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Saturday, August 22, 2009


Rats, rats, and triple rats, I have to resurrect from memory this post which I ALMOST finished but it disappeared in my search for the link... GRRRRRR....
SS, your recent poetry job was honourable, but I feel the need to make a return to the classics, as usual. Y'all will probably remember an incident from the Dale Carnegie bible of management involving a man unwittingly shut up in a disconnected refrigerator car who dies of the cold after managing to inform posterity of his tragic fate in a scribble on the boxcar walls. All about the "power of positive thinking", you know.
At least two hundred years before Dale's prosaic, and oh so unpoetic prose hit the best seller charts, Goethe came up with the following poem which was popularized throughout the Romantic revolution, set to music on several occasions, and immortalized by... you guessed it, once again, dear Franz, that consummate disciple of wanderlust.
Here goes :

Who rides so late through night and wind ?
It is the father with his child.
He has the youth fast in his arms,
He holds him safe, he keeps him warm.

"My son, why hide your face so anxiously ?"
"Father, don't you see the Elfking ?
The Elfking with crown and tail ?"
"My son, it is a wisp of fog."

"You lovely child, come, go with me !
Many a beautiful game I'll play with you ;
Many beautiful flowers are on the strand,
My mother has many golden garments."

"My Father, my father, and can't you hear ?
What the Elfking is quietly promising me ?"
"Be calm, stay calm, my child ;
In the dry leaves the wind is rustling."

"Do you want to come with me, dear boy ?
My daughters will wait on you fine ;
My daughters lead the nightly dances
and will rock and dance, and sing you to sleep."

"My father, my father, and don't you see there,
The Elfking's daughters in that gloomy place ?"
"My son, my son, I see it well enough.
The old willows are shining grey."

"I love you, your lovely form entices me,
and if you are not willing, I will take you by force."
"My father, my father, he is clutching at me !
The Elfking has struck me sorely !"

The father shudders ; he rides swiftly,
He holds the moaning child in his arms
Reaches the farm exhausted and in dread ;
In his arms the child was dead.

Now, that's ten million times better than Dale Carnegie, isn't it ??? And in the original German, it's even BETTER.
(And by the way, the power of positive thinking, is it as... potent as the power of negative thinking ? That one is open to debate, my friends...)
Goethe was another prophet for his time, and ours, if we care to listen to him now.
You can doubtless tell that the father espouses a dry, magicless, "objective", and scientifically materialist vision (a dog is a dog is a dog) of the world around him while his son...
His son has access to the magic, and poetry which infuse the world with... meaning, albeit DANGEROUS meaning.
Is there a "right" way to see things ? An "objective" one ?
In any case, Goethe's poetry, and the rhyme manage to suggest the interpenetration of father and son's world, although we MIGHT think that they are on opposite ends of the spectrum.
And at the close, the father's "objective" certainty and reassurance fall apart in the face of his apprehension and ultimate panic.
Octave Mannoni said this years ago, in a book which is a sort of Bible to me : common sense rationalizations are the last resort in the face of the overwhelming deluge that loss of faith will bring down. Yep, my own personal experience will verify that observation.
No suggestions for interpretations of Erlkönig. Maybe... Hans Hötter, whose voice I particularly like.


SS said...

Thanks for the Goethe, Deb, I liked the part on rational vs. spiritual interpretation.


SS said...

Very good comprehensive article in this weeks Atlantic Monthly:

on the U.S. health system. I believe after reading it that the problem of providing health care is a "pis-aller", second best- substitute for providing jobs which pay a living wage and one that won't work on its own. The problem is that the unemployed can't buy insurance and subsidies can hardly be sufficient for people to buy adequate insurance in the economy we have now when they are unemployed or part-time.

A better solution would be to provide decent paying jobs via a WPA (Roosevelt) type program and than insist that people buy catastrophic coverage, leaving routine Doctor visits and tests to be paid for out of income, hopefully creating greater competition. Medical school fees need to be adjusted downward or subsidized and pressure put on the AMA-Doctors and hospitals to stop trying to limit the number of same.

After all death is inevitable: lounging around unemployed, homeless without food or health care hardly, so put people to work!

There a serious post from me, one a week that should surpass my quota, after all I'm a socialist and not in it for the money!



Thai said...

SS, re: medical eduction

I completely agree!

IMO one of the largest areas for genuine reform of the health care system is with medical education and state licensing.

Alas, for complex reasons I won't go into here concerning studies on the relative acuity adjusted comparative productivity of mid-level providers (nurse practitioners and physician's assistants) vs. physicians, I don't think educational reform will be quite the panacea I once though it would be, but there is opportunity for real improvement in this area.

But I might also add that the medical education establishment is at the very center of recommending reform (on ANY side of the debate) and is thus truly in one of those proverbial fox guarding the hen house roles.


SS said...

@ Thai

Glad your back, hope the vacation was fun and restful. Take a look at the Atlantic article if you get a chance, I think you'll like it. Mentions emergency room Drs. and conditions in a generally very comprehensive fr a couple of page treatment.


Thai said...


I read the article


Is a socialist aligning himself with the the Hoover Institute and The American Enterprise Institute?

I have no problem with this solution (in fact it was the original concern the AMA had when it opposed Medicare and suffered politically for it) but I see who the looser would be under this proposal (which the article is not honest enough to admit)- the chronically ill.

This really is a zero sum issue and I can get quite nihilistic on the issue of health care if I am not careful.

I would be very interested to hear the thoughts of our resident political partisan (Okie)- whom I am very fond of. I do not think he would like this proposal one bit.

Thanks for the link, hope you are well my friend


Debra said...

Take a look at my answer to Jerome in Okie's post about health care you guys, please.
I have briefly sketched out just WHY French health care is NOT the cloud with the silver lining that apparently some people STILL think that it is.
Comments ?
And yes, welcome back, Thai. Apparently you didn't get eaten by any meese...

Thai said...

Thanks and "no", I didn't get eaten by Meese, though I did see a few and I must have seen 10 grizzly (Okie, you are right, Glacier National Park has got to be one of the most beautiful places on the planet. We stayed at the Many Glacier Lodge for a few days in the park- really not bad for $150/night.

Re: differences between national health care systems.

Have any of you ever read the book Albion's Seed?

Thai said...

Oops, typo earlier

Sorry SS, I meant the Heritage Foundation's position on health care reform, not the Hoover Institute

This is a VERY conservative solution

Debra said...

Thai, that book is over 900 pages long ; I have not read it, and I will NOT read it (although it sounds VERY VERY interesting...)
Tell me the truth, now : have YOU read ALL the way through it ???
For the past week I have been reorganizing our home library.
We must have THOUSANDS of books.
After dusting off MANY MANY of them, I have now decided that I need, not, SHOULD I SAY, MUST not buy another book before I die, because there is enough in the house to do me until they throw the dirt over my grave.
My husband agrees.
Glacier is a beautiful place ; I went there often as a child/teenager. Never came face to face with any of those bear critters, though.

SS said...

@ Thai,

Sorry about the bad company I'm keeping - Remember I did say it would only work with a guaranteed jobs program at a living wage. Otherwise it's not much different than what we have now.


Thai said...

@Dink, you make a good point re homeschooling. Oddly, while reading another article I came across this and cringed. I guess this is the totalitarian direction these ideas can take that Deb has warned us about.

PS- I do not intend to imply in any way you are totalitarian, just a FYI

Hope you are well

@SS, it is I who am sorry as you certainly need never justify to me who you do and don't agree with, even if you are being a little sarcastic. ;-)

My only point is that all sides in this debate have very valid points and I think the article you suggested is very interesting.

And in particular, I think the general point conservatives have been making for years, jokingly expressed as "if you think health care is expensive now, just wait till it's free" is an absolutely valid one.

Health care has unlimited demand, I see this with my own eyes everyday.

Health care is the ultimate tragedy of the commons IMO

@Deb, re: Albion's seed

I only recently started the book and am approx 100 pages into it. As the book has been around a while, I thought some of you might have already read it. It's 900 pages is a bit misleading as there are lots of pictures and the references are on almost every page and can easily fill 1/2 a page at times, so it is actually quite a bit smaller than the 900 pages might actually seem.

I will try to post a few links with images that explain why I asked you all, especial in reference to this discussion on health care.

This is one link.

Then look at this map from Steve Sailor's blog on the genetic legacy of these four folk pathways as seen in modern American voting.

There are strong implications for health care...

Dink said...

Welcome back, Thai! Glad to hear that Montana was enjoyable. Seems like the perfect place to take young kids ("go find fish in the river, go dig for velociraptor bones, go climb things and let dad nap under the big sky").

Re: Albion's Seed. I'm suspicious and the "pugnacious Scots-Irish" in me wants to fight. It seems the geographical breakdown might have more to do with heat, available food, and lifestyle stress. Would an identical map of men of Asian descent also follow the same trend?

"I need, not, SHOULD I SAY, MUST not buy another book before I die"-Deb

Ah, the righteous, fervent words of an addict hell-bent on reform. We'll see ;)

Re: Erlkonig- imagination is great, but the "imagineer" needs to be aware of when they are playing. Physical reality does exist.


Here's another issue with medical school and health-care reform; it turns out that the patients can be frustrating on occassion ;)

I mentioned Group Health Co-Op a while back. There was another article about them this weekend; its seems the doctor's prefer being salaried. I would imagine tracking every procedure for reimbursement would be an obnoxious hassle.

Thai said...

Dink, nice to chat again.

Remember I too am Scot-Irish ;-)

re: MD physician productivity based compensation models.

This issue really is a fascinating one (at least to me as it is obviously quite close to my wallet).

I have looked at it a lot and after all I have read and seen, I am still strongly in the pay physicians for productivity camp and not the salary model.

I certainly see that some productivity based compensation models have a problem in that they incentivize physicians for doing more on the same patient- this is not the model I work under mind you, but some models out there do this. And indeed one could design a model to pay physicians more when the do less (again not mine); in fact HMOs tried just this years ago but the courts shut it down with enormous med mal awards to injured plaintiffs and as far as I know these models have vanished.

But these are not the only kinds of productivity based compensation models out there and any good management does have ways of dealing with the "over utilization" issue, especially if they have good IT infrastructure in place.

No person (physicians are just people) wants to be called out for over utilizing, it is not a sign of competency... AND at the same time, docs, especially younger docs, have real med mal fears they think over utilization will protect them from.

And with salary based systems, I have seen data showing over a 400% difference in the productivity of high and low performers in the same facility and that the spread narrows to 75% with a 20-40% overall improvement when physicians are moved to a productivity based compensation model.

So I do see how these productivity based compensation structures can become a kind of tragedy of the commons issue; I certainly agree that poorly managed compensation structures can lead SOME individuals to work against group interests- but please understand this is a very complex issue (zero sum?).

Take the solution that conservatives have wanted for years and apparently now SS has become a fan of: "give consumers back their money and let them make decisions themselves".

If we got rid of filling out insurance company paperwork, we would then need to spend forever explaining to consumers what things do and don't cost and why certain costs are or are not justified.

And I suspect arguing with individual patients over their $ would be every bit the time consuming nightmare arguing with insurance companies is today.

I probably most agree with (I think Ezra Klein?) who once said "there are many ways to compensate physicians and all of them are equally bad"

Hope you are well

Thai said...

By the way, I liked your primary care link.

This article really sums up nicely the basic battle lines in the current health care debate (think of it as a circle cut twice by two battle lines into four pieces of pie):

1. Do we spend an even larger percentage of our GDP on health care vs. do we spend the same or less?

- currently SOME in the Obama administration want to spend and even larger % GDP... I am opposed to this as I think we may already be killing more people than we save by spending as much on health care as we do right now, as you might remember I stated here.

2. Simplicity vs. Complexity
- currently many in the Obama administration want to take from that which is complex and hence expensive, and move these funds to that which is simple (like primary care) and therefore less expensive.
I am rather agnostic on this issue: I could accept either side of this issue depending on whether other reforms were made in public spending or not- much like SS said he would take the conservative approach to health care if it accompanied a jobs program.

Thai said...

This is an example of the success of simplicity over complexity that some reformers want America to follow.

But understand, Japan is a monoculture and lifestyle behaviors that individually benefit people are far less common than in the US.

It is easy to get people to agree to pay for everything for each other when they they don't have to pay very much in the first place.

Or perhaps better analogized by the same point the author of Albion's seed is trying to make: one of the best ways to guarantee a winning team is pick the best players.

Debra said...

Two stories on the health care issue :
I am 53 years old, my mother had breast cancer, my grandmother had breast cancer, my dad died of a heart attack at 57, and HIS dad died of a heart attack at 57.
I don't want exam work to check cholesterol, and I am thinking about not getting the handout mammography that I am "entitled" to this year (I am already menopaused anyway...).
My father in law's wife is 74. Mammographies, cholesterol checks, other freebie exams under our system are no longer reimbursed after 75.
She is ENTITLED now. And she is already surreptiously complaining about that magic cut off point at 75. If she was ENTITLED to those exams at 74, just WHY isn't she ENTITLED to them at... 75?
The question is an excellent one.
It shows what happens when entitlement becomes the name of the game...
LOL. God exists... blogger has come up with "breast" to type in for this comment.
That one's for you, dinky.
And.... while you're running to get your popcorn, don't forget that copy of Eats, Shoots and Leaves...

SS said...

@ Thai

I'm becoming a bit uneasy hearing myself quoted as "switch hitting " on health care reform without mention of universal employment! Hello, socialism calling.

Looks like I might be the only non scots-irish on the blog, at least until okie ways in.
Thai- Scots Irish DAR
Okie Scots Irish
Debbie -scots irish - gone to seed - DAR
Me - pure Italian.
It takes all kinds.


Thai said...

SS, my apologies. I did mention your caveat in a later posting where I said "much like SS said he would take the conservative approach to health care if it accompanied a jobs program."

I 100% apologize if I at all seem to be misrepresenting you.

re: Italy

"Heaven is where the Police are British, the Chefs are French, the Mechanics are German, the Lovers Italian and it's all organized by the Swiss.
Hell is where the Chefs are British, the mechanics are French, the lovers are Swiss, the Police are German and it's all organized by the Italians."

Hope you are well ;-)

SS said...

@ Thai
caught the reference to unemployment later, do you actually agree with a full employment program?

As for heaven, hell, we resemble that!


Thai said...

Deb #1 don't be silly, get your entitled mammogram unless you have a good reason not to.

re: "If she was ENTITLED to those exams at 74, just WHY isn't she ENTITLED to them at... 75?
The question is an excellent one."

Answer: Because you ration health care in France!!!!!

The health care policy wonks have determined that it no longer makes sense after 75 from a public policy standpoint!

It is all about rationing- only a rose by another name does not smell as sweet so the french call it a rose. ;-)

We give mammograms to 100 year olds in the U.S.

SS, remember, this is really one of those complexity vs. simplicity issues I have no answer for and get so nihilistic about. Remember the conservation of energy.

If you took away money from health care, you would be eliminating lots of health care jobs (maybe mine?)... That is fine if that is the right thing to do so please don't misunderstand me.

But you would also free up lots and lots of money to create new jobs. And if the money freed up for these new jobs cost less than the money freed up for the old health care jobs (say they were of a lesser complexity) then you would have a net positive job gain to society for the same amount of money. Everyone is employed and everyone makes on average less (but the spread in incomes might be lower).

If you took away all the money that we spent to keep people alive for another 2 weeks or 1 even another month of life, you would again need to fire lots and lots of people from health care jobs (remember, 40% of all health care spending is done in the last year of life and a lot of this is in the last few days- this is the reason Miami spends more per person than anywhere else on the planet fwiw if you were unaware, and it is all spent in the last few days). :-(

Anyway, this would again free up lots and lots of money and if the costs of the new jobs was again lower than the costs of the old jobs (which they might be if they were of lower complexity), then it would be a net positive for the total number of jobs.

Remember, there is no free lunch and you are part of the complexity that is killing the simplicity

SS said...

@ Thai
Remember the definition of obfuscate - wearing a veil and going topless. You're doing it again. Of course things are complex and creating jobs with government money can on the margins substitute for private jobs. But we are talking about jobs so low paying that they would be a last resort when the private sector was not creating them.

It is unfair to rally around my position on health care while cuttin in half the foundation on which it is based, the ability to pay.

Now if you are not in favor of health care for all, nor jobs for all who will take them and prefer a society of come what may survival -that's ok I guess but you can't hide behind the veil of trade-offs because its an unpopular position. That's doesn't further the discussion at all.

The position is unpopular for a reason, it's unkind but leaving that aside it doesn't equate to survival of the fittest in a complex modern day society, as conservatives like to believe, but survival of the luckiest by birth, chance, circumstance, etc.

Best Regards

Thai said...

I am sorry, I do not me to obfuscate.

"Yes", I love full employment. I am the one complaining about all those loafers.

Jobs programs are a great idea

Thai said...

I think that if health care is the place you want to get money for a jobs program, that is a great idea.

I think there are lots of places we could get the funds for one besides health care but health care is definitely as good a place as any.

I was just pointing out the job loss issue.

Why not also go after the people who refuse to work (the massive increase in disability payments to the small % of people who refuse to work). This is now almost 20% of all social security payments.

Or how about both?

There is lots of money out there to get good people the money they need to survive.

I agree with you, we must make tough choices.

Thai said...
This comment has been removed by the author.
Anonymous said...

I agree, anyone who loafs rather than getting into the jobs program should get nothing. There is a problem I would guess policing disability claims but they need to be policed.


Debra said...

You guys REALLY get up my nose with your comments about loafers.
Your comments about loafers are the symptom of...
a Protestant work ethic driven entitlement society.
Duh, Thai, I HAD figured out that health care was rationed in the case of my father in law's wife's health care. SHE figured it out too. That's why she is surreptiously complaining.
On the subject of mammographies and entitlement, remember that I am a Goethe lover, and Goethe was the man who brought us the foresight to understand just WHY wearing glasses was problematic, and symptomatic in this issue. (Read Roszak, that's all I can say.)
On the subject of "loafers", you guys are STILL reasoning along the lines of 18th century suspicion, i.e. the natural tendancy of mankind is to loaf whenever he/she gets a chance.
And I don't buy that. If you spent a week on my forum, you would realize that there are people who WANT to work, but... they can't stomach the working conditions that are driving US over the edge. And they fall apart on the job.
A brief talk with a woman selling cheese over the counter at my local supermarket taught me that she has refused several permanent contracts in favor of temporary work. Why ? Because the employers are NOT paying her the money that she is WORTH to assume extra work and responsibilities at that job.
They want to pay her an entry level salary for management work.
And she tells them to go blow. As she should, by the way.
Too many employers want to pay entry level salaries of peanuts for management work. And the unemployement situation has convinced them that they have free rein to do what they please, for many of them, at least.
Remember Thai : we are NOT logical animals, as individuals, and thus there is NO REASON whatsoever to imagine that the social body is operating under "logical", "reasonable" postulates.
That kind of thinking eliminates... MASOCHISM and self hate as extraordinary motivations for much of our individual and collective behavior.
Sorry for being cheeky with you Thai. I am just rubbing you a little bit...
And... speaking of loafers, who's putting up the next post ????

Dink said...

" especially if they have good IT infrastructure in place"

Seems a tall order to please both the medical team and the accounting team.

"author of Albion's seed is trying to make: one of the best ways to guarantee a winning team is pick the best players." the biggest team in America (BMI>30, etc) would have high premiums and limited options while, say, a team of vegetarian teetotalers would have low premiums and have access to cutting-edge tech if a surprise pops up? Sweeeeet......

"40% of all health care spending is done in the last year of life"

Not smart. Jon Stewart (The Daily Show) ripped into someone about Advanced Directives. She was saying docs should not be rated on % of patients they counsel about end-of-life. Jon exploded and discussed his family's pain with grandparents who didn't have their wishes in writing and a relatives making decision under emotional duress. He's usually a pretty relaxed guy; this topic meant a lot to him.

"You guys REALLY get up my nose with your comments about loafers"

Perhaps the phrase is meaning different things to each camp. I'm all for a peaceful, unambitious life. But the calories taken from "they system" and given to "the system" should net out to be fair.

""Thai- Scots Irish DAR
Okie Scots Irish
Debbie -scots irish - gone to seed - DAR
Me - pure Italian.

DAR? If 1st Okie was supposed to be Dink, ancestry would be officially quartered Anglo-Irish-Italian-German. Thanks to my friendly and good-looking cousins the lineage now includes genes from most continents ;)

Debra said...

LOL, I may be DAR on my paternal grandmother's side of the family ; apparently the person was ENGLISH English, and not Scot/Irish, whatever.
When you start looking at the genealogy, have you noticed how things tend to get exponential rather quickly ?
Here's how it goes : Mom and Dad EACH have TWO parents. And.. EACH one of THOSE parents also has.. TWO parents. Now you know why it's called a family TREE, right ?
My mother's Mom and Dad were second generation Welsh, as it turns out, and the Welsh tend to be rather stubborn about asserting their DIFFERENCES with English/Scot/Irish, last I heard.
I like the joke, but... the SWISS running things ? OVER MY DEAD BODY.

Thai said...

"Seems a tall order to please both the medical team and the accounting team."

Yes and no; in the end it is a composite picture we are judged on and it is all about cooperation of teams.

I can't really evaluate Boeing stress numbers and I am not sure I really need a third party to tell me they are "safe", if the reputation gets out that the people of Boeing are not able to cooperate as a team and are untrustworthy, I won't fly a Boeing aircraft.

In the same way only engineers can really determine what all the numbers mean and then apply their morals to the numbers knowing everything they know, only physicians can really evaluate physician quality.

But they work with teams of IT/data people.


Thai said...

re: "Not smart"


But this whole end of life issue is a quagmire worse than the middle east. The more you look into it, the more difficult it gets. People that like to paint simple pie in the sky images around this issue clearly have little experience in the trenches on this issue.

It is clear people in health do not understand what they are discussing (how could they, the potential scenarios they face are way beyond most people's experiences). It is quite clear from every study that has looked at this that people often change their minds as they begin to see something different than what they once thought it would be; the reptilian will to survive is very very strong in all of us.

End of life scenarios are almost always different that what people imagined they would be (I hear this almost every day) and the people with POA (Power of Attorney) who make decisions for those they love do not like the "burden" of feeling like they are the executioner.

And society and the POA clearly have a conflict of interest as POAs are usually spending someone else's money (yours and mine).

And Dink, re: "so the biggest team in America (BMI>30, etc) would have high premiums and limited options while, say, a team of vegetarian teetotalers would have low premiums and have access to cutting-edge tech if a surprise pops up? Sweeeeet......"

This is the biggest battle of all in the health care debate as it is the issue of universal coverage.

Let us say that such a plan would be very much against what Obama is trying to accomplish.

The Most Fabulous Objects In The World

  • Hitchhiker's Guide To The Universe trilogy
  • Lord of the Rings trilogy
  • Flight of the Conchords
  • Time Bandits