Friday, December 31, 2010

Don't You Know It Makes Me High When You Turn Your Love My Way?

Citizen K. has been an important part of my life for three years. Writing it has sharpened my thinking, helped me choose a new direction, and introduced me to new friends who have enhanced my life in countless ways. Anyone who follows me knows of my love for reading; my parting class to you is that most male of things, Top Five lists, in this case of books (each compiled in no particular order):

Five Contemporary Novels

The Poisonwood Bible (Kingsolver)
Liars and Saints (Meloy)
White Teeth (Smith)
About a Boy (Hornby)
Birdsong (Faulks)

Five 20th C. American Novels by White American Men
The Great Gatsby (Fitzgerald)
The Sun Also Rises (Hemingway)
As I Lay Dying (Faulkner)
The Grapes of Wrath (Steinbeck)
Lonesome Dove (McMurtry)

Five Coming-Of-Age Novels
Huckleberry Finn (Dickens)
Catcher in the Rye (Salinger)
Tom Jones (Fielding)
Great Expectations (Dickens)
A Portrait of the Artist as a Young Man (Joyce)

Five Nine Non-Fiction Books
...And the Band Played On (Shilts)
The Fire Next Time (Baldwin)
Baseball's Great Experiment (Tygiel)
The Years of Lyndon Johnson (The Path to Power and Master of the Senate) (Caro)
America in the King Years (Parting the Waters, Pillar of Fire, and At Canaan's Edge) (Branch)
The World That Made New Orleans: From Spanish Silver to Congo Square (Sublette)
The Shock of the New (Hughes)

Five Contemporary Irish Novels
A Goat's Song (Healey)
The Secret Scripture (Barry)
Inishowen (O'Connor)
The Story of Lucy Gault (Trevor)
Eureka Street: A Novel of Ireland Like No Other (Wilson)

Five Baseball Novels
The Great American Novel (Roth)
Bang the Drum Slowly (Harris)
You Know Me, Al (Lardner)
Hoopla (Stein)
The Kid from Tompkinsville (Tunis)

Five Six Books You Should Just Plain Read
Black List, Section H (Stuart)
Wuthering Heights (Bronte)
Women In Love (Lawrence)
Invisible Man (Ellison)
The Country Girls (O'Brien)
Maus: A Survivor's Tale (Spiegleman)

No matter what my mood or how down I am, "Blue Sky" never fails to cheer me up. I'm sending it out with gratitude to everyone who has followed Citizen K. at any time during the past three years, and especially those who have taken their own time to better this blog with their comments. Please check out my new blog, Health Matters.

Happy New Year!

Thursday, December 30, 2010

Tomato, Tomahto

From this story about baby boomer fears that Medicare won't be there for them:
Initially, 63 percent of boomers in the poll dismissed the idea of raising the eligibility age to keep Medicare afloat financially. But when the survey forced them to choose between raising the age or cutting benefits, 59 percent said raise the age and keep the benefits.
Am I missing something? Suppose that I live to be 75 and that starting at 65 my Medicare benefit averages $500 per year for a total payout of $5000. If the eligibility age is raised to 70, the payout drops to $2500. How is that not cutting benefits?

The choice offered here is not between cutting benefits or raising eligibility age, it's between cutting benefits and cutting benefits. Medicare is in increasingly desperate need of reform, but raising the age of eligibility in a time of high unemployment and to an age higher than many people can work under any circumstances leaves people desperately hoping that they don't get sick between the ages of 65-69.

Here's a thought: Everybody buys health insurance under the auspices of a single program, with premiums determined by income and community rating, and basic coverage sold on a nonprofit basis. Remove a drag on wages and salaries by eliminating the employer tax exemption (not to mention the subsidy paid by the self-insured and uninsured), and get the government out of the insurance business while retaining its regulatory role.

What the heck:

Great Expectations (1946)

Here's the memorable opening sequence from David Lean's postwar classic:

Scottish character actor Finlay Currie had over 140 credits between 1931 and 1969, none better than his work in this scene. He performed right up until his death in 1968 at age 90.

Tuesday, December 28, 2010

Great Endings: Great Expectations

I took her hand in mind, and we went out of the ruined place; and as the morning mists had risen long ago when I first left the forge, so the evening mists were rising now, and in all the broad expanse of tranquil light they showed to me, I saw no shadow of parting from her.
Charles Dickens, Great Expectations (1861) 

Sunday, December 26, 2010

Sunday Funnies and Arts

As always, click to enlarge...

Thanks to PWALLY for the steering wheel!...

HealthMatters and the Beveridge single-payer model...

A single leaf...

Peace on earth...

Old time holiday train...

Hilliard Bridge winter...


Did he ever return? Here's the true story of man named Charlie...

The Night They Drove Old Dixie Down...

Saturday, December 25, 2010

Good Will To Men

Father Urban, and perhaps Wilf and Brother Harold, too, sensed the rare peace now reigning among them, but Jack rejoiced in it visibly. Still, a moment later, it was Jack who broke the spell. "You know, Urban, I don't feel right about those animals," he said -- not, Father Urban knew, to be critical but just to be saying something. For a moment, they had all been lifted up, and this was Jack's way of letting them lightly back down to earth, where they had to live. "I've always understood that what heat there was at Bethlehem came from the animals. By rights, they should be closer to the Holy Family. Of course, I realize that's not possible in this case."
Father Urban looked over at the tree, at the hamper of food and liquor there. "Let's open one of Billy's bottles," he said.
"A Couple Of Nights Before Christmas," Morte D'Urban, J. F. Powers (1963)

And Judy, of course...

Friday, December 24, 2010

Boob Bob Redux

During the BP Oil Catastrophe last summer, Louisiana Governor Bobby Jindal insisted that the construction of artificial sand berms was a sure-fire means of containing the spill. Government and independent scientists objected: No underlying science supported the project, it would expend money and resources better used elsewhere, the berms couldn't possibly be built in time to do any good, and they might well be counterproductive. Just federal bureaucrats getting in the way of state leadership, Jindal bawled, and amidst the general caterwauling to Do Something Anything, the government reversed its position and allowed Jindal's vanity project to proceed.

Well, as Rachel Maddow reports, it turns out the Obama administrations concerns were justified. The berms, reported a bipartisan commission, were of no use but did cost a lot of money (and, incidentally, were a gold mine for Louisiana dredging interests; this was really little more than Jindal acting as a bagman for special interests). Watch:

Thursday, December 23, 2010

Great Endings: For Whom The Bell Tolls

He was waiting until the officer reached the sunlit place where the first trees of the pine forest joined the green slope of the meadow. He could feel his heart beating against the pine needle floor of the forest.
Ernest Hemingway, For Whom The Bell Tolls (1940)

Wednesday, December 22, 2010

Lest We Forget Joe Strummer

August 21, 1952-December 22, 2002

Tuesday, December 21, 2010

All Things Must Pass

I began Citizen K. three years ago because I wanted to write about whatever I wanted to write about. I have made some wonderful friends in the process, and have enjoyed every minute of it. I've also learned and, I trust, honed my writing skills.

In the past several months, I've discovered something that I want to write about in particular. So, in the next couple of weeks, I'll be transitioning my efforts from Citizen K. to Health Matters, which I hope will serve as a forum for reasoned discourse about health care, ranging from policy to specific issues such as public health, health technology, health literacy, compensation, and overtreatment. In particular, I want to explore the health care systems of other nations with the idea of learning from them, something that Americans resist to near pathological degree. I invite you to join me.

Citizen K. will be around until the first of the year. Whatever you may have learned from me pales compared to what I have learned from you.

Sunday, December 19, 2010

Sunday Funnies and Arts

As always, click to enlarge...

The annual Famine Walk in County Mayo commemorates the death of hundreds of Irish peasants who died seeking emergency food supplies during the Great Hunger...

History, Memory, Technology: Marronage in Saint-Domingue (Haiti)...

The Republicans explain a financial crisis with politically correct dogma...

In the stacks: The Boston Public Library...

The Virginian and Hollywood's Old South...

C&A Seafood: Hot Lunch Shrimp Crawfish...

Visions of corned beef danced in her head...

Art of the Poster: The Birds...

Fall free as old confetti...

Emmylou and Dick Gaughan transcendant on "Wild Mountain Thyme"...

John Waugh explains why Hank Williams sang as well as Frank Sinatra, Tony Bennett, or anyone else for that matter...

Just A Song: "The Night They Drove Old Dixie Down"...

Woke up this morning, had them Statesboro blues:

Saturday, December 18, 2010

Jamaicans for Justice: Victim's Voices

I'll believe when I see it, but with 63 senate votes to cut off debate, the end of the stupidity of DADT is in sight. Saxby Chambliss (R-GA), whose alleged football injury and (for good measure) student deferment allowed him to spend the Vietnam war in the comfort of a fraternity house and who later accused triple amputee and Silver Star winner Max Cleland of being soft on defense, echoed past arguments against integrating the armed forces: "It the middle of a military conflict, this is not the time to do it." When would be the time, Senator?

James Inhofe (R-OK) claims that "it is working very well." How does that explain the 14,000 soldiers discharged for their sexual orientation, including Arabic linguists and others with mission critical skills? And why is it working, Senator? Because 14,000 is the right number, or because thousands more can't serve their country with suppressing who they are?

DADT has accomplished nothing but lying, shame, and subterfuge. It has deprived the military of dedicated, honorable men and women just when it needs them most. Retaining it says that it is the victims' duty is to adjust to the bigots, when it must be the other way around.

Friday, December 17, 2010

Heads They Win, Tails We Lose

Fred Kaplan writes that the situation in Afghanistan is worse than ever.

We're in a position of having to depend on an unstable  nation (Pakistan) with a political agenda that does not sync with ours. Moreover, that country's stance is dictated by its acrimonious relations with a third country that are beyond our control or influence. Moreover, we're in bed with a notoriously corrupt regime. This is the definition of an untenable position.

If containing the Taliban in Afghanistan is a vital national interest, then Americans must accept the reality of an indefinite and dangerous police presence there.

If containing the Taliban is not a vital interest, we must withdraw.

Those are the realistic terms of the debate. We should cease the fiction that any sort of conventional victory is in the cards.

Tuesday, December 14, 2010

Much Good Work to Be Done

One quarter into my MHA, here's what I learned/think about health care reform:
  • An acceptable level of overall population health at a reasonable cost requires universal access to health care via single program. This means that residents of all ages are in the same program, without the fragmentation of Medicare/Medicaid, employer insurance, self insurance, and out-of-pocket payment. (I'd leave the VA alone because those patients have unique needs that civilian health care is not set up to handle.)
  • Universal access is a prerequisite, not a guarantee
  • Improved outcomes and savings require robust federal, state, and community public health policies aimed at containing the dangerously rapid increase in obesity, and the major chronic diseases of asthma, cancer, depression, diabetes, and heart disease. (Obesity is a risk factor in all five)
  • Improved outcomes and savings also require a system based on primary care, not specialties. Currently, 30% of U.S. physicians are primary care doctors. The number should be 50%, at least.
  • Overtreatment in some areas and undertreatment in others is a problem traceable in part back to the high proportion of specialists
  • The state of health information technology is dismal
  • As politically significant an accomplishment as it is, the Affordable Care Act mostly buys time and doesn't address the issues of cost or quality. (In fairness, it isn't designed to.)
  • Only so much can be accomplished by government at any level. Much reform must come from within the system
  • Regarding the economics of American health care, it is supply driven and not demand driven. That is, an area with more heart surgeons with have more heart surgery than an area with fewer, but it is unlikely that overall cardiac health with differ significantly between the two
  • My right to access a health care system and the public interest in community health supersedes your right to choose to not access the system
In short, there's much good work to be done...

Yesterday, U.S. District Judge Henry Hudson struck down the portion of the Affordable Health Care that mandates the purchase of health insurance on the grounds that the individual right to not purchase health insurance supersedes anyone else's right to purchase it and the community interest in public health. Ian Millhiser thinks that Hudson's opinion reveals the weakness of the hand being played by the opposition. I think the ruling is not only misguided, it places ideological correctness ahead of addressing what should be considered a threat to our national security. It's simply foolish to be taking an option off the table when it doesn't involve shipping people off to gulags.

Sunday, December 12, 2010

No Sunday Funnies Today

I'm heads down on final project for school. The Sunday Funnies and Arts will be back next week.

Saturday, December 11, 2010

Wankn' Fookin' Bankers

This one deserves to go viral!

Thursday, December 9, 2010

The Flat Tax: A Bad Idea Whose Time Will Never Come

When the Republicans assume control of the House next month, they will undoubtedly start talking about tax "reform." At least some Republicans will push for a flat tax, a notion embraced in its essence by the misbegotten Deficit Commission's recommendation of a greatly flattened tax. Sounds fair and sounds tantalizing doesn't it? Everyone regardless of income pays a the same rate -- the typical proposal is 15%, although one-time presidential candidate Steve Forbes pushed for 10%. Just about everyone's bracket drops, and we all live happily ever after. What could possibly be wrong with this picture?

Lots, as it turns out. For one thing, the flat taxers never take the deficit into account. We'll see why that's important in a minute. For another, just because your top rate is, say, 25%, doesn't mean that you pay 25% of your income in taxes. Remember that the current tax system still has vestiges of progressivity, so if you file singly and earn 50K -- which puts you in the 25% bracket -- your actual income tax paid is less than 10% before deductions. That's because only the income that exceeds 34K is taxed at 25%.

Consider these five taxpayers, all filing singly:

A: Earns 20K, pays $2,581 or 12.9% (.1% of all taxes paid)
B: Earns 50K, pays $4,681 or 9.4% (.2% of taxes)
C: Earns 100K, pays $13,609 or 13.6% (.7% of taxes)
D: Earns 500K, pays $139,616 or 27.9% (7.4% of taxes)
E: Earns 5M, pays $1,714,616 or 34.3% (91.4% of taxes)

The total tax revenue is 1.875M. Let's posit that by some miracle we have a balanced budget and that expenses equal revenue. And let's remember that in the real world, there are a lot more B's and C's than anyone else (millions more than E's), meaning that their share of the total tax burden is much higher.

Now, consider the effect of a flat tax of 15%

A: pays $3,000 (.4%)
B: pays $7,500 (.9%)
C: pays $15,000 (1.8%)
D: pays $75,000 (8.8%)
E: pays $750,000 (88.2%)

Notice what has happened here. Taxpayers A, B, and C are paying more, not less, taxes. Moreover, the tax burden lowers for only one of these taxpayers (if you think it's the one most like Steve Forbes, you get a gold star); it increases for everyone else. And don't forget: The actual distribution of taxpayers means that B and C -- the middle class, in other words -- will wind up absorbing the brunt of the shift in burden.

And, it gets worse. Under a progressive system, these taxpayers raised and spent 1.875M. Under a flat tax, they raised 850K, meaning that they have to cut expenditures by 1M or create deficit. And the deficit is apportioned equally. Thus, the low income taxpayer who makes 20K must shoulder 200K of the deficit, putting himself 183K in debt (including his 3K tax liability). But taxpayer E can absorb his share of the deficit easily: In fact, his share plus his 15% tax liability comes out to less than his tax bill under progressive taxation and a balanced budget. In this scenario, a balanced budget works against him.

Which is why Republicans talk big about a balanced budget and do little. The malefactors of great wealth that bankroll Republicans from the leadership to the teabaggers not only care little about a balanced budget, they don't want one. Balancing the budget inevitably means raising taxes progressively, and the Koch brothers, Jamie Dimon et. al. would rather have the middle class crash and burn than face the prospect of actually contributing to society. So they oppose government with one hand while seeking to master it with the other.

Monday, December 6, 2010

Consumer-Driven Health Care

One of the many problems facing health care delivery in the United States is the performance of unnecessary procedures. This contributes greatly to a health care economic model driven by the supply of a particular provider, as opposed to patient need or demand, and which in turn ratchets up cost. The underlying logic is complicated, but for now it's enough to now that fraud is rarely a factor.

A -- not "the" but "a" -- recognized driver of this  is a tendency on the part of employer-insured patients to request (and get) care and procedures that they don't need simply because the cost is invisible to them: They show their insurance card, make a co-pay, and leave the rest to their employer and the insurance company. Consumer-Driven Health Care is a conservative response to this problem aimed at righting the supply-demand relationship, making the patient more prominent and responsible for health care decision making, and reducing the role of the employer so that insurance becomes portable.

Generally, this involves an individual or family establishing a Medical Savings Account (there are a number of different types) paired with catastrophic health insurance. The individual contributes pre-tax dollars to the account (some plans permit an employer match) that incur tax penalties if spent only on anything but health care. Unspent dollars roll over to the next year and the account belongs to the individual: Even if an employer matches it or sets it up as part of a health coverage plan, an individual changing jobs take the account with him or her.

Criticisms of the plan take aim at its lack of utility for the chronically ill, unsuitableness for low income people who might quickly use up their medical savings and repeatedly hit the gap between the account and the insurance policy, the issue of health literacy, and the real possibility that the pendulum will swing too far and create a situation where people don't get care that they do need. In my mind, though, none of these objections are necessarily insurmountable. (Health literacy is a complex issue that I don't deal with here.)

But I believe that the real Achilles Heel of CDHC lies elsewhere, and that if it becomes the dominant health care financing paradigm -- a real possibility -- it will if anything exacerbate the problem it is designed to solve.

It's a curious thing that when experts on left and right debate health policy, they conduct the debate from an Olympian perch that ignores one of the most important commercial forces in American life, and that has certainly happened here. When the aggregate dollars in the various accounts reach a certain level, they will attract the attention of a marketing and advertising apparatus. This apparatus will labor mightily to separate that money from the accounts and transfer it to the interests they represent. And the apparatus is very good at what it does. People will be told that they "need" certain procedures and that they should not "forget" to get a regular this or that, none of which they will actually need, at least at the pace recommended by the various advertisements.

The campaigns will work well enough that the health care system will wind up performing just as many or more unnecessary procedures. We'll be right back where we started from, except that the health care system will have deprived people of their savings and turned hospitals, clinics, and group practices into racketeers. I don't think that that is the kind of doctor-patient relationship that Hippocrates or Galen had in mind...

One of the most important ongoing health care projects is the Dartmouth Atlas of Health Care. Dr. John Wennenberg, the genius behind the atlas, discovered and first documented the phenomenon of unnecessary care driven by provider supply in a particular area. Unnecessary procedures do not affect health outcomes in a given area. For example, it's possible for heart surgeons in one area to install twice as many stents as heart surgeons in a different area but resulting in no discernible difference in overall cardiac health. In this case, we would say that the difference in the number of procedures may have been unnecessary. Use the atlas to find out which procedures in your area may be performed at an unnecessary rate...

Sunday, December 5, 2010

Sunday Funnies and Arts

As always, click to enlarge...

I didn't read the entire book, but what I did read of Christopher Hedges The Death of the Liberal Class was a tedious disappointment. The author of the excellent War Is A Force That Gives Us Meaning has a good idea: How the decay of liberal institutions such as the press and the Democratic party has opened the door to a corporate assault on the middle-class way of life. But the sections I read were just another tired left-wing assault on liberalism, the kind of thing I've been reading and hearing since high school.

Hedges can't understand, for example, why liberals detest Ralph Nader. Nader is a saint, after all. And his candidacy had nothing to do with Bush's win in 2000. Bush cheated, Gore ran a poor campaign, and anyway there is really was no difference between the two. Hedges doesn't consider why liberals found this claim wrong in 2000 and ludicrous by 2008. He merely shakes his head sorrowfully when Eric Alterman explodes at Nader in the film An Unreasonable Man.

The problem with liberalism, Hedges argues, is that it never heeds the left. But that's a two-way street: The left never listens, either. It issues policy pronouncements and then accuses liberals of selling out on imagined commitments that could have been met had they only believed more.

Progressive systemic change in this country has typically been driven by mass movements. Hedges' liberal establishment cannot by definition produce movements, but historically it has (eventually) heeded them. Despite a disappearing middle class, the left has failed -- if it's even tried -- to organize. What is needed is not yet another left wing critique of liberalism, but a left wing critique of the left...

Extending the Bush tax cuts for the wealthy is anathema to me. But I have to ask myself: If my choice is to extend the cuts and extend unemployment benefits or let the cuts expire at the price of the Republicans killing unemployment benefits, what do I do? Do I call their bluff? But what if it's not a bluff? Do I put people in danger of losing food and shelter when I can take on the tax cuts next year when when the economy may have improved?...

PWALLY takes on the red wombat eyes of the older sister...

I wish were lions...that would be nice...

Babylon Cafe, NOLA...

Song sparrow in Russian olive...

To Echo Mountain via Castle Canyon...


Volatile soup...

Saturday, December 4, 2010

Thursday, December 2, 2010

Devil in Disguise

And the LORD God commanded the man, saying, Of every tree of the garden thou mayest freely eat: But of the tree of the knowledge of good and evil, thou shalt not eat of it: for in the day that thou eatest thereof thou shalt surely die.
The Book of Genesis, 2:16-17
I don't spend much time wondering about who will head the Republican National Committee, but I did happen to glance through this article. And was rewarded with these utterly stupefying remarks from former ambassador to Luxembourg and would-be RNC Chair Ann Wagner:
I left after four years of living in and around socialism. What it really did on a daily basis for me and my children, and my deepened our love, our appreciation, and our respect for America. I believe in American exceptionalism. I believe in the soul of America and the things that make us, not better, but unique.
Think about this for a second. Four years as the American ambassador to one of the smallest and most easily traversed countries on the continent, and she can't tell the difference between socialism and a constitutional monarchy.

The half million people living in Luxembourg would no doubt be surprised to discover that their application of democratic capitalism is in fact a socialist worker's paradise. Many of them, though, might wonder exactly what Ms. Wagner finds so threatening about an unemployment rate of 6%, a deficit of 5%, the 16th-best health care system in the world, the third-highest GDP per capita in the world, and an income per capita of nearly $61,000. If this is socialism, we should welcome it with open arms.

Not that I really think that Ann Wagner or any of these fools know what socialism is. (But an ambassador? Even a Bush appointee?) It's become one of many meaningless catch-alls for "not like us," another casualty in the right's assault on the English language -- in its assault on meaning itself. That is, I think, at the root of right-wing paranoia: The fear of knowledge and the dread places it might lead. To them, knowledge is not a path to enlightenment, but the road to uncertainty and doubt. What to any sane person is the signal trait of humanity is to them the devil in disguise, with the black president nothing less than the beguiling serpent in the Eden of America.

They'd like nothing more than to return the apple to the tree. Try as they might, though, it's been plucked and we're the better for it.

Wednesday, December 1, 2010

Great Endings: The Natural (1952)

When Roy looked into the boy's eyes he wanted to say it wasn't but couldn't, and he lifted his hands to his face and wept many bitter tears.
Bernard Malamud, The Natural, 1952