Rebuilding Place in the Urban Space

"A community’s physical form, rather than its land uses, is its most intrinsic and enduring characteristic." [Katz, EPA] This blog focuses on place and placemaking and all that makes it work--historic preservation, urban design, transportation, asset-based community development, arts & cultural development, commercial district revitalization, tourism & destination development, and quality of life advocacy--along with doses of civic engagement and good governance watchdogging.

Monday, March 18, 2024

Thanks Obama! (for saving my life)

There was a conservative meme during the Obama Presidency about how bad he was for America ("‘Thanks Obama.’ The evolution of a meme that defined a presidency," Washington Post).

I had been doing some reading on the New Deal, when the US Government did so many great things.  

And that spirit of innovation marked the federal government for some time, e.g. Medicare and Medicaid were created in the 1960s, LBJ's Great Society program invested in cities and civil rights, and even Nixon created the Environmental Protection Agency.

Although the federal government hasn't stopped investment in science as discussed in the Michael Lewis book, The Fifth Risk, the government has become a lot more timid, which Lewis covers in his book on the response to covid, The Premonition: A Pandemic Story.  

Part of this is because in our current system there is zero room for mistakes, people get excoriated--despite the venture capital community saying learning from failure works for start up culture.

(Years ago then Mayor of Baltimore O'Malley said mayors want to be second with innovation, because being first sets you up for failure.)

But the primary reason, at least in the 1970s, was a loss of confidence because of the Gas Crisis, which was a major shock to the system, from which US confidence never really recovered.

This was made worse by the neoliberalism philosophy adopted soon after ("Neoliberalism – the ideology at the root of all our problems," Guardian), which exalted the market and private sector action and denigrated government as a failure.

And the anarcholibertarianism of Republicans, which militates against government generally, governance specifically, public investment and the concept of public goods, cut taxes--the revenue government needs to function, defund it, and then criticize a defunded government for acting inadequately when pressed by disaster or other great needs.

-- "You don't have to bash the federal government to make the case for local action"

I argue that because for many decades the US government overinvested in society, it was able to withstand disinvestment for some time (also see the concept of "capital shallowing").  But the Bush Administration and its failed response to Hurricane Katrina, demonstrated that the government capital surplus had finally been depleted.

A recent Reuters article, "Why Congress is becoming less productive," about how Congress is accomplishing less and less.

Government can't seem to accomplish much more than one thing, let alone great things during one four year term, maybe one, and a lot of the time, the "great thing" may not be so great.  Trump's biggest accomplishment was cutting taxes for the wealthy and corporations--1/3 of the federal deficit is attributable to Bush and Trump tax cuts, so it's not much of an achievement.  

Although the Biden Administration is actually accomplishing a lot, from investments in transportation to creation of technology hubs around the country, continued investment in broadband, etc. ("Joe Biden profile," New Yorker).

Besides a great macroeconomic response (that could have been better, "Obama’s Failure to Adequately Respond to the 2008 Crisis Still Haunts American Politics," Jacobin) which warded off a depression in response to the 2008 Great Financial Crisis, the other New Deal comparable act during the Obama Administration was the expansion of health care access to the less well off, which is commonly called Obamacare, but formally is the Affordable Care Act.

Obamacare included Medicaid expansion.  Many Republican states refused to participate in this, although a number did, and over time more red states are participating, although many still not ("2024 Session: Health care a driving issue — but don't talk about Medicaid expansion," Tallahassee Democrat).  Red states tend to have much worse health outcomes than blue states because of policy choices like this ("HOW RED-STATE POLITICS ARE SHAVING YEARS OFF AMERICAN LIVES" Washington Post).

Republicans continue to denigrate Obamacare ("GOP Guv Candidate Mark Robinson on Obamacare: It’s an Effort to ‘Enslave Everybody’," Daily Beast) or try to repeal it ("Trump says he will renew efforts to replace ‘Obamacare’ if he wins a second term," AP) but are more resigned to it because it's effective and a majority of the population support it ("Republicans abandon Obamacare repeal" NBC News).

Utah joined the program in 2019, not because the state government did the right thing, but because voters approved joining the program in a referendum vote in 2018 ("What is the Status of Medicaid Expansion in Utah?" Kaiser Family Foundation).  Voter referenda have accomplished this in a number of states, in response to conservative intransigence.

I'm poor.  I don't have an advanced degree in planning, making it harder to get a job.  I'm 63.  I moved to a new place with no network of contacts.  Covid happened.  So it was even harder to find a job.  I haven't.  Now I'm pretty sick although fortunately my mind is fully intact. So I have no real income.

I'm sick.  I didn't have insurance.  I applied to Healthcare.Gov.  Almost immediately during the process it said I was eligible for Medicaid.  The process for signing up was easy.  (Although I worry about being kicked out next year, just because, see "Most People Dropped in Medicaid ‘Unwinding’ Never Tried to Renew Coverage, Utah Finds" and "Halfway through ‘unwinding,’ Medicaid enrollment is down about 10 million," KFF).

Since September 

  1. I'd been diagnosed with colon cancer 
  2. had surgery for it in November, it was Stage II/III but with zero spread
  3. in post-op my troponin levels were so high it indicated a heart attack, which I didn't have, but it turned out I do have congestive heart failure
  4. the raised lymph nodes in my groin weren't colon cancer but a rare aggressive lymphoma that without treatment most people die within one year
  5. I started chemotherapy in December with immediate positive results, although it's on hiatus because of 6 and 8
  6. hospitalization for covid in February because it got worse, not better, with non-viral pneumonia and myocarditis
  7. since I had covid last March I've lost 1/3 of my body weight, I meet the definition of malnourished and I finally agreed to a feeding tube which was installed last Friday
  8. since November it turns out I had heart rhythm issues that would have resulted in death, but the doctors weren't really sure if it was bad or not, but just this week, I had a pacemaker installed on Tuesday after being called in the middle of the night and ordered to the hospital because there was a period of 12 seconds where my heart wasn't beating.

Medicaid covers it all.

Thanks Obama.  !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Obamacare/Affordable Care Act has saved my life.

With an assist from the residents of Utah.

And bike riding for 30 years.  My father, uncle and grandfather all died at 54 or earlier from heart disease.  So I decided at 30 to bike for transportation, because I didn't think I had the perseverance to actually go regularly to the gym.  Instead my exercise would be forced by my need for transport.

But I guess I could postpone genetics but not outrun it.  I've lived almost 10 years longer than my father.  And while I have a lot of health problems at the moment, but surprisingly pretty good prognoses.  And when I get tests other than for the specific problems my organs and such show pretty well, e.g., I have no plaques in my veins, etc.  My colorectal surgeon attributes those kinds of results to the biking...

9 Comments:

At 3:26 PM, Blogger Richard Layman said...

September to now. What a "year"! Imagine getting a call at 2:45 (it was from the device provider, not local, so I thought it was spam) then at 3am from a Utah number, so I answered and after a bit of arguing I agreed to go to the hospital and by the end of the day I was in surgery... plus I just had the feeding tube installed a couple days before.

I have my cognition though my psychomotor is s***. I'm a long way from getting an e bike.

WRT cost control..., our system is so chaotic.

Eg not unlike the social justice types who think that you can nullify responsibility for crime because of structural racism, not understanding that crime is crime and perpetrators need repercussions, a focus on chronic conditions "now" will take decades to pay off, because lots of the people with them, it's not so reversible.

But that's why physicals and certain vaccines are "free."

2. With my stuff, obviously (1) I did address chronic/or genetic issues by biking for 30 years and obviously it had positive impact but as I say, it postponed my likely genetic issues, did not ward them off.

But that is perseverance a lot of people don't have.

(2) Am impressed with nurse navigator and case managers element. CM is for insurance, since I have lots of issues. The NNs are from St. Marks. The cancer nurse is amazing. I just dealt with a cardiology one today.

I think in the old days you didn't have that kind of support outside of your PCP. And lots of PCPs don't have the specialized knowledge.

 
At 10:23 AM, Anonymous charlie said...

With healthcare, enormously complex subject. Highly regulated industry. Very little incentive on cost controls.

I think the best example in the uS is the VA system. It got overloaded when they switched from combat vets to all vets, but the basic principle is sound.

Medicare likes to boast that is a lean delivery system, but its just offloading prices onto private insurance.

For instance, my parents are paying something like 250 a month for medicare and complaining. We are paying over 1000, and they are the ones using the system!

My general rule with healthcare is incentives matter deeply, but don't get confused and think this is a market. Market are just price setting mechanisms and putting prices on this stuff is not easy or just.

The singapore model to me seems the best, but let's be honest that also runs on a lot of low cost labor for nursing. But basically everyone gets a very cheap public plan, if you want something nicer you can buy a private plan.

https://www.statnews.com/2024/03/19/methadone-clinics-opioid-addiction-private-equity/

Introducing profit displine into health care is dangerous.

Steve Brill wrote a book 10 years back.

"America's Bitter Pill"

His take is you need a nonprofit, physical driven model -- like the Cleveland Clinic, Mayo, or Mass General.

What of course has happened since then is those entities have tried expand and move into a larger provider place -- I think he book missed the insurance issue completely.

Like you, he had a bad bout of cancer and walked away impressed what the medical system can do and wanting to make sure everyone has that level of care.

It's a generous impulse.

But as you allude to, the real issue isn't the amazing care we get -- and we do -- but the continued underinvestment in primary care and chronic management.

was your cancer a right side or left side one?

 
At 10:06 PM, Blogger Richard Layman said...

left groin lymphoma (large T cell, alk negative). The colon stuff was on the right.

2. The only difference between St. Marks and Cleveland Clinic (well, not the only one) is that St. Marks (HCA) pays taxes and CC doesn't.

Not with Mayo, but Cleveland and especially MGH is they are huge conglomerates. MGH is limited to Massachusetts, CC not. CC has interests overseas. Just sold a chunk of one place for $150mm

Yes, the nonprofits do more research, provide more uncompensated care, might do more programming (St. Marks has programs though).

But theoretically, yes.

3. DK about Singapore. Will check it out.

4. Yes about Medicare and Medicaid off loading costs to private insurance. Not unlike how the US subsidizes pharmaceutical development and costs for the world.

MIL is like that, she doesn't complain about cost of Medicare, she is pretty amazed at how cheap it is. But she bitches about other costs. I had an outburst in response today. She always complains about paying taxes, the trees in the planting strip ("the city should clean up after them, it's their trees.") Today it was about the streetlight charge. I said "I'm fucking dying" (not really, but hyperbole has its purposes) and you're complaining about $100 year for streetlights?

5. Profit discipline is a real issue with the insurance companies generally, with Medicare Advantage too.

It comes up with my stuff too. There is back and forth about authorizations, and delays. My colon surgery was supposed to be delayed over authorization. The room was booked, etc., my surgeon "made me do" subterfuge to get it done on her schedule, not the insurance.

And I've gotten copies of no authorization letters. But those tend to be interim. The reality is that my care needs are highly justifiable, and in the end, although it might take months (for a particular drug, the cardiologist was giving me samples), they seem to approve it all. It's not like I'm trying to get care I don't need.

 
At 10:25 PM, Blogger Richard Layman said...

I have one pretty good registration evader. And a super good registration evader. The latter works on Chronicle of Higher Education even. But not Stat.

Then again, super duper still had problems with a couple sites, and I would send messages "does not render" and both those sites (including WSJ) now work.

I sent a does not render message on Stat.

2. TJ Butter chicken and lamb vindaloo rock. Tomorrow I get some eggplant dish. At least pre chemo, I loved eggplant, especially Asian styles. We'll see.

 
At 10:29 PM, Blogger Richard Layman said...

https://www.propublica.org/article/blue-cross-proton-therapy-cancer-lawyer-denial

 
At 10:39 PM, Blogger Richard Layman said...

although weirdly, super duper, intermittently doesn't work on the computer, even if it does on the phone.

 
At 10:18 AM, Blogger Richard Layman said...

https://www.nytimes.com/2024/03/25/opinion/trump-obamacare.html

Obamacare Is in Grave Danger, Again

But in the near future, you may well lose that hard-won access. In 2017, Donald Trump and Republicans in Congress tried to eviscerate the A.C.A. and almost succeeded in passing a bill that the Congressional Budget Office estimated would have left 22 million more Americans uninsured by 2026. There’s every reason to believe that if the G.O.P. wins control of Congress and the White House in November, it will once again try to bring back the bad old days of health coverage. And it will probably succeed, since it failed in 2017 only thanks to a principled stand by John McCain — something unlikely to happen in today’s Republican Party, where slavish obedience to Trump has become almost universal.

... And what we know is that even though Trump likes to portray himself as a populist, right-wing economic ideology still rules among congressional Republicans, who are as eager as ever to effectively destroy Obamacare. Last week, the Republican Study Committee, which includes a majority of G.O.P. members of the House of Representatives, released a budget proposal that teed up many of the 2017 “reforms” that would have caused millions of Americans to lose health coverage. (It also called for down-the-road cuts in Social Security and Medicare.)

What I found striking about the budget proposal was how its authors deal with the fact that none of the dire predictions right-wingers made about Obamacare have come true. The answer is that they simply pretend that the bad things they predicted, which didn’t happen, did. I was struck, for example, by the assertion that Obamacare “dramatically escalated the unsustainable rise in American health care spending.” Indeed, in 2010, total U.S. health care spending was 17.2 percent of G.D.P. By 2022 that number had risen to … 17.3 percent of G.D.P.

 
At 10:27 AM, Blogger Richard Layman said...

https://www.nytimes.com/2024/03/25/opinion/life-span-biden-health.html

With a Second Term, Biden Could Reverse This National Health Emergency

Today, as New York City’s health commissioner and a practicing doctor, I see a desperate need for similar focus and ambition here in the United States. The major health crisis we’re facing is not Covid or a single epidemic. It’s not cancer, diabetes or drug overdoses alone. It is the national emergency of worsened life expectancy in America. Combating our falling life spans could be a unifying focus of a second Biden administration, since it will take all of the government along with other sectors, working in alignment and investing at scale, to set our nation out on a path for longer, healthier lives.

First, we would have to break our addiction to clinical care designed to react to new ailments, and spend more on preventing health issues in the first place.

We should greatly increase spending on prevention in two main ways. The first is to directly increase funding for public health departments to expand their core work in areas like health education, infectious disease surveillance, chronic disease screening, mental health services and doula programs to address maternal and child health — activities that have proven impacts on preventing disease and long-term health issues.

The second part is to redirect hospital and health care funding for preventive health care and for social services critical to long-term health.

To achieve an industrial policy for health, we also would need to make it fundamentally easier and cheaper to make healthy choices, and harder and more costly to make unhealthy ones, for individuals and for industries.

A rethinking of the way we plan and pay for health would require policymakers to ask different questions.

The idea of incorporating health directly into policy decisions across the board is not new: From 2012 to 2016, eight states and the District of Columbia passed “Health in All Policies” laws, intended to orient the apparatus of government toward well-being. Though well intended, these initiatives lacked the funding, metrics and understanding needed to move the needle on population health outcomes.

An industrial policy for health could offer hope and direction for the future, and a salve for polarization. It’s hard to imagine a more unifying proposition than “we all deserve to live longer, healthier lives — and ensuring that we do should be our government’s No. 1 priority.”

https://www.astho.org/globalassets/pdf/hiap/state-of-hiap-2018.pdf

 
At 10:31 AM, Blogger Richard Layman said...

WRT the Krugman column

https://www.ft.com/content/b17c31d4-8da3-42c9-8c8a-7e06dad9cf15

How Republicans learnt to love bigger government

A growing body on the right now believe that Medicare and other programmes must not be cut at all

 

Post a Comment

<< Home