Conjoined

October 2, 2011

This image has been posted with express written permission. This cartoon was originally published at Town Hall.

Columbia Journalism Review:

Jim Bean is just the sort of person Social Security is intended to help. He is also the sort of person at whom the controversial recommendations from the co-chairs of the president’s deficit commission take direct aim. For Bean, now age fifty, waiting until sixty-seven to retire will be a stretch—let alone sixty-eight or sixty-nine, which might become the new retirement ages if deficit commission co-chairs Alan Simpson and Erskine Bowles have their way. Bean is a rigger—the person who climbs up to the ceiling in theaters and entertainment centers to hang the lights and the sound equipment, and do whatever else is needed to make a production work. He currently operates the spotlights.

“It’s an inherently dangerous thing to work 100 feet in the air,” he says. “Eventually I’m not going to be doing rigging. There will be a time by the time I am sixty that I won’t want to do it.” Or, if something goes wrong, he may not be able to do it. Given his work history, an early benefit from Social Security when he is sixty-two will be low, although he didn’t know how much it would be. If the retirement age is raised and the early retirement age does not go up as well, his early retirement benefit could be verylow, a point that has not been discussed up to now. The Simpson-Bowles proposal suggests a hardship exemption for people who must take their benefits at age sixty-two. Who knows whether Bean would fall into that category?

Bean, a wiry man with lots of tattoos, says he likes his job, but it’s not full-time employment. When classes are in session at the University of Illinois, he works at the Krannert Center for the Performing Arts. He is busy when there are performances. But in his business there are dry spells, although when he works the hourly pay is good. Sometimes he can make $28.50 an hour, or as much as $32 if he gets jobs in places like St. Louis. “I don’t see my income rising above $20,000,” Bean told me. “I’m not in the local (union) and do miss out on some jobs.”

We talked about Social Security disability benefits, which he had heard of but didn’t understand. “Riggers don’t carry insurance,” he said. “In our job people don’t get hurt, they die. You know that when you go up.” Between jobs as a rigger, he works as a musician. He’s a lead singer in one band and plays guitar in another. He says he lives very frugally in a tiny apartment in Champaign and helps his daughters, ages twenty-two and twenty, when he has extra money. “My oldest daughter got straight As in junior college and is now attending the University of Illinois with financial aid,” he said. “That girl has done a lot and has as much support as I can give. She has done real well.”

Our conversation got around to health insurance and health care. It turned out that Bean had had lots of interaction with the health care system. His predicament was featured inThe Wall Street Journal seven years ago, as part of a piece about the aggressive collection tactics of Champaign’s Carle Foundation Hospital. Bean was uninsured, as he is now, and attempted suicide. He said he blew a hole in his shoulder that required three surgeries at Carle Hospital in 1991, when he was despondent over the break-up of his marriage. Bills piled up, and the hospital sued him. He missed some court dates and hospital lawyers got a warrant for his arrest—a body attachment, the Journal called it. He briefly landed in jail until his brother bailed him out. When the story was published, Bean was making payments to the hospital, which had agreed to drop the interest charges on the bill. His current health plan, he says, is not to get sick…

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City Journal:

In the chill of an Afghan evening during the summer of 2001, Osama bin Laden sat chatting beside a campfire at his mountain base with Bashiruddin Mahmood, a Pakistani engineer. The subject, according to a former chief of intelligence for the U.S. Department of Energy, was how Mahmood, who had run Pakistan’s plutonium-production reactor and headed its atomic-energy agency until Islamabad fired him in 1999 for his radical beliefs, could help al-Qaida build a nuclear weapon. The problem, Mahmood said, was not designing or building such a weapon, but obtaining the necessary fissile material. Bin Laden’s chilling response inspired fears among intelligence agencies that persist to this day: “What if I already have it?”

Within a month, al-Qaida would launch the most devastating attack on America since World War II—an unconventional strike using the most conventional of weapons, commercial jet aircraft, as weapons of mass destruction. But since then, nuclear experts, intelligence analysts, and Republican and Democratic politicians alike have cited the possibility that bin Laden or a like-minded terrorist might secure a nuclear weapon as the preeminent threat to our nation. Echoing the theme at his Nuclear Security Summit, the largest American-hosted gathering of leaders since the founding of the United Nations, President Obama called nuclear terrorism “the single biggest threat to U.S. security, . . . short-term, medium-term, and long-term.”

Experts warn that the proliferation of nuclear material and expertise has put the world at the brink of what Paul Bracken, a professor at Yale’s School of Management, has called a “second nuclear age.” Graham Allison, a former Pentagon official now at Harvard, says that, absent an abrupt change of course, a nuclear terrorist attack on America in the coming decade “is more likely than not.” Billionaire investor Warren Buffett, experienced at assessing risk, has called an atomic attack on the U.S. by mid-century “virtually a certainty.” Even the publishers of the prestigiousBulletin of Atomic Scientists, keepers of the “Doomsday Clock,” have chimed in. The Clock’s first setting, in 1947, was seven minutes to “midnight,” which signified global nuclear war; today, the Clock stands at six minutes to midnight.

Are the fears of Armageddon justified? Only if Washington fails to continue the extraordinary progress that Republican and Democratic administrations have made to complicate terrorists’ ability to acquire nuclear devices. Despite the continuing spread of nuclear expertise and efforts by Iran to become a nuclear power, the battle to limit the spread of destructive weapons and fissile material has been hugely successful—so far, at least—and Americans are safer from a nuclear strike today than when the Berlin Wall fell.

One of the nation’s most important moves to prevent nuclear terrorism has been reducing the number of nuclear weapons that terrorists or rogue states might buy or steal. Since the end of the Cold War, the United States has cut its nuclear arsenal by 80 percent. Though American nukes are so well guarded that terrorists would be unlikely to steal them, the great advantage of reducing our own stockpiles is that it has led Russia to follow suit.

And Russian weapons—and the fissile material that fuels them—were far less secure, at least until recently. At its peak, the Soviet Union’s arsenal may have totaled more than 45,000 nuclear weapons, with hundreds of tons of plutonium and highly enriched uranium stored at dozens of facilities across 11 time zones. But when the USSR collapsed, security for its nuclear weapons collapsed, too. When American experts first arrived at Russian nuclear sites in the early 1990s, they found fallen fences, decrepit buildings, and broken morale. Young, underpaid, ill-trained, bored, and often drunk, Russian guards were said routinely to ignore the “two-man rule,” which forbids single individuals from accessing fissile material and is intended to prevent a lone thief from stealing it. At one nuclear-material storage facility, according to a Russian general’s published account, “a resourceful conscript, who was serving without ammunition, was asked what he would do if he saw 5–6 unknown persons with assault rifles approaching from a wooded area. He vowed to . . . ‘defend my post with a bayonet!’”…

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Miller-McCune:

It’s not what you want; it’s where you go. Dartmouth study finds cancer patients’ end-of-life care is determined by their hospital, not their hopes.

For many older Americans with advanced and incurable cancer, where and how they die — at home with their family or sedated in an ICU with a tube down their throat — may not be based on their final preferences and wishes, but on customs, care patterns, and even the financial incentives and number of beds in the hospital they and their loved ones entrusted with their care.

That’s the conclusion of a new addition to the Dartmouth Atlas, a compendium of 20 years of research on how health care usage and practices vary tremendously from one place to another.

“The bottom line is the care patients receive has less to do with what they want and more with the hospital they happen to seek care from,” said Dr. David Goodman, lead author of the Dartmouth Atlas Project and director of Dartmouth’s Center for Health Policy Research. The study found “no consistent pattern of care or evidence that treatment patterns follow patient preferences, even among the nation’s leading academic medical centers.”

Overall 1 in 3 of these patients died in the hospital, sometimes in the ICU and sometimes on life support, but there was significant variation from one region or even one hospital to another. Six percent of the patients received chemotherapy in the last two weeks of life, but in some regions and academic medical centers the rate went above 10 percent. Half got hospice but often for just a few days, too little for them and their families to fully benefit from the medical and psychosocial assistance and comfort hospice can offer.

In addition to that wide variation, the overall message was that these very sick patients — elderly patients with advanced cancers nearing the end of their lives — are getting lots of aggressive care. Given the risk of infections and complications when frail people undergo invasive inpatient procedures, this aggressive care often does not help them and may even harm them, noted Rosemary Gibson, a health care consultant who has worked extensively on end-of-life and health care quality.

“We still don’t know when to stop,” said Gibson, who read the Dartmouth report but is not part of that research team.

Goodman said the Dartmouth data was adjusted to take socioeconomic aspects of a hospital population and location into account (although some health researchers have, in the past, faulted the Dartmouth methodology). The researchers also focused on patients who have a fairly predictable poor prognosis — patients with such diseases as advanced lung or pancreatic cancer. They looked at records of more than 235,000 Medicare patients who died from 2003 to 2007.

Some of the wide variation occurred in places that have cropped up in previous reports documenting treatment disparities. Nearly 7 out of 10 of these patients were hospitalized in their last month of life in McAllen, Texas — the community depicted as a profligate health care spender in Atul Gawande’s New Yorker article that influenced the national health reform.

But in La Crosse, Wis., which has achieved national renown as a community where the medical culture emphasizes advanced planning and thoughtful conversations with patients and families, fewer than half were admitted in that final month.

That may not be a surprise; similar patterns have been identified before. But what can be quite startling is the variation between hospitals so near each other. At Lenox Hill Hospital on New York’s Upper East Side, half of the older advanced cancer patients died in the hospital. But within walking distance on the Upper East Side, at Memorial Sloan-Kettering, the rate was 1 in 3.

And Sloan-Kettering is one of those magnets that draw people from afar in hope of a miracle. The same is true of Johns Hopkins — another center known for leading-edge cancer care that still has a fairly low rate of hospital use for the dying. And Hopkins is in Baltimore, socioeconomically a far cry from the Upper East Side.

People don’t seek care at Hopkins or Sloan-Kettering to die. They go in hopes of a cure. But when a cure isn’t possible, Goodman noted, “part of the very best care in cancer is also care for comfort.” And that includes open conversations about the likely course of the disease, a patient’s options, choices and wishes.

“We understand those conversations are difficult for physicians,” said Jon Radulovic, a vice president at the National Hospice and Palliative Care Organization. But patients and families may already know in their heart what the doctors are reluctant to say; they know when their chemo is failing, when options are running out. “[Patients] might not be as surprised as many physicians think they may be.” And they may be grateful for a chance to talk about their wishes, fears and concerns.

The reasons for the wide variation in hospitalization and hospice patterns aren’t always clear. It can be the local business model and bed supply of a hospital with a pricy cancer center. It can derive from the way Medicare pays hospitals; they get a lot more for chemo and CPR than they do for palliative care and conversations.

And it can be local practice patterns. One group of doctors learns to practice in a certain way, and they pass that on to their colleagues, institutionalizing it over the years. There’s not necessarily any solid evidence to prove that one group of physicians’ approach is better than another — one reason the federal government has increased its investment in comparative effectiveness research both through the 2008 economic stimulus law and health reform.

In addition, some communities have more hospice and palliative care available than others. And to make it even more confounding, a couple of hospitals with nationally recognized palliative care teams still had a lot of patients in the hospital shortly before or at the time of death…

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Dancing With The Starving

October 2, 2011

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Capital Punishment

October 2, 2011

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