More on why medical bills are killing us, including an account of my own recent experience

TIME magazine has put its brilliant long cover article, "Why Medical Bills Are Killing Us" (March 4, 2013), behind a paywall, so if you're not a subscriber the link won't help. I understand why they did this: my husband has been in the magazine business for over 30 years, and it's awfully hard to pay staff when readers want everything free.

On the other hand, I wish every American and especially every lawmaker (local, state, and federal) would read this article. It explains better than anything else I've read why our health-care system costs way more than that of any other developed country, and why Obamacare, alas, is so unlikely to bring our costs down. It also gives a few good suggestions about ways to improve our health-care system even if we're not in the mood to give it the total overhaul it so desperately needs.

I supported Obamacare. It's awfully hard to steer a parked car, and the Affordable Care Act got us rolling. But we can't stop reforming health-care now, because our system is still broken. I agree with American economist Tsung-Mei Cheng's tongue-in-cheek Universal Laws of Health Care systems (I'm quoting from T.R. Reid's excellent book, The Healing of America, which I reviewed here, here, and here):

1. No matter how good the health care in a particular country, people will complain about it.
2. No matter how much money is spent on health care, the doctors and hospitals will argue that it is not enough.
3. The last reform always failed.

America's health-care system is not getting the results it should. See the latest report from the National Research Council and Institute of Medicine, whose title sums up our situation: "Americans Have Worse Health Than People in Other High-Income Countries; Health Disadvantage Is Pervasive Across Age and Socio-Economic Groups."

The way America's health care is financed would be hilarious if it didn't hurt so many people (go to the library and read the TIME article to be appalled). A personal example: I recently had an electrophysiology study performed at a highly rated Chicago hospital. From my arrival at 6:15 a.m. to my discharge at 9:30 p.m., the care I received was excellent. I am a big fan of most doctors and practically all nurses.

And then I got the paperwork.

• What the hospital and doctor billed my insurance company: $56,737.28
• What the insurance company agreed to pay: $18,591.77
• What I am probably going to have to pay: $858.80
• What I would be billed if I were unemployed and uninsured:  $56,737.28

Of course the hospital wouldn't be able to collect the full amount if I didn't have it, and I could always negotiate with them - that is, if my English language and negotiating skills were excellent, or if I could afford to hire a negotiator, or if I even knew that negotiation was possible. Or I could declare bankruptcy.

A lot of things still need reforming in our partially reformed health-care system. Could we start by requiring health-care services to have uniform prices for all, and to post their prices so that clients can know the cost of treatment before they sign up? And then could we ask the government not to give health-care services money unless it simultaneously puts limits on how much those health-care services can charge?

MY BELOVED WORLD by Sonia Sotomayor

I was barely awake, and my mother was already screaming. I knew Papi would start yelling in a second. That much was routine, but the substance of their argument was new ...

Sonia was seven years old, and this time her parents were fighting over who was going to give her her newly prescribed daily insulin shot. For a moment she panicked: if giving her the shot was so hard for her parents, surely her grandmother would not be up to the task either--and she'd have to give up her weekly sleepovers at her grandmother's house, her "only escape from the gloom at home." The solution was simple: Sonia would learn to inject herself.

My Beloved World covers some 30 years of Justice Sotomayor's life, from her diabetes diagnosis at age 7 to her appointment as a district court judge at age 37. It is not an account of her more than 20 years on the bench, but rather the backstory of what she had to overcome in order to get there: an alcoholic father who died when she was only 9, a hard-working mother who was rarely at home, a Bronx neighborhood full of junkies and gangs, her inability to speak English fluently until she had been in an English-speaking school for several years, and a serious disease that she expected would kill her before she reached middle age.

How did a penniless Puerto Rican girl from the projects get accepted by Princeton (from which she graduated summa cum laude) and Yale (where she became an editor of the Yale Law Journal), land a couple of good jobs (in which she advanced rapidly), and eventually get appointed to a U.S. District Court, a U.S. Court of Appeals, and the U.S. Supreme Court? Much of her success is due to her own  hard work, competitiveness, and will to succeed. Much is also due to her supportive family and friends. And a significant factor in her career success is the era in which she was born.

A few months before Sonia's 7th birthday, John F. Kennedy signed the executive order that created affirmative action. When she was 11 years old, Lyndon B. Johnson reaffirmed and strengthened the policy. When she was 13, affirmative action was expanded to include women. When she was 17, she was accepted to Princeton.

I had no need to apologize that the look-wider, search-more affirmative action that Princeton and Yale practiced had opened doors for me. That was its purpose: to create the conditions whereby students from disadvantaged backgrounds could be brought to the starting line of a race many were unaware was even being run. I had been admitted to the Ivy League through a special door, and I had more ground than most to make up before I was competing with my classmates on an equal footing. But I worked relentlessly to reach that point, and distinctions such as the Pyne Prize, Phi Beta Kappa, summa cum laude, and a spot on The Yale Law Journal were not given out like so many pats on the back to encourage mediocre students. These were achievements as real as those of anyone around me.

My Beloved World is not a political book. It gives little insight into Sotomayor's legal or judicial philosophy. But with its emphasis not only on success but also on the importance of hard work, of the support of family and friends, and of wide-open doors of opportunity for all, it may give an idea of what kind of justice Sotomajor is likely to be. Fortunately, the treatment for type 1 diabetes has come a long way since Sonia was 7 years old. She's 58 now, still giving herself injections, and likely to wear that black robe for many years to come.

Please hire me

[Working till she drops]

A couple of years ago my 40-something cardiologist earnestly told me that the Social Security/Medicare problem was a cinch to fix--all we had to do was increase the retirement age. Right, I thought - I'm in my 60s and facing open-heart surgery, but once I recover I can go pound the pavement. My cardiologist is not an economist, however, and he's a good doctor, so I held my peace.

Yesterday's New York Times ran an article by Economic Scene writer Eduardo Porter, who should know better. In "The Payoff in Delaying Retirement" Porter writes:

What if there were a way for the government to ease the strain that the aging place on the budget while actually increasing their income in retirement, at little or no cost to their benefits? A well-designed reform would even improve the nation’s rate of economic growth. The way to do it is simply to encourage older workers to spend a larger share of their increasing life spans in the work force.

 Sometimes solutions that look good on paper don't work so well in the real world.

First, most boomers are already planning to work until they drop, since they have saved practically nothing for retirement. I'm not sure they need any additional encouragement. What they need is reality therapy.

Second, over the last decade or so, a lot of companies have downsized. Their PR departments speak of this as right-sizing. What it means is that (a) fewer jobs are available; (b) older workers--the ones getting the bigger paychecks because of seniority--are in greatest peril of being laid off; and (c) the remaining jobs require much longer work days. Such policies, good as they may be for a business's bottom line, are not conducive toward extending one's working years.

Third, it's hard for laid-off older folks to get entry-level jobs. Not only are they overqualified (whatever that means), but the jobs just aren't there. Ask any recent grad.

Fourth, while some older people can work at full capacity well into their 70s and 80s, many cannot. However cheerfully chirpy AARP publications may be, 60 is not the new 40. Over 70% of Americans between ages 60 and 79 have some form of cardiovascular disease, for example, compared to fewer than 40% of people between ages 40 and 49 (see data here). For every person between ages 40 and 44 who is diagnosed with cancer, more than eight people between ages 65 and 69 are so diagnosed (see data here). And those who plan to die with their boots on should be aware that nearly 14% of people over 70 have Alzheimer's disease (see data here).

But let's neglect all those potential problems and stipulate that those of us who are capable of working really should be working, at least until--shall we say--age 70. OK, I'll offer myself as a test case. 

I am 64 years old. I have a solid work history with excellent recommendations, though I have not had a regular employer for some 13 years and my industry--book publishing--is in a hard place. With three master's degrees and a background in teaching as well as editing, writing, and management, I'm quite versatile. My health has been pretty good since my open-heart surgery a year and a half ago (I will require excellent medical insurance, however). I have an extended network of other aging publishing professionals.  

So keep me off Social Security and Medicare for another five years. Offer me a full-time job with a respectable salary and benefits.

Or isn't "encourag[ing] older workers to spend a larger share of their increasing life spans in the work force" quite as simple as Mr. Porter believes?

DOWNTON ABBEY, SEASON 4: What's next?

The long wait begins: Americans will not see Downton Abbey Season 4 until next January, though Britons will see it in September (however, they began waiting Christmas Eve). So what's going to happen?

I of course went on a Google search and learned that Lady Mary is going to be important in Season 4, and that she's going to get a new love interest, though possibly not a new husband. A nanny will be added: Julian Fellowes says there will be "a lovely nursery story." The Dowager Countess "logically must be about a hundred and something now," as Maggie Smith told 60 Minutes in a rare and delightful interview broadcast yesterday, but we can all breathe a sigh of relief--she's not leaving the show, and Fellowes has no intention of killing her off.

So what else might happen in Season 4?

Well, something interesting will surely happen with Tom Branson. With Matthew gone, he's the estate manager now: will Lord Grantham's gratitude to his first son-in-law for saving the farm extend to son-in-law number two? And Tom's a good looking man with a baby: surely another romance is in the offing (this is soap opera, after all). Trouble is, he can't really marry a chambermaid--Mrs Hughes gently made that clear last night. And he isn't invited to the best parties, so a titled wife seems unlikely. Unless she's rebellious, of course, like Lady Sybil. Which makes me think that Tom and Lady Rose MacClare are going to get along just fine. Lady Grantham and Rose's mother, after all, were commiserating about the difficulty of having headstrong daughters. And Rose is coming to live at Downton Abbey. And it is 1921, after all, when traditional matings seem so stuffy. I mean, look how Rose's parents turned out.

And dear Lady Edith. She's 27 now and still a spinster, poor dear. Will she go to live in sin with her married editor, Michael Gregson?  Matthew is no longer an obstacle, but Lord Grantham might have a heart attack--oh, right, Fellowes has said Season 4 won't be as lethal as Season 3. Or maybe Fellowes will remember Jane Eyre and have the asylum, with Mrs Gregson in it, burn to the ground, thus freeing Mr Gregson for Lady Edith. It would be a nice twist if she then refused him, bought the newspaper, and became a media mogul, wouldn't it. I doubt if that will happen, but at least she's going to glam up.

And that's just upstairs. What will happen downstairs? The cook, Mrs Patmore, narrowly escaped a bad marriage (cf Upstairs Downstairs: "The Sudden Storm," in which the cook, Mrs Bridges, has an almost identical misadventure). I'm guessing Patmore won't get another proposal, but will something develop between Mr Carson and Mrs Hughes? Will O'Brien wangle a job as lady's maid to Lady Rose's mother and get to travel to India? Has Thomas turned into a decent human being after all? Anna Bates is getting a new hairstyle--will she also have a baby?

What are your guesses?

WHAT'S A DOG FOR? by John Homans

When I saw this book's title in a New York Times review last month, I thought it might be similar to Jon Katz's engaging 2003 book, The New Work of Dogs. Katz wrote about how dogs have gone from being diligent farm workers who help us take care of our physical needs to being companions and even substitute children who help us take care of our emotional needs.

What's a Dog For?, it turns out, is wider ranging than Katz's book. It never quite answers its own question; it might have been more accurately if less attractively titled Lots of Stuff about Canines that Dog Lovers Will No Doubt Find Fascinating. For example, Homans, who is executive editor of and a frequent writer for New York magazine, looks at

• how dogs and wolves are similar and different
• the history of dogs from Newfoundland
• what kinds of emotions dogs (may) feel
• how humans have created dog breeds, mostly recently, and often by fast and reckless selective breeding
• how the animal rescue movement has both helped and hurt dogs
• how big dogs adapt to life in New York City
• how dogs think
• how Freud and Darwin related to dogs
• why it's dangerous to be a Pit Bull

--among other things.

I am a dog lover; I have lived at various times with Pepi the Toy Manchester Terrier, Willie the irrepressibly cheerful pound puppy, Baja Humbug the psychotic Chihuahua, Taco Bell the only mildly disturbed Chihuahua, Ladybug the sane but bossy Yorkie/Chihuahua, Maggie the docile but dumb Sheltie, Moose the TV-watching Maltese, and now Tiggy the perpetually distracted Mini Schnauzer mix and Muffin the Havanoodle princess. I enjoyed What's a Dog For?--a question that frequently crosses my mind--though the book may have more words than content. And I wish Homans hadn't focused quite so much on his dog Stella in particular, and on Labrador Retrievers and other big dogs in general.

Little dogs are people too, and mine would not be pleased to learn that Darwin considered them "sports of nature," i.e., spontaneous mutations. At least Homans showed some restraint: he did not descend to the level of a dear though Lab-owning friend who refers to our pups as "kick-its."

Is the West's reckless lifestyle killing our poorer neighbors?

[Africa, with Tanzania highlighted]

I spent all day Monday in an outpatient clinic (I'm fine; thanks for asking). I met a lot of nurses, and every one of them was excellent.

When Velda came to take away the remains of my lunch, I offered her my untouched can of ginger ale.

"I don't drink soft drinks," she replied. Since I rarely do either, we started chatting.

Velda grew up in Tanzania, moved to Belgium, spent several years in London, and finally came to the United States. She returns to Tanzania regularly, and she is not happy with what she sees.

"I grew up eating lots of vegetables," she told me. "We might have had ice cream once every three years. But now people are eating American-style junk food. They don't know it's not good for them."

Tanzania's cigarette industry is big. In spite of national bans on most forms of advertising, Velda vividly recalls a huge billboard for Sportsman - one of Tanzania's most popular cigarette brands - right across from a school entrance where children can't help seeing it every day. And the children are smoking - she's seen them.

Supposedly regulated drugs are easy to buy without a prescription. Velda's 18-year-old nephew, once an honor student, is now a prescription-drug addict and a drop-out.

"The thing is," Velda said, "there's no way to get treatment for most diseases. It's not like here. If people want to be healthy, they have to take care of themselves. When they get sick because of junk food or smoking or drugs, they just die."

I checked the statistics. Tanzania's per capita income is $1700 in U.S. dollars. There is one physician for every 125,000 people (compare America's ratio of one physician for every 375 people; or Cuba's of one for every 156). Tanzanians live, on average, to age 53. Velda's twin sister died at age 23.

Velda, who is a kind and gentle nurse, gets angry when she thinks about what's happening to her people. "Why?" she kept saying. Why are international companies so aggressively promoting foods and cigarettes and drugs that will shorten people's lives and even kill them? Why is nobody stopping them? Why?

The contraceptive kerfuffle: a common-sense approach

If I were Queen of America, here's what I'd do about contraceptives.

First, I'd apologize for the current kerfuffle over whether faith-based institutions (or any business whose owners disapprove of contraception) have to provide contraceptive coverage in their insurance policies, and I'd rescind the HHS directive and all its amendments. Never mind whether it's a good idea to require contraceptive coverage; it has become politically unfeasible to do so, and we might as well drop it.

Second, I'd disentangle contraception from insurance altogether. Instead, I'd make an assortment of contraceptive medications available free or at a low cost as a direct gift from Uncle Sam to anyone with a valid prescription for them. Let's name the program Common Sense, shall we?

Third, I'd require pharmaceutical companies to provide Common Sense with low-cost equivalents of every category of contraceptive drug they manufacture. At the same time, I'd prevent price gouging by putting a price ceiling on all contraceptives paid for by the Common Sense program.

Fourth, I'd encourage continued research and development by allowing pharmaceutical companies to develop all the fancy, high-priced contraceptives they wish, and by allowing insurance companies to cover these designer drugs (because such meds would not be distributed through Common Sense). I'd even throw in some government funds for research, since improvements in contraception should lead to better health and, eventually, lower prices for all.

As Queen of America I'd fund Common Sense through tax money, which would no doubt offend some of my subjects. So be it: we all are offended by something, and right now I'm mightily offended by how much of my tax money goes to military intervention around the world.

If Common Sense helped Americans reduce the number of unwanted pregnancies, we'd likely have fewer abortions, fewer high-school drop-outs, and fewer people on welfare. Common Sense might even save us money in the long run.

I'm not likely to become Queen of America, of course, and that's as well. Democracies - even contentious, inefficient ones - are generally safer than absolute monarchies. But gosh, wouldn't a little common sense be refreshing?