Arrival

I stayed up late re-watching Arrival. I decided that I love that movie. 

I was thinking about Arrival today while folding laundry, the morning after I'd stayed up late to re-watch it, wondering why this movie speaks to me so much. I often connect strongly to moody cerebral science fiction movies, so maybe it was inevitable. But more deeply, on watching the movie this second time, I connected strongly to the particular combination of fear and wonder, of feeling intellectually challenged and emotionally overwhelmed, that Amy Adams conveys for much of the movie. She is haunted but enlivened by what haunts her. She walks towards the fear, the dread. In doing so she embodies a quiet, kind power; a form of strength that incorporates curiosity and love as part of its structure.

 This is the emotional quality I seek in my work and my life. The heroic version of this quality looks easier in the movies than it is in real life, and I'm not even using advanced linguistic theory to bridge the gap between alien civilizations across time and space. I'm just trying to help people stay alive. I don't compare this experience to trying to communicate with aliens; these are my people. It's less the experience of the aliens as it is another part of the story, about grief, that I think I connected to most strongly. The idea of going towards love even if grief lives in the same room.

 And yet, these aren't my deaths to grieve. I haven't lost the people I'm closest to.

 I remember a moment when I was doing AIDS work and I saw this movie Fearless in 1993, at a time when everything seemed like it was just going to keep getting worse. And I remember losing it at this movie. Crying my eyes out for reasons I didn't totally understand, for deaths that hadn't yet occurred, for grief that wasn't really mine to grieve. And yet, was. I think I'd been getting numb for the weeks preceding seeing the movie, and then cried much more than I normally would have. Some guy's story came back to me, some horrible story that I don't remember now, and it was like I'd shut myself down after hearing his story, and then after the movie, for some reason opened myself back up to the world, to pain, to other people's stories.

 Arrival wasn't that for me last night. It was just a very evocative sinking into the deep spare melancholy of the world; of the universe. And how this connects to who I am right now, I feel like I'm still working out. But I do know there is something about Amy Adams' character that I identified with, that I found in common with how I am feeling. When I figure that out, maybe I will be able to read some alien alphabet of time and physics. Or maybe I'll just know my own language better.

* * *

 Addendum:

 Maybe something in this territory:

 From Chris Plante in The Verge:

"Arrival tells the story of one woman who chooses a life of grief to save the world. I find her so painfully relatable. As I get older, the emotional struggle of life — the one I couldn’t see when I was a child — has revealed itself. Friends and family die. Unexpected tragedies interrupt banal work weeks. To live and to love is to court inevitable grief, and we make the choice to move on. I’ve attended many funerals over the past few years, and I thought about each of them on the drive home from my screening. I don’t have the advantage of knowing my future, but I do have the memory of my past. I know the pain that comes with emotional investment, and it does not hobble me, or at least I try my best not to let it. I found Arrival’s bigger themes of communication and trust compelling. But what will stick with me is its defense of choosing life in the face of profound grief."
* * *

Don't worry: I haven't forgotten the musical note:

It seems like a good ecologic/musicologic question to ask whether the Arrival soundtrack would've sounded even a little bit the way that it did if no one had ever recorded humpback whales. I mean that as a compliment. I like listening to humpback whales. An accidental discovery leads me to recommend playing these two links by clicking them in rapid sequence to play in different browser tabs. If you make that happen, the soundtrack becomes a backing track to the whales (or vice versa?):

Arrival

Whales

Admittedly it's a little late on Saturday night and I'm listening on headphones so as not to wake anyone up. And I'm in a mood, and might have descended a little more deeply into the humpback song / Icelandic film score mash-up zone than others might choose. Still, you might consider playing them both, from the beginning, starting at the same time.

There is also a very non-whale-ish piece of music, "On the Nature of Daylight", that is not a part of the movie's score, but serves as the underpinning of a key portion of the movie. (Written by Max Richter, who wrote the score for The Leftovers, speaking of haunting science fiction.) I recommend this also via YouTube link:

Vox Care / Healing

Look, whatever I thought I might do in giving updates on Medicaid issues, is pointless. I think I thought only a few desperate people crying in the dark would defend Medicaid, and... it hasn't been quite so bad. Not good, mind you. From the point of view of this blog, though, the bigger point is that the job of keeping you posted on a daily level is being done really well right here:

Vox Care

and also here:

Andy Slavitt

...among others.


                           *   *   *


Check this while you read: "Healing." Ignore the visual. Deep house music by a band that doesn't usually swing that way. Kinda glorious.








Bubbles

"I don't care who you are, what you done, or who you done it to. If you're here, so am I."




"Ain't no shame in holding on to grief. As long as you make room for other things too."

It's been one of my professional ambitions to be Bubbles' doctor. I mean, not Bubbles himself. He's a fictional character from The Wire. (Sort of.) But people like Bubbles.

And I'd sort of forgotten about that until I was talking today about 12-step. For a lot of my patients on buprenorphine, the 12-step movement is a mixed blessing. There's wisdom there, but also judgment. But some folks find a way to put the two together. They find the help of a medication, and they find the wisdom of a community.

I can't tell you how many times I say, "One day at a time" as part of a sentence, and I really really mean it. Every day. Sometimes multiple times a day.

And there are none of my patients where I see them and I go, dude, that guy's just like Bubbles. They are each their own person. But I do see Bubbles now, and say, that guy's a lot like my patients.






2020: I didn't end your coverage, you ended your coverage // Rockabye


Sara Rosenbaum, a Jedi-level health policy wonk, breaks down the details of the draft plan as it stood last week, highlighting a number of its problems. The same Commonwealth Fund blog brings us up to date this week with this explainer which emphasizes a key problem: in the House plan, in 2020 once you are out of Medicaid, you're out for good. But many of the working poor, particularly those who work seasonally, go in and out of eligibility. Basically the plan stalls until 2020, when it stealthily, steadily, and irrevocably culls the ranks of Medicaid expansion beneficiaries. It does this by booting current beneficiaries as soon as they work too much and lose eligibility for Medicaid, (while making a lot of noise about work requirements, personal responsibility, etc, etc); then allowing no new beneficiaries; and, most of all, never explicitly admitting to the goal of reducing the number of beneficiaries.

So, in summary, it starts as an incoherent mish-mash of modifications and quietly morphs into the "I didn't end your coverage, you ended your coverage" Medicaid destruction plan.

 * * *

Nothing like a single mom song to get the blood boiling on the contraction of Medicaid expansion. 






Medicaid block grants: who to start calling, and points worth emphasizing // "Don't Let Me Down"

Kaiser Health News tells you "Everything You Need To Know About Block Grants — The Heart Of GOP’s Medicaid Plans" (h/t Audrey Provenzano).

Let's start thinking about how block grants can be defeated.

Republicans will try to pass block grants in the Senate, which is the most likely place for block grants to die, by introducing them as part of budget reconciliation, which would allow them to get it through on a 51 vote majority in the Senate. They will likely have the votes in the House... unless Republicans can be convinced by their states' governors that their constituents and states will a) get hurt by Medicaid cuts and b) will notice and c) will be mad about it.

Here's one strategy for citizen and clinician advocacy around this right now: specifically target legislators from states where federal contributions make up a significant portion of Medicaid spending. You can use this ranking (click the "federal" header to make the table sort by share of spending by federal government) to find where your state lands on this list.

This ranking is interesting as it highlights a potentially persuadable Senator, who wouldn't have come immediately to my mind: Dean Heller, in Nevada, who is up for re-election in a swing state in 2018 which also receives a large share of federal spending for Medicaid. Rob Portman, in Ohio, will also be up for re-election in a swing state in 2018, which also takes an above average federal share for Medicaid spending. Other targets for advocacy and persuasion might include Shelly Moore Capito, Republican of West Virginia, which had a significant Medicaid expansion in an impoverished state, and which ranks fifth in the nation in share of federal spending for Medicaid.

The limits of this ranking list in setting advocacy targets become clear, though, with the first state: Kentucky is a Medicaid expansion state, takes a bigger share of federal funds for Medicaid than any other state in the nation, and yet is represented by Mitch McConnell and Rand Paul, both of whom are likely to support block grants and worse. I mean, if you're from Kentucky, call their offices, but... they don't aim to represent Medicaid recipients.

Still, for the unpersuaded, the argument here is not that Medicaid block grants are bad because they hurt the healthcare of poor people. (After all, Republicans might reasonably ask, sotto voce, Isn't that what we were elected to do?)

The argument is more pragmatic: Medicaid block grants will hurt Nevada, or West Virginia, or Ohio, or Montana, or North Carolina (find your state on this list). And more to the point, they will hurt specific hospitals and community health centers. These are places that your Senator or Representative has been photographed with sick kids with cancer; cutting ribbons in front of the new women's health center; shaking hands with some urologist to "raise awareness" about prostate cancer; and, well, you know the drill. If you look on your rep's office website, odds are good that at some point in the last few months they were visiting somewhere that would get hit hard by cuts in Medicaid spending.

If you're a healthcare worker in Nevada, West Virginia, or Ohio, or any other state where Medicaid depends to a larger degree on federal contributions, not only should you consider contacting your Republican Senator about block grants--but also get your hospital or health center to start advocating as well. These are large employers--and block grants are likely to mean many of them will lose revenues and have to start laying people off. Sometimes it's jobs, rather than health or lives, that speak politically.

For calling your congressional representatives, here are some red state/swing state talking points:

"I am calling to ask Senator ____ to oppose Medicaid block grants. 

 "Medicaid in [our state] depends on federal contributions--in fact, we have the ___nth biggest federal share of Medicaid spending of all states. 

 "Medicaid can give latitude to [our state] to make our Medicaid program work best for our state--without cutting jobs and causing people to lose their health coverage. 

 "Senator _____ should instead support Medicaid funding mechanisms that give flexibility to states without shutting off needed support."

And what's the blue-state phone script? Ironically, in part because states like Massachusetts are both wealthy (entitling us to a smaller federal contribution) and liberal (willing to kick in a fair amount of state revenue), we are quite low on this ranking list. And in that sense we will initially suffer somewhat less, proportionally, from block grants. But that's only because we are already spending a lot of state money--to the point where if federal money starts getting cut, we won't be able to make up the difference. Much of what makes our state Medicaid programs innovative and effective will be endangered. We still depend on getting a large share of our Medicaid funding from the federal government, and healthcare is a big part of our economy.

Here are some key points for a blue state congress call:

"I want Senator ______ to make saving Medicaid into a bigger priority of her office's work. I know I can count on Senator ____ to oppose Medicaid block grants--but I want her to make it a bigger priority to let people know how important this is not only to our states, but to all states. 

 "Our state has done a lot of innovative things with Medicaid funding and I hope we can hold up that innovation as an example of the kind of flexibility for states that current funding allows. 

 "I'm not hearing her talk enough about Medicaid block grants and how this will hurt people in [our state] and all over the country. Getting healthcare to people who otherwise couldn't afford it should be at the center of a progressive agenda. Can you let me know when she plans to make this a bigger part of her public agenda?

 "I want to let Senator ____ know that I'm waiting for her to take a bigger leadership role on opposing Medicaid block grants and reaching out to her Republican colleagues who might be persuadable on this issue."

* * *

Theme song: The Chainsmokers' megahit "Don't Let Me Down", of course:

here's a remix that I like, on Soundcloud, and since:
1. the original video is just, terrible;
2. the better part of the Chainsmokers' "performances" of this song amount to them basically standing behind a table dancing around to the already recorded and mixed track with fireworks going off around them; and most importantly,
3. their band name alone represents a threat to the public health; 
and therefore,
let it be resolved that if we need a video, we'll just watch a cover of the song by another artist, like, say... Usher? (Huh?)

I'm not 100% sure it's a good idea to get actual high quality musicians involved in trying to interpret a song like this one, where the backing track comes from some dude playing around on his MacBook while on a plane, "and I made that, and it was pretty vibe-y", and then the vocals come from a songwriter who is hired to come in and write "the top line" (you know, the lyrics and melody that old folks are used to thinking of as, the song). And where the heart-wrenching story of adversity related to the song is that the computer crashed and lost all the files and they had to remake all the tracks again.

But lots of truly great pop songs have been written in music factories, and Usher and his crew give it a valiant shot, and hey, well, maybe it's a little too jazz-festival-ish, but maybe that's a good thing:



* * *

PS:
I don't know what to do with this. I feel like I have to keep you, dear reader, informed on any "Fast Car" versions of significance. So. Here is Justin Beiber singing "Fast Car." Don't get all nasty about it.









I strongly recommend this piece from The Body (a website for people living with HIV and those who care about them), by policy advocate Michael Kink, which most strongly articulates the direct effect of Medicaid block grants on people living with HIV, and others whose health needs are unpopular.

 The most important thing he highlights is that state control of Medicaid programs ultimately means there is no longer a right to care once you get into the specifics. What Medicaid will pay for will be the states' responsibility--or lack of responsibility. In the long run, if a state wants to restrict or even eliminate necessary treatment, it may. This is another dark side to block grants, beyond the simple funding cuts. That is, saying "the states know best" not only is a cover for cutting budgets, but a cover for justifying bad care.

This is a crucial argument that needs to be highlighted more clearly, to emphasize that although Medicaid block grants are most broadly a way of enacting cruel budget cuts, they have the potential to more specifically accomplish other terrible and pernicious policy aims as well.

* * *

Sufjan Stevens' "Casimir Pulaski Day" is a stunning song, more and more stunning the more I listen to it, and I've been listening to it for a few years now. It's about a kid whose friend-kinda-girlfriend dies of "cancer of the bone"; and the way that event makes life and the universe more sad and complicated for everyone around her.

And maybe we just leave it at that.

Or maybe we return to point out that for people with rare diseases, block grants have the potential to...

...Or not. Maybe sometimes it's best to just let the song be the song.




state of the state

Don't get me wrong, I loved Jerry Brown's State of the State speech. But it's just not true that California has had "a spirit of adventure and openness that has welcomed - since the Gold Rush of 1848 - one wave of immigration after another." It's true that California has had many waves of immigration--but it's also been home to multiple anti-immigrant movements, including brutal attacks on Chinese immigrants in the nineteenth century, embracing internment camps for Japanese-Americans in the mid-twentieth, and the anti-immigrant policies of California's Republican Party in the early 1990s.

 If there's one thing that frustrates me in leftist rhetoric as much as right-wing rhetoric, it's the frequent historical revisionism about what America is and has been. We've always been at war with each other about what America is supposed to become. There has never been one unified vision of the United States. It stuns me when people pull out these "We have always been [insert noble sentiment here]" statements.

 And that said, even in times of the unkindest politics, there have always been dissenters; always people who called on their fellow Americans to rise to more love and less hate; always people who believed in a pluralistic and small "d" democratic America where all were welcomed. It's too simple to say, for instance, that white supremacy has been the sole definition of American society; if it has been a prominent and constant political theme, it has also always been met with opposition and resistance.

 To say "America has always been" or "California has always been" is almost always the lead-in to an intellectually lazy assertion that one's own ideal of America is the truest or longest-dominant strain of American politics or thinking. If the current situation reminds us of anything, it's that there is never one America, and has never been one America, and probably never will be. However, it is possible for a kinder version of America to prevail over its opponents. And that should be our goal; not the restoration of some golden age of unity which never existed.


Medicaid round up, with Fast Car (disco/guilty pleasure) and Fast Car (legit)

from a 2011 protest... in another Medicaid battle...

Yes, it is happening. They are spewing the exact rhetoric you would predict about Medicaid block grants (see prior posts), and though governors are pushing back... I mean, governors? Sad. Losers.

Families USA has this factsheet regarding Medicaid block grants (h/t Doctors for America).

Kevin Drum at Mother Jones has a good explainer with graphics showing why pegging block grant increases to overall inflation is inevitably budget cutting.

In a related development, Medicaid block grants in Republican-dominated states will likely lead to privatization, which in Iowa has been a bad deal for providers of care, as explained in this STAT article.

And yes, Republican governors, not surprisingly, are continuing to sound the alarm, that umm, guys, that's a bunch of money you're about to take away from my state. Sadly, Governor Kasich may not wield awesome political influence in today's GOP. Because: Loser. Sad.

Investors get a warning that it's time to be bearish on any healthcare investments that involve poor people.

And for locals, here's an article on concerns of Massachusetts legislators--and how our rate of 97.2% residents being insured (this can be done! we have done it!) might be at risk, and what the state might do. Basic summary: we're not sure how we're gonna get damaged, and we're not sure how we're gonna fix it, but we're gonna get damaged, and we're gonna try to fix it.

Zooming out of Medicaid proper and into the ACA, here's why the "moderate Republican" alternative isn't viable.


And in the continuing Mu-Receptor Mixtape commitment to bring you health policy beatz, can there ever be too many Swedish-disco-house takes on "Fast Car"? Tobtok (featuring River) apparently feels the answer is no, and made a cyyyyyuuuuuute video to prove it. I have a weakness for this which can not be entirely justified aesthetically. (PS: Yes I know Jonas Blue did a prior Swedish-disco-house-style version. But the song isn't better and the video is literally just... the stupidest. I'm not even linking to it.)

Health policy verse is:

You see my old man's got a problem
He live with the bottle that's the way it is
He says his body's too old for working
His body's too young to look like his
My mama went off and left him
She wanted more from life than he could give
I said somebody's got to take care of him
So I quit school and that's what I did

Again emphasizing that the economic impact of untreated health problems extends far beyond those with the health problems. Right, Tracy Chapman? Holy crap, so many years later I still think this is a beautiful song, and children, this is the woman who actually wrote it, and the reason why even though I love that disco house music, I'm sort of ashamed to even like any of the multitude of remixed and redone versions, because: Tracy Chapman.






Alabama's 70-30 mix might become 60-40, then 50-50, then... .

This op-ed from down south does a nice job of quickly laying out the Medicaid block grant problems for a state like Alabama... and the reasons that Republican governors might want to gulp and think twice before they get on that train.

 "Alabama contributes only about 30 percent of its Medicaid program's funding, with federal money covering the remaining 70 percent. Changing Medicaid to a block grant would limit Alabama's federal Medicaid allocation to a fixed amount each year, regardless of the state contribution. Any cost increases would be borne by the state alone, with no 70-30 federal match."
Obvi, you were thinking, Alabama, so you have to rock that op-ed with the Prancing Elites. Yes I do, that is true. Please see picture above, and videos below. 

 But we also have to include the Alabama Shakes, who poignantly critique freezing that federal contribution level in "I Ain't the Same". As an aging population and decreasing social safety net combine to worsen health and threats to health and ability to recover from bad health, well then,

 I said I'd never grow old
I can't remember how that used to be
I find myself without the power
I find myself without the glory
People will start losing coverage most under a block grant system when things get worse, because then costs will go up, just when the state needs coverage more. State-level costs increase. But the federal payment still stays the same or goes down.


Who gets cut out? Hard to say for sure before it happens, but with that question, back to the Prancing Elites. Apparently you have to watch the Oxygen channel to know which Prancing Elite needs coverage for antiretrovirals.

(OK, I admit I'm like, years late to the J-sette party, but here's a J-sette battle in Memphis. Aside from wanting to put the "mix" in "Mu-Receptor Mixtape" and rock your health policy musings, another reason I keep showing all kinds of random videos from around the country is this. I want you to look at these crowds and wonder: How many are Medicaid recipients? And what's going to happen to them? In Tennessee in general, and in Memphis also, about 25% of residents are covered by Medicaid.)



 Because there's a lot of people who need Medicaid. And they're a potentially powerful force if organized. Remember, everyone, you ain't alone:

Gene Sperling vs go-go music: block parties, not block grants

Gene Sperling reminds us: don't get distracted by strategic retreats from Medicare cuts; the Medicaid cuts are coming. And who will stop them?

For this op-ed, no choice but to go with "Numbers Game" sung by Chuck Brown as a guest for the Thievery Corporation. Check the video for a view of the now-departed Godfather of Go-Go, meetin and greetin. About one of three DC residents are Medicaid beneficiaries, and in this video, Chuck Brown isn't driving around the private platinum plan neighborhoods of DC, so figure it's more than a third of the folks in this video.


Wait: You don't know go-go? (That song isn't exactly go-go: it's the DC musical collagists Thievery Corporation digging on go-go, to which I have no objection.) Go-go is kinda like DC statehood: a local idea unjustly kept local.

For me, a record store nerd on the West Coast, the briefly-glimpsed go-go true religion was Trouble Funk, which got together for their 30th year reunion... seven years ago. Like we might say back home... I'm hella old. Anyway, this is go-go, at least to my ears:





Hepatitis C


To do list item (advice to the brother I don't have):

Get your Hepatitis C treated now. Whatever medication is the right one for you (and people need different Hep C meds depending on various things), you have to do your best to take that medication perfectly. One day at a time... but every day.

12 weeks of most first-line Hepatitis C medication costs more than an SUV, and you gotta ask yourself: is the new Congress going to keep appropriating funds to buy you an SUV? Even if that SUV would save your life?




Awaiting the Dark Lord.

A group of doctors are sitting in a conference room and a lawyer is talking about legal advocacy in the medical setting.

--What if--?

--We really don't know. But it is possible.

--But what if--?

--Again, you're talking about reading tea leaves. But, that is one possibility.

--Can we really be put in that kind of position?

--It is not totally unprecedented from a legal point of view. And it's the kind of thing that President-elect Trump is talking about. So for your patients, it's important to think about that in terms of the kind of documentation you use now. 

Doesn't matter what the topic was. Just that... everyone who cares about medical care for poor people is waiting for the shadow to appear overhead.



Soundtrack from SoundCloud: from before the election, on the Mexican side of the line, Borchi decided not to take the Empire that seriously; and farther south, there's an Argentine take:



Quiet catastrophes: Medicaid block grants

While Trump distracts with visible nightmares, the hidden bad dreams are sneaking up. One of them is Medicaid block grants.

This benign-sounding administrative change to the mechanism of Medicaid funding is so wonky it's hard to explain why it's a horror show. The basic summary: you can set up federal funding for state-run programs in a couple of ways. One is the way Medicaid works now: the feds and the states divide up costs based on meeting the need, as need is defined by legislation and federal rules. Another is block grants: feds and states divide costs based on some pre-defined amount they decide they want to pay. Again, to simplify, this means that needs are defined by the pre-defined cost.

Medicaid block grants are not a new idea, as this 2005 Milbank Quarterly article explains. They are in fact a recurrent bad dream of Republican plots to tear up any social contract that includes caring about the well-being of poor people. And as the article explains, the only benefit they produce from a health policy point of view is creating predictability of federal spending; they would cause people to lose coverage and they would decrease the value of coverage. It's no exaggeration to say: over time, the block grant strategy will start killing people, and if left unchecked, will kill at a faster and faster rate as it evolves into progressive funding cuts.

Republican block grant promoters will say otherwise, but block grants are almost always a way to cut spending and ultimately, the value of programs. "[T]he most predictable result of merging social programs into broad block grants is substantial erosion in funding over time, with negative consequences for efforts to assist people in need," explains a recent think tank analysis.

Which is why, if you care about the well-being of poor people, there is only one kind of block you can support: the city block.

Tell 'em, Becky G:

That's Inglewood she's showing off; it has about a quarter of its people living in poverty. Obamacare's Medicaid expansion covers people up to 133% of the federal poverty level, so that includes a lot of folks in Inglewood.

So when you hear the phrase "block grant", think of Becky on the Block; and keep thinking of Inglewood: not only are there a lot of Medicaid recipients there, but California would be especially hard-hit by the block grant strategy.



#notmyAMA again: Dr. Tom Price, greedy tosser

If a general internist like myself were asked why I never pay up on those "dues payments" envelopes the American Medical Association is always sending to my house (Dear doctors: I have never in my life belonged to the AMA, and I don't owe any freakin dues!), I might say, off-handedly: 

 "I mean, some large part of the AMA is like, a bunch of cranky old orthopedic surgeons crying about how they hate Medicare."

 Prior to recent events, I could generally admit that is probably a primary-care-righteous parody of a more complex reality. (I mean, JAMA is a pretty decent journal, right?) But now like so much in politics these days, the AMA has just responded with an endorsement: "Yes! We will take your simplistic caricature of us and double down on it! Dr. Tom Price is exactly your exaggerated parody of our point of view and we super-duper endorse him!" 

And yeah, I know a lot of the professional organizations are sending congratulatory messages because a) it could've been worse and b) they want to kiss the ring of the man who will hold the money bags; and on that level it's not about ideology. It's just business.

 And that's the problems. I mean, let's leave aside the fact that guys like Tom Price do blustery conservative things like hate gay people and want to ban abortion and on and on. I mean, that stuff is awful and a sign of lots of bad things to come, but it may not be how Tom Price will actually harm the most people.  

 The reason he might be most dangerous is why the AMA is actually excited about him: they describe him as "a leader in the development of health policies to advance patient choice and market-based solutions". That means, quietly but surely dismantling Medicare and Medicaid. Among other things, one of his pet causes is allowing doctors to charge fees above Medicare reimbursements. For people who do one-time procedures, like orthopedic surgeons, they can collect relatively nominal fees relative to their income, and still filter out the impoverished and disabled. And if they collect larger fees, even fees accessible to middle-class people, then, they can make some more serious cash money. (Charging, say, an extra $500 bucks per procedure, when a full time orthopedic surgeon does ~30 procedures a month, is going to be within most people's reach given the stakes of having a surgeon you trust--who in turn would earn a decent chunk of change.)

 You can also predict an incoherent emphasis on "responsibility" and "empowerment" and "choice" in opaque policies that hurt the most impoverished and benefit insurers and doctors and hospitals. If you look at Indiana's Medicaid expansion--where poor people are penalized for not paying small premiums, costs don't decrease, and doctors get paid more--you might get a sense of how this is going to go just based on regulatory choices, without even having to pass legislation. (Look here at the difference between HIP Plus and HIP Basic; or here and here.) Of note: the architect of Indiana's Medicaid expansion is now going to be the director of the Centers for Medicare and Medicaid Services. 

 The good news is that Republican congresspeople are already starting to back away from Medicare privatization like it's radioactive poop in the pool. The bad news? They won't have any such hesitation on Medicaid block grants and other punish-the-poor tactics.


 Mu-receptor mixtape track of the day: a throwback 2011 health policy rap from the UK, taking a stand against conservative plans for the National Health Service:




(edited slightly Dec 10)









Pursuit of happiness.




This is from 2009: Kid Cudi, who like many great people from Cleveland, got outta Cleveland; and a song (featuring a bit of get-in-your-sacral-spine synth grind from Ratatat and MGMT) called "Pursuit of Happiness." I missed this song until recently, which I'm going to blame on the fact that I was a medical resident at the time.

If you don't watch the whole thing you might miss the ambivalence.

There's a Steve Aoki remix which subtracts most of what Ratatat and MGMT did, and adds a big techno festival sound, like the kind of thing where you're waiting for the DJ to go, "Whassup Helsinkiiiiiiiiii!!!" (beat drop, pause, four-on-the-floor beat with ascending synth air raid siren sound, etc)--which seems to be trying to take the ambivalence away and make it into a straight-up party anthem. But unlike "We Found Love" the lyrics between the chorus really count:

I'm on the pursuit of happiness and I know
Everything that's shine ain't always gonna be gold (hey)
I'll be fine once I get it, get it in, I'll be good
Tell me what you know about dreamin' (dreamin')
You ain't really know bout nothin' (nothin')
Tell me what you know about the night terrors every night
5 A-M cold sweats, waking up to the sky
Tell me what you know about dreams (dreams)
Tell me what you know about night terrors nothin'
You don't really care about the trials of tomorrow
Rather lay awake in the bed full of sorrow

Night terrors don't just go away. As of this posting, Kid Cudi is in an inpatient rehab stay struggling with depression, which he's often talked about in the past. Best wishes to Kid Cudi.