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.