Friday, February 26, 2010

The Sad Truth About Health Care

There's an old rule that roughly applies in so many situations - the "80-20 rule". It means that 20% of a population accounts for 80% of a certain result. For example, as a church treasurer I know that 20% of contributing families account for 80% of the total contributions in many churches. Or, as I look out my window this morning, I consider that 20% of the times it snows account for 80% of the total annual snowfall in Rochester. Well, the same concept likely applies to health care - 20% of us probably account for at least 80% of total health care costs.

My ten years of work on an ambulance have given me a new outlook on health care. Prior to this work, I thought that people got sick randomly and that health care costs were distributed rather widely across the entire population. Now I know that this is not true; health care costs are concentrated in a few sub-groups of our population. If we are to get these costs under control, the areas of concentration are the primary places to look for savings. Yet these areas don't seem to be discussed at all in the "great health care debate" now taking place in Washington. This lack of candor represents a failure of our governmental process.

So, where are the costs concentrated? As you might guess, we spend a lot for health care of aged people with serious chronic health problems - heart disease, respiratory disease, circulation problems, and cancer. More than 25% of total health care costs are incurred for people who are in their last year of life, and much of this is spent in the last month of life. I've met many of these people - people whose quality of life is questionable at best due to pain, invasive medical treatment, and altered mental status due to the drugs they have been administered. I have serious doubts about the value of costly medical interventions for many of these patients, and some countries have established protocols that limit such interventions. Republicans have characterized these protocols as "death panels", and perhaps they are correct. However, in my view such panels are necessary and humane. Significant cost savings would be a by-product of letting these people die with dignity.

A second area of health care cost concentration relates to people with chronic diseases; diabetes and coronary/respiratory issues are likely the major ones, although other conditions like lupus and Crohn's Disease are also common. These are diseases that require constant attention and patient compliance with treatment regimens. In my experience, patient non-compliance is often an issue that results in frequent hospitalizations and increasingly costly interventions. At some point, non-compliance should result in the categorization of the patient as not interested in being stabilized, and costly interventions should be curtailed. It seems strange, but I've often felt that non-compliance is aimed at getting attention...but should society pay a high price to deal with conditions that patients knowingly create?

Health care costs are also concentrated for older persons with very severe mental illnesses. A large number of citizens are now permanently hospitalized for severe dementia or Alsheimers - conditions where many of them do not know where they are or who their relatives or caretakers are. When these people are afflicted with life-threatening medical conditions, is it right to employ costly procedures to continue a life they often cannot comprehend? I think not. Their families should have the authority to let them pass on with dignity and without pain, and at some point should be held accountable for costs that a "panel" feels go beyond reasonability given the overall condition of the patient.

Lastly, chronic drug use causes a host of severe health problems. These persons often cycle in and out of hospitals regularly, each time incurring very large bills that they cannot pay. One might wonder if there should be a limit on the cost any person can put onto society due to voluntary behavior. This is a very difficult issue, but also one that is much larger than most people would ever guess.

The issues discussed above are relatively new. During the past 50 years, medical science has developed the ability to keep many people alive who in previous times would have expired from natural causes. I'd be the first to agree that in many cases these life-saving procedures have added years of productive life to many, and particularly to those with cancer or heart disease. I am thankful that we live in an age when terrible diseases can be cured or arrested. However, it may be that technology has now forced us to come to grips with the reality of resource allocations to health care.

When the total cost of prolonging certain lives becomes great, one must consider the benefits of employing these resources elsewhere. For a fraction of the avoidable costs I've identified above, for example, every child could receive a college education or technical training, or the infrastructure of Haiti could be rebuilt. What other great needs might be met? Or, for you, does maximizing physical life for every person outweigh all other considerations? Something to think about...

Saturday, February 20, 2010


It's not funny how so many people love to jump to negative conclusions, including those who discount Tiger Wood's contrition and subsequent vow to change his ways. Some say the apology was not sincere because he read from a script; some say it was all driven by the need to repair his commercial value; some say he left out too many details. They are all wrong, and I condemn them for disparaging someone who is trying to do the right thing. Sometimes you just can't win...

They forget that Tiger Woods had many other options, since he's rich almost beyond measure. He could have said that, for him, marriage was a mistake. He could have walked away from the limelight and tended to whatever else he fancied. He could have come back to golf right away and endured some derision until it faded; every topic wears out, you know. Instead, he said all the right things and committed himself to becoming a better man. He stated the true but simple reason for his philandering and what he had to internalize in order to stop it. I give him a lot of credit for saying exactly what needed to be said and no more. Now it's just a question of the doing.

Few of us can identify with a young man who achieved world-class fame and fortune before he was 30. How can we not understand that he had many role models - other athletes and celebrities - who cross the line every day and get away with it because that is their persona? And, of course, there were uncountable women who would do anything to get his attention. How easy it would be to fall! I believe that very few men would have been capable of withstanding that level of sexual pressure at his age, and I would not have been one of them.

I am giving Tiger my full support in his effort to come back in every way. Based on his history of incredible accomplishment, perhaps he will again set the example for making a beautiful sculpture from the trash of life. Go get'em, Tiger.

Wednesday, February 10, 2010

Earning Your Life's Prospects

Black leaders visited President Obama today and harped on the 16.5% unemployment rate for black Americans, which is much higher than the 9% rate for whites and 12.5% rate for Hispanics. The NPR news report mentioned their focus on the chronically unemployed base in the black community. I'm also aware that a high percentage of young black men are unemployed. It's a shame, but it's also their problem in far too many cases. We've got to have a little more personal accountability here.

The high schools in Rochester are open for business every day, and there are no state troopers keeping black youth out. If the students are from low income families they qualify for free breakfast and lunch at the school. Free transportation is provided to and from school. In other words, there are no institutional impediments to getting a good education in the city of Rochester. Yet only about 50% of Rochester's high school students graduate. It's not a discrimination problem; it's a social problem.

Nothing would make me happier than to see every black youth graduate from high school, then college, and then enter the work force prepared to compete on the basis of equal preparation. If the unemployment rate of high school or college-educated blacks stayed much higher than that of other races, then I'd complain about this apparent discrimination and try to do something about it. But I have little sympathy for those who don't take advantage of the opportunity to become educated and able to contribute to the U.S. economy.

I've heard all the rationalizations about kids growing up in poor, disfunctional families. I know it's tough to grow up in those conditions. At the same time, it's a matter of community pride and intent - if there isn't any, then nothing will change. Just giving money to poor, disfunctional families does not change attitudes. There has got to be an intent to succeed for success to occur.

I've been working with a group of Burmese refugees for several months. They've recently come the U.S. with only the clothes on their backs, and many come from tribal societies. Most have no English when they arrive. I'm amazed at how they have strived to adjust to American society, learn English, and get jobs. Their upward mobility from the absolute bottom is a sight to behold! The difference between them and many who surround them in poor neighborhoods is that they have decided to get with the program. There's no secret about what it takes to achieve some upward mobility in this country.

So, black leaders, go home to your communities and ask the hard questions. Tell the truth. You get what you give, and if you give no effort you can expect nothing. Chronic unemployment is not just about lack of opportunity; it is mostly about lack of preparation.

In this month of Martin Luther King day, I mourn his passing partly because he held up great expectations for the people he led. His successors seem to focus mostly on handouts. It's a darn shame!

Monday, February 08, 2010

Tim Tebow and Abortion

I'm really glad that Tim Tebow's mother did not have the abortion that doctors recommended she have. She made a great decison for herself, her family, Tim and many thousands of Florida Gator fans. She was right, they were wrong. But, she could have been wrong and she could have died as a result. You win some, you lose some. It's wrong to generalize from the results of an individual case, but that's what Focus on the Family did with their Super Bowl commercial.

I'm "pro-choice", primarily because I support the individual freedom that people are supposed to have in America. Even before being pro-choice, I'm "pro-contraception" - I don't want any babies conceived by accident or against the will of the mother. That's why we have only three children; we wanted to stop at three, and we made sure we did. But I digress...

"Freedom" means just that. If it's your body, you should be able to do what you want with it - what could be more personal than that. Not allowing a life to begin, or being able to end your own life, is the most personal expression of freedom that I can think of. I may disapprove of the decisions that some people might make in these areas, but I would never consider taking away their right to make those decisions. That's why I am perplexed by the "get government out of my life" crowd who are also vehemently anti-abortion. Huh?

Secondarily, I'm "pro-choice" because I believe families should make decisions about their future by considering all the likely outcomes of their decision to have, or not have, a baby. Many families, for example, cannot stand the strain of caring for a special needs child on top of the other major challenges they may be facing; many divorces result. Other families might have a structure that would accomodate, or even thrive with, the challenge of raising a special needs child. In short, every family is different; a "one size fits all" prescription on abortion makes no sense in the real world.

Some folks think this issue hinges on the crucial question of "when does life begin"? I don't feel that way at all, even though I'd say I have a very high respect for life. I just believe that life is full of hard choices and tragedies; any of us could be dead tomorrow, for example, from some unforseen cause either man-made or natural. There is no certainty in life, the uncertainty increases as one moves down the economic ladder, and God does not step in to save those who happen to be unlucky - including those who are not born due to someone else's choice.

Good for you, Tim Tebow. Your mother won the pregnancy lottery and you won the Heisman. It's a great story of pluck and luck. Now, let's hear the story of the child born with some terrible defect who died after enduring several years of agony, during which time its family went bankrupt and fell apart. After all, one conclusion based on anecdotal evidence deserves another, don't you think?

Saturday, February 06, 2010

An Easy Winter, Except South of Here

I've been following the news stories about the "great storm" that's hit the eastern seaboard and areas west of it during the past two days. People who never have had to contend with 20-30 inches of snow have no idea of the impact such a storm makes. Transportation is basically halted; power goes out in many areas; and, emergency services are taxed to the limit.

How would you like to experience heart attack symptoms when ambulances cannot make it through the streets, or be a weak 90 year old person who loses power and cannot keep her home warm? Those who can cope think a storm like this is fun, but there are others for whom it results in tragedy. During the three years when I managed our local ambulance corps I saw the unusual problems that a storm can bring; how about an otherwise smart person who runs a generator in a closed garage and almost kills himself, for example?

I remember taking the Xerox corporate jet into White Plains airport, just as a big storm like this hit Connecticut. Somehow I made it to the hotel where I spent the next three days as the city dug out from over 20 inches of snow. Another time, I was at a church retreat in the southern tier of New York when over 20 inches of snow hit; we enjoyed an extra day there and upon arrival at home found our 19 year old son exhausted from shoveling our long driveway. Big snows are truly paralyzing!

It seems strange to be sitting here in upstate New York watching a few snowflakes fall onto the 2-3 inches that have been on the ground for a few days, while people far south of me are trying to cope with a blizzard. We are used to the big snows and we are equipped to deal with them; we've had 62 inches already and hardly noticed it. But, how many people in D.C. own a snowblower? Good luck, you guys! I can at least imagine your pain.

Tuesday, February 02, 2010

More on Haiti

This past Sunday evening a group from my church met at our home. Late in the meeting the subject of Haiti came up. Four of us had been to Haiti, two of us twice, but none had gone together. The common opinion of us all was that Haitian culture was intractably corrupt and the Haitian mode of education and governance would not change regardless of what the "rescuing" countries did.

One of the men mentioned a conversation he'd had with a young man who'd spent 18 months in Haiti with the Peace Corps. This fellow was totally disillusioned after his stint there, and he believed that the country had little hope to become even a second world country. Americans who work in Haiti are involved, generally, in tiny projects that improve the lives of people in the countryside by providing clean water, for example. There seems to be no government interest in or capability to perform major projects that would restructure the country.

I keep hearing diplomats and other high ranking people drone on about giving the Haitians control over the rebuilding projects, but they are mistaken. There are far fewer qualified Haitians than there are projects to manage, and I'd guess that many of those Haitians are well-schooled in the art of corruption. My view is that outsiders should, with Haitian consultation, manage all the projects and employ as many Haitians as possible in responsible positions at good pay. Good training should be given to as many Haitians as possible. However, if a Haitian employee gets involved in corruption on a project, they should be fired.

If and when competent Haitian managers emerge, they should be given more responsibility. It would be wonderful to see a Haitian professional class emerge. But, until that happens, I feel the governmental and non-governmental relief and rebuilding organizations should stay in firm control of where their money goes and how things are done. Otherwise, they are likely to be pouring their resources down the drain.