Sallekhana or Suicide


images-2Several weeks ago, a prominent and beloved member of our community fell to his death from the 23rd story terrace of his downtown condominium.

I knew, without being told, that he had jumped. It seemed a horrific way to die, but I recoiled at the term “suicide,” with its connotation of an irrational action and a waste of human potential. At age 86, this man suffered from Lewy body dementia, a progressive disease that is a toxic blend of Alzheimer’s and Parkinson’s. Given his prognosis, it was hard to view his action as irrational.

“We need another word besides suicide,” noted a mutual friend, “for someone with a terminal illness who chooses not to prolong the suffering of chronic disease in old age.”

Shortly after that conversation, in one of those serendipitous coincidences that leave you breathless, I read an article entitled Sallekhanā is not Suicide. It is one of the readings for the class I’m teaching on how different religions deal with death and dying.

I had never heard of Sallekhanā (sa-lay-ka-na), although it has been around for more than two thousand years. This end-of-life ritual entails the gradual reduction of food and liquids until death occurs.

It is a core practice of the Jain community, a religious tradition that emphasizes non-violence and, like Buddhism, seeks eternal liberation from the cycle of life, death and rebirth. According to Jain texts, the term derives from the words sal (meaning ‘properly’) and lekhana (‘to thin out’). Sallekhanā is viewed as the proper thinning out of the body and its passions.

But it is not for everyone, as there are strict criteria for its use, among them that:

  • Death appears imminent from old age or incurable disease.
  • One is mentally competent and in “good emotional health” but has freed him/herself from the bodily passions and emotions (e.g., grief, fear, regret, affection, guilt).
  • Responsibilities to one’s family have been fulfilled, and permission has been granted by them and by your spiritual “master.”
  • One has practiced “fasting” (e.g., no food one day a week) for some time prior to taking the vow of Sallekhanā. After taking the vow, one simply increases the extent of the fasting regimen, with the gradual elimination of food and water.

Jain teaching is quite clear that Sallekhanā is a sacred ritual that is part and parcel of a religious life style. Any self-imposed death that involves violence or impulsive behavior in response to depression, grief, or incurable disease, would be labeled suicide, not Sallekhanā.

Clearly, Sallekhanā does not cover my friend’s decision to jump to his death. But it does bring into sharp focus the fact that, in our current culture, many treat death as something to be to be avoided or delayed if at all possible. Sallekhanā is based on the notion that death is an inexorable and desirable part of a life well lived … that one’s worth as a human being is not measured by the ability to “hang on” in the face of terminal illness and considerable pain.

What word would you use?


Planet Alzheimer’s


images-1How many of you have struggled with Alzheimer’s in a parent or spouse?

I know, from my own journey with my mother, that it can be a horrific experience watching a vibrant and capable human disappear, day by day, before your eyes.

Equally painful is the sense of helplessness … the uncertainty as to how to care for and comfort someone whose emotional and intellectual needs vary from day to day … whose behavior shows no discernible pattern or logic… who “acts out” for no identifiable reason.

Thus, it was reassuring to learn, at a recent seminar in Des Moines as part of the “Embrace Aging” series, that it is possible to make everyday life quite manageable for both dementia victims and their caregivers.

The presenter was Chuck Wurth, a Managing Partner of several retirement communities in the Midwest designed specifically for dementia patients

Living in The Eternal Present

According to Wurth, the loss of memory causes its victims to live in an increasingly eternal present.  As a result, they lose the learned knowledge of cause-and-effect … the memory function that tells us what steps to take to achieve the outcome we want. For example, a dementia patient who is cold may no longer make the connection between getting warm and putting on a sweater or turning up the thermostat.

According to Wurth, dementia patients typically “act out” because they don’t know how to express their needs and/or what to do about it. In his view, meeting the needs of Alzheimer’s patients can be pretty easy … but only if you can figure out what that unmet need actually is.

One approach that Wurth suggested was to take the time … often significant amounts of time … to actually talk to the patient. He offered four checklists—medical, physical, social, and “caregiving”— to prompt specific questions you should to ask in order to discern what the patient needs. “How are you feeling today” just isn’t going to get you the information you need.

Rules of Planet Alzheimer’s

Wurth also believes that the social and caregiving needs of an Alzheimer’s victim are as important as the medical and physical ones: loss of memory does not eradicate the need to be accepted, respected and loved.

Wurth praises the approach developed by Candace Stewart in Welcome to Planet Alzheimer’s.  Stewart uses the metaphor of a different planet, where the language and the rules are different from our everyday world. To communicate with an Alzheimer’s victim, you need to learn their rules:

  • You are not who YOU think you are — you are who THEY think you are
  • Logic and reason do not exist … follow the rules of improvisation and go with the flow
  • Nothing is gained by arguing
  • YOUR truth and THEIR truth are very different … accepting their truth is not the same as lying
  • Never take anything personally
  • Have no expectations
  • Take advantage of the shuttle back to earth at all times … you need to have your needs met as well.

To me, the rules of Planet Alzheimer’s sounded much like interacting with a young child.  According to Wurth, however, you cannot treat dementia  victims like children. They are adults with adult needs, but adults who are have forgotten many of the lessons they once learned.

Wurth insists that caregiving for a friend or family member with dementia can be a rewarding experience—but it takes a very different kind of patience … and a frequent return to the metaphorical planet earth.

If you would like to download Wurth’s four checklists, click here.

Leaning In—To Old Age


MCG & KTZ in DingbocheFor several years after my husband and I abandoned our Wall Street careers to sail around the world, I accomplished nothing of economic or social value to anyone.

We rose at daylight, went to bed when it got dark, and aimed our sailboat in whatever direction the wind, weather, and currents allowed us to go. Because there was nothing I had to do and no place I had to be—indeed, most days my biggest decision was what to fix for dinner—I discovered what it meant to simply “be.”

Those years of being rather than doing were the happiest—in the sense of pure contentment—of my life. But my inability to hang on to that sense of contentment in the years since the sailing voyage ended has been a constant source of disappointment.

I rationalized its absence while I was back in the competitive world of high finance, assuming it would re-emerge when I retired. To my dismay, it did not. Even in retirement, I seemed to still be defined by what I accomplished. Co-teaching a comparative religion class at a local university. Chairing the board of a mental health agency. Planning a trip to Rome for Kent’s 75th birthday. Editing a friend’s memoir.

But no matter how much I accomplish, the shadow of old age looms on the horizon. With each passing day, I have a few more wrinkles, a bit less energy, and an ever-increasing list of words that are no longer at the tip of my tongue.

Why am I so determined to pretend I am still in the prime of life?

That is the question at the heart of Daniel Klein’s delightful Travels with Epicurus. In this lovely little tome, Klein revisits the Greek communities he knew as a young man, as well as the philosophers—among them Epicurus—who inspired him to live life well and to the fullest.

Now, in his 70’s, he muses on how the meaning of living life well has changed over 50 years. Throughout this geographic and literary travelogue, Klein asks whether trying to “extend the prime of life into old age” causes us to miss out on what is most valuable about growing old—and being old.

Drawing on the wisdom of his philosopher friends, Klein observes that in old age, you have the freedom to savor every moment for itself rather than what it represents … your friends are companions rather than connections … the person with whom you dine is more important than what you eat.

But, he notes again and again, the ability to savor those moments and those friends depends on your ability to step away from the often self-imposed notion that your worth is based on what you do rather than who you are.

Reading his book was a bit of an epiphany. Over the years, it seems I have put “finding contentment” on the list of all those things I ought to do. Reading Klein, it struck me that if I simply allow myself to grow old—instead of trying to stay forever young—contentment might actually find me.

Are you willing to step out of the stream and lean into old age?

If you want to leave a comment on my blog, or catch up on past blogs you might have missed, just click on the blog title, and it will take you directly to my blog page.

Cooking with CRISPR


A strip of DNA

                        A strip of DNA

CRISPR sounds like some clever kitchen trick we should all know about. In fact, CRISPR is a radical new approach to medical and scientific research, one that adds a new level of urgency to a familiar question in bioethics.

Does the fact that we can do something [insert the medical or biological procedure of your choice] mean that we should do it?

Debate continues over the use of now-familiar medical technologies such as birth control, ventilators, and artificial nutrition. A whole different level of debate is associated with genetic engineering … things like stem cell research, cloning, or in vitro fertilization, as well as genetically modified organisms (GMOs) in the food supply.

Do we really know the full implications of genetic engineering on the future of the human race?

What Does CRISPR Do?

These debates take on an added urgency with the emergence of CRISPR (I will not burden you with the scientific name, which would take up nearly a full line of type)—a new tool for genetic engineering. CRISPR has been likened to the search function of a word processor.  You decide what part of a gene you want to remove and/or replace, give CRISPR the appropriate instructions, and send it on its way. Voilá, the change is made.

Genetic work of the sort done by CRISPR has been around for nearly half a century … think of research into cystic fibrosis using mice or the development of pest-resistant corn. But before CRISPR, altering a gene was a laborious manual procedure. And once you had edited that gene, you had to breed and observe several generations of your subject (be it mice or corn) before you could tell if the experiment had worked as expected. Research on a single mutation could take as much as two years to determine success or failure.

According to a recent article in the New York Times, “altered genes frequently ended up in random locations, or in widely varying numbers” making it difficult to discern whether the concept was wrong … or whether it was a good idea that failed because of errors in the editing process. Progress was further slowed because you could only edit one gene one at a time; research on diseases thought to reflect the interaction of multiple genes (e.g., many forms of cancer) was halting at best.

20150508_075515_SJM-CRISPR-0510What makes CRISPR so significant is its speed, precision and breadth. Imagine a multi-pronged tool … a kind of biologic GPS that can accurately locate one or more genes in a segment of DNA … a pair of scissors to snip out the surrounding DNA … a tool to stitch up the DNA so it appears undisturbed. Because CRISPR can address multiple genes at the same time, projects that used to take months or years can now be done in a matter of days.

According to the New York Times, CRISPR is already being used to develop better bio­fuels and create new enzymes for things as diverse as laundry detergent and paper milling. Animal breeders produce superior lean-meat animals faster and more reliably than with crossbreeding. Dannon already deploys CRISPR to create strains of bacteria designed to produce more flavorful yogurt.

CRISPR’s Possibilities

Many scientists see great promise in CRISPR. It will facilitate targeted drug research … offer new insights into the role of genetics in mental illness … perhaps find a mechanism for eliminating mosquitos that carry Zika, dengue or Guillome-Barre.

It also offers the possibility of eliminating the BRCA gene for breast cancer … for ridding the world of Hodgkin’s lymphoma or AIDS. But scientists do not begin to understand the full significance of any specific genetic trait—or the consequences of changing it permanently. As a related article in the New Yorker notes the potentially devastating sickle cell anemia was an evolutionary protection against malaria. Would eliminating the gene for sickle cell lead to a dramatic increase in malarial deaths?

More broadly, what are the risks of modifying the genetic structure of embryos or “germ cells” that develop into eggs or sperm?  Such changes would be passed on to all subsequent generations.

This concern has also been with us for nearly half a century. What is new is that genetic engineering projects that once required well-funded laboratories run by universities or corporations are now potentially available to almost anyone with a good head for science and access to decent laboratory facilities for relatively brief periods of time.

Does the fact that we can have CRISPR mean that we should use it?

P.S. A curious sidelight of this discussion is that one of the most prominent researchers in the CRISPR world is a 34-year-old scientist named Feng Zhang, who grew up in Des Moines, my home for the last 15 years.

Health Care and Patient Rights


UnknownWith every passing week, I hear another story of patient rights being trampled on—someone who got medical care that they didn’t want and/or didn’t need.  This, despite the fact that the U.S. Supreme Court has ruled, repeatedly, that patient autonomy—your right to accept or reject proposed medical treatment—is indisputably the law of the land.

But as with so many other things in life, you do need to read the fine print.  And very often, you need to read the fine print long before you actually have a medical decision to make.

The first problem may be your doctor.  Does he know what kind of medical care you’d like, and under what circumstances?  And if so, does he or she agree with you?  As Atun Gawande pointed out in his brilliant book, Being Mortal, most doctors have been trained to cure disease and fix what’s broken. They don’t necessarily stop to ask whether the proposed treatment will actually make your life better, or whether the cure will cost more in terms of dollars, physical pain and/or emotional stress than it is worth to you and your family.

As readers of my blog may remember, my interest in bioethics stemmed from my horror at the death of my father, who was bedridden after years of diabetic traumas.  His heart failed half a dozen times over the course of his last year. Despite his repeated pleas to be allowed to die, his doctor insisted on resuscitating him. My father finally died, not because his doctor accommodated his request, but because his heart just couldn’t do it one more time.

The issue is not whether my father had the right to refuse treatment.  The issue—the fine print—was that he had neither the physical nor emotional strength to challenge a doctor who was determined to “fix” his worn-out heart.

The second bit of fine print, a bit more literally, is that he never wrote down his desire to let take nature take its inevitable course.  This matters, because the Supreme Court has ruled that, when you are not competent to make a decision yourself and you have not made your wishes known through some form of Advance Directive, your doctor can use his best judgment.  My father was “competent” in the sense that he could carry on a conversation or read the newspaper, but neither he nor my mother were able to challenge his doctor on a complex medical and in a highly emotional environment.

There are rarely any adverse consequences for a doctor or a hospital that ignores the Advance Directive of non-competent patient, particularly if you don’t have a surrogate—a spouse, a child, a friend, a lawyer—who is legally empowered to advocate for your wishes through a Health Power of Attorney.  Even then, the doctor or hospital can refuse to honor your wishes; in such cases, your advocate may have to find a new doctor or move you to another hospital … heart-rending choices when you are critically or terminally ill.

And then, of course, you need to be sure that your legal advocate agrees with your wishes. I continually run into people who’ve appointed a legal surrogate, but not discussed their health care preferences … all too common when your surrogate is a family member emotionally geared to doing everything possible to keep you alive.

Then too, the Advance Directive needs to be precise enough to capture your situation.  Think, for example, about having an automobile accident and needing to be put on a ventilator. Would your answer be different if you were age 40 and healthy than if you were 90 with advanced Alzheimer’s? If you haven’t thought through and documented the kind of care you want under various scenarios, you are vulnerable to the preferences of whatever doctor or hospital is overseeing your care.

There are other health care documents you may be aware of: Do Not Resuscitate Orders (DNR)  … Physician Orders for Life Sustaining Treatment (POLST) … Fives Wishes … a Living Will.  They don’t all serve the same purpose, and many are subject to state law (which can vary dramatically from one state to another).  They all have fine print you need to read.

If you want to get up to speed, I highly recommend The Practical Guide to Health Care Advance Directives by Jo Klein Cebuhar.  It is delightfully readable, but is jam-packed with helpful hints for getting the fine print right.

A Night at the Caucus



A caucus-goer in training

A caucus-goer in training

For those of you unlucky enough to live outside of Iowa, I thought I’d share my experience of the 2016 Iowa Democratic Caucus.

To set the stage, imagine the gym of a local middle school, with royal blue bleachers … nowhere near enough seating for 420 voters (a record 62% of registered democrats in the precinct), plus assorted children, out-of-town observers, and photographers.  The crowd was mostly white, a mix of ages, and included an impressive number of first time caucus goers (indicated by show of hands).

I managed to squeeze into a bleacher seat with a dozen or so of my neighbors … all of us checking to see which of our friends were caucusing for whom.

The gym had no sound system, so the chairman of the caucus had to shout over the noise.  His first task was to count the actual voters, to confirm that voters in the gym matched the voters shown on the sign-in sheets. To accomplish this mundane task, the official “counter” walked back and forth along the bleachers and back and forth through the folks standing around the sides of the gym.  He asked the first person to call out “#1”.  Thereafter, each person he pointed to had to shout out the next number in sequence, until he got to the last person and also got to 420.

Amazingly, they got it right on the first try (Iowa’s been doing caucuses for a very long time) and announced that “viability” (at least 15% of the voters in the gym) was 63.

The Undecided's

The Undecided’s

For the next few minutes, we listened to a representative of each candidate extol the candidate’s virtues, after which we all clambered down from the bleachers and moved to our candidate’s “wall,” where we arranged ourselves in parallel lines of ten.  It reminded me of lining up for the bathroom in grade school.  With three walls and three candidates, that left the “undecided” huddling on the midline of the basketball court.

Again, the count was done by having precinct workers for each candidate walk back and forth through the lines of voters, counting them one by one.  When the count was completed, Clinton was ahead of Sanders, I think by 8 points.  O’Malley, at 32, was out of the race.  So were the undecided, all 13 of them.

The best part of the caucus was yet to come — the 30 minutes allowed to “persuade” friends, neighbors, and strangers to come over to your team.  Could you persuade O’Malley supporters and the undecided to join with Hillary or Bernie?  Good humored pandemonium reigned, with informed discussion of policies interspersed with promises to do neighborly favors like shoveling your driveway in the next snow storm (today).

IMG_2615Blessedly, we didn’t all have to return to our parallel lines.  This time the counters matched up those still undecided, those still sticking by O’Malley, and those who switched to Hillary or Bernie.  If you followed the math, there were 45 votes in play.  When the count was done, Hillary was still ahead, but this time by only 4 points.  For those of you who don’t do math, that was less a hair under 1% of the voters in gym.

We were only one caucus out of 1,681, but our paperthin margin reflected the ambivalence of Iowa.

If Iowa still has the first-in-the-nation caucus for the 2020 election, you should come to watch democracy at work. There aren’t many other places to see it in action these days.

My next blog, of course, will be back on matters of health and bioethics.

Health Care – Insurance 101



Balancing Risk for Health Insurance

Given the recurring debate over a private market vs. a single (government) payer for health insurance, I thought it might be helpful to review a few basics of the insurance business. What follows borrows from an essay by Frank J. Lysy, a retired economist at the World Bank.

What is insurance?

Well, duh … an insurance policy is a contractual agreement in which you (the insured) make regular payments. In return, you get the insurer’s promise to protect you against claims associated with events explicitly enumerated in the policy.

As with all contracts, you do need to read the fine print.

How does insurance work?  

An insurance company has to manage premium income so that it has enough cash to pay claims as they come due. While an insurer cannot predict the claims profile of a single policyholder, a “pool” of policyholders typically has identifiable claim characteristics based on things such as age (drivers under 25), location (urban vs. rural), or health factors (smoker vs. non-smoker).

If the pool reflects a statistically “normal” population, the insurer can estimate expected claims with a high degree of confidence, and set a premium rate that will generate funds sufficient to cover those claims. If, however, the pool does not reflect the population as a whole, the insurer will find it difficult to match the actual level of claims and the premium income.

Ensuring that premium income generates enough income to cover future claims is the primary management task for an insurance company, whether it’s in the auto, homeowner or health care business.  However, it is a particularly daunting challenging for health insurance.

The Health Insurance Company’s Perspective – Adverse Selection

You, the policyholder, typically know more about your health situation than your insurance company.  If you have a family history of heart disease or cancer, you’ll probably want health insurance. By contrast, if your budget is strained or you are a healthy young adult, you may opt to forego health insurance.

Another problem is “free riders” that buy health insurance only when they expect to have a significant medical expense (e.g., a planned knee replacement).  As recently seen with the “Special Enrollment Periods” (SEP’s) under the Accountable Care Act (ACA), the pool of individuals who enrolled during an SEP had significantly higher-than-average health care costs; many let their policy lapse once their medical bills were paid.

This adverse selection means the pool will have a higher-than-normal percentage of individuals with higher-than-average claims. In this situation, a premium rate that would cover claims for a statistically normal pool of individuals will not be adequate to cover actual claims. To compensate, the insurance company can raise rates in the next premium period. Unfortunately, the now higher rate may lead some policyholders—typically those at low risk of medical expenses—to drop their insurance, causing the pool to develop an even more adverse profile.

Your PerspectiveBiased Selection

Health insurance companies, of necessity, try to bring the pool closer to a normal profile by enrolling policyholders who have lower-than-average claims.

For years, they accomplished this by denying coverage if you had a pre-existing medical condition. With the ACA, that’s no longer an option. But they can still build in criteria (check that fine print!) that allow them to deny claims you thought were covered, or to impose higher co-pays on certain types of expenses. For example, you might find that your surgeon’s fee is covered but the anesthesiologist’s fee is not. Or that drugs with a reasonable co-pay are “reclassified” into a tier with a substantially higher co-pay.

These unexpected costs can be financially devastating.  A Harvard Medical School study found that 62% of personal bankruptcies in 2007 in the U.S. were caused by medical problems; 78% of those filing for medical bankruptcy had health  insurance at the start of their illness.

Another angle to encourage people with higher-than-average medical expenses to enroll in a different company’s health plan. A classic example is adding the cost of gym membership to the insurance premium. This can deter anyone not interested belonging to a gym, but appeals to someone who is already paying for it.  This strategy improves the profile of the pool because people who go to gyms are generally healthier than the overall population.

What About The Individual Mandate in the ACA?

These two problems—adverse selection and biased selection—explain why the ACA requires every American to have health insurance. If everyone is insured, there are no free riders.  You can’t game the insurance company by waiting to purchase insurance until you know your medical expenses will be high. And if everyone has to have health insurance, insurers can be more confident of having a normal claims profile. Their incentive to discourage higher-than-average claimants is offset by the larger pool of lower-than-average claimants.

The Bottom Line

My point is that, from a purely financial perspective, it doesn’t much matter whether the system for health insurance is based on a marketplace of private companies (the ACA) or a single payer (Medicare)—as long as there is universal participation. Phrased differently, neither the private health insurance market nor the single payer system will be viable in the long run without something approximating universal coverage.

There is little doubt that the ACA needs to be fixed to reduce the problems of adverse or biased selection. But when you hear a politician telling you that everything would be fine if only all health insurance was private or if we only had a single payer system, take it with a grain of salt.  You’re probably hearing an argument based on philosophy, ideology, or politics…not basic principles of economics or finance.

A Market Model for Health Care


medical_heartOn January 6th, the House and Senate passed a bill to repeal major parts of the Affordable Care Act (ACA).  While several Republicans have proposed “market-based” alternatives to the ACA, none of them had sufficient support to be a feasible replacement for the ACA. Unsurprisingly, Obama vetoed the bill.

How do those proposals differ from the ACA? One, for example, would replace the ACA subsidies with tax deductibility of individual health care insurance premiums. Another would replace subsidies for insurance premiums with age-based refundable tax credits.

Is either proposal better than the ACA? And why? Would either actually alter the quality of health care (for good or ill), or will it just change how we pay for it? Would either slow the explosive growth in insurance premiums and the health care costs they pay for? Would either proposal affect your health care—or just those insured under the ACA?

If your head is spinning, you’re in good company. Few of us understand the finer points of either the ACA or the “market-based” alternatives. But a key difference is whether you see health care as a private or a public good. Market based models assume that health care is a private good and that people purchase it in pretty much the same way they buy cars.

Stanford economist Kenneth Arrow argued that this analogy doesn’t really work.

First of all, buying a car is usually a discretionary decision. Except in rare instances, you don’t have to buy a car today, and even if you do, you still have a host of makes and models to choose from. You can test drive several models to see which one you like best. You can read consumer reports and check with your friends to see how different cars perform and compare the quality of support from different dealers.

Not so with medical care. Apart from preventive care (e.g., vaccinations), routine screenings, and discretionary things like plastic surgery, the need for medical care tends to be unpredictable in both timing and treatment. While you can choose a family physician based on recommendations from friends, you can’t “test drive” the relationship until such time as you are actually sick. And once you are sick, your ability to explore treatment protocols, hospitals and/or specialists beyond what your doctor recommends is limited, in no small measure because, when you are sick, you probably don’t have the time and energy to do so.  In an emergency — a heart attack, a broken hip, or an automobile accident—you may have no choice at all as to the hospital or the doctor.

Another issue is price. You can compare prices for different cars, or for the same car from different dealers.  You can try to negotiate, and sometimes succeed.  You can buy the cheapest car, or you can pay more to have a more reliable dealer. You can add optional features. If you’ve done your homework, you know the cost of the car before you sign on the dotted line.

That’s not how health care works. Do you know what your doctor charges for different medical services? Would it make a difference if you did? When you are faced with excruciating pain in your gut or your chest, you’re not going to start shopping for the lowest cost physician.

The situation gets even more complicated if you’re hospitalized … you may know what your doctor will charge for, say, repair of a broken hip, but you will probably not know the cost of other hospital services—anesthesia, lab work, x-rays, physical therapy, and the inevitable “misc. charges”—until long after the event. If your insurance company refuses to cover a particular service or an “out-of-network” doctor, you, of course, are stuck with the bill.

A third leg of this stool is medical expertise. You can study up about the differences in quality and performance for cars that interest you. But how do you study up on a disease you don’t know you’re going to get or an accident you don’t expect to have. And once you’re sick, you rarely have the luxury of time to become an expert on a complex disease, particularly if you have no medical background. Think about the lengthy and small print inserts that come with your prescription medicines—do you ever read them? Do you actually know what they mean?

My final observation is that inherent in the market model is the notion of profitability—of pricing the service to cover not only direct and indirect costs, but also to provide a return to the owner of the service. In the absence of some degree of regulation, owners of most medical services can charge whatever the market will bear.

You can see this feature of a “market model” with drug prices over the past couple of years. If you google Valeant Pharmaceuticals, you will learn that this Canadian company has been steadily acquiring the rights to older drugs, many of which were relatively low cost generics. In February 2015, Valeant acquired the rights to two generic heart drugs for which there are no ready substitutes. The very same day, it increased the price of one from $215.46 to $1,346.62, an increase of 525 percent.  They increased the other by a mere 212 percent from $257.80 to $805.61.

A company spokeswoman justified the increase by saying that Valeant’s “duty is to [its] shareholders and to maximize the value” of its products.  Clearly, maintaining the health of the patient was not part of its duty. Taking advantage of someone’s misfortune clearly was.

Most people would agree that our current system, a mix of regulated and market models isn’t working very well. Most observers of the health care market agree that the ACA got quite a few things wrong, and needs to be fixed. But fixing the ACA is not the same as scrapping it for a market model.

While I don’t pretend to know what the “right” health care system looks like, I’m not yet convinced that a pure market model—with no government intervention at all— is where we need to go.

What do you think?

Health Care: Private or Public?


article-1108763-02FA1BC4000005DC-843_468x323Most of my friends instinctively think of health care as a “private” matter, if only because so many health-related problems deal with the most intimate aspects of life. You want the right to choose your own doctor and to select the kind of medical care you need, when you need it. In this sense, it’s like buying a car … you want to choose the make and model that suits you best.

But many people also see health care as a “public” concern, much as education, sewage treatment, public parks, and fire departments are public concerns.

What makes health care a public concern?

One answer is that the benefits of individual good health accrue to the society as a whole. Healthier individuals make better students and more productive workers, which results in a higher standard of living for everyone over time. Widespread immunization reduces the probability of contracting infectious diseases that can be debilitating or deadly. Public programs to curtail smoking, drinking and drug abuse reduce the risks of second-hand smoke and accidents caused by incapacitated drivers. Preventative health care (e.g., an annual check-up or a flu shot) helps people to live better and longer.

Another is that health care, like education or sewage treatment, requires an upfront investment—in hospitals and clinics as well as diagnostic and treatment equipment—that is often too large for any one individual or corporation to make, given the uncertain period to generate a reasonable return.

A third is that the demand for much of our health care is relatively insensitive to price. It’s a pretty simple concept if you think about, say, end-of-summer or Black Friday sales when crowds line up to purchase cars, TVs, and computers that they wouldn’t buy—and maybe couldn’t afford—at the pre-sale price.

You can’t do that with health care. If your budget is tight, you may forego discretionary items like getting your teeth cleaned or getting a tummy tuck. But when your kid has a broken leg or your spouse has a heart attack, you don’t stop to ask how much it will cost to set the bone or have surgery to put in a stent. You get it taken care and worry about the cost later. Unlike on Black Friday, the health care services you purchase are based on your medical condition, while the price you pay is determined by a doctor, hospital or drug company without regard for your financial circumstances at the time.

The consequences for the public

This is a “public” issue because those who are most price sensitive to health care — perhaps because they do not have adequate (or any) insurance — tend to forego those discretionary items that have broader social consequences. Their kids don’t get glasses or regular dental care, so they have problems concentrating at school, which affects their learning capacity and often creates disruptive situations in the classroom. Adults — our teachers, our co-workers, our employees—don’t get the preventive care, including drugs and therapy, that would  prevent more serious and costly illness at a later time.

It is a public issue because the uninsured—regardless of age and overall health—are still at risk of serious accidents or illness. All too many people—again, people in our community that we rely for services and support—suffer or die from medical issues that could have been prevented or cured if they had had the benefits of appropriate medical care.

It is a public issues because the uninsured or under-insured often labor under enormous debt as a result of medical bills; indeed, medical debt has been estimated to be the number one cause of consumer bankruptcies in 2013.

The community pays for these health care costs one way or another. Sometimes it will be in dollars-and-cents (e.g., local businessmen hurt by customer bankruptcies or taxpayers who have to make up the shortfall in public hospital receipts). Other times, it will be through lost productivity in the work place or in our schools. Whichever way it happens, there is little doubt that your continued good health costs you substantially more than the amount you pay directly in premiums and deductibles for your own health care.

It is the balance between health care as a private or public good that lies behind much of the debate about our health care system. If you see health care as a public good, you will tend to favor a single payer nationalized health care system (as Europe and Canada have or the U.S. has with Medicare); if you see it as a private good, you may prefer the private payer system (as we have in the U.S.)

What do you think?

Christmas Greetings


Kent's feathered tree

Kent’s feathered tree

The day of the winter solstice—and first day of Christmas week—should be a time of peace, comfort, blessings and hope for the future.  So I shall pass on this week’s commentary on our less-than-comforting health care system.  Instead, I want to wish you the best of the holiday season—in whatever tradition you choose to celebrate.



For us, we still celebrate with services on Christmas Eve. But we have replaced our “for real” tree with a series of red ones. Our first—an elegant affair made from feathers—was contributed by Kent the year we met; each year, we honor our good luck with another unique addition.


Seasons Greetings and Happy New Year.