Sunday, March 25, 2012

Back Home at the Hive

We humans have made so much progress in so many areas, especially technology, that it can be hard to remember that it’s still just us inside our high-tech skins. We still order our relationships and responsibilities pretty much the way we have since Cleopatra tempted Marc Antony. There is still a lot of lust and conquering, a lot of winners and losers. We like winners and losers. Each of us plans to be the winner. We want our shot.

It’s no big surprise, then, that we don’t like being told what we can and cannot do. We may like Mary Poppins, but we’re not fond the nanny state. We want to be free to strive. If we fail, so be it.

But every failure has a cost. And lately more of those costs are being borne not just by the person who fails but by his neighbors as well. In the not-so-long-ago past, being down on your luck could kill you. Nowadays, the social safety net might well catch you. Federal law prohibits emergency rooms from turning you away if you have a bad accident. Social security will give you enough to hold body and soul together in retirement.

That’s a good thing, right? That we’ve created a safety net. But because it’s woven from tax dollars, suddenly we all have a greater financial interest in the failure of our neighbors. Most of us are willing to help our neighbors, but what about folks we’ve never met, people who might not be doing all they could to take care of themselves? What about welfare queens?

Sometimes bad things just happen to people. You’re riding along on your bicycle and the driver of a car takes his eye off the road and in a heartbeat you’re lying broken on the street. Being born into poverty is kind of like that, except the car hits you while you’re gasping your first breath in your mother’s arms.

Being down on your luck can be expensive. When I did a swan dive off my bike, the paramedic and hospital bills for a scrapped nose and a sore neck totaled $11,000. A few days later, there were two terrible accidents nearby in which bicyclists were hit by cars and suffered more serious injuries: bleeding in the brain, emergency surgery, intensive care. Those medical bills were much, much higher.

What might have been done to have avoided those accidents and their costs in pain and money? The city could have put in more bike paths to physically separate bikes from cars, but bike paths or street barriers are expensive. Even a well-meaning city like ours is not going to spend a lot of extra money to reduce costs for which it is not responsible.

What if it were? What if it had to pay the medical bills for all bike accidents within its borders? It would certainly take that potential liability into account in deciding what more it might do to increase bike safety. Would it be fair to the city to make it responsible in that way? Perhaps not, but since the city is the only one who can put in bike paths, perhaps fairness shouldn’t be the primary concern. Maybe the primary goal should be to identify who can make biking safer and give them a good reason to want to do so.

The notion is similar to the idea behind mitigating the negative effects of certain commercial conduct. Cigarette manufacturers make a product that causes health problems that are enormously costly to the public. In the past, cigarette companies bore none of these costs, but lately, with litigation and taxes, some of the social costs have been shifted to the cigarette makers. Similarly, gasoline taxes have been used to pay for highway maintenance and pollution abatement. Soda taxes are being discussed as a way to reduce consumption of the liquid sugar that has spiked diabetes rates.

The new federal health care law sets up incentives (both carrots and sticks) for hospitals to reduce infections incurred by patients who are there for other reasons. There is every reason to expect they will produce good results. Recently (before the health care law was adopted), the University of Pennsylvania hospital reduced iv line infections from 30-40 per month to one per month, just by trying harder.

Some consumer products companies have been paying more attention to social costs. Starbucks, for instance, is rolling out innovative programs to recycle its used coffee cups. In one pilot, the cups go out the door with a little latte foam in the bottom and come back as napkins.

One group that has not yet volunteered or been forced to pay one penny of the social costs of its products is gun makers. I don’t see why we put up with this. Even if the Supreme Court says we all have a right to pack heat, I doubt the Constitution guarantees that gun makers can’t be forced to pick up the tab for the resulting mayhem. We’re long past letting the Cayuga River burn, so why do we let gun makers pollute our cities with handguns and not ask them to pay for the cleanup? If guns were taxed at a rate sufficient to cover their damage to society, they would be damned expensive, and much less ubiquitous.

Aligning social costs and benefits is tricky, but gradually we are realizing that in today’s world we are less like cowboys in the wild west than honeybees in a busy hive. Ultimately, what is good for the colony is good for the individual.

The next time you see something you think is wasteful, or worse—food being thrown out after a party, a garbage bag of recyclables headed for a landfill, a child requiring urgent medical care for an asthma attack because his parents could not afford an inhaler—think about what might have been done to prevent the problem. Who has the power to change the situation? Why don’t they? What could we do to motivate them to act?

When looking for corruption, the old adage is “Follow the money.” A maxim for helping us all live together in ways that provide an overall economic benefit and improve the quality of life for all might be “Follow the social costs."

Wednesday, March 21, 2012

Medical Emergency

A month ago I took a nosedive off my bike. Hit a curb and went right over the handlebars. My own unaided fault. You know that feeling of slow motion flying through the air? Not so much. One moment I was up, the next I was lying on my back seeing stars.

A Caltrain was passing and cars and people were stopped and someone saw a policeman nearby who called 911 and before I could blink the blood out of my eyes paramedics were asking if I knew my name. I told them I thought I was okay, but they insisted on taking me to the Stanford hospital. They didn’t seem to want to give me a choice, and I was feeling a little dazed, so I didn’t fight them.

The ER doctor ordered an x-ray of my neck. (Actually, he ordered a CT scan, which is more expensive and exposes you to more radiation, but I negotiated him down to an x-ray since his examination had turned up no symptoms of nerve-damage.) Nothing broken. He gave me a neck collar to wear until the soreness abated.

The paramedics had been nice enough to bring my bike to the hospital. Meg was out of town, so I walked home pushing my bike along beside me, thinking how much I love to walk, not really interested in biking just then. My path in the darkness was lit by passing cars and the lights of the Stanford shopping center. The sun had been high overhead when I’d done my face-plant.

Now the bills for this adventure have come. Actually, they aren’t bills. I have Medicare and a supplemental insurance plan, so I won’t have to pay anything. Here are the charges:

Paramedics                                           $2,289

These guys were great, but I didn’t get a bill from the policemen (three of them) who were also on the scene. If my house were on fire, I wouldn’t expect a bill from the firemen. I don’t want to seem ungrateful, but I guess I don’t fully understand where paramedics fit in as public-safety employees if their bills are to be paid by accident victims, or, in this case, Medicare.

Stanford hospital:

ER doctor and x-ray                              $1,129

2 ibuprophen                                          $6

“Emergency department visit”                $7,328

                        Stanford total         $8,463                    

Perhaps you are wondering what the “Emergency department visit” charge was for. Why, one might ask, should it cost over seven thousand dollars for me to lie on a bed and wait for five hours for procedures that were separately billed and took fifteen minutes?

I wondered the same thing, so, out of curiosity in this age of soaring health-care costs, I called the Stanford hospital billing department to ask. The pleasant woman I spoke with gave me an answer that sounded like she was reading from a script, something benignly vague about the level of emergency care. I was a level four. I asked her if that was high. She said she didn’t know. I never did figure out what the charge was for, since all my actual care--the doctor and the x-ray--was separately itemized. I assume the huge unattributed charge must be a kind of amortization of overall emergency-room facilities and staffing costs.

I thought to myself: Wow, if Medicare is paying these kinds of bills, no wonder it is in trouble. Then I asked the woman in the billing department how much of the bill Medicare actually paid. Her answer was $286. That’s right, two hundred eighty six. The hospital wrote off over $7,600, she said, as exceeding negotiated Medicare rates. If I hadn’t had Medicare or private insurance, would the hospital have expected me to pay the whole bill of over eight thousand dollars, even though the hospital wrote off most of it for Medicare? I asked. Yes, she said.

Okay, I hardly know where to start. In the first place, the size of these bills, especially the emergency department charge over and above the bill for my actual doctor care and x-ray, is ridiculous. I’m not saying it isn’t expensive to run an emergency room, but if you land there you shouldn’t become an involuntary contributor to their capital funding campaign.

Medicare obviously agrees that the bill was way out of line. They paid only a tiny fraction of it. This makes me think Medicare is not a program that needs to be reformed but rather expanded: the folks from Medicare should negotiate hospital rates for all of us.

What sense does it make to write bills like these if the only people who are actually expected to pay them, the uninsured, are almost certainly the ones who can’t afford to? What kind of silly accounting is going on here? Who is kidding whom about what? And why?

I can’t imagine the tangle of incentives and bookkeeping machinations that has gotten us to this point, but it is hard to make any sense of it. If we can find those responsible for this Alice in Wonderland world, I suggest we handle them the way the Queen of Hearts recommended.

One last note: I was not billed for a sandwich a kindly nurse gave me with the ibuprophen. I guess there is a free lunch after all.

Monday, March 12, 2012

Fantasy Woman

The young woman is sitting there naked. Lips breathlessly parted. From both sides, men are handing her purses. You can only see the men’s hands and cuffs but the impression is that they are fully clothed, probably expensively, as they compete for the woman’s attention. Whom will she choose? More than a purse is at stake here, it seems.

What is happening here?
It’s not the cover of a romance novel or a soft-porn film, it’s a full-page Lord & Taylor advertisement in The New York Times. So, what is Lord & Taylor trying to say? Come on in guys, these purses drive women wild. Surely the ad isn’t pitched to women, even though I assume women are the most likely customers for purses. If it is, the message is something like, Why buy these baubles when you can take off your clothes and get them for free.

I like sex. I love Victoria’s Secret. Maybe I should just shut up and enjoy the show, but when I see an ad like that I can’t help feeling a little ashamed of being a man. We ought to be able to love women without trivializing them, without implying that the only way they can get what they want in the world is by undressing.

Someone--I assume it’s men, but maybe it’s some women too--has a serious hang-up about sex and women. Women who want contraception are sluts. Women who want gender equality in the workplace are bitches. What we seem to hate is not the sexualization of women, but their taking control of it. We sexualize them relentlessly, as in the Lord & Taylor ad, but that’s us. That’s our fantasy. That’s the woman we want, the submissive temptress. A real woman, with her own wants and needs, scares us.

I think I understand the male side of this, but what I cannot fathom is why women put up with it. If I were a woman, I would never buy another thing from Lord & Taylor. I would never buy anything from anyone who ran ads of naked women to sell their products. (I guess I’d have to draw the line at naked men too--sorry Calvin.)

I think men are the problem here, but perhaps women are complicit. We’re all a little confused about the line between being considered sexually attractive and being objectified. Thanks to Darwin, men can pull off sexy by showing they can afford expensive suits and watches (and could therefore provide well for a family). Darwinianly, women have to show they will be good breeders and have good genes to pass along, which means showing enough of face and figure to pass that test. Somehow we managed to propagate the species for millennia, though, without women taking it all off. Many even feel nothing is sexier than imagination.

It’s hard to imagine why women in this country--educated, rich women, women who can afford expensive purses--put up with this way of depicting them and, implicitly, their worth to society. Maybe they are confused about who they are, about what it takes to be attractive and desirable. If that’s the case, let me, on behalf of all men who love Victoria’s Secret, reassure them that we don’t want to live our fantasies. We want our partners to be like us: smart, independent, thoughtful. We want them to take our fantasies out for a wild time once in a while and show up for work in the morning. They are called fantasies because they aren’t real. Women aren’t sluts. We don’t want them to be. Why do we let advertisers treat them like they are?

Saturday, March 3, 2012

Giving Culture a Bad Name

When I was a boy, everyone who was anybody, or hoped to be somebody, wanted to be cultured. Cultured meant good taste, good manners and a good education (which, in the dictionary, at least, it still does).

Henry Higgins tempting Eliza Doolittle
Somehow though, the term has been hijacked to mean something more like tribal norms. Now, norms may be what, by common consensus, most people accept, but they aren’t necessarily cultured. Slavery was the norm in the south a hundred and fifty years ago; witch burnings in Salem a bit before that.

And so, disputes that owe more to the Hatfields and McCoys than to Henry Higgins are labeled “culture wars.” They have nothing to do with culture. They have everything to do with provincial resistance to change. They are not in good taste; they are not well mannered; and more often than not they owe little to the kind of open-minded thoughtfulness fostered by education.

The latest tribal norms to emblazon the banners of the “culture wars” are religious tenets. Historically, this is boringly unexceptional, of course. There have always been religious crusades. On all sides. Think of Christians and Muslims pushing each other back and forth across the Middle East for centuries. But those days of religious zealotry and intolerance seemed like barbaric episodes from our unenlightened past. As we became more educated, more cultured, we became more tolerant.

That’s the way it has seemed in this country for many years. Perhaps the truth is somewhat different, though. Perhaps the truth is that our tribal norms, most often expressed as religious beliefs, simply had no serious challenges. For many generations, America was a Protestant land. Most were believers, and most believed the same things. Our early settlers and founding fathers felt that their laws came from their moral beliefs, and that their moral beliefs were handed down by their Christian god. So religion and law were not separate at all, not in that sense. Religion in effect gave us our laws.

Then came the others. The Jews, of course, but they stuck to themselves. Then the Italian and Irish Catholics. Well, they weren’t so different. A few niggling differences about birth control, but most people ignored that little inconvenience anyway. But beginning in the 1950s, the secular state raised its heretical head. Not the legislative branches--they were still pandering to the accepted norms--but the Supreme Court. First in the Griswold decision striking down state bans on contraception and then in Roe v Wade.

The Supreme Court told us what the cultured believed, that contraception and abortion are matters of personal conscience, protected by a right to privacy. Apparently, some of us weren’t ready for that message. Several generations later, we are still squabbling over it, now more vociferously than in a long while.

Why is that? What’s happening here? It is the last stand of a dying norm. The Civil War of reproduction. In this case, women are the slaves. Eventually the outcome will be the same as in our first Civil War. Slavery, by color or gender, cannot endure in our society. We are too pluralistic, and too prone to libertarianism. Even when we don’t sympathize with one slave or another, we don’t want to be slaves ourselves, so we tend to band together, across norms, to fight repression.

A true culture war would be an oxymoron. People of good taste, good manners and good education can find better ways to resolve disagreements than by going to war. That’s what college dorm room discussions are for. You know, the ones that one politician recently said are threatening to indoctrinate our young people in liberalism.

Yes, that’s the threat, all right. Liberal thought. Broad mindedness. No wonder those clinging to repressive gender norms are fighting so desperately.