Thursday, January 25, 2024

ER backups and poor-quality but expensive insurance: The American Way!

The January 22 edition of the Arizona Star (Tucson) reprinted a piece from the Arizona Republic (Phoenix) titled “'I've never seen it this busy': Here's why Arizona emergency departments are jammed”. The article is paywalled, but you don’t really need to read it since that headline basically is the story: all over the state, including its two biggest cities, waits for non-emergencies (and sometimes emergencies) in ERs is many hours to, sometimes, days! The article discusses some reasons, including the increase this winter in respiratory diseases like flu, RSV, and, yes COVID (despite everyone pretending it has gone away; see NY TimesCalifornia and Oregon Ease Covid Isolation Rules, Breaking With C.D.C.”). In fact, there has been a lot of respiratory disease this winter, and as reported by “Your Local Epidemiologist”, Katelyn Jetelina, and while it seems to be declining, there could well be more peaks.

The colder weather makes the most vulnerable, those without housing, even more vulnerable. Also contributing to the ER backup in Arizona is the increase in the number of “winter visitors” (also known as “snowbirds”) who are coming back “after” the pandemic, who are often older and do not have a regular source of care here. And, yes, also that too many of us who live here year round do not have a regular source of care because, as in most places, there are not enough primary care clinicians (see “Primary Care, Private Equity, and Profit: How to ensure poor quality care for the American people”, Sept 28, 2023 and “We need more primary care to serve our people: Why do the medical schools lie?”, Dec 12, 2023). So people go to the emergency room, or to an urgent care center where they are told to go to the emergency room “if it gets worse” or, when it is serious enough, right away.

But there is something else going on here. That is the breakdown of the American health care system, particularly the insurance system and the ways people are covered (or not) for health care costs. It is breaking down at all levels: there are not enough doctors, especially in primary care (see the blog posts cited above), insurance companies and employers are covering less and less of the cost of health care and requiring those who have insurance to pay more and more, and private equity (see the referenced blog above) has taken over many practices and is squeezing them for maximum profit without regard to what it does to the quality of the “product”, which is our health care. Private equity in the healthcare sector follows the same playbook it follows everywhere: squeeze profit out, diminish services, and if it bankrupts the company too bad; they already have theirs. And when it is insurance companies that take over the practices (such as United Health Care owning Optum) the result is about the same. No one is minding the people-serving part of the store.

Yes, there are plenty of uninsured people, including the homeless, and those who are “too rich” (hah!) to get Medicaid, which in most states requires an income far below (often way less than half) the poverty level (which is about $31,000 for a family of 4), and anyway is also, in most states, pretty much limited to women with small children and virtually never covers single adults. But there are also the under-insured, those with terrible insurance coverage because it is all they can afford, as employers cut back on their contributions and insurance companies raise their rates and the financial burden on the insured including through copays, deductibles, and denied care (kind of like both raising the price and shrinking the size of a candy bar, except with much more serious outcomes). In addition, the expenditures by employers on health insurance (even when it is inadequate) is money that is not spent on wages, thereby increasing income inequality, as documented recently by Hager, Emanuel, and Mozaffarian in JAMA Open Network. And, since health insurance premiums are tax deductible for employers (although not for employees!) they prefer it to paying higher wages. What is the result of having insurance that doesn’t pay for what you hoped and expected it would when you or a family member is seriously ill? You go into debt. So the proportion of medical debt held by insured people as opposed to “self-pay” (uninsured, virtually all poor) people, has risen from 11.1% to 57.6% in 4 short years, from 2018 to 2022. Quintupled. The system, to the extent that it can be called a system at all, is broken.

But why? How? While there are still undoubtedly those, including politicians, pundits, and health administrators (all of them WELL-insured, you can be sure!) who blame it on some kind of “overuse” by patients (the medical word for “people”), there are actually 2 real causes:

  1. Abuse, corruption, and illegal behavior by insurance companies in pursuit of ever-more profit, and
  2. The failure of government entities to prevent them from doing so, or to prosecute them when they do.

Really? Really. Not only are insurance companies inadequately regulated, and able to effectively abstain from paying for care by repeatedly denying it and creating other obstacles, they frequently simply break the law, as documented in a study by ProPublica and reported by the Nonprofit Quarterly:

‘The findings point not just to bad behavior on the part of health insurance companies but also to a failure of the state regulatory apparatuses that oversee health insurance coverage to enforce laws already on the books: … If explicit laws on the books, spelling out mandatory coverage requirements, aren’t enough to prevent insurers from denying coverage, how are ordinary people to push back?

The answer, ProPublica’s Cheryl Clark found, is that those fighting for their own coverage are forced to navigate a “mind-boggling labyrinth” of bureaucracies set up by insurers and often barely regulated.”

It’s pretty bad, and it’s getting worse. Poor and uninsured people suffer the most, but employed and insured people are right behind them. Their medical debt increases in part because they think they have insurance and actually seek care, rather than avoiding it, as uninsured people often do. Which is, of course, terrible – how can there possibly be any justification at all for a “system” that encourages people to not seek care when they are sick, that provides too few primary care doctors or other clinicians to care for them, that makes them wait hours or days in ERs to be seen, and then saddles them with unpayable – but of course credit-destroying -- medical debt when they do get care?

Who are the worse criminals? The insurance companies and private equity firms who directly cause these problems by pursuing only maximum profit? Or the politicians who allow it to happen, who at best tinker around the edges, trying to limit (only occasionally with any success) the worst abuses? Should we run our fire departments like that? Police? The answer is in part tight regulation, prosecution of abuses and illegal activities including putting senior executives in prison, and really, finally, creating a universal coverage system in which each person has good coverage, can get good care, and be treated as a human being.

Like the executives, politicians and pundits expect for themselves.

Saturday, January 6, 2024

Guns good? Depends on what you believe. Guns dangerous? No question.

People like guns.

People hate guns.

People are scared of guns.

Guns are good for sport, like hunting animals.

Guns are good for war.

Guns are good for self-protection, in case “they” come for you.

Guns are good for going out and killing other people because:

·        They might otherwise come for you.

·        They are bad people because they are:

o   The wrong religion.

o   The wrong race or ethnicity.

o   Believe in abortion.

o   Are liberals.

o   Support restrictions on guns.

Guns are bad because they can be and are used for all of the reasons above.

Whether guns or good or bad or dangerous or not is irrelevant because “Second Amendment”.

If you like, substitute “automatic rifles” for guns in all or any of the above.

All the above are true.

There are definitely people who are terrified that “they” will be coming for them.  “They” could be the government (except when the government is on their side), or they could be, you know, “them”, the other.

Probably not for deer hunting; 30 or 40 rounds of high-power automatic rifle fire can really tear up the meat.

It could be post-apocalyptic, where they are, like Mad Max, fighting for survival. They believe that they need thousands of rounds of ammunition for all their guns (after all, ammo stores might not be open after the apocalypse) and high-capacity, high-speed automatic weapons are going to be more effective in protecting themselves and their families from, well, whatever.

Zombies. Or “them”.

If you believe this stuff, and your social circle and the sites that you frequent on the Internet completely reinforce these beliefs, there is no reason to doubt that it is true. Even if you used to not believe them. (Remember, perfectly rational people from the Midwest have moved to California and, after some time being among only Californians, have come to think that it is normative to believe in the healing power of crystals.)

If you do not believe this stuff, and your social circle and the sites that you frequent on the Internet completely reinforce your non-belief, you become convinced that the folks that do are both crazy and deluded. Which they may be.

If you think that these people watch too many movies and zombie TV shows, you’re right; the most important FACT is that there will be a much more limited number of people who are alive to duke it out after a nuclear war; let’s see, after nuclear winter, roughly ZERO!

If you think that there is a certain cognitive dissonance in thinking that people on the left are pansy snowflakes and also fearing that they’ll be coming after the heavily armed folks with the fears, you’re right, but so what?

Total logical contradictions have never been a problem for them in the past (see, e.g., “Donald Trump – Christian”).

There are a lot of folks in the “I need more guns and ammo” camp who are strongly opposed to mass murder, although there are pretty many (including in Congress) who are able to make arguments (sure, weird syllogisms, but hey…) defending folks who go to peaceful demonstrations with loaded weapons looking for other people to shoot. Charlottesville? Kenosha?

It is a “prevent defense”, I guess. There are even more who are opposed to slaughtering children in school (hardly anyone comes out specifically in favor of that), but are 100% against any proposal that might make it more unlikely.

Because, you know, if you make psychotic minors unable to purchase an AR-15 without a waiting period, the next thing will be government agents confiscating your deer rifle. Or Uzi.

No one is in favor of school shootings, but we have them almost every day. In every state. We look at the news, open the paper, hear our phones ding, and we see the newest one. And our Congress, and our state legislatures, all of whom are against school shootings, can’t seem to do anything to prevent them. Even though we – and they – know exactly what would do it.

Make guns very hard to get. Especially for young people. The brain does not fully mature until at least the mid-20s and the last part to develop is the frontal cortex where executive function and judgement reside.

Especially for automatic weapons.  Especially with those with histories of violence. Yes, crazies but mainly not them. Mostly those who have or have threatened to use violence. You see, shooting people, especially lots of people, that may or may not be crazy, but it is for sure violence. Any abuser of any kind, any barroom brawler, anyone who threatens violence.

But of course they won’t. Maybe because it would lose them votes, or maybe they just believe the same things. Maybe they believe their own stories.

But, you know, you can kill people with a knife. Or a baseball bat. Or a garotte. Of course, it is not easy to kill a whole lot of people from 100 feet away with any of those.

I would be remiss to not mention suicide. They constitute the majority of gun deaths. Yes, suicide is an individual’s choice, but it is not necessarily an unchangeable choice. The “successful” suicide rate among teens and young adult males 16-24 is TEN TIMES higher in the states with the loosest gun laws as in those with the most restrictive. Are young men in, say, Montana more depressed than those in, say, Connecticut? I don’t know, but suicide attempts, especially in young people, are very often impulsive, and the easy availability of a gun makes that impulse easier to follow. And attempts at suicide by gun are much more likely to be “successful” (called lethality) than those by poison, or gas, or hitting yourself on the head with  brick

In the US it is often people in poor and minority communities who suffer the most random death. But it is older white men who commit suicide most. Often with guns that they had right there.

If you think we should make guns, especially automatic weapons, less easily available, especially to those most likely to use them for killing people, great. But lots of others do not agree. Of course, they include those most likely to use them for killing people.


The rest of the wealthy world could provide an example of what to do, but you know what? They are not Americans. A number of countries have higher gun-death rates than the US, mostly those at war (e.g., Ukraine) or in the midst of narco terrorism. We are not.

But we have a lot of guns, and that helps us make up the difference.

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