Surviving the American Death Panel

When healthcare is a profit-driven, corporate industry, as it is here in the wealthiest country in the world, competitive companies and some individuals will become very rich participating in it. Sadly, people also die under such a health care system, which tends to be as expensive as the market will bear. Those who don’t die often face personal bankruptcy for bills incurred during life-saving medical interventions. These are, one supposes, the price we all pay for freedom, for the exalted Free Market. Americans should be free, under our system, to pursue unlimited wealth and damn the torpedoes. Sick people die, poor people die, not our problem or responsibility, as individuals in the Free Market or as a society.

Part of the corporate structure is hierarchy, in which each level is accountable only to the ones above. This produces natural caution, a reflex to self-justification and a tendency to ass-covering. A related side of corporate life is patriarchy, for lack of a better word. Corporations tend to dictate terms, be rigid, owe no explanation, erect obstacles to information and have procedures to ensure that their policies are inviolable and untouchable by courts of law. They are not known for flexibility, fairness, even common decency. They behave this way because they can, because they write the laws that govern them, finance the elections of their bought and paid for candidates.

What does all this have to do with my own inability, so far, to see either of the two nephrologists recommended to me by a doctor I respect? I shall tell you as briefly as I can, as I suffer silently with idiopathic kidney disease.

By chance, on the recommendation of an acquaintance of a friend, who got the doctor’s name from a list, I saw a patriarchal nephrologist, a female patriarch by chance, who dismissed my questions about nutrition, life-style, alternative treatments, supportive therapies, recent studies of my disease I could read. None of these things would help me, she said. She urged me, from our first meeting, to immediately begin side-effect rich immunosuppressive therapy. Months 1, 3 and 5 begin with three consecutive days of IV corticosteroid infusions and it takes off from there.

This immediate immunosuppressive therapy is called for, I eventually learn, only for high-risk patients, those with a high daily proteinuria count and other risk factors. All other patients are advised to wait, and watch, as a cure without this regime is about as common as a cure with the sometimes devastating immunosuppressive treatment. The statistics argue for waiting, and rechecking levels every couple of months absent a medical determination that you are in the high risk category.

This nephrologist assessed me as a high risk patient without ever checking daily proteinuria levels and even though my kidney function is normal. She did not share her diagnostic findings with me, beyond saying the disease was getting worse and urging me to start with the IV steroids. She never mentioned a risk category or the reason for the haste. She told me over and over that I need to start immunosuppressive therapy right away.

I was never told why I am at high risk as I was being pressured into starting the immunosuppressive therapy ASAP. Patriarchs and corporate types do not owe such explanations. They offer the service they deem correct. To this end, I was manipulated into having a medically unnecessary biopsy done. The necessity of the biopsy was that it is the last part of the protocol before immunosuppressive therapy. I was told it would show the precise stage the disease has progressed to. I’ve since learned it cannot really show this with any precision.

For a long list of reasons, I lost faith in the defensive, argumentative, dismissive nephrologist. I simply could not trust her, in spite of her strenuously extracted, and meaningless “unconditional apology”. She was about as sincerely repentant as Trump was about being the nation’s number one Birther.

I got a recommendation for a senior nephrologist. As luck would have it, he was in the same practice group as the original patriarchal nephrologist. I was told the two doctors would have to discuss the switch, as they generally did not see patients of other doctors in their group. I was told my nephrologist needed to consent to the change and the other doctor had to agree.

My nephrologist seemed to consent in a terse message: I have instructed my front stuff. Her front stuff told me, each time I called, that the doctors were still deliberating. After three weeks of calls to make an appointment I was told that they never, under any circumstances see a former patient of anyone in the group, it was an inviolable rule. As Jane Fonda’s character in Grace and Frankie said the other night, during a vexing moment: “fuck me in the eye!”

I went to a good deal of trouble and expense to get another recommendation. Thankfully this doctor was on my health-insurance plan. I called the number the insurance company had listed for him, to make an appointment. It was a wrong number. I called the insurance company and was given two more numbers, not available on their on-line participating providers list. They connected me to the doctor’s office.

The doctor’s receptionist informed me that they do not participate in the plan, that Healthfirst has them listed incorrectly. They only take insurance patients for the private dialysis center they run, but are not participating nephrologists for any other purpose. This receptionist was knowledgable about insurance law, telling me, for example, that it is a crime to pay a doctor out of pocket if you have insurance coverage. She referred me to an NYU nephrology group, the same one who had treated me so unethically. She was not all that sympathetic, in my opinion, and after snarling a bit, and cutting me off, hung up on me before I could tell her to fuck off.

Which was just as well, I don’t find it very satisfying or effective to tell unreasonable, nasty people that they are unreasonable or nasty. In the case of this receptionist, there was really nothing more she could do. That I had one final , quick question, which would have the same answer as all the others, was nothing compared to her duties to the patients waiting in her office as she was wasting time talking to a non-patient with an attitude problem.

“If you like the doctor you have, you can keep that doctor,” promised President Hope and Change, the former Compromiser-in-chief, while negotiating against himself during the passage of Obamacare. If you don’t rate him highly on that promise, remember that he never came in America’s mouth. Not explicitly anyway. The people we have in there now, hoo boy, talk about death panels and forcers of unwanted touching.

My task now is to figure out how to use this ill-designed system against itself to get the treatment I need for this potentially fatal disease I am up against. A disease that, thankfully, seems to take a long time to finish you off and that, as mysteriously as it comes, sometimes disappears by itself.

I don’t know how interesting this has been to read, if at all, but I note that the knot in my chest I woke up with seems to have unloosened itself by a turn or two, and that is a very good thing.

Unanswerable question

My father, the night before he died, told me I had no idea what it was like to have been the dumbest Jewish kid in Peekskill, which he claimed to have been. This stunned me. There are many things you could say about my father, some of them not at all complimentary, but it was impossible to say he wasn’t extremely bright. Well-read, with an excellent memory and a quick wit, it didn’t take more than a short chat with him to realize how intelligent he was.

I asked him how he could possibly say he’d been the dumbest Jewish kid in Peekskill.

“Hmmmmf, by far!” he huffed, more than seventy years later, still convinced he’d been the dumbest Jewish kid in Peekskill. There were a handful of Jewish families in Peekskill back then, most of them, I imagine, gathered in the tiny First Hebrew Congregation of Peekskill, a narrow white structure as austere looking as a Lutheran church. The Jewish kids of Peekskill were a fairly small, random group of kids. Unless fate had strewn an astoundingly improbable group of young Jewish geniuses in Peekskill, I had no idea how he could make this claim. He died a few hours after insisting he’d been, by far, the dumbest Jewish kid in Peekskill, so I never had a chance to follow up.

“Well, I can’t help you much here, Elie,” said the skeleton of my father. “As you know, I know pretty much what you know about any of this.”

Let us look at what is known, then. By 1929 or 1930 when you started kindergarten, you spoke no English, only Yiddish. Though you were born in New York City, you didn’t understand the most basic English questions put to you by teacher and classmates. Your mother famously went to school and faced the principal, who wanted to know how it was that an American boy came to school knowing no English. She delivered the line that had probably been fed to her, a line immortalized (so to speak) by Eli. “He’ll loin…” she assured the principal, in one of her few English sentences.

“Well, she was right about that,” said the skeleton.

Your vision was 20/400 meaning you could not clearly see your mocking little classmates’ faces, or much of anything else. Not much reading in kindergarten, so no worries there, but classmates’ feet, thrust in your path, would not be easily seen. You were bigger than the other kids, maybe your mother didn’t enroll you when you were first eligible. So, as far as you were treated by your merciless little classmates, you were the Big Dummy.

“I was the Big Dummy,” said the skeleton.

Hold on, there. If you were legally blind, and hampered by not knowing English, how is any of that a reflection on your intelligence, which is obviously far above average?

“I was the dumbest Jewish kid in that school, there is no doubt about that,” said the skeleton.

Here’s what I’m thinking. You emerge from kindergarten with half decent English and you’re put into the dumb class for first grade. Most of the Jewish kids are in the other class, as Jews were famously studious, especially back then when immigrant Jews pushed their first generation American children hard. Maybe there are a couple of Jewish kids with you in the dumb class, but they are gone by the time you are promoted, still blind, to second grade. Now we are in 1931 or 1932. The Depression is in full, depressing swing. Your family, poor before the Depression hit, is now the poorest family in that hard-hit river town.

“That much is all true,” said the skeleton.

Herbert Hoover was still the president, presiding over the shit-show that would doom his presidency. Hoover was no friend of the working man, or the unemployed man either, for that matter, or the children of such men. That’s one reason he lost the Electoral College 472-59 to Franklin Delano Roosevelt, class traitor.

“We can get into FDR some other time. He ran against a Socialist candidate and a Communist candidate, as well as Hoover. They didn’t get any electoral votes, natch, but their movements were forces in society in 1932. FDR saved America for capitalism with his New Deal, but that is not what we’re talking about here.”

I recall you telling me that the eye-glasses I selected, when I was a teenager, wire frames based on John Lennon’s, were just like the glasses you wore, the humiliating badge of being on Relief.

“They made us wear those wire rimmed glasses, the cheapest to produce, I guess, and it was a sign to everyone we passed that we were on the dole,” said the skeleton.

But here’s the question, dad, now unanswerable with anything besides my best guess: what year did you get those Relief glasses? To ask it differently: how old were you before you could finally see?

“Well, obviously, Elie, I can’t tell you that, but, before you pursue this theory, you recall that I always flipped my glasses up on top of my head and held the newspaper close to my face, I didn’t need glasses to see up close. I was near-sighted, like Magoo.”

OK, fine. You also had Lasik surgery toward the end of your life that made your vision basically 20/20.

“Yop,” said the skeleton.

I’m picturing you in first grade, in that class with the other dumbest kids in Peekskill, and the teacher is pointing at the letter A on the board in front of the room. The other kids are all chanting “A”. The teacher is holding up words that start with A, with pictures. Apple, alligator, asshole. You are muttering along with them, but could not possibly see the letters she was teaching you.

“I don’t know, I have no specific memory of this, but it sounds plausible,” said the skeleton.

At the end of Hoover’s term he passed some kind of half-hearted Relief Act, but it was directed toward the states, as far as I can tell, bailing them out of boiling water. I doubt glasses for kids were even a remote consideration in that first bill. FDR, shortly after his inauguration on March 4, 1933 (a month and a few days after Hitler was sworn in as chancellor of Germany) passed an Emergency Relief Act that might have covered glasses for poor kids. If so, your first pair of glasses might have been made around your ninth birthday, meaning you were legally blind from kindergarten to, say, fourth grade.

“Your guess is as good as a dead man’s,” said the skeleton.

If your first pair of glasses were made under the Social Security Act, that would have been 1935, when you were eleven.

“The math is right,” said the skeleton.

“I note here, while we’re doing the math, that I was fourteen when the federal minimum wage law was passed. We take Social Security and the shamefully low Minimum Wage for granted. But the same law that mandated a federal minimum wage also created the forty hour week (something else we take for granted) and banned child labor. Meaning, if my vision had been OK, any time before my bar mitzvah I could have legally been forced to work in some factory, for as many hours as required and for whatever slave wage offered, if a job had been available. Ain’t dat some shit?”

Dassum shit, as my father used to say.

Republican Health Care Plan

I inadvertently gave myself a nice taste of the shit sandwich that is the proposed Republican Health Care Plan, Trumpcare, as far as I can tell from the details I’ve learned. I heard an interview last night that laid out the main differences between Obamacare and Birthercare and realized– fuck, I did it to myself in 2017! The Republican plan would greatly increase premiums, co-pays and deductibles on older Americans, an age-based pricing scheme not currently allowed under the ACA. I’ve had a taste of that in 2017, hoping for better care than I had in 2016 I am paying 600% more for the same coverage I had last year. You don’t need me to tell you what a shit sandwich tastes like.

Obamacare, basically Romneycare, which was in part based on the Heritage Foundation’s conservative plan to keep private industry in charge of American health care, had two or three major improvements over what came before. In exchange for the mandate that would force younger, healthier people, on pain of a tax penalty, to buy insurance, thereby funding the pool for older, sicker citizens, American patients were freed from the industry’s “pre-existing condition” loophole and ensured delivery of what are deemed essential medical services. It used to be possible to sell insurance with serious limitations on, say, preventative services. No more, under Obamacare.

The details of the secret Republican plan, the culmination of a seven year partisan battle against Obama’s health care law, a law they’ve called “worse than slavery”, probably worse than any holocaust, were to be revealed a week before the up or down vote. No debate was planned because Republicans, being in the majority, believed, at first, that they could pass the law on a strict party-line vote. When some of the details were revealed, including the CBO report that 22,000,000 Americans would lose health insurance under the proposed law, the deal quickly went south. It’s hard to cast a principled vote for something with a 12% public approval rating. Even in today’s lockstep party-line political environment.

There were tremendous tax breaks to the wealthiest Americans as part of the Republican plan. This would fulfill one promise the current president made to his wealthy friends and more than reverse the tax hike Obama instituted to help fund Obamacare. Part of the Republican plan shifted more of the cost to older, sicker customers. Another part removed the mandate but instituted an alternative punishment, a six month waiting period for enrolling if you allowed your prior coverage to lapse. Under the Republican plan the customer would pay a higher percentage of the cost of medical care, from Obamacare’s 70/30 split to something much fairer to insurance companies, like 58/42. A sixty-four year old with an income of $26,000, currently paying $1,700 a year under Obamacare, would see the cost of health care increase to more than $6,500 in premiums. That number does not include increased co-payments and out-of-pocket expenses, devilish little details that could add up to another quarter of that person’s income.

Fatefully, the Republican plan would eliminate millions from the Medicaid Expansion roles. Obamacare increased the threshold for Medicaid type coverage to people up to 150% above the artificially low poverty guideline and provided subsidies for people living on up to 400% over the poverty line. 11,000,000 to 14,000,000 Americans now have low cost health insurance that is virtually Medicaid.

The costs of Medicaid Expansion are paid mostly by the federal government, the federal contribution is currently at 95%. The Republican bill scales it back 5% a year from 2021 to 2014, until it makes the program impossible for states to continue. States, under the Republican plan, would also be able to get waivers for in-state insurers to opt out of Medicaid expansion programs and offer less than the Essential Benefits mandated under the ACA. The Republican plan would allow patients currently receiving Medicaid Expansion benefits to be grandfathered in, but it is also still famously easy to be chucked off insurance, and once chucked, it’s chuck chuck bo-buck banana fana fo fuck to you for the rest of your earthly lifetime, under the Republican proposal. The proposed bill also slashes funding for Planned Parenthood. USA! USA!!!!

I’ve written critically of Obamacare, which sucks in many ways, especially its fundamental deal to keep the foxes in charge of the sickening American health care henhouse. That said, there is no question that it is more decent than the unfettered, bare knuckles medical insurance scheme that preceeded it. People who receive coverage under the ACA, whatever our many frustrations with the idiosyncrasies of the industry-written plan, prefer it to the way things were before. Most Americans, it seems, agree.

Is there still a serious debate over the “pre-existing condition” loophole that saved insurance companies billions while condemning countless sick Americans to death? Even Mitch McConnell’s bill doesn’t restore an insurance company’s right to refuse to sell insurance to somebody because they once suffered from an expensive medical condition.

It seems apparent that a big part of the motivation for this Repeal and Replace mania is a vicious partisan hatred of this nation’s first mulatto president. There’s greed by the wealthiest, sure, you always expect a certain amount of that from wealthy materialists obsessed with getting every government advantage to help them become wealthier. There’s the old partisan bickering that has become a larger and larger feature of our political landscape since Reagan.

To understand the Republican jihad to repeal Obamacare we must not discount hatred, pure and simple, of the well-spoken half black man for whom the bill is named. He comported himself with dignity even as Mitch McConnell announced that the Republicans were dedicated to making sure everything the president proposed failed and a coyly racist movement known as Birthers publicly, continually and counter-factually attacked Obama’s legitimacy to be president. The highest profile “birther” was the celebrity brand who is the president now.

“Birthers” spoke the lingua franca of millions of Americans, and said it loud and proud: “this man is a nigger and we do not have to have a nigger president of the United States. We will simply not allow ourselves to be ruled by a nigger.” If you doubt this widely shared sentiment, look at a large part of the current president’s base. Millions of readers of websites like The Stormer, named in homage to the Nazis infamous Der Sturmer, whether affiliated with a hate group or not (and these mothercuckers have proliferated wildly since Obama’s election) will have no problem endorsing this view. I guarantee that not one of these neo-nazi fucks will ever use the politically correct “n-word” to refer to our former president, except perhaps in gleeful air quotes. These angry young white men, and their fathers, and grandfathers, voted overwhelmingly for the race-baiting panderer-in-chief, an unrepentant leader of the Birthers.

Are we living in Germany 1938? I’d like to think not. On the other hand, on the eve of Hitler becoming the full-blown Hitler history remembers, the New York Times opined that the institutions of German democracy were too robust, the German people too cultured and sober, to allow the crass little shit-snot Mr. Hitler to run amok. Run amok the crass little shit-snot Mr. Hitler did. I’m not comparing this genius of audacious self-branding to any other would-be tyrant. I’m just sayin’. The proposed repeal and replacement of Obamacare would be a giant step toward the final victory of America’s crass little shit-snot-in-chief and the third of the nation on which his legitimacy stands.

Would it not?

Winning the Battle, Losing the War (2)

My family, all through the sixties, as the Vietnam war and the war for Civil Rights here in America raged on TV, had our own war every night at the dinner table. This is not my imagination speaking, it was an actual war. In case there was any mistaking it, our father would grimly remind my sister and me regularly “you may win this battle, but you’re going to lose the war.”

What kind of parents style their struggles with their children as a war? How does it nurture a child to predict that, in the end, no matter how many bloody battles they manage to win, they are going to lose the war? What war? What exactly is this fucking war, dad? Speculating about what kind of parent convinces their child that they are in a losing war is a dodgy exercise, I think. All I can say definitively is that, in my case, it was parents who’d been raised by brutal tyrants themselves, and had lifelong difficulty controlling their own over-boiling rage.

My mother loved me, there is no question about that. Yet I have a vivid, and hilarious (in retrospect, I didn’t see the grand humor at the time) memory of my mother shaking me vigorously by the shoulders at the dinner table. She was frustrated, I was small enough to be grabbed by the shoulders and vigorously shaken. As she shook me, in the manner of a terrier shaking a rat, she demanded angrily, each syllable accompanied by a shake “What did an-y-bod-y e-ver do to you to make you so fuck-ing ang-ry!!?”

I had no sensible answer at the time, though it occurs to me now I could have said “I don’t know, maybe things like what you’re doing right now. Would you let me go, please? and stop screaming, I’m a few inches away.” The point is, my mother, who I was much closer to in many ways than I was to my father, was as capable of incoherent rage as my father was. They simply did not know how to control themselves when they were frustrated, which was often.

I don’t blame them for being frustrated. Life is often frustrating. We have our noses rubbed in our powerlessness countless times every day. Corporations are people, increasingly we are not and the cards are ever more unfairly stacked for the corporate “person” against the human person. We are powerless consumers manipulated into buying things we don’t need, things we are told will make us feel better about ourselves, voting for representatives who will not hesitate to sell our interests to the highest bidder. People who pine for long-past golden days are nostalgic for a sense that we are not all endlessly manipulable saps. We always have been, but much more so now, in the age of instant data-driven demographic manipulation.

My parents were born at the dawn of our modern age of mass manipulation. My father, born in 1924, came on the scene around the time of the radio. By the time he was old enough to understand what he was hearing over the radio we had our first mass media president, FDR, skillfully using the magical new wireless medium to reach every American in their living rooms. Poor as my father’s family was, there was some radio somewhere they could huddle around to hear FDR address the nation in his Fireside Chats. Movies were the other new form of mass media, and both of my parents saw them as often as they could. My mother went every Saturday, saw the newsreel between features, watched the events unfolding in Europe and elsewhere.

Fast forward to now, every kid has a device in their pocket that shows them endless, opinionated newsreels endlessly. The torrent of targeted content is unstoppable. Kids think they are the best informed generation in history, since they have instant access to the five second answer to any question. We can think of this as “information” but it is most often slickly packaged commercially-driven manipulation. Being constantly bombarded by “content” also fractures the already shaky human ability to focus and concentrate, shatters it into one and two second twitches. The world is constantly changing, for the most part without wisdom increasing. So be it.

Anyway, I don’t blame my parents for being frustrated, for having been the victims of frustrated, violent mothers. The only thing I can blame them for, and this is a stretch, is not gaining any insight into their life-long battles with rage. You’d hope a new parent could examine their life and reactions honestly enough to realize that blaming a new-born baby for being irrationally enraged, adversarial and vicious was probably not the entire answer to the question of why life with baby seemed so impossibly hard.

Back to the war at the dinner table. The tension would be mounting all day, my mother making the famous threat of that era “wait ’til your father gets home!” As my mother served dinner, after my father came in from his exhausted nap, the sniping would begin and my father would as often as not beg our mother “feed me after them!” It was unbearable to him, trapped in his corner seat near the toaster, between the wall, my sister and the refrigerator, to have to fight this endless battle every single night after a long day at work, before he headed off to his second job.

At his second job he interacted with Jewish teenagers who seemed to love him, as many of his high school students also seemed to. He was a hip guy with a good sense of humor and no taste for bullshit. Every so often one of these kids would become a surrogate son (no surrogate daughters that I can recall). He developed a lifelong friendship with the last of these surrogate sons, a man named Benjie.

But at the dinner table, he was cursed, besieged by his own bloodthirsty offspring, at war. He was reduced to threatening his snotty, doomed children, that, although they my have been winning battle after battle against him at the table, they were destined, in the end to lose the fucking war. He guaranteed it, bitterly, angrily. “You will lose the war!” What fucking war, exactly?

“Well, of course, I can’t defend any of this,” said the skeleton of my father, “it was an existential war. I’d been raised by an angry mother who literally whipped me in the face from the time I could stand. You can judge her, decide she was psychotic or whatever judgement you’d like to make. The fact is, I was forced to eat shit and ask for more from the time I was two. From the time I could stand, I was made to shudder in fear, by my own mother. You do the math.”

I get it. Here’s what I was thinking. My sister and I did the best we could to survive in this existential war. The alliances were constantly shifting, but we could never forget that we were in an ongoing battle, in the midst of a long war we were told we were going to lose. It came to me, the other night before I fell asleep, that since we were always duking it out and fighting for our lives, we would often take it out on mom. Yeah, these two little bastards would join forces to mock and torture your ally, mom, on a regular basis. We tortured the fuck out of her.

“Don’t sound so happy about it,” said the skeleton.

I’m not happy about it. It’s sickening, really, to think about. We were being bullied regularly and we found someone to take it out on. Mom was a prime target for bullying– her mother had bullied her, you bullied her. It was irresistible to us when we were kids, being in a war anyway and sensing her vulnerability, we bullied her. She fought back, she ranted, she cried, she even lashed out at us a couple of times physically, usually with dire consequences that left her crying. But we tortured her. She may have won a few battles but we…

“Don’t even say it. Why are you telling this to a dead man?” said the skeleton, turning his face to show me his profile.

The apple, it is said, doesn’t fall far from the tree.

“That’s beneath you, Elie,” said the skeleton, shaking his head slowly.

Maybe so, but who gives a shit? You may win this particular battle, dad…

The Shoelace

Bukowski’s great poem about the killing nature of the accumulated frustrations we are powerless against captures the accursed essence of our lives here. It’s that constant swarm of trivialities, culminating in a shoelace that snaps with no time left, that finally breaks a man, sends him to the madhouse.

“I will not be broken,” he said to nobody.

Of course you won’t, nor die, either.

Toilet doesn’t flush. Call super. See you between 6 and 7, he says. At 9:30, after several chats with the lying super, his two underlings arrive. One shows me how, by forcing the flush plunger inward toward the pipe while pushing it down, you can get the broken device to flush. This works four or five times after they leave, then, kaput. Meanwhile, new part ordered for your antique toilet, will take a week. Super recommends improvising, try not to shit for a week or so, the toilet will eventually be fixed.

New York City does not have an answer, besides take the landlord to Housing Court. You look for on-line help. The help number on their handy PDF on Housing Code Violations connects you to a wrong number.

Doctor friend provides new information on best practices for treating your idiopathic (“cause unknown”) kidney disease. The medical journal article she’s copied for me calls for watchful waiting before IV steroid therapy if daily proteinuria level (the amount of unfiltered protein your kidneys pathologically spill into your urine) is below 2 grams. Doctors have no idea what my daily level is, that requires a 24 hour urine test to determine. If you think the nephrologist who charged $860 for my first visit would have known to order such a test, you think wrong. She urged me to have an unneeded, expensive, kidney biopsy instead.

It’s been complicated hearing back from my primary care doctor on the 24 hour urine, how to get the jug that I will collect 24 hours of urine in. Only two or three calls to his office so far. Maybe the third or fourth call will be the charm.

You learn, too late to save the several thousands of wasted dollars, that the so-called Silver level health insurance plan you bought, hoping for better treatment than you had last year on the “Essential Plan”, the plan you are paying almost 900% more for (after the subsidy, restored only seven months after being erroneously removed), gives you coverage identical to what you had last year on pay-as-you-go Medicaid. I must not think of the more than $4,200 flushed down the toilet– especially now that my toilet doesn’t flush.

The best things I write these days, I have to pull teeth to get any feedback on. I write these things ’til my forearms ache, and read them aloud to Sekhnet. She tells me some of the recent ones with the skeleton are excellent overviews of this ambitious, highly speculative project I embarked on almost twenty months ago. I heard an interview with Aaron Copeland, late in his life, lamenting that so few people heard his new music, wondering how a composer goes on without an audience to hear his work. I felt bad for him, even as I wondered where he got the temerity to whine about not being as famous as he used to be.

The list goes on and you begin to wonder about the futility of trying to persist. How long a NYC landlord has to fix a broken toilet, under NYC law, should not be such a mystery. It is. You take a bucket and manually flush the toilet, it takes at most two or three buckets full. The bathtub is right next to the toilet, easy to fill the bucket as many times as you like.

So, shut the fuck up and keep bailing. You’re lucky you live in a place where there are flush toilets, bountiful running water, sanitation, a medical industry, a semi-functioning government. You have fucking first world problems, white boy.

“Well, as I always said, Elie, you’d complain if you were hung with a new rope,” said the skeleton of my father. “With your fertile imagination comes an ability to brood that is beyond the powers of most people. Not that I envy you, I’m just sayin’.”

Yeah. Be careful when you bend over.

The Mooch, betrayed by reporter. SAD!

What is the world coming to when you can’t even curse your colleagues in the White House, in a private conversation with a reporter, without the fuck betraying you in the fucking lying media?

Anthony Scaramucci told an interviewer that the chief of staff, Reince Priebus, was “a fucking paranoid schizophrenic” who would be asked to resign, and that Scaramucci was not like Steve Bannon, the chief strategist, because “I’m not trying to suck my own cock”. source

Well, at least now we know why Bannon has that look on his face all the time.

Punchline and I rest my case

The previous post, detailing the intricate workings of corporate fraud? Ridiculous. The contract between me and the insurance company specifically outlines the customer’s lack of rights. I almost laughed when the lawyer pointed out the language to me, the futility of any kind of appeal or grievance. Of course. Reminded me of the great documentary about the corporation, which you can watch for free on youTube.

The screenshot below, from the film, is the checklist, from the DSM, of the characteristics of the psychopath, which the psychiatric consultant to the FBI, profiler of serial killers, discusses. This is around minute 40. The prior 17 minutes of the film have shown how consistently the modern corporate “person” displays each of these traits.

Thankfully we have also had great advances in advertising.

Fuck me blind. ROTFLMAO!

Dining With Cannibals (part one of many)

Long before he ran for president, Senator Bernie Sanders told national treasure Bill Moyers “the business model for Wall Street is fraud.” It is hard to dispute this description, even as the law winks at and lawmakers and other canny investors profit from the business model of Wall Street. The business model for American health insurance companies is fraud. Their profit is based, in part, on their ability to deny services that customers pay for. I offer the following maddening illustration.

Leave aside the debate over if it was fair to make insurance companies offer reasonably priced coverage (or any coverage) to people with ‘pre-existing conditions.’ I’d argue it is fair, but fuck my opinion. You can argue whether it’s fair to make insurance companies, collecting decent premiums from consumers, cover an annual preventative visit to the doctor. You can argue the fairness of it, it’s your absolute right as an American to argue. You can even elect a living turd to bully his party into dismantling the timid, conservative think tank-created baby step in the arguably right direction for ‘failing American health care.’ I’m here only to point out a concrete instance of the basic business model of American health insurance: fraud.

You are faced with a single choice for treatment of, let us say, chronic kidney disease. You are being strong-armed toward the one treatment available to medical science: immunosuppressive therapy, a kind of chemotherapy described as an “atom bomb that knocks out your entire immune system and hopefully straightens out your auto-immune disease when the immune system comes back on-line.” The treatment involves IV steroids and other agents with possibly severe side effects. On the other hand, one third of all sufferers of this mysterious disease are cured from it without medical intervention. Nephrology does not have a clue about this “spontaneous remission”. You seek a second opinion. You’d like a medical opinion about how to increase your chances of being in this one third who recover from the disease without undergoing a form of chemotherapy.

The only opinion you will get from an American nephrologist is that immunosuppressive treatment is the only medical treatment currently available, and that you’d probably be wise to start before you suffer permanent kidney damage. You hope for a thoughtful nephrologist, who will not prey on your fear but allow you to make a fully informed decision about treatment, but the rest is a matter of the chance and the doctor’s personal style, whether they listen well and answer questions, return calls, are supportive or dismissive, sensitive or prick-like. The one I happened to see was a jerk. Luck of the draw.

Anyway, better still, let’s leave aside the specifics of the case. To see an out-of-network provider, paid in part by the insurance company, you need to obtain pre-authorization for the visit. This pre-authorization is granted , based on medical necessity. The insurance company gives you a number for the doctor to call to get pre-authorization. They must convince the Medical Management department that the services they provide are not offered by anyone in-network.

Once the case is made, Medical Management renders a determination. A week later you learn whether or not the visit will be partially covered by insurance. Without pre-authorization insurance will never pay anything towards the visit.

Provider calls Medical Management. They are told that the patient they are calling about does not have coverage in his policy for out-of-network visits. No request for pre-authorization can be made on behalf of that patient. Thank you for calling, the end.

When the patient is informed of this, and calls the member’s services number at the insurance company, he is told that he does have coverage for out-of-network visits. The problem, he is told is that the provider did not have pre-authorization.

You point out that the provider called the number you were given to get pre-authorization. Perhaps they are referring to some pre-authorization for pre-authorization you have not been informed of. Or perhaps, since they have told the prospective doctor a plain untruth, which forecloses the request for pre-authorization, their business model is closer to fraud. If you have the ninety minutes to devote to this discussion, and sufficient patience and skill, you can get it worked out and the provider can submit a request for pre-authorization. For virtually everybody else– bingo! we just made some more money for our CEO.

You get an Initial Adverse Determination from the insurance company. There is no need for this esoteric specialist, it informs you, when we can provide you a dozen in-network doctors with the same expertise as the doctor who did not answer your questions, the one you don’t want to see anymore.

You call the insurance company to ask them what the hell this determination means, as it makes no mention of medical necessity or the argument presented, it merely denies the pre-authorization based on the fact that they have many specialists in the same field, as well qualified as the jerk you no longer trust to give you medical advice.

Here’s the kicker, though. Membership, the only number you can call, as a member, has no record of any request for pre-authorization or any determination affecting you, adverse or otherwise. You read to them from the determination you are holding. They seem to believe you, they just have no record. You are, of course, free to appeal the Adverse Determination, in fact, you have, under state law, a generous 180 days to do this. They are Member Services, after all, only the Provider side has any of this information.

It happens again with the next doctor. “This consumer has no coverage for out- of-network visits, thanks for calling.” Now it is a pattern, a pattern and practice. It is part of a fraudulent scheme. Only my opinion, of course, but can you think of a word that describes this better than fraud?

“Did you try calling the Provider number?” suggests Sekhnet, thinking outside the box.

I do. I am patient, I am persuasive, I do not pretend to be a doctor, I state my case. The representative is understanding, tries to be helpful. Her hands are pretty much tied. She speaks to a supervisor. Tells me only Member Services can help me. I describe the fraud again succinctly. She does not disagree with my description of the ingenious scheme that separates these two parts of the corporate brain. She asks me to please hold while she speaks to another supervisor. I listen to the hold music for a few minutes. She returns with helpful news.

“You can ask for an EXPEDITED APPEAL,” she tells me happily. The regular appeal takes at least a month. I ask how long the expedited appeal takes. She has no idea, but I can find out at Member Services, she believes. She can transfer me there now, she tells me for the sixth time.

I rest my case, over and over again, on my own head. I’ve got to finish that fucking letter to the New York State Attorney General, the one who got the current president to cough up a token $25,000,000 to settle the case against him for his fraudulent university. New York State needs to regulate these lucrative, legally created pseudo-person psychopaths.

Your Own Hell is Your Business

“As you grow old, Elie, you start to realize that you can do almost nothing to influence anyone’s particular stay in their own private hell,” said the skeleton of my father. “Every person lives in the situation they need to live in, for a variety of entangled psychological reasons. Just like you can’t truly know anybody else’s demons, and a fear that threatens someone else to death may be nothing to you, the personalized hells people find themselves in are largely beyond rational discussion. I’m sure you’ve realized this by now.”

I have, obviously. Terror is the subject we are least likely to be able to talk about. We are all geniuses of self-justification. Everyone believes they are doing what they must do, in the face of what they are up against.

“Not only that, Elie, the devil in each person’s hell provides just enough tenderness to make leaving impossible, that much and not a drop more. Each hell is perfectly tailored for an exact, personalized fit. Women who stay with men who abuse them, it’s always the same story. ‘He showed such remorse…’, ‘he is the only one who truly understands me,’ ‘he really loves me,’ ‘he can’t live without me…'”

“Think about this, Elie, when you felt most terrified as a child wasn’t I great about calming you down, reassuring you?”

Yes, you did seem to have a talent for soothing us when things were really scary.

“Right, so I showed you that concerned face, that empathy and kindness I usually withheld. You could see my love, my capacity to be a caring person, a supportive father. Then, as soon as the crisis passed, it was back to business as usual. I blamed you and your sister for everything. I raged at you both. I used my superior arguing skills to back you into corners in a crazed attempt to never be wrong, about anything. My skin literally cracked open from time to time, from the pressures of my life, and I had to be hospitalized. I told you that your acne was the hatred pouring out of your skin. ‘Nice, dad…’ I can imagine you saying back then, though of course, you responded angrily to the in-your-face outrage, as most people would. To this day, and be honest, your sister still believes that you and her being born ruined mom’s and my lives.”

I don’t want to go very far into what anybody else feels in this account. This conversation is between you and me. But your point is well-taken. If my sister and I had never seen your capacity to be a loving father, it would have been much easier for us both to tell you to go fuck off, permanently. There would have been nothing in it for us. The kindness you sometimes showed when we were most worried was enough to keep us hoping we were not alone in our moments of greatest vulnerability.

“It’s like a pitcher who doesn’t have a great fastball, showing it once in a while in a strategic situation, just to set up another pitch, to keep the hitter honest, off-balance. Look, Elie, I obviously feel bad about all this. My mother, may she rest in peace, and I still can’t phrase this, really… let’s just say she was not a very tender person. But she always called me ‘Sonny’. You should have heard the heart-breaking way she said it, that American term of endearment coming out of her Yiddish mouth. Every time she called me that I felt a tiny flush of tenderness, just enough to keep me from turning my back on her for good.”

This is how monsters do it, then. They show you just enough tenderness to keep you on the hook. They play on your need for mercy by letting you have just a taste once in a while. You took good care of your mother in her final years, I’m sure.

“Of course I did,” said the skeleton. “Just like you and your sister took good care of mom after I died. There was never a question of that in our family.”

Suddenly the air gets chilly. It’s hard for me to hear the phrase ‘our family’ without thinking of history, thirteen years before I was born, when all but four or five of my grandparents’ large generation were slaughtered.

“Let’s not go there today, Elie,” said the skeleton.

We were talking about personal hells, how about this one? Thirteen years before I was born, as many of grandma and pop’s twelve siblings who were still alive were marched to a ravine on the northwestern edge of Vishnevitz, babies in their arms, holding children by the hand, mom’s first cousins.

“I get it, Elie, believe me,” said the skeleton quickly. It looked like he was about to try to whistle.

While two hundred miles north other agents of hostile states were plowing your mother’s entire settlement into the marsh across the Pina from Pinsk, with no trace today.

“Yes,” said the skeleton, “I know.”

“Recursive, recursive! Neurotically recursive, this endless rumination on some horrific thing beyond digestion,” said the imaginary psychiatrist, popping his head up from a patch of clover near my father’s grave.

“Shut up!” said the skeleton and me in unison.

“He does have a point, though. This is a historical reality there is nothing you can do anything about. It’s almost incomprehensible,” said the skeleton.

Except that it happens over and over and over in human history. Look at the poor children in Yemen right now, to take one example. Does anyone know why our ally is starving them to death, with our help?

“Not an unreasonable point,” said the skeleton, peering down the hill toward the nearby Hudson, invisible through the trees.

Brought to you by our friends the Saudis

Armed with a new $110,000,000,000 shitload of top-of-the-line American military technology, supported by U.S. reconnaissance drones, our longtime ally Saudi Arabia is turning Yemen into a disease ridden slaughterhouse.

Here is an excellent short-form report on the humanitarian crisis in Yemen from Frontline. It is happening right now, and we are supporting it.

Take a few minutes to look at what the richest country in the Middle East is doing to the poorest country in the region. Every ten minutes another child dies in Yemen, of a preventable cause. Seven million Yemenis face famine, cholera has reached epidemic proportions.

Our president, after dining with the Saudi royal family, and a clumsy sword dance, promises to get our buddies the Saudis a “good deal” on that great American weaponry. Thumbs up for the photo op. This wealthy cynic is not the first American to do this dance with the Saudis, nor will he be the last.