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Programmers and system administrators are mass profession. There were approximately 435K programmers in the USA in 2006. I think number of system administrators are roughly the same so we can speak about the labor army of one million people.

Contrary to superficial impression of individual cubicles and nice environment, IT is actually very unhealthy profession. With a high chance to be unemployed after 50.  More often then not, there are periods of considerable stress. Some are caused by catastrophic failures of hardware equipment, some by unrealistic schedules and workloads, some by own errors of particular programmer or sysadmin.

Overtime is common. Job security is deteriorating as outsourcing is rampant.  Employment after 50 is not guaranteed. Environment changes way too fast, and not always for good. Fashion rules (remember The Devil Wears Prada). Toxic managers are common (remember Office Space ;-)

So sooner of later a programmer need to face "medical-industrial complex" of the USA. And this is a dangerous "for profit" beast with tremendous appetite which maims and kills annually considerable amount of people. Living under Neoliberalism with its "greed is good" mentality and "homo homini lupus est" slogan is indeed dangerous  and requires knowledge of elementary "self-defense". Hippocratic oath no longer applies to medical profession in the USA. Most doctors still follow it, but there real sharks among them (with some ending their careers in jail like regular criminals) and you need to hope for the best but  prepare for the worst.  Especially rampant abuse is with cardiac stents (Overuse of Cardiac Stents Linked to Patient Deaths) with around a dozen of cardiologists serving jail terms (see for example Stent doctor Salisbury stent doctor sentenced to federal prison )

As USA Today reported (Doctors perform thousands of unnecessary surgeries):

Since 2005, more than 1,000 doctors have made payments to settle or close malpractice claims in surgical cases that involved allegations of unnecessary or inappropriate procedures, according to a USA TODAY analysis of the U.S. government's National Practitioner Data Bank public use file, which tracks the suits. About half the doctors' payments involved allegations of serious permanent injury or death, and many of the cases involved multiple plaintiffs, suggesting many hundreds, if not thousands, of victims.

Journal of the American Medical Association reviewed records for 112,000 patients who had an implantable cardioverter-defibrillator (ICD), a pacemaker-like device that corrects heartbeat irregularities. In 22.5% of the cases, researchers found no medical evidence to support installing the devices.

"Don't just take a doctor's word," says Patty Skolnik, who founded Citizens for Patient Safety after her son, Michael, died at 22 from complications in what she says was unnecessary brain surgery. "Research your doctor, research the procedure, ask questions, including the most important one: 'What will happen if I don't get this done?'"

A 1982 study in the journal Medical Care found that a mandatory second opinion program for Massachusetts Medicaid patients led to a 20% drop in certain surgeries, such as hysterectomies, that were considered more likely to be done unnecessarily. A 1997 study in the Journal of the American College of Surgeons looked at 5,601 patients recommended for surgery and found that second opinions found no need for the operation in 9% of the cases. Among those who got the countervailing second opinion, 62% opted not to have the operation.

But many patients simply aren't inclined to question their doctors.

"We expect the physician to know what's best for a patient," says William Root, chief compliance officer at Louisiana's Department of Health and Hospitals. "

We put so much faith and confidence in our physicians, (and) most of them deserve it. But when one of them is wrong or goes astray, it can do a lot of damage."

Chronic stress, overload, long hours, unhealthy diet  and other environmental factors  deeply and negatively affects the lifestyle of programmers and system administrators.  So there is nothing surprising that despite pretty comfortable work conditions many programmers/system administrators suffer from assortments on various diseases. Like other workers who spend long periods in front of a computer terminal typing at a keyboard, programmers are susceptible to:

Additional health problems are typical for those who experience constant stress and/or are typical "diseases of civilization". Among them

Also many programmers/sysadmins works as contractors and either do not have health insurance or have very basic health insurance. This is typical for young programmers and those who are over 50 and were let go on their previous jobs die to outsourcing

Low and middle income US citizens  spends far more on health care than any other country but gets only mediocre care in return for its investment. The U.S. national average score on 37 separate measures of health care falls far short when compared either to a few centers of excellence within the country, or to other countries, the report from the Commonwealth Fund found. And that's true not only in terms of mortality statistics but also in terms of quality of life.

The main problems with US healthcare are:

Programmers and system administrators can do much better is maintaining their health. And they are naturally equipped for dealing with complex system and thus able to navigate the maze of the USA "medical industrial complex"

A lot of outcomes depends on the level of individual knowledge. Knowledge is power both for avoiding unnecessary procedures (with some causing irreversible damage) , unnecessary overprescribed drugs, and when negotiating with health care providers.

Some facts:


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[Jun 30, 2019] Life Expectancy Falters In The UK Slow Death But Fast Profits For The Agrochemical Sector by Colin Todhunter

Notable quotes:
"... "We are being poisoned by weedkiller and other pesticides in our food and weedkiller sprayed indiscriminately on our communities. The media remain silent." ..."
"... Mason notes that the agency repeatedly failed to hold Monsanto accountable for its role in the pollution (a role that Monsanto denied from the outset) and consistently downplayed the dangers of the chemicals themselves. ..."
"... In a report prepared for the agency and the local authority in 2005 but never made public, the sites contain at least 67 toxic chemicals. Seven PCBs have been identified, along with vinyl chlorides and naphthalene. The unlined quarry is still leaking, the report says: ..."
"... Apart from these events in Wales, Mason outlines the overall toxic nature of Monsanto in the UK. For instance, she discusses the shockingly high levels of weedkiller in packaged cereals. Samples of four oat-based breakfast cereals marketed for children in the UK were recently sent to the Health Research Institute, Fairfield, Iowa, an accredited laboratory for glyphosate testing. Dr Fagan, the director of the centre, says of the results: ..."
"... "These results are consistently concerning. The levels consumed in a single daily helping of any one of these cereals, even the one with the lowest level of contamination, is sufficient to put the person's glyphosate levels above the levels that cause fatty liver disease in rats (and likely in people). ..."
"... Another study notes neurotransmitter changes in rat brain regions following glyphosate exposure. The highlights from that study indicate that glyphosate oral exposure caused neurotoxicity in rats; that brain regions were susceptible to changes in CNS monoamine levels; that glyphosate reduced 5-HT, DA, NE levels in a brain regional- and dose-related manner; and that glyphosate altered the serotoninergic, dopaminergic and noradrenergic systems. ..."
"... "Our children are growing up exposed to a toxic cocktail of weedkillers, insecticides, and fungicides. It's on their food and in their water, and it's even doused over their parks and playgrounds. Many governments insist that our standards of protection from these pesticides are strong enough. But as a scientist and a lawyer who specialises in chemicals and their potential impact on people's fundamental rights, I beg to differ. Last month it was revealed that in recommending that glyphosate – the world's most widely-used pesticide – was safe, the EU's food safety watchdog copied and pasted pages of a report directly from Monsanto , the pesticie's manufacturer. Revelations like these are simply shocking. ..."
"... At that stage, PCBs, DDT, chlordane, lindane, aldrin, dieldrin, endrin, toxaphene, heptachlor, dioxin, atrazine+ and dacthal were shown to be EDCs. Many of these residues are found in humans in the UK. ..."
"... Of course, the chickens are now coming home to roost for Bayer, which bought Monsanto. Mason refers to attorneys revealing Monsanto's criminal strategy for keeping Roundup on the market and the company being hit with $2 billion verdict in the third 'Roundup trial'. ..."
"... Attorney Brent Wisner has argued that Monsanto spent decades suppressing science linking its glyphosate-based weedkiller product to cancer by ghost-writing academic articles and feeding the EPA "bad science". He asked the jury to 'punish' Monsanto with a $1 billion punitive damages award. On Monday 13 May, the jury found Monsanto liable for failure to warn claims, design defect claims, negligence claims and negligent failure to warn claims. ..."
"... "Perhaps more ominously for Bayer, Monsanto also faces cascading scientific evidence linking glyphosate to a constellation of other injuries that have become prevalent since its introduction, including obesity, depression, Alzheimer's, ADHD, autism, multiple sclerosis, Parkinson's, kidney disease, and inflammatory bowel disease, brain, breast and prostate cancer, miscarriage, birth defects and declining sperm counts. Strong science suggests glyphosate is the culprit in the exploding epidemics of celiac disease, colitis, gluten sensitivities, diabetes and non-alcoholic liver cancer which, for the first time, is attacking children as young as 10. ..."
"... Rosemary Mason shows that the health of the UK populations already lags behind other countries in Western Europe. She links this to the increasing amounts of agrochemicals being applied to crops. If the UK does a post-Brexit deal with the US, we can only expect a gutting of environmental standards at the behest of the US and its corporations and much worse to follow for the environment and public health. ..."
Jun 30, 2019 | www.zerohedge.com

Authored by Colin Todhunter via Counterpunch.org,

A special report in the Observer newspaper in the UK on 23 June 2019 asked the question: Why is life expectancy faltering? The piece noted that for the first time in 100 years, Britons are dying earlier. The UK now has the worst health trends in Western Europe.

Aside from the figures for the elderly and the deprived, there has also been a worrying change in infant mortality rates. Since 2014, the rate has increased every year: the figure for 2017 is significantly higher than the one in 2014. To explain this increase in infant mortality, certain experts blame it on 'austerity', fewer midwives, an overstrained ambulance service, general deterioration of hospitals, greater poverty among pregnant women and cuts that mean there are fewer health visitors for patients in need.

While all these explanations may be valid, according to environmental campaigner Dr Rosemary Mason, there is something the mainstream narrative is avoiding. She says:

"We are being poisoned by weedkiller and other pesticides in our food and weedkiller sprayed indiscriminately on our communities. The media remain silent."

The poisoning of the UK public by the agrochemical industry is the focus of her new report – Why is life expectancy faltering: The British Government has worked with Monsanto and Bayer since 1949 .

What follows are edited highlights of the text in which she cites many official sources and reports as well as numerous peer-reviewed studies in support of her arguments. Readers can access the report here .

Toxic history of Monsanto in the UK

Mason begins by offering a brief history of Monsanto in the UK. In 1949, that company set up a chemical factory in Newport, Wales, where it manufactured PCBs until 1977 and a number of other dangerous chemicals. Monsanto was eventually found to be dumping toxic waste in the River Severn, public waterways and sewerage. It then paid a contractor which illegally dumped thousands of tons of cancer-causing chemicals, including PCBs, dioxins and Agent Orange derivatives, at two quarries in Wales – Brofiscin (80,000 tonnes) and Maendy (42,000 tonnes) – between 1965 and 1972.

Monsanto stopped making PCBs in Anniston US in 1971 because of various scandals. However, the British government agreed to ramp up production at the Monsanto plant in Newport. In 2003, when toxic effluent from the quarry started leaking into people's streams in Grosfaen, just outside Cardiff, the Environment Agency – a government agency concerned with flooding and pollution – was hired to clean up the site in 2005.

Mason notes that the agency repeatedly failed to hold Monsanto accountable for its role in the pollution (a role that Monsanto denied from the outset) and consistently downplayed the dangers of the chemicals themselves.

In a report prepared for the agency and the local authority in 2005 but never made public, the sites contain at least 67 toxic chemicals. Seven PCBs have been identified, along with vinyl chlorides and naphthalene. The unlined quarry is still leaking, the report says:

"Pollution of water has been occurring since the 1970s, the waste and groundwater has been shown to contain significant quantities of poisonous, noxious and polluting material, pollution of waters will continue to occur."

The duplicity continues

Apart from these events in Wales, Mason outlines the overall toxic nature of Monsanto in the UK. For instance, she discusses the shockingly high levels of weedkiller in packaged cereals. Samples of four oat-based breakfast cereals marketed for children in the UK were recently sent to the Health Research Institute, Fairfield, Iowa, an accredited laboratory for glyphosate testing. Dr Fagan, the director of the centre, says of the results:

"These results are consistently concerning. The levels consumed in a single daily helping of any one of these cereals, even the one with the lowest level of contamination, is sufficient to put the person's glyphosate levels above the levels that cause fatty liver disease in rats (and likely in people). "

According to Mason, the European Food Safety Authority and the European Commission colluded with the European Glyphosate Task Force and allowed it to write the re-assessment of glyphosate. She lists key peer-reviewed studies, which the Glyphosate Task Force conveniently omitted from its review, from South America where GM crops are grown. In fact, many papers come from Latin American countries where they grow almost exclusively GM Roundup Ready Crops.

Mason cites one study that references many papers from around the world that confirm glyphosate-based herbicides like Monsanto's Roundup are damaging to the development of the foetal brain and that repeated exposure is toxic to the adult human brain and may result in alterations in locomotor activity, feelings of anxiety and memory impairment.

Another study notes neurotransmitter changes in rat brain regions following glyphosate exposure. The highlights from that study indicate that glyphosate oral exposure caused neurotoxicity in rats; that brain regions were susceptible to changes in CNS monoamine levels; that glyphosate reduced 5-HT, DA, NE levels in a brain regional- and dose-related manner; and that glyphosate altered the serotoninergic, dopaminergic and noradrenergic systems.

Little wonder, Mason concludes, that we see various degenerative conditions on the rise. She turns her attention to children, the most vulnerable section of the population, and refers to the UN expert on toxicity Baskut Tuncak. He wrote a scathing piece in the Guardian on 06/11/2017 on the effects of agrotoxins on children's health:

"Our children are growing up exposed to a toxic cocktail of weedkillers, insecticides, and fungicides. It's on their food and in their water, and it's even doused over their parks and playgrounds. Many governments insist that our standards of protection from these pesticides are strong enough. But as a scientist and a lawyer who specialises in chemicals and their potential impact on people's fundamental rights, I beg to differ. Last month it was revealed that in recommending that glyphosate – the world's most widely-used pesticide – was safe, the EU's food safety watchdog copied and pasted pages of a report directly from Monsanto , the pesticie's manufacturer. Revelations like these are simply shocking.

" Exposure in pregnancy and childhood is linked to birth defects, diabetes, and cancer. Because a child's developing body is more sensitive to exposure than adults and takes in more of everything – relative to their size, children eat, breathe, and drink much more than adults – they are particularly vulnerable to these toxic chemicals. Increasing evidence shows that even at "low" doses of childhood exposure, irreversible health impacts can result.

" In light of revelations such as the copy-and-paste scandal, a careful re-examination of the performance of states is required. The overwhelming reliance of regulators on industry-funded studies, the exclusion of independent science from assessments, and the confidentiality of studies relied upon by authorities must change."

Warnings ignored

It is a travesty that Theo Colborn's crucial research in the early 1990s into the chemicals that were changing humans and the environment was ignored. Mason discusses his work into endocrine disrupting chemicals (EDCs), man-made chemicals that became widespread in the environment after WW II.

In a book published in 1996, 'The Pesticide Conspiracy', Colborn, Dumanoski and Peters revealed the full horror of what was happening to the world as a result of contamination with EDCs.

At the time, there was emerging scientific research about how a wide range of man-made chemicals disrupt delicate hormone systems in humans. These systems play a critical role in processes ranging from human sexual development to behaviour, intelligence, and the functioning of the immune system.

At that stage, PCBs, DDT, chlordane, lindane, aldrin, dieldrin, endrin, toxaphene, heptachlor, dioxin, atrazine+ and dacthal were shown to be EDCs. Many of these residues are found in humans in the UK.

Colborn illustrated the problem by constructing a diagram of the journey of a PCB molecule from a factory in Alabama into a polar bear in the Arctic. He stated:

"The concentration of persistent chemicals can be magnified millions of times as they travel to the ends of the earth... Many chemicals that threaten the next generation have found their way into our bodies. There is no safe, uncontaminated place. "

Mason describes how EDCs interfere with delicate hormone systems in sexual development. Glyphosate is an endocrine disruptor and a nervous system disruptor. She ponders whether Colborn foresaw the outcome whereby humans become confused about their gender or sex.

She then discusses the widespread contamination of people in the UK. One study conducted at the start of this century concluded that every person tested was contaminated by a cocktail of known highly toxic chemicals that were banned from use in the UK during the 1970s and which continue to pose unknown health risks: the highest number of chemicals found in any one person was 49 – nearly two thirds (63 per cent) of the chemicals looked for.

Corruption exposed

Mason discusses corporate duplicity and the institutionalised corruption that allows agrochemicals to get to the commercial market. She notes the catastrophic impacts of these substances on health and the NHS and the environment.

Of course, the chickens are now coming home to roost for Bayer, which bought Monsanto. Mason refers to attorneys revealing Monsanto's criminal strategy for keeping Roundup on the market and the company being hit with $2 billion verdict in the third 'Roundup trial'.

Attorney Brent Wisner has argued that Monsanto spent decades suppressing science linking its glyphosate-based weedkiller product to cancer by ghost-writing academic articles and feeding the EPA "bad science". He asked the jury to 'punish' Monsanto with a $1 billion punitive damages award. On Monday 13 May, the jury found Monsanto liable for failure to warn claims, design defect claims, negligence claims and negligent failure to warn claims.

Robert F Kennedy Jr., another attorney fighting Bayer in the courts, says Roundup causes a constellation of other injuries apart from Non-Hodgkin's Lymphoma:

"Perhaps more ominously for Bayer, Monsanto also faces cascading scientific evidence linking glyphosate to a constellation of other injuries that have become prevalent since its introduction, including obesity, depression, Alzheimer's, ADHD, autism, multiple sclerosis, Parkinson's, kidney disease, and inflammatory bowel disease, brain, breast and prostate cancer, miscarriage, birth defects and declining sperm counts. Strong science suggests glyphosate is the culprit in the exploding epidemics of celiac disease, colitis, gluten sensitivities, diabetes and non-alcoholic liver cancer which, for the first time, is attacking children as young as 10.

In finishing, Mason notes the disturbing willingness of the current UK government to usher in GM Roundup Ready crops in the wake of Brexit. Where pesticides are concerned, the EU's precautionary principle could be ditched in favour of a US-style risk-based approach, allowing faster authorisation.

Rosemary Mason shows that the health of the UK populations already lags behind other countries in Western Europe. She links this to the increasing amounts of agrochemicals being applied to crops. If the UK does a post-Brexit deal with the US, we can only expect a gutting of environmental standards at the behest of the US and its corporations and much worse to follow for the environment and public health.


Sinophile , 54 minutes ago link

If a chemical is deadly to a plant, it could not possibly be deadly to anything else. Right?

******* idiots. This comment section is full of ******* idiots.

Check out this clip from the CBC:

https://www.youtube.com/watch?v=QWM_PgnoAtA

Anyway, it ain't just glyphosates. We live in a toxic world today. They sicken us with their chemicals and then reap profit from their pharmaceuticals used to treat our symptoms. Never a cure. No profit in that. Keep us alive and sick and using their pharmaceuticals to mask the symptoms. Die before you can collect SS. That's the plan.

Stormblessed , 1 hour ago link

Noise. People live for roughly 80 years, big deal. That's way longer than in the '50's or earlier.

kbohip , 4 hours ago link

Blaming glyphosate, which has been used for decades for a decline in life expectancy that began only in 2014 doesn't make any sense. If glyphosate really was that cancer causing, it would have led to a decline decades ago I would think. That being said, I have a bunch of hard to kill weeds in my backyard (not in the lawn) that I want to get rid of. One in particular is a real problem as it's not actually a weed but a plant that was put in before I moved here. It can't easily be pulled or even touched by my weed eater as it has a poison inside that burns the skin and lungs. I intend to use glyphosate if I have to, but I'm open to other suggestions from people here that would also get the job done.

AGuy , 3 hours ago link

" If glyphosate really was that cancer causing, it would have led to a decline decades ago I would think. "

Monasanto was just stupid to claim Glyphosate didn't have an pontential toxic properties. It would have just been wise to put on the label: "Do not ingest or inhale, May contain toxic and carcinogens. where protective gloves and clothing when handling. Do not apply near streams, ponds or other sources of fresh water."

If someone gets sick, they are not liable or have limited liability.

" I intend to use glyphosate if I have to, but I'm open to other suggestions from people here that would also get the job done. "

Just use protective clothing & gloves when handling what ever herbicide you use. Avoid spraying in a way that you might inhale or get exposure. FWIW: I have a hogweed growing on my property. Way too dangerous to touch of get near. I am going try using Glyphosate to kill it, if that does do it, I try another herbicide.

Hogweed is very dangerous: Like poison ivy only about 1000 times worse. Even lightly touching it can cause very nasty skin lesions. Herbicide is the only safe way to get rid of it.

Ignore This , 4 hours ago link

Weedkiller is killing people because ... we said so!
But what if it isn't weedkiller? What if it is plastic bottles or food preservative or over the counter pain remedies? We would never know because ZH says it's weed killer. It could be a combination of many things. Since this is affecting people in their late 80's, anything that generation was exposed to in the past 80 years could be to blame including during World War II. I realize that rational thought is frowned upon on ZH but have a little skepticism. This is the Internet after all.

delmar Jackson , 5 hours ago link

Roundup was sold to farmers for 30 years as a safe way to help harvest their crops and reduce the growth of mold which can be much more toxic then many man made chemicals. I am less worried about monsanto than I am drug overdoses that are killing over 70,000 people a year. Instead of bombing Iran we need to bomb China and mexico for all of the death causing drugs they have imported into our country. Over a quarter of a million people are dead from drugs like heroin and fentanyl in the last 4 years.

AGuy , 3 hours ago link

" Roundup was sold to farmers for 30 years as a safe way to help harvest their crops and reduce the growth of mold which can be much more toxic then many man made chemicals. "

Nope, its used as a herbicide to kill everything before they plant a crop so the weeds don't compete with the crop.

" I am less worried about monsanto than I am drug overdoses that are killing over 70,000 people a year. "

ODs aren't as terrible as food\water contamination. Any sane person will not abuse opioids. Look at this way: there are 70K less people living on welfare or some other gov't subsidy. However Food\Water contamination is a big deal since its difficult for even the sanest people to avoid it. OD is usually a life choice, Food\Water contamination is not.

Xena fobe , 7 hours ago link

Same in the US. Lowered standard of living. Mass migrations and elite 1% burdening the poor and middle class.

[Jun 30, 2019] Systems like the Liverpool Care Pathway may be evil enough to begin with and then they are administered by bureaucratic incompetents that insist they are doing as they are instructed while watching the patients become worse.

Jun 30, 2019 | www.zerohedge.com

OCnStiggs , 2 hours ago link

Couldn't be the British National Healthcare System now could it? You know, the one where elderly patients are wheeled on gurneys to wait out the weekend in darkened corridors with minimal attention. If they survive the weekend, they get a new room and more care. Most die a lonely death because the system has deemed them past their productive age. Only the best from Big Gubmint.

Just sayin'.

silent one , 1 hour ago link

One ploy, experienced by my mother 75, blood pressure too high so on meds to lower it, then set date of op 6 weeks in advance, take blood for testing 4 weeks before the op, turn up on day of op wait 2 hours for nurse to come and tell her the results of the blood test 4 weeks earlier indicate her sodium is to low and cancel the op, told to up the sodium and referred back to doctor, told by doctor nurse on holiday for two weeks creating a delay, 3 weeks later for blood test to decide how many salt pills to prescribe, delay for subsequent blood test, week before blood test hospital phone to say it has taken to long for the blood tests so have taken her off the waiting list and referred her back to the doctor to start the process all over again. My mother a little old lady is in a lot of pain, now talking about ending it all. THE ******* CUNTS

Mariposa de Oro , 1 hour ago link

So sorry to hear of this. I hope things get better for her. Also, is there a naturopathic doctor in the area you can take her too?

Umh , 59 minutes ago link

Incompetence has limits that can be exceeded by bureaucratic incompetence. Systems like the Liverpool Care Pathway may be evil enough to begin with and then they are administered by bureaucratic incompetents that insist they are doing as they are instructed while watching the patients become worse.

[Jun 22, 2019] 1 In 6 Insured Hospital Patients Get A Surprise Bill For Out-Of-Network Care

Notable quotes:
"... By Rachel Bluth, Kaiser Health News reporter. Originally published at Kaiser Health News . ..."
"... On average, 16% of inpatient stays and 18% of emergency visits left a patient with at least one out-of-network charge. Most of those came from doctors offering treatment at the hospital, even when the patients chose an in-network hospital, according to researchers from the Kaiser Family Foundation. Its study was based on large employer insurance claims. (Kaiser Health News is an editorially independent program of the foundation.) ..."
"... The research also found that when a patient is admitted to the hospital from the emergency room, there's a higher likelihood of an out-of-network charge. As many as 26% of admissions from the emergency room resulted in a surprise medical bill. ..."
"... Each time ..."
"... "but most people don't: an ER encounter is an "outpatient visit" for billing purposes. For Medicare benes, that makes it a "Part-B" claim subject to different (i.e. higher) deductibles and co-pays." ..."
"... inpatient stays ..."
Jun 22, 2019 | www.nakedcapitalism.com

1 In 6 Insured Hospital Patients Get A Surprise Bill For Out-Of-Network Care naked capitalism

Posted on June 22, 2019 by Lambert Strether Lambert here: But it doesn't matter. People love their health insurance companies! (And do note the role, entirely accidental I am sure, played by body shops outside staffing firms.)

By Rachel Bluth, Kaiser Health News reporter. Originally published at Kaiser Health News .

About 1 in 6 Americans were surprised by a medical bill after treatment in a hospital in 2017 despite having insurance, according to a study published Thursday.

On average, 16% of inpatient stays and 18% of emergency visits left a patient with at least one out-of-network charge. Most of those came from doctors offering treatment at the hospital, even when the patients chose an in-network hospital, according to researchers from the Kaiser Family Foundation. Its study was based on large employer insurance claims. (Kaiser Health News is an editorially independent program of the foundation.)

The research also found that when a patient is admitted to the hospital from the emergency room, there's a higher likelihood of an out-of-network charge. As many as 26% of admissions from the emergency room resulted in a surprise medical bill.

"Millions of emergency visits and hospital stays left people with large employer coverage at risk of a surprise bill in 2017," the authors wrote.

The researchers got their data by analyzing large-employer claims from IBM's MarketScan Research Databases, which include claims for almost 19 million individuals.

Surprise medical bills are top of mind for American patients, with 38% reporting they were "very worried" about unexpected medical bills.

Surprise bills don't just come from the emergency room. Often, patients will pick an in-network facility and see a provider who works there but isn't employed by the hospital. These doctors, from outside staffing firms, can charge out-of-network prices.

"It's kind of a built-in problem," said Karen Pollitz, a senior fellow at the Kaiser Family Foundation and an author of the study. She said most private health insurance plans are built on networks, where patients get the highest value for choosing a doctor in the network. But patients often don't know whether they are being treated by an out-of-network doctor while in a hospital.

"By definition, there are these circumstances where they cannot choose their provider, whether it's an emergency or it's [a doctor] who gets brought in and they don't even meet them face-to-face."

The issue is ripe for a federal solution. Some states have surprise-bill protections in place, but those laws don't apply to most large-employer plans because the federal government regulates them.

"New York and California have very high rates of surprise bills even though they have some of the strongest state statutes," Pollitz said. "These data show why federal legislation would matter."

Consumers in Texas, New York, Florida, New Jersey and Kansas were the most likely to see a surprise bill, while people in Minnesota, South Dakota, Nebraska, Maine and Mississippi saw fewer, according to the study.

Legislative solutions are being discussed in the White House and Congress. The leaders of the Senate Health, Education, Labor and Pensions Committee introduced a package Wednesday that included a provision to address it. The legislation from HELP sets a benchmark for what out-of-network physicians will be paid, which would be an amount comparable to what the plan is paying other doctors for that service.

That bill is set for a committee markup next week.

Other remedies are also being offered by different groups of lawmakers.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Arizona Slim , June 22, 2019 at 7:26 am

Seriously, who are these people who love their health insurance?

Pat , June 22, 2019 at 8:58 am

At this point, I am pretty sure with few exceptions the people who love their insurance are top management and or the companies that negotiate these profiteering contracts with those same insurance companies. Only the bubble beltway hasn't gotten the message. Witness all those people at the Fox Town Hall with Sanders that shocked the moderators when they asked the gotcha question about their employer health insurance.

Amfortas the hippie , June 22, 2019 at 7:55 am

""It's kind of a built-in problem," said Karen Pollitz, a senior fellow at the Kaiser Family Foundation and an author of the study. She said most private health insurance plans are built on networks, where patients get the highest value for choosing a doctor in the network. But patients often don't know whether they are being treated by an out-of-network doctor while in a hospital."

again no menu, no price tags, no team shirts .
it ain't a "market".

(""rational actors with perfect information" lol)

we've got around 10k in debt for the first month or so of our long emergency with cancer the period before medicaid kicked in.
some of it will get paid.
most of it will likely not(something about blood and turnips )

interestingly and apparently largely unknown is that one can get a "debt consolidation loan" for credit card, mortgage, and other "consumer" debt .but not for medical debt.
you must, instead, deal with fifty bill collectors representing many medical outfits you may have never heard of -- -imaging, labs, that guy in a white coat who walked by and looked in the door --
one of the articles of faith with the neoliberal order, is that since transactions are inherently Good, it makes sense to maximise them.
so instead of the floor doctor being employed by the hospital, itself she is employed by an LLC with an anodyne, hard to remember, name.

"It's kind of a built-in problem,"

a global economy of pickpockets.
yay.

Monty , June 22, 2019 at 10:08 am

Sounds awful. The last thing you need is extra stress at a time like that. Deepest sympathies. Here's hoping it works out for you all.

NY Geezer , June 22, 2019 at 8:20 am

The problem here is not the health insurer. It is corruption in the provision of medical services by the in network hospital that permits out of network doctor staffing agencies and doctors to perform expected medical services on its premises.

I live in the Capital district area of NY. I discovered recently that almost all the hospitals here have entered into contracts with emergency care staffing corporations for the provision of medical care. In addition, Urgent care facilities staffed by only Physician's Assistants are proliferating here. This area is apparently regarded as a good target for medical profiteers.

Pat , June 22, 2019 at 8:52 am

In a rational society, you know one where the recognizes the captive or powerless entity and provides them the protection they are denied, the hospital/medical group etc would be responsible to make sure all parities working there are in network. And by law all additional out of network charges would be theirs.

Of course in a truly enlightened and rational society we would have single payer and the government would use all its power making sure that society at all levels were healthy and well cared for when they weren't. And massive profits would be on things that were truly discretionary like private jets and yachts not on emergency care.

Bobby Gladd , June 22, 2019 at 9:29 am

In 2015 I came down with sepsis after a prostate biopsy (which turned out positive for cancer). Was admitted to John Muir hospital in Walnut Creek via the ER (I was a Muir system patient at the time). Subsequently got a bill advising that the Emergency Dept at Muir was "out of your Network" (an "independent contractor"). Eye roll.

'Nuther thing I already knew, but most people don't: an ER encounter is an "outpatient visit" for billing purposes. For Medicare benes, that makes it a "Part-B" claim subject to different (i.e. higher ) deductibles and co-pays.

ambrit , June 22, 2019 at 9:46 am

Ah. Now that's news I can use. As I mentioned below, I spoke to a claims adjuster yesterday concerning my bus accident. One of the questions she asked was about my eligibility for Medicare. So, the question wasn't just informational in nature. Real money is involved.
Thanks for the enlightenment.

Bobby Gladd , June 22, 2019 at 10:32 am

My late daughter was a Kaiser-Permanente member. She was admitted to a KP hospital several times during her recent Stage IV pancreatic cancer ordeal (she died 15 months ago). Each time , she had to go through the ER for admission. Even Kaiser , who owns their own hospitals, subs out their ERs to "independent contractors," which, of course, raised Danielle's co-pays and "co-insurance." The only route to admission was an 8-12 hr "triage" stint in the ER.

There's hardly any such thing as a through-the-front-door "elective admission" any more.

ambrit , June 22, 2019 at 11:02 am

That's the definition of fraud, right there.
When I was on a jury hearing a "pill mill" case from Biloxi Mississippi, we were told that one definition of a "pill mill" was when the 'patient' was required to go through, and pay for, a full doctors appointment for what was essentially a renewal of a pre-existing prescription. The mandatory "triage" endurance each time a "regular" patient was admitted for an already diagnosed condition fits this definition. Perhaps a resort to the RICO provision would be salutary.
Sorry about your daughter. I hope she 'passed' peacefully.

Bobby Gladd , June 22, 2019 at 4:26 pm

Thanks. Danielle died peacefully (6 weeks into home hospice care), but her illness was anything but.

Talk about "surprise bills," the night at the ER she decided to go into hospice care rather than do another futile admit, they insisted she come home via ambulance (subbed out to the city fire & rescue dept) -- all 1.9 miles to our house. After she died, I kept getting bills for her, one of which was about $2,500 for the ambulance ride ( "Seriously?" ). Needless to say, that did not get paid. Wish in one hand, [bleep] in the other, see which one fills up faster. She died way beyond broke, there was no "estate" to be probated or attached. Not that a host of claimants didn't repeatedly try. They all came to know Bad Bobby, who, while not a lawyer, was way ready for all of them (It wasn't my first rodeo, and I didn't want anyone BS'ing my grandson into assuming any bogus liabilities).

Cal2 , June 22, 2019 at 12:54 pm

Good to know, many of my friends are getting Medicare Part B insurance solicitations from Kaiser. Will inform them to look elsewhere. My condolences to you Sir.

Everyone needs to use things like Yelp and other rating services to make such things known to the curious public.

jake , June 22, 2019 at 4:14 pm

"but most people don't: an ER encounter is an "outpatient visit" for billing purposes. For Medicare benes, that makes it a "Part-B" claim subject to different (i.e. higher) deductibles and co-pays."

I don't get it. You want ER services to fall under Part B ("out patient"), because it has a relatively small deductible. And once it's satisfied, you're clear for the year.

Part A, for hospital admissions, has a much larger deductible, and it's applied per admission, not per year.

Bobby Gladd , June 22, 2019 at 5:48 pm

Well, legally, because you're not yet admitted "to the floor," it's necessarily an outpatient encounter. People just don't know that generally. You're right about the "deductible." The co-insurance is quite another matter ( apropos of both A and B). Which is why one needs a "Medi-Gap" supp. Humana Medi-gap lost their butts on me last year. In June after Danielle died I had hernia surgery, followed by open heart aortic valve replacement ("SAVR px") in late August. My OoP for the year was nil. Thank you Humana.

In a bit of irony, I'm now Kaiser, "Medicare Advantage." My OoP caps for the year at $6,700. Though, I don't expect anything major, got all my heavy lifting done in 2015 and last year.

Oh , June 22, 2019 at 9:35 am

They prey on the weak and helpless, especially the ones that go for emergency care. This is another example of hospitals not really caring for the well being of the sick. Once they capture a victim, their aim is to suck him dry.

The insurance companies are to blame too because they allow the out of network charges to occur. The insured doesn't know what service or provider is "in network". He makes a good faith attempt to go to "in network" hospitals but then the gougers take over.

ambrit , June 22, 2019 at 9:41 am

The 'attending physician' I saw during my ER sojourn after last month's bus accident was a "Body Shop Droid." The bill I received, which was the one I described earlier, the semi-threatening one, was from an "Emergency Room Physicians Management Company LLC." I have nothing to compare it to, but it came to just over $700 dollars US, for two or three 'look see's' at my battered carcass.
The ambulance "service," a properly neo-liberalized separate commercial entity, (anyone remember when ambulances were a part of the hospital apparat?,) billed me just over $1000 dollars US. I finally reached a claims adjuster for the bus companies insurance company yesterday. One of the questions she asked me, after I had established that I had been 'ambulanced' to the hospital was, how many people were transported in that one ambulance? When I quipped about 'double dipping' on the part of the ambulance "services," she laughed and said, "If you only knew."
I have still not heard from the hospital itself.

Mark , June 22, 2019 at 10:15 am

In Elisabeth Rosenthal's excellent book "An
American Sickness" she recommends adding the following statement to any consent form you sign in the hospital "Consent is limited to in-network services only and excludes out-of-network services". My wife and I carry copies of this in our wallets just in case. Haven't had occasion to try this yet and see their reaction.

Bobby Gladd , June 22, 2019 at 10:21 am

" An American Sickness ," yes, an important read.

Oh , June 22, 2019 at 12:16 pm

Yes, a well written expose.

Cal2 , June 22, 2019 at 1:07 pm

"I read 1,182 emergency room bills this year. Here's what I learned."

https://www.vox.com/health-care/2018/12/18/18134825/emergency-room-bills-health-care-costs-america

The corollary of "Someone has to pay!" is "Someone gets it for free."

What happens locally at San Franciscan General Hospital:

Undocumented person or homeless guy;
1.Get ride to hospital in ambulance.
2. Get free translator, if needed
3. Claim no I.D.
4. Get treatment.
5. Pick up free meds at pharmacy.
6. "No hope of recovery"= "Free"

American citizen with insurance
1. Walk in hospital.
2. Spend half an hour proving I have insurance.
3. Get treatment.
4. Get bill for hundreds of thousands because they "are out of network ."

https://www.vox.com/policy-and-politics/2019/1/7/18137967/er-bills-zuckerberg-san-francisco-general-hospital

A state bill is in the works to ban this. However, taxpayers will still provide free care for indigents and now, per a new state law, not only illegals in emergency rooms, but all illegals, until age 26, get full medical inpatient insurance coverage, paid by taxpayers.

https://www.nationalreview.com/news/california-to-provide-full-health-benefits-to-illegal-immigrants-under-age-26/

Joe Well , June 22, 2019 at 3:47 pm

If you have to link to the National Review to support your opinion, maybe you should rethink your opinion.

Cal2 , June 22, 2019 at 4:28 pm

E pur si muove!
https://www.sacbee.com/news/politics-government/capitol-alert/article231310348.html
Facts
https://thehill.com/homenews/state-watch/446075-california-lawmakers-vote-to-offer-health-insurance-to-undocumented
Are
https://www.sfchronicle.com/politics/article/California-will-give-health-coverage-to-13964206.php
Facts

Synoia , June 22, 2019 at 2:00 pm

I'm with Kaiser in CA.

I just send their member services this, based on the wording by Mark above.

"Kaiser Emergency Room Consent is limited to in-network services only and excludes out-of-network services."

I will post responses from Kaiser.

samhill , June 22, 2019 at 3:22 pm

Being first gen Italian I applied for Italian citizenship back before Eurolandia was consummated just in case the rules were changed. Main reason was worries over my on and off health insurance, so just to be safe. Sure enough found myself in my fifties w/o insurance, which is a seriously unwise situation, and hesitently moved to Italy. It's been rough to say the least, the country is deep in the dumps, but the health system is WONDERFUL. Yeh, everyone moans and complains about a long list of valid problems with health care here, but they have no idea the alternative. I tell everyone here to mark my words and protect what they got from the devious, erosive neo-liberal threat.

Preaching to the choir on NC but just in case anyone has doubts the positives; no financial stress to compound health stress, no corporate bureaucracy, state system is quite well streamlined, no copays if you're unemployed or poor, outweighs ALL the negatives.

dk , June 22, 2019 at 4:55 pm

I think the title is a little inaccurate, it's not 1-in-6 patients, it's 1-in-6 visits (or stays). Two visits in a year bring an individual's odds to 1-in-3, etc.

On average, 16% of inpatient stays and 18% of emergency visits left a patient with at least one out-of-network charge.

Also, note "at least," aggregation removes detail.

From the study:

Even when patients were admitted to in-network facilities, though, 16% of these stays resulted in at least one out-of-network charge for a professional service.

And out-of-network charges can occur for simple services like a blood test, this recently happened to a friend. She visited a service office listed by her insurer, but the office had contracted with an out-of-network analysis lab, resulting in a non-covered $1100+ charge. Which is a bit amazing in itself, during a recent checkup (my first in 12 years) which was covered by a Medicaid plan, I inquired about the costs for my various tests, to understand affordability; how much would this or that cost if I walked in without any coverage plan? My comprehensive blood test would have cost $183, my echo-cardiogram $118. What about the hormone-level test my friend got? Under $500. All these prices are for cash up front of course, avoiding the 25%+ in interest and finance fees that a payment plan would incur.

GroundZeroAndLovinIt , June 22, 2019 at 5:05 pm

Tangentially, I just saw an anti-Medicare for All ad on TV in my market yesterday (the DC metro area), the first such I have seen. The focus of the ad was that M4A would result in long wait times for procedures; 4 weeks for a cancer consultation, 8 weeks for a kidney replacement consultation, and so on. The ad was so patently misleading it was kind of astonishing: people already wait many many weeks for medical consultations under our gloriously inefficient "excellent" healthcare system–a fact I'm sure most Americans are familiar with. I know of people with cancer diagnoses who have had to wait months to get an appointment with a specialist. So, I'm surprised that's the tack that the lobbyists would take in their "M4A will ruin everything" scary ad. That was the whole focus of the ad: wait times. Seemed like a weak tea argument to me.

flora , June 22, 2019 at 5:16 pm

In the DC metro area?
The healthcare industry spends four times as much on lobbying as the MIC.
That ad is part of the lobbying blitz, imo.

[Jun 05, 2019] Lawmakers Push To Stop Surprise ER Billing

Jun 05, 2019 | www.nakedcapitalism.com

May 30, 2019 by Yves Smith Yves here. This article is a bit fuzzier than I'd like on the details of how the proposed California legislation to bar balanced billing would work, and past failures to halt this practice says that details matter.

However, as I read this piece, the intent is make health insurance work like old-fashioned indemnity plans, at least as far as emergency room coverage is concerned. Indemnity plans were once the norm, and the insured could go to any doctor. No network, no GP gatekeeping.

The sticky part here is the patient is supposed to be on the hook for only what he'd have to pay if he went to an emergency room that was in network. That would seem to give the upper hand to the insurance companies, since the hospital has no recourse to the patient beyond his obligation for an in-network visit. The insurer sends the same reimbursement to the out-of-network hospital as it would to an in-network hospital, and washes its hands of the matter.

One downside for the insurer is that they will now be on the hook for ER bills from any hospital. So they will wind up increasing premiums as a result. But routine care, managing chronic conditions like diabetes, and scheduled surgeries still constitute the substantial majority of what those premiums are intended to cover.

By Ana B. Ibarra, Reporter for California Healthline, based in Sacramento. Previously, she covered health in California's Central Valley for the Merced Sun-Star. She is a 2015 Center for Health Journalism fellow and a Cal Poly Pomona graduate. Originally published at Kaiser Health News

California has some of the nation's strongest protections against surprise medical bills. But many Californians still get slammed with huge out-of-network charges.

State lawmakers are now trying to close gaps in the law with a bill that would limit how much hospitals outside of a patient's insurance network can charge for emergency care.

"We thought the practice of balance billing had been addressed," said state Assemblyman David Chiu (D-San Francisco), author of the bill . "Turns out there are major holes in the law potentially impacting millions of Californians with different types of insurance."

"Balance billing," better known as surprise billing, occurs when a patient receives care from a doctor or hospital -- or another provider -- outside of her insurance plan's network, and then the doctor or hospital bills the patient for the amount insurance didn't cover. These bills can soar into the tens of thousands of dollars .

Chiu's proposal would prohibit out-of-network hospitals from sending surprise bills to privately insured emergency patients. Instead, hospitals would have to work directly with health plans on billing, leaving the patients responsible only for their in-network copayments, coinsurance and deductibles. Hospitals are fighting the proposal, calling it a form of rate-setting.

"If we are able to move this forward in California, it could be a model and standard for what happens around the country," Chiu said of his measure, which the state Assembly is expected to consider this week.

Surprise billing is a scourge for patients around the country.

Last year , a Kaiser Family Foundation poll found that two-thirds of Americans are "very worried" or "somewhat worried" about being able to afford a surprise bill for themselves or a family member. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

Health policy experts say the problem demands federal action rather than an inconsistent patchwork of state laws. And President Donald Trump has called on Congress to pass legislation this year to put a stop to surprise medical bills.

"In one swipe, the federal government can offer a universal approach in protecting consumers," said Kevin Lucia, a research professor with Georgetown University's Health Policy Institute.

Lawmakers in both the U.S. Senate and House have introduced bills to end surprise billing. But passing federal legislation promises to be an uphill battle because two influential lobbying groups -- health insurers and health providers -- have been unable to agree on a solution.

Frustrated by waiting for federal lawmakers to act, states have been trying to solve this issue. As of December 2018, 25 states offered some protection against surprise billing, and the protections in nine of those states were considered "comprehensive," according to the Commonwealth Fund . California, New York, Florida, Illinois and Connecticut are among the nine.

New state laws also have been adopted since, including in Nevada , which will limit how much out-of-network providers, including hospitals, can charge patients for emergency care, starting next year.

In California, a 2009 state Supreme Court ruling protects some patients against surprise billing for emergency care, and a state law that took effect in 2017 protects some who receive non-emergency care.

But millions remain vulnerable, largely because California's protections don't cover all insurance plans. The California Supreme Court ruling applies to people with plans regulated by the state Department of Managed Health Care. That leaves out the roughly 1 million Californians with plans regulated by the state Department of Insurance and the nearly 6 million people with federally regulated plans, most of whom have employer-sponsored insurance.

The state law governing non-emergency care also doesn't apply to the millions of residents with health plans regulated by the federal government.

Chiu's bill attempts to close those loopholes by targeting hospitals and their billing practices. With this strategy, a patient's health plan -- and the agency that regulates it -- would not matter, explained Anthony Wright, executive director of Health Access California, a Sacramento-based advocacy group that is sponsoring the legislation.

The proposal "extends protections to a broader set of Californians," Wright said.

The California Hospital Association opposes the measure, which would limit the amount hospitals could charge insurance plans to a certain rate for each service, varying by region .

The association believes that would equate to the state setting prices, which could discourage health plans from entering contracts with hospitals, said Jan Emerson-Shea, a spokeswoman for the association.

"We fully support the provision of the bill that protects patients. It is the rate-setting piece that is our concern," she said.

Chiu said his bill was prompted by the peculiar billing practices at Zuckerberg San Francisco General Hospital spotlighted by Vox in January.

Unlike most large hospitals, San Francisco General does not contract with private insurers. Vox found that the hospital considered patients with private insurance out-of-network, and was slapping many of them with whopping bills.

Stefania Kappes-Rocha was one of them.

On April 30, 2018, Kappes-Rocha, 23, landed in San Francisco General's emergency room with a fever and intense pain in her lower right back caused by a kidney infection. A student at Hult International Business School at the time, she had a private plan through the college.

"I didn't know it at the time, but that was the problem -- that I did have insurance," Kappes-Rocha said.

She was sent home a day later with ibuprofen. About two months later, she was billed $27,767.70.

"I couldn't move because of the pain," she said. The last thing on her mind was that she'd be on the hook for the entire cost of her hospital visit.

Her insurance eventually agreed to pay about $24,000 of her bill.

"I fought back, I pressured them every week," she said. "But some people don't know they should do that."

Skewered by media reports, the hospital announced in April that it would no longer balance-bill privately insured patients.


Joe Well , May 30, 2019 at 10:21 am

I think it is "balance billing" as in "your insurer pays part and you pay the remaining outstanding balance."

Thank you so much for this article on yet another crime against the 99%!

https://en.m.wikipedia.org/wiki/Balance_billing

Cal2 , May 30, 2019 at 11:40 am

There's a reason that this state bill originated in the civic disaster that is San Francisco.

San Francisco General, now named for the billionaire, used to be an excellent public teaching hospital affiliated with the University of California. It has one of the better trauma units in California, thanks to the proximity of nearby gang turf wars and housing projects that keep it replenished with fresh gunshot wounds.

Someone has to pick up the tab for San Francisco being a magnet for the uninsured homeless and undocumented from all over the western hemisphere. All this is very expensive.

The city has a dedicated health plan for the "undocumented."
https://healthysanfrancisco.org/en/

Billions have been spent on free health care for "homeless" people.
https://www.sfchronicle.com/bayarea/heatherknight/article/Businesses-must-contribute-more-to-city-s-13178743.php

More spending coming:
https://dailycaller.com/2018/11/01/san-francisco-homeless-spending-proposition-c/

The word among some locals, third generation Americans, who grew up in the city, even those who have insurance , if they go to the emergency room, is to claim to not be insured, give a false name and social security number for emergency treatment. That idea came from refugees flushing their passport down the toilet on the plane.

Joe Well , May 30, 2019 at 12:50 pm

OK, I actually followed the link to the SF Chronicle you posted to support the claim that in SF, one city, "billions have been spent on free health care for 'homeless' (scare quotes?? why??) people."

In fact, that article does not even use the word "healthcare" and implies the exact opposite of what you claim, stating that 2.2% of a $250 million annual budget dedicating to homelessness issues was spent on "health services" for the homeless. The vast bulk of the budget went to fight evictions and keep housed people from becoming homeless. It does not discuss emergency departments at all.

You're making stuff up, not just little things, but enormous things.

Might I add, IMHO, this kind of thing is typical of conservatives, and dovetails nicely with today's post about conservative ideology dying out.

Cal2 , May 30, 2019 at 1:21 pm

You corrected my pre-coffee error. Thank you.
People that make things up don't post a contradictory URL.

"Billions have been spent on the homeless in San Francisco", is what I meant to say. Healthcare is part of that, which includes ambulance rides, fire department calls. BTW, there's lots of debate about numbers. "Billions includes housing, subsidies etc.

Why "homeless" quotes? There are actual Homeless people who have been kicked out of public housing or who simply cannot afford rents. The majority of the "homeless" in San Francisco are recently arrived who have never had a home here, move from place to place and are mostly just junkies and drug users, who would continue to be, even if given "a home."

I'm a Bernie, Medicare for All, Peace in The Middle East, free transit, tax the wealthy "conservative", glad they are coming around.

Joe Well , May 30, 2019 at 10:10 pm

You should actually read that article you linked to.

Where is your figure for the billions that were supposedly spent on the homeless in San Francisco coming from? As that article makes clear, most of the money is being spent on people who live in apartments in San Francisco, to keep them from becoming homeless. Another huge chunk is spent on people who are homeless and in precarious temporary arrangements rather than on the street. Very little is being spent on the "visible homeless" as the article calls them.

Your general impression that SF is a net economic contributor in any way to American society is absurd. It is sucking wealth out with scam companies like Uber while it is casting out lower income people to every other corner of the state and country.

If SF did take in some homeless people and provide them a few thousand dollars a year of services, that would be a drop in the bucket compared to the damage its citizens have done. But you have not provided one word of evidence that the homeless in SF have primarily come from out of town, much less out of state. Given the Bay Area's efforts to gentrify over the decades, it seems quite likely that they were formerly housed inhabitants of the city.

Cal2 , May 31, 2019 at 8:53 pm

"Your general impression that SF is a net economic contributor in any way to American society is absurd."
You must be confusing me with someone else?
I think San Francisco is a giant black hole of exorbitant social services for "homeless", illegals, and profit sucking billionaires that often pay zero local taxes. i.e. Twitter, in it's special Mid Market Resurrection Zone. All those stock options think of the savings.
Add up the money spent over the last 25 years or so on homeless and preventing homelessness and it's in the billions.
$40,000 per "homeless" person per year. With the passage of Proposition C, to go to $70,000 per year.

Here's article with per year expenditures on homeless:
https://www.sfchronicle.com/bayarea/heatherknight/article/Businesses-must-contribute-more-to-city-s-13178743.php

I grew up in San Francisco and have been involved in local politics for half a century. So where are you from? Where are you getting your numbers? Please share. We can all learn from each other.

KevinD , May 30, 2019 at 11:54 am

As long as the people making the rules are monetarily above worrying about health care costs, the rest of us will continue to get squeezed out of existence. Put some people in charge who cannot afford today's medical costs and you will see them go down. Pretty simple actually ( at least in my head)

Anon , May 30, 2019 at 1:54 pm

I have direct experience with this sort of 'balance billing'. It's not just the hospitals that do it. Doctors are a big part of the problem, too.

My doctor recommended major surgery and so we scheduled a specific time and date with the hospital. My medical insurance required the use of in network doctors. So I explained to the chief nurse (in a long discussion prior to admittance) at the in-network hospital I needed to vet ALL doctors for their network status. Actually put it in writing. (I gave them a list of the known in-network doctors affiliated with the hospital.)

Survived the surgery (as you can tell). But to my surprise a 'balance bill' appeared in the mail. Then another. What?! I don't recognize any of these people (doctors). In California the Legislature has given the State Medical Board authority over hospital operating room procedure. The medical board 'requires' three doctors to be 'present' in the operating room for certain major surgeries; they are selected by the primary surgeon. These other two doctors, whom I was never introduced to (before or after surgery) had sent me the unexpected billing (with no discussion of the medical work they performed– or not) in the mail. Of course, they were not in-network and my insurance initially refused to pay them.

Long story shortened, I was able to convince my insurance provider to pay them in-network fees. The doctors refused it, we went to court, they got nothing (zero, nada, zilch). Written record carried the day.

Hospital care in America is a wild ride. You literally need a personal advocate every minute you are in one.

Joe Well , May 30, 2019 at 10:13 pm

Congratulations on your victory and for fighting the good fight.

I have tried hard to get as much of my healthcare as possible outside the US.

I am confident that many American specialist doctors are decent people, but too many of them are clearly greedy.

wilroncanada , May 31, 2019 at 4:53 pm

Canadian specialist doctors who are REALLY greedy may stay around and join those trying to privatize our system, or they may move to the US where greed is king. We made the mistake back in the 1970s of engaging an obstetrician at a maternity hospital in Vancouver for the birth of our first two children. For our oldest he showed up seconds before the birth, leaving a me and a resident who had not done a birth before. Of course, the nurses knew exactly what to do. His fee from medicare was, I guess, being there to catch. With our second two years later, he knew exactly what might happen–my wife would race through the transition phase of labour and almost immediately into delivery. That did not matter to him, he still arrived within seconds of delivery completion.
Our third was with a GP in a different city. He was a REAL doctor, present and supportive. It didn't matter, though, because the obstetrician had moved to Texas where he could schedule caesareans around his golf game.

baldski , May 30, 2019 at 10:29 pm

I have a Medicare PPO from Humana. The hospital selected by them for emergencies is Northern Nevada. I happened to fall off my porch and hurt my arm. I went to the emergency room and was told I had a fractured elbow. Some time later Humana denied the payment for the attending doctor because he was in the group of emergency physicians that man the emergency room and were not in Humana's network. Catch-22 – The emergency room bill is in network but the doctors are not.

Calling all lawyers: Please answer.

Is this not Agency of Estoppel on Humana's part?

The Emergency Room of Northern Nevada Hospital is writ large by a large neon sign. The doctors there are contracted with Northern Nevada and practice in their facility. I contend that the doctors are agents of the hospital and Humana is denying that agency by not paying the bill. Agency of Estoppel is illegal, I was taught in my limited business law course.

Any lawyer out there please respond.

run75441 , May 31, 2019 at 10:31 pm

baldski:

What you have just described is pretty common in Texas. These doctors do not have a contract with the hospital and are usually 3rd party. Is your PPO supplemental or are you in an Advantage (BS) Plan? If you are truly in Medicare and using a Supplemental for the 20% of Part B not covered, you are safe.

If you are in an Advantage Plan I would go back to Humana and ask them to negotiate a price. Not an attorney; but, doctors are agents of the hospital whether 3rd party and contracted or employed.

Paul P , June 1, 2019 at 2:23 am

The hospital is in network, they ask for your insurance,
and then supply out of network doctors, who don't contact you to enter into a contract to provide out of network services. i don't see how a contract has been
made with these out of network doctors.

You probably signed an ABN ("I'm responsible for what
insurance does not pay."} So, that is an "I gotcha" in favor of their right to bill you. I've been crossing out their ABNs and writing I will only be responsible for what insurance pays.

run75441 , June 1, 2019 at 9:58 pm

Paul:

When you go to the ER, you get whoever comes through the door which baldski got. Again what I will say, this is happening with greater frequency and especially in Texas where a hospital contracts the ER doctors out to a 3rd party and does not negotiate the ER rates. It is like having a vendor in your hospital who is contracted to the hospital and charges whatever price. There is a term for this and it is little more than entrapment.

Janie , May 30, 2019 at 2:25 pm

Every one of us should be concerned about this. We are vulnerable, even in our homes. Ambulances take you to the nearest hospital where there is space in Emergency, not necessarily to one in your network. You may be unconscious or incoherent.

Next issue:. Ongoing care. A friend had a pancreatitis attack while on vacation. After ER, he was admitted and told he needed immediate surgery. His insurance company refused to pay for the surgery, saying he could have returned home safely. As you can imagine, the bill was a big one. Insurance never came through, and he settled with the hospital for a large amount.

Joe Well , May 30, 2019 at 10:17 pm

I think the issue with balance billing is not whether the ER is in your network. Here in Massachusetts, for instance, health plans cover every ER visit to every ER on earth. The issue is that some of the doctors provide services which are for whatever reason not considered "emergency" for the purposes of your health plan and if that doctor is out of network, you get charged for the "balance" beyond whatever small amount the plan will pay. Oftentimes the doctors are greedy sharks and pile on the charges which understandably the insurer is unwilling to pay.

The ER admission itself is only a manageable amount, about $500 when I went. It was the fees and medications that added up.

run75441 , May 31, 2019 at 10:33 pm

Joe:

As you "may" know, they are 3rd party and contracted.

Bob Hertz , May 31, 2019 at 12:54 pm

In Yves's fine piece, a spokesman for hospitals complained that the new legislation was a form of 'rate setting."

Well heck yes. When consumers are helpless and a legitimate contract is impossible, it is accepted that courts and legislatures can regulate the fees.

For that matter, Maryland has had regulated hospital charges for several decades, and I know of no crisis that has occurred nor of a hospital that went broke.

The very idea that every hospital bill for emergencies should involve attorneys and the media is grotesque. Seeiing the hospital as a greedy, grabbing institution that sets fees at $100,000 and accepts $10,000 would be considered idiotic in most nations. In Germany, a bargaining unit for all hospitals meets annually with a bargaining unit for all insurers and they set all the fees. In America, hospitals
"bargain" esssentially by financial terrorism.

run75441 , May 31, 2019 at 10:53 pm

Bob:

That is Maryland which does regulate pricing.

The other 49 states do not regulate pricing and set market rates. Places like University of Michigan hospital charge more than other generic hospitals, As hospitals consolidate, there is less competition as the most recent Commonwealth Fund funded Health Affairs study determined in their findings. Indeed from 2007 to 2014, hospital-prices for inpatient care grew 42% compared to 18 percent for physician-prices for inpatient hospital care. For hospital-based outpatient care, hospital-prices rose 25 percent compared to 6 percent for physician-prices.

If you go to a hospital with 3rd party doctors, they can balance bill you. We are not in Germany and it varies state by state what can be done.

You being an insurance guy like ME should already know this as you expound about it over at Charles Gaba's site.

[May 30, 2019] Trump: Today I'm announcing principles that should guide Congress in developing bipartisan legislation to end surprise medical billing

Notable quotes:
"... May 9 - surprise medical bills will be outlawed ..."
May 30, 2019 | www.moonofalabama.org

powerandpeople , May 29, 2019 6:45:22 PM | 8

Regarding a candidate addressing a really important domestic issue in USA, Pres. Trump has drawn the teeth (to an extent) on that one, and put the Democratic party in the position of either supporting the Republican initiative, or throwing sand in the wheels of a measure which will be very popular with the American public:

May 9 - surprise medical bills will be outlawed

"...Today I'm announcing principles that should guide Congress in developing bipartisan legislation to end surprise medical billing...we have bipartisan support, which is rather shocking..."

powerandpeople , May 29, 2019 6:49:29 PM | 9

website URL for press release info on ending surprise medical billing and provision for cheap generics

https://www.whitehouse.gov/briefings-statements/remarks-president-trump-ending-surprise-medical-billing

[May 21, 2019] physical activity

May 21, 2019 | www.webmd.com

after meals has a profound impact on blood sugar levels for people with type 1 diabetes , preliminary research suggests.

"We were surprised at our findings," says Mayo Clinic endocrinologist Yogish Kudva, MBBS.

People with diabetes who engaged in basic physical activity after eating had blood sugar levels close to those of people without the condition, the study showed. Those who remained sedentary after meals had elevated blood sugar levels.

"You don't have to exercise a lot. Just walking the dog or washing the dishes after a meal, rather than going straight from the table to the TV, helps blood sugar control in people with type 1 diabetes ," Kudva tells WebMD. "Physical activity enhances insulin action, hence lowering blood glucose concentration."

Exercise and Diabetes

About 3 million Americans have type 1 diabetes , which is usually diagnosed in childhood or young adulthood. It's an autoimmune disease in which the body destroys its own ability to make insulin , which is needed to properly regulate blood sugar.

Continue Reading Below you might like

For the study, the researchers monitored 14 people without diabetes and seven people with type 1 diabetes over a four-day period at the Mayo Clinic in Rochester, Minn.

Participants were given three identical meals each day. After one meal each day, participants laid in bed for six hours. After the other meals, they engaged in physical activity. Overall, participants walked at a moderate pace for an average of 3 to 4 miles a day, "about the same as the average American," Kudva says.

The sugars in one meal a day were labeled with a safe tracing dye so the researchers could measure how much sugar from food went in and how much came out.

The findings were presented here at the annual meeting of the American Diabetes Association.

Checking Blood Sugar Levels

Among people without diabetes, post-meal blood glucose levels increased an average of 50 milligrams per deciliter (mg/dL) if they exercised after eating. That is what we like to see in healthy people," Kudva says. Readings increased by up to 100 mg/dL if they were inactive.

Continued

Among people with type 1 diabetes, blood glucose levels rose an average of 80 milligrams per deciliter if they exercised after eating and 150 mg/dL if they were inactive.

Most people without diabetes have blood sugar levels in the 70s, while people with the condition aim for a reading of 70-130 mg/dL. The recommended post-meal blood sugar level for people with diabetes is less than 180 mg/dL.

"If a diabetic patient's blood sugar is 100 or higher before eating, an increase of 150 is pretty significant," Kudva says. Over time, persistently high blood sugar can give rise to a host of complications ranging from blindness to kidney problems, he says.

Continue Reading Below

James B. Meigs, MD, of Harvard Medical School, tells WebMD that there's been a lot of debate about the right amount of exercise for people with diabetes.

"This confirms that a little exercise is better than none. It's the people who are really sedentary who have poor blood sugar control," he says.

These findings were presented at a medical conference. They should be considered preliminary as they have not yet undergone the "peer review" process, in which outside experts scrutinize the data prior to publication in a medical journal.

WebMD Health News Reviewed by Laura J. Martin, MD on June 27, 2011 Sources SOURCES:

71st Scientific Sessions of American Diabetes Association, San Diego, June 24-28, 2011.

Yogish Kudva, MBBS, department of endocrinology, Mayo Clinic, Rochester, Minn.

James B. Meigs, MD, Harvard Medical School. © 2011 WebMD, LLC. All rights reserved.

Pagination

[May 21, 2019] Why Type 2 Diabetics Should Exercise after Eating

Notable quotes:
"... First, he eliminated all processed and refined foods from his diet and focused mostly on foods with a low glycemic index of 55 or less ..."
May 21, 2019 | www.doctorshealthpress.com

My friend Paul was diagnosed with type 2 diabetes a few years ago. He was also obese and experienced other common symptoms associated with diabetes, such as blurry vision, fatigue, and an increased thirst and appetite.

Paul decided it was time to change his lifestyle and eating habits -- he understood that type 2 diabetes can eventually lead to kidney disease , nerve disorders, vision loss , hypertension, stroke, and heart disease.

Today, Paul is 30 pounds lighter and has successfully managed to regulate his blood sugar levels.

Key Ingredients for Diabetes Control: Diet and Exercise

Paul credits his success to two simple things:

When Should Diabetics Exercise?

Paul asked me if there was anything else he could do to lower his risk of developing cardiovascular issues associated with type 2 diabetes (such as heart attack or stroke).

I informed Paul of exciting new research published in the Journal of Applied Physiology . Researchers from the University of Missouri-Columbia found that people with type 2 diabetes can more effectively reduce their risk of developing a cardiovascular disease when they exercise after a meal.

The study found that resistance exercise is more effective with lowering blood sugar and fat levels after a meal. The researchers observed 13 type 2 diabetics. One day, the participants would perform resistance exercises before dinner. On another occasion they would exercise for about 45 minutes after dinner. The resistance exercises included abdominal crunches, leg curls, and seated calf raises.

The results? Participants who exercised after dinner saw a reduction in their blood fat and sugar levels, while those who exercised before dinner only saw a reduction in blood sugar levels. All of the participants consumed dinners that had a moderate carbohydrate intake.

Exercise Tips and Tricks for Type 2 Diabetics
  1. Ease into your exercise : While resistance training is best for diabetics, it is best to start slow if you are currently inactive. You can start doing any type of exercise, including walking, yoga, qigong, tai chi, or swimming. Start with 10-minute sessions each day and then move up to 30 minutes daily.
  2. Follow a regular routine : To prevent diabetes complications, like low blood sugar, it is best to exercise at similar times every day.
  3. Strength train a minimum of twice weekly : Once you are comfortable with exercising, add resistance training to your routine, such as weightlifting, crunches, squats, lunges, or resistance band exercises. Strength training twice weekly can go a long way in improving blood sugar and fat levels.
  4. Prepare for any activity : Before conducting any form of physical activity, it is best to stretch five minutes before and after your workout.
  5. Know when not to exercise : Diabetics should avoid exercising when they experience leg pain or numbness, shortness of breath, blood sugar levels over 300 mg/dl (milligrams per deciliter), tingling, or if there are ketones in the urine.
Bonus: What Should Diabetics Eat for Dinner?

What is an ideal dinner to treat or prevent diabetes? Nutrient-dense vegetables, wild seafood, organic grass-fed meats, and chicken are great choices. These simple meal choices will help balance blood sugar and lipid levels to better manage diabetes:

Sources:

Heden, T.D., et al., "Postdinner resistance exercise improves postprandial risk factors more effectively than predinner resistance exercise in patients with type 2 diabetes," Journal of Applied Physiology, March 1, 2015; 118(5): 624-634.
"Individuals with type 2 diabetes should exercise after dinner," Science Daily web site, February 18, 2015; http://www.sciencedaily.com/releases/2015/02/150218123849.htm.
"Glucose Control – Exercise," Sentry Health Monitors web site; https://www.lifeclinic.com/focus/diabetes/exercise.asp, last accessed July 8, 2015.
Murray, M., M.D., et al, The Encyclopedia of Natural Medicine (New York: Atria Paperback, 2012), 503-547.
"11 Exercise Tips for Type 2 Diabetes," WebMD web site; http://www.webmd.com/diabetes/guide/exercise-guidelines, last accessed July 8, 2015.

[May 21, 2019] Does It Matter When You Exercise Diabetes Forecastฎ

May 21, 2019 | www.diabetesforecast.org

Does It Matter When You Exercise?

How the time of day you exercise affects blood glucose

By Lindsey Wahowiak March 2015 Fitness , Get Moving woman jogging

fatchoi/Thinkstock

You've probably heard that exercise aids diabetes management. It's true: Moderate aerobic exercise -- the kind recommended 30 minutes a day, five days a week -- can help you lower your blood glucose.

And exercise has benefits beyond blood glucose control, says Michael Fowler, MD, assistant professor of medicine and director of diabetes outreach at Vanderbilt University Medical Center. "[Regular exercise is] highly, highly, highly beneficial in folks with type 2 diabetes ," Fowler says. It lowers risks of cardiovascular events in people with type 2 diabetes. The cardiovascular protection is less well proven in people with type 1 diabetes. "But we know that exercise, for everybody, makes our bodies more sensitive to insulin," he says. That includes any insulin the body makes or that a person injects. Greater sensitivity to insulin helps the body use it effectively to lower blood glucose levels.

You may wonder when to fit workouts in and whether the time of day you exercise makes a difference in blood glucose levels. Let's take a closer look.

Around the Clock

Whenever you can move your body -- a 20-minute walk in the morning or playing catch at night -- it's good for you and your diabetes, says Sheri Colberg-Ochs, PhD, a fellow with the American College of Sports Medicine. "The best time is when it fits in your schedule," she says.

Avoiding Lows

Of course, during and after exercise with diabetes, some people face the risk of blood glucose going too low. That's more likely to happen if you use insulin and sulfonylureas , which can put you at greater risk for lows overall.

One thing that may help you manage blood glucose during and after exercise is to set a regular time for it. A consistent exercise routine, says Fowler, can help you learn more about how exercise affects you. "What we typically recommend is that somebody does exercise at the same time -- that way things are more predictable. If it's going to cause low blood sugar, they learn how to predict it or adjust to accommodate [that]."

So let's rock around the clock to see what you might expect with regard to your blood glucose and exercise, keeping in mind, as always, that your response may vary -- from other people's and from day to day.

Morning

Some people like to rise and shine. And this can be a good time to exercise to combat what -- for some -- are the day's highest blood glucose levels. During sleep, the body typically maintains blood glucose levels by making hormones that tell your liver to release glucose. The body with diabetes often needs help from insulin or other diabetes medications to make sure the liver doesn't produce too much glucose, which can result in high blood glucose overnight and on awakening in the morning. Plus, the dawn phenomenon -- thought to be the result of a normal surge of hormones that the body produces to kick-start the day -- may also raise blood glucose levels.

Non-Insulin Users: Teresa Anderson, 45, of Myersville, Maryland, fits fitness into her schedule by working out first thing in the morning. "It's what I can stick with. That is the key," says Anderson, who has type 2 diabetes.

Insulin and Sulfonylurea Users: Talk to your doctor about what to eat before and after morning exercise and how to adjust insulin dosing and food to avoid lows.

Before Meals

Working out before a meal can be a great way to fit in some exercise. And while you may not see as much of a drop in blood glucose as at other times of day, it'll still do your body good.

Non-Insulin Users: If you don't take insulin, you probably need no extra preparation when exercising before a meal, says Colberg-Ochs. "The main effect of working out pre-meal -- other than breakfast -- may be a slightly lower rise in blood glucose after eating," she says.

Insulin and Sulfonylurea Users: If you frequently go low while exercising, it may help to exercise before meals instead of after meals, when bolus insulin or pills that cause the body to secrete insulin are the most active. Fast-acting insulin injected or pumped for your previous meal takes about four hours to be cleared from the body.

After Meals

Working out increases your body's insulin sensitivity, making it easier for insulin to transport glucose to the cells that will use it. So working out after a meal can be a good way to "use up" excess glucose after eating.

Non-Insulin Users: "I test after I exercise. I noticed that my numbers were definitely lower [after working out]," says Jacquelyn Weller, 37, of Reed City, Michigan, whose after-dinner exercise helps control her type 2 diabetes. "When I saw the numbers, I kind of celebrated a little bit. It really pushed me to make sure that I keep exercising so that I keep seeing those numbers."

Insulin and Sulfonylurea Users: Do exercise safely: Carefully monitor your blood glucose during and after post-meal physical activity to avoid surprise lows. "Generally, if you're really worried about hypoglycemia, avoid exercising within two hours of a meal," Colberg-Ochs says. This tends to be the time that injected or pumped mealtime insulin is most plentiful and active.

At Night

Any exercise, no matter the time of day, is a good idea. Be aware, however, that working out at night can interfere with your sleep -- which can affect your diabetes. The Division of Sleep Medicine at Harvard Medical School reports that the body secretes the stress hormone cortisol during exercise. That activates your brain's "alerting system." If you want a good night's rest, make sure to finish your workout at least three hours before bed.

Non-Insulin Users: Working out at night should not increase hypoglycemia risk for non-insulin users, says Colberg-Ochs.

Insulin and Sulfonylurea Users: Exercising too close to bedtime can be risky. When you're asleep, you may not feel a low coming on. So, if you're an insulin user who wants to work out at night, you'll want to carefully monitor blood glucose before, during, and after exercise and before bedtime. A snack before you go to sleep may be a good idea. You'll also want to check blood glucose in the middle of your sleep time (say, 3 a.m.), at least a few times while developing a regimen to be sure you're not going too low. Talk to your doctor about the best hypoglycemia prevention approaches for you and your routine.

The bottom line? There's no best time of day when it comes to exercise. Pick a time that works for you and just do it. As Cynthia Zuber, 39, of Minneapolis, has found, consistency is key. She prefers to walk after meals, but the timing is less important than doing it nearly every day. "For me, a walk is the perfect balm," says Zuber, who has type 1 diabetes. "If I walk three miles a day, diabetes is so much easier to manage. I always try to get that movement in."

Anaerobic Exercise

Different types of activities will affect your blood glucose in a variety of ways. We've already talked about aerobic exercise, but anaerobic exercise, or strength training, can increase your adrenaline, and that can raise your blood glucose. The same goes for interval training, including workouts such as CrossFit, and activities with short bursts of intense activity, such as basketball or hockey, says Jen Hanson, RKin, MEd, a registered kinesiologist and executive director of Connected in Motion, a Toronto nonprofit designed to get people with type 1 diabetes involved in adventurous exercise. Hanson, 31, lives with type 1 diabetes.

"When you're doing activities that are anaerobic, with short bursts of energy, the body is releasing large amounts of adrenaline," Hanson says. "That signals to your [liver] that it needs to dump large amounts of sugar into your bloodstream. Often then you'll see spikes in your blood sugar." This is because anaerobic exercise prompts your liver to produce glucagon, a hormone that raises blood glucose levels. When your body is being pushed to its limit -- not with gentle or moderate exercise, but real heart-pumping, high-intensity stuff -- its "fight or flight" reflex kicks in. "Your body doesn't want you to go low," Colberg-Ochs says. So instead, it signals your liver to kick out lots of glucose so you have energy.

"Usually, the spikes in blood glucose following high-intensity work come down on their own within a couple hours in non-insulin users," Colberg-Ochs says. "It can help to follow such activity with a lower-intensity cooldown." Insulin users, she says, should talk to their health care providers about whether or not to take insulin to correct post-exercise highs; if you take too much, you're likely to come crashing down later.

[May 21, 2019] Why Exercise Timing Matters -- But Not for the Reason You Think

May 21, 2019 | www.diabetesincontrol.com

Why Exercise Timing Matters -- But Not for the Reason You Think Nov 16, 2012 Share

A recent study published online in October 2012 in the British Journal of Nutrition (and reported on in Diabetes In Control ) attempted to address the issue of how timing of exercise relative to meal ingestion influences substrate balance and metabolic responses 1 .

In that study, ten sedentary, overweight men with a mean age of 28 years undertook an hour of moderate walking either before or after eating breakfast with their fat balance and postprandial metabolism monitored afterwards. Not surprisingly, exercising at either time (compared to just resting) significantly lowered insulin responses. Moreover, since more total fat was oxidized during the 8.5-hour period subjects were followed (which included the exercise period) and blood levels of triglycerides (blood fats) remained lower following pre-breakfast exercise in particular, the authors suggested that there may be an advantage for body fat regulation and lipid metabolism gained by exercising before compared with after breakfast.

The conclusions jumped to, based on studies like this, personally drive me crazy, especially when they are assumed to apply equally to people with diabetes (even though this study was done on overweight young men without diabetes). Despite the conclusions given in the article suggesting advantages in fat metabolism and weight loss, in actuality all the differences in calorie and substrate utilization over the ensuing 8.5 hours post-exercise were entirely accounted for by energy use during the exercise sessions themselves, not differences following the activity. In other words, walking before breakfast caused them to use (slightly) more fat during the activity -- not surprisingly -- than walking after their morning meal. When interviewed about these findings, Dr. Gill apparently said that while exercise in itself is good, any done before breakfast may be extra beneficial because it forces the body to rely on its stores of fat for energy.

Urgh!! That study was obviously not undertaken by or reported on by anyone with a background in exercise physiology. Conclusions like these perpetuate the myth that you have to "burn" fat to lose body fat, which is completely and utterly not true. While the loss of body fat undeniably requires a negative calorie balance, the operative word is calorie , not fat. Larger body fat losses result from a greater total calorie use, regardless of which fuels are used during the activity. Using a little bit of extra fat during a pre-breakfast walk is not going to make people lose more body fat -- it's the calorie deficit that contributes to weight loss! What's more, exercising when carbohydrate stores are limited after an overnight fast will likely result in a smaller calorie deficit since you are less likely to be able to exercise hard and/or long without eating first.

For moderate or harder exercise, carbohydrate is the body's preferred fuel, not fat, because the former is more fuel efficient. Having to rely more heavily on fat causes you to slow your pace and/or limit your total activity. Fat, however, is the body's primary fuel during recovery from any exercise, which spares blood glucose for glycogen restoration and amino acids (from protein) for muscle repair and more. Thus, most of the calories supplying your body's basal energy needs during the day come from fat, which is when body fat losses are greatest.

For those with diabetes, engaging in pre-breakfast exercise can actually be detrimental to blood glucose management. Anyone who exercises first thing in the morning before eating prolongs the fasting period and promotes an even greater release of glucose-raising hormones like cortisol, which in particular heightens insulin resistance pre-breakfast. In fact, a usual response for anyone with diabetes who exercises before eating breakfast is an increase in blood glucose levels, not the usual decline experiences during moderate physical activity. I can't tell you how many times I have advised people with diabetes to eat something first before engaging in early morning exercise to prevent elevations in their blood glucose levels!

When it comes to preventing postprandial spikes in blood glucose, exercising after dinner is much more effective than doing it before 2 . Others have shown that for people with type 2 diabetes, a prior meal helps enhance the glucose-lowering effect of physical activity 3 . So, when it comes to both body weight and blood glucose management, exercise done at any other time of day is likely better advice for the person with diabetes than exercising in a fasted state first thing in the morning. Remember, you do not have to "burn" fat during exercise to effectively lose body fat!

References:
  1. Farah NMF, Gill JMR: Effects of exercise before or after meal ingestion on fat balance and postprandial metabolism in overweight men. British J Nutrition 2012 (Oct):1-11; available on CJO2012 doi:10.1017/S0007114512004448
  2. Colberg SR, Zarrabi L, Bennington L, Nakave A, Thomas Somma C, Swain DP, Sechrist SR: Postprandial walking is better for lowering the glycemic effect of dinner than pre-dinner exercise in type 2 diabetic individuals. J Am Med Dir Assoc 2009;10:394-397
  3. Poirier P, Mawhinney S, Grondin L, Tremblay A, Broderick T, Cleroux J, Catellier C, Tancrede G, Nadeau A: Prior meal enhances the plasma glucose lowering effect of exercise in type 2 diabetes. Med Sci Sports Exerc 2001;33:1259-1264

[May 21, 2019] A1C test

Notable quotes:
"... For most adults who have diabetes, an A1C level of 7 percent or less is a common treatment target ..."
May 21, 2019 | www.mayoclinic.org
A1C level Estimated average blood sugar (glucose) level
6 percent 126 mg/dL (7 mmol/L)
7 percent 154 mg/dL (8.6 mmol/L)
8 percent 183 mg/dL (10.2 mmol/L)
9 percent 212 mg/dL (11.8 mmol/L)
10 percent 240 mg/dL (13.4 mmol/L)
11 percent 269 mg/dL (14.9 mmol/L)
12 percent 298 mg/dL (16.5 mmol/L)
For someone who doesn't have diabetes, a normal A1C level is below 5.7 percent. If your A1C level is between 5.7 and 6.4 percent, you have prediabetes (also called impaired fasting glucose), which means you have a high risk of developing diabetes in the future.

An A1C level of 6.5 percent or higher on two separate occasions shows that you have diabetes. An A1C level above 8 percent means that your diabetes is not well-controlled and you have a higher risk of developing complications of diabetes.

For most adults who have diabetes, an A1C level of 7 percent or less is a common treatment target. Lower or higher targets may be appropriate for some individuals. If your A1C level is above your target, your doctor may recommend a change in your diabetes treatment plan.

[May 21, 2019] CounterPunch

May 21, 2019 | www.counterpunch.org

May 20, 2019 Private Equity is a Driving Force Behind Devious Surprise Billings by Eileen Appelbaum Surprise medical bills are in the news almost daily. Last Thursday, the White House called for legislation to protect patients from getting surprise doctor bills when they are rushed to the emergency room and receive care from doctors not covered by insurance at an in-network hospital.

The financial burden on patients can be substantial -- these doctor charges can amount to hundreds or even thousands of dollars.

What's behind this explosion of outrageous charges and surprise medical bills? Physicians' groups, it turns out, can opt out of a contract with insurers even if the hospital has such a contract. The doctors are then free to charge patients, who desperately need care, however much they want.

This has made physicians' practices in specialties such as emergency care, neonatal intensive care and anesthesiology attractive takeover targets for private equity firms.

As health reporter Bob Herman observed , acquisition of these health services "exemplifies private equity firms' appetite for buying health care providers that wield a lot of market power."

Emergency rooms, neonatal intensive care units and anesthesiologists' practices do not operate like an ordinary marketplace. Physicians' practices in these specialties do not need to worry that they will lose patients because their prices are too high.

Patients can go to a hospital in their network, but if they have an emergency, have a baby in the neonatal intensive care unit or have surgery scheduled with an in-network surgeon, they are stuck with the out-of-network doctors the hospital has outsourced these services to.

This stands in stark contrast to other health-care providers, such as primary-care physicians, who will lose patients if they are not in insurers' networks.

It's not only patients that are victimized by unscrupulous physicians' groups. These doctors' groups are able to coerce health insurance companies into agreeing to pay them very high fees in order to have them in their networks.

They do this by threatening to charge high out-of-network bills to the insurers' covered patients if they don't go along with these demands. High payments to these unethical doctors raise hospitals' costs and everyone's insurance premiums.

That's what happened when private equity-owned physician staffing firms took over hospital emergency rooms.

A 2018 study by Yale health economists looked at what happened when the two largest emergency room outsourcing companies -- EmCare and TeamHealth -- took over hospital ERs. They found:

" that after EmCare took over the management of emergency services at hospitals with previously low out-of-network rates, they raised out-of-network rates by over 81 percentage points. In addition, the firm raised its charges by 96 percent relative to the charges billed by the physician groups they succeeded."

TeamHealth used the threat of sending high out-of-network bills to the insurance company's covered patients to gain high fees as in-network doctors. The researchers found:

" in most instances, several months after going out-of-network, TeamHealth physicians rejoined the network and received in-network payment rates that were 68 percent higher than previous in-network rates."

What the Yale study failed to note, however, is that EmCare has been in and out of PE hands since 2005 and is currently owned by KKR. Blackstone is the once and current owner of TeamHealth, having held it from 2005 to 2009 before buying it again in 2016.

Private equity has shaped how these companies do business. In the health-care settings where they operate, market forces do not constrain the raw pursuit of profit. People desperate for care are in no position to reject over-priced medical services or shop for in-network doctors.

Private equity firms are attracted by this opportunity to reap above-market returns for themselves and their investors.

Patients hate surprise medical bills, but they are very profitable for the private equity owners of companies like EmCare (now called Envision) and TeamHealth. Fixing this problem may be more difficult than the White House imagines.

This column first appeared on The Hill .

[May 18, 2019] Hemoglobin A1c (HbA1c) Test for Diabetes HbA1c Normal Levels Range

Notable quotes:
"... For people without diabetes, the normal range for the hemoglobin A1c level is between 4% and 5.6%. Hemoglobin A1c levels between 5.7% and 6.4% mean you have a higher chance of getting diabetes. Levels of 6.5% or higher mean you have diabetes. ..."
"... The target A1c level for people with diabetes is usually less than 7%. The higher the hemoglobin A1c, the higher your risk of having complications related to diabetes. ..."
May 17, 2019 | www.webmd.com
The hemoglobin A1c test tells you your average level of blood sugar over the past 2 to 3 months. It's also called HbA1c, glycated hemoglobin test, and glycohemoglobin .

People who have diabetes need this test regularly to see if their levels are staying within range. It can tell if you need to adjust your diabetes medicines. The A1c test is also used to diagnose diabetes .

What Is Hemoglobin?

Hemoglobin is a protein found in red blood cells . It gives blood its red color, and it's job is to carry oxygen throughout your body.

How the Test Works

The sugar in your blood is called glucose. When glucose builds up in your blood, it binds to the hemoglobin in your red blood cells. The A1c test measures how much glucose is bound.

Red blood cells live for about 3 months, so the test shows the average level of glucose in your blood for the past 3 months.

If your glucose levels have been high over recent weeks, your hemoglobin A1c test will be higher.

A1C and Blood Sugar A1 с (%) Average Blood Sugar (

A1C Blood sugar (mg/dL)
5 97
6 126
7 152
8 183
9 212
10 240
11 269
12 298
13 326

What's a Normal Hemoglobin A1c Test?

For people without diabetes, the normal range for the hemoglobin A1c level is between 4% and 5.6%. Hemoglobin A1c levels between 5.7% and 6.4% mean you have a higher chance of getting diabetes. Levels of 6.5% or higher mean you have diabetes.

Setting Goals for A1c Levels

The target A1c level for people with diabetes is usually less than 7%. The higher the hemoglobin A1c, the higher your risk of having complications related to diabetes.

[Apr 24, 2019] Is Dentistry a Science - The Atlantic

Apr 24, 2019 | www.theatlantic.com

The Truth About Dentistry

It's much less scientific -- and more prone to gratuitous procedures -- than you may think.

Arsh Raziuddin

I n the early 2000s Terry Mitchell's dentist retired. For a while, Mitchell, an electrician in his 50s, stopped seeking dental care altogether. But when one of his wisdom teeth began to ache, he started looking for someone new. An acquaintance recommended John Roger Lund, whose practice was a convenient 10-minute walk from Mitchell's home, in San Jose, California. Lund's practice was situated in a one-story building with clay roof tiles that housed several dental offices. The interior was a little dated, but not dingy. The waiting room was small and the decor minimal: some plants and photos, no fish. Lund was a good-looking middle-aged guy with arched eyebrows, round glasses, and graying hair that framed a youthful face. He was charming, chatty, and upbeat. At the time, Mitchell and Lund both owned Chevrolet Chevelles, and they bonded over their mutual love of classic cars.

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Lund extracted the wisdom tooth with no complications, and Mitchell began seeing him regularly. He never had any pain or new complaints, but Lund encouraged many additional treatments nonetheless. A typical person might get one or two root canals in a lifetime. In the space of seven years, Lund gave Mitchell nine root canals and just as many crowns. Mitchell's insurance covered only a small portion of each procedure, so he paid a total of about $50,000 out of pocket. The number and cost of the treatments did not trouble him. He had no idea that it was unusual to undergo so many root canals -- he thought they were just as common as fillings. The payments were spread out over a relatively long period of time. And he trusted Lund completely. He figured that if he needed the treatments, then he might as well get them before things grew worse.

Meanwhile, another of Lund's patients was going through a similar experience. Joyce Cordi, a businesswoman in her 50s, had learned of Lund through 1-800-DENTIST. She remembers the service giving him an excellent rating. When she visited Lund for the first time, in 1999, she had never had so much as a cavity. To the best of her knowledge her teeth were perfectly healthy, although she'd had a small dental bridge installed to fix a rare congenital anomaly (she was born with one tooth trapped inside another and had had them extracted). Within a year, Lund was questioning the resilience of her bridge and telling her she needed root canals and crowns.

Cordi was somewhat perplexed. Why the sudden need for so many procedures after decades of good dental health? When she expressed uncertainty, she says, Lund always had an answer ready. The cavity on this tooth was in the wrong position to treat with a typical filling, he told her on one occasion. Her gums were receding, which had resulted in tooth decay, he explained during another visit. Clearly she had been grinding her teeth. And, after all, she was getting older. As a doctor's daughter, Cordi had been raised with an especially respectful view of medical professionals. Lund was insistent, so she agreed to the procedures. Over the course of a decade, Lund gave Cordi 10 root canals and 10 crowns. He also chiseled out her bridge, replacing it with two new ones that left a conspicuous gap in her front teeth. Altogether, the work cost her about $70,000.

In early 2012, Lund retired. Brendon Zeidler, a young dentist looking to expand his business, bought Lund's practice and assumed responsibility for his patients. Within a few months, Zeidler began to suspect that something was amiss. Financial records indicated that Lund had been spectacularly successful, but Zeidler was making only 10 to 25 percent of Lund's reported earnings each month. As Zeidler met more of Lund's former patients, he noticed a disquieting trend: Many of them had undergone extensive dental work -- a much larger proportion than he would have expected. When Zeidler told them, after routine exams or cleanings, that they didn't need any additional procedures at that time, they tended to react with surprise and concern: Was he sure? Nothing at all? Had he checked thoroughly?

In the summer, Zeidler decided to take a closer look at Lund's career. He gathered years' worth of dental records and bills for Lund's patients and began to scrutinize them, one by one. The process took him months to complete. What he uncovered was appalling.

W e have a fraught relationship with dentists as authority figures. In casual conversation we often dismiss them as "not real doctors," regarding them more as mechanics for the mouth. But that disdain is tempered by fear. For more than a century, dentistry has been half-jokingly compared to torture. Surveys suggest that up to 61 percent of people are apprehensive about seeing the dentist, perhaps 15 percent are so anxious that they avoid the dentist almost entirely, and a smaller percentage have a genuine phobia requiring psychiatric intervention.

When you're in the dentist's chair, the power imbalance between practitioner and patient becomes palpable. A masked figure looms over your recumbent body, wielding power tools and sharp metal instruments, doing things to your mouth you cannot see, asking you questions you cannot properly answer, and judging you all the while. The experience simultaneously invokes physical danger, emotional vulnerability, and mental limpness. A cavity or receding gum line can suddenly feel like a personal failure. When a dentist declares that there is a problem, that something must be done before it's too late, who has the courage or expertise to disagree? When he points at spectral smudges on an X-ray, how are we to know what's true? In other medical contexts, such as a visit to a general practitioner or a cardiologist, we are fairly accustomed to seeking a second opinion before agreeing to surgery or an expensive regimen of pills with harsh side effects. But in the dentist's office -- perhaps because we both dread dental procedures and belittle their medical significance -- the impulse is to comply without much consideration, to get the whole thing over with as quickly as possible.

The uneasy relationship between dentist and patient is further complicated by an unfortunate reality: Common dental procedures are not always as safe, effective, or durable as we are meant to believe. As a profession, dentistry has not yet applied the same level of self-scrutiny as medicine, or embraced as sweeping an emphasis on scientific evidence. "We are isolated from the larger health-care system. So when evidence-based policies are being made, dentistry is often left out of the equation," says Jane Gillette, a dentist in Bozeman, Montana, who works closely with the American Dental Association's Center for Evidence-Based Dentistry , which was established in 2007. "We're kind of behind the times, but increasingly we are trying to move the needle forward."

Consider the maxim that everyone should visit the dentist twice a year for cleanings. We hear it so often, and from such a young age, that we've internalized it as truth. But this supposed commandment of oral health has no scientific grounding. Scholars have traced its origins to a few potential sources, including a toothpaste advertisement from the 1930s and an illustrated pamphlet from 1849 that follows the travails of a man with a severe toothache. Today, an increasing number of dentists acknowledge that adults with good oral hygiene need to see a dentist only once every 12 to 16 months.

Many standard dental treatments -- to say nothing of all the recent innovations and cosmetic extravagances -- are likewise not well substantiated by research. Many have never been tested in meticulous clinical trials. And the data that are available are not always reassuring.

The Cochrane organization , a highly respected arbiter of evidence-based medicine, has conducted systematic reviews of oral-health studies since 1999. In these reviews, researchers analyze the scientific literature on a particular dental intervention, focusing on the most rigorous and well-designed studies. In some cases, the findings clearly justify a given procedure. For example, dental sealants -- liquid plastics painted onto the pits and grooves of teeth like nail polish -- reduce tooth decay in children and have no known risks. (Despite this, they are not widely used, possibly because they are too simple and inexpensive to earn dentists much money.) But most of the Cochrane reviews reach one of two disheartening conclusions: Either the available evidence fails to confirm the purported benefits of a given dental intervention, or there is simply not enough research to say anything substantive one way or another.

Fluoridation of drinking water seems to help reduce tooth decay in children, but there is insufficient evidence that it does the same for adults. Some data suggest that regular flossing, in addition to brushing, mitigates gum disease, but there is only "weak, very unreliable" evidence that it combats plaque. As for common but invasive dental procedures, an increasing number of dentists question the tradition of prophylactic wisdom-teeth removal; often, the safer choice is to monitor unproblematic teeth for any worrying developments. Little medical evidence justifies the substitution of tooth-colored resins for typical metal amalgams to fill cavities. And what limited data we have don't clearly indicate whether it's better to repair a root-canaled tooth with a crown or a filling. When Cochrane researchers tried to determine whether faulty metal fillings should be repaired or replaced, they could not find a single study that met their standards.

"The body of evidence for dentistry is disappointing," says Derek Richards , the director of the Centre for Evidence-Based Dentistry at the University of Dundee, in Scotland. "Dentists tend to want to treat or intervene. They are more akin to surgeons than they are to physicians. We suffer a little from that. Everybody keeps fiddling with stuff, trying out the newest thing, but they don't test them properly in a good-quality trial."

The general dearth of rigorous research on dental interventions gives dentists even more leverage over their patients. Should a patient somehow muster the gumption to question an initial diagnosis and consult the scientific literature, she would probably not find much to help her. When we submit to a dentist's examination, we are putting a great deal of trust in that dentist's experience and intuition -- and, of course, integrity.

When Zeidler purchased Lund's practice, in February 2012, he inherited a massive collection of patients' dental histories and bills, a mix of electronic documents, handwritten charts, and X‑rays. By August, Zeidler had decided that if anything could explain the alarmingly abundant dental work in the mouths of Lund's patients, he would find it in those records. He spent every weekend for the next nine months examining the charts of hundreds of patients treated in the preceding five years. In a giant Excel spreadsheet, he logged every single procedure Lund had performed, so he could carry out some basic statistical analyses.

The numbers spoke for themselves. Year after year, Lund had performed certain procedures at extraordinarily high rates. Whereas a typical dentist might perform root canals on previously crowned teeth in only 3 to 7 percent of cases, Lund was performing them in 90 percent of cases. As Zeidler later alleged in court documents, Lund had performed invasive, costly, and seemingly unnecessary procedures on dozens and dozens of patients, some of whom he had been seeing for decades. Terry Mitchell and Joyce Cordi were far from alone. In fact, they had not even endured the worst of it.

Dental crowns were one of Lund's most frequent treatments. A crown is a metal or ceramic cap that completely encases an injured or decayed tooth, which is first shaved to a peg so its new shell will fit. Crowns typically last 10 to 15 years. Lund not only gave his patients superfluous crowns; he also tended to replace them every five years -- the minimum interval of time before insurance companies will cover the procedure again.

More than 50 of Lund's patients also had ludicrously high numbers of root canals: 15, 20, 24. (A typical adult mouth has 32 teeth.) According to one lawsuit that has since been settled, a woman in her late 50s came to Lund with only 10 natural teeth; from 2003 to 2010, he gave her nine root canals and 12 crowns. The American Association of Endodontists claims that a root canal is a "quick, comfortable procedure" that is "very similar to a routine filling." In truth, a root canal is a much more radical operation than a filling. It takes longer, can cause significant discomfort, and may require multiple trips to a dentist or specialist. It's also much more costly.

Read: Americans are going to Juarez for cheap dental care

Root canals are typically used to treat infections of the pulp -- the soft living core of a tooth. A dentist drills a hole through a tooth in order to access the root canals: long, narrow channels containing nerves, blood vessels, and connective tissue. The dentist then repeatedly twists skinny metal files in and out of the canals to scrape away all the living tissue, irrigates the canals with disinfectant, and packs them with a rubberlike material. The whole process usually takes one to two hours. Afterward, sometimes at a second visit, the dentist will strengthen the tooth with a filling or crown. In the rare case that infection returns, the patient must go through the whole ordeal again or consider more advanced surgery.

Zeidler noticed that nearly every time Lund gave someone a root canal, he also charged for an incision and drainage, known as an I&D. During an I&D, a dentist lances an abscess in the mouth and drains the exudate, all while the patient is awake. In some cases the dentist slips a small rubber tube into the wound, which continues to drain fluids and remains in place for a few days. I&Ds are not routine adjuncts to root canals. They should be used only to treat severe infections, which occur in a minority of cases. Yet they were extremely common in Lund's practice. In 2009, for example, Lund billed his patients for 109 I&Ds. Zeidler asked many of those patients about the treatments, but none of them recalled what would almost certainly have been a memorable experience.

In addition to performing scores of seemingly unnecessary procedures that could result in chronic pain, medical complications, and further operations, Lund had apparently billed patients for treatments he had never administered. Zeidler was alarmed and distressed. "We go into this profession to care for patients," he told me. "That is why we become doctors. To find, I felt, someone was doing the exact opposite of that -- it was very hard, very hard to accept that someone was willing to do that."

Zeidler knew what he had to do next. As a dental professional, he had certain ethical obligations. He needed to confront Lund directly and give him the chance to account for all the anomalies. Even more daunting, in the absence of a credible explanation, he would have to divulge his discoveries to the patients Lund had bequeathed to him. He would have to tell them that the man to whom they had entrusted their care -- some of them for two decades -- had apparently deceived them for his own profit.

Arsh Raziuddin

The idea of the dentist as potential charlatan has a long and rich history. In medieval Europe, barbers didn't just trim hair and shave beards; they were also surgeons, performing a range of minor operations including bloodletting, the administration of enemas, and tooth extraction. Barber surgeons , and the more specialized "tooth drawers," would wrench, smash, and knock teeth out of people's mouths with an intimidating metal instrument called a dental key : Imagine a chimera of a hook, a hammer, and forceps. Sometimes the results were disastrous. In the 1700s, Thomas Berdmore, King George III's "Operator for the Teeth," described one woman who lost "a piece of jawbone as big as a walnut and three neighbouring molars" at the hands of a local barber.

Barber surgeons came to America as early as 1636. By the 18th century, dentistry was firmly established in the colonies as a trade akin to blacksmithing ( Paul Revere was an early American craftsman of artisanal dentures). Itinerant dentists moved from town to town by carriage with carts of dreaded tools in tow, temporarily setting up shop in a tavern or town square. They yanked teeth or bored into them with hand drills, filling cavities with mercury, tin, gold, or molten lead. For anesthetic, they used arsenic, nutgalls, mustard seed, leeches. Mixed in with the honest tradesmen -- who genuinely believed in the therapeutic power of bloodsucking worms -- were swindlers who urged their customers to have numerous teeth removed in a single sitting or charged them extra to stuff their pitted molars with homemade gunk of dubious benefit.

In the mid-19th century, a pair of American dentists began to elevate their trade to the level of a profession. From 1839 to 1840, Horace Hayden and Chapin Harris established dentistry's first college, scientific journal, and national association. Some historical accounts claim that Hayden and Harris approached the University of Maryland's School of Medicine about adding dental instruction to the curriculum, only to be rebuffed by the resident physicians, who declared that dentistry was of little consequence. But no definitive proof of this encounter has ever surfaced.

Whatever happened, from that point on, "the professions of dentistry and medicine would develop along separate paths," writes Mary Otto, a health journalist, in her recent book, Teeth . Becoming a practicing physician requires four years of medical school followed by a three-to-seven-year residency program, depending on the specialty. Dentists earn a degree in four years and, in most states, can immediately take the national board exams, get a license, and begin treating patients. (Some choose to continue training in a specialty, such as orthodontics or oral and maxillofacial surgery.) When physicians complete their residency, they typically work for a hospital, university, or large health-care organization with substantial oversight, strict ethical codes, and standardized treatment regimens. By contrast, about 80 percent of the nation's 200,000 active dentists have individual practices, and although they are bound by a code of ethics, they typically don't have the same level of oversight.

Read: Why dentistry is separate from medicine

Throughout history, many physicians have lamented the segregation of dentistry and medicine. Acting as though oral health is somehow divorced from one's overall well-being is absurd; the two are inextricably linked. Oral bacteria and the toxins they produce can migrate through the bloodstream and airways, potentially damaging the heart and lungs. Poor oral health is associated with narrowing arteries, cardiovascular disease, stroke, and respiratory disease, possibly due to a complex interplay of oral microbes and the immune system. And some research suggests that gum disease can be an early sign of diabetes, indicating a relationship between sugar, oral bacteria, and chronic inflammation.

Dentistry's academic and professional isolation has been especially detrimental to its own scientific inquiry. Most major medical associations around the world have long endorsed evidence-based medicine. The idea is to shift focus away from intuition, anecdote, and received wisdom, and toward the conclusions of rigorous clinical research. Although the phrase evidence-based medicine was coined in 1991, the concept began taking shape in the 1960s, if not earlier (some scholars trace its origins all the way back to the 17th century). In contrast, the dental community did not begin having similar conversations until the mid-1990s. There are dozens of journals and organizations devoted to evidence-based medicine, but only a handful devoted to evidence-based dentistry.

In the past decade, a small cohort of dentists has worked diligently to promote evidence-based dentistry, hosting workshops, publishing clinical-practice guidelines based on systematic reviews of research, and creating websites that curate useful resources. But its adoption "has been a relatively slow process," as a 2016 commentary in the Contemporary Clinical Dentistry journal put it. Part of the problem is funding: Because dentistry is often sidelined from medicine at large, it simply does not receive as much money from the government and industry to tackle these issues. "At a recent conference, very few practitioners were even aware of the existence of evidence-based clinical guidelines," says Elliot Abt, a professor of oral medicine at the University of Illinois. "You can publish a guideline in a journal, but passive dissemination of information is clearly not adequate for real change."

Among other problems, dentistry's struggle to embrace scientific inquiry has left dentists with considerable latitude to advise unnecessary procedures -- whether intentionally or not. The standard euphemism for this proclivity is overtreatment . Favored procedures, many of which are elaborate and steeply priced, include root canals, the application of crowns and veneers, teeth whitening and filing, deep cleaning, gum grafts, fillings for "microcavities" -- incipient lesions that do not require immediate treatment -- and superfluous restorations and replacements, such as swapping old metal fillings for modern resin ones. Whereas medicine has made progress in reckoning with at least some of its own tendencies toward excessive and misguided treatment, dentistry is lagging behind. It remains "largely focused upon surgical procedures to treat the symptoms of disease," Mary Otto writes. "America's dental care system continues to reward those surgical procedures far more than it does prevention."

"Excessive diagnosis and treatment are endemic," says Jeffrey H. Camm, a dentist of more than 35 years who wryly described his peers' penchant for " creative diagnosis " in a 2013 commentary published by the American Dental Association. "I don't want to be damning. I think the majority of dentists are pretty good." But many have "this attitude of 'Oh, here's a spot, I've got to do something.' I've been contacted by all kinds of practitioners who are upset because patients come in and they already have three crowns, or 12 fillings, or another dentist told them that their 2-year-old child has several cavities and needs to be sedated for the procedure."

Trish Walraven, who worked as a dental hygienist for 25 years and now manages a dental-software company with her husband in Texas, recalls many troubling cases: "We would see patients seeking a second opinion, and they had treatment plans telling them they need eight fillings in virgin teeth. We would look at X-rays and say, 'You've got to be kidding me.' It was blatantly overtreatment -- drilling into teeth that did not need it whatsoever."

Studies that explicitly focus on overtreatment in dentistry are rare, but a recent field experiment provides some clues about its pervasiveness. A team of researchers at ETH Zurich, a Swiss university, asked a volunteer patient with three tiny, shallow cavities to visit 180 randomly selected dentists in Zurich. The Swiss Dental Guidelines state that such minor cavities do not require fillings; rather, the dentist should monitor the decay and encourage the patient to brush regularly, which can reverse the damage. Despite this, 50 of the 180 dentists suggested unnecessary treatment. Their recommendations were incongruous: Collectively, the overzealous dentists singled out 13 different teeth for drilling; each advised one to six fillings. Similarly, in an investigation for Reader's Digest , the writer William Ecenbarger visited 50 dentists in 28 states in the U.S. and received prescriptions ranging from a single crown to a full-mouth reconstruction, with the price tag starting at about $500 and going up to nearly $30,000.

A multitude of factors has conspired to create both the opportunity and the motive for widespread overtreatment in dentistry. In addition to dentistry's seclusion from the greater medical community, its traditional emphasis on procedure rather than prevention, and its lack of rigorous self-evaluation, there are economic explanations. The financial burden of entering the profession is high and rising. In the U.S., the average debt of a dental-school graduate is more than $200,000. And then there's the expense of finding an office, buying new equipment, and hiring staff to set up a private practice. A dentist's income is entirely dependent on the number and type of procedures he or she performs; a routine cleaning and examination earns only a baseline fee of about $200.

In parallel with the rising cost of dental school, the amount of tooth decay in many countries' populations has declined dramatically over the past four decades, mostly thanks to the introduction of mass-produced fluoridated toothpaste in the 1950s and '60s. In the 1980s, with fewer genuine problems to treat, some practitioners turned to the newly flourishing industry of cosmetic dentistry, promoting elective procedures such as bleaching, teeth filing and straightening, gum lifts, and veneers. It's easy to see how dentists, hoping to buoy their income, would be tempted to recommend frequent exams and proactive treatments -- a small filling here, a new crown there -- even when waiting and watching would be better. It's equally easy to imagine how that behavior might escalate.

"If I were to sum it up, I really think the majority of dentists are great. But for some reason we seem to drift toward this attitude of 'I've got tools so I've got to fix something' much too often," says Jeffrey Camm. "Maybe it's greed, or paying off debt, or maybe it's someone's training. It's easy to lose sight of the fact that even something that seems minor, like a filling, involves removal of a human body part. It just adds to the whole idea that you go to a physician feeling bad and you walk out feeling better, but you go to a dentist feeling good and you walk out feeling bad."

Arsh Raziuddin

In the summer of 2013, Zeidler asked several other dentists to review Lund's records. They all agreed with his conclusions. The likelihood that Lund's patients genuinely needed that many treatments was extremely low. And there was no medical evidence to justify many of Lund's decisions or to explain the phantom procedures. Zeidler confronted Lund about his discoveries in several face-to-face meetings. When I asked Zeidler how those meetings went, he offered a single sentence -- "I decided shortly thereafter to take legal action" -- and declined to comment further. (Repeated attempts were made to contact Lund and his lawyer for this story, but neither responded.)

One by one, Zeidler began to write, call, or sit down with patients who had previously been in Lund's care, explaining what he had uncovered. They were shocked and angry. Lund had been charismatic and professional. They had assumed that his diagnoses and treatments were meant to keep them healthy. Isn't that what doctors do? "It makes you feel like you have been violated," Terry Mitchell says -- "somebody performing stuff on your body that doesn't need to be done." Joyce Cordi recalls a "moment of absolute fury" when she first learned of Lund's deceit. On top of all the needless operations, "there were all kinds of drains and things that I paid for and the insurance company paid for that never happened," she says. "But you can't read the dentalese."

"A lot of them felt, How can I be so stupid? Or Why didn't I go elsewhere? " Zeidler says. "But this is not about intellect. It's about betrayal of trust."

In October 2013, Zeidler sued Lund for misrepresenting his practice and breaching their contract. In the lawsuit, Zeidler and his lawyers argued that Lund's reported practice income of $729,000 to $988,000 a year was "a result of fraudulent billing activity, billing for treatment that was unnecessary and billing for treatment which was never performed." The suit was settled for a confidential amount. From 2014 to 2017, 10 of Lund's former patients, including Mitchell and Cordi, sued him for a mix of fraud, deceit, battery, financial elder abuse, and dental malpractice. They collectively reached a nearly $3 million settlement, paid out by Lund's insurance company. (Lund did not admit to any wrongdoing.)

Lund was arrested in May 2016 and released on $250,000 bail. The Santa Clara County district attorney's office is prosecuting a criminal case against him based on 26 counts of insurance fraud. At the time of his arraignment, he said he was innocent of all charges. The Dental Board of California is seeking to revoke or suspend Lund's license, which is currently inactive.

Many of Lund's former patients worry about their future health. A root canal is not a permanent fix. It requires maintenance and, in the long run, may need to be replaced with a dental implant. One of Mitchell's root canals has already failed: The tooth fractured, and an infection developed. He said that in order to treat the infection, the tooth was extracted and he underwent a multistage procedure involving a bone graft and months of healing before an implant and a crown were fixed in place. "I don't know how much these root canals are going to cost me down the line," Mitchell says. "Six thousand dollars a pop for an implant -- it adds up pretty quick."

Joyce Cordi's new dentist says her X‑rays resemble those of someone who had reconstructive facial surgery following a car crash. Because Lund installed her new dental bridges improperly, one of her teeth is continually damaged by everyday chewing. "It hurts like hell," she says. She has to wear a mouth guard every night.

What some of Lund's former patients regret most are the psychological repercussions of his alleged duplicity: the erosion of the covenant between practitioner and patient, the germ of doubt that infects the mind. "You lose your trust," Mitchell says. "You become cynical. I have become more that way, and I don't like it."

"He damaged the trust I need to have in the people who take care of me," Cordi says. "He damaged my trust in mankind. That's an unforgivable crime."

[Apr 22, 2019] The importance of physical activity

Apr 22, 2019 | rusvesna.su

According to Boston University researchers, those people whose physical activity is 150-300 minutes a week, the aging of the brain is distant by 1.1 years for each hour of physical activity per week.

And for those who walk 7,500 steps or more per week, brain aging moves away by 1.4 to 2.2 years for every hour of physical activity per week.

[Apr 07, 2019] New York Sues Big Pharma for Opioid Crisis

Apr 07, 2019 | www.nakedcapitalism.com

In this Real News Network interview, Bill Black gives a high-level overview of the New York case against not just opioid profiteers, the Sackler family and their companies, but also other key participants, like “pain doctors” who were tied in to the Sackers’ marketing efforts.


timbers , April 6, 2019 at 8:22 am

I just want to know one thing: How many Sacklers are going to jail and for how long?

If NY wants to make the most of it's limited resources (as Black notes) then why haven't they issued arrest warrants for the Sackers and frozen their bank accounts?

Seems to me a whole lot of folks with privilege and $$$ in the news who would have be arrested on the spot had someone else (like me for example) done the same thing but w/o all that privilege and $$$ (Zuckerburg, Boeing CEO, Sacklers).

allan , April 6, 2019 at 9:16 am

Yes, more of this, please: Criminal Trial Of Opioid-Peddling Drug Company Execs Goes To The Jury [NPR]

Carl , April 6, 2019 at 8:26 am

What I hope does not get entirely forgotten in this matter is the people who need relief from pain, yet can’t get the drugs they need because doctors are so afraid to prescribe effective pain-killers, except for extreme cases, like post-op or late-stage cancers. I’m told this is the situation in New York State. Elsewhere, too?

Edward , April 6, 2019 at 1:32 pm

I wonder if the Sacklers could have gotten away with their crime if less people were killed. Suppose only 500 people were killed each year. Would the government have responded?

Iapetus , April 6, 2019 at 1:37 pm

Somehow certain aspects of this story feel vaguely familiar .

orange cats , April 6, 2019 at 3:17 pm

Oh blah blah blah. Please notice what’s absent in these “conversations” about the “opioid” crisis. The recent increase in overdose deaths is due to the (often accidental) ingestion of street fetanyl as a result of prescription opioids being restricted.

No one emphasizes the shocking absence of funding for mental health facilities; addiction research and the role of economic factors contributing to drug use; social safety nets for addicts and their children…in sum, WHY ARE SO MANY PEOPLE IN SO MUCH PAIN?
In this country you have to be sprawled unconscious in the front seat of a running car to get any help, help being prison. Jailing the Sacklers isn’t going to change that one iota.

GERMO , April 6, 2019 at 4:30 pm

The laboring class is largely being ground into hamburger. A condition of chronic, relentless pain that you can never get away from is the unchosen lifestyle for millions. That the treatment for pain (opioids) is also pretty good for despair is half an explanation for the epidemic. The other half, which is rarely mentioned, is that millions of people hurt all the time, physically or otherwise, and this is just collateral damage in the class struggle that we poor folks continue to lose.

It’s sad that the process of justice against the monsters like the Sacklers will only result in more of that pain and suffering, and to know that they won’t in the end suffer much of anything at all. The handy myth of “overprescribing” will carry the day for the higher-status class of folks who’ve never had to contend with chronic pain conditions — conditions that come about mainly because we’re so prone to being worked like dogs by psychopath bosses.

orange cats , April 6, 2019 at 5:52 pm

Thank you. I am disappointed that Bill Black and his “High-level interview” was boilerplate off-with-their-heads bunk. I admire him but do not understand why he is being recruited to opine on drug policy.

kiers , April 7, 2019 at 5:12 pm

I wonder (REALLY WONDER) if the Sacklers do not have some kind of sweet-heart insurance contract that will handle THEIR (financial) “pain” with these “suits”. Funny how A.G.s lead the chivalrous charge to “clean up” wrong-doing WELL AFTER political cover ALLOWS them to go after the elite. Funny how that works eh? Cyrus Vance gets to add to his kitty.

run75441 , April 7, 2019 at 5:15 pm

There was a major study done on the use of Opioids conducted at Boston University Medical Center, Waltham MA. The result of that study were published in a brief letter to the NEMJ.

“Recently, we examined our current files to determine the incidence of narcotic addiction in 39,946 hospitalized medical patients who were monitored consecutively. Although there were 11,882 patients who received at least one narcotic preparation, there were only four cases of reasonably well documented addiction in patients who had no history of addiction. The addiction was considered major in only one instance. The drugs implicated were meperidine in two patients, Percodan in one, and hydromorphone in one. We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.” Jane Porter; Herschel Jick; MD Boston Collaborative Drug Surveillance Program, Boston University Medical Center, Waltham, MA.

Note the key words here are: ” We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.”

This particular letter (or note as some may call it) to the NEJM was cited 608 times of which 491 times was in a positive manner about addiction being rare in medical patients. The 491 (~81%) citations fail to mention the patients given Opioids were in a hospital setting and grossly misrepresented the conclusions of the letter . 72.2% cited it as evidence that addiction was rare in patients treated with opioids.

It took 37 years before another letter to the editor studied the impact of the misuse of that citation by doctors, Purdue Pharma, other Pharmaceutical Companies, etc. The authors accomplished a bibliometric analysis of the correspondence from its publication in 1980 until March 30, 2017. For each citation, two reviewers independently evaluated the portrayal of the article’s conclusions, using an adaptation of an established taxonomy of citation behavior4 along with other aspects of generalizability. The analysis which I have posted the resulting chart from it before can be found here: https://www.nejm.org/doi/full/10.1056/NEJMc1700150

The Jick and Porter letter can be found here in the Supplemental Appendix along with various quotes by doctors: https://www.nejm.org/doi/suppl/10.1056/NEJMc1700150/suppl_file/nejmc1700150_appendix.pdf

Ten years earlier or 2007, Purdue Pharma was fined $800 million by the courts after the DOJ sued them. Three executives were convicted and sentenced. From 2006 to 2015 Opioid companies spent $800 million in a 50 state strategy. The mother of Cameron Weiss found out the power of Pharma the hard way when her push for new laws in New Mexico were defeated before a vote was even taken.

In 1980 the death rate resulting from Opioid overdose was less than 1 per 100,000 and the overall death rate from Drugs was 1 per 100,000. With the introduction of OxyContin and the abuse of the Jick and Porter Letter, the death rate associated from Opioid Overdose increased to 1 per 100,000 one year later and doubled to 2 per 100,000 in 2 years. In 2015, it has soared to ~10 per 100,000.

Without knowing what has led up to the abuse of Opioids the story has always been recreational use of drugs an Opioids has caused this epidemic without ever a mention of Purdue or the other drug companies. The explosion in the use of Opioids was very deliberate and the drug companies should be held responsible for it. Now with fewer Opioid pills being prescribed, people have moved on to Heroin and Opioid derivatives. The companies lit the fuse and left with their profits.

The reason I wrote this long comment is I believe Bill Black gave this topic the short shrift. There is a lot of history on Opioid abuse and how it came to be.

[Apr 07, 2019] Kamala Harris handing of subprime mortgage crisis and opioids abuse

Apr 07, 2019 | www.nakedcapitalism.com

The Rev Kev , April 6, 2019 at 5:50 am

Do people really want the the Trump administration, the Department of Justice and the F.D.A. involved here? Bit fuzzy on the details but wasn't there a time about a decade ago when the States were getting together to sue banks for fraudulently marketing mortgages but that Obama got ahead of this movement and basically short-circuited the whole process? And the banks got a tap on the wrist as they were busy seizing homes by the millions?

If the Trump administration got involved, I would expect that Big Pharma would have to pay a few billion dollars restitution (which they, like the banks previously, could claim back on their taxes), that there would be no criminal sentences, that nobody would be convicted of a crime or have it on their record, and that Big Pharma would promise to behave better in future – starting February 30th.

Meanwhile, another thousand Americans would be dying each and every week from what Big Pharma has created. Hopefully the States will create an almighty stink with their law suits.

Cal2 , April 6, 2019 at 1:51 pm

Rev,

Who will Trump's Kamala Harris be? (Mortgage fraud by banks versus Pharmafraud)

Kamala did squat in the mortgage settlement as California attorney general. What little she did get was handed to Jerry Brown to resuscitate the general fund of the state, not to homeowners cheated out of their homes.

She could have done what Scott Pruitt did in Oklahoma, which was to NOT accept the nationwide settlement. Oklahoma received 6x the national average in mortgage settlements because of that. "Chain of Title" by David Dayen.

like Corey Booker's pharma payoff, she got a nice donation for her next campaign for her probank activities, from Trump's man Mnuchin himself.

Pat , April 6, 2019 at 5:14 pm

Hey cut Kamala a break. My AG Schneiderman joined Obama's sideswipe, got pennies for NY and didn't end up in the Senate. She got more for CA, the bigger political payoff and even a run for president.

And unfortunately Justice for those abused by the corporations who benefitted is not really in our political mainstream calculations.

[Apr 05, 2019] Pelosi Accused of Deploying 'Most Dishonest Argument' Against Medicare for All by Jake Johnson

Pelosi: Sock Puppet For the Insurance Industry
Apr 05, 2019 | www.commondreams.org
described as "probably the most dishonest argument in the entire Medicare for All debate."

"People who love their employer-based insurance do not get to hold on to it in our current system. Instead, they lose that insurance constantly, all the time. It is a complete nightmare."
-- Matt Bruenig, People's Policy Project

In an interview with the Washington Post , the Democratic leader said she is "agnostic" on Medicare for All and claimed, "A lot of people love having their employer-based insurance and the Affordable Care Act gave them better benefits."

Matt Bruenig, founder of the left-wing think tank People's Policy Project, argued in a blog post that Pelosi's statement "implies that, under our current health insurance system, people who like their employer-based insurance can hold on to it."

"This then is contrasted with a Medicare for All transition where people will lose their employer-based insurance as part of being shifted over to an excellent government plan," Bruenig wrote. "But the truth is that people who love their employer-based insurance do not get to hold on to it in our current system. Instead, they lose that insurance constantly, all the time, over and over again. It is a complete nightmare."

To illustrate his point, Bruenig highlighted a University of Michigan study showing that among Michiganders "who had employer-sponsored insurance in 2014, only 72 percent were continuously enrolled in that insurance for the next 12 months.

"This means that 28 percent of people on an employer plan were not on that same plan one year later," Bruenig noted.

me title=

"Critics of Medicare for All are right to point out that losing your insurance sucks," Bruenig concluded. "But the only way to stop that from happening to people is to create a seamless system where people do not constantly churn on and off of insurance. Medicare for All offers that. Our current system offers the exact opposite. If you like losing your insurance all the time, then our current healthcare system is the right one for you."

All On Medicare -- a pro-Medicare for All Twitter account -- slammed Pelosi's remarks, accusing the Democratic leader of parroting insurance industry talking points:

The Speaker's alternative to the Medicare for All legislation co-sponsored by over 100 members of her caucus is a bill to strengthen the Affordable Care Act (ACA), which she introduced last week .

"We all share the value of healthcare for all Americans -- quality, affordable healthcare for all Americans," Pelosi told the Post . "What is the path to that? I think it's the Affordable Care Act, and if that leads to Medicare for All, that may be the path."

The nation's largest nurses union was among those who expressed disagreement with the Speaker's incrementalist approach.

In a statement last week, National Nurses United president Zenei Cortez, RN, said Pelosi's plan would "only put a Band-Aid on a broken healthcare system."

"National Nurses United, along with our allies, will continue to build the grassroots movement for genuine healthcare justice and push to pass Medicare for All," Cortez concluded.

This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License

[Mar 18, 2019] Daily Dose of Aspirin Risks Outweigh Benefits

Mar 18, 2019 | www.veteranstoday.com

Health Editor's Note: In the past, it has been recommended that you take a low daily dose of aspirin to try to decrease forming blood clots that can lead to heart attacks and strokes. That recommendation has changed due to the risk of the aspirin causing internal bleeding which outweighs the benefits of decreasing the production of blood clots. One of the actions of aspirin is to delay clotting time, thus decrease chances of clots forming. Doctors may still want patients who are older and at high-risk for blood clots to continue to take aspirin, but that would only be for people who are not at risk of internal bleeding.

Studies have found that aspirin does not prevent first heart attacks or strokes in people who have additional health threats such as high blood pressure, high cholesterol. and smoking.

The guidelines in Europe, for any age group, are to take no preventative clotting medicines, such as aspirin. Always the best practice for your safety and health is to talk with your own healthcare provider ..Carol

CV Primary Prevention Guidelines Updated

by Crystal Phend, Senior Associtate Editor, MedPage Today

Aspirin Update

Perhaps one of the most impactful changes, Khera said, would be changes to the aspirin recommendations.

"Historically, we've always been trying to find this balance between lowering ASCVD risk, but aspirin always causes bleeding," he said. "In the past, in the right groups -- those at higher ASCVD risk -- it was felt that that balance favored taking aspirin in the right situation. Well, as of late, there have been some new studies involving data that suggest that balance has tipped the other way."

"We've had three trials in last year ( ARRIVE, ASCEND , and ASPREE ) which really have shown us that the place for aspirin has diminished in terms of primary prevention, and that bleeding will be outweighing the benefit in our modern era with all of our recommended therapies," he added.


The guidelines now recommend that prophylactic low-dose aspirin:

"Generally no, occasionally yes," was how Khera summed up the recommendations. But he also cautioned against conflating these primary prevention recommendations to secondary prevention, for which aspirin still is recommended for use.

[Mar 05, 2019] On origin of the phase There ain't no such thing as a free lunch

Mar 20, 2017 | economistsview.typepad.com

RC AKA Darryl, Ron -> mulp ... "...TANSTAAFL" March 20, 2017 at 04:59 AM

https://en.wikipedia.org/wiki/There_ain%27t_no_such_thing_as_a_free_lunch

"There ain't no such thing as a free lunch" (alternatively, "There is no such thing as a free lunch" or other variants) is a popular adage communicating the idea that it is impossible to get something for nothing.

The acronyms TANSTAAFL, TINSTAAFL, and TNSTAAFL, are also used. Uses of the phrase dating back to the 1930s and 1940s have been found, but the phrase's first appearance is unknown.[1]

The "free lunch" in the saying refers to the nineteenth-century practice in American bars of offering a "free lunch" in order to entice drinking customers.

The phrase and the acronym are central to Robert Heinlein's 1966 science-fiction novel The Moon Is a Harsh Mistress, which helped popularize it.[2][3]

The free-market economist Milton Friedman also popularized the phrase[1] by using it as the title of a 1975 book,[4] and it is used in economics literature to describe opportunity cost.[5]

Campbell McConnell writes that the idea is "at the core of economics".

[I was a bigger fan of Robert Heinlein's than I was of Milton Friedman and even then it was "Stranger in a Strange Land" and "The Unpleasant Profession of Jonathan Hoag" rather than later works that appealed to me.]

[Feb 26, 2019] It is illegal for any insurer to offer a bare bones catastrophic plan that doesn't cover Obama's hopey-changey list of progressive surgical procedures.

Feb 26, 2019 | www.unz.com

Bragadocious , says: February 26, 2019 at 2:49 pm GMT

@animalogic I don't know if you live in the US, sounds like you don't, but one could argue that the healthcare system has already been nationalized. Consumers must shop for policies that meet Obamacare standards which include coverage for gender reassignment and other things that 10 years ago no private insurer would dream of paying for. This is a direct result of government's boot on the market's throat. (And the market likes it, based on HMO stock prices)

It is illegal for any insurer to offer a bare bones catastrophic plan that doesn't cover Obama's hopey-changey list of progressive surgical procedures. 15 years ago, those catastrophic plans were everywhere, and very affordable.

And to your point about providing healthcare to people who can't afford it. We already have that, it's called Medicaid. When those receiving it die, the government comes in and grabs all of their estate's assets, because they used a government program that was forced on them. Like I said, it's been taken over.

[Feb 22, 2019] How Stupid Do They Think We Are - Plutocrats Using Logical Fallacies to Defend the Health Care Status Quo

Notable quotes:
"... I've lived in the US and the UK for extended periods so can compare and contrast. I actually think that due to the structure of the US system that the US medical system builds a dependency on subscribing more and more drugs to people because MDs and pharmas get the money (not a shocking statement). ..."
"... Exactly. The phrase "providing access" is nauseating. It really means "preventing access" unless you pay. ..."
Feb 22, 2019 | www.nakedcapitalism.com

How Stupid Do They Think We Are? – Plutocrats Using Logical Fallacies to Defend the Health Care Status Quo Posted on February 22, 2019 by Yves Smith By Roy Poses , MD, Clinical Associate Professor of Medicine at Brown University, and the President of FIRM – the Foundation for Integrity and Responsibility in Medicine. Originally published at Health Care Renewal

In the early 21st century, the debate about health care reform in the US ramped up. The result ultimately was the Patient Protection and Affordable Care Act (PPACA, ACA, "Obamacare"), which arguably improved access to health care, made some reforms in the regulation of health care insurance, but did not affect the fundamental reliance of the US on employer-paid, for-profit health care insurance to finance health care for many patients. Nor did it really affect the issues we discuss on Health Care Renewal (look here for details).

After the tumultuous election of President Donald Trump, the debate started up again with his and his party's attempt to "repeal and replace" Obamacare. Arguably, Obamacare ended up damaged but not repealed. Once again, the issues we discuss on Health Care Renewal were ignored, including threats ot the integrity of the clinical evidence base, deceptive marketing, distortion of health care regulation and policy making, bad leadership and governance, concentration of power, abandonment of health care as a calling, perverse incentives, the cult of leadership, managerialism, impunity enabling corrupt leadership, and taboos, or the anechoic effect. (Look here for a detailed discussion. )

It is time once again to discuss health care reform in the US. Now the push is from the Democrats and the left, with the stated goals of making care more universal, and perhaps decreasing or even ending the role of for-profit commercial health care insurance companies.

It is no surprise that those who benefit the most from the current system (even as modified by Obamacare) are rushing to its defense.

Dark Money to Defend Commercial Health Insurance

We already discussed how large health care corporations, including pharmaceutical and biotechnology companies, have been using dark money to funnel money for distinctly partisan purposes, to defeat whom they perceive as too left-leaning politicians, almost all Democrats. They seem to fear such politicians might promote health care reform efforts that would be based on "anti-free-market, anti-business ideology," that is efforts to decrease the role of commercial, for-profit health insurance in financing health care.

More recently, the focus has shifted to Democratic proposals for government run single-payer, or "Medicare for all" health insurance. In early January, 2019, the Hill reported

Thomas Donohue, the president and CEO of the Chamber of Commerce, on Thursday vowed to use all of the Chamber's resources to fight single-payer health care proposals.

'We also have to respond to calls for government-run, single-payer health care, because it just doesn't work,' Donohue said during his annual 'State of American Business' address.

The US Chamber of Commerce historically has had many executives of big health care corporations on its board. We listed 10 such members in 2015. It also historically has received financial support from some corporations. We listed 17 in 2018.

Then later in January, The Hill reported that a group called Partnership for America's Health Future started digital ads attacking "Medicare for All." The Hill stated its

members include major industry players such as America's Health Insurance Plans and the Pharmaceutical Research and Manufacturers of America

So here we have the leaders of big health care corporations funneling corporate money into propaganda campaigns to defeat government run single payer health insurance, an old policy idea that suddenly is looking politically credible. Current US regulation and practice allows them to hide the exact amounts spent on such campaigns by processing them through dark money organizations.

Such stealth health policy advocacy is now not new. What is surprising now is how some top leaders are willing to jump into the debate themselves, rather than just trying to manipulate public opinion through public relations/ propaganda proxies. Here are some telling examples. in chronological order.

Quest Diagnostics CEO Attacks "Medicare-for-All" Using an Appeal to Authority, an Argument by Gibberish, the Non Sequitur Fallacy, (and an Incomplete Comparison)

On January 24, 2019, Yahoo Finance reported

A top health care CEO is sounding the alarm on 'Medicare for All,' an idea gaining steam in political circles, including from newly-elected Rep. Alexandria Ocasio-Cortez (D-NY).

' Most people don't understand the basics of health-care economics in the United States ,' said Steve Rusckowski, chairman & CEO Quest Diagnostics (DGX), in an interview with Yahoo Finance editor-in-chief Andy Serwer at the World Economic Forum in Davos, Switzerland .

Mr Rusckowski implied that he knows a lot more about health care economics than most people, so most people should listen to him. Thus, he began with an implied logical fallacy, the appeal to authority .

He then presented the justification for his argument.

'The majority of people get their health care from their employers, and the majority of healthcare costs are paid by employers and employees,' he said. 'If you look at the $3.5 trillion spent on healthcare costs, that portion is actually funding the Medicare and Medicaid programs throughout this country.'

The syntax was fractured, and so this was incoherent and confusing. In particular, it was not clear to what "this portion" referred. $3.5 trillion? Health care costs paid by employers and employees?

The context of his use of that phrase did not help. Note that US total health spending was reported to be approximately $3.5 trillion in 2017 by the US Center for Medicare and Medicaid Services (CMS) . However, that was total health spending, not just the amount spent by Medicare and Medicaid. Furthermore, Medicare and Medicaid are funded by sources other than employers and their employees. While employers and employees pay tax on employee income to fund Medicare, general funds from the federal government, and from state governments funds Medicaid. Furthermore, many employers pay parts of their employees' private health insurance premiums, while the employees make up the difference in premiums. Self-employed people may may for their own insurance, etc, etc.

Mr Ruskcowski, not to put to fine a point on it, seemed to speaking gibberish, and would use this gibberish to justify his next point. So in formal terms, he used the logical fallacy of an argument by gibberish .

When incomprehensible jargon or plain incoherent gibberish is used to give the appearance of a strong argument, in place of evidence or valid reasons to accept the argument.

In any case, Mr Rusckowski went on to argue that he

remained skeptical of a Medicare-for-all plan funded by corporations and employees. ' I don't think [corporations and employees] can afford to provide that access as described.'

However, not only were his earlier statement gibberish, they were not clearly arguments in support of his contention that corporations and employees cannot "afford to provide that access as described." So this appeared to be an example of the logical fallacy of the non-sequitur .

Mr Rusckowski's total compensation as CEO of Quest was over $10 million in 2017, as estimated by Bloomberg News . So it is perhaps not surprising that is self-interest in preserving the status quo was strong enough to motivate him to jump into the debate. One would think, however, that someone who managed to become a rich CEO of a medical diagnostic company could manage to be a bit more logical.

Anyway, he has some strange bed-fellows in this cause, including two billionaires who are not directly involved in health care corporations, but who have obviously benefited from the current economic status quo.

Michael Bloomberg and Howard Schultz Used the Incomplete Comparison Fallacy

Two billionaires provided striking examples of one logical fallacy.

First, from t he New York Times, January 29, 2019 :

Mr. Bloomberg, the former New York City mayor who is considering a 2020 bid on a centrist Democratic platform, rejected the idea of 'Medicare for all,' which has been gaining traction among Democrats.

'I think you could never afford that. You're talking about trillions of dollars ,' Mr. Bloomberg said during a political swing in New Hampshire, which holds the nation's first primary in 2020.

'I think you can have 'Medicare for all' for people that are uncovered,' he added, 'but to replace the entire private system where companies provide health care for their employees would bankrupt us for a very long time .'

Second, from CNN on January 30, 2019 :

'Why do you think Medicare-for-all, in your words, is not American?' CNN's Poppy Harlow asked Schultz on Tuesday.

'It's not that it's not American,' Schultz said. ' It's unaffordable .'

'What I believe is that every American has the right to affordable health care as a statement,' Schultz said, lauding the Affordable Care Act, otherwise known as Obamacare, as 'the right thing to do.'

He added, 'But now that we look back on it, the premiums have skyrocketed and we need to go back to the Affordable Care Act, refine it and fix it.'

He argued that the Democratic progressive platform of providing Medicare, free college education and jobs for everyone is costly and as 'false as President Trump telling the American people when he was running for president that the Mexicans were going to pay for the wall.'

So both billionaire Bloomberg and billionaire Schultz stated that Medicare-for-all would cost too much. Yet neither addressed how much our current health care system costs. However, as a subsequent op-ed in the Washington Post by Paul Waldman pointed out, it only makes sense to talk about affordability in the context of a comparison with a reasonable alternative, say, the current health care system:

there is one thing you absolutely, positively must do whenever you talk about the cost of a universal system -- and that journalists almost never do when they're asking questions. You have to compare what a universal system would cost to what we're paying now.

there have been some recent attempts to estimate what it would cost to implement, for instance, the single-payer system that Sen. Bernie Sanders (I-Vt.) advocates; one widely cited study, from a source not favorably inclined toward government solutions to complex problems, came up with a figure of $32.6 trillion over 10 years.

That's a lot of money. But you can't understand what it means until you realize that last year we spent about $3.5 trillion on health care, and under current projections, if we keep the system as it is now, we'll spend $50 trillion over the next decade.

Again, you can criticize any particular universal plan on any number of grounds. But if it costs less than $50 trillion over 10 years -- which every universal plan does -- you can't say it's 'unaffordable' or it would 'bankrupt' us, because the truth is just the opposite.

These are text-book examples of the fallacy of incomplete comparison .

By the way, buried amongst his use of gibberish and non-sequiturs, Quest Diagnostics CEO Rusckowski also opined that Medicare-for-all would be unaffordable without any reference to the costs of the status quo, and hence also provided an example of an incomplete comparison.

The Waldman op-ed noted

The fact that these two highly successful businessmen -- whose understanding of investments, costs and benefits helped them become billionaires -- can say something so completely mistaken and even idiotic is a tribute to the human capacity to take our ideological biases and convince ourselves that they're not biases at all but are instead inescapable rationality.

Maybe. However, it may also be a tribute to their arrogance bred by decades of public relations (which Bernays thought sounded better than "propaganda ") and disinformation meant to soften up the minds of the public so that they will follow the lead of the rich and powerful.

Schultz Also Added an Appeal to Tradition (or to Common Practice)

Also on January 29, the Washington Post reported that

Schultz referred to a town hall hosted Monday night by CNN in which Harris embraced a 'Medicare-for-all' single-payer health insurance system and said she would be willing to end private insurance to make it happen.

'That is the kind of extreme policy that is not a policy that I agree with,' Schultz said on 'The View,' adding that doing away with private insurers would lead to major job losses.

' That's not correct. That's not American ,' Schultz said on CBS. 'What's next? What industry are we going to abolish next? The coffee industry?'

Presumably, by saying "that's not American," Schultz means that is not what we have always done, that is not what has been traditional American practice, begging the question of whether that practice could be ill-advised. Thus Schultz appeared to ladle on an appeal to common practice, otherwise known as an appeal to tradition .

As an aside, the quote also suggests that Schultz's real concern is not with the affordability of Medicare-for-all, particularly in comparison with that of the current system, but with the financial health of the insurance industry. But that is for another day .

Summary

So, to protect against the dread "Medicare for all," that is, proposals for a government single-payer health insurance system to replace our current practice of financing health care through large, mainly for-profit insurance companies, we see an acceleration of public relations/ propaganda paid by undisclosed donors, that is, via dark money. We also see prominent multi-millionaire and billionaire executives laying down a barrage of logical fallacies to support the status quo.

It is hard to believe that the defenders of the current system are not mostly self-interested. That status quo has made some people very rich.

It is also hard to believe they are stupid. However, a close reading of their arguments suggests they may think we are stupid, or at least befuddled by repeated public relations/ propaganda/ disinformation campaigns.

In 2011, we wrote ,

Wendell Potter, author of Deadly Spin , has provided a chilling picture of health care corporate disinformation campaigns and the tactics used therein.

In particular,

Mr Potter recounted how deceptive PR campaigns subverted the health care reform plans of US President Bill Clinton, reduced the impact of Michael Moore's movie, 'Sicko,' and helped to remodel the recent health care reform bill to reduce its threat to commercial health insurers. He further noted how PR distracted public attention from the growing faults of a health care system based on commercial health insurance, and how practical and legal safeguards against abuses by insurance companies were eroded.

Furthermore, Mr Potter

described 'charm offensives;' the deliberate creation of distractions, including the planting of memes for short-term goals that went on to have long-term adverse effects; fear mongering; the use of front groups, including 'astroturf,' (faux disease advocacy and/or grass roots organizations), public policy advocacy groups, and tame (and conflicted) scientific/professional groups; and intelligence gathering. He provided some practical advice for detecting such tactics. For example, be very suspicious of policy advocacy by groups with no apparent address or an address identical to that of a PR firm, or with anonymous leaders and/or anonymous financial backing.

Now it is 2019, once again health care reform is in the air, and once again the defenders of the status quo are hard at work. Now, they are even wealthier than they were 10 years ago, and have even more sophisticated tools, like social media and its hacks, at their disposal. Still, however, their arguments are ultimately built on sand.

As I did in 2011 , it makes sense to quote Wendell Potter

onslaught drastically weakened health-care reform and how it plays an insidious and often invisible role in our political process anywhere that corporate profits are at stake , from climate change to defense policy.
[Potter, Huffington Post]

So,

The onslaughts of spin will not stop, the distortions will not diminish, and the spin will not slow down. To the contrary, spin begets spin, as the successes of corporate PR functionaries increase the revenues of their employers, further funding their employers' efforts to create a more hospitable climate for their business interests. Americans are thus being faced with increasingly subtle but effective assaults on their beliefs and perceptions. Their best defense right now is to understand and to recognize the sophisticated tactics of the spinners trying to manipulate them.

Most important is a singular mandate: Be skeptical .
[Potter, Huffington Post]

I still hope that summarizing some of Mr Potter's amazing points will help us all to be much more skeptical.

You heard it here first.


Disturbed Voter , February 22, 2019 at 4:26 am

Can any system of incentives work, for both the patients and the care providers? The tendency is for patients to seek professional help over over-the-counter remedies when it is unnecessary (hypochondria) and for care providers to over-test and over-medicate (avoid malpractice and promote snake oil). Either you use market-based incentives or bureaucratic incentives. And the bureaucratic incentive can be public or outsourced to commercial enterprise. There is no spontaneously self regulating system, it has to be designed-in.

Yves Smith Post author , February 22, 2019 at 6:26 am

Bullshit. Every other advanced economy had a fully or heavily government funded system. Their costs are 50-60% in GDP terms compared to ours with generally better health outcomes.

Hypochondria is present in only 1-5% of the population. That isn't a "tendency". The overtesting is due mainly to bad norms and bad economic incentives like it being perceived to be normal to have an EKG every year with your annual physical (another questionable practice in healthy people) when only people at heart disease risk need an EKG. MDs own the EKG equipment, so this is a profit center for them. Similarly, I knew instinctively that annual mammograms and annual Pap smears were overkill and I'd refuse those tests and get lectured for that. My take has now been confirmed. But those MDs were driven by bad collective beliefs as to what good medical practice was at the time, and not some personal liability fear.

As for overprescribing, again my perception is that this is more patient that MD driven (save possibly for elderly people who tend where they should be taken off certain meds for a month or two and tested to see if they are still needed). You forget that Big Pharma now advertises on TV and tells patient to ask their doctors about their wares! But the real sins like prescribing antibiotics for flus comes (as in with other cases) with patients wanting the doctor to Do Something.

I lived in Australia and MDs were very much of the "let's monitor this" (as in do nothing right now) school, which says that patients are perfectly fine with that if the doctor seems confident and also make clear that he'll change course if warranted.

MDs ought to be allowed to prescribe placebos or aspirin at real med prices with some mystery med name and have the pharmacy plan quietly rebate virtually all the price months later for the patients with real problems where meds are indicated (the problem need to run its course and the most that is called for is palliatives).

Redlife2017 , February 22, 2019 at 6:54 am

+1000
From my own experience I completely agree. In particular with your point about the Doctors being in the "let's monitor this" school of thought outside of the US.

I've lived in the US and the UK for extended periods so can compare and contrast. I actually think that due to the structure of the US system that the US medical system builds a dependency on subscribing more and more drugs to people because MDs and pharmas get the money (not a shocking statement).

In the UK a doctor will never overprescribe – even if you want them to. It's just not a thing at all since there is no incentive except to be a, uh, doctor. They are trying to make sure you either get or stay healthy.

The system is built to make sure people have healthcare without weird profit incentives. They even have signs at the GP stating that if you have flu you should just rest, drink lots of fluids and stay home – don't get other people sick.

And to pre-empt someone noting that the NHS is having lots of problems – that is completely the choice of the current government (and the government in their ConDem days of 2010 – 2015). The NHS would be in much better shape if they

  1. stopped all the stealth privatisation (it's shocking what is going on) and
  2. just made sure local services were properly funded.

Amfortas the hippie , February 22, 2019 at 7:55 am

aye. the stealthy neoliberal colonisation of NIH, and all the scandinavian happy places is studiously ignored.

with my own experience with healthcare -- 6 1/2 years to get a hip to replace the literally dead one i was hobbling around on and now, all the time i've spent in and around the gleaming medical center for my wife's cancer .talking to all and sundry listing to all and sundry from wastrels at the bus stop to suits riding the elevator with me healthcare is a Right, dammit. there is no place at all for markets, privatisation or profit. it is immoral to profit off the suffering of a human being, period.

that moral argument is what will win the day even the suits acknowledge it, before passing off responsibility to the System("well, yes but we can't do anything, because the Great God Moloch must be appeased")

I am a sacrificial victim to that cruel deity. I'll be in pain for the rest of my life because i couldn't get timely care i still walk around on an ankle that is an enervated bag of gravel, since no ankle guys in texas take medicaid (and i'm kicked off that, now, too,lol)

I am thankful for my hip, hard won as it was. and i am more than grateful for the level of care my wife is getting but damn.

let these ceo's walk a mile or two in bloody shoes before they lecture about affordability and access.

their sin is gross indifference to suffering in the service of their own greed.
fie.

Susan the Other , February 22, 2019 at 12:18 pm

Exactly. The phrase "providing access" is nauseating. It really means "preventing access" unless you pay.

This is nothing more than an obfuscation of blatant extortion. Do any of these patriotic capitalists understand capitalism? I don't think so. Too much liike a priest understanding god. Is god otherwise unaffordable, if you don't have a pious priestly middleman to do spiritual arbitrage? For a small fee, of course.

They really do think we are stupid. But they forget The Reformation. There just comes a point in time when you can't politely ignore the lies and destruction. It takes on a life of its own and is unstoppable.

This post is encouraging because there is a guy out there named Roy Poses who is connected with something called Health Care Renewal and there is another guy, Paul Waldman who works for the WaPo; and we are reminded of the wonderful Mr. Wendell Potter. And a whole nation on the march. Hope your hip and your wife are feeling better.

GF , February 22, 2019 at 12:29 pm

Here's a retweet from Bernie about the latest big pharma price gouge:

"Bernie Sanders
‏Verified account @SenSanders
Feb 20

Bernie Sanders Retweeted CNN Health

Catalyst's decision to raise the price of a life-saving drug from $0 to $375,000 is causing patients to suffer and ration their medication. Outrageous! Catalyst must immediately lower the price of Firdapse."

PlutoniumKun , February 22, 2019 at 10:37 am

A relative of mine is actually nearly through research on exactly the topic of prescribing differences between Europe and the US. He says he found a very different culture among US doctors (if and when its published I'll certainly let Yves know, it might make an interesting article or link here).

As you and Yves says, there is very little evidence of overprescribing or overtreatment in 'free' or heavily subsidised health systems. On the contrary, there is evidence of massive overtreatment in the US for people willing to pay and / or with good insurance.

Here in Ireland there were problems in hospitals because it used to be free to be an out-patient, so the poor/hypochondriac, etc., would clog up waiting rooms instead of going to their local doctor where they would have to pay. They introduced a charge solely to stop this. It was crude, but it worked. It would of course have been much better to co-ordinate charges or put a better system in place to triage real patients from those who just want a bit of sympathy.

Most GP's will tell you that about 5% of their patients represent 90% of their workload. Some people either need lots of care, or they are just demanding and go to the doctor for every little ache and pain, while others practically have to have a limb falling off before they'd go. That's just the way it is, and all systems come up with ways to deal with it.

Nearly all doctors will give prescriptions even when not needed, because they know people feel better for it. The doctors I know invariably give mild painkillers on prescription for minor things like colds and backaches. Its really a form of acceptable placebo. I'm lucky to have a really good local doctor who runs a small team who are very firm on explaining to people why they don't always need treatment or prescriptions, even to the point of it being a little annoying sometimes – he refused to burn off a wart I had some time ago, telling me just to go to a pharmacy and buy an over the counter freeze tab. And when I had a diagnosis for mild arthritis in my hip he told me to walk lots and eat natural anti-inflammatory foods – again, no prescription, even something very mild. He seemed surprised that I didn't argue the point.

That said, being strict on prescriptions can backfire. I know of a young man who died from a rare bone cancer. He was from a very poor background and looked like a typical junkie – pale skin, skinny, Nike sweat pants (he wasn't, he just looked like one). His doctor thought he was trying to scam opiates and told him the pain was all in his head.

He was a little bit innocent and believed her.

It was when he literally collapsed while visiting his girlfriend in hospital that he was examined and diagnosed – it was too late by then.

Carla , February 22, 2019 at 12:05 pm

Yves, thank you so much for calling bullshit on Disturbed Voter's comment. After spending more than two decades as a single-payer supporter, I cannot improve upon your response.

Disturbed Voter , February 22, 2019 at 12:33 pm

i work in medicine, do you? Mind you, you can have single-payer or Medicare-for-all but it isn't free (not free in Cuba or other locations).

And medical care will always be triaged on some basis so expect delay or denial of care.

What you see is dishonest accounting, moving costs from one column to another, and hiding the change.

And providers won't work for free either, unless you intend to enslave them. I am happy France etc has good open access care. You might ask how that is done, it isn't magic. The answer is, they pay high taxes, and don't spend that on things they don't want (like endless warfare). As far as drug prices go, Americans subsidize the cheaper prices found elsewhere (not that I agree do this).

AdamK , February 22, 2019 at 12:35 pm

+100000. It is also very common to create a package of services that are provided by the government insurance and leave the rest to private insurance. This package is revised every few years according to scientific reviews and adds or drops services. Plastic surgeries are out unless there's significant affects to the person'e quality of life. If a patient is interested in an experimental, or not proven, innovation, he can shop for it himself as long as there's solution that is covered. The same way private insurance deals with such cases presently. As for meds, with big data you can pinpoint to a patient that over uses or a physician who over prescribes, and use this info for integrative medicine purposes to optimize the use of meds to better results. Those methods do not go well with the healthcare industry of course. No one now has an incentive to cut services or meds.

In general every method has it wastes and frauds which cannot be quantified in advance, the issue here isn't just cost, it is first and foremost MORAL.

Mark , February 22, 2019 at 6:04 am

As a non American, I find it quite bizarre when claims like this are made. Universal health care and free/affordable quality education is available in many countries that are far less prosperous than the United States.

If only the US could look outside it's bubble and take a few hints from how things are done elsewhere. However being the "leader" of the "free world" seems to make the USA blind to looking outside its own sphere for how things could be done better.

(Not that the US is alone here. But it probably is one of the stronger examples.)

notabanker , February 22, 2019 at 7:30 am

The isolation that Americans live in is a problem when it comes to this. I use the Alice in Wonderland on the other side of the lookinglass metaphor frequently to describe my expat experiences. Being immersed in a different culture, you see first hand how 'normal' is so relative.

Americans do live in bubbles, and within the US there are bubbles, the country is so vast and it's media is captured. I find it encouraging when people like yourself speak up and call bullshit. I've seen some of Sanders healthcare threads on twitter completely ratio'd with Canadian, British and Aussie's calling BS on the US propagandists that try to attack their systems. We need more of that.

Kurtismayfield , February 22, 2019 at 9:49 am

The isolation that Americans live in is a problem when it comes to this. I use the Alice in Wonderland on the other side of the lookinglass metaphor frequently to describe my expat experiences. Being immersed in a different culture, you see first hand how 'normal' is so relative.

You have to consider their news sources as well.. my theory is that the only point of the 5 and 6 O'clock news is to feed into middle class anxiety or advertise a product. The corporate run media wants people scared and to buy buy buy. I would love to see a politician start a campaign where they discuss 20 different country's health care systems that are better and cheaper than ours, and see how deafening the silence will be from the corporate media.

As I have said here many times before, just get someone to propose the Swiss system . Anyone that argues that the Swiss are some bastions of communist thought can be laughed at entirely.

notabanker , February 22, 2019 at 11:36 am

I did mention the media being captured. And unlike the UK, there is no European influence to counter / add breadth to the BBC. Brits and Europeans have a far more global-centric view of things, if for no other reason than geography.

Phacops , February 22, 2019 at 10:01 am

Having to work in other countries provides a swift reality check regarding ways of social organization and doing things. I count such experiences as saving me from believing conservative propaganda here in the US.

notabanker , February 22, 2019 at 11:54 am

I am so very glad my kids spent crucial formative years outside of the US. It's the best possible gift I could have ever given to them.

Phacops , February 22, 2019 at 9:53 am

What do you expect for a people who actually hate to travel except for pre-programmed experiences or resorts walled off from the surrounding community? That, and the lack of adequate holiday time to even enjoy their own country. I don't wonder at the ignorance of the American public about better ways of providing human services and better health outcomes, though I think some such ignorance is deliberate.

Buzz , February 22, 2019 at 12:02 pm

How very, very true Mark. I've yelled and screamed this same meme over and over to no avail. Look around, we're not the only country on this planet and we DON'T always have the right answers !

Grant , February 22, 2019 at 12:40 pm

On so many issues though in this country, when we talk about the "US", we should be clear about what we are talking about. The opinions of rich people in the media, rich and corrupt politicians, strongly ideological people with a class bias that are appointed by politicians, and paid propagandists and "think tanks" don't constitute the country. I don't think that those groups have anything to learn about other countries because I think most of them are fully aware that they are not being logically factual or honest in what they say on healthcare, the critiques they give of single payer, etc. Some people maybe are (willfully) ignorant, but I think most of it is gaslighting. It doesn't matter that every single payer system has lower overhead, is more efficient, has far less social costs, is cheaper as a percentage of GDP and on a per capita basis. It doesn't matter the reasons why this is the case. There was a WHO study in 2010 that showed that administrative overhead in private systems around the world is three times higher than overhead in public systems, and why that is the case. It doesn't matter how many studies show massive aggregate savings from adopting single payer here. The data on overhead with traditional Medicare versus private insurance, polls showing that the public parts of the healthcare system (the VA, Medicare, Medicaid) are all more popular than private insurance or things like the Rand study showing that care at VA hospitals are often better than the care veterans get at private healthcare providers. None of it matters, if any person on TV actually cared about factual accuracy on stuff like this, they wouldn't be on TV. Someone else that was willing to manipulate people and lie would be in their place, and they would be paid well to do so instead of them. You can't tell me that Jake Tapper isn't fully aware of what he is doing when he "fact checks" single payer like he has done.

The public, however, does seem to get it, especially when things are described accurately to the public. Kaiser does polls, they are opposed to single payer, and so they frame their questions in really biased ways. For example, they will ask, would you support single payer if it raised taxes? Well, some respondents say not, although there is still majority support. Beyond the MMT arguments of not needing to raise taxes, let's just assume that we are trying to make single payer as revenue neutral as possible, for arguments sake. Wouldn't a more accurate question be, would you support single payer if it raised taxes, but the tax increases were more than offset by a reduction in out of pocket expenditures? Polls show strong majorities of the country support single payer, and that is with very little of those in power and with big microphones supporting the idea. We all know the studies showing the large gap between popular opinion and what the state does on policy. Like every other issue, people want one thing, and worthless people in power want another, and our system doesn't make it so that those worthless people are really directly controlled by us collectively nearly as much as donors and other interests control them.

greg , February 22, 2019 at 6:34 am

Since it is becoming increasingly obvious that our current management team of wealthy white males are both too venal and too incompetent to sustainably manage a global economy, perhaps we should start looking for alternatives.

It is delusional to think that US healthcare, or any of the problems which beset both the United States and the world, will be effectively dealt with as long as they are in charge.

It is unreasonable to expect that the over exploitation of natural resources, or sustaining the environment, addressing global warming, and so forth, will happen under their management. This is simply because they are the ones who control the earth's resources, and they are the ones who most profit from their unregulated exploitation and destruction.

It is unreasonable to expect that pollution will be effectively dealt with, because the wealthy make a profit from every ounce of pollution, and every scrap of litter, that has ever been, or will ever be, produced.

Every ounce of CO2 produced, is profit for some wealthy businessman.

Overpopulation is profitable for the wealthy. It both expands their market for goods and services, and lowers their price for labor.

Have you not noticed that we have been aware of all of these problems for over 50 years, and nothing has actually been accomplished with any of them?

Nothing effective will be done, with any of these problems, while they are in charge. It's all been talk, talk, talk, and from the wealthy, always the seeds of confusion and division.

Once a problem has been solved, it is no longer an opportunity for profit. As long as a problem festers, there is money to be made.

Every cost imposed on society is a profit opportunity for someone with wealth and power. There is money to be made, as civilization declines and collapses.

Mac na Michomhairle , February 22, 2019 at 9:23 am

You seem to start of suggesting that things would be fine, if it were not for wealthy white males being in charge.

That is a peculiar perspective that appears to attempt to divert attention from the actual horrifying system itself, and divert potential energy from attempts to change that system, to focus on a mere feature of the system.

As though, if an investment house screwed over my parents, I devote myself to bettering the world by fighting the men of Connecticut wherever I encounter them, because the house agent who was point person was from Connecticut.

If individuals in the system stand to profit from it, of course they have a stake in its continued existence; any individuals do.

Mike Mayer , February 22, 2019 at 7:39 am

Why don't businesses in the USA want to have the burden of providing health insurance taken away from them? It is a cost they bear because they need to find, negotiate, buy and administer the health plan. I am surprised most businesses are not lobbying to have the government provide it.

voteforno6 , February 22, 2019 at 9:44 am

On the other hand, the system of employer-based health insurance does offer additional ways for employers to keep the serfs in line.

rd , February 22, 2019 at 10:50 am

I tend to align with incompetence and neglect in lieu of conspiracy theories if the former can explain it, because it takes a lot of effort and smarts to pull off a conspiracy and both of those are usually in short supply across a large population.

I think we have most companies for whom the health insurance system is just something they have to have and they just go along with the flow because their competitors based in the US have similar costs.

The one organized group on this is the healthcare industrial complex that are lobbying against any nationalization type of change and even want to get more into the VA and Medicare than they already are. This IS their business and they are focused on it like a laser beam. so the conspiracy theory works for their sector.

BTW – I am surprised that the inexpensive healthcare in the rest of the developed world hasn't been a talking point of Trump's as a "subsidy" to their businesses justifying retaliatory tariffs by the US. The difference between what the US and the rest of the developed countries spends on healthcare is bigger than the entire US military budget as a percent of GDP, never mind the delta between US military spending and the other G-20 countries. So if we could drop our health care per capita spending to a bit below Switzerland's (next highest), we would have paid for the entire US military budget. If we could drop it down to Canada's level, we would have saved a year and a half's US military budget every year.

And "American Exceptionalism" pretty much ensures that nobody will look outside the US borders for solutions. If we are doing it, then it must be the best way. End of story. No further research required.

jrs , February 22, 2019 at 1:03 pm

besides the fact that it only makes a little bit of sense even as a conspiracy theory, a few people work just for healthcare and would retire otherwise (they are of course comparatively well off it goes without saying, and yes they SHOULD be able to retire, make room for those who actually NEED to work!).

But most work for survival day to day and if healthcare comes with it that's great, but many work without any form of employer provided healthcare at all (because they still need money to survive). I've heard 30-40% of the working population has NO employer provided healthcare. The serfs are still kept in line just by even more basic needs like food, shelter, and climate control, or they wouldn't show up for such jobs, but of course they do.

tegnost , February 22, 2019 at 9:59 am

IMO it's because they like the captive employees who won't quit because health care

Jim Thomson , February 22, 2019 at 12:51 pm

Bingo.

antidlc , February 22, 2019 at 10:18 am

As mentioned by other posters, companies want to use healthcare to keep employees captive. They don't want employees to leave for smaller firms or start their own companies. It's a way to limit competition.

Companies also have a vested interest in keeping the employer-based insurance model:
https://www.wsj.com/video/why-big-tech-wants-access-to-your-medical-records/F9C51DC8-5238-4D0C-B8BD-73F0FAC92048.html

They want to be able to use your medical history to decide whether to hire or fire you. The video is quite alarming.

oaf , February 22, 2019 at 8:00 am

" the financial health of the insurance industry"

Perhaps Government should mandate the profitability of all sectors of the Economy
..or justify why they pick *favorites*

Got to keep the trough full; that's an important pig!

oaf , February 22, 2019 at 8:17 am

lest we throw out the Baby with the bathwater; let's bathe in it a while longer!

zagonostra , February 22, 2019 at 8:19 am

> It is also hard to believe they are stupid. However, a close reading of their arguments suggests they may think we are stupid, or at least befuddled by repeated public relations/ propaganda/ disinformation campaigns.

Unfortunately, I think in the aggregate both are true: They are not stupid, rather cunning and evil, we are stupid, or rather easily manipulated by a very sophisticated propaganda machine that goes back to Edward Bernays. If you repeat a lie often enough it doesn't matter if it's true or not, and by the processes of association (socialism/Venezuela) we are wired in ways that makes us susceptible to blaring lies (some of Koestler's works come to mind).

There has to be a tipping point where enough people have built up defenses to the propaganda that enable "we" to go after the bloody bastards.

tegnost , February 22, 2019 at 10:16 am

I think it's less a matter of defenses and more the numbers game, the PTB have been pretty successful winnowing the field. Say a 1000 people work in an industry, someone of those 1000 figures that 100 of those can be replaced (h1b, computers, undocumented immigrants) but the amount they charge stays the same, or more likely is increased to reflect the leaner machine being more productive. Big bonus to top guy. Then it's well we have 900 employees, we could do the same with 700 employees etc and on down the line. This has worked really great for the 40 years since reagan. Add crippling student loan debt, winnow out some more people as they have been effectively neutered, basically only able at best to maintain as a steadily depreciating labor unit (hmmm, we need that persons shoes to touch the ground in a medical establishment so the gov can pay us, since that poor schlub obviously can't, thanks ACA, and once again imo, the whole reason for the medicaid aspect of the ACA) the end result is fewer and fewer successful lives being led, and more and more precarious lives being led. In 2016 the dogs wouldn't eat the dogfood. Nothing about the numbers have changed so the dogs are going to be more grumpy and indeed some of those dogs which sat on the sidelines last time might be grumpy enough to vote in 2020.

katiebird , February 22, 2019 at 8:39 am

It seems like there is a logical fallacy somewhere in this story. .

Arizona college student could die because she can't get copies of her medical records

The files are locked away in a repossessed electronic-records system while creditors of bankrupt Florence Hospital at Anthem and Gilbert Hospital bicker over who should pay for access to them.

.

The medical records are the only thing standing between her and a lifesaving surgery by a top physician at Johns Hopkins Hospital.

The doctor has refused to perform the operation without a complete understanding of Secrist's health history, including what her pancreas looked like when she was originally diagnosed, she said.

Every week that goes by, the danger increases of another attack of acute pancreatitis that could cause her organs to shut down.

"Without those records, we can't go forward. We can't make me better," said Secrist, who lives with her parents in Florence. "Having my life, practically, in the hands of a judge and people I don't even know, who don't even know my situation, it's upsetting."

Secrist and her primary-care physician sent letters this week to Maricopa County Superior Court urging swift release of her records. Federal and state law require medical facilities to send patients copies of their medical records within 60 days of a request.

taunger , February 22, 2019 at 9:00 am

Thank you for this post that clearly identifies the logical fallacies. This can be useful in conversations #fieldwork

Norb , February 22, 2019 at 9:04 am

In the long run, Medicare-for-all lays the groundwork for a more healthy and productive society. Healthy citizens require less healthcare, so there is potential savings over time. Healthcare is most efficient when built around a healthy society. But healthy citizens must be the primary goal, not some abstract argument about affordability and jobs protection. The jobs created by the system must be oriented toward societal health, not the profit generation for a few plutocrats. No wonder they are bemoaning the cost- they have been impoverishing the citizenry for 40 years and sooner or later that bill has to be paid.

The plutocrats, always attempting to hide their true motives, now seek to obfuscate their abject disdain for working people by using arguments of cost to continue restricting access to healthcare. Their inhumanity must be driven home and called out, but the social discourse is still in "polite" mode. Using the term 'stupid' to describe the plutocrats falls in this category. They know exactly what they are doing, and are given a social pass to continue acting in an inhumane and antisocial manner. Chants of USA USA are obscene in this context. The longer this trend continues, only decline can result.

If people are not responsive to a moral argument, the argument for comparative costs is the strongest one that needs to be constantly driven home. We are already paying- and as pointed out, will be paying much more in the future for less. Everyone can understand that and can see it in their own pocketbooks.

The moral bankruptcy of the current leadership must be called out. The propaganda bubble that Americans live enshrouded in is showing signs of weakness. That bubble will burst when pricked from forces outside the impirum- and there are many- failure is everywhere and the rest of the world is not as delusional as most Americans.

a different chris , February 22, 2019 at 9:19 am

Do these billionaires realize that, in this case the word "unaffordable" specifically means "go die"? Wow.

bassmule , February 22, 2019 at 9:27 am

As Lambert has frequently pointed out, NeoCon policy regarding health is this:

1. "Because markets!'
2. "Go die!"

voteforno6 , February 22, 2019 at 9:46 am

That's NeoLib The NeoCons are the ones who want to bomb everything, everywhere, because America.

polecat , February 22, 2019 at 11:19 am

Put the two together, and you have two wretched greedy fingers locked in avaricious embrace !

JBird4049 , February 22, 2019 at 12:15 pm

The two sets have been merging to where they would be almost the same in a Venn diagram. Almost the entire Washington establishment agrees on what is call the Washington Consensus which is cutting taxes, reducing regulations, free trade, and now apparently the Forever Wars.

Most of the differences that remains are cosmetic and focus on the social issues so that the selected base will organize, donate, and vote for them.

For example, gun control, LGBT rights, and pro-choice (abortion) for the Democratic Party and gun rights, religion, and pro-life (anti-abortion). Note that the goal is not to solve or even ameliorate any issue, but rather to inflame them so that they can be used as cover, distraction, and agitation.

Carolinian , February 22, 2019 at 9:46 am

It's all about the Benjamins–logic has nothing to do with it and never has. The largest business in my county is the hospital system which also has the highest paid CEO. And they just became even larger by buying a smaller competing hospital. Yves has pointed out how fearsome the DC health lobby is and, as cited above, the Chamber of Commerce is fully on board. There's been some excitement because announced Dem pres candidates support Medicare for all but Dem candidates always say they are for reform whereas in reality we get Hillary care in the '90s or Obamacare after both he and Hillary campaigned on the issue. Probably none of this will stop unless the economy crashes to the point that the medical complex has to accept reform and reality.

justsayknow , February 22, 2019 at 10:14 am

''That is the kind of extreme policy that is not a policy that I agree with,' Schultz said on 'The View,' adding that doing away with private insurers would lead to major job losses.

'That's not correct. That's not American,' Schultz said on CBS. 'What's next? What industry are we going to abolish next? The coffee industry?'

I'd say Shultz gives the game away as he reveals he sees the current "system" as a make-work-make profit center.
I imagine he and Bloomberg et al have significant investments in the health industrial complex. Otherwise wouldn't it benefit all other commerce sectors to have customers with lower health costs thereby freeing up money that could be spent with them.

Eclair , February 22, 2019 at 12:22 pm

"What industry are we going to abolish next?"

Great question, Schultzie! Where were you (or your ilk) when we 'abolished' the US textile industry? Or our furniture industry? Or our electronics industry? Or our clothing industry? Or our rail car manufacturing industry?

And the jobs that went with them.

antidlc , February 22, 2019 at 10:23 am

More from Wendell Potter:

How to be ready for the health care industry lie factory
https://www.tarbell.org/2019/02/be-ready-for-the-health-care-industry-lie-factory/

antidlc , February 22, 2019 at 10:26 am

Meet the propaganda outfit fighting against Medicare for All (podcast)

Why do we believe the things we do? Whistleblower, New York Times best selling author and Tarbell.org founder Wendell Potter, along with millennial co-host Joey Rettino, are joined by politicians, activists, journalists and pretty much everybody else to figure it out.

https://www.tarbell.org/2019/02/the-potter-report/

Summer , February 22, 2019 at 10:26 am

I laugh when they say they are worried about "jobs" of people in the health insurance industry. They aren't worried about the jobs, but exec pay. Everytime I look up there are articles about more automation and tech in the administrative and medical pafts of the industry.
It's like Uber claiming to worry about drivers while claiming their future is driverless cars.
So a good number of people that staff the health insurance industry (talking to you non-wealthy execs) need to get on board now and get their health care covered.

There aren't too many industries that aren't salivating overways to have fewer employees and then you hear all this BS from the same industry "leaders" touting how employer based system is the only thing imaginable.

rd , February 22, 2019 at 11:12 am

BTW – latest number I can find

Canada military spending 1.0% of GDP; healthcare spending 10.4%: Total military + healthcare = 11.4% of GDP

US military spending 3.5% of GDP; healthcare spending 16.9%: Total military + healthcare = 20.4% of GDP

So between those two economic sectors, Canada has an extra 9% of GDP to spend on other priorities. No wonder they can have an inflated housing market as well as paid parental leave.

Disturbed Voter , February 22, 2019 at 12:41 pm

Exactly. To reallocate resources, you have to look at the whole picture, not just the health industry. That is a huge question. What you do with a particular allocation, is pertinent.

D , February 22, 2019 at 11:13 am

i always wonder if they are really thinking through when the say that the government (us) but that if we let patients and insurance can pay for it?? Really????

Susan the Other , February 22, 2019 at 12:45 pm

Thanks for this post, Yves. It was really good. It did all the demolishing for us. Deconstructing the whole building. I love the phrase (whether facetious or not) "argument by gibberish." I mean, it could be a necessary part of a logic curriculum – please analyze this argument for gibberish – because we were once so oblivious. So, more accurately, the pushers are now the oblivious ones. The full court press against "socialism" and "unaffordable health care" and holding up the decrepit free market isn't going to work much longer.

Hepativore , February 22, 2019 at 12:58 pm

One thing that I also hope that gets changed in the US, is combining dental care with a Medicare For all Program. It is ridiculous that people have to carry both dental and health insurance as good dental care and physical well-being are related. Left untreated, oral maladies can quickly become serious and more expensive to treat. Effective dental care is far from a vanity service.

[Feb 22, 2019] Angry Bear Again, Healthcare Cost Drivers Pharma, Doctors, and Hospitals

Feb 22, 2019 | angrybearblog.com

Again, Healthcare Cost Drivers Pharma, Doctors, and Hospitals

run75441 | February 21, 2019 10:00 pm

Healthcare Hot Topics This should come as no surprise as I have written on the topic of Healthcare Costs and Its Drivers before. In particular, the overriding statistic from an earlier post was 50% of the increase in healthcare costs was due solely to price increases between 1996 and 2013 (JAMA, Factors Associated With . . . . Adjusting for inflation, "annual health care spending on inpatient, ambulatory, retail pharmaceutical, nursing facility, emergency department, and dental care increased from $1.2 trillion to $2.1 trillion or $933.5 billion between 1996 and 2013." This was broken down into 5 fundamental factors contributing to rising healthcare costs.

– Increased US population size was associated with a 23.1% increase or $269.5 billion
– An aging population was associated with an 11.6% increase or $135.7 billion
– Changes in disease prevalence or incidence (inpatient, outpatient, ED) resulted in spending reductions of 2.4% or $28.2 billion
– Changes in service utilization (inpatient, dental) were not associated with a statistically significant change in spending
– Changes in service price and intensity were associated with a 50.0% increase or $583.5 billion.

Five fundamental factors (Population size, Population aging, Disease prevalence or incidence, Service Utilization, and Service Pricing) were collectively associated with a $933.5 billion increase in annual US health care spending between 1996 through 2013. Represented pictorially, stated objectively, and categorized numerically, I can not make it any more obvious.

Some Explanation

The change in disease prevalence or incidence was associated with a spending reduction of 2.4%, or $28.2 billion while the change in service utilization did not result in a statistically significant change in spending. Said another way, these two factors had little or no impact on the rising cost of healthcare.

The increased healthcare costs from 1996 to 2013 were largely related to Healthcare Service Price and Intensity and secondarily impacted by Population Growth and Population Aging in order of impact. The bar chart reflects all of the impact in changes.

So the aging tsunami of baby boomers has not hit yet and population growth has not greatly impacted the results of this study. In patient stays at hospitals are down as well as out patient use of facilities. The big issue is the change in pricing for inpatient hospital stays and pharmaceuticals. Hospital/clinic consolidations leads to the former even though insurance has been fighting for a reduction in stays. Pharmaceutical has instituted new pricing strategies which we have all read about in the news. Old drugs such as Humalog, Viovo, and the infamous Epipens as well as others are now more expensive. This study points to pricing for pharma and service as the issues.

An example?

There is a tendency to challenge the lifestyle practices of people who indulge in too much. One factor did come out in the increased cost of healthcare. The increase in annual diabetes spending between 1996 and 2013 was $64.4 billion of which $44.4 billion of this increase was pharmaceutical spending. Said another way, two-thirds of the increase in treating diabetes was due simply to the increased pricing of pharmaceutical companies.

And yes, there should be time spent on changing habits where it can be changed and providing the means to do so. However, in 1996 Eli Lilly's Humalog was $21 per vial. By 2017, the price increased to $275 (700%) for a vial which equates to a one-month supply.

Why has the cost of Humalog increased? "The truth is the improvements in new formularies of old versions which are marginally different, and the clinical benefits of them over the older drugs have been zero." Just like slapping "new and improved" on the labels of food products with a change of ingredients (which qualifies under USDA and FDA labeling regs)., pharmaceuticals can play the same game and they do.

As the article ("Eli Lilly Raised U.S. Prices Of Diabetes Drug 700 Percent Over 20 Years ") explains, "most patients do not pay the full cost/price of a drug up front and absorb their portion of the cost via an increase in monthly healthcare premiums." This leads to pharmaceutical companies charging as much as the U.S. insurance companies will let them. Both parties profiting from increased prices. Perhaps Alex Azar the Secretary of Healthcare can explain it better as he was an officer of Eli Lilly when Humalog began its ascend?

Another Study via Health Affairs

A shorter time period extending one year longer than the Jama study, the Health Affairs study supports what is being said in the JAMA study. According to data from the Henry J. Kaiser Family Foundation, total health spending on the privately insured in the United States increased in real terms by nearly 20 percent from 2007 to 2014.

A more recent study funded by the Commonwealth Fund and published by Health Affairs examined other costs impacting healthcare. Commonwealth Fund supported researchers recently analyzed hospital and physician prices for inpatient and hospital-based outpatient services as well as for four high-volume services: cesarean section, vaginal delivery, hospital-based outpatient colonoscopy, and knee replacement. Its findings were as follows:

– From 2007 to 2014, hospital-prices for inpatient care grew 42 percent compared to 18 percent for physician-prices for inpatient hospital care
– For hospital-based outpatient care, hospital-prices rose 25 percent compared to 6 percent for physician-prices
– There was no difference in results between hospitals directly employing physicians and indirectly employing physicians
– Hospital prices accounted for over 60 percent of the total price of hospital-based care.
– Hospital prices accounted for most of the cost of the four high-volume services included in the study. The hospital component ranged from 61 percent for vaginal deliveries to 84 percent for knee replacements.

Sound familiar? The JAMA study looked at both in and out patient costs/prices associated with hospital services and said they were up. The Health Affairs study looks at in patient services for four high volume inpatient services stating they have increased significantly from 2007 to 2014.

What the Health Affairs study Showed

The Health Affairs study also presents a comparison of hospital pricing growth rates as compared to physician pricing growth rates. The study is only a few weeks old and I am surprised I am able to access as much information as I have. While Health Affairs admits the study is a start and more work differentiating other aspects must be done, the study suggests there are significant growth in the bargaining leverage of hospitals as compared to physicians.

If you recall Rusty "Tom" and I engaged in a number of different conversations on healthcare with one of them being hospital consolidations (2013). It is a power grab, as Rusty pointed out, for more market segment and pricing control with those having name-recognition gaining the most. Maggie Mahar also referenced the same issue.

In my own commentary On the Horizon After Obamacare (2014): As it stands and even with its faults, the ACA is a viable solution to many of the issues faced by the uninsured and under-insured; but in itself, it only addresses the delivery-half of the healthcare problem. The other half of the problem rests with the industry delivering the healthcare and the control of pricing through the inherent monopolistic power coming and pushing the industry into greater integration of delivery. As Longman and Hewitt posit,

"the message from Department of Health and Human Services stresses the vast savings possible through a less 'fragmented and integrated' health care delivery system. With this vision in mind, HHS officials have been encouraging health care providers to merge into so-called accountable care organizations, or ACOs"; "while on the other side of the Mall, 'pronouncements from the FTC are about the need to counter the record numbers of hospitals and doctors' practices merging and using their resulting monopoly power to drive up prices."

Two different messages from government, greater efficiencies in healthcare through consolidations as ACOs versus monopolistic pricing control in healthcare by large hospital and pharmaceutical corporations an unintended result. There is large amounts of inefficiencies, waste, and rent-taking in healthcare as well as in Medicare which is touted as the go-to by politicians and advocates of it. Lets not make a similar mistake, the creation of any forthcoming healthcare system must first address the costs of healthcare and then the delivery of it not ignoring the quality of the product and its outcome after treatment. Again Maggie Mahar was big on promoting this result emanating from any new system.

While Physician fees grew at a compounded annual rate of 6% for baby deliveries and 1% for office visits between 2003 and 2010, hospitals fees during a similar period grew at 17%.

A measurement of the competitiveness of a hospital within a certain area of the country is done utilizing the Herfindahl-Hirschman Index (HHI) . It has been used to measure competition in and around cities. The results of the HHI revealed an increase in the concentration of hospitals from mergers and acquisitions, going from moderately concentrated in 1990 with an HHI numeric of 1570, to more concentrated in 2009 with a HHI of 2500, and with some cities purely monopolistic at 10,000.

Rigorous action by the FTC would certainly go a long way in improving compositeness; however, the FTC has been purposely understaffed by cutting its funding. In place at the FTC is a staff 22 lawyers and economists to monitor a $3 trillion healthcare industry. It is too understaffed to take on such a large industry which would overwhelm it with legalese and paper. Maybe in the next election will bring forth the right person to take on healthcare.

Resources

Hospital Prices Grew Substantially Faster Than Physician Prices For Hospital-Based Care In 2007–14, Zack Cooper, Stuart Craig, Martin Gaynor, Nir J. Harish, Harlan M. Krumholz, and John Van Reenen, HealthAffairs, February 2019

Zack Cooper Hospital Care Prices Rose Faster Than the Cost of Physician Services, February, 2019

After Obamacare Phillip Longman and Paul S. Hewitt, Washington Monthly, January – February 2014


Mike Kimel , February 22, 2019 5:46 am

I have the impression that it has gotten harder to see a doctor or get a prescription filled over time. A couple of decades ago either your insurance paid or it didn't. Now it seems to me that most people have stories about arguing with insurance companies. It is sort of expected to be a part of the process. Time costs like this aren't counted with a dollar value but they surely contribute to the negative experience, and they require additional admin people at both medical providers and insurance companies. That in turns leads to more documentation and paperwork, requiring even more admin people. It's one thing if the extra personnel are a force multiplier allowing more people to be serviced. It's another if they are an impediment and an added cost.

Denis Drew , February 22, 2019 11:28 am

The political forum is too "understaffed" on all topics to fight back against (a nation of) scams because of (you know what I'm going to say) the disappearance of labor unions. Late Dean of the Washington press corps, David Broder, told a rookie reporter that when he came to DC the lobbyists were all union.

Nice to get real -- math broken down -- info beginning to tell why we pay twice as much for health care as any other country. When you add the hospitals overcharging, the drug companies bleeding us literally to death and the private insurance paper work overload, maybe we are finally sorting it out, at least a bit.

likbez , February 22, 2019 3:35 pm

The relationship between hospitals and heaths insurance companies currently somewhat resembles criminal cartel.

Often hospitals perform on the patient procedures that are best paid by the insurance companies, even if they are unnecessary, or even harmful.

An epidemic of unnecessary cardiac stents insertions in the USA is a nice illustration of the trend for costly and unnecessary (or even dangerous for the patient) procedures . Hospital cardiologists are pushed by financial incentives

"chief cardiologist Steven Nissen at the renowned Cleveland Clinic noted that doctors are paid per procedure rather than on a salary basis, while the Mayo Clinic's chief of cardiology, Raymond J. Gibbons, also cited the financial incentive of performing procedures."

And only few cardiologists that practice this racket went to jail.

That somewhat resembles relations between the car insurers and the body shops ;-)

[Feb 05, 2019] Trump and His Golfing Buddies Continue Neoliberalism s Assault on the Veteran s Administration by Lambert Strether

Notable quotes:
"... By Lambert Strether of Corrente . ..."
"... It's almost like there's a neo-liberal playbook, isn't there? No underpants gnomes , they! (1) Defund or sabotage, (2) Claim crisis, (3) Call for privatization (4) Profit! [ka-ching]. Congress underfunds the VA, then overloads it with Section 8 patients, a crisis occurs, and Obama's first response is send patients to the private system . ..."
"... Assuming that wait time is a function of resources, you can easily see how the playbook would work: (1) Reduce resources, (2) whinge about wait time, and (3) drain patients from the VA system, for profit! (Note that while Democrats are ostensibly jumping on board the #MedicareForAll train, they are, in the main, silent -- Warren and Sanders being the only notable exceptions -- about the destruction of an existing ..."
"... "This is nothing short of a steady march toward the privatization [1] of the VA," Sanders said. "It's going to happen piece by piece by piece until over a period of time there's not much in the VA to provide the quality care that our veterans deserve." ..."
"... Now, just because privatizing the Veterans Administration is a project of the political class as a whole doesn't mean that the Trump Administration hasn't brought its own special mix of corruption and buffoonery to the table. Indeed it has! Who, we might ask, were the actual factions in the Republican administration pushing for VA Mission? Three of Trump's squillionaire golfing buddies at Mar-a-Lago[2], as it all-too-believably turns out. From Pro Publica, " The Shadow Rulers of the VA ": ..."
"... The wretched excess of Trump's policy-by-golfing buddies aside, I don't see why privatiizing the Veterans Administration shouldn't become a major campaign issue, especially given Sanders' presence on the relevant committee. We send our children off to die in wars for regime change where the only winners are military contractors. ..."
Feb 03, 2019 | www.nakedcapitalism.com

February 3, 2019 By Lambert Strether of Corrente .

With the release of new proposed eligibility rules under the VA Mission Act, we see that privatization at the Veterans Administration (VA) continues to unfold, as outlined in the neoliberal playbook , to which we have alluded before:

The stories intertwine because they look like they're part of the neoliberal privatization playbook , here described in a post about America's universities:

It's almost like there's a neo-liberal playbook, isn't there? No underpants gnomes , they! (1) Defund or sabotage, (2) Claim crisis, (3) Call for privatization (4) Profit! [ka-ching]. Congress underfunds the VA, then overloads it with Section 8 patients, a crisis occurs, and Obama's first response is send patients to the private system .

Congress imposes huge unheard-of, pension requirements on the Post Office, such that it operates at a loss, and it's gradually cannibalized by private entities, whether for services or property. And charters are justified by a similar process.

(I've helpfully numbered the steps, and added 'sabotage' alongside defunding, although defunding is neoliberalism's main play, based on the ideology of austerity.)

We can see this process play out not only in public universities, public schools, the Post Office, and the TSA , but in Britain's NHS, a national treasure that the Tories are systematically and brutally dismantling .)

The political class has been trying to privatize the VA across several administrations -- " Veterans groups are angry after President Obama told them Monday that he is still considering a proposal to have treatment for service-connected injuries charged to veterans' private insurance plan" -- although it is true that the Trump administration has brought its own special brand of crassness to the project, as we shall see. As we might expect , the project has nothing to do with the wishes of veterans :

Nearly two-thirds of veterans oppose "privatizing VA hospitals and services," according to a poll released Tuesday by the Vet Voice Foundation. And some 80 percent of the veterans surveyed believe veterans "deserve their health care to be fully paid for, not vouchers which may not cover all the costs."

A plurality of veterans, or 42 percent of those surveyed, agreed with the statement that the VA "needs more doctors," according to the poll, indicating they believe the VA's problems are at least partly due to a personnel shortage [Step (1)].

Although Vet Voice is a progressive organization, the poll of 800 veterans was jointly conducted by a Democratic polling firm and a Republican one.

And the Veterans are right, because VA hospitals provide better care. Besides many anecdotes , we have this in Stars and Stripes, " Dartmouth study finds VA hospitals outperform others in same regions ":

A new study by Dartmouth College that compares Department of Veterans Affairs hospitals with other hospitals in the same regions found VA facilities often outperform others when it comes to mortality rates and patient safety.

Researchers compared performance data at VA hospitals against non-VA facilities in 121 regions. In 14 out of 15 measures, the VA performed "significantly better" than other hospitals, according to results from the study.

"We found a surprisingly high, to me, number of cases where the VA was the best hospital in the region," said Dr. William Weeks, who led the study. "Pretty rarely was it the worst hospital." "One has to wonder whether outsourcing care is the right choice if we care about veterans' outcomes," Weeks said. "The VA is, for the most part, doing at least as well as the private sector in a local setting, and pretty often are the best performers in that setting."

"One has to wonder" indeed! Be that it may, the new VA eligibility rules accelerate privatization. USA Today :

Nearly four times as many veterans could be eligible for private health care paid for by the Department of Veterans Affairs under sweeping rules the agency proposed Wednesday.

VA officials estimated the plan could increase the number of veterans eligible for private care to as many as 2.1 million – up from roughly 560,000 .

And here are the rules (apparently modeled after TriCare Prime , the military's insurance plan):

Assuming that wait time is a function of resources, you can easily see how the playbook would work: (1) Reduce resources, (2) whinge about wait time, and (3) drain patients from the VA system, for profit! (Note that while Democrats are ostensibly jumping on board the #MedicareForAll train, they are, in the main, silent -- Warren and Sanders being the only notable exceptions -- about the destruction of an existing , and highly functional, single payer system. So how do we get to this point? A previous iteration of the neoliberal playbook, of course!

* * *

Our story begins with the " hastily enacted " Veterans Choice Program of 2014 :

The program, which began in 2014, was supposed to give veterans a way around long waits in the VA. But veterans using the Choice Program still had to wait longer than allowed by law. And according to ProPublica and PolitiFact's analysis of VA data, the two companies hired to run the program [TriWest and Health Net] took almost $2 billion in fees, or about 24 percent of the companies' total program expenses .

More on those fees from Pacific Standard :

According to the agency's inspector general, the VA was paying the contractors at least $295 every time it authorized private care for a veteran. The fee was so high because the VA hurriedly launched the Choice Program as a short-term response to a crisis. Four years later, the fee never subsided -- it went up to as much as $318 per referral .. In many cases, the contractors' $295-plus processing fee for every referral was bigger than the doctor's bill for services rendered, the analysis of agency data showed.

Ka-ching! So, step (3) -- profit! -- worked out very well for TriWest and Health Net, piling up $2 billion in loot. ( Step (2) was a scandal of "35 veterans who had died while waiting for care in the Phoenix VHA system," step (1) being the usual denial of resources/sabotage). The VA Mission Act was the legislative response to Veterans Choice debacle. Naturally, it moved the privatization ball down the field. The American Prospect :

Only two of the 42 members on the House and Senate Veterans Affairs Committee opposed Mission last year , when it came up for a vote.

In other words, privatizing the Veterans Administration has strong bipartisan support. But:

One of those lawmakers, Bernie Sanders, the Vermont Democrat, reiterated his opposition to Mission in December.

"This is nothing short of a steady march toward the privatization [1] of the VA," Sanders said. "It's going to happen piece by piece by piece until over a period of time there's not much in the VA to provide the quality care that our veterans deserve."

Now, just because privatizing the Veterans Administration is a project of the political class as a whole doesn't mean that the Trump Administration hasn't brought its own special mix of corruption and buffoonery to the table. Indeed it has! Who, we might ask, were the actual factions in the Republican administration pushing for VA Mission? Three of Trump's squillionaire golfing buddies at Mar-a-Lago[2], as it all-too-believably turns out. From Pro Publica, " The Shadow Rulers of the VA ":

[Bruce Moskowitz, is a Palm Beach doctor who helps wealthy people obtain high-service "concierge" medical care] is one-third of an informal council that is exerting sweeping influence on the VA from Mar-a-Lago, President Donald Trump's private club in Palm Beach, Florida. The troika is led by Ike Perlmutter, the reclusive chairman of Marvel Entertainment, who is a longtime acquaintance of President Trump's. The third member is a lawyer named Marc Sherman. None of them has ever served in the U.S. military or government .

The arrangement is without parallel in modern presidential history.

Everything is like CalPERS.

The Federal Advisory Committee Act of 1972 provides a mechanism for agencies to consult panels of outside advisers, but such committees are subject to cost controls, public disclosure and government oversight. Other presidents have relied on unofficial "kitchen cabinets," but never before have outside advisers been so specifically assigned to one agency. During the transition, Trump handed out advisory roles to several rich associates, but they've all since faded away. The Mar-a-Lago Crowd, however, has deepened its involvement in the VA.

In September 2017, the Mar-a-Lago Crowd weighed in on the side of expanding the use of the private sector. "We think that some of the VA hospitals are delivering some specialty healthcare when they shouldn't and when referrals to private facilities or other VA centers would be a better option," Perlmutter wrote in an email to Shulkin and other officials. "Our solution is to make use of academic medical centers and medical trade groups, both of whom have offered to send review teams to the VA hospitals to help this effort."

In other words, they proposed inviting private health care executives to tell the VA which services they should outsource to private providers like themselves. It was precisely the kind of fox-in-the-henhouse scenario that the VA's defenders had warned against for years.

While it is true that the ideological ground for privatization was laid by the Koch Brothers , among others, the actual vector of tranmission, as it were, seems to have been the Mar-a-Lago crowd. There has been pushback against them, in the form of a Congressional request for a GAO investigation , and a lawsuit by veterans , but as we have seen, the neoliberal play continues to run.

* * *

The wretched excess of Trump's policy-by-golfing buddies aside, I don't see why privatiizing the Veterans Administration shouldn't become a major campaign issue, especially given Sanders' presence on the relevant committee. We send our children off to die in wars for regime change where the only winners are military contractors.

Then, when our children come home, we're going to send them into a health care system that's been as crapified as everybody else's (and that's before we get to PTSD, homelessness, and suicide). Surely a pitch along those lines would play in the heartland? If Sanders doesn't pick up the ball and run with it, Gabbard should.

NOTES

[1] More from Sanders. Common Dreams :

[SANDERS:] No one disagrees that veterans should be able to seek private care in cases where the VA cannot provide the specialized care they require, or when wait times for appointments are too long or when veterans might have to travel long distances for that care. The way to reduce wait times is to make sure that the VA is able to fill the more than 30,000 vacancies it currently has. This bill provides $5 billion for the Choice program. It provides nothing to fill the vacancies at the VA. That is wrong . My fear is that this bill will open the door to the draining, year after year, of much needed resources from the VA.

In other words, the way to solve the problem is not to take Step 1: Give the VA the resources that it needs.

[2] I continue to believe that golf play, or knowledge of golf play, should be a disqualification for high office.

[Jan 23, 2019] Getting on beneath the vaulted sky by Chris Bertram

January 22, 2019
Early last year, I began to experience some pains in my hands. I associated them with bringing a large turkey back from the butchers. Hadn't taken the car, because parking, but it was heavier than I appreciated and I struggled with the bird as the handles of the plastic bad tore on my fingers. I went to the doctor. Tendons, probably, he said. Most likely be better in a few months.

Then in September, back from a touring holiday in France which had involved a lot of lugging of boxes and cases up and down stairs, the pain was back, worse. I lacked the strength to open cans and bottles. Some movements were fine but turning a knob or using a key sometimes -- ouch!

That's where I am, basically. A few trips to the doctor and the physio later, osteoarthritis it seems. Injections in the thumb joint helped one hand, but less the other. Typing is ok, mostly, but my handwriting is worse. On public transport I steady myself by wrapping my arm around things, since gripping with a hand might hurt. I squeeze a rubber ball from time to time, as building up the muscles supposedly compensates a bit for the damage to the joints.

Not much fun, but could be worse. And only one of many things that comes past your mid fifties (I'm sixty now). I've had more blood tests in the past three years than in the previous thirty put together. Diabetes? No, thank goodness, not yet. Blood pressure is high, if not really dangerously so yet. Swallowing statins every morning, when I remember, to keep the choresterol down.

My father died in the summer of 2017. He was in good form until a week before the end though he'd had his share of health problems over the quarter-century before and a walk to the shops and back would see him needing a rest. We shared conversations to the end. He was lively, still learning German, discussing Edith Wharton. Though we all know that death is coming, a parent going is concrete. You know that will be you soon enough, so better make the best of it and concentrate on what matters.

As I've thought more about the loss of capacity. The aches and pains. The knowledge that there are things you could do but now can't. When you really ought to take more exercise because it is good for your heart and lungs, but when there's every chance that back, knee or hip won't play nicely enough to let you.

I keep returning to an image from a TV programme about John Clare. The picture was of a man on his back with

The grass below -- above the vaulted sky.

When young the vaulting is infinitely distant, and if lucky and not disabled you can vault over obstacles yourself. But age makes the sky close in. In your forties you can see the roof even if you can't touch it. Then, later, if you stretch, your fingers graze the surface. Time comes when you have to be careful not to bang your head. Some while after you stoop and then crouch. The tunnel gets narrower too. There is less space to move and perhaps, eventually, there will be no space at all.

Share this: { 12 comments read them below or add one }

Don A in Pennsyltucky 01.22.19 at 12:02 pm ( 1 )

Statins with dinner. Ask the pharmacist.
Hoping that the pain/stiffness in knuckles since the bicycle accident (2 months ago) continues to self-resolve with OTC anti-inflammatories
Matt 01.22.19 at 12:46 pm ( 2 )
I'm sorry to hear about the hand pain. It's especially bad for people who write for a living. When I was in college, I worked part time in a hospital pharmacy. We used hundreds of bottles of normal saline solution a day. The way that billing worked, each bottle had to have a sticker on it. I'd spend my slow time taking little bottles from a box, pulling a sticker from a strip, putting it on the bottle, and returning it to the box. Within a few months, I could no longer hold a pen or a pencil in my right hand. This was before lap tops, so it was a pretty big problem for a student! I had to refuse to do that task anymore. My hands, which had been strong, still give me trouble from time to time, and get sore easily. It's not fun. I hope yours won't be a persistent problem.
JimV 01.22.19 at 12:52 pm ( 3 )
It sounds like the tennis elbow I had after a long, hard-fought tennis session in my late forties. At the end I noticed I had a death grip on the racket handle which was difficult to loosen. The next day I was trying to leave a conference room at work which had a spring-loaded door knob. I couldn't turn the knob with my right hand, and had to awkwardly use my left hand. It lasted for several months, to the point where I didn't think it would ever heal, but it did eventually. When I did finally dare to play tennis again, I used a compression band around my right forearm, which seemed to help a lot. I never hit the ball as well as I had that day, though.

On the aging thing, I never needed a doctor (that I knew of) until about the age of 67. It has been one darn thing after another since then. (I'll spare the gory details.) I might make 75 but don't expect to see 80 (which of course isn't unusual and more than I deserve). My arm-chair philosophy about it it is that if death (by aging) didn't exist, evolution would have had to invent it, which it did. Otherwise, how can a species adapt to changes in the environment by trying new gene tweaks and combinations, without drastic over-population? For new things to succeed you have to get rid of the old things.

Cervantes 01.22.19 at 2:36 pm ( 4 )
It sounds like the arthritis at the base of the thumb is the biggest problem. It was for me. I couldn't even pick up a piece of paper with my left hand without pain, and it ached constantly. There is surgery available for that, which I got, and it worked. It was quite an ordeal, and it took a year to fully recover, but I got the use of my hand back and the pain is gone. I have arthritis in the distal joints of several fingers, but that is much less of a problem.

The surgery is kind of gross -- they remove the trapezium bone and, in my case, stuff the cavity with a rolled up tendon harvested from the forearm, which eventually ossifies. You will never miss the tendons. Some surgeons use a prosthesis, either a cadaver bone or an artificial product. It's quite painful at first and you have to wear a cast for six weeks, and then undergo rehab, but in the end, for me at least, it was a complete cure. Worth considering.

Omega Centauri 01.22.19 at 3:03 pm ( 5 )
I have chronic several overuse injuries that I used to be able work around athletics wise. But now I'm 67 and they seriously limit the amount of exercise I can get. You adapt and go on. And find other ways to spend your time and energy.

JimV @67. Well if evolution was kind to us we would remain healthy and vigorous then at some random time, boom its over. If the probability of boom was not age dependent, then there would be no difference in one's prospects whether 20 or 90.

Lee A. Arnold 01.22.19 at 4:00 pm ( 6 )
Mild continuous exercise helps including muscle strengthening over your whole body but never overdo, just daily. I walk about 3.5 miles a day, hit a gym in the middle of the walk and work about 20 weight machines, very light weights.

"We used to talk about girls. Now we talk about doctors."

-- Mel Brooks, on gathering with his friends.

Birdie 01.22.19 at 5:07 pm ( 7 )
It appears that sacrificing the body is an essential to join in civilized society in any meaningful way. Nobody else thinks overwork/stress injuries/industrial accidents are a big deal, so what's the matter with you, Bub? A serious "life of the mind" demands serious couch-potatoism. We're all playing in the NFL these days, but it doesn't have to be like that.
DILBERT DOGBERT 01.22.19 at 5:19 pm ( 8 )
Getting old is not for sissies!!!
My mental image of aging comes in two forms. One, is where you start life living in a large mansion of many rooms. Then in middle age you notice that a room is missing. As you age rooms keep disappearing. The next thing you know you are living in a one room hut.
The other is when young you see a clear horizon that seems very very distant. Then you see clouds on the horizon and it seems closer. At my age, 83, I can reach out and touch the fog.
The legs are shot and the pain in my feet is increasing. This time next year I could be in a wheelchair. Other than that life is good.
I encourage my young wife, 72, to keep on keeping on. She has taken that to heart and is riding her horse, skiing, scuba diving and renewing her pilots license. I am keeping on keeping on riding my horse and electric assist bike and living vicariously through my wife's adventures.
otpup 01.22.19 at 7:29 pm ( 9 )
There are probably nutritional approaches (though your doctor will be unbelieving and vegans will be offended). But osteo-a does give indications of being both immune related and a disease of modernity. Anyway ensure adequate fat soluble vitamins (and related minerals) This may require you to eat more saturated fat than is fashionable. Also glycine, and omega 3's. Eliminate any unnecessary PUFA's.
peter 01.22.19 at 9:50 pm ( 10 )
Don A @1:

Statins with dinner + alcohol = indigestion, heart burn and vomiting.

Statins with breakfast + no alcohol = no illness and Cholesterol levels normal.

Alan White 01.22.19 at 10:56 pm ( 11 )
Thanks Chris–this certainly hit home. Since you're only 60 and still working, allow me the presumption of my own data point as one of hope. I'm 65 and just finishing my first year of retirement after nearly 40 years of teaching at a 4/4 branch of the U of Wisconsin. Like you I've experienced some health concerns over the past 15 years including mild hypertension. Since I loved my career (down to the last day in the classroom), I didn't know what to expect when I was gently pushed out of it with a generous buy-out and threats of commuting to teach part of my load (I'd done that for 10 years and detested it). What I discovered is that I had no idea how stressful even a career that one enjoys can be! Within months I had lost 15 pounds and my BP went down, even a bit below normal, with no medication. I've been active my whole life, but clearly being out of the day-to-day grind of academic prep and research made the whole difference. My hope is that when you do retire, you find these same benefits.

One exercise that I've become devoted to is the elliptical machine on my campus, which I still may use as emeritus. It does a great job putting my heart to the test without straining my knees, which feel the effects of 40 years of running.

Chip Daniels 01.23.19 at 1:38 am ( 12 )
It is a turning point of sorts, that moment when you can actually grasp the length of time ahead of you.

I'm 58 and remember how even into my 30s, the remaining time in my life seemed to stretch away into inconceivable distance. Then somewhere in my 40s, I realized that even if I lived to a ripe old age, I could actually grasp how long that remaining time was.

I could remember forty odd years ago, I could suddenly understand that forty odd years into the future, my memories of midlife would be as fresh and sharp as my memories of kindergarten were.

[Jan 21, 2019] The Social Contract According to Elizabeth Warren

Notable quotes:
"... Uber passengers were paying only 41% of the actual cost of their trips; Uber was using these massive subsidies to undercut the fares and provide more capacity than the competitors who had to cover 100% of their costs out of passenger fares. ..."
"... Warren Supports Medicare for All Only Nominally ..."
"... Never mind that Warren can say, virtually in the same breath, that insurance companies "still make plenty of money" and "we have plenty of work to do to bring down health care spending." RomneyCare was the beta version of ObamaCare. We tried it, as a nation, starting in 2009, and here we are.[5] Is that's what Warren wants, fine, but why not simply advocate for it? ..."
"... Except, perhaps, one distinctly slanted toward insiders. " Work hard and play by the rules " is a Clintonite trope ..."
"... but only through the institutional framework of unions ..."
"... Warren's emphasis on the economic market for health "care?" (insurance companies making plenty of money ..."
"... I've long ago disabused myself of the notion that E. Warren is more than "lipstick" on the usual "pig", but it was good to have written support for that thesis and I will save it for my reference. ..."
"... Non-profit health insurance Company – https://www.democratandchronicle.com/story/money/business/2014/04/25/former-excellus-ceo-package-total-m/8155853/ The final retirement package for former Excellus BlueCross BlueShield CEO David Klein likely will exceed -- by millions -- the $12.9 million the company reported to the state in March. $29.8 Million in retirement. Non-profit for who? It's a complete misnomer and a huge problem in the discourse of healthcare. Hospitals are usually non-profits too. They non-profitly charge you $80,000 for a few stitches and some aspirin. ..."
"... The transcript could easily have been a speech by Hillary (and even delivered to Goldman Sachs if Hillary had had the foresight to realize that every speech would become known to everybody in the Internet age -- before Russiagate was leveraged into Social media banning of anti-establishment speech). ..."
"... The Eric Schmidt who took Google down the primrose part of spying on everybody. Warren is centrist. ..."
"... Warren 2020 campaign is DOA. If you want Trump for another four years go with Warren 2020. Bernie would have won. ..."
"... " Elizabeth Warren is Hillary Clinton reborn, and they're both unlikable, because they're both inauthentic scolds who suffer from hall monitor syndrome. They spent their entire lives breaking every rule they could find while awkwardly fantasizing about running every tiny detail of everyone else's lives . ..."
Jan 21, 2019 | www.nakedcapitalism.com

Posted on January 20, 2019 by Lambert Strether New America (board chair emeritus Eric Schmidt , President the aptronymic Anne-Marie Slaughter ), a nominally center-left Beltway think tank ( funding ) " took up the mission of designing a new social contract in 2007 and was the first organization [anywhere?] to frame its vision in these terms." On May 19, 2016, New America sponsored an annual conference (there was no 2017 iteration) entitled "The Next Social Contract." Elizabeth Warren, presidential contender, was invited to give the opening keynote ( transcript , whicn includes video). Warren shared a number of interesting ideas. I will quote portions of her speech, followed by brief commentary, much of it already familiar to NC readers, in an effort to situate her more firmly in the political landscape. But first, let me quote Warren's opening paragraph:

It is so good to be here with all of you. And yes I will be calling on people. Mostly those of you standing in the back. I always know why people are standing in the back. That's what teachers do.

Professional-class dominance games aside, it's evident that Warren is comfortable here. These are her people. And I would urge that, no matter what policy position she might take on the trail, these policies and this program are her "center of gravity," as it were. Push her left (or, to be fair, right) and, like a bobo doll , she will return to this upright position . So, to the text (all quotes from Warren from the transcript ). I'll start with two blunders, and then move on to more subtle material.

Warren Does Not Understand Uber's Business Model

Or, in strong form, Warren fell for Uber's propaganda.[1] Warren says:

Thank you to the New America Foundation for inviting me here today to talk about the gig economy You know, across the country, new companies are using the Internet to transform the way that Americans work, shop, socialize, vacation, look for love, talk to the doctor, get around, and track down ten foot feather boas, which is actually my latest search on Amazon .

These innovations have helped improve our lives in countless ways, reducing inefficiencies and leveraging network effects to help grow our economy. And this is real growth . The most famous example of this is probably the ride-sharing platforms in our cities. The taxi cab industry was riddled with monopolies, rents, inefficiencies. Cities limited the number of taxi licenses

Uber and Lyft, two ride-sharing platforms came onto the scene about five years ago, radically altered this model, enabling anyone with a smartphone and a car to deliver rides . The result was more rides, cheaper rides, and shorter wait times.

The ride-sharing story illustrates the promise of these new businesses. And the dangers. Uber and Lyft fought against local taxi cab rules that kept prices high and limited access to services .

And while their businesses provide workers with greater flexibility, companies like Lyft and Uber have often resisted efforts of those very same workers to try to access a greater share of the wealth that is generated from the work that they do. Their business model is, in part , dependent on extremely low wages for their drivers.

"In part" is doing rather a lot of work, there, even more than "the wealth that is generated," because NC readers know, Uber's business model is critically dependent on massive subsidies from investors, without which is would not exist as a firm. Hubert Horan (November 30, 2016):

Published financial data shows that Uber is losing more money than any startup in history and that its ability to capture customers and drivers from incumbent operators is entirely due to $2 billion in annual investor subsidies. The vast majority of media coverage presumes Uber is following the path of prominent digitally-based startups whose large initial losses transformed into strong profits within a few years.

This presumption is contradicted by Uber's actual financial results, which show no meaningful margin improvement through 2015 while the limited margin improvements achieved in 2016 can be entirely explained by Uber-imposed cutbacks to driver compensation. It is also contradicted by the fact that Uber lacks the major scale and network economies that allowed digitally-based startups to achieve rapid margin improvement.

As a private company, Uber is not required to publish financial statements, and financial statements disseminated privately are not required to be audited in accordance with generally accepted accounting principles (GAAP) or satisfy the SEC's reporting standards for public companies.

The financial tables below are based on private financial statements that Uber shared with investors that were published in the financial press on three separate occasions. The first set included data for 2012, 2013 and the first half of 2014 The second set included tables of GAAP profit data for full year 2014 and the first half of 2015 ; the third set included summary EBITAR contribution data for the first half of 2016. .

[F]or the year ending September 2015, Uber had GAAP losses of $2 billion on revenue of $1.4 billion, a negative 143% profit margin. Thus Uber's current operations depend on $2 billion in subsidies, funded out of the $13 billion in cash its investors have provided.

Uber passengers were paying only 41% of the actual cost of their trips; Uber was using these massive subsidies to undercut the fares and provide more capacity than the competitors who had to cover 100% of their costs out of passenger fares.

Many other tech startups lost money as they pursued growth and market share, but losses of this magnitude are unprecedented; in its worst-ever four quarters, in 2000, Amazon had a negative 50% margin, losing $1.4 billion on $2.8 billion in revenue, and the company responded by firing more than 15 percent of its workforce. 2015 was Uber's fifth year of operations; at that point in its history Facebook was achieving 25% profit margins.

Now, in Warren's defense, it is true that she, on May 19, 2016, could not have had the benefit of Horan's post at Naked Capitalism, which was published only on November 30, 2016. However, I quoted Horan's post at length to show the dates: The data was out there; it wasn't a secret; it only needed a staffer with a some critical thinking skills and a mandate to do the research to come to the same conclusions Horan did, and Uber's lack of profitabilty, easily accessible, is a ginormous red flag for anybody who takes the idea that Uber "generates wealth" seriously. How is it that the wonkish Warren is recommending policy based on what can only be superfical research in the trade and technical press? Should not the professor have done the reading?[2]

Warren Does Not Understand How Federal Taxation Works

The second blunder. Warren says:

First, make sure that every worker pays into Social Security, as the law has always intended. Right now, it is a challenge for someone who doesn't have an employer that automatically deducts payroll taxes to pay into Social Security. This can affect both a worker's ability to qualify for disability insurance after a major [injury], and it can result in much lower retirement benefits. If Social Security is to be fully funded for generations to come, and if all workers are to have adequate benefits, then electronic, automatic, mandatory withholding of payroll taxes must apply to everyone , gig workers, 1099 workers, and hourly employees.

It is laudable that Warren wants to bring all workers in the retirement system. But as NC readers know, Federal taxes do not "pay for" Federal spending, and hence Warren's thinking that Social Security will be "fully funded" through "payroll taxes" is a nonsense (and also reinforces incredibly destructive neoliberal austerity policies). I will not tediously rehearse MMT's approach to taxation, but will simply quote a recent tweet from Warren Mosler:

me title=

And if Mosler isn't good enough, here's John Stuart Mill on currency issuers:

me title=

Again, is it too much to ask that a professor do the reading? After all, MMT gotten plenty of traction, even in 2016. The Sanders staff, for example, could have been helpful to her .

Warren Supports Medicare for All Only Nominally

Warren is indeed a co-sponsor of Sanders' ( inadequate ) S1804. But read the following passages, and you will see #MedicareForAll not where her passion lies:

As greater wealth is generated by new technology, how can we ensure that the workers who support the economy can actually share in the wealth?

(The idea that workers "support" "the" [whose?] "economy," instead of driving or being the economy, is interesting, but let that pass.)

Warren then proceeds to lay out a number of policies to answer that question. She says:

Well, I believe we start with one simple principle. All workers, no matter where they work, no matter how they work, no matter when they work, no matter who they work for, whether they pick tomatoes or build rocket ships, all workers should have some basic protections and be able to build some economic security for themselves and their families. No worker should fall through the cracks. And here are some ideas about how to rethink and strengthen the worker's bargain.

So, she's not just laying out policy for the gig economy (the occasion of the speech); she's laying out a social contract (the topic of the speech). Picking through the next sections, here is the material on health care:

We can start by strengthening our safety net so that it catches anyone who has fallen on hard times, whether they have a formal employer or not. And there are three much-needed changes right off the bat on this.

I hate the very concept of a "safety net." Why should life be like a tightrope walk? Who wants that, except crazypants neoliberal professors, mostly tenured? She then makes recommendations for three policies, and sums up:

These three, Social Security, catastrophic insurance, and earned leave, create a safety net for income.

Hello? Medical bankruptcy ?[3] She then moves on from the "safety net" for income to benefits, which is the aegis under which she places health care:

Now, the second area of change to make is on employee benefits, both for healthcare and retirement. To make them fully portable. They belong to the worker, no matter what company or platform generates the income, they should follow that worker wherever that worker goes. And the corollary to this is that workers without formal employers should have access to the same kinds of benefits that some employees already have.

I want to be clear here. The Affordable Care Act is a big step toward addressing this problem for healthcare. Providing access for workers who don't have employer-sponsored coverage and providing a long term structure for portability. We should improve on that structure, enhancing its portability, and reducing the managerial involvement of employers.

Remember, this is a Democratic audience, and what do we get? "Portability," "access", and reduced "managerial involvement." That's about as weak as tea can possibly get, and this is a liberal Democrat audience. ("The same kinds of benefits that some employees already have." Eeesh.) But wait, you say! This speech iis in 2016, and in 2018, Warren supports #MedicareForAll! For example, " Health care: Supports the "Medicare for All" bill led by Bernie Sanders " (PBS, January 17, 2019). But notice how equivocal that support is. Quoting PBS again, Warren "called that approach 'a goal worth fighting for.'" Rather equivocal! And folliowing the link to that quote, we find it's from a speech Warren gave to Families USA's Health Action 2018 Conference :

I endorsed Bernie Sanders' Medicare for All bill because it lays out a way to give every single person in this country a guarantee of high-quality health care. Everybody is covered. Nobody goes broke because of a medical bill. No more fighting with insurance companies. This is a goal worth fighting for, and I'm in this fight all the way.

There are other approaches as well I'm glad to see us put different ideas on the table.

So, we have a gesture toward #MedicareForAll. But then, Warren, instead of going into detail about how #MedicareForAll would work, immediately backtracks and emits a welter of detail about minor fixes improvements, on the order of "portability," "access," and reduced "managerial involvement." (Different details, but still details). Then she moves on to Massachusetts. Read this, and it's clear where Warren's heart is:

Massachusetts has the highest rate of health insurance coverage in the nation. We are the healthiest state in the nation[4].

That didn't just happen because we woke up one morning and discovered that insurance companies had just started offering great coverage at a price everyone could afford.

We demanded that insurance companies live up to their side of the bargain. Every insurer participating in our exchange is required to offer plans with standard, easy-to-compare benefits and low up-front costs for families. Last year, we had the second-lowest premiums in the ACA market of any state in the country. Massachusetts insurers pay out 92% of the dollars they bring in through premiums to cover costs for beneficiaries – not to line their own pockets.

The rules are tough in Massachusetts, but the insurance companies have shown up and done the hard work of covering families in a responsible way. We have more than double the number of insurers participating on our exchanges, compared to the average across the country. They show up, they serve the people of Massachusetts, and they still make plenty of money.

Look, we still have plenty of work to do, particularly when it comes to bring down health spending, but we're proud of the system we have built in Massachusetts, and I think it shows that good policies can have a real impact on the health and well-being of hard working people across the country.

Never mind that Warren can say, virtually in the same breath, that insurance companies "still make plenty of money" and "we have plenty of work to do to bring down health care spending." RomneyCare was the beta version of ObamaCare. We tried it, as a nation, starting in 2009, and here we are.[5] Is that's what Warren wants, fine, but why not simply advocate for it?

Warren Has No Coherent Theory of Change

Except, perhaps, one distinctly slanted toward insiders. " Work hard and play by the rules " is a Clintonite trope, but let's search on "rules" and see what we come up with. More from the transcript:

But it is policy, rules and regulations, that will determine whether workers have a meaningful opportunity to share in the wealth that is generated.

Here, workers are passive , acted upon by rules, and those who create them. But Warren contradicts herself: "Lyft and Uber have often resisted efforts of those very same workers." Here, workers are active. But if workers are active in the second context, they are also active in the first! Where does Warren think change comes from? The generosity of Uber and its investors? More:

Antitrust laws and newly-created public utilities addressed the new technological revolution's tendency toward concentration and monopoly, and kept our markets competitive. Rules to prevent cheating and fraud were added to make sure that bad actors in the marketplace couldn't get a leg up over folks who played by the rules.

Note the lack of agency in "were added." Warren erases the entire Populist Movement ! She also can't seem to get her head round the idea that workers didn't necessarily play by the existing ruies in order to create new ones. And:

Workers have a right to expect our government to work for them. To set the basic rules of the game. If this country is to have a strong middle class, then we need the policies that will make that possible. That's how shared prosperity has been built in the past, and that is our way forward now. Change won't be easy. But we don't get what we don't fight for. And I believe that America's workers are worth fighting for.

Now, on the one hand, this is great. I, too, believe that "America's workers are worth fighting for." What Warren seems to lack, at the visceral level, is the idea that workers should be (self-)empowered to do the fighting (as opposed to having the professional classes pick their fights for them). Here is Warren on unions:

Every worker should have the right to organize, period. Full-time, part-time, temp workers, gig workers, contract workers, you bet.

Very good. More:

Those who provide the labor should have the right to bargain as a group with whoever controls the terms of their work .

The idea that workers themselves should control the terms of their work seems to elude Warren. This erases, for example, co-ops. More:

Government is not the only advocate on behalf of workers.

"Not the only?" Like, there are lots of others? This seems a tendentious, not to say naive, view of the role of government. More:

It was workers [here we go], bargaining through their unions [and the qualification], who helped [helped?] introduce retirement benefits, sick pay, overtime, the weekend, and a long list of other benefits, for their members and for all workers across this country. Unions helped build America's middle class, and unions will help rebuild America's middle class.

Here, at least, Warren grants workers (partial) agency, but only through the institutional framework of unions . That distorts the history. Granted, "helped introduce" is doing a lot of work, and who they were "helping" isn't entirely clear, but the history is enormously complicated. (Here again, Warren needs to do the reading.) For example, the history of the weekend long predates unions . And "bargaining through their unions" isn't the half of it. Take, for example, the Haymarket Affair . From the Illinois Labor History Society:

To understand what happened at Haymarket, it is necessary to go back to the summer of 1884 when the Federation of Organized Trades and Labor Unions, the predecessor of the American Federation of Labor, called for May 1, 1886 to be the beginning of a nationwide movement for the eight-hour day. This wasn't a particularly radical idea since both Illinois workers and federal employees were supposed to have been covered by an eight-hour day law since 1867. The problem was that the federal government failed to enforce its own law, and in Illinois, employers forced workers to sign waivers of the law as condition of employment.

Fine, "rules." Which weren't being obeyed! More from the Illinois Labor History Society:

Monday, May 3, the peaceful scene turned violent when the Chicago police attacked and killed picketing workers at the McCormick Reaper Plant at Western and Blue Island Avenues. This attack by police provoked a protest meeting which was planned for Haymarket Square on the evening of Tuesday, May 4. Very few textbooks provide a thorough explanation of the events that led to Haymarket, nor do they mention that the pro-labor mayor of Chicago, Carter Harrison, gave permission for the meeting . Most speakers failed to appear . Instead of the expected 20,000 people, fewer than 2,500 attended . The Haymarket meeting was almost over and only about two hundred people remained when they were attacked by 176 policemen carrying Winchester repeater rifles. Fielden was speaking; even Lucy and Albert Parsons had left because it was beginning to rain. Then someone, unknown to this day, threw the first dynamite bomb ever used in peacetime history of the United States. The next day martial law was declared, not just in Chicago but throughout the nation. Anti-labor governments around the world used the Chicago incident to crush local union movements.

This is how workers "helped introduce" the eight-hour day.

Yes, America's workers are "worth fighting for." But they also fight for themselves , and are fought against! Warren's theory of change -- which seems to involve people of good will "at the table" -- cannot give an account of events like Haymarket or why, in the present day, it's Uber's drivers who are also the drivers of change, and not benevolent rulemakers. Warren's views on the social contract are in great contrast to Sanders' "Not me, us."

NOTES

[1] Warren is far stronger in areas where she has developed academic expertise than in areas where she has not.

[2] Google is Google, i.e., crapified, but if Warren has retracted or changed her views on Uber, I can't find it. She was receiving good press for this speech as late as August 2017 .

[3] Oddly, bankruptcy is where Warren made her academic bones. I'm frankly baffled at her lack of full-throated advocacy on this, especially before a friendly audience.

[4] Warren, by juxtaposition, suggests that Massachusetts' health insurance coverage causes it to be "the healthiest state in the nation." This post hoc fallacy ignores, for example, demographics and the social determinants of health .

[5] Warren focuses on health insurance, not health care. I'm nothing like an expert in the Massachusetts health insurance system. However, looking at this chart , I'm seeing all the usual techniques to deny access to care: Deductibles, co-pays, out-of-network costs, and (naturally) high-deductible plans. Health care should be free at the point of delivery. Why is that so hard to understand?


Burritonomics , January 20, 2019 at 5:16 pm

I quickly went over the (188 page!) report referenced in Warren's claim that "Massachusetts has the highest rate of health insurance coverage in the nation. We are the healthiest state in the nation". It should be noted I went in with the expressed purpose of finding something to be snarky about, and I found it.

One of the metrics under "core measures" of clinical care was Preventable Hospitalizations. As it states in the report itself: "Preventable hospitalizations reflect the efficiency of a population's use of primary care and the quality of the primary health care received Preventable hospitalizations are more common among people without health insurance and often occur because of failure to treat conditions early in an outpatient setting". Wow! With such bang up health insurance in MA, one would figure they would do great on this metric. Nope! MA ranks 37th in the country. Many more such examples can be found, I'm sure.

I have a real dislike of these "who's best" lists, regardless of topic. Rarely do they (the aggregated ratings) contain insight beyond that captured by the individual metrics.

lambert strether , January 20, 2019 at 5:24 pm

Massachusetts is #1 on mortality (though they have issues with opioids). They have median US age, so it's not the enormous Boston student population. So they're doing something right, I'm just not sold it's health insurance or, more to the point, health insurers. They do have more physicians (and psychiatrists) per capita.

Joe Well , January 20, 2019 at 8:52 pm

What is "mortality" in this case? I'm curious about this because people often casually say that US health outcomes are worse than in other countries by looking at life expectancy (which I guess is not the same as mortality), and that comparison is rarely done on a state by state basis in the US.

Massachusetts is roughly tied with the other top ten states in life expectancy, which are almost all "blue" states . Worldwide, life expectancy among highly developed countries is roughly similar, within a few years of each other . The US comes out towards the bottom (no. 31), but only by about 1-3 years.

Also amazed just now to see that Asian American and Latino life expectancy are so much higher than for white and black Americans. Does anyone know anything about that? I'm really stunned.

Usually, lower life expectancy for blacks is given as evidence of inequality, but the white-black gap (about 1-2 years) is tiny compared with the black-Latino and black-Asian gap, or for that matter, the white-Latino or white-Asian gap, which are more like 5-10 years. I'm really floored by that.

In general, looking at the numbers just now has shaken my assumptions about poor US life expectancy and also racial disparities and I'm wondering if I'm misinterpreting them.

Joe Well , January 20, 2019 at 9:10 pm

Wow, you learn something new every day.

Apparently there is something called the "Hispanic Health Paradox" that has been studied intensively for over 30 years . The biggest reason seems to be much lower rates of smoking. There also seems to be a filtering effect whereby healthier people migrate to the US. Anecdotally, I'd suggest much lower rates of alcohol and drug abuse, but the article doesn't mention that.

So, why Mass. has a relatively high life expectancy could in part be due to it having one of the earliest and most aggressive anti-smoking movements. I'm guessing historically high smoking rates (up to 50% of adults in the 1950s with huge second-hand exposure) could also account for poorer health outcomes today.

BoyDownTheLane , January 21, 2019 at 12:49 am

One of my favorite pictures (the one I have not yet taken) would have been an elevated shot of the intersection at Longwood and Brookline Avenues (379–385 Brookline Ave) at noon on a clear, sunny spring day to see the murmuration of medical staff running between appointments, lunch, rounds, etc.

The intersection is surrounded by arguably some of the finest medical institutions in the Western world (Beth Israel Deaconess, Dana-Farber, Brigham & Women's (where Atul Gawande, author of the book "Better" and the whole entire concept of positive deviance, once held court), Harvard Medical School itself with its etched-in-granite entrace to the Countway Library that reads "Ars Longa, Vita Brevis", and the Harvard School of Public Health.

The murmuration of white coats may be at that moment the greatest single concentrated density of medical excellence at one time. It is easy to scoff. I've been the recipient of bad medicine myself, but also far more high-quality, life-saving medicine. But the public health movement in Massachusetts has been around for a very long time and is supported by and engrained within governmental regulations, oversight and policy. Insurance plans covering most of the state ranked, typically and for years, #'s 1, 2, 3 and more. The Healthcare Effectiveness Data and Information Systems report out results that are painstakingly gathered, audited to improve performance. It is fair to say that a major part of the intersection between computing and medicine was born and is overseen across the river in Cambridge. Organizations that collect or audit data for health plans and providers are screened, trained and certified by NCQA ( https://www.ncqa.org/about-ncqa/ ).

In addition, there are national, regional and state associations devoted to quality improvement and toi improvement of access. The National Association of Community Health Centers (those clinics funded Federally to serve the under-served for free or on a sliding scale) "works in conjunction with state and regional primary care associations, health center controlled networks and other public and private sector organizations to expand health care access to all in need." There are CHC's dotted everywhere around the country (albeit not enough of them), and there is a state association in almost every state. No one can ever be turned away from a CHC, especially for lack of ability to pay; the Federal government underwrites their care.

nothing but the truth , January 20, 2019 at 5:29 pm

govts can call force us to call toilet paper a pound, but i doubt they can make it worth a pound of sterling silver – if they pretend that they can produce any amount.

Brooklin Bridge , January 20, 2019 at 5:58 pm

Warren's emphasis on the economic market for health "care?" (insurance companies making plenty of money ) and particularly her whole rant on the superlatives of Massachusetts insurance care (that means, care for insurance companies) , increasingly neglects health and people care as the primary concern of medicine and the people who practice it.

As an average Joe, meaning not part of the medical world, I have come across a surprising number of doctors in both social circumstances as well as health issues of my own and of my extended family, where doctors have complained about the ever worsening constraints imposed on them by insurance companies. I know at least three doctors who retired early because of it and one of them talks about it being a significant problem in keeping highly qualified doctors in general practice. From ever more ridiculously short visits, to constant refusal to cover such and such a drug, to all manner of schemes to improve patients health by overseeing and controlling what the doctor does to finding ways to monitor what the patient does; what he or she takes as medicine and exactly when and how often – cutting the doctor out of the loop completely. Improve the patient experience my *ss. It's horrible and it all comes down to ever new ways to reduce coverage – to make more money.

Perhaps I'm being a little unjust, but Warren seems fine with this "system" where the gate keepers make, "plenty of money," as long as people are going in and out of doctors' offices in countable droves as if on run-away conveyer belts. I should at least allow that many of her superlative claims are accurate (or somewhat accurate) and that there is fairly wide coverage in this state but nevertheless stress that our excellent medical facilities in Boston proper are due to historical reasons and NOT to RomneyCare.

deplorado , January 20, 2019 at 5:59 pm

Thank you Lambert, for your cogent and discerning analysis as always. I've long ago disabused myself of the notion that E. Warren is more than "lipstick" on the usual "pig", but it was good to have written support for that thesis and I will save it for my reference.

What worries me more though is Sanders's bill and why he wouldn't go all the way? Would you do an analysis of that please – will really appreciate it.

Thanks!

Joe Well , January 20, 2019 at 6:10 pm

The vast majority of Massachusetts health plan providers are nonprofit HMOs so I'm baffled by the idea that they are making tons of money since legally they are not supposed to.

The most obvious difference between Mass and the rest of the country is precisely the preponderance of nonprofit health plans (it's not commonly called health insurance here) and nonprofit hospitals. The idea of for-profit health plans and hospitals freaks me out.

It's worth noting that Mass health coverage seems to have gotten worse in recent years, though I don't know how much of that is due to Obamacare. High deductibles, coinsurance, confusing in-network requirements combined with poor documentation and even poorer customer service to tell you what is in-network and what is not. I just got a surprise $370 bill for a provider that supposedly was out of network even though I had checked extensively that they were in-network. That is the first time that has ever happened to me in Mass. Not to mention the confusing and unnerving notices I got the last few months saying I was in danger of losing coverage. A great big ball of Weberian beaureaucratic stress.

bob , January 20, 2019 at 8:04 pm

Non-profit health insurance Company – https://www.democratandchronicle.com/story/money/business/2014/04/25/former-excellus-ceo-package-total-m/8155853/ The final retirement package for former Excellus BlueCross BlueShield CEO David Klein likely will exceed -- by millions -- the $12.9 million the company reported to the state in March. $29.8 Million in retirement. Non-profit for who? It's a complete misnomer and a huge problem in the discourse of healthcare. Hospitals are usually non-profits too. They non-profitly charge you $80,000 for a few stitches and some aspirin.

somecallmetim , January 20, 2019 at 10:08 pm

Health Care Economist / Professor Uwe Reinhardt used to comment that in the current system non-profit hospitals (The Sisters of Mercy, with a token nun on their board, in his telling) were subject to the same forces as for profit hospitals.

He also said Massachusetts has the only adult health care system, and the other states are all adolescents.

johnnygl , January 20, 2019 at 9:10 pm

We've got for-profit hospitals Cerberus took the caritas network. The hospitals dominate this state. The rest of us are just living here.

johnnygl , January 20, 2019 at 9:15 pm

Special thanks to the catholic church for selling such an important institution to a monster that guards the gates of the underworld.

I bet it was to cover the costs of child predator priests.

Joe Well , January 20, 2019 at 10:20 pm

Wow, I'd missed that (moved out of state, then came back). Thanks for the update. It looks like the Catholic Church (former owner of Caritas) has further enhanced its legacy in Massachusetts. However, I believe it is still true that the hospital market in Mass. is dominated by nonprofits (albeit greedy nonprofits).

And yes, hospitals and hospital chains (e.g., Partners Healthcare, which is nonprofit) pose huge challenges to managing healthcare costs in Mass. as the numerous Boston Globe investigative series attest, by using their market power to raises prices.

My concern is when the market becomes dominated by for-profit actors, the profit-seeking, which is already bad with nonprofits, becomes even worse, especially in an ultra-expensive market like Greater Boston.

Brooklin Bridge , January 20, 2019 at 6:16 pm

I should add (if my earlier comment get's posted), it's even more surprising how many doctor's seem just fine with all the negative changes being brought about by insurance companies' intrusive quest for control and I don't mean just the ones who say nothing.

That is, some doctors seem to enjoy the vestiges of the glow of community respect and honor that once went with being a doctor all while doing almost nothing other than sheep herding patients through the office in good file while staff (not the good doctor) attend to making the visit digital and storing it away in some cloud.

Tomonthebeach , January 20, 2019 at 7:07 pm

I agree with Warren Mosler that Elizabeth Warren's apparent ignorance of MMT, much less mastery of it, makes here a lame candidate in my book. She needs to get woke pretty quickly or settle for some cabinet appointment.

Anarcissie , January 20, 2019 at 10:10 pm

Is MMT now Scripture?

ChrisAtRU , January 20, 2019 at 10:22 pm

It's more important than 'scripture' it's how sovereign fiat money actually works .

Joe Well , January 20, 2019 at 10:57 pm

You don't even need MMT. When asked how the federal government can pay for something, people can just answer, "the same way we pay for military and intelligence spending." Any politician who won't say at least this is deeply suspicious.

David in Santa Cruz , January 20, 2019 at 7:40 pm

In The Unwinding , George Packer quotes Elizabeth Warren as describing her political views thusly:

"I was a Republican because I thought that those were the people who best supported markets"

I'm glad that she's out there, I'm glad that she's talking, and we need an open and transparent nomination process, but Bernie Sanders remains the only (potential) nominee who comes close to representing my views. Good piece.

emorej a hong kong , January 20, 2019 at 7:50 pm

The transcript could easily have been a speech by Hillary (and even delivered to Goldman Sachs if Hillary had had the foresight to realize that every speech would become known to everybody in the Internet age -- before Russiagate was leveraged into Social media banning of anti-establishment speech).

The speech's date (May 19 2016), was two days after Bernie won the Oregon primary by 14%, and two days before Hillary won the Washington state primary by 5%.

Synoia , January 20, 2019 at 8:07 pm

It was going to be BS directly after this:

New America (board chair emeritus Eric Schmidt

The Eric Schmidt who took Google down the primrose part of spying on everybody. Warren is centrist.

Synoia , January 20, 2019 at 8:11 pm

It was going to be BE after this phrase

New America (board chair emeritus Eric Schmidt,

The Eric Schmidt who took Google doen the path of spying on everybody. He has nothing to offer by centrist rhetoric. It would be very interesting in how much In-Q-Tel invested in Google.

flora , January 20, 2019 at 8:39 pm

Thanks for this post.
And thanks for the reminder that the 8 hour workday and the 40 hour workweek were not 'given' to workers, they were won by workers.

Matthew G. Saroff , January 20, 2019 at 9:48 pm

I made an a similar observation on my blog .

Compare these two quotes on Pharma looting.

Warren:

Giant companies may hate my Affordable Drug Manufacturing bill – but I don't work for them. The American people deserve competitive markets and fair prices. By fixing the broken generic drug market, we can bring the cost of prescriptions down.

Sanders:

If the pharmaceutical industry will not end its greed, which is literally killing Americans, then we will end it for them.

This is a not an insignificant difference

Mike Barry , January 20, 2019 at 10:30 pm

The best is the enemy of the good.

Yves Smith , January 20, 2019 at 11:17 pm

Tell me what about Warren not understanding how federal taxes work, which is fundamental to formulating sound fiscal policy and spending plans, not being serious about fixing our health care system, or praising the predatory gig economy, is "good".

RepubAnon , January 20, 2019 at 11:32 pm

On a side note: self-employed workers pay more out-of-pocket into Social Security than W-2 employees. W-2 employees only pay half the Social Security tax – employers pay the other half via a "payroll tax."

The self-employed pay both the employee's half of Social Security, and also pay a "Self-Employment tax" (the employer's half of Social Security). The logic is that if you are both employee and employer, you should pay both halves.

Yves Smith , January 21, 2019 at 12:58 am

This is thread jacking, plus an economist would point out that the employer clearly is paying a net wage that reflects his awareness that he is paying the employer side of the FICA taxes.

Ape , January 21, 2019 at 12:31 am

Or lesser of two evils? There really needs to be a good discussion again about reform versus structural change without Chait-like pretensions. The question isn't just whether we'll get there in time, but whether reform even out runs reaction. Once you take out patriotic myth, it's not obvious whethervthe good in the long term is even worth bothering with.

Glen , January 21, 2019 at 12:47 am

Warren 2020 campaign is DOA. If you want Trump for another four years go with Warren 2020. Bernie would have won.

The Rev Kev , January 20, 2019 at 11:01 pm

I can't help but think that if you are talking about the "Next Social Contract", them you should put something in there that if you have children going hungry then something has gone wrong with your society. Not being snarky here as I believe that a fundamental purpose of society is to protect those in need. An earlier society talked about 'women and children first' and they were not too far off the mark here.

She was invited to talk about the gig economy but in reading her speech I was under the impression that she wants the Federal government to underwrite the costs of workers for corporations to ensure that maybe these workers have food to eat while working for these very same corporations. I suspect that this is the thinking behind letting Amazon workers go for Federal assistance for the sheer basics of life while Amazon makes off like bandits.

No. The way to go is to enforce corporations like this pay a living wage and not to have them count on the country to make up the difference. If they start to protest, then start to talk about looking over their accounts for any discrepancies to make them back off. That's how they got Al Capone you know. Not for being a gangster but for not paying his taxes while doing so. And do the same for mobs like Uber and Lyft and all the other corporations.

BoyDownTheLane , January 21, 2019 at 12:16 am

" Elizabeth Warren is Hillary Clinton reborn, and they're both unlikable, because they're both inauthentic scolds who suffer from hall monitor syndrome. They spent their entire lives breaking every rule they could find while awkwardly fantasizing about running every tiny detail of everyone else's lives ."

http://sultanknish.blogspot.com/2019/01/why-no-one-likes-elizabeth-warren.html

Left in Wisconsin , January 21, 2019 at 12:38 am

Sigh. Nail hit squarely on head. The one thing I will say to Warren's credit is that she has learned in some specific ways that the world isn't invariably the pure meritocracy that is so instinctively part of her world view. That said, it seems clear there will always be plenty that she is simply not capable of seeing, so she will always say and support things that are just wrong. She will not be leading the revolution.

[Jan 19, 2019] Three Bernie Sanders Bills to Arrest the Highway Robbery in the Prescription Drug Market

Jan 19, 2019 | economistsview.typepad.com

anne , January 15, 2019 at 05:59 PM

https://prospect.org/article/three-bernie-sanders-bills-arrest-highway-robbery-prescription-drug-market

January 14, 2019

Three Bernie Sanders Bills to Arrest the Highway Robbery in the Prescription Drug Market
Allowing foreign imports, authorizing Medicare bargaining, or setting prices at what other nations pay -- all good options
By DEAN BAKER

The prescription drug market in the United States is an incredible mess. From an economic standpoint, everything is wrong. Drugs that would sell for a few hundred dollars in a free market often sell for tens or even hundreds of thousands of dollars because we give their manufacturers patent monopolies. This leads to the sort of distortions and inefficiency that would be expected from tariffs as high as many thousands percent.

From a heath perspective the situation is no better. The huge markups give drug companies enormous incentive to misrepresent the safety and effectiveness of their drugs and to push them for uses where they may not be appropriate. This is a big part of the story of the opioid epidemic.

Cumulatively, it is a huge deal in both economics and health. We spent more than $430 billion (2.2 percent of GDP) on prescription drugs last year. These drugs likely would have cost less than $80 billion in a free market. The difference of $350 billion is almost five times the annual federal budget for food stamps. This is real money.

This is the backdrop for three bills proposed last week by Senator Bernie Sanders, along with Representatives Elijah Cummings and Ro Khanna, to address the high and rapidly rising cost of prescription drugs. The three measures provide alternative paths for reducing drug prices.

The first one, "The Prescription Drug Price Relief Act," would end the patent monopoly for any drug that sold for a price exceeding the median price in five other major countries: Canada, the United Kingdom, France, Germany, and Japan. This would allow large savings since drug prices in these countries are roughly half as much as in the United States. Drug companies would have a choice of either lowering their prices or losing their patent monopoly.

In the latter case, the competition is likely to push the price well below the levels in the five countries. While these nations do regulate drug prices, patent monopolies still let the companies charge a price that is far higher than the price that would exist in a competitive market with generic competition.

The second bill is "The Medicare Drug Price Negotiation Act." This bill would allow Medicare to negotiate collectively for the drugs purchased through Medicare prescription drug insurance. Since this program spends roughly $100 billion annually on drugs, it should have serious bargaining power.

Anyone designing a rational drug insurance program would have required negotiation when the program was created, but rational design was not necessarily the top priority at the time this program was enacted.

Anyone designing a rational drug insurance program would have required negotiation when the program was created, but rational design was not necessarily the top priority at the time this program was enacted. Representative Billy Tauzin, who headed the Energy and Commerce Committee, which structured the Medicare prescription drug legislation, resigned immediately after the bill was signed into law to become head of the pharmaceutical industry's trade association.

The third bill, "The Affordable and Safe Prescription Drug Importation Act," is also an effort to take advantage of the fact that drugs are so much cheaper in other countries than in the United States. This bill would allow people to freely import drugs from other wealthy countries that have safety standards that are comparable to those in the United States.

This bill both highlights the sharp differences in prices between the United States and other countries and calls out one of the big lies used to justify these differences. Allies of the drug industry often claim that we cannot count on getting safe drugs from other countries, implying that countries like Canada and Germany do not protect their populations from unsafe drugs.

This is, of course, absurd. The standards in these countries are every bit as high as in the United States. And, if we think the quality of imported drugs is a problem, we all should already be very worried because many of the drugs and ingredients in drugs sold in the United States are already imported, largely from China. So the idea that we can't be assured of the safety of imported drugs is simply an industry talking point, not a real concern.

Which of these paths for reducing drug costs is best? Importation is probably the most far-reaching, since it should quickly bring our prices down to the level of other wealthy countries. As a practical matter, however, progressives should back anything that moves the debate forward.

We really need to turn the industry on its head, paying for research upfront and then having drugs sold in a free market, like paper plates and shovels. It is absurd to pay for research that has already been done, at the point when people are suffering from serious conditions jeopardizing their health or their life.

No one thinks it makes sense to pay firefighters based on the value of their work when they come to our burning house with our families inside, yet this is essentially how we pay for drug research under the patent monopoly system. In fact, the story is even worse with drugs, since typically we have a third party payer (either an insurance company or the government) who we are trying to get pick up most of the tab.

These bills would not fully solve the problem, but each would be a big step in the right direction. Sanders, Cummings, and Khanna have done a great service in pushing them forward.

mulp -> anne... , January 16, 2019 at 04:33 PM
"No one thinks it makes sense to pay firefighters based on the value of their work ..."

We value fire fighters as worthless, by not paying most fire fighters in the US.

After all, requiring the people saving your life to be paid kills jobs, so we end up with unpaid life savvers.

We should appply the same principle to people providing life saving food, the people building the roads needed to deliver life savings, the people making the vehicles used by those providing life saving services.

In fact, no one should be paid to work! Thats free lunch economics!

Sarcastic, yes.

Dean Baker meantioned nothing about costs, which are always labor costs.

Look, Keynes argued that when there were unemployed workers, and capital is scarce, government should tax and spend to pay workers to build capital.

For drugs, paying unemployed researchers to build capital, eg, life saving drugs, then taxing the drugs produced to repay the cost of developing the drugs, with so many new drugs developed, the private capital in drug factories, etc will produce so many drugs that drug prices fall to total labor costs per unit, plus the drug tax.

We know there are unemployed drugresearchers because NIH always runs out of money to pay all thre recent collage grads seeking grants to fund their hoped for job as a researcher.

Plp -> mulp ... , January 18, 2019 at 01:41 PM
Mulp what about monopoly profits my friend

Research could rise and marketing cuts pay for it

Yes there's slack created
In marketing jobs and funding entertainment of course

Plp -> anne... , January 17, 2019 at 08:40 AM
Bernie and Liz are too valuable to waste running for
The Dem nom

Leave that for a clever weather vane
Like Harris and that jersey senator

The gal from the Bronx
is another Bill Bryan

She is the future

anne -> Plp... , January 18, 2019 at 09:21 AM
The gal from the Bronx
is another Bill Bryan

She is the future

[ Funny and right and especially clever. ]

Julio -> Plp... , January 18, 2019 at 09:21 AM
Agreed completely.
Warren, in particular, makes a great senator but I doubt would make a great president.
Christopher H. said in reply to Julio ... , January 18, 2019 at 10:01 AM
Disagree, unfortunately in the American system the President gets all the attention and can spread the message.

Either Bernie or Warren would be good. I'd much prefer Bernie.

Plp -> Christopher H.... , January 18, 2019 at 01:43 PM
No problem if they win the POTUS job

Still I'd prefer AOC

[Jan 13, 2019] Libertarian wet dreams and reality of the Us healthcare

Jan 13, 2019 | www.nytimes.com

JB Nashville, Tennessee Jan. 11

@Bill - So you're willing to gamble with your own health and the well-being of any family or loved ones you have and trust in some ambulance chaser against an armada of $3000 suits? Good luck with that.

While I'm often skeptical of our government, I have ZERO faith in any corporation to do right by me.

Their only mission is to make as much money as they can, and even paying out the occasional lawsuit is a reasonable cost of doing business. The only way a capitalist entity can be trusted is if a more powerful authority is looking over their shoulder. The FDA is one of many federal entities standing between us and an indifferent group of shareholders and CEOs.

[Jan 11, 2019] Health Insurer Greed or Desperation An Odd Data Point From Cigna naked capitalism

Notable quotes:
"... It was for the deductible the insurer did not pay – routine – AND for another thousand dollars, which was not. ..."
"... The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home. ..."
Jan 11, 2019 | www.nakedcapitalism.com

Health Insurer Greed or Desperation? An Odd Data Point From Cigna Posted on January 9, 2019 by Yves Smith I sometimes give personal Consumerist-type anecdotes about dodgy vendor behavior in case readers have had similar experiences.

Admittedly, health insurers being difficult about paying claims is so common that they fall in the realm of "dog bites man" stories. But the elements of my latest arm-wrestle with Cigna suggest that the insurer is so eager to maximize profit and burnish its financials that it is doing the equivalent of pulling up the sofa cushions to collect change.

I've had this plan a very long time, since the early 1990s. Cigna in theory has not changed the terms (to do so, it would have to notify me and New York State) save approved rate increases. In practice it has, by among other things a few years back requiring that claims be submitted within 120 days of service. That has allowed it to engage in a new form of mischief: simply not processing some claims. No doubt the hope is that consumers won't notice, or will notice too late to get duplicate documentation and resubmit before the 120 days are up.

Mind you, for well over 15 years, I never had a single claim go astray. Now it happens with sufficiently high frequency for it to be implausible that the US Postal Service is losing so many of my letters, when other envelopes virtually never go missing. So every time I submit a claim, I have taken to recording the details necessary to locate the items in Cigna's system, as well as the mailing date.

Last July, Cigna sent a letter about a "pharmacy claim". It was a remarkably content-free document, with no reference to dates of service or any clues to allow a customer to figure out what they might be referring to, particularly since I do not have a pharmacy plan. A "pharmacy plan" is when the doctor sends a scrip to the pharmacy on behalf of a patient, and the pharmacy bills the insurer, with the patient responsible for any co-pay. My plan covers prescription drugs, including ones I get overseas (I've submitted prescription drug claims from England and Australia). I pay for the drugs and I submit for reimbursement. And until the mysterious July letter, I never had any problem with them being paid (provided, of course, Cigna didn't try claiming it had never gotten the claim).

Fortunately, because I keep good records, I could see I had sent in a claim in late June for four dates of service for less than $400 worth of meds total. The only reason the amount was that high was three of the four items were 90 day supplies.

I called Cigna and got a rep who found the four items and confirmed they were in a payment limbo and ought to be paid.

When no check had arrived by September, I called again, had the agent say that there was not reason for the claim not to have been paid, and put it in for reprocessing.

On November 28, with still no payment, I insisted on speaking to a supervisor, which it took an ungodly amount of time to reach. I started making noise about external appeal to New York state (my plan is a New York state regulated plan). She confirmed like everyone else that it should have been paid, and said the check would go out in three to five days.

Two weeks later, nothing from Cigna.

I called again. I got an agent who said the payment is pending.

By this time, steam was pouring out of my ears. I asked again to speak to a supervisor. After a 30 minute wait, I was told one would call me back. I should have known from long experience with Cigna that promises to make calls or follow up are empty, as this proved to be.

I decided to have one last go on the phone before writing the state for an external appeal. I called over the weekend. The agent said that the payment was issued on January 3, but she saw only three of the four drugs in the scans of the claims. Mind you, this was the cheapest scrip, and a shortfall versus what I should have received of about $13 (assuming that check finally arrives). But this is what this incident says about Cigna:

1. Recall that on the first call, and if my recollection serves me right, on at least one of the later calls, I confirmed the dates of the claims. The one that disappeared was the most recent in the date range, making it almost certain that I cited it most if not all calls.

This strongly suggests that the original Cigna hope was that I would not follow up adequately on their bafflegab letter, and when I did, someone went and scrubbed my record to reduce the amount Cigna would have to lay out. This is such a small amount that it would seem hardly worth the effort .which further suggests that Cigna has this sort of records-doctoring highly enough routinized to be able to do it cheaply. 1

2. Cigna has supposedly initiated payment right after the new year. Even though Cigna ought to be on an accrual as opposed to a cash accounting basis, it's not hard to infer that they kicked the payment back into a new fiscal year to flatter some sort of metric. It might not even be a financial reporting metric but some other measure that senior management and/or analysts follow.

As we said at the outset, in terms of abuses, this is small beer. But that's the point. Corporate America has been institutionalizing penny-ante scams like the one Cigna ran on me, knowing in this era when class action suits are virtually dead, that they can grift with no fear of being held to account.

The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home.

____

1 The last agent checked my records for the date of the gone-missing drug claim to see if it had somehow gotten separated from the other three and was being handled separately. She came up empty-handed. Recall that I now have a not-approved, not-noticed-as-required change to my contract of a 120 day submission limit, so disappearing that item so late in the game makes it impossible for me to resubmit that item.

Geo , January 9, 2019 at 4:09 am

The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home.

Well said. You're much more thorough and persistent than I am. I'm their target dupe that won't notice such things and just accept that it was my fault when I do notice. Very insightful read. Thanks so much!

WestcoastDeplorable , January 9, 2019 at 3:17 pm

Sorry to read of your problems, but Insurance companies aren't the only category screwing with the details; I recently transferred a balance to U.S. Bank on one of those "zero interest for 12 month" deals. In about 2 months after the transfer, all the sudden I get a late notice from them, then realize I didn't receive a statement (which was about 10 days late). And they laid a $39 charge on the account, which I was able to get waived with a trip to my local bank. Little did I realize this "late pay" also resulted in nixing the "zero interest" deal, and they levied the full interest on the balance.
Needless to say, I transferred the balance elsewhere, but seems to me lots of companies are gaming the mailing of statements to pad their coffers.

campbeln , January 9, 2019 at 3:53 pm

I had a good one with Macy's we bought a ton of stuff for the new house back here in the US and got the 0% interest for 12 months on their credit card for the first purchase or some-such. What the lady at the counter did was to run 2 separate transactions on the card so the second, much smaller, transaction fell outside of the "first purchase" and incurred the minimum monthly interest charge. Over the course of the 12 months, I'd have been in a slight deficit thanks to these additional charges, so I paid the damned thing off in full and threw it in the drawer.

So Macy's went from having a part-time AmEx card user to one that never uses it all because they didn't want to uphold their own promo Picking up pennies in front of a steamroller

Barbara , January 9, 2019 at 5:55 pm

Some years ago, I got such a 0% offer from a bank which issued one of my credit cards. This one was for existing debt and lasted until the debt was paid off. I was happily paying off my debt in reasonable monthly installments. After I paid my 6th monthly installment, I got a letter from the bank saying that they needed to raise the interest rate and would appreciate if I would concede. They added that if I continued to insist on 0%, as was my right to do, my credit card would be discontinued on the last payment. I chose to continue the 0% deal and, as promised (the only promise they kept), my credit card was cancelled thereafter.

Fast forward several years, I regularly get credit card offers from said company. Needless to say, I don't think much of people (or businesses – corporations are people too!) who renege on deals. You can guess what is not in my wallet!

The Rev Kev , January 9, 2019 at 4:18 am

Excuse for for asking but just to clarify a point. When you send mail to Cigna and you say that you record the details, are you talking about certified mail and registered mail then? The reason that I ask is that by using the same in Oz, it has saved both my daughter and I individually over a thousand dollars each when the recipient tried at first tried to deny receiving what we sent until confronted with tracking numbers that can be checked online.

Arthur Dent , January 9, 2019 at 9:15 am

More and more I am going to tracking numbers with signature required for things that have any sort of value.

The joy of focusing on shareholder value is that all other stakeholders are subservient to it. Ultimately, the sheer greed of the corporations is likely to force the general population to demand a government-run single-payer system where at least they can vote the politicians out of office instead of having unaccountable executives making their lives miserable. The inability to repeal the Affordable Care Act was just the first shot across the bow.

Spent more time in Canada over the past few weeks. Everybody I spoke to up there is utterly baffled by what is going on in the US and is seriously wondering if the US is officially insane. They cannot understand why we continue to live down here. BTW – many of these people are white people over 50 with military backgrounds and little to no college in the demographic that would have been probably voting for Trump in the US.

Octopii , January 9, 2019 at 1:05 pm

Have considered moving but they don't want us up there.

Yves Smith Post author , January 9, 2019 at 9:44 am

It takes $3+ per envelope to send something certified and a half hour tax on my time to go to the post office.

And sending a letter certified does not prove what was in the letter. It's useless from an evidentiary standpoint. Cigna could claim the envelope had no claims in it, or that the claims were "unscannable" (another "dog ate my homework" they've tried now and again). It's useless in proving a submission.

monday1929 , January 9, 2019 at 4:22 pm

Yves, you might try video-taping the mailing process, including video showing the papers as legible etc as they are sealed in envelope and handed over postal counter and showing tracking numbers.
Include in the envelope a letter explaining you will post video on you-tube if they claim "unscannable" or that envelope was empty.
United Healthcare broke dozens of promises to "call back"- they never ONCE did so. Hopefully not to far off topic, I would like to keep NC updated on current complaint with NY Office of Professional Discipline regarding a dentist who possibly hid about 100 bad (as in semi-criminal) Yelp reviews by establishing a phony company name and shifting reviews there. So far, after one month not a peep from Port Chester regional office where referred to.

beth , January 9, 2019 at 7:35 pm

Alert to United Healthcare Medicare Supp. retirees. I'm sure the UH did this not just to me but to all of those who carelessly pay all bills sent to them. When I signed up for AARP United Healthcare insurance, the rep told me that he would have to accept a check for the first month and then had to put me on a ckg acct withdrawal plan. I had never done that before and didn't like the idea. It turned out that that saved me in the long run for two reasons. First they billed me for the first month after accepting my check. I did not pay it and by the time I received it they had already taken money out for the second month. I am sure there are many seniors who just paid the bill anyway. Slick trick & sick trick.
And then a year later I was finally diagnosed with my genetic disease after all these years. I began getting the only medicine specifically for this disease which since it is an orphan drug is expensive. They rejected the first bill from the provider and told them I was not a member of the plan. I was thrilled that I had had the money taken out of my acct. so they could not say the check was late.

Kradek , January 11, 2019 at 12:25 am

Why won't these companies let us email the claims? Cheaper for all, content and dates verifiable

run75441 , January 9, 2019 at 11:00 pm

Yves:

Green Card works in court and I have used it with Ocwen

flora , January 9, 2019 at 11:17 pm

By 'green card' do you mean the usps certified return receipt green card?

vlade , January 9, 2019 at 4:33 am

Hmm.. I haven't seen "the cheque will be issued" excuse for ages now, courtesy of pretty much all European payments being direct and settled on T+1 latest.

I guess having netflix and Facebook (the "great innovations" coming out of the US) is more important to a number of US residents than a working payments system like say the EU has.

mle detroit , January 9, 2019 at 10:12 am

I've been trying unsuccessfully to decode your first sentence. What is this payments system, where can a neophyte learn about it, does the UK use it, and what how Brexit affect it?

Kpl , January 9, 2019 at 4:36 am

When bad behaviour and fraud go unpunished this is what one should expect.

Disturbed Voter , January 9, 2019 at 5:27 am

Stick to your guns, and make them meet your business performance metrics!

Heath insurance is inherently un-profitable in the long run, unless service is denied.

oh , January 9, 2019 at 3:58 pm

Not really. Denial of claims is yet another way for them to pad their profits.

Louis Fyne , January 9, 2019 at 6:32 am

cigna bought express scripts and the deal closed in december.

it could be cost-cutting-induced incompetence. it could be intentional revenue padding. could be both.

and ya, compared to the daily/weekly neoliberal microaggressions, no wonder why after 3weeks a lot of people shrug when it comes to the government shutdown

Spring Texan , January 9, 2019 at 11:06 am

Love your phrase "neoliberal microaggressions." We need to start using that more!

Very descriptive.

rd , January 9, 2019 at 12:22 pm

This government shutdown is going to get very interesting as the Trump Administration tries to expand what are "essential services" requiring workers to come in without pay. So far it hasn't interfered with my travels because the TSA and ATC workers are all there working without pay. I believe tax refunds are going to be declared "essential" so those workers will be called back to process them without pay. This will likely be occurring in numerous other areas as the Administration gradually discovers that government workers actually do something.

Thad Allen had an interesting interview on NPR this morning as he discussed the Coast Guard working without pay: https://www.npr.org/2019/01/09/683501454/coast-guard-members-may-have-to-work-without-pay-during-shutdown

The GOP may have finally figured out how to pay for tax cuts: you still provide the services but you don't pay the workers!

Octopii , January 9, 2019 at 1:08 pm

Reminds one of the old Soviet saying, "They pretend to pay us and we pretend to work."

ambrit , January 9, 2019 at 1:10 pm

This dynamic is beginning to resemble the joke attributed to Lenin. "The Capitalists will sell us the rope with which we hang them."
I cannot think of a better way to energize a general strike than this.

Oh , January 9, 2019 at 4:02 pm

The TSA is just a pretend act anyway. It's all for show.

Larry , January 9, 2019 at 7:01 am

Perhaps the plan is to fatigue customers over small amounts to condition them to give up appeals over larger disputes.

Homard Mard Hankee Ospetsua , January 9, 2019 at 7:05 am

For most of the year 1982, I worked as a parlegal for a workmen's comp law firm representing petitioners (the sick or injured workers). Almost all of the cases we handled were from workers whose disability checks had stopped after six weeks. Always six weeks. That's the point at which the insurer would stop sending the checks and the worker would call us. Then, someone (like me) from the law firm would call the insurer. There would be one of a a stock set of about half a dozen responses, ranging from "my desk is so messy haha, but I know I saw that check in these papers somewhere" to "we don't have the proper medical documentation" (even though of course there needed to be medical documentation for them to send the first 6 weeks' worth of checks). After one or two phone calls from us, the checks would begin to flow again in a week or two (including checks for any week that the insurer had missed).

Oh, and 95% of these cases were from workers whose first language wasn't English.

The theory of the folks who'd been at this business for awhile was that, by having a built-in delay at the six-week mark, the insurers were making a little extra interest.

cnchal , January 9, 2019 at 7:17 am

> . . . in terms of abuses, this is small beer . . .

Tens of millions of small beers ends up being a gigantic vat of beer for Davos Man running Cigna. This is the result of Davos Man purchasing laws to prevent class action suits, which was paid for by stealing small beers from the peasants for decades.

I do pity the human capital at Cigna. Their worth to Davos Man is how well they steal small beers, the more they steal the higher in the organization they go, aspiring to be the next Davos Man.

Brenda Pawloski , January 9, 2019 at 8:33 am

If you are able to send your pharmacy claims online and keep an electronic copy, you can resubmit easier, faster and more often. I have done this with Cigna. I agree it is odd how they choose to ignore random claims, but it happens enough that it seems to be intentional.

BRUCE STONE , January 9, 2019 at 8:36 am

Have you tried sending the mailed correspondence by priority mail? Like Certified Mail–you get a tracking number– and documentation of delivery–but it's half the cost and my insurer will routinely refuse to accept certified mail to the claim's PO box number.
They can't refuse to participate in the priority mail tracking systems -- and it's as good in court as certified mail–although it does lack the signature credo from return receipt.

Also–my insurer routinely loses my docs and has a similar time limit on claims–but I have successfullly re-submitted based on documenting the previous sent item and the tracking data from USPS–most such systems require them to accept a resubmit when you can prove you sent it within the timeframe .

Yves Smith Post author , January 9, 2019 at 9:47 am

See the comment above. Won't help. Only proves I sent a letter in, not what was in the letter. They can say they got the earlier letter but the claim was not in it or was unscannable.

Questa Nota , January 9, 2019 at 8:54 am

Expecting reimbursement is a pre-existing condition and is not covered by the Plan for which you have eligibility. Refer to paragraph x.xx in section q.qq of user agreement #.##.

Yves Smith Post author , January 9, 2019 at 9:48 am

Not germane. Please don't offer irrelevant comments.

Kiwi , January 9, 2019 at 10:35 am

The comment was a joke

mle detroit , January 9, 2019 at 10:17 am

Good one, QN. Hope you didn't get scorched when you poked the Dragon.

RMO , January 9, 2019 at 4:39 pm

"You've chosen the 'never pay" plan option which clearly states (in this microdot that also serves as a period at the end of paragraph 4) that no claims you make will be honored. It's a good choice if you never get sick. Oh I hate to see a grown man cry Rev So get out of my office!" (adapted from the Pythons)

beth , January 9, 2019 at 7:40 pm

Do I sense a little hostility? Maybe you can be more explicit with what you are angry about.

Medical Quack , January 9, 2019 at 9:25 am

Well I gave a speech last year to a big doctors group about a lot of this and have written about it for years, it's called the Healthcare Algo Cartel. What folks can't see and don't want to believe is that there's tons of quants (called non traditional actuaries in healthcare) modeling policies and finding new areas every day where coverage for certain items can be "scored" to reduce the amount the insurer will pay.

I just don't know how long you all want to keep living in virtual perceptions and not realize this has been going on for years, just like the stock market, algos and their query results are running everything, and folks are too busy on Facebook or screaming at a box (Alexa) to take time out and learn up. Cigna is basically emulating United Healthcare and using the same models, but they don't own a PBM like United does or they don't own a bank like United does (an industrial bank). That bank by the way holds a lot of HSA money and United a couple years ago bought all the Wells Fargo HSA accounts, that's how they grow.

Nobody mentions an exit fine either for Cigna and Express Scripts. There's 5 years left for Cigna to be required to OptumRX as a PBM, contract signed with Catamaran, which OptumRX bought. Those folks with OptumRX as their PBM with Cigna have 5 more years before a switch to Express Scripts can be facilitated unless Cigna takes out another bond sale to pay it off.

People need to learn up and see what's going on, insurers are big data people and nobody seems to get that but just hang around long enough and more will come out about United Healthcare and what they and Apple are doing together, you already have United pimping Apple watches and all Apple employees are given an Optum Bank HSA account with one scratching the others back already.

Cigna by the way has Express Scripts hitting the big coupon savings route to compete, you can search that one up. Did you know that if you use a coupon to save money on your RX that that money can't be applied against a deductible? Time to learn up folks and see what the healthcare algos are doing, they're denying your care and access and there's more MBA quants on their way to be hired at insurers to model even more ways to profit by "scoring" consumers into oblivion, it's how you don't qualify done by queries and predictive models. The more complex they make it, the more insurers profit off of consumers not understanding the game and we don't have the ability to fight back (we don't have the algos and computer code).

Kris Alman , January 9, 2019 at 12:21 pm

The Cigna-Express Scripts merger is brilliant financial engineering to further consolidate insurance companies with PBMs in the fight between them and PhRMA over price gouging.

The coupons that you can get through Good Rx is a scheme of Express Scripts. https://www.biopharmadive.com/news/express-scripts-goodrx-roll-out-cost-savings-program/442197/

Now that Trump has signed bills lifting pharmacist 'gag clauses' on drug prices, the pharmacist can point you in the direction of drugs cheaper than your co-pays, which you pay-out-of-pocket and can't claim toward your deductible. What a win for Cigna/ExpressScripts!

Yves, I can't believe you have been so patient with Cigna! Complain to your insurance division. Though, I will add that while this may work at the individual level, it does nothing to create systemic changes.

JerryDenim , January 9, 2019 at 12:48 pm

Sorry to be so dense, but can you elucidate a bit more on "scoring" and how health insurance companies are using your personal data they've purloined or surreptitiously obtained to deny care? If you're not self-insured but receiving subsidized insurance through an employer plan are you still affected by "scoring"?

I would never knowingly register any health monitoring device with a health insurer or employer and I've always thought those who do are foolish, but recently I was considering buying an Apple Watch solely for the express purpose of being able to surf while being on call for my job. I believe there may be other waterproof, cellular-enabled wrist devices in the consumer space now besides Apple, but they all seem to be equipped with health monitoring sensors as well. I would never voluntarily register such a device with any programs in exchange for discounts, but it seems like linking a watch/wrist-phone to my cell phone account would be an iron identity shackle. I would really like a tiny robust cell phone reciever to screen calls while I'm in the water, which has the ability to increase my quality of life, but I don't want my heart rate and vitals logged and sold. I modified a song lyric a couple of decades ago to coin my own phrase; "Never mind what you're buying, it's what you're selling" – It becomes more true each passing year.

jfleni , January 9, 2019 at 9:31 am

RE: Health Insurer Greed or Desperation? An Odd Data Point From Cigna.

The "Nitty-gritty" A Scam wrapped in a Swindle, with a Fraud right on top!
Run -do not walk – to Medicare for ALL!

jefemt , January 9, 2019 at 9:58 am

Not fun to do the work, but imagine a few million Cigna clients at $13.00 a pop. Will pay for attorneys and accountants.

As to Priority Mail/ tracking/proof, why do we tolerate such a byzantine battle-prone system? Think of the man-hours Yves and countless others spend on running down this hors*#t. If she and others (doc offices/ care providers?) billed Cigna and others at a reasonable but market-based hourly rate for the collective man-hours spent on claims, Cigna et al would be out of business.

Its a level of complexity that is completely unnecessary. Our complacency, tolerance, and acceptance is pretty astounding. Must be the very real primacy of the threat and fear that personal health prompts. Immoral to lever off of this. Care versus insurance. Insuring a mortal being. Ridiculous premis only Wall Street could concoct. And we buy it because markets, capitalism, rugged individualism, American Exceptionalism.

Doc friends and family consistently state 35-40% of their costs, staff deals with billing, coding, reimbursement. There is huge savings to be gained in the process if we would go to a single payor system.

But you all know that- preaching to the choir.

I am still trying to figure out how to tie personal health choices, like diet and exercise, moderate alcohol use, etc.. and some incentivized skin-in-the game, some 'pain' disincentivises folks from over-using single payor and insisting on the highest dollar cost latest most expensive treatments -- how can this be institutionalized?

But , no need to reinvent the wheel- countless other nation-states have figured it out. For a nation of business-persons, we appear to be, as my old dad used to say, dumberthanwhaleshit

hunkerdown , January 9, 2019 at 12:04 pm

If they're overusing the system, what's the underlying reason? Probably loneliness or neurosis, either treatable on an outpatient basis as a mental/community health matter. If they demand heroic treatments or frivolous diagnostics , what's the underlying reason? Probably the consumer model of medicine and direct-to-patient marketing of interventions, also easily treatable (through restriction of advertising) and known to work well in other nation-states. If they eat crap, what's the underlying reason? The standard American diet is a consequence of national policy to grow grain instead of vegetables, which can be changed slowly and with effort as a public health hazard. If they don't exercise, what's the underlying reason? Built environments and lifestyles that are hostile to pedestrian traffic, which is not necessarily such an easy problem to solve due to the private interests and investments in the status quo, but whose opposing public interests would grow much stronger under a single-payer system.

Yet, all of these solutions, however difficult and world-changing they might be, are more effective over the long term and less resentment-inducing than having citizens pay to be individually scourged as a service in the name of individual incentive.

Yves Smith Post author , January 9, 2019 at 3:10 pm

The overwhelming majority of people do not elect to overconsume medical care.

People who don't exercise often don't have the time or money to do so (gym membership). Do not say "Anyone can run." Running on pavement is knee replacement futures. And there are people like me who could never jog even when young.

The ones that do fall into a few categories:

1. Ones with "lifestyle" diseases, like diabetes due to overweight/poor diet and smoking-related diseases. Problem is that these are typically the result of stress. Very hard to get off cigarettes and harder if you are subject to stress/use nicotine as a performance drug. Obesity significantly due to American portion sizes. too many refined carbs, and again, stress. And once people get fat, it is very hard for them to take and keep the weight off. I have managed to do so by virtue of seriously undereating for 40 years (<1200 calories/day, and that includes when I was exercising vigorously pretty much daily). Most people can't do that for social reasons. It is hard to be a meager eater when you are eating with other people.

2. People who are already have a problem and have been marketed to to demand tests and treatments. The classic version of this is doctors prescribing antibiotics to people with flus. The patients demand a treatment and the MD does not want to get in an argument. More extreme is patients not wanting to hear that there aren't any good options for what they have and shopping for an MD who will intervene anyhow. Another is all those new pricier drugs marketed on TV "Ask your doctor about..."

beth , January 9, 2019 at 8:15 pm

The best information about obesity is still the UCSF researcher Robert Lustig. He now has his own website but it not organized well to my taste and fails to keep the best long lectures there. Actually the best information in the shortest time is his first lecture that has been seen millions of times by geeks like me is "Sugar: The Bitter Truth" a one hour and 29 minute lecture he did in 2009. Youtube cuts it up and wants me to pay for it. But each time I have seen it has been on UCTV or UCSF. For those of us who want to understand the science this one is a must. There is good videos after that, but this is the foundational scientific information.

I can't give you a link because Google and the sugar industry makes it maddingly hard to find and moves it around.

flora , January 9, 2019 at 9:46 pm

It's a very good presentation. Thanks for the reminder. From UCTV:

https://www.uctv.tv/shows/Sugar-The-Bitter-Truth-16717

bob , January 9, 2019 at 3:21 pm

"I am still trying to figure out how to tie personal health choices some incentivized skin-in-the game "

You're trying to noeliberalize it. "How do we build in the need for 18 layers of very well paid bureaucrats who deal out spite, and lack of care, as part of their job descriptions?"

I can't imagine any more 'skin in the game' than all of the skin, and literally all of the person.

Do you ghouls even read what you write?

k. , January 9, 2019 at 9:59 am

As someone who managed a medical billing office in the 80s and 90s I can assure you that insurance companies losing claims is nothing new. That's why the advent of electronic billing to Medicare and Medicaid and BCBS and others was so wonderful. Finally, Medicare stopped "losing" all those claims we offices had to refile all of the time.

Sometimes it helped me to envision the office I was sending the paper claim to, imagining a constant turnover of new employees who didn't know what they were doing, or throwing away a stack of bills at the end of the day because they hadn't met their quota.

It's like borrowing "your" money longer, not paying what's owed in a contract.

EoH , January 9, 2019 at 10:38 am

Thanks for sharing.

This seems reminiscent of bank ATM fee scams. A dollar here, $2.50 there – systemwide – and soon you're talking about real money. It also matters whose budget the costs or income are shifted to, which is often a highly-competitive internal game. Same with the now ubiquitous and easily incurred penalty charges, which banks use to generate the outlandish returns they now consider their due.

Coincidentally, I was recently helping a friend with her latest medical bill. Always good sport if it's not your bill. It was "only" for about a thousand dollars. Her insurer paid the amount, minus her deductible.

The hospital system sent her a follow-up bill for the same service. It was for the deductible the insurer did not pay – routine – AND for another thousand dollars, which was not.

Here's the hospital's argument: It had billed the insurer and the patient only a thousand dollars. But the insurer considered bills for up to two thousand dollars for that service. Having, in effect, underbilled the insurer, the hospital added the difference between its first bill and the maximum amount the insurer would consider.

But the hospital did not bill the insurer for the higher amount, only the patient. That routine also happily avoided any reasonable and customary cap the insurer and hospital had agreed to.

The hospital does this routine systemically. Its "customer service" operators have a canned response for outraged patients: You'll pay it in the end and we'll dock your credit score in the bargain. Film at eleven.

Steven Hoel , January 9, 2019 at 10:39 am

I have found this letter (or to be used as script to be read over the phone) to be 100% effective so far. I suspect it gets kicked up to a supervisor who wants to get rid of the crazy customer:

"To: "Big Corporation"
Regarding Inv #

Hello,

You have issued your fourth notice. Please note that this is now my third notice to you of whom to bill. If I must spend more time on this issue, I will be billing out at $200 per hour in ½ hour increments. Sending a further notice without contacting "XYZ Healthshare" for payment will indicate acceptance of my terms.

This blood work was for my annual Physical. I am covered under "XYZ Healthshare" and they cover one physical per year.

Please submit above referenced invoice for payment to:

"XYZ Healthshare"
Payor ID:
P.O. Box 1234
Anytown USA 12345

Insured: John Doe
Policy # 123456789

It is not acceptable to simply send me another payment notice when you are not billing as I instructed. I will send my billable hours in return and submit a copy to my attorney.

Best Regards,

John Doe"

NotTimothyGeithner , January 9, 2019 at 10:44 am

The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home.

Perfect.

jrs , January 9, 2019 at 12:56 pm

Of course Trump's misdeeds are becoming abuses much closer to home, having one's government closed becomes real impractical even on the day to day level.

Spring Texan , January 9, 2019 at 11:08 am

Wow, this makes me very happy I work for a self-insured employer which unfailingly pays bills in good faith. Awful.

California Bob , January 9, 2019 at 12:10 pm

I was with United Healthcare in the private sector for years, with good coverage and no serious issues (PPOs only). When I went on Medicare, I stayed with AARP-endorsed UHC; I figure the last thing UHC would want is a bunch of angry retirees with time on their hands. So far, so good.

Jimmie Q , January 9, 2019 at 5:40 pm

I don't know about that. I've not been able to login to the AARP/UHC website for 2 months.
They admit that there is a problem. After 2 months I'd say they are correct.
You'd think they would go back to the last working version of their log-in software.
What kind of testing was performed before inflicting this crap on their users. None, by the looks of it.
It's pretty obvious when you can't login. How stupid are these people ?

Oregoncharles , January 9, 2019 at 12:17 pm

Not medical, but a similar penny-ante scam that we encountered from a car rental, which I will name: it was Dollar/thrifty – they're the same company. Ironically, we were happy with their service, given the price, UNTIL we turned the car in at the Indianapolis airport. The agent claimed the system was down, so couldn't give me a receipt; foolishly, and feeling time-pressured, I walked away without one (don't do that).

The company first claimed the car had not been turned in, then discovered that it had been re-rented the next day, so charged us for an extra day. I refused to pay it, since an agent had agreed that our boarding passes from the airline proved when we'd turned it in. In fact I got the credit card company to reverse the extra amount (their service was exemplary). Attempts to clear it up on the phone led to hangups at their end, and ultimately they sent the $50 difference to collection. When I got a call, I started yelling about it being a fraudulent charge and making legal threats; never heard from them again – not worth it for such a small amount. I felt that principle was involved.

And now the oddity: Dollar/Thrifty belongs to Hertz, but we've had no trouble renting from Hertz. Go figure.

JerryDenim , January 9, 2019 at 1:21 pm

One scam I've seen Hertz attempt on me twice, was claiming a car wasn't returned completely full, like 1/16th shy of full, then they proceed to charge you for a full tank of gas (15, 20 gallons or whatever that means based on the vehicle) at some outrageous price like $9.00 a gallon. It's a scam that is always going to add up to over a hundred dollars. It's a quick, vicious one-time burn (sharp practice as Yves would say) they try to pull on customers they figure may never rent from them again anyway. Algos I'm sure. Always document, document, document with rental cars. Cell phone cameras are great in this regard. Photos of the odometer with gas gauge displayed work great for refuting such charges.

beth , January 9, 2019 at 8:32 pm

I was definitely scammed by Dollar/Thrifty. I have switched to using Enterprise but they sometimes don't have an airport location. So far so good. I usually take only one trip a year.

Oregoncharles , January 9, 2019 at 12:21 pm

Afterthought: Insurance is a service business, which would normally depend on providing reasonably good service – granted, in this case Yves is locked into an old contract, so they might be trying to get rid of her.

I wonder if this sort of behavior means they see the political handwriting on the wall, figure the business can't last much longer, and are trying to extract the last dime, because it IS the last?

EoH , January 9, 2019 at 3:13 pm

Standard business model. Nothing special.

I question whether insurance is any longer a service, at least for the customer. Health insurance used to be a business that offered a reasonable service, service tracking and payment processing for employers, who purchased the service for their employees as a form of deferred compensation, in exchange for a reasonable fee.

The model seems to have changed to one of open and notorious self-dealing. The intermediary has become a principal, and no fee and no level of profit is too great. The intermediary makes decisions that look to the lay person like practicing medicine – not seemingly in the interest of savings its employer customers money, but it making it for themselves. The model is a major reason for the extraordinary cost of medical care in the US.

Synoia , January 9, 2019 at 12:26 pm

Small claims court?

ambrit , January 9, 2019 at 12:57 pm

That would be a tax on her time, she has to physically show up in court for the 'trial', and money, as in, filing fees. A small claims judgement does not guarantee payment. That could take a second suit. (I had to go for a second filing to get my judgement paid.)
This is a systemic problem. The remedy in that elusive "perfect world" is to change the system.

AdamK , January 9, 2019 at 12:55 pm

"Corporate America has been institutionalizing penny-ante scams "

Don't get me started. 24 hour fitness sold membership for super sport facilities at a higher price promoting the deal that gives free towels to members while at the gym. 3 years after, towels are gone. Price was raised several times, and there is no difference between regular facility and super sport. No one complained. They simply got the news and adjusted. Saying something is not considered appropriate, so we continue to pay more and more and getting less and less.

ambrit , January 9, 2019 at 1:05 pm

Same dynamic used for Internet services, telecom services and cable services. Life is legally an "ethics free zone" today.
Reminds me of one of the more vulgar posters I once saw. A mid range shot of a woman's "private parts" with a 'tattoo' above the mons pubis saying; "Abandon all hope, ye who enter or exit here."

WheresOurTeddy , January 9, 2019 at 2:32 pm

seems germane:

"The political crisis we are facing is simple. American commerce, law, finance, and politics is organized around cheating people." – Matt Stoller

https://twitter.com/matthewstoller/status/893848256769171458

JerryDenim , January 9, 2019 at 1:10 pm

This story is strangely similar to the battles I used to wage years ago with Sallie Mae to pay down my student loan principal ahead of schedule. I would send checks that would never be cashed. If they ever were the amount would always be applied to interest and never principal. Tons of emails, phone calls and letters stretching out over months all about one check or another.

"Oh you sent the check to that address? No that's all wrong, try this one." "Oh, no, you have to write a letter stating you want the amount to be applied to principal. Oh, you did already? Oh, well send one to this department at this address instead and your next one should be be applied to principal."

Absent an aggressive regulator corporations can play infuriating games like this for years until the consumer gives up or lawyers up. Lawyering up is no guarantee of victory and doesn't make financial sense for small penny-ante grievances. Most people stuck dealing with hassles like these don't have the money to lawyer up anyway and corporations know it. I remember back in 1995 when my phone service was changed without my permission and I received an outrageous bill. I placed one phone call to the FCC that lasted a few minutes and I received a $250 credit and my phone service was free for the next year. I miss those days.

"The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home."

Absolutely. It's really tough for working class Americans to shed a tear for Central American border jumpers having a rough go of things with ICE when their own government refuses to protect them from thousands of small capitalist depredations that they are subjected to on a daily basis.

tongorad , January 9, 2019 at 1:11 pm

Corporate America has been institutionalizing penny-ante scams like the one Cigna ran on me
I received an errant charge when I chose to cancel my account with a phone-carrier giant. Lots of time on the phone speaking to different people, demanding to be sent an invoice/bill.
In the end, I just paid. I was losing sleep over it.
I have a feeling that these kinds of extractions are commonplace.
What a world

beth , January 9, 2019 at 8:41 pm

If we are discussing scams, I had an earthlink account for about a year when I noticed that rather than billing me monthly, they were billing me every 20 days and when I noticed it, they said they would refund my money at my request.

And what do you think happened?

M Morrissey , January 9, 2019 at 1:20 pm

File a complaint with your state insurance department. Most departments have dedicated staff who will follow up on such issues. If you one of many victims, it can lead to a "Targeted Market Conduct Examination" of the company.

Once that happens, the insurer will readily settle claims such as yours because besides fines, the impact of an examination damages their reputation. Also, if there is a pattern of misconduct, the complaint information is shared between the 50 states, who may also initiate targeted examinations. Don't get mad–get even.

monday1929 , January 9, 2019 at 6:06 pm

You are kidding, right?
And ."damage their reputation"- thank you, I needed a laugh.

JBird4049 , January 9, 2019 at 1:37 pm

The more people are in need of medical care the less likely they are to have the time, energy, or even money to maintain their records, read all their letters and emails, and write and call enough times to finally get their money. The sicker are the less likely you will get paid. Truly vulture capitalism.

Dan , January 9, 2019 at 1:57 pm

I tend to agree that these 'billing mistakes' are a conscious strategy on the part of insurers. For several years Kaiser (Northern California) would attempt to bill me $15 every time for routine physical visits (which my physician had requested!). Routine physicals, of course, are meant to be free under the ACA. Every time the receptionist would request payment in advance, I would decline an tell them that the appointment should be free. They then would proceed to bill me by mail, and I had to spend time calling them to resolve the issue. Unlike Yves' experience with Cigna, Kaiser customer service was always friendly and promptly resolved the 'error'.

Since we changed from a Covered California plan to a small business plan this practice appears to have stopped, at least for me. Nonetheless, this annual ritual was a ridiculous tax on my time, and I wonder how many people who were less informed/hostile to their insurer than I am have just paid these false and illegal fees up front. The consistency of this practice over a period of years makes it hard for me to believe that there is really error involved, as opposed to a subtle fraud by the insurer.

monday1929 , January 9, 2019 at 6:13 pm

It is never an "error", and it is always in their favor (proof it is not an error).
They target the sickest, least likely to fight back. There is an MBA somewhere who wrote an algorithm designed to screw the old and sick. My nightmare with United "healthcare" (why are they allowed to call themselves or imply they are healthcare providers?) was on behalf of someone else who never could have fought these scammers.

tiebie66 , January 9, 2019 at 3:31 pm

So, they legislate to permit disruption against you and not against them, but year after year – figuratively speaking – you send the same people back there. The system is beyond reform, is that not clear by now? Vote for anyone –except– a Democrat or Republican. It would create upheaval at first, like spring cleaning, but it is as necessary. If you are too timid to make changes, you will only get weaker and weaker until you are too weak to resist. Don your yellow jackets!

But on a different level – where does this originate? My sense is that it is a failure of education. The nation can neither read, nor write, nor think. This makes for easy victims. Do teachers really deserve better pay? Is teaching not a 'calling' rather than a career? Should teachers not do better? But perhaps the failure of education is also, in part, institutionalized?

Big Tap , January 9, 2019 at 4:55 pm

Speaking of insurance scams some involve a PPO type policy. More and more often I'm told at the time of service of a doctors visit to pay up front. With a PPO policy you usually don't know exactly what you owe till after the insurance company tells you what your co-pay is and then you're billed. When you pay up front bring overcharged intentially is the scam. Getting a refund of your own money can time consuming.

Pft , January 9, 2019 at 6:49 pm

Not only health insurance. Good luck if your house burns down and you want them to honor the contract in a timely fashion. They hold off until you accept less hoping you hate living in 2nd rate accomodations enough to cave. My sisters contract called for full replacement of all contents regardless of age. She paid a hefty premium for that. They held out for months offering less saying some of the contents were older and not worth the replacement cost which is what she wanted to avoid by paying the extra premium for the upgrade. Came to an agreement somewhere between but took 15 months before she could move back in.

EoH , January 9, 2019 at 7:37 pm

There is the basic problem that with almost every medical service, the customer does not know the price until the bill(s) show up in the mail. (Nor have they any training or experience that would enable them to choose alternative treatments or vendors.) Only later still does an insured customer find out what portion of that bill is her responsibility. And that's without errors and intentional mis-billing, which are common.

The usual conservative refrain that patients need more skin in the game studiously ignores that patients always have all their skin in the game, even though no one tells them the game or the rules until it's too late. It is an environment that could only make predatory behavior flourish.

Katherine , January 9, 2019 at 9:57 pm

This is one of the most unsettling posts I have read on NC since becoming hooked about 6 months ago.

cat sick , January 10, 2019 at 2:44 am

Live a healthy lifestyle and self insure

I am sure not dealing with insurance companies is a sure way to lower stress levels and therefore require much less healthcare.

As a fairly healthy 50 year old I find that even though I have access to a good free first world healthcare system (Singapore ), never using it and paying doctors direct for all my needs is the way to go and probably costs me 10% of what a US citizen might pay for an insurance policy.

When I am in the US and so many people you meet have "meds" that they take on a daily basis it leads me to believe that not only are the insurance companies in on the scam but also the doctors and drug companies plying people with drugs that in most cases probably make them worse off

The first $20 of care I would reccomend is to buy one copy each of "how not to die" and "the case against sugar" read these and then do all you can to avoid both insurance companies and doctors .

[Jan 09, 2019] $3.5 Trillion A Year- Is America's Health Care System The World's Largest Money-Making Scam- -

Jan 09, 2019 | www.zerohedge.com

Authored by Michael Snyder via The Economic Collapse blog,

If the U.S. health care system was a country, it would have the fifth largest GDP on the entire planet. At this point only the United States, China, Japan and Germany have a GDP that is larger than the 3.5 trillion dollar U.S. health care market. If that sounds obscene to you, that is because it is obscene. We should want people to be attracted to the health care industry because they truly want to help people that are suffering, but instead the primary reason why people are drawn to the health care industry these days is because of the giant mountains of money that are being made. Like so many other things in our society, the health care industry is all about the pursuit of the almighty dollar, and that is just wrong.

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In order to keep this giant money machine rolling, the health care industry has to do an enormous amount of marketing. If you can believe it, a study that was just published found that at least 30 billion dollars a year is spent on such marketing.

Hoping to earn its share of the $3.5 trillion health care market, the medical industry is pouring more money than ever into advertising its products -- from high-priced prescriptions to do-it-yourself genetic tests and unapproved stem cell treatments.

Spending on health care marketing nearly doubled from 1997 to 2016, soaring to at least $30 billion a year , according to a study published Tuesday in JAMA.

This marketing takes many different forms, but perhaps the most obnoxious are the television ads that are endlessly hawking various pharmaceutical drugs. If you watch much television, you certainly can't miss them. They always show vibrant, smiling, healthy people participating in various outdoor activities on bright, sunny days, and the inference is that if you want to be like those people you should take their drugs. And the phrase "ask your doctor" is usually near the end of every ad

The biggest increase in medical marketing over the past 20 years was in "direct-to-consumer" advertising, including the TV commercials that exhort viewers to "ask your doctor" about a particular drug. Spending on such ads jumped from $2.1 billion in 1997 to nearly $10 billion in 2016 , according to the study.

As a result of all those ads, millions of Americans rush out to their doctors to ask about drugs that they do not need for diseases that they do not have.

And on January 1st, dozens of pharmaceutical manufacturers hit Americans with another annual round of massive price increases.

But everyone will just keep taking those drugs, because that is what the doctors are telling them to do. But what most people never find out is that the pharmaceutical industry goes to great lengths to get those doctors to do what they want. According to NBC News , the big drug companies are constantly "showering them with free food, drinks and speaking fees, as well as paying for them to travel to conferences".

It is a legal form of bribery, and it works.

When you go to most doctors, they will only have two solutions to whatever problem you have – drugs or surgery.

And since nobody really likes to get cut open, and since drugs are usually the far less expensive choice, they are usually the preferred option.

Of course if doctors get off the path and start trying to get cute by proposing alternative solutions, they can get in big trouble really fast

Today's medical doctors are not allowed to give nutritional advice, or the American Medical Association will come shut them down , and even if they were, they don't know the right things to say, because they weren't educated that way in medical college. So instead, M.D.s just sling experimental, addictive drugs at symptoms of deeper rooted sicknesses, along with immune-system-destroying antibiotics and carcinogenic vaccines.

That's why any medicine that wrecks your health is easy to come by, just like junk food in vending machines. The money isn't made off the "vending" products, the money is made off the sick fools who are repeat offenders and keep going back to the well for more poison – it's called chronic sick care or symptom management. Fact: Prescription drugs are the fourth leading cause of death in America, even when "taken as directed."

Switching gears, let's talk about hospitals for a moment.

When you go to the hospital, it is often during a great time of need. If you are gravely ill or if an accident has happened and you think you might die, you aren't thinking about how much your medical care is going to cost. At that moment you just want help, and that is a perfect opportunity for predators to take advantage of you.

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Just consider the example of 24-year-old Nina Dang. She broke her arm while riding her bicycle in San Francisco, and so she went to the emergency room.

The hospital that Facebook CEO Mark Zuckerberg donated so much money to definitely fixed her arm, but later they broke her bank account when they hit her with a $24,000 bill

A bystander saw her fall and called an ambulance. She was semi-lucid for that ride, awake but unable to answer basic questions about where she lived. Paramedics took her to the emergency room at Zuckerberg San Francisco General Hospital, where doctors X-rayed her arm and took a CT scan of her brain and spine. She left with her arm in a splint, on pain medication, and with a recommendation to follow up with an orthopedist.

A few months later, Dang got a bill for $24,074.50 . Premera Blue Cross, her health insurer, would only cover $3,830.79 of that -- an amount that it thought was fair for the services provided. That left Dang with $20,243.71 to pay , which the hospital threatened to send to collections in mid-December.

Most Americans assume that if they have "good health insurance" that they are covered if something major happens.

But as Dang found out, you can still be hit with crippling hospital bills even if you have insurance.

Today, medical debt is the number one reason why Americans declare bankruptcy. Because of the way our system is set up, most families are just one major illness away from financial ruin.

And this kind of thing is not just happening in California. The median charge for a visit to the emergency room nationally is well over a thousand dollars , and you can be billed up to 30 dollars for a single pill of aspirin during a hospital stay.

Our health care system is deeply broken, and it has been designed to squeeze as much money out of all of us as it possibly can.

Unfortunately, we are stuck with this system for now. The health care industry is certainly not going to reform itself, and the gridlock in Washington is going to make a political solution impossible for the foreseeable future.


the_river_fish , 3 minutes ago link

Healthcare has displaced Retail as the largest employer in the United States

https://thistimeitisdifferent.com/healthcare-us-january-2019

Consuelo , 9 minutes ago link

The ghost of Ted Kennedy that keeps on giving...

He played an outsized role in the trashing of the doctor/patient relationship.

css1971 , 10 minutes ago link

Most big hospital ERs negotiate prices for care with major health insurance providers and are considered "in-network." Zuckerberg San Francisco General has not done that bargaining with private plans, making them "out-of-network." That leaves many insured patients footing big bills.

HMOs.

Constrain supply. Increase the price.

https://en.wikipedia.org/wiki/Health_Maintenance_Organization_Act_of_1973

That was the purpose of the 1973 HMO act. It was at this point, that US medical costs began to escalate far beyond the rest of the world.

https://pusz4frog.files.wordpress.com/2012/04/healthcare-costs-oecdchart_3.gif

LawsofPhysics , 10 minutes ago link

Considering the demographics of the country and the fact that fraud is the status quo now, this should not surprise anyone.

LawsofPhysics , 21 minutes ago link

That's a tough question considering we don't really know how much is flowing to the military industrial complex. My guess healthcare spending is in second place.

[Jan 08, 2019] Risk On Again - Distractions from the Real Problems and Issues

Jan 08, 2019 | jessescrossroadscafe.blogspot.com

Stocks and Precious Metals Charts - Risk On Again - Distractions from the Real Problems and Issues

"On April 3, Nina Dang, 24, found herself in a position like so many San Francisco bike riders -- on the pavement with a broken arm.

A bystander saw her fall and called an ambulance. She was semi-lucid for that ride, awake but unable to answer basic questions about where she lived. Paramedics took her to the emergency room at Zuckerberg San Francisco General Hospital, where doctors X-rayed her arm and took a CT scan of her brain and spine. She left with her arm in a splint, on pain medication, and with a recommendation to follow up with an orthopedist.

A few months later, Dang got a bill for $24,074.50. Premera Blue Cross, her health insurer, would only cover $3,830.79 of that -- an amount that it thought was fair for the services provided. That left Dang with $20,243.71 to pay, which the hospital threatened to send to collections in mid-December..."

Sarah Kliff, A $20,243 bike crash: Zuckerberg hospital's aggressive tactics leave patients with big bills

"Monopolies hurt the public and the republic alike; the job of policing that power must be taken seriously."

Elizabeth Warren

Within so many of the corporate dominant monopolies like Healthcare, Banking, Pharmaceuticals, some companies seem to be free to do just about whatever they wish in billing consumers.

Healthcare in the US is bordering on insane when it comes to billing practises and lack of practical recourse or common sense, with Big Pharma running a close second. But the Banks are not all that far behind.

I have met many, many dedicated professionals in the healthcare industry, but like most participants they are just being swept along because they have little practical recourse or power. To speak up is to be punished, and severely.

A simple law that states that when a patient is brought into a hospital emergency room for treatment, their private insurance and the treatments must be provided at the network rates in their insurance policy, or at the prevailing rate for a Medicare patient, whichever is lower. And any uncollectible services to be written off or compensated by government will be done at the Medicare rate and not at some ficitonal billing statement.

I believe that New York State has a law requiring ER and Hospital doctors to accept private insurance for patients as if they are in-network. This includes those 'consultations' which happen during a hospital stay by doctors who accept no insurance and who charge whatever they feel like charging for some service, of which provider or price the patient is never informed beforehand.

The real solution is of course universal healthcare, which has been implemented for years by every major developed nation but the US. This will not happen for the same reason that we are seeing no movement towards meaningful reform in Pharma or Banking. And you know exactly why, unless you have been living in a bubble or are willfully blind.

Stocks managed to extend their rally today despite some setbacks.

We will see what Trumpolini has to say about our 'crisis' at the southern border this evening, and the trade war, and probably whatever else crosses his mind. My only certainly is that it will not involve any meaningful reform in healthcare, finance, insurance, or pharmaceuticals.

Have a pleasant evening.

[Dec 24, 2018] Phone in sick: its a small act of rebellion against wage slavery

Notable quotes:
"... By far the biggest act of wage slavery rebellion, don't buy shit. The less you buy, the less you need to earn. Holidays by far the minority of your life should not be a desperate escape from the majority of your life. Spend less, work less and actually really enjoy living more. ..."
"... How about don't shop at Walmart (they helped boost the Chinese economy while committing hari kari on the American Dream) and actually engaging in proper labour action? Calling in sick is just plain childish. ..."
"... I'm all for sticking it to "the man," but when you call into work for a stupid reason (and a hangover is a very stupid reason), it is selfish, and does more damage to the cause of worker's rights, not less. I don't know about where you work, but if I call in sick to my job, other people have to pick up my slack. I work for a public library, and we don't have a lot of funds, so we have the bear minimum of employees we can have and still work efficiently. As such, if anybody calls in, everyone else, up to and including the library director, have to take on more work. ..."
Oct 24, 2015 | The Guardian

"Phoning in sick is a revolutionary act." I loved that slogan. It came to me, as so many good things did, from Housmans, the radical bookshop in King's Cross. There you could rummage through all sorts of anarchist pamphlets and there I discovered, in the early 80s, the wondrous little magazine Processed World. It told you basically how to screw up your workplace. It was smart and full of small acts of random subversion. In many ways it was ahead of its time as it was coming out of San Francisco and prefiguring Silicon Valley. It saw the machines coming. Jobs were increasingly boring and innately meaningless. Workers were "data slaves" working for IBM ("Intensely Boring Machines").

What Processed World was doing was trying to disrupt the identification so many office workers were meant to feel with their management, not through old-style union organising, but through small acts of subversion. The modern office, it stressed, has nothing to do with human need. Its rebellion was about working as little as possible, disinformation and sabotage. It was making alienation fun. In 1981, it could not have known that a self-service till cannot ever phone in sick.

I was thinking of this today, as I wanted to do just that. I have made myself ill with a hangover. A hangover, I always feel, is nature's way of telling you to have a day off. One can be macho about it and eat your way back to sentience via the medium of bacon sandwiches and Maltesers. At work, one is dehydrated, irritable and only semi-present. Better, surely, though to let the day fall through you and dream away.

Having worked in America, though, I can say for sure that they brook no excuses whatsoever. When I was late for work and said things like, "My alarm clock did not go off", they would say that this was not a suitable explanation, which flummoxed me. I had to make up others. This was just to work in a shop.

This model of working – long hours, very few holidays, few breaks, two incomes needed to raise kids, crazed loyalty demanded by huge corporations, the American way – is where we're heading. Except now the model is even more punishing. It is China. We are expected to compete with an economy whose workers are often closer to indentured slaves than anything else.

This is what striving is, then: dangerous, demoralising, often dirty work. Buckle down. It's the only way forward, apparently, which is why our glorious leaders are sucking up to China, which is immoral, never mind ridiculously short-term thinking.

So again I must really speak up for the skivers. What we have to understand about austerity is its psychic effects. People must have less. So they must have less leisure, too. The fact is life is about more than work and work is rapidly changing. Skiving in China may get you killed but here it may be a small act of resistance, or it may just be that skivers remind us that there is meaning outside wage-slavery.

Work is too often discussed by middle-class people in ways that are simply unrecognisable to anyone who has done crappy jobs. Much work is not interesting and never has been. Now that we have a political and media elite who go from Oxbridge to working for a newspaper or a politician, a lot of nonsense is spouted. These people have not cleaned urinals on a nightshift. They don't sit lonely in petrol stations manning the till. They don't have to ask permission for a toilet break in a call centre. Instead, their work provides their own special identity. It is very important.

Low-status jobs, like caring, are for others. The bottom-wipers of this world do it for the glory, I suppose. But when we talk of the coming automation that will reduce employment, bottom-wiping will not be mechanised. Nor will it be romanticised, as old male manual labour is. The mad idea of reopening the coal mines was part of the left's strange notion of the nobility of labour. Have these people ever been down a coal mine? Would they want that life for their children?

Instead we need to talk about the dehumanising nature of work. Bertrand Russell and Keynes thought our goal should be less work, that technology would mean fewer hours.

Far from work giving meaning to life, in some surveys 40% of us say that our jobs are meaningless. Nonetheless, the art of skiving is verboten as we cram our children with ever longer hours of school and homework. All this striving is for what exactly? A soul-destroying job?

Just as education is decided by those who loved school, discussions about work are had by those to whom it is about more than income.

The parts of our lives that are not work – the places we dream or play or care, the space we may find creative – all these are deemed outside the economy. All this time is unproductive. But who decides that?

Skiving work is bad only to those who know the price of everything and the value of nothing.

So go on: phone in sick. You know you want to.

friedad 23 Oct 2015 18:27

We now exist in a society in which the Fear Cloud is wrapped around each citizen. Our proud history of Union and Labor, fighting for decent wages and living conditions for all citizens, and mostly achieving these aims, a history, which should be taught to every child educated in every school in this country, now gradually but surely eroded by ruthless speculators in government, is the future generations are inheriting. The workforce in fear of taking a sick day, the young looking for work in fear of speaking out at diminishing rewards, definitely this 21st Century is the Century of Fear. And how is this fear denied, with mind blowing drugs, regardless if it is is alcohol, description drugs, illicit drugs, a society in denial. We do not require a heavenly object to destroy us, a few soulless monsters in our mist are masters of manipulators, getting closer and closer to accomplish their aim of having zombies doing their beckoning. Need a kidney, no worries, zombie dishwasher, is handy for one. Oh wait that time is already here.

Hemulen6 23 Oct 2015 15:06

Oh join the real world, Suzanne! Many companies now have a limit to how often you can be sick. In the case of the charity I work for it's 9 days a year. I overstepped it, I was genuinely sick, and was hauled up in front of Occupational Health. That will now go on my record and count against me. I work for a cancer care charity. Irony? Surely not.

AlexLeo -> rebel7 23 Oct 2015 13:34

Which is exactly my point. You compete on relevant job skills and quality of your product, not what school you have attended.

Yes, there are thousands, tens of thousands of folks here around San Jose who barely speak English, but are smart and hard working as hell and it takes them a few years to get to 150-200K per year, Many of them get to 300-400K, if they come from strong schools in their countries of origin, compared to the 10k or so where they came from, but probably more than the whining readership here.

This is really difficult to swallow for the Brits back in Britain, isn't it. Those who have moved over have experiences the type of social mobility unthinkable in Britain, but they have had to work hard and get to 300K-700K per year, much better than the 50-100K their parents used to make back in GB. These are averages based on personal interactions with say 50 Brits in the last 15 + years, all employed in the Silicon Valley in very different jobs and roles.

Todd Owens -> Scott W 23 Oct 2015 11:00

I get what you're saying and I agree with a lot of what you said. My only gripe is most employees do not see an operation from a business owner or managerial / financial perspective. They don't understand the costs associated with their performance or lack thereof. I've worked on a lot of projects that we're operating at a loss for a future payoff. When someone decides they don't want to do the work they're contracted to perform that can have a cascading effect on the entire company.

All in all what's being described is for the most part misguided because most people are not in the position or even care to evaluate the particulars. So saying you should do this to accomplish that is bullshit because it's rarely such a simple equation. If anything this type of tactic will leaf to MORE loss and less money for payroll.


weematt -> Barry1858 23 Oct 2015 09:04

Sorry you just can't have a 'nicer' capitalism.

War ( business by other means) and unemployment ( you can't buck the market), are inevitable concomitants of capitalist competition over markets, trade routes and spheres of interests. (Remember the war science of Nagasaki and Hiroshima from the 'good guys' ?)
"..capital comes dripping from head to foot, from every pore, with blood and dirt". (Marx)

You can't have full employment, or even the 'Right to Work'.

There is always ,even in boom times a reserve army of unemployed, to drive down wages. (If necessary they will inject inflation into the economy)
Unemployment is currently 5.5 percent or 1,860,000 people. If their "equilibrium rate" of unemployment is 4% rather than 5% this would still mean 1,352,000 "need be unemployed". The government don't want these people to find jobs as it would strengthen workers' bargaining position over wages, but that doesn't stop them harassing them with useless and petty form-filling, reporting to the so-called "job centre" just for the sake of it, calling them scroungers and now saying they are mentally defective.
Government is 'over' you not 'for' you.

Governments do not exist to ensure 'fair do's' but to manage social expectations with the minimum of dissent, commensurate with the needs of capitalism in the interests of profit.

Worker participation amounts to self managing workers self exploitation for the maximum of profit for the capitalist class.

Exploitation takes place at the point of production.

" Instead of the conservative motto, 'A fair day's wage for a fair day's work!' they ought to inscribe on their banner the revolutionary watchword, 'Abolition of the wages system!'"

Karl Marx [Value, Price and Profit]

John Kellar 23 Oct 2015 07:19

Fortunately; as a retired veteran I don't have to worry about phoning in sick.However; during my Air Force days if you were sick, you had to get yourself to the Base Medical Section and prove to a medical officer that you were sick. If you convinced the medical officer of your sickness then you may have been luck to receive on or two days sick leave. For those who were very sick or incapable of getting themselves to Base Medical an ambulance would be sent - promptly.


Rchrd Hrrcks -> wumpysmum 23 Oct 2015 04:17

The function of civil disobedience is to cause problems for the government. Let's imagine that we could get 100,000 people to agree to phone in sick on a particular date in protest at austerity etc. Leaving aside the direct problems to the economy that this would cause. It would also demonstrate a willingness to take action. It would demonstrate a capability to organise mass direct action. It would demonstrate an ability to bring people together to fight injustice. In and of itself it might not have much impact, but as a precedent set it could be the beginning of something massive, including further acts of civil disobedience.


wumpysmum Rchrd Hrrcks 23 Oct 2015 03:51

There's already a form of civil disobedience called industrial action, which the govt are currently attacking by attempting to change statute. Random sickies as per my post above are certainly not the answer in the public sector at least, they make no coherent political point just cause problems for colleagues. Sadly too in many sectors and with the advent of zero hours contracts sickies put workers at risk of sanctions and lose them earnings.


Alyeska 22 Oct 2015 22:18

I'm American. I currently have two jobs and work about 70 hours a week, and I get no paid sick days. In fact, the last time I had a job with a paid sick day was 2001. If I could afford a day off, you think I'd be working 70 hours a week?

I barely make rent most months, and yes... I have two college degrees. When I try to organize my coworkers to unionize for decent pay and benefits, they all tell me not to bother.... they are too scared of getting on management's "bad side" and "getting in trouble" (yes, even though the law says management can't retaliate.)

Unions are different in the USA than in the UK. The workforce has to take a vote to unionize the company workers; you can't "just join" a union here. That's why our pay and working conditions have gotten worse, year after year.


rtb1961 22 Oct 2015 21:58

By far the biggest act of wage slavery rebellion, don't buy shit. The less you buy, the less you need to earn. Holidays by far the minority of your life should not be a desperate escape from the majority of your life. Spend less, work less and actually really enjoy living more.

Pay less attention to advertising and more attention to the enjoyable simplicity of life, of real direct human relationships, all of them, the ones in passing where you wish a stranger well, chats with service staff to make their life better as well as your own, exchange thoughts and ideas with others, be a human being and share humanity with other human beings.

Mkjaks 22 Oct 2015 20:35

How about don't shop at Walmart (they helped boost the Chinese economy while committing hari kari on the American Dream) and actually engaging in proper labour action? Calling in sick is just plain childish.

toffee1 22 Oct 2015 19:13

It is only considered productive if it feeds the beast, that is, contribute to the accumulation of capital so that the beast can have more power over us. The issue here is the wage labor. The 93 percent of the U.S. working population perform wage labor (see BLS site). It is the highest proportion in any society ever came into history. Under the wage labor (employment) contract, the worker gives up his/her decision making autonomy. The worker accepts the full command of his/her employer during the labor process. The employer directs and commands the labor process to achieve the goals set by himself. Compare this, for example, self-employed providing a service (for example, a plumber). In this case, the customer describes the problem to the service provider but the service provider makes all the decisions on how to organize and apply his labor to solve the problem. Or compare it to a democratically organized coop, where workers make all the decisions collectively, where, how and what to produce. Under the present economic system, a great majority of us are condemned to work in large corporations performing wage labor. The system of wage labor stripping us from autonomy on our own labor, creates all the misery in our present world through alienation. Men and women lose their humanity alienated from their own labor. Outside the world of wage labor, labor can be a source self-realization and true freedom. Labor can be the real fulfillment and love. Labor together our capacity to love make us human. Bourgeoisie dehumanized us steeling our humanity. Bourgeoisie, who sold her soul to the beast, attempting to turn us into ever consuming machines for the accumulation of capital.

patimac54 -> Zach Baker 22 Oct 2015 17:39

Well said. Most retail employers have cut staff to the minimum possible to keep the stores open so if anyone is off sick, it's the devil's own job trying to just get customers served. Making your colleagues work even harder than they normally do because you can't be bothered to act responsibly and show up is just plain selfish.
And sorry, Suzanne, skiving work is nothing more than an act of complete disrespect for those you work with. If you don't understand that, try getting a proper job for a few months and learn how to exercise some self control.

TettyBlaBla -> FranzWilde 22 Oct 2015 17:25

It's quite the opposite in government jobs where I am in the US. As the fiscal year comes to a close, managers look at their budgets and go on huge spending sprees, particularly for temp (zero hours in some countries) help and consultants. They fear if they don't spend everything or even a bit more, their spending will be cut in the next budget. This results in people coming in to do work on projects that have no point or usefulness, that will never be completed or even presented up the food chain of management, and ends up costing taxpayers a small fortune.

I did this one year at an Air Quality Agency's IT department while the paid employees sat at their desks watching portable televisions all day. It was truly demeaning.

oommph -> Michael John Jackson 22 Oct 2015 16:59

Thing is though, children - dependents to pay for - are the easiest way to keep yourself chained to work.

The homemaker model works as long as your spouse's employer retains them (and your spouse retains you in an era of 40% divorce).

You are just as dependent on an employer and "work" but far less in control of it now.


Zach Baker 22 Oct 2015 16:41

I'm all for sticking it to "the man," but when you call into work for a stupid reason (and a hangover is a very stupid reason), it is selfish, and does more damage to the cause of worker's rights, not less. I don't know about where you work, but if I call in sick to my job, other people have to pick up my slack. I work for a public library, and we don't have a lot of funds, so we have the bear minimum of employees we can have and still work efficiently. As such, if anybody calls in, everyone else, up to and including the library director, have to take on more work. If I found out one of my co-workers called in because of a hangover, I'd be pissed. You made the choice to get drunk, knowing that you had to work the following morning. Putting it into the same category of someone who is sick and may not have the luxury of taking off because of a bad employer is insulting.


[Dec 17, 2018] Extreme temperatures may raise risk of premature cardiovascular death

Notable quotes:
"... Exposure to extreme temperatures can trigger changes in blood pressure, blood thickness, cholesterol and heart rate, according to previous research. ..."
"... "With increasing rates of obesity and related conditions, including diabetes, more people will be vulnerable to extreme temperatures and that could increase the future disease burden of extreme temperatures," Huang said. ..."
Sep 18, 2012 | medicalxpress.com

Circulation: Cardiovascular Quality and Outcomes , an American Heart Association journal.

The study in Brisbane, Australia, is the first in which researchers examined the association between daily average temperature and "years of life lost" due to CVD. Years of life lost measures premature death by estimating years of life lost according to average life expectancy .

The findings are important because of how the body responds to temperate extremes, the growing obesity trend and the earth's climate changes, said Cunrui Huang, M.Med., M.S.P.H., the study's lead researcher and a Ph.D. scholar at the School of Public Health and Institute of Health and Biomedical Innovation at Queensland University of Technology (QUT) in Brisbane, Australia.

Exposure to extreme temperatures can trigger changes in blood pressure, blood thickness, cholesterol and heart rate, according to previous research.

"With increasing rates of obesity and related conditions, including diabetes, more people will be vulnerable to extreme temperatures and that could increase the future disease burden of extreme temperatures," Huang said.

[Dec 12, 2018] You can buy a cheap chicken today, but we all pay for it in the long run

Dec 12, 2018 | www.ianwelsh.net

[Dec 09, 2018] Millions of Americans Could Face Surprise Emergency Room Bills in January

Dec 09, 2018 | www.bloomberg.com

A flood of surprise hospital bills could start arriving in U.S. mailboxes as early as January unless two giant for-profit health care companies resolve a dispute over whether thousands of doctors remain in patients' insurance networks.

America's biggest health insurer, UnitedHealthcare, is pitted against one of the country's largest employers of doctors, Envision Healthcare, in a massive contract fight over prices that Envision's 25,000 emergency doctors, anesthesiologists and other hospital-based clinicians charge.

A contract impasse would mean that UnitedHealthcare's 27 million privately insured patients could face expensive, unexpected doctor bills as of Jan. 1 when Envision doctors would become out-of-network.

Envision has already been criticized for its billing practices in situations where its doctors don't participate in patients' health plans. A Florida man got a bill for $2,255 from an Envision subsidiary after being treated by an out-of-network emergency doctor in 2014 for a facial injury, according to a lawsuit he filed earlier this year.

In another case, a California woman went to an in-network hospital for abdominal pain and found she needed emergency gallbladder surgery. The operation was covered, but she faced $4,447 in bills from Envision for two trips to the emergency department.

A judge dismissed the Florida case, and the case in California is in settlement talks.

[Dec 03, 2018] American Life Expectancy Continues to Fall: Rise in Suicides, Overdose Deaths the Big Culprit naked capitalism

Notable quotes:
"... My dentist who I think is Republican told me when I brought up Medicare for all said "I don't think we can afford Medicare for all." ..."
Dec 03, 2018 | www.nakedcapitalism.com

The evidence of social decay in America is becoming more visible. As other countries continue to show increases in life expectancy, the US continues its deterioration.

Life expectancy in the US fell to 78.6 years in 2017, a o.1 year fall from 2016 and a 0.3 year decline from the peak.

From CNN :

Overdose deaths reached a new high in 2017, topping 70,000, while the suicide rate increased by 3.7%, the CDC's National Center for Health Statistics reports.

Dr. Robert Redfield, CDC director, called the trend tragic and troubling. "Life expectancy gives us a snapshot of the Nation's overall health and these sobering statistics are a wakeup call that we are losing too many Americans, too early and too often, to conditions that are preventable," he wrote in a statement.

While this assessment is technically correct, it is too superficial in seeing the rising rate of what Angus Deaton and Ann Case called "deaths of despair" as a health problem, rather than symptoms of much deeper societal ills. Americans take antidepressants at a higher rate than any country in the world. The average job tenure is a mere 4.4 years. In my youth, if you changed jobs in less than seven or eight years, you were seen as an opportunist or probably poor performer. The near impossibility of getting a new job if you are over 40 and the fact that outside hot fields, young people can also find it hard to get work commensurate with their education and experience, means that those who do have jobs can be and are exploited by their employers. Amazon is the most visible symbol of that, working warehouse workers at a deadly pace, and regularly reducing even white collar males regularly to tears.

On top of that, nuclear families, weakened communities, plus the neoliberal expectation that individuals be willing to move to find work means that many Americans have shallow personal networks, and that means less support if one suffers career or financial setbacks.

But the big driver, which the mainstream press is unwilling to acknowledge, is that highly unequal societies are unhealthy societies. We published this section from a Financial Times comment by Michael Prowse in 2007, and it can't be repeated often enough :

Those who would deny a link between health and inequality must first grapple with the following paradox. There is a strong relationship between income and health within countries. In any nation you will find that people on high incomes tend to live longer and have fewer chronic illnesses than people on low incomes.

Yet, if you look for differences between countries, the relationship between income and health largely disintegrates. Rich Americans, for instance, are healthier on average than poor Americans, as measured by life expectancy. But, although the US is a much richer country than, say, Greece, Americans on average have a lower life expectancy than Greeks. More income, it seems, gives you a health advantage with respect to your fellow citizens, but not with respect to people living in other countries .

Once a floor standard of living is attained, people tend to be healthier when three conditions hold: they are valued and respected by others; they feel 'in control' in their work and home lives; and they enjoy a dense network of social contacts. Economically unequal societies tend to do poorly in all three respects: they tend to be characterised by big status differences, by big differences in people's sense of control and by low levels of civic participation .

Unequal societies, in other words, will remain unhealthy societies – and also unhappy societies – no matter how wealthy they become. Their advocates – those who see no reason whatever to curb ever-widening income differentials – have a lot of explaining to do.

And this extract comes from a 2013 article, Why Are Americans' Life Expectancies Shorter than Those of People in Other Advanced Economies?

Let's talk life expectancy.

The stats first. They tell a clear story: Americans now live shorter lives than men and women in most of the rest of the developed world. And that gap is growing.

Back in 1990, shouts a new study published last week in the prestigious Journal of the American Medical Association, the United States ranked just 20th on life expectancy among the world's 34 industrial nations. The United States now ranks 27th -- despite spending much more on health care than any other nation.

Americans, notes an editorial the journal ran to accompany the study, are losing ground globally "by every" health measure.

Why such poor performance? Media reports on last week's new State of U.S. Health study hit all the usual suspects: poor diet, poor access to affordable health care, poor personal health habits, and just plain poverty.

In the Wall Street Journal, for instance, a chief wellness officer in Ohio opined that if Americans exercised more and ate and smoked less, the United States would surely start moving up in the global health rankings.

But many epidemiologists -- scientists who study health outcomes -- have their doubts. They point out that the United States ranked as one of the world's healthiest nations in the 1950s, a time when Americans smoked heavily, ate a diet that would horrify any 21st-century nutritionist, and hardly ever exercised.

Poor Americans, then as now, had chronic problems accessing health care. But poverty, epidemiologists note, can't explain why fully insured middle-income Americans today have significantly worse health outcomes than middle-income people in other rich nations.

The University of Washington's Dr. Stephen Bezruchka has been tracking these outcomes since the 1990s. The new research published in the Journal of the American Medical Association, Bezruchka told Too Much last week, should worry Americans at all income levels.

"Even if we are rich, college-educated, white-skinned, and practice all the right health behaviors," he notes, "similar people in other rich nations will live longer."

A dozen years ago, Bezruchka published in Newsweek the first mass-media commentary, at least in the United States, to challenge the conventional take on poor U.S. global health rankings.

To really understand America's poor health standing globally, epidemiologists like Bezruchka posit, we need to look at "the social determinants of health," those social and economic realities that define our daily lives.

None of these determinants matter more, these researchers contend, than the level of a society's economic inequality, the divide between the affluent and everyone else. Over 170 studies worldwide have so far linked income inequality to health outcomes. The more unequal a society, the studies show, the more unhealthy most everyone in it -- and not the poor alone.

Just how does inequality translate into unhealthy outcomes? Growing numbers of researchers place the blame on stress. The more inequality in a society, the more stress on a daily level. Chronic stress, over time, wears down our immune systems and leaves us more vulnerable to disease.

The Wall Street Journal has more detail on the breakdown of the further decline in US life expectancy , and also points out how other countries are continuing to show progress:

Data the Centers for Disease Control and Prevention released on Thursday show life expectancy fell by one-tenth of a year, to 78.6 years, pushed down by the sharpest annual increase in suicides in nearly a decade and a continued rise in deaths from powerful opioid drugs like fentanyl. Influenza, pneumonia and diabetes also factored into last year's increase.

Economists and public-health experts consider life expectancy to be an important measure of a nation's prosperity. The 2017 data paint a dark picture of health and well-being in the U.S., reflecting the effects of addiction and despair, particularly among young and middle-aged adults, as well as diseases plaguing an aging population and people with lower access to health care

Life expectancy is 84.1 years in Japan and 83.7 years in Switzerland, first and second in the most-recent ranking by the Organization for Economic Cooperation and Development. The U.S. ranks 29th..

White men and women fared the worst, along with black men, all of whom experienced increases in death rates. Death rates rose in particular for adults ages 25 to 44, and suicide rates are highest among people in the nation's most rural areas. On the other hand, deaths declined for black and Hispanic women, and remained the same for Hispanic men .

Earlier this century, the steady and robust decline in heart-disease deaths more than offset the rising number from drugs and suicide, Dr. Anderson said. Now, "those declines aren't there anymore," he said, and the drug and suicide deaths account for many years of life lost because they occur mostly in young to middle-aged adults.

While progress against deaths from heart disease has stalled, cancer deaths -- the nation's No. 2 killer -- are continuing a steady decline that began in the 1990s, Dr. Anderson said. "That's kind of our saving grace," he said. "Without those declines, we'd see a much bigger drop in life expectancy."

Suicides rose 3.7% in 2017, accelerating an increase in rates since 1999, the CDC said. The gap in deaths by suicide widened starkly between cities and the most rural areas between 1999 and 2017, the data show. The rate is now far higher in rural areas. "There's a much wider spread," Dr. Hedegaard said.

"This is extremely discouraging," Christine Moutier, chief medical officer of the American Foundation for Suicide Prevention, said of the suicide-rate increase. Studies show that traumas such as economic difficulties or natural disasters, along with access to lethal means including guns and opioid drugs, and lack of access to care can affect suicide rates, she said. More accurate recording of deaths may also have added to the numbers, she said.

Japan leads the pack in life expectancy and pretty much every other measure of social well being. Yet when its financial bubbles were bigger than the ones in the US pre our crisis, and it's on its way to having a lost three decades of growth. On top of that, Japan has one of the worst demographic crunches in the world, in terms of the aging of its population. So how it is that Japan is coping well with decline, while the US is getting sicker in many ways (mental health, obesity, falling expectancy)?

It's easy to hand-wave by saying "Japanese culture," but I see the causes as more specific. The Japanese have always given high employment top priority in their economic planning. Entrepreneurs are revered for creating jobs, not for getting rich. Similarly, Japan was long criticized by international economist types for having an inefficient retail sector (lots of small local shops), when they missed the point: that was one way of increasing employment, plus Japanese like having tight local communities.

After their crisis, Japanese companies went to considerable lengths to preserve jobs, such as by having senior people taking pay cuts and longer term, lowering the already not that large gap between entry and top level compensation. The adoption of second-class workers (long-term temps called "freeters") was seen as less than ideal, since these workers would never become true members of the company community, but it was better than further reducing employment.

Contrast that to our crisis response. We reported in 2013 that the top 1% got 121% of the income gains after the crisis. The very top echelon did better at the expense of everyone else. Longer term, lower-income earners have fallen behind. From a 2017 MarketWatch story, quoting a World Economic Forum report: "America has experienced 'a complete collapse of the bottom 50 percent income share in the U.S. between 1978 to 2015.'"

There is a lot of other data that supports the same point: inequality continues to widen in America. The areas that are taking the worst hits are states like West Virginia and Ohio that have been hit hard by deindustrialization. But the elites are removed in their glamorous cities and manage not to notice the conditions when they transit through the rest of America. They should consider themselves lucky that America's downtrodden are taking out their misery more on themselves than on their betters.

The Rev Kev , November 30, 2018 at 6:30 am

God, this is so depressing to read. The worse aspect of it is that it never had to be this way but that these deaths were simply 'collateral damage' to the social and economic changes in America since the 1970s – changes by choice. This seems to be a slow motion move to replicate what Russia went through back in the 1990s which led to the unnecessary, premature deaths of millions of its people. Dmitry Orlov has a lot to say about the subject of collapse and there is a long page in which Orlov talks about how Russia got through these bad times while comparing it with America as he lives there now. For those interested, it is at-

http://energyskeptic.com/2015/dmitry-orlov-how-russians-survived-collapse/

What gets me most is how these deaths are basically anonymous and are not really remembered. When AIDS was ravishing the gay community decades ago, one way they got people to appreciate the numbers of deaths was the AIDS Memorial Quilt which ended up weighing over 50 tons. It is a shame that there can not be an equivalent project for all these deaths of despair.

Yves Smith Post author , November 30, 2018 at 6:47 am

There were pictures in the Wall Street Journal article I didn't pull over due to copyright issues, but it did show people commemorating these deaths Captions:

People in Largo, Fla., hold candles at a vigil on Oct. 17 to remember the thousands who succumbed to opioid abuse in their community.

More than 1,000 backpacks containing belongings of suicide victims and letters with information about them are scattered across a lawn during a demonstration at the University of Tennessee at Chattanooga on March 22.

But to your point, these seem isolated and are not getting press coverage at anywhere near the level of the AIDS crisis.

Carla , November 30, 2018 at 1:24 pm

Great post, Yves, thank you! One suggestion: might you consider putting the last word in quotes, as in "betters" ?

Spanish reader , November 30, 2018 at 1:35 pm

It focuses too much on peak oil. As if the social collapse of the United States (and the Soviet Union) was some kind of natural consequence of resources dryinf out instead of a premeditated looting.

Eclair , November 30, 2018 at 2:24 pm

Orlov's posts on how Russians survived the collapse is a small masterpiece. I read it a couple of years back and it affected me greatly. I just reread it, thanks, Rev Kev, and it seems even more relevant now.

Small gems: Money becomes useless: items or services that can be swapped are paramount. Bottles of alcohol, fresh homegrown veggies (and pot), I re-fashion your old suit and you fix my broken window.

Social networks keep you alive. Know and be on good terms with your neighbors. Communal gardens keep you fed.

War-hardened men (and the women who love them), who thrive on violence abound. They will either be hired as security or rove about as free-lancers. A community is better able either to hire them, or defend against them.

Our ancestors lived and thrived without: central heating, electric lights, hot and cold running water, flush toilets, garbage collection, the Internet. We can too; it just takes forethought and planning. Densely packed cities without these amenities are hell.

Cultivate an attitude of disdain for the 'normal' things that society values, especially if you are a middle-aged male; career, large house and SUV, foreign vacations, a regular salary. Enjoy contemplating nature. When the former disappear, you have the latter to fall back upon. And consider a second career as a recycler of abandoned buildings, or a distiller of potatoes. (Think of all the Medieval structures built from crumbling Roman edifices.)

Russians, in many ways, had more resilience built in to their system: housing was State-owned, so there was less homelessness. Private automobiles were relatively rare, but public transportation was wide-spread and remained in good-running order. Minimal universal health care existed.

Cease from trying, futilely, to change the System. Ain't gonna happen. Instead, prepare to survive, if only just, the coming dismantling.

Steve H. , November 30, 2018 at 7:24 am

> Once a floor standard of living is attained, people tend to be healthier when three conditions hold: they are valued and respected by others; they feel 'in control' in their work and home lives; and they enjoy a dense network of social contacts.

"Sapolsky: We belong to multiple hierarchies, and you may have the worst job in your corporation and no autonomy and control and predictability, but you're the captain of the company softball team that year and you'd better bet you are going to have all sorts of psychological means to decide it's just a job, nine to five, that's not what the world is about. What the world's about is softball. I'm the head of my team, people look up to me, and you come out of that deciding you are on top of the hierarchy that matters to you."

iirc, there was a perspective of some economists that infinite groaf could be carried by the creative, emergent, and infinite wants of homo sapiens. But that creates compounding deprivations, never enough time, money, resources. With the 2:1 ratio of loss aversion, what is compounded are bad affects.

That 'dense network of social contacts' means smaller groups with symmetric interactions. The multiple dominance heirarchies is the healthy version of creative emergence, but supplying needs, not creating wants.

rd , November 30, 2018 at 9:02 am

I think that one of the most valuable tools used by government in the Great Depression was the CCC, WPA, and TVA set of programs that provided jobs to people while they created valuable infrastructure and art. How many of those people could go back to the dams or state parks and tell their spouses and kids that "I helped build that." During a time of despair, it was a way of making people believe they had value.

Today, it would be viewed as a waste of money that could be better spent on the military or another tax cut for the wealthy.

Wukchumni , November 30, 2018 at 9:24 am

I'd mentioned some wrongheaded policies of Sequoia NP of 90 years ago yesterday, and they seem ridiculous in retrospect, and we no longer treat natural places as ad hoc zoos, where everybody gets to see the dancing bears @ a given hour.

Our methodology as far as our rapport with fire was just as stupid, but we've really done nothing to repair our relationship with trees and the forests they hang out in.

There's an abundance of physical labor needed to clear out the duff, the deadfalls and assorted debris from huge swaths of guaranteed employment until the job is done, which could take awhile.

There's really few graft possibilities though, we're talking chainsaws, Pulaskis, never ending burn pile action and lots of sweat equity. If KBR wanted to be in charge of backcountry camps housing crews, that'd be ok, they'd be doing something useful for a change.

False Solace , November 30, 2018 at 12:33 pm

Yes, why do you think video games appeal so much to young males? Because of the pixels? What these gamers are really after is the ability to excel in a niche hierarchy. It doesn't (usually) appeal to females as much as more traditional kinds of success but it serves a psychological need.

divadab , November 30, 2018 at 8:13 am

A traitorous ruling class that has sold out its workers in favor of foreign workers.

And it's very lucrative – the Walton's fortune was made by being an agent of communist Chinese manufacturers. In direct competition with US manufacturers. Does this not seem like treason to you?

Phillip Allen , November 30, 2018 at 9:10 am

The word 'communist' in relation to the Chinese government and party is void of content. 'Communist' in the current Chinese context is legacy branding, nothing more. Its use in this comment is inflammatory, as is the too-loose bandying of 'treason'. The Waltons are loyal to their class (however fierce their disputes may be with rival oligarch factions), and since the state exists to serve the interests of their class, how can they be traitors to the state?

divadab , November 30, 2018 at 10:34 am

"Communist" is what they call themselves. They're totalitarians. Which is what most people think "communist" means – because all countries that called themselves communist used authoritarian rule. Methinks you might be a marxist idealist. Offended by the misuse of your ideal State word by totalitarians.

Similarly, I used "treason" in the sense of acting against the interests of the citizens, not in the sense of a crime against the state. You clearly believe the state to be representative of only the ruling class. And I don't disagree wrt the USA and its imperial machine. Which would make the State treasonous, according to the sense of the word I used.

NotTimothyGeithner , November 30, 2018 at 10:51 am

One could always say communism is an end point developed through a process preceded by socialism and before that capitalism which replaces feudalism. The idea being Chinese Communists, the rich Chinese have bug out spots for a reason, believe Mao and the Soviets moved too quickly skipping a Marxist historical epoch.

The Communist Party officially is always a vanguard for the future society not the Communist society. Phrases such as "under communism" aren't Soviet features as much as they are propaganda from the West.

When the Reds were the only game in town, the greedy class joined the CCP, but since 1991, they skipped signing up, leaving believers in control. What the party congress believes is probably important.

As far as branding goes, all Communists are branded because the are all vanguard parties, not parties of blocs or even current populations. Star Trek is the only communist society. The Soviet thinkers definitely wrote about what an Ideal society would look like, the nature of work, and self and societal improvement.

Overthrowing a long established government shouldn't be done for light and transient reasons, and Xi has seemed to be concerned with the demands of the party congress. The party at large doesn't have a single voice to rally behind which makes it difficult to overthrow a government.

rob , December 1, 2018 at 7:01 am

the word is "communist". The gov't isn't anything of the sort these days. Isn't the chinese gov't of today "fascist". just like the national socialists of the german stripe? They are the state that may be lord over controller of private institutions, and ruler of other state institutions, all intermixed into what is "the chinese economy". They allow the private wealth creation in a controlled sense. that is state function serving private wealth. and if you are a party loyal, private wealth may come to you some day too.
It is just another part of the world trend "everyone is turning into full fledged fascists"
No wonder people in the states are dying earlier.. to get back on topic

Polar Donkey , November 30, 2018 at 8:29 am

Last night, my wife and I took our boys to meet Santa at my older son's school. Elementary school in Mississippi. The town is an outer suburb of Memphis. A mile east of the town you are in rural Mississippi. I noticed 2 or 3 parents with visible drug addiction issues. These folks were still people. Want their kids to see Santa and have a better life. The country doesn't care.

Janie , November 30, 2018 at 9:49 am

I'll guess that you're near Byhalia. Happy memories of visiting family there from late forties through sixties. Wonder what its like now – how the economic changes have affected it.

Polar Donkey , November 30, 2018 at 7:41 pm

Byhalia is a little further down highway 78. Kids from Byhalia drive up to Olive Branch to go to a McDonald's and other fast food. Things may be changing because they just completed an outer interstate loop that passes close by Byhalia. Byhalia was just in news a couple months ago because a kid died during a football game. People were up in arms about no doctor at game and a 30 to 40 minute drive to closest hospital. There aren't any doctors offices in Byhalia. Then toxicology report came back. Kid had cocaine in his system. Holly Springs and Byhalia area are big drug smuggling area. Close to Memphis and it's distribution network, but across state line in poor rural Mississippi. NBA players linked to this area and smuggling networks.

Wukchumni , November 30, 2018 at 8:44 am

I'm always amazed @ the suicide by gun numbers, as it strikes me as a not so fool proof way of checking out, exacerbated by perhaps dying slowly in a painful way?

Oh, and bloody, very much so.

Fentanyl seems an easier way out, you just drift into the ether and leave a presentable corpse for everybody you knew, who all wonder if they could have done something to stop it from happening, posthaste.

NotTimothyGeithner , November 30, 2018 at 10:10 am

It's cheap and fairly efficient, and the drug way out can be tricky. Silent film legend, Lupe Valez, is the famed example of suicide by drugs gone wrong. She still died but not on her own terms because the sleeping pills she took didn't react well with her last meal.

How many people have tried to check out and had it not work is something to consider.

Martin Finnucane , November 30, 2018 at 2:28 pm

Re Lupe Valdez: probably not true, at least according to the Wikipedia page . Not that it affects your point too much, I guess.

timbers , November 30, 2018 at 8:44 am

The level of denial people are capable of can be daunting.

1). My dentist who I think is Republican told me when I brought up Medicare for all said "I don't think we can afford Medicare for all." This was not an immediate response to my raising the topic, but something he told me after several visits and having thought about what I had said and around the time Sanders got media coverage introducing a Medicare for all bill (I was getting a crown and required many visits). Talking to your dentist can be a one sided conversation for obvious reasons, but I thought "don't you mean we can't afford NOT to have Medicare for all?"

2). A co-worker of mine who is African American. When I said U.S. life expectancy is falling, this is a sign of extreme policy failure and should affect how we rate the ACA (read that here, of course!) replied "You're assuming health has an impact on life expectancy." I was stunned and didn't know what to say for a second and finally said "yes, absolutely."

TroyMcClure , November 30, 2018 at 9:47 am

These are the types that are more than happy to hand the place over to the next Bolsonaro if only to protect the status gap between themselves and those beneath them.

False Solace , November 30, 2018 at 12:42 pm

They also "hand the place over" when the Bolsonaro types tell everyone they have the solution and the opposition party is tainted by austerity and corruption.

Massinissa , November 30, 2018 at 12:49 pm

"You're assuming health has an impact on life expectancy"

I have absolutely no idea how I would respond to this either. Was this comment by this person some kind of built in knee-jerk response to criticism of the ACA/Obama?

timbers , December 1, 2018 at 9:09 am

Opps I meant to write "You're assuming health CARE has an impact on life expectancy."

In response to your question, I think so, yes.

jrs , November 30, 2018 at 1:03 pm

actually you are assuming health coverage, even if it was real coverage for what one needed, has that much of an impact on life expectancy and from what I've read it probably doesn't compared to things like poverty *regardless* of health coverage. Because the greatest link to say heart attacks is with poverty (not diet etc.)

At this point though it doesn't even make sense to talk about the ACA circa now and say it's Obama's ACA, it wasn't that great to begin with. But Trump has made it worse.

Left in Wisconsin , November 30, 2018 at 2:06 pm

My dentist who I think is Republican told me when I brought up Medicare for all said "I don't think we can afford Medicare for all."

When I brought up Medicare for All to my dentist, after listening to him describe some of his ER work where he claims to routinely see people who have intentionally damaged their teeth in order to obtain painkillers (which he is not allowed to proscribe to them regardless), he said he would never want to have the kind of inferior health care they have "in Europe." He seemed genuinely surprised when I reported that my wife had done most of a pregnancy in Italy in the mid-90s and got pre-natal care that was better than anything she ever got in this country.

My dentist is definitely a Repub. And he socializes with other medical professionals, which I presume gives him a very distorted image of the health care system. I often hear him railing against the idiotic dictates of insurance companies and he seems genuinely proud that, unlike the inscrutable and BS pricing of hospitals, dentists have to have straightforward pricing because many people do pay 100% out of pocket (so he says).

This is a part of the 10% that is going to be very hard to reach. But I tell him socialists need dental care too and so he will always have work even after we take over.

Tom Stone , November 30, 2018 at 9:27 am

Suicide can be a rational and sensible choice.
Bluntly, if the quality of your life is shitty and not going to improve why stick around?
That the reason so many people's lives are bad enough that they decide death is preferable to life is societal doesn't change their circumstances.
If you are old and sick, barely surviving financially or in poor health and unable to afford care suicide might look like your best alternative.
The "Hemlock Society" has been around for quite a while, that its membership is growing in the short term says a great deal about America.

In the Land of Farmers , November 30, 2018 at 12:15 pm

Suicide is never rational. It is arrogance that one could weigh the pros and cons of suicide like they think the have all the pertinent information. The only truth is that we have no idea what happens when we die or if there is some kind of experience that continues in a form that might not be a personal consciousness. Also, why don't you see the decision to die is made under duress and therefor invalid like signing a contract with a gun pointed at your head? There were several times in my life that I determined "the quality of [my] life is shitty and not going to improve [so] why stick around", but yet, I became better off going through the struggle. As a result I have made others lives better with the understanding I have gained going through the Shaman's journey.

By considering suicide you are considering trading a known (suffering) for an unknown (Death). In what way can that be considered rational?

The sad fact is that we spend our whole lives avoiding suffering and never take the time to understand it. Opioids, all drugs, are a route to avoid suffering, to avoid looking at our trauma. Materialism is about avoiding our suffering. Suicide is materialistic because it supposes there is a mind that we can stop.

But even in the Buddhist centers I visit it has turned away from the spiritual and people go there not to understand their suffering, but rather only to escape it.

American society does not have an economic problem, it has a spiritual problem.

Eclair , November 30, 2018 at 2:48 pm

I respect your view that suicide is an arrogant act and that suffering is an unavoidable part of life. I totally agree with the latter philosophy. You suffer, and you wade through it and come out on the other side as a better person. Forged in fire, so to speak.

Plus, I am, by nature, an optimist. There is always something to look forward to, every morning.

But, a few years ago, I suffered a cascade of bodily failures, whose symptoms were at first ignored, then misdiagnosed, resulting in my taking medications that made me worse off. At one point, for two months, I had constant nerve pain (comparable to having teeny barbed wire wrapped around my torso and and being zapped by an electric charge every few seconds.) Plus back pain. I could not eat, and when I did, I vomited. I lost 20 pounds. I could not sleep for more than hour at a time, and that hour happened only once a day. I walked only with the aid of two walking sticks. I was totally constipated for a month (gross, but this condition just adds to one's misery.) There was no end in sight and my condition just kept worsening with each round of new medication.

I did not seriously contemplate suicide. But I did give some thought to what I would do if I had to face life without sleep, without food, without the ability to walk, and death came up as one of the better solutions. Fortunately, I changed doctors.

In the Land of Farmers , November 30, 2018 at 6:10 pm

I empathize with your struggles, and I have contemplated suicide myself, but contemplating death is part of the shaman's journey. I do not think that suicide is arrogant, I think it is a misunderstanding.

IMHO, medical doctors will disrupt this journey. They should be consulted but with the understanding that they know very little about the balance of the body and what is needed to heal.

Truth is, we will die. The greater the suffering the easier to find out "who" that is suffering.

sangweq , November 30, 2018 at 10:35 pm

"Life teaches you how to live it, if you live long enough.".

-Tony Bennett

witters , November 30, 2018 at 7:44 pm

"Suicide is never rational" is an arrogant assertion.

Massinissa , November 30, 2018 at 12:53 pm

Even if it *is* a 'rational' choice, that is because the system is absolutely broken and must be changed.

In the Land of Farmers , November 30, 2018 at 1:33 pm

+1000

I get in fights with my therapist all the time about this. She is always advocating for ME to change when I feel if she wants to help us all she should be helping us change the system.

jrs , November 30, 2018 at 1:58 pm

Well roles like therapist are part of what props up the system and they get paid for precisely that.

I mean if we are just living our lives we see that things are both individual and systematic. And some things are strongly systematic (economic problems), and others probably have a significantly personal component (phobias etc.). And so we have to exist with both being true, but if we are drowning in economic problems the rest doesn't matter. But therapists have a specific role to individualize all problems. But if people are just doing therapy to get stuff off their chest, who can blame them. Enough people are, although it's not how therapists like to see their role.

Ojia , November 30, 2018 at 9:34 am

Lifespan dropping, mortality going up

Are we tired of winning yet???

Jason Boxman , November 30, 2018 at 9:58 am

The only real visible sign of decay on the train to DC from Boston is Baltimore, which nearly appears bombed out.

NotTimothyGeithner , November 30, 2018 at 11:34 am

The train goes right by Chester, Pa, and you can see decay along the tracks all along BosWash. Except for Biden, a corrupt tool who hasn't figured out how to cash in, the elites don't take the train.

Tomonthebeach , November 30, 2018 at 1:07 pm

Remember the Kingsman movie where the president was going to let all the dopers die? Think Trump.

Not only is the WH response to the opioid problem merely cosmetic, they (and NIH) refuse to link it to the economics of human obsolescence. How convenient. As jobs die, the workers do too – less welfare burden. That is fascist thinking, and it is evident today.

Finally, let us recall that all public health leaders are Trump appointees – i.e., incompetent. CDC too refuses to link suicide to the economy. It's bad politics. They can do this because there are no national standards for reporting deaths as suicides or even drug overdoses. It is entirely up to the elected coroner. Thus 10s of thousands of suicides are reported as natural or accidental either intentionally to ease the grief of family members or because they lack the manpower to investigate suspicious deaths. Note the bump in accidental deaths. Driving your car into a concrete abutment or over a cliff might be an accident, but more often than not, the driver was pickled (Irish courage) and the death was intentional.

So, until we do a better job of measuring the causes of death, the administration can continue to blame the deaths on moral weakness rather than its cruel economic policies.

djrichard , November 30, 2018 at 2:19 pm

Well we might not be thriving, but our empire is thriving. And the empire has a simple message for us: embrace the suck.

How is it legal , November 30, 2018 at 2:20 pm

Sadly, I believe if suicide attempts were taken into account, the picture would even look far bleaker, and likely include far more Metro areas. In those Metro areas there are likely far less gun/rifle owners (reportedly the most successful method), far quicker ambulance response times, and significant expenditures have been made, and actions taken, to thwart attempts on transit lines and bridges, along with committing suicidal persons to locked down psychiatric facilities (which then adds further financial burden, significant employment issues, and possibly ugly, forced medication side effects); while doing absolutely nothing whatsoever to address the causes.

What a sickening blotch on the US , with such wealth and power – sovereign in its own currency – that it's citizens are increasingly attempting and committing suicide because they can no longer afford to live in any manner that's considered humane. That, while its Fourth Estate deliberately obscures the deadly problem – which cannot be cured by forcing Pharma™, Therapy™, and Psychiatric Confinement™ at it, when a predatory crippling of economic stability is the entire cause – and refuses to hold the Government and Elites accountable.

Bobby Gladd , November 30, 2018 at 3:36 pm

I would commend to all Beth Macy's riveting book " Dopesick : Dealers, Doctors, and the Drug Company that Addicted America ."

Equal parts nicely written investigative reporting and painful personal stories. I'd thought that the "opioid epidemic" meme was hyperbolic. I was wrong.

WorkerPleb , December 1, 2018 at 5:32 pm

This happened in Russian and Eastern European countries too didn't it?

[Nov 26, 2018] >Revealed: faulty medical implants harm patients around world by Hilary Osborne , Hannah Devlin and Caelainn Barr

Notable quotes:
"... In the US, the Food and Drug Administration (FDA) has collected 5.4m "adverse event" reports over the past decade, some from manufacturers reporting problems in other parts of the world. ..."
"... Interviews with patients and doctors have revealed flaws in how the medical devices industry is regulated. ..."
Nov 25, 2018 | www.theguardian.com
The Implant Files investigation reveals damage caused by poor regulation and lax testing rules

Why we're examining the implants industry

Patients around the world are suffering pain and many have died as a result of faulty medical devices that have been allowed on to the market by a system dogged by poor regulation, lax rules on testing and a lack of transparency, an investigation has found.

Pacemakers, artificial hips, contraceptives and breast implants are among the devices that have caused injuries and resulted in patients having to undergo follow-up operations or in some cases losing their lives.

In some cases, the implants had not been tested in patients before being allowed on to the market.

In the UK alone, regulators received 62,000 "adverse incident" reports linked to medical devices between 2015 and 2018. A third of the incidents had serious repercussions for the patient, and 1,004 resulted in death.

In the US, the Food and Drug Administration (FDA) has collected 5.4m "adverse event" reports over the past decade, some from manufacturers reporting problems in other parts of the world.

These included 1.7m reports of injuries and almost 83,000 deaths. Nearly 500,000 mentioned an explant – surgery to remove a device.

The figures come from research by 252 journalists from 59 media organisations in 36 countries, which has uncovered a litany of problems in the global $400bn (£310bn) industry.

Examples of failure in the market include:

Replacement hips and vaginal mesh products sold to hospitals without any clinical trials. Patients relying on faulty pacemakers when manufacturers were aware of problems. Complications with hernia mesh that ruled one of Britain's top athletes out of competing for years. Regulators approving spinal disc replacements that later disintegrated and migrated in patients. Surgeons admitting they were unable to tell patients about the risks posed by implants because of a lack of central registers. Patients in Australia being given devices that the regulator has approved on the basis they have been approved in Europe.

The findings raise concerns about the level of scrutiny devices undergo before and after they go on the market, and whether regulators detect and act upon findings quickly enough.

Information about problems with devices is, in many countries, kept under wraps, making it difficult for patients to research procedures that have been recommended to them.

Interviews with patients and doctors have revealed flaws in how the medical devices industry is regulated.

Prof Derek Alderson, the president of the Royal College of Surgeons, said there had been enough incidents involving flawed devices to "underline the need for drastic regulatory changes", including the introduction of mandatory national registries for all implantable devices.

"In contrast to drugs, many surgical innovations are introduced without clinical trial data or centrally held evidence," he said. "This is a risk to patient safety and public confidence."

The Guardian and organisations including the BBC , Le Monde and Süddeutsche Zeitung, coordinated by the International Consortium of Investigative Journalists (ICIJ), have trawled through thousands of documents, many obtained through freedom of information (FoI) requests, to unearth some of the biggest problems.

Alongside interviews with patients and doctors, these have revealed flaws in the way the industry is regulated that are unlikely to be fixed by rules due to come into force in Europe.

Among the concerns raised by the Implant Files project are that manufacturers are in charge of testing their own products after faults have developed – and are allowed to shop around for approval to market their products, without declaring any refusals.

The Guardian has also heard about doctors who have close industry ties or seem eager to be early adopters of the latest devices to enhance their professional standing.

Plans for tougher EU rules have been watered down after industry lobbying, according to a huge trove of documents uncovered by the project.

[Nov 09, 2018] One treatment that works for me is to put your hands on a thick peace foam bed cover

Nov 09, 2018 | www.moonofalabama.org

likbez , Nov 6, 2018 6:57:47 PM | link

b wrote:

The pain in my right shoulder is much better now, and I can somewhat use my arm again.

The issue isn't serious but likely just a reaction to constant overuse under not ideal ergonomic circumstances. I was told to refrain from typing and using the mouse for another day or two or until I feel no more pain at all.


This is way too optimistic. This issue usually is chronic and subside very slowly, often when you lost any hope that it can be eliminated. Typically pain lasts at least one month, and often half a year even with medication and physiotherapy.

Typically this is the first sign of a chronic condition that is very difficult to cure. I think that switching to your left hand for the mouse is a must and should be the first adjustment step.

One treatment that works for me is to put your hands on a thick peace foam bed cover. Cut a part corresponding to the area of the table where you mouse and keyboard are located, then cut the hole in it for keyboard and mousepad. Or just cut two strips which is simpler, but they tend to slide.

After then put your hand on foam why typing and using the mouse. This damping of vibration (or whatever) provided by 4-5 cm thick foam help to eliminate pain pretty effectively.

Also, you might benefit from getting Microsoft Natural Ergonomic Keyboard 4000 for Business ($37 on Amazon) as well. It is cheap and helps in such conditions. It allows to increase the angle between your elbow and provides reverse tilt for the keyboard.

I also tried a dozen of creams and physical therapy methods. Looks like Aspirin-containing cream (for example, Aspercream) works better.

Among exercises that might work (but did not work for me, at least did not produce significant effects), I would mention self-massage (look at youtube videos) as well as the exercise of rotating a plastic tube (you can buy a special on Amazon, or use those used for swimming) with two hands in opposite directions, and squeezing a tennis ball while walking.

The key here is that they help to provide adequate attention to this serious problem so even when they are useless, they re helpful by keeping you alert to the problem ;-)

rjj , Nov 8, 2018 2:45:57 AM | link

b, stopped using anti-ergonomic move-around-on-pad mouse in 1990s. pains and hand spasms went away when I switched to trackballs. big ball kensingtons were great but they were expensive and broke down easily -- possibly due to cheetos fines ... could have been mayonnaise. anyway have used low end logiteks for 20 years.

https://wiki.ezvid.com/best-trackball-mice

[Nov 08, 2018] Technology Detox The Health Benefits of Unplugging Unwinding by Sara Tipton

Notable quotes:
"... Another great tip is to buy one of those old-school alarm clocks so the smartphone isn't ever in your bedroom. ..."
Nov 07, 2018 | www.zerohedge.com

Authored by Sara Tipton via ReadyNutrition.com,

Recent studies have shown that 90% of Americans use digital devices for two or more hours each day and the average American spends more time a day on high-tech devices than they do sleeping: 8 hours and 21 minutes to be exact. If you've ever considered attempting a "digital detox", there are some health benefits to making that change and a few tips to make things a little easier on yourself.

Many Americans are on their phones rather than playing with their children or spending quality family time together. Some people give up technology, or certain aspects of it, such as social media for varying reasons, and there are some shockingly terrific health benefits that come along with that type of a detox from technology. In fact, more and more health experts and medical professionals are suggesting a periodic digital detox; an extended period without those technology gadgets. Studies continue to show that a digital detox, has proven to be beneficial for relationships, productivity, physical health, and mental health. If you find yourself overly stressed or unproductive or generally disengaged from those closest to you, it might be time to unplug.

DIGITAL ADDICTION RESOLUTION

It may go unnoticed but there are many who are actually addicted to their smartphones or tablet. It could be social media or YouTube videos, but these are the people who never step away. They are the ones with their face in their phone while out to dinner with their family. They can't have a quiet dinner without their phone on the table. We've seen them at the grocery store aimlessly pushing around a cart while ignoring their children and scrolling on their phone. A whopping 83% of American teenagers claim to play video games while other people are in the same room and 92% of teens report to going online daily . 24% of those users access the internet via laptops, tablets, and mobile devices.

Addiction therapists who treat gadget-obsessed people say their patients aren't that different from other kinds of addicts. Whereas alcohol, tobacco, and drugs involve a substance that a user's body gets addicted to, in behavioral addiction, it's the mind's craving to turn to the smartphone or the Internet. Taking a break teaches us that we can live without constant stimulation, and lessens our dependence on electronics. Trust us: that Facebook message with a funny meme attached or juicy tidbit of gossip can wait.

IMPROVE RELATIONSHIPS AND BE MORE PERSONABLE

Another benefit to keeping all your electronics off is that it will allow you to establish good mannerisms and people skills and build your relationships to a strong level of connection. If you have ever sat across someone at the dinner table who made more phone contact than eye contact, you know it feels to take a backseat to a screen. Cell phones and other gadgets force people to look down and away from their surroundings, giving them a closed off and inaccessible (and often rude) demeanor. A digital detox has the potential of forcing you out of that unhealthy comfort zone. It could be a start toward rebuilding a struggling relationship too. In a Forbes study , 3 out of 5 people claimed that they spend more time on their digital devices than they do with their partners. This can pose a real threat to building and maintaining real-life relationships. The next time you find yourself going out on a dinner date, try leaving your cell phone and other devices at home and actually have a conversation. Your significant other will thank you.

BETTER SLEEP AND HEALTHIER EATING HABITS

The sleep interference caused by these high-tech gadgets is another mental health concern. The stimulation caused by artificial light can make you feel more awake than you really are, which can potentially interfere with your sleep quality. It is recommended that you give yourself at least two hours of technology-free time before bedtime. The "blue light" has been shown to interfere with sleeping patterns by inhibiting melatonin (the hormone which controls our sleep/wake cycle known as circadian rhythm) production. Try shutting off your phone after dinner and leaving it in a room other than your bedroom. Another great tip is to buy one of those old-school alarm clocks so the smartphone isn't ever in your bedroom. This will help your body readjust to a normal and healthy sleep schedule.

Your eating habits can also suffer if you spend too much time checking your newsfeed. The Rochester Institute of Technology released a study that revealed students are more likely to eat while staring into digital media than they are to eat at a dinner table. This means that eating has now become a multi-tasking activity, rather than a social and loving experience in which healthy foods meant to sustain the body are consumed. This can prevent students from eating consciously, which promotes unhealthy eating habits such as overeating and easy choices, such as a bag of chips as opposed to washing and peeling some carrots. Whether you're an overworked college student checking your Facebook, or a single bachelor watching reruns of The Office , a digital detox is a great way to promote healthy and conscious eating.

IMPROVE OVERALL MENTAL HEALTH

Social media addicts experience a wide array of emotions when looking at the photos of Instagram models and the exercise regimes of others who live in exotic locations. These emotions can be mentally draining and psychologically unhealthy and lead to depression. Smartphone use has been linked to loneliness, shyness, and less engagement at work. In other words, one may have many "social media friends" while being lonely and unsatisfied because those friends are only accessible through their screen. Start by limiting your time on social media. Log out of all social media accounts. That way, you've actually got to log back in if you want to see what that Parisian Instagram vegan model is up to.

If you feel like a detox is in order but don't know how to go about it, start off small. Try shutting off your phone after dinner and don't turn it back on until after breakfast. Keep your phone in another room besides your bedroom overnight. If you use your phone as an alarm clock, buy a cheap alarm clock to use instead to lessen your dependence on your phone. Boredom is often the biggest factor in the beginning stages of a detox, but try playing an undistracted board game with your children, leaving your phone at home during a nice dinner out, or playing with a pet. All of these things are not only good for you but good for your family and beloved furry critter as well!

[Nov 03, 2018] Using non-dominand hand for mouse helps to alliviate symptoms

Nov 03, 2018 | www.moonofalabama.org

time2wakeupnow , Nov 3, 2018 4:28:28 PM | link

b,

I'm a longtime computer tech and have suffered on and off from serious carpal tunnel syndrome - or whatever they call it these days. After trying all kinds of remedies, one of my clients/friends suggested that I try and retrain myself to use my dominant hand and use other non-dominant arm (left) for the cursor and laptop trackpad.

It was really awkward and very frustrating at first, but after a week or so of attempting this, it slowly started to become easier - even though I still resorted to the other very painful hand from time to time. It did take me almost a month of these right to left handed retraining efforts to finally attain some level of comfort and relative ease - to the point where I didn't reflexively resort to switching hands when the going (clicking) got tough.

A couple of months down the line, I became quite fluent with my non-dominant hand: to the point where I considered myself somewhat semi-ambidextrous, and the excruciating pain that I had earlier experienced with my dominant hand slowly began fading away. I'm typing this very post with my left hand.

Technology is sometimes a great and very useful tool that we all engage in nearly everyday, or more. But the downsides are many, and in the physical body realm, it's slowly taking it's toll on all of us in countless ways. Just this morning, I read an article on Slashdot titled: Are touchscreens Robbing a Generation of Surgeons of Their Dexterity?

https://science.slashdot.org/story/18/11/03/0339208/are-touchscreens-robbing-a-generation-of-surgeons-of-their-dexterity

I'm currently typing this very post with my now, semi-dominant left hand.

b. well.

uncle tungsten , Nov 3, 2018 5:22:05 PM | link

@b #1

Try deep tissue massage first. It is one of the best remedies for most aches and really helps the entire system. A one hour deep tissue session is great every 6 months :)

donkeytale , Nov 3, 2018 5:42:34 PM | link
Anton,

Sudden, sharp pains should be checked out especially if they persist for a time, although I agree with you getting sucked into the vortex of the medical industrial complex in our absurd "free market" healthcare system can be both very expensive and a huge investment of time, especially if you are unlucky enough to find the wrong physician.

b is in Europe I believe where there is less (or hopefully, no) profiteering by doctors.

Anton Worter , Nov 3, 2018 5:59:18 PM | link
33

What b is experiencing in repetitious stress syndrome myalgia. It's very painful, and it down not go away. Most especially, getting looped on pain meds is a great way to *permanently* have myelitis and myalgia, and have to run to the medicine closet for your opioids every two hours for the rest of your life.

I sent b a detailed message that didn't get posted, so I'll repeat what I just said above. Change over to your left hand immediately. Immobilize your arm at the writing desk with a sling, while in the evening, you begin strengthening therapy with weights, then pull-ups.

The pain in the arm can last for months if ignored, but the hospital is the very *last* place you want to go. Just start using your left hand on the mouse, and start doing exercise, weight training and yoga. The lessons of the masters.

Or, get hooked on meds for the rest of your life, like my friend with the twitching eyelids, who, after he was told he didn't have cancer, should just take 'this prescription' twice a day, and now if he misses his pill, his whole body is wracked with pain, he has no appetite and can't sleep.

Quackery.

[Oct 27, 2018] Surgery on a Sunny Afternoon Got Me Thinking About Healthcare

Notable quotes:
"... Millions young and old, caught up in the struggle for Healthcare and now there's a consensus. ..."
caucus99percent
span y divineorder on Sat, 10/27/2018 - 1:52pm Millions young and old, caught up in the struggle for Healthcare and now there's a consensus.

Yesterday we caught the bus downtown to the Dragon Room in the Santa Fe Plaza area for Happy Hour to meetup with friends we hadn't seen in a year. Heh. As happens with we seniors, part of the time was spent catching on health issues.

Our friend is facing knee replacement surgery with complications. Carpenter property manager by day, musician by night, he was worried about how things would turn out. But at least he had coverage through his wife's employment. Millions still don't have healthcare, and many who do, face denial of coverage and worse.

It clearly is a huge issue for some in the upcoming midterms.

Senior or no, perhaps you, too are worried about how things will turn out?.

Medicare Advantage vs. Medicare for All https://t.co/EFG1G4QKCS

-- Alice Marshall (@PrestoVivace) May 31, 2018

For those who followed the healthcare debacle during Empty Suit era it has been gratifying to see the coverage and movement toward single payer.

But there are still serious obstacles.

Dr. @awgaffney details the barriers to #SinglePayer reform: "Obstacle number one is the corporate opposition, obstacle number two is the potential that #MedicareForAll could be co-opted or sort of mutated into a lesser thing." https://t.co/E4xTSBPx2E via @businessinsider

-- PNHP (@PNHP) October 26, 2018

Here's another link for those who want to educate themselves on MA vs IMFA.
http://healthoverprofit.org/2018/03/27/medicare-advantage-vs-medicare-fo...

Over the last few decades, insurers participating in Medicare Advantage have schmoozed Congress into compensating them with more money per person than is allocated to traditional Medicare. Don McCanne of Physicians for a National Health Program writes:

"Each year the administration, whether Democratic or Republican, uses quirky arcane rules to ensure an adequate revenue buffer so that private insurers can compete favorably with the traditional Medicare program by offering lower premiums and cost sharing and expanded benefits Once a critical mass has enrolled in private plans, Congress will gradually reduce the relative value of the voucher-equivalent, reducing the government component of the funding of Medicare by shifting more costs to the Medicare beneficiaries."

We see this happening right now, with top leaders of Republican Party expressing a strong interest in cutting Medicare. In response, physician advocates argue that the private Medicare Advantage HMOs should be isolated as a source of wasteful government spending, and that benefits offered by these plans should be expanded into traditional Medicare. Physicians for a National Health Program (PNHP), the doctor-led think tank for single payer policymaking, has been putting forward a strong case against Medicare Advantage for some years.

PNHP points to a number of studies that show the Medicare Advantage HMOs cherry pick healthy patients and lemon drop expensive, unhealthy ones. This is done through narrow coverage networks and poor access to specialized care , driving patients with heavy medical burdens into traditional Medicare – where they can choose their own providers. A 2015 Brown University study showed that of Medicare Advantage patients who had long-term stays in nursing homes, 17% switched to traditional Medicare the next year. The report's lead author, Momotazur Rahman, told NPR news that there are incentives, including "steep cost-sharing as patients need more expensive care" and "limitations on expensive treatments",that because sick patients to drop out of Medicare Advantage plans. A 2017 Government Accountability Office (GAO) report found that of 126 Medicare Advantage plans, 35 plans saw disproportionally high numbers of sick enrollees dropping out into traditional Medicare.

In 2017, a Kaiser Family Foundation (KFF) study found one out of every three Americans enrolled in Medicare Advantage plans were given narrow physician networks. It concluded that plans offering broader networks tended to have much higher premiums than narrow-network plans. KFF also found that one out of every five plans do not include a regional academic medical center in their networks, and estimated that 40% of Medicare Advantage networks included top-quality cancer centers.

The Medicare Advantage insurers can also increase their profits by upcoding the severity of the diseases that their patients have. HMOs are paid per capita based on the number of patients they cover. The payments are also risk adjusted according to the severity of the illnesses of those covered: the more severely ill, the higher the compensation. So it is to the Medicare Advantage plans' advantage to upcode, to make patients seem sicker. Investigations by the Center for Public Integrityand the work of academics show that there is both direct and indirect evidence of massive upcoding in Medicare Advantage, costing the government and taxpayers tens of billions of dollars.

While Medicare Advantage is not an efficient or an equitable means of offering care to senior and disabled Americans, it's important to look into some of the benefits that satisfied patients (who tend to be healthy) are grateful for. All of these benefits would be offered (and enhanced) through a national health insurance system like National Improved Medicare for All (NIMA).

Sorry for leaving out the extensive hot links in the above quote.

So as before its a crapshoot that the Dems and their Repub buds won't screw this up for us.

My wife C99er jakkalbessie and I rode our pedal assist bikes down the Arroyo de Chamisa Urbano to the grocery store this morning, and it is one beautiful fall day here in
The City Different. Leaves are changing, there's a little snow up on the mountains east and west. Such a glorious day to be alive, and able to pedal around still!

I got to get my butt in gear and get ready for MOHS surgery. Spending too much time out in the sun, I guess.

Running through my mind are thoughts like " How much will I have to end up paying? Will my Medicare Advantage Employer group coverage try to deny it?"

What if I were like millions, with no coverage at all? My brother has a much larger problem on his face and no insurance what so fcking ever.

It's all but guaranteed that Trumpco will finally strangle ACA to death and soon. And then there's the worry about how corpadems can fck everything up.

What are people going to do? All the best to you and yours, good health to all.

Of course its not just we mouldy odies that care about this sheet.

AP-NORC/MTV Poll: Young people back single-payer health care https://t.co/pnBGhCq0Pq

-- Health Care For All (@HCASFV) October 26, 2018

Young Americans called health care a very important issue in deciding how to vote. Sixty-two percent of those who will be old enough to vote in the midterms rated it as such. That's the most who said the same of any issue in the poll, including... https://t.co/K2oMRAXPRz

-- Big Easy Magazine (@bigeasy_mag) October 27, 2018


More power to us all.

Wish me luck! Hoping to be in the 94% success rate for this surgery. Divineorder.

[Oct 27, 2018] Even a 10-Minute Walk May Be Good for the Brain

Oct 27, 2018 | www.nytimes.com

By Gretchen Reynolds

Ten minutes of mild, almost languorous exercise can immediately alter how certain parts of the brain communicate and coordinate with one another and improve memory function, according to an encouraging new neurological study. The findings suggest that exercise does not need to be prolonged or intense to benefit the brain and that the effects can begin far more quickly than many of us might expect.

We already know that exercise can change our brains and minds. The evidence is extensive and growing.

Multiple studies with mice and rats have found that when the animals run on wheels or treadmills, they develop more new brain cells than if they remain sedentary. Many of the new cells are clustered in the hippocampus, a portion of the brain that is essential for memory creation and storage.

The active animals also perform better on tests of learning and memory.

Equivalent experiments examining brain tissue are not possible in people. But some past studies have shown that people who exercise regularly tend to have a larger, healthier hippocampus than those who do not, especially as they grow older. Even one bout of exercise, research suggests, can help most of us to focus and learn better than if we sit still.

But these studies usually have involved moderate or vigorous exercise, such as jogging or brisk walking and often for weeks or months at a time.

Whether a single, brief spurt of very easy exercise will produce desirable changes in the brain has remained unclear.


EK NY Oct. 26

Those of you with walkers: do you really need them? I think seniors are being coerced to use them lest we fall.

Reply Recommend
Grace Portland Oct. 26

@EK This is interesting to learn. For general aging problems, there are lots of things to do before going to a walker. I don't have balance problems at this point but I'm careful. What I do now to prevent falls is strength training in my legs (which ultimately helps prevent shuffling) and balance poses or exercises like standing on one leg. (I know from experience that I can restore my balance in a couple of days of one-legged standing.)

In dicey situations like ice, mud, uneven terrain, I use one or two trekking poles or even some kind of locally-available walking stick: nothing is going to ever keep me from using these kinds of walking aids.

Finally there's the habit of mindfully keeping one's eyes on the ground while walking: absolutely necessary in some places, but sometimes even in first-world cities when sidewalks might be buckling here or there due to a nice tree canopy (a recent fall, no serious repercussions, reminded me of that!) If you do this you can get a pretty decent pace going. The rule is: stop moving first before looking around.

Reply 1 Recommend
Rosemarie North Kuala Lumpur Oct. 26

I wonder if 10 minutes of relative rest were what made the difference, in these hectic, over-stimulated times.

NWwell Portland, OR Oct. 25

A lot of these articles make me narrow my eyes in disbelief. What about the energy it takes the average American to get up from the couch, shuffle towards the kitchen, reach for a bag of Doritos, walk back, sit down, open the bag, eat its contents, all the while clicking on the remote? I don't see how a 10 minute stroll for healthy young adults is more difficult than that.

Reply 4 Recommend
NWwell.weebly.com Portland, OR Oct. 25

@NWwell I forgot to finish my thought - though I'd walked 6 miles yesterday - hm. If such a minute amount of activity led to noticeable improvment in cognition then we'd all be super geniuses. A ten minute walk to a healthy young adult is not even exercise. It's below the threshold I would consider physical activity. I don't know what the conclusion from all this is. I'm confident that being physically active is the single most important thing one can do for their health, physical and mental. Any amount is better than nothing. The more the better, up to a point. But I doubt that 10 minutes of, basically breathing, make you better than ...10 other minutes of, basically breathing. This makes no sense.

B.D. Champaign, IL Oct. 24

Would like to have seen some non-author commentary. The time it would take between exercise and fmri, it seems to imply that any 10-minute exercise would matter for quite a while after exercise occurred. So if any subjects walked to the study building, they may also have residual effects!
I also wonder whether fmri, which measures oxygenated blood, has previously shown exercise or deep breathing differences? Does everything light up more when there is just more oxygen in the system in a sudden fashion? Would people in casinos with pumped-in oxygen be similar in effects? Finally, it would be great to rule out effects of arousal and things like excitation transfer. Right now it leaves open the possibility that showing horror movies might also lead to better memory for our young people, though that has less savory policy implications :)

Doris Los Angeles 1m ago

@B.D. I have similar questions. I work in a creative field, and for many years my experience (and that of others I know) has been that ideas can be encouraged to arrive in two ways: (1) after aerobic exercise and (2) in a hot shower. I always thought it had something to do with oxygen. In neither case does the effect last more than an hour or so. That seems very different from "exercise to make your brain work better all day long." (Not that I'm arguing against exercise.) It would be helpful to have more details about how this study worked.

joan sarasota Oct. 24

@Karen B, not so bizarre if one is 77 with heart failure and very painful osteoarthritis. But worry not, I'm in the pool 4 or 5 days a week for far longer than 10 minutes. Probably takes me 10 minutes to get to the pool with my walker to park right next to steps into the pool.

My real point is think about others before you label their behavior bizarre, especially in these divisive days.

Raindrop US Oct. 25

Many elderly people do not have much stamina or a safe place to walk with a walker, or because it is dangerous when the sidewalks are icy, wet, or snowy. Many people in American cities do not have a safe place to walk due to crime. Many children in suburbs are forbidden from playing outside by their parents because of overblown fears of abduction. There are many reasons other than moral failing for why people do what they do.

J David La Oct. 24

well, i walk on my treadmill about 30 mn/day about 2.2mph...i figure that's good enough

Reply 10 Recommend
Phyllis Mazik Stamford, CT Oct. 24

Immediately thought of students who could use some exercise to combat rigor mortis. Get the blood circulating. Also, kids need a decent diet, otherwise the body screams out for help and then people often turn to substance abuse instead. Years ago, people ate home cooked meals and walked to school. Good food and exercise costs very little and we should access the free stuff. (Junk food and drugs are costly in many ways.)

tpw Plainfield Massachusetts Oct. 26

A sound mind in a sound body

[Oct 27, 2018] We Slow as We Age, but May Not Need to Slow Too Much

Oct 27, 2018 | www.nytimes.com

Although declines in running and other activities are unavoidable, they may be less steep than many of us fear.

Image
Bernard Lagat crosses the finish line in Atlanta on July 4, 2018. Credit Credit Curtis Compton/Atlanta Journal-Constitution, via Associated Press

By Gretchen Reynolds

Most of us who are older competitive runners are not able to race at anywhere near the same speed as we did when we were 30.

But we can perhaps aim to slow down at the same pace as Bernard Lagat, Ed Whitlock and other greats of masters running, according to a timely new analysis by two professors from Yale University.

The new analysis, which refines famous past research by one of the scientists, finds that, although declines in running performance with age are ineluctable, they may be less steep than many of us fear.

And, perhaps most important, the new research updates a popular formula and calculator that runners past the age of 40 can use to determine how fast we can expect to slow down and provides us with reasonable, age-appropriate finishing-time targets for ourselves.

Scientists do not know precisely why, from a physiological standpoint, we are less able to maintain our old, swifter pace as we reach middle age.

There is evidence from past studies that even in lifelong athletes, hearts become a bit less efficient over time at pumping blood and delivering oxygen and muscles a bit less adept at creating sustained power.

Go beyond the headlines.

Subscribe to The Times

Changes deep within our cells, particularly in the energy-producing mitochondria, are thought to contribute to these age-related performance declines, as are simpler explanations such as creeping weight gain and a drop-off in hard training.

But the upshot is that, after a certain point, we cannot keep up with the kids or with our own previous bests.

Professor Ray Fair, an economist at Yale who mainly analyzes and predicts election outcomes, is familiar with this tribulation, since, now in his mid-70s, he is also an experienced masters marathon runner whose times have been slowing year by year.

About a decade ago, he began to wonder whether his rate of performance decline was typical and, being a predictive statistical modeler, decided to find out.

He turned first to information about world records for runners by age group. These times represent what is possible by the best runners in the world as they age.

And cumulatively, he found, the records proved that champion runners slow like the rest of us.

But there was a pattern to the slowing, Dr. Fair realized. As he reported in a 2007 study , the masters world record times rose in a linear fashion, with some hiccups, until about age 70, when they begin to soar at a much higher rate.

Using statistical modeling based on this pattern, Dr. Fair developed a formula that could predict how fast other, less-exceptional runners might expect to run as they grew older. He incorporated this formula into an influential calculator that he made available free on his website. (The calculator also predicts age-related performance declines in swimming and chess, using the same statistical techniques.)

The calculator soon became popular with runners, for whom it provided age-adjusted viable goal times, allowing them to swap despondency about their current plodding for gratification if they had managed to remain at or near their "regression line," as Dr. Fair termed the age-adjusted predicted finishes.

But recently, Dr. Fair began to question whether his statistical model provided the best estimates of people's likely race times and, for the new analysis, which was published in print this month in The Review of Economics and Statistics , he approached a Yale colleague, Edward Kaplan.

Dr. Kaplan is an expert in a complex type of statistical analysis known as extreme value theory, which focuses on exceptional deviations from the norm.

By definition, world records are exceptional deviations from the norm.

Together, Dr. Fair and Dr. Kaplan reanalyzed data about world masters running records through 2016 for the 5K, 10K, half marathon and marathon events, up to age 95.

They used only men's records, since the number of older female participants has been small, Dr. Fair says, making current women's records statistically suspect.

They then ran the numbers, using several different models, and found that, over all, age-adjusted finishing times are slightly slower now than in the 2007 version, rising about 1 percent a year.

But runners seem to be maintaining that rate of decline longer, until they are about age 80, when slowness drastically intensifies.

But even for 90-year-olds, the decline is limited, Dr. Fair points out.

Nonagenarians can expect to be "about twice as slow as they were in their prime," he says, "which I think is encouraging."

Interestingly, the new study's extreme-value analysis also suggests that

[Oct 26, 2018] Preventing Muscle Loss as We Age by Jane Brody

Oct 10, 2018 | www.nytimes.com

"Use it or lose it." I'm sure you're familiar with this advice. And I hope you've been following it. I certainly thought I was. I usually do two physical activities a day, alternating among walking, cycling and swimming. I do floor exercises for my back daily, walk up and down many stairs and tackle myriad physical tasks in and around my home.

My young friends at the Y say I'm in great shape, and I suppose I am compared to most 77-year-old women in America today. But I've noticed in recent years that I'm not as strong as I used to be. Loads I once carried rather easily are now difficult, and some are impossible.

Thanks to an admonition from a savvy physical therapist, Marilyn Moffat, a professor at New York University, I now know why. I, like many people past 50, have a condition called sarcopenia -- a decline in skeletal muscle with age. It begins as early as age 40 and, without intervention, gets increasingly worse, with as much as half of muscle mass lost by age 70. (If you're wondering, it's replaced by fat and fibrous tissue, making muscles resemble a well-marbled steak.)

"Sarcopenia can be considered for muscle what osteoporosis is to bone," Dr. John E. Morley, geriatrician at Saint Louis University School of Medicine, wrote in the journal Family Practice . He pointed out that up to 13 percent of people in their 60s and as many as half of those in their 80s have sarcopenia.

As Dr. Jeremy D. Walston, geriatrician at Johns Hopkins University School of Medicine , put it, "Sarcopenia is one of the most important causes of functional decline and loss of independence in older adults."

Yet few practicing physicians alert their older patients to this condition and tell them how to slow or reverse what is otherwise an inevitable decline that can seriously impair their physical and emotional well-being and ability to carry out the tasks of daily life. Sarcopenia is also associated with a number of chronic diseases, increasingly worse insulin resistance, fatigue, falls and, alas, death.

A decline in physical activity, common among older people, is only one reason sarcopenia happens. Other contributing factors include hormonal changes, chronic illness, body-wide inflammation and poor nutrition.

But -- and this is a critically important "but" -- no matter how old or out of shape you are, you can restore much of the strength you already lost. Dr. Moffat noted that research documenting the ability to reverse the losses of sarcopenia -- even among nursing home residents in their 90s -- has been in the medical literature for 30 years, and the time is long overdue to act on it.

In 1988, Walter R. Frontera and colleagues at the Department of Agriculture Human Nutrition Research Center on Aging at Tufts University demonstrated that 12 previously sedentary men aged 60 to 72 significantly increased their leg strength and muscle mass with a 12-week strength-training program three times a week.

Two years later in JAMA, Dr. Maria A. Fiatarone and colleagues at the Tufts research center reported that eight weeks of "high-intensity resistance training" significantly enhanced the physical abilities of nine frail nursing home residents aged 90 and older. Strength gains averaged 174 percent, mid-thigh muscle mass increased 9 percent and walking speed improved 48 percent.

So, what are you waiting for? If you're currently sedentary or have a serious chronic illness, check first with your doctor. But as soon as you get the go-ahead, start a strength-training program using free weights, resistance bands or machines, preferably after taking a few lessons from a physical therapist or certified trainer.

Proper technique is critical to getting the desired results without incurring an injury. It's very important to start at the appropriate level of resistance. Whether using free weights, machines, bands or tubes, Dr. Moffat offers these guidelines:

"Start with two repetitions and, using correct form through the full range of motion, lift slowly and lower slowly. Stop and ask yourself how hard you think you are working: 'fairly light,' 'somewhat hard' or 'hard.' If you respond 'fairly light,' increase the weight slightly, repeat the two reps and ask yourself the same question. If you respond 'hard,' lower the weight slightly and do two reps again, asking the question again.

"If you respond truthfully 'somewhat hard,' you are at the correct weight or machine setting to be exercising at a level that most people can do safely and effectively to strengthen muscles. Continue exercising with that weight or machine setting and you should fatigue after eight to 12 reps."

Of course, as the weight levels you're working at become easier, you should increase them gradually or increase the number of repetitions until you fatigue. Strength-training will not only make you stronger, it may also enhance bone density.

The fact that you may regularly run, walk, play tennis or ride a bike is not adequate to prevent an incremental loss of muscle mass and strength even in the muscles you're using as well as those not adequately stressed by your usual activity. Strengthening all your skeletal muscles , not just the neglected ones, just may keep you from landing in the emergency room or nursing home after a fall.

Dr. Morley, among others, points out that adding and maintaining muscle mass also requires adequate nutrients, especially protein, the main constituent of healthy muscle tissue.

Protein needs are based on a person's ideal body weight, so if you're overweight or underweight, subtract or add pounds to determine how much protein you should eat each day. To enhance muscle mass, Dr. Morley said that older people, who absorb protein less effectively, require at least 0.54 grams of protein per pound of ideal body weight, an amount well above what older people typically consume.

Thus, if you are a sedentary aging adult who should weigh 150 pounds, you may need to eat as much as 81 grams (0.54 x 150) of protein daily. To give you an idea of how this translates into food, 2 tablespoons of peanut butter has 8 grams of protein; 1 cup of nonfat milk, 8.8 grams; 2 medium eggs, 11.4 grams; one chicken drumstick, 12.2 grams; a half-cup of cottage cheese, 15 grams; and 3 ounces of flounder, 25.5 grams. Or if you prefer turkey to fish, 3 ounces has 26.8 grams of protein.

"Protein acts synergistically with exercise to increase muscle mass," Dr. Morley wrote, adding that protein foods naturally rich in the amino acid leucine -- milk, cheese, beef, tuna, chicken, peanuts, soybeans and eggs -- are most effective.

Do You Have Sarcopenia?

To help doctors screen patients for serious muscle loss, Dr. John E. Morley and Theodore K. Malmstrom devised a simple questionnaire that anyone can use. It asks how difficult it is for you to lift and carry 10 pounds, walk across a room, transfer from a chair or bed or climb a flight of 10 stairs. It also asks how often you have fallen in the past year. The more challenging these tasks and more often you've fallen, the more likely you have sarcopenia.

This is the first of two columns on countering muscle loss. Read the second here . How to Get Strong

You don't have to lift like a bodybuilder (or look like one) to benefit from resistance training. And the best part is that it's never too late to get started. Read our latest subscriber guide.

Sept. 18, 2018

Jane Brody is the Personal Health columnist, a position she has held since 1976. She has written more than a dozen books including the best sellers "Jane Brody's Nutrition Book" and "Jane Brody's Good Food Book."


Martha Grady CO Oct. 5

Jane, How about including the protein available in whole foods / plant based choices? Listing only animal sources of protein perpetuates the myth that you must eat meats to meet protein requirements.

don salmon asheville nc Sept. 26

I don't understand the protests - what about pleasure, stop making us do all this work can't we just relax etc etc

My wife and I (we're in our mid to late 60s) take a 6:15 aerobics class at the YWCA 3 mornings a week. We love it! It's SO much fun. Some of the students have been with the teacher for several decades and the class feels like a family.

After the class (which includes aerobics and light weights) I spend 20 minutes in the gym doing heavier lifting.

Three mornings a week I do a HIIT walk (alternating fast/moderate pace) here in the mountains of Western North Carolina - extraordinarily beautiful views, and I live in a working class neighborhood where everyone is friendly and knows each other. It's a fantastic way to get the day going after morning contemplation.

I do a Qigong routine (8 brocades) several times a day (just takes a minute or two to do a brief version) to stand up and stretch, and if I'm in a mood for something more vigorous, I keep my mini trampoline and light kettlebells in my home office (and k-bells in the work office as well).

And my wife and I go for LOTS of walks in this extraordinarily beautiful region. And we often go for walks with friends as well. We also keep TV (netflix, that is, on the computer) to a 3 night maximum, and stretch throughout.

How in the world is this "work" or lacking in pleasure? We're in the midst of creating videos for others to do the Qigong break. The whole morning routine's about 6 hours

DC Rez DC Sept. 24

The sad fact is that in our sedentary world big majority of people who take up weightlifting based on an article like this will not lift hard enough for the real benefits to take hold. The lower body work everyone now understands is hyper-beneficial to long term health takes a lot out of you. If you dont sleep like a baby the night you lift weights you arent trying hard enough. And be warned, the longer you wait to start the harder it's going to be to get to where you want to be. Meanwhile people who have been lifting for 10-20yrs find that even at say 45yrs old they are stronger than majority of 25yrs olds at their gym. Heavy resistance training is, by far, the single best thing you can do for your physical self.

KT IL Oct. 3

While weight training is wonderful exercise, the simple act of walking 5-6 miles per day is the single best and most accessible exercise for every human on Planet Earth.

Alesia Stanford San Diego Sept. 23

I am an Essentrics exercise teacher. This dynamic stretch program helps lengthen, strengthen and tone the body through a series of gentle stretch exercises. It's also wonderful for healing little aches and pains. Most of my clients are 50+ and all have benefited from taking the classes. After a few weeks, they report better balance, being able to lift their arms higher or walk with more confidence. I see the changes as well. You don't have to do anything fancy to get in shape. We use mats for the floor, chairs for "barre" work and sometimes yoga blocks to sit up a little higher. This is an amazing program. I only wish more people knew about it.

bill annandale, VA Sept. 23

I'm 85 and in rather good shape...actually quite strong. When younger, forties and fifties, I was a road racer and lifted weights regularly.

Now I'm very active in the house climbing stairs and walking outdoors as often as I can...but not at all slavish about it.

But my main exercise program now is a comprehensive set of isometric moves. I've been at it for years but have pushed harder in the last year.

Isometrics are - in my view - a lot easier on the joints, and if done in a relatively wide range of motions will add strength and mass.

I don't know why exercise professionals do not mention isometrics as an alternative, especially for seniors with arthritic joints.
When done in connection with ordinary walking, household chores, and stair climbing, the results do indeed stop muscle and strength loss.

Mr C Cary NC Sept. 21

I used to be a couch potato. But I have been going to the gym everyday. My SLIVER sneaker. The benefits are many above and beyond what has been said. First it gives me an opportunity to go out regularly and be in a different environment other than the confines of my apartment (I have downsized from a large house to a modest apartment, like many in my age group). Second, the day goes fast as I go in the morning and by the time I am home, it's lunch time! Third, you get good sleep as your body had been working. Fourth, as you work hard at the gym, huffing and puffing and sweating a bit, you forget other things and your mind gets a rest. So don't wait, get up and join a gym. By the way, don't spend money buy the equipment, it doesn't work.

Tom NYC Sept. 17

Lots of the usual woulda shoulda coulda in the comments here. Brody's advice has always tended to be prescriptive. Think back to her high-carb diet -- not good for pre-diabetics. But muscle loss is very serious as we age. I see it in myself at late 77. I'm no gym rat but I will try to find my own path.

Nino B Amityville, NY Sept. 16

Nine years ago at the age of 54 I purchased a Concept2 rowing machine and have never looked back. It provides a low impact full body cardiovascular workout. I typically row for 30 minutes. Sometimes it's a straight 30 minute session. Other times I will do three sessions of 2000 meters each. From time to time I will do intervals of short bursts at maximum output. I log each workout and am approaching 12 Million meters to date. I also use dumbbells for arm strength and do 120 inclined crunches a day. At 65 years young I am obviously a HUGE fan or my rower. I recommend you give one a try. It's not easy but taken in small increments at first you will see results. I might add that like all excercise it is worth the effort!

Andy Wohl Bethesda MD Sept. 15

My answer: racquetball!

Apple Jack Oregon Cascades Sept. 14

If you live in the country, chop firewood. Lifting an eight pound maul might seem to be an exhausting task at first. Soon you'll be lifting & bearing down with ease.
There's a reason top flight boxers chop wood. No pulling punches when follow through on the down swing with an ax or maul is perfected in training..
Many muscle problems with seniors when walking come about because of unnatural mental manipulations of leg musculature resulting in strains & tension. Place attention on foot placement rather than leg movement when moving to remain trouble free. Enjoy.

Reply 5 Recommend
Tom Hennessy Calgary, Ab, Canada Sept. 14

As we age we gain what is called, age related iron accumulation.
"Iron accumulation with age, oxidative stress and functional decline."

Tom Hennessy Calgary, Ab, Canada Sept. 14

"increased non-heme iron, might contribute to muscle atrophy due to disuse particularly in aged muscle."

dsws whocaresaboutlocation Sept. 14

You say that, thanks to your therapist, you know why you have sarcopenia. But then (unless I missed it) you don't tell us why. More importantly, you don't tell us how often protein deficiency is the main cause, how often it's lack of exercise at the right level of resistance or intensity, and how often it's something else.

richard conner Bay Ares, CA Sept. 13

As we age, strength gradually lessens and we need to use our muscles more to keep strength from fading. Free weights have always been the best for me, nothing heavy, but heavy enough to tire muscles after 10-12 repetitions, 3 times a week.

Then, lots of walking, uphill a bit if you can. Uphill walking gives a better workout in a shorter distance than on the level. Endurance and strength gained from walking 2+ miles a day is just as important as keeping the rest of the body strong using weights. It also helps to get rid of extra weight(77 years young and now the same weight as in college). Take good care of yourself; you deserve it.

Reply 21 Recommend
LorneB Vancouver, CA Sept. 13

I am 64 and have always disliked gyms and doing repetitive weight exercises. Truly boring. But 20 years ago, I discovered hatha and ashtanga yoga. We use our own body weight as resistance effectively to build muscles. Downward dogs, and chatarangas, and lunges and warrior positions and planks all use different muscles. Even my gluteus not so maximus has improved. And after all that I have a nice sense of well-being. So for any one who doesn't enjoy repetitive weight exercises, maybe yoga may be for them. Just make sure you go to a class with a VERY qualified instructor.

Reply 29 Recommend
Round the Bend Bronx Sept. 13

Many of my friends are afraid to lift weights as I do, fearing they'll injure themselves. I get it. It's a bummer to hurt yourself when you're old. But it doesn't have to be that way. The key is success is to be conservative and think long-term. My motto is "go slow and live to lift another day."

I'm a 66 year-old woman who weights 110 lbs. I do body building and weightlifting three times a week at a cheap, no-frills gym. This includes once-a-week sessions of deadlifts with 80 lbs. on the bar. Post-knee surgery, I asked my DPT (doctor of physical therapy) for strength-training and fitness advice. Based on my issues, which include osteoporosis and osteoarthritis, he designed a program that I took to the gym and now do on my own. About once a month, I see him for a progress report, new exercises and to make sure my form is correct. Many of the exercises I can do at home with little or no equipment, others require a trip to the gym.

The word of the day is "hypertrophy," which is the development of larger muscles. I used to think this was just for vain people who liked to flex their muscles in the mirror. But no. Seniors need to focus on hypertrophy as well as on strength building, so we can compensate for the loss of muscle mass that accompanies old age.

Trust me when I tell you that this kind of workout is not only good for you, but afterwards you feel like a million bucks. Start now. Start yesterday!

Reply 22 Recommend
Judith Spruance Wilmington DE Sept. 13

By all means get a weight program but Honestly! you don't have to do nothing but the gym! Try Vacuuming your house and doing some lunges while you are doing that. Empty the dishwasher and do squats while gathering the knives and forks rather than carrying the carrier over to the drawer to put them away. Haul some hoses around the yard, if you have one, to water your thirsty plants, and spend some time coiling that hose. Fold some king size sheets. There is a lot of '"weight" work in normal living if you look for it. Good luck and think of me, 80 years old, zipping around garden and house working out and getting things done- sort of!

Reply 29 Recommend
A. Stanton Dallas, TX Sept. 13

Wanting to improve my image of myself, I stopped looking in mirrors about ten years ago.

And it has worked.

Reply 17 Recommend
Analyst SF BAY Sept. 13

For easy to prepare and digest protein, try whey isolate. One scoop is 30 grams protein. It comes in many flavors. It's broken to small proteins. I usually have digestive problems with milk proteins but not with whey isolate.

Reply 4 Recommend
Joan In California California Sept. 13

If 80 grams of protein sounds like a lot, one ounce is approximately 30 grams. 80 grams is not quite three ounces. Of course we must allow some leeway for the elements that aren't strictly protein.

Reply 1 Recommend
MSalmon Bay Area, CA Sept. 15

@Joan In California I just looked up salmon and 4 ozs has about 20 grams of protein, a cup of non-fat milk has 8 grams and egg has 6 grams.

Reply 1 Recommend
Carol Avri n Caifornia Sept. 12

Unfortunately at 86 my equilibrium is severely impaired and a parathyroid tumor robbed my bones of calcium. However, due to fact that I exercised all my life, I have pretty good coordination and when I can't walk, I exercise on my bed using a band and small weights. Don't give up as long as you can still move.

Reply 47 Recommend
BloUrHausDwn Berkeley, CA Sept. 12

Back in the '80s, Jane Brody's "Good Food Book: Living the High-Carbohydrate Way" was my food bible. I made countless meals from that book. Then -- oh dear! -- we found out that high carbs were NOT the answer...and Jane dutifully followed the current thinking and expounded other ideas. Food is like fashion, and "scientific" thinking keeps changing. What will it be next year?

Reply 25 Recommend
badman Detroit Sept. 17

@BloUrHausDwn

I find it amazing how flawed some docs thinking is. Especially their math (probability) understanding. Vitamin D is (was?) a good example. Prescription of statins for cholesterol management. Perhaps Phizer (et al) has "brain-washed" them. The good docs know this - the trick is to find the good thinkers.

Reply 1 Recommend
Doug Dudfield Stamford , Ct Sept. 12

I go to the gym every day. I do a complete workout . All muscels. It is amazing. I keep adding weight. Everybody should go to a gym when you are my age. 76.

Reply 22 Recommend
Randy Santa Fe Sept. 13

@Doug Dudfield At 57, I've been a gym rat for 35 years, through injuries and a hip replacement. I'm mortified by the terrible physical condition of so many men and women my age attributable to poor diet and a sedentary life.

I'm inspired by the folks in your age group I see at my gym, cranking it out, making the most of their workouts. I aspire to be like you in 20 years!

Reply 6 Recommend
Larry Lamar London Sept. 13

@Doug Dudfield Instead of doing a complete workout every day, you might want to try focusing on one muscle group each day -- arms one day, back the next, legs the next. That's the way the pros do it. It not only gives that muscle group more of a workout, but crucially, it allows it time to recover and recuperate, which is when muscle growth takes place. I just started doing that instead of circuit training and was amazed at the progress I started making all of a sudden. Very dramatic.

Reply 18 Recommend
Karen Brooklyn Sept. 12

I feel like my 61 year old body is trying to make me weak! I am an avid cyclist, have worked out on weight machines at the gym for many years, but it requires effort just to stay the same. If I miss working out for a week, I loose strength right away and it takes me much longer to build back to where I was.

Weakness is especially profound and alarming in my smaller muscles that don't get much focus at the gym, like my fingers and wrists, toes and ankles. Because of weak ankles and feet my balance sucked. I recently started yoga classes and it helps a lot! I have also started what I call "lap-top calisthenics" where I lift the computer I am typing on using my wrists and fingers. That has really helped also.

Reply 12 Recommend
james.m Dallas Sept. 13

Try adding standing free weights that require hands, wrist and lower extremety may help. I use kettlebells for this purpose.

Reply 3 Recommend
badman Detroit Sept. 17

@Karen

It's called old age. Our strength, O2 intake (lung capacity), speed, all decline. There is basic cellular change - physiology. The trick is to manage all this so you can "keep on keepin' on." I won my 5K age group at age 72 but I was slower than previously. Doesn't matter - normal.

Reply 1 Recommend
Richard Sullivan Keaau, Hawaii Sept. 12

Those who justify their lack of desire to put out the effort to strength train to keep themselves mobile and strong by claiming injury, whether valid or not, need to know that proper form is EVERYTHING. Proper form makes all the difference between great results in a shorter period of time and avoiding injury. The article writer rightly recommends hiring a personal trainer, but which many cannot afford. YouTube is a great source for free workout videos although only a minority are made by people who truly know what they're talking about. YouTuber Mike Thurston has a great series: search "Common Gym Mistakes Mike Thurston" for guidance on proper form and injury avoidance.

Reply 7 Recommend
Paolo NYC Sept. 12

Perhaps some specifics on which muscles to target might help. What I'm imagining is people overdoing biceps, pectorals, and the six pack part of their abs. Why? That's what they see in the mirror. Too much targeting of these mirror muscles can lead to postural imbalance and pain. It's as much about staying in balance as it is about gaining measurable strength. Re: the nursing home study of 90+ people: how many in the study, what was their baseline (if they were barely able to walk a 48% increase in speed is meaningless.), and how did their function improve? More independent? Easier grooming? Or just a better momentary result of isolated muscles during testing time.
But thanks Jane, you're an asset to the city.

Reply 5 Recommend
DILLON North Fork Sept. 12

I'm 69 and, on a recent trip to Paris, I fell twice! My kids and wife were shocked but other than a skinned knee I was just fine, my son gave me a hand and I jumped right up. (I was a bit embarrssed.) The reason I was just fine is because I started weight lifting and running in High School and I haven't stopped since. Aside from bragging, I say this because exercise is very important. You don't even need any studies done at universities - everyone knows this is true. Even if you have never exercised, a qualified personnel trainer can help you.

Reply 14 Recommend
Lorraine Davis Houston Sept. 12

I've been weight training since the 1970s and now at 66 I can still run and bike and swim and haul my suitcases around. I walk quickly. My reflexes are still quick. And I still feel like I did at 40. I just look older. I don't feel older though.

Reply 20 Recommend
Shannon Nevada Sept. 12

Superb information and gives those of us who are over 50, or any age really, a boost to continue doing what we're doing, or start what we need to muscle up. I have a lifestyle that affords frequent, routine, heavy lifting - carrying 40 lb bags of chicken and dog food, hiking daily with 30 lb pack, hunting and packing out harvests. I'm definitely stronger than most all other women my age 57, and boy do I plan to keep it up! My husband says I'm stronger than most men he knows. If you're weaker start gradually and work up to avoid stress and injury, but follow the advice and strengthen your bods!

Reply 19 Recommend
Tom NYC Sept. 17

@Shannon: packing out harvests? No, packing out kills. Legal hunting is nothing to be ashamed of.

Reply Recommend
poslug Cambridge Sept. 12

No mention of injury resulting from weight lifting. I am very active but weights tend to lead to ligament and tendon injury that impacts my overall activity not to mention the costs from PT. I love resistance and weights but my body does not. Careful exercise helps only minimally or not at all. Five reps with a three pound weight is enough to have a shoulder or hand be out of service. It would have been helpful if the article addressed this concern.

Reply 18 Recommend
Allan Boston Sept. 12

@poslug I have good news for you. You may be able to minimize the injuries by reducing the weight you lift, making sure your form is correct, and doing enough repetitions to fatigue your muscles. You will see the same benefits as using heavier weights (as long as you fatigue your muscles), but will significantly reduce your risk of injury. Good luck!

Reply 10 Recommend
Tish Packman Tallahassee Sept. 12

L-glutamine is also an important amino acid that is food for muscles's health.

Reply 4 Recommend
Nanda Rome Sept. 12

I am close to 70 and have adopted the ASEA cellular REDOX supplement and see quite a difference in my muscle(s) performance in addition to lack of fatigue and extreme focus capability. I recommend that swing at this new tech cellular regeneration

Reply 2 Recommend
Jane L France Sept. 12

Why on earth not mention plant-based protein sources?

Reply 19 Recommend
Ed New York Sept. 12

@Jane L, last time I checked, peanut butter came from plants.

Reply 4 Recommend
mhschmidt Escondido, CA Sept. 12

@Jane L
Soybeans were also mentioned....

Reply Recommend
Rachel California Sept. 11

How can an older person get 80 grams of protein per day on a plant-based diet? Is it possible?
What enjoyable outdoor exercise can make muscles grow? -- my feet won't permit running and my shoulder can't take bicycling or swimming. I walk a lot but I know that isn't very intense.
I dislike indoor gymnasium intensely.
Would Tai Chi or yoga help build muscle mass?

Reply 14 Recommend
Larry Lamar London Sept. 13

@Rachel Soy protein supplements. Or if you're not vegan, whey protein (I know, it's not plant based, but it doesn't have any saturated fat, either.)

Reply Recommend
CoolTheSwamp D.C. Metro Sept. 15

@Rachel, Underweight, have fibromyalgia and have done slow, non-combat Tai Chi for 18 months. It's more for flexibility and balance than building muscle because it's mostly upright on two legs. Depending on the type of yoga, you may get more "burn" holding those poses--1hr is harder than it looks. Both are slow-paced, so individual instructor attention and class sociability, however small at first, are important so you don't feel isolated. Good luck!

Reply Recommend
Sheilah Goodman Mamaroneck NY Sept. 10

Thank you for this essential information. I am a 73 year old health educator and believe that we don't know enough about how to help our bodies to be healthy. I walk a lot and do strength training twice a week at the local Y. I have noticed that when I am gardening, cooking, or doing any kind of stand up work for more than 4 or 5 hours, I need to sit down and rest. I have suspected that this is due to muscle fatigue. I do eat a lot of protein (cottage cheese, chicken, and more). I will ramp up my stretching and strength work. When is part 2 going to be published? Best health to all of us.

Reply 13 Recommend
joseph usa Sept. 11

My wake up call was when I started having difficulty carrying a case of wine to my car . I started weight training and all is ok now .

Reply 53 Recommend
itsmildeyes philadelphia Sept. 11

Not sure why, but I love Joseph's comment.

Reply 34 Recommend
Michael Piscopiello Higganum CT Sept. 10

Started using a personal trainer at local YMCA this past January. Weight lifting core strengthening, aerobic workouts. At 67 with heart bypass surgery may be in best shape of my life. Hope to continue for as long as possible.

Reply 18 Recommend
Eric King Washougal Wa Sept. 9

I eat watermelon before lifting weights as this is supposed to help with muscle soreness and has electrolytes. The best way to combat muscle loss is full body excersizes not isolated ones, squats and lifts for example.

One issue is back pain but the best solution I have found is the farmer's walk where you carry two weights around at your sides for a minute or as long as you can, this builds core strength and strengthens your back in its best position with the good curves of standing straight-it has eliminated back pain for me which is probably most people's issue with lifting weights-

Reply 11 Recommend
Cindy Williams NYC Sept. 9

This is one of those articles that leaves me scratching my head, in that it focuses on a problem in which the suggested "cure" causes more problems than the original issue. It presents confounding information that is hard to reconcile with what we now know about the dangers of high protein diets, especially for the aging. For example, heart disease, kidney disease, and osteoporosis, all of which are far more likely to kill an older person than sarcopenia. It could be argued that more muscle mass helps reduce falls, which then reduces the risk for fractures, which are, in fact, often the beginning of the end for the elderly. However, it is the osteoporosis that is the underlying critical issue here, and high protein diets are linked to osteoporosis. Furthermore, in order to consume the amounts of protein recommended in this article, which is extreme, one who have to eat practically an all-protein diet or become obese. Obesity has it's own correlated health risks - a long list, and growing - which, again, are far greater than sarcopenia. Just this week, The New York Times published an article on a well-designed research study that showed an astonishing increase in the muscle-producing cells when aging people engaged in intensive exercise. There are much safer and healthier ways to maintain and increase muscle as we age than eating extremely high protein diets.

Reply 24 Recommend
The Pooch Wendell, MA Sept. 10

@Cindy Williams
Higher protein diets _protect_ against all of those things. More protein protects against obesity by satisfying appetite with fewer total calories. Combined with weight-bearing activity, protein _protects_ against osteoporosis by building muscle and bone. Bones are 1/3 protein by weight, and osteoporosis is a loss of both calcium and protein from bones.

Reply 4 Recommend
Emilia Zurich Sept. 11

@Cindy Williams Thank you for your comments. I enjoyed reading this article until I got to the diet/ protein recommendations section. As you mentioned, while a protein dense diet of "milk, cheese, beef, tuna, chicken, peanuts, soybeans" ... might reduce the risk of sacropenia (who knows if this is true), this diet may very well increase the risk of cancer and other very common health problems. Additionally, eating the listed set of foods is also very detrimental for the environment... The author should have instead recommended plant based foods high in protein for example: almonds, broccoli, quinoa, lentils or pumpkin seeds. Thanks for your comments and references.

Reply 7 Recommend
Rose TN Sept. 9

Ms. Brody, thanks again for articulating a health need that had been bothering me. 35+ years ago your article on gluten intolerance made my life bearable again. I have been wondering about loss of muscle tone and what to do about it. Again, you have stepped up and made a difference for me. Thanks!

Reply 8 Recommend
amskej Northern Europe Sept. 9

This active male is turning 61 next week. After doing 10 push-ups 4 days a week off & on for years I decided some weeks ago to increase this by 1 extra push every 2 weeks (currently at 24), 1- minute planks 6 days a week (what back issues?), yoga every day, cross trainer @ home twice a week (max heart rate 165) climb 7 flights of stairs, 3 times /day, 5 days a week @ work, use standing desk @ work, got rid of my bike 10 years ago and walk, have a love affair for oatmeal with blueberries & good nutrition in general. Granted, this is a hobby & I've seen myself as an amateur athlete since high school football. I also currently live in a country where great nutrition / healthcare is affordable for all and that promotes work / life balance. And while I could kil over & die before I click 'submit' to share this comment (Memento Mori) I must say that a lifetime of physical fitness has made me a rich man (in some ways)..

Reply 20 Recommend
whatever, NY New York Sept. 11

if you have your health' you have your wealth

Reply 11 Recommend
MRH Ohio Sept. 9

I advise all seniors to do some form of muscle strengthening exercises regularly and to keep their body weight within a normal range. I am a 73 year old RN who specializes in wound care and works in a nursing home. My job is physically active, I only take the stairs in the facility, swim, and belong to a fitness center where I lift weights and do cardio. On my job I have many residents who are younger than I am. While some of our residents have chronic diseases or some catastrophic incident which put them there, the overriding factors I see which landed them in a nursing home is lack of physical exercise to keep themselves in shape and obesity which makes exercise difficult and contributes to all sorts of other physical problems. This results in falls, fractures, wounds, incontinence and a decreased quality of life. Physical exercise is hard work but the refusal to take responsibility for yourself has worse negative consequences. Don't keep yourself fit and live long enough and you'll eventually end up in a nursing home.

Reply 43 Recommend
Carolyn Jones Seattle Sept. 9

I am a 68-yr-old female home health RN who also does wound care, which involves lots of squatting to get at heel and leg wounds. My two supply bags each weigh 12 lbs. I go to the gym every Sat morning and do an hour on the treadmill (while listening to Wait Wait Don't Tell Me and laughing) and 30 min of weights. 12-lb for free wts; 50 lbs in the machines, 20 or 30 reps. I've worked up to this over the past few years. I also do yoga, and can finally do a plank-lowered-to-prone for the first time in my life. My cholesterol and fasting glucose are kept in range with the muscle mass. My last DEXA scan moved me from osteoporosis to osteopenia -- a 7% improvement. I feel stronger and am able to balance better than when I was younger. My advice is also use-it-or-lose-it. Plus exercise and good nutrition are great stress reducers. PS. Thanks for such great health articles in the NYT!!!!

Reply 31 Recommend
Rachel California Sept. 11

@MRH Please remember in your work with the elderly that even a very fit person will eventually become weak, incontinent, etc. My dad hauled water to drink and chopped wood to keep warm (in Canada) until he was 91. He hiked around his 168 acres every day. Fortunately we are able to care for him at home. I agree with your advice--he did make it to 91 on his own--but I don't like your "blame the victim" attitude regarding older people who "landed themselves in a nursing home" or "refuse to take responsibility for themselves." Debility and dependency and dementia will come for all of us if we don't manage to die while still in good general health.

Reply 31 Recommend
Excessive Moderation Little Silver, NJ Sept. 9

I'm 75 and I've been a gym rat since I was 40. I row on an ERG, use a stairmaster, work with weights, some heavy, some light. Deadlifts are part of my routine as well as balance exercises. Balance is a MUST for those of us with chronological maturity. When I can outdo a 45-year-old it feeds the ego which is healthy too. BTW I have had both shoulders replaced and delight in replacement parts. Yearly ski weeks also help.

Reply 12 Recommend
Beverly Kronquest Florida Sept. 11

@Excessive Moderation
Please tell me about shoulder replacement, doc and recovery time. I'm 81, excercised most of my life with triathlons in 40's and 50's, now at gym 3 days a week w moderate weight machines and tai chi. Humerous severed years ago, now have rod w screws and debilating arthritis and leary of shoulder replacement.

Reply 1 Recommend
DaveD Wisconsin Sept. 12

@Excessive Moderation

Rowing is tough on the shoulders. I leave oars to the Crew members.

Reply Recommend
DWS Boston Sept. 9

I'm a 60 year old female and didn't really start exercising until 56. I still don't like the exercise part, but I liked losing the 40 lbs, buying new clothes, and feeling much much better.

I don't do anything elaborate or expensive, just a 45 minute routine of treadmill, free weights, and planks at the YMCA. I should add more, but feel it's also important to have a routine that is simple and doable. When I was younger, I didn't really have time to exercise, but it's never too late to start.

Reply 35 Recommend
Mary Sullivan Roanoke VA Sept. 9

I'm 43 and reading this article is what spurred me to go back to the gym for the first time in years. Thank you! It's encouraging to read comments from others who began exercising regularly later in life. I think, "If they can do it, so can I." So, thank you all! :-)

Reply 35 Recommend
Andy Europe Sept. 9

As my grandfather regularly went hiking and climbing mountains above 12,000 ft until the ripe young age of 84 (when a chronic knee injury stopped him for good), I remember him as an incredibly fit and strong man. Looking at pictures from his days in WW2 I could not discern any significant muscle loss compared to his late 70s, or even his early 80s. He even spent an entire summer volunteering to rebuild a mountaineers' hut (which was actually more like a very large house) when he was 72, working hard at high altitude with men 1/3 of his age!

At the end it was his knee injury that precipitated things: unable to exercise as he was used to, and grieving for the loss of his wife of 55 years, his body rapidly lost all its strength and he died at 90 as a shadow of the "young man" he'd been until 85.

I can only hope to follow in my grandfather's steps when it comes to old-age fitness; there's clearly a genetic component there, but I am realistically aware that it can also all end very abruptly and unexpectedly. Just enjoy your fitness as long as you can, folks!

Reply 45 Recommend
Mike M Ridgefield, Ct. Sept. 9

But, today, we all have knee replacements available to us, which I consider one of the great advancements of medical science for older people. I have met many skiers and other active people with new knees and hips that have no complaints about their new parts. One older fellow was hard to keep up with skiing the trees in Montana last season. No longer are we doomed to a depressing end of life confined to a chair, inactive. And, Medicare pays for it!

Reply 16 Recommend
Jay Ryan San Francisco Sept. 9

Sarcopenia is indeed a serious problem in the elderly. Its effects are evident to even casual observers as we watch culturally iconic celebrities shrink with advancing age. This is especially evident in those who have adapted extreme diets in efforts to reduce cardiovascular risk, etc. One likely hormonal/cytokine culprit in sarcopenia may be myostatin, which can increase with age and acts as a "brake" on skeletal muscle mass. Animals with disrupted or mutant myostatin genes (such as the "bully whippet") are impressively muscular but otherwise healthy. Inhibition of Myostatin remains a viable and potent therapeutic strategy for many conditions of aging, including sarcopenia. As a physician I tell my patients to exercise and eat better, but this usually works as well as my "thoughts and prayers" do for gun violence. Most patients would rather have a medicine to make it all better. Perhaps blocking antibodies to myostatin may help here. it almost makes you want to believe in science! Almost, anyway.

Reply 10 Recommend
cchina39 massachusetts Sept. 11

@Jay Ryan
Is myostatin related to statin drugs, such as atorvastatin and pravastatin used by my wife and me respectively?
I read that many statins (but not pravastatin) have side effects of muscle pain and myopathy. Is myopathy related to sarcopenia?

Reply 5 Recommend
Jay Ryan San Francisco Sept. 12

@cchina39
No. Myostatin is a naturally occurring protein hormone. It is not a drug but rather a target for blocking drugs. The myositis or myopathy associated with statin drugs is due to rhabdomyolysis or toxic muscle rupture that is a drug side effect. Statin drugs and myostatin are not related but sound similar.

Reply Recommend
Andrew S Saratoga Springs Sept. 9

I cycle my bike everyday for 10 miles!

Reply 4 Recommend
g.i. l.a. Sept. 8

I just turned 74. I belong to L.A.Fitness. Thanks to a nationwide program called Silver Sneakers, my membership is free. Check it out. Forty five minutes, three times a week is all I need. On the other days I walk.

Reply 20 Recommend
Tom Lang Chicago Sept. 8

As a former YMCA Active Older Adults (55+) personal trainer, I always start with "the 3 rules."
Avoid Injury, Avoid Injury, and ...yes. Avoid Injury!

Ask questions of a pro or fitness staff person, take it slow, and don't "Load Up" with reps or weight... as if that helps you progress.
Injuries discourage older people, since we take much longer (I'm 72) to heal and return to the activity.

Reply 19 Recommend
Roswitha Bormann san Rafael,Mendoza, Argentina Sept. 8

Once again, a good article Ms. Brody. I have 76 years on my back, have been taking calcium since my childhood, I was born lactose intolerant. I have had bone densitometry scans done throughout my life, that have shown that I had the bones of a 20 something person. My new scan was three months ago, it showed that my bone density actually increased to that of an even younger person! And all that without doing weight lifting, eating a redigluless amount of protein, lots of exercise, etc. An anomaly? Why should we have to worry at our age about having lift heavy things, that is what we have help from younger people for. My grandmother's (she died at 94) motto: just live a healthy life and you will age well.

Reply 7 Recommend
Mike M Ridgefield, Ct. Sept. 8

Why I spend so much time in the gym. And, yes, biking and swimming are not enough for muscle strength. I found that out the hard way, thinking 2-3000 miles on the bike a year took care of my legs. Nope. Mix it up. Cycling and swimming and hiking for aerobic, weights for strength. It's hard work, staying in shape when you're old. takes up a lot of time. But, at almost 66, I fell pretty darn good. Better than the alternative, as they say.

Reply 14 Recommend
Nestor Potkine Paris France Sept. 8

A useful warning, says this 58 year-old.

Reply 7 Recommend
Jean Holland, Ohio Sept. 8

I have a Walk Vest. It was developed to help women who have osteoporosis or are at risk. There are little pouches that circle the torso of the vest and hold slender weights. You can start with just 2-5 pounds, and increase as comfortable with it.

The idea is to wear it while taking walks. In hot weather, I go without it ( since weighs interfere with evaporation from sweat) But much of the year I wear it as I walk my dog.

I also wear it sometimes when I walk around the house doing laundry, cooking or vacuuming.

Reply 16 Recommend
JG Tallahassee, FL Sept. 8

one cup cooked pinto beans = 15.4 grams protein
1/2 cup cooked spinach = 3 grams protein
one medium baked potato = 5 grams protein
one cup green peas = 8.5 grams protein
one cup cooked edamame = 18 grams protein
1/4 cup almonds = 6 grams protein
one cup cooked lentils = 18 grams protein
You get the idea. Check out these vegan athletes:
https://www.businessinsider.com/elite-athletes-who-are-vegan-and-what-ma...

Reply 30 Recommend
JQGALT Philly Sept. 8

I love meat and dairy but trying to wean off.

Trying a 3:2:2 diet.

3 days vegan
2 days vegetarian
2 days meat

Better for me. Better for the environment. Working so far (fingers crossed.)

Reply 11 Recommend
Elizabeth Miranti⚾️ Palatine Sept. 9

Hmm. Sounds like you want everyone to be on your diet because it works for you.

I have three daughters, one who is vegan, one who is vegetarian, and one who is vegetarian plus poultry. Each one finds their diet perfect for themselves, enjoyable, easy, and healthy. I am a meat eater who tried vegetarian and could never feel full despite constant eating. I eat a tiny bit of meat and am satiated.

Each of us must find our own workable diet and keep tinkering to make health improvements.

Reply 9 Recommend
Cynthia Rose NYC Sept. 8

I am 65 year sold and several months ago began using a Power Plate to exercise. It has not only increased my muscle mass but I feel as though my muscles are tighter to the bone, like when I was younger. I use the machine twice a week for about 20 minutes doing planks, squats,triceps dips and an assortment of balance exercises, which are quite challenging. I also do some stretches on it (There are many videos with workouts on YouTube). Other days I go to the gym and do yoga, or a spin class, sometimes a Barre class and I have noticed much better stamina and less soreness after the classes. It's also supposed to be excellent fo rebuilding bone density.

I tried to get my gym to purchase one for the workout floor but couldn't get them to do it so I purchased the home model which slides under the bed. Sometimes I use the back of a chair for stability.

Reply 5 Recommend
Ron A NJ Sept. 8

@Cynthia Rose
You're doing plenty of exercises, for sure, but I'm not sure about Barre class or the Power Plate being helpful for bone density. I'm under the impression that it takes something like box jumps, with its high impact forces, to strengthen leg bones. For the upper body, it would take lifting heavy weights.

Reply 1 Recommend
rafael. latorre NY, NY Sept. 8

As a 57 yrs old practicing physician and commuter cyclist I can attest to the incredible benefits of excercise very well explained on this article. I would just add the incredible mental and cognitive benefits of exercise in all ages,our natural immunity, hormones, neurotransmitters including our natural endocannabinoids will increase, most free radicals (Cancer causing toxins) will be faster cleared by our kidneys and liver due to the increase in the blood flow of these organs, cholesterol fatty deposits in our vessels including the brain circulation will benefit in dementia prevention.

Reply 24 Recommend
Joe Riley Seattle, WA Sept. 8

Thank you for summarizing many of the additional benefits of exercise. One benefit to mention is that multiple studies show that exercise can help prevent or slow the progression of Alzheimer's.

I would add that there are significant psychological benefits. If you feel vital (and look it), there is less "invisibility."

At 60, I was in horrible shape and knew that I had to change. I'm now 68 and in better shape than most decades younger. What I would like to suggest is that losing weight or looking good isn't the goal. If you live a healthy lifestyle, all the benefits come along for the ride.

And working on your core (and posture) will save you a lot of pain.

If I can do it, anyone can. Do not go gentle....

Reply 27 Recommend
Sarasota Blues Sarasota, FL Sept. 8

Great article covering 2 key components of The Big Exercise Picture...

1. Strength training
2. Nutrition (specifically protein)

I agree 100% with the article based on personal and client results (I'm a musician AND fitness trainer).

Allow me to toss in an upper range for protein requirements... 1 gram per lb. of body weight. This was documented in a recent (?) NYT fitness article, and I have a 30 year old fitness book by Arnold that states exactly that as well.

Combine a consistent strength training program with sufficient daily protein intake and prepare to be amazed at how your body will transform. You can't change your chronological age, but you can damn sure change your biological age.

Reply 10 Recommend
Colenso Cairns Sept. 8

As we age, we need to work on our strength and our speed more than our stamina. As I approached sixty, I had plenty of stamina, more than I had in my thirties, but I had lost strength and I had lost shocking amounts of the speed I had in my youth.

In part, this is because the more stamina work we do, our fast twitch muscle fibres will change into slow twitch, but (supposedly) not the other way around. Over the years, as many of us do, I had moved from being a so-so sprinter to an OK middle distance runner to a better long distance runner. But my speed had gone and I missed it.

We can't have speed without strength. Moreover, the product of strength and speed is power, the hallmark of every Olympian and Ancient Greek Hero.

I switched from lifting iron to lifting body mass. But our local council replaced the 28 mm or 32 mm OD overhead bar, in galvanised steel, perfect for pull-up, chins and muscle ups, with a super slippery, fat, electropolished 42 mm bar in marine grade stainless steel that nobody could manage to grip properly, even the two guys pounding out muscle ups.

The solution? Gymnasts' and rock climbers' magnesium carbonate chalk. To cut a long story short, at the age of sixty I've gone from barely being able to do three half pull-ups on the new fat bar to doing three hundred full-drop chins in thirty sets of ten. I'm far better now at chins than I was thirty and forty years ago.

Set yourself high goals. Don't aim for mediocrity. Aim for the stars.

Reply 11 Recommend
Margo Atlanta Sept. 8

As I'm starting back at the gym, the timing of this piece couldn't be better. I'm looking forward to the second part

Reply 10 Recommend
Larry Oswald Coventry CT Sept. 8

"at least 0.54 grams of protein per pound"

What would Sheldon Cooper think of mixing the British imperial and metric systems like this?

Where is the outrage? Have we no pride?

Reply 13 Recommend
Nestor Potkine Paris France Sept. 8

@Larry Oswald Drop the darn British imperial and go for the logical stuff.

Reply 4 Recommend
James Gramprie Ann Arbor Sept. 8

1. With an increase in protein, more muscle may be made though you may not live as long.
https://www.nih.gov/news-events/nih-research-matters/protein-consumption...
https://academic.oup.com/ageing/article/45/4/443/1680839
2. As was pointed out in response to Ms Brody's article

Reply 2 Recommend
A. Brown Windsor, UK Sept. 9

@James Gramprie No. It says those over 65 BENEFITED from increased protein.

Reply 1 Recommend
The Pooch Wendell, MA Sept. 10

@James Gramprie
Eating more protein has never been demonstrated to shorten the lifespan of real life protein-eating humans.

Even if it did shorten lifespan, we're looking at a lifespan vs. healthspan trade-off. I would rather have more strength, mobility, and quality of life in the here and now, rather than hypothetical gains in lifespan.

Reply 1 Recommend
tmann202 DC Sept. 8

"Protein acts synergistically with exercise to increase muscle mass," Dr. Morley wrote, adding that protein foods naturally rich in the amino acid leucine -- milk, cheese, beef, tuna, chicken, peanuts, soybeans and eggs -- are most effective."

Didn't your last column warn against fats such as dairy and beef? Shouldn't we be replacing these with processed vegetable oils??

Yeah probably not.

Reply 2 Recommend
Martha Ohio Sept. 8

Is there no end to this nonsense? How long are we supposed to function, function, function? I'm in my 50s and I'm already exhausted by all the bossy health rules inflicted on us all. I like the idea of being active, like walking and swimming, for a long time, but who the heck cares if I can't move furniture when I'm a great grandma?? I'll be happy to putter around my house, knit, watch Netflix, and let other people do the heavy lifting for Pete's sake. Can't we just get a REST from all this insistence we live hyper active lives forever? Are we ever going to be allowed to just die in peace?

Reply 63 Recommend
Mary Sullivan Roanoke VA Sept. 9

Both of my parents recently died. When you are weak, you tend not to die in peace or pass quickly. You may slowly suffer as you shuffle off. So, perhaps being as fit as you can will keep your quality of life up so that you can enjoy the knitting, etc.

Reply 6 Recommend
Forsythia715 Hillsborough, NC Sept. 12

@Martha I so agree with you, Martha. I'm 71 years old and in reasonably good shape. I do moderate amounts of exercise (which I thoroughly enjoy) and I'm not overweight. I try to eat a reasonable vegetarian diet, but have no intention of giving up ice cream, chocolate, cookies, and all the lovely French pastries/cakes I adore. I'm not going to live forever no matter how much attention I pay to my body. At this time of life, I want my remaining years to be as meaningful and generous-spirited as possible. I want to notice each passing day and revel in it. I want to cultivate kindness, patience, wisdom and gratitude. To me, that's at least as important as as spending large blocks of time trying to outrun the ticking clock imposed by my aging. Life is good. Enjoy it. It won't last forever no matter what you do.

Reply 2 Recommend
Walter McCarthy Henderson, nv Sept. 8

Sarcopenia also known as couch potato syndrome.

Reply 9 Recommend
Chuck Burton Steilacoom, WA Sept. 8

My experience suggests that fit and healthy older people (like me) enjoy reading articles like this, because it brings self-validation. On the other hand, those most in need of this advice will skip it or at most scan it quickly. Like most of us, they are more than aware of their shortcomings and hate to be lectured.

Reply 22 Recommend
Adolph Lopez New Orleans Sept. 8

What about joint pain and the way it seems to work against you. I climb as many stairs and lift as many weights as I ever did -- even at age 64 -- but knees, ankles, wrists hurt more often than not. I generally push through the joint pain, but I think it's subconsciousely slowing me down.

How do deal with these together and still get the benefit?

Reply 11 Recommend
LW West Sept. 8

@Adolph Lopez

I completely understand. While decades of long-distance running has kept the joints in my lower body arthritis- and pain-free, I have developed the same arthritis in my fingers and wrists that my mother and grandmother did. While I can adapt to some extent by carrying heavy grocery bags or suitcases by shoulder straps rather than gripping them in my hands, "pushing through" most recommended weight workouts, yoga classes and most housework requiring scrubbing or moving furniture end up with me kept awake all night with aching and stabbing pains in my affected joints.

Reply 9 Recommend
Bob Walters Los Angeles, CA Sept. 8

@Adolph Lopez I'm 62. I've found I needed to add time to my workout routine to isolate small muscles, especially wrist, forearms, neck, lower back (back extensions) and rotator cuff (front and back). I also no longer ignore the romboids and scapula. At the same time, the likelihood of an abdominal hernia rises with age, so either lighten the weight on abdominal and leg press/squats or wear a support belt.

Reply Recommend
hakan seattle Sept. 8

12 reps? That's too many for muscle gain. One needs to lift as heavy and be in the 5-8 rep range to build muscle. She doesn't even mention protein supplementation. Nutrition is key in building muscle. I guess this is intended for geriatric types.

Reply 2 Recommend
Nativetex Houston, TX Sept. 8

?? Ms. Brody gives three paragraphs to protein. You must not have read the whole article.

Reply 6 Recommend
Bob Walters Los Angeles, CA Sept. 8

@hakan I beg to disagree. Muscle fatigue will generate repair causing muscle growth.

You're right though, the heavier you lift, the faster you can become stronger. From my 20's to my early 50's I followed your suggestion. However, the rules change for those over 50 or so. IMHO no weight should be lifted unless one can do at least ten reps after age 50. Otherwise, the risk of injury outweighs the potential benefit of the extra gain.

Reply 9 Recommend
Marcus NJ Sept. 8

At 82 and after two back surgeries,I am aware that I can no longer do long hikes with steep climbs,however I still do 5 or 6 miles on relatively flat trails,walk as much as I can and do proper stretching exercises as instructed by a therapist.My philosophy is, keep your mind and body as healthy as you can by doing what you enjoy,avoid excessive stress at all cost and let nature take it's course.

Reply 39 Recommend
karen nw arkansas Sept. 8

I am familiar with the Tufts study. The book is "Strong Women Stay Young" by Miriam E. Nelson, Ph.D. and the first edition came out in 1997. I have been following her program for a little over 12 years; started after 'hormonal changes' aka peri-menopause and menopause started really kicking in.

I bought the equipment at Academy Surplus for under $100, follow the instructions and graphics in the book as closely to the letter as possible, and do this alone, at home, while paying close attention to form and 'muscle memory'. The exercises are truly simple and easy to start from a beginner's level.

Now, I am at about 40 minutes a session about 2x a week, give or take some sessions and/or minutes, and allowing for travel, illness, self-sabotage, etc.

I was astounded at how quickly the physical, mental and emotional benefits appeared. And, they accrue. I am pushing 65, and more often than not, I feel somewhere between pretty good to awesome.

I work from home at a somewhat-stressful, very sedentary job, eat regularly and 'healthily' but don't stress over details or 'forbidden' foods (although I did move away from alcohol, sweets and most highly-processed foods - they just don't taste or feel good anymore).

This is truly something for everyone - not just for those with lots of time and/or money; most especially it is for those of us who, for no good reason, think we can't do it. We can.

Reply 33 Recommend
LJIS Los Angeles Sept. 13

@karen (and others!) I am exhausted from waking up every hour sweating during my perimenopause. I don't have the energy to exercise and am concerned about muscle loss that I can already see. It's all I can do to drag myself out to walk a couple of miles every day! Thank you for posting. What I'm hearing is that you CAN recover muscles after this time of life. I sure hope so. For now I have a low-starch low-sugar diet with plenty of green vegetables and lean protein and do my best. I wish there was more support around this.

Reply Recommend
Tom New Mexico Sept. 8

This article seems to imply that sarcopenia and muscle loss associated with aging are the same thing since the prescription is targeted exercise. If sarcopenia is a pathologic condition how is it different from age-related muscle loss - the article does not address this.

Reply 7 Recommend
gd Kansas Sept. 8

Muscle loss happens to everyone, regardless of what you do. Of course, it can be slowed by vigorous exercise, but let's be honest about it. Despite continuous vigorous exercise, I have seen my strength decline steadily, so that now, at 81, it is difficult to run a distance of several miles, despite having done it regularly for fifty years. I have to content myself with switching to shorter runs along with walking at a brisk pace. We need to manage the decline of aging, not deny it, or call it a fancy name.

Reply 33 Recommend
Jus' Me, NYT Round Rock, TX Sept. 8

@gd

"Vigorous exercise" is NOT the same as quality resistance training, as you very well note the outcome of your own experience.

Long distance runners get plenty of "vigorous exercise," right? Look at their bodies, then the bodies of sprinters.

Case closed.

Reply 1 Recommend
tbaker Massachusetts Sept. 8

The excercise being recommended here is not vigorous aerobic exercise. It is strength building options with weights and/or resistance. Miriam Nelson, who was among the researchers at Tufts who were part of the findings mentioned in this article, reported in her series of books how strength builidng exercises should be prioritized prior aerobic options for their muscle building and maintaining results. Those results will in turn support aerobic acitivty. The claim isn't that there won't be diminished capacity in older years, but that is can be signifcantly countered and preserve independence. Here's a link to research on Miriam Nelson's strenght training program results for women ages 29-89: https://projects.ncsu.edu/ffci/publications/2012/v17-n2-2012-summer-fall...

Reply 17 Recommend
JimmyMac Valley of the Moon Sept. 8

Statins are often the cause of muscle weakness.

Reply 11 Recommend
Susan In Ventura Camarillo Sept. 8

@JimmyMac
I would like to read about this.

Reply 1 Recommend
SWA Des Moines Sept. 8

The key to being active and maintaining muscle mass over a life time is to find something you truly enjoy doing. I disagree with the author that that has to be weight lifting or using bands or tubes. Many people, including myself, find these workouts- typically done in gyms- repetitive and boring. I want to be outdoors and doing things that seem natural and gone be done with a group. For me that is cycling (competitive). Jane writes that cycling alone is not enough even for the muscles used in the activity. That is definitely not my experience. I see many riders in their fifties and sixties ( I am 55) who are extremely active, competitive and have very muscular legs. You just need to ride, or run, or swim strenuously. Also, I think yoga should be suggested as a great group strength building activity. Find something you love, do it routinely and with increasing intensity, vary your workouts and stay active.

Reply 14 Recommend
Jus' Me, NYT Round Rock, TX Sept. 8

@SWA

Prevention of sarcopenia DOES require resistance training. There is no alternative.

I too, hate "the gym" and the boring work. But it's that or sarcopenia.

Reply 11 Recommend
LW West Sept. 8

@SWA

I try to add in those repetitive and boring (I completely agree with your description!) as part of a cool-down stretching routine after an enjoyable vigorous workout (for me it's running, and I'm also mid-fifties). It's a little less monotonous if you can do it outside (grass field, playground equipment) or at home with a TV show on (I rarely watch TV, and tape things I'd otherwise miss as further motivation). When all else fails, I invite the dogs and/or cats to join me and turn the "weight work" into an impromptu wrestling/agility match. My mother, at 88, has never participated in any formal exercise, but still does most of her own housework, gardening, shopping, and so forth. Obviously she has good genes, but I see too many people her age and younger that do nothing but sit still all day, then blame their loss of mobility solely on aging.

Reply 8 Recommend
bonmom Arcata, CA Sept. 8

Very good advice, but in the process of compiling an exercise program, there are really 5 important things to consider: strength, anatomy, cardiovascular, flexibilty, and nutrition.

Everyone brings his/her own physical quirks and limits to an exercise program. Not everyone can or should carry a heavy weight, as it increases the load on the knees. Walking stairs can be hard on hips and knees as well. Arthritis is a reality and can be caused to flare with too much of the wrong exercises. Backs can be fragile until strengthened properly.

Be sure to warm up and do not do something that is painful in the wrong way. A groan with an effort is one thing; a sharp wince is another. Listen to your body and push its limits, but do not push into injury territory. You take one step forward and two back if you do.

Also, working and strengthening the muscles increases their tone but can decrease flexibility. Balance and suppleness are very important to avoid falls as well, so mix in some yoga to keep that good posture and reach.

We are more likely to have injuries as we age and/or are deconditioned, so be sure to take care not cause the very thing you are trying to avoid.

Reply 13 Recommend
Herb Silver, PT, DSc Atlanta, GA Sept. 8

@bonmom 1. If exercising with weights through full range of motion, you add sarcomeres, the contractile units in muscle and you will increase flexibility. There is nothing in the structure of muscles that actually stretches significantly. I have done yoga for almost 50 years. I am pretty close to as flexible as I was as a teenager but I am not a contortionist. My hamstrings actually get longer when I do hamstring curls (but I am not consistent enough). 2. Yes, doing exercise correctly and only doing certain exercises and avoiding others is necessary, but the most obvious observation is that people with knee pain need to exercise more not less. I am not suggesting exercising through pain but research studies are pretty consistent that strengthening tge lehs reduces knee pain.3. It also has been should that physical therapy interventions that include manual therapy interventions is an additional benefit over exercise alone.

Reply 7 Recommend
shirley seattle Sept. 11

@bonmom An excellent response!!!!!\

Reply Recommend
Bathsheba Robie Lucketts, VA Sept. 8

I have a condition called pudendal neuralgia. It was caused by medical malpractice. I cannot sit without awful pain and am on pain killers. I have a long list of activities I must avoid, including . House work. I am not allowed to lift anything over ten pounds. Any kinds of exercises which involve sitting are verboten.

Of course, no one can live this way, but I am careful. I still do grocery shopping and most of my chores. I had a cat for 22 years and want to get another. Kitty litter doesn't come in ten pound weights.

I thought I had a high protein consumption but it's nowhere bear what you recommend so protein supplements will be necessary.

Reply 6 Recommend
magicisnotreal earth Sept. 8

@Bathsheba Robie
If I may suggest, look at some Tai Chi videos on YouTube. It is basically a slow moving dance where you activate your muscles to move your body. It is very well designed to hit all the major and minor muscles.
I am not yet 60 and while aware of muscle deficits, some life long due to injury I was still surprised that muscles I never thought of simply were not activating when I tried to do the movement correctly.

Reply 8 Recommend
JenD NJ Sept. 8

@Bathsheba Robie I am familiar with chronic pelvic pain conditions, including pudendal neuralgia. I hope you have been able to get treatment with a physical therapist who specializes in pelvic disorders, as well as a physician who specializes in these problems. Wishing you the best.

Reply 1 Recommend
joanne South Central PA Sept. 8

I am only 68, but started several years ago to try and strengthen my arm and leg muscles. Every day while I am brushing my teeth in the morning I stand on my left leg for 30 seconds, then the right and repeat again. Every night while also brushing my teeth I do at least 15 squats, and after that 20+ push-ups against the edge of the vanity. While not prescribed exercises, I believe they help tremendously to keep my muscles strong. It is easy to remember to do them because it is tied into something (teeth brushing) that needs to be done twice a day.

Some time ago I was listening to a radio program about elder health. The doctor being interviewed was asked what one thing contributes most to aging decline. His answer: "Living in a one floor house". Without that daily climb up and down the stairs as a minimum exercise leg muscles decline quickly as does independence. I think that is a good piece of advice, but one seldom followed even in communities for the elderly. Housing is built for how people are rather than for what they should aspire to be.

Reply 20 Recommend
Lisa Merullo-Boaz San Diego, CA Sept. 8

@joanne
I love that you said, "only 68." Bravo! I turn 65 next month, and I don't know what's harder to stay healthy: physical exercise or mental, reminding myself that I'm not completely old yet. Thanks!
LMB

Reply 4 Recommend
Nestor Potkine Paris France Sept. 8

@joanne smart idea, the mixing of exercices with repeated chores !!!!!

Reply 2 Recommend
Boregard NYC Sept. 8

As a retired personal trainer...one of the biggest mistakes the "profession" does with older adult clients is not use heavier weights when applicable. But many trainers immediately shy away from them due to biases about the older client. (some are correct, but the client must be properly assessed physically, not just verbally.)

Loaded carries are a prime example. Carrying a weight (dumbbells or kettlebells, sand bag) in one hand or both, or cradled in the arms, over a distance. It promotes allover strength, and is perhaps one of the most "functionally" driven exercises there is, mimicking a common complaint of the older clients."I cant carry my groceries anymore. My grip strength fails...my shoulders hurt, my legs give out..."

Too many trainers, too often go for basic bodybuilding type exercises - dumbbell curls, presses. Or use machines for exercises (tricep push-downs, lat pull-downs - please stop those completely!) that are more a bodybuilding finishing exercise, then strength builder. An older client will not gain the needed strength from a lat pull-down, no way. Its both too risky (for most clients, of any age) but an uncomfortable movement for those with range of motion (ROM) issues.

Train the non-trained older client by having them do movements, under-load when possible, that mimic everyday movements. Walking, carrying, pushing, getting up from a chair to start, and when possible from the floor.

Creativity for the older client is crucial.

Reply 79 Recommend
bearsvilleboy bearsville, ny Sept. 8

I am 75 and my first exercise at the gym 3x/week is to balance myself on each side of a Bosu Ball for 60 secs. I believe this builds muscle memory and prevents falls.

Reply 14 Recommend
Cone Maryland Sept. 8

How inspirational! I have just had a pacemaker implanted and it will be some time before I can fully use my left arm but I can bring back my weights and get started. I have a physical therapist to work with too.

Signed, an 81 year-old.

Reply 9 Recommend
Bill South Carolina Sept. 8

I am a 74 year old man who has been an lifelong exerciser. Before I retired, I ran 15-20 miles per week and lifted weights 2-3 times per week. Running injuries made me a walker who still does 10-15 miles per week in a mountain community.

I noticed at around 70 years of age that I was not able to lift as much as in earlier years. I always try to do better, but have to take care not to injure myself.

I agree with the tone of the article in that exercise is key to a better old age. I see to many of my friends who play golf only(if that) and eat way more than they need. I should post this article in my local wellness center. Unfortunately only those who don't need this advice will see it.

Reply 13 Recommend
Lisa Merullo-Boaz San Diego, CA Sept. 8

@Bill
Post it anyway. Even if only one person reads it and takes it to heart, you've made a difference!
LMB

Reply 7 Recommend
Richard Albany, New York Sept. 8

As a physician with many elderly patients, my sense is that as you get older (70's on) the relative benefit of resistance training (especially in conjunction with balance and flexibility training, which can be integrated) increases. Someone in their 40's can be pretty fit and have good quality of life with just aerobic training. Aerobic training is good as one gets old (brisk walking is great), but without resistance trying, functionality decreases more rapidly. Just 2 days a week can make a huge difference. My biggest problem is figuring out how to motivate people and give them ideas for exercise in a short office visit.

Reply 23 Recommend
M. Lyon Seattle and Delray Beach Sept. 8

@Richard As I mentioned in another comment, I highly recommend Canadian physiotherapist Margaret Martin's website, www.melioguide.com . The website offers superb strength-training, balance, and flexibility exercise programs for women over 50, complete with videos of each exercise. The exercises can be done at home and require just a few pieces of equipment. Margaret Martin's programs (beginner to elite) are targeted at those with low bone density, but those with stronger bones will derive great benefits, too. I rarely rave about such things, but this website has changed my 50-something life.

Reply 3 Recommend
Jo Marin California Sept. 8

Yeah, I'm in my late forties, and do fine with aerobic exercise, but on my to-do list for the next year or so is to start resistance training for the long run.

Reply 2 Recommend
Gandhian NJ Sept. 8

I am vegetarian from India who rarely consumes eggs. My grandfather was a vegetarian who ate mainly rice twice a day but being a farmer was physically active all his life . He lived up to 90. My father was also a vegetarian who ate mainly rice twice a day but did not do much of exercise as he moved to city to make a living. He lived to 86. My uncles all lived to mid 80s and all were strict vegetarians. On the female side all my ancestors lived to mid 70 to mid 80s. They were all thin just like me. All these health articles and research, I believe are focused on white folks whose genes are perhaps different from Indian genes. It would be best if there were some statistics on diversity.

Reply 42 Recommend
Jus' Me, NYT Round Rock, TX Sept. 8

@Gandhian

And the Indian descended head of the American Vegetarian Society, or something like that, dropped dead in his early 60's.

This article is not about longevity. It is about a quality of life achieved by specific regimens.

Reply Recommend
LW West Sept. 8

@Gandhian

My mother, born in Germany and of German-Swiss, has always eaten a high-fat diet heavy in animal products, as has most of her family. She, her brother, and most of her cousins and friends back in Germany and Switzerland are living active and independent lives in their late 80's and early 90's, and most of their parents and grandparents died in their late 90's and many over 100. Not all are or were thin, but none were ever obese. In their case, I credit both good genetics and lifelong activity (not formal exercise, but walking, living alone and doing their own housework, gardening, shopping, and so forth). I agree there should be more statistics on diversity as well as diet and exercise or lifelong activity, but there is a lot of diversity within racial groups as well.

Reply 3 Recommend
Gerald Portsmouth, NH Sept. 8

My ancient mother in the UK turns 97 in October. She lives on the second floor, with no elevator. Her doctor actually encourages her to use the stairs, which she does 4 or 5 times a day. He also told her to hide the remote control for the TV so she has to get up every time she wants to change the channel or volume. She lives on her own and still insists on cooking for us when we visit. She eats well. She was an avid walker all her life and was never happy if she couldn't exercise. She is my role model for aging and staying active. I'm almost 72 and plan to emulate her.

Reply 54 Recommend
Nagesh Ramamurthy Bangalore, India Sept. 12

@Gerald That is amazing! To be 72 and to have a 97 yeaar old, fit mother! Living on the 2nd floor, and taking the stairs 4-5 times a day! Wow! My sincere regards to her!

Reply Recommend
Ivy CA Sept. 7

This is just too much food, even for me 25 years younger.
And as noted by others, all animal-based sources.
Lift weights yes, eat protein yes, but from a variety of sources.
Also some meds have side effect of sarcopenia--how does this work for elders?

Reply 7 Recommend
James Gramprie Ann Arbor Sept. 7

1. Increased protein intake may be needed for increased muscle mass but this increased protein may occur at the expense of shortened lifespan. "Blue zone" inhabitants do not eat a lot of protein, and most of what they do eat is not from animals.
https://blogs.scientificamerican.com/food-matters/blue-zones-what-the-lo...
https://www.nih.gov/news-events/nih-research-matters/protein-consumption...
https://academic.oup.com/ageing/article/45/4/443/1680839
2. To my frustration, Ms. Brody mentions no non-meat sources of protein. This is reminiscent of a previous article where she raised concerns about plant-based protein sources. "Complete" protein foods have all 9 essential amino acids. These include soy, the ingredient in the widely available tofu, and quinoa (remarkably tasty - and selected by NASA for long-duration space flights). And, of course, you don't need to get all 9 essential amino acids with only one food source.

Reply 31 Recommend
Ron A NJ Sept. 8

@James Gramprie
Thanks for the links. They were interesting and I ordered a copy of the Blue Zones Solution. Thing is, the US and UK studies do recommend a high protein diet for people over 65. The long-living people of the Blue Zones do not eat a lot of protein but, then, there is no recommendation against it, either.

A quote from the 2014 study funded by the National Institute on Aging:
"... in participants ages 65 and older, those who consumed high amounts of protein had a 28% lower risk of dying from any cause and a 60% lower risk of dying from cancer. These associations weren't influenced by whether the protein was derived from animal or plant sources."

Reply 8 Recommend
The Pooch Wendell, MA Sept. 10

@James Gramprie
Humans and human ancestors have thrived by obtaining their protein (and many other nutrients) from meat, fish, and eggs, since forever.

Reply 2 Recommend
Nina Bay village Ohio Sept. 7

People age. They need assistance. Instead of pretending aging will not take its toll or it can be prevented, we should provide help and assistance. It is cruel to continually insist that if only old people would do this or that, they can retain what is lost with aging.

Reply 19 Recommend
Jo Marin California Sept. 8

There is a huge difference between aging badly and aging well. I have watched both. People who were sedentary, and could barely walk at 80, and people who were always active still walking comfortably at ninety. That's ten years of a higher quality of life! That is no small thing.

Reply 14 Recommend
vmdicerbo Upstate NY Sept. 8

@Nina That was not what I took away from the article. No one will deny that aging will eventually take its toll on our bodies. As a lifelong exerciser my primary motivation is my QUALITY of life. I want to get the most out of my limited time here.

Reply 7 Recommend
SteveRQA Main St. USA Sept. 7

Weight training or resistance training is, as we know, the best thing we can do to maintain or increase muscle mass in the body.

In my opinion, weight training SLOWS the aging process, forcing the body to constantly repair the micro tears we make in our muscles when we weight train.

So yes, Weight training or resistance training is good, so we should do it. That's easy for folks who like to, (yes, we are out there). But what if you don't like to weight train? Best bet is to get a friend who also wants to weight train and become training partners so you can push each other.

The is still another roadblock. Pain and injury. Nothing can stop you dead in your tracks like pain. Folks who are lucky enough to have enough not to have Pain or injury will of course be able to train.

Lastly and the most important. Get into a routine and DO NOT STOP. This is the most common mistake folks make. Whatever exercise you prefer to do, KEEP DOING IT. Its not easy, but your body and life will be better if you can.

Reply 54 Recommend
Jeffrey Dach MD Davie Florida Sept. 7

One of the best discussions of this topic of sarcopenia comes from Dr. Sgr๒ from Rome Italy in Feb 2018 Aging Male. Dr Sgro suggests the three pillars to fight sarcopenia are: 1) Physical exercise, 2) nutrition and 3) hormones. I think Dr Sgro is quite correct. A huge consideration concerning nutrition is the age related gastric atrophy with decline in gastric acid production needed for protein absorption. How many of the elderly are suffering needlessly from sarcopenia because of gastric atrophy? For more see: https://jeffreydachmd.com/2013/03/hair-loss-from-low-stomach-acid-lady-i...

Reply 5 Recommend
hb mi Sept. 7

I'm over 60, and I still love and crave excersize. There is no better feeling than your heart beating rhythmically on exertion. I just can't comprehend the sedentary, the lazy, the obese. They are not alive but are merely existing. Start slow and never stop.

Reply 12 Recommend
Mary NYC Sept. 7

Surely there's a way to do this without a gym?

Reply 3 Recommend
Anne Arizona Sept. 7

@Mary I bought free weights (five- and ten-pound dumbbells), a yoga mat, resistance bands, five-pound ankle weights, and I exercise at home. Plus I try to walk a lot, but it's exercising with the weights and bands that really make a difference. No gym necessary.

Reply 25 Recommend
Diane Newton, MA Sept. 7

@Mary I have been working out at home, with good TV shows for entertianment, for 20+ years. I see a trainer every few years to get a tune-up. The best exercise program is the one you do so if you hate the gym (I do) start at home.

Reply 11 Recommend
Meredith New York Sept. 7

Oh no! Give us a break, Jane.
"The critically important "but" -- no matter how old or out of shape you are, you can restore much of the strength you already lost."

Well, isn't that great to look forward to? Even people in their 90s, in a nursing home, no matter how out of shape, can work to restore much of their strength? So we'll have this great 'responsibility'?

You mean we won't be able to relax even in our 90s? And in a nursing home yet? Is their no rest? Let's start a movement for R&R for the elderly!

" high-intensity resistance training" significantly enhanced the physical abilities of nine frail nursing home residents aged 90 and older."

"Frail"? Yikes, high intensity? Then feel guilt if we don't "keep in shape" like a 90 year old SHOULD? We owe it to ourselves? I see.

What's the reason it's long overdue to act on this info known for 30 years? Maybe 90 year olds don't want to be bothered with this in their nursing homes. And doctors/nurses don't want to burden them. 90 year olds want to relax, and they deserve it! Give them a break already. Sarcopenia? But muscle loss with aging isn't a disease.

Jane Brody has always written with pride in her great exercise routines, swimming, walking, etc keeping her strong and healthy. Bully for her. I go to exercise class and I appreciate her helpful advice but --- maybe she's a bit too fanatical. I hope if I go to a nursing home, I'm not in the clutches of anyone like that.

Reply 24 Recommend
Margo Atlanta Sept. 8

I don't expect any extreme effects from weight training, but I know that stronger back muscles mean my backaches go away and I'm less fatigued after gardening. Given the choice of a lighter weight barbell or a pain reliever, I'd prefer the barbell.

Reply 11 Recommend
Jo Marin California Sept. 8

You need to spend time with more elderly people. The difference in quality of life at higher ages is night and day between those who stay active and those that don't. All 90 year olds do not have identical qualities of life, or eighty year olds, or seventy year olds, and a major factor that makes a difference is exercise.

Reply 1 Recommend
SB Vermont Sept. 7

Yoga and gardening also work. I won't be a slave to the gym -- boring! Do what give you joy.

Reply 12 Recommend
Jus' Me, NYT Round Rock, TX Sept. 8

@SB

Yoga and gardening will NOT prevent sarcopenia, any more than walking around the grocery store.

Muscles need to be stressed. Nothing about gym slavery. Buy your own weights or bands.

Reply 4 Recommend
F. Cox MD Rochester, MN Sept. 7

For those who wish to increase their protein intake, there are some caveats. The September 2018 issue of the Harvard Medical School "Harvard Health Letter" warns of "The hidden dangers of protein powders" and recommends consulting the nonprofit The Clean Label Project's website ( www.cleanlabelproject.org) for information on contamination with toxins.
You may also be interested in the September 2018 issue of "Nutrition Action Health Letter" which has a several page article on dietary protein consumption. The Letter has been in existence for more than 40 years, has a prestigious science advisory board and is published by non-profit Center For Science In The Public Interest which lobbies Congress on health issues related to food. (Not all lobbyists are evil. This one lobbies in the public interest.)

Reply 8 Recommend
Stephen Spang New Jersey Sept. 7

Interesting article, but Dr Morely's statement on protein requirements seems higher than the USRDA, Are there references for his statements in peer reviewed journals?

Reply 7 Recommend
Margareta Braveheart Midwest Sept. 8

The USRDA protein numbers are minimal necessary, not optimal. If you do a search on the net, you'll find a number of NIH studies that support Dr. Morely's statement.

Reply 4 Recommend
Mary Hafer MD Boise Idaho Sept. 7

If the expert opinion is that older people need AT LEAST 0.54 g protein for each pound ideal body weight, then the following statement should read , not " need as much as " 81 g protein per day, but AT LEAST 81 g protein per day for an individual with ideal body weight of 150 lb. The beneficial effects of protein on preventing and treating Sarcopenia appear to be dose related , meaning even more protein than the 81 g per day example in the article would be advisable. Even in this article highlighting the benefits and importance of dietary protein, the example lowballed the recommendations. Ignorance and ambivalence about the science supporting a diet higher in protein is rampant and helps perpetuate a host of chronic health problems including Sarcopenia

Reply 3 Recommend
F. Cox MD Rochester, MN Sept. 7

@Mary Hafer MD I agree with your comment. And my son who has a Ph.D. in Nutritional Biology from UC Davis and has been the editor for a research volume on sarcopenia says he agrees too. And for the other readers, the article is correct in pointing out that the protein consumed should contain significant quantities of the branched chain amino acids (leucine, isoleucine and valine) because it is the level of these amino acids which turns on protein synthesis needed for muscle hypertrophy. I can also recommend "The Healthy-Aging Diet" report published by Health & Nutrition Letter/Tufts University Friedman School of Nutrition and "The Mayo Clinic Diet" book by Donald Hensrud, M.D., M.P.H.. Dr. Hensrud is Director of the Mayo Clinic Healthy Living Program where a program of classes in health and nutrition (including cooking classes) is taught to the general public and to physicians. DVD recordings of his lectures on The Mayo Clinic Diet are also available from The Great Courses.

Reply 10 Recommend
Ivy CA Sept. 7

@F. Cox MD What older person can or will eat that many calories? My Mother was active into her mid-80s and even then ate more than me at 30+ younger. I fed her a balanced diet and often we went out for her favorite hamburgers (I couldn't cook, I had salmon burgers)--but is a burger even that much protein? I understand the science but seems off.

Reply 1 Recommend
Erin B.Y. OC, CA Sept. 7

Ok, these aren't the comments from the anonymous op-ed piece...unless I missed the part about yoga in there

Reply 2 Recommend
Old Lifter California Sept. 7

I think our expectations should be much less modest than the comments and article suggest. I am in my mid/late 60's and between my 50's and now was able to rebuild every bit of muscle mass that I had lost by sitting in an office chair at work every day followed by more sitting at home over decades. I started very modestly with the proverbial 5 pound dumbells and built up slowly over 15 plus years of steady lifting. Exercise and lifting is the highlight of my day, mostly because of the enhanced ability to enjoy day to day life more as a fitter person. With steady progress over a period of years you will be astounded at what you can do. I understand that this seems to not be most peoples cup of tea, and most people seem to get bored with it. In some ways I look at it like brushing your teeth and flossing. I do not skip brushing just because I am not in the mood, and I don't skip lifting either. Don't go overboard, but don't attach undue weight to what your doctor says either. There is insufficient research for any doctor to really know anything about this. As one person noted, each type of doctor sees exercise through their own lens. If I had listened to my doctor I would still be lifting 5 pound dumbells and would not have even one additional ounce of muscle mass. Do whole body exercises. To the extent that your flexibility allows learn and do squats, deadlifts etc. Start with body weight and go up from there. Walk or bike everywhere. But stick with it over the long haul.

Reply 45 Recommend
RMH Houston Sept. 6

For the aging body I strongly recommend a program of: yoga for flexibility, balance, strength and serenity; weight/resistance training for strength; and aerobics for cardiovascular health. Strength training by itself is not sufficient.

Reply 35 Recommend
LW West Sept. 8

@RMH True, except that my aerobic exercise gives me serenity. I do yoga for the other benefits, but find it more annoying than peaceful. Still, I feel better when the class or routine is over!

Reply 2 Recommend
Shelley Kath Montreal, Quebec, Canada Sept. 6

Thank you so much for this important article. Finding out more about what can be done to prevent and even address sarcopenia is something that will be so valuable to so many! More details....please! And of all the factoids in this article, I think it was the visual of marbled meat that most motivated me to look around for my free weights. -- Many thanks, SK

Reply 8 Recommend
Philip Greider Los Angeles Sept. 6

Of all the studies in the medical literature that I've read over the years that compared exercise to pretty much anything else when treating cardiopulmonary disease, depression, osteoporosis, insulin resistance, etc, etc, almost every single one of them showed exercise to be superior. So it shouldn't be at all surprising that exercise prevents sarcopenia better than anything else. The hard thing will be to get enough people to actually follow that recommendation because, as we have seen, all the ills of a sedentary lifestyle have become more and more common despite the knowledge that exercise prevents them,

Reply 14 Recommend
Sneeral NJ Sept. 6

Yes. But the main reason no one should be surprised that exercise is the best way to stave off and reverse sarcopenia is because it's about muscles!

Reply 1 Recommend
Robert Shaffer appalachia Sept. 6

At seventy, I think of the old farmers I grew up around with a nostalgic view of the way they lived. Life was hard. Many of them were as muscled and wiry as old locust posts and still died young. Some sat down in rocking chairs at the age of 60 exhausted after decades of hard, heavy labor, timbering and farming, and never picked up a shovel or tool again, and lived to be old. Many of them did the kind of physical work we don't do today. They tugged and lifted, and walked, and climbed and moved heavy objects,by hand, with their backs and...you get the idea. Then they ate everything put in front of them, vegetables put up in jars, fruit from orchards, bacon, hams, beef, most of it fried, or baked and boiled, baked goods with dough slathered in lard. Were they strong and healthy? Some were as strong as mules and lived to be old men. Some grizzled fellows, tough as old leather but died young from all the things we fear today, heart disease, cancer, diabetes, etc. In other words, there never seemed to be any rhyme or reason to longevity relative to heavy, lifting, muscle work. I agree it can't hurt to exercise, lift weights, and more, but I think a lot of folks just need to relax enjoy a piece of apple pie, put down the extra fries, and take my grandmother's advice, "everything in moderation."

Reply 77 Recommend
F. Cox MD Rochester, MN Sept. 7

@Robert Shaffer Your personal experience is only anecdotal at best. The science of medicine has been working under the auspices of "evidence based medicine" for more than 40 years. The very lowest and rarely used category of evidence in this hierarchy is professional experience but even that is better than what you propose because the observer is highly trained. The overwhelming mass of evidence based medicine/epidemiologic studies have shown a correlation between exercise and a number of positive health benefits (longevity, prevention of heart disease, stroke, diabetes, high blood pressure, etc.). Some noted authorities have even hypothesized that a lifestyle of exercise, a healthy diet, nonsmoking, non-obese body mass index and very modest alcohol consumption would lead to an elimination of close to 80% of all human chronic disease. If you prefer a laissez-faire, only pleasure seeking lifestyle, then you should have to pay much higher health insurance premiums rather than burden your healthy lifestyle peers. You're going to need the health care. e.g.: "Impact of Healthy Lifestyle Factors on Life Expectancies in the U.S. Population", Circulation, vol 138, Issue 4, pp. 345-355, July 24, 2018. (www.ahajournals.org/journal/circ/)

Reply 10 Recommend
KBD San Diego Sept. 6

Having done "heavy" weight lifting all my adult life, at 71 I am still aggressively training to increase my totals. All articles I have read on this critical subject should have advocated a far more demanding weight lifting regime. Of course everybody needs to start at the level they can safely manage, with good form, but they should be encouraged to go beyond that as rapidly as possible. Key to this is certainly increased intake of protein. Another possible key, which the medical profession avoids with statements about "normal" hormonal levels for a given age begs the question of what should be considered normal for a basically enfeebled sample population.

Reply 4 Recommend
Kay White Washington, DC Sept. 6

Girls should be encouraged to begin lifting weights in school. There has always been this hysteria that if women lift weights, they will bulk up like men. It's not physically possible for women to have men's bodies from weight lifting! (That's accomplished only by taking steroids and extreme dieting.) I started lifting in high school - one of the few girls in weight lifting class. I still lift... Lifted this morning before work, as a matter of fact. I'm 47, strong, and I feel great. And as strong as I am, I don't look like a man! I hope I can lift until the day I die. Women, you will age so much better if you lift. You will feel sexier if you lift! Don't be afraid to start today!

Reply 83 Recommend
Debbie M Work Sept. 6

@Kay White Funny, my little country high school in the South, where you would think women would be encouraged to be extra-feminine, required weight lifting for girls at PE. We never got bulky but we were faster and stronger for it. Back then (class of '79) there was a program called President's Physical Fitness test. It was a good measure of areas we needed to work on to be fit. I'm not sure why that is no longer used at public schools, but I wonder if there would be advantages to resuming it.

Reply 13 Recommend
Raindrop US Sept. 8

We had a presidential fitness test when I was in high school. It was replaced in 2012; read more at Presidential Youth Fitness Program, or https://pyfp.org . Do you think the president could pass the old test?

Reply 1 Recommend
Samantha Arey Boston, MA Sept. 6

"'Use it or lose it'" is a very interesting was to start this article. As someone who has taken psychology in school, I associate that phrase with the loss of neural connections or even the ability to perform certain activities. I did not know that this simple phrase also related to muscle as one ages. It seems that part of sarcopenia is not just a decline in activity, but also a result of the aging process. If hormonal changes, inflammation, chronic illness, and poor nutrition also affect sarcopenia and the accompanying symptoms, this condition seems more complex than the phrase "Use it or lose it". For many people, working out more often or strength-training programs might not be the best fit. It makes sense that it is important to strengthen all muscles in the body and eat well, especially for someone who is older. However, I wonder if the reason few physicians tell patients about sarcopenia is because they have other health priorities to worry about with their patients. As sarcopenia affects the emotional and physical well-being of individuals, it seems crucial that physical therapists and doctors work with patients to reduce fall-risk and increase their independence. As a freshman in college studying physical therapy, I am interested to see further research on this condition. I want to see how exercise and lifestyle can reverse the muscle losses, and how individuals can slow the rate at which muscles are replaced with fat and fibrous tissue.

Reply 4 Recommend
Kim North Carolina Sept. 6

I am 60 and began weight training a year ago. I was overweight, my blood pressure was going up, my knees hurt all the time from playing football and doing martial arts in my youth, and I had developed gout and early arthritis. I followed a program called 3x5's which is three separate free weight exercises doing three repetitions five times. In other words you are going to do 15 reps with each exercise. Every other day you add five pounds to the barbell, or if that proved too much add five pounds each week. I tend to do weight training at least three times a week then on the days off from weight training do other excercise such as walking, yoga, bike riding and boxing on the heavy bag. I started just with the barbell (it weighs 45 pounds) now I can do 190 pounds deep squats, bench-press 145 and dead lift 250 pounds. I feel great, my knees no longer hurt and while I have not lost weight (all the muscle I have added weighs more than fat) I have lost three inches off my waist. I feel younger, stronger and now love going to the gym to workout.

Reply 26 Recommend
Mon Chicago Sept. 6

Very important and informative article. However, the recommendation on increasing protein intake to an ideal of 81 g and listing foods that have high protein but also a high-level of fat is not helpful in figuring out how much protein is needed. One needs to adjust the protein to their level of exercise which needs to be adjusted to the extent of the sarcopenia, gender, exercise tolerance, and many other factors.

Reply 4 Recommend
Vaibhav USA Sept. 6

So, ideally usage of ipad to be reduced and restart using the laptops. This will help me use my hand muscles. Why so? Because I tend to skip gym and love to walk. Laptop will work for me as weight training program. :)

Reply Recommend
Russell Eaton Ecuador Sept. 6

Sarcopenia is not a disease. It is a normal process of aging. To ask the question: do you have Sarcopenia, is meaningless. As we age we gradually lose muscle. But why do we lose muscle? This happens because our body must always maintain a minimum amount of glucose in the blood. When blood glucose drops below the default level, our body strips protein from lean muscle tissue to make emergency supplies of glucose until enough is forthcoming from the diet. This is known as gluconeogenesis. We mostly lose muscle at night when we sleep because that is when glucose levels in the blood drop more than usual. This is perfectly normal, but this is how we lose muscle gradually over time. The best way to minimize gluconeogenesis is to avoid low-carb and intermittent fasting diets, and other lifestyle factors that make your blood glucose plummet in your daily life. Also avoid sugary foods that make glucose zoom up, because insulin will then make your glucose plummet and galvanize gluconeogenesis. Exercise and strength training help, but only very marginally.

Reply 8 Recommend
Ty Thomas Los Angeles, CA Sept. 6

@Russell Eaton - I believe your recommendations, while knowledgeable, may not be accompanied by a great deal of personal experience. Or that perhaps your perspective stems from someone with a situation that is not typical of the norm. Your advice about minimizing gluconeogenesis by avoiding low-carb and intermittent fasting diets is reasonable. It's the "other lifestyle factors" that tends to be rather vague because it encompasses such a broad spectrum of possibilities. To say that strength training results in marginal quality of life differences is detrimental and contrary to good sound advice because it is incorrect. In many cases, strength training can make a world of difference for the average individual who knows what they're doing or has someone knowledgeable helping them. As someone who have exercised and participated in strength training for most of their life, I have seen the difference first hand between working out and not working out and working out is better 100% of the time. Maintaining good blood circulation and keeping muscles active daily reduces aches and pains caused by conditions such as degenerative arthritis, a condition that has no cure. Keeping muscles around the affected area strong and active, can help to ease pain and discomfort for many. Of course, everyone is different and I'm sure there are those who would not benefit as much from strength training, but in most typical situations "marginal benefit" is simply not the case at all.

Reply 9 Recommend
GGBound Brunswick, Georgia Sept. 7

@Russell Eaton It is difficult to know if sarcopenia is "normal" if the entire population is diseased. That's how 'normal' adult lipid levels were originally established. Then the studies appear that show that every time you lower LDL, even below 'normal', mortality improves

Reply Recommend
Brian Tilbury London Sept. 6

This and other articles propounding weight training for seniors often ignore the two major obstacles holding back many seniors, which are arthritis and replaced joints. With one bad and one replaced shoulder joint, I have been limited by medical advice from lifting more than two pounds, and with two fake hips, one of which is liable to dislocation, I'm super cautious. Add to that degenerative discs, and I stick with gentle walking and pool exercises. One size doesn't fit all seniors when it comes to exercise.

Reply 22 Recommend
ring0 Somewhere ..Over the Rainbow Sept. 6

@Brian Tilbury I have learned this important point is not grasped until one experiences age-related disabilities.

Reply 10 Recommend
Ty Thomas Los Angeles, CA Sept. 6

@Brian Tilbury - As you say most accurately, one size does not fit all. This is the case for really anything in life and exercise for seniors is no different. Everyone is different and we all have different circumstances. This is why strength training should always be custom fit to each individual. If you can only lift 2 pounds and you can only lift it in one direction, then lift that 2 pounds as much as you can until you can't lift it anymore. Then two more sets lifting that 2 pounds to complete exhaustion. If anything starts to hurt and it's something other than sore muscles, stop. If it goes away after a day or so, resume daily exercises. If not, get it checked. Hopefully the goal here is obvious: Do whatever you can. If you have one good arm, workout with it. Anything you can do to keep your blood circulating and your muscles active, do it if it doesn't hurt. The end result will benefit you more than you know. If you're not sure about technique and proper lifting, work with someone who is sure or hire a trainer. Always get a doctors recommendation before beginning any workout regiment. Anything he clears you for that he deems safe, start doing it. Start light and work up from there. I guarantee you that 2 pounds you're lifting will soon be 4 pounds, then 6 and so on as you gain strength. With strength comes a higher quality of life and a feeling of freedom.

Reply 6 Recommend
Sergio Stagnaro Italy Sept. 6

To countering the serious problem of muscle loss, physicians need to know the clinical assessment of tissue oxygenation, Co Q10 deficiency syndrome as well as Carnetine deficiency syndrome, wich can be bedside diagnosed with a stethoscope and removed by replacement therapy, i. e., Reconstructing Mitochondrial Quantum Therapy.

Reply Recommend
R. Anderson South Carolina Sept. 6

This is helpful because it motivates older people to step up their workouts a bit more.

Reply 6 Recommend
Jane NYC Sept. 6

My head's spinning. Lotsa protein. Not lotsa protein. Hang out and enjoy getting old. Cardio. Free weights. Bands. Walk. Plank. Elliptical. Resist (it's patriotic!) Could it be that it's personal and we can tailor this to our bodies and individual profiles and psyches? Health and longevity are both genetic and personal. Do you think we're the captains of our rented ships and don't we all want upper cabins? It'd be great, but it's not always gonna be the case. Where we can help ourselves, lets! I appreciate this article and everyone's personal and helpful advice. There are wonderful things, too, about this saggy and often unpleasant stage. I'm the happiest I've ever been and grateful for every day. There's value in waking up to the fact that our bodies are rentals and that we should treat them with love and care and cherish each breath. As Thich Nhat Hanh says, "Peace is Every Step".

Reply 16 Recommend
Marjorie Sheffield MA Sept. 6

Commonly prescribed statin drugs cause muscle loss and weakness .

https://academic.oup.com/jcem/article-abstract/103/1/75/4364961?redirect...

Reply 9 Recommend
Carole San Diego Sept. 6

I cannot believe what I'm reading. I am 87 and I eat what I like. I also walk my dog twice a day. She's a "herder", so the walks are fairly long ones. I also do light yard work and all my own house work. Only recently, have I discovered I can't lift things I used to and my arms have that "old lady" look. It's depressing, but I don't have the stamina to add daily weight training to my life. Perhaps all you 50 year olds should just learn to enjoy life and not worry about losing your finely honed bodies later on. And, have some ice cream and maybe a croissant now and then.

Reply 32 Recommend
william matthews clarksvilletn Sept. 6

Get you 100% and agree that you have a point for some people but if people are losing the strength to enjoy life through declining functionality it is very good to know that there are ways to halt decline. Basically it is a personal choice.@Carole

Reply 9 Recommend
Jus' Me, NYT Round Rock, TX Sept. 8

@Carole

I'm 72 and refuse to become decrepit in the matters that I can prevent.

I noticed my arms getting flappy last year. A goodly amount of hard resistance training has almost taken care of that.

If you are happy at being not-so-fit, that's your choice. But it WILL impact others and the whole health care system. Which at our age means taxpayer funded Medicare.

Reply Recommend
R Hoff Michigan Sept. 6

Gentle yoga once a week, with advice to daily get on the floor then get up at least 3 x, plus the normal strength training. I'm a youngster at 65 , and hopefully have decades of mobility ahead of me. As an athlete until 55, it's all about balancing expectations and new realities.

Reply 7 Recommend
Birddog Oregon Sept. 6

@R Hoff So true! scads of research indicates that regularly participating in a yoga program ,which if performed on a regular basis a few times a week, can also increase the average person's strength, endurance and metabolic functioning, even into our elder years. And I note as a physiotherapist, that in fact many physical therapists and athletic trainers now employ yoga exercises to help strengthen and stabilize their clients back and major muscle groups. So yes please do think about including yoga in your daily exercise routine-But also remember to check with your physician before beginning any type of new exercise or athletic activity if you are elderly or in fragile health.

Reply 6 Recommend
Norbert Switzerland Sept. 6

Gain muscle at any age: Hit training, simply said: Let your muscle know that it is not strong enough by going to your limit. You must leave your comfort zone therefore. It works and does not take much time. Add creatine and magnesium as a food supplement and of course enough protein. You will be surprised.

Reply 7 Recommend
impegleg NJ Sept. 6

What constitutes a Rep?

Reply 2 Recommend
June NYC Sept. 6

@impegleg 1 rep is doing one complete exercise one time. Like one squat. 10 squats is 10 reps. 3 rounds of squats is 10 squats done 3 times with a short break inbetween rounds.

Reply 1 Recommend
Jackie Boston Sept. 6

I am a personal trainer certified with the American College of Sports Medicine who has worked with many clients ages 18-92 and while I absolutely love bringing to light strength training as a tool, I do take issue with some of the language in this article. As defined, sarcopenia is not a "condition," it is honestly just the natural loss of muscle with age. Calling it a "condition" makes it sound like some form of disease, and the reason it isn't talked about may be due to it not being a completely diagnosable illness but something that is perceived as being a part of the aging process. Doctors tend to only "see" patients through the eyes of what is in their scope of practice; meaning that if you see a doctor who is a PCP with a background in internal medicine then they will see you through that lens. If you see a cardiologist then they will only see you through the eyes of your heart, if you see a neurologist they will only see you through the eyes of your brain and nerves. If you are truly concerned about your muscle and bone health then absolutely speak to a sports medicine specialist or orthopedist because those are the folks who will be the most help in that specific field. They are also the clinicians who will have the resources to find physical therapists or personal trainers who will be the best match for you, because if someone who is working so closely with your body doesn't "get" you or doesn't "click" then you may not get as much out of it. We are here for you!

Reply 13 Recommend
Kathy Proulx Canada Sept. 5

I am 67 with rheumatoid and osteo