Thursday, March 23, 2017

Making Health Insurance Affordable

One of the complaints about the Affordable Care Act (ACA, also known as Obamacare) is that for some people it contributed to an increase in the premiums they had to pay for health insurance.  The observation was made that they were being forced to pay for health insurance that included more "essential health benefits" than they had previously had, and that drove up premium costs.  Metaphorically, they were being forced to buy a Cadillac when they had been perfectly content with a Chevette.

Insurance is a mechanism for sharing risk.  Thus it works best when everyone participates.  If people with low risk opt out, choosing to go without insurance and take their chances, and only people at higher risk (or who are most risk-averse) are in the "risk pool," premium costs will be higher.  The people who are uninsured may get sick or hurt and require care that they then cannot afford.  Most likely that care will be provided anyway, resulting in their financial ruin, and since they will be unable to pay for it, the cost of that care must be spread among all who do buy into the risk pool.

This is the rationale for requiring everyone to play.  This was also the trade-off for getting the insurance companies to drop their exclusion of pre-existing conditions.  If you are not allowed to wait until you get sick or hurt and NEED coverage to buy it, there can be no justification for denying you coverage for a problem you already had when you bought insurance.

So, what about this "essential benefits" package?  Why do we have to do that?  Why pay for coverage we think we will never need and didn't have before?

When you buy auto insurance, there is something called "comprehensive" coverage, which covers everything other than collisions.  So if someone dumps a bucket of red paint on your white car, it's covered.  Likewise if you return to the car you parked in a high-risk neighborhood and find it perched on blocks with its wheels missing, or someone's ex-girlfriend mistook your car for that of her jerk of an ex-boyfriend and carved obscenities into most of the painted surfaces, or she took a baseball bat to the hood and fenders.  Or maybe you parked it under a tree with a limb you didn't realize was dead and which then fell onto the roof while you were in a nearby store stocking up on beer for this weekend's March Madness games.

You wouldn't think the coverage was very comprehensive if, for example, it didn't cover damage to your car caused by someone who didn't like you, and the insurance company thought you had it coming, or the policy excluded "acts of God," and the insurance company, declaring God all-powerful, used that to refuse to pay for just about anything.

So, back to health insurance.  Suppose you were presented with a long list of things that could be covered or not.  You could go through and pick all the things that you thought would be expensive and that you were unlikely to need, and leave them out, thereby lowering your premiums.  The insurance company would then do an actuarial (risk) analysis and charge you an accordingly low premium.  But maybe your assessment of your own risk was wrong, or you were just unlucky, and now you have expenses that aren't covered because of the choices you made.  You are now in the same situation you would have been in if you had been able to decide not to buy insurance at all.

To prevent this, policymakers had to decide what coverage everyone should have to buy.  Inevitably it includes something you will never need.  It may cover expenses related to pregnancy, and if you are a middle-aged widower, you may be quite correct in thinking that is coverage you will never need.  Similarly, you may not want to pay for coverage for mental illness if you have never had one and have no family history of that, but mental health problems are common, and it may be very expensive if you're wrong in your risk assessment.

But many people deride the ACA - especially the "Affordable" part of its name - if it made their premiums go up because they had to pay for coverage they never had before.

Here's a policy you can almost certainly afford: it will cover you for injuries sustained if you step on a land mine near your home in rural Iowa.  No other risks to your health are covered.  Oh, and you are on the hook for the first $10,000 in expenses, but after that the insurance policy kicks in.  I can assure you, the premiums for this coverage will be VERY affordable.  And the value of the coverage to you will be essentially nil.  This will really be the same as having no health insurance at all, unless your Iowa neighbors take a strong dislike to you and start planting landmines along the perimeter of your property.  By reputation, at least, Iowans are not like that.

The now-proposed American Health Care Act (AHCA) will allow people to buy health insurance that is much less comprehensive than under the ACA.  The appeal of lower premiums with such an approach is strong.  The AHCA's critics from the right call it "Obamacare lite."  (Tastes great, less filling, right?)  Because if it still requires you to have health insurance, it's still an unacceptable government intrusion into your life.

Until you find out that what wasn't included in your new policy is something you actually need.  Oh, no!  Why did Uncle Sam say it was OK to buy coverage that didn't include the costs of rehab after the surgery for my broken hip?  Why didn't anyone tell me I should pay for maternity benefits even though I wasn't planning ever to get pregnant because life doesn't always go as planned?

If there is an essential benefits package, that everyone pays for, then there is enough money going into the risk pool, and everyone is covered for all the things the experts say the average American may need.  That's how risk sharing works.

Maybe you think that's just too costly.  There are many other ways of reducing costs.  Skimping on coverage is the wrong approach.

Wednesday, November 16, 2016

Dialogue - Not Plato, But Timely

I have long been intrigued by the give-and-take on social media websites.  Some of it is witty, brilliant, even coruscating.  But some of it is - I hesitate to use this word, given its recent context - deplorable.

To use a clever remark whose originator I wish I knew, I am proud to be an American until I read the comments.

Last week I posted a short essay, the sort I think worth writing but too short for this blog.  The situation: a physician colleague had posted something about her angst, in the post-election period, as a professional woman of color in the toxic atmosphere created by the campaign of the candidate who won election and who made many statements during the campaign that were derogatory about women and about certain minority groups.  This was posted in a professional group, which one might think would be supportive.

Yet some of my colleagues responded in ways that bristled and brusquely rejected her views. And so I offered my thoughts in the closing weeks of the most bizarre year of American political history that I have witnessed in the half century I have been paying attention to American politics:

As I read the comments in this thread I sit here shaking my head. I am looking out through the vast expanse of my family room's picture window at a crystal clear, blue autumn sky and a pasture behind my house where horses frolic when their owner lets them out of the barn.

I live a life of remarkable privilege. Not wealthy, but upper middle class. It isn't the stratum of society in which I grew up, but it used to be relatively easy for a boy from the working class to pursue higher education and a professional degree. Now, sadly, the USA is among the worst in the First World in measures of upward social mobility.

Two of my closest friends in my high school years were African-American. We were brought together by our love for classical music. Throughout my adult life I have been drawn to people who were different: intrigued, fascinated, curious. If they were different in appearance, origin, language, or outlook on life, I wanted to know them.

But this is because I am an intellectual, and we live in a nation in which anti-intellectualism is very much in fashion.

We have just elected a president whose candidacy shone a bright light into the darkest corners of the American psyche, and the reflection that we all saw was shockingly hideous.  We learned that racism, xenophobia, nativism, jingoism, misogyny, and homophobia all had powerful resonance with a frighteningly large segment of our population.

If you believe that racism is exaggerated, or if you believe the same of any other "isms" or "phobias" (whereby phobia is used as a euphemism for hatred), then I urge you to seek out people who are other and ask them to tell you about their experiences being other.  There is a great deal of well-founded fear in their lives, founded in experiences that may not occur every day but occur far too often.

Frederick Douglass
White America's attitude toward black America used to be based on deeply held beliefs that people with black skin, originating on the African continent, were genetically inferior to people of white European ancestry. Now it is based on resentment that blacks refuse to "get over" their outrage about centuries of enslavement in North America followed by another century of oppression, and only in the last half century beginning to make some progress in the direction of justice and equality. Why can't they get over it? we ask. Why are they still an economic underclass living in wretched urban ghettoes? Why will they not pull themselves up by their bootstraps?

And we rail against their sense of entitlement, belittling them as multigenerational welfare families that will never make anything of themselves because they don't want to, because they are too lazy, because they'd rather work the system than work for a living.

We resent Mexican immigrants for "stealing" American jobs, when we know that they are doing things US citizens don't want to do. I do not want to cut my grass. I don't have much free time, and I don't enjoy it. I pay a local company to cut it on a schedule. The workers are Mexican immigrants. They are the people who want those jobs. They are not taking jobs away from anyone. And I live nowhere near the border.

We resent immigrants from India and Pakistan for coming to America and taking high-tech jobs, ignoring the many ways in which these immigrants have enriched our nation. How many doctors from that part of the world are colleagues you admire and whose friendship you enjoy? Ask them to tell you something about their experiences of being the "other" in America, especially outside of their professional setting.

A good friend is a black physician whose experiences of life in dark skin in these United States he has occasionally shared with me. And while I embrace him as a friend, and - thankfully - I long ago shed the hints of racism that inhabited the dark corners of my own psyche because I grew up in a city with near-total racial segregation and absorbed racism from that toxic environment - when I listen to his stories I am deeply ashamed of our society.

So, I implore you: seek out and listen to the stories of our colleagues who are "other" in a nation that calls itself a melting pot yet harbors shocking levels of intolerance. Listen to their stories. Simmer in them. Think long and deep. And learn, from doing so, that we must judge not the "other" among us until we judge ourselves and identify all the ways in which we must work to improve ourselves and our society.

I will begin to judge people of color living in America when I have done all I can to make American society one in which their lives are no more difficult than mine because of their "otherness." That will not be any time soon.

You've been waiting for the dialogue, because the title was a teaser.

So, take a gander at this comment:

"Pure, unadulterated, Leftist bullshit, which you believe sincerely, because all you know is the propaganda fed to you, and don't research the facts directly."

You can imagine what I thought about that.  And remember, you have to be a doctor in my specialty (emergency medicine) to belong to this group. This isn't some skinhead white supremacist writing this.

My reply, admittedly a little thin-skinned:

"You don't know the first thing about me, and what I now know about you is that you are willing to judge a person definitively, absent a shred of insight into that person. I daresay I've read more of this nation's history - political, military, economic, and social - than you and your ten best educated friends combined. So do not presume to call bullshit on me, Sir. That is a right you have not earned."

Our new friend was undeterred:

"It's bullshit on the face of it. Canned, leftist liberal psychobabble talking points. 
You're so brainwashed, and so out of touch with reality that it is a shockingly wondrous thing. 
What I do know is what you posted, which is a presumptious (sic), condescending piece of arrogant tripe.
Do not PRESUME to tell White Americans hat (sic) their attitude toward Black America is, you haughty, bigoted, racist fool. Why is it OK to judge one group based on color, and lump them all together by pigment percent, and assume they're monolithic? 
You, sir, are a blind fool. And an incredibly egotistical one at that. 
I believe my favorite line from your verbal diarrheal event was this :"But this is because I am an intellectual". 
Holy crap. Get on some medication. And get out more."

No, I didn't make this up.

And no, there was no steam coming from my ears as I read that.  Rather, I was amazed at the ideas he found in what I wrote that weren't there.  They weren't on the screen, they weren't in my head, they weren't even between the lines.  They were the product of our correspondent's imagination.  And yet he suggested to me that I should be medicated.  I believe psychologists call that projection.

The main problem seems to be that he is taking statements I made that were obviously generalizations based on observations and interpreting them as though I meant that they were true of all people in a given group.  Any sensible reader would, I think, understand that when I say white Americans want black Americans to "get over it," I am not talking about all white Americans; rather I am talking about a subset who are contributing to the problems I've described.

In case you were wondering what prompted my thoughts about white Americans' attitudes toward black Americans, in the context of the re-election, you might look at some of the exit polling and what Trump voters said when asked such interesting questions as whether Lincoln should have issued the Emancipation Proclamation (a third of South Carolina primary Trump voters said no) and whether the nation would be better off if the Confederacy had won the Civil War (a third of them said yes to that).

Oh, and I couldn't help being amused that he took my statement about being an intellectual out of context, in which it clearly meant that I have intellectual curiosity, and chose to interpret it to mean that I am egotistical about my intelligence.

At that point another member of the group interjected:

"Nasty. Is this how you respond when a patient disagrees with you? We should treat our colleagues with AT LEAST as much respect as we treat our patients."

Not about to accept such criticism, our prickly friend responded thus:

"Hmmm. Nasty. His post was far nastier, and far darker, but veiled in a veneer of inclusiveness and civility, while carrying menace. The typical hypocrisy, and projection of the Left. My post is a bit more straightforward.
In answer to your question: this is how I respond when I'm lectured by a pompous bigot, with deep psychological issues, who hates the country in which I live."

Impressive.  Someone read my original short essay and found it nasty and menacing, and further managed to deduce that beneath my "veneer of inclusiveness and civility" I am "a pompous bigot with deep psychological issues who hates the country in which I live."

Jeepers!  I'll give him credit for getting something right: I do not deny that I am pompous, at least occasionally.  But honestly, I didn't see any of that in what I wrote in my little snippet of social criticism.

Why, you might be wondering, have I chosen to share this "dialogue" with readers of my blog?  Well, I've been blogging for several years, although not much this year, because I have spent so much time trying - mostly on Facebook - to convince my friends, and anybody else who might pay any attention to what I write - that they should vote for Bernie.  Oh, and I did blast Trump rather mercilessly.  I did both of those things here in my blog, but endlessly on Facebook.  Many of my blog essays have been far more provocative than what I wrote that clearly provoked this fellow.  And I have never seen such vitriol posted in comments following any of my blog essays.

But I'm still proud to be an American, even after reading the comments, and even after about half the people who voted chose the Mangled Apricot Hellbeast.  (Oh, my, how I wish I could meet the Scot who tweeted that description and buy him a beer!)

And I hope you are still proud to be an American.  After feeling the way I felt on Election Night, I realized that shame and sadness are quite separate.  Am I ashamed that messages of racism, nativism, jingoism, xenophobia, misogyny, and homophobia resonated with a sizable segment of the electorate?  Of course I am.  But I will not let that make me ashamed to be an American, because Americans like the colleague (yes, that shocks me, I admit) who wrote such blindingly hateful things are, I am convinced, a very small minority.

Thursday, July 21, 2016

Hillary and the Truth

Many people have been posting on social media links to stories about Politifact's finding that Hillary Clinton's public statements have been more consistently truthful than those of most other candidates for president in this election season, showing her in a virtual tie with Bernie.

This is, of course, contrary to the longstanding narrative.  HRC's defenders point to conservative commentator William Safire who, many years ago, called Hillary a "congenital liar" and never modified this appraisal because he never found reason to do so.  Safire is responsible, they say, for establishing this negative perception of her - and, they say, he was wrong.

Let me offer my own judgment of this latest take on Hillary's honesty and Politifact's appraisal of it.

I'm willing to give Hillary the benefit of the doubt and withhold judgment regarding whether Safire's harsh criticism was fair.

Or at least I was willing to do that at the beginning of this electoral process.

Disclaimer: I am a Bernie guy.  Why does that matter?  Bernie is as honest as the day is long.  If he says something, you know he believes it.  Does that make it true?  No, of course not, but Bernie has been in public service for a long time, so when speaking of issues and problems and public concerns of all sorts, he generally knows the facts, and he generally tries to avoid making statements about things of which he knows little.  Contrast that last part with the behavior of Donald Trump, who might never say anything about anything if he followed that example.

I watched most of the Democratic debates, and I saw Bernie consistently talking about the problems facing this nation and his proposed solutions.  His statements were plainspoken, and his facts were accurate.  When he talked about HRC, he said some positive things, and his criticisms were fair and a direct reflection of the record.

Hillary, on the other hand, repeatedly and consistently distorted Bernie's record and sometimes told flat-out whoppers about it.  At the very least she viewed Bernie through a prism that afforded no room for nuance.  Bernie, meanwhile, defended some of HRC's votes in the Senate by explaining to viewers that sometimes one votes for a bill because it has things in it one likes, even when there are other things in it with which one disagrees.  Yes, he was defending himself at the same time, but he said voters should understand this when examining the voting record of any senator.

When speaking of Bernie's record, Hillary deserved Politifact's "pants-on-fire" rating more often than not.  Why didn't she get that rating from Politifact as often as she might have?

She is very artful with the language, parsing words and phrases carefully, producing statements that are quite misleading but can still be rated by Politifact as at least "partly true" - or even mostly true - when a (or even the) key element of the statement is blatantly false.

Here's what I think tells us all we need to know about her honesty.  She was asked whether, if elected, she was prepared to make the same promise Jimmy Carter did in 1976, when he famously said he would never lie to us.  Her answer?  She said she would always do her best to level with the American people.  That sounds like a "yes," doesn't it?  But in fact it is a resounding "no."

What that statement really means is No, I'll be honest when it suits my purposes.  Being charitable, it could mean she believes there are times when it is in the nation's best interests for the president to be less than forthcoming, to shade the truth, or even to say things that are false so as to avoid creating fear or panic or an undesirable public mood or opinion.  ("You can't handle the truth.")

Taken at face value, understanding the plain meaning of the words and exactly why Hillary chose to answer that question that way (as opposed to saying yes), it is clear that she meant for her answer to be interpretable as "yes" - or at least close enough to "yes" to be satisfactory to those who want the president to be honest with the people all the time - while binding her to do no such thing, because the real meaning of her answer is No, I will tell the truth when it seems the best option, and only then.

And so I consider this to be the most honest public statement she has made in the last year, if you understand what it really means.

So, getting back to Politifact: Hillary is mostly honest?  In scientific investigation there is something called "face validity."  A statement or conclusion that is strongly counter-intuitive, or contrary to what we are pretty sure we know to be true based on the available evidence, is said to lack face validity.  That is how I would describe Politifact's finding.  Not that I disagree that her statements are true more often than Trump's - although so many of his statements are false because he is an idiot and has false beliefs - but the idea that she is in a virtual tie with Bernie on the honesty scale is nothing short of preposterous.  Politifact is misled, and thus is misleading us, because they give her credit for partial truths, and her wording is so artful and clever that she gets credit for far more truth than is actually present.

Does this mean you shouldn't vote for her?  Make up your own mind about that.  Historically the American people do not vote in presidential elections for candidates they do not believe are trustworthy and honest.  And polling shows they do not believe Hillary is trustworthy and honest.  But not all of us make our voting decisions with honesty as a paramount criterion.  One of my friends said he wants an effective president, not a Girl Scout.  And she is running against a GOP candidate who, in my assessment, is the least qualified major party candidate for president this nation has ever seen.

Although the election is more than three months away, I will go out on a limb and say that, despite recent polling showing key battleground states are close, Hillary will be our 45th president.  Just don't expect much unvarnished truth to emanate from the Oval Office over the subsequent four years.  Instead, watch press briefings, watch how the White House press secretary chooses words very carefully when answering journalists' questions, and watch how reporters ask follow-up questions to pin down the press secretary and cut through the BS to get a straight answer.  That will help you to understand how difficult it can be to get a straight answer - and to recognize when we get very few of those from the second President Clinton.


Sunday, July 10, 2016

Toward a "Post-Racial" America - A Differing View

Recent events - two more shootings of black men by police under dubious circumstances and the apparent "revenge" shooting of eleven uniformed officers by a sniper overlooking what seemed to be a peaceful protest organized by the group Black Lives Matter in Dallas - have further sharpened the public focus on racism in the United States of America. 

My long-time readers will not, I'm sure, be surprised to know I have a somewhat different view of the current state of race relations in the USA.  Different from what you're hearing from the pundits on television and online.  I posted a somewhat shorter version of these thoughts on Facebook, and a friend suggested it be made into an essay for this blog.

I have many friends who think African Americans should just "get over it" and "take race out of the equation," accepting the notion that all lives matter, and it's really just a matter of embracing the notion that people must stop killing each other.  Effectively, they are declaring that Barack Obama's vision of a post-racial society has been realized, or at least we should all behave as though it has, and somehow by doing that we will make it so.  In other words, it is really all a matter of state of mind, and all we need to solve the problem is the power of positive thinking.

Get over it?  Just take race out of the equation?  These directives reveal monumental ignorance and misunderstanding.

Taking race out of the equation is not something that can happen in a nation in which such a large proportion of citizens of African descent are trapped in an economic underclass by centuries of mistreatment.

African Americans went from enslavement to citizenship as a result of the American Civil War and the subsequent amendments to the Constitution.   But constitutional citizenship was unaccompanied by opportunity, and Reconstruction was ultimately one of America's great sociopolitical failures.

Then, in 1896, the Supreme Court of the United States declared, in its abominable decision in Plessy versus Ferguson, that ours could be a "separate but equal" society.  Never mind that white society was unprepared to allow blacks anything remotely resembling equality. 

Nearly six decades later, in Brown versus the Board of Education of Topeka, Kansas, the high court reversed its shameful stance, but that led to forced desegregation that yielded only intensification of bitter racism among Southern whites and many Northern working class whites.

Then, another decade brought the civil rights legislation of the 1960s that we have been struggling to enforce and to make meaningful for the last half century.  The struggle was severely hampered by two developments in the 1990s: welfare reform, which threw millions of black Americans off public assistance and deeper into poverty; and a crime bill that facilitated, among other things, a war on drugs that was really a war on the black urban underclass, and dramatically increased the number of black men in America's prisons.

And now we have arrived in one of the ugliest places in this nation's history of race relations, in which America's wealthy, in a craven effort to distract attention from their unbridled greed, have created a new class warfare.

Historically "class warfare" has meant everyone else against the rich.  But in the last two generations, the wealthy have pursued a very successful propaganda campaign to reframe class warfare as everyone else against the poor.  The most important part of this construct is setting the lower and middle strata of the middle class against the poor: those who are working hard to build a middle class life for their families are told that the undeserving poor are the economic enemy, living on government entitlement programs.

This is code for the new racism: it is the lazy, shiftless, inner-city blacks who are stealing from hard-working middle class whites.  All you folks in the lower-middle and middle-middle classes, struggling to get a little bit ahead of living paycheck to paycheck, take heed: the undeserving poor are the enemy.  It is they who are wasting your tax dollars and keeping you from achieving a more comfortable lifestyle.

[Never mind that the percentage of the federal budget spent on things like housing subsidies and food stamps is quite small or that many of the recipients of such aid are the working poor.]

This is how the wealthy are using third-millennial class warfare, fueling it with racism, to protect themselves from the next French Revolution.

If the struggling white working class and the black urban underclass ever figure out that neither is the other's enemy, and instead they have a common enemy, and it is the unrestrained greed of the top 0.1-0.5%, there will be blood in the streets, making the Reign of Terror look like a day at a Six Flags amusement park.  The blood will not be the blood of the police or of urban blacks.  It will be the blood of the 21st-Century aristocracy, and it will signal the end of the oligarchy and the return of this country to the people.

The storm is coming.

Thursday, May 12, 2016

It's Not My Fault: An Ode to Morpheus

Pardon me for jolting you out of the Third Millennium, where today journalists are vacillating between wall-to-wall coverage of Donald Trump's presidential candidacy and blaming doctors for the opioid addiction epidemic, but I want to take you back to the early 1800s, when Thomas Jefferson was president of the United States and Friedrich Wilhelm Adam Sertürner was a pharmacist's apprentice in Paderborn (then part of Prussia).

Sertürner purified one of the active alkaloids from the opium poppy and named it morphine, after the Greek god of sleep and dreams, Morpheus.  Morphine was given that name because of its propensity for inducing drowsiness.  It also stimulates receptors in the human central nervous system involved in perception of pain, and so it has analgesic effects.  And it can elevate mood  - produce euphoria.  Thus morphine - and later its many derivatives and congeners - was added to the list of things we now called "mood-altering substances."

Morphine was brought to market by Merck, the German chemical company, in 1827.  Then in 1874 Charles Romley Alder Wright, a British chemist and physicist, was tinkering with morphine and added two acetyl groups to the molecule, creating diacetylmorphine.

When injected intravenously diacetylmorphine has a more rapid onset of action than morphine and is more potent (a smaller dose is required to produce an effect of the same magnitude).

Heinrich Dreser, a chemist working for Bayer (another German chemical company) continued testing diacetylmorphine, and Bayer brought the drug to market in 1888 as a cough suppressant and pain reliever under the trade name Heroin.  Twenty-five years later, recognizing its potential for causing addiction, Bayer withdrew it from the market.

Most Americans think of heroin as an illegal drug because it has that status in the United States.  By contrast it is used medicinally in the United Kingdom and is superior to some other agents because of its rapidity of onset of action and its more favorable side effect profile.

In the U.S. it is on Schedule I of the Drug Enforcement Administration's list of controlled substances.  Schedule I is supposed to be reserved for drugs that are considered dangerous and have no recognized, legitimate medical use.  As heroin does not meet the second criterion (except by arbitrary and unscientific edict), it does not belong on Schedule I.

Since the 19th Century we have developed many synthetic derivatives of the substances isolated from the opium poppy, and we call them, collectively, opioids.  Although at one time such substances could be purchased without prescription in the US, at present only codeine (the other active alkaloid from the opium poppy) can be obtained without prescription, and only in certain formulations, from some pharmacies, in about a dozen states.

Given that people have been cultivating opium for at least 5,000 years, it is interesting to contemplate the fact that some mood-altering substances humans have derived from plants (opium, coca) are considered to have such high potential for abuse and addiction that they are very strictly controlled, while others (alcohol by fermentation of the sugars in plants, and tobacco) are regulated but easy to purchase legally.  Addiction to opioids and cocaine and addiction to alcohol and nicotine have many similarities, and all of these substances can be damaging to health and lethal in overdose.

We experimented with prohibition of ethanol in the US, and that is viewed by most as having been a spectacularly unsuccessful experiment.

And that brings us into the 20th Century, when we decided that opioids should be available only by prescription.  This means that if you have need of the most effective of the pain relievers, you must consult a physician.  That is obviously rather arbitrary.  Stressful day at work?  If you go home and have a glass or two of wine to relax and unwind, that is considered no problem, and meets a common definition of moderate drinking.  If instead you wanted to have 5 or 10 mg of oxycodone, that is considered a very serious problem.  You can, I suppose, guess that I don't see a substantive difference.  But I can order wine by the case and have it delivered to my house.  If I tried to order oxycodone by the case for personal use, my medical license and controlled substances permit would be gone in a flash. 

Sociologists and criminologists use the term "social problems" to describe a vast array of societal ills, and misuse of opioids is, in my view, a social problem. Many things that are social problems cross the very blurred lines and are also viewed as medical problems, and of course misuse of mood-altering substances can be regarded as a medical problem.  But in its strictest sense, it is only the complications of the misuse that are medical problems: overdose, infectious complications of injection drug use, etc.

In my specialty (emergency medicine) we find ourselves addressing social problems a great deal of the time, both because the profession has "medicalized" many social and behavioral problems and because the emergency department is often the place to which people turn for help when they have no idea what to do.

The truly vexing thing about opioid abuse as a social problem is that doctors are getting blamed for creating it.

Dude!  Seriously?  Abuse of, and addiction to, opium has been around for millennia.  This is not our fault.  Blame it on something that, in pharmacology, is called the "fallacy of the specific."

The fallacy of the specific means that one should never assume - because the assumption will usually be wrong - that a drug will do one thing, its intended effect.  In this case, opioids relieve pain, but they also have effects on mood. Those latter effects get some people into trouble, because they like that feeling, and they may start using a drug for relief of pain and then use it partly to relieve pain and partly to feel good more generally, and before you know it they are using it as much for mood elevation as for pain relief, or even entirely for mood elevation, without even realizing that is happening.  And then they may find themselves using it to keep from getting symptoms of withdrawal from the drug. A person may find anything from a general unease to restlessness, cramps, vomiting, diarrhea, and sweats occurring because the nervous system has gotten used to the drug, and now it's not being provided.  Then the addict is using the drug not to feel good but to keep from feeling terrible.

Legal acquisition of opioids requires consultation with a physician, and a prescription, and many addicts start with prescribed opioids and end up using far too much of them and engaging in all sorts of deceptive behaviors to get them from insufficiently wary (or blatantly unethical) doctors, or they switch to illicit sources and start snorting, smoking, or injecting heroin.  So ... let's blame the doctors for this social problem.

That's right.  The problem of abuse of and addiction to mood-altering substances has been part of the human condition for thousands of years, and modern medicine has been around for about a century, but it's doctors' fault.

Believe it or not, I have no problem understanding this.  You see, I have been married for more than 30 years, so I have grown quite accustomed to accepting blame for problems that are not my fault, apologizing for them, and doing my best to fix them.

And I am willing to do the same thing here.  But not without pointing out the obvious: it really isn't my fault.  And no, I'm not even going to lay the blame at the doorstep of all the well-meaning but seriously misguided regulators who have been telling us how to practice medicine all the years I have been a doctor, first telling us we under-treat pain and then telling us we have turned America into a nation of addicts.  And I'm not going to blame the ridiculous, single-minded focus on patient satisfaction, which has led so many doctors to have, at the center of every encounter with a patient, the goal of finding out what the patient wants or expects and giving it to him whether it's a good idea or not.

Nope.  It's not the regulators and administrators, and it's not the weak-willed tendency of doctors just to give patients whatever it takes to make them happy.

What is it, then?

Human existence is miserable.  Not for everyone, but for a sizable minority of us.  And that's what mood-altering substances are all about.  We smoke tobacco; we drink beer, wine, and liquor; and we use opioids and other potentially dangerous drugs like cocaine - all to find a temporary escape from the misery, or at least drudgery, of human existence.

Are opioids really more dangerous than alcohol?  Spend a few hours searching for good statistics, and you will find plenty about the number of lives ruined and deaths caused by alcohol abuse.  Alcohol and opioids have much in common and many differences.  In the emergency department I see dozens of people who've died or been snatched from the jaws of death after an opioid overdose for every one person who dies suddenly from consuming too much alcohol in a single episode.  So the opioid-related deaths really get our attention, especially as they often involve young people who had previously been healthy.

Here's what's unique about opioids: they have a legitimate medical use - relief of severe pain - coupled with effects that lead to misuse, and we have given authority over their legal availability to physicians.

With authority comes responsibility.  But there's a catch.  I have authority over the decision about who needs strong pain medicine.  I do not have authority - or control - over what is done with the opioid after the patient gets it from the pharmacy.  Can I peer deep into a patient's psyche and tell who might abuse the drug?  I think I'm pretty good at that, but that is part of the art of medicine and not the science, at least for now.

I like to think that, as a practitioner of medicine as an art, I'm much closer to Renoir than to the kindergartner trying to color inside the lines.  But I will not always be right.  And if you expect doctors always to be right in the decisions they make about prescribing these drugs, you have wildly unrealistic expectations.

At its foundation this is more a social problem than a medical problem.  My colleagues and I will do all we can to help to solve it.  But we didn't create the problem, and we cannot solve it alone.  I am pleased to report that my patients are catching on.  More and more often when I ask someone with an illness or injury that is painful, "Do you think you will need something stronger than acetaminophen or ibuprofen for pain relief?" the patient's answer is no.

We all need a lot more insight.  I'll do my part.  You do yours.

Sunday, March 13, 2016

Trump in Chicago: Wrong Again

A campaign rally for Donald Trump was scheduled to be held last week on the campus of the University of Illinois at Chicago.

Rewind nearly 40 years.  In 1977 the modern American version of the Nazi party sought to hold a political rally in Marquette Park in Chicago.  Permission was denied when the city authorities banned political demonstrations at the park.  The organization's leadership then decided they would conduct a march through Skokie, Illinois, a town with a large Jewish population that included many Holocaust survivors. The subsequent legal battle focused on the wearing of the swastika, the Nazi symbol, and whether doing so was protected by the First Amendment and therefore could not be prohibited.

Local and state courts enjoined the political demonstration and the march, and the case went to the US Supreme Court.  The Supreme Court ordered the state courts to hold a hearing focused on the First Amendment issues.  Those proceedings initially prohibited the use of the swastika, but the Illinois Supreme Court subsequently ruled that the wearing of the symbol was protected and did not constitute "fighting words."

The Skokie case became famous for its protection of provocative expression.  It illustrates just how far we are willing to go, in the United States, to support the principle that the First Amendment was intended to protect political expression, even when it is exceptionally unpopular or despicable.

Fast forward once more to 2016, when Donald Trump is a candidate for president.  His candidacy attracts supporters with whom some of his darkest rhetoric resonates powerfully.  His detractors observe that he repeatedly expresses ideas that are nativistic, xenophobic, jingoistic, misogynistic, homophobic, and racist.  Immigrants, racial and ethnic minorities, women, and the LGBT community find his appeal to a segment of the American public to be a shocking reflection of a broad and deep streak of intolerance that remains in American society despite decades of effort to enhance tolerance and acceptance of groups that constitute the "other" in our culture.

The United States has one of the most heterogeneous societies on earth, and this has long been a source of pride, as people have come here seeking not only economic opportunity but religious freedom and the tolerance for people of varied backgrounds for which this nation has been greatly admired.

At any rally by supporters of the Trump candidacy for the nation's highest office, speech and conduct displaying intolerance of all sorts, the antithesis of our spirit of inclusiveness, have been very much in evidence.  People attending the rallies who have differing views, even if they are quiet and their differing views are suggested only by something they are wearing (such as an article of clothing bearing the name or symbol of another candidate) or even by the color of their skin (non-white) have sometimes been heckled or threatened by Trump's supporters and escorted from the premises by law enforcement officers, ostensibly for the purpose of preventing trouble.  Trump himself has repeatedly endorsed such conduct: "Get him out!" he demands, referring to any detractor who might be in attendance at one of his rallies.

One could predict that in a city with the racial and ethnic diversity of Chicago, a Trump rally might draw a sizable number of protestors.  Thus, the selection of a site for the rally should be made with some consideration of that possibility.

On the other hand, perhaps there is an intent to be provocative.  If so, one might choose a location full of people most likely to find Trump's views and the sentiments and inclinations of his supporters to be especially disagreeable.

Among the possibilities suggesting themselves as most likely to fit that bill is the University of Illinois at Chicago.  This is an institution of higher learning noted for diversity and inclusiveness in the selection of students for admission.  Here is a college campus on which the diversity of color of skin, ancestry and national origin, ethnic background, and gender and sexual orientation is perhaps greater than just about any other in the country.  Aside from its educational mission, this is a university that exists to welcome students of diverse backgrounds.  Thus, this is a university whose community is most likely to find the prospect of Trump as a political leader for this nation truly appalling and the views and behavior of his supporters a shocking representation of the deep-rooted intolerance that persists among a segment of the populace.

So how might one view the selection of the University of Illinois at Chicago as a site for a Trump campaign rally?

"Asking for trouble" comes to mind.

And trouble, not surprisingly, ensued.  Protestors recruited or encouraged by various groups that promote diversity and inclusiveness and that are, in their philosophy, reactionary against the reactionary in American political life, turned out by the thousands.

There was much disturbance of the peace.  The rally was cancelled.  The protestors cheered.  Trump's supporters cried foul and strenuously objected to intolerance of their intolerance.  Irony abounded as protestors who believe passionately in First Amendment rights of all sorts - speech, press, assembly, religious belief, practice and expression - clearly felt that a Trump rally on this site simply went too far and was intended to be provocative in the most disruptive and potentially dangerous manner.

Among the protestors were many supporters of another presidential candidate, a man whose history has been one of championing the civil rights and seeking to better the economic lot of minorities of all sorts.  The supporters of Bernie Sanders made no secret of their political preference in this election year.  While the Sanders campaign had nothing to do with his supporters' decisions to protest the holding of the Trump rally on the UIC campus, Sanders himself found no reason to criticize or apologize for their participation.

Trump personally responded to the participation by Sanders' supporters, calling on Sanders to condemn their participation.  In doing so, rather than maintaining any sort of decorum that might have made it possible to take seriously his expression of dismay over the intolerance of those who preach tolerance, Trump ridiculed Sanders as a "communist" and mocked him by saying "Bernie" with the drawn-out, sing-song intonation of a schoolyard bully.

Condemnation of Trump and his pronouncements on what it will take to "make America great again" has come from all corners.  Rather than softening any of his rhetoric, Trump has mostly doubled down on his expressions of antipathy for all who are not part of white Christian America.  He has been marginalized by most of the leadership of the party whose presidential nomination he seeks, despite his standing in the polls and his garnering of votes on primary election days.  This has led many party leaders to look, as an alternative, to Ted Cruz - a candidate who, as a member of the United States Senate, is liked by virtually none of his colleagues in that body.  What could be a more powerful indication of the contempt in which Trump is held by the GOP establishment?

Many apparently believe Trump's unpopularity with the political establishment is evidence of his merit as an outsider who can go to Washington, DC and shake things up.

It is very clear that Trump wants to shake things up, and that he is very good at that, and that he doesn't care how many people he offends, or how deeply, in so doing.  Trump has succeeded in marginalizing himself more than any of his opponents could ever succeed in marginalizing him.  One might even think he is intent upon proving that he has no place in a civil society - certainly not in the one we have striven to build in the United States.

The publication founded by that intellectual luminary of the modern American conservative movement, William F. Buckley - the magazine National Review - devoted an entire issue recently to making the case "Against Trump."

The decision to hold a campaign rally on the campus of the University of Illinois at Chicago, with the full knowledge that it would be provocative to the point of being incendiary - and apparently seeking that outcome - is further evidence that all thinking Americans who believe in the broad social values this great nation represents should, together, stand Against Trump.

Saturday, February 13, 2016

I Am a Banker

Not really.  This is a thought experiment.
I run a bank in an average American community.

My customers save money.  They have passbook savings accounts, certificates of deposit, and individual retirement accounts.

My customers borrow money.  They have personal loans, car loans, home mortgages, and credit cards.

I make plenty of money as a banker.  I take the money my customers are saving and lend it to others at interest rates higher than what I am paying the savers.

I also charge fees for some of the services I provide.

Some of customers are not very well off.  They are struggling.  They live paycheck to paycheck.  That means that by the time they get a paycheck, they have run out of money from the last one.

Sometimes it is hard for them to pay their bills on time.  Sometimes they miss due dates.

This is an opportunity for me to make more money.

You see, if they are afraid of missing a due date, because being late with a payment will result in late charges and may harm their credit rating, they may write a check for a payment and hope it doesn't hit before their next paycheck goes into their account.  But they don't want the check to bounce.  So they have authorized me to pay the check with money that's not in the account yet, even though that means I will charge them an overdraft fee.  Their account may be overdrawn by only a few dollars, for only a day - or maybe only a few hours.  No matter.  I will still charge them an overdraft fee of $37.50.  And if two checks come in before the paycheck, it will be $75.00.  I know it's $75.00 they don't have, and the record keeping didn't actually cost me a penny, but the $75.00 is pure profit, and I'll take that any time I can get it.

I can also make big bucks on the credit card account they have with me.  The federal government lets me charge 20% interest.  This is a gold mine when I'm dealing with people who often cannot pay off the balance every month.  I charge my best customers much lower rates, because they are credit-worthy.  I charge the highest rates to the people whose credit ratings are lower.  Yes, I know, that takes money from them they cannot afford, makes it more likely they'll make a late payment, keeping their credit rating low and their interest rates high, but that's the way this business works (because I like it that way), and I am going to keep charging them high rates to make up for the fact that every once in a while someone declares bankruptcy and I may take a loss.

What's that, you say?  It isn't right for me to charge the highest rates and fees to the people who can least afford it?  You cannot be serious.  I am not running this bank as a charity.  I'm here to make money.  I can't be worried about these customers as people.  What kind of businessman would I be if I did that?

The socialists say the way I run my business contributes to the plight of the working poor, making the problem of little upward mobility for them worse.  Cry me a river.  I am in business to make money.  If I try to make money from customers who have plenty of money, they will take their business elsewhere. They know their business is valuable, and they act accordingly.  The folks who are scraping by have no idea if the bank down the street will give them a credit account or a car loan, and they are afraid to find out.  So they'll stay put.  That's the way I like it.

How do I sleep at night?  Very well, thank you.  I'm one of the 1%, you see.  If you think I lie awake at night worrying about the well-being of the 99%, you have another think coming.  They aren't even smart enough to go to the polls and vote in their own economic interest.  A lot of these working class folks vote Republican!  Can you believe that?  They should vote for democratic socialists, but they believe what they are told about class warfare and the politics of envy, so they keep voting for politicians who promise them a rising tide that will lift all boats, even if mine is a luxury yacht and theirs is a canoe.  And never you mind that sometimes their canoe is foundering while it's full steam ahead for my yacht.  Let me know if you hear them yell for help when their canoe overturns, and I'll see if I can find something buoyant to toss in their direction.  Maybe their church can help.

Socialism will never take hold here in the good old US of A, as long as the masses remain convinced they are not an exploited proletariat but merely temporarily embarrassed millionaires.  They'll never be millionaires.  Certainly not with any help from me.  After all, I have to make a profit.

I love America: the country that allows me to buy politicians who will keep the rules the way I like them.