tell me — we use a literature-based primer, a textbook that features fiction, essays and creative nonfiction, some drama and a lot of poetry. The chance to teach an interesting array of poems, along with some classic and also obscure stories, made the class more than just a dry effort at teaching students the basics of making an argument.

But it also posed some serious challenges. As you can see from Donnelly’s point about Stevens, poems are not especially suited to this kind of approach — yes, the sonnet has a rhetorical structure, but the best poetry finds a way to inhabit the space between sense and sense, meaning it must both prick the senses and stretch the boundaries of simple meaning.

Students, however, are rarely taught this. Most have been taught by well-meaning high-school English teachers whose job it is to “analyze the poem” and help students arrive at its true meaning. This, of course, is bunk — what is the meaning of Blake’s “The Tyger” and why do we assume there is just one? And why do we assume that the poem’s meaning is its most important feature?

This brings me back to Donnelly’s essay. It seems, he says,

that when we talk about poems in our seminars, in our essays, in our reviews, and even in our workshops, we so often prioritize their thought-content, grappling with what we think they mean and not with finding words for how they make us feel, or not with expressing our disinterested appreciation for the way they were constructed.

He doesn’t discount meaning. Meaning, he says, “plays no small role in the overall value of the poems we love best, let’s be honest, it is their skeleton.”

But since meaning is the component of a poem’s value most easily discussed, or perhaps the one that seems most appropriate to discuss in an academic environment, much of what makes a poem a living thing goes unnoticed, unarticulated, left soft and unrewarded. I think this is a problem.

Part of the issue is that we have created “poor readers of poetry” and we maybe asking them to read “impoverished poems,” to use Donnelly’s language.

That makes a lot of sense to me. What happens when you present poetry to students who have little experience with it aside from high school is one of two things. Either they plan to tune it out or they read too much into it, assuming that they must come up with fanciful explanations for passages they may not at first grasp. To address this, I’ve found that I have to take the poems back to their basics and remind the students that they can read what is there literally, that they should revel in the sounds and sense of the poem, and that they should follow their instincts. When they think or feel something after reading a poem, they need to know that what they think or feel is generally valid. Our job as teachers, I think, is to avoid interfering with their engagement with the poem. We can add the analytical framework — make them consider what in the poem may make them feel the way they do and to get them to talk and write about it — but we should resist the urge to impose from on high a “right” reading that will narrow their connection to the work. That is counterproductive and will only continue to drive students away from the wonders of poetry.

The U.S. Department of Labor released its preliminary job numbers for the month of April this morning, and the news is moderately good:

The United States economy created 165,000 jobs in April, slightly more than forecasters had estimated, pushing the unemployment rate down modestly to 7.5 percent, the government reported Friday.

After starting off strong in 2013, the economy has been showing signs of weakness more recently, prompting experts to warn of a third consecutive spring swoon.

April’s rate of job creation compares with an average of 168,000 jobs added per month in the first quarter this year and 209,000 in the fourth quarter of 2012. Before Friday’s announcement, experts on Wall Street had estimated that 140,000 jobs were added.

So why am I feeling pessimistic?

The answer is simple: The sequester — a Washington-created crisis born of gridlock and a failure to understand the principles of economics — looms large, with economists like Diane Swonk, chief economist for Mesirow Financial in Chicago, telling The New York Times that

the economy would be showing much more momentum if it were not for the combination of higher payroll taxes that went into effect in January, as well as the process of automatic spending cuts known as sequestration that began to bite last month.

“What’s the biggest drag on the economy? The government,” Ms. Swonk said. “If the government simply did no harm, we could be at escape velocity.”

Without the impact of federal cuts and higher taxes, Ms. Swonk estimates, annual economic growth would be close to 4 percent, above the 2.5 percent pace she is expecting in 2013.

In The Washington Post, the jobs report was seen as good news.

“This is a good report,” said John Silvia, chief economist at Wells Fargo. “There’s a lot of strength… It’s good for the economy. It’s good for people’s income.”

The stronger job growth suggests that the federal budget cutting “does not mean recession,” Silvia said. “It does not mean a dramatic slowdown.”

That’s a huge stretch. The vast majority of cuts associated with sequestration have just gone into effect, with most of the harm being done to those already in need. We are about to witness a scaling back of federal aid to the uninsured and to those in poverty — even as Congress has managed to keep business fliers in the air.

As the government pulls back — as it spends less on everything from defense to aid to the poor — it also is taking money out of the economy at a time when the economy needs every dollar it can get, whether it be from the private or public sector.

Of course, the sequester is not really the problem — it’s the mindset behind the sequester that has continued to mire the nation in stagnation. And that is what we must call it. While we have continued to add jobs, we do so at an anemic pace — one that not only has not gained back the jobs lost during the 2008 meltdown, but has no chance at keeping up with population growth. Overall economic growth is glacial, wages are frozen in place for most, and the only people who seem to be doing well are corporations, which are raking in record profits but not sharing them with the broader workforce.

At the same time, we have bought into the false promise of austerity — the idea that we can slash government spending and trigger growth. There is no historical precedent for this happening during recessions and much real-life evidence to the contrary — Japan in the 1990s, the current state of the Eurozone and England, etc.

Rather than look for ways to trim government and deal with a deficit problem caused primarily by the revenue lost to mass unemployment, we should be looking for ways to invest in rebuilding the nation and aid those slammed the hardest by the economy’s punch.

Rebuilding schools, roads, bridges and other public infrastructure, expanding energy conservation measures and investing in green sources, rehiring teachers and police officers, and providing a strong social safety net will help create jobs and will put money in the pockets of those most likely to spend it.

We will not turn the economy around by pretending that the jobs held by public employees do not matter or that the things government spends money on are superfluous. We have to be smart in what we spend our money on (we already give the oil and gas company’s too much money, for instance, and we cannot abide by wasted resources), but we have to spend it.

Repeal the sequester and repeal the austerity mindset that has led us down this dark and dangerous road to stagnation.