An Insight from Ezekiel on the Health Care fiasco in America

Today, I suppose I am going to sound like a preacher. But when the spirit is the problem, perhaps preaching is in order. I was reading Ezekiel the other day and a verse jumped out at me. Ezekiel is upset with Tyre, and ancient nation that is known to be wonderfully productive, but the explanation he gives for its downfall is very revealing. Ezekiel 28:18 says: You defiled your holiness with lust for gain; therefore I brought forth fire from your own actions and let it burn you to ashes upon the earth in the sight of all those watching you. This translation is from The Living Bible, but I could not think of a better way to explain exactly what is wrong with health care in America. It started out a holy and sacred duty to care for the weak and helpless, but the lust for gain that is extant in it now (often under the name of innovation) is actually burning up the system from the inside out. There is no new thing under the sun. If you depend on services to the weak to provide your wealth, it will backfire on you. The weak don't actually have wealth.

In the Fall 2010 health care news letter from a local hospital I found an excellent example of how what Ezekiel says happens. The article is about the recent practice of cooling a person to promote self healing after a major cardiac crisis. I will not name the devise, but the article indicated that instead of ice packs and water blankets this medical devise system allows precise body temperature control. In case you did not catch it, ice packs are cheap, and this brand name, probably patented system is available for who knows what cost from your local health supply salesman who gets a cut for his or her sale which comes with very bright advertisement brochures, and you can see how the cost gets higher and higher. Now you might counter that science needs precision, and the doctor deserves the tool that makes the practice most predictable. But where does this stop? As soon as the precision tool instead of the care taking practice (ice bags) becomes the standard, then the doctors who try to treat for less cost begin to be held liable for not actually maintaining a strict temperature when they could have, and even if no law suits are ever brought over body temperature, insurance companies will require higher standards for all. The simple availability of medical innovations is like a built in way to create new liability because the standard of care changes with what is possible in the market instead of what is possible for the patient. Health care is too expensive because we have demanded that only expensive health care be practiced. This demand is due to a delusion that only expensive care is real care, but delusional as it is, the most expensively controlled care (dependant on machines and data instead of human observation and care) is what is driving us over the cliff on health care. When I was in Jr. High I remember little story illustrations encouraging us to be content in life. These stories usually talked about a great struggle to get to the top and then once there the discovery that there was nothing up there. Our health care monetary practices are about the opposite. Everyone is reaching to this bottomless pit where they believe great wealth exists if they can just get down there, and when they do, there is nothing there. Or to put it Ezekiel's way, burned by your own actions.

Noble Values and Health Care

As I was visiting a friend at a hospital very close to my home, I found the following in a display of their history.

To the fifteen thousand citizens of Dayton and The Greater Miami Valley who subscribed one million dollars for the creation of a new institution of healing and mercy; and to the Sisters of Charity who, without thought of material reward, consecrate their lives to the sublime task of alleviating human suffering this Souvenir Edition of The Dayton Catholic Parishioner is dedicated. May 24 1931.

The official hospital history writes this on their web site.

In 1928, the city of Dayton partnered with the Sisters of Charity in Cincinnati to raise $1 million to finance the construction of GSH (Good Samaritan Hospital). The project took four years to complete, and when GSH opened in 1932, it was due to the efforts of the Sisters as well as the businesses and citizens of Dayton. Each had worked together to make their shared vision a reality, with the latest in health care technology now available to Dayton residents. The Sisters of Charity brought their health care expertise and experience to the new hospital, along with their noble values that are still the cornerstone of GSH today.

Looking at these two clips shows a necessary part of making health care work: noble values without thought of material reward.

But where are the people in America today who understand that being poor with noble values has a life strength that money cannot break? And even more importantly, who are the monetarily empowered people who can appreciate this strength and keep nobility in our values?

Why it is impossible to pay to have everyone live right

My blogging seems to have reduced itself to monthly rather than weekly. Maybe I have said about all I have to say, and maybe I'm hoping the Health Care Plan will go away. On September 4th a very well meaning Dr. with personal experience in both giving and receiving medical care wrote a piece with the following headline: Millions Die due to Withheld Medical treatment. His name is Mark Hyman, MD, and the article was sent to me from The Huffington Post. The withheld medical treatment was dietary and life style changes that no insurance company pays for. As thrilling as the article was about the revelation to people that self control rather than expensive procedures is the best answer to successful health care, the theme of his article poses an economic conundrum. Do we really think we can pay everyone to live right? If we are paying people to live right will they be motivated? If we refuse them care because they won't live right are we oppressive? I am not going to make any thematic propositions regarding these questions. I have tried to show the radical problem of reducing the health care system to numbers and figures because the individuality of care is a thing that does not fit on a spread sheet. Dr. Hyman's plea for "rational" insurance that actually pays for what people need just shows the economic impossibility of the task of universal health care in The United States of America.

Sort the Issues in Health Care

I am having horrible malaise about this health care issue. At this time it seems more reasonable to pray that November brings about a big change than to spend any more time trying to figure out what has happened. On the other hand, health care is broken with or without the political things that are going on, so today I will simply submit a test to determine whether you have the foundation to think rightly about health care needs, provisions, and economics. The goal of the test is to take the following twelve things and organize them into meaningful patterns. This is like a Sukudo, but with sorted concepts instead of number patterns.

Here are the twelve things:

Dialysis
Feed and Clean the weak
Health care: Care
Glucose imbalance in Diabetes
Hospital Days
Varicose Veins
Preventative Education
Health care: Purchases
Teach about illness
Infections
Health care: Corrections
Pain Relief

The imaginary "grid" is four boxes across and three rows down. The topics are pretty easy to spot, but even they must be ordered by a meaningful pattern.

Once the headings are placed, the goal is to have in remaining nine boxes ordered issues where the least expensive is at the top left and the most expensive at the bottom right. As in Sukudo, the items in the columns must relate up and down and left to right. The left to right is pretty easy as I gave you the topics, and I am not dealing with the angles.

I will put the answers at the bottom, but now I will lead a discussion in figuring out the answers, so stop reading and work it out for yourself on paper now if you don't want any clues.

First, locate the three headings. Since there are only three of them, not four, they obviously belong in the first column on the left. They are Health care: Care, Purchases and Corrections. It will be hard to order them until associated terms give some clues, but the goal is to have the one at the top that is most controllable by the person and family and thus least expensive, and the one at the bottom that is least controllable by the person and family and thus most expensive.

The next word on the list is Dialysis. Dialysis could be care, a lot of care is needed. It cannot be corrections because we know it does not fix the problem of kidney failure, and it certainly requires purchasing. No one can achieve dialysis without purchasing health care, not even the dialysis Dr. because the entire procedure requires a team of operatives from diagnosis to administration so it must be purchased by any person who is going to have it. Thus, we will put it with purchases.

Feed and Clean the weak. By this I mean any weak, the babies, the geriatric patients, the people with broken legs, those sick from disease, etc. etc. etc. This is that basic level of personal care that makes one human being dependant on another for health because without assistance they will not have nourishment or be clean. Hopefully by my examples you can see that it is not necessarily a correcting or purchased health care need. Most mothers take care of their own babies. Parents help out independent children when they end up with a cast, etc. etc. So this goes with Health care: Care.

O.K. We are up to glucose imbalance in diabetes. There is a fundamental difference between fixing glucose imbalance and doing dialysis. Dialysis does a function the body no longer can do, but it does not change body function. Fixing glucose imbalance whether by losing weight in type II diabetes or administering insulin in type I diabetes fixes (or prevents) much much worse medical issues from occurring. Is that enough to get you to see that this belongs in health care corrections?

Hospital Days. There was a time in the origin of hospitals where hospital days were not the biggest possible health care purchase a patient made. Those times are gone now. Just by reading the list you should know that the very last box on the bottom right is the place where Hospital Days goes - most expensive, least controllable by consumer.

Varicose Veins. Most of us get these, a certain number of us suffer pain because of them, and a lot of people buy services to get them fixed. Since they do fix, instead of require ongoing purchases to be effective, I have them in the correction category.

Preventative Education. If you don't know by now that this is the least expensive part of health care and the most controllable by the consumer then you haven't really listened to anything that anyone advocating government action in health care has said. As it is not correcting anything you are already sick with or requiring the purchase of something to deal with illness, it goes with the heading Care.

Skipping the heading, we go to Teach about Illness. Again, this is a Care issue. Information is available for free and the consumer has a lot of control over it.

Infections. This is clearly identifiable as health care that corrects a problem.

And the last non heading issue is pain relief. While pain relief seems like a basic care issue and can be fixed, pain is a symptom, not an underlying disease process alone, so anything exerted on pain has to be done over and over until the cause is changed. If you are anywhere in the health care market right now, you know that pain relief is one of the biggest sellers and you would easily place that in health care services that a consumer buys.

So lets take the three "Buy" issues, Pain Relief, Dialysis and Hospital Days. We know Hospital Days is the most expensive. Clearly Pain relief is the least expensive - although some pain relief can get very expensive.

Since we already pointed out that Hospital Days is the least controllable by the consumer and the most expensive, we know that this "Buy" category is going to be on the bottom row.

So the bottom row of the graph reads

Health care: Buy - Pain Relief - Dialysis - Hospital Days.

Which of the two remaining headings (Health care: Care) and (Health care: Corrections) is the least expensive. In spite of the current panic about nursing shortages and trying to pay salaries to do all the care that is needed right now for nursing homes, etc. Health care: Care is actually less expensive than Health care: Corrections. This is because personal care can actually be done without expending money. A high school graduate who is doing on line college classes can stay home with grandma so that nursing care is not needed. A parent can take FMLA to stay home with the sick kid for two days. Grandma can move in for a month when the next baby is born, and Grandpa can move in if he needs to rather than go to a home when his wife dies. These are simple, but non-monetary solutions that are under the control of the health care consumer. Of course choices have to be made, but all "fixes" also require some purchase where as the things under "care" have some totally non-monetary expenditure items.

So if Care is at the top, what order do they fall into on the expense scale. Obviously if you do preventative education and do not get any problem, that is the most frugal solution. If you have an illness and can learn what to do, you will also save a lot of money, or may not need any money. While Feeding and Cleaning the weak may not require monetary outlay, it will require reassignment of resources which can be costly in non-monetary ways ie: The on-line college student doesn't get to rub shoulders with peers and doesn't have quite the network for future growth, taking FMLA looks bad on the work record, Grandma will have disruptions to her routines, and depending on Grandpa's disposition, a family may decide that paying for a nursing home is less of a cost than putting up with him in the house.

So the top row looks like this:

Health care:Care - Preventative Education - Teaching about Illness - Feeding and Cleaning of the Weak

It should be fairly easy to assign the middle rows by looking at what is left. Start with the topic Health Care: Corrections on the left. Which of the three previously identified corrections fits with Preventative Education and Pain Relief? If you said Varicose Veins, you are right. While I admit that at times it is much correct infections than it is to correct varicose veins, to keep the theme we have to consider that good leg support, keeping the weight down, and adequate exercise all help decrease the possibility of varicose veins. If the veins are not fixed and cause pain then there will be no end of purchasing to try to buy pain relief, so fixing them is a less expensive solution than buying services to put up with them and the row works.

If you know anything about diabetes, you will identify that dialysis is required if diabetic problems end up destroying the kidneys, so correcting glucose imbalances is the corrective health care procedure that will save money by not requiring constant repurchasing of dialysis.

So the final thing I will explain is how Infections can be considered a costly correction when most of us very easily call a Dr. and for $4.00 at Walmart get our infections under control.

In the context of the column that starts with Feed and Clean the Weak, infections are one of the costliest health care items when people choose to pay for the Feeding and Cleaning of the Weak rather than do it themselves in the setting of family and friends. Think: children in daycare sharing colds, nursing home patients continually having urinary track infections, Rehab patients getting MRSA during two week post surgical hospitalization. And the infections get costlier and costlier as they get stronger and research can not keep up with keeping them under control.

So Here is the whole Graph.


CARE: preventative education, teaching about illness, Feeding and Cleaning the Weak

CORRECTION: Varicose Veins, Glucose imbalance in Diabetes, Infections

BUY: Pain Relief, Dialysis, Hospital Days


So lets look at the graph and make some generalizations about the benefit of spending money in these areas.

First, spending money on instructions for preventative health benefits everyone, but it does not control anything. Preventative health care is most under the power of the individual and the government can not control the individual (I'm pretty sure that is against the spirit of the Constitution). So when the government does things to promote prevention, it solves nothing, it only puts money into the hope that people will empower themselves with the knowledge.

On the other end of the scale, the government has always known that hospital days are expensive, and in no program have they ever been willing to pay the whole cost. Medicare comes closer than Medicaid to covering the cost of hospital days, but most hospitals run on a deficit. There is a sense that the government has been spoiled in having this privilege, and if they now dictate all assignments of money for hospital beds, they will have to stop undercutting, or they will simply ruin hospitals as the hospitals have to reduce costs to match payment received. One could theorize that the elimination of hospital beds as a plan for economizing health care is one option. It would set our society back about 200 years to the 1800's, but it is not as outlandish a potential as it seems. There are already many empty hospital buildings around the country and the potential that they all fail, or enough of them fail for them to stop being a significant part of the health care economy is possibly only a value added tax away.

The government has done a lot for the middle of the scale and has many programs to empower diabetics to care for themselves and keep their glucose balanced.

The malaise jumps up again. Every time I think about the issues that arise when the government tries to help (ie exerts control) on any part of the health care scene, I just get crazy. Hospitals come from hospitality. Healing comes from faith. Personal care comes from community. None of these are characteristics that our government was set up to have. But they are not things that flow gently out of the open market, either. I think I'll stick with praying for a change in November. At least if the market fails people are free to start over and reinvent the services they really want. If the government takes it over, it will become a bigger albatross than it already is.

Enough for today.

Trust is Healing

"Knowledge is Power" is a very well known American phrase, emblazoned all over our capitol city and possessed by our American existence beyond any other common belief. I remember a radio comedian in Cincinnati who had as an intro to one of his regular "secret microphone" sketches the line "Your right to know supersedes your right to exist." I loved the line for its funny truth because our culture screams if in real life even the most powerful potential move by the government is not 'transparent,' but adores TV characters who regularly look at people and deny them information until they 'need to know.'We are an unrealistic group of children who can neither take care of ourselves nor identify and appreciate the people who can take care of us. Or, to quote an ancient prophet "All we like sheep. . ."
So I would like to address today how our belief in our power through knowledge has affected our perceptions on health care. In the area of healthy diet, people can totally control their own intake if they desire and make many things change, such as pain in the case of gluten intolerant people. Others can adjust their weight, lower their blood pressure, or calm their nerves by adjusting to eating patterns that serve the needs of their own body. But when it comes to medication, the "client" is no longer in control. The FDA has chemicals that are available over the counter and chemicals that require a professional assessment and recommendation. So now, our desire to have one thing or another for our health comes into conflict with our need to get professional judgment about whether the drug is needed. As a mental health nurse, I see daily the struggle between self reliance and professional service as people regularly medicate themselves by purchasing street drugs, either illegal or prescription, to avoid depending on the services of a professional to treat their mental anguish. The expanded "knowledge" about drugs through required ads and warning data has changed our perception of chemical medicine treatment. Patients regularly order up prescriptions, sometimes motivated by TV ads, rather than wait for an expert opinion from their doctor. Now I am not disagreeing with the idea that knowledge is power, but like every other market motivated equalizer, it does not function purely when applied to the setting of illness and health care. Some people are quite capable of understanding their own chemical needs, and some doctors, raised and educated in the age of unlimited knowledge have given up trying to know the special facets of chemical treatment because there is just too much to deal with. But the thing that keeps faith in medical care is not some type of supply and demand smorgasbord of options that smart patients chose well and oblivious patients choose poorly. The thing that keeps faith in medical care is trust. Whether the patient is asking his doctor to let him try something or asking the doctor what on earth is wrong with him, the facts that are needed to solve medical issues do not present themselves without trust. Most of America is crying over health care now because they do not trust it. Without being able to express the facts, they feel that the services rendered are more about getting money out of them than healing them, and they do not trust it anymore. When I really see it for what it has become, it is hard to care whether it fails or not. This has nothing to do with the current governmental health care reform. That is just another wave of the same thing we have now with different people in control. It will change nothing substantial about the fact that health care offerings in America are really a way to gather money instead of a way to heal the people. But the worst part about this is that a very small percentage of the care that gathers money even offers healing. That is because, as I am sure I have said somewhere along the path of this blog, you can't buy health. You can discipline yourself, change your life, repent of your body wrecking life style and do the things that improve health, but you can't buy health. And you especially cannot demand that others buy you health in whatever way your knowledge has concluded works for your own power. As the wonder of modern medicine melts away like a wet witch because the patient is trying to get out of it's control, look for those you can genuinely trust to build it back up. It is not the ones with things to sell or buy who can be counted on for healing but the ones you know you can trust.

Keeping it Real

So, I have passed another week unable to look at that crazy health bill again. I know I am not keeping my promise here to evaluate it, but it is phenomenally vague, causing the law itself to look like it is meaningless until the rules come out that fulfil it. And of course, that is how the government actually takes things over. Administrative law can be incredibly oppressive for the sake of accomplishing the overall goal, but at that level, comprehending how the rules affect freedom and rights is so difficult the oppressiveness gets by without question. Here is a lovely example. The quote of the week on conservative talk shows is the one where the newly appointed director of Medicaid, Donald Berwick indicates that our health care will be superior to that in Europe or wherever else because we will "ration services with our eyes open." Of course this has every talk show person bouncing with "I told you sos" but truly, those of us who are in health care know that there are not enough resources for every single person to be serviced without limitation by any program. The man is saying a truth (that services must be rationed) and is stepping up to be "open" by saying we will ration them with good judgment and fairness (our eyes open). And here, America, is your opportunity to see what is really happening. The past ten years of medical market advertising that has caused you to somewhat magically think that health services are unlimited for everyone at all times has finally been washed away, and you can look at the real issue. At all points in time medical services have been rationed and limited and only given when very specific benefits were in place (whether economic or charitable) and the real thing that is happening is who is going to decide how they are rationed. No one has been thinking clearly about this because everyone has been drinking the kool-aid of advertisements and acting like unlimited health is a right of nature. It isn't. Health is a personal responsibility and medical services are a limited commodity. Now, open your eyes and get your right to services back not by trusting the government, but by demanding that the government get out of it. When health care is a private and personal endeavor, irresponsible people are kept under control. The government is totally unable to keep irresponsible people under control. As a crisis worker I have heard plenty of stories from people about how the local doctor gave free care to them when they couldn't afford it. But you can be sure that that free care was exactly the care the person needed, and not every piddly thing the person wanted because the whole dynamic of thankfulness and dependence when there is no obligation lets the doctor call the shots. Now try to apply that to a free governmental clinic. All of a sudden the person who can't afford care is no longer obligated to a professional who can properly limit the complaints that will be addressed. Every service is now something the Dr. is being paid for, so the client no longer appreciates getting free service and wants to control the decision making instead of going to the doctor requesting help. But these problems are not just about money. When it comes down to it, personal care is exactly that: personal. If a proper relationship does not exist, care does not happen. So in every clinic, when the professional begins to feel that the client is not grateful, is not respectful, and basically does not want help, only wants to demand things, care will stop. Treatment won't. There will still be lots of orders, tests, prescriptions,etc. But the process will lose that extra value called care, and the over treated patient is as likely to die from neglect as the untreated patient because no real issues are being addressed because no one is really talking to anyone anymore because no one cares. This situation already exists so extensively it is hard to believe anyone is pushing for more of it by wanting government intervention. And if you imagine that non-caring over treatment is less expensive than no care, you are wrong and you can open the books of every medical system in Europe for proof of that. In his science fiction allegory The Great Divorce, C.S. Lewis sets up a Hell where no one has needs because everyone gets what they want just by imagining it. Of course nothing is actually real, so even though you have everything you want, no one is satisfied. Our health care is on its way to being exactly such a hell. By trying to provide things everyone wants without any knowledge of what it takes to meet needs, the government is creating a service that will not be real health care. No doubt Dr. Berwick is hoping to counter this, and believes his knowledge will be the thing that makes the system right. But the nation as a whole has too many conflicting needs to be figured out from the top. Smaller groups are the parties that have the capacity to care. Even beyond that, individuals are often the only ones gifted enough to know and enforce what is needed. Even if Berwick can bring miraculous wisdom to Medicaid, there is a very long train of workers who will be pegged into that system who will not have the talent to carry on the miracle. When health care is no longer an individual endeavor but is a process and procedure that citizens go through as a part of civic responsibility instead of private life, it will no longer be health care, it will be oppression. The road to hell is paved with good intentions.

Immigration problems shed light on why health care won't work

I'm sure people realize that the health care law is long, boring and almost meaningless when it comes to telling you what is actually going to happen to you. So to take a break from that law and address the newest issue on the government's plate, I'm going to tell you a little something I know about Immigration reform. I had been a law student for four weeks when the terrorists flew planes into the World Trade Center, Pentagon, and then passengers downed the fourth plane in a field in Pennsylvania. And I took Immigration Law in the fall of 2002 when the Department of Homeland Security was being formed. So I did a long research paper on what was wrong with US Immigration and whether or not the creation of Homeland Security was going to change anything. What was wrong with Immigration was really very simple. No one in charge of it really cared about it.
Now that may seem like a horrible thing to say, but by 1998 advise was on the table that stated the primary problem with US immigration is that the task of legally getting people into America was not a priority and even though ignoring the need for good service in that area had increased illegal entry exponentially, the government still had not changed anything.
All the priority and power was given to enforcement of those trying to go "outside" the gate, and no one was addressing the fact that smoother direction to the appropriate gate and better facility of legal entry would help the illegal problem. So for decades, governmental advisers had been asking that a separate entity be created, like the EPA for just the supervision of people coming properly to the country. To make a long story short, since The Department of Homeland Security was set up for the sake of security, it hardly made a priority out of making legal immigration function well, and of course the border issue is even worse than before.
So why should I mention this on a blog about health care? Because the issue really is government, not health care. My research says that for almost two decades advisers had been trying to get the government to change and get someone who cared about the art of service to the immigrant to make the flow better so that we would be seen as a peaceable neighbor and not a walled city that had to be overcome. And yet, no change had happened, and after catastrophe occurred, no good change was possible. And now look at our mess.
My personal opinion is that if the government did that to itself, it did it to itself, and since who comes and goes in this country really is the government's right to decide, a twenty year negligence of their own administrative responsibility probably explains why they have the trouble they have now, and they probably deserve it, though I feel very sorry for the people caught in the middle.
But what is going to be the situation when that kind of negligence works its way into the health care of citizens.
Sometime in the past month I had to commit a patient to a State facility. No less than 10 professionals were involved over two days to jump through all the hoops to get the permission for this to happen. By the time I was able to connect with the professional who could receive the patient, eight of those professionals were eating dinner and two of us were working overtime to actually get the care to happen. Both of us were cursing the system that took two days and 10 approvals to function and was still so dysfunctional that it burdened off shift workers with extra work. But ask anyone you know who works in government and they will tell you that the only way things actually get done is the occasional person who is motivated handles it. Otherwise, things are lost in the hours of paper shuffling and getting to dinner on time.
The government of the United States is simply not set up to accomplish things well. They are protective, slow and unwieldy. They are reactive and defensive. They have not been able to maintain good immigration policy in spite of that being a primary governmental duty, they certainly have no foundation to maintain good health care policy.
I have one hope for immigration lessons that may help with getting this crazy health care bill off our necks. If the Feds do challenge Arizona and tell them in court that immigration is a Federal role, not Arizona's prerogative, then maybe Arizona and the rest of the States can get a foot hold to say, Hey Feds, health care is our problem, get yourself out of our business, because we may have troubles, but we know carrying your weight is just going to make it worse.

The Mad Scientist and his Tubes

Sorry about last Tuesday. I am a psychiatric nurse and last Tuesday the world was working up to the full moon. I was busy.

So the next part of this extraordinarily bizarre bill is Subtitle B on Medicare with the following subsections.


Subtitle B--Medicare
Sec. 1101. Closing the medicare prescription drug “donut hole”.
Sec. 1102. Medicare Advantage payments.
Sec. 1103. Savings from limits on MA plan administrative costs.
Sec. 1104. Disproportionate share hospital (DSH) payments.
Sec. 1105. Market basket updates.
Sec. 1106. Physician ownership-referral.
Sec. 1107. Payment for imaging services.

The donut hole is the poster child for why the government can not manage health care because they are a money based system and health care is a love based system. In case you are not aware, Medicare has a "gap" in its medication plans. At a certain level no meds are covered until the total cost goes up to an astronomical expense and then all meds are covered. But a person either needs to be below the gap or above the gap. Middle sitters are out of luck. There is no doubt that this "gap" was designed to stop unnecessary dependence on medication for every possible complaint. Though I cannot prove it, I suspect someone took actuarial tables and looked at the costs of true long term illness and needed dependence and placed the upper level resumption of benefits to make sure that these kinds of things are covered, but then pushed open this "gap" so that people could make choices about medication based on their own ability to pay over a certain amount, and not just lean on government money. But such rational, objective cut offs never work in real life when people and their lives are involved, so of course the donut hole is getting chopped up at a greater expense to the government. Now mind you, I'm not supporting the radical initial attempt to ruthlessly manage medicine coverage, but I know that whatever its original purpose, those people and the people who understood it, are GONE. All we have left is people who look at it now in horror and wonder how such ruthless decisions could have been made and then tear into it to save the day. No one even goes back to the understanding that before the "ruthless" plan, no body got anything. O.K. Maybe it wasn't quite "nothing." but the truth is, no law passes without a benefit to someone, and then each increased benefit (for the purpose of correcting those left out) simply ignores the original reality that nothing could have been expected before, so what is available now may not be quite as harsh as people say.

And there is the perfect example of Test Tube thinking. Since the "donut hole" is clearly such an unfair way to limit coverage, legislators don't go back to the original ground and say "Wait, maybe we should review and figure out whether Medicare D is functional." Instead they take this world where the donut hole is unfair and they put it in a nice sheltered think tank (test tube) to figure out how to solve that. Section 1101 of this Act eliminates that "bad, bad, unfair" donut hole, but does it address how money will be provided now that there is no stop gap for the spending? I don't think so. This is test tube thinking.

And as I read the other sections in this Medicare portion I began to think of the great complex of tubes that Dr. Frankenstein or any mad scientist of the horror movie age always had on hand. The intricacies could be thrilling with vials of liquid popping up here and there connected with tubes that bent and dipped and occasionally had a long rectangular flask connected along the way and at another point had an orb with tubes entering and exiting in opposite angles to each other.
This bill reads like such a concoction. It has five sentences of adjustment to myriads of former bills and laws that are supposed to make each more health care cost conscious. It won't work folks. The right hand not understanding the left is why the current situation is broken. Having the government substitute their own moments of test tube thinking into a new way of managing is just more of the same: different mistake maker.

Medicare was a crutch program that was supposed to give a little more money (by keeping the elderly from becoming indigents) to the health care system that was set up to care for indigents. Now that the health care organizations are no longer set up to care for indigents primarily but are set up to make money primarily, the original premise doesn't work and any adjustments based on the premise are by definition faulty. I learned that my first year of college: solutions based on a faulty premise are necessarily faulty. We are being administratively beat to a pulp because no one remembers the basis of resolution which begins by making sure you have a functional premise.

When people were outraged by the donut hole, they never should have removed it. They should have looked at why it was there, and made such major changes to Medicare that the financial protection of the donut hole would not be necessary. But Congress does not understand Medicare. That department is so large and complicated it probably doesn't even understand itself.

Healing is personal, but the payment method is impersonal. The two will never match, and that mismatch always works better when it is directly applied in the local and private setting, and not strung up on regulations that can not be upheld every time someone is angered with perceived unfairness.

Evaluating HCEAR Act of 2010 Title I Subtitle A

After a lovely vacation to Hawaii, I am back on the blog.

My goal now is to go through The Health Care and Education Affordability Reconciliation Act of 2010 and find out what it says.

As is already known, this bill, and or many of its sections will have to go through legal battles before its provisions are enacted, but it is officially law at this time, regardless of what happens as it moves along.

The beginning of the Law is a declaration of the title of the Law and a listing of the Table of Contents. The Table of Contents shows that the law has two Titles with multiple sections in each title.

Title I Subtitle A is Coverage

There are five sections to Coverage:

Sec. 1001. Tax credits.

Sec. 1002. Individual responsibility.

Sec. 1003. Employer responsibility.

Sec. 1004. Income definitions.

Sec. 1005. Implementation funding.

These sections pick through the Internal Revenue Code of 1986 and the Social Security Act to make detailed changes in those two current laws that will make the Health Care Act more palatable. I would have to have the Codes handy to compare each change, and perhaps I will another day, but the most well known of these changes is to increase the age of adult dependents from 21 to 27 when considering the money spent on medical expenses for tax deductions.

Probably the most distressing of these sections is section 5 which allows a billion dollars for costs of setting up the administration of the law.

I have been noticing for years the carrot and stick approach to control that The Federal Government has been wielding against the States. The super power that the Feds have through the Internal Revenue Code has created constant monetary motives for States to change policy and conform to what the Federal government wants because money is offered.

The constant run for the money is part of what is making our nation fall apart. Practicalities of region and relationship are second class citizens to the way things have to be handled because of federal requirements.

As anybody who has really studied this will tell you, that change occurred in the New Deal. Here is an example of legal battles that occurred at that time.

In CHAS. C. STEWARD MACH. CO. v. DAVIS, 301 U.S. 548 (1937)
Argued April 8-9, 1937.
Decided May 24, 1937.

The issue was the validity of the tax imposed by the Social Security Act (42 U.S.C. A. 301-1305) on employers of eight or more.

The dissent to the case complained not because government was making employers send money in for workman's compensation, but because the federal government was making the states do it for the workers whether or not the states felt that was a good idea.

Justice Butler said the following in his dissent.

The terms of the measure make it clear that the tax and credit device was intended to enable federal officers virtually to control the exertion of powers of the states in a field in which they alone have jurisdiction and from which the United States is by the Constitution excluded.

A trillion dollars to bait and maneuver the whole health care system is a scary, scary Fund. It is a drop in the bucket considering what health care consists of now, but it is such a tempting amount of money that many very private, self controlled organizations will look at and abandon all kinds of safe, normal habits for the conformity of the government and the money, and when they lose their own good knowledge to take on the ways of the money, they will fail. You think health care is broken now, just wait until everyone starts dancing for the money that the Federal government will now be able to bestow to get things their way. Wannabe Favorites, start lining up now. Pinocchio has an extra set of ears for you - and a tail.

Sociopath Week

Being a psychiatric nurse, I am always aware of the seven days beginning April 15th, because as my peers and I dubbed it in our conversations this week: it is Sociopath week. Since today is the anniversary of Columbine this blog will be limited to that particular episode in this week of evil spirits.

I remember exactly where I was when I first heard about Columbine. I was a staff nurse in the best mental health unit for children and adolescents in our city and I had just left work and was driving to a coffee shop to have a cup of after work coffee with a male co-worker. We had had after work beers with groups of friends, and an occasional private chat, but this was the first time we were having coffee together. I heard just enough of the headlines at 3:30p to know that the event was bad and that it concerned children like those we cared for, but my mind was not on the world at that moment and I turned it off to stop for coffee. I was not completely divorced at the time, never imagined dating someone younger than myself, and had in my mind that I was going to set up this lively musician with my musically inclined sister. By the end of the coffee I realized I was not going to set up this kindred spirit with my sister and I needed not to see him until I was actually divorced.

I share those personal details because if my activity of the day had not been so in the world of a man and a woman who care for kids enjoying each other's company Columbine might not have affected me the way it did. I do not have my own children. The mentally tender children rotating through the hospital unit were my children at the time, and as I left coffee and got more of the news, my heart broke for what was going on. From the moment of impact, my impression was not about individuals or schools, but about families. I knew enough about kids who were left out and odd, that I never once thought the easy target "goth" or "skin head" was the real picture of what was going on. I knew lots of weird kids, and many of them were very tight with their parents, it was just that the parents were enough standard deviations off of normal that the kids had no information to pull forward with socially. I really didn't mind such situations. Securely loved kids who just don't have enough information about the outside world are much easier to help than very well informed kids who don't feel secure with their parents. You can just tell the first set what they need to know. The second set has many life experiences to go through to achieve grounding.

I knew what created powerful reactivity, and that was powerful hypocrisy. I developed a personal theory about Columbine. It was based on one little note in the early reporting that mentioned since the day was April 20th a post it board somewhere did not have the month spelled out as usual, but said 420 - the code word for marijuana insiders everywhere. I learned about marijuana from the teenagers I cared for. This was not my world, but I had many of them telling me about making money off of it at high school, needing it to calm their nerves, etc. etc., and I also knew it was a powerful point of hypocritical contention in many homes.
Parents would lie about marijuana use and then severely punish their children for use. The kids were not stupid enough to think this was right, and marijuana hypocrisy was a point of righteous indignation that kids clung to to avoid having to obey any other parental dictum. So I have wondered all these years whether the two perpetrators of this crime were in that situation, either because of their own parents or some other legal authority at school or elsewhere. I wondered if the real hypocrisy of the world they were being given was part of their unreal objection to cooperation with norms.

Like every other long distance, news dependant analyst, I was wrong which I found out this week by reading Dave Cullen's book Columbine. April 20th had nothing to do with the planning of this personal vendetta against the world. The boys were trying to join in the bigger sociopath day April 19th and just didn't get their plans together in time.

I liked Dave's book. It said what I who have done both state and private adolescent unit work already knew. Some people are just determined to carry out their worst instincts. Sometimes others can stop them. Sometimes they can't. If we lived in a way that would make sure something like Columbine never ever happened, we would not live in a free world. Obviously, every time something surprises us like Columbine did, we learn more about watching out for those who are not motivated to be productive, but never the less, if we expect bad, we will end up getting so much more of it than if we expect good and learn to spot the exceptions.

To relate the rest of the story, my co-worker and I have stayed friends in spite of no longer working together. Neither of us have our own children. Both of us have other partners. He was the kind who distracted kids from their own pathology, made them laugh, didn't let them take themselves too seriously, and never let them know what had stopped them from the overblown reactions they were on the verge of having. I was the kind who watched for what the kids actually cared about and set choices in front of them with the resulting consequences, and achieved with their own logic and desires what they could not learn from the expectations of others.

We were a good team, but we had a locked down environment to work in, and we were not emotionally attached to the children we were helping raise, and we never had to stay and deal with whatever happened; eventually, we changed shifts or the kids went home.

Dave's book was good closure for me. Not that I was a community member of Columbine, but because I am a community member of those who care for mental health in children and I have seen both the Dylans and the Erics, and I know that not all of them kill others. That is a very good thing to know.

The Federalism Pill

I got this patriotic notion about the beginning of Lent that it would be a good idea to run as an independent candidate for my State Senate District Seat. I live in a district that does not have a high voter turn out so the percentage of signatures an independent has to get is paltry compared to the available registered voters. I primarily decided that since the State legislatures are the ones that will have to make the health care agendas work, that I should step up with my thirty years of hospital care experience and try to make a difference.

I am sorry to say that I just couldn't make it work at this time. What a wonderful time I had trying, though. I want to personally thank the 135 voters who did sign my petitions as I started out my adventure. Everyone was kind, some were worried about me for what I might be getting into, and others were incredibly supportive considering we met for only moments. I plan to try this again sometime when I personally feel more prepared to include that type of dedication to public service in my life.

I ran into a very small percentage of people who did not want to sign, and learned from them that the issues that are happening right now in our nation are troubling and create fear.

So now that I have decided I can not make the push to be a decision maker in these times of medical care crisis, I have to re-evaluate what my duty is. I have been telling myself since I started this blog that my goal was to read and compare the new health care bill to what I know from the practice of both medicine and law and make predictions on how effective it will be. I will start doing that in May.

But as I walked and talked informing people of my concern that people who do not know what health care is are trying to make decisions about health care, voters wanted to know what I would do. I don't think I answered very definitely at first, but as I got used to the question and more comfortable with my answers, I came up with this.

As a health care professional it is difficult for me to say whether I agree or disagree with the bill. I primarily think that the bill was written by people who know business and money better than service and health care, and thus the bill is neither right nor wrong, but ignorant. Obviously, I was not in favor of ignorant law. As I read it, I will point out the areas where I think the money factors have been appropriately addressed by the bill, and the areas where they are ignorant of the realities of health care.

But if I were President and had to treat the Health Care Bedlam chaos that I illustrated in my earlier blogs, I don't think I would treat the nation with the health insurance pill like the legislature has done. Instead, I would treat the nation with the Federalism pill. In other words, I don't think the overall mess can be handled in one way by one entity. The appropriate doctoring needs to address which entity - state, fed, private, etc. needs to address which problem - regulation, provision, liability, etc. When the right entity is given control of the appropriate issue then better solutions will be found. Sorting is so often the best way out of a mess.

Our Constitution was set up with specific governing duties for the Federal Government and the State Governments. This split of responsibility is called Federalism. By getting back to the true power in the States, and limited government in the Federal government, we could change from the never ending rat race of the States to qualify for money from the Feds into locally functional solutions that meet the needs of people where they are instead of on paper as statistics.

Taxing the hospitals in Ohio

In my fifty years of life the word radical has had an number of connotations. As a college student in the 80's the word meant those who stuck close to the root and really understood what things were about due to their grounding in simple basics. In the 90's the word disappeared from my life, but maybe that is because I was stuck on those simple basics and everyone else looked at me as a radical. Now that we have reached the 21st Century, radical seems to popularly mean anyone who doesn't look like he or she plays well with others. I do play well with others, I just don't think all the games are worth playing.

I have been notified in the last month, that the non-profit hospital where I earn my money is being taxed by the State Government, and in my simple understanding of what is supposed to be right and wrong according to the law, this is wrong.

So here are the games as I understand them. The actual Ohio budget provision for getting money out of the hospitals is a franchise fee, not a tax. However, the basis for evaluating the fee is what is spent by the hospital. This general theory is not inconsistent with governmental rights to exercise franchise fees at a very low percent to support administrative costs of business activity. Commerce requires regulation, and the more activity in the hospital, the more regulation. The State is responsible for many governance issues (in this case, especially those related to Medicare), and supposedly needs to charge a fee for these tasks.

The fundamental problem is that historically hospital activity is non-profit activity, not money making activity, and is supported by private funds. Thus, the State's role in regulation was supposed to be well worth the nominal cost because the State had no capacity to do what the hospital did, and the benefit to everyone was greater than if the hospital did not exist and thus did not require State supervision. I have worked in both State and private institutions and I know that the State cannot operate what the private sector can when it comes to health care.

A Franchise fee indicates an expectation of profit. It is the price like a value added tax that allows the governmental entity supervising a community to get something when people in that community are spending a lot and the government feels it will have extra duties because of the service or product. The fee is supposed to be commiserate with expected governmental expense to serve whatever is coming into the community through the purchase of the service or product. When you evaluate the source of monetary income for hospitals, how is it increasing governmental obligations? The hospitals themselves are objecting to this concept of taking from the community and are trying to remind the State that they provide jobs and income taxes to the governmental entities around them and direct taxing (which is how they see these fees) is going to prevent a lot of useful activity that would do the community good.

What this really looks like is a desire on the part of government to get a part of the money that has been protected from them by non-profit enterprise. When I survey the downfall of our institutions of health, I clearly see that people who saw the money these thrifty, care-controlled rather than profit-controlled institutions had, they set out to get it, and now not just the entrepreneurs with their fancy new health care products, but even the government wants a piece of what used to be protected for the truly disenfranchised.

So let's investigate the particulars of this money grab. The State really could have made advances on legal changes for non-profit investment if they thought non-profit activities were a charade for profit, but they didn't, so it looks like something else is involved.

As was mentioned before, Medicare kept getting kicked around in this game. It had a place, a factor in the agreements and bargains. Now I do not claim to have inside information on any one's purpose, but looking at it as a spectator, this is what will happen. The State increases Medicare payments to the hospitals, the hospitals pay a franchise fee back to the State, and the State ends up getting Medicare money back in its general coffers. The only entity that benefits from this is the State. Medicare never covers all of a hospital's cost (a tribute to the old belief that hospitals were non-profit and were expected to have supplemental income to cover the rest of the cost.) The hospitals, as has been pointed out by many others, will lose more money by doing more Medicare business even if a little more of the costs are covered. The Medicare system does not benefit from the State increasing coverage payments, because Medicare, as was earlier discussed, cannot be seen as having unlimited resources. The limitations of Medicare have to be accepted by the private and public users of the system. But the State will benefit, because Medicare money will pass through the system and contribute to their general fund.

Now I like my State, I don't really want it to go down in health care history as the Enron-Madoff of creative health care stealing. I seriously doubt anyone followed the fishing line to its inevitable conclusion, but at this point, at least the amount of expense the hospitals spend on Medicare has to be eliminated from the franchise fee basis for the tax to be even close to ethical, and possibly to even be legal.

The Ohio Hospital Association, the group that informed me of what was happening, also holds that the hospital's franchise bases should subtract the amount of uncompensated expenses they offer rather than taking a percentage fee on services they are never paid for. That the OHA even has to ask this is an indication that the government has forgotten what the purpose of a private, non-profit hospital is to the government's capacity to function. Hospitals are the whipping post of unfunded mandates in that they are told they are legally liable for all kinds of things they will never be paid for. As a psychiatric nurse in a State that has closed most of its institutions for the chronically mentally ill and developmentally disabled, I am daily made aware of what the private hospitals have to do to make up for things the State refuses to do. For the State, which has been closing these institutions for twenty years to suddenly decide that this unreimbursed care must be taxed is a slap in the face to the groups that have been trying hold the safety net under the cracking system.

And the final request of the OHA is that the tax rate (franchise fee according to the governor) be decreased from 1.61% to 1.5%. If the institutions involved have evaluated the situation and realized that State activity has also received unfunded mandate by Federal activity and are willing to contribute a "franchise fee" the percent is very important. The percent has to reflect something the hospitals can manage. These groups are not making money (remember that Medicare reimbursement is at about 85% of cost), they may be like your rich uncle who has money, but they are also "sending everyone to college" like the rich uncle does, and when the money is gone, the service will be gone also. Every week more doctors refuse to take new Medicare patients, or drop out of the reimbursement system entirely. Services are not like products where the product will go on with robots whether the people work or not. If the care providers are not happy, many will stop providing. While things are changing between the government and private, non-profit institutions, if the government does not listen and keep them happy, the government has the most to lose. Remember, the government can not cease to exist, but the institutions can. Don't imagine that things will be better if they are forced out. Give them the rate reduction.

Simple basic principle: non-profit means non-taxed. Don't tax the hospitals. If life has changed enough in the world of health care regulation that hospital activity really is a stress on the government, make sure the hospitals are happy with the franchise fee, or else have them pay for governmental services that they have to have to exist. But above all, don't take the Federal government's money by passing it through non-profit private institutions.

The real reason the Federal Government is forbidden from giving money for abortion

Difference of opinion on the appropriateness of having abortion be a legal instead of illegal action has caused a time warp of passionate activism that has turned the entire issue into a impassible screaming match about right and wrong. These things are not of interest to me in my topic today. I've never really noticed that people behave according to right and wrong, regardless of what they think. People will do what they feel they want and need to do in the circumstances they are in. Even in retrospect, they rarely ask if they were right or wrong, but may ask if they were short sighted at the time of the decision. They may even believe it is wrong and do it or right and not do it. There is a great amount of debate on whether the current health care bill allows public money to be used to fund abortions. While I am not trying to say that the bill does or does not allow this, I am going to give the reasons why the bill should be interpreted according to tradition which absolutely disallows any use of public, governmental money for elective abortion.

Today is passover (Well Tuesday is passover, but this may not post until after midnight making the date Wednesday). It is the remembrance of the day that Moses led the Hebrew slaves out of Egypt to become a free nation. As we have been reminded in the news and literature of this holy week, Moses is a national icon, and for both the Founding Fathers and the Civil Rights movement, a man to revere. But in case you have forgotten, Moses existed because his mother had to hide him from a national abortion program. The Egyptians were afraid the Hebrews were going to become too strong to be kept as slaves, so one of the Pharaohs started a birth control program where the midwives had specific directions on how to maintain the balance of power by killing the male babies as they were in the birthing process. Moses' mother managed to bear him without a midwife and hide him in a basket which was sent floating down the river for a princess to find, and the rest is history as they say, which you can watch this Saturday night by tuning into The Ten Commandments.

Now a days, governments aren't quite as rankly power seeking as the reports from ancient Egypt seem to indicate they used to be, and programs for birth control are billed as human rights, so that the poor can have the potential of increasing their economic status without the interference of unwanted extra mouths to feed. It is primarily the rich who sit around and discuss these needs of the poor. Every totally destitute person I have ever met has cared only about their child, not about their economic status in life. But then, I am not in the business of urban renewal or economic stimulation. I am a nurse, and hanging onto people over possessions is a lot of what the world of healing is based on.

To prepare for this posting I read a few United Nations reports and discussions of over population and the plans that have been considered to cope with over population. These proposals made me wonder if no one had ever heard of Darwin, that they had to calculate who would survive as opposed to allowing nature to take its course, but I suppose Darwin is too brutal for consciences social scientists to accept, and trying to create a survivable world up front by controlling populations seems less cruel than having everyone "duke" it out for survival in an uncontrolled setting.

But again, I am not trying to judge or limit any one's personal opinion or scholarship about the best ways to approach our duty to love our neighbor as our self. There are many ways to fulfill this duty, and some seem extremely paradoxical.

What I think should be understood is the limitation of power that is required by the U.S. Constitution that eliminates the government from paying for abortion. Now I know that I can not quote the Constitution to prove this. But did you know that the Declaration of Independence complains about population issues? In the list of grievances, King George is blamed for trying to "prevent the population of these States: for that purpose obstructing the Laws for Naturalization of Foreigners; refusing to pass others to encourage their migrations" etc.etc. Similar to the concept of Pharaoh reducing the population by killing babies so they would not become strong enough to oppose him, the Founding Fathers accused the King of preventing their population from growing so that they would have strength in numbers.

We seem to think now that increasing numbers of people are a negative rather than a positive thing, but I am living in a city where empty buildings are a dime a dozen, so I think we should be taking another look at what nature says is a strength. But whether we get personally philosophical about the subject or not, we have to admit that our system of government was specifically set up to prevent the government from having the kind of power that Pharaoh and King George had: power to make decisions that can change the power of the people through numbers.

Now you may say that since the individual mother is the one asking for the abortion that it isn't a matter of the government making a choice, so it doesn't matter if the government pays the bill. But government is not an issue of choice, government is an issue of power. As soon as the government is providing the money, the government has power - ask any State Legislature about this one. We need to keep the tradition that keeps government money away from abortion because we don't want the government to cross that line of having power in the arena of abortion. To make abortion legal is to give power to the citizen by allowing choice. To pay for it is to pull strings around that choice. Of course the law won't be made for the purpose of pulling strings, but eventually that little bit of control will become a crack in the wall between individual choice and policy making for the greater good, and more surprising things than Pharaoh or King George could happen.

To give you an example of the kinds of things that happen when policy makers provide money for birth control, I refer you to the quarrels of the late 90's that the UN had with its birth control programs. They saw it as a human right, but poorer countries saw it as a way to control their people. In South America there were accusations that governments were using UN money for forced sterilization of poor peoples or minority groups. Of course this was bitterly disputed, and I am not interested here in who was right or wrong. The International Criminal Court considers sterilizing people against their will a crime against humanity and the quarrels are usually interpretations of "willingness." I am simply trying to show that without strong walls about certain activities (bright lines in law as we say) trouble abounds. It would be good for the Feds to avoid paying for abortions so that they don't wander into an accusation of minimizing the growth of minority groups who may be the default groups that would use such a benefit.

But even more than that, it is a principle of our "people-based" nation that the government should not have basic control over our lives. The government is given the right to pay for war and executions, but all other activities are about life and productivity, not death. We don't want the government to have any power over citizen death that is not allowed by the Constitution and all its procedural safe guards, and that means no government money for abortion.

The Lunatic is in the Hall

No doubt when I write what I know I get more interest. In conversations about my Health Care Bedlam from last week, I have been challenged to think more about the analogy.  The political events since last week have fed the illustration also.

One of my co-workers wants to know who the narcissists are. My immediate response is that narcissists rarely end up in the mental health unit because they are so internally motivated and self-vision minded that they don't meet the decompensation traits that require intense treatment. I've seen them visit the unit when their daughters are there with anorexia, or their colleagues are there with suicidal ideation, but they are rarely the patients. However, after a few days thought, I did come up with a group that fits the pattern of narcissist. It is hard to put this out there, because more than any other group, I belong to this group, or I should say of the groups I have belonged to in health care, this is the one where I feel most at home. Secondly, the narcissism of this group is not dysfunctional to the group - but then, that is the goal of narcissism, to watch out for ones self. And even more, the narcissism is not even necessarily a personal choice. There are aspects of this narcissism that are legally binding and demand that this group stay to itself and not interfere or get involved with the issues of the other health care craziness.

The narcissists in the current health care crisis are the religious or private organizations that are running health care systems as a part of their reason to be. These are the church organizations, or the social club networks, or the religious structures that have a vast membership of likeminded folks who are driven by similar principles and as a part of that disciplined and directed life style have been able to expand on their social power to provide health services for themselves and others. To call the good Samaritans the narcissists for my illustration sounds like the height of ingratitude, but I am not painting the picture from the perspective of God and the final judgment, I am painting the picture from the perspective of social welfare under the current government of the United States of America. There is a vast denial among private institutions that what the government does is going to affect them because they are private and often religious, so they are standing oblivious to others and focusing on their First Amendment rights. They have an old fashioned trust in the barrier between profit and non-profit that they feel will guard them from being controlled by whatever it is that is going on in that asylum up the hill. They also have a legal obligation, as long as they are non-profit and taking government money for Medicaid, etc. to avoid any political overtures on policy. Although the most satisfying healing has historically been in the private, religious setting, the current debate on health care cannot include what really works because it must keep a separation between "church" and state. Unfortunately for these head in the sand policies, the lunatics are already loose in their halls, and the political insanity is spreading its tentacles through the wall of private institutions, attaching to the stones and rooting out the foundation from the bottom line. Narcissus died in sorrow gazing at his own reflection. As a member of a church who knows how great some of our parachurch educational and health care systems were, I see us sitting at the river wondering why we are a mere reflection of what we used to be, and not understanding before we are destroyed.

But back to Bedlam.

Last week, in spite of trying to open my eyes to the dynamics of what was happening, I totally overlooked a group of players. There have been times in the past when the whole health care debate was framed as "health insurance reform" and I did not say anything about where the health insurance companies fit in the picture. What is quite obvious is that health insurance is the magic pill that the political doctors are trying to use to cure the crazy health care patients.  If everyone has health insurance (if everyone takes their medicine) then all will be fine. Health insurance will bolster the weary hospitals, health insurance will cover the costs of medicine for the drug company, health insurance will satisfy the needs of the medical equipment companies, health insurance will give the doctors what they need, health insurance will make it so the States don't have to cut on themselves anymore. The inexperienced psychiatrist who has read all about wonderful medicines that can cure things that used to cause problems tends to look for the right pill, and not look for the cause and effect dynamics to gain insight in solving problems. Obama is prescribing health insurance for the health care problems, and expects that now everything will be fine, because everybody knows that the ones with health insurance are taken care of, so if everyone has health insurance then everything will be fine. Although I haven't analyzed every possible news source, I think the health insurance companies are not exactly cheering at the thought of being the big fix. Why should they? Health insurance is a carefully crafted statistical gamble. It  functions fine in a vacuum tube with tightly limited parameters, but burst that controlled setting, and suddenly they have no bases upon which to gamble, and their advantage is gone. With no advantage, they have no motivation.

The other nurses with whom I share an office have brought to my attention that the entire past weekend was an exercises in "crazymaking." Apparently this word grew up in the social psychology world to describe the confusion that occurs when people use language to demand things that are in direct contradiction to the language being used. As a linguist, I am not surprised I never noticed this term, because I believe that meaning exists before words, not as a result of them, and "crazymaking" requires words to have stand alone meanings that are only defined by the user and can be changed at the users whim. This does explain why Obama is totally ignoring the Tea Party movement. In his mind, they are "crazymaking", and do not see or understand how good things will be. Of course, to them, Obama and friends are "crazymaking" and do not see or understand how bad things will be. The crux of "crazymaking" is to divert from real issues. For example, in Hogan's Heroes, every time the guys wanted to make a diversion work so that they could control something, LeBeau would run around yelling: "Panic, everybody, panic."  It doesn't matter if you want to divert from the lack of resources, the lack of equality, or the lack of choice, to behave as though ones own reality is the thing that is best for everyone else is in DIRECT contradiction to the principles of freedom. Such diversion is actually for the purpose of control, and control is not the function of our government. The function of our government is balance of power.

A comment on what makes people turn to "crazy making" indicated they were experiencing the deprivation of their right to know, right to feel, right to impact their own decisions and right of space. I've said before that time and space are the two biggest factors in recovering from crisis. The patients need time to know what is going on, time to feel what is true to themselves, time to make their decisions, and space to feel safe. If the Tea Parties look crazy, maybe it is because the policy is being handed down in a "crazymaking" manner.

Since the U.S.A. has no foundational creed or code of principles to call on for times of crisis, and each person or group must stand for his or her own principles , it is hard to cope in crisis. Ancient peoples pray in crisis, or appoint a Czar, or find some way to do things more efficiently than the processes of problem solving require. And as much as people want to claim that the Constitution is that foundational creed, it really isn't, because it guarantees individual creed, and individual right to thought, so it cannot support one primary thought that the people can all rally to in time of crisis: Except for the ultimate goal of balancing powers, which is to do the right thing, the right way.

If  there is any over arching principle to drive us as citizens together, it should be that the Constitution gives us a guide in doing the right thing the right way. Sorting, pinpointing imbalance, analyzing capacities, all of the time and effort functions that slowly evolve into a new path as people pursue proper channels is the answer to our problems. Health care needs some old fashioned psychoanalysis and a reality check. The dreams have been a little too out there which we are in denial of, and the responsibilities have been vastly overlooked, but we don't want to work on it, we just want the magic pill.

Well, there is a character who always takes charge when you just want the pill to make everything better. Her name is Nurse Ratched, and once she gets in power, the pill becomes the only answer whether you like it or not.

Beware of what you have asked for. You may get it, and you may never know what happened.

Health Care Bedlam

Bedlam means a scene of uproar. The word comes from a shortening of the name of Bethlehem Hospital in London which became one of the first "lunatic" asylums in 1547. What one doctor considered a lunatic in 1547, another doctor would probably have a more definitive diagnosis for in 2010 like schizophrenic, manic, obsessive or even Alzheimer's. I have done no study on the comparisons of people who were locked up in the 1500's to those locked up in 2010, but I suspect that they were very different.

Regardless of the practice of mental health care, the end result in the unit can be very much the same. The bringing together of all the individuals who need specialized attention to tolerate structured society still creates a scene of uproar in many cases. As a nurse who has worked in mental health patient units for over thirty years, the uproar isn't always just the pathology of the patient, it is also very much the pathology of the treatment.

Just as doctors in the 1500's were unaware of many of the chemical and social pressures that caused things they called "lunacy," mental health treatment is often still a stab in the dark at offering answers for things that may not be understood for years, or possibly ever. The main goal of the mental health unit is to provide safety to the patient and to others from the patient until a higher level of stabilization can be reached. Just the fact that getting from unstable to stable is part of the goal of a locked unit indicates how much uproar is occurring.

When I got up this morning I wasn't sure what I was going to blog on today. The president has said that all that can be said has been said about health care, and I know I have enjoyed reading the well researched comments of others today more than I have enjoyed trying to puzzle out things that are 2,000 pages long.

So today's blog is going to be a little picture of bedlam. A little allegory of the treatment that is being performed on our health care and the uproar that that has caused.

Let's make the patients in the unit, not individuals with health care needs, but the different, individually operating parts of the health care system. We have the Bipolar drug companies who lavish money on doctors, research and ads in their high moments of great discoveries, and then become suicidal when they can not charge and keep "patents" or are pressed to offer drugs at prices people can afford rather than prices that cover their lavish expenses. We have the schizophrenic doctors who live in the multiple worlds of money, charity, urgency and necessary risk prevention. They still have traditional duties such as not to harm and to provide for the poor off of the capacities of the rich  yet they are losing power to control their own actions so quickly, that much of their practice has become empty attempts at appeasement to demand rather than carefully studied exploration of need and treatment. We have the deeply depressed hospitals who have given and given and given, and tried to cooperate with laws, regulations and demand and still are being emptied of their capacity to serve. We have the sociopathic medical supply companies that suck money out of health care by keeping their wares at free market competitive levels with no thought that they are pricing health care through the sky. They are the new leaches that bleed the needy through money the way doctors did in the past with leaches. We have the obsessive-compulsive Medicare and Medicaid systems who demand that things be done exactly as they want them all the time, without fail, or fault, or variation which is of course impossible, but they have to keep believing it is possible. And last but not least, we have the self mutilating States, who are so confused about what is helpful and right to do, that they have started cutting themselves up hoping to find some answers.

President Obama is the young, newly graduated psychiatrist who has studied it all in a book and is doing his best to make it match reality - but it never does. The Senate is the staff - therapists, nurses and social workers who try to show the patients what they need to do to help themselves, but the advise never quite gels  because what the patient reports when locked up is not exactly revealing of what is happening at home, or in the work place, or even deep in their soul no matter what is seen on the outside.  And the House is the Patients Rights Group. They are trying to make sure the patients get their rights because they are convinced that all those who have complete access to all their rights will get the best outcome.

My Bedlam is not far fetched.  In fact, it is just a clearer picture of what everyone is saying when they observe that our health care system is broken. It is broken in spirit, unable to function for social productivity, and on the verge of self destruction.

The House is trying to guarantee rights, which will not empower health care. The Senate is trying to force it to do what it needs to do, which won't happen. The President is trying to understand, diagnose and treat it, but he is not competent enough for the job. Change does not occur until it is self determined. The biggest secrets to fixing crisis are giving them time and space to fix themselves.

In general, more pressure equals more crisis, less pressure equals less crisis.

I see in the great health care reform bill the same treatment pathology that repeats itself over and over in psychiatric units across the country. The patient is able to avoid facing truth and responsibility because someone will believe in their suffering enough to argue that someone else should take responsibility. The patient goes forward looking for who it is that should be responsible and never figures out that they can actually do something themselves to make things different. The therapists in my little allegory are not healing anyone, they are trying to fix things as they think they should be, and that never works.

I liked the self-determined attitude of the people who were demonstrating in D.C. today against the health care bill. They wanted to figure it out and be left alone to make a difference for themselves. I'm pretty sure that is what being an American is about. It isn't easy, but in the long run, it is the only thing that produces success.

Healthcare Bedlam

Religion: A Primary Force in Health

As the daughter of medical missionaries, I grew up with religion being a strong part of health and health care. I have worked in both government and religious health institutions and I admit that I always felt the most comfortable when the work of the institution was considered a service to God as well as to the people involved. This especially helped when caring for unappreciative people (as I often do in mental health) because God appreciates the work even if the receiver does not.

I was wonderfully reminded of the style of health ideals that I grew up with when I saw a new documentary this weekend called "The Adventists." This movie by Journey Films traces the history of The Seventh Day Adventist Church and their passion for health and wellness as a part of their religion that drives them to serve others also. Probably the most famous of their hospitals is the one at Loma Linda, California. The Adventists happen to be vegetarians, and I am not trying to say here that I believe we should all do as they do, but their model of passion about life for spiritual reasons is the big boom energizer of health that has become forgotten in the rush to find profitable markets to heal the sick.

I hear plenty of talk about changing our health care from an illness based system to a preventative and wellness based system, but I hear nothing of how to make people want to discipline their lives to be healthy. Certainly the government does not have this kind of motivational power; even the things they make illegal are abundantly used by citizens.

There are some individuals who have the self fortitude to discipline themselves for the sake of their own self esteem, or so that they can live longer with their children, or be an example for their children, but this percentage of our population is dwindling as we constantly increase the numbers of obese and morbidly obese people and children in our nation. Many of my generation were raised with health habits drilled into us by our mothers, but the sway of mothers over the diet of children is also a decreasing factor as mothers work and children fend for themselves with fast food.

The stunning theme that this documentary portrays is that passionate belief in something greater than ones self has been the motivation for healthy habits that have led to our great health care systems of today. I'm not Adventist, but I recognized the fervor and group discipline in them that I experienced in my own religious upbringing.


There is a telling little exchange in the movie "Mars Attacks" where a reformed prisoner who was a prize boxer talks about wanting to live cleanly instead of do a "job" for a wealthy loan shark. The boxer talks about getting in touch with Allah and giving up pork and finding out about peace in life. After this heart felt soliloquy the loan shark says "So you gave up pork?" Clearly the loan shark couldn't understand why someone would do anything that abandoned bacon and good chops, which made him oblivious to the spiritual strides also. But the point is possibly better made by the lack of understanding than a responding empathy. Those who reach the level of self control where they can make disciplined choices that end up improving their health and lives all together, do not fit into the world of risk, profit, gain and indulgence that drives a progressive economy. They become immune to the call to consume because they have their mind on something else.

There is an interesting observation in the documentary that people do not come into the discipline of healthy living until they fail or reach the bottom of their own attempt to live as they wish. Since I work in the mental health and substance abuse field, I am well aware that most treatment is wasted until the person really wants to change. This becomes a real conundrum when it comes to preventative medicine goals, because many people simply will not comply until they are ill and have no choice but to change.

When people who have come to illness through refusing to maintain wellness want health care, they want it to fix them while they continue to live their unhealthy life style. They want the pill or the treatment that will just put things back to where they were before their body wore out with their unhealthy habits. So they want to buy fixes, they don't want to learn changes. Here is where the role of religion and group dogma rescues people in a way consumerism medicine never can. Commitment to principles is inexpensive and self empowering. Consuming treatments costs money and creates dependency. The person who adds a passion for principled life to his or her health care considerations becomes free from illness and the system. The person who keeps trying to find some fix that will keep him or her from having to change becomes poor trying each new thing and dependant on the system to keep offering options other than change.

But submission to principle is no longer a significant factor of our society. At least, it is not expected anymore although it is sometimes admired when it is seen. And I pose the question again: Where will such truly healthy disciplines come from as religion declines in the country? The most ancient religious rules of our Judeo-Christian heritage had food and cleanliness guidelines. We now know that such things led to health among the people, but we have a governmental system that cannot dictate that. We have a governmental system that presumes that people will be self controlled for reasons other than government enforcement. When we were a widely religious nation, keeping our various food and life style restrictions, this worked. Since the current trend of bodily care has turned away from spiritual things and into a philosophy of self indulgence, we have big problems.

The Adventists documentary is a good picture of how things way outside the world of science and logic actually drive the benefits we have found in science and logic - in this case, specifically in health care. If we try to re-invent these benefits in health care without having the motivating factors, we will fail, like a house without a foundation.

My blog in general is dedicated to finding the lost spirit of health care in America. In this posting I have come, though the example of the documentary, as close as ever to showing that the health care crisis is in actuality a spiritual crisis and as such can only be fixed by spiritual means.

How Capitalism provides for Social Needs

When I review the health care plan that was presented in Feb 2010: something I am in the process of doing; I will be judging it according to some very strict expectations about what is real and productive and what is not.

For example, It is real and productive to allow big tax breaks for people who contribute to non-profit hospitals such as The Shriner's to provide free care to very needy groups of health care consumers who could never afford the thing they need.

It is not real and productive to make promises that every single health gripe that anyone has will be immediately covered by the best possible care. There is not enough money or love in the world to provide that unless it is God's love. But in general, we are not allowed to count on the healing power of God for the poor or disenfranchised as an option for health care in The USA; so we must deal with lack of resources in spite of the fact that no one wants to come out and say who it is who will be on the short end of the lack of resources.

We have started thinking about health care like it is a right (noted in the 1963 article of my last blog) and since it is a right, whether or not one can pay is not to be considered. Instead, the problem is approached emphasising the need and assuming the resources for it will be provided. This is not practical. One of the major problems in health care is that it is not really a productive market upon which to exercise the economic principals of capitalism. Health care ultimately requires a contributor. Private ownership was the first contributor, charity was the second contributor, local government was the third, insurance plans were the fourth, and federal government plans were the fifth. When private ownership and charity were the economic force no speculation was involved, and services were limited to whatever was provided at the will of the provider. When insurance and local governments were involved speculation began to influence the factors of provision and services became a tug of war between expectations and resources. When the federal government became the provider it was PURPOSEFULLY set up to get more service than market price would provide and services were expected to be provided regardless of the will of the provider for recompense. Our own government defied the rules of our capitalistic system when they declared that Medicare and Medicaid would not expect to cover costs. They created a dysfunctional support that is now falling apart. Of course they did this because they were trying to address a social need. They were not saying that all health care should be given regardless of cost, they were trying to boost the cause of the disenfranchised by guaranteeing some money to those who cared for them. But breaking the rules is still breaking the rules. Doing a non-capitalistic exercise in the face of a very capitalistic system has simply made health care the dog of the day for the fleas to suck blood out of. The art of capitalism has inflicted the financial pain that health care is in because there was a source of money that was not subject to the restrictions of the market, and it attracted exploiters. Every exploiter had a good motive - look at what great gizmos and guarantees we have in our health care - but their good intentions have still paved the way to our health care hell.

So what is the proper way to handle social needs inside capitalism? The answer is non-profits. There has to be a way for people to block themselves from the ruthless realities of capitalism to have a sheltered way to manage their money for social need. And these non-profits have to have the right to govern themselves and choose the risks and coverage that they as a group want to take. In the old days we called such an organization a hospital, usually a religious hospital, that had a large doner base and people committed to the cause who productively managed the resources at hand and did not have to answer to anyone other than their own private management. Of course the advent of extreme insurance claims has broken down the barriers between non-profit right to control and public market, but that is a subject for a different day.

I am personally the third generation of people who ran and started such hospitals all around the world. These mission hospitals were started when national efforts of fund raising by churches provided the resources to set them up. But I can see clearly that such strong networks of related peoples do not exist anymore, and the social bases that supported these social institutions are just not there.

So how do we keep the economic structures pure and find the social support to run something that is not run by the government? Well, I think the Senator for North Dakota is on the right track.

The following is an excerpt from Senator Kent Conrad's website (Just Google it if you want to read it, I'm an old lady and don't have the URL handy)

Kent Conrad Promotes Co-op plans for health care reform:
"How would this be better than a government-run public plan option? The co-op plan aims to achieve the same benefits for consumers as a public option without government control of health insurance. It does so by creating private, consumer-driven, non-profit health plans. Because these plans will be owned by their members, they will focus on getting the best value for consumers, rather than maximizing plan revenues or profits. In addition, since the federal government would not be backing the cooperatives, there is no government liability or support beyond the seed money. Finally, the co-op plan uses the tools of the marketplace to address the health care reform principles of choice, quality and cost. "

I recognize this pattern. The government becomes the "church" that sets up the co-op, so in a way it is the contributor, but once the institution is set up, it is supposed to become self-sufficient - the goal of any good mission institution- and the government no longer has a fiscal responsibility for it and as such cannot dictate what will happen. The will of the group is the dictator of what will happen. Does this mean some inequality in health care will exist and some people will not have the resources? Yes. But the philosophy of capitalism is that when the rules are kept, human nature provides the best distribution of resources through capitalism because everyone has an ability to affect the outcome as opposed to faulty judgement of a few for the others. And one of the rules is that social need money must be protected from market money by non-profit status.

The Senator's co-ops will return us to the very productive pattern of health care where the provider decides what will be provided. If you want a good service, it is best to give the service provider control.

A healthcare history lesson

Since I am a 50 year old woman, there are days, weeks even at times, when I simply cannot think. Today is one of them. So instead of trying to think, I am simply going to report.
When I was going through boxes I inherited from my Grandmother, I found a Saturday Evening Post magazine from June 15, 1963 with a cover story: Exclusive-A penetrating study of The American Doctor, Troubled by his wealth and his changing image.
The article was written by Evan Hill, a World War II Veteran who spent four years in a military rehabilitation hospital and wrote about those experiences in a May 1960 article called My Memorial Day. Mr. Hill's article about his war experiences show him to be someone who experienced healing in a very intimate way. He watched and knew about patients and doctors. So I have selected quotes from his cover story on the modern doctor of 1963. The remainder of this is direct quotes, no commentary. As I said at first I cannot think today.

The American Doctor: Death of a Legend in an era of Miracles, by Evan Hill

"Old Doc could do almost nothing for pneumonia and many other diseases except relieve pain, stress and distress. . . Today Young Doc uses a magic needle instead of a magic personality. . . there is often little more than swift, lifesaving science and almost equally swift medical and pharmacy bills."

"The result of specialization is impersonalness, but the fact that it's impersonal does not mean that it's poor medicine. . . Both doctor and patient have difficulty adjusting to what Doctor Gipstein calls the 'general dehumanizing of everything throughout society.'"

"Yet. . .the AMA and the great complex of city, county and state medical societies which is identified as organized medicine has served the nation very well. Perhaps 80 percent of it's efforts and money have been devoted to science and the education of public and physician alike in medical matters. But this work goes on quietly, with scientific caution, for the medical profession - not unlike other highly trained professions - seems to have an innate distrust of both the patient's and the public's judgment."

"Today, with such a small number of uncollected bills, there is little justification for the old time Robin Hood philosophy of soaking the rich to take care of the poor. Yet there are still physicians who adhere to this practice. This is where the grievance committee comes in."

"In all fairness it must be pointed out that the doctors receive only a fraction of what the public spends for its health. Physicians fees were 27.6 percent off the health-care dollar in 1961, and they have risen less than have all services listed in the Consumer Price index."

"The desire for independence is perhaps the most significant facet in the profile of the doctor."

"The physician, like the Amish, is so used to doing things in one economic way for years that he is simply resisting change. He feels, as a minority, that he is fighting for his rights. In fact, much of his resistance to an intermediary- whether government, unions or insurance companies-is simply because he doesn't want to feel he's working for someone other than himself."

"This brings us to that much discussed doctor-patient relationship, the sanctity of which organized medicine sees threatened by Medicare, group practice, hospital insurance and any other alterations in the pattern of medical practice which it opposes. Organized medicine warns that the relationship will suffer greatly, or entirely disappear, if American medicine ever is 'socialized' Yet , closer examination of the problem shows that the forces of society and science are stripping the doctor of his warmth, often preventing the patient from receiving it when offered. Neither the patient nor the doctor has time to get acquainted."

"Times have changed: science has changed the patient has changed, and so has the doctor."

"The doctor's innate independence is not helping form a fonder image, and he is unlikely to change. The patient will not become less educated, less demanding, or less critical. I addition, Americans, despite the cries of organized medicine, are beginning to feel that medical care is a 'right' and not much different from such established services as education, fire protection and public roads, regardless of who pays for it or how."

"It is true, as a mid-western physician says, that the profession has deteriorated in the public eye even though medical care is better than ever before."

"The public does not hate the profession- Generally it has great respect for it, and it has reason for such respect. But it has little love-at least not the love it had for Old Doc-because neither the New Doc nor the new patient has much time for love. And with the immense growth of specialization coupled to the phenomena of the vanishing family doctor, the patient finds it somewhat unrewarding to love a scientific instrument."

"The fact is that the problems of the American doctor are born, not of despair, but of progress."