But Americans don't have to wait for health care ... do we?

[Lovis Corinth, Self-portrait with skeleton, 1896]

The Commonwealth Fund's just-released annual report on health care in 14 developed countries shows that, once again, America spends more than anybody else on health care--50% more per capita than the next-most-expensive nation, Norway, and 182% more than the least expensive nation in this survey, Italy.

Well, yes, say some proud Americans, and we get what we pay for. We have the best health care in the world.

Maybe not. Other surveys regularly report that Americans die younger than people in other developed nations. Commonwealth reports that America leads the pack in avoidable deaths per 100,000 population: 96 in America compared with 55 (France) to 83 (U.K.) in the other nations surveyed. I was surprised to learn that America has fewer doctors per 1000 population than all the other countries except Japan.

OK, say defenders of America's health care, but people in those other countries have to wait much, much longer to see a doctor, and they wait nearly forever for elective surgery such as hip replacement.

Nope.

Commonwealth surveyed wait times in eleven of the countries, and here's where America stands:

• If you're sick and need a same-day or next-day appointment, you're more likely to get it in Australia, France, Germany, the Netherlands, New Zealand, Sweden, or the U.K.
• If you need care after hours, you're more likely to find it in Australia, Germany, the Netherlands, New Zealand, Norway, Switzerland, or the U.K.
• America has a lot of specialists, but you're still more likely to get a speedy appointment with one in Germany or Switzerland.
• America is quick to schedule elective surgery, but not quite as quick as Germany and the Netherlands. France, New Zealand, Switzerland, and the United States are all a little slower than those two, but not by much.

Ethical question: If a nation has poor access to basic health care but good access to expensive specialized health care, what does that say about its priorities?

Practical question: If Germany, which spends about half of what the U.S. spends per capita on health care, can insure nearly everybody and still maintain speedier access to all forms of health care, why can't we?

In the bleak midwinter (or dreary midautumn) - watch a British TV series!

[Foyle's War - one of the best!]

Yesterday I posted this update on my Facebook page:

During the months when it's too cold to walk my little dogs, I ride an exercise bike planted in front of my TV. I love watching long British TV series while I pedal: Upstairs, Downstairs, Doc Martin, As Time Goes By. I just finished Foyle's War. Any suggestions for what I should watch next?

The response was amazing - more than 70 comments to date. I decided to make a list for future reference, and I thought you might like to see it too.

First, to keep the list focused, I weeded out Irish, Australian, and American productions as well as stand-alone films, though some good ones were recommended. Then I added links for all the series that made the cut. As I was doing this, I remembered more UK series I've enjoyed--Midsomer Murders, Poirot, Miss Marple, the House of Cards trilogy with Ian Richardson, The Amazing Mrs Pritchard, Fawlty Towers (of course), Inspector Morse, Cadfael ... and the names keep coming.

Here are the British TV series my Facebook pals recommended. Ones I've watched and enjoyed are in bold.

Seven friends recommended Call the Midwife. I started watching once but forgot to continue. Tonight I re-watched the first episode, and this time I'll persist. It won't be hard. I read Jennifer Worth's first book last year and enjoyed it very much (see my review here).

Four friends recommended Prime Suspect. Yes! One of my all-time favorites. Helen Mirren is fantastic.

Three each suggested Lark Rise to Candleford, Miranda, and Rev. Winter in Illinois is long. I'm glad to have these to look forward to.

Two each mentioned Ballykissangel, The Bletchley Circle, Broadchurch, Downton Abbey, Dr Who, The Inbetweeners, Inspector Lewis, Luther, Monarch of the Glen, and Sherlock. I watched the first episode of The Bletchley Circle tonight. A bit grisly in places, but promising.

These made the list too:

At Home with the Braithwaites, A Bit of Fry & Laurie, Black Adder, Bleak House, Brideshead Revisited, Cranford, Father Brown, The Grand, The House of Eliott, Hustle, Inspector George Gently, Jeeves & Wooster, Kingdom, Land Girls, Little Dorrit, Lovejoy, Misfits, Mr Bean, New Tricks, The No. 1 Ladies’ Detective Agency, Our Mutual Friend, Parade’s End, The Promise, Rosemary & Thyme, Rumpole of the Bailey, The Sandbaggers, Seven Up (a film series, really, but close enough), Sharpe, To the Manor Born, The Tudors, Vera, The Vicar of Dibley, The White Queen, Wives & Daughters, A Year in Provence.

And then there are the wonderful Adam Dalgleish series starring Roy Marsden, based on mysteries by P.D. James, and the Inspector Lynley series based on Elizabeth George's sprawling novels, and ... well, there are just too many to name. They almost make me want to ride my stationary bike--or at least sit in the recliner in front of the TV.

"We hate the government, except for the large part of it that helps us"

[Colin Woodard's map of 11 American nations]

I just got back from another nation.

According to Colin Woodard, author of American Nations (and this recent article summarizing that book's thesis), the United States comprises eleven distinct cultures. By upbringing and acculturation, I belong to two of them, The Left Coast and Yankeedom. Earlier this week, I got together with friends in The Far West. I am still scratching my head.

Some of these friends hate the federal government, especially its Democratic representatives, and particularly the Obama administration. My views about government, Democrats, and Obama are radically different from theirs, though I understand why some people fear government overreach, I accept that good Republicans exist, and I occasionally disagree with President Obama myself.

But here's what baffles me. Everyone in the group of Far West friends I saw this week is a huge fan of VA hospitals, even though the US Department of Veterans Affairs is the second-largest department of the US government, and even though, as T.R. Reid points out in The Healing of America, VA healthcare is one of the world's purest examples of "socialized medicine."

Everyone in the group is also a huge fan of Medicare, even though Medicare is a US government program that closely resembles Canada's National Health Insurance, often derided by Obamacare opponents.

When I suggested that it would be nice if everybody in America had access to healthcare as good as that provided by VA hospitals or Medicare, everyone nodded. I think they were agreeing with me, though perhaps they were just being polite.

The thing is, we wouldn't have VA hospitals or Medicare if we didn't have a strong federal government.

• The Veterans Health Administration, established during the Truman years as the Department of Medicine and Surgery, today "operates the nation’s largest integrated health care system."
• Medicare, signed into law by Lyndon B. Johnson with Harry S Truman by his side, accounts for 14% of today's national budget--and that's without including the government's healthcare programs for the poor. Add Medicaid and the Children's Health Insurance Program (CHIP) and you bring the total up to 21%.

Of the seven of us gathered around a table at El Adobe Cafe earlier this week, five get Medicare, one gets VA benefits, and one is a caregiver. My friends love these programs because they need them, and they know what their lives would be like without them. At the same time, some of them hate the federal government that makes the programs possible.

I don't get it, but I've learned that arguing gets me nowhere. Even if these people are biting the government's outstretched hand, I'm glad they're getting fed. And speaking of food, El Adobe Cafe serves some of the best Mexican food I've ever eaten. The Far West gets some things exactly right.

Gimme that old-time health insurance ...

Yes, President Obama said that if we like our health insurance, we can keep it. 

Yes, that turned out to be false for a few million people.

Yes, the President chose his words poorly. Whether or not health reform became the law of the land, there’s no way any President could have known if we’d be able to keep our health insurance from one year to the next.

And with the changes mandated by the Affordable Care Act, insurance continuity would be even more of a crap shoot. Companies would tinker with benefits and prices in hopes of keeping the cash flowing after the reforms kicked in. They would certainly cut unprofitable policies or raise their prices stratospherically, or both. This was happening long before Obama took office; surely it would happen even more as insurance companies were required to, well, insure people.

So President Obama should not have made a promise he couldn’t keep.

However, I don’t think the President intentionally lied. I don't think he was naïve about insurance companies. I think he was naïve about Americans. I suspect he had no idea that so many Americans would actually like and want to keep those individual policies that 

• cost significantly more than work-based policies 
• hire people for the express purpose of finding trivial reasons to deny payment on claims
• respond to claims by shutting down people’s policies or raising their prices way beyond affordability
• refuse to insure people with any pre-existing conditions (e.g., people who have been kicked off their previous policies because they actually had to use them)
• set limits on how much they will pay that are way lower than the cost of treating most serious illnesses

And that pretty much describes most of the policies that have shut down as a result of the Affordable Care Act.

Oh, how they will be missed.

KNOCKING ON HEAVEN'S DOOR by Katy Butler

On an autumn day in 2007, while I was visiting from California, my mother made a request I both dreaded and longed to fulfill. She'd just poured me a cup of tea from her Japanese teapot shaped like a little pumpkin; beyond the kitchen window, two cardinals splashed in her birdbath in the weak Connecticut sunlight. Her white hair was gathered at the nape of her neck, and her voice was low. She put a hand on my arm. "Please help me get your father's pacemaker turned off," she said. I met her eyes, and my heart knocked.

That's the first paragraph of Knocking on Heaven's Door, Katy Butler's memoir about caring for her parents in their declining years. If you have ever taken care of a demented or dying loved one, or if you know somebody who has done so, you should read this book. If your paycheck comes from the healthcare sector (now 18% of the U.S. economy), or if you find that even the reduced insurance rates under Obamacare are too high for your budget, you really should read this book. Like all good memoirs, it's about so much more than one person's experience.

Jeffrey Butler, a retired Wesleyan University professor of history, had dodged death several times--as a teenager, when he arrived seconds too late to jump into a car carrying several of his friends to a fatal crash; as a young soldier in Italy during World War II, when he nearly bled to death after a German shell blew off his left arm; and again in his late 70s, when a sudden stroke left him helpless.

His wife, née Valerie de la Harpe, was also a survivor. In her forties, she discovered a walnut-sized lump in her left breast. It turned out to be malignant, and her subsequent radical mastectomy--which removed not only the breast but also much of the chest wall and four cancerous lymph nodes--revealed the possibility of further metastasis. After enduring six months of radiation treatments, she chose to have her right breast removed as well. Her cancer did not recur.

Katy, their daughter, was no stranger to loss either. For much of her life she had an on-again-off-again relationship with her challenging parents and her semi-estranged brothers. After a divorce in her 20s, she had trouble committing to a new love. And yet, like her parents, she repeatedly picked herself up and kept going, creating a career as a memoirist and investigative journalist.

But experienced as the Butlers were in suffering and loss, they were not prepared for the technologically enhanced torments of old age.

Knocking on Heaven's Door tells what can happen when a person's mind and body endure a series of shocks that would naturally lead to decline and death--except that, through various technological interventions, the body is not allowed to decline along with the mind.

In Professor Butler's case, a major stroke wiped out most of his ability to function independently and set him on the road to dementia. At the same time, his heart was slowing down. A year after his stroke, over the opposition of his primary care physician, Butler was fitted with a pacemaker. His cardiologist strongly recommended it. He needed hernia surgery, the doctor said, and his heart was not likely strong enough to survive the operation. So he had the pacemaker installed, he had the surgery, and he was rewarded with another six years of increasingly hellish existence--not only for himself, but also for his wife and his daughter. His mind was shot. His body would not do what he wanted it to do. But his artificially assisted heart kept relentlessly ticking away.

Not long after her husband finally died, Valerie Butler, then 84, learned that her own heart was giving out. She would need a double-valve surgery plus a bypass operation, her doctor told her. Without surgery, she had a 50/50 chance of dying within two years. With surgery, she could live another six. There was, however, a risk of stroke ...

Valerie Butler said no. She died within months.

She died of old age, sickness, and death [Katy writes]. She died of a heart calcified and broken by six years of nonstop caregiving. She died of being eighty-four. She was continent and lucid to her end. She took back her body from her doctors. She died the death she chose, not the death they had in mind. She reclaimed her moral authority from the broken medical system that had held her husband hostage. She died like a warrior. Her dying was painful, messy, and imperfect, but that is the uncontrollable nature of dying. She faced it head-on. My brother Jonathan called it a triumph.

This is not a book about assisted suicide or euthanasia. Do not read it to find ammunition for or against whatever you believe about those ethical issues, because that is not why Katy Butler wrote it. It is partly a very personal memoir about an already troubled family who found caregiving much, much harder than they ever expected. It is partly a love letter to the father Katy alternately fled and adored, and to the mother she admired but could not get along with. It is also a look at what the contemporary American approach to healthcare is doing to elderly people and to those who care for them.

And it is a clear-eyed recognition of a truth so many of us try to avoid: that it is our nature to die, that there is nothing we can do to escape death. Thanks to technology, we may be able to postpone it. We may be able to make the dying process take a lot longer (and be a lot more miserable). We can choose to add weeks to our lives and hundreds of thousands of dollars to our hospital bills by dying in an ICU rather than in hospice or at home. But we can't stave off the grim reaper forever.

If we refuse to accept our mortality, if we are willing to pay any price and bear any burden to make our lives longer (though not better), if we continue to pass healthcare laws that refuse to subsidize doctors for discussing end-of-life issues but that give carte blanche to businesses that value corporate profits over compassionate care--then death will continue to be not only an enemy, but an increasingly ferocious one.

What do you mean, "middle-aged"?

[Stages of a Man's Life from the Cradle to the Grave, c. 1848]

Yesterday on Facebook I referred to my daughters, who are in their early forties, as middle-aged. One of their friends, who is 43, wrote, "Middle-aged???"

"For sure," I wrote back. "I know it hurts." But then I Googled middle age and discovered that its borders seem to be shifting. Once defined as ages 40 to 60, it is now often defined as ages 45 to 64 (though Merriam-Webster wants to have it both ways).

When I turned 40, everyone was talking about the midlife crisis, that scary feeling when people in the work force fear their careers may have peaked and when caregivers at home notice their nests are practically empty (except for all that stuff in the basement). Midlife hit at age 40 back then--a bit optimistic, perhaps, considering that U.S. life expectancy in 1988 was 74.9 years. Columnist Bob Greene may have been closer to the truth when he wrote that "middle age starts at 36."

American life expectancy has increased in the last 25 years: it's now 78.62 years. I suppose that makes the shift in middle-age limits understandable, especially since so many people nowadays seem to think adulthood doesn't begin until age 30. But still, isn't Bridget Jones a bit old to be having a midlife crisis at age 51? And what's with those Brits who, in a 2012 survey, thought middle age begins at age 55 or later? Brits do live longer than Americans, but only by a couple of years.

In her lively review of Patricia Cohen's In Our Prime: The Invention of Middle Age, Laura Shapiro suggests why the definition of middle age is so fluid:

Despite the fact that researchers have been studying middle age intensively for decades, the term itself seems to have no fixed definition. Nearly any span between 40 and dementia appears to qualify, depending in part on whether we’re talking about ourselves (“But I feel just the same as I did when I was 20”) or all those people who show up at our college reunions (“Everyone looks so old”).

This is probably why some people prefer a descriptive rather than a chronological view of middle age: see, for instance, Shelley Emling's article "40 Signs You Are Middle Aged." The list is amusing, but the really telling comment comes in her introduction, where she quotes Paul Keenan, head of communications for a healthcare provider. "People no longer see ‘middle age’ as a numerical milestone," he said. "I’m 54 myself, with the mind-set of a thirty-something--perhaps sometimes even that of a teenager!” If anything is a sure and certain indication of middle-age--or even old age--it's a remark like that.

Maybe it's because, at 65, I've just left the ranks of the middle-aged, but I don't see why people want to delay its onset. By the time you're middle-aged, you've probably finished your education and those painful first jobs. Chances are you're in a responsible position, earning more money than you were a decade or two ago. You're probably married. You very likely own a house. If you have children, they are becoming more independent. Your parents are probably still in reasonably good health.

At 40, you are well past the torments of adolescence and young adulthood, and you still have a long way to go before the serious trials of old age begin. You are at the midpoint of your allotted years and at the beginning of an excellent couple of decades. Why pretend to be young long past the time when anybody who is truly young would claim you?

Believe it or not, those truly young adults respect you. They think you may have learned something in the 15 or 20 years since you left college. At the same time, you're not in an entirely alien world like, say, their parents.

In 1935 Will Rogers starred in a movie called Life Begins at Forty. I suspect it still does.

A Canadian who loves her health-care system

This morning a Canadian woman wrote such an interesting comment on an old post of mine, "Rationing is not a four-letter word," that I want to share it with you. I don't know the author, her full name (though she tells me her first name is LaVonne, so she's obviously a great person), or her contact information, so I can't give her full credit. But thanks, LaVonne-in-Canada: I learned a lot from you.

Here's what she wrote about how Canadian health care works for her. I've added a few comments in red, in case you want to compare the situation of LaVonne-in-Canada with that of LaVonne-in-the-United-States.

As a Canadian, I can't understand why a medicare plan such as we have is not feasible in the USA.

As a a retired person, I pay $65/mo. When I was working, it was less - employer paid a touch more than half. [As an American retired person, this year I paid $265.85/mo--that would be $104.90 for Medicare Part B (medical insurance), $44.10 for Medicare Part D (prescription insurance), and $116.85 for Medigap Plan G (to cover Medicare's very high co-pays). When my husband was employed, my insurance cost was half that amount because his employer paid about 3/4 of the total cost--but three months ago, the employee's cost for that policy at least doubled.]

Since 2008 I have had two major operations which didn't cost me anything except $35 per day for a private room in the hospital (my choice...a 4-bed ward would have been free). [In 2011, before going on Medicare, I had a major operation which cost me $2,111.35, which seemed like a real bargain since the hospital bill was originally $172,833.97. Insurance agreed to pay $116,748.28. Earlier this year--again, before going on Medicare--I had an outpatient procedure that cost me nothing, even though the hospital bill was originally $47,914.28. Insurance agreed to pay $15,763.77. It's a strange way of doing business.]

Moreover, no charge to Canadians for doctor's office visits. We don't have to delay need for care, might save worsening condition. [Because I bought a Medigap policy (Plan G), I first pay a $147 yearly deductible, after which I am not charged for doctor's office visits. Under our former Blue Cross Blue Shield plan, I was charged $20 to see my primary care provider and $40 to see a specialist.]

We have a population of less than 35 million. Our population can support a universal healthcare plan. The USA has more than 10 times the population of Canada. Surely 350 million people can support a universal health care plan successfully - many more people to pay into it, and as well, more healthy employed people than sick people by far to support the plan, I should think.

By the way, my $65/mo covers 60% of my dental care, too, however this is an option my former employee-plan (union job) allowed me to take. If I'd wanted to pay in more, I could have opted for 80% dental coverage, or 100%. Medicare without the dental would cost $57/mo.(rather than $65). [Alas, my $265.85 includes no dental coverage. And even though I pay for prescription insurance, I also pay out-of-pocket for prescriptions: in my case another $57/mo as long as I don't need anything next year that I'm not already taking.]

Do you think that if your legislators could corrall Big Pharma and Big Insurance Co., that maybe your country could get something even better going? The current Obama-care is not the whole way your President wanted to go (he wanted something more along the lines of the Canadian plan) but he was hog tied, he had to compromise.

We are not socialists in Canada. We have a capitalist system, too. However we don't fret at the thought of socially subsidized provision for people's health, and I think as a consequence we might have a healthier population. The Native Indian people in Canada have totally free healthcare - they don't have to pay any monthly premiums at all.

Now if you happen to think that the Affordable Care Act (aka Obamacare, in spite of what Jimmy Kimmel's interviewees believed) will give us a Canadian system, please, please, please read "Obamacare vs. Canada: Five key differences." The two systems are very, very different--and the differences help to explain why I pay hundreds of dollars more a month than LaVonne-across-the-border, and get significantly less.

And if you're itching to point out that Canadians have to wait longer than Americans for health care, or that Canadians stream over the border to American hospitals, or that Canadian seniors can't get hip replacements, please, please, please read "5 Myths About Canada's Health Care System" and learn what is really happening across our northern border. It's probably not what you think. It's certainly not what the U.S. anti-health-care lobby wants you to think.

These are short articles. You have time.

The truth is, as LaVonne-in-Canada noted, the Affordable Care Act is not exactly what President Obama wanted. He had to compromise, and as a result, Obamacare is not nearly as effective as Canadian health care--though it's somewhat better than what we had before. And Canadian health-care benefits aren't as amazingly good as, say, French or Swiss benefits (which still cost considerably less than ours, by the way), though if our aim is to keep costs as low as possible while still insuring everybody, we still  might choose to imitate Canada rather than some of the more generous countries.

But until the American people come to realize that our current mishmash of a system is costing them a lot more than a more centralized system could--and until our lawmakers find the courage "to grapple in a systematic fashion with the overall inefficiencies in health care delivery and financing, the administrative burden of multiple payers, providers and plans, and the cost pressures of defensive medicine," as the "Obamacare vs. Canada" article suggests--we will keep on paying more, getting less, and regularly shutting down the U.S. government and (who knows?) maybe crashing the entire world's economy.