Crime: Perception vs. Reality

The Daily Escape:

Saguaros and poppies, Catalina SP, Tucson, AZ – March 2024 photo by Paul J Van Helden

From Jeff Asher, a crime analyst based in New Orleans:

“Murder plummeted in the United States in 2023, likely at one of the fastest rates of decline ever recorded. What’s more, every type of Uniform Crime Report Part I crime with the exception of auto theft is likely down a considerable amount this year relative to last year according to newly reported data through September from the FBI.”

We all knew that crime rates skyrocketed between the mid-1960s and the late 1980s. Then they went into a slow 35-year decline. Now, homicide, violent crime, and property crime rates have returned to what they were prior to the latest 20-year increase. This means that if you’re under 55, crime rates have been falling for most of your adult life.

But America perceives that crime rates are high. A Gallup poll released last November found 77% of Americans believed there was more crime in America than the year before. And 63% felt there was either a “very” or “extremely” serious crime problem — the highest in the poll’s history going back to 2000.

Wrongo doesn’t truly believe the polls since Pew revealed that 12% of people under 30 and 24% of Hispanic people who opt into online polls claim they have a license to operate a nuclear submarine, but here’s a chart:

(This is based on Gallup’s annual Crime survey, conducted Oct. 2023)

The question is, why the disconnect? NPR quoted Jeff Asher:

“There’s never been a news story that said, ‘There were no robberies yesterday, nobody really shoplifted at Walgreens….Especially with murder, there’s no doubt that it is falling at [a] really fast pace right now.’”

One theory you might have is that since the Covid pandemic caused social disorder, dysfunction in our government, and all sorts of problems, including that spike in crime, you might expect crime to remain high even after the country went back to work and school.

Another theory is that when people say “crime“, they don’t exclusively mean “people breaking the law“. Instead maybe they mean “behavior which upsets me“. For example, when the Philadelphia DA tries to focus on eliminating bail for simple drug arrests, while opposing police corruption, he’s said to be soft on crime. Then Republicans (and Trump) tried to impeach him, saying that they’re being “tough on crime” and crime remains a politicized news story.

Another theory is that the narrative around homeless people drives perception of crime. The idea that “homeless people have been violent“, or simply that “homeless people live near me and I don’t want any shelters built nearby,” strengthens the perception that crime is everywhere. For people who feel that way, the statement “Crime is a big problem” is equivalent to the statement “I always see homeless people when I go into town”.

This may explain why crime rates “near me” are perceived to be substantially lower than how national crime is perceived. Few of the homeless are encamped in their suburbs.

If you look back on the 1980s, there were a large number of visible homeless people in Washington DC, and Reagan dismissed them as “homeless by choice“. Today, there are plenty of homeless people on the streets in every city. It’s important to remember that when St. Reagan was governor of California, he released mental patients onto the streets.

This was part of “deinstitutionalization”: The emptying of state psychiatric hospitals that began in the 1950s. As hospitals were shut down, patients were discharged with no place to get psychiatric care. They ended up on the streets, some eventually committing crimes that got them arrested.

In 1963, JFK signed the Mental Retardation Facilities and Community Health Centers Construction Act. (It turned out to be the last bill Kennedy would sign.) The law was designed to replace “custodial mental institutions” with community mental health centers, thus allowing patients to live—and get psychiatric care—in their communities.

However, a sufficient number of community mental health centers were never built.

In 1965, Medicaid accelerated the shift from inpatient to outpatient care: One key part of the Medicaid legislation stipulated that the federal government would not pay for inpatient care in psychiatric hospitals. This further pushed states to move patients out of their state facilities.

That’s when homeless people began to be visible to most of us.

Later, in the 1970s, Nixon declared a war on drugs, setting the stage for tough-on-crime policies. Laws, like mandatory minimum sentences for possession and other drug-related crimes, disproportionately affected people of color and pushed incarceration rates to record levels. Between 1972 and 2009, America’s prison population grew by 700%.

The homeless get blamed for the bad behavior of a small minority of their group. But since an awful lot of the dysfunctional are homeless because their families or friends couldn’t cope with their behavior, it’s logical that the general public would also find their behavior a problem.

And it’s more than just the homeless. In Wrongo’s small Connecticut town, long-time residents resent people who have moved in recently. They are appalled by the occasional drug arrest or stolen car that was left unlocked in a driveway.

This scales up to people in our town bellowing about CHICAGO!!!! Or LA or Portland, OR. They see the far enemy as young Black/Hispanic men in certain zip codes destroying each other. And just possibly turning their attention to our tight, white community here in the Litchfield Hills.

It’s a good thing that overall crime and especially violent crime rates are much lower than they were 30 years ago. But we’re still faced with the overriding perception that people see their families at greater risk now.

This has spilled over into how parents treat their children. NO parent today would allow their kids to get on a bike and roam miles from home. Everything is monitored. If you ask why, the near-universal response is: “It just isn’t safe out there. Not like it used to be.”

Used to be? Most kids were tooling around on their bikes Goonies-style during the 1980s, when crime nationwide was at its peak.

People just seem hell bent on seeing the world as a massively scary place, one filled with predators.

There are major political implications, when data aren’t facts, when truths are lies.

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Florida Lets Measles Run Free

The Daily Escape:

Highland Lighthouse, North Truro, Cape Cod, MA – February 2024 photo by Barbra A. Bentley

Let’s take a break this Saturday from a) Russia’s infiltration of the Republican Party and b) the growing realization that unless House Speaker Mike Johnson Johnsonless whips his members into shape before March 1st, we’ll have a government shutdown. Instead let’s focus today on Measles.

You are a witness the continued collapse in US public health standards since Florida’s Surgeon General has said its ok for unvaccinated kids to attend public school even though there are measles outbreaks. From KFF News:

“With a brief memo, Florida Surgeon General Joseph Ladapo has subverted a public health standard that’s long kept measles outbreaks under control. On Feb. 20, as measles spread through Manatee Bay Elementary in South Florida, Ladapo sent parents a letter granting them permission to send unvaccinated children to school amid the outbreak.”

More:

“The Department of Health ‘is deferring to parents or guardians to make decisions about school attendance,’ wrote Ladapo, who was appointed to head the agency by Florida Gov. Ron DeSantis, whose name is listed above Ladapo’s in the letterhead.”

With his brief memo, Ladapo has subverted a public health standard that’s long kept measles outbreaks under control. This is where you wind up after decades of indoctrination of libertarianism and neoliberalism, where “freedom” becomes anarchy, a rejection of the ability of the state to impose restrictions, even in the name of public safety.

Everyone in America knows that measles is highly contagious, that it kills, and can do lasting damage. More from KFF:

“Most people who aren’t protected by a vaccine will get measles if they’re exposed to the virus. This vulnerable group includes children whose parents don’t get them vaccinated, infants too young for the vaccine, those who can’t be vaccinated for medical reasons…”

The CDC advises that unvaccinated students stay home from school for three weeks after exposure. About 1 in 5 people with measles end up hospitalized, 1 in 10 develop ear infections that can lead to permanent hearing loss, and about 1 in 1,000 die from respiratory and neurological complications. They reported that in 2023, childhood immunization rates had hit a 10-year low.

Worse, only about a quarter of Florida’s counties had reached the 95% threshold at which communities are considered protected against measles outbreaks, according to data posted by the Florida Department of Health in 2022.

Rebekah Jones, a data scientist who was removed from her post at Florida’s health department in 2020, over a rift regarding Coronavirus data, said:

“I think this is the predictable outcome of turning fringe, anti-vaccine rhetoric into a defining trait of the Florida government,”

A strategy of letting measles spread (which can wipe out your body’s immunity memory) while Covid is still pin-balling its way around the country? Sounds legit.

The way that things are going with public health in the US, it’s only a matter of time until the health departments of other western countries start issuing travel health notices for their citizens wanting to visit the US, advising them of the diseases that are being left to run free, particularly in Florida.

From The Nation:

“In 2022, Georgetown University political scientist Donald Moynihan wrote a piece on how to undermine the administrative state….No country becomes a world power without a capable public service.”

Perhaps the corollary, as stated by The Nation’s Gregg Gonsalves is this:

“No country becomes healthy without a capable public health system.”

That describes America today. More from The Nation:

“We did terribly on Covid…part of the reason was that our fundamentals were weak, but our politics are also set up to undermine public health….This has implications well beyond…the pandemic. It’s about how we expect to survive and thrive in America….This is a disaster in slow motion, and we’re watching it unfold as bystanders.”

There you have it: another thing to lose sleep over, and the election is still 7+ months away. Will there be enough infant deaths to generate sufficient outrage to roll this decision back?

Highly doubtful.

Wrongo is leaving you with that thought and is segueing into our Saturday Soother, where we take a break from doom scrolling and spend a few stolen moments alone with our thoughts. Here on the Fields of Wrong, there is still snow on the ground. So while we hope that spring is just around the corner, there’s little evidence to support it.

To help you relax, grab a seat by a south-facing window and watch and listen to Samuel Barber’s “Adagio for Strings”, played here by the Vienna Philharmonic, and conducted by Gustavo Dudamel. Dudamel is scheduled to become music director of the New York Philharmonic in 2026. This performance was a part of the annual free Vienna Summer Night Concert in 2019.

This is the fourth time Wrongo has featured this composition, although you are seeing this particular version for the first time.

Barber finished the Adagio in 1936. In January 1938, Barber sent an orchestrated version of the Adagio for Strings to Arturo Toscanini. The conductor returned the score without comment, which annoyed Barber. Toscanini later sent word that he was planning to perform the piece and had returned it simply because he had already memorized it!

It was performed for the first time by Toscanini in November, 1938. Here, it is conducted by Gustavo Dudamel in 2019, like Toscanini did, without a score:

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Wake Up To Monday’s Hot Links

The Daily Escape:

Cypress trees, Lake Verritt, LA – November 2023 photo by Rick Berk Photography. Note the egret in the background.

For today’s Wake Up Call, we return to a staple of yesteryear, some hot links that caught Wrongo’s eye over the past few days.

Wrongo isn’t happy with how the Ukraine War has slipped from the consciousness of America’s media and thereby, from our view. Saturday’s WSJ offered an intriguing idea with its column, “Does the West Have a Double Standard for Ukraine and Gaza? (free link). The article makes two excellent points. First, how these two wars have divided the world. Here’s a view of the division:

From the WSJ: (emphasis by Wrongo)

“Outrage and political mobilization have become subordinated to geopolitical allegiances—a selective empathy that often treats ordinary Ukrainians, Palestinians and Israelis as pawns in a larger ideological battle within Western societies and between the West and rivals such as China and Russia.”

Second, the article concludes by saying that the main difference between the two wars is that the Israeli-Palestinian conflict, with all its complexities, lacks the moral clarity of the Ukrainian resistance to Russia. They quote British lawmaker Alex Sobel:

“There is no moral justification for the Russian invasion. Zero. It’s just about Russian imperialism….But in Israel and Palestine, it’s about the fact that there are two peoples on a very small amount of land, and political and military elites on both sides are unwilling to settle for what’s on offer.”

Yes, America may have the moral high ground in both cases, and views can differ on how both wars are being waged. But as the article says in its second paragraph:

“The Russian invasion of Ukraine in February 2022 was unprovoked, while Israel sent troops into Gaza because of a mass slaughter of Israeli civilians…”.

Make of the article what you will, but it’s important to think through why you (like Biden) think both wars are morally equivalent.

Link #2 is apropos of the COP28 conference now underway in Dubai. Grist Magazine has an article: “Where could millions of EV batteries retire? Solar farms.” As solar energy expands, it’s becoming more common to use batteries to store the power as it’s generated and transmit it through the grid later. One new idea is to source that battery back up at least in part from used electric vehicle batteries:

“Electric vehicle batteries are typically replaced when they reach 70 to 80% of their capacity, largely because the range they provide at that point begins to dwindle. Almost all of the critical materials inside them, including lithium, nickel, and cobalt, are reusable. A growing domestic recycling industry, supported by billions of dollars in loans from the Energy Department and incentives in the Inflation Reduction Act, is being built to prepare for what will one day be tens of millions of retired EV battery packs.”

More:

“Before they are disassembled…studies show that around three quarters of decommissioned packs are suitable for a second life as stationary storage.”

Apparently there are already at least 3 gigawatt-hours of decommissioned EV battery packs sitting around in the US that could be deployed, and that the volume of them being removed from cars is doubling every two years.

Link #3 also shows the impact of the Inflation Reduction Act. Wolf Richter writes that:

“In October, $18.5 billion were plowed into construction of manufacturing plants in the US ($246 billion annualized), up by 73% from a year ago, by 136% from two years ago, and by 166% from October 2019.”

More:

“The US is the second largest manufacturing country by output, behind China and has a greater share of global production than the next three countries combined, Germany, Japan, and India.”

All of this construction spending will take time to turn into production. When these new plants are up and running and producing at scale, manufacturing’s share of US GDP will rise. And much of the new construction is happening in fly-over America, which can use the help.

Finding factory workers in sufficient numbers to support the new capacity will be a key. America has energy in abundance and has robotic manufacturing. So pulling production from overseas with fewer workers needed will be a giant plus for the US.

Link #4 is a downer. Civic Science says in this week’s 3 things to know column, that “Nearly 3 in 10 Americans say they have had to forgo seeing a doctor in the past year due to costs.” Here’s their chart”:

Civic Science says that 12% of US adults have had to miss or make a late payment on medical bills in the last 90 days, a two percentage point increase over September 2022.

A far larger percentage of Americans – 27% of the general population and about 30% of respondents under 55 years old or with an annual household income under $100,000 – report they could not go to a doctor in the past 12 months because they could not afford the cost. Gen Z adults and households making between $25K-$50K are more likely to have held off seeing a doctor due to cost (34% and 31% respectively).

We all know that medical costs have continued to rise and that medical debt is the leading cause of personal bankruptcy in the US. If Congress was really interested in helping provide for the general welfare, they would deal with this out of control problem.

Time to wake up America! There’s plenty going on that isn’t getting visibility in the mainstream media or on social media. You have to cast your net widely to be on top of the good and bad happening in the US.

To help you wake up, we turn to Shane MacGowan, frontman for the Irish group the Pogues who died last week. He left behind a body of work that merged traditional Irish music and punk rock. He wrote many songs that could easily be mistaken for traditional Irish tunes including this one, which was also used as the music for wakes by the Baltimore Police Department in the great, great HBO series, “The Wire“. Here’s “The Body Of An American” from their 1986 album, “Poguetry in Motion”:

RIP Shane.

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How Can America Handle The Costs Of Elder Care?

The Daily Escape:

The start of US Highway 6, outside of Bishop, CA – September 2023 photo by Steve Wolfe

(There will be no Saturday Soother this week. Wrongo is on the road.)

Millions of older Americans from the Silent Generation and the Baby Boomers are facing a dilemma as they “age in place.” They must figure out how to pay for increasingly complex medical care. The NYT quotes Richard W. Johnson, director of the program on retirement policy at the Urban Institute:

“People are exposed to the possibility of depleting almost all their wealth….”

The prospect of dying broke is an imminent threat for the Boomers. About 10,000 of them turn 65 every day between now and 2030. They’re expecting to live into their 80s and 90s at the same time as the price tag for long-term care (LTC) is exploding. Currently LTC expense is outpacing inflation and approaching a half-trillion dollars a year, according to federal researchers.

By 2050, the population of Americans 65 and older is projected to increase by more than 50% to 86 million. The number of people 85 or older will nearly triple to 19 million. The Times has a chart of how many of those who need long-term care will die broke:

Some older Americans have prepared for this possible future by purchasing LTC insurance back when it was still affordable. Since then they’ve paid the monthly premiums, even as those premiums continued to rise. But this isn’t the norm. Many adults have no plan at all or assume that Medicare, which kicks in at age 65, will cover their health costs. But Medicare doesn’t cover the kind of long-term daily care, whether in the home or in a full-time nursing facility, that millions of elderly Americans require.

For that, you either pay out-of-pocket or you spend down your assets until you have less than $2,000 in assets in order to qualify for Medicaid. Remember that Medicaid provides health care, including home health care, to more than 80 million low-income Americans.

And even if you qualify, the waiting list for home care assistance for those on Medicaid tops 800,000 people and has an average wait time of more than three years.

Here is a snapshot of how long-term care is paid for in the US:

Governments provide 71.4% of the total. The largest non-government source is people who pay out-of-pocket, and private insurance is becoming increasingly expensive. More from the NYT:

“The boomer generation is jogging and cycling into retirement, equipped with hip and knee replacements that have slowed their aging. And they are loath to enter the institutional setting of a nursing home. But they face major expenses for the in-between years: falling along a spectrum between good health and needing round-the-clock care in a nursing home.”

That has led them to enter assisted-living centers run by for-profit companies and private equity funds. The NYT says that about 850,000 people aged 65 or older now live in these facilities and when in them,  they are largely ineligible for federal funds. Some facilities provide only basics like help getting dressed and taking medication while others offer luxury amenities like day trips, gourmet meals, and spas.

In either case, the bills can be staggering. More:

“Half of the nation’s assisted-living facilities cost at least $54,000 a year, according to Genworth, a long-term care insurer. That rises substantially in many metropolitan areas with lofty real estate prices. Specialized settings, like locked memory care units for those with dementia, can cost twice as much.”

Home care is costly, too. According to Genworth, agencies charge about $27 an hour for a home health aide. Hiring someone who spends six or seven hours a day cleaning and helping an older person get out of bed or take medications can add up to $60,000 a year.

It’s worse for people with dementia because they need more services. The number who are developing dementia has soared, as have their needs. Five million to seven million Americans over age 65 have dementia, and that’s expected to grow to nearly 12 million by 2040.

The financial threat posed by dementia also weighs heavily on adult children who in many cases become guardians of aged parents. The Times included this chart:

The reality is that families go broke either caring for, or finding care for their loved ones. The alternative: Women in the family give up their lives and jobs to care for their family members instead, which worsens the gender wage gap.

The NYT article makes it clear that older Americans receive far less government support than their peers in other countries. The “why” question is easily answered: It’s a combination of the concerted effort for any public support to be demonized as “welfare”. It’s also partly the result of our failed experiment with long term care insurance. The politicians’ idea was that “the market” would take care of it, so government help for retirees could be limited to Medicaid-paid nursing homes.

But, the LTC insurance industry has largely imploded. Insurers had little experience with the product and grossly overestimated the lapse rates. If a policyholder stops paying, the insurer gets to keep the money and use it to provide services to everyone remaining in the pool. The surprise was that very few people stopped paying. A second miscalculation was that people who held these policies were living longer than forecasted. Longer life equaled higher and larger payouts (insurers also benefit when customers die before they’ve used up all the policy benefits).

A final factor is the rising levels of dementia described above.

And since demand for support outside of family members exceeds the supply of beds, nursing homes and assisted living facilities that aren’t terrible want residents to join during the independent living phase (which requires very little care, so those fees subsidize intensive nursing home care). Many of these facilities require a $400,000-$500,000 buy-in, which may not be refundable at death, even if the resident is current on their monthly fees.

There’s got to be a better way. Medicaid can’t be the only option to pay for LTC. Congress needs to establish a better system for middle-class Americans to finance LTC.

How we handle the growing costs of long-term care is just another reminder that we get LITTLE for our tax dollars beyond a giant military. Americans are responsible for their own medical care, childcare, college tuition, retirement and nursing home care. Some or all of which are provided in other rich countries.

This is a loudly ticking time bomb, and the demographics of the problem won’t change for decades. And yet, the Republicans seem bent on making it worse. They’re actively trying to bring about their dream of privatizing Social Security and Medicare.

Wake up America! We have real problems to solve.

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Biden’s Plan To Cut Drug Prices

The Daily Escape:

Mars on left, Earth on right – image by alofeed

The Biden administration released its list of 10 prescription medicines that will be subject to the first-ever price negotiations by Medicare. This is a big deal because Medicare covers 66 million older Americans, people who routinely take very expensive drugs.

Until recently it was illegal for Medicare to negotiate prices with drug companies. But the Inflation Reduction Act (IRA), passed last August, gives Medicare that power. It also forces companies to pay a rebate to Medicare if their drug prices rise faster than inflation. The Congressional Budget Office estimates that price-capping measures will reduce Medicare expenses (and the federal deficit) by $96 billion by 2031.

The list includes drugs for diabetes, arthritis, and Crohn’s disease, and could sharply lower medical costs for patients. Reuters says that the US Centers for Medicare & Medicaid Services (CMS) spent $50.5 billion between June 1, 2022 and May 31, 2023 on these 10 drugs. That was about 20% of the total cost of drugs in the Medicare prescription drug program known as Part D.

The WaPo had an opinion piece by David Goldhill, CEO of SesameCare.com, a digital marketplace for discounted health services: (brackets and emphasis by Wrongo)

“The pharmaceutical industry earns almost 50% of its worldwide revenue here [the US], as do medical information-technology firms. [Medical] Device makers earn 40% of their money in the US. And this understates things, because US revenue is generated from higher prices, so margins are greater. If the US accounts for half of a company’s revenue, it probably contributes at least 75% of its profits.”

This has always been the business plan for Big Pharma: Make your money in the US and take whatever scraps of profit you can get in other markets.

That market subsidy is paid by American taxpayers generally (through the funding of Medicare) and by US pill-takers specifically when they pay higher co-pay prices for the drugs that help with their chronic conditions. The Economist points out that prescription medicines in America cost two to three times more on average than in other wealthy countries:

The blue dots are the price paid in the US for brand name drugs. The grey dots are prices paid in the various countries for all US drugs sold in those countries. The comparison of brand name to generics shows how much greater the cost is to an American.  It also follows that US patients’ out-of-pocket expenses, (the slice of drug costs not covered by insurance), are among the highest in the world.

It’s understandable why Biden’s move to start negotiations on some of the most expensive drugs has been fiercely opposed by the pharmaceutical industry. Essentially, high US drugs costs underwrite what amounts to a subsidy for buyers of the same drug sold when it’s outside the US.

Many of the Big Pharma have jumped on the legal bandwagon, challenging price-setting provisions in the IRA. More from the Economist:

“Since the law’s passage over 50 companies have blamed the IRA in earnings calls for clouding their prospects.”

A quick primer on drugs. Most medicines are either small-molecule drugs or large-molecule drugs. The former are the kind of pills that line our medicine cabinets. Large-molecule drugs, (also called biologics), are more complex and must be injected. The IRA grants biologics 13 years of pricing freedom after a drug is approved, while small-molecule drugs get only nine years post-approval before they must face Medicare’s bean counters. The industry estimates that small-molecule brands could lose between 25% and 40% in overall revenue due to the earlier cap on prices.

PhRMA, the pharma Industry’s lobbyist argues (and Republicans back them) that high US prices reflect the high cost of drug development. The pharmaceutical manufacturers are, of course, suing to stop the price negotiations. They say that allowing the government to negotiate lower bulk prices for drugs will stifle innovation, and will cut funds for research.

One thing that Big Pharma wants to avoid showing us is that they rely on smaller, more agile biotech firms for ideas. Between 2015 and 2021, 65% of the 138 new drugs launched by Big Pharma originated mostly from smaller firms. So, while innovation isn’t totally gone from the big firms, what they’re mostly doing is marketing the intellectual property of small pharmaceutical firms.

It didn’t take long for Republicans to jump on the decision to allow Medicare to negotiate drug prices. From Politico:

“Piggybacking on the pharmaceutical industry’s strategy, Republicans are working to persuade Americans that the Biden plan will stifle innovation and lead to price controls.”

Politico quotes Joel White, a Republican health care strategist:

“The price control is a huge departure from where we have been as a country….It gets politicians and bureaucrats right into your medicine cabinet.”

Politico says that the GOP effort to reframe the drug price debate may hurt them, since they plan largely to run on inflation, while the Biden plan will lower drug prices. Also they quote a new poll from the Kaiser Family Foundation (KFF) that shows 58% of independent voters trust Democrats to lower drug costs compared with 39% of Republicans.

Our politicians and pundits have bleated at us for years about being an “exceptional nation” – but what we really are is exceptionally gullible. As long as the large healthcare and pharmaceutical companies insist on standing between American consumers and their health needs, maximizing their profit will always come first.

We also continue to elect leaders who lobby for keeping corporations unleashed so that they can make as much profit as possible, while saying that the “market” will decide where the public good is prioritized. This keeps us hopelessly mired in a grossly expensive, and often ineffective healthcare system.

We continue to let ourselves be convinced by corporations and our politicians that reforming healthcare is impossible. That the solutions and methodologies used by other developed nations are substandard, and/or somehow immoral.

The Hill reported that the 14 leading US drug companies paid out more in stock buybacks and dividends from 2016 to 2020 than they spent on research and development. Those firms spent $577 billion from 2016 to 2020 on stock buybacks and dividends, $56 billion more than the $521 billion they spent on R&D. So, it’s oblivious how Big Pharma could easily fund their R&D with lower drugs prices.

It is also useful to remember that America has more healthcare billionaires AND healthcare bankruptcies than any other country. Those two things are inextricably linked.

As long as the pharmaceutical companies can maximize profits by buying politicians rather than by charging higher prices in other countries – the American people are the ones who will continue to get screwed.

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Rural Hospitals Are No Longer Providing Maternity Care

The Daily Escape:

Perseid meteor shower, from Mt. Evans, CO – August 13, 2023 photo by Paul Blais Photography

Welcome to our Saturday Soother, but first, Wrongo intends to spin you up before eventually letting you slow down.

There’s a crisis in rural healthcare in America. Rural hospitals are closing at a rapid rate. Our county (Litchfield) in Connecticut has one of three remaining hospitals that are designated as rural in the state (Sharon Hospital).

A problem for rural hospitals is that many are closing down their labor and delivery services in order to try and remain economically viable. WSHU, a CT-based NPR affiliate, has covered the impact of these closures to Connecticut. They quote Peiyin Hung, a researcher on maternal and rural health at the University of South Carolina:

“My team has been tracking nationwide, hospital-based obstetric unit closures since 2008 up to 2022,…. Almost 300 hospitals closed their OB units.”

WSHU points out that more than 60% of those closures were in rural areas. Why are so many hospital groups moving away from delivering babies in rural locations?

WSHU quotes Dr. Robert Roose, chief medical officer at Johnson Memorial, a hospital in rural Stafford Springs, CT that closed its obstetric unit. He said that it’s a safety issue. Hospitals with fewer than 200 deliveries a year, like Johnson Memorial, are considered low-volume birthing centers:

“There is a clear and critically important correlation between volume and quality of services provided when it pertains to labor and delivery and maternity care…”.

Three years ago, Hartford HealthCare’s Windham Hospital in Willimantic, CT stopped delivering babies, citing the same concern.

Also, malpractice insurance rates go up for low birth-volume hospitals because insurers feel the risk is higher if doctors aren’t getting sufficient practice with birthing. Hung says another problem is the level of reimbursement:

“Medicaid…pays half as much on average [as] private insurance pays for labor and delivery across the country”.

That’s important because about four in 10 of all Connecticut deliveries are covered by Medicaid. Simply put, delivering babies doesn’t pencil out for many rural hospitals.

There are other factors: Rural America’s demographics skew older. Young families in general prefer living in the suburbs or exurban areas. Couple that with America’s lower birth rate and rural hospitals really can’t maintain the birthing volume they need to remain economically viable.

The Center for Healthcare Quality and Payment Reform, (CHQPR) a Pittsburg-based health policy group published “A Crisis in Rural Maternity Care in the United States” which shows the problem:

“Fewer than half (45%) of the rural hospitals in the US currently offer labor and delivery services, and in 9 states, less than one-third do. Over the past decade, more than 200 rural hospitals across the country have stopped delivering babies”.

More:

“Hundreds of additional communities are at risk of losing maternity care because of the financial challenges rural hospitals are facing….More than 1/3 of the rural hospitals that still have labor & delivery services have been losing money on patient services, so their ability to continue delivering maternity care is at risk.”

CHQPR reports that more than half of small rural maternity care hospitals lost money in 2021-22.

They suggest that a primary reason rural hospitals are losing money is that private insurance plans pay them less than what it costs to deliver many of the services they offer patients, not only maternity care. They point out that while rural hospitals are losing money on uninsured patients and Medicaid patients, the losses from private payers have the biggest impact on their overall profit margins.

CHQPR suggests that a potential solution is to require that health insurance payments actually cover the cost of rural maternity care. With more than 40% of births (on average) in rural communities paid for by private health plans, having the private insurers pay more would help keep rural maternity care viable:

“Payment amounts must be higher in communities that have difficulty attracting staff, and payments must also be higher in communities with smaller numbers of births to ensure that revenues cover the fixed costs.”

This means that the fee-for-service model isn’t working in low-volume hospitals. Rural hospitals are only paid when they actually provide a service, but a small hospital has proportionally higher overheads than larger hospitals, since they must be staffed and ready to deliver a baby at all times, even if there are no deliveries at all. Read CHQPR’s report “A Better Way to Pay Rural Hospitals”.

Back to Connecticut, Sharon Hospital has proposed closing its labor and delivery unit. There will be a public hearing to consider the closure later this year. But Sharon is about an hour from its affiliated hospital (Danbury Hospital) that has a fully-staffed labor and delivery facility. Sharon may actually be closer to two other unaffiliated hospitals in New York state than it is to its own parent facility.

It’s now time for our Saturday Soother. Litchfield County is having beautiful weather this weekend. We’re taking advantage of it by going to a live Baroque music concert, and possibly heading off to the annual fair in a local town.

To help you relax and zone out from all of the Trump indictment analysis, grab a chair outside in the shade and watch and listen to “Gortoz a Ran” (I’m Waiting) sung by Denez Prigent and Lisa Gerrard. The language in the song is Breton, spoken in Brittany, France. It is closely related to Cornish and Welsh, and all three are Celtic tongues. When the Angles, Saxons and Jutes invaded Britain in the fifth century (400-500 AD), many of the Britons in Cornwall, Devon, and the West Country fled across the English Channel to France. Because of the influx of Britons, the region became known as Brittany.

Most of the images in the video are of Scotland, England, Wales, and Brittany. Lisa Gerrard isn’t singing in any language; she’s just vocalizing. The Uilleann pipes, an Irish instrument, are heard at 3:50:

Lyrics: English Translation

I was waiting, waiting for a long time
In the dark shadow of grey towers
In the dark shadow of grey towers

In the dark shadow of rain towers
You will see me waiting forever
You will see me waiting forever

One day it will come back
Over the lands, over the seas

The blue wind will return
And take back with it my wounded heart

I will be pulled away by its breath
Far away in the stream, wherever it wishes

Wherever it wishes, far away from this world
Between the sea and the stars

The song describes waiting, possibly forever: Aren’t we all waiting? What are we waiting for? For whom are we waiting? Happy Saturday!

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Saturday Soother – March 11, 2023

The Daily Escape:

Sunset, Santa Elena Canyon, Big Bend NP, TX – March 2023 photo by Rick A. Ludwig. Cliff on left is in Mexico, the one on the right is in US. The Rio Grande is in the middle.

Signs that we’re starting to think about the 2024 election are everywhere. Wrongo wants to connect a few dots regarding Biden’s recent efforts to move the Democratic Party more to the middle on crime and immigration while staying left on financing the country’s social and military needs.

Biden proposed a budget to reduce the deficit, protect Medicare and Social Security, and raise taxes on wealthy individuals and corporations. From the NYT:

“In a speech in Philadelphia on Thursday, Mr. Biden said that his budget was designed to ‘lift the burden on hard working Americans’ and drew sharp contrasts with the proposals that Republicans have offered, which the president argued would threaten the nation’s social safety net programs and benefit the rich.”

This contrasts with Biden’s right-leaning position on the recent DC crime bill. Since DC is controlled by the Congress, it’s legislation can be vetoed by the US Senate. Also from the NYT:

“The Senate…voted overwhelmingly to block a new District of Columbia criminal code that reduces mandatory minimum sentences for some violent offenses, with Democrats bowing to Republican pressure to take a hard line on crime in a move that underscored the rising political potency of the issue ahead of the 2024 elections.”

By an 81-to-14 vote, with 31 Democrats voting with the Republicans, the Senate passed the Republican-written measure to undo the District’s law. It now goes to Biden, who after initially opposing it abruptly changed course and said he would sign it.

So, Biden’s tacking left on spending but to the center-right on crime. He’s making a series of calculated moves to position his Party to compete successfully in 2024. Still, it’s disappointing that Biden and 31 Democrats joined with the Right to deny DC residents the right to govern their own city.

But this shouldn’t be surprising. Last year, Biden and the Democrats turned their backs on labor during their contract battle with the railroads.

Here’s Nick Catoggio in the Dispatch: (Brackets by Wrongo)

“[Biden has]…begun to tiptoe toward the center lately on another major Democratic liability, immigration…..Centrist analysts…have warned Biden and his Party that their political viability depends on escaping the…“cultural bubble” in which an unsecured border is treated as a civic good.”

And last week Biden changed his immigration policy. He’s requiring asylum seekers to seek refuge in nations they pass through rather than waiting to do so in the US.

These new policies bring Biden closer to public opinion. Among Democrats, a plurality want to see the number of asylum applicants increased rather than reduced. Among the overall public, it’s the opposite. Biden is tilting toward the latter.

Biden wants to be seen as strong on crime. Democrats walk a fine line of being against crime but not wanting to wholly support the police. Doing that would risk looking anti-Black in cities that are so important to their political success. Dems support compassionate justice and not retributive justice, so they get tied up in knots when violent crime increases, which is rising in America. The problem of course is that the descriptor “violent” isn’t consistently applied.

Biden’s idea is to try to win more votes from people who are not fanatic MAGA types. That means picking off White suburban voters, Asian voters and Hispanic and Black voters, all of whom are concerned about crime.

Tom Sullivan points out that while the moderate-to-conservative White population is in slow decline, their votes remain significant, and that Democrats shouldn’t ignore them over the next two years:

“Sadly, Democrats often do. Campaigning in concentrated urban areas that tend to vote your way is simply easier and more cost-effective. What it means for largely rural states like North Carolina is that while it remains possible to elect a Democrat like Roy Cooper as governor, Democrats’ urban focus bequeaths him a Republican-dominated legislature…”

Sullivan says the Democrats need to start acting like the big-tent party that they used to be.

And that’s what Biden is attempting to do.

Time to say “enough” to war-gaming the 2024 election. It’s time for our Saturday Soother. The daffodils have sprung through the snow, a sure sign of spring. We turn back the clocks tomorrow night, another win for those who hate dark days.

So, it’s time to take a few minutes to center yourself. Start by sitting in a comfy chair and watch and listen to Lili Boulanger’s “D’un matin de Printemps” (On a spring morning). She wrote this piece in 1917 when she was 23. Boulanger battled bronchial pneumonia throughout her short life, dying a year later at age 24. Here, it is played by the Seattle Symphony conducted by Cristian Măcelaru.

Listen and think about her writing this during the darkest days of her life:

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What To Do About Social Security and Medicare

The Daily Escape:

Lupine and poppies, near Glendale, AZ – March 2023 photo by Marion Cart

From Joe Perticone:

“Social Security and Medicare are headed for insolvency—that’s just a mathematical, demographic fact. But when it comes to addressing the problem, there’s virtually nothing the two parties actually agree on. For years, Republicans have waffled between proposing cuts and kicking the can down the road.”

Republicans are correct that Social Security (SS) and Medicare (M) are marching toward insolvency. But they trip over their own feet with their proposals to save them. Republicans are wrong to think they can solve the solvency questions without raising taxes. Once the Republicans take taxes off the table, they’re left without any real solutions to propose.

The Biden administration has done a good job in pre-emptively going after Republican’s ideas about cuts in Social Security and Medicare benefits. The result is that the GOP is squabbling between themselves and scrambling to come up with a plan they could take to the public.

It’s not just the federal debt that should be discussed. Dr. Donald Berwick head of Medicare and Medicaid during the Obama administration wrote in JAMA: (emphasis by Wrongo):

“A total of 41% of US adults, 100 million people, bear medical debts. One of every 8 individuals owes more than $10,000. In Massachusetts, 46% of adults say they skip needed care because of costs. As of 2021, 58% of all debt collections in the US are for medical bills.”

The WaPo explains why people who live in the American South have bad credit scores. It turns out that neither race nor poverty were the deciding factors. It was medical debt:

“Of the 100 counties with the highest share of adults struggling to pay their medical debt, 92 are in the South, and the other eight are in neighboring Oklahoma and Missouri…”

But why the South? Yes, as a region, it’s unhealthy. But there are several Northeastern states where residents struggle with chronic health conditions but have good credit. One thing that stands out is the lack of Medicaid:

“…a recent analysis in the Journal of the American Medical Association…found that medical debt became more concentrated in lower-income communities in states that did not expand Medicaid after key provisions of the Affordable Care Act took effect in 2014.”

So bad health and bad credit are because of Republican governors’ refusal to expand Medicaid to cover more poor people. Leave it to the south to show a MAGA future for all of us: undereducated, unhealthy, and neck-deep in debt.

More from WaPo:

“In states that immediately expanded Medicaid, medical debt was slashed nearly in half between 2013 and 2020. In states that didn’t expand Medicaid, medical debt fell just 10%, the JAMA team found. And in low-income communities in those states, debt levels actually rose.”

It’s probably not a surprise that deep medical indebtedness isn’t a threat in any other developed nation on earth. It isn’t a surprise that health care in the US costs nearly twice as much as care in any other developed nation, while US health status and longevity lag far behind.

Legislating in the US is always a process. That means Congress labors to find incremental gains they dress up as reforms. The 1983 deal struck by Reagan and Democratic Speaker Tip O’Neill is considered to be one of the great bipartisan compromises. It combined benefit cuts with revenue increases to put Social Security back on a sound financial footing that has lasted for decades.

This time, getting rid of the income cap on the SS tax would help to keep it funded for an additional 35 years. At that point the Baby Boom demographic bulge will be over, and a different set of reforms can be proposed.

Medicare is the second largest program in the federal budget, equaling 10% of the total. Medicare spending is also a major driver of long-term federal spending and is projected to rise from 4% of GDP in FY 2021 to about 6% in FY 2052 due to the retirement of the Baby Boom generation and the continuing rapid growth of per capita healthcare costs:

Medicaid accounts for another 9%. But it’s also the largest source of federal revenues for state budgets. As a result of the federal dollar matching structure, Medicaid has a unique role in state budgets as both an expenditure item and a source of revenue.

Over the next few years, we’re going to need to come up with solutions to the problem of what to do about growing health care costs that are (along with lower tax revenues from recent Republican tax cuts) driving our ever larger US budget deficits.

Both sides are going to have to compromise. There’s no way we’re going to balance the budget in 10 years (or ever) unless we talk about increasing revenues while slowing the growth in the costs of health care that our entitlement programs cover.

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Monday Wake Up Call – February 20, 2023

The Daily Escape:

Oatman, AZ on Route 66 – February 2023 photo by Laurel Anne Lindsay

Some of you may have heard about a study called “The Hidden Tribes of America” by the group More in Common. It’s trying to understand the forces driving political polarization in America today. They classify the American electorate into seven distinct groups, they call “Tribes”.

But their key conclusion is that most people don’t belong on the far left or far right: (brackets by Wrongo)

“…the largest group that we uncovered in our research has so far been largely overlooked. It is a group of Americans we call the Exhausted Majority…representing a two-thirds majority of Americans, who aren’t part of the Wings….most members of the Exhausted Majority aren’t [simply] political centrists or moderates. On specific issues, their views range across the spectrum.”

More:

“But while they hold a variety of views, the members of the Exhausted Majority are also united in important ways: They are fed up with the polarization plaguing American government and society….. [they] are so frustrated with the bitter polarization of our politics that many have checked out completely….. they aren’t ideologues who dismiss as evil or ignorant the people who don’t share their exact political views. They want to talk and to find a path forward.

This chart from the study graphically illustrates the seven tribal groups of the American populace. As you can see, there is a left-wing group that is about 8% of the US population. And there are two right-wing groups that equal about 25% of Americans. That leaves four groups in what the authors call the “Exhausted Majority”. They are 67% of the American populace.

Here are some demographic characteristics of the seven groups:

  • Progressive Activists: younger, highly engaged, secular, cosmopolitan, angry.
  • Traditional Liberals: older, retired, open to compromise, rational, cautious.
  • Passive Liberals: unhappy, insecure, distrustful, disillusioned.
  • Politically Disengaged: young, low income, distrustful, detached, patriotic,
  • Moderates: engaged, civic-minded, middle-of-the-road, pessimistic, Protestant.
  • Traditional Conservatives: religious, middle class, patriotic, moralistic.
  • Devoted Conservatives: white, retired, highly engaged, uncompromising,

Wrongo identifies as one of the Traditional Liberals, their description rings true.

The authors say that in their research, this tribal membership predicted differences in Americans’ views on various political issues better than demographic, ideological, and partisan groupings. You can read or download the whole study here.

An “Exhausted Majority” may be a positive political development. Wrongo spends nearly every day thinking that there are just two opposing camps. And that they each view each other with fear and loathing, refusing to listen to anything that doesn’t fit their existing narrative. As we’re entering the next presidential campaign, it’s good to know that Wrongo’s view of our polarization might be well, wrong.

Is the “Exhausted Majority” merely a new response to our dysfunctional politics? Wrongo isn’t alone in thinking that what’s wrong with our country will take decades to overcome. Faced with that, people start to look for quick fixes, or a way to stop listening to the wrangling. And you don’t have to be unaligned with either Party to share this sense of exasperation.

The people described in the “Exhausted Majority” are similar. It’s also true that for most people, politics isn’t the be-all-end-all of their lives. They’d prefer that the business of government didn’t require their involvement. They’re trying to get their kids educated, and to keep them safe. They prefer to see political compromise happen without needing to be involved.

But if you can walk away from politics when it frustrates you, then you’re in the lucky minority:

  • There are large numbers of parents who have discovered that their child is addicted to opioids.
  • There are many people who had lost their health insurance when they were laid off.
  • Many sent their daughter to college in the South only to learn that she no longer has any reproductive rights.
  • Many are worried that books are being taken from public school libraries.
  • Some fear that they may lose the right to vote.

These people can’t simply throw up their hands and walk away. Only political action will help them. We all know that the political radicals are irredeemable. We also know they make the most noise, but they’re a minority.

The fed-up people on both sides and in the middle have to find a way to take the country back from the radicals, instead of allowing ourselves to be herded into existing opposing camps.

Time to wake up America! We can’t simply drop out. There’s too much at stake. Democrats need to find candidates and a message that can motivate an additional 5%-15% of the “Exhausted Majority” to vote with them. To help you wake up, watch, and listen to the RedMolly band play a very nice cover of Richard Thompson’s “Vincent Black Lightning 1952”. It’s a surprise how beautifully it adapts to a bluegrass idiom, and the dobro work makes it:

Vincent Black Lightning” is one of the most perfect songs ever written. We saw Thompson perform it live at Tanglewood last summer.

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Monday Wake Up Call – February 6, 2023

The Daily Escape:

Sea smoke, South Portland, ME looking towards Portland Head light – February 2023 photo by Benjamin Williamson Photography

On Saturday, Wrongo and Ms. Right went to a dinner party with friends and two generations of family. The after dinner talk turned to how quite a few of the kids and grandkids weren’t planning on having children.

We tossed around ideas about why they were unlikely to procreate, and somethings stood out. First, they see climate change as an existential threat that society is unwilling to solve, even though the technology already exists. Why bring a kid into that?

Second, society seems broken. Our group meant that we face simultaneous crises, layered on top of each other.  This situation involving simultaneous global challenges, for which we have few solutions, is called Polycrisis.

And a crisis in one global system can spill over into other global systems. They interact with each another so that each new crisis worsens the overall harm. The Polycrisis environment weakens every individual’s sense of security and their place in the world.

One impact that seems related to the simultaneous climate, health, economic and geopolitical challenges are the effects on children. The needs for special education and special services for the very young has never been greater in America. It’s forcing big changes in public school budgets across the country.

No one is really sure why this is happening.

Wrongo isn’t proposing a solution, just suggesting we need to think more about how the problems of declining birth rates, coupled with the growing issues our young children are facing, might be interrelated.

Noah Smith an economist, has an interesting newsletter about how we define community:

“In the past, our communities were primarily horizontal — they were simply the people we lived close to….Increasingly, though, new technology has enabled us to construct communities that I’ve decided to call vertical — groups of people united by identities, interests, and values rather than by physical proximity.”

Smith says that in the past few decades, Americans became disengaged from their local communities, hunkering down in their houses, and failing to interact with the people around them. That led to a well-documented decline in Americans’ participation in civic organizations, local clubs, etc. Our neighbors can also be stifling and/or repressive because they impose uncomfortable community norms on us.

We’ve always had Smith’s vertical communities: “the Jewish community”, “the LGBT community”, and many others. But in the past, an identity grouping wasn’t a true community. We all have identities that connect us with faraway people — other Irishmen, other Taylor Swift fans.

Prior to the internet, we couldn’t have much contact with them. These loose vertical communities weren’t efficient ways to exchange ideas. Before email, text and streaming video, getting the word out was very slow, and our horizontal communities would decide whether what we wanted to share was worthwhile.

Now, we’re no longer isolated. The internet brought us a world of human interaction: social media feeds, chat apps, and so on. Suddenly we’re surrounded by people through their words, their pictures, and their videos.

Now we organize much of our human interaction around virtual vertical communities. Former occasional connections became Facebook groups, subreddits and personal networks on Twitter. And like our small towns back in the day, vertical communities use social ostracism to punish those who deviate from consensus norms.

But vertical communities can’t provide things like public education, national defense, courts of law, property rights, product standards, and infrastructure that we all depend on.

These require a government to administer them. And governments are organized horizontally; mostly defined by lines on maps. But what if we socialize, cooperate, and fall in love with the people from our vertical community? What if we grow apart from the people next door and the relationship is irreparable?

We see this every day in America when citizens go to a PTA meeting and discover a bunch of strangers saying things that they despise.

Wrongo isn’t saying that vertical communities are another enemy. But they can and do exacerbate the polycrisis by making truth harder to see. And by making effective action more difficult.

If you doubt this, remember how powerful the anti-vaxx vertical was at the height of the Covid pandemic. Today’s vertical communities are strong enough to keep our government from getting much of anything done. How can we work together with neighbors when we share few common bonds?

America today is a predatory society. We predate on politics, ideas, values, and culture. Biden’s trying to change this, but can he succeed? How many of us are trying to help? Changing a society that’s this broken, one that’s moving deeper into vertical communities will be a very heavy lift.

Time to wake up America! What can we do to maintain what Lincoln in his first inaugural address said:

“We are not enemies, but friends. We must not be enemies. Though passion may have strained, it must not break our bonds of affection.”

To help you wake up, listen and watch the Nitty Gritty Dirt Band’s 2022 cover of Bob Dylan’s “I Shall Be Released” with Larkin Poe (Rebecca Lovell and Megan Lovell) on vocals and a fabulous slide guitar solo:

Sample of Lyrics:

Standing next to me in this lonely crowd
Is a man who swears he’s not to blame
All day long I hear him shout so loud
Just crying out that he was framed

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