Thoughts from Steve Miles

MinnPost's Susan Perry interviews the brilliant Dr. Steve Miles on whether (or not!) our society is ready for the coming wave of old people -- medically, infrastructurally, and more.

This guy is so amazing, there's too much to quote.

MinnPost: ...our medical system seems more set up for acute care during those last few days or months of life, not for helping people deal with the last 5 to 10 years.

Stephen Miles: Well, I think that’s true, but I’m going to make a provocative comment here. Medicare was really normed on a male life course, not a female life course. When Medicare benefits were set up, [they were based on the shorter] life trajectories of men. There would be a female caregiver available to care for the old guy, who passed at a relatively young old age. The women were more likely to develop chronic conditions and then move into institutional settings because they didn’t have a caregiver.

MP: But then men started living longer.

SM: When men started requiring medicines for chronic disease, that was when we added on Part D of Medicare [Medicare’s prescription drug benefit]. Men still don’t occupy nursing homes anything like the degree to which women do, and so that’s why nursing homes still sit on the Medicaid side of the budget, which is a state/federal share. 

And:

Obviously one of the interesting things about that phenomenon, the female caregiver problem, is that it has a really far-reaching effect on the life trajectory of women workers. At the time when they should be eligible for promotions to leadership positions, they take up caregiving roles that essentially cut their work course participation as professionals substantially.

Plus this on how we, generally, think death happens in the U.S. vs. the reality:

MP: What are some of the misconceptions that we have about aging that get in the way of us — as individuals — from realistically thinking about how we’re going to map out our life for our last couple of decades?

SM: ... One of the interesting things is that if you ask people what percentage of deaths in the United States are preceded by decisions to withhold or withdraw sustaining treatment, they’ll typically give you numbers like 1 percent, 2 percent, or 5 percent, something like that. The real number is actually 95 percent, and the reason for that is that there are three trajectories of late-life care in the United States.

One goes like this: Somebody gets Alzheimer’s disease and dies. What happens is that they have a period of decline, possibly at home, and then they move to a nursing home. They may go back and forth to the hospital for a while, but then they’re kept in the nursing home and treated with palliative measures as they pass.

The second trajectory of end-of-life care in the United States is one that goes [like this]: Somebody gets something like pancreatic cancer. They’re treated aggressively for a while, and then they’re moved into a hospice program. They may go back to the hospital, perhaps for a few short pain-relief things, and then they pass with a supportive care plan.

The third course is some sort of catastrophic illness with septic shock. They are briefly evaluated, and then a limited treatment plan is set up.

But the problem is, if the population does not understand the planning for these decisions as normal life work rather than an exceptional one, they don’t undertake the task.

And then about infrastructure:

MP: What kind of late-in-life support services are needed, including here in Minnesota?

SM: Supportive services have to be [thought of] as a total ecology. The Twin Cities metro area is extremely poorly designed for this late-in-life lifestyle. The freeway system is not traversable, even for us younger guys. The housing is far spread out, which makes home-care services extremely difficult. Walking to essential services is quite a bit more difficult than in Europe. Bus service is scattered in routes that are far removed from any houses. And, particularly, once one moves to the first-ring and certainly the second-ring suburbs — and I won’t even comment on the third-ring suburbs — we basically have an urban and suburban architecture that is incompatible of supporting older people.

This is only part one of the interview... Perry follows up tomorrow with more on psychological issues of aging and declining health.

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Here's part two, including this quote from the photo caption: "Miles on fighting depression among the elderly: 'Medications can get you 20 percent of the way there. Congregate dining will do much more, [as will] getting out of the house, moving, sunshine in the afternoon, socializing and exercise.'"

Coal Must Go

Thanks to Jim Davidson of St. Paul for his commentary in today's Star Tribune, in response to a pro-coal piece by Republican State Rep. Jim Newberger that ran earlier in the week.

Like Davidson, I know that changing an economy from one organizing principal to another is hard, and that I'm not the one who will have to deal with it first-hand, as will Newberger's constituents. But we can't keep mining and burning coal. There are jobs to be had in making clean energy.

More than 2,000 Minnesota jobs have been created by wind and solar energy in recent years. The pace will be much faster in coming years as technology reduces the costs of such energy by another 30 percent. Just weeks ago, the state Public Utilities Commission granted a contract to increase sevenfold Minnesota’s current solar capacity. That bid was won on economics alone. Coal will never again win a bid against wind or solar energy. That is our new reality.

Coal is “clean,” or so Newberger says. He never mentions the elephant in the room: carbon dioxide emissions (CO2). He brags of Sherco’s ability to service 2.5 million people. He touts its 2,400-megawatt capacity. Yes, both true. But at what cost to future generations, as climate warms and oceans rise?

Sherco burns 9 millions tons of coal yearly, emitting 26 million tons of CO2 — a harmful global-warming gas. Result: Each Sherco residential customer inherits 10 tons of CO2 emissions per year. Newberger boasts that such emissions are clean. Many find such misuse of language offensive and dangerous — not to mention politically motivated.

Sadly, Newberger is stalwart in his conviction that solar and wind power are not quite ready for prime-time mass production. That is but a feel-good fantasy of a person in denial. The coal industry is dying. Coal is a terribly dirty business — at all stages — and is destined for the dust bin. Wise political leaders will see the future coming, accept the opportunities and help build those economic realities in their districts.

Finally, for “dirty coal,” Newberger points a finger at Russia and China. He informs us they have “few, if any, pollution standards.” Perhaps. Yet China is adding wind and solar much faster than the United States. And China produces only 6 tons of CO2 per person; Russia, 11 tons per person. The United States, on the other hand? We produce 18 tons of CO2 per person. We have less than 5 percent of the world’s population, yet we produce 24 percent of the world’s carbon emissions.

This single Sherco coal facility (as good as it might be) emits 10 tons of CO2 per year — per customer. How dare anyone call such an ancient and outdated energy clean?

The Faults in Their Movie Stars

John Green's novel The Fault in Our Stars shows why the best books should never be made into movies. There's nothing particularly wrong with the film that just opened. It's just that it's a film and not a book.

First, there's the fact that it visualizes all of the stuff your mind was responsible for visualizing when you were reading. And so you are less involved, more passive.

Then there's the fact that how they visualize it can never meet every (or any) reader's vision. I don't even know how how I visualized it, I just know the film is wrong. From the moment I saw photos of Shailene Woodley and Ansel Elgort, who play the two main characters, I reacted against their mushy, nondescript pretty faces. And would it kill Hollywood to hire actors as parents who have even a passing resemblance to their "children"? Not to mention the locations, props, cars… It's all so shiny and catalog-perfect.

What I liked about the book was that it wasn't sentimental or cloying, despite its subject (teenagers with terminal cancer). But a first-person narrator just can't translate into film voice-over without gaining kitsch. I wish the director had dispensed with the narration, as difficult as that would have been structurally.

Something also seems to have been lost in the wonderful exchange the teenagers have with the reclusive writer they are pursuing, hoping for answers to their questions about his ambiguous novel. Willem Dafoe as the author is probably the best thing in the film, and yet I found the outcome of his interaction with the main characters unsatisfying, while in the book I thought it was brilliant. Maybe, once again, I, as a reader, was filling in the unsaid and unwritten, while the film puts it all out on the screen, revealing that it's not as revelatory as I thought.

Finally, the film makes it clear the male ingenue Gus is a Mary Sue, which I somehow missed in the book. Maybe it's a loss of complexity from the translation to image, or maybe he was always like that and I just missed it, caught up in the emotional involvement of the novel.

Or possibly I would have thought less of the book on a second read. But now the movie interferes with my ability to do that assessment without hearing Shailene Woodley's voice in my head. Darn.

Patents Are Killing People

A recent Vox story on four ways we could decrease costs in American health care discusses allowing more immigrant doctors, letting nurse practitioners and physician assistants do more to treat patients, and following the state of Maryland in its move to "all-payer rate setting," where a government commission sets a price for each type of treatment (rather than each hospital and clinic negotiating its own price with insurance companies. See Steve Brill's Time magazine article for more on how these negotiations work.)

This would be similar to how Medicare negotiates rates so that they're in line with the actual cost -- including the costs of medical education and covering uninsured people -- but not as extravagant as the current "chargemaster" rates.

The fourth item discussed by Vox is curtailing pharmaceutical monopolies, and that's what moved me to write today. They mention the idea, proposed by economists like Joseph Stiglitz, of funding drug research through taxpayer-financed prizes, rather than by granting exclusive patents.

A large cash prize creates an incentive to innovate just as much as a patent does, but offers several important advantages. First, nobody needs to be priced out. All those $1000 hepatitis pills generate a lot of revenue, but also a lot of patients who end up with no pills at all. With a prize, the money is raised in a way that doesn't need to exclude anyone. Prizes can also direct R&D efforts at problems that are genuinely important, rather than ones that happen to interest a large market. The patent system is better at generating treatments for conditions that annoy rich people (baldness) than conditions that kill poor people (malaria).

Last but by no means least, a prize-based system would reduce the amount of money and effort firms currently spend on trying to game the patent system. Right now, for example, companies like AstraZeneca spend time doing things like reformulating the active ingredient from Prilosec into a quasi-new drug called Nexium in order to get a new high-margin product to sell. Prizes could be targeted at innovations with real health benefits, rather than the current mix of payoffs for innovation and payoffs for hacking patent law.

So, for instance, the need for new antibiotics or a universal flu vaccine could rise to the top, instead of more dubious ways to treat chronic conditions or cosmetic vanity.

A great example of the wrongness of the current patent system is the EpiPen. Anyone with a serious allergy, from peanuts to bee stings, should have a couple of these on hand every day. They pass their expiration dates fairly quickly, though (definitely within a year), and become ineffective whenever the liquid is discolored or cloudy.

The drug in question, epinephrine, is cheap, according to a doctor friend of mine. The thing that costs money is the one-shot, anyone-can-administer-it needle device. Sold in two-packs, the local price is almost $400.

Another friend, who recently has been having extreme reactions to insect bites and is going to be traveling in the South Pacific, was planning to buy one to take along until she saw the price and the fact that you have to buy two at a time. Her insurance only covers $20 of it.

The patent on the device doesn't expire until 2025. I wonder how many people will die because they didn't have an over-priced EpiPen?

Hope from Katharine Hayoe

People like Katherine Hayoe give me a bit of hope that the Right may begin to recognize climate change and global warming not only as facts they need to acknowledge but as problems they need to help solve. She was featured on NPR's Weekend Edition Sunday this morning.

As the story shows, she's a Christian climate scientist who has made it her mission to convert nonbelievers. She answers all of their questions, from "How can this happen if God is in charge?" to "Wouldn't it be good for the world to end soon anyway?" (Seriously, they ask that.)

Now if she and Republican former Congressman Bob Inglis can just talk to enough people, maybe we can make this the consensus issue it should be. Then all we have to do is fight over how to do it, rather than whether to do it. Duh.

Impressed Words

It has been a rainy, busy day. Here's a photo noting three activities I had no time for today:


Maybe tomorrow.

Semi Legal

I saw this on I-94 in Minneapolis yesterday:


I wasn't sure what it meant, but it turns out it's the name of a legitimate trucking company based in Blaine, a suburb north of the Twin Cities. Nice to see a company with a sense of humor.

They use the acronym SLA to refer to themselves. I wonder if they remember the Symbionese Liberation Army and Patty Hearst?

Ben Suarez in the News

Ben Suarez is spending some time at the court house in recent days, as he is tried for illegal campaign finance activities. The Cleveland Plain Dealer has a story on it just about every day, so I guess it's a big deal in Ohio. So far, Suarez's daughter and son-in-law have testified that his company reimbursed them for their $10,000 campaign contributions to two Republican candidates.

Yesterday, the paper ran a summary of Suarez's run-ins with the law and other activity related to elections, like that thing about ousting Jack Brooks from Congress because he wanted to tax mail-order purchases.

It's ironic that the activity Suarez is accused of (funneling donations through his employees and relatives) would be legal if Clarence Thomas and Antonin Scalia had their way with U.S. election law. I wonder if he'll get out of jail if the Supreme Court overturns the last vestiges of donation limits?

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My past posts about Ben Suarez:

Do I Dare Say "Ben Suarez" in the Title?

When Does Free Speech Become Coercion?

Paying for Campaigns, Legally or Not

Children Are Not Adults

Twenty-nine states, including Wisconsin, have laws that require anyone older than 10 years of age who is charged with homicide to be treated as an adult. I disagree with this, believing that juveniles should face juvenile justice.

Wisconsin is relevant because of the 12-year-old girls who stabbed their friend in Waukesha recently. Maybe you've heard about it; I guess it's sensational enough to be on the national news. Here's today's AP story about it from the Star Tribune:


And a close-up of the secondary headline:


See... how can anyone who wants to impress a fictional character be treated as an adult? How can she aid in her own defense, let alone understand the consequences of her actions?

What does justice mean in this country?

A Name that's Stupid for Business

Okay, so it's not a name that's bad for business (unlike these, these, these, or this), but it's certainly a stupid name.


They're snap peas, darn it, and stealing one of their Ps and smashing the words together makes, if anything, a word that sounds like snah-pee.

Tabs for the Beginning of June

Tabs, tabs, tabs, once again.

Racism and implicit bias show themselves in the smallest of ways, including how pedestrians are treated at crosswalks:

Three black and three white participants were selected to be crosswalk pedestrians for the study.... All six of the pedestrian volunteers were men in their 20s, and were matched based on their height and build. They wore an identical outfit; a long-sleeved gray shirt and khaki pants, to achieve a neutral look without any obvious social or socio-economic characteristics.

Researchers chose an unsignalized, marked crosswalk, located mid-block so that drivers’ yielding wouldn’t be influenced by cross traffic or turning. It was on a two-lane, one-way street in downtown Portland, Ore.

Each pedestrian did 15 crossing trials. These trials resulted in 168 driver subjects.

In each trial, three trained observers stood out of sight of oncoming cars and recorded whether the first car to approach yielded, how many cars passed before someone yielded, and the number of seconds that elapsed before the pedestrian was able to cross.

As hypothesized, the results differed based on race: black pedestrians got passed by twice as many cars, and waited 32 percent longer than white pedestrians.

And get this: "Previous crosswalk studies have shown that driver yielding behavior changes based on social factors. Drivers have been shown to yield differently based on the relative ages of the driver and the pedestrian, the social class of the driver, and the apparent physical disability of the pedestrian (one study equipped pedestrians with canes, and drivers responded with quicker yielding and shorter wait times)." That makes me wonder if the black men in the race study were (once again) falling on the wrong end of a human/empathy continuum, where disabled people evoke the most empathy and able-bodied black folks the least. Just as black children are thought to older than they are, black men (possibly black women, too, who knows, since that wasn't examined here) either are not perceived as needing "help" as much as white men or are not as human as white men.

I came across the blog SheRights because of this post about the language of dude feminism. Loved the post, but was also enchanted by the site's clever, pithy logo:


And this additional post on access to "feminine hygiene" products as an important part of women and girls' equality.

Here's another article on the likelihood that parents helping their kids with school work doesn't improve their outcomes, mentioned in this earlier Too Many Tabs post. The Atlantic tells us:

...although conventional wisdom holds that poor children do badly in school because their parents don’t care about education, the opposite is true. Across race, class, and education level, the vast majority of American parents report that they speak with their kids about the importance of good grades and hope that they will attend college. Asian American kids may perform inordinately well on tests, for example, but their parents are not much more involved at school than Hispanic parents are—not surprising, given that both groups experience language barriers. So why are some parents more effective at helping their children translate these shared values into achievement?

Robinson and Harris posit that greater financial and educational resources allow some parents to embed their children in neighborhoods and social settings in which they meet many college-educated adults with interesting careers. Upper-middle-class kids aren’t just told a good education will help them succeed in life. They are surrounded by family and friends who work as doctors, lawyers, and engineers and who reminisce about their college years around the dinner table. Asian parents are an interesting exception; even when they are poor and unable to provide these types of social settings, they seem to be able to communicate the value and appeal of education in a similarly effective manner.

The Twin Cities has a good counter example to this Asian "model minority" myth. We are home to the largest population of Hmong people outside of Southeast Asia. Hmong-Americans have been here for going on 30 years now and are still "mired," as it is so often put, in cultural pathologies not usually associated with Asian-Americans. Most Asian immigrants from other cultures are not refugees and are parts of communities made up largely of legal immigrants with advanced degrees, so even if a child's own parents don't meet that criterion, there are others in the community who do and provide a culture of high expectations. The Hmong didn't have people like that in their community, and they're only just now beginning to get some locally grown achievers to lead the way.

Minnesota comes out well in another Richard Florida piece called Americans Like Living in States With Less Income Inequality. When asked if their state was a good place to live, Americans came up with the following:


Compare that with the Gini Coefficient for each state (shown at right) and you'll find that Texans think their state is a great place to live even though the rich are getting richer more than most places. Note that Texas is the only state in the historic South where a comfortable majority of residents thought it was a good place to live. (While other conservative states like Alaska, Utah, and Wyoming have no such inferiority complex... and more income equality, too.)

Southern states and cities also are much more dangerous places to be a pedestrian, too.

Government Regulations Saved My Life. David Cay Johnston's paean to Ralph Nader and the National Highway Traffic Safety Agency.

Richard Florida on Why People Perceive Some Cities as Safer Than Others. Hey, the Twin Cities comes up at the top of the list of places that residents perceive as safe (though the number is only 80 percent). It's easy to think that these perceptions are based in the reality of lower crime rates in some places than others, except there was "no statistically significant association between perceived safety and a range of crime per capita measures based on the FBI Uniform Crime Reports, including for violent crime and property crime." But the perception of safety also didn't correlate with income equality (Gini Coefficient) or home-ownership levels. Great levels of religiosity, interestingly, were correlated with increased perceptions of danger.

The Case for Term-Limiting Supreme Court Justices by Matt Bruenig. I never would have thought I'd find this persuasive, but he got me with the idea of "single, staggered 18-year terms, such that a new judge would be appointed every two years. This fixes the issue of randomness [among the presidents appointing justices], which can create huge judicial windfalls for certain presidencies. It also fixes the strategic retirement problem, since judges would be forced out after 18 years. Furthermore, it allows the court to change in line with the political tides of the country. The ideological composition of the court at any given time should generally mirror that of the presidency in the 18 years prior."

The Racist Narrative of "Failing" Schools and a nice summary of why external rewards don't work.

I've written before about Ursula LeGuin's book The Dispossessed, and particularly a quote by a character named Odo on the idea of deserving. YA author John Green recently posted a video discussing that same idea. Like author Michael Lewis, Green ascribes a lot to luck and privilege and not a bit to deserving.

Speaking of deserving, here's Matt Bruenig ruminating on "just desert" theory. (Yes, desert, not dessert.)

And then there's this fascinating analysis of the Real Origins of the Religious Right. Hint: It's a more "colorful" reason than Roe v. Wade.

Photos of the devastation that is the tar sands wastelands of Canada.

And on that note, enough tabs for one day.

The More Dangerous Drug

Reihan Salam writes for National Review, so I probably wouldn't usually agree with him, but his recent piece for Slate, Alcohol Taxes Should Be Tripled, sounds about right to me. He points out that almost 70 percent of the public now realize alcohol is more harmful to society than marijuana. So while we're heading toward legalization of pot, it's time to reconsider how we regulate alcohol.

...alcohol is crazily dangerous, and it needs to be more tightly controlled. Everyone knows that Prohibition was a disaster. What most of us forget is that the movement for Prohibition arose because alcohol abuse actually was destroying American society in the first decades of the 20th century, and the strictly-regulated post-Prohibition alcohol market was shaped by still-fresh memories of the pre-Prohibition era.

For a nightmare vision of where heavy drinking can lead a society, consider Russia, where the pervasiveness of binge drinking contributes to an epidemic of cardiovascular disease and a death rate from fatal injuries that you’d normally see in wartime. Political economist Nicholas Eberstadt has gone so far as to suggest that drunkenness is a key reason why Russia, a country with universal literacy and a level of educational attainment that is (technically) in the same ballpark as countries like Australia and Sweden, has roughly the same living standards as Ecuador.

Closer to home, Great Britain has seen a staggering increase in alcohol consumption since the 1990s, much of it among teenagers. Tim Heffernan, writing in the Washington Monthly, has attributed Britain’s binge-drinking crisis to its laissez-faire alcohol market, which has allowed for the vertical integration of the liquor business. America has been shielded from U.K.–style liquor conglomerates by those post-Prohibition regulations that inflate the cost of making, moving, and selling booze, but that’s now changing thanks to big multinationals like Anheuser-Busch InBev and MillerCoors, which are working hand in glove with national retail chains like Costco to make alcohol as cheap and accessible as they can.

....In Marijuana Legalization: What Everyone Needs to Know, the authors estimate that at current beer prices, it costs about $5 to $10 to get drunk, or a dollar or two per drunken hour. To get a sense of what the world would look like if that price fell significantly, go to a typical town square in England on a weekend night, where alcohol-fueled violence is rampant, or to Russia, where the ruling class has used cheap vodka as a tool to keep the population drunk, passive, and stupid for generations.

We shouldn’t be satisfied with keeping the per dollar cost of getting drunk where it is today. We should make it higher. Much higher. [Researchers] have suggested tripling the federal alcohol tax from 10 cents a drink to 30 cents a drink, an increase that they estimate would prevent 6 percent of homicides and 6 percent of motor vehicle deaths, thus sparing 3,000 lives (1,000 from the drop in homicides, 2,000 from safer highways) every year. Charging two-drink-per-day drinkers an extra $12 per month seems like a laughably small price to pay to deter binge drinking. Then, of course, there is the fact that a higher alcohol tax would also raise revenue. If you’re going to tax tanning beds and sugary soft drinks, why on earth wouldn’t you raise alcohol taxes too? If anything, 30 cents a drink isn’t high enough. Let’s raise the alcohol tax to a point just shy of where large numbers of people will start making illegal moonshine in their bathtubs.