Health Care and Patient Dignity

So let’s say you are having a medical crisis. Maybe you were hit by a car, or one of your organs are failing, or you suffered a ruptured cranial aneurysm.

The last thing you will be thinking is “how are these doctors and nurses getting paid?”

Trust me.

Of course doctors and nurses must be compensated for their time and expertise. I can’t imagine anyone thinking otherwise.

The issue is that the dying (or potentially dying) patient is not the person who is in the right frame of mind to consider the welfare of the on-duty medical staff.

As I have mentioned previously, Americans are deeply conflicted over who pays for health care. Why this is, is a tangled mess of politics, ideology, and the degree to which one believes in capitalism.

In today’s Washington Post, the art and architecture critic Philip Kennicott has a piece that asks legitimate questions about form, function, and the element of human dignity in health care.

And to that end, he says that certain aspects of our health care system are rendered more daunting than they ought to be by the “inequities in health care, the industrialization of the process and the capitalist mentality that has made what should be a human right merely a consumer service.”

It’s that last bit that gets me.

Free market capitalism relies on people being in the right frame of mind to make choices between competing options. When you are potentially dying, your “right frame of mind” goes out the window.

So how it is that capitalists want us to rely on market economics for health care is, for me, unexplained.

Removing the market from the equation seems like the better option. If you disagree, I’m open to comments.

More Thoughts on Iron John and Misguided Men

I opened my newspaper today to find that the poet Robert Bly has died.

A few months ago, I wrote a post about what is probably Bly’s most famous prose work, Iron John, and how it has weirdly, in my view, been co-opted by conspiracy-believing Trump supporters.

Bottom line is that I felt that these Trump-worshippers were reading something into Iron John that wasn’t there, and wasn’t intended to be there. In other words, it’s my feeling that they have somehow taken their conclusions about how the world ought to be and fit Iron John into that framework, all the while saying that it was the book that somehow launched them down this path toward undying devotion to Trump.

Turns out, I am right. The obituary published in the Washington Post includes the views of Robert Bly himself on the book’s reception:

“I think the men’s seminars were not threatening to the women’s movement at all,” he insisted, often emphasizing that his purpose was in no way to return to chauvinistic or misogynistic models of the past. “A lot of the critics of Iron John missed the point.”

Apparently, a lot of fans of Iron John missed the point too.

Photo: Nic McPhee/Wikimedia

Unfortunately, art and literature do take on lives of their own beyond the control of the artist or author. I’d like to believe that Iron John will not become some kind of bible for this bizarre subculture of American male, but only time will tell.

Sherry Is Indeed a Drink

Back in the late 1980s, I was out on the town with college friends. We stopped at a bar/restaurant for some drinks and a bite to eat. My friends ordered beer or mixed drinks. I ordered sherry.

I pause this story to note that sherry–real sherry, made in Sherry/Jerez/Xeres, Spain–has a not insignificant global market. If you add the sherry copycats, such as Taylor Wine Company, the business is even larger.

When I ordered the sherry, the server was momentarily speechless. As if I was speaking in a language they did not understand. As if I had asked to take them outside for a quick bam-a-lamma before we got our drinks.

The flummoxed server said, “What, you mean like cooking sherry?”

A reasonably priced sherry, thus one of my favorites. (Photo: unknown)

I pause the story to say that cooking sherry is an abomination created by a misanthrope who wants all people to be miserable. It is some sherry-like substance adulterated with so much salt that if one were to drink it, one would swear off the stuff for eternity.

I said, “No, like sherry. You know, the drink?” I wasn’t sure I was getting through.

The server had to excuse themselves and disappear for a bit, I guess to find out if sherry is actually a thing.

Sherry is indeed a thing. It is the product of a complex process that involves old wine, new wine, distilled wine, and a fermentation and oxidation process that brings out complex flavors rarely found elsewhere. And the good stuff is made exclusively in Spain.

Somewhere along the line, sherry obtained a reputation, and not a good one. It was what old ladies drink. And not just any old lady. Rather, the old lady who claims to never drink but somehow has a (large) glass of sherry every night. Thus, hypocritical, sanctimonious old ladies.

(Hypocritical, sanctimonious old men, I guess, are supposed to drink scotch.)

I wish I knew where this reputation came from because it is undeserved. Sherry has several forms, from very sweet to bone dry. My favorite style is medium amontillado (yes, that amontillado, of the Edgar Allen Poe fame – something one would die for, yes?).

Back to my friends in the restaurant: the server eventually returned and served me a glass of something. It was not cooking sherry because it was drinkable. But I have to wonder: if sherry was not something that this establishment normally served–judging by the server’s blank reaction– where did it come from? Did someone run out an buy a bottle just because of me? I was not shown the bottle it came from, so I will never know for sure.

Undeterred, I continue to have sherry in my repertoire to this day. But I do wonder about the server. Are they still pondering over what sherry is? Or have they come to accept that it is a legitimate, non-stodgy staple of any well-stocked bar?

Today My Sister Would Have Been 60

Cecilie and me in November 2008. I think this is a pretty good picture.

Today would have been my sister’s 60th birthday.

Twelve years ago, Cecilie died from cancer, so she didn’t make it to 60. Not even to 50.

She was, you might say, difficult to know. She had undiagnosed behavioral issues. My brother and other sister think it was probably something on the autism spectrum, but my parents never sought to have an official assessment. I don’t know why.

Cecilie lived in Fremont, California, when she finally was functional enough to live on her own. She liked to travel and went to many places, including visiting me on occasion.

One time, I was waiting to pick her up at the Baltimore airport and decided to buy a copy of Khaled Hosseini’s novel, The Kite Runner. I didn’t read it right away.

In fact, I am only just now reading it. A significant portion of the story takes place within the Afghan community in Fremont. I had no idea.

On what may have been the last time I visited her–about two months before she died–Cecilie suggested we go to the pool at her apartment building. She didn’t swim, but she liked pools. She sat by the pool while I swam a few laps. It was one of those sunny, dry days you get in Fremont, California, with the water cool but the sun warm.

It’s a good memory.

My Experience with Applying for Medicaid Was Awful

Medicaid was created in 1965 by an act of Congress to create a health care insurance system for those who do not have sufficient means to pay for medical care themselves.

The law says that Medicaid is to furnish medical assistance on behalf of various individuals, including families with dependent children and elderly people, whose income and resources are insufficient to meet the costs of necessary medical services.

Instead what we have today is a mind-numbingly complex state-run bureaucratic system that creates barriers to fulfilling its own mission, as I learned first hand over the past year and a half.

Full disclosure: I was applying to Medicaid on behalf of, not myself, but my mother. In November 2017, my mother became disabled by a stroke. At the time she was living in a retirement community in California and had care available to her. She also is enrolled in Medicare, the federal health insurance program for all people over 65 years old.

But Medicare has limits to what it will pay for. Specifically, if someone needs medical care for a condition that lasts more than 100 days, Medicare won’t pay for it.

The stroke my mother had left her dependent on a wheelchair, unable to get into and out of the wheelchair without assistance due to a paralyzed left arm and leg, and with aphasia (or maybe dys­phasia) that disrupts her verbal speech. She now lives in the nursing home section of the retirement community. The cost of her care ate through her remaining assets in a short amount of time, leaving her bankrupt.

Medi-Cal’s cheery promotional material hides the grim reality.

At that time, the family was advised the apply for Medicaid. (The California version of Medicaid is called Medi-Cal, but I will use the term “Medicaid” throughout this piece unless the context warrants otherwise.)

Here is what we learned:

Applying for Medicaid is not easy. The State of California gives the impression that applying for Medicaid is not complicated. Perhaps it’s a bit like enrolling in school: there are some forms to fill out but it’s mostly a matter of getting the right information together. “There is no wrong door when applying for health coverage in California,” the state tells you.

In reality, applying for Medicaid is time consuming, opaque, and frustrating. So much so that there are people/organizations that serve as an advocate on one’s behalf to ensure that you get the benefits you are entitled to receive. In California, Medi-Cal’s website includes information about Enrollment Centers and Certified Enrollers that, presumably, help individuals through the process. I applied online–an option that the state implies is no better or no worse than the other options. However, the director of accounting at my mother’s nursing home said at the time that “most don’t apply that way.”

That should have been a red flag. One elder law firm says that for someone living in a nursing home who needs to apply for Medicaid, “submitting an application for nursing home benefits without an attorney’s help is not a good idea.”

Health care in retirement is expensive and insurance coverage is not guaranteed. According to at least one source, “Seven out of ten couples reaching 65 can expect at least one partner to use a nursing home. The average cost of a nursing home can range from $8,800 to $25,000 [per month] without Medi-Cal Benefits.” As noted above, Medicare does not cover care that lasts longer than 100 days (long-term care). With my mother, her health care costs have averaged about $12,500 per month. She’s at reasonably decent but not overly luxurious nursing home. In California, the statewide average cost is about $9,000 per month, or about $110,000 per year if you are paying out of pocket, which is twice the cost of paying full price to attend Harvard. And this is the average cost that would pay for average care.

Medicaid does not have an incentive to act quickly. According to the state of California, the time between a completed Medicaid application and the beginning of benefits is “normally” 45 days. However, I applied on Mom’s behalf in March 2020. It was not until August of 2021 that she was approved. Way beyond 45 days. Thankfully my mother is somewhere where her care continued while the application was pending and after nearly a year of waiting, the nursing home hired lawyers to help. I feel sorry for people who are in urgent need to receive Medicaid benefits, as the waiting must create an extreme hardship for them, and they’re unlikely to be able to afford lawyers.

Remember, Medicaid programs exist for the precise purpose of providing a way for people of low or no income to pay for necessary health care. To not deliver that looks to me like a failure to achieve the mission.

Applying for Medicaid is a Byzantine process: As I discuss further below, Medicaid has many barriers built in because the lawmakers who created or amend the laws and the bureaucrats who implement the Medicaid programs are very suspicious. Granted there is a significant amount of waste and fraud in Medicaid, but it seems that the systems put in place to try to address that only end up hurting the people who legitimately need the resources.

In my mother’s case, her paralysis and her inability to verbally communicate meant that she could not apply for Medicaid herself and I, holding power of attorney for her, was the one who did it for her. I live in Maryland and submitted the application online (no wrong door, remember?). I was subsequently told that one gets better results if one engages directly with the county human services agency, as in making an appointment and showing up in person. Of course, that is prohibitively difficult for someone like me who does not live in the county. Not to mention that there is a global infectious disease pandemic going on this whole time.

I received some items in the mail acknowledging the application and saying it would be referred to the county human services agency — a bad sign I now realize. One of the documents said this: “The Medi-Cal office in your county will contact you if they need more information.” Again, according to California, a county social services office may be in contact by mail or by phone to request paper verification if income, citizenship, and other criteria cannot be verified electronically. If that contact happened, it wasn’t with me. Frankly, I’m baffled about who they contacted, if anyone.

Shortly after that, I have received a “notice of action” letter from Medi-Cal, and it was to deny benefits because I failed to submit additional documentation that was never requested by them. It feels like I was set up to fail because they counted on the fact that I was out-of-state and therefore could not deal with the situation in person. The application I submitted was under suspicion from the beginning, and it took lawyers to break the logjam.

The bottom line for me is this: Americans are deeply conflicted over who pays for health care. While some modern democracies have implemented (successfully) a national health care system, America continues to have a slap-dash, jury-rigged system, filled with suspicion and political maneuvering.

This is at least in part because a significant number of Americans feel that one must earn or be deserving of health insurance, rather than it being a right that all citizens and noncitizen residents should have. Hence, people receiving Medicaid are receiving “entitlements” and “handouts* rather than simply receiving health care. This ambivalence, along with much hand-wringing over controlling costs, creates a system filled with empty promises.

As the elder care law firm says, “Congress does not want you to move into a nursing home on Monday, give all your money to your children (or whomever) on Tuesday, and qualify for Medicaid on Wednesday.” But what is so wrong with that? Where is the harm in that? I think this setup has little to do with any material reasons and everything to do with philosophical and political belief.

*Quotes from the report linked to: “However, the real problem in welfare is neither an accounting issue (how poverty is measured) nor bureaucratic inefficiency but the moral hazard of existing welfare programs’ tendency to discourage self-support through work and marriage.” And Medicaid and other assistance to low-income individuals are “a massive system of ever-increasing welfare handouts distributed to an ever-enlarging population of beneficiaries.”