Is Health Care Too Expensive?

I recently spent 36 hours at Passavant Area Hospital. A bad stomach pain, which I first attributed to eating too much clam dip while watching the Super Bowl, got much worse, so I arrived at the emergency ward at 1:30 AM looking for help. A day and a half later, my stomach pain was gone. I had received professional care from warm, friendly people, who restored my health and revived my spirits. I also had a bill for $12,074.

That’s a lot of money. Median household income of Americans after taxes is less than $50,000. So my $12,000 bill for a common stomach bug would be a financial disaster for anyone without good health insurance.

I admit that I don’t know how to think about the cost of my brief hospital stay. Was that too much? Or a bargain?

Here’s what I got. In the emergency room, I saw an intake receptionist, two doctors and four nurses. Once I was transferred to a semi-private room, I saw three RN’s, two CNA’s, a nursing student, a dietician, an X-ray technician, a room cleaner, a chaplain, and my own family doctor. Also contributing to my successful stay were security personnel, food service workers, a billing department, and various administrators. The president of the hospital came into my room to ask that I fill out a survey, so they could find out what might be done better.

A portable X-ray machine was wheeled into my ER cubicle to see what was wrong. Later I had blood tests and a CAT scan, which were analyzed almost immediately, allowing the doctors to diagnose me quickly and correctly. Then I received an IV of antibiotics and fluids, which cured my bug and kept me functioning.

The technology was expensive. The CAT scan alone cost $5300, nearly half the total bill. The blood tests added another $1500. My room was billed at $1400 a day.

Hidden in those prices are the costs of all those people who cared for me. About 60% of total hospital costs nationwide are for people. I asked what everybody made at Passavant. The CNA’s make $10 to $15 an hour, which comes to $20,000 to $30,000 a year. RN’s make $50,000 or more. The ER doctors earn about $200,000 a year, family practice doctors up to $400,000, and surgeons (fortunately I didn’t have to see any of them) upwards of $600,000.

To most people, I would guess, doctors’ incomes seem enormous. Perhaps the huge gap between what doctors and nurses earn should be disturbing. In terms of caring for me, the whole patient, beyond my particular ailments, nurses tend to do much better than doctors.

But my doctors have been successful, so far, in keeping me healthy, and after my one serious injury as a teenaged touch football player, in keeping me alive. Who could say that surgeons make too much money, when professional athletes and stock brokers and bankers and corporate managers make many times more? Average compensation for CEOs at the 3000 companies in the Russell index was $5.8 million. Doctors’ compensation is not too high – nurses’ is too low, compared to the importance of their work.

Those are my subjective reactions to the financial side of our health care system. I’m glad that I have a good health insurance plan and that my employer pays part of that cost. I can’t say that any of the care I received was unnecessary or too expensive. I think every American deserves that same quality of care.

Most people have an opinion about our health care system and its costs, but most people don’t know any more than I do. In fact, wrong ideas about the Affordable Care Act (“Obamacare”) are responsible for most of the opposition to it.

About 40% of Americans still believe in “death panels” of bureaucrats deciding whether patients get treatment, a nightmare invented by Republican politicians trying to defeat the ACA. More than half believe the law requires free treatment of illegal immigrants. More than one-third believe smokers will have to pay $1000 extra a year. These incorrect beliefs about unpopular ideas promote opposition.

On the other side, many people are sure that very popular provisions of the law are not in it: 20% don’t realize that children under 26 can be included under their parents’ insurance; nearly 30% don’t realize that insurance companies will have to cover people with preexisting conditions; and 40% don’t realize that insurance companies will be prevented from limiting the total amount paid for a person’s health care.

No wonder opposition to “Obamacare” hovers near 40%. Here’s what the researchers who conducted this survey said about the connection between correct knowledge and support: “If the public had perfect understanding of the elements that we examined, the proportion of Americans who favor the bill might increase from the current level of 32% to 70%”.

Politicians could help us have that perfect understanding, so we could make good decisions about what system we would prefer. They don’t, and they won’t until we demand that they do.

Steve Hochstadt

Jacksonville IL

Published in the Jacksonville Journal-Courier, February 26, 2013

Seeking True Representation

This may be the first time you hear about the latest news in Jacksonville’s electoral politics. It’s Sunday as I write this, and I haven’t seen any reports yet about the public meeting on Friday organized by our local citizens to promote ward-based voting for the Jacksonville School Board. I attended because I support this proposal enthusiastically.

The issue is simple. All members of the School Board are currently elected at large. Every winner must get a majority of votes coming from the whole city, including South Jacksonville and Murrayville. That means an expensive media campaign, rather than a door-to-door campaign. The result is that the northeastern part of Jacksonville has rarely been represented on the Board, because few people who live there could afford such a campaign. Board members, in the past and now, overwhelmingly come from the wealthier parts of town. When the Board voted to close the Franklin Elementary School, nobody represented the part of town served by that school. The Board recently decided to eliminate 5th grade band except in the Eisenhower Elementary School.

Ward-based elections for School Board members would insure that each part of the city is represented. Campaigns in single wards are much cheaper to run, and elections would be determined by candidates who know each ward. School Board decisions would benefit from the input of members who represent every part of the city, not just the better-off sections.

Make no mistake, this is a racial issue. Local leaders of the NAACP, whose activities rarely make the local news, have been supportive from the beginning of this campaign. The two African American women who gave enthusiastic, even inspiring keynotes, Doris Turner from Springfield and Jeanette Norman from Decatur, described how at-large systems disadvantage African Americans, other minorities, and anyone who is poor.

Turner, who serves on the Springfield city council, explained that no African Americans served on the city council until elections shifted from at-large to ward-based. Suddenly Springfield’s economic, ethnic and geographical diversity was better represented. More parents began to participate in the education of their children. a better voting system led to broader public engagement in the local schools.

Our federal elections show exactly how having bigger districts means lower minority representation. In the 112th Congress, which just ended, there were 2 Hispanic Senators, 2 Asian Senators, and no African American Senators, exactly 4%, elected at-large in every state. The House of Representatives, whose districts within a state are just like wards in a city, included 44 African Americans, 25 Hispanics, 7 Asians, and one Native American, 18% of the total.

Higher costs of running in larger districts mean that personal wealth is more important in at-large elections. There are only 33 Senators who claimed to be worth less than $1 million (one-third of the total), while 250 House members (58% of the total) managed to win election without being millionaires.

Here is something about this campaign that is unusual. It is the furthest thing from partisan. Friday’s meeting brought together your conservative and liberal neighbors, including political activists, because of the wide agreement that ward-based voting is the superior method for our town. I asked Richard Brahler, with whom I disagree on many issues, why he was supporting ward-based voting. He asked me, “Aren’t we all for the same thing? The best education for our children?” What is there to disagree about?

He was under no illusion that electing one School Committee member in each city ward, beginning in 2015, would revolutionize our schools. Emily Ralph, the political inspiration of this campaign, has always been clear that giving people better representation would not create excellent schools overnight. It is one step toward bringing the whole community into the schools and having the school system’s managers represent the whole community.

But it’s a big step. The campaign is already uniting disparate parts of Jacksonville behind the desire for fuller representation, for more fairness, for more community involvement in the schools. Let’s keep going.

Steve Hochstadt
Jacksonville IL
published in the Jacksonville Journal-Courier, February 19, 2013

Looking for Reason in the Middle

In the never-ending debate between liberals and conservatives over political issues, both sides present their positions forcefully. But not always reasonably. The extreme versions of proposals get in the way of finding the middle ground which is necessary for actually creating good policy. Only compromise between reasonable positions will satisfy the majority of Americans, who find themselves in the middle of the political spectrum.

So let’s think about the Boy Scouts. After many years of insisting that boys who are gay could not be Scouts, the national organization is now reconsidering. Many troops are organized by churches who do not tolerate homosexuality among their members, so vocal opposition has arisen to any change in Scouting policy. I personally find any discrimination against homosexuals offensive, just as if church-led organizations said that they were not open to Jews, who commit a sin against their doctrines by not believing in the divinity of Jesus.

But it is unreasonable to demand that every Scouting organization be opened now to homosexual boys and leaders. If a church wishes to exclude homosexuals from membership or leadership positions at this time, I would accept that.

I also believe it is unreasonable to demand that no Boy Scout unit can accept homosexuals, which is the position advocated by many people today. That demand reflects the religious doctrine of some, but not all Christians. Thus it insists that the Boy Scouts officially retain a particular religious ideology of exclusion.

How can I call that position “unreasonable”? Who says what’s unreasonable?

In the 1940s, when I was born, the demand that homosexuals should be able to enjoy the same marriage rights and privileges as heterosexuals was thought by most people to be unreasonable. It certainly was unusual.

Reason has changed. We have learned a great deal about homosexuality in my lifetime. We have heard the revelations about Nazi persecution and mass murder of homosexuals, and we have read about the physical abuse and sometimes murder of homosexuals in America. We know more about how socially stigmatizing a group makes it easier to believe myths about them, and we understand more about the biological causes of homosexuality and other behaviors that were traditionally thought of as sinful. We recognize how much like heterosexuals homosexuals are and how they are different. We see that our celebrities and leaders, our heroes and heroines, our friends and our relatives are gay.

It is not any more reasonable to discriminate on the basis of sexuality, than it is to discriminate on the basis of gender. Just because there is a long tradition of considering females and gays to be inferior and sinful, just because some of those traditions are religious, does not make that discrimination reasonable.

Until World War II, nearly every Christian tradition considered Jews to be inferior and sinful, preached those values unendingly, and asserted that they came from the word of God. Seeing the genocidal results of those beliefs and learning more about what Jews really are like, nearly every Christian tradition has changed its definition of reasonable. In the Catholic church, the moment when the Pope publicly said that previous Popes were wrong was 50 years ago, in the encyclical “Nostra Aetate”, first written by Cardinal Augustin Bea for Pope John XXIII in 1961, considered by the Second Vatican Council in 1965, passed by the bishops of the world by a vote of 2,221 to 88, and then promulgated by Pope Paul VI.

What Catholics had considered reasonable, even mandatory to believe, had become unreasonable. There continued to be votes and voices against this change, but they were no longer persuasive.

Like the Constitution, the Bible also gets reinterpreted, as human society learns more about itself. Although Deuteronomy demands that a woman who is betrothed and then raped before marriage, and a woman who is not a virgin when she marries, both be stoned to death, now Christians criticize Islam for suggesting that women be stoned. What once was reasonable has become unacceptable.

So why don’t I demand that every barrier to homosexuals, within the Boy Scouts and everywhere else, be immediately dropped? Why is a slower path to equality reasonable?

This is not mainly about changing rules. If the goal is equality, that must be created through persuasion. Those who argue against equality of man and woman, against equality of Christian and Jew, against equality of black and white, have lost the argument and have become unreasonable. That happened by changing people’s minds. I believe this inequality of sexual identity will also succumb to reason. None of these changes have been easy or quick. Those of us who had to fight for our equality have suffered. But suffering won’t be diminished by fixing only on the goal and not on the process.

Allowing individual troops to make their own decisions about homosexual members and leaders will be a big change for the Boy Scouts. Many will leave in a huff, shouting about tradition and morality. They will become the unreasonable ones, because the best human society has not only reached reasonable moral positions, but also is reasonable in how it gets there.

Steve Hochstadt
Jacksonville IL
published in the Jacksonville Journal-Courier, February 12, 2013

Putting Movies to the Test

We saw a nice movie the other day – “Silver Linings Playbook”. The people on the screen were attractive, sympathetic and believable. There were no devils or angels, but real people struggling with their past, making the same bad decisions again and again, yet learning from experience how to give and find love.

“Silver Linings Playbook” rivets our attention on Bradley Cooper as the crazy good guy, so thoughtful, so compassionate, despite his obsessive fantasy about why his marriage broke up, occasionally exploding out of his control. As in real life, crazy isn’t so easy to tell from the rest of us. Then crazy good guy meets crazy good girl and off we go on an exciting ride to Happyland. We smiled at the ending, the one designed to tug our heartstrings right into the theater. But that’s not always real life.

It’s not just the happy ending that makes this a fantasy. If you step out of the dark theater back into the real world and think about this film, and all the other films we can see, a big question pops up – where are the women? and what are they doing?

In 1985, one of the dykes in Alison Bechdel’s comic strip “Dykes to Watch Out For” explained to her friend how she rates movies: “I have this rule, see. I only go to a movie if it satisfies three basic requirements. One, it has to have at least two women in it, who, two, talk to each other about, three, something besides a man.”

This Bechdel test is not about feminism, or any political ideas, unless wondering where the women are is being political. It doesn’t matter what the women talk about or think about, as long as it’s not always about some man. Lesbian porn, if there’s any dialog, and alien invasions can both pass the test. Hundreds of great films fail the test and some terrible ones can pass it.

The Bechdel test is just a reality check. Does a film portray life as we know it, where even if women don’t have half the power, they are half of life itself? Or does the film present some imaginary world, where every scene, every action, every conversation, is mostly about men?

The Bechdel test sets a pretty low standard – one conversation, however brief, between any women, even if they are not named characters, gives a pass. One website that allows people to rate movies shows 91 of 155 films from 2012 passing the test. But if you just raise the bar to two different scenes with women talking to each other, many more films fail.

More interesting than finding out if one film passes or fails is to examine the film industry. So let’s look at the Oscar nominees. Of the 9 films nominated for best picture, 2 failed the test. Most of the 7 which passed, however, just barely passed. “Silver Linings Playbook” has one conversation between women. In “Les Miserables” only unnamed female characters conversed. “Lincoln”, “Argo”, and “Zero Dark Thirty” are dominated by male characters, passing the test by one or two brief conversations.

The 5 best actor nominees all starred in films in which they were the main characters. But men were also the main characters in 3 of the 5 of the films nominated for best actress. All the best director nominees were men; only one woman has ever won that Oscar.

Thinking about the Bechdel test, and other measurements of how men and women are portrayed in films, helps us think about Hollywood and which slice of life it shows us. For example, Hollywood often borrows from best sellers, and loves suspense, action, and murder. Murder mysteries still sell millions of copies and offer great, usually flawed protagonists of both sexes. Female sleuths sell as many books as male sleuths: on mysteryguild.com’s list of the top 50 best sellers, 23 have female leads. But when Hollywood chooses which detectives to make into movie heros, it’s nearly always the heros and not the heroines.

It’s fine that films are fantasies – going to the movies means a brief respite from the daily grind. But why must it also be a vacation from women, a male-dominated zone, where films which have women talking to each other are derisively labeled “chick flicks”?

At the end of the strip which defined “The Rule”, the two friends decide to skip the flicks, go home and make popcorn. If more us did that, perhaps Hollywood would get the message that men having fantasies about men is not the slice of life that we all crave.

Steve Hochstadt

Jacksonville IL

published in the Jacksonville Journal-Courier, February 5, 2013

Problems in American Higher Education

American higher education has some big problems. We still have a world-class network of colleges and universities. Students from less developed and from highly developed nations come to the US to get BA’s and advanced degrees. Our teaching practices are copied, our researchers have made English a universal scientific language, and our graduates can compete across the globe.

The hundreds of small colleges scattered across the US represent a unique American contribution to undergraduate education, which is being copied in Europe. Not only has American higher education led the world in the integration of women and minorities into faculties and administration, but American scholars have developed the broadest critique of economic inequality, abuse of political authority, and social discrimination.

Yet in recent decades, three major problems have developed in American universities which threaten the whole system: exorbitant funding of athletics, replacement of full-time faculty with temporary part-time staff, and the growth of for-profit institutions.

Sports as entertainment is beginning to overwhelm the educational enterprise at large universities. Admission is driven by athletic recruiting, professors are paid a fraction of what coaches receive, and ethical transgressions in the name of winning no longer even make headlines. Big-time sports have become a central mission of what used to be fine academic institutions. Can you imagine a sexual scandal in some philosophy department bringing down an entire administration, as Penn State’s scandal in the athletic department did?

If we follow the money, we can see the outsized role of sports at major universities. Among the 120 Football Bowl Subdivision institutions, average yearly spending per athlete in 2010 was $92,000, while spending per student was less than $14,000. That gap has been growing rapidly. In the 240 universities in the FBS and the Football Championship Subdivision, that is most of the large universities across the country, spending per athlete between 2005 and 2010 increased about 50%, while spending per student grew only 23%.

Where does all this money come from? Although television rights and ticket sales bring in millions to a few of the best-known universities, most athletic programs are funded by the institutions themselves, that is, by students, by government grants, and by endowment. Fewer than one in four of the 97 public universities in the FBS make money on their athletic programs. Across the FBS, student fees and institutions contribute an average of 18% of the athletic budget; in the less prestigious FCS, the contribution is 70%, and in those Division I schools with no football, the contribution is 78%.

Most of the professors at American colleges and universities do not really belong to the faculties or to the institutions. They are “contingent employees” or “adjuncts”, usually part-time, with few benefits and little allegiance to the institution. Very often, they are hired at the last minute, so they cannot adequately prepare. They do not receive the same institutional support for their teaching that the traditional full-time tenure-track professor enjoys: office space to meet with students, secretarial help, advanced technology, sometimes even a telephone. They often are unacquainted with other members of their department and thus with departmental practices and expectations. At 4-year institutions across the country, two-thirds of the teaching staff are impermanent, a proportion which is increasing every year.

Adjuncts are woefully underpaid. A new report about adjunct pay in the Chronicle of Higher Education shows an average of less than $1000 per credit-hour. The average salary for untenured assistant professors in 2012 was $66,500. For an adjunct to earn that much they would have to teach 22 three-credit courses in a year.

Many adjuncts are excellent teachers. But the sub-standard conditions under which adjuncts teach in most universities means that students pay the salaries of the tenured professors, but are often taught by part-time gypsies, flying from one job to another, trying to put together a living.

The third problem comes from the boom in for-profit universities, which enroll about one-tenth of students in higher ed. The graduation rate at for-profits is about 30%, less than half of the rate of traditional non-profit institutions. Enormous quantities of federal student loans are going to students at institutions owned by Wall Street companies who will never graduate or pay them back. The loan default rate of their students is twice that of public universities and three times that of private institutions.

Each of these weaknesses in American higher education is connected to money. Universities spend far too much money on athletes and sports. They try to save money by hiring part-time faculty to teach students. Students try to save money by enrolling in for-profit institutions which make money for big corporations by promising more than they can deliver and getting government to pay for it.

There is no cheap way to educate the next generation of scientists, teachers, and business leaders. Education is not a money-maker, and athletics is not education. We are watching the greatest educational system in history slowly fall apart.

Steve Hochstadt

published in the Jacksonville Journal-Courier, January 29, 2013

Should We Worry About the National Debt?

I understand debt. My wife and I have owned two houses, and we took on debt much greater than what we earned in a year. That was scary: the mortgage for our first house in the 1980s was so much bigger than any amount of money I had ever thought about. The payments pushed our budget to the brink. Our children remember lots of pasta dinners just before our monthly salary checks arrived, beginning another brief cycle of boom and bust.

I didn’t think about it then, but our little house in Maine made us speculators in the global real estate and financial markets. Fortunately things all worked out perfectly. We got small raises every year, a bit over the rate of inflation. By the time we paid off the house in 2006, 20 years after we bought it, the portion of our salary that we spent on the mortgage was only about half as large as it had been at the beginning. At the same time, the average value of houses in the US had tripled.

Our gamble with debt had paid off handsomely, but it was just good timing. The years from 1966 to 1993 were unique in the 20^th century: only one year in that period had less than 3% inflation. Inflation is good for debtors, because it reduces the value of what they owe. If you took out a 30-year mortgage in 1966, the value of your debt had dropped 80% by the time of your last payment.

Unlucky timing led to the opposite results for people who bought property in 2007. The bubble in home values burst, and many mortgages went under water: at the end of 2012 over 28% of homeowners owed more than their property was worth. Unemployment jumped, so lots of people lost jobs and couldn’t make their payments.

The same amount of debt had very different meanings, depending on the state of the national, even global economy. The national debate about deficits and debt is driven as much by different meanings and assumptions placed on these numbers as by the numbers themselves.

Our national debt is a very large number, which according to the debt clock as I am writing is $16,444,380,503,861.39. At the moment you are reading this, it is much higher, because it increases more than a billion a day; you can check it out at http://www.brillig.com/debt_clock/. What does a $16 trillion debt mean?

The total debt that American consumers have signed up for was about $11.3 trillion at end of 2012. About three-quarters of that comes from mortgages, with the rest on credit cards, from student loans, or as home equity loans. So the debt created by the federal government is not much larger than that voluntarily assumed by consumers.

Another way to grasp the meaning of the national debt is to compare it to the size of our economy. The ratio of debt to gross domestic product allows us to see how the national debt has changed its shape over time. Taking a long view, it is clear that debt goes up during wars and recessions, then comes down again when the economy recovers and military spending drops. The debt to GDP ratio reached a peak at the end of World War II, then began a long decline until 1980, even though the size of the debt tripled. Since 1980, the ratio climbed during the Reagan presidency, fell under Clinton, remained stable in George Bush’s first term, and then jumped during his second term and Obama’s first, due to the combined effects of wars and recession.

Our national debt is now high in relation to the size of our economy. As the economy gradually recovers, tax revenues rise from the recent tax increase, and the troops come home, we can expect the ratio to fall again. But liberals and conservatives see these numbers very differently, because they see the whole economy differently. Republican voters are hearing mainly bad news about the US economy, while Democrats overwhelmingly hear good news. So Republicans worry that the deficits will continue to grow unless something drastic is done about spending, while Democrats believe the recovery will mean lower deficits without drastic spending cuts.

Who’s right? It all depends on what meaning is attached to debt. But here’s one more way to look at debt. Giant businesses routinely go deep into debt. The debt load of many major corporations is many times their shareholders’ equity. Nobody seems to worry if a major corporation owes 3, 4, or even 5 times as much as their total shareholders’ equity. If the company grows, the debt will shrink, even if it never goes away. Maybe that’s the way to think about the national debt – it’s an investment in our future prosperity.

Steve Hochstadt

Jacksonville IL

Published in the Jacksonville Journal-Courier, January 22, 2013